Improving access to geriatric mental health services: a randomized trial comparing treatment engagement with integrated versus enhanced referral care for depression, anxiety, and at-risk alcohol use

The Role of Proximity to Coordinated Specialty Care For Early Psychosis And Program Engagement in Washington State: The Interaction of Travel Time, Race, and Ethnicity

OBJECTIVE

Proximity to mental health services is a predictor of timely access to services. The present study sought to investigate whether travel time was associated with engagement in coordinated specialty care (CSC) for early psychosis, with specific attention to whether the interaction of travel time by race and ethnicity had differential impact.

DATA SOURCE/STUDY SETTING

Data collected between 2019 and 2022 as part of the New Journeys evaluation, the CSC model in Washington State.

STUDY DESIGN

This cross-sectional study included a sample of 225 service users with first episode psychosis (FEP) who had received services from New Journeys.

DATA COLLECTION

Service users' addresses, and the physical location of CSC were geocoded. Spatial proximity was calculated as travel time in minutes. Scheduled appointments, attendance and program status were captured monthly by clinicians as part of the New Journeys measurement battery.

PRINCIPAL FINDINGS

Proximity was significantly associated with the number of appointments scheduled and attended, and program status (graduation/completion and disengagement). Among Hispanic service users with spatial proximity further away from CSC (longer commutes) was associated with a lower likelihood of graduating/completing CSC compared to non-Hispanic service users (p = .04). Non-white services users had a higher risk of disengagement from CSC compared to white service users (p = .03); additionally, the effects of spatial proximity on disengagement were amplified for non-White service users (p = .03).

CONCLUSIONS

Findings suggest that proximity is associated with program engagement and partially explains potential differences in program status among ethnoracial group.

Older Adults in Administrative Quagmire: A Scoping Review of Policy and Program Coordination Across Six Marginalized Older Adult Populations

BACKGROUND AND OBJECTIVES

Coordination of governmental action is crowded with policies and programs that are highly interdependent, sometimes operating in silos if not contradicting each other. These dilemmas, or administrative quagmires, are heightened for older adults in general, but they are particularly problematic for marginalized older adults because these groups often require public assistance and support. This scoping review studies the coordination of governmental action on aging published in social science journals, focusing on 6 groups of marginalized older adults: those with histories of immigration, individuals with severe mental health problems, those who have had experiences of homelessness, formerly incarcerated individuals, members of the LGBT (lesbian, gay, bisexual, and transgender) community, and individuals living in a rural area.

RESEARCH DESIGN AND METHODS

A 5-stage scoping review methodology was followed, and 53 articles (published between 2000 and 2022) from 5 social science databases were analyzed.

RESULTS

The analysis revealed a limited number of contributions with coordination as a primary focus. Understandings of coordination varied but tended to examine structure, organization, and relationships between sectors. When coordination was the primary object of a study, it was often analyzed in 1 specific policy area or within a clinical setting along the lines of facilitating care coordination.

DISCUSSION AND IMPLICATIONS

This scoping review reveals a mutual neglect on the part of public administration and policy scholars toward marginalized older adults and a lack of public administration considerations on the part of scholars studying long-term care and social service programs for these marginalized older adults.

Engaging primary care patients at risk for suicide in mental health treatment: user insights to inform implementation strategy design

BACKGROUND

Given that the majority of suicide decedents visit primary care in the year preceding death, primary care has been identified as a key setting in which to engage patients at risk for suicide in mental health services. The objective of this research was to identify barriers and facilitators to engagement in mental health services among primary care patients at risk for suicide to inform the development of strategies to increase engagement.

METHODS

Seventy-four semi-structured qualitative interviews were conducted with primary care patients (n = 20), primary care (n = 18) and behavioral health (n = 12) clinicians, mental health intake coordinators (n = 4), and health system and clinic leaders (n = 20). Patients who had been referred for mental health services from primary care and reported an elevated score (≥ 1) on item 9 on the Patient Health Questionnaire at the time of referral were eligible to participate. Eligible clinicians and leaders were employed in a primary care or behavioral health setting in a single large health system with an integrated mental health program. Interviews typically lasted 30-60 min, were completed over video conference or phone, and were coded by members of the research team using a rapid qualitative analysis procedure.

RESULTS

Participants were primarily female (64.9%), white (70.3%) and non-Hispanic/Latine (91.9%). The most identified barriers to mental health care engagement were waitlists, capacity limits, insurance, patient characteristics, communication, collaboration, and/or difficulties surrounding travel. The most commonly cited facilitators of engagement included telehealth, integrated care models, reminders, case management support, psychoeducation, motivational enhancement, and scheduling flexibility. Concrete suggestions for improving engagement in mental health services included increasing communication between providers, streamlining referral and intake processes, providing reminders and follow ups, and advocacy for increased reimbursement for suicide risk assessment.

CONCLUSIONS

Results underscore the myriad barriers patients at risk for suicide encounter when attempting to engage in mental health care in a primary care setting. Facilitators of engagement and suggestions for improving connections to care were also identified, which can inform the design of implementation strategies to improve engagement in mental health services among primary care patients at risk for suicide.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT05021224 (Registered August 19, 2021).

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.

Interventions targeting patients with co-occuring severe mental illness and substance use (dual diagnosis) in general practice settings - a scoping review of the literature

BACKGROUND

People with dual diagnosis die prematurely compared to the general population, and general practice might serve as a setting in the healthcare system to mend this gap in health inequity. However, little is known about which interventions that have been tested in this setting.

AIM

To scope the literature on interventions targeting patients with dual diagnosis in a general practice setting, the outcomes used, and the findings.

DESIGN AND SETTING

A scoping review of patients with dual diagnosis in general practice.

METHODS

From a predeveloped search string, we used PubMed (Medline), PsychInfo, and Embase to identify scientific articles on interventions. Studies were excluded if they did not evaluate an intervention, if patients were under 18 years of age, and if not published in English. Duplicates were removed and all articles were initially screened by title and abstract and subsequent fulltext were read by two authors. Conflicts were discussed within the author group. A summative synthesis of the findings was performed to present the results.

RESULTS

Seven articles were included in the analysis. Most studies investigated integrated care models between behavioural treatment and primary care, and a single study investigated the delivery of Cognitive Behavioral treatment (CBT). Outcomes were changes in mental illness scores and substance or alcohol use, treatment utilization, and implementation of the intervention in question. No studies revealed significant outcomes for patients with dual diagnosis.

CONCLUSION

Few intervention studies targeting patients with dual diagnosis exist in general practice. This calls for further investigation of the possibilities of implementing interventions targeting this patient group in general practice.

Place-Based FACT: Treatment Outcomes and Patients' Experience with Integrated Neighborhood-Based Care

Locating specialized mental healthcare services in the neighborhood of people with severe mental illnesses (SMI) has been suggested as a way of improving treatment outcomes by increasing patient engagement and integration with the local care landscape. The current mixed methods study aimed to examine patient experience and treatment outcomes in three Flexible Assertive Community Treatment (FACT) teams that relocated to the neighborhood they served, compared to seven teams that continued to provide FACT as usual from a central office. Routine Outcome Measurement (ROM) and care use data were analyzed to compare change in treatment outcomes for patients in place-based FACT (n = 255) and FACT as usual (n = 833). Additionally, retrospective in-depth interviews were conducted with twenty patients about their experience with place-based FACT. Quantitative analysis showed mental health admission days decreased more in place-based than FACT as usual, although this difference was small. Both groups showed improved quality of life, psychosocial functioning, and symptomatic remission rates, and decreased unmet and overall needs for care. There was no change over time in met needs for care, employment, and daily activities. Qualitative analysis showed that patients experienced place-based FACT as more accessible, a better safety net, a more personal approach, better integrated with other forms of care, involving their social network, and embedded in their neighborhood and daily environment. This study showed that location and integration matter to patients, and the long term impact of place-based FACT on treatment outcomes should be explored.

