A Self-Help Crisis Outreach Effort for At-Risk Primary Care Patients: A Pilot Study of Veterans During the COVID-19 Pandemic

Stressful events can exacerbate symptoms of psychiatric disorders among primary care patients, putting them at increased risk for suicide. In a pilot study that ran from August to December of 2020, researchers evaluated the acceptability and implementation of Managing Emotions in Disaster and Crisis (MEDIC), a self-help intervention designed to assist at-risk primary care patients. A total of 108 at-risk veterans completed baseline and 6-week assessments. Results were promising, with high patient acceptability and engagement along with improvement in all measures of mental illness symptoms from baseline to posttreatment. Self-help interventions like MEDIC may offer a low-burden way for primary care providers to support more patients.

Factors Influencing Patient Receptivity to Brief Alcohol Interventions in Primary Care: An Application of Conjoint Analysis

Background: Brief alcohol interventions (BAIs) are an evidence-based practice for addressing hazardous alcohol use in primary care settings. However, numerous barriers to implementation of BAIs in routine practice have been identified, including concerns about patient receptivity to BAIs. Despite this being a commonly identified barrier to BAI implementation, little BAI implementation research has focused on patient receptivity. Objectives: This study aimed to identify the treatment preferences of primary care patients who screened positive for hazardous alcohol use and to evaluate factors that may influence patients' receptivity to BAIs delivered in primary care. We conducted a mailed survey of primary care patients (N = 245) who screened positive for hazardous alcohol use on annual screening measures based on electronic medical record data. Patients completed measures assessing treatment preferences and a conjoint analysis questionnaire designed to evaluate the relative importance of three factors (focus of the BAI, tailoring of the BAI, and familiarity with the provider delivering the BAI) for patient receptivity. Results: Conjoint analysis results revealed that familiarity with provider (with patients preferring BAIs delivered by providers they have previously met) was the most important factor in predicting patients' receptivity to BAIs. Additionally, patients preferred to discuss alcohol use in the context of another concern (focus of the BAI) and preferred personalized information tailored based on their specific health concerns (tailoring of the BAI), although these factors were not statistically significant when accounting for familiarity with provider. Conclusions: Findings of the present study have potential to inform future research on implementation of BAIs.

Barriers to and facilitators of using evidence-based, cognitive-behavioral anxiety interventions in integrated primary care practice

Cognitive-behavioral treatment for anxiety disorders and symptoms remains underutilized in integrated primary care (IPC), in part because the many treatments developed for specialty care are not readily translated to this unique setting. The objective of this study was to identify barriers and facilitators to behavioral health providers (BHPs) delivering evidence-based cognitive--behavioral anxiety interventions within IPC practice. We conducted semistructured interviews with a national sample of 18 BHPs (50% psychologists, 33% social workers, 17% registered nurses) working in IPC in the Veterans Health Administration. We assessed barriers to and facilitators of using psychoeducation, exposure, cognitive therapy, relaxation training, mindfulness/meditation, Acceptance and Commitment Therapy-based interventions, and problem-solving therapy. Qualitative coding and conventional content analysis revealed barriers and facilitators at three levels: IPC, provider, and patient. Themes suggested key barriers of poor fit with the IPC model, BHP training deficits, and lack of patient buy-in, and key facilitators of good perceived fit of the intervention (e.g., scope, duration) with the IPC model, BHPs feeling well equipped, and utility for patients. BHPs select interventions based on fit for the individual patient. Some results were consistent with prior work from specialty care, but the IPC model itself introduces significant implementation challenges. BHPs would benefit from flexible intervention options and training on IPC treatment goals and how to deliver the essence of evidence-based interventions in small doses. Our findings will help to inform adaptation of behavioral anxiety interventions to better fit IPC practice and development of beneficial training and resources for BHPs to reduce implementation challenges. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Does it work and can we do it? Hybrid research that answers both questions

The perceived disconnect between research and clinic contexts may thus result in frontline clinicians and administrators questioning the approachability and applicability of science to their day-to-day work with patients and families in integrated care. Science grinds along so painstakingly slowly that even within the research community, some thought leaders have called for a moratorium on RCTs in favor of approaches that will yield more immediate public health impact (Kessler & Glasgow, 2011). The aim of this editorial is to describe a both/and research approach called "hybrid studies" and to discuss achievable strategies for doing this kind of work on the front lines. Sure, you can get a multimillion-dollar grant and do a formal research study, but real people on the frontlines can do this type of work too! Hybrid studies have the capacity to answer the two essential questions in healthcare science concurrently and advance the progress of science translation (usable science). (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Brief, modular, transdiagnostic, cognitive-behavioral intervention for anxiety in veteran primary care: Development, provider feedback, and open trial

Anxiety is undertreated in primary care, and most treatment provided is pharmacological rather than behavioral. Integrating behavioral health providers (BHPs) using the Primary Care Behavioral Health (PCBH) model can help address this treatment gap, but brief interventions suitable for use in PCBH practice are needed. We developed a modular, cognitive-behavioral anxiety intervention, Modular Anxiety Skills Training (MAST), that is evidence-based, transdiagnostic, feasible for PCBH, and patient-centered. MAST comprises up to six 30-min sessions emphasizing skills training. This article describes the rationale for and development of MAST as well as pilot work in the Veterans Health Administration (VA) to tailor and refine MAST for delivery to Veterans in VA primary care (MAST-V) to improve feasibility for VA BHPs and acceptability to Veterans. We used a convergent mixed-methods design with concurrent data collection. In phase one, we interviewed five BHPs to obtain feedback on the treatment manual. BHPs assessed MAST-V to be highly compatible with PCBH and provided suggestions to enhance feasibility. In phase two, we conducted an open trial in which six Veterans experiencing clinically significant anxiety received and provided feedback on all nine possible modules; we also assessed changes in mental health symptoms and functioning as well as treatment satisfaction and credibility. Veterans found MAST-V to be highly acceptable, and pre-post clinical outcomes were very promising with large effect sizes. Findings from this initial pilot provide preliminary support for the feasibility, acceptability, and efficacy of MAST-V and suggest further research with a randomized clinical trial is warranted. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Peer review: The jury duty of science

