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. Author manuscript; available in PMC: 2021 Jun 1.
Published in final edited form as: J Clin Psychol Med Settings. 2020 Jun;27(2):207–216. doi: 10.1007/s10880-019-09684-6

Program evaluation of an integrated behavioral health clinic in an outpatient women’s health clinic: Challenges and considerations

Allison J Carroll a,b, Anna E Jaffe a,c, Kimberley Stanton a,d, Constance Guille a, Gweneth B Lazenby e, David E Soper e, Amanda K Gilmore a,f,*, Lauren Holland-Carter a,*
PMCID: PMC7225040  NIHMSID: NIHMS1547012  PMID: 31858362

Abstract

Many women receive their regular check-ups and preventive care through a women’s health clinic, including their behavioral health needs. Most of these clinics have not yet developed the capacity to adequately manage behavioral health concerns. We describe our clinical experience integrating behavioral health services into a women’s health clinic. In one year, 108 patients (54% White, Mage=35) were referred for behavioral health symptoms; 47% were identified using a screening questionnaire, 51% were referred by their provider, and 2% were self-referred. The most common presenting concerns were anxiety (52%) and depressive symptoms (48%). Sixty-one (56%) patients completed an intake assessment, of whom 33 (54%) engaged in follow-up treatment (M=3.7 treatment sessions, SD=3.0). Behavioral health screening and treatment appears to be feasible and effective within a women’s health setting. Research is needed to overcome barriers to referrals and treatment engagement in this population.

Keywords: gynecology, women’s health, behavioral health, primary care integration

Introduction

Nearly half of women in the U.S. identify their reproductive health provider or gynecologist as their sole medical provider and receive their preventive health care services through women’s health clinics (Scholle, Chang, Harman, & McNeil, 2004; Stormo, Saraiya, Hing, Henderson, & Sawaya, 2014). Given the regularity with which behavioral health conditions are presented and treated in primary care settings (Auxier et al., 2012; Bridges et al., 2015; National Center for Health Statistics, 2014), it follows that women also frequently present behavioral health concerns to their gynecologist. Approximately half of women presenting to a gynecology office report general distress, up to one third have significantly elevated levels of anxiety, and 10 to 20% endorse symptoms consistent with a depressive episode (Glover, Novakovic, & Hunter, 2002; Miranda, Azocar, Komaromy, & Golding, 1998). In addition, gynecology patients commonly present with chronic pain, substance use, obesity, significant trauma histories, and concerns about intimate partner violence (Miranda et al., 1998; Poleshuck et al., 2009; Shaw, Caughey, & Edelman, 2012; Woolhouse, Gartland, Hegarty, Donath, & Brown, 2012). These conditions are often comorbid (Poleshuck et al., 2009), rendering behavioral health treatment a crucial service for this population.

Integrated services extend the reach of behavioral health to those populations who might otherwise go undetected or unserved in traditional mental health settings (Bartels et al., 2004; Bridges et al., 2017). Guidelines from the U.S. Preventive Services Task Force dictate best practices in primary care settings for effective screening and treatment of behavioral health concerns that are also commonly presented in women’s health clinics (e.g., perinatal depression: USPSTF, 2019). Results from the system-wide integration of behavioral health services into primary care settings in the Veterans Health Administration have identified factors associated with the successful integration of behavioral health providers, including: well-defined infrastructure and leadership, standardized screening, assessment, and interventions, clearly defined patient flow, and adequate staffing (Pomerantz, Kearney, Wray, Post, & McCarthy, 2014). The primary care behavioral health (PCBH) model has demonstrated improved health care utilization (Possemato et al., 2018), improved physical health outcomes (Scharf et al., 2016), and reduced health care costs (Ross et al., 2019). A review of the PCBH model concluded that, “The PCBH model offers a tremendous opportunity for changing the delivery of behavioral healthcare in primary care settings,” while recognizing that an area for growth is “to understand important implementation and contextual variables that account for variability in effectiveness” (pg. 141, Hunter et al., 2018).

