Collaborative care to improve the management of depressive disorders: a community guide systematic review and meta-analysis

Enhancing Behavioral Health Implementation in a Care Coordination Program at a Federally Qualified Health Center: A Case Study Applying Implementation Frameworks

Federally Qualified Health Centers are charged with providing comprehensive health care in traditionally underserved areas, underscoring their importance in caring for and promoting health equity for the large portion of historically marginalized communities in this setting. There is a significant need to ensure Federally Qualified Health Centers are equipped to appropriately address the immense behavioral health needs common among patients served. Care coordination is an evidence-based model that is increasingly utilized in Federally Qualified Health Centers to improve care equity and outcomes. Addressing and supporting behavioral health needs is a key aspect of such care coordination models. Context-specific considerations and programmatic supports, particularly those that address the needs of care coordinators and the complex patients they serve, are needed to ensure such models can appropriately meet and address the behavioral health concerns of the diverse populations served. The goal of this study was to present a mixed-methods case study that systematically applies implementation frameworks to conduct a needs and context assessment to inform the development and testing of evidence-based practice strategies and implementation support as part of a care coordination program within a partnered Federally Qualified Health Center.

Understanding and Navigating the Unique Barriers Rural Primary Care Settings Face when Implementing Collaborative Care for Mental Health

Rural primary care (RPC) clinics may face unique barriers to implementing the Collaborative Care Model (CoCM). We used mixed methods to explore RPC staff and practice facilitator (PF) perspectives on CoCM implementation. PFs reported on barriers and facilitators experienced after each monthly meeting with clinics (n = 459 surveys across 23 clinics). Data were analyzed descriptively and informed qualitative interviews with a purposive sample (n = 11) of clinic staff and PFs. Interviews were analyzed using Rapid Assessment Process and triangulated with quantitative data. The most prominent barriers experienced were: (1) the COVID-19 pandemic, (2) limited availability of site staff to participate in implementation activities, and (3) hiring of new CoCM staff. Qualitative data further characterized the ways these barriers uniquely influenced RPC settings and promising implementation strategies. RPC settings face unique challenges to CoCM implementation, but several promising implementation strategies - when tailored to RPC contexts - may help.

Community-based Collaborative Care for Serious Mental Illness: A Rapid Qualitative Evidence Synthesis of Health Care Providers' Experiences and Perspectives

Community-based collaborative care (CBCC) is an effective approach for addressing the needs of people with mental health conditions. However, even with the established components of CBCC in place, CBCCs effectiveness for serious mental illnesses (SMIs) remains unknown. This review aims to synthesize qualitative evidence of health care providers' experiences of CBCC in order to identify key factors that facilitate or hinder collaboration in the specific context of SMIs. We searched databases to identify 3368 studies. The eligibility criteria included qualitative studies focusing on health care providers' experiences in delivering a CBCC intervention for people with SMIs. Studies were included if they had at least 2 of 3 CBCC components: a multidisciplinary team, case management, and structured communication. Thematic analysis was used to synthesise the findings, and the Standards for Reporting Qualitative Research framework was used to assess the quality of included studies. The protocol is registered on Prospero. Of the 19 studies included in our review, 5 had achieved collaboration, which was driven by several key ingredients: the availability of on-site case managers and psychiatrists, or the psychiatrists' willingness to travel to the site; the psychiatrists' efforts in actively engaging and supporting the CBCC team; the primary care clinicians' willingness to collaborate with the team and reduce traditional hierarchical engagement; the team's understanding of CBCC; and case managers with strong interpersonal and professional skills. The inclusion of CBCC components do not guarantee collaboration. The findings emphasise the importance of on-site mental health specialists, clearly defined roles, and proactive providers in achieving collaboration.

Effective Components of Collaborative Care for Depression in Primary Care: An Individual Participant Data Meta-Analysis

Importance

Collaborative care is a multicomponent intervention for patients with chronic disease in primary care. Previous meta-analyses have proven the effectiveness of collaborative care for depression; however, individual participant data (IPD) are needed to identify which components of the intervention are the principal drivers of this effect.

Objective

To assess which components of collaborative care are the biggest drivers of its effectiveness in reducing symptoms of depression in primary care.