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.

Patterns of health care interactions of individuals with alcohol use disorder: A latent class analysis

INTRODUCTION

Given the high rates at which individuals with alcohol use disorder (AUD) utilize health care for co-existing conditions, health systems are promising venues for interventions that will facilitate access to AUD treatment. However, how individuals with AUD interact with such systems and, thus, how systems should intervene is unclear. In this study, we seek to identify patterns in how individuals diagnosed with AUD within an academic health system interacted with the system prior to diagnosis.

METHODS

We use electronic health records from a single academic health system in a major US metropolitan area to create a deidentified retrospective cohort including all individuals age 18+ diagnosed with AUD 2010-2019 (n = 26,899). Latent class analysis (LCA) identified subgroups defined by aspects of previous system interaction and health status, including having an in-system primary care provider, previous utilization of primary and specialty care, diagnosis setting, payer, and presence of other chronic conditions. We then assessed subgroup differences in demographics and associations with in-system AUD treatment receipt in the year following diagnosis, adjusting for demographics.

RESULTS

The population was on average 38.6 years old (standard deviation = 15.4) and predominantly male (66.1 %), White (64.5 %), and not of Hispanic/Latino ethnicity (87.8 %). Only 4.7 % received in-system treatment following diagnosis. We deemed the four-class model the optimal LCA model. This model identified subgroups that can be described as 1) average utilization (20.7 % of population), 2) low utilization (54.5 %), 3) high health burden and low utilization (14.2 %), and 4) high health burden and high utilization (10.6 %). Predicted membership in the high health burden and high utilization subgroup and low utilization subgroup were associated with higher and lower odds of treatment receipt, respectively, compared with predicted membership in the average utilization subgroup (odds ratio (OR) for high/high subgroup = 1.21, 95 % confidence interval (CI) = 1.01, 1.27; OR for low subgroup = 0.29 95 % CI = 0.24, 0.34).

CONCLUSION

Individuals diagnosed with AUD within a health system interact with that system in markedly different ways and are unlikely to benefit uniformly from system-based interventions to facilitate treatment. Group-tailored interventions are more likely to have impact and provide returns on investments for systems.

Mental health integrated care models in primary care and factors that contribute to their effective implementation: a scoping review

BACKGROUND

In the state of Victoria, Australia, the 111-day lockdown due to the COVID-19 pandemic exacerbated the population's prevailing state of poor mental health. Of the 87% of Australians who visit their GP annually, 71% of health problems they discussed related to psychological issues. This review had two objectives: (1) To describe models of mental health integrated care within primary care settings that demonstrated improved mental health outcomes that were transferable to Australian settings, and (2) To outline the factors that contributed to the effective implementation of these models into routine practice.

METHODS

A scoping review was undertaken to synthesise the evidence in order to inform practice, policymaking, and research. Data were obtained from PubMed, CINAHL and APA PsycINFO.

RESULTS

Key elements of effective mental health integrated care models in primary care are: Co-location of mental health and substance abuse services in the primary care setting, presence of licensed mental health clinicians, a case management approach to patient care, ongoing depression monitoring for up to 24 months and other miscellaneous elements. Key factors that contributed to the effective implementation of mental health integrated care in routine practice are the willingness to accept and promote system change, integrated physical and mental clinical records, the presence of a care manager, adequate staff training, a healthy organisational culture, regular supervision and support, a standardised workflow plan and care pathways that included clear role boundaries and the use of outcome measures. The need to develop sustainable funding mechanisms has also been emphasized.

CONCLUSION

Integrated mental health care models typically have a co-located mental health clinician who works closely with the GP and the rest of the primary care team. Implementing mental health integrated care models in Australia requires a 'whole of system' change. Lessons learned from the Mental Health Nurse Incentive Program could form the foundation on which this model is implemented in Australia.

Health outcomes and service use patterns associated with co-located outpatient mental health care and alcohol and other drug specialist treatment: A systematic review

ISSUES

Despite long-standing recommendations to integrate mental health care and alcohol and other drug (AOD) treatment, no prior study has synthesised evidence on the impact of physically co-locating these specialist services on health outcomes.

APPROACH

We searched Medline, PsycINFO, Embase, Web of Science and CINAHL for studies examining health outcomes associated with co-located outpatient mental health care and AOD specialist treatment for adults with a dual diagnosis of substance use disorder and mental illness. Due to diversity in study designs, patient populations and outcome measures among the included studies, we conducted a narrative synthesis. Risk of bias was assessed using the MASTER scale.

KEY FINDINGS

Twenty-eight studies met our inclusion criteria. We found provisional evidence that integrated care that includes co-located mental health care and AOD specialist treatment is associated with reductions in substance use and related harms and mental health symptom severity, improved quality of life, decreased emergency department presentations/hospital admissions and reduced health system expenditure. Many studies had a relatively high risk of bias and it was not possible to disaggregate the independent effect of physical co-location from other common aspects of integrated care models such as care coordination and the integration of service processes.

IMPLICATIONS

There are few high-quality, peer-reviewed studies establishing the impact of co-located mental health care and AOD specialist treatment on health outcomes. Further research is required to inform policy, guide implementation and optimise practice.

CONCLUSION

Integrated care that includes the co-location of mental health care and AOD specialist treatment may yield health and economic benefits.

Estimating Joint Health State Utility Algorithms Under Partial Information

OBJECTIVES

We explored the performance of existing joint health state utility estimators when data are not available on utilities that isolate single-condition health states excluding any co-occurring condition.

METHODS

Using data from the National Epidemiologic Survey on Alcohol and Related Conditions-III, we defined 2 information sets: (1) a full-information set that includes the narrowly defined health state utilities used in most studies that test the performance of joint health state utility estimators, and (2) a limited information set that includes only the more broadly defined health state utilities more commonly available to researchers. We used an example of alcohol use disorder co-occurring with cirrhosis of the liver, depressive disorder, or nicotine use disorder to illustrate our analysis.

RESULTS

We found that the performance of joint health state utility estimators is appreciably different under limited information than under full information. Full-information estimators typically overestimate the joint state utility, whereas limited-information estimators underestimate the joint state utility, except for the minimum estimator, which is overestimated in all cases.

CONCLUSIONS

Researchers using joint health state utility estimators should understand the information set available to them and use methodological guidance appropriate for that information set. We recommend the minimum estimator under limited information based on its ease of use, consistency (and therefore a predictable direction of bias), and lower root mean squared error.

Health Psychology Services for People in Disadvantaged Regions of Hungary: Experiences from the Primary Health Care Development Model Program

BACKGROUND

The importance of community health psychology in providing complex bio-psycho-social care is well documented. We present a mixed-method outcome-monitoring study of health psychology services in the public-health-focused Primary Health Care Development Model Program (2012-2017) in four disadvantaged micro-regions in northeast Hungary.

METHODS

Study 1 assessed the availability of the services using a sample of 17,003 respondents. Study 2 applied a follow-up design to measure the mental health outcomes of the health psychology services on a sample of 132 clients. In Study 3, we conducted focus-group interviews to assess clients' lived experiences.

RESULTS

More mental health issues and higher education predicted a higher probability of service use. Follow-up showed that individual and group-based psychological interventions resulted in less depression and (marginally) higher well-being. Thematic analysis of the focus-group interviews indicated that participants deemed topics such as psychoeducation, greater acceptance of psychological support, and heightened awareness of individual and community support important.

