A Qualitative Study of Barriers and Facilitators to Transitions From the Emergency Department to Outpatient Mental Health Care

OBJECTIVE

People with psychiatric disorders are among the most frequent users of emergency departments (EDs). The transition of care from the ED to outpatient mental health treatment may be important for continuity of care; however, little is known about the barriers and facilitators that patients experience in transitions to and engagement in outpatient mental health care. In this qualitative study, the authors examined the perspectives of patients and providers on these barriers and facilitators at the patient, provider, and health care system levels.

METHODS

The authors (trained interviewers) conducted 30 semistructured interviews with patients and 15 interviews with 13 mental health providers. Data were analyzed by using thematic analysis.

RESULTS

Patients and providers discussed similar barriers and facilitators to patient transitions and engagement in care. Patients with psychiatric disorders experienced barriers and facilitators at multiple levels when engaging in mental health care after discharge from the ED. Patient-level themes included openness to treatment and logistical challenges. Provider-level themes focused on the connection between patients and providers and on establishing and maintaining contact. Themes at the health care system level were coordination between the ED and outpatient clinics, managing appointments, and health care resources.

CONCLUSIONS

Key factors that influence transitions of care from the ED to outpatient treatment include patients' complex health and life circumstances, the establishment of a relationship with providers built on trust and compassion, and the level of coordination between care settings.

Improving Physical Health Among People With Serious Mental Illness: The Role of the Specialty Mental Health Sector

People with serious mental illness die 10-20 years earlier, compared with the overall population, and the excess mortality is driven by undertreated physical health conditions. In the United States, there is growing interest in models integrating physical health care delivery, management, or coordination into specialty mental health programs, sometimes called "reverse integration." In November 2019, the Johns Hopkins ALACRITY Center for Health and Longevity in Mental Illness convened a forum of 25 experts to discuss the current state of the evidence on integrated care models based in the specialty mental health system and to identify priorities for future research, policy, and practice. This article summarizes the group's conclusions. Key research priorities include identifying the active ingredients in multicomponent integrated care models and developing and validating integration performance metrics. Key policy and practice recommendations include developing new financing mechanisms and implementing strategies to build workforce and data capacity. Forum participants also highlighted an overarching need to address socioeconomic risks contributing to excess mortality among adults with serious mental illness.

Supporting the Mental Health Workforce During and After COVID-19

The COVID-19 pandemic has catalyzed structural changes in the public mental health sector, including a shift to telehealth and telesupervision, financial strain for community mental health organizations and clinicians, and risk of burnout among clinicians and staff. This Open Forum considers how technical assistance organizations have supported community mental health providers in adapting to these changes. Moving forward, knowledge gained through this work can help to build the body of practice-based evidence to inform future technical assistance activities in a postpandemic world.

Self-Help Groups And Medication Use In Opioid Addiction Treatment: A National Analysis

Self-help groups and medications (buprenorphine, methadone, and naltrexone) both play important roles in opioid addiction treatment. The relative use of these two treatment modalities has not been characterized in a national study. Using national treatment data, we found that self-help groups were rarely provided in conjunction with medication treatment: Among all adult discharges from opioid addiction treatment in the period 2015-17, 10.4 percent used both self-help groups and medications, 29.2 percent used only medications, 29.8 percent used only self-help groups, and 30.5 percent used neither self-help groups nor medications. Use of self-help groups without medication is most common in residential facilities, among those with criminal justice referrals, and among uninsured or privately insured patients, as well as in the South and West regions of the US. These subgroups may be important targets for future efforts to identify and overcome barriers to medication treatment and create multimodal paths to recovery.

Redesigning Public Mental Health Systems Post-COVID-19

The COVID-19 pandemic has disrupted public mental health systems across the country, nowhere more than in New York State (NYS). The authors describe the NYS public health agency's response to the pandemic and offer ideas for redesigning public mental health systems post-COVID-19.

Associations between mental health shortage areas and county-level suicide rates among adults aged 25 and older in the USA, 2010 to 2018

OBJECTIVE

Suicide is a serious public health concern, but little is known about the relationship between access to mental health care and suicide deaths, and whether suicide rates differ by mental health provider Health Professional Shortage Areas (HPSAs). This study investigated the associations between mental health HPSAs and suicide rates.

METHOD

We used generalized linear mixed models to test the associations between HPSAs and suicide rates from 2010 to 2018. For each county during a 3-year period, the total number of suicides was obtained from Centers for Disease Control and Prevention's Wide-ranging Online Data for Epidemiologic Research (WONDER).