Data Sources

Data were obtained from MEDLINE, Embase, Cochrane Library, PubMed, and PsycInfo as well as references of relevant systematic reviews. Searches were conducted in December 2023, and eligible data were collected until March 14, 2024.

Study Selection

Two reviewers assessed for eligibility. Randomized clinical trials comparing the effect of collaborative care and usual care among adult patients with depression in primary care were included.

Data Extraction and Synthesis

The study was conducted according to the IPD guidance of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses reporting guideline. IPD were collected for demographic characteristics and depression outcomes measured at baseline and follow-ups from the authors of all eligible trials. Using IPD, linear mixed models with random nested effects were calculated.

Main Outcomes and Measures

Continuous measure of depression severity was assessed via validated self-report instruments at 4 to 6 months and was standardized using the instrument's cutoff value for mild depression.

Results

A total of 35 datasets with 38 comparisons were analyzed (N = 20 046 participants [57.3% of all eligible, with minimal differences in baseline characteristics compared with nonretrieved data]; 13 709 [68.4%] female; mean [SD] age, 50.8 [16.5] years). A significant interaction effect with the largest effect size was found between the depression outcome and the collaborative care component therapeutic treatment strategy (-0.07; P < .001). This indicates that this component, including its key elements manual-based psychotherapy and family involvement, was the most effective component of the intervention. Significant interactions were found for all other components, but with smaller effect sizes.

Conclusions and Relevance

Components of collaborative care most associated with improved effectiveness in reducing depressive symptoms were identified. To optimize treatment effectiveness and resource allocation, a therapeutic treatment strategy, such as manual-based psychotherapy or family integration, may be prioritized when implementing a collaborative care intervention.

Assessing the impact of an innovate behavioral health clinic: a retrospective cohort study

BACKGROUND

Patients experiencing a mental health crisis often present to the emergency department and are admitted to an inpatient facility for treatment. This can cause incontinuity in care, increased costs, and may worsen clinical outcomes compared to treatment in the outpatient setting. An innovative behavioral health clinic (BHC) was established to provide a number of critical mental health services such as individual therapy, crisis stabilization, partial hospitalization, substance abuse intensive outpatient services, specialized intensive adult group therapy, medication management (including long-acting injectable antipsychotic administration), and a peer living room. The primary outcome of this study was to assess the impact of the BHC on length of stay (LOS), psychiatric rehospitalization rate, and all-cause emergency department (ED) visits. The secondary outcome was to analyze the interaction of various patient characteristics with the primary outcome.

METHODS

The study site was a community-based health system in the southeastern United States. A retrospective review of medical records was performed for adult patients with a psychiatric hospitalization in 2019 (pre-BHC) and 2022 (post-BHC). Primary outcomes were analyzed using Chi-Square testing and Mann-Whitney U testing. Secondary outcomes were analyzed using Poisson and logistic regression modeling. This study was deemed exempt from review by the health system and university institutional review boards.

RESULTS

Following the establishment of the BHC, mean LOS was significantly longer (+ 1.26 days, p = 0.001) and there was a statistically significant reduction in 30-day (-10.3%, p < 0.001) and 1-year (-28.2%, p < 0.001) rehospitalization as well as 30-day (-8.3%, p = 0.004) and 1-year (-13.5%, p < 0.001) ED visit rate. A diagnosis of schizophrenia and prescription of a LAI were associated with a significant increase in LOS, while being uninsured was associated with a significant decrease. Male gender and a diagnosis of schizophrenia were associated with a significant increase in ED visits, while identifying as White or Caucasian, being uninsured or carrying private insurance, and prescription of a LAI were associated with a significant decrease.

CONCLUSIONS

The implementation of an innovative BHC positively impacted patient care outcomes in the study population. Patient characteristics were identified which independently interacted with these outcomes.

User-Centered Design of a Preference-Driven Patient Activation Tool for Optimizing Depression Treatment in Integrated Primary Care Settings (The Transform DepCare Study)

BACKGROUND

Few patient engagement tools incorporate the complex patient experiences, contexts, and workflows that limit depression treatment implementation.

OBJECTIVE

Describe a user-centered design (UCD) process for operationalizing a preference-driven patient activation tool.