CONCLUSIONS

The results of the monitoring study demonstrate the important role health psychology services can play in primary healthcare in disadvantaged regions in Hungary. Community health psychology can improve well-being, reduce inequality, raise the population's health awareness, and address unmet social needs in disadvantaged regions.

Evaluating the Implementation of a Model of Integrated Behavioral Health in Primary Care: Perceptions of the Healthcare Team

OBJECTIVES

This study aims to compare primary care providers and medical assistants in degrees of comfort, confidence, and consistency when addressing behavioral health concerns with patients before and after the implementation of a model of integrated behavioral health in primary care (IBHPC), and evaluate whether these perceptions differ based on increased access to behavioral health clinicians.

METHODS

This longitudinal study was conducted at 2 primary care clinics in Northern California while implementing an IBHPC model. The Integrated Behavioral Health Staff Perceptions Survey was administered to assess the comfort, confidence, and consistency of behavioral health practices. Confidential online surveys were distributed to primary care faculty and staff members before and post-implementation. Responses from providers and medical assistants were compared between pre- and post-implementation with linear regression analyses. The relationships between accessibility to behavioral health clinicians and a change in comfort, confidence, and consistency of behavioral health practices were explored using a linear mixed-effects model.

RESULTS

A total of 35 providers and medical assistants completed the survey both before and post-implementation of IBHPC. Over time, there were increasingly positive perceptions about the consistency of behavioral health screening (P = .03) and overall confidence in addressing behavioral health concerns (P = .005). Comfort in addressing behavioral health concerns did not significantly change for either providers or staff over time. Medical assistants were initially more confident and comfortable addressing behavioral health concerns than providers, but providers' attitudes increased post-IBHPC implementation. Improved access to behavioral health clinicians was associated with greater consistency of screening and referral to specialty mental health care (P < .001).

CONCLUSION

The present study is the first to explore differences in provider and medical assistant perceptions during the course of an IBHPC implementation. Findings underscore the importance of integrating medical assistants, along with providers, into all phases of the implementation process.

Integration of pharmacotherapy for alcohol use disorder treatment in primary care settings: A scoping review

BACKGROUND

Alcohol use disorder (AUD) represents the most prevalent addiction in the United States. Integration of AUD treatment in primary care settings would expand care access. The objective of this scoping review is to examine models of AUD treatment in primary care that include pharmacotherapy (acamprosate, disulfiram, naltrexone).

METHODS

The team undertook a search across MEDLINE, PsycINFO, CINAHL, the Cochrane Central Register of Controlled Trials, and Web of Science on May 21, 2021. Eligibility criteria included: patient population ≥ 18 years old, primary care-based setting, US-based study, presence of an intervention to promote AUD treatment, and prescription of FDA-approved AUD pharmacotherapy. Study design was limited to controlled trials and observational studies. We assessed study bias using a modified Oxford Centre for Evidence-based Medicine Rating Framework quality rating scheme.

RESULTS

The qualitative synthesis included forty-seven papers, representing 25 primary studies. Primary study sample sizes ranged from 24 to 830,825 participants and many (44 %) were randomized controlled trials. Most studies (80 %) included a nonpharmacologic intervention for AUD: 56 % with brief intervention, 40 % with motivational interviewing, and 12 % with motivational enhancement therapy. A plurality of studies (48 %) included mixed pharmacologic interventions, with administration of any combination of naltrexone, acamprosate, and/or disulfiram. Of the 47 total studies included, 68 % assessed care initiation and engagement. Fewer studies (15 %) explored practices surrounding screening for or diagnosing AUD. Outcome measures included receipt of pharmacotherapy and alcohol consumption, which about half of studies included (53 % and 51 %, respectively). Many of these outcomes showed significant findings in favor of integrated care models for AUD.

CONCLUSIONS

The integration of AUD pharmacotherapy in primary care settings may be associated with improved process and outcome measures of care. Future research should seek to understand the varied experiences across care integration models.

Comorbidity and Management of Concurrent Psychiatric and Medical Disorders

Aging increases susceptibility to medical and psychiatric comorbidity via interrelated biological, psychological, and social mechanisms. Mental status changes or other psychiatric symptoms occurring in older adults with medical disorders most often result from delirium, depression, or the onset of Alzheimer's disease and related dementias (ADRD). Clinicians can use evidence-based tools to evaluate such symptoms including the 4A's Test for delirium, the Saint Louis University Mental Status Exam, and the Geriatric Depression Scale. Innovative models such as collaborative care can improve the outcome of care of older adults with medical disorders requiring treatment for depression or ADRD..

Collaborative Care for Low-Income Patients From Racial-Ethnic Minority Groups in Primary Care: Engagement and Clinical Outcomes

OBJECTIVE

To assess model impact and opportunities for improvement, this study examined collaborative care model (CoCM) engagement and clinical outcomes among low-income patients from racial-ethnic minority groups with depression and anxiety.

METHODS

Starting in 2015, the CoCM was implemented in seven primary care practices of an urban academic medical center serving patients from racial-ethnic minority backgrounds, predominantly Medicaid beneficiaries. Eligible individuals scored positive for depressive or anxiety symptoms (or both) on the Patient Health Questionnaire-2 (PHQ-2) and PHQ-9 and the Generalized Anxiety Disorder Scale-2 (GAD-2) and GAD-7 during systematic screening in primary care settings. Screening rates and yield, patient characteristics, and CoCM engagement and outcomes were examined. Clinical improvement was measured by the difference in PHQ-9 and GAD-7 scores at baseline and at 10-to-14-week follow-up.

RESULTS

High rates of screening (87%, N=88,236 of 101,091) and identification of individuals with depression or anxiety (13%, N=11,886) were observed, and 58% of 3,957 patients who engaged in minimally adequate CoCM treatment had significant clinical improvement. Nevertheless, only 56% of eligible patients engaged in the model, and 25% of those individuals did not return for at least one follow-up appointment. Being female with clinically significant comorbid anxiety and depressive symptoms and having Medicaid or commercial insurance increased the likelihood of CoCM engagement.

CONCLUSIONS

CoCM can help engage vulnerable patients in behavioral health care and improve clinical symptoms. However, significant opportunity exists to advance the model's impact in treating depressive and anxiety disorders and decreasing health disparities by addressing engagement barriers.

Piloting a Dementia Caregiver Intervention in a Primary Care Setting

OBJECTIVES

The purpose of this pilot study is to examine the efficacy of a theoretically based, 6-week dementia caregiver support group in a primary care setting.

METHODS

Using a quasi-experimental design, 22 participants completed the caregiver support group. Participants were mostly in their mid-60 s (M = 63 years old), female (n = 19), Caucasian (n = 14), and identified as either the care recipient's child or spouse (n = 19). At baseline and 6 weeks, participants completed self-report measures related to demographic information, caregiver preparedness, strain, and depressive symptoms, and care recipient's neuropsychiatric symptoms. Participants also completed a satisfaction survey. Within-subjects t-tests were run to determine if participants' scores changed over time.

RESULTS

Results revealed that participants demonstrated a significant increase in mean caregiver preparedness scores. No significant effects were found for caregiver strain, depressive symptoms, and distress related to neuropsychiatric symptoms. Participants rated being largely satisfied with the program.

CONCLUSIONS

Results suggest that this 6-week caregiver support group may be a promising caregiver intervention in primary care clinics.

CLINICAL IMPLICATIONS

Findings support the importance of caregiver support for persons with dementia in primary care.

Mental Health Care Use Among U.S. Military Veterans: Results From the 2019-2020 National Health and Resilience in Veterans Study

OBJECTIVE

Psychiatric and substance use disorders are prevalent among U.S. military veterans, yet many veterans do not engage in treatment. The authors examined characteristics associated with use of mental health care in a nationally representative veteran sample.

