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Wang J, Pasyk SP, Slavin-Stewart C, Olagunju AT. Barriers to Mental Health care in Canada Identified by Healthcare Providers: A Scoping Review. ADMINISTRATION AND POLICY IN MENTAL HEALTH AND MENTAL HEALTH SERVICES RESEARCH 2024; 51:826-838. [PMID: 38512557 DOI: 10.1007/s10488-024-01366-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/04/2024] [Indexed: 03/23/2024]
Abstract
The mental health treatment gap remains wide across the world despite mental illness being a significant cause of disability globally. Both end-user and healthcare provider perspectives are critical to understanding barriers to mental healthcare and developing interventions. However, the views of providers are relatively understudied. In this review, we synthesized findings from current literature regarding providers' perspectives on barriers to mental healthcare in Canada. We searched Medline, PsycINFO, Embase, and CINAHL for eligible Canadian studies published since 2000. Analysis and quality assessment were conducted on the included studies. Of 4,773 reports screened, 29 moderate-high quality studies were reviewed. Five themes of barriers emerged: health systems availability and complexity (reported in 72% of the studies), work conditions (55%), training/education (52%), patient accessibility (41%), and identity-based sensitivity (17%). Common barriers included lack of resources, fragmented services, and gaps in continuing education. Interestingly, clinicians often cited confusion in determining the ideal service for patients due to an overwhelming number of potential services without clear descriptions. These five domains of barriers present a synthesized review of areas of improvement for mental healthcare spanning both patients and clinicians. Canadian mental health systems face a need to improve capacity, clinician training, and in particular service navigability and collaboration.
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Affiliation(s)
- Jeffrey Wang
- Department of Psychiatry and Behavioral Neurosciences, McMaster University/St Joseph's Healthcare Hamilton, 100 West 5th Street, Hamilton, ON, L8N 3K7, Canada
| | - Stanislav P Pasyk
- Department of Psychiatry and Behavioral Neurosciences, McMaster University/St Joseph's Healthcare Hamilton, 100 West 5th Street, Hamilton, ON, L8N 3K7, Canada
| | - Claire Slavin-Stewart
- Department of Psychiatry and Behavioral Neurosciences, McMaster University/St Joseph's Healthcare Hamilton, 100 West 5th Street, Hamilton, ON, L8N 3K7, Canada
| | - Andrew T Olagunju
- Department of Psychiatry and Behavioral Neurosciences, McMaster University/St Joseph's Healthcare Hamilton, 100 West 5th Street, Hamilton, ON, L8N 3K7, Canada.
- Discipline of Psychiatry, The University of Adelaide, North Terrace, Adelaide, SA, 5000, Australia.
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Hargraves JL, Cosenza C, Cleary PD. Measuring Access to Mental Health Services Among Primary Care Patients. Med Care 2024; 62:559-566. [PMID: 38842445 PMCID: PMC11226347 DOI: 10.1097/mlr.0000000000002029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2024]
Abstract
BACKGROUND The lifetime risk of mental health disorders is almost 50% and, in any year, about 25% of the population have a psychiatric disorder. Many of those people are cared for in primary care settings. RESEARCH OBJECTIVE Measure access to mental health services, such as getting counselling or prescription mental health medications, using new patient survey questions that can be added to Consumer Assessment of Healthcare Providers and Systems (CAHPS) surveys. STUDY DESIGN Surveys were conducted with a stratified probability sample of patients receiving primary care services in a single state in 2018-2019. Medicaid and privately insured patients were surveyed by mail or telephone, respectively. RESULTS Approximately 14% of sampled patients responded to a survey. More than 10% of privately insured respondents and about 20% of Medicaid respondents got or tried to get appointments for mental health care. About 15% of privately insured respondents and 11% of Medicaid respondents reported problems getting appointments with counselors. Only 8%-9% of respondents seeking mental health medicines reported problems getting appointments for prescriptions. A composite measure combining access to counselors and prescribers of mental health medicines evidenced adequate internal consistency reliability. Group level reliability estimates were low. CONCLUSIONS Many respondents got or tried to get mental health services and a substantial number reported problems getting appointments or getting mental health prescriptions. The tested questions can be combined into an Access to Mental Health Care measure, which can be included in patient experience surveys for ambulatory care to monitor access to behavioral health care.
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Affiliation(s)
- J. Lee Hargraves
- Center for Survey Research, University of Massachusetts Boston, 100 William T. Morrissey Blvd. Boston, MA 02125-3393
| | - Carol Cosenza
- Center for Survey Research, University of Massachusetts Boston, 100 William T. Morrissey Blvd. Boston, MA 02125-3393
| | - Paul D. Cleary
- Yale School of Public Health, 60 College St, New Haven, CT 06510
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Rathnam S, Hart KL, Sharma A, Verhaak PF, McCoy TH, Doshi-Velez F, Perlis RH. Heterogeneity in Antidepressant Treatment and Major Depressive Disorder Outcomes Among Clinicians. JAMA Psychiatry 2024:2821076. [PMID: 38985482 PMCID: PMC11238069 DOI: 10.1001/jamapsychiatry.2024.1778] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2023] [Accepted: 04/16/2024] [Indexed: 07/11/2024]
Abstract
Importance While abundant work has examined patient-level differences in antidepressant treatment outcomes, little is known about the extent of clinician-level differences. Understanding these differences may be important in the development of risk models, precision treatment strategies, and more efficient systems of care. Objective To characterize differences between outpatient clinicians in treatment selection and outcomes for their patients diagnosed with major depressive disorder across academic medical centers, community hospitals, and affiliated clinics. Design, Setting, and Participants This was a longitudinal cohort study using data derived from electronic health records at 2 large academic medical centers and 6 community hospitals, and their affiliated outpatient networks, in eastern Massachusetts. Participants were deidentified clinicians who billed at least 10 International Classification of Diseases, Ninth Revision (ICD-9) or Tenth Revision (ICD-10) diagnoses of major depressive disorder per year between 2008 and 2022. Data analysis occurred between September 2023 and January 2024. Main Outcomes and Measures Heterogeneity of prescribing, defined as the number of distinct antidepressants accounting for 75% of prescriptions by a given clinician; proportion of patients who did not return for follow-up after an index prescription; and proportion of patients receiving stable, ongoing antidepressant treatment. Results Among 11 934 clinicians treating major depressive disorder, unsupervised learning identified 10 distinct clusters on the basis of ICD codes, corresponding to outpatient psychiatry as well as oncology, obstetrics, and primary care. Between these clusters, substantial variability was identified in the proportion of selective serotonin reuptake inhibitors, selective norepinephrine reuptake inhibitors, and tricyclic antidepressants prescribed, as well as in the number of distinct antidepressants prescribed. Variability was also detected between clinician clusters in loss to follow-up and achievement of stable treatment, with the former ranging from 27% to 69% and the latter from 22% to 42%. Clinician clusters were significantly associated with treatment outcomes. Conclusions and Relevance Groups of clinicians treating individuals diagnosed with major depressive disorder exhibit marked differences in prescribing patterns as well as longitudinal patient outcomes defined by electronic health records. Incorporating these group identifiers yielded similar prediction to more complex models incorporating individual codes, suggesting the importance of considering treatment context in efforts at risk stratification.
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Affiliation(s)
- Sarah Rathnam
- Harvard John A. Paulson School of Engineering and Applied Sciences, Cambridge, Massachusetts
| | - Kamber L. Hart
- Center for Quantitative Health, Massachusetts General Hospital, Boston
- Department of Psychiatry, Harvard Medical School, Boston, Massachusetts
| | - Abhishek Sharma
- Harvard John A. Paulson School of Engineering and Applied Sciences, Cambridge, Massachusetts
| | - Pilar F. Verhaak
- Center for Quantitative Health, Massachusetts General Hospital, Boston
| | - Thomas H. McCoy
- Center for Quantitative Health, Massachusetts General Hospital, Boston
- Department of Psychiatry, Harvard Medical School, Boston, Massachusetts
| | - Finale Doshi-Velez
- Harvard John A. Paulson School of Engineering and Applied Sciences, Cambridge, Massachusetts
| | - Roy H. Perlis
- Center for Quantitative Health, Massachusetts General Hospital, Boston
- Department of Psychiatry, Harvard Medical School, Boston, Massachusetts
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Smith AM, Prom MC, Ng LC. A Qualitative Investigation of Characteristics Impacting Clinical Decision-Making in Integrated Behavioral Health Care. J Behav Health Serv Res 2024:10.1007/s11414-024-09891-6. [PMID: 38982024 DOI: 10.1007/s11414-024-09891-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/04/2024] [Indexed: 07/11/2024]
Abstract
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.
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Affiliation(s)
- Ash M Smith
- Boston Medical Center, 720 Harrison Ave, Boston, MA, 02118, USA
- Psychology Department, The Graduate Center, City University of New York, New York, NY, USA
| | - Maria C Prom
- Boston Medical Center, 720 Harrison Ave, Boston, MA, 02118, USA
- Department of Psychiatry, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Lauren C Ng
- Boston Medical Center, 720 Harrison Ave, Boston, MA, 02118, USA.
- Psychiatry Department, Boston University School of Medicine, Boston, MA, USA.
- Department of Psychology, University of California Los Angeles, Psychology Building 1285, Box 951563, Los Angeles, CA, 90095, USA.
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Haun MW, van Eickels D, Tönnies J, Graue L, Ayoub-Schreifeldt M, Wensing M, Hartmann M, Szecsenyi J, Wild B, Friederich HC. An integrated mental health video consultations model for patients with somatic symptom disorder in primary care: The randomized VISION pilot trial. J Psychosom Res 2024; 182:111801. [PMID: 38761536 DOI: 10.1016/j.jpsychores.2024.111801] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2024] [Revised: 04/16/2024] [Accepted: 05/12/2024] [Indexed: 05/20/2024]
Abstract
OBJECTIVE Symptoms of somatic symptom disorder (SSD) are one of the most common reasons for consultations in primary care. However, specialized psychological services are mostly unavailable. This pilot trial aimed to determine the feasibility, acceptability, and safety of the integrated mental health video consultations VISION model for patients with SSD in primary care. METHODS We conducted a parallel group, randomized controlled pilot trial involving fifty-one patients with SSD from ten primary care practices in Germany, who we randomized to the VISION model or enhanced treatment-as-usual (eTAU). The VISION model comprised five video consultations which featured diagnostic clarification, psychoeducation (acknowledging and legitimizing of symptoms), and brief psychological therapy. eTAU included training primary care practice teams on the DSM-5 concept of SSD and on current guideline recommendations for its treatment in primary care. We assessed feasibility as the primary outcome at 6-months, measuring efficiency of recruitment, intervention acceptability, and safety. RESULTS Recruitment was efficient reflected in an overall recruitment yield (number randomized per number screened) of 55% (51/92) and a consent rate (number randomized per number eligible) of 94% (51/54). Acceptability of the intervention was high with 98% (123/125) of the video consultations conducted as planned. No serious adverse events were reported in either group. CONCLUSION An integrated mental health video consultations VISION model for patients with SSD presenting to primary care is feasible, acceptable, and safe. Potential clinical effectiveness of the model should be evaluated in confirmatory trial implementing the multifaceted approach tailored to the individual patient with SSD directly into primary care practice. TRIAL REGISTRATION The trial protocol was registered at German Clinical Trials Register (number: DRKS00026075, https://www.drks.de).
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Affiliation(s)
- Markus W Haun
- Department of General Internal Medicine and Psychosomatics, Heidelberg University, Germany.
| | - Deborah van Eickels
- Department of General Internal Medicine and Psychosomatics, Heidelberg University, Germany
| | - Justus Tönnies
- Department of General Internal Medicine and Psychosomatics, Heidelberg University, Germany
| | - Leike Graue
- Department of General Internal Medicine and Psychosomatics, Heidelberg University, Germany
| | | | - Michel Wensing
- Department of General Practice and Health Services Research, Heidelberg University, Germany
| | - Mechthild Hartmann
- Department of General Internal Medicine and Psychosomatics, Heidelberg University, Germany
| | - Joachim Szecsenyi
- Department of General Practice and Health Services Research, Heidelberg University, Germany
| | - Beate Wild
- Department of General Internal Medicine and Psychosomatics, Heidelberg University, Germany
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Culmer NP, Smith TB, Berryhill MB, Gurenlian J, Simpson L, Ogden S, Parrish J, Ryan L, White N, Bettis M, Greenwood C. Mental health screening and referral to treatment in dental practices: A scoping review. J Dent Educ 2024; 88:445-460. [PMID: 38282325 DOI: 10.1002/jdd.13444] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Accepted: 12/15/2023] [Indexed: 01/30/2024]
Abstract
OBJECTIVE The purpose of this study was to conduct a scoping review to examine and summarize the characteristics of research related to mental health (MH) screenings and/or referrals to treatment in dental practices. METHODS We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines for Scoping Reviews and searched multiple databases for terms connected with dental care, MH concerns, screening, and referral. Included articles: (1) described care provided in a dental practice, (2) described a situation where the patient is experiencing the potential MH problem, (3) did not involve dental anxiety exclusively, and (4) involved some form of MH screening and/or referral to treatment. Article analysis included a summary of key study characteristics, types of evidence, study design, and central concepts and definitions. RESULTS The search generated 2050 records, with 26 ultimately included. Most studies involved only adults (22, 85%), but only three (12%) reported on rurality (two urban; one mixed) and only two each (8%) reported race or ethnicity. Fifteen (58%) articles were prospective and 11 (42%) were retrospective. The studies varied widely in study designs, from 11 (42%) cross-sectional methodologies to only one (4%) randomized controlled trial. Thirty-four screening tools were used to screen for symptoms of 43 MH conditions, with depression and anxiety screened for most frequently. Few articles discussed making referrals, practice workflows, or follow-up outcomes. CONCLUSIONS Included studies provide evidence of viable options for dental practitioners regarding MH screening, referring, and conducting follow-up, but lack specificity regarding these processes. Overall, more research is needed to clarify what workflows are most efficient for dental practitioners and efficacious in identifying patients with MH concerns.
