Clinician screening and treatment of alcohol, drug, and mental problems in primary care: results from healthcare for communities

Alcohol use recording in adults with depression in English primary care: a cross-sectional study

OBJECTIVES

To investigate alcohol use recording in people with newly diagnosed depression in English primary care and individual characteristics associated with the recording of alcohol use.

DESIGN

A population-based cross-sectional study.

SETTING

Primary care data from English practices contributing to the UK Clinical Practice Research Datalink.

PARTICIPANTS

We included adults (18+ years) diagnosed with depression between 1 January 2011 and 1 January 2017 without previous antidepressant use and at least 1 year of registration before diagnosis.

PRIMARY AND SECONDARY OUTCOME MEASURES

We described the proportion of individuals with alcohol use and level of alcohol use recorded at four time points (the date of depression diagnosis, 3 months before or after depression diagnosis, 12 months before or after depression diagnosis and any point pre or postdepression diagnosis). We used logistic regression to investigate individual characteristics associated with alcohol use recording in the 3 months before or after depression diagnosis.

RESULTS

We identified 36 424 adults with depression. 538 (2%) had alcohol use recorded in the 3 months before or after depression diagnosis using formal validated methods such as the Alcohol Use Disorders Identification Test and its abbreviated versions. At each time point, most individuals with alcohol use recorded were low risk drinkers. Alcohol use recording in the 3 months before or after depression diagnosis was associated with male sex (OR=1.38, 95% CI 1.29 to 1.48) and several other individual-level factors.

CONCLUSIONS

Our study shows low levels of alcohol use recording in the 3 months before or after depression diagnosis. Levels of alcohol use recording varied depending on individual characteristics. Incentivised recording of alcohol use will increase completeness, which could improve clinical management and reduce missed opportunities for care in people with depression.

Leveraging technology to address unhealthy drug use in primary care: Effectiveness of the Substance use Screening and Intervention Tool (SUSIT)

Background: Screening for unhealthy drug use is now recommended for adult primary care patients, but primary care providers (PCPs) generally lack the time and knowledge required to screen and deliver an intervention during the medical visit. To address these barriers, we developed a tablet computer-based 'Substance Use Screening and Intervention Tool (SUSIT)'. Using the SUSIT, patients self-administer screening questionnaires prior to the medical visit, and results are presented to the PCP at the point of care, paired with clinical decision support (CDS) that guides them in providing a brief intervention (BI) for unhealthy drug use. Methods: PCPs and their patients with moderate-risk drug use were recruited from primary care and HIV clinics. A pre-post design compared a control 'screening only' (SO) period to an intervention 'SUSIT' period. Unique patients were enrolled in each period. In both conditions, patients completed screening and identified their drug of most concern (DOMC) before the visit, and completed a questionnaire about BI delivery by the PCP after the visit. In the SUSIT condition only, PCPs received the tablet with the patient's screening results and CDS. Multilevel models with random intercepts and patients nested within PCPs examined the effect of the SUSIT intervention on PCP delivery of BI. Results: 20 PCPs and 79 patients (42 SO, 37 SUSIT) participated. Most patients had moderate-risk marijuana use (92.4%), and selected marijuana as the DOMC (68.4%). Moderate-risk use of drugs other than marijuana included cocaine (15.2%), hallucinogens (12.7%), and sedatives (12.7%). Compared to the SO condition, patients in SUSIT had higher odds of receiving any BI for drug use, with an adjusted odds ratio of 11.59 (95% confidence interval: 3.39, 39.25), and received more elements of BI for drug use. Conclusions: The SUSIT significantly increased delivery of BI for drug use by PCPs during routine primary care encounters.

Treating Excessive Consumers With Brief Intervention to Reduce Their Alcohol Consumption

Abstract. Background: General Practitioners’ (GP) readiness to implement screening and brief intervention to reduce alcohol consumption of excessive consumers is low. Although several barriers were identified by past research, improving these conditions has not led to improved implementation. Based on Expectancy Value Theory of Achievement Motivation we assume that low seriousness of the health problem in association with the treatment of excessive alcohol consumers may be considered as a crucial barrier too. Aims: By our study, we tested for the influence of the seriousness of the health problem on the GP’s readiness to implement brief intervention (BI) in comparison to crucial barriers such as insufficient financial reimbursement and low patient adherence. Method: In order to manipulate the seriousness of the health problem GPs were confronted with three different situations each introducing a fictitious patient with either excessive alcohol consumption, or binge drinking, or harmful alcohol consumption. Results: Questionnaires of 185 GPs were analyzed. As hypothesized GPs were less ready to treat patients with excessive consumption in comparison to patients with harmful consumption, t(184) = 5.51, p < .001, d = .40, and binge drinking, t(184) = 6.14, p < .001, d = .43. Their readiness was higher in case of high adherence, F(1, 181) = 17.35, p < .001, η2 = .09. Limitations: Recruitment of GPs was based on voluntary participation. GPs had to assess their readiness in the artificial context of case vignettes. Conclusion: GPs’ readiness to implement a BI was influenced by the seriousness of the health problem and expected patient adherence. No such effect was found for financial reimbursement.

General Practice Patients' Readiness to be Treated With Brief Intervention to Reduce Alcohol Consumption: A Cross-Sectional Study With Between-Subject Design

AIMS

To treat excessive alcohol consumption, general practices (GPs) are recommended to use non-directive implementation strategies. Directive implementation, however, may be perceived by general practice patients as something positive because of possibly indicating higher GP engagement and a more consistent treatment. In our study, we aimed to assess the readiness of patients to be treated with BI in the hypothetical event of excessive alcohol consumption either by a GP using non-directive recommendations according to WHO or by a GP using directive instructions. Additionally, we assessed the patients' dispositional readiness to disclose alcohol-associated personal information, termed alcohol consumption self-disclosure, in order to analyze its influence on their readiness to be treated with brief intervention (BI).

METHODS

When consulting their GP, a convenience sample of general practice patients was asked by questionnaire. By means of a between-subject design, they were asked for the readiness to be treated either with non-directive BI or with directive BI. Repeated-measure ANCOVA was used to analyze the main- and interaction effects.

RESULTS

A sample of 442 general practice patients preferred the non-directive BI, F(1, 423) = 5.56, P < 0.05. We found moreover a two-way interaction between implementation and alcohol consumption self-disclosure, F(1, 423) = 18.89, P < 0.001, showing that only patients with low self-disclosure preferred the non-directive BI, t(428) = 3.99, P < 0.001.

CONCLUSIONS

Future research should investigate the reasons for the patients' preference for the non-directive BI and may develop strategies to overcome the possibly low readiness of general practice patients to be treated with BI.

Predictors of Chronic Opioid Use: A Population-level Analysis of North Carolina Cancer Survivors Using Multi-Payer Claims

Background

No population-based studies have examined chronic opioid use among cancer survivors who are diverse with respect to diagnosis, age group, and insurance status.

