Collaborative care for depression and anxiety problems

Collaborative care for common mental disorders in low- and middle-income countries: A systematic review and meta-analysis

BACKGROUND

Low- and middle-income countries (LMICs) face high burden of common mental disorders (CMDs). Most of the evidence for the Collaborative Care (CC) model effectiveness comes from high-income countries (HICs) and may not generalise to LMICs. A systematic review was conducted to assess effectiveness of CC for CMDs in LMICs.

METHODS

We searched eight-databases, two trial registries (2011-November 2023). Randomised controlled trials (RCTs) of adults (≥18 years) with depression/anxiety diagnosis, reporting remission/change in symptom severity were eligible. Random effects meta-analyses were conducted for: short-(0-6 months), medium-(7-12 months), long-(13-24 months), and very long-term (≥25 months) follow-up. Quality was assessed with Cochrane RoB2 tool. PROSPERO registration: CRD42022380407.

RESULTS

Searches identified 7494 studies, 12 trials involving 13,531 participants were included; nine had low-risk of bias. CC was more effective than usual care for depression: dichotomous outcomes (short-term, 7 studies, relative risk (RR) 1.39, 95%CI 1.31, 1.48; medium-term, 6 studies, RR 1.35, 95%CI 1.28, 1.43); and continuous outcomes (short-term, 8 studies, standardised mean difference (SMD) -0.51, 95%CI -0.80, -0.23; medium-term, 8 studies, SMD -0.59, 95%CI -1.00, -0.17). CC was found to be effective at long-term (one study), but not at very long-term. Improvement in anxiety outcomes with CC (2 studies, 340 participants) reported up to 12-months; improvements in quality-of-life were not statistically significant (3 studies, 796 participants, SMD 0.62, 95%CI -0.10, 1.34).

LIMITATIONS

Pooled estimates showed high heterogeneity.

CONCLUSIONS

In LMICs, CC was more effective than usual care for improving depression outcomes at short and medium-term follow-up. A similar improvement was found for anxiety outcomes, but evidence is limited.

Understanding and Navigating the Unique Barriers Rural Primary Care Settings Face when Implementing Collaborative Care for Mental Health

Rural primary care (RPC) clinics may face unique barriers to implementing the Collaborative Care Model (CoCM). We used mixed methods to explore RPC staff and practice facilitator (PF) perspectives on CoCM implementation. PFs reported on barriers and facilitators experienced after each monthly meeting with clinics (n = 459 surveys across 23 clinics). Data were analyzed descriptively and informed qualitative interviews with a purposive sample (n = 11) of clinic staff and PFs. Interviews were analyzed using Rapid Assessment Process and triangulated with quantitative data. The most prominent barriers experienced were: (1) the COVID-19 pandemic, (2) limited availability of site staff to participate in implementation activities, and (3) hiring of new CoCM staff. Qualitative data further characterized the ways these barriers uniquely influenced RPC settings and promising implementation strategies. RPC settings face unique challenges to CoCM implementation, but several promising implementation strategies - when tailored to RPC contexts - may help.

Primary care mental health integration to improve early treatment engagement for veterans who screen positive for depression

OBJECTIVE

To examine the relationship between the penetration (or reach) of a national program aiming to integrate mental health clinicians into all primary care clinics (PC-MHI) and rates of guideline-concordant follow-up and treatment among clinic patients newly identified with depression in the Veterans Health Administration (VA).

DATA SOURCES/STUDY SETTING

15,155 screen-positive patients 607,730 patients with 2-item Patient Health Questionnaire scores in 82 primary care clinics, 2015-2019.

STUDY DESIGN

In this retrospective cohort study, we used established depression care quality measures to assess primary care patients who (a) newly screened positive (score ≥3) and (b) were identified with depression by clinicians via diagnosis and/or medication (n = 15,155; 15,650 patient-years). Timely follow-up included ≥3 mental health, ≥3 psychotherapy, or ≥3 primary care visits for depression. Minimally appropriate treatment included ≥4 mental health visits, ≥3 psychotherapy, or ≥60 days of medication. In multivariate regressions, we examined whether higher rates of PC-MHI penetration in clinic (proportion of total primary care patients in a clinic who saw any PC-MHI clinician) were associated with greater depression care quality among cohort patients, adjusting for year, healthcare system, and patient and clinic characteristics.

DATA COLLECTION/EXTRACTION METHODS

Electronic health record data from 82 VA clinics across three states.

PRINCIPAL FINDINGS

A median of 9% of all primary care patients were seen by any PC-MHI clinician annually. In fully adjusted models, greater PC-MHI penetration was associated with timely depression follow-up within 84 days (∆P = 0.5; SE = 0.1; p < 0.001) and 180 days (∆P = 0.3; SE = 0.1; p = 0.01) of a positive depression screen. Completion of at least minimal treatment within 12 months was high (77%), on average, and not associated with PC-MHI penetration.

CONCLUSIONS

Greater PC-MHI program penetration was associated with early depression treatment engagement at 84-/180-days among clinic patients newly identified with depression, with no effect on already high rates of completion of minimally sufficient treatment within the year.

Decision Support and Behavioral Health for Reducing High-Dose Opioids in Comorbid Chronic Pain, Depression and Anxiety: Stepped-Wedge Cluster Randomized Trial

BACKGROUND

High prevalence of depression or anxiety with opioid use for chronic pain complicates co-management and may influence prescribing behaviors.

OBJECTIVE

Compare clinical effectiveness of electronic medical record clinical decision support (EMR-CDS) versus additional behavioral health (BH) care management for reducing rates of high-dose opioid prescriptions.

DESIGN

Type 2 effectiveness-implementation hybrid stepped-wedge cluster randomized trial in 35 primary care clinics within a health system in LA, USA.

PARTICIPANTS

Patients aged 18+ receiving chronic opioid therapy for non-cancer pain with depression or anxiety and matched controls.

INTERVENTION

EMR-CDS included opioid risk mitigation procedures. BH care included cognitive behavioral therapy; depression or anxiety medication adjustments; and case management.

MAIN MEASURES

Outcomes of interest included difference-in-difference (DID) estimate of changes in probability for prescribing high-dose morphine equivalent daily dose (MEDD ≥50 mg/day and MEDD ≥90), average MEDD, and rates of hospitalization, emergency department use, and opioid risk mitigation.

KEY RESULTS

Most participants were female with 3+ pain syndromes. Data analysis included 632 patients. Absolute risk differences for MEDD≥50 and ≥90 decreased post-index compared to pre-index (DID of absolute risk difference [95%CI]: -0.036 [-0.089, 0.016] and -0.029 [-0.060, 0.002], respectively). However, these differences were not statistically significant. The average MEDD decreased at a higher rate for the BH group compared to EMR-CDS only (DID rate ratio [95%CI]: 0.85 [0.77, 0.93]). There were no changes in hospitalization and emergency department utilization. The BH group had higher probabilities of new specialty referrals and prescriptions for naloxone and antidepressants.

CONCLUSIONS

Incorporation of a multidisciplinary behavioral health care team into primary care did not decrease high-dose prescribing; however, it improved adherence to clinical guideline recommendations for managing chronic opioid therapy for non-cancer pain.

TRIAL REGISTRATION

ClinicalTrials.gov ID NCT03889418.

Optimizing Patient Engagement in Treatment for Opioid Use Disorder: Primary Care Team Perspectives on Influencing Factors

BACKGROUND

Opioid use disorder (OUD) care engagement rates in primary care (PC) settings are often low. Little is known about PC team experiences when delivering OUD treatment and potential factors that influence their capacity to engage patients in treatment. Exploring PC team experiences may inform needed supports that can optimize OUD care delivery and improve outcomes for patients with OUD.

OBJECTIVE

We explored multidisciplinary PC team perspectives on barriers and facilitators to engaging patients in OUD treatment.

DESIGN

Qualitative study using in-depth interviews.

PARTICIPANTS

Primary care clinical teams.

APPROACH

We conducted semi-structured interviews (n = 35) with PC team members involved in OUD care delivery, recruited using a combination of criterion and maximal variation sampling. Data collection and analysis were informed by existing theoretical literature about patient engagement, specifically that patient engagement is influenced by factors across individual (patient, provider), interpersonal (patient-provider), and health system domains. Interviews were professionally transcribed and doubled-coded using a coding schema based on the interview guide while allowing for emergent codes. Coding was iteratively reviewed using a constant comparison approach to identify themes and verified with participants and the full study team.

KEY RESULTS

Analysis identified five themes that impact PC team ability to engage patients effectively, including limited patient contact (e.g., phone, text) in between visits, varying levels of provider confidence to navigate OUD treatment discussions, structural factors (e.g., schedules, productivity goals) that limited provider time, the role of team-based approaches in lessening discouragement and feelings of burnout, and lack of shared organizational vision for reducing harms from OUD.

CONCLUSIONS

While the capacity of PC teams to engage patients in OUD care is influenced across multiple levels, some of the most promising opportunities may involve addressing system-level factors that limit PC team time and collaboration and promoting organizational alignment on goals for OUD treatment.

"I Felt Like I Mattered": Caring is a key ingredient of collaborative care for chronic illness

OBJECTIVES

To identify perceptions and experiences related to caring science and collaborative care in intervention participants of the Collaborative Care to Alleviate Symptoms and Adjust to Illness (CASA) study, a randomized, multi-site clinical trial for patients with chronic heart failure and reduced health status.

METHODS

Forty-five participants completed semi-structured, telephone interviews with a focus on intervention components, impact of the intervention on participants' lives, and recommendations for intervention change. Data were analyzed using an inductive content analysis approach focusing on the presence and frequency of text to identify patterns, categories, and themes across participants without an a priori code book. The validity of the identified categories was enhanced through triangulation.

RESULTS

Three themes were identified: (1) intervention providers' caring/helping attitude and caring/helping communication; (2) care team availability to respond to concerns or questions; and (3) help with understanding and navigating the healthcare system.