DESIGN

Informed by UCD and behavior change/implementation science principles, we designed a preference-driven patient activation prototype for engaging patients in depression treatment. We conducted three usability cycles using different recruitment/implementation approaches: near live/live testing in primary care waiting rooms (V1-2) and lab-based think aloud testing (V3) oversampling older, low-literacy, and Spanish-speaking patients in the community and via EHR algorithms. We elicited clinician and "heuristic" expert input.

MAIN MEASURES

We administered the system usability scale (SUS) all three cycles and pre-post V3, the patient activation measure, decisional conflict scale, and depression treatment barriers. We employed descriptive statistics and thematically analyzed observer notes and transcripts for usability constructs.

RESULTS

Overall, 43 patients, 3 clinicians, and 5 heuristic (a usability engineering method for identifying usability problems) experts participated. Among patients, 41.9% were ≥ 65 years old, 79.1% female, 23.3% Black, 62.8% Hispanic, and 55.8% Spanish-speaking and 46.5% had ≤ high school education. We described V1-3 usability (67.2, 77.3, 81.8), treatment seeking (92.3%, 87.5%, 92.9%), likelihood/comfort discussing with clinician (76.9%, 87.5%, 100.0%), and pre vs. post decisional conflict (23.7 vs. 15.2), treatment awareness (71.4% vs. 92.9%), interest in antidepressants (7.1% vs. 14.3%), and patient activation (66.8 vs. 70.9), with fewer barriers pertaining to cost/insurance, access/coordination, and self-efficacy/stigma/treatment efficacy. Key themes included digital literacy, understandability, high acceptability for aesthetics, high usefulness of patient/clinician videos, and workflow limitations. We adapted manual entry/visibility/content; added patient activation and a personalized algorithm; and proposed flexible, care manager delivery leveraging clinic screening protocols.

DISCUSSION

We provide an example of leveraging UCD to design/adapt a real-world, patient experience and workflow-aligned patient activation tool in diverse populations.

Evaluating the effectiveness of a collaborative care digital mental health intervention on obsessive-compulsive symptoms in adolescents: A retrospective study

Objective

Obsessive-compulsive (OC) symptoms, characterized by distressing and repetitive thoughts and behaviors, frequently onset during adolescence for individuals with obsessive-compulsive disorder or anxiety disorders. Digital mental health interventions (DMHIs) offer a promising platform to deliver mental health treatment, which may address OC symptoms. The purpose of this retrospective study was to determine the effects of a DMHI, Bend Health, on various domains of OC symptoms, including contamination, responsibility (for harm), unwanted thoughts, and symmetry, in adolescents.

Methods

OC symptoms were assessed at baseline (before beginning care) and monthly in adolescents engaged in different care programs involving coaching and/or therapy with the DMHI. Retrospective analyses were used to identify characteristics associated with OC symptoms (N = 2151) and to characterize treatment responsiveness of adolescents with elevated OC symptoms (n = 553).

Results

Adolescents with elevated OC symptoms (32.2%; n = 693 of 2151) were more likely than those with non-elevated OC symptoms to be female (p < .001), to have comorbid symptoms (e.g. anxiety and depression; p < .001), and participate in therapy (p < .001). Further, their caregivers had higher rates of sleep problems and burnout (p < .05). OC symptoms improved for 87.7% (n = 485 of 532) of adolescents during care with the DMHI, and 46.6% (n = 249 of 534) reported clinically substantive improvement. Scores decreased significantly over months in care (t1187 = -8.06, p < .001). Improvements were also identified for OC symptom dimensions (contamination, responsibility (for harm), unwanted thoughts, and symmetry).

Conclusions

Our results deliver compelling preliminary evidence that participation in coaching and therapy with a DMHI may mitigate a variety of OC symptoms for adolescents. Improvements were observed across different OC symptom types, demonstrating the broad applicability of the DMHI to address various presentations and complexities of OC symptoms.

Implementation cost analysis of collaborative care for perinatal mental health in community health centers

Background

Although costs are of key importance to clinic leadership when considering adoption of new programs, few studies examine real-world resource needs associated with implementing complex interventions for chronic conditions in primary care. This analysis sought to identify the costs necessary to implement the evidence-based collaborative care model (CoCM), an integrated behavioral health program for common mental disorders in primary care.

Methods

Ten federally qualified health centers (FQHCs) adopted CoCM as part of a larger national randomized trial evaluating implementation strategies for CoCM when adapted for perinatal mental health. The Cost of Implementing New Strategies (COINS) tool was used to assess implementation costs associated with activities completed by sites as they progressed through the implementation process. National wage norms were used to calculate cost estimates for staff time.