RESULTS

Mental health HPSAs had higher suicide rates (adjusted incidence rate ratio (IRR), 1.06 [95% CI, 1.03-1.09]). The interaction terms of mental health HPSAs and time (adjusted IRR, 1.01 [95% CI, 1.00-1.01]) showed that the association between mental health shortage areas and suicide rates has increased over time.

CONCLUSIONS

Suicide rates are more common in mental health provider shortage areas, and this association has been growing over time. The study's findings suggest that many communities in the US are likely facing simultaneous challenges of limited access to mental health care, social and economic disadvantage, and high burden of suicide.

Trends in personal and family member opioid prescriptions prior to a diagnosis of an opioid-related problem among adolescents and young adults

Background: Efforts to reduce the risk of opioid misuse are often focused on reducing unnecessary prescriptions for opioid medications or reducing the dose prescribed; however, not all misuse occurs in individuals with a personal prescription. This study examined trends in the proportion of adolescents and young adults (AYAs) who had an opioid-related problem (ORP) and who also had a personal opioid prescription drug claim or had a family member with an opioid prescription drug claim prior to the ORP diagnosis. Methods: A retrospective cohort design was used to analyze longitudinal claims data. We identified individuals aged 12 to 25 years who had a newly diagnosed ORP in the years 2006 to 2014. Trends over time in personal or family opioid prescription drug claims within 1 year prior to ORP diagnosis were examined. Results: We identified 53,560 AYAs with an ORP diagnosis. Over the entire study period, 40% of AYAs with an ORP diagnosis had a personal opioid prescription in the year prior to diagnosis, and 48% had a family member with an opioid prescription in the prior year. While the proportion of AYAs with a family prescription remained constant, the proportion with a personal prescription fell from 77.1% in 2006 to 27.3% in 2014. Conclusions: The number of AYAs with an ORP increased over time, yet the proportion with a personal opioid prescription claim prior to their diagnosis decreased over time. This suggests that providers are paying greater attention to prescribing opioids to AYAs directly, although prescriptions to family members may still remain a point of access.

Developing Regional Mental Health Priorities: Mixed-Methods Needs Assessment of Eight States in the Southeastern United States

State mental health agencies (SMHAs), which provide a variety of services to meet their residents' mental health needs, typically work within their own state, with little opportunity for cross-state collaboration and information exchange. This column describes a mixed-methods needs assessment conducted by the Southeast Mental Health Technology Transfer Center (MHTTC) to identify regional mental health priorities in eight states of the southeastern United States. The six priority areas identified were mental health workforce, school-based mental health, suicide prevention, peer workforce, criminal justice and mental health, and supported housing. These regional priorities inform the Southeast MHTTC's activities and can be used to promote collaborative exchange and problem solving among SMHAs.

Mental Health Policy in the Era of COVID-19

The response to the global COVID-19 pandemic has important ramifications for mental health systems and the patients they serve. This article describes significant changes in mental health policy prompted by the COVID-19 crisis across five major areas: legislation, regulation, financing, accountability, and workforce development. Special considerations for mental health policy are discussed, including social determinants of health, innovative technologies, and research and evaluation. These extraordinary advances provide an unprecedented opportunity to evaluate the effects of mental health policies that may be adopted in the post-COVID-19 era in the United States.

Neighborhood Predictors of Outpatient Mental Health Visits Among Persons With Comorbid Medical and Serious Mental Illnesses

OBJECTIVE

Individuals with serious mental illnesses are at risk of receiving inadequate outpatient mental health services, increasing the likelihood of medication nonadherence, readmission, and self-harm. The purpose of this study was to identify individual- and neighborhood-level factors associated with outpatient mental health visits.

METHODS

This study included 418 participants from two randomized trials of patients with comorbid medical conditions and serious mental illnesses across two study sites between 2011 and 2017. On the basis of individual addresses, data were collected about participants' distance to the nearest mental health facility and 13 neighborhood characteristics from the American Community Survey. Three neighborhood-level factors were derived from factor analysis. Poisson regression was used to assess associations between individual- and neighborhood-level characteristics and the number of visits to mental health providers. Known individual-level risk factors for outpatient follow-up were mutually adjusted in a model with neighborhood covariates added.

RESULTS

Male gender, older age, unemployment, and lower education level were associated with less outpatient mental health service utilization. Neighborhood-level residential mobility, defined as the combination of percentage of residents living in a different house in the past year and percentage of non-owner-occupied housing, was significantly associated with fewer mental health service visits even after controlling for other neighborhood- and individual-level factors.

