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

Primary care-based mindfulness intervention for posttraumatic stress disorder and depression symptoms among Black adults: A pilot feasibility and acceptability randomized controlled trial

OBJECTIVE

There is support for the use of mindfulness-based approaches with trauma-exposed adults. However, limited data are available on feasibility and acceptability of group-based mindfulness interventions in urban medical clinics serving primarily Black adults with low socioeconomic resources, where rates of trauma exposure are high. The present randomized pilot study evaluated the feasibility and acceptability of an 8-week adapted mindfulness-based cognitive therapy (MBCT) group for trauma-exposed Black adults who screened positive for posttraumatic stress disorder (PTSD) and depression in an urban primary care clinic setting.

METHOD

Participants were randomized to waitlist control (WLC) or MBCT. Feasibility and acceptability were assessed through examination of retention rates, measures of group satisfaction and treatment barriers, and qualitative interview. Forty-two Black adults (85% women) were consented; of those, 34 (81%) completed preassessment and randomization.

RESULTS

Feasibility of study design was shown, with > 75% (n = 26) of randomized participants completing the study through postassessment. Twenty-four individuals (70.5%) completed through 1-month follow-up. Results showed high levels of group acceptability across quantitative and qualitative measures. Perceived barriers to psychological treatment were high, with an average of > 6 barriers present.

CONCLUSIONS

The findings indicate feasibility and acceptability of MBCT group interventions in urban primary care settings with trauma-exposed patients with significant psychopathology. However, substantial barriers to treatment engagement were endorsed and to improve numbers for successful engagement in the intervention, continued efforts to reduce treatment barriers and increase access to mindfulness-based interventions in underresourced communities are needed. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Rising Rates of Suicidal Behaviors and Large Unmet Treatment Needs Among US Adults With a Major Depressive Episode, 2009 to 2020

OBJECTIVE

To examine recent 12-year trends in the incidence of suicidal ideation (SI) and suicide attempts (SAs) and receipt of mental health treatment among individuals experiencing a past-year major depressive episode (MDE).

PATIENTS AND METHODS

Using data from the National Survey of Drug Use and Health, we estimated the annual percentage of individuals with MDE who reported past-year SI or SAs and their use of mental health services from 2009 to 2020 and calculated odds ratios (ORs) for longitudinal change adjusting for potentially confounding factors.

RESULTS

During our study period, the weighted unadjusted proportion of patients with a past-year MDE who reported SI increased from 26.2% (668,690 of 2,550,641) to 32.5% (1,068,504 of 3,285,986; OR, 1.38; 95% CI, 1.25 to 1.51) and remained significant in the multivariable-adjusted analysis (P<.001). The greatest increase in SI was seen among Hispanic patients, young adults, and individuals with alcohol use disorder. Similar trends were seen for past-year SAs, increasing from 2.7% (69,548 of 2,550,641) to 3.3% (108,135 of 3,285,986; OR, 1.29; 95% CI, 1.04 to 1.61), especially among Black individuals, patients with incomes greater than $75,000, and those with substance use disorders. In multivariable-adjusted analyses, the temporal trend of increasing SI and SAs remained significant (P<.001 and P=0.04, respectively). Among individuals with past-year SI or SAs, there was no notable change in the mental health service use, and over 50% of individuals with MDE and SI (2,472,401 of 4,861,298) reported unmet treatment needs. No notable differences were observed between 2019 and 2020, reflecting the coronavirus disease 2019 pandemic.

CONCLUSION

Among individuals with MDE, rates of SI and SAs have increased, especially among racial minorities and individuals with substance use disorders, without a corresponding change in mental health service use.

The Impact of a Primary Care Telepsychiatry Program on Outcomes of Managed Care Older Adults

OBJECTIVE

The goal of this study was to assess the outcomes of a primary-based telepsychiatry intervention program for older managed care enrollees with depression/anxiety and with limited access to in-person psychiatric care.

DESIGN

A pre-post design was used to examine service use (n = 218) and severity of depression (n = 204). Enrollment, claims, and depression and anxiety score data were obtained from the medical group. The implementation process and self-reported outcomes were examined.

SETTING AND PARTICIPANTS

The program was funded by the Senior Care Action Network (SCAN) group and implemented by a large medical group serving older adults who were identified as needing outpatient psychiatric care, including those with psychiatric hospitalizations, depression/anxiety disorders, comorbid substance use disorders, or other multiple comorbidities.

METHODS

Poisson regressions were used to examine changes in predicted rates of outpatient services, emergency department visits, and hospitalizations up to 24 months prior and 24 months following the first telepsychiatry visit. Changes in predicted severity of depression up to 2 quarters prior and 3 quarters following the first telepsychiatry visit were examined.

RESULTS

The number of outpatient services declined significantly by 0.24 per patient per 6-month time frame following the first telepsychiatry visit. The number of emergency department visits and hospitalizations also declined after the first visit (0.07 and 0.03 per patient per 6-month time frame, respectively). Depression severity scores also declined in the quarters following the first visit (1.52). The medical group reported improvements in both wait time for appointments and no-show rates with the integration of telepsychiatry in primary care.