To our knowledge, no specific guidelines exist for identifying and treating behavioral health symptoms that may be addressed by a behavioral health provider embedded in the women’s health setting, which has unique considerations. First, although many women present to their women’s health provider for primary care needs, the types of screenings, procedures, and counseling offered during annual wellness exams differ between women’s health and primary care providers. For example, women with a history of sexual trauma may have difficulty with aspects of a gynecological exam which they may experience as trauma reminders (Robohm & Buttenheim, 1997), warranting special care and consideration.

Second, medical specialists including gynecologists, do not receive training in behavioral health and therefore are not equipped to identify and provide treatment for behavioral health concerns. As a result, gynecologists fail to identify a majority of women who meet criteria for depression (Cerimele et al., 2013) and provide less counseling, especially for more general behavioral health concerns, compared to primary care providers (Hall, Patton, Crissman, Zochowski, & Dalton, 2015; Scholle et al., 2004; Stormo et al., 2014). In addition, more than half of women presenting to their gynecologist report that they would not talk with their provider about depression (Bennett et al., 2009).

Third, even when women’s health providers do identify a behavioral health concern, few providers feel adequately prepared to treat psychological distress (Coleman, Carter, Morgan, & Schulkin, 2008; Leddy, Lawrence, & Schulkin, 2011). When provided with a referral, patients frequently indicate that they have doubts about engaging in behavioral health services (Leddy et al., 2011), and only half of patients follow through with external behavioral health referrals (Bartels et al., 2004). Perhaps as a result, gynecologists are approximately twice as likely to prescribe medication rather than provide a referral to a behavioral health provider (Leddy et al., 2011), even with substantial availability of evidence-based behavioral treatments. A model of care that maximizes both identification of behavioral health concerns and engagement in appropriate treatment is needed in women’s health clinics.

In sum, although gynecology is not a primary care specialty, many women use their women’s health providers as their sole medical providers and therefore present ill-equipped gynecologists with behavioral health issues that primary care physicians typically address (Scholle et al., 2004; Stormo et al., 2014). Although research has consistently demonstrated a positive impact on behavioral health engagement when services are co-located in a traditional primary care clinic, less research has been conducted in women’s health settings. The few studies that do exist have focused on treating depression (e.g., Melville et al., 2014) or on obstetrics (pregnant and post-partum women; e.g., Lenze & Potts, 2017) rather than a more general women’s health population. Even in the Veterans Health Administration, a national leader in behavioral health integration in primary care, the identification and treatment of behavioral health concerns in women’s health clinics is lacking (Bean-Mayberry et al., 2011; Oishi et al., 2011).

In an effort to address these gaps in clinical care, we established a behavioral health clinic focused on gynecology patients within a women’s health clinic. To build upon previous research dedicated to treating depression, women seeking obstetric care, or women veterans, we conducted a program evaluation of the implementation and engagement during the first year of the behavioral health clinic. Herein we describe our experience with the benefits of and limitations to the integration of behavioral health services in a women’s health clinic to inform future clinical practice.

Methods

Clinic setting and population

Patients were seen at an outpatient obstetrics and genecology clinic located within an academic medical center between August, 2017 and July, 2018. Services were provided free of charge as part of a clinical training grant. The behavioral health clinic was developed based on a co-located, collaborative care model.