DISCUSSION

Patients highly value caring attitudes and communication, availability, and empowerment to understand and navigate healthcare systems. These attitudes and behaviors may be important mediators of the success of collaborative care programs. These are consistent with the theory of caring science, a framework that is relevant more broadly to patient-centered and team-based care models.

Management of Depression in Adults: A Review

Importance

Approximately 9% of US adults experience major depression each year, with a lifetime prevalence of approximately 17% for men and 30% for women.

Observations

Major depression is defined by depressed mood, loss of interest in activities, and associated psychological and somatic symptoms lasting at least 2 weeks. Evaluation should include structured assessment of severity as well as risk of self-harm, suspected bipolar disorder, psychotic symptoms, substance use, and co-occurring anxiety disorder. First-line treatments include specific psychotherapies and antidepressant medications. A network meta-analysis of randomized clinical trials reported cognitive therapy, behavioral activation, problem-solving therapy, interpersonal therapy, brief psychodynamic therapy, and mindfulness-based psychotherapy all had at least medium-sized effects in symptom improvement over usual care without psychotherapy (standardized mean difference [SMD] ranging from 0.50 [95% CI, 0.20-0.81] to 0.73 [95% CI, 0.52-0.95]). A network meta-analysis of randomized clinical trials reported 21 antidepressant medications all had small- to medium-sized effects in symptom improvement over placebo (SMD ranging from 0.23 [95% CI, 0.19-0.28] for fluoxetine to 0.48 [95% CI, 0.41-0.55] for amitriptyline). Psychotherapy combined with antidepressant medication may be preferred, especially for more severe or chronic depression. A network meta-analysis of randomized clinical trials reported greater symptom improvement with combined treatment than with psychotherapy alone (SMD, 0.30 [95% CI, 0.14-0.45]) or medication alone (SMD, 0.33 [95% CI, 0.20-0.47]). When initial antidepressant medication is not effective, second-line medication treatment includes changing antidepressant medication, adding a second antidepressant, or augmenting with a nonantidepressant medication, which have approximately equal likelihood of success based on a network meta-analysis. Collaborative care programs, including systematic follow-up and outcome assessment, improve treatment effectiveness, with 1 meta-analysis reporting significantly greater symptom improvement compared with usual care (SMD, 0.42 [95% CI, 0.23-0.61]).

Conclusions and Relevance

Effective first-line depression treatments include specific forms of psychotherapy and more than 20 antidepressant medications. Close monitoring significantly improves the likelihood of treatment success.

A Qualitative Investigation of Characteristics Impacting Clinical Decision-Making in Integrated Behavioral Health Care

To support implementation of integrated behavioral health care (IBHC) models in local settings, providers may benefit from clinical decision-making support. The present analysis examines perspectives on patient characteristics appropriate or inappropriate for, and currently managed within, IBHC at a large medical center to inform recommendations for provider decision-making. Twenty-four participants (n = 13 primary care providers; n = 6 behavioral health providers; n = 5 administrators) in an IBHC setting were interviewed. Thematic analysis was conducted with acceptable interrater reliability (κ = 0.75). Responses indicated behavioral health symptom and patient characteristics that impact perceptions of appropriateness for management in IBHC, with high variability between providers. Many patients with characteristics identified as inappropriate for IBHC were nonetheless currently managed in IBHC. Interactions between patient ability to engage in care and provider ability to manage patient needs guided decisions to refer a patient to IBHC or specialty care. A heuristic representing this dimensional approach to clinical decision-making is presented to suggest provider decision-making guidance informed by both patient and provider ability.

The role of an advanced practice midwife in perinatal mental health: Outlining the process of role development and implementation

INTRODUCTION

Perinatal mental health disorders (PMDs) are a global health concern. In industrialized countries, the prevalence of PMDs is estimated to be 20%, and they are associated with serious negative effects for women, their children and their families, along with high societal costs related to long-term impacts. In Switzerland, the PMD detection rate during obstetrical healthcare provision is very low (1-3%), and specialized healthcare services are limited. This study aimed to develop and implement an advanced practice midwife (APM) role at a Swiss obstetrics and gynecology hospital using the PEPPA framework to provide adequate screening and first-consultation services.

METHODS

The study uses a qualitative approach and follows the research stages using the 8-step from the participatory, evidence-based, patient-focused process for advanced practice nursing role development, implementation and evaluation (PEPPA) framework to develop and implement the APM role.

RESULTS

Utilizing the PEPPA framework, we were able to develop, implement, and evaluate the APM role in the field of perinatal mental health. Through appropriate screening and first-consultation services, we were able to identify affected women early and facilitate treatment.

CONCLUSIONS

In addition to stakeholder engagement and interprofessional collaboration, PEPPA serves as a beneficial framework for the process of role development, implementation, and evaluation in the midwifery profession. This study aims to assist midwives with Master's degrees in establishing corresponding roles within their practice areas, thereby enhancing care delivery. Furthermore, the current APM approach is intended to be continuously evaluated to gain new insights into its effectiveness.

Change in suicidal ideation, depression, and anxiety following collaborative care in the community

BACKGROUND

The Collaborative Care Model (CoCM) increases access to mental health treatment and improves outcomes among patients with mild to moderate psychopathology; however, it is unclear how effective CoCM is for patients with elevated suicide risk.

METHODS

We examined data from the Penn Integrated Care program, a CoCM program including an intake and referral management center plus traditional CoCM services implemented in primary care clinics within a large, diverse academic medical system. In this community setting, we examined: (1) characteristics of patients with and without suicidal ideation who initiated CoCM, (2) changes in suicidal ideation (Patient Health Questionnaire-9 [PHQ-9] item 9), depression (PHQ-9 total scores), and anxiety (Generalized Anxiety Disorder Scale-7 scores) from the first to last CoCM visit overall and across demographic subgroups, and (3) the relationship between amount of CoCM services provided and degree of symptom reduction.

RESULTS

From 2018 to 2022, 3,487 patients were referred to CoCM, initiated treatment for at least 15 days, and had completed symptom measures at the first and last visit. Patients were 74% female, 45% Black/African American, and 45% White. The percentage of patients reporting suicidal ideation declined 11%-7% from the first to last visit. Suicidal ideation severity typically improved, and very rarely worsened, during CoCM. Depression and anxiety declined significantly among patients with and without suicidal ideation and across demographic subgroups; however, the magnitude of these declines differed across race, ethnicity, and age. Patients with suicidal ideation at the start of CoCM had higher depression scores than patients without suicidal ideation at the start and end of treatment. Longer CoCM episodes were associated with greater reductions in depression severity.

CONCLUSIONS

Suicidal ideation, depression, and anxiety declined following CoCM among individuals with suicidal ideation in a community setting. Findings are consistent with emerging evidence from clinical trials suggesting CoCM's potential for increasing access to mental healthcare and improving outcomes among patients at risk for suicide.

A formative evaluation to inform integration of psychiatric care with other gender-affirming care

BACKGROUND

Transgender, non-binary, and/or gender expansive (TNG) individuals experience disproportionately high rates of mental illness and unique barriers to accessing psychiatric care. Integrating TNG-specific psychiatric care with other physical health services may improve engagement, but little published literature describes patient and clinician perspectives on such models of care. Here we present a formative evaluation aiming to inform future projects integrating psychiatric care with physical health care for TNG individuals.

METHODS

In this qualitative pre-implementation study, semi-structured interview guides were developed informed by the Consolidated Framework for Implementation Research to ensure uniform inclusion and sequencing of topics and allow for valid comparison across interviews. We elicited TNG patient (n = 11) and gender-affirming care clinician (n = 10) needs and preferences regarding integrating psychiatric care with other gender-affirming clinical services. We conducted a rapid analysis procedure, yielding a descriptive analysis for each participant group, identifying challenges of and opportunities in offering integrated gender-affirming psychiatric care.

RESULTS

Participants unanimously preferred integrating psychiatry within primary care instead of siloed service models. All participants preferred that patients have access to direct psychiatry appointments (rather than psychiatrist consultation with care team only) and all gender-affirming care clinicians wanted increased access to psychiatric consultations. The need for flexible, tailored care was emphasized. Facilitators identified included taking insurance, telehealth, clinician TNG-competence, and protecting time for clinicians to collaborate and obtain consultation.

CONCLUSIONS

This health equity pre-implementation project engaged TNG patients and gender-affirming care clinicians to inform future research exploring integration of mental health care with primary care for the TNG community and suggests utility of such a model of care.

Clinical Variables Associated with Successful Treatment of Depression or Anxiety in Collaborative Care

Collaborative Care, an evidence-based model, has proven effective in treating depression and anxiety in healthcare settings. However, limited attention has been paid to exploring treatment outcome differences by clinical variables and diagnosis within this model. While previous research suggests that early and frequent contacts and swift treatment access lead to positive outcomes for depression and anxiety, these aspects have not been comprehensively examined in Collaborative Care. This study investigates the impact of clinical variables on treatment completion in patients primarily diagnosed with anxiety or depression who received collaborative care treatment as a treatment program. Analysis was completed as an observational study of patients (n =2018) with behavioral health diagnoses spanning from 2016 to 2023. Classification analysis offers insights into optimal practices for implementing Collaborative Care across diverse healthcare populations from pediatric to geriatric. Identifying clinical characteristics associated with successful treatment in Collaborative Care has far-reaching implications for model adoption and enhancing patient outcomes. Across all results, patients who received more clinical support and had shorter enrollment durations showed a strong association with successful treatment completion.

Collaborative care approaches for people with severe mental illness

BACKGROUND

Collaborative care for severe mental illness (SMI) is a community-based intervention that promotes interdisciplinary working across primary and secondary care. Collaborative care interventions aim to improve the physical and/or mental health care of individuals with SMI. This is an update of a 2013 Cochrane review, based on new searches of the literature, which includes an additional seven studies.

OBJECTIVES

To assess the effectiveness of collaborative care approaches in comparison with standard care (or other non-collaborative care interventions) for people with diagnoses of SMI who are living in the community.

SEARCH METHODS

We searched the Cochrane Schizophrenia Study-Based Register of Trials (10 February 2021). We searched the Cochrane Common Mental Disorders (CCMD) controlled trials register (all available years to 6 June 2016). Subsequent searches on Ovid MEDLINE, Embase and PsycINFO together with the Cochrane Central Register of Controlled Trials (with an overlap) were run on 17 December 2021.

