Use of services by persons with mental and addictive disorders. Findings from the National Institute of Mental Health Epidemiologic Catchment Area Program

Association between sociodemographic factors, clinic characteristics and mental health screening rates in primary care

BACKGROUND

Screening for mental health problems has been shown to be effective to detect depression and initiate treatment in primary care. Current guidelines recommend periodic screening for depression and anxiety. This study examines the association of patient sociodemographic factors and clinic characteristics on mental health screening in primary care.

DESIGN

In this retrospective cohort study, electronic medical record (EMR) data from a 14-month period from 10/15/2021 to 12/14/2022 were analyzed. Data were retrieved from 18 primary care clinics from the Corewell Health healthcare system in West Michigan. The main outcome was documentation of any Patient Health Questionnaire (PHQ-4/PHQ-9/GAD-7) screening in the EMR within the 14-month period at patient level. General linear regression models with logit link function were used to assess adjusted odds ratio (aOR) of having a documented screening.

RESULTS

In total, 126,306 unique patients aged 16 years or older with a total of 291,789 encounters were included. The prevalence of 14-month screening was 79.8% (95% CI, 79.6-80.0). Regression analyses revealed higher screening odds for patients of smaller clinics (<5,000 patients, aOR 1.88; 95% CI 1.80-1.98 vs. clinics >10.000 patients), clinics in areas with mental health provider shortages (aOR 1.69; 95% CI 1.62-1.77), frequent visits (aOR 1.80; 95% CI, 1.78-1.83), and having an annual physical / well child visit encounter (aOR 1.52; 95% CI, 1.47-1.57). Smaller positive effect sizes were also found for male sex, Black or African American race, Asian race, Latinx ethnicity (ref. White/Caucasians), and having insurance through Medicaid (ref. other private insurance).

DISCUSSION

The 14-month mental health screening rates have been shown to be significantly lower among patients with infrequent visits seeking care in larger clinics and available mental health resources in the community. Introducing and incentivizing mandatory mental health screening protocols in annual well visits, are viable options to increase screening rates.

Depression in Primary Care, 2010-2018

BACKGROUND

Depression is common in primary care and significantly reduces quality of life. Our study aimed to examine the prevalence of depression in primary care visits, examine patterns of depression treatment and referral, and determine how often depression screening occurred over an 8-year timespan.

METHODS

From the 2010-2018 National Ambulatory Medical Care Survey, a national probability sample of non-federal, ambulatory encounters, we identified adults being seen in a primary care clinic. We assessed the prevalence of depression screening, diagnosis, and treatment.

RESULTS

During these 8 years, 13.1% of primary care encounters involved a patient with a diagnosis of depression. The prevalence of depression did not change over time. Patients were screened for depression 4.1% of the time, with screening increasing over time. Depression was more likely to be diagnosed when screening occurred (odds ratio 9.9; 95% confidence interval, 6.8-14.5%). Most patients were treated with a selective serotonin reuptake inhibitor.

CONCLUSION

Depression is common in primary care, though screening was infrequent. Practices should consider instituting universal screening.

Developing, Implementing, and Evaluating an Artificial Intelligence-Guided Mental Health Resource Navigation Chatbot for Health Care Workers and Their Families During and Following the COVID-19 Pandemic: Protocol for a Cross-sectional Study

Background

Approximately 1 in 3 Canadians will experience an addiction or mental health challenge at some point in their lifetime. Unfortunately, there are multiple barriers to accessing mental health care, including system fragmentation, episodic care, long wait times, and insufficient support for health system navigation. In addition, stigma may further reduce an individual’s likelihood of seeking support. Digital technologies present new and exciting opportunities to bridge significant gaps in mental health care service provision, reduce barriers pertaining to stigma, and improve health outcomes for patients and mental health system integration and efficiency. Chatbots (ie, software systems that use artificial intelligence to carry out conversations with people) may be explored to support those in need of information or access to services and present the opportunity to address gaps in traditional, fragmented, or episodic mental health system structures on demand with personalized attention. The recent COVID-19 pandemic has exacerbated even further the need for mental health support among Canadians and called attention to the inefficiencies of our system. As health care workers and their families are at an even greater risk of mental illness and psychological distress during the COVID-19 pandemic, this technology will be first piloted with the goal of supporting this vulnerable group.

Objective

This pilot study seeks to evaluate the effectiveness of the Mental Health Intelligent Information Resource Assistant in supporting health care workers and their families in the Canadian provinces of Alberta and Nova Scotia with the provision of appropriate information on mental health issues, services, and programs based on personalized needs.

Methods

The effectiveness of the technology will be assessed via voluntary follow-up surveys and an analysis of client interactions and engagement with the chatbot. Client satisfaction with the chatbot will also be assessed.

Results

This project was initiated on April 1, 2021. Ethics approval was granted on August 12, 2021, by the University of Alberta Health Research Board (PRO00109148) and on April 21, 2022, by the Nova Scotia Health Authority Research Ethics Board (1027474). Data collection is anticipated to take place from May 2, 2022, to May 2, 2023. Publication of preliminary results will be sought in spring or summer 2022, with a more comprehensive evaluation completed by spring 2023 following the collection of a larger data set.

Conclusions

Our findings can be incorporated into public policy and planning around mental health system navigation by Canadian mental health care providers—from large public health authorities to small community-based, not-for-profit organizations. This may serve to support the development of an additional touch point, or point of entry, for individuals to access the appropriate services or care when they need them, wherever they are.

International Registered Report Identifier (IRRID)

PRR1-10.2196/33717

Patients' attitudes toward conventional and herbal treatments for depression and anxiety: A cross-sectional Israeli survey

BACKGROUND

As many patients view conventional antidepressants and anxiolytics negatively, it is not surprising that the willingness to apply these treatments is far from ideal, thus posing a critical barrier in promoting an effective and durable treatment.