METHODS

Using 2019-2020 data from the National Health and Resilience in Veterans Study (N=4,069), the authors examined predisposing, enabling, and need factors and perceived barriers to care as correlates of mental health care utilization (psychotherapy, counseling, or pharmacotherapy). Hierarchical logistic regression and relative importance analyses were used.

RESULTS

Among all veterans, 433 (weighted prevalence, 12%) reported current use of mental health care. Among 924 (26%) veterans with a probable mental or substance use disorder, less than a third (weighted prevalence, 27%) reported care utilization. Mental dysfunction (24%), posttraumatic stress disorder symptom severity (18%), using the U.S. Department of Veterans Affairs as primary health care provider (14%), sleep disorder (12%), and grit (i.e., trait perseverance including decision and commitment to address one's needs on one's own; 7%) explained most of the variance in mental health care utilization in this subsample. Grit moderated the relationship between mental dysfunction and use of care; among veterans with high mental dysfunction, those with high grit (23%) were less likely to use services than were those with low grit (53%).

CONCLUSIONS

A minority of U.S. veterans engaged in mental health care. Less stigmatized need factors (e.g., functioning and sleep difficulties) may facilitate engagement. The relationship between protective and need factors may help inform understanding of veterans' decision making regarding treatment seeking and outreach efforts.

Health care utilisation two years prior to suicide in Sweden: a retrospective explorative study based on medical records

OBJECTIVE

Previous literature has suggested that identifying putative differences in health care seeking patterns before death by suicide depending on age and gender may facilitate more targeted suicide preventive approaches. The aim of this study is to map health care utilisation among individuals in the two years prior to suicide in Sweden in 2015 and to examine possible age and gender differences.

METHODS

Design: A retrospective explorative study with a medical record review covering the two years preceding suicide.

SETTING

All health care units located in 20 of Sweden's 21 regions.

PARTICIPANTS

All individuals residing in participating regions who died by suicide during 2015 (n = 949).

RESULTS

Almost 74% were in contact with a health care provider during the 3 months prior to suicide, and 60% within 4 weeks. Overall health care utilisation during the last month of life did not differ between age groups. However, a higher proportion of younger individuals (< 65 years) were in contact with psychiatric services, and a higher proportion of older individuals (≥ 65 years) were in contact with primary and specialised somatic health care. The proportion of women with any type of health care contact during the observation period was larger than the corresponding proportion of men, although no gender difference was found among primary and specialised somatic health care users within four weeks and three months respectively prior to suicide.

CONCLUSION

Care utilisation before suicide varied by gender and age. Female suicide decedents seem to utilise health care to a larger extent than male decedents in the two years preceding death, except for the non-psychiatric services in closer proximity to death. Older adults seem to predominantly use non-psychiatric services, while younger individuals seek psychiatric services to a larger extent.

Neurocognitive and substance use disorders in older adults: challenges and evidence

Purpose

This study aims to review the presentation of substance use disorders in older adults, how addiction intertwines with neurocognitive disorders and how to approach this vulnerable population.

Design/methodology/approach

Electronic data searches of PubMed, Medline and the Cochrane Library (years 2000–2021) were performed using the keywords “neurocognitive,” “dementia,” “substance use,” “addiction,” “older adults” and “elderly.” The authors, in consensus, selected pivotal studies and conducted a narrative synthesis of the findings.

Findings

Research about substance use disorders in older adults is limited, especially in those with superimposed neurocognitive disorders. Having dual diagnoses can make the identification and treatment of either condition challenging. Management should use a holistic multidisciplinary approach that involves medical professionals and caregivers.

Originality/value

This review highlights some of the intertwining aspects between substance use disorders and neurocognitive disorders in older adults. It provides a comprehensive summary of the available evidence on treatment in this population.

Older adults’ mental health information preferences: a call for more balanced information to empower older adults’ mental health help-seeking

A small minority of older adults seek psychological help when they need it. Barriers to mental health service use among older adults include low mental health literacy and reduced opportunities for shared decision-making in health care. There is a gap in the literature examining the mental health information preferences of older adults. The objectives of this study were to describe the information preferences and predictors of preferences among older adults. In total, 229 adults aged 50 years and older in central Canada responded to a questionnaire investigating socio-demographic, psycho-social and health-related characteristics, as well as mental health information preferences. Descriptive analysis quantified participants’ ratings of information preferences and hierarchical linear regression analysis determined predictors of their preferences. Older adults rated all mental health content items as very important. Most participants preferred detailed information (two to six pages) on all treatment options (psychological, pharmacological, combined and self-help). Older adults significantly preferred discussion with a heath-care provider and written information, in comparison to other formats. Older adults also significantly preferred to consult family, friends and heath-care professionals over other sources. Socio-demographic and psycho-social characteristics accounted for some of the variance in predicting older adults’ information preferences. Findings highlight older adults’ desire to be involved in decisions concerning mental health supports. Providing balanced information concerning mental health treatment may increase empowerment in mental health help-seeking.

Digital mental health intervention for orthopedic patients with symptoms of depression and/or anxiety: Pilot feasibility study

BACKGROUND

Symptoms of depression and anxiety commonly coexist with chronic musculoskeletal pain, and when this occurs, standard orthopedic treatment is less effective. Nevertheless, addressing mental health is not yet a routine part of standard orthopedic treatment, in part due to access related barriers. Digital mental health intervention offers the potential to be a scalable resource that could feasibly be incorporated into orthopedic care.

OBJECTIVE

The primary purpose of this study was to assess the feasibility of introducing a digital mental health intervention (Wysa) within an outpatient orthopedic setting to patients who endorse coexisting symptoms of depression and/or anxiety. The secondary purpose was to perform a preliminary effectiveness analysis of the intervention.

METHODS

In this single-arm, prospective cohort study, participants included adult patients (18 years and older) who presented to a non-surgical orthopedic specialist at a single tertiary care academic center for evaluation of a musculoskeletal condition and who self-reported symptoms of depression and/or anxiety (Patient-Reported Outcomes Measurement Information System (PROMIS) Depression and/or Anxiety score ≥ 55). Enrollment was performed face-to-face by a research coordinator immediately after the participant's encounter with an orthopedic clinician. Participants were provided two months of access to a mobile app called Wysa, which is an established, multi-component digital mental health intervention that uses chatbot technology and text-based access to human counselors to deliver cognitive behavioral therapy, mindfulness training, and sleep tools, among other features. For this study, Wysa access also included novel, behavioral activation based features specifically developed for users with chronic pain. Primary feasibility outcomes included the study recruitment rate, retention rate, and engagement rate with Wysa (defined as engaging with a therapeutic Wysa tool at least once during the study period). Secondary effectiveness outcomes were between-group differences in mean longitudinal PROMIS mental and physical health score changes at two-month follow-up between high Wysa users and low Wysa users, defined by a median split.

RESULTS

The recruitment rate was 61/208 (29%), retention rate was 51/61 (84%), and engagement rate was 44/61 (72%). Compared to low users, high Wysa users achieved greater improvement in PROMIS Anxiety (between-group difference -4.2 points [95% CI -8.1 to -0.2], P=.044) at two-month follow-up. Between-group differences in PROMIS Depression (-3.2 points [-7.5 to 1.2], P=.15) and Pain Interference (-2.3 points [-6.3 to 1.7], P=.26) favored high users but did not meet statistical significance. Improvements in PROMIS Physical Function were comparable between groups.

CONCLUSIONS

Delivery of a digital mental health intervention within the context of orthopedic care is feasible and demonstrates potential to improve mental health and pain-related impairment to a clinically meaningful degree. Participants' engagement rates exceeded industry standards, and additional opportunities to improve recruitment and retention were identified. Further pilot study followed by a definitive, randomized controlled trial is warranted.