SELECTION CRITERIA

Randomised controlled trials (RCTs) where interventions described as 'collaborative care' were compared with 'standard care' for adults (18+ years) living in the community with a diagnosis of SMI. SMI was defined as schizophrenia, other types of schizophrenia-like psychosis or bipolar affective disorder. The primary outcomes of interest were: quality of life, mental state and psychiatric admissions at 12 months follow-up.

DATA COLLECTION AND ANALYSIS

Pairs of authors independently extracted data. We assessed the quality and certainty of the evidence using RoB 2 (for the primary outcomes) and GRADE. We compared treatment effects between collaborative care and standard care. We divided outcomes into short-term (up to six months), medium-term (seven to 12 months) and long-term (over 12 months). For dichotomous data we calculated the risk ratio (RR) and for continuous data we calculated the standardised mean difference (SMD), with 95% confidence intervals (CIs). We used random-effects meta-analyses due to substantial levels of heterogeneity across trials. We created a summary of findings table using GRADEpro.

MAIN RESULTS

Eight RCTs (1165 participants) are included in this review. Two met the criteria for type A collaborative care (intervention comprised of the four core components). The remaining six met the criteria for type B (described as collaborative care by the trialists, but not comprised of the four core components). The composition and purpose of the interventions varied across studies. For most outcomes there was low- or very low-certainty evidence. We found three studies that assessed the quality of life of participants at 12 months. Quality of life was measured using the SF-12 and the WHOQOL-BREF and the mean endpoint mental health component scores were reported at 12 months. Very low-certainty evidence did not show a difference in quality of life (mental health domain) between collaborative care and standard care in the medium term (at 12 months) (SMD 0.03, 95% CI -0.26 to 0.32; 3 RCTs, 227 participants). Very low-certainty evidence did not show a difference in quality of life (physical health domain) between collaborative care and standard care in the medium term (at 12 months) (SMD 0.08, 95% CI -0.18 to 0.33; 3 RCTs, 237 participants). Furthermore, in the medium term (at 12 months) low-certainty evidence did not show a difference between collaborative care and standard care in mental state (binary) (RR 0.99, 95% CI 0.77 to 1.28; 1 RCT, 253 participants) or in the risk of being admitted to a psychiatric hospital at 12 months (RR 5.15, 95% CI 0.67 to 39.57; 1 RCT, 253 participants). One study indicated an improvement in disability (proxy for social functioning) at 12 months in the collaborative care arm compared to usual care (RR 1.38, 95% CI 0.97 to 1.95; 1 RCT, 253 participants); we deemed this low-certainty evidence. Personal recovery and satisfaction/experience of care outcomes were not reported in any of the included studies. The data from one study indicated that the collaborative care treatment was more expensive than standard care (mean difference (MD) international dollars (Int$) 493.00, 95% CI 345.41 to 640.59) in the short term. Another study found the collaborative care intervention to be slightly less expensive at three years.

AUTHORS' CONCLUSIONS

This review does not provide evidence to indicate that collaborative care is more effective than standard care in the medium term (at 12 months) in relation to our primary outcomes (quality of life, mental state and psychiatric admissions). The evidence would be improved by better reporting, higher-quality RCTs and the assessment of underlying mechanisms of collaborative care. We advise caution in utilising the information in this review to assess the effectiveness of collaborative care.

Meaningful Engagement in Depression and Anxiety Collaborative Care: Associations With Systematic Case Review

BACKGROUND

Collaborative care (CC) is an evidence-based model of care for treating behavioral health conditions in primary care settings. The CC team consists of a primary care provider, behavioral health care manager (CM), and a consultant psychiatrist who collaborate to create treatment plans. To date, there is limited data on factors associated with meaningful engagement in CC programs.

OBJECTIVE

To identify the proportion of patients who were meaningfully engaged and to investigate the factors associated with meaningful engagement in a CC program.

METHODS

Data was collected from a CC program implemented across 27 adult primary care clinics in a Midwestern, U.S. academic medical system. Logistic regression (n = 5218) was used to estimate the odds of receiving meaningful engagement.

RESULTS

Data was collected from 6437 individuals with 68% being female and a mean age of 45 years old (standard deviation 17.6). Overall, 57% of patients were meaningfully engaged; however, this proportion differed based on demographic and clinical factors. Among modifiable clinical factors, systematic case reviews between the CM and psychiatrist (odds ratio: 10.2, 95% confidence interval: 8.6-12.1) and warm handoffs (odds ratio: 1.3, 95% confidence interval: 1.1-1.5) were associated with a higher likelihood of receiving meaningful engagement.

CONCLUSIONS

The presence of systematic case reviews between the behavioral health CM and the consultant psychiatrist was highly associated with meaningful engagement. When implementing such programs, high fidelity to the core principles including regularly scheduled systematic case reviews should be pursued.

Barriers and facilitators to collaborative care implementation within the New York State Collaborative Care Medicaid Program

BACKGROUND

Since 2015, the New York State Office of Mental Health has provided state primary care clinics with outreach, free training and technical assistance, and the opportunity to bill Medicaid for the Collaborative Care Model (CoCM) as part of its Collaborative Care Medicaid Program. This study aims to describe the characteristics of New York State primary care clinics at each step of CoCM implementation, and the barriers and facilitators to CoCM implementation for the New York State Collaborative Care Medicaid Program.

METHODS

In this mixed-methods study, clinics were categorized into RE-AIM (Reach, Effectiveness, Adoption, Implementation, and Maintenance) steps. Clinics were sent a survey, which included questions related to payer mix, funding sources, billing codes used, and patient population demographics. Qualitative interviews were conducted with clinic representatives, focusing on barriers or facilitators clinics experienced affecting their progression to the next RE-AIM step.

RESULTS

One thousand ninety-nine surveys were sent to primary care clinics across New York State, with 107 (9.7%) completing a survey. Significant differences were observed among the different RE-AIM steps for multiple demographic variables including primary payer, percentage of patients with a diagnose of depression or anxiety, and percent of behavioral health services that are reimbursed, in addition to others. Three main themes regarding barriers and facilitators to implementing CoCM for New York State Medicaid billing emerged from 31 qualitative interviews: (1) Billing requirements, (2) Reimbursement rates, and (3) Buy-in to CoCM.

CONCLUSIONS

Survey data align with what we would expect to see demographically in NYS primary care clinics. Qualitative data indicated that CoCM billing requirements/structure and reimbursement rates were perceived as barriers to providing CoCM, particularly with New York State Medicaid, and that buy-in, which included active involvement from organizational leaders and providers that understand the Collaborative Care model were facilitators. Having dedicated staff to manage billing and data reporting is one way clinics minimize barriers, however, there appeared to be a disconnect between what clinics can bill for and the reimbursed amount several clinics are receiving, illustrating the need for stronger billing workflows and continued refinement of billing options across different payers.

Core Components and Implementation Determinants of Multilevel Service Delivery Frameworks Across Child Mental Health Service Settings

Multilevel service delivery frameworks are approaches to structuring and organizing a spectrum of evidence-based services and supports, focused on assessment, prevention, and intervention designed for the local context. Exemplar frameworks in child mental health include positive behavioral interventions and supports in education, collaborative care in primary care, and systems of care in community mental health settings. Yet, their high-quality implementation has lagged. This work proposes a conceptual foundation for multilevel service delivery frameworks spanning diverse mental health service settings that can inform development of strategic implementation supports. We draw upon the existing literature for three exemplar multilevel service delivery frameworks in different child mental health service settings to (1) identify core components common to each framework, and (2) to highlight prominent implementation determinants that interface with each core component. Six interrelated components of multilevel service delivery frameworks were identified, including, (1) a systems-level approach, (2) data-driven problem solving and decision-making, (3) multiple levels of service intensity using evidence-based practices, (4) cross-linking service sectors, (5) multiple providers working together, including in teams, and (6) built-in implementation strategies that facilitate delivery of the overall model. Implementation determinants that interface with core components were identified at each contextual level. The conceptual foundation provided in this paper has the potential to facilitate cross-sector knowledge sharing, promote generalization across service settings, and provide direction for researchers, system leaders, and implementation intermediaries/practitioners working to strategically support the high-quality implementation of these frameworks.

Palliative Care Psychiatry: Building Synergy Across the Spectrum

PURPOSE OF REVIEW

Palliative care (PC) psychiatry is a growing subspecialty focusing on improving the mental health of those with serious medical conditions and their caregivers. This review elucidates the current practice and ongoing evolution of PC psychiatry.

RECENT FINDINGS

PC psychiatry leverages training and clinical practices from both PC and psychiatry, addressing a wide range of needs, including enhanced psychiatric care for patients with serious medical illness, PC access for patients with medical needs in psychiatric settings, and PC-informed psychiatric approaches for individuals with treatment-refractory serious mental illness. PC psychiatry is practiced by a diverse workforce comprising hospice and palliative medicine-trained psychiatrists, psycho-oncologists, geriatric psychiatrists, other mental health professionals, and non-psychiatrist PC clinicians. As a result, PC psychiatry faces challenges in defining its operational scope. The manuscript outlines the growth, current state, and prospects of PC psychiatry. It examines its roles across various healthcare settings, including medical, integrated care, and psychiatric environments, highlighting the unique challenges and opportunities in each. PC psychiatry is a vibrant and growing subspecialty of psychiatry that must be operationalized to continue its developmental trajectory. There is a need for a distinct professional identity for PC psychiatry, strategies to navigate administrative and regulatory hurdles, and greater support for novel clinical, educational, and research initiatives.