AIM

The present study aimed to explore patients' attitudes toward conventional and herbal treatments for depression and anxiety, while considering cultural and demographic factors, to further elucidate the antecedes that putatively determine the treatment's outcome.

METHODS

During June 2017, a cross-sectional survey was conducted using stratified sampling from a large-scale Israeli volunteer online panel. The final sample included 591 Jewish Israeli adults that reported they were suffering from depression or anxiety.

RESULTS

A heterogeneous range of attitudes toward treatment was found: for example, a large group of patients did not utilize prescription medications (39%), a professional consultation (12.9%), or any form of treatment (17.4%). Interestingly, these patients were significantly more likely to support naturally-derived treatments and were less concerned with scientific proof. Further, adverse effects were demonstrated as a prominent factor in the choice of treatment. A higher incidence of adverse effects was associated with an increased willingness to consider an alternative herbal treatment. Noteworthy attitudes were found in orthodox-Jewish individuals, who showed similar consultation rates, but utilized more psychological, rather than pharmacological treatments.

CONCLUSIONS

It is proposed that patients' perspectives and cultural backgrounds are needed to be taken into consideration during the clinical assessment and choice of treatment. The findings imply that a particular emphasis should be placed on patients that discard conventional pharmacological options and on distinct cultural aspects. Several recommendations for revising the current policy are advocated to promote more culturally-informed and patient-oriented care.

A Grounded Theory Study: How Non-Treatment-Seeking Substance Users Make Sense of Their Behaviour “I Want To Be Me but I Don’t Know Who Me Is”

Despite the global impact of substance misuse, there are inadequate levels of specialist service provision and continued difficulties with treatment engagement. Within policy and research, there is substantial consideration of the importance of these factors. However, there is little empirical evidence of the views of non-treatment-seeking substance users, who make up the majority of the substance using population. The aim of this study was to understand how these individuals make sense of their behaviour and their reasons for not accessing treatment. A constructivist grounded theory approach was used to interview eight individuals who were currently using substances and not seeking help to stop. The analysis highlighted the importance of attachment to an identity associated with substance use, and relational variables such as connectedness to others, for treatment decisions for individuals who use substances. Understanding these influences, through trauma- and attachment-informed service provision, may reduce barriers to help-seeking and improve treatment uptake.

Reducing the Impacts of Mental Health Stigma Through Integrated Primary Care: An Examination of the Evidence

The reduction of mental health stigma (MHS) was an expected benefit of integrating behavioral health in primary care (IPC). However, unlike other barriers discussed in agency reports on IPC, discussions of MHS lack research support. To fill this gap, the authors conducted a literature review identifying seven studies. Given the dearth of research, we also examine general IPC research on probable indicators of MHS reduction in IPC, as well as, facets of IPC potentially influencing MHS related factors negatively associated with help-seeking. Using the data from these three types of research, the evidence suggests the potential of IPC to reduce MHS impact on care utilization, but indicates it is premature to draw firm conclusions. Given the possible benefits of primary care and the known benefits of decreased MHS, this review highlights the importance of further research examining this question and provides specific research and program development recommendations.

Professional service use among older African Americans, Black Caribbeans, and Non-Hispanic Whites for serious health and emotional problems

This study examined racial and ethnic differences in professional service use by older African Americans, Black Caribbeans, and Non-Hispanic Whites in response to a serious personal problem. The analytic sample (N = 862) was drawn from the National Survey of American Life. Findings indicated that African Americans and Black Caribbeans were less likely to use services than Whites. Type and race of providers seen varied by respondents' race and ethnicity. Among respondents who did not seek professional help, reasons for not seeking help varied by ethnicity. Study findings are discussed in relation to practice implications.

Association Between Mental Health Staffing Level and Primary Care-Mental Health Integration Level on Provision of Depression Care in Veteran's Affairs Medical Facilities

We examined the association of mental health staffing and the utilization of primary care/mental health integration (PCMHI) with facility-level variations in adequacy of psychotherapy and antidepressants received by Veterans with new, recurrent, and chronic depression. Greater likelihood of adequate psychotherapy was associated with increased (1) PCMHI utilization by recurrent depression patients (AOR 1.02; 95% CI 1.00, 1.03); and (2) staffing for recurrent (AOR 1.03; 95% CI 1.01, 1.06) and chronic (AOR 1.02; 95% CI 1.00, 1.03) depression patients (p < 0.05). No effects were found for antidepressants. Mental health staffing and PCMHI utilization explained only a small amount of the variance in the adequacy of depression care.

Substance-induced anxiety disorder after one dose of 3,4-methylenedioxymethamphetamine: a case report

Background

In this report, we describe a case of a patient with substance-induced anxiety disorder occurring after a single dose of 3,4-methylenedioxymethamphetamine. Furthermore, we describe the use and efficacy of the Primary Care Behavioral Health model, a collaborative approach to integrative primary mental health care, in evaluating and treating this rare mental health disorder.

Case presentation

Three days following ingestion of one dose of 3,4-methylenedioxymethamphetamine, a 35-year-old Hispanic man with no significant prior mental health history and no history of prior 3,4-methylenedioxymethamphetamine use presented to our hospital with severe, acute anxiety and panic symptoms. He was initially treated with a combination of behavioral therapy and the serotonin agonist buspirone. Buspirone ultimately proved ineffective, so it was discontinued in favor of the selective serotonin reuptake inhibitor sertraline. While awaiting the pharmacological onset of sertraline, the patient worked with a behavioral health consultant, who provided psychoeducation on the experience of panic, building relaxation skills, and modifying maladaptive thought patterns. Enhanced communication between the primary care provider and behavioral health consultant facilitated the planning and enactment of the patient’s care plan. Approximately 2.5 months after his initial ingestion of 3,4-methylenedioxymethamphetamine, the patient’s symptoms subsided. This improvement was attributed to the combination of the behavioral health intervention and sertraline at a dose of 50 mg daily. Six months after 3,4-methylenedioxymethamphetamine ingestion, the patient began to gradually taper sertraline and has had no resurgence of anxiety symptoms to date.