Training and supervision of clinicians

Behavioral health services were provided by pre-doctoral clinicians supervised by a licensed clinical psychologist. Over the course of the year, three clinicians provided services to patients, with availability 3 days per week, on average. The clinicians were all female, with between 4–6 years of doctoral training in clinical intervention and various levels of previous training in integrated care settings. All pre-doctoral clinicians were masters level clinicians in their final year of their doctoral-level clinical training and all came from APA-accredited clinical psychology doctoral training programs. Individual supervision was provided weekly for at least one hour and all session documentation was reviewed by the supervising licensed clinical psychologist to ensure fidelity to the empirically supported treatments implemented. In addition to weekly supervision, clinician competency (including ability to implement empirically supported treatments with fidelity) was formally evaluated on a quarterly basis with the clinicians. Review of the clinicians’ formal evaluations indicated all three were rated as “Advanced” across all levels of clinical competency, which was operationalized as a level of competence that is approximate to competence needed for entry into independent practice.

Referral procedures

Upon initiation of the clinic, the women’s health providers were introduced to the clinicians and provided with information about appropriate referral questions. Physicians, midwives, and nurses were encouraged to send referrals to the behavioral health clinic. Referrals included: warm hand-offs, in which the women’s health provider facilitated an in-person introduction between the patient and a behavioral health clinician during her clinic visit; scheduled referrals, in which the provider assisted the patient in scheduling an intake appointment with a behavioral health clinician; or direct referrals, in which the provider asked a behavioral health clinician to reach out to a patient and engage her in treatment.

Engaging patients in treatment

The clinicians attempted to contact all patients who were referred to the behavioral health clinic or who endorsed a behavioral health concern on the questionnaire and indicated they would like to speak to a provider. By telephone, patients were provided with a brief description of the clinic and behavioral health treatment outcomes. If interested, they were scheduled for an intake. Treatment was described as a short-term, targeted intervention focused on developing cognitive and behavioral strategies to manage distress or improve health behaviors.

The intake assessment comprised four primary goals. First, the clinician conducted a clinical interview to assess the presenting problem, mental health and treatment history, and social background. Second, the patient completed symptom assessments using validated measures as indicated, such as the Patient Health Questionnaire (PHQ-9; Kroenke, Spitzer, & Williams, 2001), the Generalized Anxiety Disorder 7-item (GAD-7; Spitzer, Kroenke, Williams, & Löwe, 2006), the Beck Anxiety Inventory (BAI; Beck & Steer, 1993), or the Alcohol Use Disorders Identification Test (AUDIT; Babor, de la Fuente, Saunders, & Grant, 1992). Third, the clinician provided the patient with a new skill or coping strategy, such as mindful breathing, activity pacing, pleasant event scheduling. Finally, the clinician and the patient collaboratively discussed treatment options, such as brief treatment in the women’s behavioral health clinic, referrals to external behavioral health providers for longer-term follow-up, or referral to a psychiatrist for psychiatric medication management.

Providing treatment

When it was appropriate and the patient was amenable, patients were engaged in treatment with one of the clinicians. Treatment was intended to be brief (≤8 sessions), problem-focused (i.e., current symptoms), and empirically supported (based on Division 12 of the American Psychological Association’s empirically supported treatments: https://www.div12.org/psychological-treatments/). Given that the purpose of this clinic was to provide psychological treatments in a real-world setting, the clinician tailored the treatment to the patient’s individual needs and goals for treatment. The majority of these treatments were based in cognitive behavioral therapies or mindfulness- and acceptance-based treatments.

Outcomes assessed included treatment attendance, treatment duration, and symptom improvement as reported by the patient and observed by the clinician.

Results

Screening questionnaire development

To assist in generating referrals, a brief self-report screening questionnaire was developed to assess the behavioral health concerns of the clinic population (Appendix A). The questionnaire was administered at all new patient visits and at annual exams concurrent with other routine self-report questionnaires implemented in the clinic workflow. This questionnaire included 13 items that were adapted from evidence-based mental health screens (e.g., AUDIT-C, DAST, PHQ-2, GAD-7) or based on the needs identified by women’s health providers (e.g., cigarette smoking, substance use) and formatted for ease of patient completion. At the end of the questionnaire, patients were then asked to indicate whether or not they were interested in speaking with a provider about the endorsed concerns. We also incorporated feedback from the women’s health providers to ensure successful implementation. Based on feedback from the clinic staff, only questionnaires for patients interested in speaking to someone about behavioral concerns were returned to the clinicians to reduce burden on the clinic staff.