Results

On average, clinics spent $40,778 (SD=$30,611) on implementation, with clinics ranging widely from $4,502 to $103,156. Three out of 10 participating clinics achieved competency in the intervention during the 2-year implementation period. Costs among competent clinics ranged from $20,944 to $65,415 (mean=$41,788). Clinics that did not achieve competency were more varied, with both the lowest and highest resource use. Significant staff effort was required to complete all implementation stages; clinical staff and program champions showed greatest effort.

Conclusions

Site implementation costs for this complex behavioral health intervention were substantial and varied dramatically, particularly among sites who did not achieve competence. Additional work is needed to identify optimal site resource investment related to implementation success for CoCM.

Trial registration

ClinicalTrials.gov.NCT02976025. Registered on November 23, 2016.

Clinical Variables Associated with Successful Treatment of Depression or Anxiety in Collaborative Care

Collaborative Care, an evidence-based model, has proven effective in treating depression and anxiety in healthcare settings. However, limited attention has been paid to exploring treatment outcome differences by clinical variables and diagnosis within this model. While previous research suggests that early and frequent contacts and swift treatment access lead to positive outcomes for depression and anxiety, these aspects have not been comprehensively examined in Collaborative Care. This study investigates the impact of clinical variables on treatment completion in patients primarily diagnosed with anxiety or depression who received collaborative care treatment as a treatment program. Analysis was completed as an observational study of patients (n =2018) with behavioral health diagnoses spanning from 2016 to 2023. Classification analysis offers insights into optimal practices for implementing Collaborative Care across diverse healthcare populations from pediatric to geriatric. Identifying clinical characteristics associated with successful treatment in Collaborative Care has far-reaching implications for model adoption and enhancing patient outcomes. Across all results, patients who received more clinical support and had shorter enrollment durations showed a strong association with successful treatment completion.

A global perspective: Access to mental health care for perinatal populations

Perinatal mental health care differs around the world. We provide a global perspective on the current status of service provision, barriers and facilitators to access, and strategies to improve access in high-income and low- and middle-income countries across five continents (Asia, Africa, Europe, North America and South America). Many of the countries considered do not have universal healthcare coverage. This poses a challenge to perinatal mental health care access. However, there are other social and structural barriers to access, including stigma and other sources of marginalization and discrimination. Yet there are opportunities discussed herein to learn more about what perinatal mental health services work for what populations* and in what circumstances, by adopting a global lens to examine innovative solutions utilized across geographical settings.

A Qualitative Investigation of Characteristics Impacting Clinical Decision-Making in Integrated Behavioral Health Care

To support implementation of integrated behavioral health care (IBHC) models in local settings, providers may benefit from clinical decision-making support. The present analysis examines perspectives on patient characteristics appropriate or inappropriate for, and currently managed within, IBHC at a large medical center to inform recommendations for provider decision-making. Twenty-four participants (n = 13 primary care providers; n = 6 behavioral health providers; n = 5 administrators) in an IBHC setting were interviewed. Thematic analysis was conducted with acceptable interrater reliability (κ = 0.75). Responses indicated behavioral health symptom and patient characteristics that impact perceptions of appropriateness for management in IBHC, with high variability between providers. Many patients with characteristics identified as inappropriate for IBHC were nonetheless currently managed in IBHC. Interactions between patient ability to engage in care and provider ability to manage patient needs guided decisions to refer a patient to IBHC or specialty care. A heuristic representing this dimensional approach to clinical decision-making is presented to suggest provider decision-making guidance informed by both patient and provider ability.

Implementation of collaborative care for depression in VA HIV clinics: Translating Initiatives for Depression into Effective Solutions (HITIDES): protocol for a cluster-randomized type 3 hybrid effectiveness-implementation trial

BACKGROUND

Depression is the most diagnosed mental health condition among people living with HIV. Collaborative care is an effective intervention for depression, typically delivered in primary care settings. The HIV Translating Initiatives for Depression into Effective Solutions (HITIDES) clinical intervention involves a depression care team housed off-site that supports depression care delivery by HIV care providers. In a randomized controlled trial, HITIDES significantly improved depression symptoms for veterans living with HIV and delivered cost savings. However, no HIV clinics in the Veterans Health Administration (VHA) have implemented HITIDES; as such, it is unclear what implementation strategies are necessary to launch and sustain this intervention.

