Developing an innovative pediatric integrated mental health care program: interdisciplinary team successes and challenges

Introduction

Children and adolescents often do not receive mental healthcare when they need it. By 2021, the complex impact of the COVID-19 pandemic, structural racism, inequality in access to healthcare, and a growing shortage of mental health providers led to a national emergency in child and adolescent mental health in the United States. The need for effective, accessible treatment is more pressing than ever. Interdisciplinary, team-based pediatric integrated mental healthcare has been shown to be efficacious, accessible, and cost-effective.

Methods

In response to the youth mental health crisis, Rady Children's Hospital-San Diego's Transforming Mental Health Initiative aimed to increase early identification of mental illness and improve access to effective treatment for children and adolescents. A stakeholder engagement process was established with affiliated pediatric clinics, community mental health organizations, and existing pediatric integrated care programs, leading to the development of the Primary Care Mental Health Integration program and drawing from established models of integrated care: Primary Care Behavioral Health and Collaborative Care.

Results

As of 2023, the Primary Care Mental Health Integration program established integrated care teams in 10 primary care clinics across San Diego and Riverside counties in California. Measurement-based care has been implemented and preliminary results indicate that patient response to therapy has resulted in a 44% reduction in anxiety symptoms and a 62% decrease in depression symptoms. The program works toward fiscal sustainability via fee-for-service reimbursement and more comprehensive payor contracts. The impact on patients, primary care provider satisfaction, measurement-based care, funding strategies, as well as challenges faced and changes made will be discussed using the lens of the Reach, Effectiveness, Adoption, Implementation and Maintenance framework.

Discussion

Preliminary results suggest that the Primary Care Mental Health Integration is a highly collaborative integrated care model that identifies the needs of children and adolescents and delivers brief, evidence informed treatment. The successful integration of this model into 10 primary care clinics over 3 years has laid the groundwork for future program expansion. This model of care can play a role addressing youth mental health and increasing access to care. Challenges, successes, and lessons learned will be reviewed.

The Effect of COVID-19 Lockdown on PHQ Depression Screening Scores for High School Athletes

Adolescent behavioral health was in crisis before COVID-19. The shutdown and reopening of in-person learning and extracurricular activities may have worsened this crisis. We examined high school athletes’ depression before and during the pandemic. Data were collected as part of a pilot program incorporating Patient Health Questionnaire (PHQ) screenings during high school sports physicals before the COVID-19 lockdown and three timepoints after. Statistical comparisons were made using logistic regression. A total of 927 individual scores were analyzed: 385 from spring 2020; 145 from fall 2020; 163 from fall 2021; and 234 from spring 2022. Fall 2020 students were 3.7 times more likely to have elevated PHQ-2 scores than spring 2020 students (95% CI = 1.8, 7.6). Fall 2021 and spring 2022 scores did not differ significantly from pre-pandemic, although trends of elevated scores persisted (OR = 1.6; 95% CI = 0.7, 3.5, and OR = 1.2; 95% CI = 0.6, 2.4, respectively). A significant difference in PHQ-9 depression severity classification was detected over time (p < 0.01). Elevated PHQ scores were found after the onset of the COVID-19 pandemic. After the initial peak in fall 2020, scores decreased but did not reach pre-pandemic levels.

Controlled fabrication of nanopores using a direct focused ion beam approach with back face particle detection

We report a direct, ion drilling technique that enables the reproducible fabrication and placement of nanopores in membranes of different thickness. Using a 30 keV focused Ga ion beam column combined with an in situ, back face, multi-channelplate particle detector, nanopores are sputtered in Si(3)N(4) and W/Si(3)N(4) to have diameters as small as 12 nm. Transmission electron microscopy shows that focused ion beam-drilled holes are near-conical with the diameter decreasing from entry to exit side. By monitoring the detector signal during ion exposure, the drilled hole width can be minimized such that the exit-side diameter is smaller than the full width at half-maximum of the nominally Gaussian-shaped incident beam. Judicious choice of the beam defining aperture combined with back face particle detection allows for reproducible exit-side hole diameters between 18 and 100 nm. The nanopore direct drilling technique does not require potentially damaging broad area exposure to tailor hole sizes. Moreover, this technique successfully achieves breakthrough despite the effects of varying membrane thickness, redeposition, polycrystalline grain structure, and slight ion beam current fluctuations.