Dynamic referral procedures

Due to feedback from women’s health providers, additional procedures were implemented to improve the referral process and increase the number of referrals. Through ongoing meetings and education regarding behavioral health services, providers were encouraged to conduct a “warm hand-off” with the behavioral medicine clinician during the patient’s clinic visit. If a behavioral health clinician was not available, providers were encouraged to send an electronic referral by 1) sending an email directly to the behavioral health clinicians, 2) notifying the behavioral health clinician by routing the clinical note in the electronic health record, or 3) entering a formal referral for behavioral health services in the electronic health record.

Patient population and referrals

A total of 108 patients were referred to the clinic between August 1, 2017 and July 31, 2018 (Table 1). The women who were referred to the behavioral health clinic were 54% white, 45% black, and 1% Latina and were between 18 and 73 years old (M=35, SD=13). On average, patients reported 2.2 (SD=1.7) behavioral health concerns out of the 11 categories assessed, with patients endorsing from zero to eight concerns. Nearly equal proportions of patients were identified by positive responses on the screening questionnaire (n=51, 47%) or were referred by their health care provider (n=55, 51%).

Table 1.

Women’s Behavioral Health Clinic Patient Characteristics and Referrals (N=108)

N (%) or M (SD)
Race
 White 58 (54%)
 Black/African American 49 (45%)
 Latina 1 (1%)
Age, years (range: 18–73) 35 (13)
Behavioral Health Concernsa, N (range: 0–8) 2.2 (1.7)
 Depression 48 (48%)
 Anxiety or panic 53 (52%)
 Abuse, trauma, or violence 16 (16%)
 Weight 35 (35%)
 Sleep disturbance 28 (28%)
 Sexual health 25 (25%)
 Perinatal or postpartum concerns 6 (6%)
 Cigarette smoking 6 (6%)
 Alcohol use 8 (8%)
 Prescription medication misuse 6 (6%)
 Illicit substance use 4 (4%)
Referral type
 Screening questionnaire 51 (47%)
 Warm hand-off 21 (19%)
 Scheduled referral 22 (20%)
 Direct referral 12 (11%)
 Self-referral 2 (2%)
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a

Behavioral health concern categories are not mutually exclusive. Seven patients did not complete a questionnaire and did not attend an intake session, and thus information about the behavioral health concerns of those patients were unavailable.

Behavioral health treatment engagement

Figure 1 depicts the flow of patient referrals, attendance, and treatment engagement. Of the 108 referrals, 102 (94%) were contacted by the behavioral health clinicians, 78 (72%) scheduled an intake appointment, and 61 (56%) completed the intake assessment. The 32 patients (30%) who engaged in further treatment attended between one and 12 treatment sessions (M=3.7, SD=3.0), for a total of 117 completed treatment sessions. Each session was lasted approximately 45–60 minutes, pending patient preference and clinician availability. During the course of treatment, a majority of treatment engagers rescheduled or canceled at least one appointment, with 68% of treatment engagers canceling at least one appointment (39 total cancelations) and 34% missing at least one appointment (18 total no-shows). Treatment involved addressing a wide range of presenting concerns with cognitive-behavioral, mindfulness, and acceptance-based principles.

Figure 1.

Figure 1.

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Flow-diagram of patient referral and attendance.

Challenges and considerations

Overall, the integration of behavioral health services into the women’s health outpatient clinic setting was readily welcomed by the clinic staff and patients. The challenges we experienced with the clinic implementation were broadly categorized into difficulties generating referrals and barriers to engaging patients in treatment. An overview of potential strategies to address these challenges are outlined in Table 2. Further discussion of the challenges and possible solutions is provided below.

Table 2.

