Population Of US Practicing Psychiatrists Declined, 2003-13, Which May Help Explain Poor Access To Mental Health Care

Barriers and Facilitators to Staff Recruitment and Retention for ACT Teams: Perspectives of Staff and Participants

The behavioral health workforce has been experiencing deepening problems with recruitment and retention, particularly in publicly funded settings serving individuals with serious mental illnesses. This quality improvement project gathered Assertive Community Treatment (ACT) participant (service user) and provider perspectives on workforce challenges. The authors conducted 8 interviews with ACT participants and 9 focus groups with ACT current staff, team leaders, and former staff. Interviewees discussed barriers to recruitment and retention, including inadequate compensation, work becoming more task-oriented during periods of short staffing, a lack of understanding of what ACT work entails, and elements of the team-based model of care; and facilitators of recruitment and retention, including other aspects of the team-based model of care, connections with colleagues and ACT participants, and flexibility. ACT participants had variable experiences regarding availability of their teams. Recommendations from focus groups and interviews include increasing flexibility, improving awareness of ACT work, optimizing team functioning, addressing staff wellness, and attending to risk. Findings include key insights that may help address the critical workforce shortages in public behavioral health settings.

Insurance acceptance and cash pay rates for psychotherapy in the US

Cost and insurance coverage remain important barriers to mental health care, including psychotherapy and mental health counseling services ("psychotherapy"). While data are scant, psychotherapy services are often delivered in private practice settings, where providers frequently do not take insurance and instead rely on direct pay. In this cross-sectional analysis, we use a large national online directory of 175 083 psychotherapy providers to describe characteristics of private practice psychotherapy providers who accept and do not accept insurance, and assess self-reported private pay rates. Overall, about one-third of private practice psychotherapists did not accept insurance, with insurance acceptance varying substantially across states. We also found significant session rate differentials, with Medicaid rates being on average 40% lower than reported cash pay rates, which averaged $143.26 a session. Taken together, low insurance acceptance across a broad swath of mental health provider types means that access to care is disproportionately reliant on patients' ability to afford out-of-pocket payments-even when covered by insurance. While our findings are descriptive and may not be representative of all US psychotherapists, they add to scant existing knowledge about the cash pay market for an important mental health service that has experienced increased use and demand over time.

Explaining How Psychotherapy Affects the Brain Can Increase the Perceived Effectiveness of Psychotherapy: A Randomized Controlled Trial

Past studies repeatedly found that biological explanations of mental disorders cause laypeople and clinicians to doubt the effectiveness of psychotherapy. This could be clinically detrimental, as combined pharmacotherapy and psychotherapy is often optimal. The distrust of psychotherapy is theorized to stem from dualistic reasoning that psychotherapy, perceived as occurring in the mind, does not necessarily affect the brain. The current study aims to mitigate this belief in a randomized controlled trial. Participants (individuals with symptoms of depression (n = 262), the general public (n = 374), and mental health clinicians (n = 607)) rated the efficacy of psychotherapy for a depression case before and after learning that the case was biologically caused. Participants also received either an intervention passage describing how psychotherapy results in brain-level changes, an active control passage emphasizing the effectiveness of psychotherapy without explaining the underlying biological mechanisms, or no intervention. Unlike the active control and no-intervention control conditions, the intervention caused participants to judge psychotherapy as significantly more effective than at baseline even though they learned that depression was biologically caused. An intervention counteracting dualism can mitigate the belief that psychotherapy is less effective for biologically caused depression. Future research should examine the durability of this intervention in clinical settings.

Physician assistants/associates in psychiatry: a workforce analysis

BACKGROUND

Physician assistants/associates (PAs) provide services in diverse medical specialties globally, including psychiatry. While health professionals in psychiatry have been described for many years, little is known about PAs practicing in this discipline.

METHODS

We describe US PAs practicing in psychiatry using robust national data from the National Commission on Certification of Physician Assistants (NCCPA). Analyses included descriptive and inferential statistics comparing PAs in psychiatry to PAs in all other medical and surgical specialties.

RESULTS

The percentage of PAs practicing in psychiatry has increased from 1.1% (n = 630) in 2013 to 2.0% (n = 2 262) in 2021. PAs in psychiatry differed from PAs practicing in all other specialties in the following: they identified predominately as female (71.4% vs. 69.1%; p = 0.016), were more racially diverse (Asian [6.6% vs. 6.0%], Black/African American [5.5% vs. 3.4%], multi-race [2.8% vs. 2.1%], and other races [Native Hawaiian/Pacific Islander, American Indian/Alaska Native, or other; 3.7% vs. 3.6%]; p < 0.001), and resided in the South (43.8% vs. 34.1%; p < 0.001). PAs in psychiatry vs. all other specialties were more likely to work in office-based private practice settings (41.6% vs. 37.3%; p < 0.001) and nearly twice as likely to provide telemedicine services for their patients (62.7% vs. 32.9%; p < 0.001). While one-third (31.9%) of PAs in psychiatry experienced one or more burnout symptoms, and 8.1% considered changing their current position, the vast majority of PAs in psychiatry (86.0%) were satisfied with their position.

CONCLUSIONS

Understanding the attributes of PAs in psychiatry is essential in medical labor supply and demand research. Our findings suggest that the number of PAs working in psychiatry is steadily increasing. These PAs were predominantly female, exhibited greater racial diversity, and were primarily located in the South and Midwest regions of the US. A striking difference was that PAs in psychiatry were almost twice as likely to provide telemedicine services for their patients. Although nearly a third of PAs in psychiatry acknowledged having one or more symptoms of burnout, few were considering changing their employment, and the vast majority reported high job satisfaction.

Wearable Devices: Implications for Precision Medicine and the Future of Health Care

Wearable devices are integrated analytical units equipped with sensitive physical, chemical, and biological sensors capable of noninvasive and continuous monitoring of vital physiological parameters. Recent advances in disciplines including electronics, computation, and material science have resulted in affordable and highly sensitive wearable devices that are routinely used for tracking and managing health and well-being. Combined with longitudinal monitoring of physiological parameters, wearables are poised to transform the early detection, diagnosis, and treatment/management of a range of clinical conditions. Smartwatches are the most commonly used wearable devices and have already demonstrated valuable biomedical potential in detecting clinical conditions such as arrhythmias, Lyme disease, inflammation, and, more recently, COVID-19 infection. Despite significant clinical promise shown in research settings, there remain major hurdles in translating the medical uses of wearables to the clinic. There is a clear need for more effective collaboration among stakeholders, including users, data scientists, clinicians, payers, and governments, to improve device security, user privacy, data standardization, regulatory approval, and clinical validity. This review examines the potential of wearables to offer affordable and reliable measures of physiological status that are on par with FDA-approved specialized medical devices. We briefly examine studies where wearables proved critical for the early detection of acute and chronic clinical conditions with a particular focus on cardiovascular disease, viral infections, and mental health. Finally, we discuss current obstacles to the clinical implementation of wearables and provide perspectives on their potential to deliver increasingly personalized proactive health care across a wide variety of conditions.

COVID-19 and Adolescent Outpatient Mental Health Service Utilization

OBJECTIVE

The COVID-19 pandemic created challenges in accessing mental health (MH) services when adolescent well-being declined. Still, little is known about how the COVID-19 pandemic affected outpatient MH service utilization for adolescents.

METHODS

Retrospective data were collected from electronic medical records of adolescents aged 12-17 years at Kaiser Permanente Mid-Atlantic States, an integrated health care system from January 2019 to December 2021. MH diagnoses included anxiety, mood disorder/depression, anxiety and mood disorder/depression, attention-deficit/hyperactivity disorder, or psychosis. We used interrupted time series analysis to compare MH visits and psychopharmaceutical prescribing before and after the COVID-19 onset. Analyses were stratified by demographics and visit modality.

RESULTS

The study population of 8121 adolescents with MH visits resulted in a total of 61,971 (28.1%) of the 220,271 outpatient visits associated with an MH diagnosis. During 15,771 (7.2%) adolescent outpatient visits psychotropic medications were prescribed. The increasing rate of MH visits prior to COVID-19 was unaffected by COVID-19 onset; however, in-person visits declined by 230.5 visits per week (P < .001) from 274.5 visits per week coupled with a rise in virtual modalities. Rates of MH visits during the COVID-19 pandemic differed by sex, mental health diagnosis, and racial and ethnic identity. Psychopharmaceutical prescribing during MH visits declined beyond expected values by a mean of 32.8 visits per week (P < .001) at the start of the COVID-19 pandemic.

CONCLUSIONS

A sustained switch to virtual visits highlights a new paradigm in care modalities for adolescents. Psychopharmaceutical prescribing declined requiring further qualitative assessments to improve the quality of access for adolescent MH.

