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Cerimele JM, Blanchard BE, Johnson M, Russo J, Bauer AM, Veith RC, Unützer J, Fortney JC. Effectiveness of Collaborative Care and Colocated Specialty Care for Bipolar Disorder in Primary Care: A Secondary Analysis of a Randomized Clinical Trial. J Acad Consult Liaison Psychiatry 2023; 64:349-356. [PMID: 36764483 PMCID: PMC10688610 DOI: 10.1016/j.jaclp.2023.02.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2022] [Revised: 02/03/2023] [Accepted: 02/03/2023] [Indexed: 02/11/2023]
Abstract
BACKGROUND Individuals with bipolar disorder commonly present for treatment in primary care settings. Collaborative care and colocated specialty care models can improve quality of care and outcomes, though it is unknown which model is more effective. OBJECTIVE To compare 12-month treatment outcomes for primary care patients with bipolar disorder randomized to treatment with collaborative care or colocated specialty care. METHODS We conducted a secondary analysis of 191 patients diagnosed with bipolar disorder treated for 12 months during a comparative effectiveness trial in 12 Federally Qualified Health Centers in three states. Characteristics and outcomes were assessed at enrollment and 12 months. The primary outcome was mental health quality of life scores (Veterans RAND 12-Item Health Survey Mental Health Component Summary), and secondary outcomes included depression and anxiety symptom scores, euthymic mood state, and recovery. T-tests and multiple linear and logistic regression models were used. RESULTS Among participants (mean age: 40 years; 73% women), the Veterans RAND 12-Item Health Survey Mental Health Component Summary increased in both arms over 12 months (baseline: collaborative care 21.99, SD 10.78; colocated specialty 24.15, SD 12.05; 12-month collaborative care 30.63, SD 13.33; colocated specialty 34.16, SD 12.65). The mean Mental Health Component Summary change did not differ by arm (collaborative care: MΔ = 9.09; colocated specialty: MΔ = 10.73; t = -0.67, P = 0.50). Secondary outcomes also improved at 12 months compared to baseline measured by the Hopkins Symptoms Checklist (MΔ = -0.75; SD = 0.85), Generalized Anxiety Disorder-7 (MΔ = -3.92; SD = 6.48), and Recovery Assessment Scale (MΔ = 0.37; SD = 0.65) and did not differ significantly by arm. The proportion of participants with euthymic mood state increased from 11% to 25% with no statistically significant difference by arm. CONCLUSIONS The effectiveness of collaborative care and that of colocated specialty care were similar. Both were associated with substantial improvements in mental health quality of life and symptom reduction.
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Affiliation(s)
- Joseph M Cerimele
- Department of Psychiatry & Behavioral Sciences, University of Washington School of Medicine, Seattle, WA.
| | - Brittany E Blanchard
- Department of Psychiatry & Behavioral Sciences, University of Washington School of Medicine, Seattle, WA
| | - Morgan Johnson
- Department of Psychiatry & Behavioral Sciences, University of Washington School of Medicine, Seattle, WA
| | - Joan Russo
- Department of Psychiatry & Behavioral Sciences, University of Washington School of Medicine, Seattle, WA
| | - Amy M Bauer
- Department of Psychiatry & Behavioral Sciences, University of Washington School of Medicine, Seattle, WA
| | - Richard C Veith
- Department of Psychiatry & Behavioral Sciences, University of Washington School of Medicine, Seattle, WA
| | - Jürgen Unützer
- Department of Psychiatry & Behavioral Sciences, University of Washington School of Medicine, Seattle, WA
| | - John C Fortney
- Department of Psychiatry & Behavioral Sciences, University of Washington School of Medicine, Seattle, WA; Department of Veterans Affairs, HSR&D Center of Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System, Seattle, WA
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Moise N, Bauer AM. Current and future directions in the application of implementation science to accelerate the adoption of evidence-based practices in behavioral health. Gen Hosp Psychiatry 2022; 77:88-91. [PMID: 35576715 DOI: 10.1016/j.genhosppsych.2022.05.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Accepted: 05/03/2022] [Indexed: 11/17/2022]
Affiliation(s)
- Nathalie Moise
- Department of Medicine, Columbia University Irving Medical Center, New York, NY, USA
| | - Amy M Bauer
- Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, WA, USA.
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LaRocco-Cockburn A, Jakupcak M, Bauer AM, Bowen DJ, Bechtel J, Koconis N, Fortney JC. Care managers' experiences in a collaborative care program for the treatment of bipolar disorder and PTSD in underserved communities. Gen Hosp Psychiatry 2022; 76:16-24. [PMID: 35313202 DOI: 10.1016/j.genhosppsych.2022.03.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2021] [Revised: 02/17/2022] [Accepted: 03/03/2022] [Indexed: 01/18/2023]
Abstract
OBJECTIVES To understand care managers' experiences treating primary care patients with bipolar disorder and PTSD in a telepsychiatry collaborative care (TCC) program, as part of a large pragmatic trial. METHODS We conducted individual qualitative interviews with 12 care managers to evaluate barriers and facilitators to implementation of a previously completed TCC intervention for patients with bipolar disorder and/or PTSD. We used directed and conventional content analysis and Consolidated Framework for Implementation Research (CFIR) constructs to organize care manager experiences. RESULTS Participants described clinical and medication management support from telepsychiatrists and satisfaction with the TCC model as facilitators of success for patients with bipolar disorder and PTSD in underserved communities. Participants also described onboarding of primary care providers and clinic leadership as keys to successful team-care and credited satisfaction with providing Behavioral Activation as essential to sustained delivery of the psychotherapy component of TCC. CONCLUSIONS Participants described high satisfaction with TCC for patients with bipolar disorder and PTSD. Challenges included lack of clinic leadership and PCP engagement. Early and ongoing promotion of integrated care and prioritizing telepsychiatry consultation with patients, behavioral health professionals and PCPs, may improve patient care, provide ongoing training and improve workforce satisfaction.
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Affiliation(s)
- Anna LaRocco-Cockburn
- Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, 1959 NE Pacific Street, Box 356560, Seattle, WA 98195-6560, United States of America; LaRocco Counseling, PLLC, 2366 Eastlake Ave E, Suite 234, Seattle, WA 98102, United States of America.
| | - Matthew Jakupcak
- Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, 1959 NE Pacific Street, Box 356560, Seattle, WA 98195-6560, United States of America; Lyra Health, 287 Lorton Ave, Burlingame, CA 94010, United States of America.
| | - Amy M Bauer
- Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, 1959 NE Pacific Street, Box 356560, Seattle, WA 98195-6560, United States of America.
| | - Deborah J Bowen
- Department of Bioethics and Humanities, University of Washington, Box 357120, Seattle, WA, United States of America.
| | - Jared Bechtel
- Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, 1959 NE Pacific Street, Box 356560, Seattle, WA 98195-6560, United States of America.
| | - Natalie Koconis
- University of Washington, Institute for Public Health Genetics, in association with the Department of Psychiatry and Behavioral Sciences, 1959 NE Pacific Street, Box 356560, Seattle, WA 98195-6560, United States of America.
| | - John C Fortney
- Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, 1959 NE Pacific Street, Box 356560, Seattle, WA 98195-6560, United States of America; Department of Veterans Affairs, HSR&D Center of Innovation for Veteran-Centered and Values-Driven Care, VA Puget Sound Health Care System, Seattle, WA, United States of America.
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Cerimele JM, Russo J, Bauer AM, Hawrilenko M, Pyne JM, Dalack GW, Kroenke K, Unützer J, Fortney JC. The Patient Mania Questionnaire (PMQ-9): a Brief Scale for Assessing and Monitoring Manic Symptoms. J Gen Intern Med 2022; 37:1680-1687. [PMID: 34145517 PMCID: PMC9130397 DOI: 10.1007/s11606-021-06947-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Accepted: 05/20/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Measurement-based care is an effective clinical strategy underutilized for bipolar disorder partly due to lacking a widely adopted patient-reported manic symptom measure. OBJECTIVE To report development and psychometric properties of a brief patient-reported manic symptom measure. DESIGN Secondary analysis of data collected in a randomized effectiveness trial comparing two treatments for 1004 primary care patients screening positive for bipolar disorder and/or PTSD. PARTICIPANTS Two analytic samples included 114 participants with varied diagnoses and test-retest data, and 179 participants with psychiatrist-diagnosed bipolar disorder who had two or more assessments with the nine-item Patient Mania Questionnaire-9 [PMQ-9]). MAIN MEASURES Internal and test-retest reliability, concurrent validity, and sensitivity to change were assessed. Minimally important difference (MID) was estimated by standard error of measurement (SEM) and by standard deviation (SD) effect sizes. KEY RESULTS The PMQ-9 had high internal reliability (Cronbach's alpha = 0.88) and test-retest reliability (0.85). Concurrent validity correlation with manic symptom measures was high for the Internal State Scale-Activation Subscale (0.70; p<0.0001), and lower for the Altman Mania Rating Scale (0.26; p=0.007). Longitudinally, PMQ-9 was completed at 1511 clinical encounters in 179 patients with bipolar disorder. Mean PMQ-9 score at first and last encounters was 14.5 (SD 6.5) and 10.1 (SD 7.0), a 27% decrease in mean score during treatment, suggesting sensitivity to change. A point estimate of the MID was approximately 3 points (range of 2-4). CONCLUSIONS The PMQ-9 demonstrated excellent test-retest reliability, concurrent validity, internal consistency, and sensitivity to change and was widely used and acceptable to patients and clinicians in a pragmatic clinical trial. Combined with the Patient Health Questionnaire-9 (PHQ-9) measure of depressive symptoms this brief measure could inform measurement-based care for individuals with bipolar disorder in primary care and mental health care settings given its ease of administration and familiar self-report response format.
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Affiliation(s)
- Joseph M Cerimele
- Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle, WA, USA.
| | - Joan Russo
- Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle, WA, USA
| | - Amy M Bauer
- Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle, WA, USA
| | - Matt Hawrilenko
- Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle, WA, USA
- Department of Veterans Affairs, HSR&D Center of Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System, Seattle, WA, USA
| | - Jeffrey M Pyne
- Department of Psychiatry and Behavioral Sciences, College of Medicine, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Gregory W Dalack
- Department of Psychiatry, University of Michigan, Ann Arbor, MI, USA
| | - Kurt Kroenke
- Center for Health Services and Outcomes Research, Regenstrief Institute, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Jürgen Unützer
- Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle, WA, USA
| | - John C Fortney
- Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle, WA, USA
- Department of Veterans Affairs, HSR&D Center of Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System, Seattle, WA, USA
- Department of Health Services, University of Washington School of Public Health, Seattle, WA, USA
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Fortney JC, Bauer AM, Cerimele JM, Pyne JM, Pfeiffer P, Heagerty PJ, Hawrilenko M, Zielinski MJ, Kaysen D, Bowen DJ, Moore DL, Ferro L, Metzger K, Shushan S, Hafer E, Nolan JP, Dalack GW, Unützer J. Comparison of Teleintegrated Care and Telereferral Care for Treating Complex Psychiatric Disorders in Primary Care: A Pragmatic Randomized Comparative Effectiveness Trial. JAMA Psychiatry 2021; 78:1189-1199. [PMID: 34431972 PMCID: PMC8387948 DOI: 10.1001/jamapsychiatry.2021.2318] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Accepted: 06/29/2021] [Indexed: 11/14/2022]
Abstract
Importance Only one-third of patients with complex psychiatric disorders engage in specialty mental health care, and only one-tenth receive adequate treatment in primary care. Scalable approaches are critically needed to improve access to effective mental health treatments in underserved primary care settings. Objective To compare 2 clinic-to-clinic interactive video approaches to delivering evidence-based mental health treatments to patients in primary care clinics. Design, Setting, and Participants This pragmatic comparative effectiveness trial used a sequential, multiple-assignment, randomized trial (SMART) design with patient-level randomization. Adult patients treated at 24 primary care clinics without on-site psychiatrists or psychologists from 12 federally qualified health centers in 3 states who screened positive for posttraumatic stress disorder and/or bipolar disorder and who were not already receiving pharmacotherapy from a mental health specialist were recruited from November 16, 2016, to June 30, 2019, and observed for 12 months. Interventions Two approaches were compared: (1) telepsychiatry/telepsychology-enhanced referral (TER), where telepsychiatrists and telepsychologists assumed responsibility for treatment, and (2) telepsychiatry collaborative care (TCC), where telepsychiatrists provided consultation to the primary care team. TER included an adaptive intervention (phone-enhanced referral [PER]) for patients not engaging in treatment, which involved telephone outreach and motivational interviewing. Main Outcomes and Measures Survey questions assessed patient-reported outcomes. The Veterans RAND 12-item Health Survey Mental Component Summary (MCS) score was the primary outcome (range, 0-100). Secondary outcomes included posttraumatic stress disorder symptoms, manic symptoms, depressive symptoms, anxiety symptoms, recovery, and adverse effects. Results Of 1004 included participants, 701 of 1000 (70.1%) were female, 660 of 994 (66.4%) were White, and the mean (SD) age was 39.4 (12.9) years. Baseline MCS scores were 2 SDs below the US mean; the mean (SD) MCS scores were 39.7 (14.1) and 41.2 (14.2) in the TCC and TER groups, respectively. There was no significant difference in 12-month MCS score between those receiving TCC and TER (β = 1.0; 95% CI, -0.8 to 2.8; P = .28). Patients in both groups experienced large and clinically meaningful improvements from baseline to 12 months (TCC: Cohen d = 0.81; 95% CI, 0.67 to 0.95; TER: Cohen d = 0.90; 95% CI, 0.76 to 1.04). For patients not engaging in TER at 6 months, there was no significant difference in 12-month MCS score between those receiving PER and TER (β = 2.0; 95% CI, -1.7 to 5.7; P = .29). Conclusions and Relevance In this comparative effectiveness trial of patients with complex psychiatric disorders randomized to receive TCC or TER, significantly and substantially improved outcomes were observed in both groups. From a health care system perspective, clinical leadership should implement whichever approach is most sustainable. Trial Registration ClinicalTrials.gov Identifier: NCT02738944.