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Affiliation(s)
- Nathan P Culmer
- College of Community Health Sciences, The University of Alabama, Tuscaloosa, Alabama, USA
| | - Todd Brenton Smith
- Capstone College of Nursing, The University of Alabama, Tuscaloosa, Alabama, USA
| | - M Blake Berryhill
- Department of Human Development and Family Studies, The University of Alabama, Tuscaloosa, Alabama, USA
| | - JoAnn Gurenlian
- Education and Research Division, American Dental Hygienists' Association, Chicago, Illinois, USA
- Department of Dental Hygiene, Idaho State University, Pocatello, Idaho, USA
| | - Lance Simpson
- University Libraries, The University of Alabama, Tuscaloosa, Alabama, USA
| | - Shawnna Ogden
- College of Community Health Sciences, The University of Alabama, Tuscaloosa, Alabama, USA
| | - Jonathan Parrish
- College of Dental Medicine, Roseman University of Health Sciences, South Jordan, Utah, USA
- College of Arts and Sciences, The University of Alabama, Tuscaloosa, Alabama, USA
| | - Lacey Ryan
- College of Arts and Sciences, The University of Alabama, Tuscaloosa, Alabama, USA
| | - Nicole White
- Department of Psychology, The University of Mississippi, Oxford, Mississippi, USA
| | - Merrill Bettis
- College of Arts and Sciences, The University of Alabama, Tuscaloosa, Alabama, USA
| | - Charlotte Greenwood
- College of Arts and Sciences, The University of Alabama, Tuscaloosa, Alabama, USA
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Olfson M, McClellan C, Zuvekas SH, Wall M, Blanco C. Trends in Psychological Distress and Outpatient Mental Health Care of Adults During the COVID-19 Era. Ann Intern Med 2024; 177:353-362. [PMID: 38316009 DOI: 10.7326/m23-2824] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2024] Open
Abstract
BACKGROUND In addition to the physical disease burden of the COVID-19 pandemic, concern exists over its adverse mental health effects. OBJECTIVE To characterize trends in psychological distress and outpatient mental health care among U.S. adults from 2018 to 2021 and to describe patterns of in-person, telephone, and video outpatient mental health care. DESIGN Cross-sectional nationally representative survey of noninstitutionalized adults. SETTING United States. PARTICIPANTS Adults included in the Medical Expenditure Panel Survey Household Component, 2018 to 2021 (n = 86 658). MEASUREMENTS Psychological distress was measured with the Kessler-6 scale (range of 0 to 24, with higher scores indicating more severe distress), with a score of 13 or higher defined as serious psychological distress, 1 to 12 as less serious distress, and 0 as no distress. Outpatient mental health care use was measured via computer-assisted personal interviews. RESULTS Between 2018 and 2021, the rate of serious psychological distress among adults increased from 3.5% to 4.2%. Although the rate of outpatient mental health care increased from 11.2% to 12.4% overall, the rate decreased from 46.5% to 40.4% among adults with serious psychological distress. When age, sex, and distress were controlled for, a significant increase in outpatient mental health care was observed for young adults (aged 18 to 44 years) but not middle-aged (aged 45 to 64 years) and older (aged >65 years) adults and for employed adults but not unemployed adults. In 2021, 33.4% of mental health outpatients received at least 1 video visit, including a disproportionate percentage of young, college-educated, higher-income, employed, and urban adults. LIMITATION Information about outpatient mental health service modality (in-person, video, telephone) was first fully available in the 2021 survey. CONCLUSION These trends and patterns underscore the persistent challenges of connecting older adults, unemployed persons, and seriously distressed adults to outpatient mental health care and the difficulties faced by older, less educated, lower-income, unemployed, and rural patients in accessing outpatient mental health care via video. PRIMARY FUNDING SOURCE None.
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Affiliation(s)
- Mark Olfson
- Department of Psychiatry, College of Physicians and Surgeons, Columbia University and New York State Psychiatric Institute, New York, New York (M.O., M.W.)
| | - Chandler McClellan
- Agency for Healthcare Research and Quality, Rockville, Maryland (C.M., S.H.Z.)
| | - Samuel H Zuvekas
- Agency for Healthcare Research and Quality, Rockville, Maryland (C.M., S.H.Z.)
| | - Melanie Wall
- Department of Psychiatry, College of Physicians and Surgeons, Columbia University and New York State Psychiatric Institute, New York, New York (M.O., M.W.)
| | - Carlos Blanco
- National Institute on Drug Abuse, Bethesda, Maryland (C.B.)
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Peake E, Miller I, Flannery J, Chen L, Lake J, Padmanabhan A. Preliminary Efficacy of a Digital Intervention for Adolescent Depression: Randomized Controlled Trial. J Med Internet Res 2024; 26:e48467. [PMID: 38324367 PMCID: PMC10882470 DOI: 10.2196/48467] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Revised: 06/28/2023] [Accepted: 10/25/2023] [Indexed: 02/08/2024] Open
Abstract
BACKGROUND Adolescent depression is a significant public health concern; however, access to effective mental health care is limited. Digital therapeutics (DTx) can improve access to evidence-based interventions; however, their efficacy in adolescents is sparsely documented. OBJECTIVE This study aims to examine the efficacy of a mobile app DTx versus an active control as an adjunct treatment for adolescent depression symptoms. METHODS An internet-based open-label randomized control trial was conducted nationwide with a partial crossover design, and 168 adolescents aged 13 to 21 years with symptoms of depression were recruited between November 2020 and September 2021. Participants were randomized (1:1) to the cognitive behavioral therapy-based treatment app (Spark) or to a psychoeducational control app (control), which they would use for a duration of 5 weeks. The primary outcome was a between-group (Spark vs control) difference in the change in depression symptoms from baseline to postintervention, as measured by the Patient Health Questionnaire-8 (PHQ-8) using a linear mixed-effects analysis. The PHQ-8 ranges from 0 to 24, with scores of 5 to 9 indicating mild depression symptoms, scores of 10 to 14 indicating moderate symptoms, scores of 15 to 19 indicating moderately severe symptoms, and scores of 20 to 24 indicating severe symptoms. A minimal clinically important difference (5-point reduction between baseline and postintervention) in the Spark arm and group differences in remission and treatment response rates based on the PHQ-8 at postintervention were also investigated. RESULTS A total of 160 participants were randomized, 80 in the Spark arm (mean age 16.89, SD 2.5 y) and 80 in the control arm (mean age 16.79, SD 2.59 y). Data from 121 participants (Spark: n=63; control: n=58) with moderate to severe (PHQ-8≥10) symptoms at baseline were included in the primary analyses following a modified intention-to-treat principle. A linear mixed-effect analysis revealed a nonsignificant difference between the study arms in depression symptom change over the intervention period. The Spark arm met a minimal clinically important difference threshold (mean -5.08, 95% CI -6.72 to -3.42). The remission rate in the Spark arm was significantly higher than that in the control arm (11/63, 17% vs 2/58, 3%; χ21=6.2; P=.01; false discovery rate-adjusted P=.03). The treatment response rates were not significantly different between the study arms (P=.07; false discovery rate-adjusted P=.16). Post hoc analyses including participants with mild to severe (PHQ-8 score ≥5) symptoms at baseline revealed promising evidence that Spark is effective in those with mild to severe symptoms. CONCLUSIONS There is initial evidence that a self-guided, cognitive behavioral therapy-based DTx intervention may effectively treat mild to severe depression symptoms in adolescents. DTx may improve access to mental health care for adolescents or serve as an important adjunct to the standard of care. TRIAL REGISTRATION ClinicalTrials.gov NCT04524598; https://clinicaltrials.gov/study/NCT04524598.
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Affiliation(s)
- Emily Peake
- Limbix Health Inc, San Francisco, CA, United States
- Big Health Inc, San Francisco, CA, United States
| | - Ian Miller
- Limbix Health Inc, San Francisco, CA, United States
- Digital Medicine Society, Boston, MA, United States
| | - Jessica Flannery
- Limbix Health Inc, San Francisco, CA, United States
- Akili, Boston, MA, United States
| | - Lang Chen
- Neuroscience Unit, Santa Clara University, Santa Clara, CA, United States
| | - Jessica Lake
- Limbix Health Inc, San Francisco, CA, United States
- Big Health Inc, San Francisco, CA, United States
| | - Aarthi Padmanabhan
- Limbix Health Inc, San Francisco, CA, United States
- Big Health Inc, San Francisco, CA, United States
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Lieff SA, Mijanovich T, Yang L, Silver D. Impacts of the Affordable Care Act Medicaid Expansion on Mental Health Treatment Among Low-income Adults Across Racial/Ethnic Subgroups, 2010-2017. J Behav Health Serv Res 2024; 51:57-73. [PMID: 37673829 DOI: 10.1007/s11414-023-09861-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/08/2023] [Indexed: 09/08/2023]
Abstract
This study examines whether the Affordable Care Act (ACA) Medicaid expansion (ME) was associated with changes in racial/ethnic disparities in insurance coverage, utilization, and quality of mental health care among low-income adults with probable mental illness using the National Survey on Drug Use and Health with state identifiers. This study employed difference-in-difference models to compare ME states to non-expansion states before (2010-2013) and after (2014-2017) expansion and triple difference models to examine these changes across non-Hispanic White (NHW), non-Hispanic Black (NHB), and Hispanic/Latino racial/ethnic subgroups. Insurance coverage increased significantly for all racial/ethnic groups in expansion states relative to non-expansion states (DD: 9.69; 95% CI: 5.17, 14.21). The proportion low-income adults that received treatment but still had unmet need decreased (DD: -3.06; 95% CI: -5.92, -0.21) and the proportion with unmet need and no mental health treatment increased (DD: 2.38; 95% CI: 0.03, 4.73). ME was not associated with reduced disparities.
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Affiliation(s)
- Sarah A Lieff
- Department of Social and Behavioral Sciences, New York University School of Global Public Health, 708 Broadway, New York, NY, 10003, USA.
| | - Tod Mijanovich
- Department of Applied Statistics, Social Science, and Humanities, New York University Steinhardt School of Culture, Education, and Human Development, New York, NY, USA
| | - Lawrence Yang
- Department of Social and Behavioral Sciences, New York University School of Global Public Health, 708 Broadway, New York, NY, 10003, USA
| | - Diana Silver
- Department of Public Health Policy and Management, New York University School of Global Public Health, New York, NY, USA
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Savoie MB, Poeschla A, Lu N, Zhang Y, Bolster MB, Schoenfeld S, Castelino FV. Clinically Recognized Depression and Mental Health Treatment in a Single Center Cohort of Patients with Systemic Sclerosis. Int J Rheumatol 2023; 2023:6141790. [PMID: 38148989 PMCID: PMC10751161 DOI: 10.1155/2023/6141790] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2023] [Revised: 11/20/2023] [Accepted: 11/26/2023] [Indexed: 12/28/2023] Open
Abstract
Introduction In this study, we investigated the prevalence of depression, depression treatment, and symptom burden in patients with systemic sclerosis (SSc) and examined their associations with the center for epidemiologic studies depression scale revised (CESD-R) scores. Methods The Prospective Registry in Scleroderma at Massachusetts General Hospital (PRISM) is a longitudinal registry of patients with SSc. Among participants with CESD-R score ≥ 16, indicating possible depression, a chart review was performed for mental health diagnoses and treatments. We examined the relation of demographic and clinical factors to the presence of mental health diagnoses or treatment using logistic regression. We evaluated the association of SSc symptoms and the COVID-19 pandemic with a CESD-R score using quantile regression. Results Of 214 patients enrolled in PRISM, 129 participants (38% diffuse and 59% limited) completed at least one CESD-R questionnaire. In the first survey, 29% had possible depression (CESD - R ≥ 16) and 16% had probable depression (CESD - R ≥ 23). Of 20 participants with probable depression, 90% received treatment for a mood disorder. In a multivariable logistic regression model among participants with CESD - R ≥ 16, none of the evaluated variables (CESD-R score, age, gender, employment status, race, and ethnicity) was associated with mental health diagnosis or treatment. Higher baseline dyspnea index, modified Rodnan skin score, and the University of California Los Angeles Scleroderma Clinical Trials Consortium Gastrointestinal total score and subscores were associated with higher CESD-R score. Conclusion In this single-center cross-sectional study, 16% of participants had significant depressive symptoms. Dyspnea, extent of skin involvement, and gastrointestinal symptoms were associated with depression symptoms.
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Affiliation(s)
| | - Alexandra Poeschla
- Department of Medicine, Division of Rheumatology, Allergy, and Immunology, Massachusetts General Hospital, USA
| | - Na Lu
- Arthritis Research Canada, Canada
| | - Yuqing Zhang
- Department of Medicine, Division of Rheumatology, Allergy, and Immunology, Massachusetts General Hospital, USA
| | - Marcy B. Bolster
- Department of Medicine, Division of Rheumatology, Allergy, and Immunology, Massachusetts General Hospital, USA
| | - Sara Schoenfeld
- Department of Medicine, Division of Rheumatology, Allergy, and Immunology, Massachusetts General Hospital, USA
| | - Flavia V. Castelino
- Department of Medicine, Division of Rheumatology, Allergy, and Immunology, Massachusetts General Hospital, USA
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Hostutler C, Wolf N, Snider T, Butz C, Kemper AR, Butter E. Increasing Access to and Utilization of Behavioral Health Care Through Integrated Primary Care. Pediatrics 2023; 152:e2023062514. [PMID: 37969039 DOI: 10.1542/peds.2023-062514] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/29/2023] [Indexed: 11/17/2023] Open
Abstract
OBJECTIVES To evaluate changes in access to and utilization of behavioral health (BH) services after the integration of psychologists into primary care clinics compared with clinics without integrated psychologists. METHODS We integrated 4 of 12 primary care clinics within our academic health system. We used the median wait time for BH services as a proxy for changes in access and defined BH utilization as the percentage of primary care visits that resulted in contact with a BH clinician within 180 days. We compared changes in access and utilization from the year before integration (September 2015 to September 2016) with the 2 years after integration (October 2016 to October 2018) within integrated clinics and between integrated and nonintegrated clinics. We used difference-in-difference analysis to test the association of study outcomes with the presence of integrated psychologists. RESULTS Access and utilization were similar across all practices before integration. After integration, BH utilization increased by 143% in integrated clinics compared with 12% in nonintegrated clinics. The utilization of BH services outside of the medical home (ie, specialty BH service) decreased for integrated clinics only. In clinics with integrated psychologists, 93% of initial BH visits happened on the same day as a need was identified. The median wait time for the 7% in integrated clinics who were not seen on the same day was 11.4 days (interquartile range = 5.3-17.7) compared with 48.3 days (interquartile range = 20.4-93.6) for nonintegrated clinics. CONCLUSIONS A team-based integration model increased BH utilization and access.