Workforce Diversity, Equity, and Inclusion: A Crucial Component of Professionalism in Psychiatry

Documented disparities have profoundly impacted the training and careers of physicians from socially and historically marginalized groups, including women, people with disabilities, people who identify with racial and ethnic minority groups, and the lesbian, gay, bisexual, transgender, and queer or questioning+ community. Professionalism is a core component of medical training and practice, yet a focus on workforce diversity, equity, and inclusion is often absent. This report aims to encourage the adoption of workforce diversity, equity, and inclusion as a crucial component of professionalism, with an emphasis on the field of psychiatry.

Care transitions from the specialty to the primary care setting: A scoping literature review of potential barriers and facilitators with implications for mental health care

BACKGROUND, AIMS AND OBJECTIVES

This scoping review aimed to understand potential barriers and facilitators in transitioning patients from specialty to primary care settings, to inform the implementation of an intervention to promote active consideration of psychiatrically stable patients for transition from the specialty mental health setting back to primary care.

METHODS

Guided by Levac and colleagues' six-stage methodological framework for conducting scoping studies, we systematically searched electronic article databases for peer-reviewed literature from January 2000 to May 2016. We included identified articles that discuss findings related to potential barriers and facilitators in transitioning patients from specialty to primary care settings. We performed descriptive and thematic analyses of results to generate emergent codes and their categorizations.

RESULTS

Our database search yielded 906 unique articles, 23 of which we included in our scoping review. All but one of the included studies were conducted in North America. Identified potential barriers and facilitators spanned eight emergent themes-(i) primary care accessibility, especially in terms of timely availability of appointments, (ii) clarity in respective roles of specialty care and primary care in managing a patient, (iii) timely exchange of information, (iv) transition process management, (v) perceived ability of primary care providers to manage specialty conditions, (vi) perceived ability of patients to self-manage, (vii) leadership support and (viii) support for implementing initiatives to promote transitions.

CONCLUSIONS

Findings from this scoping review enable an increased understanding of current practices and considerations regarding care transitions from specialty to primary care settings. The importance of role clarification, shared clinical information systems, confidence in care competency, and adequate organizational support to promote appropriate transitions were themes most widely reported across the reviewed studies. Few studies specifically examined the transition from specialty mental health to primary care. Future studies should account for mental health-specific symptomatic patterns and recovery trajectories, such as prevalent chronicity and frequency of relapse, in planning and conducting transitions from specialty mental health back to primary care.

Antidepressant Prescription Behavior Among Primary Care Clinician Providers After an Interprofessional Primary Care Psychiatric Training Program

Primary care providers (PCPs) are increasingly called upon to screen for and treat depression. However, PCPs often lack the training to diagnose and treat depression. We designed an innovative 12-month evidence and mentorship-based primary care psychiatric training program entitled the University of California, Irvine (UCI) School of Medicine Train New Trainers Primary Care Psychiatry (TNT PCP) Fellowship and examined whether this training impacted clinician prescription rates for antidepressants. We retrieved information on 18,844 patients and 192 PCPs from a publicly insured health program in Southern California receiving care between 2017 and 2021. Of the 192 PCPs, 42 received TNT training and 150 did not. We considered a patient as exposed to the provider's TNT treatment if they received care from a provider after the provider completed the 1-year fellowship. We utilized the number of antidepressant prescriptions per patient, per quarter-year as the dependent variable. Linear regression models controlled for provider characteristics and time trends. Robustness checks included clustering patients by provider identification. After PCPs completed TNT training, "exposed" patients received 0.154 more antidepressant prescriptions per quarter-year relative to expected levels (p < 0.01). Clustering of standard errors by provider characteristics reduced precision of the estimate (p < 0.10) but the direction and magnitude of the results were unchanged. Early results from the UCI TNT PCP Fellowship demonstrate enhanced antidepressant prescription behavior in PCPs who have undergone TNT training. A novel, and relatively low-cost, clinician training program holds the potential to empower PCPs to optimally deliver depression treatment.

Estimates of Major Depressive Disorder and Treatment Among Adolescents by Race and Ethnicity

Importance

The COVID-19 pandemic has contributed to poorer mental health and a greater need for treatment. Nationally representative estimates of major depressive disorder (MDD) and mental health treatment among US adolescents during the pandemic are needed.

Objective

To estimate MDD prevalence among adolescents, evaluate mental health treatment use among adolescents with MDD, and assess differences by race and ethnicity.

Design, Setting, and Participants

This cross-sectional analysis of the nationally representative 2021 National Survey on Drug Use and Health included noninstitutionalized US adolescents between the ages of 12 and 17 years (n = 10 743). Analytic weights were applied to all rates and model estimates to be nationally representative and account for sample design and survey nonresponse. Data were collected from January 14 to December 20, 2021, and analyzed from February 11 to April 3, 2023.

Exposures

Self-reported race and ethnicity.

Main Outcomes and Measures

Dichotomous outcomes of MDD as defined by the Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition), MDD-specific mental health treatment, any type of mental health treatment, telehealth visits, and delays in mental health treatment.

Results

The sample included 10 743 adolescents (51.1% male). Self-reported race and ethnicity included 5.1% Asian, 14.1% Black, 23.3% Latinx, 51.2% White, and 6.3% more than 1 race. Ages were evenly distributed: 34.0% aged 12 to 13 years; 33.3% aged 14 to 15 years; and 32.7% aged 16 to 17 years. Adolescents of more than 1 race or ethnicity had the highest MDD rate (26.5%). Compared with White adolescents, the lowest rates of any MDD treatment overall were found among Latinx adolescents (29.2% [95% CI, 22.2%-36.2%]) and those of more than 1 race or ethnicity (21.1% [95% CI, 11.6%-30.7%]). Similar results were found for treatment by any clinician (Latinx, 25.6% [95% CI, 18.8%-32.4%]; >1 race or ethnicity, 19.1% [95% CI, 9.7%-28.6%]), treatment by a mental health specialist (Latinx, 22.9% [95% CI, 16.9%-28.9%]; >1 race or ethnicity, 16.7% [95% CI, 7.1%-26.3%]), treatment by a nonspecialist clinician (Latinx, 7.3% [95% CI, 3.3%-11.3%]; >1 race or ethnicity, 4.8% [95% CI, 1.9%-7.7%]), and use of any psychotropic medication prescription (Latinx, 11.6% [95% CI, 7.3%-15.9%]; >1 race or ethnicity, 8.3% [95% CI, 2.8%-13.7]). Compared with White adolescents, Black adolescents had lower rates of MDD treatment by any clinician (31.7% [95% CI, 23.7%-39.8%]) and by nonspecialist clinicians (8.4% [95% CI, 3.8%-13.2%]) and experienced lower prescription rates for any psychotropic medication (12.6 [95% CI, 4.6%-20.6%]). Asian (16.0% [95% CI, 5.0%-27.2%]) and Latinx (17.8% [95% CI, 12.6%-23.0%]) adolescents had lower rates of virtual mental health treatment compared with White adolescents. Black (19.1% [95% CI, 14.1%-24.2%]) and Latinx (17.9% [95% CI, 15.0%-21.1%]) adolescents had lower rates of appointments transition to telehealth, while Black adolescents (14.1% [95% CI, 10.7%-17.4%]) experienced delays getting their prescriptions.

Conclusions and Relevance

During the first full calendar year of the pandemic, approximately 1 in 5 adolescents had MDD, and less than half of adolescents who needed treatment had any mental health treatment. Adolescents in racial and ethnic minority groups, particularly Latinx, experienced the lowest treatment rates. Federal policy should target adolescents as a whole, and minority populations in particular, to ensure equitable treatment access. Efforts should consider the social, racial, ethnic, and cultural determinants of health.

Neuroscience-based nomenclature as a teaching tool, introduction and pilot study

Neuroscience-based nomenclature (NbN) is a pharmacologically-driven nomenclature aiming to replace the current disease-based nomenclature of psychotropics, focusing on pharmacology and mode-of-action to encourage scientifically-minded prescribing. NbN might also be used as a teaching tool as it presents the depth and richness of the neuroscience of psychotropics. This study examines the effect of using NbN in student curriculum. Fifty-six medical students during clerkship in psychiatry, divided into a control group ( n  = 20), taught standard psychopharmacology, and an intervention group ( n  = 36) introduced with NbN. Both groups filled out identical questionnaires at the beginning and end of the clerkship, including questions of knowledge on psychopharmacology, views on current terminology and interest in psychiatric residency. Comparing the average change in scorings (delta post-pre) for each item in intervention vs. control questionnaires, the intervention group showed a significantly larger positive delta in 6 out of 10 items than the control group. Mean scores did not differ significantly between the two groups in the pre-questionnaires, while significantly higher scores were shown for the intervention group in within- and between-group comparisons. Introduction of NbN was associated with a better educational experience, a deeper understanding of psychotropics and increased interest in psychiatric residency.