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Affiliation(s)
- John C. Fortney
- Department of Psychiatry and Behavioral Sciences, School of Medicine, University of Washington, Seattle
- Department of Veterans Affairs, Health Services Research and Development, Center of Innovation for Veteran-Centered and Value-Driven Care, Seattle, Washington
| | - Amy M. Bauer
- Department of Psychiatry and Behavioral Sciences, School of Medicine, University of Washington, Seattle
| | - Joseph M. Cerimele
- Department of Psychiatry and Behavioral Sciences, School of Medicine, University of Washington, Seattle
| | - Jeffrey M. Pyne
- Department of Psychiatry and Behavioral Sciences, College of Medicine, University of Arkansas for Medical Sciences, Little Rock
- Department of Veterans Affairs, Health Services Research and Development, Center for Mental Healthcare and Outcomes Research, Little Rock, Arkansas
| | - Paul Pfeiffer
- University of Michigan Medical School, Ann Arbor
- Department of Veterans Affairs, Health Services Research and Development, Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan
| | - Patrick J. Heagerty
- Department of Biostatistics, School of Public Health, University of Washington, Seattle
| | - Matt Hawrilenko
- Department of Psychiatry and Behavioral Sciences, School of Medicine, University of Washington, Seattle
| | - Melissa J. Zielinski
- Department of Psychiatry and Behavioral Sciences, College of Medicine, University of Arkansas for Medical Sciences, Little Rock
| | - Debra Kaysen
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Palo Alto, California
| | - Deborah J. Bowen
- Department of Bioethics and Humanities, University of Washington, Seattle
| | - Danna L. Moore
- School of Economic Sciences, Washington State University, Pullman
| | - Lori Ferro
- Department of Psychiatry and Behavioral Sciences, School of Medicine, University of Washington, Seattle
| | | | | | - Erin Hafer
- Community Health Plan of Washington, Seattle
| | | | | | - Jürgen Unützer
- Department of Psychiatry and Behavioral Sciences, School of Medicine, University of Washington, Seattle
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Howland M, Tennant M, Bowen DJ, Bauer AM, Fortney JC, Pyne JM, Shore J, Cerimele JM. Psychiatrist and Psychologist Experiences with Telehealth and Remote Collaborative Care in Primary Care: A Qualitative Study. J Rural Health 2021; 37:780-787. [PMID: 33022079 PMCID: PMC8518862 DOI: 10.1111/jrh.12523] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
PURPOSE Availability of mental health services is limited in the rural United States. Two promising models to reach patients with limited access to care are telehealth referral and collaborative care. The objective of this study was to assess telepsychiatrist- and telepsychologist-level facilitators and barriers to satisfaction with and implementation of these 2 telehealth models in rural settings. METHODS Focus groups were held in 2019 using a semistructured interview guide. Participants were off-site telepsychiatrists (N = 10) and telepsychologists (N = 4) for primary care clinics across 3 states (Washington, Michigan, and Arkansas) involved in a recent pragmatic comparative effectiveness trial. Qualitative analysis occurred inductively by 2 independent coders. FINDINGS Participants were satisfied with the models partly owing to good patient rapport and expanding access to care. Teamwork was highlighted as a facilitator in collaborative care and was often related to work with care managers. However, participants described communication with primary care providers as a challenge, especially in the telehealth referral arm. Barriers centered on variability of logistical processes (eg, symptom monitoring, scheduling, electronic medical record processes, and credentialing) among sites. Staff turnover, variable clinic investment, and inadequacy of training were possible explanations for these barriers. CONCLUSIONS Participants described high motivation to provide team-based, remote care for patients, though they experienced operational challenges. Centralized credentialing, scheduling, and record keeping are possible solutions. These findings are important because consulting psychiatrists and psychologists may play a leadership role in the dissemination of these models.
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Affiliation(s)
- Molly Howland
- Department of Psychiatry and Behavioral SciencesUniversity of Washington School of MedicineSeattleWashington
| | - McKenna Tennant
- Department of Public Health GeneticsUniversity of Washington School of Public HealthSeattleWashington
| | - Deborah J. Bowen
- Department of Bioethics and HumanitiesUniversity of WashingtonSeattleWashington
| | - Amy M. Bauer
- Department of Psychiatry and Behavioral SciencesUniversity of Washington School of MedicineSeattleWashington
| | - John C. Fortney
- Department of Psychiatry and Behavioral SciencesUniversity of Washington School of MedicineSeattleWashington
- Department of Veterans Affairs, HSR&D Center of Innovation for Veteran‐Centered and Value‐Driven CareVA Puget Sound Health Care SystemSeattleWashington
- Department of Health ServicesUniversity of Washington School of Public HealthSeattleWashington
| | - Jeffrey M. Pyne
- Department of Psychiatry and Behavioral Sciences, College of MedicineUniversity of Arkansas for Medical SciencesLittle RockArkansas
| | - Jay Shore
- Helen and Arthur E. Johnson Depression Center, Anschutz Medical Campus, Departments of Psychiatry and Family MedicineUniversity of Colorado School of MedicineAuroraColorado
- Centers for American Indian and Alaska Native Health, Colorado School of Public HealthUniversity of Colorado Anschutz Medical CampusAuroraColorado
| | - Joseph M. Cerimele
- Department of Psychiatry and Behavioral SciencesUniversity of Washington School of MedicineSeattleWashington
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Bauer AM, Cerimele JM, Ratzliff A. Development of research methods curriculum for an integrated care fellowship. Gen Hosp Psychiatry 2021; 71:55-61. [PMID: 33940511 DOI: 10.1016/j.genhosppsych.2021.04.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Revised: 04/19/2021] [Accepted: 04/20/2021] [Indexed: 12/11/2022]
Abstract
OBJECTIVE To describe the design and delivery of a curriculum in research methods for clinical fellows in integrated care. METHOD To design the curriculum, a standard curriculum development approach was applied through an iterative improvement process with input from researchers, clinical educators, and the first cohort of fellows. The curriculum has three central goals: (1) develop fellows' capacity to interpret the integrated care literature and apply findings in practice; (2) develop fellows' capacity for conducting quality improvement programs informed by knowledge of clinical research methods; and (3) enhance workforce capacity for practice-based research partnerships by increasing research understanding among clinical providers. A variety of educational strategies were employed to introduce each research method and apply these to the integrated care literature. RESULTS A description, rationale, and resources for each content domain is presented. The curriculum was delivered to two cohorts of fellows. Evaluation data supports the curriculum's relevance and quality. CONCLUSIONS A rigorous development process yielded a brief research curriculum targeting the needs of clinical fellows in integrated care. The curriculum is well-received by fellows and adaptable for other subspecialties. It may serve as a model for other clinical training programs seeking to enhance their fellows' fluency in research methods.
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Affiliation(s)
- Amy M Bauer
- Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, WA, United States of America.
| | - Joseph M Cerimele
- Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, WA, United States of America
| | - Anna Ratzliff
- Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, WA, United States of America
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Bauer AM, Jakupcak M, Hawrilenko M, Bechtel J, Arao R, Fortney JC. Outcomes of a health informatics technology-supported behavioral activation training for care managers in a collaborative care program. Fam Syst Health 2021; 39:89-100. [PMID: 32853001 DOI: 10.1037/fsh0000523] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
INTRODUCTION Health informatics-supported strategies for training and ongoing support may aid the delivery of evidence-based psychotherapies. The objective of this study was to describe the development, implementation, and practice outcomes of a scalable health informatics-supported training program for behavioral activation for patients who screened positive for posttraumatic stress disorder and/or bipolar disorder. METHOD We trained 34 care managers in 12 rural health centers. They used a registry checklist to document the delivery of 10 behavioral activation skills for 4,632 sessions with 455 patients. Care managers received performance feedback based on registry data. Using encounter-level data reported by care managers, we described the implementation outcomes of patient reach and care manager skill adoption. We used cross-classified multilevel modeling to explore variation in skill delivery accounting for patient characteristics, provider characteristics, and change over time. RESULTS Care managers engaged 88% of patients in behavioral activation and completed a minimum course for 57%. The average patient received 5.9 skills during treatment, with substantial variation driven more by providers (63%) than patients (29%). Care managers significantly increased the range of skills offered to patients over time. DISCUSSION The registry-based checklist was a feasible training and support tool for community-based providers to deliver behavioral activation. Providers received data-driven performance feedback and demonstrated skill improvement over time, promoting sustainment. Future research will examine patient-level outcomes. Results underscore the potential public health impact of a simple registry-based skills checklist coupled with a scalable remote training program for evidence-based psychotherapy. (PsycInfo Database Record (c) 2021 APA, all rights reserved).
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Affiliation(s)
- Amy M Bauer
- Department of Psychiatry and Behavioral Sciences, University of Washington
| | - Matthew Jakupcak
- Department of Psychiatry and Behavioral Sciences, University of Washington
| | - Matt Hawrilenko
- Department of Psychiatry and Behavioral Sciences, University of Washington
| | - Jared Bechtel
- Department of Psychiatry and Behavioral Sciences, University of Washington
| | - Rob Arao
- Department of Psychiatry and Behavioral Sciences, University of Washington
| | - John C Fortney
- Department of Psychiatry and Behavioral Sciences, University of Washington
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Bechtel JM, Lepoire E, Bauer AM, Bowen DJ, Fortney JC. Care manager perspectives on integrating an mHealth app system into clinical workflows: A mixed methods study. Gen Hosp Psychiatry 2021; 68:38-45. [PMID: 33310012 DOI: 10.1016/j.genhosppsych.2020.10.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Revised: 09/24/2020] [Accepted: 10/08/2020] [Indexed: 12/24/2022]
Abstract
OBJECTIVE mHealth can be a valuable means of monitoring symptoms and supporting care for rural patients, but barriers to implementation remain. This study aimed to examine care manager perspectives on the adoption, use and impact of an mHealth system deployed within a pragmatic Collaborative Care trial for rural patients with PTSD and/or Bipolar Disorder. METHOD Sixteen care managers at 12 Federally Qualified Health Centers in 3 states participated in semi-structured interviews. Interviews were transcribed, coded, and thematically analyzed using the Unified Theory of Adoption and Use of Technology as a conceptual framework. App metadata was used to assess the frequency of a care manager reported phenomenon, clinically disengaged app use. RESULTS 4 themes were identified: infrastructural limitations; redundant and incompatible clinical and mHealth workflows; cross platform and web access; and patient engagement and clinically disengaged app use. Most users had a period of consistently submitting symptom measures via the app while disengaged from care for >4 weeks.
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Affiliation(s)
- Jared M Bechtel
- University of Washington, Department of Psychiatry and Behavioral Sciences, USA.
| | - Erin Lepoire
- University of Washington, Department of Psychiatry and Behavioral Sciences, USA
| | - Amy M Bauer
- University of Washington, Department of Psychiatry and Behavioral Sciences, USA
| | - Deborah J Bowen
- University of Washington, Department of Psychiatry and Behavioral Sciences, USA
| | - John C Fortney
- University of Washington, Department of Psychiatry and Behavioral Sciences, USA
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Suh J, Williams S, Fann JR, Fogarty J, Bauer AM, Hsieh G. Parallel Journeys of Patients with Cancer and Depression: Challenges and Opportunities for Technology-Enabled Collaborative Care. ACTA ACUST UNITED AC 2020; 4. [PMID: 32656502 DOI: 10.1145/3392843] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Depression is common but under-treated in patients with cancer, despite being a major modifiable contributor to morbidity and early mortality. Integrating psychosocial care into cancer services through the team-based Collaborative Care Management (CoCM) model has been proven to be effective in improving patient outcomes in cancer centers. However, there is currently a gap in understanding the challenges that patients and their care team encounter in managing co-morbid cancer and depression in integrated psycho-oncology care settings. Our formative study examines the challenges and needs of CoCM in cancer settings with perspectives from patients, care managers, oncologists, psychiatrists, and administrators, with a focus on technology opportunities to support CoCM. We find that: (1) patients with co-morbid cancer and depression struggle to navigate between their cancer and psychosocial care journeys, and (2) conceptualizing co-morbidities as separate and independent care journeys is insufficient for characterizing this complex care context. We then propose the parallel journeys framework as a conceptual design framework for characterizing challenges that patients and their care team encounter when cancer and psychosocial care journeys interact. We use the challenges discovered through the lens of this framework to highlight and prioritize technology design opportunities for supporting whole-person care for patients with co-morbid cancer and depression.
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Affiliation(s)
- Jina Suh
- University of Washington, USA and Microsoft Research, USA
| | | | - Jesse R Fann
- University of Washington, USA and Seattle Cancer Care Alliance, USA
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Cerimele JM, LePoire E, Fortney JC, Hawrilenko M, Unützer J, Bauer AM. Bipolar disorder and PTSD screening and telepsychiatry diagnoses in primary care. Gen Hosp Psychiatry 2020; 65:28-32. [PMID: 32447194 DOI: 10.1016/j.genhosppsych.2020.05.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2019] [Revised: 05/11/2020] [Accepted: 05/12/2020] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To describe clinical diagnoses from telepsychiatrist consultation in safety net primary care settings for adult patients screening positive for bipolar disorder, PTSD, or both. METHODS Patients were administered the PTSD Checklist (PCL-6) and the Composite International Diagnostic Interview 3.0 (CIDI) for bipolar disorder. Positive screening result definitions were PCL-6 score of ≥14 and CIDI positive stem question responses and score of ≥8. Patient characteristics were assessed by survey. Psychiatrists consulted in primary care via telehealth and recorded clinical diagnoses. RESULTS Among 767 patients attending consultation with a telepsychiatrist, 495 (65%) screened PCL-6 positive only, 249 (32%) screened both PCL-6 and CIDI positive, and 23 (3%) screened CIDI positive. Approximately two-thirds screening PCL-6 positive were diagnosed with PTSD, and most had comorbid mood disorder diagnoses, with bipolar disorder diagnosis occurring more often in those screening CIDI positive compared to negative (42% vs. 15%). Positive predictive values were 64.9% for PCL-6 and 43.8% for CIDI. CONCLUSION Most individuals screening positive for PTSD and/or bipolar disorder had two or more psychiatric diagnoses; misclassification exists for both instruments but was greater for CIDI. Psychiatrist consultation early in treatment for individuals screening positive on the PCL-6 and/or CIDI could help clarify diagnoses and improve treatment planning.
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Affiliation(s)
- Joseph M Cerimele
- Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle, WA, United States of America.
| | - Erin LePoire
- Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle, WA, United States of America
| | - John C Fortney
- Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle, WA, United States of America; Department of Veterans Affairs, HSR&D Center of Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System, Seattle, WA, United States of America; Department of Health Services, University of Washington School of Public Health, Seattle, WA, United States of America
| | - Matt Hawrilenko
- Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle, WA, United States of America; Department of Veterans Affairs, HSR&D Center of Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System, Seattle, WA, United States of America
| | - Jürgen Unützer
- Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle, WA, United States of America
| | - Amy M Bauer
- Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle, WA, United States of America
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Bhat A, Bennett IM, Bauer AM, Beidas RS, Eriksen W, Barg FK, Gold R, Unützer J. Longitudinal Remote Coaching for Implementation of Perinatal Collaborative Care: A Mixed-Methods Analysis. Psychiatr Serv 2020; 71:518-521. [PMID: 31996114 PMCID: PMC7196015 DOI: 10.1176/appi.ps.201900341] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
The collaborative care model (CoCM) is a multicomponent, team-based integrated behavioral health framework. Its effectiveness in the treatment of perinatal depression is established, but implementation has been limited. The authors used longitudinal remote coaching (LRC) as a novel implementation strategy to support systematic case review in a multistate cluster-randomized trial of CoCM for perinatal depression. They describe LRC for perinatal CoCM in three clinics and use of a mixed-methods analysis of data from LRC feedback forms and interviews with participants. LRC is a scalable implementation strategy with potential to support complex models of integrated behavioral health, such as perinatal CoCM.