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Affiliation(s)
- Cody Hostutler
- Department of Pediatric Psychology and Neuropsychology
- Department of Pediatrics, The Ohio State University College of Medicine, Columbus, Ohio
| | - Noelle Wolf
- Department of Pediatric Psychology and Neuropsychology
- Department of Pediatrics, The Ohio State University College of Medicine, Columbus, Ohio
| | - Tyanna Snider
- Department of Pediatric Psychology and Neuropsychology
- Department of Pediatrics, The Ohio State University College of Medicine, Columbus, Ohio
| | - Catherine Butz
- Department of Pediatric Psychology and Neuropsychology
- Department of Pediatrics, The Ohio State University College of Medicine, Columbus, Ohio
| | - Alex R Kemper
- Division of Primary Care Pediatrics, Nationwide Children's Hospital, Columbus, Ohio
- Department of Pediatrics, The Ohio State University College of Medicine, Columbus, Ohio
| | - Eric Butter
- Department of Pediatric Psychology and Neuropsychology
- Department of Pediatrics, The Ohio State University College of Medicine, Columbus, Ohio
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Furman DJ, Hall SA, Avina C, Kulikov VN, Lake JI, Padmanabhan A. Assessing the Efficacy and Safety of a Digital Therapeutic for Symptoms of Depression in Adolescents: Protocol for a Randomized Controlled Trial. JMIR Res Protoc 2023; 12:e48740. [PMID: 37971800 PMCID: PMC10690536 DOI: 10.2196/48740] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Revised: 09/23/2023] [Accepted: 09/27/2023] [Indexed: 11/19/2023] Open
Abstract
BACKGROUND Depression is a serious, prevalent, recurrent, and undertreated disorder in adolescents. Low levels of treatment seeking and treatment adherence in this age group, combined with a growing national crisis in access to mental health care, have increased efforts to identify effective treatment alternatives for this demographic. Digital health interventions for mental illness can provide cost-effective, engaging, and accessible means of delivering psychotherapy to adolescents. OBJECTIVE This protocol describes a virtual randomized controlled trial designed to evaluate the efficacy and safety of a self-guided, mobile app-based implementation of behavioral activation therapy, SparkRx, for the adjunct treatment of symptoms of depression in adolescents. METHODS Participants are recruited directly through web-based and print advertisements. Following eligibility screening and consenting, participants are randomly assigned to a treatment arm (SparkRx) or a control arm (assessment-enhanced usual care) for 5 weeks. The primary efficacy outcome, total score on the 8-item Patient Health Questionnaire (PHQ-8), is assessed at the end of the 5-week intervention period. Additional participant-reported outcomes are assessed at baseline, the postintervention time point, and 1-month follow-up. The safety of the intervention is assessed by participant report (and legal guardian report, if the participant is younger than 18 years) and by patterns of symptom deterioration on the PHQ-8, as part of a larger clinical safety monitoring protocol. The primary efficacy outcome, total PHQ-8 score at the postintervention time point, will be compared between SparkRx and enhanced usual care arms using mixed effect modeling, with baseline PHQ-8 and current antidepressant medication status included as covariates. Secondary efficacy outcomes, including the proportion of participants exhibiting treatment response, remission, and minimal clinically significant improvement (all derived from total PHQ-8 scores), will be compared between groups using chi-square tests. Symptom severity at 1-month follow-up will also be compared between arms. Planned subgroup analyses will examine the robustness of treatment effects to differences in baseline symptom severity (PHQ-8 score <15 or ≥ 15) and age (younger than 18 years and older than 18 years). The primary safety outcome, the number of psychiatric serious adverse events, will be compared between trial arms using the Fisher exact test. All other adverse events will be presented descriptively. RESULTS As of May 2023, enrollment into the study has concluded; 223 participants were randomized. The analysis of the efficacy and safety data is expected to be completed by Fall 2023. CONCLUSIONS We hypothesize that the results of this trial will support the efficacy and safety of SparkRx in attenuating symptoms of depression in adolescents. Positive results would more broadly support the prospect of using accessible, scientifically validated, digital therapeutics in the adjunct treatment of mental health disorders in this age range. TRIAL REGISTRATION ClinicalTrials.gov NCT05462652; https://clinicaltrials.gov/study/NCT05462652. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) DERR1-10.2196/48740.
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Affiliation(s)
- Daniella J Furman
- Limbix Health, Inc, San Francisco, CA, United States
- Big Health, Inc, San Francisco, CA, United States
| | - Shana A Hall
- Limbix Health, Inc, San Francisco, CA, United States
- Big Health, Inc, San Francisco, CA, United States
| | - Claudia Avina
- Limbix Health, Inc, San Francisco, CA, United States
| | | | - Jessica I Lake
- Limbix Health, Inc, San Francisco, CA, United States
- Big Health, Inc, San Francisco, CA, United States
| | - Aarthi Padmanabhan
- Limbix Health, Inc, San Francisco, CA, United States
- Big Health, Inc, San Francisco, CA, United States
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13
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Tönnies J, Graue L, Ayoub-Schreifeldt M, Wensing M, Szecsenyi J, Friederich HC, Haun MW. [Integrated Care for Patients with Somatic Symptom Disorder in Primary Care - A Qualitative Participatory Evaluation of a Randomised Feasibility Trial]. Psychother Psychosom Med Psychol 2023; 73:465-472. [PMID: 37487506 DOI: 10.1055/a-2105-3402] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/26/2023]
Abstract
OBJECTIVE The VISION intervention is a manualized short-term treatment for people with somatic symptom disorder, integrated into the primary care and delivered by psychotherapists via video consultations. As an innovative technology-based approach, the intervention was most recently piloted in a randomized feasibility trial. During the qualitative accompanying study presented here, the intervention was evaluated and optimised from the user perspective of patients who participated in the feasibility study. METHODS We interviewed a total of N=10 patients included in the intervention group in three semi structured focus group discussions focusing on how they (1) assess the intervention in terms of acceptance and individual benefit and (2) which adjustments are necessary from the user perspective for further optimization of the intervention. We performed a qualitative content analysis using MAXQDA Plus 2022. RESULTS Respondents reported initial reservations on their part regarding care via video consultation. After a brief period of habituation, the intervention was universally accepted. Main suggestions for improvement included a stronger focus on supporting patients find follow-up psychotherapy (if indicated) more flexible settings (e. g., location of video consultation), and a stronger integration of treatment into primary care. DISCUSSION AND CONCLUSION The study provides systematically elaborated comprehensive findings on participants' practical experiences with the intervention. The model is appropriate for treating people with somatic symptom disorder. Before implementation, important suggestions for improvement should be thoroughly considered with continued patient and public involvement.
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Affiliation(s)
- Justus Tönnies
- Klinik für Allgemeine Innere Medizin und Psychosomatik, Universitätsklinikum Heidelberg, Deutschland
| | - Leike Graue
- Klinik für Allgemeine Innere Medizin und Psychosomatik, Universitätsklinikum Heidelberg, Deutschland
| | - Marayah Ayoub-Schreifeldt
- Klinik für Allgemeine Innere Medizin und Psychosomatik, Universitätsklinikum Heidelberg, Deutschland
| | - Michel Wensing
- Abteilung Allgemeinmedizin und Versorgungsforschung, Universitätsklinikum Heidelberg, Deutschland
| | - Joachim Szecsenyi
- Abteilung Allgemeinmedizin und Versorgungsforschung, Universitätsklinikum Heidelberg, Deutschland
| | - Hans-Christoph Friederich
- Klinik für Allgemeine Innere Medizin und Psychosomatik, Universitätsklinikum Heidelberg, Deutschland
| | - Markus W Haun
- Klinik für Allgemeine Innere Medizin und Psychosomatik, Universitätsklinikum Heidelberg, Deutschland
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Malgaroli M, Hull TD, Zech JM, Althoff T. Natural language processing for mental health interventions: a systematic review and research framework. Transl Psychiatry 2023; 13:309. [PMID: 37798296 PMCID: PMC10556019 DOI: 10.1038/s41398-023-02592-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Revised: 08/31/2023] [Accepted: 09/04/2023] [Indexed: 10/07/2023] Open
Abstract
Neuropsychiatric disorders pose a high societal cost, but their treatment is hindered by lack of objective outcomes and fidelity metrics. AI technologies and specifically Natural Language Processing (NLP) have emerged as tools to study mental health interventions (MHI) at the level of their constituent conversations. However, NLP's potential to address clinical and research challenges remains unclear. We therefore conducted a pre-registered systematic review of NLP-MHI studies using PRISMA guidelines (osf.io/s52jh) to evaluate their models, clinical applications, and to identify biases and gaps. Candidate studies (n = 19,756), including peer-reviewed AI conference manuscripts, were collected up to January 2023 through PubMed, PsycINFO, Scopus, Google Scholar, and ArXiv. A total of 102 articles were included to investigate their computational characteristics (NLP algorithms, audio features, machine learning pipelines, outcome metrics), clinical characteristics (clinical ground truths, study samples, clinical focus), and limitations. Results indicate a rapid growth of NLP MHI studies since 2019, characterized by increased sample sizes and use of large language models. Digital health platforms were the largest providers of MHI data. Ground truth for supervised learning models was based on clinician ratings (n = 31), patient self-report (n = 29) and annotations by raters (n = 26). Text-based features contributed more to model accuracy than audio markers. Patients' clinical presentation (n = 34), response to intervention (n = 11), intervention monitoring (n = 20), providers' characteristics (n = 12), relational dynamics (n = 14), and data preparation (n = 4) were commonly investigated clinical categories. Limitations of reviewed studies included lack of linguistic diversity, limited reproducibility, and population bias. A research framework is developed and validated (NLPxMHI) to assist computational and clinical researchers in addressing the remaining gaps in applying NLP to MHI, with the goal of improving clinical utility, data access, and fairness.
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Affiliation(s)
- Matteo Malgaroli
- Department of Psychiatry, New York University, Grossman School of Medicine, New York, NY, 10016, USA.
| | | | - James M Zech
- Talkspace, New York, NY, 10025, USA
- Department of Psychology, Florida State University, Tallahassee, FL, 32306, USA
| | - Tim Althoff
- Department of Computer Science, University of Washington, Seattle, WA, 98195, USA
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15
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Wood BM, Cubbin C, Rubalcava Hernandez EJ, DiNitto DM, Vohra-Gupta S, Baiden P, Mueller EJ. The Price of Growing Up in a Low-Income Neighborhood: A Scoping Review of Associated Depressive Symptoms and Other Mood Disorders among Children and Adolescents. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:6884. [PMID: 37835154 PMCID: PMC10572337 DOI: 10.3390/ijerph20196884] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Revised: 09/24/2023] [Accepted: 09/29/2023] [Indexed: 10/15/2023]
Abstract
Neighborhoods, as built and social environments, have significant implications for mental health. Children raised in high-poverty neighborhoods, who are disproportionately Black, Indigenous, and people of color, have a greater risk of adverse life outcomes. Neighborhood gentrification is also salient when examining mental health outcomes as neighborhood economic contexts shift around a child. This review scopes, describes, synthesizes, and critiques the existing literature on the relationship between neighborhood poverty/gentrification and mood disorder symptoms among children ages 3-17 in the United States (U.S.). Given the history of structural racism in the creation of U.S. neighborhoods, inclusion criteria required that study samples be racially diverse. Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines for scoping reviews, seven databases and grey literature were searched; 17 studies were included (total n = 122,089). Fourteen studies found significant associations between neighborhood poverty/gentrification and child depression. Three longitudinal studies found significant results suggesting that childhood neighborhood poverty/gentrification may have a lagged effect, with depression emerging later in life. Neighborhood poverty and gentrification require further examination as social determinants of mental health. Researchers should examine neighborhood poverty and gentrification as social determinants of mental health. Policies that reduce neighborhood economic disparities are needed across the U.S.
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Affiliation(s)
- Bethany M. Wood
- School of Social Work, The University of Texas at Arlington, 211 S Cooper St, Arlington, TX 76019, USA; (E.J.R.H.); (P.B.)
| | - Catherine Cubbin
- Steve Hicks School of Social Work, The University of Texas at Austin, 1925 San Jacinto Boulevard, Austin, TX 78712, USA; (C.C.); (D.M.D.); (S.V.-G.)
| | | | - Diana M. DiNitto
- Steve Hicks School of Social Work, The University of Texas at Austin, 1925 San Jacinto Boulevard, Austin, TX 78712, USA; (C.C.); (D.M.D.); (S.V.-G.)
| | - Shetal Vohra-Gupta
- Steve Hicks School of Social Work, The University of Texas at Austin, 1925 San Jacinto Boulevard, Austin, TX 78712, USA; (C.C.); (D.M.D.); (S.V.-G.)
| | - Philip Baiden
- School of Social Work, The University of Texas at Arlington, 211 S Cooper St, Arlington, TX 76019, USA; (E.J.R.H.); (P.B.)
| | - Elizabeth J. Mueller
- School of Architecture, The University of Texas at Austin, 310 Inner Campus Drive, Austin, TX 78712, USA;
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16
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McCradden M, Hui K, Buchman DZ. Evidence, ethics and the promise of artificial intelligence in psychiatry. JOURNAL OF MEDICAL ETHICS 2023; 49:573-579. [PMID: 36581457 PMCID: PMC10423547 DOI: 10.1136/jme-2022-108447] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/29/2022] [Accepted: 11/29/2022] [Indexed: 05/20/2023]
Abstract
Researchers are studying how artificial intelligence (AI) can be used to better detect, prognosticate and subgroup diseases. The idea that AI might advance medicine's understanding of biological categories of psychiatric disorders, as well as provide better treatments, is appealing given the historical challenges with prediction, diagnosis and treatment in psychiatry. Given the power of AI to analyse vast amounts of information, some clinicians may feel obligated to align their clinical judgements with the outputs of the AI system. However, a potential epistemic privileging of AI in clinical judgements may lead to unintended consequences that could negatively affect patient treatment, well-being and rights. The implications are also relevant to precision medicine, digital twin technologies and predictive analytics generally. We propose that a commitment to epistemic humility can help promote judicious clinical decision-making at the interface of big data and AI in psychiatry.
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Affiliation(s)
- Melissa McCradden
- Joint Centre for Bioethics, University of Toronto Dalla Lana School of Public Health, Toronto, Ontario, Canada
- Bioethics, The Hospital for Sick Children, Toronto, Ontario, Canada
- Genetics & Genome Biology, Peter Gilgan Centre for Research and Learning, Toronto, Ontario, Canada
| | - Katrina Hui
- Everyday Ethics Lab, Centre for Addiction and Mental Health, Toronto, Ontario, Canada
- Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada
| | - Daniel Z Buchman
- Joint Centre for Bioethics, University of Toronto Dalla Lana School of Public Health, Toronto, Ontario, Canada
- Everyday Ethics Lab, Centre for Addiction and Mental Health, Toronto, Ontario, Canada
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17
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Zhu JM, Meiselbach MK, Drake C, Polsky D. Psychiatrist Networks In Medicare Advantage Plans Are Substantially Narrower Than In Medicaid And ACA Markets. Health Aff (Millwood) 2023; 42:909-918. [PMID: 37406238 PMCID: PMC10377344 DOI: 10.1377/hlthaff.2022.01547] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/07/2023]
Abstract
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.
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Affiliation(s)
- Jane M Zhu
- Jane M. Zhu , Oregon Health & Science University, Portland, Oregon
| | | | - Coleman Drake
- Coleman Drake, University of Pittsburgh, Pittsburgh, Pennsylvania
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18
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Lunders C, Dillon EC, Mitchell D, Cantril C, Jones JB. The Unmet Needs of Breast Cancer Navigation Services: Reconciling Clinical Care With the Emotional and Logistical Challenges Experienced by Younger Women with Breast Cancer in a Healthcare Delivery System. J Patient Exp 2023; 10:23743735231171126. [PMID: 37323760 PMCID: PMC10265349 DOI: 10.1177/23743735231171126] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/17/2023] Open
Abstract
This study explores the experience of the breast cancer journey for younger women receiving patient navigation services in a healthcare delivery system and any remaining challenges that navigation services may leave unaddressed. In this qualitative analysis, we used a purposeful sampling approach to conduct a semistructured in-person interview with 19 younger women (under 50 years at the time of diagnosis) at various stages of breast cancer treatment and receiving care that included some form of patient navigation services/within the Sutter Health system. Thematic analysis was performed using an inductive grounded theory approach. The patient experience revealed that women receiving navigation services throughout their cancer journey had little concern related to clinical decision-making and treatment. Rather, emotional, and logistical challenges dominate their experience and perceptions of the cancer journey. Managing day-to-day life and the emotional aspects of a cancer diagnosis cannot be disentangled from clinical care. Navigating the emotional and logistical aspects of the cancer journey is an ongoing unmet need for women under age 50, and navigation services can potentially be enhanced to help address these specific needs. Women with breast cancer may benefit from navigation programs focused not only on clinically related challenges but also on recognizing the daily needs of younger women and guiding them through family and job-related obstacles encountered while navigating cancer care. Health systems could enhance existing nurse navigation programs and redesign other aspects of care to focus on meeting these needs.