Navigating Countertransference in Inpatient Settings: Optimizing Interventions for Patients with Borderline Personality Disorder and Repeated Acute Hospitalizations

Over the years, the psychiatric inpatient treatment paradigm has shifted to more brief stays focused on acute stabilization and psychopharmacologic-focused interventions, rather than individual psychotherapeutic engagement. Unfortunately, this has allowed patients with complex interpersonal dynamics, particularly borderline personality disorder, to slip through the cracks of effective treatment. This can contribute to repeated inpatient admissions, where both patients and clinicians feel trapped in a maladaptive, unhelpful cycle. In this article, we examine the evolution of inpatient treatment with de-emphasized psychotherapy practices, review the particular dynamics that patients with borderline personality disorder may evoke within an interdisciplinary treatment team, and provide a framework of clinically based vignettes for scenarios that may arise within inpatient treatment of this patient population. With attention to countertransference patterns and common pitfalls of communication, we offer alternative approaches and conversations with the hopes of improving outcomes and alliances in a new landscape of psychiatric practice.

Telemedicine Visits in US Skilled Nursing Facilities

Importance

Telemedicine in skilled nursing facilities (SNFs) has the potential to improve access and timeliness of care. During the COVID-19 pandemic in 2020 to 2022, telemedicine coverage expanded, but little is known about patterns of use in SNFs.

Objective

To describe patterns of telemedicine use in SNFs.

Design, Setting, and Participants

This cohort study used 2018 to 2022 Medicare fee-for-service claims and Minimum Data Set 3.0 records to identify short- and long-term care SNF residents. Clinician visits were grouped into routine SNF visits (ie, regular primary care within SNF) and other outpatient visits (ie, with non-SNF affiliated primary and specialty care clinicians). Using a difference-in-differences approach, assessments included whether off-hours visits (measured as weekend visits), new specialist visits, psychiatrist visits, or visits for residents with limited mobility changed differentially between 2018 to 2019 and 2020 to 2021 for SNFs with high compared with low telemedicine use in 2020.

Exposure

Telemedicine adoption at SNF after 2020.

Main Outcomes and Measures

Number and proportion of telemedicine SNF and outpatient visits.

Results

Across 15 434 SNFs and 4 463 591 residents from the period January 2019 through June 2022 (mean [SD] age, 79.7 [11.6] years; 61% female in 2020), telemedicine visits increased from 0.15% in January 2019 to February 2020 to 15% SNF visits and 25% outpatient visits in May 2020. By 2022, telemedicine dropped to 2% of SNF visits and 8% of outpatient visits. The proportion of SNFs with any telemedicine visits annually dropped from 91% in 2020 to 61% in 2022. The facilities with high telemedicine use were more likely to be rural (adjusted odds ratio vs urban, 2.06; 95% CI, 1.77 to 2.40). Psychiatry visits differentially increased in high vs low telemedicine-use SNFs (20.2% relative increase; 95% CI, 1.2% to 39.2%). In contrast, there was little change in outpatient visits for residents with limited mobility (7.2%; 95% CI, -0.1% to 14.6%) or new specialist visits (-0.7%; 95% CI, -2.5% to 1.2%).

Conclusions and Relevance

In this cohort study of SNF residents, telemedicine was rapidly adopted in early 2020 but subsequently stabilized at a low use rate that was nonetheless higher than before 2020. Higher telemedicine use in SNFs was associated with improved access to psychiatry visits in SNFs. A policy to encourage continued telemedicine use may facilitate further access to important services as the technology matures.

Psychiatrist Networks In Medicare Advantage Plans Are Substantially Narrower Than In Medicaid And ACA Markets

Medicare Advantage now covers twenty-eight million older adults, many of whom have mental health needs. Enrollees are often restricted to providers who participate in a health plan's network, which may present a barrier to care. We used a novel data set linking network service areas, plans, and providers to compare psychiatrist network breadth-the percentage of providers in a given area that are considered "in network" for a plan-across Medicare Advantage, Medicaid managed care, and Affordable Care Act plan markets. We found that nearly two-thirds of psychiatrist networks in Medicare Advantage were narrow (that is, they contained fewer than 25 percent of providers in a network's service area) compared with approximately 40 percent in Medicaid managed care and Affordable Care Act plan markets. We did not observe similar differences in network breadth for primary care physicians or other physician specialists across markets. Amid efforts to strengthen network adequacy, our findings suggest that psychiatrist networks in Medicare Advantage are particularly narrow, which may disadvantage enrollees as they attempt to obtain mental health services.

Veterans Health Administration Outpatient Psychiatry Staffing Model: Longitudinal Analysis on Mental Health Performance

BACKGROUND

An adequate supply of mental health (MH) professionals is necessary to provide timely access to MH services. Veterans Health Administration (VHA) continues to prioritize the expansion of the MH workforce to meet increasing demand for services.

OBJECTIVE

Validated staffing models are essential to ensure timely access to care, to plan for future demand, to ensure delivery of high-quality care, and to balance the demands of fiscal responsibility and strategic priorities.

DESIGN

Longitudinal retrospective cohort of VHA outpatient psychiatry, fiscal years 2016-2021.

PARTICIPANTS

Outpatient VHA psychiatrists.

MAIN MEASURES

Quarterly outpatient staff-to-patient ratios (SPRs), defined as the number of full-time equivalent clinically assigned providers per 1000 veterans receiving outpatient MH care, were calculated. Longitudinal recursive partitioning models were created to identify optimal cut-offs for the outpatient psychiatry SPR associated with success on VHA's measures of quality, access, and satisfaction.

KEY RESULTS

Among outpatient psychiatry staff, the root node identified an outpatient SPR of 1.09 for overall performance (p < 0.001). For metrics associated with Population Coverage, a root node identified an SPR of 1.36 (p < 0.001). Metrics associated with continuity of care and satisfaction were associated with a root node of 1.10 and 1.07 (p < 0.001), respectively. In all analyses, the lowest SPRs were associated with the lowest group performance on VHA MH metrics of interest.

CONCLUSIONS

Establishing validated staffing models associated with high-quality MH care is critical given the national psychiatry shortage and increasing demand for services. Analyses support VHA's current recommended minimum outpatient psychiatry-specific SPR of 1.22 as a reasonable target to provide high-quality care, access, and satisfaction.

Experiences that matter in bipolar disorder: a qualitative study using the capability, comfort and calm framework

BACKGROUND

When assessing the value of an intervention in bipolar disorder, researchers and clinicians often focus on metrics that quantify improvements to core diagnostic symptoms (e.g., mania). Providers often overlook or misunderstand the impact of treatment on life quality and function. We wanted to better characterize the shared experiences and obstacles of bipolar disorder within the United States from the patient's perspective.

METHODS

We recruited 24 individuals diagnosed with bipolar disorder and six caretakers supporting someone with the condition. Participants were involved in treatment or support services for bipolar disorder in central Texas. As part of this qualitative study, participants discussed their everyday successes and obstacles related to living with bipolar disorder during personalized, open-ended interviews. Audio files were transcribed, and Nvivo software processed an initial thematic analysis. We then categorized themes into bipolar disorder-related obstacles that limit the patient's capability (i.e., function), comfort (i.e., relief from suffering) and calm (i.e., life disruption) (Liu et al., FebClin Orthop 475:315-317, 2017; Teisberg et al., MayAcad Med 95:682-685, 2020). We then discuss themes and suggest practical strategies that might improve the value of care for patients and their families.

RESULTS

Issues regarding capability included the struggle to maintain identity, disruptions to meaningful employment, relationship loss and the unpredictable nature of bipolar disorder. Comfort related themes included the personal perception of diagnosis, social stigma and medication issues. Calm themes included managing dismissive doctors, finding the right psychotherapist and navigating financial burdens.

CONCLUSIONS

Qualitative data from patients with bipolar disorder helps identify gaps in care or practical limitations to treatment. When we listen to these individuals, it is clear that treatments must also address the unmet psychosocial impacts of the condition to improve patient care, capability and calm.

Medicaid Expansion and mental health treatment: Evidence from the Affordable Care Act

This study uses a difference-in-differences design within an event-study framework to examine how state decisions to expand Medicaid following the passage of the Affordable Care Act (ACA) affected mental health treatment. The findings suggest that expansion states experienced increased admissions to mental health treatment facilities and Medicaid-reimbursed prescriptions for medications used to treat common forms of mental illness. The results also indicate an increase in admissions with trauma, anxiety, conduct, and depression disorders. There is also suggestive evidence of an increase in the number of mental health treatment facilities accepting Medicaid as a form of payment. Lastly, as with previous studies, I find weak evidence of a decrease in suicides in Medicaid expansion states. These findings highlight the vital role of the ACA in providing access to mental health treatment for low-income Americans.