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Affiliation(s)
- Amritha Bhat
- Department of Psychiatry and Behavioral Sciences (Bhat, Bennett, Bauer, Unützer) and Department of Family Medicine (Bennett), University of Washington, Seattle; Department of Psychiatry (Beidas), Department of Medical Ethics and Health Policy (Beidas), and Department of Family Medicine and Community Health (Eriksen, Barg), Perelman School of Medicine, University of Pennsylvania, Philadelphia; Penn Implementation Science Center, Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia (Beidas); Kaiser Permanente Northwest Center for Health Research, Portland, Oregon (Gold). Benjamin G. Druss, M.D., M.P.H., and Gail Daumit, M.D., M.H.S., are editors of this column
| | - Ian M Bennett
- Department of Psychiatry and Behavioral Sciences (Bhat, Bennett, Bauer, Unützer) and Department of Family Medicine (Bennett), University of Washington, Seattle; Department of Psychiatry (Beidas), Department of Medical Ethics and Health Policy (Beidas), and Department of Family Medicine and Community Health (Eriksen, Barg), Perelman School of Medicine, University of Pennsylvania, Philadelphia; Penn Implementation Science Center, Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia (Beidas); Kaiser Permanente Northwest Center for Health Research, Portland, Oregon (Gold). Benjamin G. Druss, M.D., M.P.H., and Gail Daumit, M.D., M.H.S., are editors of this column
| | - Amy M Bauer
- Department of Psychiatry and Behavioral Sciences (Bhat, Bennett, Bauer, Unützer) and Department of Family Medicine (Bennett), University of Washington, Seattle; Department of Psychiatry (Beidas), Department of Medical Ethics and Health Policy (Beidas), and Department of Family Medicine and Community Health (Eriksen, Barg), Perelman School of Medicine, University of Pennsylvania, Philadelphia; Penn Implementation Science Center, Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia (Beidas); Kaiser Permanente Northwest Center for Health Research, Portland, Oregon (Gold). Benjamin G. Druss, M.D., M.P.H., and Gail Daumit, M.D., M.H.S., are editors of this column
| | - Rinad S Beidas
- Department of Psychiatry and Behavioral Sciences (Bhat, Bennett, Bauer, Unützer) and Department of Family Medicine (Bennett), University of Washington, Seattle; Department of Psychiatry (Beidas), Department of Medical Ethics and Health Policy (Beidas), and Department of Family Medicine and Community Health (Eriksen, Barg), Perelman School of Medicine, University of Pennsylvania, Philadelphia; Penn Implementation Science Center, Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia (Beidas); Kaiser Permanente Northwest Center for Health Research, Portland, Oregon (Gold). Benjamin G. Druss, M.D., M.P.H., and Gail Daumit, M.D., M.H.S., are editors of this column
| | - Whitney Eriksen
- Department of Psychiatry and Behavioral Sciences (Bhat, Bennett, Bauer, Unützer) and Department of Family Medicine (Bennett), University of Washington, Seattle; Department of Psychiatry (Beidas), Department of Medical Ethics and Health Policy (Beidas), and Department of Family Medicine and Community Health (Eriksen, Barg), Perelman School of Medicine, University of Pennsylvania, Philadelphia; Penn Implementation Science Center, Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia (Beidas); Kaiser Permanente Northwest Center for Health Research, Portland, Oregon (Gold). Benjamin G. Druss, M.D., M.P.H., and Gail Daumit, M.D., M.H.S., are editors of this column
| | - Frances K Barg
- Department of Psychiatry and Behavioral Sciences (Bhat, Bennett, Bauer, Unützer) and Department of Family Medicine (Bennett), University of Washington, Seattle; Department of Psychiatry (Beidas), Department of Medical Ethics and Health Policy (Beidas), and Department of Family Medicine and Community Health (Eriksen, Barg), Perelman School of Medicine, University of Pennsylvania, Philadelphia; Penn Implementation Science Center, Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia (Beidas); Kaiser Permanente Northwest Center for Health Research, Portland, Oregon (Gold). Benjamin G. Druss, M.D., M.P.H., and Gail Daumit, M.D., M.H.S., are editors of this column
| | - Rachel Gold
- Department of Psychiatry and Behavioral Sciences (Bhat, Bennett, Bauer, Unützer) and Department of Family Medicine (Bennett), University of Washington, Seattle; Department of Psychiatry (Beidas), Department of Medical Ethics and Health Policy (Beidas), and Department of Family Medicine and Community Health (Eriksen, Barg), Perelman School of Medicine, University of Pennsylvania, Philadelphia; Penn Implementation Science Center, Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia (Beidas); Kaiser Permanente Northwest Center for Health Research, Portland, Oregon (Gold). Benjamin G. Druss, M.D., M.P.H., and Gail Daumit, M.D., M.H.S., are editors of this column
| | - Jürgen Unützer
- Department of Psychiatry and Behavioral Sciences (Bhat, Bennett, Bauer, Unützer) and Department of Family Medicine (Bennett), University of Washington, Seattle; Department of Psychiatry (Beidas), Department of Medical Ethics and Health Policy (Beidas), and Department of Family Medicine and Community Health (Eriksen, Barg), Perelman School of Medicine, University of Pennsylvania, Philadelphia; Penn Implementation Science Center, Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia (Beidas); Kaiser Permanente Northwest Center for Health Research, Portland, Oregon (Gold). Benjamin G. Druss, M.D., M.P.H., and Gail Daumit, M.D., M.H.S., are editors of this column
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13
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Fortney JC, Heagerty PJ, Bauer AM, Cerimele JM, Kaysen D, Pfeiffer PN, Zielinski MJ, Pyne JM, Bowen D, Russo J, Ferro L, Moore D, Nolan JP, Fee FC, Heral T, Freyholtz-London J, McDonald B, Mullins J, Hafer E, Solberg L, Unützer J. Study to promote innovation in rural integrated telepsychiatry (SPIRIT): Rationale and design of a randomized comparative effectiveness trial of managing complex psychiatric disorders in rural primary care clinics. Contemp Clin Trials 2020; 90:105873. [PMID: 31678410 DOI: 10.1016/j.cct.2019.105873] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2019] [Revised: 10/23/2019] [Accepted: 10/24/2019] [Indexed: 01/17/2023]
Abstract
OBJECTIVE Managing complex psychiatric disorders like PTSD and bipolar disorder is challenging in Federally Qualified Health Centers (FQHCs) delivering care to U.S residents living in underserved rural areas. This protocol paper describes SPIRIT, a pragmatic comparative effectiveness trial designed to compare two approaches to managing PTSD and bipolar disorder in FQHCs. INTERVENTIONS Treatment comparators are: 1) Telepsychiatry Collaborative Care, which integrates consulting telepsychiatrists into primary care teams, and 2) Telepsychiatry Enhanced Referral, where telepsychiatrists and telepsychologists treat patients directly. METHODS Because Telepsychiatry Enhanced Referral is an adaptive intervention, a Sequential, Multiple Assignment, Randomized Trial design is used. Twenty-four FQHC clinics without on-site psychiatrists or psychologists are participating in the trial. The sample is patients screening positive for PTSD and/or bipolar disorder who are not already engaged in pharmacotherapy with a mental health specialist. Intervention fidelity is measured but not controlled. Patient treatment engagement is measured but not required, and intent-to-treat analysis will be used. Survey questions measure treatment engagement and effectiveness. The Short-Form 12 Mental Health Component Summary (SF-12 MCS) is the primary outcome. RESULTS A third (34%) of those enrolled (n = 1004) are racial/ethnic minorities, 81% are not fully employed, 68% are Medicaid enrollees, 7% are uninsured, and 62% live in poverty. Mental health related quality of life (SF-12 MCS) is 2.5 standard deviations below the national mean. DISCUSSION We hypothesize that patients randomized to Telepsychiatry Collaborative Care will have better outcomes than those randomized to Telepsychiatry Enhanced Referral because a higher proportion will engage in evidence-based treatment.
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Affiliation(s)
- John C Fortney
- Department of Psychiatry and Behavioral Sciences, School of Medicine, University of Washington, Seattle, WA, USA; Department of Veterans Affairs, Health Services Research and Development, Center of Innovation for Veteran-Centered and Value-Driven Care, Seattle, WA, USA.
| | - Patrick J Heagerty
- Department of Biostatistics, School of Public Health, University of Washington, Seattle, WA, USA
| | - Amy M Bauer
- Department of Psychiatry and Behavioral Sciences, School of Medicine, University of Washington, Seattle, WA, USA
| | - Joseph M Cerimele
- Department of Psychiatry and Behavioral Sciences, School of Medicine, University of Washington, Seattle, WA, USA
| | - Debra Kaysen
- Department of Psychiatry and Behavioral Sciences, School of Medicine, University of Washington, Seattle, WA, USA
| | - Paul N Pfeiffer
- University of Michigan Medical School, Ann Arbor, MI, USA; Department of Veterans Affairs, Health Services Research and Development, Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
| | - Melissa J Zielinski
- Department of Psychiatry, College of Medicine, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Jeffrey M Pyne
- Department of Psychiatry, College of Medicine, University of Arkansas for Medical Sciences, Little Rock, AR, USA; Department of Veterans Affairs, Health Services Research and Development, Center for Mental Healthcare and Outcomes Research, Little Rock, AR, USA
| | - Deb Bowen
- Department of Bioethics and Humanities, University of Washington, Seattle, WA, USA
| | - Joan Russo
- Department of Psychiatry and Behavioral Sciences, School of Medicine, University of Washington, Seattle, WA, USA
| | - Lori Ferro
- Department of Psychiatry and Behavioral Sciences, School of Medicine, University of Washington, Seattle, WA, USA
| | - Danna Moore
- Social and Economic Sciences Research Center at Washington State University, Pullman, WA, USA
| | | | - Florence C Fee
- NHMH - No Health without Mental Health, San Francisco, CA, Arlington, VA, USA
| | | | | | - Bernadette McDonald
- Department of Psychiatry and Behavioral Sciences, School of Medicine, University of Washington, Seattle, WA, USA
| | - Jeremey Mullins
- Department of Psychiatry and Behavioral Sciences, School of Medicine, University of Washington, Seattle, WA, USA
| | - Erin Hafer
- Community Health Plan of Washington, Seattle, WA, USA
| | | | - Jürgen Unützer
- Department of Psychiatry and Behavioral Sciences, School of Medicine, University of Washington, Seattle, WA, USA
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14
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Abstract
Conducting systematic case reviews (SCRs) is a critical skill for psychiatrists leveraging their expertise to provide collaborative care in a primary care setting; however, there is little literature to guide best practices for executing an SCR. This column offers guidance to psychiatrists on best practices for conducting SCRs by drawing on experience from psychiatrists who teach collaborative care and who directly observe SCRs in established programs. Furthermore, it describes several common threats to successful SCR and presents potential solutions to assist programs in implementing indirect psychiatric care, an essential component of collaborative care.
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Affiliation(s)
- Amy M Bauer
- Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle (Bauer, Ratzliff, Unützer); Department of Psychiatry and Psychology, Division of Integrated Behavioral Health, Mayo Clinic, Rochester, Minnesota (Williams). Benjamin G. Druss, M.D., M.P.H., and Gail Daumit, M.D., M.H.S., are editors of this column
| | - Mark D Williams
- Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle (Bauer, Ratzliff, Unützer); Department of Psychiatry and Psychology, Division of Integrated Behavioral Health, Mayo Clinic, Rochester, Minnesota (Williams). Benjamin G. Druss, M.D., M.P.H., and Gail Daumit, M.D., M.H.S., are editors of this column
| | - Anna Ratzliff
- Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle (Bauer, Ratzliff, Unützer); Department of Psychiatry and Psychology, Division of Integrated Behavioral Health, Mayo Clinic, Rochester, Minnesota (Williams). Benjamin G. Druss, M.D., M.P.H., and Gail Daumit, M.D., M.H.S., are editors of this column
| | - Jürgen Unützer
- Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle (Bauer, Ratzliff, Unützer); Department of Psychiatry and Psychology, Division of Integrated Behavioral Health, Mayo Clinic, Rochester, Minnesota (Williams). Benjamin G. Druss, M.D., M.P.H., and Gail Daumit, M.D., M.H.S., are editors of this column
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15
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Fortney JC, Veith RC, Bauer AM, Pfeiffer PN, Valenstein M, Pyne JM, Dalack GW, Kramer TL, Ferro LJ, Metzger K, Shore JH, Carlo AD, Coates S, Ward‐Jones S, Larkins E, Hafer E, Shushan S, Weaver DL, Unützer J. Developing Telemental Health Partnerships Between State Medical Schools and Federally Qualified Health Centers: Navigating the Regulatory Landscape and Policy Recommendations. J Rural Health 2019; 35:287-297. [PMID: 30288797 PMCID: PMC7379613 DOI: 10.1111/jrh.12323] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
BACKGROUND Federally Qualified Health Centers (FQHCs) deliver care to 26 million Americans living in underserved areas, but few offer telemental health (TMH) services. The social missions of FQHCs and publicly funded state medical schools create a compelling argument for the development of TMH partnerships. In this paper, we share our experience and recommendations from launching TMH partnerships between 12 rural FQHCs and 3 state medical schools. EXPERIENCE There was consensus that medical school TMH providers should practice as part of the FQHC team to promote integration, enhance quality and safety, and ensure financial sustainability. For TMH providers to practice and bill as FQHC providers, the following issues must be addressed: (1) credentialing and privileging the TMH providers at the FQHC, (2) expanding FQHC Scope of Project to include telepsychiatry, (3) remote access to medical records, (4) insurance credentialing/paneling, billing, and supplemental payments, (5) contracting with the medical school, and (6) indemnity coverage for TMH. RECOMMENDATIONS We make recommendations to both state medical schools and FQHCs about how to overcome existing barriers to TMH partnerships. We also make recommendations about changes to policy that would mitigate the impact of these barriers. Specifically, we make recommendations to the Centers for Medicare and Medicaid about insurance credentialing, facility fees, eligibility of TMH encounters for supplemental payments, and Medicare eligibility rules for TMH billing by FQHCs. We also make recommendations to the Health Resources and Services Administration about restrictions on adding telepsychiatry to the FQHCs' Scope of Project and the eligibility of TMH providers for indemnity coverage under the Federal Tort Claims Act.