In this editorial, the authors explain the function and process of peer review, challenges they experienced in the wake of the COVID-19 pandemic, and strategies for ensuring that this fundamental process continues with integrity. In conclusion, the efforts of this editorial team to maintain a robust reviewer pool by inspiring, rewarding, training, and growing diversity cannot be the only efforts in this area. Those who "decline" jury duty may experience punitive consequences; however, there are no direct consequences for a qualified professional who declines to review, even routinely. Ultimately, the scientific community suffers, with a slower process that can then deteriorate. As a collective of professionals who value the contributions of science, we must all work to protect and grow participation in reviewing. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Prevalence and predictors of team-based care activities between primary care providers and embedded behavioral health providers: a national survey

Primary care (PC) settings increasingly use team-based care activities with embedded behavioral health providers (BHPs) to enhance patient care via group medical visits, conjoint appointments, team huddles, and warm handoffs. Aim 1 was to describe the variation of team-based care activities within integrated PC clinics. Aim 2 was to explore whether factors associated with the BHP (e.g., gender, training, and experience) and the PC setting (e.g., perceived teamwork) predict engagement in team-based activities. A national sample of eligible BHPs (n = 345; 14.2% response rate) completed an anonymous survey assessing the presence/intensity of team-based care activities. 90% of BHPs reported regularly engaging in team-based care activities with PC teams. Most engagement occurred when providing feedback to PC providers (90.4% at least daily) and during warm handoffs (90.4% at least once daily). Engagement in team-based care was predicted by the level of teamwork occurring within the PC clinic (βs = .41-.47; ps < .001) and BHP characteristics, such as the number of years spent in PC (βs = .24-.26, ps < .001). Although these data are promising, with many BHPs reportedly engaging in team-based activities with PC teams, there is significant variation. Researchers should continue to explore whether the engagement in these team-based care activities enhances patient care.

Relationship Health and Intimate Partner Violence in Integrated Primary Care: Individual Characteristics and Preferences for Relationship Support across Risk Levels

This study explores differences in characteristics and relationship treatment preferences across different levels of intimate partner violence (IPV) among Veterans Affairs (VA) primary care patients. In Fall 2019, we sent a mail-in survey assessing relationship healthcare needs to N = 299 Veterans randomly sampled from 20 northeastern VA primary care clinics (oversampling female and younger Veterans). We compared those reporting past year use or experience of physical/sexual aggression, threats/coercion, or injury (Severe IPV; 21%), to those only reporting yelling and screaming (Verbal Conflict; 51%), and denying any IPV (No IPV; 28%). Participants across groups desired 2-6 sessions of face-to-face support for couples' health and communication. No IPV participants were older and had preferred treatment in primary care. The Verbal Conflict and Severe IPV groups were both flagged by IPV screens and had similar interest in couple treatment and relationship evaluation. The Severe IPV group had higher rates of harms (e.g., depression, alcohol use disorder, relationship dissatisfaction, fear of partner) and higher interest in addressing safety outside of VA. Exploratory analyses suggested differences based on use vs. experience of Severe IPV. Findings highlight ways integrated primary care teams can differentiate services to address dissatisfaction and conflict while facilitating referrals for Severe IPV.

Sexual assault predicts unhealthy weight management among college women: A longitudinal, prospective study

Objective: To examine whether sexual assault prospectively predicts unhealthy weight management behaviors in college women. Method: Participants were female college students (N = 483) with monthly assessments across the first year, including the frequency and severity of sexual assault and unhealthy weight management behaviors. Results: Frequency of sexual assault prior to college predicted dieting, purging, and diet pill use, over the first year. Severity of those experiences predicted dieting and diet pill use. Frequency of sexual assault during the first semester predicted purging and diet pill use during the second semester. Severity predicted all three unhealthy weight management behaviors. Findings held consistently when controlling for socioeconomic status (SES), race/ethnicity, body mass index (BMI), and pre-college mood, anxiety, and eating disorders, as well as unhealthy weight management behaviors during the first semester in longitudinal analyses. Reverse models were non-significant. Conclusions: This research documents the detrimental effects of sexual assault on unhealthy weight management behaviors in college women, and highlights the importance of prevention and intervention.

Enhancing equity, diversity, and inclusion in Families, Systems, & Health

Our annual coeditors' retreat is a time to step back from the words on the page and reflect on our values for this work. Our values set the course for goals and subsequent actions for the year. In our 3 days away from the office to focus on the journal, we have the quiet space to set intentions. Then, we set timelines, we send emails, we put things in motion. We came to this year's retreat prepared to consider a critical topic: equity, diversity, and inclusion (EDI). That Families, Systems, & Health (FSH) recruit, welcome, review, and publish science that is representative of the widest range of experience and perspective is a core value for us as coeditors. We feel we have a moral and ethical obligation as leaders, scientists, and humans, to pursue social justice and equitable health outcomes for all. Such efforts are needed to help rectify the longstanding history of systemic racism and discrimination against minoritized communities that continues even today. In the context of recent events including protests against racial injustices as well as health disparities experienced by people of color during the coronavirus disease 2019 (COVID-19) pandemic, the scientific community is realizing we can no longer remain bystanders. Our role as coeditors of a journal affords the opportunity to support equitable and inclusive practices representing a diverse array of individuals and communities throughout the peer review and publication process, which not only enhances equity but also improves science. In exploratory conversations with our leadership team (i.e., coeditors, associate editors, and department editors) and editorial board, we knew that all of us were of a mind in our values and aspirations to improve EDI in FSH. We write this editorial to transparently communicate in a way that provides context for recent and upcoming changes in journal processes designed to support EDI. We want to clearly state our intentions to work on improving EDI throughout all aspects of FSH. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Building research and evaluation into the Collaborative Family Healthcare Association with intention

In 2013, a bunch of us ran around collecting paper surveys off chairs after a plenary address at the Collaborative Family Healthcare Association's (CFHA) annual conference. From 150 responses, we found that less than a quarter would take the time to attend a workshop about research and evaluation. Fast forward 5 years: The organization showed robust attendance at research and evaluation training sessions, and interest in a preconference had risen to 77%. What prompted this shift? In response to survey findings, the Research and Evaluation Committee (REC), supported by the CFHA, engaged a data-informed and stakeholder-responsive approach to cultivating empiricism within the CFHA. The activities led by the REC demonstrate the need for creativity and leadership in this area and the CFHA's strong. organizational values around such efforts. As past and present leaders in the CFHA's REC initiatives, we write this editorial to make explicit the value of research to the organization and the value of the organization to the evidence base. In addition, we document some key institutional history in this area and, with input from the CFHA's current chief executive officer, Neftali Serrano, and REC chair, Will Lusenhop, forecast a vision for the future. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Anxiety treatment preferences among veteran primary care patients: Demographic, mental health, and treatment-related correlates

INTRODUCTION

Anxiety symptoms are common, yet undertreated, among primary care patients. Accommodating patient treatment preferences improves engagement and retention. In contrast to depression, little is known about primary care patients' preferences for anxiety treatment.