Methods

We conducted a retrospective cohort study using North Carolina cancer registry data linked with claims from public and private insurance (2006-2016). We included adults with nonmetastatic cancer who had no prior chronic opioid use (n = 38 366). We used modified Poisson regression to assess the adjusted relative risk of chronic opioid use in survivorship (>90-day continuous supply of opioids in the 13-24 months following diagnosis) associated with patient characteristics.

Results

Only 3.0% of cancer survivors in our cohort used opioids chronically in survivorship. Predictors included younger age (adjusted risk ratio [aRR] 50-59 vs 60-69 = 1.23, 95% confidence interval [CI] = 1.05 to 1.43), baseline depression (aRR = 1.22, 95% CI = 1.06 to 1.41) or substance use (aRR = 1.43, 95% CI = 1.15 to 1.78) and Medicaid (aRR vs private = 1.93, 95% CI = 1.56 to 2.40). Survivors who used opioids intermittently (vs not at all) before diagnosis were twice as likely to use opioids chronically in survivorship (aRR = 2.62, 95% CI = 2.28 to 3.02). Those who used opioids chronically (vs intermittently or not at all) during active treatment had a nearly 17-fold increased likelihood of chronic use in survivorship (aRR = 16.65, 95% CI = 14.30 to 19.40).

Conclusions

Younger and low-income survivors, those with baseline depression or substance use, and those who require chronic opioid therapy during treatment are at increased risk for chronic opioid use in survivorship. Our findings point to opportunities to improve assessment of psychosocial histories and to engage patients in shared decision-making around long-term pain management, when chronic opioid therapy is required during treatment.

Early implementation of screening for substance use in rural primary care: A rapid analytic qualitative study

Background: Few primary care patients are screened for substance use. As part of a phased feasibility study examining the implementation of electronic health record-integrated screening with the Tobacco, Alcohol, and Prescription Medication Screening (TAPS) Tool and clinical decision support (CDS) in rural primary care clinics, focus groups were conducted to identify early indicators of success and challenges to screening implementation. Method: Focus groups (n = 6) were conducted with medical assistants (MAs: n = 3: 19 participants) and primary care providers (PCPs: n = 3: 13 participants) approximately one month following screening implementation in three Federally Qualified Health Centers in Maine. Rapid analysis and matrix analysis using Proctor's Taxonomy of Implementation Outcomes were used to explore implementation outcomes. Results: There was consensus that screening is being used, but use of the CDS was lower, in part due to limited positive screens. Fidelity was high among MAs, though discomfort with the CDS surfaced among PCPs, impacting adoption and fidelity. The TAPS Tool's content, credibility and ease of workflow integration were favorably assessed. Challenges include screening solely at annual visits and self-administered screening for certain patients. Conclusions: Results reveal indicators of implementation success and strategies to address challenges to screening for substance use in primary care.

Nursing Knowledge of Alcohol and Other Drugs (AOD) in a Regional Health District: An Exploratory Study

Nurses remain at the forefront of direct patient care due to the nature of their role; they are in a position to provide assessment, response and referral of individuals in healthcare settings with problematic alcohol and other drug (AOD) use. We aim to determine the AOD knowledge of nurses in a regional health district in Australia and the awareness of an AOD service operating in the clinical environment. We employed a cross-sectional online survey, with descriptive and correlational analysis performed to explore relations between knowledge and both assessment and referral practices for individuals with problematic AOD use. Results indicate good knowledge of the AOD service, with confidence to refer to the service associated with recent contact. Lower satisfaction levels with the AOD service were found in nurses who had no recent contact with the service. Awareness of the service was also positively associated with completion of the electronic AOD assessment. These results indicate that the presence of experienced AOD clinicians may increase familiarity with AOD services and increase screening. Given the link between familiarity and comfort with the AOD service and referral, establishing specialised AOD nursing positions remains an important strategy. We argue that the presence of specialised AOD nurses has a flow on effect in maintaining continuing screening and encouraging nurses to refer individuals with problematic AOD use for ongoing care and treatment.

Electronic screening and brief intervention for unhealthy alcohol use in primary care waiting rooms - A pilot project

Background: In primary care, electronic self-administered screening and brief interventions for unhealthy alcohol may overcome some of the implementation barriers of face-to-face intervention. We developed an anonymous electronic self-administered screening brief intervention device for unhealthy alcohol use and assessed its feasibility and acceptability in primary care practice waiting rooms. Two modes of delivery were compared: with or without the presence of a research assistant (RA) to make patients aware of the device's presence and help users. Using the device was optional. Methods: The devices were placed in 10 participating primary care practices waiting rooms for 6 weeks, and were accessible on a voluntary basis. Number of appointments by each practice during the course of the study was recorded. Access to the electronic brief intervention was voluntary among those who screened positive. Screening and brief intervention rates and characteristics of users were compared across the modes of delivery. Results: During the study, there were 7270 appointments and 1511 individuals used the device (20.8%). Mean age of users was 45.3 (19.5), and 57.9% screened positive for unhealthy alcohol use. Of them, 53.8% accessed the brief intervention content. The presence of the RA had a major impact on the device's usage (59.6% vs 17.4% when absent). When the RA was present, participants were less likely to screen positive (49.4% vs 60.7%, P = 0.0003) but more likely to access the intervention (62.7% vs 51.4%, P = 0.009). Results from the satisfaction survey indicated that users found the device easy to use (93.5%), questions useful (89-95%) and 77.2% reported that their friends would be willing to use it. Conclusions: This pilot project indicates that the implementation of an electronic screening and brief intervention device for unhealthy alcohol is feasible and acceptable in primary care practices but that, without human support, its use is rather limited.

Barriers and facilitators affecting the implementation of substance use screening in primary care clinics: a qualitative study of patients, providers, and staff

Background

Alcohol and drug use are leading causes of morbidity and mortality that frequently go unidentified in medical settings. As part of a multi-phase study to implement electronic health record-integrated substance use screening in primary care clinics, we interviewed key clinical stakeholders to identify current substance use screening practices, barriers to screening, and recommendations for its implementation.

Methods

Focus groups and individual interviews were conducted with 67 stakeholders, including patients, primary care providers (faculty and resident physicians), nurses, and medical assistants, in two urban academic health systems. Themes were identified using an inductive approach, revised through an iterative process, and mapped to the Knowledge to Action (KTA) framework, which guides the implementation of new clinical practices (Graham et al. in J Contin Educ Health Prof 26(1):13–24, 2006).

Results

Factors affecting implementation based on KTA elements were identified from participant narratives. Identifying the problem: Participants consistently agreed that having knowledge of a patient’s substance use is important because of its impacts on health and medical care, that substance use is not properly identified in medical settings currently, and that universal screening is the best approach. Assessing barriers: Patients expressed concerns about consequences of disclosing substance use, confidentiality, and the individual’s own reluctance to acknowledge a substance use problem. Barriers identified by providers included individual-level factors such as lack of clinical knowledge and training, as well as systems-level factors including time pressure, resources, lack of space, and difficulty accessing addiction treatment. Adapting to the local context: Most patients and providers stated that the primary care provider should play a key role in substance use screening and interventions. Opinions diverged regarding the optimal approach to delivering screening, although most preferred a patient self-administered approach. Many providers reported that taking effective action once unhealthy substance use is identified is crucial.