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Affiliation(s)
- John C. Fortney
- Department of Psychiatry and Behavioral Sciences, School of MedicineUniversity of WashingtonSeattleWashington
- Department of Veterans Affairs, Health Services Research and DevelopmentCenter of Innovation for Veteran‐Centered and Value‐Driven CareSeattleWashington
| | - Richard C. Veith
- Department of Psychiatry and Behavioral Sciences, School of MedicineUniversity of WashingtonSeattleWashington
| | - Amy M. Bauer
- Department of Psychiatry and Behavioral Sciences, School of MedicineUniversity of WashingtonSeattleWashington
| | - Paul N. Pfeiffer
- Department of PsychiatryUniversity of Michigan Medical SchoolAnn ArborMichigan
- VA Center for Clinical Management ResearchVA Ann Arbor Healthcare SystemAnn ArborMichigan
| | - Marcia Valenstein
- Department of PsychiatryUniversity of Michigan Medical SchoolAnn ArborMichigan
- VA Center for Clinical Management ResearchVA Ann Arbor Healthcare SystemAnn ArborMichigan
| | - Jeffrey M. Pyne
- Department of Psychiatry, College of MedicineUniversity of Arkansas for Medical SciencesLittle RockArkansas
- Department of Veterans Affairs, Health Services Research and DevelopmentCenter for Mental Healthcare and Outcomes ResearchLittle RockArkansas
| | - Gregory W. Dalack
- Department of PsychiatryUniversity of Michigan Medical SchoolAnn ArborMichigan
| | - Teresa L. Kramer
- Department of Psychiatry, College of MedicineUniversity of Arkansas for Medical SciencesLittle RockArkansas
| | - Lori J. Ferro
- Department of Psychiatry and Behavioral Sciences, School of MedicineUniversity of WashingtonSeattleWashington
| | - Karla Metzger
- Department of PsychiatryUniversity of Michigan Medical SchoolAnn ArborMichigan
| | - Jay H. Shore
- Helen and Arthur E. Johnson Depression CenterUniversity of Colorado Anschutz Medical CampusAuroraColorado
| | - Andrew D. Carlo
- Department of Psychiatry and Behavioral Sciences, School of MedicineUniversity of WashingtonSeattleWashington
| | - Sara Coates
- Michigan Primary Care AssociationLansingMichigan
| | | | - Ed Larkins
- Family Medical Center of MichiganTemperanceMichigan
| | - Erin Hafer
- Community Health Plan of WashingtonSeattleWashington
| | | | - Donald L. Weaver
- National Association of Community Health CentersBethesdaMaryland
| | - Jürgen Unützer
- Department of Psychiatry and Behavioral Sciences, School of MedicineUniversity of WashingtonSeattleWashington
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16
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Abstract
Abstract
An evolutionary perspective on gecko adhesion was previously hampered by a lack of an explicit phylogeny for the group and of robust comparative methods to study trait evolution, an underappreciation for the taxonomic and structural diversity of geckos, and a dearth of fossil evidence bearing directly on the origin of the scansorial apparatus. With a multigene dataset as the basis for a comprehensive gekkotan phylogeny, model-based methods have recently been employed to estimate the number of unique derivations of the adhesive system and its role in lineage diversification. Evidence points to a single basal origin of the spinulate oberhautchen layer of the epidermis, which is a necessary precursor for the subsequent elaboration of a functional adhesive mechanism in geckos. However, multiple gains and losses are implicated for the elaborated setae that are necessary for adhesion via van der Waals forces. The well-supported phylogeny of gekkotans has demonstrated that convergence and parallelism in digital design are even more prevalent than previously believed. It also permits the reexamination of previously collected morphological data in an explicitly evolutionary context. Both time-calibrated trees and recently discovered amber fossils that preserve gecko toepads suggest that a fully-functional adhesive apparatus was not only present, but also represented by diverse architectures, by the mid-Cretaceous. Further characterization and phylogenetically-informed analyses of the other components of the adhesive system (muscles, tendons, blood sinuses, etc.) will permit a more comprehensive reconstruction of the evolutionary pathway(s) by which geckos have achieved their structural and taxonomic diversity. A phylogenetic perspective can meaningfully inform functional and performance studies of gecko adhesion and locomotion and can contribute to advances in bioinspired materials.
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Affiliation(s)
- A M Bauer
- Department of Biology, Villanova University, 800 Lancaster Avenue, Villanova, PA 19085, USA
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Hilty DM, Chan S, Hwang T, Wong A, Bauer AM. Advances in Mobile Mental Health: Opportunities and Implications for the Spectrum of E-Mental Health Services. Focus (Am Psychiatr Publ) 2018; 16:314-327. [PMID: 32015712 DOI: 10.1176/appi.focus.16301] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Reprinted with permission from mHealth (2017), 3:34.
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18
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Bauer AM, Baldwin SA, Anguera JA, Areán PA, Atkins DC. Comparing Approaches to Mobile Depression Assessment for Measurement-Based Care: Prospective Study. J Med Internet Res 2018; 20:e10001. [PMID: 29921564 PMCID: PMC6030575 DOI: 10.2196/10001] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2018] [Revised: 03/26/2018] [Accepted: 03/27/2018] [Indexed: 01/14/2023] Open
Abstract
BACKGROUND To inform measurement-based care, practice guidelines suggest routine symptom monitoring, often on a weekly or monthly basis. Increasingly, patient-provider contacts occur remotely (eg, by telephone and Web-based portals), and mobile health tools can now monitor depressed mood daily or more frequently. However, the reliability and utility of daily ratings are unclear. OBJECTIVE This study aimed to examine the association between a daily depressive symptom measure and the Patient Health Questionnaire-9 (PHQ-9), the most widely adopted depression self-report measure, and compare how well these 2 assessment methods predict patient outcomes. METHODS A total of 547 individuals completed smartphone-based measures, including the Patient Health Questionnaire-2 (PHQ-2) modified for daily administration, the PHQ-9, and the Sheehan Disability Scale. Multilevel factor analyses evaluated the reliability of latent depression based on the PHQ-2 (for repeated measures) between weeks 2 and 4 and its correlation with the PHQ-9 at week 4. Regression models predicted week 8 depressive symptoms and disability ratings with daily PHQ-2 and PHQ-9. RESULTS The daily PHQ-2 and PHQ-9 are highly reliable (range: 0.80-0.88) and highly correlated (r=.80). Findings were robust across demographic groups (age, gender, and ethnic minority status). Daily PHQ-2 and PHQ-9 were comparable in predicting week 8 disability and were independent predictors of week 8 depressive symptoms and disability, though the unique contribution of the PHQ-2 was small in magnitude. CONCLUSIONS Daily completion of the PHQ-2 is a reasonable proxy for the PHQ-9 and is comparable to the PHQ-9 in predicting future outcomes. Mobile assessment methods offer researchers and clinicians reliable and valid new methods for depression assessment that may be leveraged for measurement-based depression care.
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Affiliation(s)
- Amy M Bauer
- Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, WA, United States
| | - Scott A Baldwin
- Department of Psychology, Brigham Young University, Provo, UT, United States
| | - Joaquin A Anguera
- Department of Neurology, University of California, San Francisco, San Francisco, CA, United States
| | - Patricia A Areán
- Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, WA, United States
| | - David C Atkins
- Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, WA, United States
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19
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Bauer AM, Hodsdon S, Bechtel JM, Fortney JC. Applying the Principles for Digital Development: Case Study of a Smartphone App to Support Collaborative Care for Rural Patients With Posttraumatic Stress Disorder or Bipolar Disorder. J Med Internet Res 2018; 20:e10048. [PMID: 29875085 PMCID: PMC6010837 DOI: 10.2196/10048] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2018] [Revised: 03/22/2018] [Accepted: 03/22/2018] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Despite a proliferation of patient-facing mobile apps for mental disorders, there is little literature guiding efforts to incorporate mobile tools into clinical care delivery and integrate patient-generated data into care processes for patients with complex psychiatric disorders. OBJECTIVE The aim of this study was to seek to gain an understanding of how to incorporate a patient-provider mobile health (mHealth) platform to support the delivery of integrated primary care-based mental health services (Collaborative Care) to rural patients with posttraumatic stress disorder and/or bipolar disorder. METHODS Using the Principles for Digital Development as a framework, we describe our experience designing, developing, and deploying a mobile system to support Collaborative Care. The system consists of a patient-facing smartphone app that integrates with a Web-based clinical patient registry used by behavioral health care managers and consulting psychiatrists. Throughout development, we engaged representatives from the system's two user types: (1) providers, who use the Web-based registry and (2) patients, who directly use the mobile app. We extracted mobile metadata to describe the early adoption and use of the system by care managers and patients and report preliminary results from an in-app patient feedback survey that includes a System Usability Scale (SUS). RESULTS Each of the nine Principles for Digital Development is illustrated with examples. The first 10 patients to use the smartphone app have completed symptom measures on average every 14 days over an average period of 20 weeks. The mean SUS score at week 8 among four patients who completed this measure was 91.9 (range 72.5-100). We present lessons learned about the technical and training requirements for integration into practice that can inform future efforts to incorporate health technologies to improve care for patients with psychiatric conditions. CONCLUSIONS Adhering to the Principles for Digital Development, we created and deployed an mHealth system to support Collaborative Care for patients with complex psychiatric conditions in rural health centers. Preliminary data among the initial users support high system usability and show promise for sustained use. On the basis of our experience, we propose five additional principles to extend this framework and inform future efforts to incorporate health technologies to improve care for patients with psychiatric conditions: design for public health impact, add value for all users, test the product and the process, acknowledge disruption, and anticipate variability.
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Affiliation(s)
- Amy M Bauer
- Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, WA, United States
| | | | - Jared M Bechtel
- Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, WA, United States
| | - John C Fortney
- Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, WA, United States
- Health Services Research and Development Service Center of Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System, Seattle, WA, United States
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Sowa NA, Jeng P, Bauer AM, Cerimele JM, Unützer J, Bao Y, Chwastiak L. Psychiatric Case Review and Treatment Intensification in Collaborative Care Management for Depression in Primary Care. Psychiatr Serv 2018; 69:549-554. [PMID: 29385955 PMCID: PMC6063310 DOI: 10.1176/appi.ps.201700243] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE This study examined whether psychiatric case review was associated with depression medication modification in a large implementation program of collaborative care for depression in safety-net primary care clinics. METHODS Registry data were examined from an implementation of the collaborative care model in Washington State. A total of 14,960 adults from 178 primary care clinics who initiated care between January 1, 2008, and September 30, 2014, and who had a baseline Patient Health Questionnaire-9 (PHQ-9) score of 10 or higher were included. Rates of psychiatric case reviews and receipt of new depression medications were extracted from the registry for all patients and for a subset of patients who did not improve by eight weeks of treatment (did not achieve a PHQ-9 score of less than 10 or a reduction in PHQ-9 score of 50% or more, compared with baseline). RESULTS One-half of patients received a new depression medication. Psychiatric case review in any given month was associated with a doubling of the probability of receiving a new medication in the following month. Among patients who did not improve by eight weeks of treatment, a psychiatric case review during weeks 8-12 was associated with a higher rate of receipt of new medications during weeks 8-16 or weeks 8-20. CONCLUSIONS In a collaborative care program, psychiatric case review was associated with higher rates of subsequent receipt of a new depression medication. This finding supports the importance of psychiatric case review in reducing clinical inertia in collaborative care treatment of depression.
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Affiliation(s)
- Nathaniel A Sowa
- Dr. Sowa, Dr. Bauer, Dr. Cerimele, Dr. Unützer, and Dr. Chwastiak are with the Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle. Mr. Jeng and Dr. Bao are with the Department of Healthcare Policy and Research, Cornell University Joan and Sanford I. Weill Medical College, New York
| | - Philip Jeng
- Dr. Sowa, Dr. Bauer, Dr. Cerimele, Dr. Unützer, and Dr. Chwastiak are with the Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle. Mr. Jeng and Dr. Bao are with the Department of Healthcare Policy and Research, Cornell University Joan and Sanford I. Weill Medical College, New York
| | - Amy M Bauer
- Dr. Sowa, Dr. Bauer, Dr. Cerimele, Dr. Unützer, and Dr. Chwastiak are with the Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle. Mr. Jeng and Dr. Bao are with the Department of Healthcare Policy and Research, Cornell University Joan and Sanford I. Weill Medical College, New York
| | - Joseph M Cerimele
- Dr. Sowa, Dr. Bauer, Dr. Cerimele, Dr. Unützer, and Dr. Chwastiak are with the Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle. Mr. Jeng and Dr. Bao are with the Department of Healthcare Policy and Research, Cornell University Joan and Sanford I. Weill Medical College, New York
| | - Jürgen Unützer
- Dr. Sowa, Dr. Bauer, Dr. Cerimele, Dr. Unützer, and Dr. Chwastiak are with the Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle. Mr. Jeng and Dr. Bao are with the Department of Healthcare Policy and Research, Cornell University Joan and Sanford I. Weill Medical College, New York
| | - Yuhua Bao
- Dr. Sowa, Dr. Bauer, Dr. Cerimele, Dr. Unützer, and Dr. Chwastiak are with the Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle. Mr. Jeng and Dr. Bao are with the Department of Healthcare Policy and Research, Cornell University Joan and Sanford I. Weill Medical College, New York
| | - Lydia Chwastiak
- Dr. Sowa, Dr. Bauer, Dr. Cerimele, Dr. Unützer, and Dr. Chwastiak are with the Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle. Mr. Jeng and Dr. Bao are with the Department of Healthcare Policy and Research, Cornell University Joan and Sanford I. Weill Medical College, New York
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21
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Bauer AM, Iles-Shih M, Ghomi RH, Rue T, Grover T, Kincler N, Miller M, Katon WJ. Acceptability of mHealth augmentation of Collaborative Care: A mixed methods pilot study. Gen Hosp Psychiatry 2018; 51:22-29. [PMID: 29272712 PMCID: PMC6512981 DOI: 10.1016/j.genhosppsych.2017.11.010] [Citation(s) in RCA: 58] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2017] [Revised: 11/03/2017] [Accepted: 11/24/2017] [Indexed: 12/14/2022]
Abstract
OBJECTIVE To assess the feasibility and acceptability of a mobile health platform supporting Collaborative Care. METHOD Collaborative Care patients (n=17) used a smartphone app to transmit PHQ-9 and GAD-7 scores and sensor data to a dashboard used by one care manager. Patients completed usability and satisfaction surveys and qualitative interviews at 4weeks and the care manager completed a qualitative interview. Mobile metadata on app usage was obtained. RESULTS All patients used the app for 4weeks, but only 35% (n=6) sustained use at 8weeks. Prior to discontinuing use, 88% (n=15) completed all PHQ-9 and GAD-7 measures, with lower response rates for daily measures. Four themes emerged from interviews: understanding the purpose; care manager's role in supporting use; benefits of daily monitoring; and privacy / security concerns. Two themes were user-specific: patients' desire for personalization; and care manager burden. CONCLUSIONS The feasibility and acceptability of the mobile platform is supported by the high early response rate, however attrition was steep. Our qualitative findings revealed nuanced participant experiences and uncovered some concerns about mobile health. To encourage retention, attention may need to be directed toward promoting patient understanding and provider engagement, and offering personalized patient experiences.
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Affiliation(s)
- Amy M. Bauer
- Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, United States,Corresponding author at: Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, 1959 NE Pacific Street, Box 356560, Seattle, WA 98195-6560, United States. (A.M. Bauer)
| | - Matthew Iles-Shih
- Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, United States
| | - Reza Hosseini Ghomi
- Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, United States
| | - Tessa Rue
- Department of Biostatistics and Institute of Translational Health Sciences, University of Washington, Seattle, United States
| | - Tess Grover
- Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, United States
| | | | - Monica Miller
- University of Washington Neighborhood Clinics, United States
| | - Wayne J. Katon
- Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, United States
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22
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Hilty DM, Rabinowitz T, McCarron RM, Katzelnick DJ, Chang T, Bauer AM, Fortney J. An Update on Telepsychiatry and How It Can Leverage Collaborative, Stepped, and Integrated Services to Primary Care. Psychosomatics 2017; 59:227-250. [PMID: 29544663 DOI: 10.1016/j.psym.2017.12.005] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 09/07/2017] [Revised: 12/15/2017] [Accepted: 12/18/2017] [Indexed: 01/01/2023]
Abstract
INTRODUCTION In this era of patient-centered care, telepsychiatry (TP; video or synchronous) provides quality care with outcomes as good as in-person care, facilitates access to care, and leverages a wide range of treatments at a distance. METHOD This conceptual review article explores TP as applied to newer models of care (e.g., collaborative, stepped, and integrated care). RESULTS The field of psychosomatic medicine (PSM) has developed clinical care models, educates interdisciplinary team members, and provides leadership to clinical teams. PSM is uniquely positioned to steer TP and implement other telebehavioral health care options (e.g., e-mail/telephone, psych/mental health apps) in the future in primary care. Together, PSM and TP provide versatility to health systems by enabling more patient points-of-entry, matching patient needs with provider skills, and helping providers work at the top of their licenses. TP and other technologies make collaborative, stepped, and integrated care less costly and more accessible. CONCLUSION Effective health care delivery matches the intensity of the services to the needs of a patient population or clinic, standardizes interventions, and evaluates both process and clinical outcomes. More research is indicated on the application of TP and other technologies to these service delivery models.