Mental Health Service Integration in Hospice Organizations: A National Survey of Hospice Clinicians and Medical Leadership

Background: Unmet mental health needs are associated with a range of negative consequences for individuals at the end of life. Despite the high prevalence of mental health needs among individuals enrolled in hospice, there is a paucity of data describing mental health service integration in hospices in the United States. Objectives: 1. To identify patterns of mental health service integration in hospice organizations nationally; 2. To characterize gaps in mental health service delivery in hospice settings as perceived by hospice clinicians and medical leadership. Methods: A cross-sectional survey querying hospice clinicians and hospice medical leadership nationally. Results: A total of 279 surveys were included. Clinically significant mental health symptoms were common among hospice patients; the most frequently encountered symptom groups were depression, anxiety, dementia, and delirium. A minority of hospices maintained relationships with psychiatrists (23%, n = 60), psychiatric nurse practitioners (22%, n = 56), or psychologists (19%, n = 49). Only 38% (n = 99) of respondents were satisfied with their patients' access to services and only 45% (n = 118) were satisfied with the quality of these services. Common limitations to providing adequate mental health services included lack of specialist services, short length of stay for patients, and reluctance of patients to engage in these services. Conclusions: Significant mental health symptoms are common among hospice patients, and hospice organizations perceive these needs are not being met. Further research is needed to better understand the current treatment landscape and design interventions to address these needs.

Effects of intervention stage completion in an integrated behavioral health and primary care randomized pragmatic intervention trial

Purpose

A pragmatic, cluster-randomized controlled trial of a comprehensive practice-level, multi-staged practice transformation intervention aimed to increase behavioral health integration in primary care practices and improve patient outcomes. We examined association between the completion of intervention stages and patient outcomes across a heterogenous national sample of primary care practices.

Methods

Forty-two primary care practices across the U.S. with co-located behavioral health and 2,426 patients with multiple chronic medical and behavioral health conditions completed surveys at baseline, midpoint and two year follow-up. Effects of the intervention on patient health and primary care integration outcomes were examined using multilevel mixed-effects models, while controlling for baseline outcome measurements.

Results

No differences were found associated with the number of intervention stages completed in patient health outcomes were found for depression, anxiety, fatigue, sleep disturbance, pain, pain interference, social function, patient satisfaction with care or medication adherence. The completion of each intervention stage was associated with increases in Practice Integration Profile (PIP) domain scores and were confirmed with modeling using multiple imputation for: Workflow 3.5 (95% CI: 0.9-6.1), Integration Methods 4.6 (95% CI: 1.5-7.6), Patient Identification 2.9 (95% CI: 0.9-5.0), and Total Integration 2.7 (95% CI: 0.7-4.7).

Conclusion

A practice-centric flexible practice transformation intervention improved integration of behavioral health in primary care across heterogenous primary care practices treating patients with multiple chronic conditions. Interventions that allow practices to flexibly improve care have potential to help complex patient populations. Future research is needed to determine how to best target patient health outcomes at a population level.

Developing criteria for a profession to be considered as profession of allied health in Malaysia: a qualitative study from the Malaysian perspective

BACKGROUND

The Malaysian Allied Health Profession Act (Act 774) regulates the practice of allied health practitioners in Malaysia, with two described professions viz. allied health profession (AHP) and profession of allied health (PAH). While AHPs have been clearly identified by the law, comprehensive implementation of the act requires development of specific criteria in defining any profession as PAH in the Malaysian context. Hence, the research aims to explore and identify the criteria for defining such professions for healthcare policy direction in Malaysia.

METHODS

This research utilised two methods of qualitative research (document review and focus group discussions (FGDs) involving 25 participants from four stakeholders (higher education providers, employers, associations and regulatory bodies). Both deductive and inductive thematic content analysis were used to explore, develop and define emergent codes, examined along with existing knowledge on the subject matter.

RESULTS

Sixteen codes emerged from the FGDs, with risk of harm, set of competency and skills, formal qualification, defined scope of practice, relevant training and professional working within the healthcare team being the six most frequent codes. The frequencies for these six codes were 62, 46, 40, 37, 36 and 18, correspondingly. The risk of harm towards patients was directly or indirectly involved with patient handling and also relates to the potential harms that may implicate the practitioners themselves in performing their responsibilities as the important criterion highlighted in the present research, followed by set of competency and skills.

CONCLUSIONS

For defining the PAH in Malaysia, the emerged criteria appear interrelated and co-exist in milieu, especially for the risk of harm and set of competency and skills, with no single criterion that can define PAH fully. Hence, the integration of all the empirically identified criteria must be considered to adequately define the PAH. As such, the findings must be duly considered by policymakers in performing suitable consolidation of healthcare governance to formulate the appropriate regulations and policies for promoting the enhanced framework of allied health practitioners in Malaysia.

Effectiveness of care models for chronic disease management: A scoping review of systematic reviews

OBJECTIVE

To conduct a scoping review of models of care for chronic disease management to identify potentially effective components for management of chronic traumatic brain injury (TBI).

METHODS

Information sources: Systematic searches of three databases (Ovid MEDLINE, Embase, and Cochrane Database of Systematic Reviews) from January 2010 to May 2021.

ELIGIBILITY CRITERIA

Systematic reviews and meta-analyses reporting on the effectiveness of the Chronic Care Model (CCM), collaborative/integrated care, and other chronic disease management models.

DATA

Target diseases, model components used (n = 11), and six outcomes (disease-specific, generic health-related quality of life and functioning, adherence, health knowledge, patient satisfaction, and cost/health care use).

SYNTHESIS

Narrative synthesis, including proportion of reviews documenting outcome benefits.

RESULTS

More than half (55%) of the 186 eligible reviews focused on collaborative/integrated care models, with 25% focusing on CCM and 20% focusing on other chronic disease management models. The most common health conditions were diabetes (n = 22), depression (n = 16), heart disease (n = 12), aging (n = 11), and kidney disease (n = 8). Other single medical conditions were the focus of 22 reviews, multiple medical conditions of 59 reviews, and other or mixed mental health/behavioral conditions of 20 reviews. Some type of quality rating for individual studies was conducted in 126 (68%) of the reviews. Of reviews that assessed particular outcomes, 80% reported disease-specific benefits, and 57% to 72% reported benefits for the other five types of outcomes. Outcomes did not differ by the model category, number or type of components, or target disease.

CONCLUSIONS

Although there is a paucity of evidence for TBI per se, care model components proven effective for other chronic diseases may be adaptable for chronic TBI care.

Reduction of anxiety symptoms among women within a collaborative care model and women's health settings

AIM

The purpose of this study is to focus on changes in anxiety symptoms among women treated in women's health practices and under a collaborative care model.

BACKGROUND

Research on collaborative care has largely focused on improving depressive and anxiety symptoms among adults in primary care settings. The applicability of collaborative care in other healthcare settings is underreported with limited research investigating if collaborative care has advantages in subpopulations treated in both traditional primary care settings and other healthcare settings, such as women's health practices.

METHODS

This study, completed through secondary data analysis of the electronic record of N = 219 women across three women's healthcare centers, evaluated if instituting a collaborative care model is associated with reduced anxiety symptoms and which factors (eg, primary diagnosis, duration of care, and use of psychotropic medications) are associated with anxiety outcomes. Anxiety symptoms were assessed using the Generalized Anxiety Disorder 7-item scale (GAD-7) at entry into and at termination from collaborative care services.

RESULTS

Overall, there was a significant reduction in average anxiety scores from baseline to termination of collaborative care (t(218) = 12.41, P < 0.001). There was a main effect for the duration of time receiving collaborative care services on anxiety score reduction (β = -0.28, SE = 0.06, P < 0.001) with a significant reduction in anxiety symptoms at the 90-day mark (t(218) = 10.58, P < 0.001). Therefore, collaborative care can be useful in women's health practices in reducing anxiety symptoms over a 90-day time period.

Access, Utilization, and Quality of Behavioral Health Integration in Medicaid Managed Care

Importance

Many states have moved from models that carve out to those that carve in or integrate behavioral health in their Medicaid managed care organizations (MCOs), but little evidence exists about the effect of this change.

Objective

To assess the association of the transition to integrated managed care (IMC) in Washington Medicaid with health services use, quality, health-related outcomes, and measures associated with social determinants of health.

Design, Setting, and Participants

This cohort study used difference-in-differences analyses of Washington State's 2014 to 2019 staggered rollout of IMC on claims-based measures for enrollees in Washington's Medicaid MCO. It was supplemented with interviews of 24 behavioral health agency leaders, managed care administrators, and individuals who were participating in the IMC transition. The data were analyzed between February 1, 2023, and September 30, 2023.

Main Outcomes and Measures

Claims-based measures of utilization (including specialty mental health visits and primary care visits); health-related outcomes (including self-harm events); rates of arrests, employment, and homelessness; and additional quality measures.

Results

This cohort study included 1 454 185 individuals ages 13 to 64 years (743 668 female [51.1%]; 14 306 American Indian and Alaska Native [1.0%], 132 804 Asian American and Pacific Islander [9.1%], 112 442 Black [7.7%], 258 389 Hispanic [17.8%], and 810 304 White [55.7%] individuals). Financial integration was not associated with changes in claims-based measures of utilization and quality. Most claims-based measures of outcomes were also unchanged, although enrollees with mild or moderate mental illness experienced a slight decrease in cardiac events (-0.8%; 95% CI, -1.4 to -0.2), while enrollees with serious mental illness experienced small decreases in employment (-1.2%; 95% CI -1.9 to -0.5) and small increases in arrests (0.5%; 95% CI, 0.1 to 1.0). Interviews with key informants suggested that financial integration was perceived as an administrative change and did not have substantial implications for how practices delivered care; behavioral health agencies lacked guidance on how to integrate care in behavioral health settings and struggled with new contracts and regulatory policies that may have inhibited the ability to provide integrated care.

Conclusions and Relevance

The results of this cohort study suggest that financial integration at the MCO level was not associated with significant changes in most measures of utilization, quality, outcomes, and social determinants of health. Additional support, including monitoring, training, and funding, may be necessary to drive delivery system changes to improve access, quality, and outcomes.