Conclusions

Our patient’s case not only demonstrates a rare presentation of 3,4-methylenedioxymethamphetamine-induced anxiety disorder but also provides support for the use of the Primary Care Behavioral Health model to deliver individualized, timely mental health care in a primary care setting.

Male views on help-seeking for depression: A Q methodology study

OBJECTIVES

To identify viewpoints among men with depression about depression and its treatment, consider how these might influence help-seeking behaviour, and generate ideas for interventions and future research.

DESIGN

Q methodology.

METHODS

Twenty-nine men with depression completed a Q sort by ranking a set of statements about depression and help-seeking according to their relative agreement with each statement. Factor analysis was used to identify viewpoints relating to male understandings of depression and help-seeking, which were interpreted in the context of participant characteristics and additional information from post-sorting interviews.

RESULTS

A two-factor solution accounting for 45% of the total variance was considered the best fit for the data. The 2 factors were: (1) Help is available if you can get to the point of asking for it (34% of the variance) and (2) depression should be dealt with in private; help-seeking makes you vulnerable (11% of the variance). Participants who were significantly associated with both factors described a sense of shame, relating to their own or others' views that being depressed and help-seeking are in conflict with socially constructed 'masculine' values, such as strength and self-sufficiency. In the viewpoint represented by Factor 1, however, the benefits of help-seeking outweigh the negatives. In contrast, the viewpoint represented in Factor 2 holds that depression should remain a private struggle and that help-seeking is too risky a move to make.

CONCLUSIONS

In order to access treatment, men must first recognize depression, then overcome considerable perceived and internalized stigma to ask for help. Improving public knowledge about the nature of depression; positive messages about the act of help-seeking, types of treatment available, and effectiveness of treatments; and work to overcome the challenges posed by long waiting times and other service constraints may increase rates of help-seeking, and represent areas for future research.

PRACTITIONER POINTS

Interventions to improve recognition of depression symptoms, particularly in the absence of recent negative life events or suicidal ideation, might help to improve help-seeking rates among men. Media campaigns should consider focusing on the positive elements of help-seeking and potential for recovery, and the impact of such campaigns should be evaluated. Improving public knowledge of the types of non-medical intervention that are available for depression may help to increase help-seeking rates. Clinical services and commissioners should be aware of the impact of long waiting times and strict discharge policies on service users, especially those who have difficulty asking for help.

Effect of Case Management Interventions for Patients with Substance Use Disorders: A Systematic Review

BACKGROUND

Substance use disorder (SUD) is an important health problem that requires a complex range of care because of the chronic nature of the disorder and the multiple psychosocial problems involved. Current outpatient programs often have difficulties in delivering and coordinating ongoing care and access to different health-care providers. Various case management (CM) models have been developed, first for patients in other psychiatric domains and then for patients with SUD, in order to improve treatment outcomes.

AIM

This paper aims to assess the effectiveness of CM for patients with SUD.

METHODS

We performed a systematic review of CM interventions for patients with SUD by analyzing randomized controlled studies published on the subject between 1996 and 2016 found on the electronic database PubMed.

RESULTS AND CONCLUSION

Fourteen studies were included in the analysis. Differences between studies in outcome measures, populations included, and intervention characteristics made it difficult to compare results. Most of these studies reported improvement in some of the chosen outcomes. Treatment adherence mostly improved, but substance use was reported to decrease in only a third of the studies. Overall functioning improved in about half of the studies. The heterogeneity of the results might be linked to these differences between studies. Further research is needed in the field.

An Open Trial of a Smartphone-assisted, Adjunctive Intervention to Improve Treatment Adherence in Bipolar Disorder

We evaluated the feasibility and acceptability of a novel, 12-week, adjunctive, smartphone-assisted intervention to improve treatment adherence in bipolar disorder. Eight participants completed 4 in-person individual therapy sessions over the course of a month, followed by 60 days of twice-daily ecological momentary intervention (EMI) sessions, with a fifth in-person session after 30 days and a sixth in-person session after 60 days. Perceived credibility of the intervention and expectancy for change were adequate at baseline, and satisfaction on completion of the intervention was very high. Participants demonstrated good adherence to the intervention overall, including excellent adherence to the in-person component and fair adherence to the smartphone-facilitated component. Qualitative feedback revealed very high satisfaction with the in-person sessions and suggested a broad range of ways in which the EMI sessions were helpful. Participants also provided suggestions for improving the intervention, which primarily related to the structure and administration of the EMI (smartphone-administered) sessions. Although this study was not designed to evaluate treatment efficacy, most key outcome variables changed in the expected directions from pretreatment to posttreatment, and several variables changed significantly over the course of the in-person sessions or during the EMI phase. These findings add to the small but growing body of literature suggesting that EMIs are feasible and acceptable for use in populations with bipolar disorder.

Roles for Mental Health Consumers in Self-Help Group Research

This article describes emerging roles of mental health consumers in self-help group research. Examples taken from recent empirical studies of self-help group activities among people with long-term and serious mental health disabilities illustrate new roles that transcend traditional relationships in research. A working typology for these roles include informed participant, key informant, advisor, staff member, and co-investigator as practical additions to the more traditional role of the research subject. Current guidelines for the protection of human subjects in research are limited in their ability to address ethical and procedural issues that arise out of these new role relationships. Self-help group research should address ethical issues that are not currently addressed by the established requirements of informed consent and IRB oversight. The author recommends that consumer review and approval be included as an integral part of the development and evaluation of human subject issues in clinical services research.