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Affiliation(s)
- Donald M Hilty
- Mental Health, Northern California, Veterans Administration Health Care System, Mather, CA; Department of Psychiatry & Behavioral Sciences, UC Davis, 10535 Hospital Way, Mather, CA 95655 (116/SAC).
| | - Terry Rabinowitz
- Departments of Psychiatry and Family Medicine, Burlington, Vermont; Division of Consultation Psychiatry and Psychosomatic Medicine, University of Vermont College of Medicine, Burlington, Vermont; University of Vermont Medical Center, Burlington, Vermont
| | - Robert M McCarron
- Psychiatry & Behavioral Sciences and Department of Internal Medicine, University of California, Irvine Health System, Irvine, CA
| | - David J Katzelnick
- Department of Psychiatry and Division of Integrated Behavioral Health, Mayo Clinic, Rochester, MN
| | - Trina Chang
- Depression Clinical and Research Program, Massachusetts General Hospital, Boston, MA; Department of Psychiatry, Harvard Medical School, Boston, MA
| | - Amy M Bauer
- Department of Psychiatry & Behavioral Sciences, the University of Washington, Seattle, WA; Behavioral Health Integration Program (BHIP) and Washington State's Mental Health Integration Program (MHIP), Seattle, WA
| | - John Fortney
- Division of Population Health, Seattle, WA; Department of Psychiatry & Behavioral Sciences, the University of Washington, Seattle, WA
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Bauer AM, Hodsdon S, Hunter S, Choi Y, Bechtel J, Fortney JC. Lessons from the Deployment of the SPIRIT App to Support Collaborative Care for Rural Patients with Complex Psychiatric Conditions. Proc ACM Int Conf Ubiquitous Comput 2017; 2017:772-780. [PMID: 29075683 DOI: 10.1145/3123024.3125610] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
We report the design and deployment of a mobile health system for patients receiving primary care-based mental health services (Collaborative Care) for post-traumatic stress disorder and/or bipolar disorder in rural health centers. Here we describe the clinical model, our participatory approach to designing and deploying the mobile system, and describe the final system. We focus on the integration of the system into providers' clinical workflow and patient registry system. We present lessons learned about the technical and training requirements for integration into practice that can inform future efforts to incorporate health technologies to improve care for patients with psychiatric conditions.
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Affiliation(s)
- Amy M Bauer
- Psychiatry & Behavioral Sciences, University of Washington, Seattle WA 98195-6560, USA
| | | | - Suzanne Hunter
- Psychiatry & Behavioral Sciences, University of Washington, Seattle WA 98195-6560, USA
| | - Youlim Choi
- Psychiatry & Behavioral Sciences, University of Washington, Seattle WA 98195-6560, USA
| | - Jared Bechtel
- Psychiatry & Behavioral Sciences, University of Washington, Seattle WA 98195-6560, USA
| | - John C Fortney
- Psychiatry & Behavioral Sciences, University of Washington, Seattle WA 98195-6560, USA
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24
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Bauer AM, Rue T, Munson SA, Ghomi RH, Keppel GA, Cole AM, Baldwin LM, Katon W. Patient-oriented health technologies: Patients' perspectives and use. ACTA ACUST UNITED AC 2017; 6:1-10. [PMID: 28936236 DOI: 10.7309/jmtm.6.2.1] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
BACKGROUND For patient-oriented mobile health tools to contribute meaningfully to improving healthcare delivery, widespread acceptance and use of such tools by patients are critical. However, little is known about patients' attitudes toward using health technology and their willingness to share health data with providers. AIMS To investigate primary care patients' comfort sharing health information through mobile devices, and patients' awareness and use of patient portals. METHODS Patients (n=918) who visited one of 6 primary care clinics in the Northwest US completed a survey about health technology use, medical conditions, and demographics. RESULTS More patients were comfortable sharing mobile health information with providers than having third parties store their information (62% vs 30%, Somers D=.33, p<0.001). Patients older than 55 years were less likely to be comfortable sharing with providers (AORs 0.37-0.42, p<0.01). Only 39% of patients knew if their clinic offered a patient portal; however, of these, 67% used it. Health literacy limitations were associated with lower portal awareness (AOR=0.55, p=0.005) but not use. Portal use was higher among patients with a chronic condition (AOR= 3.18, p=0.004). CONCLUSION Comfort, awareness, and use of health technologies were variable. Practices introducing patient-facing health technologies should promote awareness, address concerns about data security, and provide education and training, especially to older adults and those with health literacy limitations. Patient-facing health technologies provide an opportunity for delivering scalable health education and self-management support, particularly for patients with chronic conditions who are already using patient portals.
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Affiliation(s)
- Amy M Bauer
- Psychiatry and Behavioral Sciences, University of Washington, Seattle, USA
| | - Tessa Rue
- Biostatistics, University of Washington, Seattle, USA.,Institute of Translational Health Sciences, University of Washington, Seattle, USA
| | - Sean A Munson
- Human Centered Design & Engineering, University of Washington, Seattle, USA
| | | | - Gina A Keppel
- Institute of Translational Health Sciences, University of Washington, Seattle, USA.,Human Centered Design & Engineering, University of Washington, Seattle, USA
| | - Allison M Cole
- Institute of Translational Health Sciences, University of Washington, Seattle, USA.,Human Centered Design & Engineering, University of Washington, Seattle, USA
| | - Laura-Mae Baldwin
- Human Centered Design & Engineering, University of Washington, Seattle, USA
| | - Wayne Katon
- Psychiatry and Behavioral Sciences, University of Washington, Seattle, USA
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25
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Hallgren KA, Bauer AM, Atkins DC. Digital technology and clinical decision making in depression treatment: Current findings and future opportunities. Depress Anxiety 2017; 34:494-501. [PMID: 28453916 PMCID: PMC6138456 DOI: 10.1002/da.22640] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2017] [Revised: 04/07/2017] [Accepted: 04/11/2017] [Indexed: 12/21/2022] Open
Abstract
Clinical decision making encompasses a broad set of processes that contribute to the effectiveness of depression treatments. There is emerging interest in using digital technologies to support effective and efficient clinical decision making. In this paper, we provide "snapshots" of research and current directions on ways that digital technologies can support clinical decision making in depression treatment. Practical facets of clinical decision making are reviewed, then research, design, and implementation opportunities where technology can potentially enhance clinical decision making are outlined. Discussions of these opportunities are organized around three established movements designed to enhance clinical decision making for depression treatment, including measurement-based care, integrated care, and personalized medicine. Research, design, and implementation efforts may support clinical decision making for depression by (1) improving tools to incorporate depression symptom data into existing electronic health record systems, (2) enhancing measurement of treatment fidelity and treatment processes, (3) harnessing smartphone and biosensor data to inform clinical decision making, (4) enhancing tools that support communication and care coordination between patients and providers and within provider teams, and (5) leveraging treatment and outcome data from electronic health record systems to support personalized depression treatment. The current climate of rapid changes in both healthcare and digital technologies facilitates an urgent need for research, design, and implementation of digital technologies that explicitly support clinical decision making. Ensuring that such tools are efficient, effective, and usable in frontline treatment settings will be essential for their success and will require engagement of stakeholders from multiple domains.
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Affiliation(s)
- Kevin A. Hallgren
- Department of Psychiatry and Behavioral Sciences, Behavioral Research in Technology and Engineering (BRiTE) Center; University of Washington; WA USA
| | - Amy M. Bauer
- Department of Psychiatry and Behavioral Sciences, Behavioral Research in Technology and Engineering (BRiTE) Center; University of Washington; WA USA
| | - David C. Atkins
- Department of Psychiatry and Behavioral Sciences, Behavioral Research in Technology and Engineering (BRiTE) Center; University of Washington; WA USA
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26
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Cerimele JM, Bauer AM, Fortney JC, Bauer MS. Patients With Co-Occurring Bipolar Disorder and Posttraumatic Stress Disorder: A Rapid Review of the Literature. J Clin Psychiatry 2017; 78:e506-e514. [PMID: 28570791 DOI: 10.4088/jcp.16r10897] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2016] [Accepted: 09/13/2016] [Indexed: 10/19/2022]
Abstract
OBJECTIVE To summarize the current literature on epidemiology, clinical correlates, and treatment of individuals with co-occurring bipolar disorder and posttraumatic stress disorder (PTSD). DATA SOURCES We conducted a focused, time-sensitive review called "rapid review" in November 2015, using keyword searches (including keywords bipolar disorder, post-traumatic stress disorder, PTSD, and others) in PubMed for studies of adults with co-occurring bipolar disorder and PTSD. STUDY SELECTION Results were sorted and systematically searched. An article was excluded if it did not describe adult patients with co-occurring PTSD and bipolar disorder or did not report original data on epidemiology, clinical correlates, or treatment. DATA EXTRACTION Information on study characteristics including population studied and key findings were extracted onto a data collection tool. RESULTS Thirty-two articles were included. Over two-thirds of articles reported epidemiology of co-occurring bipolar disorder and PTSD. Prevalence of PTSD among individuals with bipolar disorder ranged from 4% to 40%, with women and those with bipolar I versus bipolar II disorder experiencing higher prevalence of PTSD. Prevalence of bipolar disorder among individuals with PTSD ranged from 6% to 55%. Baseline PTSD or bipolar disorder was associated with incidence of the other illness. Individuals with co-occurring bipolar disorder and PTSD experienced high symptom burden and low quality of life. No studies evaluated prospective treatment of patients with co-occurring bipolar disorder and PTSD. CONCLUSIONS Bipolar disorder and PTSD commonly co-occur and result in greater symptom burden than either condition alone. Few published treatment strategies exist for patients with both conditions.
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Affiliation(s)
- Joseph M Cerimele
- Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, 1959 NE Pacific St, Box 356560, Seattle, WA 98195-6560. .,Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle, Washington, USA
| | - Amy M Bauer
- Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle, Washington, USA
| | - John C Fortney
- Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle, Washington, USA.,Department of Veterans Affairs, Health Services Research and Development Service Center of Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System, Seattle, Washington, USA
| | - Mark S Bauer
- Harvard Medical School and VA Boston Healthcare System, Boston, Massachusetts, USA
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27
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Hilty DM, Chan S, Hwang T, Wong A, Bauer AM. Advances in mobile mental health: opportunities and implications for the spectrum of e-mental health services. Mhealth 2017; 3:34. [PMID: 28894744 PMCID: PMC5583042 DOI: 10.21037/mhealth.2017.06.02] [Citation(s) in RCA: 62] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2016] [Accepted: 06/16/2017] [Indexed: 12/30/2022] Open
Abstract
Mobile health (mHealth), telemedicine and other technology-based services facilitate mental health service delivery and may be considered part of an e-mental health (eMH) spectrum of care. Web- and Internet-based resources provide a great opportunity for the public, patients, healthcare providers and others to improve wellness, practice prevention and reduce suffering from illnesses. Mobile apps offer portability for access anytime/anywhere, are inexpensive versus traditional desktop computers, and have additional features (e.g., context-aware interventions and sensors with real-time feedback. This paper discusses mobile mental health (mMH) options, as part of a broader framework of eMH options. The evidence-based literature shows that many people have an openness to technology as a way to help themselves, change behaviors and engage additional clinical services. Studies show that traditional video-based synchronous telepsychiatry (TP) is as good as in-person service, but mHealth outcomes have been rarely, directly compared to in-person and other eMH care options. Similarly, technology options added to in-person care or combined with others have not been evaluated nor linked with specific goals and desired outcomes. Skills and competencies for clinicians are needed for mHealth, social media and other new technologies in the eMH spectrum, in addition to research by randomized trials and study of health service delivery models with an emphasis on effectiveness.
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Affiliation(s)
- Donald M. Hilty
- Department of Psychiatry & Addiction Medicine, Kaweah Delta Medical Center, Visalia, California, USA
- Department of Psychiatry & Behavioral Sciences, Keck School of Medicine at USC, Los Angeles, California, USA
| | - Steven Chan
- Division of Hospital Medicine, Digital Health & Behavioral Sciences Research, University of California, California, USA
| | - Tiffany Hwang
- Department of Psychiatry, University of California, San Diego, California, USA
| | - Alice Wong
- Department of Psychiatry, Maimonides Medical Center, Brooklyn, NY, USA
| | - Amy M. Bauer
- Department of Psychiatry & Behavioral Sciences, the University of Washington, Seattle, Washington, USA
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28
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Bauer AM, Parker MM, Moffet HH, Schillinger D, Adler NE, Adams AS, Schmittdiel JA, Katon WJ, Karter AJ. Depressive symptoms and adherence to cardiometabolic therapies across phases of treatment among adults with diabetes: the Diabetes Study of Northern California (DISTANCE). Patient Prefer Adherence 2017; 11:643-652. [PMID: 28392679 PMCID: PMC5373834 DOI: 10.2147/ppa.s124181] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVE Among adults with diabetes, depression is associated with poorer adherence to cardiometabolic medications in ongoing users; however, it is unknown whether this extends to early adherence among patients newly prescribed these medications. This study examined whether depressive symptoms among adults with diabetes newly prescribed cardiometabolic medications are associated with early and long-term nonadherence. PATIENTS AND METHODS An observational follow-up of 4,018 adults with type 2 diabetes who completed a survey in 2006 and were newly prescribed oral antihyperglycemic, antihypertensive, or lipid-lowering agents within the following year at Kaiser Permanente Northern California was conducted. Depressive symptoms were examined based on Patient Health Questionnaire-8 scores. Pharmacy utilization data were used to identify nonadherence by using validated methods: early nonadherence (medication never dispensed or dispensed once and never refilled) and long-term nonadherence (new prescription medication gap [NPMG]: percentage of time without medication supply). These analyses were conducted in 2016. RESULTS Patients with moderate-to-severe depressive symptoms had poorer adherence than nondepressed patients (8.3% more patients with early nonadherence, P=0.01; 4.9% patients with longer NPMG, P=0.002; 7.8% more patients with overall nonadherence [medication gap >20%], P=0.03). After adjustment for confounders, the models remained statistically significant for new NPMG (3.7% difference, P=0.02). There was a graded association between greater depression severity and nonadherence for all the models (test of trend, P<0.05). CONCLUSION Depressive symptoms were associated with modest differences in early and long-term adherence to newly prescribed cardiometabolic medications in diabetes patients. Interventions targeting adherence among adults with diabetes and depression need to address both initiation and maintenance of medication use.