Utilization of Whole Health and Longitudinal Outcomes After Screening Positive for Possible Depression Documented in Veterans Health Administration's Electronic Health Record

Objectives: Depression is common among Veterans. Veterans Health Administration (VHA) is transforming into a Whole Health system of care that includes holistic treatment planning, well-being programs, and health coaching. This evaluation explores the impact of Whole Health on improving symptoms of depression among Veterans who screen positive for possible depression diagnosis. Materials and Methods: We examined a cohort of Veterans who started using Whole Health after screening positive for possible depression (having a PHQ-2 score ≥3) at 18 VA Whole Health sites. We compared Whole Health users with non-Whole Health users on their follow-up PHQ-2 scores (9-36 months after baseline), using propensity score matching with multivariable regression to adjust for baseline differences. Results: Of the 13,559 Veterans screening positive for possible depression on the PHQ-2 and having a follow-up PHQ-2, 902 (7%) began using Whole Health after their initial positive PHQ-2. Whole Health users at baseline were more likely than non-Whole Health users to have posttraumatic stress disorder or acute stress (43% vs. 29%), anxiety (22% vs. 12%), ongoing opioid use (14% vs. 8%), recent severe pain scores (15% vs. 8%), or obesity (51% vs. 40%). Both groups improved at follow-up, with mean PHQ-2 scores decreasing from 4.49 to 1.77 in the Whole Health group and 4.46 to 1.46 in the conventional care group, with the Whole Health group significantly higher at follow-up. Also, the proportion continuing to screen positive at follow-up trended higher in the Whole Health group (26% and 21%, respectively). Conclusions: After screening positive for depression, Veterans with more mental and physical health conditions were more likely to subsequently use Whole Health services, suggesting that Whole Health is becoming a tool used in VHA to address the needs of complex patients. Nevertheless, the Whole Health group did not improve compared to the Conventional Care group. Results add to the growing body of literature that Whole Health services may play an important role among patients with complex symptom presentations by promoting self-management of symptoms and targeting "what matters most" to Veterans.

Too late for early intervention? The Healthy Ageing Service's mental health response

OBJECTIVES

This paper describes the rationale for and development of an innovative mental health service for people aged over 65 years living in Northern and Eastern Melbourne, Victoria, Australia.

CONCLUSION

The Healthy Ageing Service (HAS) was established in July 2020 to provide care for people aged over 65 years experiencing mild-to-moderate mental health concerns. It embraces a prevention and early intervention model of care. It provides primary consultation and brief intervention, secondary consultation, and capacity building to the primary healthcare sector. This innovative service is a Commonwealth-funded partnership between two tertiary mental health service providers that incorporates the recommendations from two major Royal Commissions. It demonstrates a service that acts as a bridge between primary and specialist mental health care, thereby extending mental health services to target the 'missing middle' and is potentially a model for mental health service provision throughout Victoria and Australia.

Prevention of psychosocial distress consequences in somatic hospital inpatients via a stepped and collaborative care model: protocol of SomPsyNet, a stepped wedge cluster randomised trial

INTRODUCTION

Approximately 30% of somatic hospital inpatients experience psychosocial distress, contributing to increased (re-)hospitalisation rates, treatment resistance, morbidity, and direct and indirect costs. However, such distress often remains unrecognised and unaddressed. We established 'SomPsyNet', a 'stepped and collaborative care model' (SCCM) for somatic hospital inpatients, aiming at alleviating this issue through early identification of distress and provision of appropriate care, providing problem-focused pathways and strengthening collaborative care. We report the protocol of the 'SomPsyNet' study, aiming to evaluate implementation and impact of the SCCM on distressed patients' health-related quality of life. Secondary objectives include assessing efficacy of the screening procedures, influence of SCCM on other health outcomes and associated costs.

METHODS AND ANALYSIS

Our stepped wedge cluster randomised trial conducted at three tertiary hospitals comprises three conditions: treatment as usual (TAU) without screening for distress (phase 0), TAU with screening but without consequences (phase I, main comparator) and TAU with screening and psychosomatic-psychiatric consultations for those distressed (phase II). The time-of-transition between phases I and II was randomised. Sample size target is N=2200-2500 participants, with 6 month follow-up for distressed (anticipated n=640-700) and a subsample of non-distressed (anticipated n=200) patients. Primary outcome is mental health-related quality of life (SF-36 'Mental Health Component Summary score'); secondary outcomes include psychosocial distress, anxiety, depressive and somatic symptoms, symptom burden and distress, resilience, social support and qualitative of life, assessed by internationally accepted instruments, with good psychometric properties. Further, health claims data will be used to assess SCCM's impact on direct and indirect costs.

ETHICS AND DISSEMINATION

SomPsyNet adheres to the Helsinki Declaration and is approved by the 'Ethikkommission Nordwest- und Zentralschweiz' (2019-01724). Findings will be published in peer-reviewed journals and communicated to participants, healthcare professionals and the public.

TRIAL REGISTRATION NUMBER

Swiss National Clinical Trials Portal; ClinicalTrials.gov (NCT04269005, updated 19.09.2023).

The effectiveness of collaborative care delivered via telehealth in a pediatric primary care population

Introduction

The prevalence of mental health conditions among children and adolescents in the United States has become a pressing concern, exacerbated by the COVID-19 pandemic. Collaborative care is an evidence-based model for identifying and treating depression and anxiety in healthcare settings, with additional promise for remote healthcare delivery. This study aims to evaluate the impact of a telehealth collaborative care model for adolescents with depression and anxiety in pediatric and primary care settings.

Methods

Secondary analysis was conducted using de-identified national data from Concert Health, a behavioral health medical group offering remote collaborative care across 17 states. Baseline, 90-day, and 120-day assessments of the PHQ-9 and GAD-7 were collected, along with baseline covariates. Stepwise regression analysis was performed to determine the contribution of select covariates to improvement rates.

Results

Among the analyzed data, 263 participants had complete PHQ-9 data, and 230 had complete GAD-7 data. In both the PHQ-9 and GAD-7 groups, over 50% of patients experienced treatment success based on success at discharge, as well as 90- and 120-day improvement rates. Predictors of success at discharge for the GAD-7 group included age at enrollment (OR 1.2258, 95% CI 1.01-1.496), clinical touchpoints (OR 1.1469, 95% CI 1.086-1.218), and lower baseline GAD-7 score (OR 0.9319, 95% CI 0.874-0.992). For the PHQ-9 group, Medicaid was significantly associated with not achieving a 50% reduction in PHQ-9 score at 120 days (OR 0.5874, 95% CI 0.349-0.979).

Discussion

Collaborative care has demonstrated its effectiveness in treating adolescent populations, providing an opportunity to expand access to evidence-based behavioral health treatment for young individuals. Notably, collaborative care is already integrated into the Medicaid fee schedule for 22 states and accepted by all commercial payers. Given that individuals often turn to their trusted primary care providers for behavioral health care, offering collaborative care to adolescents can play a crucial role in addressing the ongoing mental health crisis.

Needs of multimorbid heart failure patients and their carers: a qualitative interview study and the creation of personas as a basis for a blended collaborative care intervention

Introduction

Involving patients and carers in the development of blended collaborative care (BCC) interventions for multimorbid heart failure (HF) patients is recommended but rarely practised, and research on the patient perspective is scarce. The aim of this study is to investigate patients' and carers' care-related needs and preferences to better customize a novel international BCC intervention.

Methods

A qualitative study design using framework analysis was employed. The study was performed in accordance with the EQUATOR standards for reporting qualitative research (SRQR). Patients aged at least 65 years with HF and at least two other physical diseases as well as their carers completed semistructured interviews in Germany, Italy, and Denmark. Based on these interviews, personas (prototype profiles of patients and carers) were created.

Results

Data from interviews with 25 patients and 17 carers were analysed. Initially, seven country-specific personas were identified, which were iteratively narrowed down to a final set of 3 personas: (a) the one who needs and wants support, (b) the one who has accepted their situation with HF and reaches out when necessary, and (c) the one who feels neglected by the health care system. Carers identifying with the last persona showed high levels of psychological stress and a high need for support.

Discussion

This is the first international qualitative study on patients' and carers' needs regarding a BCC intervention using the creation of personas. Across three European countries, data from interviews were used to develop three contrasting personas. Instead of providing "one size fits all" interventions, the results indicate that BCC interventions should offer different approaches based on the needs of individual patients and carers. The personas will serve as a basis for the development of a novel BCC intervention as part of the EU project ESCAPE (Evaluation of a patient-centred biopSychosocial blended collaborative CAre Pathway for the treatment of multimorbid Elderly patients).

Virtual Collaborative Behavioral Health Model in a Community Pediatric Network: Two-Year Outcomes

Due to the pervasive shortage of behavioral health (BH) specialists, collaborative partnerships between pediatric primary care practitioners (PPCPs) and BH specialists can enhance provision of BH services by PPCPs. We aimed to create a new model of collaborative care that was mostly virtual, affordable, and scalable. The pilot program was implemented in 18 practices (48 PPCPs serving approximately 150 000 patients) in 2 consecutive cohorts. Outcomes were assessed by administering pre-program and post-program surveys. Across the 18 practices, PPCPs reported significantly increased confidence in their BH knowledge and skills, and significantly increased their provision of target BH services. Barriers to BH service provision (resources, time, and staff) were unchanged. This compact, mostly virtual model of BH collaboration appears to be beneficial to PPCPs while also offering convenience to patients and affordability and scalability to the practice network.

Advancing Collaborative Care for Autistic Children and Adolescents

This Viewpoint discusses an implementation strategy for the Collaborative Care Model to address the need for proper evaluation and treatment for autistic children with a co-occurring mental health condition.

A scoping review of the barriers and facilitators to accessing and utilising mental health services across regional, rural, and remote Australia

BACKGROUND

Inadequate healthcare access and utilisation are implicated in the mental health burden experienced by those living in regional, rural, and remote Australia. Facilitators that better enable access and utilisation are also reported in the literature. To date, a synthesis on both the barriers and facilitators to accessing and utilising mental health services within the rural Australian context has not been undertaken. This scoping review aims to (1) synthesise the barriers and facilitators to accessing and utilising mental health services in regional, rural, and remote Australia, as identified using the Modified Monash Model; and (2) better understand the relationship between barriers and facilitators and their geographical context.