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Affiliation(s)
- Chelsea Lunders
- Center for Health Systems Research, Sutter Health, Walnut Creek, CA, USA
| | - Ellis C Dillon
- Center for Health Systems Research, Sutter Health, Palo Alto, CA, USA
- Center on Aging, UConn Health, Farmington, CT, USA
| | - Diamonne Mitchell
- Center for Health Systems Research, Sutter Health, Walnut Creek, CA, USA
| | | | - JB Jones
- Center for Health Systems Research, Sutter Health, Walnut Creek, CA, USA
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19
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Leiferman JA, Lee-Winn AE, Lacy R, Paulson JF. Evaluating an Online Intervention to Improve Provider Management of Prenatal Depression: A Randomized Controlled Trial. Womens Health Issues 2023; 33:175-181. [PMID: 36266225 DOI: 10.1016/j.whi.2022.08.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Revised: 07/29/2022] [Accepted: 08/24/2022] [Indexed: 11/05/2022]
Abstract
INTRODUCTION Prenatal depression is associated with numerous deleterious maternal and child health outcomes. Providers play a significant role in managing (i.e., identifying and treating or referring to care for) prenatal depression. We conducted a randomized controlled trial to test the effects of a brief online training on self-reported provider management practices related to prenatal depression. METHODS Providers (i.e., physicians, nurses, mental health specialists, and public health educators) were randomized into intervention (i.e., online training) or waitlist control arms. The online training covered guidelines and evidence-based practices related to managing prenatal depression. Changes in providers' knowledge, attitudes, and self-reported practices were assessed by the Management of Maternal Depression Inventory at baseline (T1), 6 weeks after baseline (T2), and 12 weeks after baseline (T3). RESULTS A total of 108 providers from Colorado and Virginia participated in the trial. Over the three time periods, repeated measures analysis of variance revealed Time × Group relative improvements for the intervention group with respect to satisfaction with working with mental health services, F(1,97) = 10.89, p = .001, partial η2 = 0.10, and increased self-reported screening, counseling, and referral for prenatal depression, F(1,97) = 6.25, p = .014, partial η2 = 0.06. A similar improving pattern was observed for self-efficacy, F(1,99) = 2.48, p = .13, partial η2 = .02. CONCLUSIONS Findings from our study suggest a brief online training may enhance the likelihood of providers screening, treating, and/or referring at-risk patients for follow-up care for prenatal depression.
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Affiliation(s)
- Jenn A Leiferman
- Department of Community and Behavioral Health, Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Aurora, Colorado.
| | - Angela E Lee-Winn
- Department of Epidemiology, Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Rachael Lacy
- Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - James F Paulson
- Department of Psychology, Old Dominion University, Norfolk, Virginia
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Robbins-Welty GA, Gagliardi JP. Integrated Care for Complicated Patients: A Role for Combined Training and Practice. Am J Geriatr Psychiatry 2023; 31:222-231. [PMID: 36437177 DOI: 10.1016/j.jagp.2022.10.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2022] [Revised: 10/29/2022] [Accepted: 10/31/2022] [Indexed: 11/09/2022]
Abstract
Patients with chronic medical disease frequently have comorbid psychiatric illness, yet mental and physical healthcare is frequently siloed in the United States. Integrated behavioral healthcare models, such as medicine-psychiatry services, are feasible, improve patient outcomes, and reduce costs. The Duke University Hospital medicine-psychiatry service provides holistic patient care and serves as a model for those interested in developing combined services or training programs elsewhere. Combined residency training in psychiatry is a way to provide a workforce of physician-scientist educators adept at providing coordinated, integrated care for complex patients with comorbid illness.
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Affiliation(s)
- Gregg A Robbins-Welty
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center (GAR-W, JPG), Durham, NC; Department of Medicine, Duke University Medical Center (GAR-W, JPG), Durham, NC.
| | - Jane P Gagliardi
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center (GAR-W, JPG), Durham, NC; Department of Medicine, Duke University Medical Center (GAR-W, JPG), Durham, NC
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21
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Fu E, Carroll AJ, Rosenthal LJ, Rado J, Burnett-Zeigler I, Jordan N, Carlo AD, Ekwonu A, Kust A, Brown CH, Csernansky JG, Smith JD. Implementation Barriers and Experiences of Eligible Patients Who Failed to Enroll in Collaborative Care for Depression and Anxiety. J Gen Intern Med 2023; 38:366-374. [PMID: 35931910 PMCID: PMC9362538 DOI: 10.1007/s11606-022-07750-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2022] [Accepted: 07/20/2022] [Indexed: 10/31/2022]
Abstract
BACKGROUND Effective and efficient implementation of the Collaborative Care Model (CoCM) for depression and anxiety is imperative for program success. Studies examining barriers to implementation often omit patient perspectives. OBJECTIVES To explore experiences and attitudes of eligible patients referred to CoCM who declined participation or were unable to be reached, and identify implementation barriers to inform strategies. DESIGN Convergent mixed-methods study with a survey and interview. PARTICIPANTS Primary care patients at an academic medical center who were referred to a CoCM program for anxiety and depression by their primary care clinician (PCC) but declined participation or were unable to be reached by the behavioral health care manager to initiate care (n = 80). Interviews were conducted with 45 survey respondents. MAIN MEASURES Survey of patients' referral experiences and behavioral health preferences as they related to failing to enroll in the program. Interview questions were developed using the Consolidated Framework for Implementation Research version 2.0 (CFIR 2.0) to identify implementation barriers to enrollment. KEY RESULTS Survey results found that patients were uncertain about insurance coverage, did not understand the program, and felt services were not necessary. Referred patients who declined participation were concerned about how their mental health information would be used and preferred treatment without medication. Men agreed more that they did not need services. Qualitative results exhibited a variety of implementation determinants (n = 23) across the five CFIR 2.0 domains. Barriers included mental health stigma, perceiving behavioral health as outside of primary care practice guidelines, short or infrequent primary care appointments, prioritizing physical health over mental health, receiving inaccurate program information, low motivation to engage, and a less established relationship with their PCC. CONCLUSIONS Multiple barriers to enrollment led to failing to link patients to care, which can inform implementation strategies to address the patient-reported experiences and concerns.
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Affiliation(s)
- Emily Fu
- Department of Psychiatry and Behavioral Sciences, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Allison J Carroll
- Department of Psychiatry and Behavioral Sciences, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Lisa J Rosenthal
- Department of Psychiatry and Behavioral Sciences, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
- Northwestern Medicine, Chicago, IL, USA
| | - Jeffrey Rado
- Department of Psychiatry and Behavioral Sciences, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
- Northwestern Medicine, Chicago, IL, USA
| | - Inger Burnett-Zeigler
- Department of Psychiatry and Behavioral Sciences, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Neil Jordan
- Department of Psychiatry and Behavioral Sciences, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
- Center of Innovation for Complex Chronic Healthcare, Hines VA Hospital, Hines, IL, USA
| | - Andrew D Carlo
- Department of Psychiatry and Behavioral Sciences, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Adaora Ekwonu
- Department of Psychiatry and Behavioral Sciences, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
- University of Chicago Pritzker School of Medicine, Chicago, IL, USA
| | - Ariella Kust
- Department of Psychiatry and Behavioral Sciences, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - C Hendricks Brown
- Department of Psychiatry and Behavioral Sciences, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - John G Csernansky
- Department of Psychiatry and Behavioral Sciences, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Justin D Smith
- Department of Psychiatry and Behavioral Sciences, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.
- Department of Population Health Sciences, Spencer Fox Eccles School of Medicine at the University of Utah, Salt Lake City, UT, USA.
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Dillon EC, Huang Q, Deng S, Li M, de Vera E, Pesa J, Nguyen T, Kiger A, Becker DF, Azar K. Implementing universal suicide screening in a large healthcare system's hospitals: rates of screening, suicide risk, and documentation of subsequent psychiatric care. Transl Behav Med 2023; 13:193-205. [PMID: 36694929 DOI: 10.1093/tbm/ibac117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
Implementation of suicide risk screening may improve prevention and facilitate mental health treatment. This study analyzed implementation of universal general population screening using the Columbia-Suicide Severity Rating Scale (C-SSRS) within hospitals. The study included adults seen at 23 hospitals from 7/1/2019-12/31/2020. We describe rates of screening, suicide risk, and documented subsequent psychiatric care (i.e., transfer/discharge to psychiatric acute care, or referral/consultation with system-affiliated behavioral health providers). Patients with suicide risk (including those with Major Depressive Disorder [MDD]) were compared to those without using Wilcoxon rank-sum -tests for continuous variables and χ2 tests for categorical variables. Results reported are statistically significant at p < 0.05 level. Among 595,915 patients, 84.5% were screened by C-SSRS with 2.2% of them screening positive (37.6% low risk [i.e., ideation only], and 62.4% moderate or high risk [i.e., with a plan, intent, or suicidal behaviors]). Of individuals with suicide risk, 52.5% had documentation of psychiatric care within 90 days. Individuals with suicide risk (vs. without) were male (48.1% vs 43.0%), Non-Hispanic White (55.0% vs 47.8%), younger (mean age 41.0 [SD: 17.7] vs. 49.8 [SD: 20.4]), housing insecure (12.5% vs 2.6%), with mental health diagnoses (80.3% vs 25.1%), including MDD (41.3% vs 6.7%). Universal screening identified 2.2% of screened adults with suicide risk; 62.4% expressed a plan, intent or suicidal behaviors, and 80.3% had mental health diagnoses. Documented subsequent psychiatric care likely underestimates true rates due to care fragmentation. These findings reinforce the need for screening, and research on whether screening leads to improved care and fewer suicides.
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Affiliation(s)
- Ellis C Dillon
- Center on Aging, University of Connecticut, Farmington, CT
| | - Qiwen Huang
- Sutter Health Center for Health Systems Research and Palo Alto Medical Foundation Research Institute, Sutter Health, Palo Alto, CA
| | - Sien Deng
- Sutter Health Center for Health Systems Research and Palo Alto Medical Foundation Research Institute, Sutter Health, Palo Alto, CA
| | - Martina Li
- Sutter Health Center for Health Systems Research and Palo Alto Medical Foundation Research Institute, Sutter Health, Palo Alto, CA
| | - Ernell de Vera
- Mental Health & Addiction Care, Sutter Health, Sacramento, CA
| | - Jacqueline Pesa
- Real World Value & Evidence, Janssen Scientific Affairs, Titusville, NJ
| | - Tam Nguyen
- Mental Health & Addiction Care, Sutter Health, Sacramento, CA
| | - Anna Kiger
- Office of the System Chief Nurse Officer, Sutter Health, Sacramento, CA
| | - Daniel F Becker
- Department of Psychiatry and Behavioral Sciences, University of California San Francisco, San Francisco, CA
| | - Kristen Azar
- Institute for Advancing Health Equity, Sutter Health, Walnut Creek, CA.,Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, CA
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23
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Toward a Demand-Driven, Collaborative Data Agenda for Adolescent Mental Health. J Adolesc Health 2023; 72:S20-S26. [PMID: 35931647 DOI: 10.1016/j.jadohealth.2022.05.027] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Revised: 05/26/2022] [Accepted: 05/29/2022] [Indexed: 11/18/2022]
Abstract
PURPOSE Existing datasets and research in the field of adolescent mental health do not always meet the needs of practitioners, policymakers, and program implementers, particularly in the context of vulnerable populations. Here, we introduce a collaborative, demand-driven methodology for the development of a strategic adolescent mental health research agenda. Ultimately, this agenda aims to guide future data sharing and collection efforts that meet the most pressing data needs of key stakeholders. METHODS We conducted a rapid literature search to summarize common themes in adolescent mental health research into a "topic map". We then hosted two virtual workshops with a range of international experts to discuss the topic map and identify shared priorities for future collaboration and research. RESULTS Our topic map identifies 10 major themes in adolescent mental health, organized into system-level, community-level, and individual-level categories. The engagement of cross-sectoral experts resulted in the validation of the mapping exercise, critical insights for refining the topic map, and a collaborative list of priorities for future research. DISCUSSION This innovative agile methodology enables a focused deliberation with diverse stakeholders and can serve as the starting point for data generation and collaboration practices, both in the field of adolescent mental health and other topics.
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24
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McCord C, Ullrich F, Merchant KAS, Bhagianadh D, Carter KD, Nelson E, Marcin JP, Law KB, Neufeld J, Giovanetti A, Ward MM. Comparison of in-person vs. telebehavioral health outcomes from rural populations across America. BMC Psychiatry 2022; 22:778. [PMID: 36496352 PMCID: PMC9736702 DOI: 10.1186/s12888-022-04421-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Accepted: 11/24/2022] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND This study investigates outcomes from two federal grant programs: the Evidence-Based Tele-Behavioral Health Network Program (EB THNP) funded from September 2018 to August 2021 and the Substance Abuse Treatment Telehealth Network Grant Program (SAT TNGP) funded from September 2017 to August 2020. As part of the health services implementation program, the aims of this study were to evaluate outcomes in patient symptoms of depression and anxiety across the programs' 17 grantees and 95 associated sites, with each grantee having data from telehealth patients and from an in-person comparison group. METHODS The research design is a prospective multi-site observational study. Each grantee provided data on a nonrandomized convenience sample of telehealth patients and an in-person comparison group from sites with similar rural characteristics and during the same time period. Patient characteristics were collected at treatment initiation, and clinical outcome measures were collected at baseline and monthly. The validated clinical outcome measure instruments included the Patient Health Questionnaire-9 (PHQ-9) for depression symptoms and the Generalized Anxiety Disorder-7 (GAD-7) scale for anxiety-related symptoms. Linear mixed models, with grantee as the random effect, were used to determine the association of behavioral health delivery (telehealth versus in-person) on the one-month change in PHQ-9 and GAD-7 while adjusting for covariates. RESULTS Across a total of 1,514 patients, one-month change scores were improved indicating that PHQ-9 and GAD-7 scores decreased from baseline to the one-month follow-up at similar rates in both the in-person and telehealth groups. Reduction in scores averaged 2.8 for the telehealth treatment group and 2.9 for the in-person treatment group in the PHQ-9 subsample and 2.0 for the telehealth treatment group and 2.4 for the in-person treatment group in the GAD-7 subsample. There was no statistically significant association between the modality of care (telehealth treatment group versus in-person comparison group) and the one-month change scores for either PHQ-9 or GAD-7. Individuals with higher baseline scores demonstrated the greatest decrease in scores for both measures. Upon adjusting for baseline scores and grantee program, patient demographics were not found to be significantly associated with change in anxiety or depression symptoms. CONCLUSION In our very large pragmatic study comparing behavioral health treatment delivered to a population of patients in rural, underserved communities, we found no clinical or statistical differences in improvements in depression or anxiety symptoms as measured by the PHQ-9 and GAD-7 between patients treated via telehealth or in-person.