Problems in Assessing Prevalence and Membership Characteristics of Self-Help Group Participants

Relying on secondary analysis of three surveys, this study examines the prevalence of self-help group (SHG) use. Two of the surveys are based on large household probability samples (Epidemiological Catchment Area and Mellinger-Balter surveys) and the third on the population of self-help groups in California. Based on the best available survey information, an estimated 7.5 million adults participated in a SHG during 1992. Self-help group use for mental health problems appears to be a predominately White, middle-class phenomenon. Use of services is overlapping; those who seek out help do so in multiple service delivery modalities. Highlighted in this article are the problems of accurately assessing SHG participation based on current survey information.

The Pocket Psychiatrist: Tools to enhance psychiatry education in family medicine

Primary care is the setting where the majority of patients seek assistance for their mental health problems. To assist family medicine residents in providing effective care to patients for mental health problems during residency and after graduation, it is essential they receive training in the assessment, diagnosis, and treatment of common mental health conditions. While there is some limited education time with a psychiatrist in our department, residents need tools and resources that provide education during their continuity clinics even when the psychiatrist is not available. Information on two tools that were developed is provided. These tools include teaching residents a brief method for conducting a psychiatric interview as well as a means to access evidence-based information on diagnosis and treatment of mental health conditions through templates available within our electronic medical record.

Behavior medicine specialist

Total Health is a vision for the future and a strategy to prevent preventable disease, save lives, and make health care more affordable. Total Health means health of mind (behavior health) and health of body (physical health). To achieve Total Health we need healthy people in healthy communities. A behavior medicine specialist is a psychologist who works in the medical home with the primary care physician instead of in the Mental Health Department with a psychiatrist. The key to achieving Total Health will be to transform our current health care system from a focus on treating disease to a focus on preventing disease. This transformation will require complex behavior change interventions and services not usually provided in the medical home. The behavior medicine specialist will bring the knowledge and experience used to treat mental illness into the medical home to help the primary care physician improve the care of all patients in the medical home. The behavior medicine specialist will help improve outcomes in synergy with the primary care physician by universal screening of high-risk diseases, stepped care protocols, and efficient use of all resources available to care for patients in the medical home (health education classes, wellness coaches, and online social networking lifestyle management programs). These interventions should increase patient satisfaction, increase access to specialty care (psychiatry), and help us achieve Total Health.

Profiles Associated Respectively with Substance Dependence Only, Mental Disorders Only and Co-occurring Disorders

This study sought to identify profiles associated with substance dependence only, mental disorders only and co-occurring disorder respectively, using a broad range of socio-demographic, socio-economic, health beliefs, clinical and health services utilization variables concurrently. Based on a broad analytic framework, 423 participants diagnosed with substance dependence only, mental disorders only or co-occurring disorders within a 12-months period were studied. The study used comparison analysis, and a multinomial logistic regression model. Participants with dependence only and mental disorders only were in contrast in terms of gender, age, marital status, self-perception of physical health, perception of the physical conditions of their neighbourhood, impulsiveness, psychological distress and visit with a family physician in previous 12-months, while those with co-occurring disorders were in an intermediary position between the other two groups. Public authorities should especially promote strategies that could increase the capacity of family physicians to take care of individuals with substance dependence only.

Framework for classifying compliance and medical immediacy among low-acuity presentations at an urban trauma center

Background

This research offers two exploratory frameworks, one for medical regimen compliance and one for medical immediacy. The first classifies compliance awareness, compliance mitigation, and financial limitation for those patients that exhibit nonadherence with a medical regimen. The second classifies medical immediacy and characterizes avoidable utilization.

Methods

Representative sampling of adult patients presenting at an emergency department (62,000/ppy) triaged as low acuity; emergency department physician assessment of noncompliance with medical regimen for those patients with a complaint related to a chronic condition; and emergency department physician assessment of medical immediacy and avoidable utilization.

Results

Physicians report 48.3% (95% confidence interval (CI) 43.5% to 53.1%) of patients with at least a single chronic condition are presenting with symptoms or complaint related to a chronic condition, and 39.6% (CI 31.7% to 47.4%) of these exhibit noncompliance with the medical regimen associated with that chronic condition. 16.4% (CI 6.6% to 26.1%) of the patients exhibit pseudo compliance, a belief that the medical regimen is in compliance when in fact it is not. If the patient had been in compliance, 85.9% (CI 77.0% to 94.8%) of the presenting conditions may have been mitigated. Noncompliance cases (34.5% (CI 22.0% to 47.1%)) are partly attributable to financial constraints. Further, 19.1% (CI 15.7% to 22.5%) are assessed as requiring no medical intervention and 3.4% (CI 1.8% to 4.9%) require immediate stabilization.

Conclusions

A large portion of low-acuity presentations are related to a chronic condition and noncompliance with the associated medical regimen contributes to the need to seek medical services. Interventions addressing literacy and financial constraints may increase compliance and decrease utilization.

The Cost of Child Behaviour Therapy: The First Step to Demonstrating Cost-effectiveness

There has been extensive debate over the last three decades about which professional groups should receive government-funded rebates in the mental health field. Cognitive-behaviour therapists appear to be in the best position to demonstrate clinical efficacy, but have failed to demonstrate cost-effectiveness of cognitive-behaviour therapy. There is a need to demonstrate the cost of behaviour therapy as the first step in determining the cost-effectiveness of behaviour therapy compared to the traditional (medical-based) interventions. Using archival data from a university-based psychology clinic specialising in cognitive-behavioural interventions with child and adolescent problems, the present research determined the cost of successful treatment programs with the clinic's major referral areas: nocturnal enuresis, behaviour management, and education-based problems. Analysing 77 cases, it was found that there were significant between group differences in the number and total duration of face-to-face interviews, in the number of other contacts between therapist and client, in total therapist time, and in the estimated average cost of cases. There emerged different treatment patterns for each clinical problem, and these were reflected in costing. A number of research and methodological issues are explored. Implications for future research on cost-effectiveness and the subsequent collection of comparative data across clinics and a variety of clinical problem areas are discussed.