METHOD

Participants were 144 veterans experiencing anxiety symptoms but not receiving psychotherapy who were recruited from primary care. Preferences for 11 anxiety treatment attributes (method; location; type; format; provider; frequency, length, and number of appointments; psychotherapy orientation; symptom focus; and topic/skill) and demographic, mental health (e.g., anxiety symptom severity), and treatment-related (e.g., psychotherapy history) variables were assessed via mailed survey. We used chi-square goodness of fit tests to identify patient preferences for each attribute and multivariate multinomial logistic regression models to explore demographic, mental health, and treatment-related correlates of treatment preferences.

RESULTS

Patient preferences were largely consistent with integrated primary care models, particularly Primary Care Behavioral Health, with a few exceptions. Patients preferred longer appointments (e.g., 45-60 minutes) and a longer duration of treatment (e.g., ≥13 appointments) than is typically offered in primary care. Several variables, particularly education level, perceived need for help, anxiety symptom severity, and attitudes toward psychotherapy, were repeatedly associated with preferences for various anxiety treatment attributes.

DISCUSSION

Results from this study suggest that patients tend to have distinct preferences for anxiety treatment in primary care that are largely consistent with common integrated primary care models. Results also identify several variables that may be associated with specific preferences, which may help match patients to their preferred type of care. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Virtual integrated primary care teams: Recommendations for team-based care

INTRODUCTION

Integrated primary care teams are increasingly relying upon virtual care, including both telehealth and team members who are teleworking, due to the COVID-19 pandemic. This shift to virtual care can present challenges for the coordination and provision of team-based care in primary care. The current report uses extant literature on teams to provide recommendations to support integrated primary care teams, including behavioral health providers, in adapting to and sustaining virtual team-based care.

METHOD

We used the Seven C's framework by Salas and colleagues (2015) to organize our findings and recommendations, focusing on coordination, cooperation, cognition, and communication.

RESULTS

Integrated primary care teams may benefit from tending to both implicit and explicit forms of coordination and the use of debriefs to improve team coordination. Given the potential challenge of trust in a virtual team, documentation of care coordination and reexamination of how feedback is provided to primary care providers may benefit team cooperation. Sharing team goals and crosstraining on specific aspects of team processes, such as communicating essential information to behavioral health providers for a warm handoff, may improve the cognition of the team. Teams may also benefit by findings ways to incorporate informal communication into the workflow and using closed-loop communication to decrease missed communications.

DISCUSSION

This report provides initial recommendations based on extant team literature to support integrated primary care teams in adapting to virtual care. Future work should build off this report by examining virtual integrated primary care teams and providing evidence-based recommendations to optimize virtual care. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Practical Opportunities for Biopsychosocial Education Through Strategic Interprofessional Experiences in Integrated Primary Care

Even with the expansion of primary care teams to include behavioral health and other providers from a range of disciplines, providers are regularly challenged to deliver care that adequately addresses the complex array of biopsychosocial factors underlying the patient's presenting concern. The limits of expertise, the ever-changing shifts in evidence-based practices, and the difficulties of interprofessional teamwork contribute to the challenge. In this article, we discuss the opportunity to leverage the interprofessional team-based care activities within integrated primary care settings as interactive educational opportunities to build competencies in biopsychosocial care among primary care team members. We argue that this approach to learning while providing direct patient care not only facilitates new provider knowledge and skills, but also provides a venue to enhance team processes that are key to delivering integrated biopsychosocial care to patients. We provide three case examples of how to utilize strategic planning within specific team-based care activities common in integrated primary care settings-shared medical appointments, conjoint appointments, and team huddles-to facilitate educational objectives.

Sexual Revictimization in College Women: Mediational Analyses Testing Hypothesized Mechanisms for Sexual Coercion and Sexual Assault

A precollege history of sexual victimization predicts revictimization during college, making it important to understand the mechanisms underlying the victimization-to-revictimization pathway. The study aimed to test whether heavy episodic drinking and personal and peer hookup norms mediate revictimization for two types of unwanted sexual contact: sexual coercion (attempted and/or completed sexual assault by the use of verbal coercion) and sexual assault (attempted and/or completed sexual assault by the use of force, threats, or incapacitation). At college entry, 483 first-year college women completed self-report measures of their precollege experiences, including history of sexual victimization and health behaviors (i.e., alcohol use, personal and peer hookup norms). At the end of the first and second semesters, they also completed measures assessing incident sexual victimization. Nearly one half of women (48%) reported an experience of attempted or completed sexual coercion or assault prior to entering college; 33% endorsed sexual coercion and 15% endorsed sexual assault in their first year of college. Structural equation models demonstrated that heavy episodic drinking and personal and peer hookup norms partially mediated revictimization for sexual assault, but not for sexual coercion. Sexual coercion was the most common tactic leading to unwanted sexual contact in this sample. Alcohol use and personal and peer hookup norms mediated revictimization by force, threats, or incapacitation. In contrast, the hypothesized mediators did not explain the revictimization pathway for verbally coerced assaults. Given the prevalence of sexual coercion, research needs to identify risk factors for verbal coercion to guide prevention efforts.

Treating depressive symptoms among veterans in primary care: A multi-site RCT of brief behavioral activation

BACKGROUND

Behavioral activation is ideal for embedded behavioral health providers (BHPs) working in primary care settings treating patients reporting a range of depressive symptoms. The current study tested whether a brief version of Behavioral Activation (two 30-minute appointments, 2 boosters) designed for primary care (BA-PC) was more effective than primary care behavioral health treatment-as-usual (TAU) in reducing depressive symptoms and improving quality of life and functioning.