CONCLUSIONS

Among individuals with comorbid medical conditions and serious mental illnesses, living in neighborhoods with higher residential mobility was associated with fewer visits to outpatient mental health providers. This finding suggests the importance of recognizing social conditions that may shape clinical interactions.

Randomized Trial of a Mobile Personal Health Record for Behavioral Health Homes

OBJECTIVE

Behavioral health homes, which provide onsite primary medical care in mental health clinics, face challenges in integrating information across multiple health records. This study tested whether a mobile personal health record application improved quality of medical care for individuals treated in these settings.

METHODS

This randomized study enrolled 311 participants with a serious mental illness and one or more cardiometabolic risk factors across two behavioral health homes to receive a mobile personal health record application (N=156) or usual care (N=155). A secure mobile personal health record (mPHR) app provided participants in the intervention group with key information about diagnoses, medications, and laboratory test values and allowed them to track health goals. The primary study outcome was a chart-derived composite measure of quality of cardiometabolic and preventive services.

RESULTS

At 12-month follow-up, participants in the mPHR group maintained high quality of care (70% of indicated services at baseline and at 12-month follow-up), in contrast to a decline in quality for the usual-care group (71% at baseline and 67% at follow-up), resulting in a statistically significant but clinically modest differential impact between the groups. No differences between the study groups were found in secondary self-reported outcomes, including delivery of chronic illness care, patient activation, and quality of life related to mental or general medical health.

CONCLUSIONS

Use of a mPHR app was associated with a statistically significant but clinically modest differential benefit for quality of medical care among individuals with serious mental illness and comorbid cardiometabolic conditions.

Mental Health Service Use by Medicaid-Enrolled Children and Adolescents in Primary Care Safety-Net Clinics

OBJECTIVE

Little is known about the role of primary care safety-net clinics, including federally qualified health centers and rural health clinics, in providing mental health services to youths. This study examined correlates and quality of mental health care for youths treated in these settings.

METHODS

Medicaid claims data (2008-2010) from nine states were used to identify youths initiating medication for attention-deficit hyperactivity disorder (ADHD) (N=6,433) and youths with an incident depression diagnosis (N=13,209). The authors identified youths who received no ADHD or depression-related visits in a primary care safety-net clinic, some (but less than most) visits in these clinics, and most visits in these clinics. Using bivariate and regression analyses, they examined correlates of mental health treatment in these settings and whether mental health visits in these settings were associated with quality measures.

RESULTS

Only 13.5% of the ADHD cohort and 7.2% of the depression cohort sought any ADHD- or depression-related visits in primary care safety-net clinics. Residence in a county with a higher (versus lower) percentage of residents living in an urban area was negatively associated with receiving the majority of mental health visits in these settings (p<0.05). Compared with youths with no visits in these settings, youths who received most of their mental health treatment in these settings received lower-quality care on five of six measures (p<0.01).

CONCLUSIONS

As investment in the expansion of mental health services in primary care safety-net clinics grows, future research should assess whether these resources translate into improved mental health care access and quality for Medicaid-enrolled youths.

The Effect of Medical Marijuana Laws on Marijuana-Related Attitude and Perception Among US Adolescents and Young Adults

Marijuana liberalization policies are gaining momentum in the USA, coupled with limited federal interference and growing dispensary industry. This evolving regulatory landscape underscores the importance of understanding the attitudinal/perceptual pathways from marijuana policy to marijuana use behavior, especially for adolescents and young adults. Our study uses the restricted-access National Survey on Drug Use and Health (NSDUH) 2004-2012 data and a difference-in-differences design to compare the pre-policy, post-policy changes in marijuana-related attitude/perception between adolescents and young adults from ten states that implemented medical marijuana laws during the study period and those from the remaining states. We examined four attitudinal/perception pathways that may play a role in adolescent and young adult marijuana use behavior, including (1) perceived availability of marijuana, (2) perceived acceptance of marijuana use, (3) perceived wrongfulness of recreational marijuana use, and (4) perceived harmfulness of marijuana use. We found that state implementation of medical marijuana laws between 2004 and 2012 was associated with a 4.72% point increase (95% CI 0.15, 9.28) in the probability that young adults perceived no/low health risk related to marijuana use. Medical marijuana law implementation is also associated with a 0.37% point decrease (95% CI - 0.72, - 0.03) in the probability that adolescents perceived parental acceptance of marijuana use. As more states permit medical marijuana use, marijuana-related attitude/perception need to be closely monitored, especially perceived harmfulness. The physical and psychological effects of marijuana use should be carefully investigated and clearly conveyed to the public.