Impact of mood disorders on oral health-care utilization among middle-aged and older adults

BACKGROUND

Good oral health improves quality of life and is an integral part of active aging. Similar to some other systemic diseases, mood disorders are more prevalent in middle to older ages and have an associated risk of developing poor oral health. Consequently, people with mood disorders need to have regular dental care. There is scarce evidence in Canada linking mood disorders to the use of professional oral care services. The purpose of this study was to investigate the association between mood disorders and utilization of oral health-care services in a population-based sample of middle aged and older adults in Canada.

METHODS

Data were extracted from Canadian Community Health Survey - Healthy Aging, 2008. Multinomial logistic regression was used to investigate the association between mood disorders and oral care utilization, adjusted for the confounders.

RESULTS

Among 30,354 respondents included in our sample, 2162 (6.9%) reported having mood disorders. After adjusting for age, sex, education, marital status, and dental insurance status, the respondents who had mood disorders had a significant increased odds of not visiting a dental professional in the past year (OR:1.21, 95% CI: 1.08-1.35). The association of never visiting a dental professional and mood disorders was even stronger (OR: 1.49, 95% CI: 0.91-2.46).

CONCLUSION

Mood disorders were found to have a strong association with underutilization of oral care services among aging adults of Canada. Given the associated poor oral health risks for elderly with mood disorders, oral health planners should strengthen the implementation of surveillance programs directed toward better oral health for this disadvantaged subpopulation.

Lo studio internazionale multicentrico dell'Organizzazione Mondiale della Sanità sui disturbi psichici nella medicina generale: risultati relativi all'area di Verona

Objectives - To present the results obtained from a cross-sectional evaluation of a sample of primary care attenders selected in Verona in the framework of the World Health Organization International Multicentre Study on Psychological Problems in Primary Care Settings. Methods - Among consecutive attenders at 16 primary care clinics in Verona during the period April 1991/February 1992, a random sample, stratified on the basis of GHQ-12 scores, was selected for a thorough evaluation of psychological status, physical status and disability in occupational and other daily activities. All patients with psychopathological symptoms at baseline assessment and a 20% random sample of those without psychopathological symptoms were interviewed again after 3 and 12 months (data not presented here). Results - Overall, 1,656 subjects were approached at the primary care clinics and 1,625 met inclusion criteria. The screening procedure was completed by 1,558 subjects and the second-stage evaluation by 250. Psychiatric disorders according to ICD-10 criteria were diagnosed in 12.4% of consecutive primary care attenders; of these, about one-third (4.5% of consecutive primary care attenders) satisfied ICD-10 diagnostic criteria for two or more disorders. Current Depressive Episode (4.7%) and Generalized Anxiety Disorder (3.7%) were the most common diagnoses. In addition, 11.2% of consecutive primary care attenders had ‘sub-threshold’ psychiatric disorders (i.e., they suffered from symptoms in at least two different areas among those listed in ICD-10, but they did not satisfy diagnostic criteria for well-defined disorders). Psychiatric disorders were more common among females and those aged 24-44 years. Only 20.6% of the subjects with psychiatric disorders contacted the general practitioner for their psychological symptoms, 5.7% complained of symptoms which might have had a psychological origin, whereas in about 70% of the cases the psychiatric disorder was concealed behind the presentation of somatic symptoms, pains in various parts of the body or chronic physical illness. Sixty-two percent of the subjects with psychiatric disorders rated their health status as fair or poor, as compared to 52.0% of those with chronic physical illness and 31.3% of those without such disorders. According to the general practitioner, 40.1% of the subjects with psychiatric disorders and 45.3% of those with chronic physical illness had a fair or poor health status, compared to 14.4% of those without such disorders. Disability in occupational and other daily activities was reported by 52.5% of the subjects with psychiatric disorders (in 40.1% of the cases disability was moderate or severe), 44.4% of those with chronic physical illness (in 26.8% of the cases disability was moderate or severe), and 15.0% of the subjects without such disorders (in 9.1% of the cases disability was moderate or severe). According to the interviewer, disability was identified in 48.4% of the subjects with psychiatric disorders, 39.0% of those with chronic physical illness, and 27.6% of the subjects without such disorders. Sixty per cent of the subjects with psychiatric disorders suffered from concurrent chronic physical illness; these subjects had a poorer health status and higher disability levels than those with psychiatric disorders only. Conclusions - Psychiatric disorders among primary care attenders are frequent and represents a major public health problem, since they entail severe functional limitations for the patients and high costs for the society. Thus, appropriate programs for their recognition and treatment are needed.

Nosocomial suicide

OBJECTIVE AND METHOD

To consider the possibility that adverse aspects of psychiatric hospitalisation may precipitate suicide contributing significantly to the increased rate of suicide among inpatients, given little has been published about this.

RESULTS AND CONCLUSIONS

It is likely that psychiatric hospitalisation itself contributes to some inpatient suicides. This has significant implications for the delivery of inpatient psychiatric care.

Strategies for managing symptoms of anxiety

The purpose of this article is to summarize strategies for effectively managing the symptoms of anxiety. The distinction between the cognitive, physiological and behavioral components of fear and anxiety is explained and various treatment targets are outlined. Empirically-supported strategies that are effective in alleviating common symptoms of anxiety are reviewed. These include various forms of psychosocial intervention (i.e., cognitive and behavioral therapies), pharmacotherapy, in addition combined treatment approaches. Expert consensus guidelines, prognostic factors, patient preferences and accessibility issues are discussed with regard to treatment selection in addition to emerging challenges in the field and future research directions.