CONCLUSIONS AND IMPLICATIONS

The telepsychiatry program lowered service use, depression severity, and increased better access to psychiatry care. The findings highlight the potential benefits of sustaining and expanding the telepsychiatry program by SCAN and other plans facing a limited supply of psychiatrists.

National trends of suicidal ideation and mental health services use among US adults with opioid use disorder, 2009-2020

BACKGROUND

The substantial increase in deaths by overdose and potential underlying suicidal intent in such deaths suggest the importance of understanding trends of suicidal ideation in individuals with opioid use disorder (OUD). This study aimed to examine the trends and correlates of past-year suicidal ideation (SI) and mental health service use among US adults with past-year OUD from 2009 to 2020.

METHODS

We used data from the National Survey on Drug Use and Health. Participants included non-institutionalized US civilians aged ≥18 with past-year OUD (n=5386). SI was measured by self-reported thoughts of killing oneself. Mental health service utilization was assessed with questions concerning receipt of any past-year outpatient or inpatient mental health services or prescription medications. We examined the prevalence and correlates of SI and adjusted odds ratios (aORs) for changes over time adjusting for potentially confounding sociodemographic and clinical characteristics. Further, trends in utilization of mental health services were explored.

FINDINGS

From 2009 to 2020, the prevalence of SI increased from 22.8% to 29.8% (average annual percent change, 3.64% [95% CI, 1.01-2.10%]) in adults with OUD. Subgroups including individuals aged 18-25 (aOR, 1.72 [95% CI, 1.09-2.71]; P=0.020), residing in non-metropolitan areas (aOR, 1.43 [95% CI, 1.04-1.97]; P = 0.029), with co-occurring past-year major depressive episode (aOR, 5.28 [95% CI, 4.27-6.53]; P < 0.001) and alcohol (aOR, 1.55 [95% CI, 1.23-1.97]; P < 0.001), cocaine (aOR, 1.42 [95% CI, 1.03-1.97]; P = 0.034), and sedative use disorders (aOR, 1.48 [95% CI, 1.11-1.98]; P = 0.008) were associated with SI after adjusting for covariates. No significant change in mental health service use was observed. Individuals with SI were 2.5 times more likely to report an unmet need for treatment compared to individuals without SI (53.6% vs 21.4%; P < 0.001).

INTERPRETATION

The prevalence of SI in adults with OUD increased substantially without a corresponding change in mental health service use. These results underscore the potential benefit of routine screening for suicidality and improved access to care for individuals with OUD, especially those with co-occurring depression and/or polysubstance use.

FUNDING

None reported.

Psychosocial screening in a pediatric diabetes clinic: Adolescents' and mothers' perspectives

OBJECTIVE

Adolescents with type 1 diabetes (T1D) frequently experience psychosocial concerns, and mental health screening is becoming increasingly common in routine diabetes care. However, little is known about what adolescents or their caregivers think about the role of mental health screening and intervention within the context of comprehensive diabetes care, or how their diabetes care providers should be involved in navigating mental health concerns. This study used qualitative methods to obtain the perspectives of adolescents with T1D and their caregivers regarding these issues.

METHODS

Participants were 13 adolescents with T1D (ages 12-19 years; M = 15.1 years; 53.8% female; 61.5% Hispanic/Latinx White) and 13 mothers, recruited from an outpatient pediatric endocrinology clinic in South Florida, who participated in semi-structured interviews via video teleconference. Thematic content analysis was used to evaluate participants' responses.

RESULTS

Adolescents and their mothers reported positive experiences with the clinic's psychosocial screening procedures and appreciated meeting with the psychology team during visits. They wanted the clinic to offer more opportunities for peer support. Mothers highlighted barriers to seeking mental health care outside of the clinic and the importance of mental health professionals understanding diabetes. Mothers also wanted the clinic to offer more on-site therapeutic services.

DISCUSSION

Study participants valued psychosocial screening and supported addressing mental health as a routine part of diabetes comprehensive care.

Applying Psychiatry and Psychology Principles to Lifestyle Approaches for Mental and Behavioral Health

Research suggests that mental health symptoms and disorders are historically underdiagnosed and undertreated, in part due to the siloed nature of medicine. Yet, approximately 50 million American adults experience a mental health disorder. As the field of lifestyle medicine continues to emerge and grow, there is an important opportunity to address mental health from a lifestyle medicine perspective, as well as to ensure that lifestyle medicine can be utilized for all patients, including those with mental health conditions. To effectively address mental health, the field of lifestyle medicine would benefit from understanding and leveraging the decades of science and practice from the fields of psychiatry and psychology, as well as the expertise of psychiatrists and psychologists who are familiar with the science and trained in lifestyle medicine. Incorporating empirical literature from other areas, utilizing well-established conceptual frameworks, and addressing the overlap between lifestyle medicine and mental health early in, and throughout, training and education, are important steps to move toward addressing mental and behavioral health with a lifestyle medicine approach.