Challenges and possible solutions to integrating behavioral health services into a women’s health clinic

Challenge Possible solutions
Difficulty generating referrals

  • Patient-level: assess and accommodate the behavioral health treatment and delivery needs of this population

  • Provider-level: allow time and space for the provider to meet with patients upon referral, while simultaneously protecting patient privacy and confidentiality and maximizing presence and integration of behavioral health providers into the same setting to increase visibility of behavioral health services
Barriers to treatment engagement

  • Provision of psychiatric medications, in collaboration with women’s health providers or psychiatrists

  • Intensive reminder calls, texts, or notifications

  • Alternative methods of treatment delivery:
    • Home-based delivery of behavioral health services
    • mHealth approaches using telephone, video conferencing, or smartphone applications
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Discussion

During the first year of integrating behavioral health services into an academic women’s health practice, we received over 100 referrals. A multi-pronged approach to generating referrals was helpful, as referrals were nearly equally split between direct referrals from the providers as well as systematically screening all women presenting as a new patient or for their annual exam. Unfortunately, nearly half of the women who were referred for behavioral health services did not attend any sessions with our providers. Among those who engaged in treatment, attendance rates were similar to those seen in other co-located, primary care-type settings (Auxier et al., 2012; Bartels et al., 2004; Bryan, Morrow, & Appolonio, 2009): the modal number of sessions attended was one, and the average length of treatment was between three and four sessions. In some aspects, however, our behavioral health clinic implementation differed from the traditional PCBH model (Gatchel & Oordt, 2003), including the measures used, the length of the intake and treatment sessions, and the number of sessions for some patients (e.g., up to 12 sessions). It will be prudent for others to consider these differences when developing and implementing a behavioral health clinic into other women’s health clinics.

Nonetheless, to our knowledge, this is the first report of a behavioral health clinic integrated into a general women’s health clinic to address a wide variety of behavioral health concerns, despite the high rates of women presenting to their gynecologists for primary care needs including behavioral health concerns (Miranda et al., 1998; National Center for Health Statistics, 2014; Stormo et al., 2014). The Veterans Health Administration is a model for effectively integrating behavioral health services into primary care settings, as evidenced by the successful roll-out of primary care mental health integration (PCMHI) model adopted in 2007 (Pomerantz et al., 2014). And yet, there are indisputable differences between the needs of a veteran population and those of a civilian population, particularly the population of civilian women presenting to a women’s health clinic. To address the behavioral health needs of the population of women presenting to their gynecologists may require tailored interventions that differ from a standard behavioral health integration model (e.g., Gatchel & Oordt, 2003). It was to address this gap in clinical care that we evaluated the reach of and engagement with our behavioral health services in a women’s health clinic. In the future, clinical trials using standardized protocols and control groups are needed to best determine the best practices for integration of behavioral health services in women’s health clinics.

In the following discussion, we outline the primary challenges we faced and propose considerations and potential solutions for future behavioral health integration in this setting. Though not an exhaustive list, we believe these concepts will be the most broadly applicable to others who plan to integrate behavioral health services into a women’s health clinic.

First, we had an unexpectedly low number of referrals. Our referrals increased with adaptations to our referral process, especially introducing electronic referral methods (e.g., via email or the electronic medical records). Nonetheless, it is clear from national numbers that behavioral health symptoms among gynecological samples are high (Poleshuck & Woods, 2014). It is probable that many patients who would have benefitted from behavioral health services were not referred to the behavioral health clinic and remains an important direction for future research. For example, conducting a needs assessment among the women who were interested in care but did not attend a behavioral health appointment to determine how their needs could be better addressed.