Feasibility and Acceptability of a Mobile Intervention to Improve Treatment Adherence in Bipolar Disorder: A Pilot Study

We evaluated the feasibility and acceptability of a 2-week-long ecological momentary intervention (EMI), delivered via personal digital assistants (PDAs), to improve treatment adherence in bipolar disorder. EMIs use mobile technology to deliver treatment as clients engage in their typical daily routines, in their usual settings. Overall, participants (N = 14) stated that EMI sessions were helpful, user-friendly, and engaging, and reported satisfaction with the timing and burden of sessions, as well as the method of delivery. All participants completed the study, and all PDAs were returned undamaged. On average, participants completed 92% of EMI sessions. Although this study was not designed to assess efficacy, depression scores decreased significantly over the study period and data suggest relatively high rates of treatment adherence; missed medication was reported 3% of the time and three participants reported missing a total of six mental health appointments. Negative feedback largely involved technical and logistical issues, many of which are easily addressable. These preliminary findings add to the growing body of literature indicating that mobile-technology-assisted interventions are feasible to implement and acceptable to patients with serious mental illnesses.

The integrated behavioral health service delivery system model

Costs and effective management of health care in general, and behavioral health care in particular, have been of primary importance and concern to federal, state, and local governments. With the passage of Health Care Reform (HCR) these concerns will only escalate. Thus, the necessity for the development of innovative, successful, and integrated cost-effective treatments and procedures is evident. The behavioral health care model presented here is proposed to address these needs. The model centers on the composition of effective psychosocial treatment and provides a cost analysis of social work and its services. By defining the problems that need to be addressed in health care management and cost containment, and applying findings of evidence-based studies, this article provides an effective model for health care organizations. It also presents a profile of the behavioral health social worker, defining the requisite abilities for effectiveness in the role and looking at the key impact areas for a behavioral health model. This comprehensive guide will prepare new social workers entering health care organizations as well as provide a valuable reference for existing social workers, academics, and practitioners of behavioral health care.

Assessment of psychological pain in major depressive episodes

Severe psychological or mental pain is defined as an experience of unbearable torment which can be associated with a psychiatric illness (e.g., major depressive disorder) or a tragic loss such as the death of a child. A brief self-rating scale (Mee-Bunney Psychological Pain Assessment Scale [MBPPAS]) was developed to assess the intensity of psychological pain. The scale was used to measure psychological pain in 73 major depressive episode (MDE) patients and 96 non-psychiatric controls. In addition to the MBPPAS, all subjects completed four additional instruments: Suicidal Behavior Questionnaire (SBQ), Beck Depression Inventory (BDI), Beck Hopelessness Scale (BHS), and the Brief Pain Inventory (BPI). Known-groups, content and convergent validity, and internal reliability of the scale were established. MDE and control subjects were ranked according to MBPPAS scores. A threshold was set at 32 representing 0.5 SD above the mean for MDEs. MDE subjects above the threshold of 32 had significantly higher SBQ scores than those below. A significant linear correlation between psychological pain and SBQ suicidality scores was observed. This is the first study to contrast psychological pain in controls and patients with MDE. Our results suggest that psychological pain is a useful and unique construct in patients with MDE that can be reliably assessed and may aid in the evaluation of suicidal risk.

Counseling and wellness services integrated with primary care: a delivery system that works

INTRODUCTION

The continuity and coordination of care between medical and behavioral health services is a major issue facing our health care delivery system. Barriers to basic communication between providers of medical services and providers of behavioral health services, include: no coordination of services, and poor recognition of the relationship between medical and behavioral issues.

METHODS

Colocating behavioral health counselors and nutritionists alongside primary care physicians and clinicians (PCPs).

RESULTS

Grand Valley Health Plan (GVHP) established the national benchmark for patients using ambulatory services for mental health, and ranked first in Michigan on all six HEDIS "effectiveness of care" measures for behavioral health. One result was a 54% decrease in mental health hospitalization.

DISCUSSION

Up to 70% of primary care visits are driven by psychosocial factors, with 25% of patients having a diagnosable mental disorder, and comorbidity occurring in up to 80%. With colocated services, PCPs now often explain to patients that "this is just how we deliver care to you," when introducing health coaches to patients and asking them to be involved.

Factors associated with attendance in 12-step groups (Alcoholics Anonymous/Narcotics Anonymous) among adults with alcohol problems living with HIV/AIDS

BACKGROUND

Despite the value of 12-step meetings, few studies have examined factors associated with attendance among those living with HIV/AIDS, such as the impact of HIV disease severity and demographics.

OBJECTIVE

This study examines predisposing characteristics, enabling resources and need on attendance at Alcoholic Anonymous (AA) and Narcotics Anonymous (NA) meetings among those living with HIV/AIDS and alcohol problems.

METHODS

Secondary analysis of prospective data from the HIV-Longitudinal Interrelationships of Viruses and Ethanol study, a cohort of 400 adults living with HIV/AIDS and alcohol problems. Factors associated with AA/NA attendance were identified using the Anderson model for vulnerable populations. Generalized estimating equation logistic regression models were fit to identify factors associated with self-reported AA/NA attendance.

RESULTS

At study entry, subjects were 75% male, 12% met diagnostic criteria for alcohol dependence, 43% had drug dependence and 56% reported attending one or more AA/NA meetings (past 6 months). In the adjusted model, female gender negatively associated with attendance, as were social support systems that use alcohol and/or drugs, while presence of HCV antibody, drug dependence diagnosis, and homelessness associated with higher odds of attendance.

CONCLUSIONS

Non-substance abuse related barriers to AA/NA group attendance exist for those living with HIV/AIDS, including females and social support systems that use alcohol and/or drugs. Positive associations of homelessness, HCV infection and current drug dependence were identified. These findings provide implications for policy makers and treatment professionals who wish to encourage attendance at 12-step meetings for those living with HIV/AIDS and alcohol or other substance use problems.