Emergency Removal of Supervision Requirements for Psychiatric Mental Health Nurse Practitioners: A Mixed-Methods Survey

OBJECTIVE

Physician supervision of nurse practitioners (NPs) was temporarily waived in Massachusetts in response to a state of emergency due to the COVID-19 pandemic. The authors examined the impact of the scope-of-practice changes and pandemic-related demands on psychiatric mental health NPs (PMHNPs) during the state's first COVID-19 surge.

METHODS

A mixed-methods Web-based survey was conducted in May and June of 2020. Fisher's exact test was used to compare associations across certification types, and inductive content analysis was applied to open-ended responses.

RESULTS

The survey response rate was 41% (N=389 of 958), consisting of 26 PMHNPs and 363 other NPs. Compared with other NPs, PMHNPs were significantly more likely to work in a telehealth setting (42% vs. 11%, p<0.001), to spend more time working during the initial surge (50% vs. 26%, p<0.05), and to believe that the waiver improved clinical work (52% vs. 25%, p<0.01). Content analysis of PMHNPs' open-ended responses identified four themes: the supervision waiver reduced burden on PMHNPs, collaboration and mentorship models persisted, the pandemic exacerbated the already high demand for psychiatric care, and telehealth helped meet the high demand for such care.

CONCLUSIONS

PMHNPs may be more sensitive to the scope-of-practice changes and telehealth expansion than other NPs because of the constraints of the psychiatrist shortage and high relative uptake of telehealth in psychiatric care. The interactions of workforce supply, telehealth expansion, and scope-of-practice laws are important to consider in the development of policies to improve access to mental health care.

Characteristics of Specialty Mental Health Provider Networks in Oregon Medicaid

OBJECTIVE

Provider networks for mental health are narrower than for other medical specialties. Providers' influence on access to care is potentially greater in Medicaid because enrollees are generally limited to contracted providers, without out-of-network options for nonemergency mental health care. The authors used claims-based metrics to examine variation in specialty mental health provider networks.

METHODS

In a cross-sectional analysis of 2018 Oregon Medicaid claims data, claims from adults ages 18-64 years (N=100,515) with a psychiatric diagnosis were identified. In-network providers were identified as those associated with any medical claims filed for at least five unique Medicaid beneficiaries enrolled in a health plan (coordinated care organization [CCO]) during the study period. Specialty mental health providers were categorized as prescribers (psychiatrists and mental health nurse practitioners) and nonprescribers (therapists, counselors, clinical nurse specialists, psychologists, and social workers). Measures of network composition, provider-to-population ratio, continuity, and concentration of care were calculated at the CCO level; the correlation between these measures was estimated to describe the degree to which they capture unique dimensions of provider networks.

RESULTS

Across 15 CCOs, the number of prescribing providers per 1,000 patients was relatively stable. CCOs that expanded their networks did so by increasing the number of nonprescribing providers. Moderately negative correlations were found between the nonprescriber provider-to-population ratio and proportions of visits with prescribers as well as with usual provider continuity.

CONCLUSIONS

This analysis advances future research and policy applications by offering a more nuanced view of provider network measurement and describing empirical variation across networks.

The methodology to estimate the demand and supply of national psychiatric services in Taiwan from 2005 to 2030

BACKGROUND

The transformation from institutionalization to community-based mental healthcare may increase the difficulty of psychiatric workforce estimation and change the role of psychiatrists in hospitals and private clinics.

METHODS

This study aimed to estimate the growth and forecast psychiatric services in hospitals and private clinics in Taiwan from 2005 to 2030. We first examined the correlation between the number of psychiatrists and several indicators of psychiatric services. The forecast of the national demand for psychiatrists was based on projected outpatient psychiatrist visits from historical data. We also estimated the supply of psychiatrists by the number of psychiatrists practicing in hospitals or private clinics from Taiwan's Medical Affairs System and examined the supply and demand of the psychiatrist workforce through 2030.

RESULTS

Outpatient visit was the most relevant indicator of psychiatric services to psychiatrist workforce. Growth rates in private clinics were higher than the hospital counterparts within the following decade (172.3 % vs. 37.7 %) and in the following decade (42.3 % vs. 13.3 %). The hospital-clinic disparity in the growth of psychiatric services also reflects the shortage of psychiatrists in private clinics but not in hospitals through 2030. The supply of 1158 psychiatrists in hospitals would nearly equal the clinical-based demand of 1156 psychiatrists in 2030. By contrast, the supply of 514 psychiatrists in private clinics would be lower than the clinical-based demand of 636 psychiatrists in 2030.

CONCLUSION

The hospital-clinic disparity in the growth of psychiatric services reflects the transformation from hospital-based to community-based mental healthcare in Taiwan.

Trends in Suicidal Ideation-Related Emergency Department Visits for Youth in Illinois: 2016-2021

BACKGROUND AND OBJECTIVES

Increasing suicide rates and emergency department (ED) mental health visits reflect deteriorating mental health among American youth. This population-based study analyzes trends in ED visits for suicidal ideation (SI) before and during the coronavirus disease 2019 (COVID-19) pandemic.

METHODS

We analyzed Illinois hospital administrative data for ED visits coded for SI from January 2016 to June 2021 for youth aged 5 to 19 years. We characterized trends in patient sociodemographic and clinical characteristics, comparing three equal 22 month periods and analyzed patient and hospital characteristics associated with the likelihood of hospitalization.

RESULTS

There were 81 051 ED visits coded for SI at 205 Illinois hospitals; 24.6% resulted in hospitalization. SI visits accounted for $785 million in charges and 145 160 hospital days over 66 months. ED SI visits increased 59% from 2016 through 2017 to 2019 through 2021, with a corresponding increase from 34.6% to 44.3% of SI principal diagnosis visits (both P < .001). Hospitalizations increased 57% between prepandemic fall 2019 and fall 2020 (P = .003). After controlling for demographic and clinical characteristics, youth were 84% less likely to be hospitalized if SI was their principal diagnosis and were more likely hospitalized if coded for severe mental illness, substance use, anxiety, or depression, or had ED visits to children's or behavioral health hospitals.

CONCLUSIONS

This study documents child ED SI visits in Illinois spiked in 2019, with an additional surge in hospitalizations during the pandemic. Rapidly rising hospital use may reflect worsening mental illness and continued difficulty in accessing low cost, high-quality outpatient mental health services.

Mobile App to Enhance Patient Activation and Patient-Provider Communication in Major Depressive Disorder Management: Collaborative, Randomized Controlled Pilot Study

BACKGROUND

Enhanced patient-provider engagement can improve patient health outcomes in chronic conditions, including major depressive disorder (MDD).

OBJECTIVE

We evaluated the impact of a digitally enabled care mobile app, Pathway, designed to improve MDD patient-provider engagement. Patients used a mobile interface to assess treatment progress and share this information with primary care providers (PCPs).

METHODS

In this 52-week, real-world effectiveness and feasibility study conducted in primary care clinics, 40 patients with MDD who were recently prescribed antidepressant monotherapy were randomized to use a mobile app with usual care (20/40, 50%) or usual care alone (20/40, 50%). Patients in the app arm engaged with the app daily for 18 weeks; a report was generated at 6-week intervals and shared with the PCPs to facilitate shared treatment decision-making discussions. The patients discontinued the app at week 18 and were followed through year 1. Coprimary outcome measures, assessed via research visits, included change from baseline in the 13-item Patient Activation Measure (PAM-13) and 7-item Patient-Provider Engagement Scale scores at week 18. Additional outcome measures included depression severity (9-item Patient Health Questionnaire [PHQ-9]) and cognitive symptoms (5-item Perceived Deficits Questionnaire-Depression).

RESULTS

All 37 patients (app arm: n=18, 49%; usual care arm: n=19, 51%) who completed the 18-week follow-up period (n=31, 84% female, mean age 36, SD 11.3 years) had moderate to moderately severe depression. Improvements in PAM-13 and PHQ-9 scores were observed in both arms. Increases in PAM-13 scores from baseline to 18 weeks were numerically greater in the app arm than in the usual care arm (mean 10.5, SD 13.2 vs mean 8.8, SD 9.4; P=.65). At 52 weeks, differences in PAM-13 scores from baseline demonstrated significantly greater improvements in the app arm than in the usual care arm (mean 20.2, SD 17.7 vs mean 1.6, SD 14.2; P=.04). Compared with baseline, PHQ-9 scores decreased in both the app arm and the usual care arm at 18 weeks (mean 7.8, SD 7.2 vs mean 7.0, SD 6.5; P=.73) and 52 weeks (mean 9.5, SD 4.0 vs mean 4.7, SD 6.0; P=.07). Improvements in 7-item Patient-Provider Engagement Scale and WHO-5 scores were observed in both arms at 18 weeks and were sustained through 52 weeks in the app arm. Improvements in WHO-5 scores at 52 weeks were significantly greater in the app arm than in the usual care arm (41.5 vs 20.0; P=.02).