METHODS

Parallel-arm, multi-site randomized controlled trial. 140 Veterans were randomized to BA-PC or TAU and completed assessments at baseline, 6 weeks, 12 weeks, and 24 weeks.

RESULTS

Reductions in depressive symptoms were observed in both groups between baseline and 3-weeks prior to any treatment, with continued reductions among those in the BA-PC condition through 12-weeks. However, there was no significant condition X time interaction at 12-weeks. Quality of life and mental health functioning were significantly improved for those in the BA-PC condition, compared to TAU, at 12 weeks.

LIMITATIONS

Generalizability to a broader population may be limited as this sample consisted of veterans. Although engagement in TAU matched other prior work, it was lower than engagement in BA-PC, which also may compromise results.

CONCLUSIONS

Although this study found that both TAU and BA-PC participants showed a decline in depressive symptoms, improvements in functioning and quality of life within those assigned to BA-PC, strong treatment retention and feasibility of BA-PC, and significant reductions in depressive symptoms among those with more severe baseline depressive symptoms are encouraging and support continued research on BA-PC. This trial was registered in clinicaltrials.gov as Improving Mood in Veterans in Primary Care (NCT02276807).

Clinical considerations in designing brief exposure interventions for primary care behavioral health settings

INTRODUCTION

Prevalence rates of anxiety disorders and symptoms in primary care (PC) settings are very high. Behavioral health consultants in primary care behavioral health (PCBH) settings enable increased access to evidence-based anxiety treatment. Despite strong extant support for exposure-based therapy for anxiety disorders, the use of exposure to treat anxiety in PC settings is low. Although barriers to exposure therapy (ET) may be exacerbated in PC settings, many anxiety presentations in PC warrant an exposure-based approach to treatment. Thus, exploration of feasibility and efficacy of ET in PC represents a critical area for advancing evidence-based treatment of anxiety symptoms.

METHODS

The current article addresses this gap through the presentation of two case examples of ET conducted in PCBH. Theoretical and practical information regarding the implementation of exposure using a brief (≤ 30 min), time-limited (4-6 visit) approached are presented.

RESULTS

Results from the case examples demonstrate feasibility of conducting exposure in a brief format consistent with a PCBH approach. Additionally, patient outcomes presented suggest that ET conducted in PCBH reduces anxiety symptoms and may facilitate referral to specialty care settings.

DISCUSSION

Exposure may offer promise in improving the quality of anxiety treatment in PC. Future work documenting both effectiveness and implementation outcomes of exposure in PC in clinical work and research trials is needed. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Anxiety interventions delivered in primary care behavioral health routine clinical practice

INTRODUCTION

Although anxiety is highly prevalent in primary care and a top reason for referral to primary care behavioral health (PCBH) services, there are limited data on which anxiety interventions are used in routine PCBH practice. The objective of this study was to identify interventions delivered when treating anxiety in PCBH practice.

METHOD

We conducted an online survey of PCBH providers regarding their clinical practice with patients who present for treatment of anxiety symptoms. The final sample comprised 209 PCBH providers recruited from e-mail listservs of national professional organizations (59.3% psychologists, 23.4% social workers, 12.4% counselors, 4.8% other). Providers reported on use (yes/no) of 17 interventions in their most recent session with their most recent adult patient presenting with a primary concern of non-trauma-related anxiety.

RESULTS

On average, patients were reported to be 42.2 (14.73) years old, White (73.7%), and male (56.5%) with anxiety symptoms of moderate severity (65.6%). Most reportedly had comorbid sleep difficulties (63.6%), depressive symptoms (58.4%), and/or stress/adjustment (56.0%). Providers reported delivering an average of 5.77 (2.05, range: 1-15) interventions, with psychoeducation (94.7%), relaxation training (64.1%), and supportive therapy (60.8%) being most common. Several highly efficacious evidence-based interventions for anxiety, including cognitive therapy (45.0%) and exposure (21.1%), were less common.

DISCUSSION

While PCBH providers delivered numerous brief interventions for anxiety, cognitive therapy and exposure were underutilized. Furthermore, PCBH patients with anxiety symptoms were complex, with significant severity and comorbidity. These results suggest implications for research, clinical training, intervention design, and future implementation efforts. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

The Association Between Sexual Behavior and Affect: Moderating Factors in Young Women

Sexual behavior is associated with increased positive affect and decreased negative affect. However, contextual variables such as partner type, behavior type, and condom use may moderate these associations. The goal of the present research was to examine these contextual moderators using monthly longitudinal data from a sample of young women. Female first-year college students (N = 477) completed monthly assessments of their sexual behaviors and positive and negative affect. Participants reported more negative affect in months in which they engaged in sexual behavior compared to months in which they did not. This association was moderated by partner type, such that only sexual behavior with casual partners was associated with increased negative affect. Participants reported more positive affect during months with kissing/touching only compared to months without sexual behavior; however, this association did not differ significantly from the association between oral/vaginal sex and positive affect. Condom use did not moderate the association between vaginal sex and positive or negative affect. In this sample of young women transitioning to college, engaging in sexual behavior was generally associated with negative affect; however, changes in affect depended on partner type and sexual behaviors. Findings have implications for sexual health education.

Longitudinal assessment of heavy alcohol use and incapacitated sexual assault: A cross-lagged analysis

Researchers have argued there are bidirectional associations between heavy alcohol use and sexual assault; however, research in this area is inconclusive due to methodological differences, particularly in study design. The purpose of this study is to clarify the longitudinal associations between heavy alcohol use and incapacitated sexual assault among first-year college women, accounting for hypothesized autoregressive effects within each construct over their first year of college. A sample of 483 women completed regular surveys that assessed a range of health behaviors, including alcohol use and sexual behavior, during their first year of college. We used cross-lagged analyses to examine prospective associations between incapacitated sexual assault and heavy alcohol use (frequency of heavy episodic drinking and peak blood alcohol content). There were significant autoregressive effects, such that women who were engaging in heavier alcohol use as they entered college continued to be heavier alcohol users throughout their first year, and women with a history of assault at college entry were at greater risk for assault during their first year of college. There was a significant cross-lagged effect from precollege incapacitated assault to first-semester alcohol use after controlling for pre-college alcohol use. There were no significant cross-lag paths from alcohol use to subsequent incapacitated assault. Women with a history of incapacitated sexual assault engaged in heavier drinking during their transition to college, but heavy alcohol use did not predict subsequent assault risk.