CLINICALTRIAL

ClinicalTrials.gov NCT202005219.

Applying Geriatric Principles to Hazardous Drinking in Older Adults

Older adults continue to drink as they age. Aging changes alcohol kinetics just as with any other drug. Older adults have increased sensitivity to acute alcohol intake that accounts for the increased risk of falls, traffic accidents, and other injury. The Annual Medicare Wellness Exam is an excellent opportunity to introduce screening for unsafe drinking along with accumulated risks and deficits of aging. Older adults have responded well to brief interventions for unhealthy drinking. In the presence of alcohol use disorder or serious comorbidity including psychiatric illness, referral to specialized multidisciplinary care can be lifesaving.

Comparison of Teleintegrated Care and Telereferral Care for Treating Complex Psychiatric Disorders in Primary Care: A Pragmatic Randomized Comparative Effectiveness Trial

Importance

Only one-third of patients with complex psychiatric disorders engage in specialty mental health care, and only one-tenth receive adequate treatment in primary care. Scalable approaches are critically needed to improve access to effective mental health treatments in underserved primary care settings.

Objective

To compare 2 clinic-to-clinic interactive video approaches to delivering evidence-based mental health treatments to patients in primary care clinics.

Design, Setting, and Participants

This pragmatic comparative effectiveness trial used a sequential, multiple-assignment, randomized trial (SMART) design with patient-level randomization. Adult patients treated at 24 primary care clinics without on-site psychiatrists or psychologists from 12 federally qualified health centers in 3 states who screened positive for posttraumatic stress disorder and/or bipolar disorder and who were not already receiving pharmacotherapy from a mental health specialist were recruited from November 16, 2016, to June 30, 2019, and observed for 12 months.

Interventions

Two approaches were compared: (1) telepsychiatry/telepsychology-enhanced referral (TER), where telepsychiatrists and telepsychologists assumed responsibility for treatment, and (2) telepsychiatry collaborative care (TCC), where telepsychiatrists provided consultation to the primary care team. TER included an adaptive intervention (phone-enhanced referral [PER]) for patients not engaging in treatment, which involved telephone outreach and motivational interviewing.

Main Outcomes and Measures

Survey questions assessed patient-reported outcomes. The Veterans RAND 12-item Health Survey Mental Component Summary (MCS) score was the primary outcome (range, 0-100). Secondary outcomes included posttraumatic stress disorder symptoms, manic symptoms, depressive symptoms, anxiety symptoms, recovery, and adverse effects.

Results

Of 1004 included participants, 701 of 1000 (70.1%) were female, 660 of 994 (66.4%) were White, and the mean (SD) age was 39.4 (12.9) years. Baseline MCS scores were 2 SDs below the US mean; the mean (SD) MCS scores were 39.7 (14.1) and 41.2 (14.2) in the TCC and TER groups, respectively. There was no significant difference in 12-month MCS score between those receiving TCC and TER (β = 1.0; 95% CI, -0.8 to 2.8; P = .28). Patients in both groups experienced large and clinically meaningful improvements from baseline to 12 months (TCC: Cohen d = 0.81; 95% CI, 0.67 to 0.95; TER: Cohen d = 0.90; 95% CI, 0.76 to 1.04). For patients not engaging in TER at 6 months, there was no significant difference in 12-month MCS score between those receiving PER and TER (β = 2.0; 95% CI, -1.7 to 5.7; P = .29).

Conclusions and Relevance

In this comparative effectiveness trial of patients with complex psychiatric disorders randomized to receive TCC or TER, significantly and substantially improved outcomes were observed in both groups. From a health care system perspective, clinical leadership should implement whichever approach is most sustainable.

Trial Registration

ClinicalTrials.gov Identifier: NCT02738944.

What Are Patient Preferences for Integrated Behavioral Health in Primary Care?

Background: Behavioral health services, integrated into primary care practices, have become increasingly implemented. Although patient satisfaction has been studied, limited information exists about patient preferences for integrated behavioral health in primary care and how perceptions may vary. Objective: To determine patient preferences for integrated behavioral health within primary care and explore differences across patient groups. Methods: A self-report survey was distributed within a quality improvement initiative in an academic health system. A brief 8-item self-report questionnaire of perceptions and preferences for integrated behavioral health was administered to 752 primary care patients presenting before their visits at two primary care clinics. Participation was voluntary, responses were anonymous, and all patients presenting during a three-week timeframe were eligible. Results: In general, patients preferred to have behavioral health concerns addressed within primary care (n = 301; 41%) rather than referral to a specialist (7.5%; n = 55). There was no evidence of variation in preferences by demographic characteristics. Comfort levels to receive behavioral health services (P < .001) and perceived needs being met were significantly associated with preferences for receiving IBHPC (P < .001). Conclusion: This project provided valuable data to support the implementation of integrated behavioral health services in primary care clinics. In general, patients prefer to have behavioral health issues addressed within their primary care experience rather than being referred to specialty mental health care. This study adds to an expanding pool of studies exploring patient preferences for integrated behavioral health in primary care.

The graying of integrated health: the specialized role of psychology in geriatric primary care

OBJECTIVES

Integrating behavioral health services into primary care is an important global initiative to improve access to mental health services. Within the Veterans Health Administration (VHA), Geriatric Patient Aligned Care Teams (GeriPACTs) are one model of integrated care for frail older adults to serve older Veterans with geriatric syndromes and increased probability of cognitive impairment. Understanding of the role of psychology in GeriPACT is limited. This study examines this role, describes the practice of these psychologists, and evaluates the integration of psychology into geriatric primary care.

METHODS

A mixed-methods design was used. Recruitment occurred through two VHA listservs for GeriPACT and Primary Care Mental Health Integration (PC-MHI) psychologists. Surveys examined referral processes, service access, clinical services provision, and use of psychotherapy modalities. Twenty psychologists participated. Structured follow-up interviews were conducted with five participants.

RESULTS

A large minority of psychologists did not have FTE allotted for GeriPACT work they provided (40%). Sixty percent were assigned to one GeriPACT team. Twenty percent served four to seven GeriPACT teams. Eighty percent provided same-day services. Cognitive assessment was provided weekly by over sixty percent of providers who had FTE allotment to this role. Qualitative data provided a rich description of psychologists' perceptions of their role, team functioning, referral processes, visit structure, and other factors.

CONCLUSION

Findings are discussed in the context of the World Health Organization's guidelines for integrating mental health into primary care. Data suggest a need for an integrated model that adapts to the special needs of older adults in primary care.

Integrated Community Collaborative Care for Seniors with Depression/Anxiety and any Physical Illness

Background

We report on the feasibility and effectiveness of an integrated community collaborative care model in improving the health of seniors with depression/anxiety symptoms and chronic physical illness.

Methods

This community collaborative care model integrates geriatric medicine and geriatric psychiatry with care managers (CM) providing holistic initial and follow-up assessments, who use standardized rating scales to monitor treatment and provide psychotherapy (ENGAGE). The CM presents cases in a structured case review to a geriatrician and geriatric psychiatrist. Recommendations are communicated by the CM to the patient’s primary care provider.

Results

187 patients were evaluated. The average age was 80 years old. Two-thirds were experiencing moderate-to-severe depression upon entry and this proportion decreased significantly to one-third at completion. Qualitative interviews with patients, family caregivers, team members, and referring physicians indicated that the program was well-received. Patients had on average six visits with the CM without the need to have a face-to-face meeting with a specialist.

Conclusion

The evaluation shows that the program is feasible and effective as it was well received by patients and patient outcomes improved. Implementation in fee-for-service publicly funded health-care environments may be limited by the need for dedicated funding.