METHODS

This hybrid type-3 effectiveness-implementation trial examines the implementation and effectiveness of HITIDES in 8 VHA HIV clinics randomly assigned to one of two implementation arms. Each arm uses a different implementation strategy package. Arm 1 includes an intervention operations guide; an on-site clinical champion who, with the help of a peer community of practice, will work with local clinicians and leadership to implement HITIDES at their site; and patient engagement in implementation tools. Arm 2 includes all strategies from Arm 1 with assistance from an external facilitator. The primary implementation outcomes is reach; secondary outcomes include adoption, implementation dose, depressive symptoms, and suicidal ideation. We will conduct a budget impact analysis of the implementation strategy packages. We hypothesize that Arm 2 will be associated with greater reach and adoption and that Arm 1 will be less costly.

DISCUSSION

Preliminary work identified implementation strategies acceptable to veterans living with HIV and HIV care providers; however, the effectiveness and cost of these strategies are unknown. While the depression care team can deliver services consistently with high quality, the ability of the depression care team to engage with HIV care providers at sites is unknown. Findings from this study will be used to inform selection of implementation strategies for a broad rollout to enhance depression and suicide care for people living with HIV.

TRIAL REGISTRATION

ClinicalTrials.gov ID: NCT05901272, Registered 10 May 2023, https://clinicaltrials.gov/study/NCT05901272.

Depression Part 2: Treatment

Depression treatment strategies are within the scope of pediatric practice and among the competencies recommended by the Academy of Pediatrics and The American Board of Pediatrics. Treatments that may be provided through collaborative care include nonpharmacologic therapies such as psychosocial treatments and evidence-based psychotherapies, and pharmacotherapy and monitoring processes for depression. Abundant support and guidance are available to pediatricians in depression care, including mental health consultation and online materials.

Depression Part 1: Evaluation

By young adulthood, 1 in 5 teens will experience an episode of major depression. The second leading cause of death among youths aged 15 to 24 years is suicide, most of which will have been caused by untreated or undiagnosed depression. Depression is a highly heritable condition: depressed children often have depressed parents. Support to caregivers is important because depressed parents can have negative effects on children's development and future mental health. Groups more vulnerable to mental health disorders such as depression include Black, Indigenous, and persons of color and lesbian, gay, bisexual, transgender, or queer/questioning, who in recent years have the highest rate of suicide attempts (Black teens, sexual minority youth), the highest increases in suicide rates (Black children and youths), and the highest suicide rates (American Indian/Alaskan native). They frequently experience more adverse childhood events, which increases the risk of depression and suicide attempts. Pediatricians are most likely to care for these vulnerable youths, who often are less engaged in specialty mental health care for a variety of reasons, including stigma and barriers to access. By offering behavioral and mental health care to vulnerable populations in primary care, mental health equity may be achieved. Screening for depression and assessment for suicide are within the scope of pediatric practice and among the competencies recommended by the American Academy of Pediatrics and The American Board of Pediatrics.

Healing the Whole: An International Review of the Collaborative Care Model between Primary Care and Psychiatry

The collaborative care model (CCM) was created to improve the delivery of mental health care and is reported to improve access, enhance treatment outcomes, and reduce healthcare costs. To understand the impacts of the CCM on symptom management, diverse populations, and sustainability in healthcare systems, a systematic review was conducted. Several databases were searched for articles assessing the CCM. The inclusion criteria limited the studies to those (1) published between January 2008 and January 2024; (2) written in the English language; (3) analyzing adult patients; (4) analyzing symptom improvement in major depressive disorder, generalized anxiety disorder, or post-traumatic stress disorder; and (5) fitting the given definition of a CCM. We identified 9743 articles. Due to missing information or duplication, 4702 were excluded. The remaining articles were screened, yielding 468 articles for full-text analysis, of which 16 articles met the inclusion criteria. Of these articles, five primarily focused on individual patient outcomes, five focused on specific populations, and six reviewed system impacts; eleven articles studied US populations and five studied international populations. An analysis revealed that in 12 of the final articles, the CCM led to a statistically significant improvement in anxiety and depression symptoms with viable implementation and sustainability strategies. The CCM is an effective method for improving patient symptoms and can be potentially affordable in healthcare systems.