Conclusions

Participants expressed support for substance use screening as a valuable part of medical care, and identified individual-level as well as systems-level barriers to its implementation. These findings suggest that screening programs should clearly communicate the goals of screening to patients and proactively counteract stigma, address staff concerns regarding time and workflow, and provide education as well as treatment resources to primary care providers.

Electronic supplementary material

The online version of this article (10.1186/s13722-018-0110-8) contains supplementary material, which is available to authorized users.

A Brief Smoking Cessation Intervention for Heavy Drinking Smokers: Treatment Feasibility and Acceptability

Approximately 20-25% of regular smokers report heavy drinking. Abstinent smokers are five times as likely to experience a smoking lapse during drinking episodes. Current efforts seek to improve treatments for this subgroup of heavy-drinking smokers. This study tested the feasibility and acceptability of addressing alcohol use in a brief, single session smoking cessation intervention (SMK+A) compared to smoking cessation counseling only (SMK); these interventions were grounded in a motivational interview framework and included personalized feedback, decisional balance, quit day setting, and tailored skills building (e.g., breathing techniques, coping with urges, dealing with social pressures) to maintain abstinence. Descriptive outcomes included reported helpfulness of intervention skills, readiness to change scores, and feasibility of participant recruitment and retention. We also assessed 7-day point prevalence of smoking cessation, and smoking and drinking reduction at 1-month follow-up. Participants (N = 22) were community-based treatment-seeking daily smokers (≥5 cigarettes/day) who were also heavy drinkers (≥14 drinks/week for men, ≥ 7 drinks/week for women; or ≥5 drinks on one episode in past week for men, ≥4 for women). Twenty five percent of interested individuals were eligible after initial phone screen, and all randomized participants were retained through follow up. All skills demonstrated high acceptability (i.e., rated between moderately and very helpful), and a significant proportion of participants in each condition reported taking action to reduce cigarette smoking and/or alcohol use at 1-month post-quit. Three participants in each condition (27.3%) attained bioverified (CO ≤ 4 parts per million and cotinine ≤ 3 ng/mL) smoking quit at follow-up. Given the modified intervention's acceptability and flexibility, larger studies may help to elucidate this intervention's effects on readiness to change, smoking cessation, and alcohol reduction.

The Early Impact Of The 'Alternative Quality Contract' On Mental Health Service Use And Spending In Massachusetts

Accountable care using global payment with performance bonuses has shown promise in controlling spending growth and improving care. This study examined how an early model, the Alternative Quality Contract (AQC) established in 2009 by Blue Cross Blue Shield of Massachusetts (BCBSMA), has affected care for mental illness. We compared spending and use for enrollees in AQC organizations that did and did not accept financial risk for mental health with enrollees not participating in the contract. Compared with BCBSMA enrollees in organizations not participating in the AQC, we found that enrollees in participating organizations were slightly less likely to use mental health services and, among mental health services users, small declines were detected in total health care spending, but no change was found in mental health spending. The declines in probability of use of mental health services and in total health spending among mental health service users attributable to the AQC were concentrated among enrollees in organizations that accepted financial risk for behavioral health. Interviews with AQC organization leaders suggested that the contractual arrangements did not meaningfully affect mental health care delivery in the program's initial years, but organizations are now at varying stages of efforts to improve mental health integration.

Casting a wider net in behavioral health screening in primary care: a preliminary study of the Outcome Rating Scale

Introduction The integration of behavioral health services into primary care has led to enhanced use of brief screening measures to identify mental health problems. Although useful, such instruments are largely symptom based and diagnosis specific. This narrow focus can potentially limit the identification of broader social or relational distress in patients that affect medical outcomes, as well as present feasibility challenges using a multi-measure approach in identifying mental health comorbidities.

METHOD

This exploratory study of adult primary care patients compared an ultra-brief, and widely used measure of global distress across life functioning, the Outcome Rating Scale (ORS), with the Patient Health Questionnaire (PHQ-9 and PHQ-2).

RESULTS

Correlations between the ORS and the PHQ-9 and PHQ-2 indicated agreement between the measures in classifying patients, and the ORS identified significantly more patients in the clinical range. Discussion Although results are preliminary, the ORS may cast a wider net in identifying patients with significant distress in primary care.

Alcohol Screening and Intervention Among United States Adults who Attend Ambulatory Healthcare

BACKGROUND

There is limited data on the extent to which indicated alcohol interventions are delivered in U.S. ambulatory care settings.

OBJECTIVE

To assess the receipt of alcohol-related services, including assessment of use, advice to reduce drinking, and information about alcohol treatment, during ambulatory care visits.

DESIGN

Secondary data analysis of the 2013 National Survey on Drug Use and Health, a cross-sectional, nationally representative survey of civilians in the non-institutionalized U.S. general population (response rate 71.7 %).

PARTICIPANTS

Adult ambulatory care users in the public use data file who did not obtain emergency or inpatient services (n = 17,266).

MAIN MEASURES

Measurements included respondents' alcohol consumption, heavy episodic drinking, alcohol use disorder, healthcare use, and receipt of alcohol-related interventions.

KEY RESULTS

Approximately 71.1 % of ambulatory care users received an alcohol assessment. Among past-month heavy episodic drinkers without an alcohol use disorder who reported receiving an alcohol assessment, 4.4 % were advised to cut back. Among individuals with alcohol abuse and alcohol dependence who reported receiving an alcohol assessment, 2.9 % and 7.0 %, respectively, were offered information about treatment.

CONCLUSIONS

Rates of alcohol screening and assessment were relatively high among adults who attended healthcare visits, but rates of intervention were low, even when individuals were assessed for use. Efforts are needed to expand delivery of interventions when patients are identified as positive for risky drinking, hazardous alcohol use, and alcohol use disorders during ambulatory care visits.

[Trauma and posttraumatic stress symptoms in patients in German primary care settings]

BACKGROUND

Primary care settings have an important gatekeeping function to detect mental diseases, including trauma and posttraumatic stress disorders.

OBJECTIVES

To assess the prevalence of trauma and posttraumatic symptoms in a first sample of northeast German primary care patients and to evaluate the diagnostic sensitivity and specificity of the general practitioners.

MATERIAL AND METHODS

Traumatic experiences and posttraumatic stress disorders (PTSD) were assessed with self-rating questionnaires in a sample of N = 400 patients from 3 primary care facilities. Additionally, knowledge and diagnostic accuracy of the general practitioners were evaluated.

RESULTS

According to the results of the patient health questionnaire (PHQ-15) data from all patients, the majority of patients questioned showed slight to moderate stress from somatic symptoms. Of the patients with complete data 7 % (n = 25) had a complete PTSD according to the results of the questionnaire, which was also identified in the medical assessment with a sensitivity of 40 %. The stress resulting from posttraumatic symptoms was closely associated with the extent of somatic complaints.