METHODS

A systematic search of Medline Complete, EMBASE, PsycINFO, Scopus, and CINAHL was undertaken to identify peer-reviewed literature. Grey literature was collated from relevant websites. Study characteristics, including barriers and facilitators, and location were extracted. A descriptive synthesis of results was conducted.

RESULTS

Fifty-three articles were included in this scoping review. Prominent barriers to access and utilisation included: limited resources; system complexity and navigation; attitudinal and social matters; technological limitations; distance to services; insufficient culturally-sensitive practice; and lack of awareness. Facilitators included person-centred and collaborative care; technological facilitation; environment and ease of access; community supports; mental health literacy and culturally-sensitive practice. The variability of the included studies precluded the geographical analysis from being completed.

CONCLUSION

Both healthcare providers and service users considered a number of barriers and facilitators to mental health service access and utilisation in the regional, rural, and remote Australian context. Barriers and facilitators should be considered when re-designing services, particularly in light of the findings and recommendations from the Royal Commission into Victoria's Mental Health System, which may be relevant to other areas of Australia. Additional research generated from rural Australia is needed to better understand the geographical context in which specific barriers and facilitators occur.

Associations of Discrimination, Low Social Support, and Limited English Proficiency with Depression in South Asian Immigrants

South Asians face stressors as a growing immigrant group in America. Work is needed to understand how these stressors impact mental health to identify those at risk of depression and design interventions. This study examined associations of three stressors (discrimination, low social support, limited English proficiency) with depressive symptoms in South Asians. Using cross-sectional data from the Mediators of Atherosclerosis in South Asians Living in America study (N = 887), we fit logistic regression models to evaluate independent/joint effects of three stressors on depression. Overall prevalence of depression was 14.8%; 69.2% of those with all three stressors had depression. The combined effect of high discrimination/low social support was significantly greater than the sum of the individual factors. Experiences of discrimination, low social support, or limited English proficiency, as well as a combination of these factors, should be considered when diagnosing/treating South Asian immigrants in a culturally appropriate manner.

Mapping the scientific research on integrated care: a bibliometric and social network analysis

Background

Integrated care (IC) is the cornerstone of the sustainable development of the medical and health system. A thorough examination of the existing scientific literature on IC is essential for assessing the present state of knowledge on this subject. This review seeks to offer an overview of evidence-based knowledge, pinpoint existing knowledge gaps related to IC, and identify areas requiring further research.

Methods

Data were retrieved from the Web of Science Core Collection, from 2010 to 2020. Bibliometrics and social network analysis were used to explore and map the knowledge structure, research hotspots, development status, academic groups and future development trends of IC.

Results

A total of 7,501 articles were obtained. The number of publications on IC was rising in general. Healthcare science services were the most common topics. The United States contributed the highest number of articles. The level of collaboration between countries and between authors was found to be relatively low. The keywords were stratified into four clusters: IC, depression, integrative medicine, and primary health care. In recent years, complementary medicine has become a hotspot and will continue to be a focus.

Conclusion

The study provides a comprehensive analysis of global research hotspots and trends in IC, and highlights the characteristics, challenges, and potential solutions of IC. To address resource fragmentation, collaboration difficulties, insufficient financial incentives, and poor information sharing, international collaboration needs to be strengthened to promote value co-creation and model innovation in IC. The contribution of this study lies in enhancing people's understanding of the current state of IC research, guiding scholars to discover new research perspectives, and providing valuable references for researchers and policymakers in designing and implementing effective IC strategies.

Collaborative depression care sensitive to the needs of underserved patients with cancer: Feasibility, acceptability and outcomes

PURPOSE

A single-arm trial evaluated the feasibility, acceptability, and outcomes of COPE-D, a collaborative care intervention for underserved cancer patients with depression.

METHODS

Bilingual (Spanish and English) care managers provided counseling and/or medication management in consultation with physicians. Outcomes were treatment improvement (≥ 5-point reduction in PHQ-9), treatment response (≥ 50% reduction in PHQ-9), suicidal ideation resolution, and changes in depression (PHQ-9), anxiety (GAD-2), sleep disturbance (PSQI), global mental and physical health (PROMIS), social isolation (PROMIS), and qualitative feedback.

RESULTS

193 patients consented to participate. 165 initiated and 141 completed treatment, with 65% and 56% achieving treatment improvement and response, respectively. Outcomes did not differ by ethnicity (31% Hispanic), cancer stage (71% stages III-IV), income, or education. Suicidal ideation, depression, anxiety, sleep disturbance, and social isolation also improved. Qualitative feedback was largely positive.

CONCLUSION

COPE-D improved depression and quality of life among underserved patients, with acceptable retention rates.

Impact of remuneration, extrinsic and intrinsic incentives on interprofessional primary care teams: protocol for a rapid scoping review

INTRODUCTION

Interprofessional teams and funding and payment provider arrangements are key attributes of high-performing primary care. Several Canadian jurisdictions have introduced team-based models with different payment models. Despite these investments, the evidence of impact is mixed. This has raised questions about whether team-based primary care models are being implemented to facilitate team collaboration and effectiveness. Thus, we present a protocol for a rapid scoping review to systematically map, synthesise and summarise the existing literature on the impact of provider remuneration mechanisms and extrinsic and intrinsic incentives in team-based primary care. This review will answer three research questions: (1) What is the impact of provider remuneration models on team, patient, provider and system outcomes in primary care?; (2) What extrinsic and intrinsic incentives have been used in interprofessional primary care teams?; and (3) What is the impact of extrinsic and intrinsic team-based incentives on team, patient, provider and system outcomes?

METHODS AND ANALYSIS

We will conduct a rapid scoping review in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for scoping reviews guidelines. We will search electronic databases (Medline, Embase, CINAHL, PsycINFO, EconLit) and grey literature sources (Google Scholar, Google). This review will consider all empirical studies and full-text English-language articles published between 2000 and 2022. Reviewers will independently perform the literature search, data extraction and synthesis of included studies. The Mixed Methods Appraisal Tool will be used to appraise the quality of evidence. The literature will be synthesised, summarised and mapped to themes that answer the research question of this review.

ETHICS AND DISSEMINATION

Ethics approval is not required. Findings from this study will be written for publication in an open-access peer-review journal and presented at national and international conferences. Knowledge users are part of the research team and will assist with disseminating findings to the public, clinicians, funders and professional associations.

The effects of behavioral health integration in Medicaid managed care on access to mental health and primary care services-Evidence from early adopters

OBJECTIVE

To evaluate the impacts of a transition to an "integrated managed care" model, wherein Medicaid managed care organizations moved from a "carve-out" model to a "carve-in" model integrating the financing of behavioral and physical health care.

DATA SOURCES/STUDY SETTING

Medicaid claims data from Washington State, 2014-2019, supplemented with structured interviews with key stakeholders.

STUDY DESIGN

This mixed-methods study used difference-in-differences models to compare changes in two counties that transitioned to financial integration in 2016 to 10 comparison counties maintaining carve-out models, combined with qualitative analyses of 15 key informant interviews. Quantitative outcomes included binary measures of access to outpatient mental health care, primary care, the emergency department (ED), and inpatient care for mental health conditions.

DATA COLLECTION

Medicaid claims were collected administratively, and interviews were recorded, transcribed, and analyzed using a thematic analysis approach.

PRINCIPAL FINDINGS

The transition to financially integrated care was initially disruptive for behavioral health providers and was associated with a temporary decline in access to outpatient mental health services among enrollees with serious mental illness (SMI), but there were no statistically significant or sustained differences after the first year. Enrollees with SMI also experienced a slight increase in access to primary care (1.8%, 95% CI 1.0%-2.6%), but no sustained statistically significant changes in the use of ED or inpatient services for mental health care. The transition to financially integrated care had relatively little impact on primary care providers, with few changes for enrollees with mild, moderate, or no mental illness.

CONCLUSIONS

Financial integration of behavioral and physical health in Medicaid managed care did not appear to drive clinical transformation and was disruptive to behavioral health providers. States moving towards "carve-in" models may need to incorporate support for practice transformation or financial incentives to achieve the benefits of coordinated mental and physical health care.

Does use of primary care-based behavioral health programs differ by race and ethnicity? Evidence from a multi-site collaborative care model

BACKGROUND

Collaborative care models (CoCM) that integrate mental health and primary care improve outcomes and could help address racial and ethnic mental health disparities. We examined whether use of these programs differs by race/ethnicity.

METHODS

This retrospective study examined two CoCM interventions implemented across primary care clinics in a large health system in Massachusetts: 1) a primary care-based behavioral health program for depression or anxiety (IMPACT model) and 2) referral to community-based specialty care services (Resource-finding). Outcomes included enrollment, non-completion, and symptom screening rates, and discharge status for Black, Hispanic and White patients referred for CoCM, 2017-2019.

RESULTS

Black and Hispanic vs. White patients referred to CoCM (n = 17,280) were more likely to live in high poverty ZIP codes (34% and 40% vs. 9%). Rates of program enrollment, non-completion, and symptom screening were similar across groups (e.g., 76%, 77%, and 75% of Black, Hispanic, and White patients enrolled). Hispanic vs. White patients were more likely to be enrolled in IMPACT (56%) vs. Resource-finding (43%). Among those completing IMPACT, Hispanic vs. White patients were more likely to be stepped to psychiatry vs. discharged to their primary care provider (51% vs. 20%, aOR = 1.55, 95% CI: 1.02-2.35).

CONCLUSIONS

Black and Hispanic patients referred to CoCM were similarly likely to use the program as White patients. Hispanic patients completing IMPACT were more frequently referred to psychiatry.

IMPLICATIONS

These results highlight the promise of CoCMs for engaging minority populations in mental healthcare. Hispanic patients may benefit from additional intervention or earlier linkage to specialty care.