At the provider-level, guidelines for integrating behavioral health services typically recommend a common space to encourage greater exposure to and interactions with interdisciplinary providers. Limited space is a common barrier to integrating behavioral health services into medical settings (Gunn et al., 2015). Lack of space poses a challenge to behavioral health providers attempting to be immediately available for intervention, quickly establish therapeutic rapport, discuss sensitive topics, and encourage treatment engagement. Unfortunately, patients are unlikely to follow through with a behavioral health referral to an off-site service (Smith et al., 2009). Therefore, we advocated for and were fortunate to have an office designated for the behavioral health provider to reliably see patients in a comfortable, co-located setting (consistent with the co-located collaborative care model; Hunter, Goodie, Oordt, & Dobmeyer, 2009) within the women’s health clinic. Although this may have conferred some advantages to patients when seeing the behavioral health provider, having a designated room separate from the medical providers could have also interfered with referral processes.

Approaching integration at multiple levels would leverage distinct opportunities to ensure that the appropriate patients are referred to behavioral health services to receive effective behavioral treatments.

Second, among those patients who were referred to the clinic, we faced several challenges to engaging them in treatment. In our model, engagement and follow-up may have been limited because the behavioral health providers were not able to prescribe psychiatric medications. Therefore, patients who were only interested in psychiatric medication were referred to the psychiatry clinic, located in a different building on the same campus. To encourage behavioral health treatment engagement, greater collaboration and ongoing communication between the women’s health provider, behavioral health provider, and the patient may increase provision of appropriate psychiatric medications as well as behavioral health treatment. Alternatively, with a large enough behavioral health clinic it may be possible to incorporate a psychiatrist for the purposes of psychiatric medication prescriptions.

One of the core components of integrated behavioral health services is the warm handoff, in which the medical provider directly introduces their patient to the behavioral health provider, which is believed to increase engagement in these services (American Psychiatric Association & Academy of Psychosomatic Medicine, 2016). Unfortunately, our clinicians were unable to see patients in the medical appointment exam rooms because medical providers were concerned that it would disrupt patient flow through the high-volume clinic. If patients could have been reached within the exam room and screened by the behavioral health provider in a timelier manner, we believe that behavioral health integration would have been more successful overall, potentially increasing referrals and retention.

Individual patient characteristics may have impacted treatment engagement. These women were often working and had childcare responsibilities, which may have limited their availability to attend in-person sessions. Many patients who attend this women’s health clinic travel long distances from rural areas. All of these characteristics can make attendance of regular appointments, such as weekly therapy sessions, extremely difficult. Even among treatment engagers, a majority of patients rescheduled or canceled at least one appointment. Unfortunately, those who miss appointments are much more likely to drop out of treatment altogether (Mitchell & Selmes, 2018), indicating a need to stem the tide of nonattendance.

Integrated behavioral health research continues to evaluate evidence-based strategies to promote treatment engagement. Intensive reminder systems effectively reduce rates of missed appointments (Gurol-Urganci, de Jongh, Vodopivec-Jamsek, Atun, & Car, 2013; Kauppi et al., 2014). Providing home-based health services can also increase engagement in treatment. For example, one study found that in-home mental health services were more utilized than clinic-based services among pregnant/postpartum women referred for psychiatric care (Albaugh, Friedman, Yang, & Rosenthal, 2018). However, home-based services are costly and will not reach the rural populations that clinics like ours serve.

One potential solution may be to increase utilization of mobile health (mHealth) interventions in this setting (World Health Organization, 2016). In the United States, there is widespread access to mobile devices (95% of adults own a cell phone and 77% own a smartphone; Pew Research Center, 2018), which can increase patients’ access to care. Despite evidence that mHealth technologies are effective for delivering behavioral health services and are well utilized in primary care settings (Free et al., 2013; Price et al., 2014; Staeheli, Aseltine, Schilling, Anderson, & Gould, 2017), little research has been conducted to examine the effectiveness of mHealth approaches in women’s health clinics with embedded behavioral health services (Mehralizade et al., 2017).