Mental Health Staffing at HRSA-Funded Health Centers May Improve Access to Care

OBJECTIVE

The study objective was to examine the association between mental health staffing at health centers funded by the Health Resources and Services Administration (HRSA) and patients' receipt of mental health treatment.

METHODS

Data were from the 2014 HRSA-funded Health Center Patient Survey and the 2013 Uniform Data System. Colocation of any mental health staff, including psychiatrists, psychologists, and other licensed staff, was examined. The outcomes of interest were whether a patient received any mental treatment and received any such treatment on site (at the health center). Analyses were conducted with multilevel generalized structural equation logistic regression models for 4,575 patients ages 18-64.

RESULTS

Patients attending health centers with at least one mental health full-time equivalent (FTE) per 2,000 patients had a higher predicted probability of receiving mental health treatment (32%) compared with those attending centers with fewer than one such FTE (24%) or no such staffing (22%). Among patients who received this treatment, those at health centers with no staffing had a significantly lower predicted probability of receiving such treatment on site (28%), compared with patients at health centers with fewer than one such FTE (49%) and with at least one such FTE (65%). The predicted probability of receiving such treatment on site was significantly higher if there was a colocated psychiatrist versus no psychiatrist (58% versus 40%).

CONCLUSIONS

Colocating mental health staff at health centers increases the probability of patients' access to such treatment on site as well as from off-site providers.

Integrated behavioral health treatments: innovations to achieve population impact

Translational Behavioral Medicine is a journal that brings together relevant scholars and practitioners to produce articles of scientific and practical significance in a variety of fields. Here, we published a call for manuscripts detailing the study of innovations in the field of implementation of integrated care in the USA. We present 13 articles, all peer reviewed and all targeting some aspect of integrated care implementation. These articles include medical and community-based settings, as well as interventions that effectively engage peers, family members, and other social systems to support and extend care. The behavioral health conditions of interest include but were not limited to those that carry the greatest population disease burdens: depression, posttraumatic stress disorder, bipolar disorder, anxiety disorders, and substance abuse disorders. Examples of cross-cutting issues of high interest include research focused on provider and system barriers to integrated care implementation, interventions to improve the use of innovative treatments, disparities in access to care and quality of treatment, the intersection of behavioral health disorders and complex chronic conditions as it affects regimen adherence, health services organization and quality of care, policy effects, innovative methods using health information and mHealth technologies, and personalized/precision medicine. This introduction briefly summarizes some of the relevant topics and background literature. We close with an eye toward future research activities that will continue to advance the field and offer directions to stimulate new research questions in the area.

Factors associated with healthcare utilization and mortality in alcohol use disorder hospitalization

OBJECTIVE

To examine the outcomes of alcohol use disorder (AUD)-hospitalizations.

METHODS

We used the U.S. National Inpatient Sample (NIS) data from 1998 to 2016 to examine predictors of Healthcare utilization (total hospital charges, discharge destination, length of hospital stay) and in-hospital mortality for AUD-hospitalization outcomes. We used logistic regression to assess the association of patient demographics (age, sex, race/ethnicity, household income), comorbidity (Deyo-Charlson index), insurance payer (Medicare, Medicaid, private, self-pay or other), and hospital characteristics (location/teaching status; hospital bed size; and region) with outcomes RESULTS: There were 5,590,952 primary AUD-hospitalizations from 1998 to 2016; of these 106,419 (1.9 %) died in-hospital. The mean age was 48 years, 73 % were male, 59 % white, and 57 % had a Deyo-Charlson comorbidity score of zero. In multivariable-adjusted analyses of AUD-hospitalizations, older age, female sex, higher Deyo-Charlson index, rural location or hospitals with medium or large bed sizes were associated with significantly higher in-hospital mortality and healthcare utilization. Similarly, South or Western U.S. hospital location, White race, or high income quartile were associated with higher healthcare utilization. Compared to a private insurance payer, Medicare or Medicaid insurance payers were associated with higher healthcare utilization, but lower in-hospital mortality.

CONCLUSIONS

We identified several independent associations of modifiable and non-modifiable factors with healthcare utilization and mortality outcomes for AUD-hospitalizations. These findings provide an opportunity for prognosis, resource allocation and the development of interventions to improve outcomes of AUD-hospitalizations in the future.

Can the Random Forests Model Improve the Power to Predict the Intention of the Elderly in a Community to Participate in a Cognitive Health Promotion Program?

Background:

We aimed to develop a model predicting the participation of the elderly in a cognitive health program using the random forest algorithm and presented baseline information for enhancing cognitive health.

Methods:

This study analyzed the raw data of Seoul Welfare Panel Study (SWPS) (20), which was surveyed by Seoul Welfare Foundation for the residents of Seoul from Jun 1st to Aug 31st, 2015. Subjects were 2,111 (879 men and 1232 women) persons aged 60 yr and older living in the community who were not diagnosed with dementia. The outcome variable was the intention to participate in a cognitive health promotion program. A prediction model was developed by the use of a Random forests and the results of the developed model were compared with those of a decision tree analysis based on classification and regression tree (CART).

Results:

The random forests model predicted education level, subjective health, subjective friendship, subjective family bond, mean monthly family income, age, smoking, living with a spouse or not, depression history, drinking, and regular exercise as the major variables. The analysis results of test data showed that the accuracy of the random forests was 72.3% and that of the CART model was 70.9%.

Conclusion:

It is necessary to develop a customized health promotion program considering the characteristics of subjects in order to implement a program effectively based on the developed model to predict participation in a cognitive health promotion program.

The primary care assessment and research of a telephone intervention for neuropsychiatric conditions with education and resources study: Design, rationale, and sample of the PARTNERs randomized controlled trial

While most patients with depression, anxiety, or at-risk drinking receive care exclusively in primary care settings, primary care providers experience challenges in diagnosing and treating these common problems. Over the past two decades, the collaborative care model has addressed these challenges. However, this model has been adopted very slowly due to the high costs of care managers; inability to sustain their role in small practices; and the perceived lack of relevance of interventions focused on a specific psychiatric diagnosis. Thus, we designed an innovative randomized clinical trial (RCT), the Primary Care Assessment and Research of a Telephone Intervention for Neuropsychiatric Conditions with Education and Resources study (PARTNERs). This RCT compared the outcomes of enhanced usual care and a novel model of collaborative care in primary care patients with depressive disorders, generalized anxiety, social phobia, panic disorder, at-risk drinking, or alcohol use disorders. These conditions were selected because they are present in almost a third of patients seen in primary care settings. Innovations included assigning the care manager role to trained lay providers supported by computer-based tools; providing all care management centrally by phone - i.e., the intervention was delivered without any face-to-face contact between the patient and the care team; and basing patient eligibility and treatment selection on a transdiagnostic approach using the same eligibility criteria and the same treatment algorithms regardless of the participants' specific psychiatric diagnosis. This paper describes the design of this RCT and discusses the rationale for its main design features.

Improving Geropsychology Competencies of Veterans Affairs Psychologists

Older adults are more likely to seek mental health care through integrated care settings such as primary care. Currently, there exists a significant shortage of mental health providers trained in geropsychology and integrated care competencies. To address this need within the Veterans Health Administration, a national workforce development program was extended to include psychologists, which is called the Geriatric Scholars Program-Psychology Track (GSP-P). The GSP-P has two overarching educational program aims: (1) to improve geropsychology competencies of practicing VA psychologists, particularly those working within integrated settings (e.g., primary care) and (2) enrich psychologists' abilities to enact change in their clinical settings. Ninety-eight VA clinicians participated in the GSP-P, which includes a multi-day in-person course, from 2014 to 2018. Participants completed measures assessing confidence and self-reported knowledge in geropsychology and integrated care competencies pre-course and 3-months post-completion. Two-weeks post-course participants responded to open-ended survey questions regarding their perceptions of the course and potential applications of learning. Significant improvements in confidence in and knowledge of geropsychology and integrated care competencies emerged from pre-course to 3-months post-completion. Qualitative findings demonstrated that participants valued the face-to-face, integrated multimodal educational program. Findings provided insights regarding clinicians' planned application of the knowledge acquired, such as modifying treatments for older patients. Specialized workforce programs such as the GSP-P have a significant, positive impact on the care of older Veterans.