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Affiliation(s)
- Amy M Bauer
- Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle, WA
- Correspondence: Amy M Bauer, Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, 1959 NE Pacific Street, Box 356560, Seattle, WA 98195-6560, USA, Tel +1 206 221 8385, Fax +1 206 543 9520, Email
| | | | | | - Dean Schillinger
- Division of General Internal Medicine, University of California, San Francisco
- Center for Vulnerable Populations, San Francisco General Hospital and Trauma Center
| | - Nancy E Adler
- Department of Psychiatry and Pediatrics, Center for Health and Community, University of California, San Francisco, CA, USA
| | | | | | - Wayne J Katon
- Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle, WA
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29
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Sullivan MD, Bauer AM, Fulton-Kehoe D, Garg RK, Turner JA, Wickizer T, Franklin GM. Trends in Opioid Dosing Among Washington State Medicaid Patients Before and After Opioid Dosing Guideline Implementation. J Pain 2016; 17:561-8. [PMID: 26828802 DOI: 10.1016/j.jpain.2015.12.018] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/27/2015] [Revised: 11/19/2015] [Accepted: 12/22/2015] [Indexed: 11/16/2022]
Abstract
UNLABELLED By 2007, opioid-related mortality in Washington state (WA) was 50% higher than the national average, with Medicaid patients showing nearly 6 times the mortality of commercially-insured patients. In 2007, the WA Interagency Guideline on Opioid Dosing for Chronic Non-cancer Pain was released, which recommended caution in prescribing >120 mg morphine-equivalent dose per day for patients not showing clinically meaningful improvement in pain and function. We report on opioid dosing in the WA Medicaid fee-for-service population for 273,200 adults with a paid claim for an opioid prescription between April 1, 2006 and December 31, 2010. Linear regression was used to test for trends in dosing over that time period, with quarter-year as the independent variable and median daily dose as the dependent variable. Prescription opioid use among WA Medicaid adults peaked in 2009, as evidenced by the unique number of opioid users (105,232), the total number of prescriptions (556,712), and the total person-years of prescription opioid use (29,442). Median opioid dose was unchanged from 2006 to 2010 at 37.5 mg morphine-equivalent dose, but doses at the 75th, 90th, 95th, and 99th percentiles declined significantly (P < .001). These results suggest that opioid treatment guidelines with dosing guidance may be able to reduce high-dose opioid use without affecting the median dose used. PERSPECTIVE Some fear that opioid dosing guidelines might restrict access to opioid therapy for patients who could benefit. However, there is evidence that high-dose opioid therapy entails significant risks without demonstrated benefit. These findings indicate that high-dose opioid therapy can be reduced without altering median opioid dose in a Medicaid population.
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Affiliation(s)
- Mark D Sullivan
- Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, Washington.
| | - Amy M Bauer
- Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, Washington
| | - Deborah Fulton-Kehoe
- Department of Environmental and Occupational Health Sciences, University of Washington, Seattle, Washington
| | - Renu K Garg
- Department of Epidemiology, University of Washington, Seattle, Washington
| | - Judith A Turner
- Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, Washington; Department of Rehabilitation Medicine, University of Washington, Seattle, Washington
| | - Thomas Wickizer
- Department of Health Services, University of Washington, Seattle, Washington
| | - Gary M Franklin
- Department of Environmental and Occupational Health Sciences, University of Washington, Seattle, Washington; Department of Health Services, University of Washington, Seattle, Washington; Department of Neurology, University of Washington, Seattle, Washington; Washington State Department of Labor and Industries, Olympia, Washington
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30
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Abstract
Depression is one of the more common diagnoses encountered in primary care, and primary care in turn provides the majority of care for patients with depression. Many approaches have been tried in efforts to improve the outcomes of depression management. This article outlines the partnership between the University of Washington (UW) Neighborhood Clinics and the UW Department of Psychiatry in implementing a collaborative care approach to integrating the management of anxiety and depression in the ambulatory primary care setting. This program was built on the chronic care model, which utilizes a team approach to caring for the patient. In addition to the patient and the primary care provider (PCP), the team included a medical social worker (MSW) as care manager and a psychiatrist as team consultant. The MSW would manage a registry of patients with depression at a clinic with several PCPs, contacting the patients on a regular basis to assess their status, and consulting with the psychiatrist on a weekly basis to discuss patients who were not achieving the goals of care. Any recommendation (eg, a change in medication dose or class) made by the psychiatrist was communicated to the PCP, who in turn would work with the patient on the new recommendation. This collaborative care approach resulted in a significant improvement in the number of patients who achieved care plan goals. The authors believe this is an effective method for health systems to integrate mental health services into primary care. (Population Health Management 2016;19:81-87).
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Affiliation(s)
- Peter M McGough
- 1 UW Medicine Neighborhood Clinics , and Department of Family Medicine, Seattle, Washington
| | - Amy M Bauer
- 2 Department of Psychiatry and Behavioral Sciences, University of Washington , Seattle, Washington
| | - Laura Collins
- 3 Psychiatry and Behavioral Sciences, PCS, University of Washington , Seattle, Washington
| | - David C Dugdale
- 4 Care Management and Population Health, UW Medicine, and Department of Medicine, UW School of Medicine, University of Washington
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Bauer AM, Davydow DS. Depressed older adults who are adherent to medications have a lower risk of hospitalisation for coronary artery disease. Evid Based Mental Health 2015; 18:e4. [DOI: 10.1136/eb-2014-101981] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/12/2014] [Accepted: 02/17/2015] [Indexed: 11/04/2022]
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Garg RK, Fulton-Kehoe D, Turner JA, Bauer AM, Wickizer T, Sullivan MD, Franklin GM. Changes in opioid prescribing for Washington workers' compensation claimants after implementation of an opioid dosing guideline for chronic noncancer pain: 2004 to 2010. J Pain 2014; 14:1620-8. [PMID: 24290443 DOI: 10.1016/j.jpain.2013.08.001] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/14/2013] [Revised: 07/19/2013] [Accepted: 07/28/2013] [Indexed: 11/28/2022]
Abstract
UNLABELLED An opioid overdose epidemic emerged in the United States following increased opioid prescribing for chronic noncancer pain. In 2007, Washington State agencies implemented an opioid dosing guideline on safe prescribing for chronic noncancer pain. The objective of this population-based observational study was to evaluate opioid use and dosing before and after guideline implementation. We identified 161,283 workers aged 18 to 64 years with ≥1 opioid prescriptions in Washington Workers' Compensation, April 1, 2004, to December 31, 2010. Prevalence and incidence rates of opioid use were assessed. We compared pre- and postguideline chronic and high-dose use (≥120 mg/d) among incident users. The mean monthly prevalence of opioid use declined by 25.6% between 2004 (14.4%) and 2010 (10.7%). Fewer incident users went on to chronic opioid therapy in the postguideline period (4.7%; 95% confidence interval [CI], 4.5-5.0%) than in the preguideline period (6.3%; 95% CI, 6.1-6.6%). Compared with preguideline incident users, postguideline incident users were 35% less likely to receive high doses (adjusted odds ratio = .65; 95% CI, .59-.71). Although the extent to which decreases were due to the guidelines is uncertain, to our knowledge, this is the first report of significant decreases in chronic and high-dose prescription opioid use among incident users. PERSPECTIVE Evidence-based strategies for opioid risk management are needed to help abate the epidemic of opioid-related morbidity and mortality. The study findings suggest that opioid dosing guidelines that specify a "yellow flag" dosing threshold may be a useful tool in preventing escalation of doses into ranges associated with increased mortality risk.
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Affiliation(s)
- Renu K Garg
- Department of Epidemiology, University of Washington, Seattle, Washington.
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Bauer AM, Parker MM, Schillinger D, Katon W, Adler N, Adams AS, Moffet HH, Karter AJ. Associations between antidepressant adherence and shared decision-making, patient-provider trust, and communication among adults with diabetes: diabetes study of Northern California (DISTANCE). J Gen Intern Med 2014; 29:1139-47. [PMID: 24706097 PMCID: PMC4099457 DOI: 10.1007/s11606-014-2845-6] [Citation(s) in RCA: 100] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Depression and adherence to antidepressant treatment are important clinical concerns in diabetes care. While patient-provider communication patterns have been associated with adherence for cardiometabolic medications, it is unknown whether interpersonal aspects of care impact antidepressant medication adherence. OBJECTIVE To determine whether shared decision-making, patient-provider trust, or communication are associated with early stage and ongoing antidepressant adherence. DESIGN Observational new prescription cohort study. SETTING Kaiser Permanente Northern California. PATIENTS One thousand five hundred twenty-three adults with type 2 diabetes who completed a survey in 2006 and received a new antidepressant prescription during 2006-2010. MEASUREMENTS Exposures included items based on the Trust in Physicians and Interpersonal Processes of Care instruments and the Consumer Assessment of Healthcare Providers and Systems (CAHPS) communication scale. Measures of adherence were estimated using validated methods with physician prescribing and pharmacy dispensing data: primary non-adherence (medication never dispensed), early non-persistence (dispensed once, never refilled), and new prescription medication gap (NPMG; proportion of time without medication during 12 months after initial prescription). RESULTS After adjusting for potential confounders, patients' perceived lack of shared decision-making was significantly associated with primary non-adherence (RR = 2.42, p < 0.05), early non-persistence (RR = 1.34, p < 0.01) and NPMG (estimated 5% greater gap in medication supply, p < 0.01). Less trust in provider was significantly associated with early non-persistence (RRs 1.22-1.25, ps < 0.05) and NPMG (estimated NPMG differences 5-8%, ps < 0.01). LIMITATIONS All patients were insured and had consistent access to and quality of care. CONCLUSIONS Patients' perceptions of their relationships with providers, including lack of shared decision-making or trust, demonstrated strong associations with antidepressant non-adherence. Further research should explore whether interventions for healthcare providers and systems that foster shared decision-making and trust might also improve medication adherence.
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Affiliation(s)
- Amy M Bauer
- Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, 1959 NE Pacific Street, Box 356560, Seattle, WA, 98195-6560, USA,
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Rocha LA, Aleixo A, Allen G, Almeda F, Baldwin CC, Barclay MVL, Bates JM, Bauer AM, Benzoni F, Berns CM, Berumen ML, Blackburn DC, Blum S, Bolaños F, Bowie RCK, Britz R, Brown RM, Cadena CD, Carpenter K, Ceríaco LM, Chakrabarty P, Chaves G, Choat JH, Clements KD, Collette BB, Collins A, Coyne J, Cracraft J, Daniel T, de Carvalho MR, de Queiroz K, Di Dario F, Drewes R, Dumbacher JP, Engilis A, Erdmann MV, Eschmeyer W, Feldman CR, Fisher BL, Fjeldså J, Fritsch PW, Fuchs J, Getahun A, Gill A, Gomon M, Gosliner T, Graves GR, Griswold CE, Guralnick R, Hartel K, Helgen KM, Ho H, Iskandar DT, Iwamoto T, Jaafar Z, James HF, Johnson D, Kavanaugh D, Knowlton N, Lacey E, Larson HK, Last P, Leis JM, Lessios H, Liebherr J, Lowman M, Mahler DL, Mamonekene V, Matsuura K, Mayer GC, Mays H, McCosker J, McDiarmid RW, McGuire J, Miller MJ, Mooi R, Mooi RD, Moritz C, Myers P, Nachman MW, Nussbaum RA, Foighil DÓ, Parenti LR, Parham JF, Paul E, Paulay G, Pérez-Emán J, Pérez-Matus A, Poe S, Pogonoski J, Rabosky DL, Randall JE, Reimer JD, Robertson DR, Rödel MO, Rodrigues MT, Roopnarine P, Rüber L, Ryan MJ, Sheldon F, Shinohara G, Short A, Simison WB, Smith-Vaniz WF, Springer VG, Stiassny M, Tello JG, Thompson CW, Trnski T, Tucker P, Valqui T, Vecchione M, Verheyen E, Wainwright PC, Wheeler TA, White WT, Will K, Williams JT, Williams G, Wilson EO, Winker K, Winterbottom R, Witt CC. Specimen collection: an essential tool. Science 2014; 344:814-5. [PMID: 24855245 DOI: 10.1126/science.344.6186.814] [Citation(s) in RCA: 139] [Impact Index Per Article: 13.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Affiliation(s)
- L A Rocha
- California Academy of Sciences, San Francisco, CA 94118, USA.