Exploring the acceptability, barriers, and facilitators to psychosis screening in the integrated behavioral health primary care setting: a qualitative study

BACKGROUND

A longer duration of untreated psychosis (DUP) is associated with poorer treatment outcomes. Screening for psychosis spectrum disorders in the primary care setting could help support the earlier detection and treatment of individuals in need. However, the acceptability of screening for psychosis in this setting as part of routine care is currently unknown.

METHODS

We conducted a qualitative interview study with providers and service users who participated in an early psychosis screening program conducted in an integrated behavioral health primary care (IBH-PC) setting. Interviews were recruited from one of eight WellSpace Federally Qualified Health Center IBH-PC clinics in the Sacramento, CA area. Transcripts of the recorded interviews were analyzed using thematic analysis.

RESULTS

In total, 12 providers and eight service users participated in the interviews. Most service user and provider participants were supportive of psychosis screening in an IBH-PC setting, but not as part of the general practitioner consultation due to the brief, non-behavioral health nature of many of the appointments, and the expected low prevalence of psychosis in this population. The support of leadership, adequate training and support, staff turnover, and organizational changes were all seen to impact the successful implementation of the program. Different barriers and facilitators were considered important at each stage of the process from introducing the screening procedures to service users; to determining when, where, and how to screen; and how to effectively manage the referral and post-referral stages.

CONCLUSIONS

Despite the additional challenges of screening in an IBH-PC setting relative to secondary mental health services, the process was considered acceptable and feasible to providers and service users. Services that plan to conduct psychosis screening in their clinics need to consider the challenges and their potential solutions to implementation at each stage of the screening process.

Mental health recovery in a collectivist society: Saudi consumers, carers and nurses' shared perspectives

In 2019, the World Health Organization urged a global shift towards recovery-focused practices in mental health care. In Western nations, this transition often prioritised individualism over collectivism. In contrast, collectivist societies prioritise recovery through community and social support. This study explored mental health recovery from the perspectives of consumers, carers and registered nurses in a mainly collectivist society (Saudi Arabia) using a qualitative exploratory descriptive design. Sixteen consumers, ten carers and eight registered nurses participated in online semi-structured interviews. Inductive thematic analysis was employed to analyse English-translated versions of the 34 interviews. Consolidated criteria for reporting qualitative studies 32-item checklist were used. The study found that recovery was perceived as a process of transforming towards living a meaningful life of goals and values supported by trusted people who share moments of comfort and empowerment. A unique finding was the 'bond of recovery' a collectivist value that aid consumers' community integration in society. Saudi consumers' experiences of recovery were similar to consumers' movement narratives of recovery. Future research should establish a recovery-focused educational program that incorporates our findings into a recovery-oriented approach. This will facilitate providing a collaborative care between consumers, carers and nurses that centres around consumers' recovery goals and values.

The design and implementation of a multi-center, pragmatic, individual-level randomized controlled trial to evaluate Baby2Home, an mHealth intervention to support new parents

BACKGROUND

Becoming a parent is a transformative experience requiring multiple transitions, including the need to navigate several components of health care, manage any mental health issues, and develop and sustain an approach to infant feeding. Baby2Home (B2H) is a digital intervention built on the collaborative care model (CCM) designed to support families during these transitions to parenthood.

OBJECTIVES

We aim to investigate the effects of B2H on preventive healthcare utilization for the family unit and patient-reported outcomes (PROs) trajectories with a focus on mental health. We also aim to evaluate heterogeneity in treatment effects across social determinants of health including self-reported race and ethnicity and household income. We hypothesize that B2H will lead to optimized healthcare utilization, improved PROs trajectories, and reduced racial, ethnic, and income-based disparities in these outcomes as compared to usual care.

METHODS

B2H is a multi-center, pragmatic, individual-level randomized controlled trial. We will enroll 640 families who will be randomized to: [1] B2H + usual care, or [2] usual care alone. Preventive healthcare utilization is self-reported and confirmed from medical records and includes attendance at the postpartum visit, contraception use, depression screening, vaccine uptake, well-baby visit attendance, and breastfeeding at 6 months. PROs trajectories will be analyzed after collection at 1 month, 2 months, 4 months, 6 months and 12 months. PROs include assessments of stress, depression, anxiety, self-efficacy and relationship health.