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

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

A Systematic Review of Barriers Faced by Older Adults in Seeking and Accessing Mental Health Care

Older adults in the United States have lower rates of mental health care utilization than young adults. To understand these lower rates of mental health care, we performed a systematic review, in accordance with PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, of barriers that prevent older adults from seeking and accessing treatment. We searched PubMed, PsycINFO, and Clinical Key to identify studies of barriers to mental health treatment in the older adult population (in individuals 50 y of age and older). Thirty-two articles met inclusion criteria (English language and focused on barriers to care in older adults) and exclusion criteria (focus on non-United States populations, focus on younger adults, or no focus on barriers to care). We identified 5 categories of barriers to mental health care in older adults: (1) attitudes and knowledge among older adults; (2) comorbid medical conditions; (3) provider-related factors; (4) other extrinsic barriers (eg, cost, transportation, reliance on caregivers); and (5) unique factors that affect older adults in minority populations. Large studies have primarily identified intrinsic barriers, including negative attitudes toward mental health care and lack of perceived need for treatment, as preventing older adults from seeking mental health care. Minority populations have also been found to face cultural barriers and increased levels of stigma compared with non-Hispanic whites, although several of the identified articles concerning barriers among minority older adults involved qualitative studies with small samples. Larger quantitative studies may help clarify the relative importance of barriers affecting this population. Interventions that have been shown to increase access to mental health services for older adults include community-based care and integrated primary and psychiatric care, but these strategies can be difficult to implement in low-resource settings. More research is needed to determine which interventions and policies are most effective in targeting particular barriers.

The AAGP Scholars Program: Predictors of Pursuing Geriatric Psychiatry Fellowship Training

OBJECTIVE

The American Association for Geriatric Psychiatry (AAGP) Scholars Program was developed to recruit trainees into geriatric psychiatry fellowships and is considered a pipeline for fellowship recruitment. Nonetheless, the number of trainees entering geriatric psychiatry fellowship is declining, making it important to identify modifiable factors that may influence trainees' decisions to pursue fellowship. We analyzed survey data from Scholars Program participants to identify demographic characteristics, attitudes toward program components, and behaviors after the program that were independently associated with the decision to pursue fellowship.

METHODS

Web-based surveys were distributed to all 289 former Scholars participants (2010-2018), whether or not they had completed geriatric psychiatry fellowships. We conducted a hierarchical binary logistic regression analysis to examine demographics, program components, and behaviors after the program associated with deciding to pursue geriatric psychiatry fellowship.

RESULTS

Sixty-one percent of Scholars decided to pursue geriatric psychiatry fellowship. Attending more than one AAGP annual meeting (relative variance explained [RVE] = 34.2%), maintaining membership in the AAGP (RVE = 28.2%), and rating the Scholars Program as important for meeting potential collaborators (RVE = 26.6%) explained the vast majority of variance in the decision to pursue geriatric psychiatry fellowship.

CONCLUSION

Nearly two-thirds of Scholars Program participants decided to pursue geriatric psychiatry fellowship, suggesting the existing program is an effective fellowship recruitment pipeline. Moreover, greater involvement in the AAGP longitudinally may positively influence Scholars to pursue fellowship. Creative approaches that encourage Scholars to develop collaborations, maintain AAGP membership, and regularly attend AAGP annual meetings may help attract more trainees into geriatric psychiatry.

Racial and Ethnic Disparities in Treatment and Treatment Type for Depression in a National Sample of Medicaid Recipients

OBJECTIVE

The purpose of this secondary data analysis was to describe racial-ethnic disparities in receipt of depression treatment and treatment modality among adult Medicaid beneficiaries with depression from a nationally representative sample-28 states and the District of Columbia-of Medicaid beneficiaries (N=599,421).

METHODS

Medicaid claims data were extracted from the full 2008-2009 Medicaid Analytic Extract file. The primary outcome was type of depression treatment: medication only, therapy only, medication and therapy, and no treatment. The secondary outcome was treatment for depression (yes-no). Crude and adjusted odds ratios (AORs) were generated for univariate and multivariate models, respectively, and 95% confidence intervals of odds ratios and p values were calculated.

RESULTS

There were 599,421 individuals in the sample. Rates of depression treatment were lower for African Americans and Hispanics, compared with Caucasians. Percentages receiving no treatment were 19.9% of African Americans, 15.2% of Hispanics, and 11.9% of Caucasians. After full adjustment, African Americans were about half as likely as Caucasians to receive treatment (AOR=0.52), Hispanics were about a third as likely (AOR=0.71), and those from other racial-ethnic groups were about a fifth as likely (AOR=0.84). Caucasians were more likely than any other group to receive medication only.

CONCLUSIONS

This study contributes to evidence about the intersection of social factors and health outcomes and discusses health care engagement, stigma, and policy drivers of racial-ethnic disparities. The study is the first to identify disparities in rates and types of depression treatment among racial-ethnic subgroups of Medicaid beneficiaries in a nationally representative sample.

Exploring older adults’ experiences seeking psychological services using the network episode model

Older adults’ mental health problems are a growing public health concern, especially because their rate of mental health service use is particularly low. Decades of mental health service utilisation models have been developed, yet key assumptions from these models focus primarily on factors that facilitate or inhibit access into the treatment system without taking into considering the dynamics of how individuals respond to their mental health problems and engage in service utilisation. More recently, dynamic models like the Network Episode Model (NEM-II) have been developed to challenge the underlying, rational choice assumption of traditional utilisation models. Given the multifaceted and complex nature of older adults’ mental health problems, the objective of this study was to examine whether the NEM-II is a helpful and appropriate model for understanding the dynamic process of how older adults navigate the mental health system, including factors that advanced and delayed help-seeking. Our qualitative analyses from 15 interviews with older adults revealed that their backgrounds, social supports and treatment systems influence, and are influenced by, their illness careers. Factors that delayed help-seeking included: a lack of support, ‘inappropriate’ referrals/advice from treatment professionals and poor mental health literacy. This research suggests the NEM-II is a helpful and appropriate theory for understanding older adults’ pathways to treatment, and has implications to enhance older adults’ access to psychological services.

Increasing access to care using clinical pharmacy specialist providers in outpatient mental health: Successful practice integration within the Department of Veterans Affairs

BACKGROUND

To highlight the role and impact of the mental health (MH) clinical pharmacist provider in outpatient MH through successful practice integration into team-based care.

OBJECTIVE

The MH clinical pharmacy specialist (CPS) provider serves in many key roles to improve patient-centered care and medication outcomes by supporting the needs of the MH team, patients, and caregivers in areas of comprehensive medication management. MH CPS providers are integrated as MH providers in general and specialty MH clinics, behavioral health clinics embedded in primary care, residential rehabilitation facilities, specialty MH programs, and in inpatient MH units to improve access, quality, and safety.

PRACTICE DESCRIPTION

There is a shortage of psychiatrists across the United States, which affects the ability to provide MH care to patients.

PRACTICE INNOVATION

There is a need to transform the MH team to include clinicians focused on providing services to the growing population with MH conditions; hence, the expertise of the MH CPS is an asset to increase access to comprehensive medication management services.