Closing the gap between screening and depression prevention: a qualitative study on barriers and facilitators from the perspective of public health professionals in a school-based prevention approach

BACKGROUND

The prevalence of depression has increased among adolescents in western countries. Prevention is needed to reduce the number of adolescents who experience depression and to avoid negative consequences, including suicide. Several preventive interventions are found to be promising, especially multi-modal approaches, for example combining screening and preventive intervention. However, an important bottleneck arises during the implementation of preventive intervention. Only a small percentage of adolescents who are eligible for participation actually participate in the intervention. To ensure that more adolescents can benefit from prevention, we need to close the gap between detection and preventive intervention. We investigated the barriers and facilitators from the perspective of public health professionals in screening for depressive and suicidal symptoms and depression prevention referral in a school-based setting.

METHODS

We conducted 13 semi-structured interviews with public health professionals, who execute screening and depression prevention referral within the Strong Teens and Resilient Minds (STORM) approach. The interviews were recorded, transcribed verbatim, and coded in several cycles using ATLAS.ti Web.

RESULTS

Three main themes of barriers and facilitators emerged from the interviews, namely "professional capabilities," "organization and collaboration," and "beliefs about depressive and suicidal symptoms and participation in prevention". The interviews revealed that professionals do not always feel sufficiently equipped in terms of knowledge, skills and supporting networks. Consequently, they do not always feel well able to execute the process of screening and prevention referral. In addition, a lack of knowledge and support in schools and other cooperating organizationorganizations was seen to hinder the process. Last, the beliefs of public health professionals, school staff, adolescents, and parents -especially stigma and taboo-were found to make the screening and prevention referral process more challenging.

CONCLUSIONS

To further improve the process of screening and prevention referral in a school-based setting, enhancing professional competence and a holding work environment for professionals, a strong collaboration and a joint approach with schools and other cooperating organizations and society wide education about depressive and suicidal symptoms and preventive intervention are suggested. Future research should determine whether these recommendations actually lead to closing the gap between detection and prevention.

Improving Integrated Mental Health Care Through an Advanced Practice Registered Nurse-Led Program: Challenges and Successes

Integrated and collaborative care delivery models have demonstrated efficacy for the management of psychiatric conditions in the primary care environment, yet organizations struggle with implementation of integrated efforts in clinical practice. Delivering care with a population focus versus face-to-face encounters with individual patients requires financial investment and adjustment in care delivery. We discuss the early implementation process of an advanced practice registered nurse (APRN)-led integrated behavioral health care program, including the challenges, barriers, and successes in the first 9 months of the program (January-September 2021), for an academic institution in the Midwest. A total of 161 Patient Health Questionnaire 9 (PHQ-9) and 162 Generalized Anxiety Disorder (GAD-7) rating scales were completed on 86 patients. The mean PHQ-9 score at the initial visit was 11.3 (moderate depression); after 5 visits, it decreased significantly to 8.6 (mild depression) (P < .001). The mean GAD-7 score at the initial visit was 10.9 (moderate anxiety); after 5 visits, it decreased significantly to 7.6 (mild anxiety) (P < .001). A survey completed by 14 primary care physicians 9 months after program launch revealed improvements in satisfaction with collaboration but, most notably, in perception of access to and overall satisfaction with behavioral health consultation/patient care services. Program challenges included adapting the environment to enhance leadership roles for the program and adjusting to virtual availability of psychiatric support. A case example highlights the value of integrated care along with improved depression and anxiety-related outcomes. Next steps should include efforts that capitalize on nursing leadership strengths while also promoting equity among integrated populations.

Dancing with the patient: a qualitative study of general practitioners' experiences of managing patients with multimorbidity and common mental health problems

BACKGROUND

Patients with multimorbidity, having two or more chronic diseases, suffer frequently from undiagnosed common mental health problems and are an increasing challenge in primary care. There is a call to improve care delivery to address all these patients' needs at the same time. The aim of this study was to identify general practitioners' experiences of managing patients with multimorbidity and common mental health problems in primary care.

METHODS

We conducted five focus group interviews with 28 physicians (3-8 participants in each group) in 5 primary care practices in and outside of Stockholm, Sweden. We used a semi-structured interview guide, and we analysed the data using reflexive thematic analysis. The methodological orientation of the study was inductive, latent constructivism.

RESULTS

We generated two themes from the data: Unmet patient needs and fragmented care send patients and physicians off balance and Dancing with the patient individually and together with others leads to confident and satisfied patients and physicians. The two themes are related as general practitioners expressed a need to shift from disease-specific fragmentation to relational continuity, teamwork, and flexibility to meet the needs of patients with multimorbidity and common mental health problems.

CONCLUSIONS

These findings can provide guidance in developing future interventions for patients with multimorbidity and common mental health problems in primary care in general, and in Sweden in particular.

Association Between Antenatal Depression Symptom Trajectories and Preterm Birth

OBJECTIVE

To evaluate whether, among pregnant people referred for mental health care, improvement in antenatal depression symptoms before delivery was associated with a reduction in preterm birth.

METHODS

This retrospective cohort study included all pregnant people referred to a perinatal collaborative care program for mental health care who delivered between March 2016 and March 2021. Those referred to the collaborative care program had access to subspecialty mental health treatment, including psychiatric consultation, psychopharmacotherapy, and psychotherapy. Depression symptoms were monitored with the self-reported PHQ-9 (Patient Health Questionnarie-9) screens in a patient registry. Antenatal depression trajectories were determined by comparing the earliest prenatal PHQ-9 score after collaborative care referral with the score closest to delivery. Trajectories were categorized as improved, stable, or worsened according to whether PHQ-9 scores changed by at least 5 points. Bivariable analyses were performed. A propensity score was generated to control for confounders that were significantly different on bivariable analyses according to trajectories. This propensity score was then included in multivariable models.

RESULTS

Of the 732 pregnant people included, 523 (71.4%) had mild or more severe depressive symptoms (PHQ-9 score 5 or higher) on their initial screen. Antenatal depression symptoms improved in 256 (35.0%), remained stable in 437 (59.7%), and worsened in 39 (5.3%); the corresponding incidence of preterm birth was 12.5%, 14.0%, and 30.8%, respectively ( P =.009). Compared with those with a worsened trajectory, pregnant people who had an improved antenatal depression symptom trajectory had a significantly decreased odds of preterm birth (adjusted odds ratio 0.37, 95% CI 0.15-0.89).

CONCLUSION

Compared with worsened symptoms, an improved antenatal depression symptom trajectory is associated with decreased odds of preterm birth for pregnant people referred for mental health care. These data further underscore the public health importance of incorporating mental health care into routine obstetric care.

Psychological distress and associated factors among cancer patients in public hospitals, Addis Ababa, Ethiopia: a cross-sectional study

BACKGROUND

Cancer has great implications for psychological, social, economic, and emotional dimensions. Psychological distress is overwhelming among cancer patients following a confirmed diagnosis. However, little is known about the prevalence of psychological distress and associated factors among cancer patients in Africa Sub-Saharan. Thus, this study aimed to assess the prevalence of psychological distress and associated factors among cancer patients in public hospitals in Addis Ababa, Ethiopia.

METHODS

An institution-based cross-sectional study was conducted among cancer patients from September 15, 2019, to June 30, 2020. A total of 386 cancer patients selected through a simple random sampling technique participated in the study. Data were collected by an interview-administered questionnaire to evaluate psychological distress with a distress thermometer and social support with the Oslo 3-items Social Support Scale. The collected data were entered into Epi-data version 4.2 and exported into SPSS 25 for analysis, and then binary and multivariate logistic regressions were done to identify the association between dependent and independent variables.

RESULTS

A total of 386 study participants were included in the study with a response rate of 91.4%. The prevalence of psychological distress among cancer patients in public hospitals in Addis Ababa, Ethiopia was 64.5%. Age > 45 years [AOR = 0.41; 95% CI (0.22-0.77)], marital status of being divorced [AOR = 3.3; 95%CI (1.23-8.71)] and married [AOR = 3.2; 95%CI (1.03-10.40)], rural residence [AOR = 1.5; 95%CI (1.15-5.18)], cancer stage II [AOR = 3.9; 95%CI (1.90-15.50)], stage III [AOR = 3.5;95%CI (1.45-8.44)] and stage IV [AOR = 3.4; 95%CI (1.90-10.11)], co-morbidity [AOR = 0.07; 95%CI: (0.03-0.17)], and moderate social support [AOR = 0.36; 95%CI (0.14-0.60)] and strong social support [AOR = 0.06; 95%CI (0.03-0.12)] were found to be significantly associated with psychological distress.

CONCLUSION

The prevalence of psychological distress among cancer patients in public hospitals in Addis Ababa, Ethiopia was high, and age, marital status, place of residence, cancer stage, co-morbidity, and social support were associated with psychological distress. Therefore, interventions focusing on these findings require special emphasis during designing interventions aimed at decreasing psychological distress.

"We are the sun for our community:" Partnering with community health workers/promotores to adapt, deliver and evaluate a home-based collaborative care model to improve equity in access to quality depression care for older U.S. Latino adults who are underserved

Background

While depression is a leading cause of poor health, less than half of older adults receive adequate care. Inequities in both access and outcomes are even more pronounced for socially disadvantaged older adults. The collaborative care model (CCM) has potential to reduce this burden through community-based organizations (CBOs) who serve these populations. However, CCM has been understudied in diverse cultural and resource-constrained contexts. We evaluated the implementation and effectiveness of PEARLS, a home-based CCM adapted with and for community health workers/promotores (CHWs/Ps).

Methods

We used an instrumental case study design. Our case definition is a community-academic partnership to build CHW/P capacity for evidence-based depression care for older U.S. Latino adults in the Inland Empire region of California (2017-2020). We aimed to understand adaptations to fit local context; acceptability, feasibility, and fidelity; clinical effectiveness; and contextual determinants of implementation success or failure. Data sources included quantitative and qualitative administrative and evaluation data from participants and providers. We used descriptive statistics and paired t-tests to characterize care delivery and evaluate effectiveness post-intervention, and deductive thematic analysis to answer other aims.