"Puss caterpillar" envenomation: a report from North Carolina

A 41-year-old white man with no specific past medical history presented to the Emergency Department on October 13, 1997, following what he described as a "caterpillar bite." The insect was subsequently identified as a "puss caterpillar" (Megalopyge opercularis). The patient experienced immediate excruciating pain that radiated throughout his left arm and gradually spread to the left chest area. He presented to a nearby emergency department several hours later and received treatment. The patient was subsequently admitted for observation and released several days later. Viewed in the context of previous clinical reports, this case highlights the broad range of clinical symptoms that can result from the puss caterpillar sting.

Advances in non-nicotine pharmacotherapy for smoking cessation

Progress in understanding the pharmacological nature of tobacco addiction, along with the modest success rates achieved by the nicotine replacement therapies, has provided the major impetus for the development of non-nicotine drugs as smoking cessation aids. This article reviews evidence from controlled trials of several non-nicotine medications for the treatment of nicotine dependence. Clonidine was the first non-nicotine medication to show efficacy for smoking cessation in multiple studies, but its effect was found to be limited at best. Positive results across several trials have been consistently demonstrated for amfebutamone (bupropion). Encouraging results have also been observed for nortriptyline and moclobemide. Studies of combined treatments using non-nicotine medications (amfebutamone, mecamylamine, oral dextrose) with nicotine replacement therapy suggest increased efficacy relative to treatments using one or the other treatment strategy alone. Thus, available evidence indicates that non-nicotine drug treatments offer a promising panoply of therapeutic strategies for the addicted smoker.

Hearts and minds: suicide among United States combat troops in Vietnam, 1957-1973

The literature on suicides among military personnel in a combat zone remains anecdotal. Although one finds literary and journalistic accounts of the problem, it has not been systematically analyzed. This paper will examine suicides among American combat troops during their tour of duty in Vietnam. Utilizing statistical data from the Southeast Asia Combat Area Casualties Database (SACACD), the authors will survey its epidemiology among U.S. ground troops in Vietnam from 1957 to 1973. The results suggest that certain types of combat troops were significantly more likely than others to commit suicide. These findings not only provide important predictors for military health professionals in the assessment of suicide risk, they also raise disturbing questions about the nature of organized armed conflict.

Tanning facility compliance with state and federal regulations in North Carolina: a poor performance

BACKGROUND

Little is known about the compliance of commercial tanning facilities with regulations governing their operation. We inspected some tanning parlors to assess the degree to which they follow federal and North Carolina state regulations.

METHODS

An inspection of 32 tanning facilities was conducted between March and May 1991 as part of an ongoing effort to educate tanning parlor operators and proprietors about UV light safety. Compliance with each of 21 distinct state and federal requirements was recorded for each facility.

RESULTS

Only 1 of 32 facilities was in complete compliance with both state and federal regulations. The number of infractions ranged from none to 21 (mean [+/- SD] 7.1 +/- 4.1). Nineteen percent of facilities had timers that were not within the required +/- 10% accuracy level. Twenty-two percent also had timers that did not meet Code of Federal Regulations standards. The estimated proportion of the total light output in the UVB spectrum ranged from 0.5% to 5.0% (mean 4.25% +/- 0.95%).

CONCLUSIONS

These limited data suggest that many commercial tanning establishments are not uniformly compliant with regulations. Although we cannot extrapolate these findings to other states, we anticipate that facilities in states with less rigorous regulations than North Carolina have similar or inferior safety profiles.

Lead-induced leukocytosis in female mice

Lead acetate was shown to stimulate a striking leukocytosis in young adult female mice. The effect was manifest 4 days after lead injection and continued throughout the following 4 days. At the higher treatment level, lead induced an increase of 300% for both monocytes and neutrophils. The leukocytosis was due primarily to the elevated levels of neutrophils as suggested by a decrease in the ratios of peripheral agranulocytes to granulocytes. No differences from normal leukocyte cytology were observed in blood samples collected from animals receiving lead.