Prevalence and correlates of service utilization and help seeking in a national college sample of female rape victims

This study examines prevalence and correlates of help seeking for emotional problems among undergraduate female rape victims. A national college sample of women endorsing a lifetime history of rape (N=228) were interviewed in 2006 to assess demographic characteristics, rape history, rape characteristics, psychopathology, and substance abuse. Participants were asked if they ever sought help for emotional problems, and what type(s) of services were sought (medical professional, religious figure, or mental health professional). Prevalence of help seeking was 52%. Of help-seekers, 93% went to a mental health professional, 48% went to a medical doctor, and 14% sought religious counsel. Only PTSD was related to ever seeking help (OR=2.35). Findings suggest that university-based mental health and medical facilities should be well prepared to identify and treat PTSD and other rape-related sequelae. Health promotion campaigns are needed to target substance abusing and depressed rape victims, who were less likely to seek help.

Unexplained chest pain in the ED: could it be panic?

PURPOSE

This study aimed at (1) establishing the prevalence of paniclike anxiety in emergency department (ED) patients with unexplained chest pain (UCP); (2) describing and comparing the sociodemographic, medical, and psychiatric characteristics of UCP patients with and without paniclike anxiety; and (3) measuring the rate of identification of panic in this population.

BASIC PROCEDURE

A structured interview, the Anxiety Disorders Interview Schedule for the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, was administered to identify paniclike anxiety and evaluate patients' psychiatric status. Anxious and depressive symptoms were evaluated with self-report questionnaires. Medical information was extracted from patients' medical records.

MAIN FINDINGS

The prevalence of paniclike anxiety was 44% (95% CI, 40%-48%) in the sample (n = 771). Psychiatric disorders were more common in panic patients (63.4% vs 20.1%), as were suicidal thoughts (21.3% vs 11.3%). Emergency physician diagnosed only 7.4% of panic cases.

PRINCIPAL CONCLUSIONS

Paniclike anxiety is common in ED patients with UCP, and this condition is rarely diagnosed in this population.

Self-help groups and mental health/substance use agencies: the benefits of organizational exchange

Self-help groups benefit clients by linking them to people who have "been there" and are successfully coping with their situations. Mental health/substance use agencies can increase access to evidence-based benefits of self-help groups by engaging them in organizational exchanges. Organizational theories are used to frame beneficial exchanges with self-help groups. Adaptational theory is used to frame exchanges with self-help groups and various service agency subunits, e.g., board, practitioner, and client units. Institutional theory is used to frame joint agency/self-help initiatives to promote community acceptance of self-help groups, which in turn may enhance the credibility of the professional agency.

Preferences for Professional Assistance for Distress in a Diverse Sample of Older Adults

Older adults (N=140; 68.6% minority) participating in community health screenings reported their use and preferences for various professionals and services to deal with distress. Race/ethnicity was recorded based on self-report. A third of participants had discussed distress with some professional within the past year. Compared to Whites, Asian and Black elders were less likely to see a mental health professional or receive counseling in the past year. Almost all participants (89.3%) were willing to discuss distress with some professional; most preferred medical (37.9%) or religious professionals (21.4%). Fewer Asians expressed willingness across most professionals and services. Findings support efforts to integrate mental health with other services, and suggest the need for additional strategies to enhance willingness to use mental health services, especially for Asian elders.

Factors associated with depression and suicidal ideation among individuals with arthritis or rheumatism: findings from a representative community survey

OBJECTIVE

To investigate factors associated with depression and suicidal ideation among individuals with arthritis or rheumatism.

METHODS

The nationally representative Canadian Community Health Survey 2000-2001 included 130,880 respondents (response rate 84.7%). Respondents were diagnosed as depressed using a subset of items from the Composite International Diagnostic Interview. There were 23,405 respondents age > or =20 years who reported that they had been diagnosed with arthritis or rheumatism by a health professional. Logistic regression analyses were conducted to investigate depression and suicidal ideation.

RESULTS

One in 10 Canadians with arthritis had clinically relevant levels of major depression. The age- and sex-adjusted odds ratios (ORs) of major depression (OR 2.24, 95% confidence interval [95% CI] 2.11-2.38) and suicidal ideation (OR 2.01, 95% CI 1.75-2.31) among those with arthritis were approximately twice that of those without arthritis. The adjusted ORs of major depression among those with arthritis were significantly higher among women, the unmarried, younger, and poorer individuals. Individuals in pain, with limitations in activities of daily living, with limitations in instrumental activities of daily living, and with greater numbers of chronic conditions had higher odds of major depression. Less than half of those with major depression had consulted a mental health professional. One in 5 individuals with arthritis and major depression had been suicidal in the past year.

CONCLUSION

The majority of individuals with arthritis and major depression were not receiving adequate treatment for major depression. Clients should be screened for major depression and suicidal ideation, particularly if they fall into the identified vulnerable groups.

Disparities in use of mental health and substance abuse services by persons with co-occurring disorders

OBJECTIVES

Individuals with co-occurring mental and substance use disorders require psychiatric and substance abuse treatments. A critical question is whether these individuals are treated for both disorders.

METHODS

This study prospectively examined 24-month service utilization patterns of 224 persons with co-occurring disorders who were recruited from crisis residential programs in the mental health treatment system (N=106) and from crisis residential detoxification programs in the substance abuse treatment system (N=118) in San Francisco. Utilization data were collected from the billing-information systems of both treatment systems. Demographic and clinical data were obtained in interviews with participants. Data were analyzed for group differences with chi square tests and logistic, linear, and zero-truncated negative binomial regression.

RESULTS

After the analyses controlled for demographic and clinical factors, participants recruited from the substance abuse treatment system were less likely than those from the mental health treatment system to obtain any mental health services, mental health day treatment, transitional residential care, case management, and other outpatient services (p<.001 for all comparisons). They were more likely to obtain crisis residential detoxification (p=.003), had more days of drug residential treatment (p=.028), but received fewer hours of outpatient services (p=.012).