Medicaid Acceptance by Psychiatrists Before and After Medicaid Expansion

This study uses National Ambulatory Medical Care Survey data to assess the percentage of psychiatrists who have accepted Medicaid-insured patients before and after Medicaid expansion.

Trends in Treatment and Spending for Patients Receiving Outpatient Treatment of Depression in the United States, 1998-2015

CONTEXT

After marked increases from 1987 to 1997, trends in depression treatment in the United States increased modestly from 1998 to 2007. However, multiple policy changes that expanded insurance coverage for mental health conditions may have shifted these trends again since 2007.

OBJECTIVE

To examine national trends in outpatient treatment of depression from 1998 to 2015, with particular focus on 2007 to 2015.

DESIGN, SETTING, AND PARTICIPANTS

This analysis of the use of health services and spending for treatment of depression in the United States assessed data from the 1998 (n = 22 953), 2007 (n = 29 370), and 2015 (n = 33 893) Medical Expenditure Panel Surveys (MEPSs). Participants included respondent households to the nationally representative survey. Data were analyzed from June 15 through December 18, 2018.

MAIN OUTCOMES AND MEASURES

Rates of outpatient and pharmaceutical treatment of depression; counts of outpatient visits, psychotherapy visits, and prescriptions; and expenditures.

RESULTS

The analysis included 86 216 individuals from the 1998, 2007, and 2015 MEPSs. Respondents' mean (SD) age was 37.2 (22.7) years; 45 086 (52.3%) were female, 24 312 (28.2%) were Hispanic, 15 463 (17.9%) were black, and 62 926 (72.9%) were white. Rates of outpatient treatment of depression increased from 2.36 (95% CI, 2.12-2.61) per 100 population in 1998 to 3.47 (95% CI, 3.16-3.79) per 100 population in 2015. The proportion of respondents who were treated for depression using psychotherapy decreased from 53.7% (95% CI, 48.3%-59.1%) in 1998 to 43.2% (95% CI, 39.0%-47.4%) in 2007 and then increased to 50.4% (95% CI, 46.0%-54.9%) in 2015, whereas the proportion receiving pharmacotherapy remained steady at 81.9% (95% CI, 77.9%-85.9%) in 1998, 82.4% (95% CI, 79.3%-85.4%) in 2007, and 80.8% (95% CI, 77.9%-83.7%) in 2015. After adjusting for inflation using 2015 US dollars, prescription expenditures for these individuals decreased from $848 (95% CI, $713-$984) per year in 1998 to $603 (95% CI, $484-$722) per year in 2015, whereas the mean number of prescriptions decreased from 7.64 (95% CI, 6.61-8.67) in 1998 to 7.03 (95% CI, 6.51-7.56) in 2015. National expenditures for outpatient treatment of depression increased from $12 430 000 000 in 1997 to $15 554 000 000 in 2007 and then to $17 404 000 000 in 2015, consistent with a slowing growth in national outpatient expenditures for depression. The percentage of this spending that came from self-pay (uninsured) individuals decreased from 32% in 1998 to 29% in 2007 and then to 20% in 2015. This decrease was largely associated with increasing Medicaid coverage, because the percentage of this spending covered was 19% in 1998, 15% in 2007, and 36% in 2015.

CONCLUSIONS AND RELEVANCE

Recent policy changes that increased insurance coverage for depression may be associated with reduced uninsured burden and with modest increases in the prevalence of and overall spending for outpatient treatment of depression. The lower-than-expected rate of treatment suggests that substantial barriers remain to individuals receiving treatment for their depression.

Racial and Ethnic Differences in Minimally Adequate Depression Care Among Medicaid-Enrolled Youth

OBJECTIVE

To examine racial and ethnic disparities in the receipt of minimally adequate depression treatment in Medicaid-enrolled youth.

METHOD

Medicaid claims data of 2008 through 2011 were used to derive a cohort of youth (5-17 years old) who were diagnosed with a new episode of major depression (N = 45,816) across 9 states. Dichotomous outcomes measured the receipt of minimally adequate psychotherapy (≥4 psychotherapy visits within 12 weeks of initiation); minimally adequate medication (filled antidepressants for 84 of 144 days); any minimally adequate treatment (psychotherapy or medication); and no psychotherapy or medication. Racial/ethnic disparities in the outcome measures were estimated using logistic regression models that controlled for predisposing, enabling, and need-related factors.