| | - A Aleixo
- Museu Paraense Emílio Goeldi, Belém, PA, 66040-170, Brazil
| | - G Allen
- Western Australian Museum, Perth, WA, 6986, Australia
| | - F Almeda
- California Academy of Sciences, San Francisco, CA 94118, USA
| | - C C Baldwin
- Smithsonian Institution, Washington, DC 20560, USA
| | | | - J M Bates
- Field Museum of Natural History, Chicago, IL 60605, USA
| | - A M Bauer
- Villanova University, Villanova, PA 19085, USA
| | - F Benzoni
- University of Milano-Bicocca, Milan, 20126, Italy
| | | | - M L Berumen
- King Abdullah University of Science and Technology, Thuwal, 23955, Saudi Arabia
| | - D C Blackburn
- California Academy of Sciences, San Francisco, CA 94118, USA
| | - S Blum
- California Academy of Sciences, San Francisco, CA 94118, USA
| | - F Bolaños
- Universidad de Costa Rica, San José, 11501-2060, Costa Rica
| | - R C K Bowie
- University of California, Berkeley, CA 94720-3161, USA
| | - R Britz
- Natural History Museum, London, SW7 5BD, UK
| | - R M Brown
- University of Kansas, Lawrence, KS 66045, USA
| | - C D Cadena
- Universidad de los Andes, Bogotá, 4976, Colombia
| | - K Carpenter
- Old Dominion University, Norfolk, VA 23529, USA
| | - L M Ceríaco
- Museu Nacional de História Natural e da Ciência, Lisbon, 7005-638, Portugal
| | - P Chakrabarty
- Louisiana State University, Baton Rouge, LA 70803, USA
| | - G Chaves
- Universidad de Costa Rica, San José, 11501-2060, Costa Rica
| | - J H Choat
- James Cook University, Townsville, 4811, Australia
| | - K D Clements
- University of Auckland, Auckland, 1142, New Zealand
| | - B B Collette
- NOAA Systematics Laboratory, Washington, DC 20013, USA
| | - A Collins
- NOAA Systematics Laboratory, Washington, DC 20013, USA
| | - J Coyne
- University of Chicago, Chicago, IL 60637, USA
| | - J Cracraft
- American Museum of Natural History, New York, NY 10024, USA
| | - T Daniel
- California Academy of Sciences, San Francisco, CA 94118, USA
| | | | - K de Queiroz
- Smithsonian Institution, Washington, DC 20560, USA
| | - F Di Dario
- Universidade Federal do Rio de Janeiro, Macaé, RJ, 27965-045, Brazil
| | - R Drewes
- California Academy of Sciences, San Francisco, CA 94118, USA
| | - J P Dumbacher
- California Academy of Sciences, San Francisco, CA 94118, USA
| | - A Engilis
- University of California, Davis, CA 95616, USA
| | - M V Erdmann
- Conservation International, Denpasar, Bali, 80235, Indonesia
| | - W Eschmeyer
- California Academy of Sciences, San Francisco, CA 94118, USA
| | - C R Feldman
- University of Nevada, Reno, NV 89557-0314, USA
| | - B L Fisher
- California Academy of Sciences, San Francisco, CA 94118, USA
| | - J Fjeldså
- Natural History Museum of Denmark, Copenhagen, DK-2100, Denmark
| | - P W Fritsch
- California Academy of Sciences, San Francisco, CA 94118, USA
| | - J Fuchs
- Muséum National d'Histoire Naturelle, Paris, 75005, France
| | - A Getahun
- Addis Ababa University, Addis Ababa, 1176, Ethiopia
| | - A Gill
- University of Sydney, Sydney, NSW, 2006, Australia
| | - M Gomon
- Museum Victoria, Melbourne, 3001, VIC, Australia
| | - T Gosliner
- California Academy of Sciences, San Francisco, CA 94118, USA
| | - G R Graves
- Smithsonian Institution, Washington, DC 20560, USA
| | - C E Griswold
- California Academy of Sciences, San Francisco, CA 94118, USA
| | - R Guralnick
- University of Colorado, Boulder, CO 80309-0334, USA
| | - K Hartel
- Harvard University, Cambridge, MA 02138, USA
| | - K M Helgen
- Smithsonian Institution, Washington, DC 20560, USA
| | - H Ho
- University of California, Davis, CA 95616, USA
| | - D T Iskandar
- Conservation International, Denpasar, Bali, 80235, Indonesia
| | - T Iwamoto
- California Academy of Sciences, San Francisco, CA 94118, USA
| | - Z Jaafar
- Smithsonian Institution, Washington, DC 20560, USA. National University of Singapore, 117543, Singapore
| | - H F James
- Smithsonian Institution, Washington, DC 20560, USA
| | - D Johnson
- Smithsonian Institution, Washington, DC 20560, USA
| | - D Kavanaugh
- California Academy of Sciences, San Francisco, CA 94118, USA
| | - N Knowlton
- Smithsonian Institution, Washington, DC 20560, USA
| | - E Lacey
- University of California, Berkeley, CA 94720-3161, USA
| | - H K Larson
- Museum and Art Gallery of the Northern Territory, Darwin, 0820, NT, Australia
| | - P Last
- CSIRO Marine & Atmospheric Research, Hobart, TAS, 7000, Australia
| | - J M Leis
- Australian Museum, Sydney, NSW, 2010, Australia
| | - H Lessios
- Smithsonian Tropical Research Institute, Balboa, 0843-03092, Panamá
| | - J Liebherr
- Cornell University, Ithaca, NY 14853, USA
| | - M Lowman
- California Academy of Sciences, San Francisco, CA 94118, USA
| | - D L Mahler
- University of California, Davis, CA 95616, USA
| | - V Mamonekene
- Université Marien Ngouabi, Brazzaville, B.P. 69, Republic of Congo
| | - K Matsuura
- National Museum of Nature and Science, Tsukuba, 305-0005, Japan
| | - G C Mayer
- University of Wisconsin-Parkside, Kenosha, WI 53141-2000, USA
| | - H Mays
- Cincinnati Museum Center, Cincinnati, OH 45203, USA
| | - J McCosker
- California Academy of Sciences, San Francisco, CA 94118, USA
| | | | - J McGuire
- University of California, Berkeley, CA 94720-3161, USA
| | - M J Miller
- Smithsonian Tropical Research Institute, Balboa, 0843-03092, Panamá
| | - R Mooi
- California Academy of Sciences, San Francisco, CA 94118, USA
| | - R D Mooi
- The Manitoba Museum, Winnipeg, MB, R3B 0N2, Canada
| | - C Moritz
- Australian National University, Canberra, ACT, 0200, Australia
| | - P Myers
- University of Michigan, Ann Arbor, MI 48109-1079, USA
| | - M W Nachman
- University of California, Berkeley, CA 94720-3161, USA
| | - R A Nussbaum
- University of Michigan, Ann Arbor, MI 48109-1079, USA
| | - D Ó Foighil
- University of Michigan, Ann Arbor, MI 48109-1079, USA
| | - L R Parenti
- Smithsonian Institution, Washington, DC 20560, USA
| | - J F Parham
- California State University, Fullerton, CA 92831, USA
| | - E Paul
- The Ornithological Council, Chevy Chase, MD 20815, USA
| | - G Paulay
- University of Florida, Gainesville, fl32611, USA
| | - J Pérez-Emán
- Universidad Central de Venezuela, Caracas, 1041, Venezuela
| | - A Pérez-Matus
- Pontif cia Universidad Católica de Chile, Santiago 6513677, Chile
| | - S Poe
- University of New Mexico, Albuquerque, NM 87131-0001, USA
| | - J Pogonoski
- CSIRO Marine & Atmospheric Research, Hobart, TAS, 7000, Australia
| | - D L Rabosky
- University of Michigan, Ann Arbor, MI 48109-1079, USA
| | - J E Randall
- Bernice P. Bishop Museum, Honolulu, HI 96817, USA
| | - J D Reimer
- University of the Ryukyus, Nishihara, 903-0213, Japan
| | - D R Robertson
- Smithsonian Tropical Research Institute, Balboa, 0843-03092, Panamá
| | - M-O Rödel
- Museum für Naturkunde, Berlin, 10115, Germany
| | - M T Rodrigues
- Universidade de São Paulo, São Paulo, SP, 05508-090, Brazil
| | - P Roopnarine
- California Academy of Sciences, San Francisco, CA 94118, USA
| | - L Rüber
- Naturhistorisches Museum der Burgergemeinde Bern, Bern, CH-3005, Switzerland
| | - M J Ryan
- University of New Mexico, Albuquerque, NM 87131-0001, USA
| | - F Sheldon
- Louisiana State University, Baton Rouge, LA 70803, USA
| | - G Shinohara
- National Museum of Nature and Science, Tsukuba, 305-0005, Japan
| | - A Short
- University of Kansas, Lawrence, KS 66045, USA
| | - W B Simison
- California Academy of Sciences, San Francisco, CA 94118, USA
| | | | - V G Springer
- Smithsonian Institution, Washington, DC 20560, USA
| | - M Stiassny
- American Museum of Natural History, New York, NY 10024, USA
| | - J G Tello
- American Museum of Natural History, New York, NY 10024, USA. Long Island University, Brooklyn, NY 11201-8423, USA
| | - C W Thompson
- University of Michigan, Ann Arbor, MI 48109-1079, USA
| | - T Trnski
- Auckland Museum, Auckland, 1142, New Zealand
| | - P Tucker
- University of Michigan, Ann Arbor, MI 48109-1079, USA
| | - T Valqui
- Centro de Ornitologia y Biodiversidad, Lima, 33, Peru
| | - M Vecchione
- NOAA Systematics Laboratory, Washington, DC 20013, USA
| | - E Verheyen
- Royal Belgian Institute of Natural Sciences, Brussels, 1000, Belgium
| | | | - T A Wheeler
- McGill University, Montreal, QC, H9X 3V9, Canada
| | - W T White
- CSIRO Marine & Atmospheric Research, Hobart, TAS, 7000, Australia
| | - K Will
- University of California, Berkeley, CA 94720-3161, USA
| | - J T Williams
- Smithsonian Institution, Washington, DC 20560, USA
| | - G Williams
- California Academy of Sciences, San Francisco, CA 94118, USA
| | - E O Wilson
- Harvard University, Cambridge, MA 02138, USA
| | - K Winker
- University of Alaska Museum, Fairbanks, AK 99775, USA
| | | | - C C Witt
- University of New Mexico, Albuquerque, NM 87131-0001, USA
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Ishikawa RZ, Cardemil EV, Alegría M, Schuman CC, Joseph RC, Bauer AM. Uptake of depression treatment recommendations among Latino primary care patients. Psychol Serv 2014; 11:421-32. [PMID: 24512538 DOI: 10.1037/a0035716] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Primary care providers (PCP) are the entry point for public sector depression treatment for many Latino patients. However, many Latino patients do not initiate their PCPs' recommended treatment, which likely contributes to ethnic disparities in depression treatment. This study examined factors related to Latino patients' uptake of their PCPs' recommendations for depression treatment. METHOD Ninety Latino primary care patients who received a depression treatment recommendation from their PCP participated in a telephone interview. Patients rated their working alliance with their PCP and their PCP's cultural competence. They also reported their treatment preference, the type of recommendation, and their intended and actual uptake of the recommendation. Patients were contacted at two time points (Time 1: M = 14 days after PCP appointment; Time 2: M = 84 days after PCP appointment) to report their uptake status. RESULTS At Time 1, 23% of patients had initiated uptake of the treatment recommendation, increasing to 53% at Time 2. Patients who received a medication recommendation were more likely to have followed though on the recommendation, compared with patients who received a psychotherapy recommendation. The working alliance was positively associated with intention to follow up on a treatment recommendation, and also mediated the relationship between cultural competence and intention of following up on the recommendation. CONCLUSION PCP's treatment recommendation and the PCP-patient alliance play a role in Latino primary care patients intention to follow a treatment recommendation for depression. An improved understanding of this role could enhance efforts to improve depression treatment uptake.
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Affiliation(s)
| | | | - Margarita Alegría
- Center for Multicultural Mental Health Research, Cambridge Health Alliance, Harvard Medical School
| | | | - Robert C Joseph
- Department of Psychiatry, Cambridge Health Alliance, Harvard Medical School
| | - Amy M Bauer
- Department of Psychiatry, University of Washington
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Fulton-Kehoe D, Garg RK, Turner JA, Bauer AM, Sullivan MD, Wickizer TM, Franklin GM. Opioid poisonings and opioid adverse effects in workers in Washington state. Am J Ind Med 2013; 56:1452-62. [PMID: 24122929 DOI: 10.1002/ajim.22266] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/10/2013] [Indexed: 11/08/2022]
Abstract
OBJECTIVE To examine trends in opioid poisonings and adverse effects in Washington (WA) State and nationally. METHODS We calculated rates of opioid poisonings and adverse effects and examined opioid prescriptions in the WA workers' compensation system, 2004-2010. Using Health Care Cost and Utilization Project (HCUP), Nationwide Inpatient Sample (NIS) data, we also calculated national rates of opioid poisonings and adverse effects, 1993-2010. RESULTS We identified 96 opioid poisonings and 312 opioid-related adverse effects in WA, 2004-2010. The rates did not change substantially over these years. Most poisonings and adverse effects occurred in cases without chronic opioid use and with prescribed doses <120 mg/day morphine-equivalent dose. Nationally, the rates of opioid poisonings and adverse effects increased significantly from 1993 to 2010. CONCLUSIONS Many poisonings and adverse effects occurred in patients without high dose or long-term opioid therapy, suggesting that opioid dosing and duration guidelines may not be sufficient to reduce morbidity related to prescription opioid use.
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Affiliation(s)
- Deborah Fulton-Kehoe
- Department of Environmental and Occupational Health Sciences; University of Washington School of Public Health; Seattle Washington
| | - Renu K. Garg
- Department of Epidemiology; University of Washington School of Public Health; Seattle Washington
| | - Judith A. Turner
- Department of Psychiatry and Behavioral Sciences; University of Washington School of Medicine; Seattle Washington
- Department of Rehabilitation Medicine; University of Washington School of Medicine; Seattle Washington
| | - Amy M. Bauer
- Department of Psychiatry and Behavioral Sciences; University of Washington School of Medicine; Seattle Washington
| | - Mark D. Sullivan
- Department of Psychiatry and Behavioral Sciences; University of Washington School of Medicine; Seattle Washington
| | - Thomas M. Wickizer
- Division of Health Services Management and Policy; College of Public Health, Ohio State University; Columbus Ohio
| | - Gary M. Franklin
- Department of Environmental and Occupational Health Sciences; University of Washington School of Public Health; Seattle Washington
- Department of Health Services; University of Washington School of Public Health and Community Medicine; Seattle Washington
- Washington State Department of Labor and Industries; Olympia Washington
- Department of Neurology; University of Washington School of Medicine; Seattle Washington
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Bauer AM, Schillinger D, Parker MM, Katon W, Adler N, Adams AS, Moffet HH, Karter AJ. Health literacy and antidepressant medication adherence among adults with diabetes: the diabetes study of Northern California (DISTANCE). J Gen Intern Med 2013; 28:1181-7. [PMID: 23512335 PMCID: PMC3744297 DOI: 10.1007/s11606-013-2402-8] [Citation(s) in RCA: 78] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2012] [Revised: 01/28/2013] [Accepted: 02/15/2013] [Indexed: 12/20/2022]
Abstract
BACKGROUND Previous studies have reported that health literacy limitations are associated with poorer disease control for chronic conditions, but have not evaluated potential associations with medication adherence. OBJECTIVE To determine whether health literacy limitations are associated with poorer antidepressant medication adherence. DESIGN Observational new prescription cohort follow-up study. PARTICIPANTS Adults with type 2 diabetes who completed a survey in 2006 and received a new antidepressant prescription during 2006-2010 (N = 1,366) at Kaiser Permanente Northern California. MAIN MEASURES Validated three-item self-report scale measured health literacy. Discrete indices of adherence based on pharmacy dispensing data according to validated methods: primary non-adherence (medication never dispensed); early non-persistence (dispensed once, never refilled); non-persistence at 180 and 365 days; and new prescription medication gap (NPMG; proportion of time that the person is without medication during 12 months after the prescription date). KEY RESULTS Seventy-two percent of patients were classified as having health literacy limitations. After adjusting for sociodemographic and clinical covariates, patients with health literacy limitations had significantly poorer adherence compared to patients with no limitations, whether measured as early non-persistence (46 % versus 38 %, p < 0.05), non-persistence at 180 days (55 % versus 46 %, p < 0.05), or NPMG (41 % versus 36%, p < 0.01). There were no significant associations with primary adherence or non-persistence at 365 days. CONCLUSIONS Poorer antidepressant adherence among adults with diabetes and health literacy limitations may jeopardize the continuation and maintenance phases of depression pharmacotherapy. Findings underscore the importance of national efforts to address health literacy, simplify health communications regarding treatment options, improve public understanding of depression treatment, and monitor antidepressant adherence.
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Affiliation(s)
- Amy M Bauer
- Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle, WA 98195-6560, USA.
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Huang H, Chan YF, Bauer AM, Suzuki J, Katon W, Russo J, Hogan D, Unützer J. Specialty behavioral health service use among chronically ill medicare advantage patients with substance use problems. Psychosomatics 2013; 54:546-51. [PMID: 23932530 DOI: 10.1016/j.psym.2013.05.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/14/2013] [Revised: 05/07/2013] [Accepted: 05/09/2013] [Indexed: 11/18/2022]
Abstract
OBJECTIVE This study examines the use of substance abuse and mental health services among older adults with substance use disorders. METHODS Participants were members of Humana Cares, a subsidiary of Humana, Inc., a care management program for chronically ill Medicare Advantage members, between 2008 and 2010. All adults aged 65 and older with a substance use disorder identified with International Classification of Diseases-9 codes were included. We compared utilization of substance abuse and mental health services among participants with no psychiatric comorbidity (n = 585), with comorbid depression (n = 605), and with comorbid severe and persistent mental illness (severe and persistent mental illness, n = 95). RESULTS Twenty-eight percent utilized substance abuse services and 36% utilized mental health services. After adjusting for covariates, comorbid depression (odds ratio = 4.27, 95% confidence interval: 3.22-5.65) and severe and persistent mental illness (odds ratio = 10.75, 95% confidence interval: 5.22-20.13) were independently associated with specialty service use (either substance abuse or mental health services). CONCLUSION Although few chronically ill older adults with substance use disorders in this Medicare Advantage program received any specialty substance abuse or mental health services, utilization was higher among those who had concurrent psychiatric disorders.
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Affiliation(s)
- Hsiang Huang
- Department of Psychiatry, Cambridge Health Alliance, Harvard Medical School, Cambridge, MA.