CONCLUSIONS

There were disparities in patterns of service utilization, although there were no significant diagnostic differences between the two groups. These findings should be valuable in considering systems development and modification. Furthermore, they can contribute to research about factors that underlie results. Study replications should be conducted to assess the robustness of these findings in other locales.

Across the great divide: introduction to the special issue on psychology in medicine

Health psychology has made limited progress becoming an accepted part of mainstream medical research and practice. Although abundant efficacy research has generated considerable evidence-based interventions that are effective primary medical interventions or adjuncts to other medical treatments, evidence of acceptance within medicine and especially primary care is meager. This special edition of the Journal of Clinical Psychology is an effort to assist movement in this area. It is a combination of commentaries concerning aspects of clinical collaboration within primary care, a discussion of issues that are barriers to implementation, and a wide range of research efforts supporting models of collaborative interventions between health psychology and primary care. It also identifies mechanisms that may account for the effectiveness of certain types of interventions. Taken as a whole the volume supports the importance and viability of clinical health psychology research and practice in an area of fundamental importance--the general health of patients in medical settings--the location where most people present psychological problems and receive treatment in response.

Identifying and screening for psychological and comorbid medical and psychological disorders in medical settings

There is increased attention to the medical and economic consequences of psychological problems comorbid with medical issues. There is also a clear awareness that most psychological problems are assessed and responded to in nonpsychiatric medical settings. This has furthered interest and attention in implementing screening procedures to better identify psychological, behavioral, and substance abuse problems in medical settings. Such interest is taking the form of recommendations from federal government task forces, and the funding of large projects to include screening in medical settings. At the same time there has been further attention to brief, valid, and reliable measures with which to capture psychological comorbidities. However, there have been multiple concerns raised about a variety of issues concerning the utility and effectiveness of such screening procedures and the identification of multiple issues to be considered in screening design. The author outlines and reviews the rationale and concerns about screening, identifies the issues that need to be considered in screening program development, and describes the efforts to develop a screening capacity in a rural family practice.

Service utilization and help seeking in a national sample of female rape victims

OBJECTIVE

Many women with mental health problems do not seek help. Despite substantial research on predictors of help seeking, little is known about factors associated with help seeking in at-risk populations (for example, rape victims). This study examined various forms of help seeking for emotional problems in relation to key variables in a national sample of female rape victims.

METHODS

Telephone interviews were conducted with a representative sample of 3,001 women (aged 18 to 76 years). All interviews were conducted between January 23, 2006, and June 26, 2006. Those endorsing a lifetime history of rape were included in the analyses presented here (N=556). Demographic characteristics, rape history, rape characteristics, psychopathology, and substance abuse were assessed. Help seeking was assessed by asking whether participants ever sought help for emotional problems, and if so, what types of services were sought (services provided through a medical professional, religious figure, or mental health professional).

RESULTS

Help seeking was endorsed by 60% of the sample. The final multivariable model showed that ever seeking help was associated with being white (OR=2.61), being married (OR=.42), and having posttraumatic stress disorder (OR=3.45). Specific forms of help seeking revealed unique predictor sets.

CONCLUSIONS

Although lifetime history of help seeking among rape victims was high, 40% of respondents had never sought help for emotional problems. Odds of help seeking were generally increased by the presence of a mental disorder. The findings suggest that some respondents may have sought help from general medical professionals or religious figures for emotional problems related to being raped. Education and training regarding rape and associated disorders should be available to other professionals to support provision of care. Public policy should be strengthened regarding professionals' service provision and should include reimbursement for mental health services so victims do not have to pay for services.

Unexplained chest pain: when is it panic disorder?

Noncardiac chest pain is a common costly phenomenon in the cardiology setting. Recent research suggests that panic disorder, a highly distressful yet treatable anxiety disorder, occurs in a significant proportion of noncardiac chest pain patients. This article reviews research on the prevalence of panic disorder in patients seen in cardiology settings for unexplained chest pain. Financial, psychosocial, and historical aspects of noncardiac chest pain are described. Panic disorder and the potential consequences of its nonrecognition by physicians are examined. Current psychological and pharmacologic treatments are reviewed. Recommendations on the management of panic patients in the cardiology setting are provided.

Success of mental health referral among pregnant and postpartum women with psychiatric distress

OBJECTIVE

This study measured rates of and determined factors associated with mental health service use among a cohort of 465 pregnant and postpartum women receiving care from publicly funded obstetric clinics.

METHODS

Women underwent a diagnostic evaluation, were provided with at least one mental health referral and were encouraged to seek treatment; follow-up with provision of additional referrals occurred at 1, 3 and 6 months after the initial assessment. Logistic regression was used to estimate the relationship between clinical and psychosocial factors and self-reported mental health service use.

RESULTS

Of the referred women, 38.1% attended at least one mental health visit, while only 6% remained in treatment during the entire 6-month follow-up interval. Postpartum women were more likely than pregnant women to attend a mental health treatment visit [odds ratio (OR)=4.17]. Being born in the United States (OR=2.06), being exposed to interpersonal violence (OR=2.52) and being unemployed (OR=2.69) were associated with attending at least one mental health-care visit. Women who received a behavioral health referral to the same site as their prenatal or postpartum care were more likely than those referred offsite to attend a mental health treatment visit (OR=3.23).

CONCLUSIONS

Despite active follow-up, rates of accessing and particularly continuing in mental health treatment were low. More work is needed to support the integration of specialty behavioral health services in primary care settings accessed by perinatal women.

Personality traits and mental health treatment utilization

Recent theory and research suggest a relation between five-factor model personality traits and mental health treatment utilization, even after controlling for psychiatric disorders and global functioning. The current report further tests this hypothesis in a large clinical sample, using a wider array of treatment modalities than has been previously studied. Overall, results were limited and inconsistent. Although neuroticism was related to utilization across treatment modalities, many of these relationships resulted from its association with psychiatric diagnoses. Other traits showed limited and inconsistent relations to the use of psychosocial and psychiatric treatments.