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Affiliation(s)
- Carly McCord
- Department of Psychiatry and Behavioral Sciences, Texas A&M University, College Station, TX, USA. .,Department of Educational Psychology, Texas A&M University, College Station, TX, USA.
| | - Fred Ullrich
- grid.214572.70000 0004 1936 8294Department of Health Management and Policy, University of Iowa, Iowa City, IA USA
| | - Kimberly A. S. Merchant
- grid.214572.70000 0004 1936 8294Department of Health Management and Policy, University of Iowa, Iowa City, IA USA
| | - Divya Bhagianadh
- grid.430387.b0000 0004 1936 8796School of Social Work, Rutgers University, New Brunswick, NJ USA
| | - Knute D. Carter
- grid.214572.70000 0004 1936 8294Department of Biostatistics, University of Iowa, Iowa City, IA USA
| | - EveLynn Nelson
- grid.412016.00000 0001 2177 6375Department of Pediatrics, University of Kansas Medical Center, Kansas City, KS USA
| | - James P. Marcin
- grid.27860.3b0000 0004 1936 9684Department of Pediatrics, University of California, Davis School of Medicine, Sacramento, CA USA
| | - Kari Beth Law
- grid.268154.c0000 0001 2156 6140Department of Behavioral Medicine and Psychiatry, West Virginia University, Morgantown, WV USA
| | - Jonathan Neufeld
- grid.17635.360000000419368657Institute for Health Informatics, University of Minnesota, Minneapolis, MN USA
| | - Annaleis Giovanetti
- grid.266515.30000 0001 2106 0692Department of Psychology, University of Kansas, Kansas City, KS USA
| | - Marcia M. Ward
- grid.214572.70000 0004 1936 8294Department of Health Management and Policy, University of Iowa, Iowa City, IA USA
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25
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Copeland JN, Jones K, Maslow GR, French A, Davis N, Greiner MA, Heilbron N, Pullen SJ. Use of North Carolina Medicaid Collaborative Care Billing Codes After Statewide Approval for Reimbursement. Psychiatr Serv 2022; 73:1420-1423. [PMID: 35734864 DOI: 10.1176/appi.ps.202200027] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Effective October 2018, North Carolina Medicaid approved reimbursement for collaborative care model (CoCM) billing codes. From October 2018 through December 2019, only 915 of the estimated two million eligible Medicaid beneficiaries had at least one CoCM claim, and the median number of claims per patient was two. Availability of reimbursement for CoCM Medicaid billing codes in North Carolina did not immediately result in robust utilization of CoCM. Furthermore, the low median number of claims per patient suggests lack of fidelity to CoCM. A better understanding of barriers to CoCM implementation is necessary to expand utilization of this evidence-based model.
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Affiliation(s)
- J Nathan Copeland
- Department of Psychiatry and Behavioral Sciences (Copeland, Maslow, French, Davis, Heilbron, Pullen) and Department of Population Health Sciences (Jones, Greiner), Duke University School of Medicine, Durham, North Carolina
| | - Kelley Jones
- Department of Psychiatry and Behavioral Sciences (Copeland, Maslow, French, Davis, Heilbron, Pullen) and Department of Population Health Sciences (Jones, Greiner), Duke University School of Medicine, Durham, North Carolina
| | - Gary R Maslow
- Department of Psychiatry and Behavioral Sciences (Copeland, Maslow, French, Davis, Heilbron, Pullen) and Department of Population Health Sciences (Jones, Greiner), Duke University School of Medicine, Durham, North Carolina
| | - Alexis French
- Department of Psychiatry and Behavioral Sciences (Copeland, Maslow, French, Davis, Heilbron, Pullen) and Department of Population Health Sciences (Jones, Greiner), Duke University School of Medicine, Durham, North Carolina
| | - Naomi Davis
- Department of Psychiatry and Behavioral Sciences (Copeland, Maslow, French, Davis, Heilbron, Pullen) and Department of Population Health Sciences (Jones, Greiner), Duke University School of Medicine, Durham, North Carolina
| | - Melissa A Greiner
- Department of Psychiatry and Behavioral Sciences (Copeland, Maslow, French, Davis, Heilbron, Pullen) and Department of Population Health Sciences (Jones, Greiner), Duke University School of Medicine, Durham, North Carolina
| | - Nicole Heilbron
- Department of Psychiatry and Behavioral Sciences (Copeland, Maslow, French, Davis, Heilbron, Pullen) and Department of Population Health Sciences (Jones, Greiner), Duke University School of Medicine, Durham, North Carolina
| | - Samuel J Pullen
- Department of Psychiatry and Behavioral Sciences (Copeland, Maslow, French, Davis, Heilbron, Pullen) and Department of Population Health Sciences (Jones, Greiner), Duke University School of Medicine, Durham, North Carolina
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26
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Muench U, Jura M, Thomas CP, Perloff J, Spetz J. Rural-urban prescribing patterns by primary care and behavioral health providers in older adults with serious mental illness. BMC Health Serv Res 2022; 22:1440. [PMID: 36447260 PMCID: PMC9706942 DOI: 10.1186/s12913-022-08813-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2022] [Accepted: 11/08/2022] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Older adults with serious mental illness (SMI) often have multiple comorbidities and complex medication schedules. Shortages of behavioral health specialists (BHSs), especially in rural areas, frequently make primary care providers (PCPs) the only clinician managing this complex population. The aim of this study was to describe rural/urban psychiatric medication prescribing in older adults with SMI by PCPs and BHSs, and by clinician type. METHODS This retrospective descriptive analysis used 2018 Medicare data to identify individuals with a bipolar, major depression, schizophrenia, or psychosis diagnosis and examined medication claims for antianxiety, antidepressants, antipsychotics, hypnotics, and anticonvulsants. Descriptive statistics summarized percentage of medications provided by PCPs and BHSs stratified by rural and urban areas and by drug class. Additional analyses compared psychiatric prescribing patterns by physicians, advanced practice registered nurses (APRNs), and physician assistants (PAs). RESULTS In urban areas, PCPs prescribed at least 50% of each psychiatric medication class, except antipsychotics, which was 45.2%. BHSs prescribed 40.7% of antipsychotics and less than 25% of all other classes. In rural areas, percentages of psychiatric medications from PCPs were over 70% for each medication class, except antipsychotics, which was 60.1%. Primary care physicians provided most psychiatric medications, between 36%-57% in urban areas and 47%-65% in rural areas. Primary care APRNs provided up to 13% of prescriptions in rural areas, which was more than the amount prescribed by BHS physicians, expect for antipsychotics. Psychiatric mental health APRNs provided up to 7.5% of antipsychotics in rural areas, but their prescribing contribution among other classes ranged between 1.1%-3.6%. PAs provided 2.5%-3.4% of medications in urban areas and this increased to 3.9%-5.1% in rural areas. CONCLUSIONS Results highlight the extensive roles of PCPs, including APRNs, in managing psychiatric medications for older adults with SMI.
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Affiliation(s)
- Ulrike Muench
- grid.266102.10000 0001 2297 6811UCSF Department of Social and Behavioral Sciences, School of Nursing, University of California, Box 0612, 490 Illinois St., Floor 12, San Francisco, CA 94143 USA ,grid.266102.10000 0001 2297 6811Philip R. Lee Institute for Health Policy Studies, School of Medicine, University of California, San Francisco, USA ,grid.266102.10000 0001 2297 6811Healthforce Center, University of California, San Francisco, USA
| | - Matthew Jura
- grid.266102.10000 0001 2297 6811Philip R. Lee Institute for Health Policy Studies, School of Medicine, University of California, San Francisco, USA
| | - Cindy Parks Thomas
- grid.253264.40000 0004 1936 9473The Heller School, Brandeis University, Waltham, MA USA
| | - Jennifer Perloff
- grid.253264.40000 0004 1936 9473The Heller School, Brandeis University, Waltham, MA USA
| | - Joanne Spetz
- grid.266102.10000 0001 2297 6811Philip R. Lee Institute for Health Policy Studies, School of Medicine, University of California, San Francisco, USA ,grid.266102.10000 0001 2297 6811Healthforce Center, University of California, San Francisco, USA
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27
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Wulz AR, Miller GF, Kegler SR, Yard EE, Wolkin AF. Assessing Female Suicide From a Health Equity Viewpoint, U.S. 2004-2018. Am J Prev Med 2022; 63:486-495. [PMID: 35927105 PMCID: PMC9513679 DOI: 10.1016/j.amepre.2022.04.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2021] [Revised: 03/30/2022] [Accepted: 04/18/2022] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Geographic and urbanization differences in female suicide trends across the U.S. necessitates suicide prevention efforts on the basis of geographic variations. The purpose of this study was to assess female suicide rates by mechanism within Census divisions and by urbanicity to help inform geographically tailored approaches for suicide prevention strategies. METHODS Data from 2004 to 2018 were obtained from the National Vital Statistics System (analyzed in 2021). Annual counts of female suicides were tabulated for firearm, suffocation, and drug poisoning and stratified by the U.S. Census division and urbanicity. Age-adjusted rates were calculated to describe female suicide incidence by geographic areas and urbanicity. Data were analyzed annually and by 5-year timeframes. Trends in annual female suicide rates by mechanism for 3 urbanization levels were identified using Joinpoint Regression. Annual percent change estimates were calculated for age-adjusted female suicide rates between 2004 and 2018. RESULTS Female suicide rates by mechanism were not homogeneous within Census divisions or by urbanization levels. Suicide rates by mechanism across Census divisions within the same urbanization level varied (range=3.38-11.15 [per 100,000 person per year]). From 2014 to 2018 in large metropolitan areas in the northern divisions, rates for suffocation were higher than for firearms and drug poisoning. During the same period, in all urbanization levels in southern divisions, rates for firearms were higher than for suffocation and drug poisoning. CONCLUSIONS Female suicide mechanisms vary by urbanization level, and this variation differs by region. These results could inform female suicide prevention strategies on the basis of mechanism, urbanization, and geographic region.
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Affiliation(s)
- Avital R Wulz
- National Center for Injury Prevention and Control (NCIPC), Centers for Disease Control and Prevention, Atlanta, Georgia.
| | - Gabrielle F Miller
- National Center for Injury Prevention and Control (NCIPC), Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Scott R Kegler
- National Center for Injury Prevention and Control (NCIPC), Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Ellen E Yard
- National Center for Injury Prevention and Control (NCIPC), Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Amy F Wolkin
- National Center for Injury Prevention and Control (NCIPC), Centers for Disease Control and Prevention, Atlanta, Georgia
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28
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Gao YN, Olfson M. Insurance and inpatient admission of emergency department patients with depression in the United States. Gen Hosp Psychiatry 2022; 78:28-34. [PMID: 35841753 PMCID: PMC9474607 DOI: 10.1016/j.genhosppsych.2022.07.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Revised: 07/01/2022] [Accepted: 07/07/2022] [Indexed: 11/23/2022]
Abstract
OBJECTIVE To estimate the contribution of insurance on rates of inpatient admission for emergency department visits with depression diagnoses. METHODS We identified 3,681,581 visits for depression in the National Emergency Department Sample (2007-2018). We classified them by concurrent injury, suicidal ideation, or neither. Payer categories were defined, non-exclusively, as Medicare, Medicaid, private insurance, and no insurance. Logistic regression models, adjusted for age, year, and comorbidities, were used to describe differences in rates of inpatient admission by payer type, stratified by visit features. RESULTS Rates of inpatient admission for visits with neither injury nor suicidal ideation (31.9%; 95%CI, 30.8-33.0) were lower than for visits with injury (37.9%; 95%CI, 36.7-39.1) or with suicidal ideation (39.7%; 95%CI, 37.3-42.1). Rates of admission were significantly lower for those without insurance (26.6%; 95%CI, 25.5-27.8) than for those with insurance (37.1%; 95%CI, 36.1-38.1). In adjusted models, insurance was associated with increased likelihood (OR = 1.81, 95%CI, 1.69-1.94) of admission. Insurance continued to be a significant predictor of admission among ED visits for depression with concurrent injury (OR = 1.39; 95%CI, 1.29-1.51). CONCLUSION After controlling for demographic characteristics and medical comorbidities, patients with depression who have insurance are significantly more likely to be admitted to the hospital compared to those without insurance.
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Affiliation(s)
- Y Nina Gao
- Department of Psychiatry, Columbia University and New York State Psychiatric Institute, New York, USA.
| | - Mark Olfson
- Department of Psychiatry, Columbia University and New York State Psychiatric Institute, New York, USA
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29
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Jegede O, Rhee TG, Stefanovics EA, Zhou B, Rosenheck RA. Rates and correlates of dual diagnosis among adults with psychiatric and substance use disorders in a nationally representative U.S sample. Psychiatry Res 2022; 315:114720. [PMID: 35834863 DOI: 10.1016/j.psychres.2022.114720] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2021] [Revised: 07/02/2022] [Accepted: 07/07/2022] [Indexed: 11/17/2022]
Abstract
Treatment needs of adults diagnosed with both psychiatric and substance use disorders (i.e., dual diagnosis) have not received detailed characterization in a nationally representative US sample. Data from the National Epidemiologic Survey on Alcohol and Related Conditions Wave III were used to compare socio-behavioral, diagnostic, and service use characteristics of dually diagnosed adults to those with psychiatric disorders or SUDs alone. Adults with dual diagnosis were estimated to constitute 25.8% of those with any psychiatric disorder; 36.5% of those with any SUD and 17.8% of the 75.8 million adults with either disorder. Among those with psychiatric disorders, the independent correlates of dual diagnosis reflected substantial social or psychopathological disadvantages (e.g., violent behavior, poor mental health-related quality of life [HRQOL], police trouble, homelessness, and incarceration). Similarly, among those with SUD all independent correlates of dual diagnosis also reflected social or psychopathological disadvantages including poor mental HRQOL, witnessing trauma in childhood, childhood sex abuse, drug use diagnoses, suicide attempt, medical problems, having more than one SUD diagnosis, child neglect, repeated adult traumas, and less social support. Provision of medical, psychiatric, addiction and especially diverse social services in an integrated and accessible setting appear necessary and deserve further study.
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Affiliation(s)
- Oluwole Jegede
- Department of Psychiatry, Yale School of Medicine, 300 George Street, Suite 901, New Haven, CT 06511, United States; Connecticut Mental Health Center, 34 Park Street, New Haven CT 06519, United States.
| | - Taeho Greg Rhee
- Department of Psychiatry, Yale School of Medicine, 300 George Street, Suite 901, New Haven, CT 06511, United States; U.S. Department of Veterans Affairs New England Mental Illness Research, Education, and Clinical Center, 950 Campbell Avenue, West Haven, CT, United States; Department of Public Health Sciences, University of Connecticut School of Medicine, 263 Farmington Avenue, Farmington, CT, United States
| | - Elina A Stefanovics
- Department of Psychiatry, Yale School of Medicine, 300 George Street, Suite 901, New Haven, CT 06511, United States; U.S. Department of Veterans Affairs New England Mental Illness Research, Education, and Clinical Center, 950 Campbell Avenue, West Haven, CT, United States
| | - Bin Zhou
- Yale School of Public Health, New Haven, CT, United States
| | - Robert A Rosenheck
- Department of Psychiatry, Yale School of Medicine, 300 George Street, Suite 901, New Haven, CT 06511, United States; U.S. Department of Veterans Affairs New England Mental Illness Research, Education, and Clinical Center, 950 Campbell Avenue, West Haven, CT, United States
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30
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Alolama FM, Mohammad HM, Alhmid IH, Alhammadi HM. Designing and validating the Dubai Tool for Developmental Screening (DTDS). Front Pediatr 2022; 10:924017. [PMID: 36071880 PMCID: PMC9441853 DOI: 10.3389/fped.2022.924017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Accepted: 07/28/2022] [Indexed: 11/13/2022] Open
Abstract
Background Early detection of developmental problems is vital for facilitating early access to targeted intervention and augmenting its beneficial outcomes. Standardized developmental screening tools are known to enhance detection rates of developmental problems compared to clinical judgment alone and are widely recommended to be used in infants and young children. Most of the available developmental screening tools have been developed in Western countries. Many of their items may not be suitable for other cultures while others are expensive. Currently, none of the developmental screening tools have been validated in the United Arab Emirates (UAE), with only a few available in the Arabic language. Objective To create and validate a developmental screening tool, in both English and Arabic, that is simple, quick to use, and culturally relevant to the United Arab Emirates (UAE) child population aged 9-48 months. Methods The available literature was used to create a list of developmental milestones in five domains for children aged 9-48 months, divided into seven age groups. The selected milestones were used to create questionnaires in both English and Arabic, which were pilot tested twice. Each time, the results were analyzed and used to select, modify, and rephrase questions. Validation of the Dubai Tool for Developmental Screening (DTDS) was done against Parents' Evaluation of Developmental Status (PEDS) as a gold standard instrument. The DTDS and PEDS were administered cross-sectionally to parents of 1,400 children in seven age groups. Sensitivity, specificity, and kappa agreement of the DTDS compared with PEDS were calculated. Results The DTDS had a sensitivity of 100% in four age groups and 75-78% in the other three age groups. Specificity ranged from 96 to 99% across all age groups. The kappa measure showed substantial agreement in five age groups, a moderate agreement in one age group, and a fair agreement in one age group. Conclusions The DTDS is a valid screening tool for early identification of developmental delays and disabilities in early childhood.