CONCLUSION

Patients with a history of trauma and posttraumatic symptoms are prevalent in primary care settings. An early diagnosis by the general practitioner can help patients to receive adequate treatment. Patients with somatoform disorders in particular should be screened for trauma and posttraumatic symptoms.

Feasibility and acceptability of an audio computer-assisted self-interview version of the Alcohol, Smoking and Substance Involvement Screening Test (ASSIST) in primary care patients

BACKGROUND

This study explores the feasibility and acceptability of a computer self-administered approach to substance use screening from the perspective of primary care patients.

METHODS

Forty-eight patients from a large safety net hospital in New York City completed an audio computer-assisted self-interview (ACASI) version of the Alcohol, Smoking and Substance Involvement Screening Test (ASSIST) and a qualitative interview to assess feasibility and acceptability, comprehension, comfort with screening questions, and preferences for screening mode (interviewer or computer). Qualitative data analysis organized the participants' feedback into major themes.

RESULTS

Participants overwhelmingly reported being comfortable with the ACASI ASSIST. Mean administration time was 5.2 minutes (range: 1.6-14.8 minutes). The major themes from the qualitative interviews were (1) ACASI ASSIST is feasible and acceptable to patients, (2) Social stigma around substance use is a barrier to patient disclosure, and (3) ACASI screening should not preclude personal interaction with providers.

CONCLUSIONS

The ACASI ASSIST is an appropriate and feasible approach to substance use screening in primary care. Because of the highly sensitive nature of substance use, screening tools must explain the purpose of screening, assure patients that their privacy is protected, and inform patients of the opportunity to discuss their screening results with their provider.

Problem gambling and family violence: prevalence and patterns in treatment-seekers

The primary aim of this study was to explore the prevalence and patterns of family violence in treatment-seeking problem gamblers. Secondary aims were to identify the prevalence of problem gambling in a family violence victimisation treatment sample and to explore the relationship between problem gambling and family violence in other treatment-seeking samples. Clients from 15 Australian treatment services were systematically screened for problem gambling using the Brief Bio-Social Gambling Screen and for family violence using single victimisation and perpetration items adapted from the Hurt-Insulted-Threatened-Screamed (HITS): gambling services (n=463), family violence services (n=95), alcohol and drug services (n=47), mental health services (n=51), and financial counselling services (n=48). The prevalence of family violence in the gambling sample was 33.9% (11.0% victimisation only, 6.9% perpetration only, and 16.0% both victimisation and perpetration). Female gamblers were significantly more likely to report victimisation only (16.5% cf. 7.8%) and both victimisation and perpetration (21.2% cf. 13.0%) than male gamblers. There were no other demographic differences in family violence prevalence estimates. Gamblers most commonly endorsed their parents as both the perpetrators and victims of family violence, followed by current and former partners. The prevalence of problem gambling in the family violence sample was 2.2%. The alcohol and drug (84.0%) and mental health (61.6%) samples reported significantly higher rates of any family violence than the gambling sample, while the financial counselling sample (10.6%) reported significantly higher rates of problem gambling than the family violence sample. The findings of this study support substantial comorbidity between problem gambling and family violence, although this may be accounted for by a high comorbidity with alcohol and drug use problems and other psychiatric disorders. They highlight the need for routine screening, assessment and management of problem gambling and family violence in a range of services.

From policy to practice: implementing frontline community health services for substance dependence--study protocol

Background

Substance abuse is a worldwide public health concern. Extensive scientific research has shown that screening and brief interventions for substance use disorders administered in primary care provide substantial benefit at relatively low cost. Frontline health clinicians are well placed to detect and treat patients with substance use disorders. Despite effectiveness shown in research, there are many factors that impact the implementation of these practices in real-world clinical practice. Recently, the Ministry of Health and Social Services in Quebec, Canada, issued two policy documents aimed at introducing screening and early intervention for substance abuse into frontline healthcare clinics in Quebec. The current research protocol was developed in order to study the process of implementation of evidence-based addiction treatment practices at three primary care clinics in Montreal (Phase 1). In addition, the research protocol was designed to examine the efficacy of overall policy implementation, including barriers and facilitators to addictions program development throughout Quebec (Phase 2).

Methods/Design

Phase 1 will provide an in-depth case study of knowledge translation and implementation. The study protocol will utilize an integrated knowledge translation strategy to build collaborative mechanisms for knowledge exchange between researchers, addiction specialists, and frontline practitioners (guided by the principles of participatory-action research), and directly examine the process of knowledge uptake and barriers to transfer using both qualitative and quantitative methodologies. Evaluation will involve multiple measures, time points and domains; program uptake and effectiveness will be determined by changes in healthcare service delivery, sustainability and outcomes. In Phase 2, qualitative methods will be utilized to examine the contextual facilitators and barriers that frontline organizations face in implementing services for substance dependence. Phase 2 will provide the first study exploring the wide-scale implementation of frontline services for substance dependence in the province of Quebec and yield needed information about how to effectively implement mandated policies into clinical practice and impact public health.

Discussion

Findings from this research program will contribute to the understanding of factors associated with implementation of frontline services for substance dependence and help to inform future policy and organizational support for the implementation of evidence-based practices.

Using propensity scores in difference-in-differences models to estimate the effects of a policy change

Difference-in-difference (DD) methods are a common strategy for evaluating the effects of policies or programs that are instituted at a particular point in time, such as the implementation of a new law. The DD method compares changes over time in a group unaffected by the policy intervention to the changes over time in a group affected by the policy intervention, and attributes the "difference-in-differences" to the effect of the policy. DD methods provide unbiased effect estimates if the trend over time would have been the same between the intervention and comparison groups in the absence of the intervention. However, a concern with DD models is that the program and intervention groups may differ in ways that would affect their trends over time, or their compositions may change over time. Propensity score methods are commonly used to handle this type of confounding in other non-experimental studies, but the particular considerations when using them in the context of a DD model have not been well investigated. In this paper, we describe the use of propensity scores in conjunction with DD models, in particular investigating a propensity score weighting strategy that weights the four groups (defined by time and intervention status) to be balanced on a set of characteristics. We discuss the conceptual issues associated with this approach, including the need for caution when selecting variables to include in the propensity score model, particularly given the multiple time point nature of the analysis. We illustrate the ideas and method with an application estimating the effects of a new payment and delivery system innovation (an accountable care organization model called the "Alternative Quality Contract" (AQC) implemented by Blue Cross Blue Shield of Massachusetts) on health plan enrollee out-of-pocket mental health service expenditures. We find no evidence that the AQC affected out-of-pocket mental health service expenditures of enrollees.

Barriers to improving primary care of depression: perspectives of medical group leaders

Using clinical trials, researchers have demonstrated effective methods for treating depression in primary care, but improvements based on these trials are not being implemented. This might be because these improvements require more systematic organizational changes than can be made by individual physicians. We interviewed 82 physicians and administrative leaders of 41 medical groups to learn what is preventing those organizational changes. The identified barriers to improving care included external contextual problems (reimbursement, scarce resources, and access to/communication with specialty mental health), individual attitudes (physician and patient resistance), and internal care process barriers (organizational and condition complexity, difficulty standardizing and measuring care). Although many of these barriers are challenging, we can overcome them by setting clear priorities for change and allocating adequate resources. We must improve primary care of depression if we are to reduce its enormous adverse social and economic impacts.