Findings

This case study included 152 PEARLS participants and nine data sources (N = 67 documents). The CBO including their CHWs/Ps partnered with the external implementation team made adaptations to PEARLS content, context, and implementation strategies to support CHWs/Ps and older adults. PEARLS was acceptable, feasible and delivered with fidelity. Participants showed significant reductions in depression severity at 5 months (98% clinical response rate [mean (SD), 13.7 (3.9) drop in pre/post PHQ-9; p < 0.001] and received support for 2.6 social needs on average. PEARLS delivery was facilitated by its relative advantage, adaptability, and trialability; the team's collective efficacy, buy-in, alignment with organization mission, and ongoing reflection and evaluation during implementation. Delivery was challenged by weak partnerships with clinics for participant referral, engagement, reimbursement, and sustainability post-grant funding.

Discussion

This case study used existing data to learn how home-based CCM was adapted by and for CHWs/Ps to reduce health inequities in late-life depression and depression care among older Latino immigrants. The CBOs and CHWs/Ps strong trust and rapport, addressing social and health needs alongside depression care, and regular internal and external coaching and consultation, appeared to drive successful implementation and effectiveness.

Implementation Barriers and Experiences of Eligible Patients Who Failed to Enroll in Collaborative Care for Depression and Anxiety

BACKGROUND

Effective and efficient implementation of the Collaborative Care Model (CoCM) for depression and anxiety is imperative for program success. Studies examining barriers to implementation often omit patient perspectives.

OBJECTIVES

To explore experiences and attitudes of eligible patients referred to CoCM who declined participation or were unable to be reached, and identify implementation barriers to inform strategies.

DESIGN

Convergent mixed-methods study with a survey and interview.

PARTICIPANTS

Primary care patients at an academic medical center who were referred to a CoCM program for anxiety and depression by their primary care clinician (PCC) but declined participation or were unable to be reached by the behavioral health care manager to initiate care (n = 80). Interviews were conducted with 45 survey respondents.

MAIN MEASURES

Survey of patients' referral experiences and behavioral health preferences as they related to failing to enroll in the program. Interview questions were developed using the Consolidated Framework for Implementation Research version 2.0 (CFIR 2.0) to identify implementation barriers to enrollment.

KEY RESULTS

Survey results found that patients were uncertain about insurance coverage, did not understand the program, and felt services were not necessary. Referred patients who declined participation were concerned about how their mental health information would be used and preferred treatment without medication. Men agreed more that they did not need services. Qualitative results exhibited a variety of implementation determinants (n = 23) across the five CFIR 2.0 domains. Barriers included mental health stigma, perceiving behavioral health as outside of primary care practice guidelines, short or infrequent primary care appointments, prioritizing physical health over mental health, receiving inaccurate program information, low motivation to engage, and a less established relationship with their PCC.

CONCLUSIONS

Multiple barriers to enrollment led to failing to link patients to care, which can inform implementation strategies to address the patient-reported experiences and concerns.

Citalopram in the treatment of elderly chronic heart failure combined with depression: A systematic review and meta-analysis

Background

Depression is an independent factor to predict the hospitalization and mortality in the chronic HF patients. Citalopram is known as an effective drug for depression treatment. Currently, there is no specific recommendation in the HF guidelines for the treatment of psychological comorbidity. In recent years, many studies have shown that the citalopram may be safe in treating of chronic HF with depression.

Objective

To evaluate the efficacy and safety of the citalopram in the treatment of elderly chronic HF combined with depression.

Methods

PubMed, EMBASE, Cochrane, Web of Science, CNKI, VIP, CBM, and Wanfang were searched from their inception to May 2022. In the treatment of elderly chronic HF combined with depression, randomized controlled studies of the citalopram were included. Independent screening and extraction of data information were conducted by two researchers, and the quality was assessed by the Cochrane bias risk assessment tool. Review manager 5.4.1 was employed for statistical analysis.

Results

The results of meta-analysis prove that the citalopram treatment for depressed patients with chronic HF has a benefit for HAMD-24 (MD: -8.51, 95% CI: -10.15 to -6.88) and LVEF (MD: 2.42, 95% CI: 0.51 to 4.33). Moreover, the score of GDS decreases, and NT-proBNP (MD: -537.78, 95% CI: -718.03 to -357.54) is improved. However, the comparison with the control group indicates that there is no good effect on HAMD-17 (MD: -5.14, 95% CI: -11.60 to 1.32), MADRS (MD: -1.57, 95% CI: -3.47 to 0.32) and LVEDD (MD: -1.45, 95% CI: -3.65 to -0.76). No obvious adverse drug reactions were observed.

Conclusion

Citalopram treatment for depressed patients with chronic HF has a positive effect on LVEF and NT-proBNP. It can alleviate HAMD-24 and GDS, but the relative benefits for LVEDD, HAMD-17 and MADRS still need to be verified.Systematic Review Registration: PROSPERO [CRD42021289917].

Integrating Routine Screening for Opioid Use Disorder into Primary Care Settings: Experiences from a National Cohort of Clinics

BACKGROUND

The U.S. Preventive Services Task Force recommends routine population-based screening for drug use, yet screening for opioid use disorder (OUD) in primary care occurs rarely, and little is known about barriers primary care teams face.

OBJECTIVE

As part of a multisite randomized trial to provide OUD and behavioral health treatment using the Collaborative Care Model, we supported 10 primary care clinics in implementing routine OUD screening and conducted formative evaluation to characterize early implementation experiences.

DESIGN

Qualitative formative evaluation.

APPROACH

Formative evaluation included taking detailed observation notes at implementation meetings with individual clinics and debriefings with external facilitators. Observation notes were analyzed weekly using a Rapid Assessment Process guided by the Consolidated Framework for Implementation Research, with iterative feedback from the study team. After clinics launched OUD screening, we conducted structured fidelity assessments via group interviews with each site to evaluate clinic experiences with routine OUD screening. Data from observation and structured fidelity assessments were combined into a matrix to compare across clinics and identify cross-cutting barriers and promising implementation strategies.

KEY RESULTS

While all clinics had the goal of implementing population-based OUD screening, barriers were experienced across intervention, individual, and clinic setting domains, with compounding effects for telehealth visits. Seven themes emerged characterizing barriers, including (1) challenges identifying who to screen, (2) complexity of the screening tool, (3) staff discomfort and/or hesitancies, (4) workflow barriers that decreased screening follow-up, (5) staffing shortages and turnover, (6) discouragement from low screening yield, and (7) stigma. Promising implementation strategies included utilizing a more universal screening approach, health information technology (HIT), audit and feedback, and repeated staff trainings.

CONCLUSIONS

Integrating population-based OUD screening in primary care is challenging but may be made feasible via implementation strategies and tailored practice facilitation that standardize workflows via HIT, decrease stigma, and increase staff confidence regarding OUD.

Primary care patients' experiences of video consultations for depression and anxiety: a qualitative interview study embedded in a randomized feasibility trial

BACKGROUND

Integrated mental health care models that provide rapid access to video consultations with mental health specialists for primary care patients are a promising short-term, low-threshold treatment option and may reduce waiting times for specialist care. This qualitative study, nested within a randomized feasibility trial, aimed to explore participants' views on this type of care model, its influence on the lived experience of patients, and barriers and facilitators for its delivery.

METHODS

In five primary care practices, 50 adults with depression and/or anxiety were randomly assigned to either an integrated care model (maximum of five video consultations with a mental health specialist) or usual care (primary care or another treatment option). Prior to obtaining the trial results, interviews were held with participants who had received video consultations. Interviews were transcribed and analysed thematically.

RESULTS

Twenty of the 23 patients who received video consultations participated in the interviews. Patients engaged well with the care model and reported positive effects on their most pressing needs, while denying safety concerns. Generally, they perceived the usability of video consultations as high, and temporary connectivity failures were not considered a substantial barrier. We identified two key mechanisms of impacts on the patients' lived experience: fast access to specialist mental healthcare and the emerging rapport with the specialist. In particular, patients with no prior mental healthcare experience indicated that familiarity with the primary practice and their physician as a gatekeeper were important facilitators of proactive treatment.

CONCLUSIONS

From the patients' perspective, mental health care models integrating video consultations with mental health specialists into primary care are linked to positive lived experiences. Our findings imply that primary care physicians should promote their role as gatekeepers to (1) actively engage patients, (2) apply integrated care models to provide a familiar and safe environment for conducting mental health care video consultations, and (3) be able to regularly assess whether certain patients need in-person services. Scaling up such models may be worthwhile in real-world service settings, where primary care physicians are faced with high workloads and limited specialist services.

TRIAL REGISTRATION

DRKS00015812.

Predictors and outcomes in primary depression care (POKAL) - a research training group develops an innovative approach to collaborative care

BACKGROUND

The interdisciplinary research training group (POKAL) aims to improve care for patients with depression and multimorbidity in primary care. POKAL includes nine projects within the framework of the Chronic Care Model (CCM). In addition, POKAL will train young (mental) health professionals in research competences within primary care settings. POKAL will address specific challenges in diagnosis (reliability of diagnosis, ignoring suicidal risks), in treatment (insufficient patient involvement, highly fragmented care and inappropriate long-time anti-depressive medication) and in implementation of innovations (insufficient guideline adherence, use of irrelevant patient outcomes, ignoring relevant context factors) in primary depression care.

METHODS

In 2021 POKAL started with a first group of 16 trainees in general practice (GPs), pharmacy, psychology, public health, informatics, etc. The program is scheduled for at least 6 years, so a second group of trainees starting in 2024 will also have three years of research-time. Experienced principal investigators (PIs) supervise all trainees in their specific projects. All projects refer to the CCM and focus on the diagnostic, therapeutic, and implementation challenges.

RESULTS

The first cohort of the POKAL research training group will develop and test new depression-specific diagnostics (hermeneutical strategies, predicting models, screening for suicidal ideation), treatment (primary-care based psycho-education, modulating factors in depression monitoring, strategies of de-prescribing) and implementation in primary care (guideline implementation, use of patient-assessed data, identification of relevant context factors). Based on those results the second cohort of trainees and their PIs will run two major trials to proof innovations in primary care-based a) diagnostics and b) treatment for depression.

CONCLUSION

The research and training programme POKAL aims to provide appropriate approaches for depression diagnosis and treatment in primary care.