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Affiliation(s)
- Fatma Mohammad Alolama
- Child Health Section, Specialized Programs Services Department, Primary Health Care Sector, Dubai Health Authority, Dubai, United Arab Emirates
| | - Haitham Mahmoud Mohammad
- Child Health Section, Specialized Programs Services Department, Primary Health Care Sector, Dubai Health Authority, Dubai, United Arab Emirates
| | - Idris Helal Alhmid
- Child Health Section, Specialized Programs Services Department, Primary Health Care Sector, Dubai Health Authority, Dubai, United Arab Emirates
| | - Hanan Mohammed Alhammadi
- Medical Affairs Department, Primary Health Care Sector, Dubai Health Authority, Dubai, United Arab Emirates
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Khazanov GK, Jager-Hyman S, Harrison J, Candon M, Buttenheim A, Pieri MF, Oslin DW, Wolk CB. Leveraging behavioral economics and implementation science to engage patients at risk for suicide in mental health treatment: a pilot study protocol. Pilot Feasibility Stud 2022; 8:181. [PMID: 35964151 PMCID: PMC9375238 DOI: 10.1186/s40814-022-01131-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Accepted: 07/19/2022] [Indexed: 12/03/2022] Open
Abstract
BACKGROUND Primary care is an ideal setting to connect individuals at risk for suicide to follow-up care; however, only half of the patients referred from the primary care attend an initial mental health visit. We aim to develop acceptable, feasible, low-cost, and effective new strategies to increase treatment initiation among at-risk individuals identified in primary care. METHODS We will conduct a multi-phase, mixed-methods study. First, we will conduct a chart review study by using administrative data, including medical records, to identify characteristics of primary care patients at risk for suicide who do or do not attend an initial mental health visit following a referral. Second, we will conduct a mixed methods study by using direct observations and qualitative interviews with key stakeholders (N = 65) to understand barriers and facilitators to mental health service initiation among at-risk individuals. Stakeholders will include patients with suicidal ideation referred from primary care who do and do not attend a first mental health visit, primary care and behavioral health providers, and individuals involved in the referral process. We also will collect preliminary self-report and behavioral data regarding potential mechanisms of behavior change (i.e., self-regulation and social support) from patients. Third, we will leverage these findings, relevant frameworks, and the extant literature to conduct a multi-arm, non-randomized feasibility trial. During this trial, we will rapidly prototype and test strategies to support attendance at initial mental health visits. Strategies will be developed with subject matter experts (N = 10) and iteratively pilot tested (~5 patients per strategy) and refined. Research will be completed in the Penn Integrated Care Program (PIC), which includes fourteen primary care clinics in Philadelphia that provide infrastructure for electronic referrals, patient communication, and data access. DISCUSSION We will leverage frameworks and methods from behavioral economics and implementation science to develop strategies to increase mental health treatment initiation among individuals at risk for suicide identified in primary care. This project will lead to an evaluation of these strategies in a fully powered randomized trial and contribute to improvements in access to and engagement in mental health services for individuals at risk for suicide. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT05021224.
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Affiliation(s)
- Gabriela Kattan Khazanov
- Mental Illness Research, Education, and Clinical Center of the Veterans Integrated Service Network 4, Crescenz Veterans Affairs Medical Center, Philadelphia, PA, USA.
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA.
| | - Shari Jager-Hyman
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA
- Department of Psychiatry, University of Pennsylvania School of Medicine, Philadelphia, PA, USA
| | - Joseph Harrison
- Center for Health Incentives and Behavioral Economics, University of Pennsylvania School of Medicine, Philadelphia, PA, USA
- Philadelphia College of Osteopathic Medicine, School of Professional and Applied Psychology, Philadelphia, PA, USA
| | - Molly Candon
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA
- Department of Psychiatry, University of Pennsylvania School of Medicine, Philadelphia, PA, USA
| | - Alison Buttenheim
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA
- Center for Health Incentives and Behavioral Economics, University of Pennsylvania School of Medicine, Philadelphia, PA, USA
- Department of Family and Community Health, University of Pennsylvania School of Nursing, Philadelphia, PA, USA
| | - Matteo F Pieri
- Department of Psychiatry, University of Pennsylvania School of Medicine, Philadelphia, PA, USA
| | - David W Oslin
- Mental Illness Research, Education, and Clinical Center of the Veterans Integrated Service Network 4, Crescenz Veterans Affairs Medical Center, Philadelphia, PA, USA
- Department of Psychiatry, University of Pennsylvania School of Medicine, Philadelphia, PA, USA
| | - Courtney Benjamin Wolk
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA
- Department of Psychiatry, University of Pennsylvania School of Medicine, Philadelphia, PA, USA
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Pad RA, Okut H, Zackula R, Macaluso M, Huprich SK. Understanding the relationship between personality pathology and attachment style in the context of the DSM-5 Alternative Model of Personality Disorders. Personal Ment Health 2022; 16:163-179. [PMID: 34608765 DOI: 10.1002/pmh.1530] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2021] [Revised: 07/01/2021] [Accepted: 09/02/2021] [Indexed: 11/07/2022]
Abstract
This study utilizes the two different criteria of the DSM-5 Alternative Model of Personality Disorder Assessment to evaluate the relationship between attachment style and personality pathology. One-hundred forty patients from a combined sample of psychiatric and internal medicine clinics were given a survey composed of the DSM-5 Levels of Personality Functioning Questionnaire (DLOPFQ), the Personality Inventory for DSM-5-Brief Form (PID-5-BF), and the Relationship Questionnaire (RQ). Analysis of variance indicated that attachment styles were differentiated across all four the DLOPFQ scales and the Detachment trait domain. Elastic net regression modeling with bootstrap was used to assess the strength of the level of personality functioning dimensions and trait domains in the prediction of attachment style, both independently and interactively while accounting for multicollinearity. This study offers readers insight to a novel statistical approach to model building that addresses two issues among psychiatric data: high correlation and small sample size.
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Affiliation(s)
- Rachel A Pad
- Department of Psychology, University of Detroit Mercy, Detroit, Michigan, USA
| | - Hayrettin Okut
- Department of Psychiatry and Behavioral Science, University of Kansas School of Medicine, Wichita, Kansas, USA
| | - Rosey Zackula
- Department of Psychiatry and Behavioral Science, University of Kansas School of Medicine, Wichita, Kansas, USA
| | - Matthew Macaluso
- Department of Psychiatry and Behavioral Neurobiology, School of Medicine, The University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Steven K Huprich
- Department of Psychology, University of Detroit Mercy, Detroit, Michigan, USA.,Department of Psychiatry and Behavioral Science, University of Kansas School of Medicine, Wichita, Kansas, USA.,Department of Psychiatry, Michigan State University College of Human Medicine, Grand Rapids, Michigan, USA
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Muench U, Fraze TK. The Future of Behavioral Health-Harnessing the Potential of Psychiatric Mental Health Nurse Practitioners. JAMA Netw Open 2022; 5:e2224365. [PMID: 35904788 DOI: 10.1001/jamanetworkopen.2022.24365] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- Ulrike Muench
- School of Nursing, Department of Social and Behavioral Sciences, University of California, San Francisco
- School of Medicine, Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco
- Healthforce Center, School of Medicine, University of California, San Francisco
| | - Taressa K Fraze
- School of Medicine, Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco
- Healthforce Center, School of Medicine, University of California, San Francisco
- School of Medicine, Department of Family and Community Medicine, University of California, San Francisco
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Patel H, Barnes J, Osazuwa-Peters N, Bierut LJ. Association of State Medicaid Expansion Status With Rates of Suicide Among US Adults. JAMA Netw Open 2022; 5:e2217228. [PMID: 35704315 PMCID: PMC9201676 DOI: 10.1001/jamanetworkopen.2022.17228] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
IMPORTANCE In the US, suicide is the 10th leading cause of death and a serious mental health emergency. National programs that address suicide list access to mental health care as key in prevention, and more large-scale policies are needed to improve access to mental health care and address this crisis. The Patient Protection and Affordable Care Act (ACA) Medicaid Expansion Program was implemented in several states with the goal of increasing access to the health care system. OBJECTIVE To compare changes in suicide rates in states that expanded Medicaid under the ACA vs states that did not. DESIGN, SETTING, AND PARTICIPANTS In this cross-sectional study, state-level mortality rates were obtained from the National Center for Health Statistics for US individuals aged 20 to 64 years from January 1, 2000, to December 31, 2018. Data analysis was performed from April 18, 2021, to April 15, 2022. EXPOSURES Changes in suicide mortality rates among nonelderly adults before and after Medicaid expansion in expansion and nonexpansion states were compared using adjusted difference-in-differences analyses via hierarchical bayesian linear regression. MAIN OUTCOMES AND MEASURES Suicide rates using death by suicide as the primary measure. RESULTS Of the total population at risk for suicide, 50.4% were female, 13.3% were Black, 79.5% were White, and 7.2% were of other races. The analytic data set contained suicide mortality data for 2907 state-age-year units covering the general US population. A total of 553 912 deaths by suicide occurred during the study period, with most occurring in White (496 219 [89.6%]) and male (429 580 [77.6%]) individuals. There were smaller increases in the suicide rate after 2014 in Medicaid expansion (2.56 per 100 000 increase) compared with nonexpansion states (3.10 per 100 000 increase). In adjusted difference-in-differences analysis, a significant decrease of -0.40 (95% credible interval, -0.66 to -0.14) suicides per 100 000 individuals was found, translating to 1818 suicides that were averted in 2015 to 2018. CONCLUSIONS AND RELEVANCE In this cross-sectional study, although suicide rates increased in both groups, blunting of these rates occurred among nonelderly adults in the Medicaid expansion states compared with nonexpansion states. Because this difference may be linked to increased access to mental health care, policy makers should consider suicide prevention as a benefit of expanding access to health care.
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Affiliation(s)
- Hetal Patel
- Department of Psychiatry, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - Justin Barnes
- Department of Radiation Oncology, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - Nosayaba Osazuwa-Peters
- Deputy Editor, Diversity, Equity, and Inclusion, JAMA Otolaryngology–Head and Neck Surgery
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina
- Department of Head and Neck Surgery & Communication Sciences, Duke University School of Medicine, Durham, North Carolina
| | - Laura Jean Bierut
- Department of Psychiatry, Washington University School of Medicine in St Louis, St Louis, Missouri
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Vohs JL, Shi M, Holmes EG, Butler M, Landsberger SA, Gao S, Ouyang F, Teal E, Merkitch K, Kronenberger W. Novel Approach to Integrating Mental Health Care into a Primary Care Setting: Development, Implementation, and Outcomes. J Clin Psychol Med Settings 2022; 30:3-16. [PMID: 35543900 DOI: 10.1007/s10880-022-09882-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/16/2022] [Indexed: 10/18/2022]
Abstract
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.
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Affiliation(s)
- Jenifer L Vohs
- Department of Psychiatry, Indiana University School of Medicine, Indianapolis, IN, USA.
| | - Molin Shi
- Department of Psychiatry, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Emily G Holmes
- Department of Psychiatry, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Melissa Butler
- Department of Psychiatry, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Sarah A Landsberger
- Department of Psychiatry, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Sujuan Gao
- Department of Biostatistics and Health Data Science, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Fanqian Ouyang
- Department of Biostatistics and Health Data Science, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Evgenia Teal
- Regenstrief Institute, Inc, Indianapolis, IN, USA
| | - Kristen Merkitch
- Department of Psychiatry, Indiana University School of Medicine, Indianapolis, IN, USA
| | - William Kronenberger
- Department of Psychiatry, Indiana University School of Medicine, Indianapolis, IN, USA
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Abstract
OBJECTIVE This article summarizes the existing literature on psychiatric electronic consultation (e-consultation or e-consult) to provide guidance on psychiatric e-consult practice and suggest next steps in research on psychiatric e-consults. METHOD A narrative review was conducted using relevant search terms in PubMed and Google Scholar. RESULTS AND DISCUSSION The psychiatric e-consult is a method of asynchronous consultation between primary care providers and psychiatric specialists that is associated with primary care provider satisfaction and promotes access to specialist guidance in mental health care. Major themes in the literature include contextual factors that affect implementation of psychiatric e-consult services, outcomes associated with psychiatric e-consults, and specific practical considerations that may affect psychiatric e-consult technique. CONCLUSIONS Psychiatric e-consults may help address the widespread lack of access to specialty psychiatric care. Further studies are needed to examine clinical outcomes based on psychiatry e-consults.
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Shettler JA, Ott RC, Reitz RS. Implementation of collaborative psychiatric care in a family medicine clinic: A quality assurance study. Int J Psychiatry Med 2022; 58:190-200. [PMID: 35446166 DOI: 10.1177/00912174221092511] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
In recent decades, numerous primary care clinics throughout the United States have implemented a collaborative care model of psychiatry in their practice. In this care model, patients with a psychiatric diagnosis meet with a team commonly composed of a primary care provider, behavioral health provider, and psychiatric consultants to develop a well-informed treatment plan. The St. Mary's Family Medicine Center in Grand Junction, Colorado implemented this care model in March 2020. Here, we evaluated its implementation and assessed its efficacy in producing favorable patient outcomes. We performed retrospective chart reviews and database queries in the clinic's electronic medical record system to gather relevant patient care information. We then analyzed this data through various statistical methods to assess the care model's effects on patient outcomes. Through this, we found evidence that this care model facilitates brief referral times with psychiatric specialists, and that treatment plans created here may contribute to a reduction in depressive and anxiety symptoms in a variety of patients.