Brief behavioral activation intervention for depressive symptoms: Patient satisfaction, acceptability, engagement, and treatment response

Depressive symptoms are the most common reason for referral to integrated behavioral health providers in primary care. Although evidence-based brief psychotherapies for depression in primary care exist, treatment duration is a significant barrier to implementation. In this open trial, we examined the patient experience of receiving a brief behavioral activation intervention designed for use in primary care (BA-PC), which comprised 2 30-min appointments and 2 boosters spaced 2-3 weeks apart across 12 weeks, and its impact on depression symptoms. Participants were 22 patients recruited from primary care who reported at least moderate depressive symptoms (score ≥ 10 on the Patient Health Questionnaire-9 [PHQ-9]). Patient experiences were examined through assessing patient engagement, satisfaction, acceptability, and treatment response. Fidelity of intervention delivery in delivering the BA-PC within a 12-week period was also assessed. Participants reported a high level of satisfaction with and acceptability of the BA-PC intervention, materials, and format. Within-subject t tests revealed a significant reduction in depressive symptoms from baseline at the 12-week assessment, based on PHQ-9 total score, t(21) = 3.80, p = .001. Evidence of fidelity included 81% of patients completing the 2 BA-PC appointments, average appointment lengths of approximately 30 min, and high content fidelity within each appointment. These preliminary findings suggest that overall experience of a brief BA-PC intervention was positive, with high patient satisfaction, patient acceptability, and treatment fidelity as well as positive patient treatment response. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Suicide risk among Veteran primary care patients with current anxiety symptoms

BACKGROUND

Although anxiety is prevalent in primary care, the association between anxiety symptoms and suicide risk remains understudied.

OBJECTIVES

This cross-sectional study aimed to (i) assess the prevalence of suicide risk among Veteran primary care patients with anxiety symptoms and (ii) compare suicide risk between patients with a positive (versus negative) depression screen.

METHODS

Participants were 182 adult primary care patients (84.6% male, Mage = 58.3 years) with current anxiety symptoms, but no psychotherapy in specialty care in the past year, at a Veterans Health Administration medical center in New York. Participants completed self-report measures of anxiety, depression and suicide risk via telephone.

RESULTS

Forty percent endorsed ≥1 suicide risk item. Suicide risk was more common among those screening positive (versus negative) for depression (50.5% versus 26.5%, χ2 (1) = 10.88; P = 0.001). Participants with a negative depression screen constituted 31% of all those with any suicide risk. Logistic regression revealed that anxiety symptom severity was not associated with suicide risk (P = 0.14) after controlling for age, sex and depression screen status (P = 0.01).

CONCLUSIONS

A substantial proportion of primary care patients with anxiety was classified as at risk for suicide, even in the absence of a positive depression screen. Primary care providers should assess suicide risk among patients with anxiety symptoms, even if the patients are not seeking specialty mental health treatment, the anxiety symptoms are not severe or do not rise to the level of an anxiety disorder, and comorbid depressive symptoms are not present.

Perceived barriers and facilitators to implementation of peer support in Veterans Health Administration Primary Care-Mental Health Integration settings

Peer support is increasingly recognized as consistent with the goals of integrated primary care and is being implemented in primary care settings as a patient-centered approach that increases patient activation and access to care. Within the Veterans Health Administration (VHA), peer support specialists (PSSs) have traditionally worked in specialty mental health settings and only recently started working in Primary Care-Mental Health Integration (PC-MHI) settings. Prior research has identified implementation challenges, such as role confusion, when integrating peer support into new settings. In this qualitative descriptive study, we conducted semistructured interviews on perceived barriers and facilitators to implementing peer support in PC-MHI with 25 key stakeholders (7 PSSs, 6 PSS supervisors, 6 PC-MHI providers, and 6 primary care providers). We used conventional content analysis to code responses within four a priori implementation categories: barriers, initial facilitators, long-term facilitators, and leadership support. Perceived barriers included poor program functioning, inadequate administrative support, role confusion, and negative stakeholder attitudes. Key perceived facilitators of initializing and maintaining peer support were similar; administrative support was emphasized followed by program functioning and team cohesion. Stakeholder buy-in and access/visibility were perceived to facilitate initial implementation, whereas evidence of success was believed to facilitate maintenance. Stakeholder buy-in and administrative support were considered key elements of leadership support. Results were consistent with prior research from specialty mental health settings, but identified unique considerations for PC-MHI settings, particularly clarifying the PSS role based on local PC-MHI needs, obtaining buy-in, and facilitating integration of PSSs into the primary care team. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Alcohol consequences, not quantity, predict major depression onset among first-year female college students

Alcohol use and its consequences have often been associated with depression, particularly among female college students. Interpretation of this association has been challenging due to potential reverse causation. The current study sought to clarify the temporality of these relationships. We examined: (1) the association between alcohol consumption and onset depression among female college students, and (2) the association between drinking consequences and onset depression among drinkers only. We used a prospective longitudinal design. Participants were first-year female college students who completed a baseline survey at study entry, and monthly assessments of alcohol consumption, drinking consequences, and depression symptoms. Cox proportional hazards regression with time-varying covariates were constructed among the full sample (N = 412) and the drinkers only sample (N = 335). Adjusted hazard ratios accounted for known risk factors for depression such as race/ethnicity, academic challenge, not getting along with one's roommate, sexual victimization prior to college, marijuana use, and socioeconomic status. For each additional average drink per week, adjusting for all covariates, there was no (95% CI: -4%, +4%) increased risk of onset depression. For each additional alcohol consequence, adjusting for all covariates, there was a 19% (95% CI: 5%, 34%) increased risk of onset depression. This significant relationship remained after adjusting for quantity of alcohol consumption. Quantity of alcohol consumed did not predict incident depression. However, experiencing alcohol consequences, regardless of consumption, did increase the risk of incident depression. College substance use and mental health interventions should aim to reduce not only alcohol consumption, but also alcohol-related consequences.