CONCLUSIONS

Patients with MDD will engage with a mobile app designed to track treatment and disease progression. PCPs will use the data generated as part of their assessment to inform clinical care. The study results suggest that an app-enabled clinical care pathway may enhance patient activation and benefit MDD management.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03242213; https://clinicaltrials.gov/ct2/show/NCT03242213.

Predicting non-initiation of care and dropout in a blended care CBT intervention: Impact of early digital engagement, sociodemographic, and clinical factors

Objective

This study examines predictors of non-initiation of care and dropout in a blended care CBT intervention, with a focus on early digital engagement and sociodemographic and clinical factors.

Methods

This retrospective cohort analysis included 3566 US-based individuals who presented with clinical levels of anxiety and depression and enrolled in a blended-care CBT (BC-CBT) program. The treatment program consisted of face-to-face therapy sessions via videoconference and provider-assigned digital activities that were personalized to the client's presentation. Multinomial logistic regression and Cox proportional hazard survival analysis were used to identify predictors of an increased likelihood of non-initiation of therapy and dropout.

Results

Individuals were more likely to cancel and/or no-show to their first therapy session if they were female, did not disclose their ethnicity, reported poor financial status, did not have a college degree, endorsed more presenting issues during the onboarding triage assessment, reported taking antidepressants, and had a longer wait time to their first appointment. Of those who started care, clients were significantly more likely to drop out if they did not complete the digital activities assigned by their provider early in treatment, were female, reported more severe depressive symptoms at baseline, reported taking antidepressants, and did not disclose their ethnicity.

Conclusions

Various sociodemographic and clinical predictors emerged for both non-initiation of care and for dropout, suggesting that clients with these characteristics may benefit from additional attention and support (especially those with poor early digital engagement). Future research areas include targeted mitigation efforts to improve initiation rates and curb dropout.

Trends In Mental Health Care Delivery By Psychiatrists And Nurse Practitioners In Medicare, 2011-19

The supply of psychiatrists in the United States is inadequate to address the unmet demand for mental health care. Psychiatric mental health nurse practitioners (PMHNPs) may fill the widening gap between supply of and demand for mental health specialists with prescribing privileges. Using Medicare claims for a 100 percent sample of fee-for-service beneficiaries (average age, sixty-one years) who had an office visit for either a psychiatrist or a PMHNP during the period 2011-19, we examined how the supply and use of psychiatrists and PMHNPs changed over time, and we compared their practice patterns. Psychiatrists and PMHNPs treated roughly comparable patient populations with similar services and prescriptions. From 2011 to 2019 the number of PMHNPs treating Medicare beneficiaries grew 162 percent, compared with a 6 percent relative decrease in the number of psychiatrists doing so. During the same period, total annual mental health office visits per 100 beneficiaries decreased 11.5 percent from 27.4 to 24.2, the net result of a 29.0 percent drop in psychiatrist visits being offset by a 111.3 percent increase in PMHNP visits. The proportion of all mental health prescriber visits provided by PMHNPs increased from 12.5 percent to 29.8 percent during 2011-19, exceeding 50 percent in rural, full-scope-of-practice regions. PMHNPs are a rapidly growing workforce that may be instrumental in improving mental health care access.

Cost Burden Impacts Cancer Patient Service Utilization Behavior in a US Commercial Plan

Objectives: The burden of affording high-cost medical treatment (eg, cancer therapy) may impact whether some patients choose to access other needed health services within US commercial plans. However, deferring needed care for a mental or behavioral health (M/BH) condition could result in preventable hospital utilization. This research investigates how income level and total out-of-pocket costs (OOPC) interact to influence the service utilization behavior of insured adult cancer patients with a comorbid M/BH diagnosis. Methods: A cross-sectional, retrospective analysis was performed using medical service claims (July 2017-June 2018) and administrative data from eligible members of a large US commercial health benefits plan ( N =5,054). Nonparametric tests were used to examine variation in mean utilization by patient income level and OOPC decile. Negative binomial regression modeling was performed to analyze independent variable effects on count outcomes for outpatient behavioral visits and emergency department (ED) visits. Results: There was significant variation in patient service utilization by income level and total OOPC. Overall, as OOPC increased patients used less outpatient behavioral care ( p <.000). Compared to average and higher incomes, those with lower incomes (<$50,000/year) utilized significantly fewer outpatient visits ( p <.000) and significantly more ED visits ( p <.001) relative to increasing OOPC. Conclusions: The interaction of income level and OOPC (ie, cost burden) could inhibit patients' decision to access supportive behavioral care in the commercial plan. The cumulative cost burden from cancer treatment may promote underutilization of outpatient services and greater ED reliance, particularly among lower income plan members.

Psychiatric Hospitalization Associated with Emergency Department Visits

Psychiatric boarding in an emergency department (ED) has personal and social consequences that can increase healthcare expenditure through a variety of inter-related mechanisms. This study aimed to compare health outcomes (e.g., length of stays, the severity of illness) between patients who stayed in an emergency department and those who did not visit an emergency department before the hospitalization. With the National Inpatient Sample dataset in the United States, we compared psychiatric inpatient service utilization outcomes between those who had stated in an emergency department and those who had not. Results: Among those with ED visits, the in-hospital mortality was 0.80 times lower (95% CI: 0.79-0.81). The length of hospital stays and the total charges were not significantly different from those without ED visits. The integration of primary care with psychiatric inpatient services can improve the management of psychiatric prevention and treatment, with the reduction of ED visits. This study provides an essential value in reducing emergency visits as the plan for psychiatric inpatient utilization to achieve more cost-effective and adequate healthcare outcomes.

Workforce Diversity, Equity, and Inclusion: A Crucial Component of Professionalism in Psychiatry

Documented disparities have profoundly impacted the training and careers of physicians from socially and historically marginalized groups, including women, people with disabilities, people who identify with racial and ethnic minority groups, and the lesbian, gay, bisexual, transgender, and queer or questioning+ community. Professionalism is a core component of medical training and practice, yet a focus on workforce diversity, equity, and inclusion is often absent. This report aims to encourage the adoption of workforce diversity, equity, and inclusion as a crucial component of professionalism, with an emphasis on the field of psychiatry.

Anxiety, depression, and substance experimentation in childhood

Previous research has demonstrated that adults with comorbid depressive and anxiety disorders are significantly more likely to show pathological use of drugs or alcohol. Few studies, however, have examined associations of this type in children. A better understanding of the relationships between affective disorders and substance experimentation in childhood could help clarify the complex ways in which pathological substance use symptoms develop early in life. The present study included 11,785 children (Mage = 9.9) participating in the Adolescent Brain Cognitive Development (ABCD) study. Depressive and anxiety disorder diagnoses were evaluated as concurrent predictors of experimentation with alcohol and tobacco. A series of linear regressions revealed that children with either depressive or anxiety disorders were significantly more likely to experiment with alcohol or tobacco. However, children with both depressive and anxiety diagnoses were not more likely to experiment than children without a diagnosis. These results suggest that anxiety or depressive diagnoses in childhood may be associated with a greater likelihood of substance experimentation, but severe psychological distress may suppress these effects.

Novel Approach to Integrating Mental Health Care into a Primary Care Setting: Development, Implementation, and Outcomes

It is now widely accepted that there is a growing discrepancy between demand and access to adequate treatment for behavioral or mental health conditions in the United States. This results in immense personal, societal, and economic costs. One rapidly growing method of addressing this discrepancy is to integrate mental health services into the primary care setting, which has become the de facto service provider for these conditions. In this paper, we describe the development and implementation of a novel integrated care program in a large mid-western university-based healthcare system, drawn from the collaborative care model, and describe the benefits in terms of both health care utilization and depression outcomes. Limitations and proposed future directions are discussed.

A Community-Embedded Implementation Model for Mental-Health Interventions: Reaching the Hardest to Reach

The mental-health-care treatment gap remains very large in low-resource communities, both within high-income countries and globally in low- and middle-income countries. Existing approaches for disseminating psychological interventions within health systems are not working well enough, and hard-to-reach, high-risk populations are often going unreached. Alternative implementation models are needed to expand access and to address the burden of mental-health disorders and risk factors at the family and community levels. In this article, we present empirically supported implementation strategies and propose an implementation model-the community-embedded model (CEM)-that integrates these approaches and situates them within social settings. Key elements of the model include (a) embedding in an existing, community-based social setting; (b) delivering prevention and treatment in tandem; (c) using multiproblem interventions; (d) delivering through lay providers within the social setting; and (e) facilitating relationships between community settings and external systems of care. We propose integrating these elements to maximize the benefits of each to improve clinical outcomes and sustainment of interventions. A case study illustrates the application of the CEM to the delivery of a family-based prevention and treatment intervention within the social setting of religious congregations in Kenya. The discussion highlights challenges and opportunities for applying the CEM across contexts and interventions.