RESULTS

Less than four-tenths (38.3%) of the cohort received minimally adequate psychotherapy, 19.2% received minimally adequate pharmacotherapy, and 49.9% received any minimally adequate treatment; conversely, 16.4% received no treatment. Adjusted percentages of black (42.3%; p < .001) and Hispanic (48.2%; p < .001) youth who received minimally adequate treatment were significantly smaller than for non-Hispanic whites (54.7%) because of lower likelihoods of receiving minimally adequate psychotherapy and/or minimally adequate pharmacotherapy. In addition, adjusted percentages of black (20.2%; p < .001) and Hispanic (15.0%; p < .01) youth who received no treatment were significantly larger than for non-Hispanic white youth (12.9%).

CONCLUSION

The percentage of Medicaid-enrolled youth who receive minimally adequate treatment for depression is small overall and even smaller for racial/ethnic minorities than for whites. Future research is needed to identify strategies that improve the overall quality of depression treatment in Medicaid-enrolled youth and decrease disparities in care.

Integrating Health and Mental Health Services: A Past and Future History

The authors trace the modern history, current landscape, and future prospects for integration between mental health and general medical care in the United States. Research and new treatment models developed in the 1980s and early 1990s helped inform federal legislation, including the 2008 Mental Health Parity and Addiction Equity Act and the 2010 Affordable Care Act, which in turn are creating new opportunities to further integrate services. Future efforts should build on this foundation to develop clinical, service-level, and public health approaches that more fully integrate mental, medical, substance use, and social services. [AJP AT 175: Remembering Our Past As We Envision Our Future July 1928: A President Takes Stock Adolf Meyer: "I sometimes feel that Einstein, concerned with the relativity in astronomy, has to deal with very simple facts as compared to the complex and erratic and multicontingent performances of the human microcosmos, the health, happiness and efficiency of which we psychiatrists are concerned with." (Am J Psychiatry 1928; 85(1):1-31 )].

Applying a Model of Stakeholder Engagement to a Pragmatic Trial for People With Mental Disorders

Stakeholder engagement is an important component of pragmatic trials seeking to improve mental health care in real-world settings. Models of stakeholder engagement outline the benefits of involving a diverse array of partners in all phases of research. This column describes a stakeholder engagement plan for a comparative-effectiveness pragmatic trial of a care navigator program to increase linkage between emergency departments and outpatient treatment at community mental health centers. Benefits of stakeholder engagement include meaningful input on program design and implementation, insights into balancing the need for flexibility among clinical sites while implementing the program with fidelity, and early discussions about program sustainability and dissemination.

Mental and Addictive Disorders and Medical Comorbidities

PURPOSE OF REVIEW

Mental and addictive disorders commonly co-occur with medical comorbidities, resulting in poor health and functioning, and premature mortality. This review provides an overview of the intertwined causal pathways and shared risk factors that lead to comorbidity. Additionally, this review examines the strategies to prevent the onset of and to effectively manage chronic medical conditions among people with mental and addictive disorders.

RECENT FINDINGS

Recent research provides further evidence for the shared genetic and biological, behavioral, and environmental risk factors for comorbidity. Additionally, there is evidence of effective approaches for screening, self-management, and treatment of medical conditions among people with mental disorders. There are promising health system models of integrated care, but additional research is needed to fully establish their effectiveness. A combination of public health and clinical approaches are needed to better understand and address comorbidity between mental and addictive disorders and chronic medical conditions.

Peer-Led Self-Management of General Medical Conditions for Patients With Serious Mental Illnesses: A Randomized Trial

OBJECTIVE

Individuals with serious mental illnesses have high rates of general medical comorbidity and challenges in managing these conditions. A growing workforce of certified peer specialists is available to help these individuals more effectively manage their health and health care. However, few studies have examined the effectiveness of peer-led programs for self-management of general medical conditions for this population.

METHODS

This randomized study enrolled 400 participants with a serious mental illness and one or more chronic general medical conditions across three community mental health clinics. Participants were randomly assigned to the Health and Recovery Peer (HARP) program, a self-management program for general medical conditions led by certified peer specialists (N=198), or to usual care (N=202). Assessments were conducted at baseline and three and six months.

RESULTS

At six months, participants in the intervention group demonstrated a significant differential improvement in the primary study outcome, health-related quality of life. Specifically, compared with the usual care group, intervention participants had greater improvement in the Short-Form Health Survey physical component summary (an increase of 2.7 versus 1.4 points, p=.046) and mental component summary (4.6 versus 2.5 points, p=.039). Significantly greater six-month improvements in mental health recovery were seen for the intervention group (p=.02), but no other between-group differences in secondary outcome measures were significant.

CONCLUSIONS

The HARP program was associated with improved physical health- and mental health-related quality of life among individuals with serious mental illness and comorbid general medical conditions, suggesting the potential benefits of more widespread dissemination of peer-led disease self-management in this population.