The Role of Integrated Primary Care in Increasing Access to Effective Psychotherapies in the Veterans Health Administration

American military veterans have higher rates of psychiatric disorders, and timely access to high-quality mental health treatment in the Veterans Health Administration (VHA) is a persistent challenge. Integrated primary care (IPC) is one of many strategies implemented by VHA to increase access to care. IPC, including collaborative care and primary care behavioral health services, successfully increases access to initial behavioral health services in primary care (e.g., brief psychotherapies, pharmacotherapy) and continued engagement in specialty mental health services. IPC components that drive increased access include population-based care, response to patient preferences, and team-based care. The state of the evidence for IPC interventions for common behavioral health concerns in primary care (depression, anxiety, posttraumatic stress disorder, alcohol use, tobacco use, and insomnia) is reviewed, with areas for future research and implementation discussed, including how technology can assist IPC services and the importance of incorporating evidence-based psychotherapies into IPC.

Behavioral medicine interventions for adult primary care settings: A review

INTRODUCTION

Health care organizations are embracing integrated primary care (IPC), in which mental health and behavioral health are addressed as part of routine care within primary care settings. Behavioral medicine concerns, which include health behavior change and coping with medical conditions, are common in primary care populations. Although there are evidence-based behavioral interventions that target a variety of behavioral medicine concerns, integrated behavioral health providers need interventions that are sufficiently brief (i.e., ≤6 appointments) to be compatible with IPC.

METHOD

We conducted a literature review of published studies examining behavioral interventions that target prevalent behavioral medicine concerns and can feasibly be employed by IPC providers in adult primary care settings.

RESULTS

A total of 67 published articles representing 63 original studies met eligibility criteria. We extracted data on the behavioral interventions employed, results comparing the active intervention to a comparison group, general fit with IPC, and methodological quality. The vast majority of studies examined brief interventions targeting sleep difficulties and physical activity. The most commonly employed interventions were derived from cognitive-behavioral therapy and motivational interviewing. Outcomes were generally statistically significantly in favor of the active intervention relative to comparison, with highly variable methodological quality ratings (range = 0-5; M = 2.0).

DISCUSSION

Results are discussed in relation to the need for further evidence for brief behavioral interventions targeting other behavioral medicine concerns beyond sleep and physical activity, as well as for more specificity regarding the compatibility of such interventions with IPC practice. (PsycINFO Database Record

Mental health consequences of sexual assault among first-year college women

OBJECTIVE

One in five college women experience unwanted sexual contact while in college, with first-year women being at the greatest risk. Given these data, we investigate how first-semester sexual assault impacts college women's mental health.

PARTICIPANTS

483 female first-year students enrolled in the study during the first month of college.

METHODS

All participants completed a health questionnaire when they arrived on campus and again at the end of their first semester.

RESULTS

Twelve percent of participants reported sexual assault during the first semester of college. After controlling for baseline mental health and precollege sexual assault history, sexual assault during the first semester predicted clinically significant levels of anxiety and depression at the end of that semester.

CONCLUSIONS

The occurrence of sexual assault early in college has adverse mental health consequences.

Patient outcomes associated with primary care behavioral health services: A systematic review

OBJECTIVE

This systematic review focused on Primary Care Behavioral Health (PCBH) services delivered under normal clinic conditions that included the patient outcomes of: 1) access/utilization of behavioral health services, 2) health status, and 3) satisfaction.

METHOD

Following PRISMA guidelines, comprehensive database searches and rigorous coding procedures rendered 36 articles meeting inclusion criteria. The principle summary measures of odd ratios or Cohen's d effect sizes were reported.

RESULTS

Due to significant limitations in the methodological rigor of reviewed studies, robust findings only emerged for healthcare utilization: PCBH is associated with shorter wait-times for treatment, higher likelihood of engaging in care, and attending a greater number of visits. Several small, uncontrolled studies report emerging evidence that functioning, depression, and anxiety improve overtime. There was no evidence of greater improvement in patient health status when PCBH was compared to other active treatments. The limited available evidence supports that patient satisfaction with PCBH services is high.

CONCLUSIONS

The implementation of PCBH services is ahead of the science supporting the usefulness of these services. Patient outcomes for PCBH are weaker than outcomes for Collaborative Care. More rigorous investigations of patient outcomes associated with PCBH are needed to allow for optimization of services.

Self-Management Strategies for Stress and Anxiety Used by Nontreatment Seeking Veteran Primary Care Patients

INTRODUCTION

One of the most common reasons individuals do not seek mental health treatment is a preference to manage emotional concerns on their own. Self-management refers to the strategies that individuals use on their own (i.e., without professional guidance) to manage symptoms. Little research has examined self-management for anxiety despite its potential utility as the first step in a stepped care approach to primary care. The objectives of this study were to describe patients' anxiety self-management strategies, identify which types were perceived to be effective, and explore potential correlates.

MATERIALS AND METHODS

This was an exploratory descriptive study (N = 182) of nontreatment seeking Veterans Health Administration primary care patients (M = 58.3 years of age, SD = 14.9) who reported current anxiety symptoms (≥8 on Generalized Anxiety Disorder-7). The Institutional Review Board approved the study, and all participants provided informed consent. We assessed self-management strategies, anxiety and depression symptoms, and past-year treatment via telephone. Two independent raters coded strategies into 1 of 7 categories (kappa = 0.85) and 23 subcategories (kappa M = 0.82, SD = 0.16).

RESULTS

Participants reported nearly universal (98%) use of self-management, with an average of 2.96 (SD = 1.2) strategies used in the past 3 months, and 91% of all strategies perceived as effective. Self-care (37.0%), cognitive (15.8%), and avoidance (15.1%) strategies were reported most commonly; the most prevalent subcategories were exercise (11.0% of all strategies), redirecting thoughts (9.1%), and family/friends (8.1%). Age and depression screen status were associated with self-management strategy use.