Responding to a Behavioral Health Crisis: Applying a New Care Model in the Emergency Department

OBJECTIVES

Emergency department (ED) visits for behavioral health (BH) emergencies continue to rise, and institutions across the country encounter barriers and struggle to put BH processes in place to address their needs. After learning of an unanticipated closure of a local psychiatric crisis response center (CRC), our ED implemented quality improvement interventions to respond to an acute surge of BH patients.

METHODS

Interventions included an enhanced BH database, the role of social workers as extenders, shared electronic health record documentation, increased staffing, clinical pathway updates, and processes to improve communication. We aimed to develop a care model to maintain safe care with timely evaluation and patient disposition despite an anticipated surge of ED patients.

RESULTS

After the CRC closure, 7383 patients met our cohort definition over 18 months, whereas 4326 patients met the cohort definition in the 18 months prior the CRC closure. Of the total patients seen in the study period, 42% were evaluated by the ED team with psychiatry and social work, and the median length of stay for discharged patients evaluated by this team decreased from 4.2 hours to 3.5 hours after CRC closure.

CONCLUSIONS

A multifaceted approach allowed our ED to successfully respond to an unexpected surge of BH patients. Other institutions may be able to apply a population health and quality improvement approach when addressing the rising prevalence of ED BH visits. Future studies and practices should explore the optimal role of the acute care setting in the continuum of care of these patients.

Development and Implementation of an Integrated Care Fellowship

INTRODUCTION

Integrated care is a common approach to leverage scarce psychiatric resources to deliver mental health care in primary care settings. To date, a formal clinical fellowship devoted to professional development for this role has not been described.

METHODS

The development of a formal year-long clinical fellowship in integrated care is described. The curriculum consists of an Integrated Care Didactic Series, Integrated Care Clinical Skill Experiences, and Integrated Care System-Based Leadership Experiences. Evaluation of impact was assessed with descriptive statistics.

RESULTS

We successfully recruited three classes of fellows to the Integrated Care Fellowship, with 5 program graduates in the first 3 years. All five graduated fellows were hired into integrated care and/or telepsychiatry positions. Integrated Care fellows had a high participation rate in didactics (mean attendance = 80.6%; n=5). We received a total of 582 didactic evaluations for the 151 didactic sessions. On a scale of 1 (poor) to 6 (fantastic), the mean quality of the interactive learning experience was rated as 5.33 (n=581), and the mean quality of the talk was 5.35 (n=582). Rotations were rated with the mean overall teaching quality of 4.98/5 (n = 76 evaluations from 5 fellows).

CONCLUSIONS

The Integrated Care clinical fellowship serves as a model for training programs seeking to provide training in clinical and systems-based skills needed for practicing integrated care. Whether such training is undertaken as a standalone fellowship or incorporated into existing Consultation-Liaison Psychiatry programs, such skills are increasingly valuable as integrated care becomes commonplace in practice.

Trends in Outpatient Psychotherapy Provision by U.S. Psychiatrists: 1996-2016

OBJECTIVE

Previous work has demonstrated significant declines in the provision of outpatient psychotherapy by U.S. psychiatrists. The objective of this study was to characterize patterns and trends of psychotherapy by U.S. psychiatrists from 1996 to 2016.

METHODS

A retrospective, nationally representative analysis of psychiatrist visits from 21 waves of the U.S. National Ambulatory Medical Care Survey between 1996 and 2016 (N=29,673) was conducted to assess rates of outpatient psychotherapy provision by U.S. psychiatrists. Provision was modeled as risk differences and adjusted by clinical, sociodemographic, geographic, and financial characteristics.

RESULTS

Between 1996 and 2016, the weighted percentage of visits involving psychotherapy declined significantly from 44.4% in 1996-1997 to 21.6% in 2015-2016. Declines were most marked among patients diagnosed with social phobia (29% to 8%), dysthymic disorder (65% to 30%), and personality disorders (68% to 17%). For patients diagnosed with schizophrenia, psychotherapy provision remained stable (10%-12%). In the 2010-2016 period, about half of psychiatrists (53%) no longer provided psychotherapy at all. Antidepressant, antipsychotic, and sedative-hypnotic prescriptions were negatively associated with psychotherapy provision. During the study period, sociodemographic disparities grew, with older, White patients residing in metropolitan areas in the Northeast or West increasingly becoming the most likely to receive psychotherapy. Self-pay predicted access to solo-practice psychiatrists, who saw fewer patients but more frequently, and were more likely to provide psychotherapy.

CONCLUSIONS

Previously reported declines in psychiatrist provision of psychotherapy continued through 2016, affecting nearly all clinical categories. In the 2010s, about half of psychiatrists practiced no psychotherapy at all, creating new challenges to the integration of neurobiological and psychosocial elements of clinical care.

Association between Care Modality and Utilization with Treatment Response among Members Accessing Virtual Mental Health Services: A Real-World Observational Study (Preprint)

Background

There is a growing bottleneck in mental health care, as the demand for services has outpaced the availability of mental health professionals. Consequently, many health systems have shifted to teletherapy as a scalable approach to increasing accessibility to care. Within these care models, various treatment modalities (eg, coaching and clinical care) are used to deliver support for anxiety and depression. However, more research is needed to better understand the differences in treatment responses.

Objective

The purpose of this study was to examine the association between different care modalities and the levels of use with symptom score changes for members seeking virtual care services.

Methods

We conducted an observational study of 4219 members who accessed Ginger, an on-demand mental health service, between September 2020 and September 2021. Using a mobile app, members can access text-based behavioral health coaching and virtual clinical services. This study focused on members with clinically elevated depression or anxiety levels at baseline. Logistic regressions were used to assess the association between care modalities and the levels of use with treatment response in depression and anxiety, using the Patient Health Questionnaire and Generalized Anxiety Disorder Assessment, respectively.

Results

Of the 4219 members, 1623 (38.47%) demonstrated a full response to depression, and 1684 (39.91%) demonstrated a full response to anxiety. Members who completed care (ie, text-based coaching, virtual clinical therapy, hybrid of coaching, and clinical care) beyond the introductory session showed significantly increased odds of a full response compared with those who completed only limited care. Members who completed a hybrid of care had the highest odds of improvement; the odds of showing a full response in depression were 2.31 times higher (95% CI 1.91-2.80; P<.001) and in anxiety were 2.23 times higher (95% CI 1.84-2.70; P<.001) compared with members who completed limited care. For members who completed only coaching or clinical care, the largest effects were observed among those with high use. For members who completed a hybrid care program, we observed similar treatment responses across all levels of use.

Conclusions

Our real-world study found that members who completed text-based coaching achieved full treatment responses at similar rates compared with members who completed virtual clinical care and members who completed a hybrid of care. There were no significant differences in the predicted probabilities of full treatment response between coaching and clinical care. Generally, the odds for a full response were highest among members with high use within each care modality; however, there were no differences in full-response treatment odds across levels of use with hybrid care. The results support the utility of digital behavioral health interventions and further highlight text-based coaching protocols as an accessible and suitable option when considering virtual care for treating anxiety and depression.

Perceptions of clinical pharmacy specialists' contributions in mental health clinical teams

Introduction

Mental health (MH) clinical pharmacy specialists (CPS) are increasingly functioning as integral providers in MH care teams. MH providers may delegate many medication management tasks to the CPS. As there is a shortage of primary care and specialist MH providers, CPS are increasingly being utilized in MH care clinics. We assess provider and CPS perceptions of the contributions of CPS to MH clinical teams in the Veterans Health Administration.

Methods

We examined the roles and functions of CPS in MH clinics through surveys (n = 374) and semistructured interviews (n = 16) with MH CPS and other members of MH clinical teams (psychiatrists, nurse practitioners, registered nurses, social workers) to gain insight into how CPS were integrated in these settings. We assessed perceptions of CPS contributions to MH teams, interactions between CPS and other providers, and challenges of integrating CPS into MH clinical teams.

Results

Contributions of CPS in MH were received positively by clinical team members. Clinical pharmacy specialists providing comprehensive medication management were especially valuable in the management of clozapine. The knowledge and training of CPS reassured providers who frequently referred to them with questions about medication and medication therapy management. MH CPS were also perceived to be received well by patients.

Discussion

The integration of MH CPS into MH teams was well received by team members and patients alike. The MH CPS have become important members of the MH team and are widely viewed as being able to improve access, quality, and workflow.

Changes in healthcare costs following engagement with a virtual mental health system: a matched cohort study of healthcare claims data

The COVID-19 pandemic has exacerbated the pressing need for mental health services. Digital mental health interventions could increase access to care and be an effective approach to reducing anxiety and depression at scale; however, research on their impact on healthcare expenditure is in the nascent stage and requires further investigation. The current study used claims data to examine the associations between use of an on-demand digital mental health platform and healthcare utilization costs compared to a matched control cohort. The study found that there were no significant differences between cohorts in total healthcare costs and pharmacy costs. There was a 16.8% reduction in outpatient costs (p=.08). On-demand digital mental health interventions can serve as a scalable approach to addressing the current mental health demands and potentially lower outpatient costs.