Of course, mHealth alternatives are not without unique challenges. For example, reimbursement rates and allowances for behavioral health services vary between states, complicating matters for patients who reside in a different state than their provider (Mace, Boccanelli, & Dormond, 2018). Patients may be less invested or engaged in mHealth appointments (e.g., if children are present). Finally, mHealth still requires adequate work space for behavioral health providers to maintain patient privacy and confidentiality while providing services. Expanding the availability, reach, and efficacy of these interventions remains an area of active research.

Some limitations of our personal experience with developing a behavioral health clinic within the women’s health setting should be noted. First, the behavioral health clinicians were master’s level, pre-doctoral trainees. As such, they were not yet independent providers and may have had less experience and expertise in integrated behavioral health. While all clinicians had several years training in the implementation of empirically supported interventions, they may have had less expertise specific to functioning as a member of an integrated team. Likewise, the clinicians were not embedded, full-time employees in the clinic and so same-day warm hand-offs, a cornerstone of the integrated behavioral health model, were not always possible. Second, the development and implementation of this clinic was the result of a clinical training grant that allowed services to be provided free-of-charge, which limits the generalizability of our experience to other women’s health clinics. However, it is notable that these services were provided within the context of a clinic that required payment and, therefore, all patients had insurance or means to pay for gynecological services at the clinic. Finally, this was not a formal, prospective research study. Rather, outcome data were gathered as part of standard clinical practice during the first year of the implementation of a behavioral health clinic. We presented these data here in the hopes that others will learn from the challenges we encountered when implementing a behavioral health clinic within the women’s health clinic setting. Future research should specifically evaluate the adaptation of the PCBH model (Gatchel & Oordt, 2003; Hunter et al., 2018) into women’s health clinics.

Behavioral health services within the women’s health clinic were welcome by medical providers and generated referrals. Nonetheless, even in an academic medical setting in which integrated clinics and behavioral health services are prevalent and highly valued, we faced several challenges that limited our reach and effect. Most notably, we experienced difficulty in generating referrals and engaging patients in behavioral health treatment. Women are increasingly presenting to their gynecologists with mental health concerns, and yet little research has sought to understand how to best identify and treat these patients. Our experience illustrates how behavioral health symptoms in this population can be addressed by brief, evidence-based interventions combined with appropriate referrals, and indicate that this is an avenue of research worth pursuing. Methods of integrating behavioral health services into primary care clinics (e.g., Gatchel & Oordt, 2003; Hunter et al., 2009) and among obstetrics populations may serve as a basis for the gynecology patients, but this population is unique and may require different modes of intervention. Further work is needed to ensure that the women presenting to women’s health clinics who are interested in and would benefit from behavioral health services are identified and provided evidence-based treatment.

Supplementary Material

10880_2019_9684_MOESM1_ESM

Funding:

Manuscript preparation was partially supported by a grant from the National Institute on Drug Abuse (K23DA042935; PI: Gilmore). The efforts of Dr. Constance Guille were funded by the National Institute on Drug Abuse (1K23DA039318-01). We would like to acknowledge the clinical staff and nurses who contributed to the clinical services described in the current manuscript. We would also like to acknowledge the Graduate Psychology Education grant from the Health Resources and Services Administration (Award #D40HP25774-04; Interdisciplinary Behavioral Science Training in Primary Care”) that funded the clinic that was awarded to Drs. Dan Smith and Dean Kilpatrick.

Footnotes

Publisher's Disclaimer: This Author Accepted Manuscript is a PDF file of an unedited peer-reviewed manuscript that has been accepted for publication but has not been copyedited or corrected. The official version of record that is published in the journal is kept up to date and so may therefore differ from this version.

Conflict of interest statement: The authors declare that they have no conflict of interest.

Research involving human participants: All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Informed consent: Data for the present study were collected during a newly created integrated clinic for patients eligible for behavioral health services in the women’s health clinic. The project was determined to be quality improvement, which was certified by the institutional review board. Therefore, informed consent was not required nor obtained.

Ethical approval: All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

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