CONCLUSION

Our results demonstrate the ubiquity and high perceived effectiveness of self-management for anxiety among Veteran primary care patients. Although avoidance strategies were fairly common, self-care strategies, particularly exercising, and cognitive strategies, such as redirecting thoughts, were most prevalent in this sample. Strengths of the study include its novelty, our sample of non-treatment seeking Veteran primary care patients with current symptoms, and the open-ended format of the strategies questions. Limitations include reliance on self-report data, dichotomous response options for the perceived effectiveness item, limited number of potential correlates, and sampling from a single medical center. Overall, this research highlights the opportunity that health care providers have to engage primary care patients around self-management to determine what strategies they are using and how effective those strategies may be. Future directions include identification of the most effective and feasible self-management strategies for anxiety to facilitate promotion of evidence-based self-management among primary care patients.

Psychological interventions for anxiety in adult primary care patients: A review and recommendations for future research

Anxiety symptoms are prevalent in primary care, yet treatment rates are low. The integration of behavioral health providers into primary care via the Primary Care Behavioral Health (PCBH) model offers a promising way to improve treatment options by adding a team member with the necessary skillset to deliver evidence-based psychological interventions for anxiety. We conducted a narrative review of psychological interventions for anxiety applied within adult primary care settings (k = 44) to update the literature and evaluate the fit of existing interventions with the PCBH model. The majority of studies were randomized controlled trials (RCTs; 70.5%). Most interventions utilized cognitive-behavioral therapy (68.2%) and were delivered individually, face-to-face (52.3%). Overall, 65.9% of interventions (58.6% of RCTs, 91.7% of pre-post) were effective in reducing anxiety symptoms, and 83.3% maintained the gains at follow-up. Although it is encouraging that most interventions significantly reduced anxiety, their longer formats (i.e., number and duration of sessions) and narrow symptom targets make translation into practice difficult. Methodological limitations of the research included homogenous samples, failure to report key procedural details, pre-post designs, and restrictive eligibility criteria. We offer recommendations to guide future research to improve the likelihood of successful translation of anxiety interventions into clinical practice.

Real-world program evaluation of integrated behavioral health care: Improving scientific rigor

INTRODUCTION

Designing systematic, scientifically rigorous program evaluations (PE) is 1 way to contribute to the significant need to build best practices and a stronger evidence base for integrated behavioral health care. However, there are many potential pitfalls when conducting PE in real-world settings, and many clinicians and administrators may be hesitant to engage in PE due to lack of training or resources. Rigorous PE can be achieved feasibly and efficiently.

METHOD

This article discusses common challenges that arise when conducting PE in integrated behavioral health care settings and illustrates ways to increase the methodological quality of PE efforts using lessons learned from 2 real-world case examples. The first example included a PE of a training program for brief alcohol interventions, and the second example included a PE of a depression medication monitoring service.

RESULTS/DISCUSSION

The case examples demonstrate the need for strategic planning beforehand, including the use of a conceptual framework as well as appropriate study designs/methodology, measurement, and the need for consistency to achieve a well-designed PE. Using the recommendations within this article, it is hoped that the quality of PEs can be improved resulting in more generalizable data that can be used to inform organizations and policymakers to improve health care delivery. (PsycINFO Database Record

Insomnia treatment experience and preferences among veterans affairs primary care patients

Insomnia is common, but undertreated, among primary care patients. Within the Veterans Health Administration (VA), increasing attention has been given to the treatment of insomnia within primary care settings, but little research has examined Veterans' treatment preferences. We examined preferences for sleep treatment among VA primary care patients. Participants (N = 126: 98% male, 89% white; M age = 60 years) completed a brief survey. On the basis of Insomnia Severity Index scores, 22% reported subthreshold and 13% moderate insomnia. Fifty percent reported having issues with sleep (falling asleep, staying asleep, or sleeping too much) in the past 12 months; among these, only 44% reported any discussion of medication (34%) or other strategies (32%) to improve sleep with medical providers. The most preferred treatment approach was to work it out on one's own, followed by consulting the primary care provider (PCP). The most preferred modality was a one-on-one meeting with the PCP, followed by a one-on-one meeting with the behavioral health provider. In conclusion, VA primary care patients preferred handling sleep problems on their own, but if seeking help, they preferred working with PCPs over behavioral health providers. The majority of Veterans preferred individual treatment and strategies other than medication.

Benefits of Hooking Up: Self-Reports from First-Year College Women

OBJECTIVES

This study explored the benefits of hooking up among first-year college women.

METHODS

Two authors coded for the presence of 10 benefits (kappas: 0.76-0.97) in 262 women's responses to an open-response survey question regarding benefits of their most recent hookup.

RESULTS

The most common benefits identified were sexual satisfaction (23%), general positive emotions (21%), increased confidence (11%), and clarification of feelings (11%). Overall, 71% reported at least one benefit, but 29% reported no benefits.

CONCLUSIONS

For some young women, hooking up has benefits that can include meeting their needs for social connection, sexual exploration and intimacy, and fun/enjoyment.

Precollege Predictors of Incapacitated Rape Among Female Students in Their First Year of College

OBJECTIVE

The first year of college is an important transitional period for young adults; it is also a period associated with elevated risk of incapacitated rape (IR) for female students. The goal of this study was to identify prospective risk factors associated with experiencing attempted or completed IR during the first year of college.

METHOD

Using a prospective cohort design, we recruited 483 incoming first-year female students. Participants completed a baseline survey and three follow-up surveys over the next year. At baseline, we assessed precollege alcohol use, marijuana use, sexual behavior, and, for the subset of sexually experienced participants, sex-related alcohol expectancies. At the baseline and all follow-ups, we assessed sexual victimization.

RESULTS

Approximately 1 in 6 women (18%) reported IR before entering college, and 15% reported IR during their first year of college. In bivariate analyses, precollege IR history, precollege heavy episodic drinking, number of precollege sexual partners, and sex-related alcohol expectancies (enhancement and disinhibition) predicted first-year IR. In multivariate analyses with the entire sample, only precollege IR (odds ratio = 4.98, p < .001) remained a significant predictor. However, among the subset of sexually experienced participants, both enhancement expectancies and precollege IR predicted IR during the study year.

CONCLUSIONS

IR during the first year of college is independently associated with a history of IR and with expectancies about alcohol's enhancement of sexual experience. Alcohol expectancies are a modifiable risk factor that may be a promising target for prevention efforts.