Intercepting binge drinkers in medical settings: a view from California

The argument for universal alcohol screening in primary care is based on the assumption that most heavy drinkers routinely visit a doctor. This study examines whether drinking status is associated with higher or lower odds of visiting a doctor in the past year among California adults. As a point of comparison, the study also examines whether drinking status is associated with the odds of visiting an emergency room. Data came from the 2007 California Health Interview Survey. Multivariate logistic regression was used to examine the odds of visiting a doctor and an emergency room for abstainers, moderate drinkers, monthly binge drinkers, and weekly binge drinkers. After controlling for demographics, health coverage, and health status, binge drinkers had the same odds of visiting a doctor and the emergency room as moderate drinkers. Among binge drinkers, female gender, health coverage, and high blood pressure were associated with visiting a primary care doctor.

Harmful drinking and talking about alcohol in primary care: New Zealand population survey findings

OBJECTIVE

Existing evidence suggests low recognition of alcohol problems in primary care. This study aimed to determine the 12-month prevalence of harmful or hazardous drinking (HHD) in a population sample and to measure the relationship between HHD and talking about alcohol in primary care consultations in that period.

METHOD

A New Zealand population survey of 12 488 adults. Alcohol use in the past 12 months was assessed by the Alcohol Use Disorders Identification Test (AUDIT), with HHD defined as a total score of eight or above. Talking about alcohol was self-reported.

RESULTS

HHD was present in 17.7% and was commoner in men and in younger age groups, with the highest prevalence 53.6% in men aged 18-24. Three per cent of those who attended their usual primary care provider in the past 12 months reported being talked to about alcohol. Talking about alcohol increased with AUDIT score, but was not commoner in young people despite their higher prevalence of HHD. Overall, 9.4% of attendees with HHD reported talking about alcohol.

CONCLUSION

HHD is common but largely not detected in primary care. Improved detection would permit the delivery of effective treatments such as brief interventions.

How can we use our knowledge of alcohol-tobacco interactions to reduce alcohol use?

Currently, 8.5% of the US population meets criteria for alcohol use disorders, with a total cost to the US economy estimated at $234 billion per year. Alcohol and tobacco use share a high degree of comorbidity and interact across many levels of analysis. This review begins by highlighting alcohol and tobacco comorbidity and presenting evidence that tobacco increases the risk for alcohol misuse and likely has a causal role in this relationship. We then discuss how knowledge of alcohol and tobacco interactions can be used to reduce alcohol use, focusing on whether (a) smoking status can be used as a clinical indicator for alcohol misuse, (b) tobacco policies reduce alcohol use, and (c) nicotinic-based medications can be used to treat alcohol use disorders.

Recognition and treatment of depression and anxiety symptoms in heart failure

OBJECTIVE

The aim of this prospective study was to examine the prevalence, recognition, and treatment of depression and anxiety in ambulatory patients with heart failure.

METHOD

A total of 158 heart failure participants were enrolled between November 2006 and April 2007. Each patient completed a telephone screening interview that included an assessment of heart-failure severity (New York Heart Assciation criteria) as well as measures for depression (Geriatric Depression Scale [GDS]) and anxiety (Geriatric Anxiety Inventory [GAI]). Following study recruitment, each patient's electronic medical record was comprehensively reviewed for the 12 months prestudy and 6 months poststudy assessments to determine whether patients had been recognized as having and/or treated for depression or anxiety.

RESULTS

Prevalence of depression (GDS score ≥ 6) was 41.8%, and prevalence of anxiety (GAI score ≥ 9) was 25.3%. Of patients with a positive GDS or GAI result, 57.5% had a diagnosis or medical-record notation for depression and/or anxiety, and 60.3% received mental health treatment during the 18-month period of the EMR review. Of patients with a documented diagnosis of depression or anxiety, 92.3% received mental health treatment. Results showed that higher GDS scores were associated with recognition of depression/anxiety in the medical record, and a positive primary care depression screening predicted documented mental health treatment.

CONCLUSION

These data suggest that symptomatic depression and anxiety are underrecognized in heart failure patients and that mental health screening may be important for receipt of care. Notably, once depression and/or anxiety was documented in the medical record, patients were highly likely to receive mental health treatment.

Clinical recognition and recording of alcohol disorders by clinicians in primary and secondary care: meta-analysis

BACKGROUND

Clinicians have considerable difficulty identifying and helping those people with alcohol problems but no previous study has looked at this systematically.

AIMS

To determine clinicians' ability to routinely identify broadly defined alcohol problems.

METHOD

Data were extracted and rated by two authors, according to PRISMA standard and QUADAS criteria. Studies that examined the diagnostic accuracy of clinicians' opinion regarding the presence of alcohol problems as well as their written notation were evaluated.

RESULTS

A comprehensive search identified 48 studies that looked at the routine ability of clinicians to identify alcohol problems (12 in primary care, 31 in general hospitals and 5 in psychiatric settings). A total of 39 examined alcohol use disorder, 5 alcohol dependence and 4 intoxication. We separated studies into those using self-report and those using interview. The diagnostic sensitivity of primary care physicians (general practitioners) in the identification of alcohol use disorder was 41.7% (95% CI 23.0-61.7) but alcohol problems were recorded correctly in only 27.3% (95% CI 16.9-39.1) of primary care records. Hospital staff identified 52.4% (95% CI 35.9-68.7) of cases and made correct notations in 37.2% (95% CI 28.4-46.4) of case notes. Mental health professionals were able to correctly identify alcohol use disorder in 54.7% (95% CI 16.8-89.6) of cases. There were limited data regarding alcohol dependency and intoxication. Hospital staff were able to detect 41.7% (95% CI 16.5-69.5) of people with alcohol dependency and 89.8% (95% CI 70.4-99.4) of those acutely intoxicated. Specificity data were sparse.

CONCLUSIONS

Clinicians may consider simple screening methods such as self-report tools rather than relying on unassisted clinical judgement but the added value of screening over and above clinical diagnosis remains unclear.

Yield of practice-based depression screening in VA primary care settings

BACKGROUND

Many patients who should be treated for depression are missed without effective routine screening in primary care (PC) settings. Yearly depression screening by PC staff is mandated in the VA, yet little is known about the expected yield from such screening when administered on a practice-wide basis.

OBJECTIVE

We characterized the yield of practice-based screening in diverse PC settings, as well as the care needs of those assessed as having depression.

DESIGN

Baseline enrollees in a group randomized trial of implementation of collaborative care for depression.

PARTICIPANTS

Randomly sampled patients with a scheduled PC appointment in ten VA primary care clinics spanning five states.

MEASUREMENTS

PHQ-2 screening followed by the full PHQ-9 for screen positives, with standardized sociodemographic and health status questions.