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Affiliation(s)
- Amy M Bauer
- Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, Washington, USA
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Huang H, Russo J, Bauer AM, Chan YF, Katon W, Hogan D, Unützer J. Depression care and treatment in a chronically ill Medicare population. Gen Hosp Psychiatry 2013; 35:382-6. [PMID: 23557895 PMCID: PMC3692601 DOI: 10.1016/j.genhosppsych.2013.02.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2012] [Revised: 02/18/2013] [Accepted: 02/26/2013] [Indexed: 10/27/2022]
Abstract
OBJECTIVE The purpose of this study is to examine depression care among chronically ill Medicare Advantage beneficiaries. METHODS This study includes 5898 Medicare Advantage members with a depression diagnosis enrolled between 2008 and 2010 in a care management program. Two depression care indicators were created: (a) any depression care (≥ 1 antidepressant prescription or ≥ 1 specialty mental health visit) and (b) among those receiving any depression care, those receiving an antidepressant prescription for ≥ 90 days or ≥ 2 specialty visits. Multivariable analysis using logistic regression was used to examine correlates of depression care. RESULTS Among those <65 years old, 72% received any depression care with 75% receiving ≥ 90 days of an antidepressant and/or ≥ 2 specialty visits. Among ≥ 65 years old, 65% received any depression care with 67% receiving ≥ 90 days of an antidepressant and/or ≥ 2 specialty visits. For both age groups, female gender, medical comorbidities and dual eligibility were positively associated with an antidepressant prescription. In the older group, female gender was positively associated with at least a 90-day supply of an antidepressant prescription, while substance use disorders were negatively associated with receiving a minimum of 90 days of an antidepressant. Regional differences and certain psychiatric comorbidities were also associated with receiving depression care. CONCLUSION Two thirds of the depressed patients in this Medicare Advantage population received depression care. Further studies are needed to examine the effects of quality improvement efforts in the context of care management programs for chronically ill older adults.
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Affiliation(s)
- Hsiang Huang
- Department of Psychiatry, Cambridge Health Alliance, Harvard Medical School, Cambridge, MA 02139, USA.
| | - Joan Russo
- Department of Psychiatry & Behavioral Sciences, University of Washington Medical School, Seattle, WA
| | - Amy M. Bauer
- Department of Psychiatry & Behavioral Sciences, University of Washington Medical School, Seattle, WA
| | - Ya-Fen Chan
- Department of Psychiatry & Behavioral Sciences, University of Washington Medical School, Seattle, WA
| | - Wayne Katon
- Department of Psychiatry & Behavioral Sciences, University of Washington Medical School, Seattle, WA
| | | | - Jürgen Unützer
- Department of Psychiatry & Behavioral Sciences, University of Washington Medical School, Seattle, WA
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Huang H, Bauer AM, Wasse JK, Ratzliff A, Chan YF, Harrison D, Unützer J. Care managers' experiences in a collaborative care program for high risk mothers with depression. Psychosomatics 2012. [PMID: 23194928 DOI: 10.1016/j.psym.2012.07.011] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
OBJECTIVES The aim of this study was to understand care managers' experiences in caring for depressed mothers in an integrated behavioral health program. METHODS As part of a quality improvement project, we conducted a focus group interview with six care managers caring for low income mothers with behavioral health needs in a safety net program in King County, WA. Using thematic analysis, codes were organized into themes that described the care managers' experiences. RESULTS Two organizing themes along with associated themes emerged: (1) Assets for improving depression outcomes: patient-provider interactions, including the importance of engagement; program resources such as care coordination and (2) Barriers to improved depression outcomes: patient-provider interactions, including difficulty engaging patient; patient-related factors such as multiple stressors; program resources such as need for more psychiatric support; and difficulty accessing outside resources. CONCLUSIONS Numerous potentially modifiable factors including levels of engagement, motivational interviewing, and increased psychiatric support were identified by care managers as affecting depression care and outcomes. Implications for care management training and approaches to psychiatric consultations are discussed.
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Affiliation(s)
- Hsiang Huang
- Cambridge Health Alliance, Department of Psychiatry, Harvard Medical School, 1493 Cambridge Street, Cambridge, MA 02139, USA.
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Huang H, Chan YF, Katon W, Tabb K, Sieu N, Bauer AM, Wasse JK, Unützer J. Variations in depression care and outcomes among high-risk mothers from different racial/ethnic groups. Fam Pract 2012; 29:394-400. [PMID: 22090192 PMCID: PMC3408881 DOI: 10.1093/fampra/cmr108] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
UNLABELLED PURPOSE. To examine variations in depression care and outcomes among high-risk pregnant and parenting women from different racial/ethnic groups served in community health centres. METHODS As part of a collaborative care programme that provides depression treatment in primary care clinics for high-risk mothers, 661 women with probable depression (Patient Health Questionnaire-9 ≥ 10), who self-reported race/ethnicity as Latina (n = 393), White (n = 126), Black (n = 75) or Asian (n = 67), were included in the study. Primary outcomes include quality of depression care and improvement in depression. A Cox proportional hazard model adjusting for sociodemographic and clinical characteristics was used to examine time to treatment response. RESULTS We observed significant differences in both depression processes and outcomes across ethnic groups. After adjusting for other variables, Blacks were found to be significantly less likely to improve than Latinas [hazard ratio (HR): 0.53, 95% confidence interval (CI): 0.44-0.65]. Other factors significantly associated with depression improvement were pregnancy (HR: 1.52, 95% CI: 1.27-1.82), number of clinic visits (HR: 1.26, 95% CI: 1.17-1.36) and phone contacts (HR: 1.45, 95% CI: 1.32-1.60) by the care manager in the first month of treatment. After controlling for depression severity, having suicidal thoughts at baseline was significantly associated with a decreased likelihood of depression improvement (HR: 0.75, 95% CI: 0.67-0.83). CONCLUSIONS In this racially and ethnically diverse sample of pregnant and parenting women treated for depression in primary care, the intensity of care management was positively associated with improved depression. There was also appreciable variation in depression outcomes between Latina and Black patients.
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Affiliation(s)
- Hsiang Huang
- Department of Psychiatry & Behavioral Sciences, University of Washington Medical School, Seattle, WA 98195-6560, USA.
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Bauer AM, Chen CN, Alegría M. Associations of physical symptoms with perceived need for and use of mental health services among Latino and Asian Americans. Soc Sci Med 2012; 75:1128-33. [PMID: 22694987 DOI: 10.1016/j.socscimed.2012.05.004] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2011] [Revised: 03/23/2012] [Accepted: 05/04/2012] [Indexed: 10/28/2022]
Abstract
Although many believe that low rates of perceived mental health need and service use among racial/ethnic minorities are due, in part, to somatization, data supporting this notion are lacking. This study examined two hypotheses: (1) increased physical symptoms are associated with lower perceived need for mental health services and actual service use; and (2) physical symptoms are most strongly associated with perceived mental health need and service use among first-generation individuals. Data come from the National Latino and Asian-American Study, a nationally-representative household survey in the United States conducted from 2002 to 2003. Participants reported on the presence of fourteen physical symptoms within the past year. Perceived mental health need was present for individuals who endorsed having an emotional or substance use problem or thinking they needed treatment for such a problem within the past year. After adjusting for sociodemographic and clinical covariates, the number of physical symptoms was positively associated with perceived mental health need and service, an effect that differed by generation. Among first-generation individuals, physical symptoms were associated with increased perceived need and service use. Physical symptoms were not significantly associated with perceived need or service use among third-generation Latinos, but were associated with service use among third-generation Asian-Americans. Physical symptoms do not appear to interfere with mental health problem recognition or service use. In contrast, individuals, especially of the first-generation, with more physical symptoms were more likely to perceive need for and utilize mental health services. Our findings do not support the notion that physical symptoms account for low rates of perceived mental health need and service use among Latino and Asian-Americans.
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Affiliation(s)
- Amy M Bauer
- Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, WA, USA.
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Bauer AM, Azzone V, Alexander L, Goldman HH, Unützer J, Frank RG. Are patient characteristics associated with quality of depression care and outcomes in collaborative care programs for depression? Gen Hosp Psychiatry 2012; 34:1-8. [PMID: 22018769 PMCID: PMC3253908 DOI: 10.1016/j.genhosppsych.2011.08.019] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2011] [Revised: 08/23/2011] [Accepted: 08/30/2011] [Indexed: 11/18/2022]
Abstract
OBJECTIVE To determine whether demographic or clinical characteristics of primary care patients are associated with depression treatment quality and outcomes within a collaborative care model. METHODS Collaborative depression care, based on principles from the Improving Mood-Promoting Access to Collaborative Treatment (IMPACT) trial, was implemented in six community health organizations serving disadvantaged patients. Over 3 years, 2821 patients were treated. Outcomes were receipt of quality treatment and depression improvement. RESULTS Logistic regression analyses revealed that patients who were older, more depressed or more anxious were more likely to be retained in treatment and to receive appropriate pharmacotherapy. Whereas gender and depression severity were unrelated to depression outcomes, significantly more patients who preferred Spanish (59.1%) than English (48.5%, P<.01) improved within 12 weeks in multivariate analyses. High baseline anxiety was associated with a lower probability of improvement, and older age showed a similar trend. Survival analyses demonstrated that patients who preferred Spanish or were less anxious improved significantly more rapidly than their counterparts (P<.001). CONCLUSIONS Patients with more anxiety received higher quality care but experienced worse depression outcomes than less anxious patients. Spanish language preference was strongly associated with depression improvement. This collaborative care program attained admirable outcomes among disadvantaged Spanish-speaking patients without extensive cultural tailoring of care.
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Affiliation(s)
- Amy M Bauer
- Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, WA 98195-6560, USA.
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Bauer AM, Azzone V, Goldman HH, Alexander L, Unützer J, Coleman-Beattie B, Frank RG. Implementation of collaborative depression management at community-based primary care clinics: an evaluation. Psychiatr Serv 2011; 62:1047-53. [PMID: 21885583 PMCID: PMC3250309 DOI: 10.1176/appi.ps.62.9.1047] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE This study evaluated a large demonstration project of collaborative care of depression at community health centers by examining the role of clinic site on two measures of quality care (early follow-up and appropriate pharmacotherapy) and on improvement of symptoms (score on Patient Health Questionnaire-9 reduced by 50% or ≤ 5). METHODS A quasi-experimental study examined data on the treatment of 2,821 patients aged 18 and older with depression symptoms between 2006 and 2009 at six community health organizations selected in a competitive process to implement a model of collaborative care. The model's key elements were use of a Web-based disease registry to track patients, care management to support primary care providers and offer proactive follow-up of patients, and organized psychiatric consultation. RESULTS Across all sites, a plurality of patients achieved meaningful improvement in depression, and in many sites, improvement occurred rapidly. After adjustment for patient characteristics, multivariate logistic regression models revealed significant differences across clinics in the probability of receiving early follow-up (range .34-.88) or appropriate pharmacotherapy (range .27-.69) and in experiencing improvement (.36 to .84). Similarly, after adjustment for patient characteristics, Cox proportional hazards models revealed that time elapsed between first evaluation and the occurrence of improvement differed significantly across clinics (p<.001). CONCLUSIONS Despite receiving similar training and resources, organizations exhibited substantial variability in enacting change in clinical care systems, as evidenced by both quality indicators and outcomes. Sites that performed better on quality indicators had better outcomes, and the differences were not attributable to patients' characteristics.
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Affiliation(s)
- Amy M Bauer
- Department of Psychiatry and Behavioral Sciences, University of Washington, 1959 NE Pacific St, Box 356560, Seattle, WA 98195, USA.
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Abstract
This article reviews the principles and skills involved with psychosomatic medicine and their potential ability to improve global health care. New awareness of the escalating global public health impact of noncommunicable diseases, including chronic medical conditions and mental disorders, has stimulated interest in determining how best to organize health services. Home to the biopsychosocial model, the field of psychosomatic medicine is well-suited to inform such efforts by virtue of its emphasis on cross-disciplinary collaboration and specialized knowledge at the interface of medicine and psychiatry that takes into account individual and contextual influences on health. Consistent with the principles of psychosomatic medicine, promising strategies to improve global health care include integrating mental health care into primary care, applying the chronic care model in programs aimed at enhancing disease self-management, and using innovative models such as Internet-based therapy and telemedicine to increase access to quality care.
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Affiliation(s)
- Amy M Bauer
- Department of Psychiatry, Cambridge Health Alliance, MA 02140, USA.
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Abstract
Geckos in the Western Hemisphere provide an excellent model to study faunal assembly at a continental scale. We generated a time-calibrated phylogeny, including exemplars of all New World gecko genera, to produce a biogeographical scenario for the New World geckos. Patterns of New World gecko origins are consistent with almost every biogeographical scenario utilized by a terrestrial vertebrate with different New World lineages showing evidence of vicariance, dispersal via temporary land bridge, overseas dispersal or anthropogenic introductions. We also recovered a strong relationship between clade age and species diversity, with older New World lineages having more species than more recently arrived lineages. Our data provide the first phylogenetic hypothesis for all New World geckos and highlight the intricate origins and ongoing organization of continental faunas. The phylogenetic and biogeographical hypotheses presented here provide an historical framework to further pursue research on the diversification and assembly of the New World herpetofauna.
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Affiliation(s)
- T Gamble
- Department of Genetics, Cell Biology and Development, University of Minnesota, Minneapolis, MN 55455, USA.
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Bauer AM, Fielke K, Brayley J, Araya M, Alem A, Frankel BL, Fricchione GL. Tackling the global mental health challenge: a psychosomatic medicine/consultation-liaison psychiatry perspective. Psychosomatics 2010; 51:185-93. [PMID: 20484715 DOI: 10.1176/appi.psy.51.3.185] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND Consultation-liaison (C-L) psychiatry, informed by principles of psychosomatic medicine, is well-positioned to address the global impact of mental disorders through primary care C-L models. OBJECTIVE/METHOD The authors review the international burden of mental disorders, highlighting medical comorbidity, undertreatment, and the rationale for enhancing primary-care management. RESULTS C-L psychiatry fosters the skills required for global mental health work. The authors describe successful C-L models developed in a low-income country (Ethiopia) and an under-resourced region of a high-income country (Australia). CONCLUSION C-L psychiatrists have the potential to marshal their unique skill-set to reduce the global burden of mental disorders.
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Affiliation(s)
- Amy M Bauer
- Department of Psychiatry, Cambridge Health Alliance, 1493 Cambridge St., Cambridge, MA 02139, USA.
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Abstract
OBJECTIVE This literature review examined the effects of patients' limited English proficiency and use of professional and ad hoc interpreters on the quality of psychiatric care. METHODS PubMed, PsycINFO, and CINAHL (Cumulative Index to Nursing and Allied Health Literature) were systematically searched for English-language publications from inception of each database to April 2009. Reference lists were reviewed, and expert sources were consulted. Among the 321 articles identified, 26 met inclusion criteria: peer-reviewed articles reporting primary data on clinical care for psychiatric disorders among patients with limited proficiency in English or in the provider's language. RESULTS Evaluation in a patient's nonprimary language can lead to incomplete or distorted mental status assessment. Although both untrained and trained interpreters may make errors, untrained interpreters' errors may have greater clinical impact, compromising diagnostic accuracy and clinicians' detection of disordered thought or delusional content. Use of professional interpreters may improve disclosure in patient-provider communications, referral to specialty care, and patient satisfaction. CONCLUSIONS Little systematic research has addressed the impact of language proficiency or interpreter use on the quality of psychiatric care in contemporary U.S. settings. Findings are insufficient to inform evidence-based guidelines for improving quality of care among patients with limited English proficiency. Clinicians should be aware of the ways in which quality of care can be compromised when they evaluate patients in a nonprimary language or use an interpreter. Given U.S. demographic trends, future research should help guide practice and policy by addressing deficits in the evidence base.
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Affiliation(s)
- Amy M Bauer
- Department of Psychiatry, Cambridge Health Alliance, Cambridge, MA 02139, USA.
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Bauer AM, Fielke K, Brayley J, Araya M, Alem A, Frankel BL, Fricchione GL. Tackling the Global Mental Health Challenge: A Psychosomatic Medicine/Consultation–Liaison Psychiatry Perspective. Psychosomatics 2010. [DOI: 10.1016/s0033-3182(10)70684-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
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