Improving Family Medicine Residents' Confidence to Assess and Manage Psychiatric Crises in an Outpatient Clinic

Background and Objectives:

Primary care physicians (PCPS) are increasingly responsible for managing mental health, which can involve assessment and management of a psychiatric crisis. Psychiatric crises can include acute suicidal or homicidal ideation and capacity-impairing psychosis. Evidence suggests PCPs do not consistently assess or manage psychiatric crises and it is unclear how to train PCPs to address these potentially lethal scenarios. The main objective was to increase PCP resident confidence in assessing and managing a range of psychiatric crises.

Methods:

In a family medicine residency program that trains PCPs, we developed a three, 1-h didactic series and point-of-care reference documents. The curriculum focused on screening, outpatient management, inpatient criteria, logistics of voluntary and involuntary admission, and legal considerations. Resident confidence was measured by questionnaire before and 3 months after curriculum completion.

Results:

Prior to training, residents did not feel confident in assessing and managing psychiatric crises, except a slight majority (62%) in screening for suicidal and homicidal ideation. Resident confidence significantly increased for every aspect of assessing and managing psychiatric crises after the training (all P-values < .05), with the largest improvements for further assessing hallucinations, delusions, and suicidal and homicidal ideation.

Conclusions:

As PCPs increasingly manage mental illness, they will encounter a range of psychiatric crises in clinic. This study demonstrates that a brief training intervention and point-of-care resources can significantly increase PCP confidence to assess and manage these urgent, dangerous scenarios.

Health-Related Quality of Life among Members using an On-Demand Behavioral Health Platform: A Pilot Observational Study (Preprint)

Background

Despite the well-known adverse health conditions and negative economic outcomes associated with mental health problems, accessing treatment is difficult due to reasons such as availability and cost. As a solution, digital mental health services have flooded the industry, and new studies are quickly emerging that support their potential as an accessible and cost-effective way to improve mental health outcomes. However, many mental health platforms typically use clinical tools such as the Patient Health Questionnaire-9 (PHQ-9) or General Anxiety Disorder-7 (GAD-7). Yet, many individuals that seek out care do not have clinical symptomatology and thus, traditional clinical measures may not adequately capture symptom improvement in general well-being. As an alternative, this study used the health-related quality of life (HRQoL) tool from the Centers for Disease Control and Prevention “Healthy Days” measure. This subjective measure of well-being is an effective way to capture HRQoL and might be better suited as an outcome measure for treatments that include both clinical and subclinical individuals.

Objective

The purpose of this study was to describe changes in HRQoL in clinical and subclinical members assessing virtual care and to examine the association between text-based behavioral coaching and virtual clinical sessions with changes in HRQoL.

Methods

A total of 288 members completed the 4-item HRQoL measure at baseline and at 1 month following use of the Ginger on demand behavioral health platform. Baseline anxiety and depression levels were collected using the GAD-7 and PHQ-9, respectively.

Results

Members completed on average 1.92 (SD 2.16) coaching sessions and 0.91 (SD 1.37) clinical sessions during the assessment month. Paired samples t tests revealed significant reductions in the average number of unhealthy mental health days between baseline (mean 16, SD 8.77 days) and follow-up (mean 13.2, SD 9.02 days; t₂₈₇=5.73; P<.001), and in the average number of days adversely impacted (mean_baseline 10.9, mean_follow-up 8.19; t₂₈₇=6.26; P<.001). Both subclinical members (t₁₀₃=3.04; P=.003) and clinical members (t₁₈₃=5.5; P<.001) demonstrated significant improvements through reductions in adversely impacted days over a month. Clinical members also demonstrated significant improvements through reductions in unhealthy mental health days (t₁₈₃=5.82; P<.001). Finally, member engagement with virtual clinical sessions significantly predicted changes in unhealthy mental health days (B=–0.96; P=.04).

Conclusions

To our knowledge, this study is one of the first to use the HRQoL measure as an outcome in an evaluation of a digital behavioral health platform. Using real-world longitudinal data, our preliminary yet promising results show that short-term engagement with virtual care can be an effective means to improve HRQoL for members with subclinical and clinical symptoms. Further follow-up of reported HRQoL over several months is needed.

Outpatient Off-Label Gabapentin Use for Psychiatric Indications Among U.S. Adults, 2011-2016

OBJECTIVE

Gabapentin is widely prescribed off label in medical practice, including psychiatry. The U.S. Food and Drug Administration (FDA) warned of risks associated with gabapentin combined with central nervous system depressant (CNS-D) drugs, which are commonly prescribed in psychiatric treatment. This study examined off-label outpatient gabapentin use for psychiatric indications and concomitant CNS-D medication use.

METHODS

National Ambulatory Care Medical Survey data (2011-2016) were used to identify encounters involving gabapentin (gabapentin visits) for adults (ages ≥18) (N=5,732). FDA-approved uses and off-label psychiatric use indications were identified with ICD-9-CM and ICD-10-CM diagnosis codes. CNS-D drugs examined were opioids, benzodiazepines, sedatives-hypnotics, antidepressants, antipsychotics, first-generation antihistamines, and skeletal muscle relaxants. Concomitance was prescription of one or more CNS-D medications at the same visit. Visits were stratified by provider type and specialty.

RESULTS

Between 2011 and 2016, 2.8% of visits listed gabapentin prescriptions (weighted estimate of 129.6 million visits). A small proportion (<1%) listed an FDA-approved indication. Among off-label gabapentin visits, 5.3% listed a depressive disorder, 3.5% an anxiety disorder, and 1.8% bipolar disorder. Over 6 years, 58.4% of off-label gabapentin visits listed one or more concomitant CNS-D medications, most frequently antidepressants (24.3%), opioids (22.9%), and benzodiazepines (17.3%). Most gabapentin visits were with primary care providers (34.9%) and other provider specialties (i.e., not primary care, neurology, or psychiatry) (48.1%).

CONCLUSION

In this nationally representative sample, <1% of outpatient gabapentin use was for approved indications. High concomitant use of CNS-D drugs and off-label gabapentin for psychiatric diagnoses underlines the need for improved communication about safety.

Perceptions of School Nurses in Addressing Student Mental Health Concerns: An Integrative Review

Mental health disorders in school-aged children are on the rise. The need for mental health care is well recognized, and the provision of this care in schools is recommended. An integrative review explored how school nurses view their role in addressing students' mental health. Fourteen articles were identified, eleven using a qualitative design and three using a quantitative design. Findings suggest that school nurses see their role as trusted members of the school community. They perceive upholding standards of practice as an integral part of their position and recognize competence in mental health care to be highly important. Practice recommendations include providing school nurses with evidence-based training on managing the mental health needs of students, as well as ensuring access to school nurses who can provide mental health supervision in the community.

Assessment of Perceptions of Mental Health vs Medical Health Plan Networks Among US Adults With Private Insurance

IMPORTANCE

Ten years after the Mental Health Parity and Addiction Equity Act, patients continue to report insurance-related barriers to specialty mental health care.

OBJECTIVES

To assess privately insured patients' perceptions of the adequacy of their health plan's provider network (provider network includes physicians, clinicians, other health care professionals, and their institutions that constitute the network), whether practitioners frequently leave plans, and whether practitioner plan participation affected patients' plan choice.

DESIGN, SETTING, AND PARTICIPANTS

A nationally representative, population-based internet survey study of English-speaking US adults participating in KnowledgePanel, an online research panel, was conducted from August to September 2018. Data analysis was performed from November 12, 2020, to May 12, 2021. From a sample of 29 854 panelists aged 18 to 64 years, 19 602 initiated the screener (completion rate of 66%), and 728 met study criteria: adults with private insurance receiving both specialty mental health and medical care in the past year.

EXPOSURE

Health plan's provider network.

MAIN OUTCOMES AND MEASURES

Self-report of plan inadequacy, whether a practitioner left the plan and the participant's responses (stopped treatment, switched practitioner, or continued treatment), and whether participation of a specific practitioner was considered when a health plan was chosen. Experiences with both mental health and medical provider networks were assessed. Analyses were weighted to match the sample to the US population. Weights provided by KnowledgePanel were also adjusted for panel recruitment, attrition, oversampling, and survey nonresponse.

RESULTS

Of a total of 728 study participants, 204 (39%) were aged 18 to 34 years, 504 (61%) were women, 82 (17%) were Hispanic, and 551 (66%) were non-Hispanic White individuals. Serious psychological distress was reported by 262 participants (36%), and 214 participants (29%) also received mental health treatment from a primary care practitioner. Participants rated their mental health provider network as inadequate more frequently than their medical provider network (163 [21%] vs 70 [10%]; odds ratio [OR], 2.69; 95% CI, 1.64-4.40; P < .001). However, among the 193 participants also receiving mental health treatment from a primary care practitioner, there was no significant difference in the ratings of mental health and medical provider networks (44 [14%] vs 18 [9%]; OR, 1.55; 95% CI, 0.65-3.67; P = .32). Sixty participants (8%) reported that a mental health practitioner had left their plan's insurance network in the past 3 years. Of the 523 participants with a choice of plan, 98 (20%) considered whether a specific mental health practitioner was in network before choosing a plan.