RESULTS

Practice-based screening of 10,929 patients yielded 20.1% positive screens, 60% of whom were assessed as having probable major depression based on the PHQ-9 (11.8% of all screens) (n = 1,313). In total, 761 patients with probable major depression completed the baseline assessment. Comorbid mental illnesses (e.g., anxiety, PTSD) were highly prevalent. Medical comorbidities were substantial, including chronic lung disease, pneumonia, diabetes, heart attack, heart failure, cancer and stroke. Nearly one-third of the depressed PC patients reported recent suicidal ideation (based on the PHQ-9). Sexual dysfunction was also common (73.3%), being both longstanding (95.1% with onset >6 months) and frequently undiscussed and untreated (46.7% discussed with any health care provider in past 6 months).

CONCLUSIONS

Practice-wide survey-based depression screening yielded more than twice the positive-screen rate demonstrated through chart-based VA performance measures. The substantial level of comorbid physical and mental illness among PC patients precludes solo management by either PC or mental health (MH) specialists. PC practice- and provider-level guideline adherence is problematic without systems-level solutions supporting adequate MH assessment, PC treatment and, when needed, appropriate MH referral.

Yield of practice-based depression screening in VA primary care settings

BACKGROUND

Many patients who should be treated for depression are missed without effective routine screening in primary care (PC) settings. Yearly depression screening by PC staff is mandated in the VA, yet little is known about the expected yield from such screening when administered on a practice-wide basis.

OBJECTIVE

We characterized the yield of practice-based screening in diverse PC settings, as well as the care needs of those assessed as having depression.

DESIGN

Baseline enrollees in a group randomized trial of implementation of collaborative care for depression.

PARTICIPANTS

Randomly sampled patients with a scheduled PC appointment in ten VA primary care clinics spanning five states.

MEASUREMENTS

PHQ-2 screening followed by the full PHQ-9 for screen positives, with standardized sociodemographic and health status questions.

RESULTS

Practice-based screening of 10,929 patients yielded 20.1% positive screens, 60% of whom were assessed as having probable major depression based on the PHQ-9 (11.8% of all screens) (n = 1,313). In total, 761 patients with probable major depression completed the baseline assessment. Comorbid mental illnesses (e.g., anxiety, PTSD) were highly prevalent. Medical comorbidities were substantial, including chronic lung disease, pneumonia, diabetes, heart attack, heart failure, cancer and stroke. Nearly one-third of the depressed PC patients reported recent suicidal ideation (based on the PHQ-9). Sexual dysfunction was also common (73.3%), being both longstanding (95.1% with onset >6 months) and frequently undiscussed and untreated (46.7% discussed with any health care provider in past 6 months).

CONCLUSIONS

Practice-wide survey-based depression screening yielded more than twice the positive-screen rate demonstrated through chart-based VA performance measures. The substantial level of comorbid physical and mental illness among PC patients precludes solo management by either PC or mental health (MH) specialists. PC practice- and provider-level guideline adherence is problematic without systems-level solutions supporting adequate MH assessment, PC treatment and, when needed, appropriate MH referral.

Alcohol-related discussions in health care--a population view

AIMS

The present study aimed to evaluate the frequency and the target group of alcohol screening and brief interventions in health-care settings and how well this level of activity reflects public opinion.

DESIGN

A general population survey.

SETTING AND PARTICIPANTS

A random sample of Finns aged 15-69 years with a 74% response rate (n = 2725).

MEASUREMENTS

Frequency counts were used to evaluate the level of activity. Logistic regression models were used to examine which groups were asked and advised about alcohol use and which groups considered it useful.

FINDINGS

More than 90% had positive attitudes towards being asked about their alcohol use. Of those who had been in contact with health care (n = 2062) in the 12 months before the survey, 33.3% had been asked about their alcohol use, being most often men, young, heavy drinkers and those of high socio-economic status. Thirty-seven per cent of those who had been asked were given advice, being most often heavy drinkers and those with a normal body mass index. However, 50% of heavy drinkers who had been asked about their alcohol use had not been advised about it. Of those who had been advised, 71.9% considered it useful, especially older subjects, and also including heavy episodic drinkers, although less than others.

CONCLUSIONS

In Finland, the frequency of health-care professionals asking and giving advice on alcohol is relatively low. However, public opinion towards these discussions is positive. Our results encourage the support and uptake of systematic screenings and brief interventions in health-care settings.

Does Depression Screening Have an Effect on the Diagnosis and Treatment of Mood Disorders in General Medical Settings? An Instrumental Variable Analysis of the National Ambulatory Medical Care Survey

This study examined the association of depression screening with the diagnoses of mood disorders and prescription of antidepressants in 73,712 visits to nonpsychiatrist physician offices drawn from the 2005-2007 U.S. National Ambulatory Medical Care Survey. Physicians used depression screening selectively for patients whom they perceived as more likely to have a mood disorder. In bivariate probit analyses with instrumental variables, depression screening did not increase the prevalence of either mood disorder diagnoses or prescription of antidepressants. However, screening was associated with lower rates of antidepressants prescription without a diagnosis of a mood disorder. In visits in which antidepressants were prescribed, 47.4% of the screened visits compared with 16.3% of nonscreened visits had a mood disorder diagnosis. As currently practiced in medical settings, depression screening may help improve targeting and appropriate use of antidepressant medications. Wider use of depression screening may help curb the growing trend of off-label antidepressant prescriptions.

Providing competency-based family medicine residency training in substance abuse in the new millennium: a model curriculum

BACKGROUND

This article, developed for the Betty Ford Institute Consensus Conference on Graduate Medical Education (December, 2008), presents a model curriculum for Family Medicine residency training in substance abuse.

METHODS

The authors reviewed reports of past Family Medicine curriculum development efforts, previously-identified barriers to education in high risk substance use, approaches to overcoming these barriers, and current training guidelines of the Accreditation Council for Graduate Medical Education (ACGME) and their Family Medicine Residency Review Committee. A proposed eight-module curriculum was developed, based on substance abuse competencies defined by Project MAINSTREAM and linked to core competencies defined by the ACGME. The curriculum provides basic training in high risk substance use to all residents, while also addressing current training challenges presented by U.S. work hour regulations, increasing international diversity of Family Medicine resident trainees, and emerging new primary care practice models.

RESULTS

This paper offers a core curriculum, focused on screening, brief intervention and referral to treatment, which can be adapted by residency programs to meet their individual needs. The curriculum encourages direct observation of residents to ensure that core skills are learned and trains residents with several "new skills" that will expand the basket of substance abuse services they will be equipped to provide as they enter practice.

CONCLUSIONS

Broad-based implementation of a comprehensive Family Medicine residency curriculum should increase the ability of family physicians to provide basic substance abuse services in a primary care context. Such efforts should be coupled with faculty development initiatives which ensure that sufficient trained faculty are available to teach these concepts and with efforts by major Family Medicine organizations to implement and enforce residency requirements for substance abuse training.