IMPLICATIONS

If B2H proves effective, it would provide a scalable digital intervention to improve care for families throughout the transition to new parenthood.

Factors Associated with Mental Illness in a Primary Healthcare Setting in the Kingdom of Saudi Arabia: A Case-Control Study

BACKGROUND/OBJECTIVES

Mental health conditions are a leading cause of morbidity and mortality worldwide, with a 13% rise within the last decade. This study aimed to investigate the factors associated with mental illness in patients presenting to a primary healthcare center in the Kingdom of Saudi Arabia (KSA).

METHODS

Data were extracted from the electronic health records of 46 primary care centers in Riyadh, Saudi Arabia from March 2022 to March 2023. A total of 2418 age-matched mental health cases and controls were evaluated. Descriptive and logistic regression analyses were performed to examine the distribution and association of relevant risk factors. A total of 1209 cases were age-matched to 1209 controls presenting to a primary clinic.

RESULTS

The odds of mental illness in females were 2.2 times that of males. Clinical conditions associated with mental illness were stroke, diabetes, and obesity. Neurodegenerative disorders were also associated with mental illness.

CONCLUSIONS

Primary clinics in the KSA can serve as focal points in removing the barriers to mental healthcare. There is an urgent need to spread awareness, remove the stigma, and provide appropriate care and referrals for mental health conditions in the KSA.

Strategies to improve implementation of collaborative care for functional disorders and persistent somatic symptoms: A qualitative study using a Research World Café design

INTRODUCTION

Persistent somatic symptoms and functional disorders (PSS/FD) are often complex conditions requiring care from multiple disciplines. One way of bringing the different disciplines together is through collaborative care. Little is known about the implementation barriers faced and relevant strategies to tackle the barriers in this field. Therefore, using expert knowledge, we aim to develop realistic strategies for dealing with implementation barriers of collaborative care in PSS/FD.

METHODS

The Research World Café method is a single-session, expert-based method with multiple focus-groups forming and reforming to answer a set of inter-related questions, under the guidance of moderators. Using this method, participants involved in PSS/FD care across different areas of healthcare in the Netherlands developed several realistic strategies for dealing with ten implementation barriers for collaborative care in PSS/FD that were previously identified in a Delphi study. Strategies were grouped into strategy clusters using a card-sorting task.

RESULTS

Thirty-three participants took part, representing ten different disciplines, most commonly physiotherapists, psychologists, and physicians. In total, 54 strategies, identified in response to the ten barriers, were grouped into eight strategy clusters. The strategy clusters were professional education, communication, care coordination, care pathways, joint consults, funding, patient involvement, and prevention.

CONCLUSION

We identified a number of useful strategies for dealing with implementation barriers for collaborative care in PSS/FD. Many strategies provided ways to deal with multiple barriers at once. The effects of applying these strategies in collaborative care in PSS/FD will need testing through implementation studies, as well as in other areas needing multidisciplinary care.

Asynchronous Versus Synchronous Screening for Depression and Suicidality in a Primary Health Care System: Quality Improvement Study

Background

Despite being a debilitating, costly, and potentially life-threatening condition, depression is often underdiagnosed and undertreated. Previsit Patient Health Questionnaire-9 (PHQ-9) may help primary care health systems identify symptoms of severe depression and prevent suicide through early intervention. Little is known about the impact of previsit web-based PHQ-9 on patient care and safety.

Objective

We aimed to investigate differences among patient characteristics and provider clinical responses for patients who complete a web-based (asynchronous) versus in-clinic (synchronous) PHQ-9.

Methods

This quality improvement study was conducted at 33 clinic sites across 2 health systems in Northern California from November 1, 2020, to May 31, 2021, and evaluated 1683 (0.9% of total PHQs completed) records of patients endorsing thoughts that they would be better off dead or of self-harm (question 9 in the PHQ-9) following the implementation of a depression screening program that included automated electronic previsit PHQ-9 distribution. Patient demographics and providers' clinical response (suicide risk assessment, triage nurse connection, medication management, electronic consultation with psychiatrist, and referral to social worker or psychiatrist) were compared for patients with asynchronous versus synchronous PHQ-9 completion.