Adapting evidence-based, cognitive-behavioral interventions for anxiety for use with adults in integrated primary care settings

Evidence-based treatments for adult patients with anxiety are greatly needed within primary care settings. Psychotherapy protocols, including those for cognitive-behavioral therapy (CBT), are often disorder-specific and were developed for specialty mental health settings, rendering them infeasible in primary care. Behavioral health consultants (BHCs) integrated into primary care settings are uniquely positioned to provide anxiety treatment. However, due to the dearth of empirically supported brief treatments for anxiety, BHCs are tasked with adapting existing treatments for use in primary care, which is quite challenging due to the abbreviated format and population-based approach to care. CBT protocols are highly effective in the treatment of anxiety and fit well with the self-management emphasis of integrated primary care. We review the rationale and procedure for 6 evidence-based CBT intervention techniques (psycho-education, mindfulness and acceptance-based behavioral techniques, relaxation training, exposure, cognitive restructuring, and behavioral activation) that can be adapted for use in the brief format typical of integrated primary care. We offer tips based on our clinical experience, highlight resources (e.g., handouts, websites, apps), and discuss 2 case examples to aid BHCs in their everyday practice. Our goal is to provide BHCs with practical knowledge that will facilitate the use of evidence-based interventions to improve the treatment of anxiety in primary care settings. (PsycINFO Database Record

Hookah Tobacco Smoking During the Transition to College: Prevalence of Other Substance Use and Predictors of Initiation

INTRODUCTION

The prevalence of hookah tobacco smoking is increasing, and the transition to college is a vulnerable time for initiation. Hookah use is associated with other forms of substance use, but most research has been cross-sectional, thus limiting our understanding of temporal patterns of use. The goals of this longitudinal study were to assess the prevalence of hookah use and initiation, as well as other forms of substance use among hookah users, and identify which forms of substance use predicted hookah initiation during the first 30 days of college.

METHODS

Incoming students (N = 936, 50% female) reported on past 30-day substance use prior to the start of the Fall 2011 semester and again 30 days later (n = 817). Substances included hookah, cigarettes, other forms of tobacco, alcohol, marijuana, and other illegal drugs.

RESULTS

Current prevalence of hookah use increased from 9.0% before college to 13.1% during the first month of college. At baseline and follow-up, current hookah users were more likely than nonusers to report current use of cigarettes, cigars/little cigars/clove cigarettes, smokeless tobacco, marijuana, and alcohol. Among pre-college hookah never users, 13.8% initiated hookah use in the first month of college. Alcohol (adjusted odds ratio [AOR] 1.11, 95% confidence interval [CI] 1.05, 1.17) and marijuana (AOR 1.30, 95% CI 1.03, 1.65) were the only substances predictive of hookah initiation.

CONCLUSIONS

Findings indicate that hookah prevention and intervention is needed during the transition to college, and interventions may need to address comorbid alcohol, marijuana, and hookah use.

IMPLICATIONS

To our knowledge this is the first longitudinal study examining predictors of hookah initiation among male and female incoming first-year college students. While hookah users were more likely than nonusers to use all other substances before and during the first month of college, pre-college marijuana and alcohol use were the only two predictors of hookah initiation during the first 30 days of college. Collectively, these findings provide additional support for the need for efficacious hookah prevention and intervention programs. The transition to college appears to be an ideal time to deliver prevention programs given the increased prevalence of hookah use during the first 30 days of college. In addition to prevention, former users may benefit from targeted relapse prevention as one-fifth of former hookah smokers resumed use during the first 30 days of college.

Incapacitated and forcible rape of college women: prevalence across the first year

PURPOSE

The purpose of this study was to document the point and cumulative prevalence of incapacitated rape (IR) and forcible rape (FR) among first-year college women.

METHODS

Female students (N = 483) completed a health questionnaire (1) on arrival on campus; (2) at the end of the fall semester; (3) at the end of the spring semester; and (4) at the end of the summer following their first year of college.

RESULTS

Before entering college, 18% reported IR (attempted and/or completed), and 15% reported FR (attempted and/or completed). During the first year of college, 15% reported IR (attempted or completed) and 9% reported FR (attempted or completed). By the start of the second year (lifetime prevalence), 26% and 22% had experienced IR and FR (attempted or completed), respectively.

CONCLUSIONS

Both incapacitated and forcible sexual assaults and rape have reached epidemic levels among college women. Interventions to address sexual violence on campus are urgently needed.

Implementation of universal behavioral health screening in a university health setting

Universal screening at university health centers can facilitate early identification and treatment of behavioral health problems common among college students. This article describes the (a) process of implementing behavioral health screening at a university health center and (b) results of universal screening for depression, suicidal ideation, alcohol misuse, tobacco use, and sleep problems. We discuss the decision points involved in screening, including what to screen for, whom to screen, how to implement the screening measure, and how to deal with patients who screen positive. During the Spring and Fall 2010 academic semesters, 4,126 screening questionnaires were completed by students (62% female) accessing a university health center. Each semester, 9-13% of students screened positive for depression, 2.5-3% for suicidal ideation, and 33-38% for alcohol misuse, while 10% wanted help with smoking cessation and 12-13% with sleep problems. The results suggest that behavioral health screening in a university health center can help identify students with behavioral health concerns to increase access to care.

Brief Behavioral Interventions for Symptoms of Depression and Insomnia in University Primary Care

OBJECTIVE

To describe how behavioral activation (BA) for depression and stimulus control (SC) for insomnia can be modified to a brief format for use in a university primary care setting, and to evaluate preliminarily their effectiveness in reducing symptoms of depression and insomnia, respectively, using data collected in routine clinical care.

PARTICIPANTS/METHODS

Chart review data were obtained for 11 patients treated between August 2009 and December 2010 with 1 session of brief BA for depression and 17 patients treated with 1 session of brief SC for insomnia.

RESULTS

At 2-week follow-up, patients reported significant decreases in symptoms of depression on the Patient Health Questionnaire-9, t(10) = 3.95, p < .05, and insomnia on the Insomnia Severity Index, t(16) = 5.43, p < .05, respectively.

CONCLUSIONS

This case report provides preliminary evidence of the external validity of brief BA and SC after they were adapted for use within university primary care.