CONCLUSIONS AND RELEVANCE

This study's findings suggest that more participants perceived their mental health networks to be inadequate compared with their medical networks. Increasing the availability of mental health treatment in primary care practices may aid plans in constructing adequate mental health provider networks and improve patient access to mental health care.

Transitioning patients from outpatient mental health services to primary care: A rapid literature review

Background

A lack of access to mental health services is a critical barrier to obtaining evidence-based care. One strategy to improve access is to transition stable patients out of mental health specialty services and into primary care, thus opening availability for new patients and those with acute mental health needs. To support these transitions, organizations might explore a range of new practices and implementation strategies.

Methods

We conducted a rapid literature review to summarize descriptions from the research literature about practices for transitioning stable patients from outpatient mental health services to primary care, as well as implementation strategies to enhance the adoption and sustainment of these practices. We searched PsycINFO and Cumulated Index to Nursing and Allied Health Literature (CINAHL) for articles published between January 2000 and August 2019. For articles meeting inclusion criteria, we abstracted data on study characteristics, transition practices, and implementation strategies.

Results

We included 11 articles representing diverse study designs, settings, and health care organizations. Across these articles, we identified six categories of commonly described transition practices, with patient engagement appearing the most frequently (10 articles), followed by shared treatment planning (eight articles), assessment of recovery and stability, care coordination, follow up and support, and medication management (seven articles each). Less frequently, articles included descriptions of implementation strategies, with five articles describing efforts to train and educate stakeholders and four articles describing the use of evaluative and iterative strategies.

Conclusions

We identified descriptions of several common practices to help patients transition from mental health specialty services to primary care, but there are opportunities for an increased focus on implementation strategies to enhance the adoption and sustainment of these transition practices. More research is needed to better understand the effectiveness of specific transition interventions and the feasibility of deploying these interventions in heterogeneous health care settings.

Collaborative care for depression management in primary care: A randomized roll-out trial using a type 2 hybrid effectiveness-implementation design

Background

The Collaborative Care Model (CoCM) is a well-established treatment for depression in primary care settings. The critical drivers and specific strategies for improving implementation and sustainment are largely unknown. Rigorous pragmatic research is needed to understand CoCM implementation processes and outcomes.

Methods

This study is a hybrid Type 2 randomized roll-out effectiveness-implementation trial of CoCM in 11 primary care practices affiliated with an academic medical center. The Collaborative Behavioral Health Program (CBHP) was developed as a means of improving access to effective mental health services for depression. Implementation strategies are provided to all practices. Using a sequential mixed methods approach, we will assess key stakeholders’ perspectives on barriers and facilitators of implementation and sustainability of CBHP. The speed and quantity of implementation activities completed over a 30-month period for each practice will be assessed. Economic analyses will be conducted to determine the budget impact and cost offset of CBHP in the healthcare system. We hypothesize that CBHP will be effective in reducing depressive symptoms and spillover effects on chronic health conditions. We will also examine differential outcomes among racial/ethnic minority patients.

Discussion

This study will elucidate critical drivers of successful CoCM implementation. It will be among the first to conduct economic analyses on a fee-for-service model utilizing billing codes for CoCM. Data may inform ways to improve implementation efficiency with an optimization approach to successive practices due to the roll-out design. Changes to the protocol and current status of the study are discussed.

Pilot Study on Reducing Symptoms of Anxiety with a Heart Rate Variability Biofeedback Wearable and Remote Stress Management Coach

We assessed the feasibility of using a consumer friendly, heart rate variability biofeedback (HRVB) wearable device in conjunction with a remote stress management coach to reduce symptoms of anxiety. We utilized a discreet, continuously wearable electrocardiogram device, the Lief Smart Patch, which measures and records heart rate and HRV in real time, and guides HRVB exercises using vibrations and visual cues. During the 8-week study, participants (N = 14) wore the Lief Smart Patch, participated in HRVB with the device, utilized the mobile app, and communicated with a remote stress management coach. We collected self-report survey responses to measure symptoms of anxiety (GAD-2) and depression (PHQ-2) every 2 weeks, as well as HRV data throughout the study. Participants’ mean GAD-2 score began at 4.6 out of 6. By the trial’s completion, the group’s mean GAD-2 score dropped to 1.7 (t₍₁₃₎ = 11.0, p < .001) with only 2 of the 14 subjects remaining over the clinical threshold of high anxiety. Similarly, the group’s mean PHQ-2 score dropped from 2.93 to 1.29 (t₍₁₃₎ = 3.54, p < .01). In addition, participants increased their HRV (RMSSD) by an average of + 11.4 ms after participating in a low dose biofeedback exercise. These findings suggest that engaging in HRVB through a discreet wearable device in conjunction with a remote stress management program may be effective for reducing symptoms of anxiety and depression.

Beyond non-inferior: how telepsychiatry technologies can lead to superior care

Telepsychiatry refers to the use of technology to support the remote provision of psychiatric services. Discussions of this technology have often focussed on the use of video conferencing in place of in-person visits and how such care is found to be non-inferior to traditional care. New developments in the fields of remote-sensing and digital phenotyping have the potential to overcome the limitations inherent in remote visits as well as the limitations of current outpatient care models more generally. Such technologies may enable the collection of more relevant, objective clinical data which could lead to improved care quality and transformed care delivery models. The development and implementation of these new technologies raise important ethical questions.

Incorrect Provider Directories Associated With Out-Of-Network Mental Health Care And Outpatient Surprise Bills

Mental health services are up to six times more likely than general medical services to be delivered by an out-of-network provider, in part because many psychiatrists do not accept commercial insurance. Provider directories help patients identify in-network providers, although directory information is often not accurate. We conducted a national survey of privately insured patients who received specialty mental health treatment. We found that 44 percent had used a mental health provider directory and that 53 percent of these patients had encountered directory inaccuracies. Those who encountered inaccuracies were more likely (40 percent versus 20 percent) to be treated by an out-of-network provider and four times more likely (16 percent versus 4 percent) to receive a surprise outpatient out-of-network bill (that is, they did not initially know that a provider was out of network). A federal standard for directory accuracy, stronger enforcement of existing laws with insurers liable for directory errors, and additional monitoring by regulators may be needed.

Improving Primary Care Behavioral Health Integration in an Academic Internal Medicine Practice: 2-Year Follow-Up

This report details ongoing efforts to improve integration in the 2 years following implementation of the Primary Care Behavioral Health model at a general internal medicine clinic of an urban academic medical center. Efforts were informed by a modified version of the validated Level of Integration Measure, sent to all faculty and staff annually. At baseline, results indicated that the domains of systems integration, training, and integrated clinical practices had the greatest need for improvement. Over the 2 years, the authors increased availability of behavioral medicine appointments, improved depression screening processes, offered behavioral health training for providers, disseminated clinical decision support tools, and provided updates about integration progress during clinic meetings. Follow-up survey results demonstrated that physicians and staff perceived improvements in integration overall and in targeted domains. However, the main ongoing barrier to integration was insufficient behavioral health staff to meet patient demand for behavioral health services.

The Effect of Supervision Waivers on Practice: A Survey of Massachusetts Nurse Practitioners During the COVID-19 Pandemic

BACKGROUND

While optimal utilization of the nurse practitioner (NP) workforce is an increasingly popular proposal to alleviate the growing primary care shortage, federal, state, and organizational scope of practice policies inhibit NPs from practicing to the full extent of their license and training. In March of 2020, NP state-specific supervisory requirements were temporarily waived to meet the demands of the coronavirus disease 2019 (COVID-19) pandemic in Massachusetts.

OBJECTIVE

The objective of this study was to examine the impact of temporarily waived state practice restrictions on NP perception of care delivery during the initial surge of the COVID-19 pandemic in Massachusetts.

RESEARCH DESIGN

Mixed methods descriptive analysis of a web-based survey of Massachusetts NPs (N=391), conducted in May and June 2020.

RESULTS

The vast majority (75%) of NPs believed the temporary removal of practice restriction did not perceptibly improve clinical work. Psychiatric mental health NPs were significantly more likely than other NP specialties to believe the waiver improved clinical work (odds ratio=6.68, P=0.001). NPs that experienced an increase in working hours during the pandemic surge were also more likely to report a positive effect of the waiver (odds ratio=2.56, P=0.000).

CONCLUSIONS

Temporary removal of state-level practice barriers alone is not sufficient to achieve immediate full scope of practice for NPs. The successful implementation of modernized scope of practice laws may require a collective effort to revise organizational and payer policies accordingly.