Impact of vital signs screening & clinician prompting on alcohol and tobacco screening and intervention rates: a pre-post intervention comparison

Background

Though screening and intervention for alcohol and tobacco misuse are effective, primary care screening and intervention rates remain low. Previous studies have increased intervention rates using vital signs screening for tobacco misuse and clinician prompts for screen-positive patients for both alcohol and tobacco misuse. This pilot study's aims were: (1) To determine the feasibility of combined vital signs screening for tobacco and alcohol misuse, (2) To assess the impact of vital signs screening on alcohol and tobacco screening and intervention rates, and (3) To assess the additional impact of tobacco assessment prompts on intervention rates.

Methods

In five outpatient practices, nurses measuring vital signs were trained to routinely ask a single tobacco question, a prescreening question that identified current drinkers, and the single alcohol screening question for current drinkers. After 4-8 weeks, clinicians were trained in tobacco intervention and nurses were trained to give tobacco abusers a tobacco questionnaire which also served as a clinician intervention prompt. Screening and intervention rates were measured using patient exit interviews (n = 622) at baseline, during the "screening only" period, and during the tobacco prompting phase. Changes in screening and intervention rates were compared using chi square analyses and test of linear trends. Clinic staff were interviewed regarding patient and staff acceptability. Logistic regression was used to evaluate the impact of nurse screening on clinician intervention, the impact of alcohol intervention on concurrent tobacco intervention, and the impact of tobacco intervention on concurrent alcohol intervention.

Results

Alcohol and tobacco screening rates and alcohol intervention rates increased after implementing vital signs screening (p < .05). During the tobacco prompting phase, clinician intervention rates increased significantly for both alcohol (12.4%, p < .001) and tobacco (47.4%, p = .042). Screening by nurses was associated with clinician advice to reduce alcohol use (OR 13.1; 95% CI 6.2-27.6) and tobacco use (OR 2.6; 95% CI 1.3-5.2). Acceptability was high with nurses and patients.

Conclusions

Vital signs screening can be incorporated in primary care and increases alcohol screening and intervention rates. Tobacco assessment prompts increase both alcohol and tobacco interventions. These simple interventions show promise for dissemination in primary care settings.

Perceived need for treatment for alcohol use disorders: results from two national surveys

OBJECTIVES

Most individuals with alcohol use disorders receive no treatment for their disorder. Past research suggests that a major reason for this is that individuals with alcohol use disorders do not perceive a need for treatment. The research presented here had two objectives. First, to provide updated estimates of the percentage of individuals with alcohol use disorders who perceive a need for treatment, and among those, the percentage who receive any treatment for alcohol use disorders. And second, to investigate the determinants of perceived need for and utilization of treatment for alcohol use disorders.

METHODS

Secondary data analyses were performed for two national surveys, the National Epidemiologic Survey on Alcohol and Related Conditions (3,305 individuals with alcohol use disorders) and the National Survey on Drug Use and Health (7,009 individuals with alcohol use disorders).

RESULTS

In both surveys fewer than one in nine individuals with an alcohol use disorder perceived a need for treatment. In predicting perceived need, the explanatory power of diagnostic variables was much greater than that of demographic variables. Among those with perceived need, two out of every three persons reported receiving treatment in the past year.

CONCLUSIONS

Our results suggest that failure to perceive need continues to be the major reason that individuals with alcohol use disorders do not receive treatment. On the other hand, among those who perceived a need, a majority received treatment. It is likely that high levels of unmet need for treatment services for alcohol use disorders will persist as long as perceived need is low. Efforts are needed to increase levels of perceived need among those with alcohol use disorders.

Management of psychosocial distress by oncologists

OBJECTIVE

Little is known about the nature of psychosocial care delivered by oncologists. The goal of this study was to survey oncologists about their management of psychosocial distress, referencing the National Comprehensive Cancer Network guidelines.

METHODS

A random sample of 1,000 oncologists were sent an e-mail requesting their participation in an online survey; nonrespondents were sent the survey through postal mail. Regression analyses were conducted to identify independent predictors of care.

RESULTS

Forty-six percent (448 of 965) of oncologists responded. Practice locations included: community (63%), cancer center (25%), and hospital (7%). Respondents estimated that over one-third of their patients (mean+/-SD=38%+/-22%) experience psychosocial distress warranting intervention, although only 225 of 447 (50%) indicated having mental health services affiliated with their practice. Nearly half (212 of 447, 47%) reported only initiating a referral for psychosocial services, and 214 of 447 (48%) reported both making a referral and starting psychiatric medications, mainly selective serotonin reuptake inhibitors and benzodiazepines.

CONCLUSIONS

Most oncologists delivered some level of psychosocial care, although only half had affiliated mental health services.

Gaps in addressing problem drinking: overcoming primary care and alcohol treatment deficiencies

Despite the high prevalence of problem drinking among Americans, primary care physicians often fail to address this major health threat. In addition, once alcohol use disorders are identified, patients often fail to receive coordinated medical and substance abuse treatment. This article reviews four types of barriers as well as potential facilitators to improving the prevention and management of problem drinking. First, primary care physicians are poorly trained about the clinical relevance of addressing alcohol problems in their daily patient care. Second, primary care physicians are concerned about the stigma and health insurance problems encountered by patients diagnosed with alcohol use disorders. Third, primary care practices have limited organizational and financial support to identify and address alcohol problems. Fourth, primary care and alcohol treatment settings communicate and collaborate poorly in delivering patient care. Opportunities to overcome these challenges are discussed and must be initiated to reduce the myriad of adverse outcomes resulting from problem drinking.

Trends in prescribed opioid therapy for non-cancer pain for individuals with prior substance use disorders

Long-term opioid therapy for non-cancer pain has increased. Caution is advised in prescribing for persons with substance use disorders, but little is known about actual health plan practices. This paper reports trends and characteristics of long-term opioid use in persons with non-cancer pain and a substance abuse history. Using health plan data (1997-2005), the study compared age-sex-standardized rates of incident, incident long-term and prevalent long-term prescription opioid use, and medication use profiles in those with and without substance use disorder histories. The CONsortium to Study Opioid Risks and Trends study included adult enrollees of two health plans, Kaiser Permanente of Northern California (KPNC) and Group Health Cooperative (GH) of Seattle, Washington. At KPNC (1999-2005), prevalence of long-term use increased from 11.6% to 17.0% for those with substance use disorder histories and from 2.6% to 3.9% for those without substance use disorder histories. Respective GH rates (1997-2005), increased from 7.6% to 18.6% and from 2.7% to 4.2%. Among persons with an opioid disorder, KPNC rates increased from 44.1% to 51.1%, and GH rates increased from 15.7% to 52.4%. Long-term opioid users with a prior substance abuse diagnosis received higher dosage levels, were more likely to use Schedule II and long-acting opioids, and were more often frequent users of sedative-hypnotic medications in addition to their opioid use. Since these patients are viewed as higher risk, the increased use of long-term opioid therapy suggests the importance of improved understanding of the benefits and risks of opioid therapy among persons with a history of substance abuse, and the need for more careful screening for substance abuse history than is the usual practice.