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Affiliation(s)
- Joshua A Shettler
- Department of Mathematics and Statistics, 3580Colorado Mesa University, Grand Junction, CO, USA
| | - Rick C Ott
- Department of Mathematics and Statistics, 3580Colorado Mesa University, Grand Junction, CO, USA
| | - Randall S Reitz
- St Mary's Family Medicine Residency, 3581SCL Health St. Mary's Medical Center, Grand Junction, CO, USA
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Haun MW, Tönnies J, Graue L, Hartmann M, Wensing M, Szecsenyi J, Wild B, Friederich HC. Mental health specialist video consultations for patients with somatic symptom disorder in primary care: protocol for a randomised feasibility trial (the VISION trial). BMJ Open 2022; 12:e058150. [PMID: 35410935 PMCID: PMC9003599 DOI: 10.1136/bmjopen-2021-058150] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION General practitioners (GP) report increasing difficulties in referring patients with somatic symptom disorder (SSD) in specialised psychosocial care. Barriers are structural conditions of the respective healthcare system and patients' reservations against receiving specialised psychosocial care. As patients with SSD often predominantly assume somatic influencing factors for the development and maintenance of their somatic complaints, close collaboration between the GP and mental health specialist (MHS) seems particularly important. Integrating internet-based video consultations by remotely located MHS and primary care can improve effective treatment of patients with SSD by overcoming structural barriers and provide low-threshold and timely care. The aim of this randomised controlled feasibility trial is to investigate the feasibility of implementing MHS video consultations in primary care practices. METHODS AND ANALYSIS Fifty primary care patients with SSD will be individually randomised in two groups receiving either enhanced treatment as usual as provided by their GP (control group) or two versus five video consultations conducted by an MHS additionally to enhanced treatment as usual. The video consultations focus on (a) diagnostic clarification, (b) the development of a biopsychosocial disorder model, and (c) development of a treatment plan against the background of a stepped-care algorithm based on clinical outcomes. We will investigate the following outcomes: effectiveness of the recruitment strategies, patient acceptance of randomisation, practicability of the technical and logistical processes related to implementing video consultations in the practices' workflows, feasibility of the data collection and clinical parameters. ETHICS AND DISSEMINATION This trial has undergone ethical scrutiny and has been approved by the Medical Faculty of the University of Heidelberg Ethics Committee (S-620/2021). The findings will be disseminated to the research community through presentations at conferences and publications in scientific journals. This feasibility trial will prepare the ground for a large-scale, fully powered randomised controlled trial. TRIAL REGISTRATION NUMBER DRKS00026075.
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Affiliation(s)
- Markus W Haun
- Department of General Internal Medicine and Psychosomatics, Heidelberg University, Heidelberg, Germany
| | - Justus Tönnies
- Department of General Internal Medicine and Psychosomatics, Heidelberg University, Heidelberg, Germany
| | - Leike Graue
- Department of General Internal Medicine and Psychosomatics, Heidelberg University, Heidelberg, Germany
| | - Mechthild Hartmann
- Department of General Internal Medicine and Psychosomatics, Heidelberg University, Heidelberg, Germany
| | - Michel Wensing
- Department of General Practice and Health Services Research, Heidelberg University, Heidelberg, Germany
| | - Joachim Szecsenyi
- Department of General Practice and Health Services Research, Heidelberg University, Heidelberg, Germany
| | - Beate Wild
- Department of General Internal Medicine and Psychosomatics, Heidelberg University, Heidelberg, Germany
| | - Hans-Christoph Friederich
- Department of General Internal Medicine and Psychosomatics, Heidelberg University, Heidelberg, Germany
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Kaitz JE, Steinhilber KM, Harris JI. Influence of Provider Gender on Mental Health Stigma. Community Ment Health J 2022; 58:536-540. [PMID: 34052962 DOI: 10.1007/s10597-021-00849-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Accepted: 05/25/2021] [Indexed: 11/28/2022]
Abstract
This study examined gender differences in mental health providers' stigma toward people with mental illness. As part of a larger professional education needs assessment at a VA healthcare system, 77 mental health providers of various disciplines completed a self-report measure of stigma towards people with various mental health diagnoses. Results indicated that male mental health providers hold significantly more stigmatizing views toward people with schizophrenia and posttraumatic stress disorder (PTSD), which is consistent with provider gender differences found in other areas of study and theories of stigma and masculinity. These results can be used to build on stigma reduction interventions. Future research should continue to examine the underlying reasons for gender differences among providers.
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Affiliation(s)
- Jenesse E Kaitz
- Center for Healthcare Organization and Implementation Research (CHOIR), VA Bedford Healthcare System, 200 Springs Rd, Bedford, MA, 01730, USA.
| | | | - J Irene Harris
- Veterans Integrated Service Network #1, Mental Illness Research, Education, and Clinical Center, VA Bedford Healthcare System, 200 Springs Rd, Bedford, MA, 01730, USA.,Medical School Department of Psychiatry, University of Minnesota, 606 24th Ave. S, Minneapolis, MN, 55454, USA
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Patient and Provider Views on Psychosocial Screening in a Comprehensive Diabetes Center. J Clin Psychol Med Settings 2022; 30:92-110. [PMID: 35316442 PMCID: PMC8938639 DOI: 10.1007/s10880-022-09867-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/02/2022] [Indexed: 12/02/2022]
Abstract
Guidelines recommend routinely screening adults with diabetes for psychological concerns, but few diabetes clinics have adopted screening procedures. This study assessed patient and provider perspectives regarding the role of mental health in diabetes care, psychosocial screening procedures, and patients’ support needs. Patients with diabetes (n = 15; 73.3% type 2) and their medical providers (n = 11) participated in qualitative interviews. Thematic content analysis was used to categorize results. Participants believed that mental health was important to address within comprehensive diabetes care. Patients expressed positive or neutral opinions about psychosocial screening. Providers had mixed reactions; many thought that screening would be too time-consuming. Both groups emphasized that screening must include referral procedures to direct patients to mental health services. Patients and providers interviewed in this study viewed psychosocial screening as compatible with diabetes care. Including a mental health professional on the treatment team could reduce potential burden on other team members.
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Bernstein EE, Bentley KH, Nock MK, Stein MB, Beck S, Kleiman EM. An Ecological Momentary Intervention Study of Emotional Responses to Smartphone-Prompted CBT Skills Practice and the Relationship to Clinical Outcomes. Behav Ther 2022; 53:267-280. [PMID: 35227403 PMCID: PMC8891654 DOI: 10.1016/j.beth.2021.09.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2021] [Revised: 07/12/2021] [Accepted: 09/04/2021] [Indexed: 02/08/2023]
Abstract
The practice of therapeutic skills outside of sessions in which they are learned is one presumed key component of cognitive behavioral therapy (CBT). Yet, our understanding of how skills practice relates to clinical outcomes remains limited. Here, we explored patients' emotional responses to CBT skills practice in a pilot study pairing smartphone-app-delivered skills reminders and guided practice (ecological momentary intervention [EMI]) using ecological momentary assessment (EMA). Participants (n = 25) were adults recently hospitalized for a suicide attempt or severe suicidal thinking. They received brief inpatient CBT (1 to 3 sessions covering core CBT skills from the Unified Protocol), followed by 1 month of EMI and EMA after discharge. On average, participants reported modest reductions in negative affect after skills use (i.e., immediate responses; median time elapsed = 4.30 minutes). Additionally, participants tended to report less negative affect when the timepoint preceding the current assessment included EMI skills practice, rather than EMA alone (i.e., delayed responses; median time elapsed between prompts = 2.17 hours). Immediate effects were unrelated to longer-term clinical outcomes, whereas greater delayed effects were associated with lower symptom severity at follow-up. Future studies should further examine how CBT skills use in daily life may alleviate symptoms.
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Affiliation(s)
| | - Kate H Bentley
- Massachusetts General Hospital/Harvard Medical School; Harvard University
| | | | | | - Stuart Beck
- Massachusetts General Hospital/Harvard Medical School
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Moon K, Sobolev M, Kane JM. Digital and Mobile Health Technology in Collaborative Behavioral Health Care: Scoping Review. JMIR Ment Health 2022; 9:e30810. [PMID: 35171105 PMCID: PMC8892315 DOI: 10.2196/30810] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2021] [Revised: 09/08/2021] [Accepted: 10/20/2021] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND The collaborative care model (CoCM) is a well-established system of behavioral health care in primary care settings. There is potential for digital and mobile technology to augment the CoCM to improve access, scalability, efficiency, and clinical outcomes. OBJECTIVE This study aims to conduct a scoping review to synthesize the evidence available on digital and mobile health technology in collaborative care settings. METHODS This review included cohort and experimental studies of digital and mobile technologies used to augment the CoCM. Studies examining primary care without collaborative care were excluded. A literature search was conducted using 4 electronic databases (MEDLINE, Embase, Web of Science, and Google Scholar). The search results were screened in 2 stages (title and abstract screening, followed by full-text review) by 2 reviewers. RESULTS A total of 3982 nonduplicate reports were identified, of which 20 (0.5%) were included in the analysis. Most studies used a combination of novel technologies. The range of digital and mobile health technologies used included mobile apps, websites, web-based platforms, telephone-based interactive voice recordings, and mobile sensor data. None of the identified studies used social media or wearable devices. Studies that measured patient and provider satisfaction reported positive results, although some types of interventions increased provider workload, and engagement was variable. In studies where clinical outcomes were measured (7/20, 35%), there were no differences between groups, or the differences were modest. CONCLUSIONS The use of digital and mobile health technologies in CoCM is still limited. This study found that technology was most successful when it was integrated into the existing workflow without relying on patient or provider initiative. However, the effect of digital and mobile health on clinical outcomes in CoCM remains unclear and requires additional clinical trials.
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Affiliation(s)
- Khatiya Moon
- Zucker Hillside Hospital, Northwell Health, Glen Oaks, NY, United States
| | - Michael Sobolev
- Zucker Hillside Hospital, Northwell Health, Glen Oaks, NY, United States.,Cornell Tech, Cornell University, New York City, NY, United States
| | - John M Kane
- Zucker Hillside Hospital, Northwell Health, Glen Oaks, NY, United States
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Schoenfelder Gonzalez E, Jungbluth N, McCarty CA, Hilt R. Barriers to Increasing Access to Brief Pediatric Mental Health Treatment From Primary Care. Psychiatr Serv 2022; 73:235-238. [PMID: 34126777 DOI: 10.1176/appi.ps.202000457] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
A quality improvement process targeted mental health care uptake and system capacity in an underserved region. The pediatric program created pathways for rapid referral from primary care and schools to four sessions of evidence-based treatments for disruptive behavior and depression with community clinicians. Of 250 referrals, 46 families enrolled in treatments for disruptive behavior and 21 for depression. Many families did not respond or required more intensive treatment. Acceptability of the program was high for participating families, referrers, and clinicians. Brief treatment met most participating families' needs. The process demonstrated barriers to mental health care access and delivery and the need for integrated and multitiered care delivery.
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Affiliation(s)
- Erin Schoenfelder Gonzalez
- Seattle Children's Hospital, Seattle (all authors); Department of Psychiatry and Behavioral Medicine (Schoenfelder Gonzalez, Hilt) and Department of Pediatrics (McCarty), University of Washington School of Medicine, Seattle. Marcela Horvitz-Lennon, M.D., Kenneth Minkoff, M.D., and Esperanza Diaz, M.D., are editors of this column
| | - Nathaniel Jungbluth
- Seattle Children's Hospital, Seattle (all authors); Department of Psychiatry and Behavioral Medicine (Schoenfelder Gonzalez, Hilt) and Department of Pediatrics (McCarty), University of Washington School of Medicine, Seattle. Marcela Horvitz-Lennon, M.D., Kenneth Minkoff, M.D., and Esperanza Diaz, M.D., are editors of this column
| | - Carolyn A McCarty
- Seattle Children's Hospital, Seattle (all authors); Department of Psychiatry and Behavioral Medicine (Schoenfelder Gonzalez, Hilt) and Department of Pediatrics (McCarty), University of Washington School of Medicine, Seattle. Marcela Horvitz-Lennon, M.D., Kenneth Minkoff, M.D., and Esperanza Diaz, M.D., are editors of this column
| | - Robert Hilt
- Seattle Children's Hospital, Seattle (all authors); Department of Psychiatry and Behavioral Medicine (Schoenfelder Gonzalez, Hilt) and Department of Pediatrics (McCarty), University of Washington School of Medicine, Seattle. Marcela Horvitz-Lennon, M.D., Kenneth Minkoff, M.D., and Esperanza Diaz, M.D., are editors of this column
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Chien AT, Leyenaar J, Tomaino M, Woloshin S, Leininger L, Barnett ER, McLaren JL, Meara E. Difficulty Obtaining Behavioral Health Services for Children: A National Survey of Multiphysician Practices. Ann Fam Med 2022; 20:42-50. [PMID: 35074767 PMCID: PMC8786429 DOI: 10.1370/afm.2759] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Revised: 05/21/2021] [Accepted: 06/21/2021] [Indexed: 11/09/2022] Open
Abstract
PURPOSE In the United States, primary care practices rely on scarce resources to deliver evidence-based care for children with behavioral health disorders such as depression, anxiety, other mental illness, or substance use disorders. We estimated the proportion of practices that have difficulty accessing these resources and whether practices owned by a health system or participating in Medicaid accountable care organizations (ACOs) report less difficulty. METHODS This national cross-sectional study examined how difficult it is for practices to obtain pediatric (1) medication advice, (2) evidence-based psychotherapy, and (3) family-based therapy. We used the National Survey of Healthcare Organizations and Systems 2017-2018 (46.9% response rate), which sampled multiphysician primary and multispecialty care practices including 1,410 practices that care for children. We characterized practices' experience as "difficult" relative to "not at all difficult" using a 4-point ordinal scale. We used mixed-effects generalized linear models to estimate differences comparing system-owned vs independent practices and Medicaid ACO participants vs nonparticipants, adjusting for practice attributes. RESULTS More than 85% of practices found it difficult to obtain help with evidence-based elements of pediatric behavioral health care. Adjusting for practice attributes, the percent experiencing difficulty was similar between system-owned and independent practices but was less for Medicaid ACO participants for medication advice (81% vs 89%; P = .021) and evidence-based psychotherapy (81% vs 90%; P = .006); differences were not significant for family-based treatment (85% vs 91%; P = .107). CONCLUSIONS Most multiphysician practices struggle to obtain advice and services for child behavioral health needs, which are increasing nationally. Future studies should investigate the source of observed associations.
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Affiliation(s)
- Alyna T Chien
- Division of General Pediatrics, Department of General Pediatrics, Boston Children's Hospital, Boston, Massachusetts .,Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - JoAnna Leyenaar
- Department of Pediatrics, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire.,The Dartmouth Institute for Health Policy & Clinical Practice, Lebanon, New Hampshire
| | - Marisa Tomaino
- The Dartmouth Institute for Health Policy & Clinical Practice, Lebanon, New Hampshire
| | - Steven Woloshin
- The Dartmouth Institute for Health Policy & Clinical Practice, Lebanon, New Hampshire.,The Lisa Schwartz Foundation for Truth in Medicine, Norwich, Vermont
| | - Lindsey Leininger
- The Dartmouth Institute for Health Policy & Clinical Practice, Lebanon, New Hampshire
| | - Erin R Barnett
- The Dartmouth Institute for Health Policy & Clinical Practice, Lebanon, New Hampshire.,Department of Psychiatry, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Jennifer L McLaren
- The Dartmouth Institute for Health Policy & Clinical Practice, Lebanon, New Hampshire.,Department of Psychiatry, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Ellen Meara
- The Dartmouth Institute for Health Policy & Clinical Practice, Lebanon, New Hampshire.,National Bureau of Economic Research, Cambridge, Massachusetts.,Harvard T.H. Chan School of Public Health, Boston, Massachusetts
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McMahan K, Martin KM, Greenfield MJ, Hay P, Bates Redwine M, Fargason R, Lokken K. Using a tele-behavioral health rapid intake model to address high demand for psychotherapy at an academic medical center during COVID-19. Front Psychiatry 2022; 13:989838. [PMID: 36620684 PMCID: PMC9815605 DOI: 10.3389/fpsyt.2022.989838] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2022] [Accepted: 11/28/2022] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Long wait times for mental health appointments have been a chronic dilemma for academic medical centers. This problem intensified worldwide with the onset of the COVID-19 pandemic. Approximately 70% of mental health services experienced pandemic-related disruption in care provision, while simultaneously experiencing a substantial increase in patient demand. Wait times for mental health appointments also increased, varying across populations from 3 to 18 months. As prolonged wait time is positively associated with severity of psychiatric symptoms and negative outcomes, the authors implemented a novel rapid intake telemedicine clinic model to shorten wait time and increase patient access to psychological care at an academic medical center. METHODS To address an overwhelming influx of mental health referrals and a growing wait-time-until-first appointment at an academic medical center serving as a lone safety net hospital during the COVID-19 pandemic, a 5-provider Psychology Rapid Intake Team was established using a hybrid of telehealth and in-person appointments based on patient preference. Data on new patient volumes, wait time for 1st appointment, and wait time to begin therapeutic intervention were compared during the same calendar 3-month period immediately prior to and following implementation of the rapid intake clinic. RESULTS A paired-samples t-test was conducted to compare new patient volumes pre- vs. post- intervention. Results revealed a significant increase in the number of new patients the providers were able to accommodate in the post-implementation (M = 62.00, SD = 7.21) compared to the pre-implementation (M = 31.00, SD = 2.61) condition; t(2) = -8.60, p < 0.05. There was a significant decrease in the average wait times for 1st appointment post-implementation (M = 24.99, SD = 2.38) compared to the pre-implementation (M = 37.32, SD = 1.47) condition; t(2) = 5.56, p < 0.05. In addition, days to begin therapeutic intervention decreased dramatically (394%) from the pre- (M = 142.50) to post-implementation (M = 28.84) period. CONCLUSION The COVID-19 pandemic strained a mental healthcare system which led to increasingly long wait times for intake appointments and delayed psychotherapy interventions. The Psychology Rapid Intake Team initiative served to improve access, reduce patient risk related to prolonged wait times, and accelerated patient engagement with psychotherapy services. The model can serve as a unique, sustainable infrastructure for behavioral health delivery for low acuity mental health problems in large health care systems.