EVALUATION

The MH CPS provider serves patients with a variety of MH conditions, managing medication-related adverse events, performing ongoing and acute medication monitoring, and collaborating with other health care providers for management of new diagnoses.

RESULTS

The MH CPS provider improves access to care, clinical outcomes, and safety when deployed as direct patient care providers on Veterans Affairs (VA) interprofessional care teams. VA MH clinical pharmacy practice continues to demonstrate what the MH CPS provider, practicing at the top of their license, can achieve as a core member in MH team-based care.

CONCLUSION

These foundational concepts can be applied to further expand MH clinical pharmacy practice into non-VA settings through the use collaborative practice agreements and integration into interprofessional care teams, providing access to patients in need of MH care.

Integrated Care for Older Adults with Serious Mental Illness and Medical Comorbidity: Evidence-Based Models and Future Research Directions

The excess risk of early mortality, medical comorbidity, early institutionalization, and high costs among older adults with serious mental illness necessitates development and dissemination of effective and sustainable integrated care models that simultaneously address mental and physical health needs. This overview highlights current, evidence-based integrated care models, which predominantly adopt the following approaches: (1) psychosocial skills training, (2) integrated illness self-management, and (3) collaborative care and behavioral health homes. Finally, innovative models that build on these approaches by incorporating novel uses of telehealth, mobile health technology and peer support, and strategies from developing economies are discussed.

The role of relapse prevention for depression in collaborative care: A systematic review

BACKGROUND

Relapse (the re-emergence of depression symptoms before full recovery) is common in depression and relapse prevention strategies are not well researched in primary care settings. Collaborative care is effective for treating acute phase depression but little is known about the use of relapse prevention strategies in collaborative care. We undertook a systematic review to identify and characterise relapse prevention strategies in the context of collaborative care.

METHODS

We searched for Randomised Controlled Trials (RCTs) of collaborative care for depression. In addition to published material, we obtained provider and patient manuals from authors to provide more detail on intervention content. We reported the extent to which collaborative care interventions addressed four relapse prevention components.

RESULTS

93 RCTs were identified. 31 included a formal relapse prevention plan; 42 had proactive monitoring and follow-up after the acute phase; 39 reported strategies for optimising sustained medication adherence; and 20 of the trials reported psychological or psycho-educational treatments persisting beyond the acute phase or focussing on long-term health/relapse prevention. 30 (32.3%) did not report relapse prevention approaches.

LIMITATIONS

We did not receive trial materials for approximately half of the trials, which limited our ability to identify relevant features of intervention content.

CONCLUSION

Relapse is a significant risk amongst people treated for depression and interventions are needed that specifically address and minimise this risk. Given the advantages of collaborative care as a delivery system for depression care, there is scope for more consistency and increased effort to implement and evaluate relapse prevention strategies.

Improving Care Provision to Older Adults with Dual Diagnosis: Recommendations from a Mixed-Methods Study

Older adults with dual diagnosis remain an under-diagnosed population in mental health services, with complex needs and high rates of medical comorbidity. Dual diagnosis is a significant challenge to contemporary mental health services, with recognition of the increased rate of relapse and costs of care of poorly managed dual diagnosis identified through comprehensive research. Unfortunately, the research attention paid to those with dual diagnosis in younger age groups has not been replicated in the older adult cohort, with few studies specifically exploring the treatment needs of these individuals. Of the studies that do exist, many identify poor screening and assessment, clinician frustration and a lack of cohesive treatment for co-occurring alcohol and other drug use disorders for older adults. We draw from a mixed methods exploratory study conducted in an inner Melbourne community older adult mental health service providing care to consumers with dual diagnosis to formulate recommendations to improve the care provision to this cohort. We discuss changes to the way older adult mental health services operate that are essential to improve the care and response to consumers presenting with dual diagnosis. Ultimately, we aim to discuss how older adult mental health services can improve to provide timely, responsive care to those with dual diagnosis.

Program Evaluation of an Integrated Behavioral Health Clinic in an Outpatient Women's Health Clinic: Challenges and Considerations

Many women receive their regular check-ups and preventive care through a women's health clinic, including their behavioral health needs. Most of these clinics have not yet developed the capacity to adequately manage behavioral health concerns. We describe our clinical experience integrating behavioral health services into a women's health clinic. In one year, 108 women (54% White, M_age= 35) were referred for behavioral health treatment 47% were identified using a screening questionnaire, 51% were referred by their women's health provider and 2% were self-referred. The most common presenting concerns were anxiety (52%) and depressive symptoms (48%). Sixty-one (56%) patients completed an intake assessment, of whom 33 (54%) engaged in follow-up treatment (M = 3.7 treatment sessions, SD = 3.0). Behavioral health screening and treatment appears to be feasible and effective within a women's health setting. Further research is needed to overcome barriers to referrals and treatment engagement in this population.

Suicide among Nursing Home Residents: Development of Recommendations for Prevention Using a Nominal Group Technique

This research aimed to develop and prioritize recommendations for prevention of suicide among nursing home residents. The study employed a nominal group technique, comprising three rounds, including two forums and a follow-up survey to prioritize recommendations for prevention. Participants included experts and stakeholders in aged care, geriatric psychiatry, suicide prevention, and public policy. The study was conducted and described in accordance with the consolidated criteria for reporting qualitative studies (COREQ). Nine participants (n = 6 males, 66%) developed eleven recommendations for prevention. The top three prioritized recommendations included expanding state and national suicide prevention frameworks, aligning nursing home life with community living, and improving residents' access to mental health services. The recommendations provide a foundation for suicide prevention strategies in Australian nursing homes and contribute to the limited international knowledge base on prevention of suicide among nursing home residents.

Disparities in mental health care utilization among inpatients in various types of health institutions: a cross-sectional study based on EHR data in Shanghai, China

BACKGROUND

Reform of the health care system in China has prompted concerns about the utilization of mental health services. This study aims to compare the utilization of mental health services among inpatients in various types of health institutions in Shanghai (community health care centres, secondary general hospitals, tertiary general hospitals, and specialty hospitals).

METHODS

Based on electronic health record (EHR) data, we extracted all of the mental hospitalization data from various types of public health institutions in Pudong New Area, Shanghai, China, from 2013 to 2016. The distribution of mentally ill inpatients and the possible factors contributing to the observed differences in these institutions were analysed.

RESULTS

Specialty psychiatric hospitals in Pudong New Area, Shanghai, admitted more inpatients and treated in patients with more severe disorders (49.73%). However, those who were male (OR = 0.545), were elderly (OR = 20.133), had inferior insurance (urban social insurance for citizens: OR = 4.013; paying themselves, OR = 29.489), had a longer length of stay (OR = 1.001) and had lower costs (OR = 0.910) were more likely to choose community health centres than specialty hospitals. Those who preferred the secondary and tertiary hospitals to the specialty ones were more likely to be in the male, elderly, married, shorter length of stay and higher-cost groups. Notably, compared to those with urban social insurance for workers, those who had urban social insurance for citizens (OR = 3.136) or paid out-of-pocket (OR = 9.822) were significantly clustered in the tertiary hospitals rather than the specialty hospitals.

CONCLUSIONS

Inpatients who were male, were older, had inferior insurance, had a longer length of stay and had lower costs preferred the elementary health services. However, the utilization of mental health care in high-tier institutions reflected defects, especially the fact that the current health insurance system does not adequately restrict patients' choices, and those who paid more tended to choose tertiary hospitals instead of professional specialty ones. We suggest that psychiatric services should be enhanced by instituting reforms, including public education, improved health insurance, a forceful referral system, and competency reinforcement for primary care physicians, to provide a more integrated mental health system.