A treatment for substance abusing pregnant women

We describe the adaptation of a manualized behavioral treatment for substance using pregnant women that includes components of motivational interviewing and cognitive therapy. In a pilot study conducted in 2006-2007, five non-behavioral health clinicians were trained to provide the treatment to 14 women. Therapy was administered concurrent with routine prenatal care at inner-city maternal health clinics in New Haven and Bridgeport, Connecticut, small urban cities in the USA. Substance use was monitored by self report, and urine and breath tests. Treatment fidelity was assessed using the Yale Adherence and Competence System. Behavioral treatment delivery in this setting is feasible and is being evaluated in a randomized, controlled, clinical trial.

Substance Abuse and Dependence Treatment in Outpatient Physician Offices, 1997–2004

OBJECTIVE

To examine patient, physician, and visit characteristics associated with treatment for substance abuse during outpatient physician visits.

METHODS

Secondary data was obtained from the 1997-2004 National Ambulatory Medical Care Survey.

RESULTS

A substance abuse diagnosis was recorded in .9% of general and family practice visits, .8% of internal medicine visits, and 5.1% of psychiatry visits. Multivariable logistic regression found that women, elderly, non-White, and established patients were less likely to be given a substance abuse diagnosis.

CONCLUSION

Increased screening, particularly of existing patients, may lead to decreased gender, age, and racial disparities in diagnosis and treatment.

Relationship between the presence of practice systems and the quality of care for depression

A valid measure of practice systems for improving chronic disease care is needed as a guide for both improvement and public accountability. We tested whether a new survey measure of the presence of practice systems (the PPC-R) is associated with performance measure rates for depression among 40 medical groups in Minnesota. These PPC-R scores were compared with standardized medical group measures of antidepressant persistence. Only 54% of potentially important systems were present, and there was high variability. However, there was a positive correlation between systems and quality on the 90-day measure of antidepressant persistence, both overall (r = .33, P = .04) and for the Chronic Care Model domains of decision support (r = .38, P = .02) and delivery system redesign (r = .31, P = .05). Thus, practice systems overall and several domains of the Chronic Care Model appear to be associated with higher quality care for depression. This questionnaire may help practices identify particular systems to improve.

Development of the ASK-20 adherence barrier survey

OBJECTIVE

Poor medication adherence is widespread among patients with chronic conditions requiring long-term drug therapy. Medication adherence is determined by multiple patient-, context-, and therapy-dependent factors. This paper describes the development and initial validation of the ASK-20 survey, created to identify actionable risk factors for medication nonadherence and to improve communication about adherence.

METHODS

A pool of 30 items was generated through comprehensive literature review. Items were refined and the item pool was expanded through an expert panel review and patient focus groups to yield 47 candidate items, each with five response options ranging from either Strongly Agree to Strongly Disagree or from In the Last Week to Never. The pool of 47 candidate items was administered to a web-based sample of 605 patients taking medications and reporting a diagnosis of asthma, diabetes, or depression for psychometric testing and item reduction.

RESULTS

Eleven multi-item factor groupings with two additional unique items were identified on the basis of principal components analysis and interpretability. Twenty (20) items representing ten factor groupings were selected for the final instrument. Each of the final items was dichotomized as positive - indicating a barrier, or negative. Two summary scores - the sum of all positive barriers or Total Barrier Count (TBC) and the sum of raw item scores, the ASK-20 score - were calculated. Concurrent validity of the dichotomously scored individual items, the TBC and ASK-20 scores in relation to self-reported adherence was generally good. Cronbach's alpha coefficient was 0.77 for the TBC and 0.85 for the ASK-20 score.

CONCLUSIONS

ASK-20 consists of 20 clinically actionable items representing multiple factors that affect medication adherence. The ASK-20 survey demonstrated satisfactory validity and internal consistency and may be used to identify actionable barriers to adherence across a spectrum of chronic diseases. Future research using more objective measures of adherence is warranted to confirm the exploratory validity and reliability of ASK-20 reported in this study.

Acceptability of common screening methods used to detect distress and related mood disorders-preferences of cancer specialists and non-specialists

A new questionnaire of clinicians' attitudes and practices in relation to screening for mood disorder was distributed to 300 cancer professionals (specialists and non-specialists) working across the UK. From 226 (75.3%) health professionals working in cancer care who responded, approximately two-thirds always or regularly attempted to detect mood disorder during consultations but a substantial minority relied on patients spontaneously mentioning an emotional issue. The highest rate of routine questioning was performed by clinicians working in palliative medicine (76.3%) as well as nurse specialists working in all areas (72%). Despite these relatively high rates of enquiry, 10% or less of all specialists used a validated questionnaire, most preferring to rely on their own clinical skills or recalling the two simple questions of the short Patient Health Questionnaire (PHQ2). Staff suggested that ideal screening practice was to use one, two or three simple questions or a short validated questionnaire but not to refer to a specialist for a diagnosis. The main barrier to successful screening was lack of time but insufficient training and low confidence were also influential. Once distress was detected, 90% of nurses but only 40% of doctors were prepared to give distressed patients as much time as they needed. Predictors of clinicians' willingness to use more advanced screening methods were length of follow-up appointments and time clinicians were prepared to spend detecting distress. We suggest that future field studies of screening tools should also measure the issue of acceptability.

Collaborative mental health and primary care for bipolar disorder

This article discusses the use of integrated care models, in particular, collaborative care, in the treatment of bipolar disorder. Dr. Williams first discusses how care delivered via a collaboration between primary care and psychiatric providers has the potential to improve both mental health and general medical outcomes for patients with bipolar disorder. He describes promising findings from studies of the use of collaborative care in the treatment of depression, an area where this model has received the most study. Dr. Williams then discusses how such collaborative care models might best be implemented in the treatment of bipolar disorder. In the second half of the article, Dr. Manning focuses on five key issues that are an especially appropriate focus for collaborative care for bipolar disorder and for which the STAndards for BipoLar Excellence (STABLE) Project developed quality improvement performance measures: assessment for risk of suicide, assessment for substance use/abuse, monitoring for extrapyramidal symptoms, monitoring of metabolic parameters (e.g., monitoring for weight gain, hyperglycemia, hyperlipidemia), and provision of bipolar-specific psychoeducation.

Improving substance abuse screening and intervention in a primary care clinic

Despite recent efforts to educate primary care providers in the identification and management of patients presenting with substance abuse problems, many opportunities to identify and intervene with these patients are overlooked. This project was designed to identify factors that interfere with rates of screening and brief intervention (SBI) of substance abuse problems in a primary care clinic in a major academic medical center in New York City. Six informants representing the disciplines of medicine, nursing, and social work in the primary care clinic provided information regarding SBI. Analysis was focused on substantiation of the need for enhanced diffusion of knowledge related to screening for substance abuse problems to improve rates of SBI in primary care. Recommendations for improvement included continued promotion of SBI by influential role models and opinion leaders, improvement in primary care providers' perceptions of the perceived characteristics of SBI to improve rates of adoption, implementation of interdisciplinary educational initiatives toward the goal of improving rates of SBI in the primary care clinic, and initiation of translational research at the clinic supporting SBI in primary care.