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Affiliation(s)
- Kristina McMahan
- Department of Psychiatry and Behavioral Neurobiology, University of Alabama at Birmingham, Birmingham, AL, United States
| | | | - Melissa J Greenfield
- Department of Psychiatry and Behavioral Neurobiology, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Pamela Hay
- Department of Psychiatry and Behavioral Neurobiology, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Madison Bates Redwine
- Department of Psychiatry and Behavioral Neurobiology, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Rachel Fargason
- Department of Psychiatry and Behavioral Neurobiology, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Kristine Lokken
- Department of Psychiatry and Behavioral Neurobiology, University of Alabama at Birmingham, Birmingham, AL, United States
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Carroll AR, Hall M, Brown CM, Johnson DP, Antoon JW, Kreth H, Ngo ML, Browning W, Neeley M, Herndon A, Chokshi SB, Plemmons G, Johnson J, Hart SR, Williams DJ. Association of Race/Ethnicity and Social Determinants with Rehospitalization for Mental Health Conditions at Acute Care Children's Hospitals. J Pediatr 2022; 240:228-234.e1. [PMID: 34478747 PMCID: PMC8712354 DOI: 10.1016/j.jpeds.2021.08.078] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Revised: 08/02/2021] [Accepted: 08/26/2021] [Indexed: 01/03/2023]
Abstract
OBJECTIVE To evaluate associations of race/ethnicity and social determinants with 90-day rehospitalization for mental health conditions to acute care nonpsychiatric children's hospitals. STUDY DESIGN We conducted a retrospective cohort analysis of mental health hospitalizations for children aged 5-18 years from 2016 to 2018 at 32 freestanding US children's hospitals using the Children's Hospital Association's Pediatric Health Information System database to assess the association of race/ethnicity and social determinants (insurance payer, neighborhood median household income, and rurality of patient home location) with 90-day rehospitalization. Risk factors for rehospitalization were modeled using mixed-effects multivariable logistic regression. RESULTS Among 23 556 index hospitalizations, there were 1382 mental health rehospitalizations (5.9%) within 90 days. Non-Hispanic Black children were 26% more likely to be rehospitalized than non-Hispanic White children (aOR 1.26, 95% CI 1.08-1.48). Those with government insurance were 18% more likely to be rehospitalized than those with private insurance (aOR 1.18, 95% CI 1.04-1.34). In contrast, those living in a suburban location were 22% less likely to be rehospitalized than those living in an urban location (suburban: aOR 0.78, 95% CI 0.63-0.97). CONCLUSIONS Non-Hispanic Black children and those with public insurance were at greatest risk for 90-day rehospitalization, and risk was lower in those residing in suburban locations. Future work should focus on upstream interventions that will best attenuate social disparities to promote equity in pediatric mental healthcare.
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Affiliation(s)
- Alison R Carroll
- Monroe Carell Jr Children's Hospital at Vanderbilt, Division of Hospital Medicine, Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, TN.
| | - Matt Hall
- Children's Hospital Association, Lenexa, KS
| | - Charlotte M Brown
- Monroe Carell Jr Children's Hospital at Vanderbilt, Division of Hospital Medicine, Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, TN
| | - David P Johnson
- Monroe Carell Jr Children's Hospital at Vanderbilt, Division of Hospital Medicine, Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, TN
| | - James W Antoon
- Monroe Carell Jr Children's Hospital at Vanderbilt, Division of Hospital Medicine, Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, TN
| | - Heather Kreth
- Monroe Carell Jr Children's Hospital at Vanderbilt, Division of Hospital Medicine, Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, TN
| | - My-Linh Ngo
- Monroe Carell Jr Children's Hospital at Vanderbilt, Division of Hospital Medicine, Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, TN
| | - Whitney Browning
- Monroe Carell Jr Children's Hospital at Vanderbilt, Division of Hospital Medicine, Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, TN
| | - Maya Neeley
- Monroe Carell Jr Children's Hospital at Vanderbilt, Division of Hospital Medicine, Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, TN
| | - Alison Herndon
- Monroe Carell Jr Children's Hospital at Vanderbilt, Division of Hospital Medicine, Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, TN
| | - Swati B Chokshi
- Monroe Carell Jr Children's Hospital at Vanderbilt, Division of Hospital Medicine, Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, TN
| | - Gregory Plemmons
- Monroe Carell Jr Children's Hospital at Vanderbilt, Division of Hospital Medicine, Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, TN
| | - Jakobi Johnson
- Monroe Carell Jr Children's Hospital at Vanderbilt, Division of Hospital Medicine, Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, TN
| | - Sarah R Hart
- Monroe Carell Jr Children's Hospital at Vanderbilt, Division of Hospital Medicine, Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, TN
| | - Derek J Williams
- Monroe Carell Jr Children's Hospital at Vanderbilt, Division of Hospital Medicine, Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, TN
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Boucher EM, Harake NR, Ward HE, Stoeckl SE, Vargas J, Minkel J, Parks AC, Zilca R. Artificially intelligent chatbots in digital mental health interventions: a review. Expert Rev Med Devices 2021; 18:37-49. [PMID: 34872429 DOI: 10.1080/17434440.2021.2013200] [Citation(s) in RCA: 46] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
INTRODUCTION Increasing demand for mental health services and the expanding capabilities of artificial intelligence (AI) in recent years has driven the development of digital mental health interventions (DMHIs). To date, AI-based chatbots have been integrated into DMHIs to support diagnostics and screening, symptom management and behavior change, and content delivery. AREAS COVERED We summarize the current landscape of DMHIs, with a focus on AI-based chatbots. Happify Health's AI chatbot, Anna, serves as a case study for discussion of potential challenges and how these might be addressed, and demonstrates the promise of chatbots as effective, usable, and adoptable within DMHIs. Finally, we discuss ways in which future research can advance the field, addressing topics including perceptions of AI, the impact of individual differences, and implications for privacy and ethics. EXPERT OPINION Our discussion concludes with a speculative viewpoint on the future of AI in DMHIs, including the use of chatbots, the evolution of AI, dynamic mental health systems, hyper-personalization, and human-like intervention delivery.
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Shim RS, Tierney M, Rosenzweig MH, Goldman HH. Improving Behavioral Health Services in the Time of COVID-19 and Racial Inequities. NAM Perspect 2021; 2021:202110c. [PMID: 34901776 DOI: 10.31478/202110c] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Ryan KA, Smith SN, Yocum AK, Carley I, Liebrecht C, Navis B, Vest E, Bertram H, McInnis MG, Kilbourne AM. The Life Goals Self-Management Mobile App for Bipolar Disorder: Consumer Feasibility, Usability, and Acceptability Study. JMIR Form Res 2021; 5:e32450. [PMID: 34898452 PMCID: PMC8713087 DOI: 10.2196/32450] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Revised: 09/08/2021] [Accepted: 11/05/2021] [Indexed: 12/12/2022] Open
Abstract
Background Life Goals is an evidence-based self-management intervention that assists individuals with bipolar disorder (BD) by aligning BD symptom coping strategies with their personal goals. The intervention can be availed via in-person and telephonic sessions, and it has been recently developed as an individualized, customizable mobile app. Objective We examined the feasibility, usability, and acceptability of the Life Goals self-management app among individuals diagnosed with BD who used the app for up to 6 months. Methods A total of 28 individuals with BD used the Life Goals app on their personal smartphone for 6 months. They completed key clinical outcome measurements of functioning, disability, and psychiatric symptoms at baseline, 3 months, and 6 months, in addition to a poststudy survey about usability and satisfaction. Results Participants used the app for a median of 25 times (IQR 13-65.75), and for a longer time during the first 3 months of the study. The modules on depression and anxiety were the most frequently used, accounting for 35% and 22% of total usage, respectively. Overall, the study participants found the app useful (15/25, 60%) and easy to use (18/25, 72%), and they reported that the screen displayed the material adequately (22/25, 88%). However, less than half of the participants found the app helpful in managing their health (10/25, 40%) or in making progress on their wellness goals (9/25, 36%). Clinical outcomes showed a trend for improvements in mental and physical health and mania-related well-being. Conclusions The Life Goals app showed feasibility of use among individuals with BD. Higher user engagement was observed in the initial 3 months with users interested more frequently in the mood modules than other wellness modules. Participants reported acceptability with the ease of app use and satisfaction with the app user interface, but the app showed low success in encouraging self-management within this small sample. The Life Goals app is a mobile health technology that can provide individuals with serious mental illness with more flexible access to evidence-based treatments.
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Affiliation(s)
- Kelly A Ryan
- Department of Psychiatry, University of Michigan, Ann Arbor, MI, United States
| | - Shawna N Smith
- Department of Health Management and Policy, School of Public Health, University of Michigan, Ann Arbor, MI, United States
| | - Anastasia K Yocum
- Department of Psychiatry, University of Michigan, Ann Arbor, MI, United States
| | - Isabel Carley
- Department of Psychiatry, University of Michigan, Ann Arbor, MI, United States
| | - Celeste Liebrecht
- VA Ann Arbor Healthcare System, United States Department of Veterans Affairs, Ann Arbor, MI, United States.,Department of Learning Health Sciences, University of Michigan, Ann Arbor, MI, United States
| | - Bethany Navis
- Department of Psychiatry, University of Michigan, Ann Arbor, MI, United States
| | - Erica Vest
- Department of Psychiatry, University of Michigan, Ann Arbor, MI, United States
| | - Holli Bertram
- Department of Psychiatry, University of Michigan, Ann Arbor, MI, United States
| | - Melvin G McInnis
- Department of Psychiatry, University of Michigan, Ann Arbor, MI, United States
| | - Amy M Kilbourne
- VA Ann Arbor Healthcare System, United States Department of Veterans Affairs, Ann Arbor, MI, United States.,Department of Learning Health Sciences, University of Michigan, Ann Arbor, MI, United States
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Haun MW, Hoffmann M, Wildenauer A, Tönnies J, Wensing M, Szecsenyi J, Peters-Klimm F, Krisam R, Kronsteiner D, Hartmann M, Friederich HC. Health providers' experiences with mental health specialist video consultations in primary care: a qualitative study nested within a randomised feasibility trial. BMJ Open 2021; 11:e047829. [PMID: 34753752 PMCID: PMC8578962 DOI: 10.1136/bmjopen-2020-047829] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2020] [Accepted: 10/21/2021] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE Despite available effective treatments for mental health disorders, few patients in need receive even the most basic care. Integrated telepsychiatry services may be a viable option to increase access to mental healthcare. The aim of this qualitative process evaluation embedded in a randomised controlled feasibility trial was to explore health providers' experiences with a mental healthcare model integrating mental health specialist video consultations (MHSVC) and primary care. METHODS A qualitative process evaluation focusing on MHSVC in primary care was conducted. In 13 semistructured interviews, we assessed the experience of all mental health specialists, primary care physicians and medical assistants who participated in the trial. A thematic analysis, focusing on the implementation, mechanisms of impact and context, was applied to investigate the data. RESULTS Considering (1) the implementation, participants evaluated the consultations as feasible, easy to use and time saving. Concerning (2) the mechanisms of impact, the consultations were regarded as effective for patients. Providers attributed the patients' improvements to two key aspects: the familiarity of the primary care practice and the fast access to specialist mental healthcare. Mental health specialists observed trustful therapeutic alliances emerging and described their experience as comparable to same-room care. However, compared with same-room care, specialists perceived the video consultations as more challenging and sometimes more exhausting due to the additional effort required for establishing therapeutic alliances. Regarding (3) the intervention's context, shorter travel distances for patients positively affected the implementation, while technical failures, that is, poor Internet connectivity, emerged as the main barrier. CONCLUSIONS MHSVCs in primary care are feasible and successful in improving access to mental healthcare for patients. To optimise engagement and comfort of both patients and health providers, future work should focus on empirical determinants for establishing robust therapeutic alliances with patients receiving MHSVC (eg, leveraging non-verbal cues for therapeutic purposes). TRIAL REGISTRATION NUMBER DRKS00015812; Results.
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Affiliation(s)
- Markus W Haun
- Department of General Internal Medicine and Psychosomatics, Heidelberg University, Heidelberg, Baden-Württemberg, Germany
| | - Mariell Hoffmann
- Department of General Internal Medicine and Psychosomatics, Heidelberg University, Heidelberg, Baden-Württemberg, Germany
| | - Alina Wildenauer
- Department of General Internal Medicine and Psychosomatics, Heidelberg University, Heidelberg, Baden-Württemberg, Germany
| | - Justus Tönnies
- Department of General Internal Medicine and Psychosomatics, Heidelberg University, Heidelberg, Baden-Württemberg, Germany
| | - Michel Wensing
- Department of General Practice and Health Services Research, Heidelberg University, Heidelberg, Baden-Württemberg, Germany
| | - Joachim Szecsenyi
- Department of General Practice and Health Services Research, Heidelberg University, Heidelberg, Baden-Württemberg, Germany
| | - Frank Peters-Klimm
- Department of General Practice and Health Services Research, Heidelberg University, Heidelberg, Baden-Württemberg, Germany
| | - Regina Krisam
- Institute of Medical Biometry and Informatics, Heidelberg University, Heidelberg, Baden-Württemberg, Germany
| | - Dorothea Kronsteiner
- Institute of Medical Biometry and Informatics, Heidelberg University, Heidelberg, Baden-Württemberg, Germany
| | - Mechthild Hartmann
- Department of General Internal Medicine and Psychosomatics, Heidelberg University, Heidelberg, Baden-Württemberg, Germany
| | - Hans-Christoph Friederich
- Department of General Internal Medicine and Psychosomatics, Heidelberg University, Heidelberg, Baden-Württemberg, Germany
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