Results

Of the 1683 patients (female: n=1071, 63.7%; non-Hispanic: n=1293, 76.8%; White: n=831, 49.4%), Hispanic and Latino patients were 40% less likely to complete a PHQ-9 asynchronously (odds ratio [OR] 0.6, 95% CI 0.45-0.8; P<.001). Patients with Medicare insurance were 36% (OR 0.64, 95% CI 0.51-0.79) less likely to complete a PHQ-9 asynchronously than patients with private insurance. Those with moderate to severe depression were 1.61 times more likely (95% CI 1.21-2.15; P=.001) to complete a PHQ-9 asynchronously than those with no or mild symptoms. Patients who completed a PHQ-9 asynchronously were twice as likely to complete a Columbia-Suicide Severity Rating Scale (OR 2.41, 95% CI 1.89-3.06; P<.001) and 77% less likely to receive a referral to psychiatry (OR 0.23, 95% CI 0.16-0.34; P<.001). Those who endorsed question 9 "more than half the days" (OR 1.62, 95% CI 1.06-2.48) and "nearly every day" (OR 2.38, 95% CI 1.38-4.12) were more likely to receive a referral to psychiatry than those who endorsed question 9 "several days" (P=.002).

Conclusions

Shifting depression screening from in-clinic to previsit led to a dramatic increase in PHQ-9 completion without sacrificing patient safety. Asynchronous PHQ-9 can decrease workload on frontline clinical team members, increase patient self-reporting, and elicit more intentional clinical responses from providers. Observed disparities will inform future improvement efforts.

Missing link: a qualitative analysis of community-based organisations' contributions to partnered collaborative care to treat late-life depression

OBJECTIVE

Extending collaborative care, a model integrating mental health services into primary care, to include community-based organisations (CBOs) may improve older patient health outcomes by increasing access to care and addressing patients' social needs; however, little is known about how CBOs contribute to such partnered depression care. We explored how six primary care clinic and CBO partnerships came together to provide late-life depression care through the Care Partners funded in 2014.

DESIGN

43 key informant interviews and 15 focus groups were conducted with care managers, administrators and primary care providers partnering to provide late-life depression care. Data were coded and analysed iteratively using qualitative thematic analysis.

SETTING

Six primary care clinic-CBO sites across California.

PARTICIPANTS

Care managers, administrators and primary care providers participated in this study.

RESULTS

Three unique contributions of CBOs to depression care in these clinic-CBO partnerships were identified: (1) CBOs added new services that focus on social needs and enhanced depression care; (2) CBOs strengthened core aspects of collaborative care for depression; (3) CBOs provided new avenues for building connections and trust with underserved patients.

CONCLUSIONS

CBOs, when partnered with clinics, enhanced both medical and social aspects of depression treatment for older adults. CBOs are well positioned to assist primary care clinics in treating the complex health needs of older adults by providing new and strengthening existing aspects of partnered depression care while building patient trust among culturally diverse populations.

Barriers and facilitators to collaborative care implementation within the New York State Collaborative Care Medicaid Program

BACKGROUND

Since 2015, the New York State Office of Mental Health has provided state primary care clinics with outreach, free training and technical assistance, and the opportunity to bill Medicaid for the Collaborative Care Model (CoCM) as part of its Collaborative Care Medicaid Program. This study aims to describe the characteristics of New York State primary care clinics at each step of CoCM implementation, and the barriers and facilitators to CoCM implementation for the New York State Collaborative Care Medicaid Program.

METHODS

In this mixed-methods study, clinics were categorized into RE-AIM (Reach, Effectiveness, Adoption, Implementation, and Maintenance) steps. Clinics were sent a survey, which included questions related to payer mix, funding sources, billing codes used, and patient population demographics. Qualitative interviews were conducted with clinic representatives, focusing on barriers or facilitators clinics experienced affecting their progression to the next RE-AIM step.

RESULTS

One thousand ninety-nine surveys were sent to primary care clinics across New York State, with 107 (9.7%) completing a survey. Significant differences were observed among the different RE-AIM steps for multiple demographic variables including primary payer, percentage of patients with a diagnose of depression or anxiety, and percent of behavioral health services that are reimbursed, in addition to others. Three main themes regarding barriers and facilitators to implementing CoCM for New York State Medicaid billing emerged from 31 qualitative interviews: (1) Billing requirements, (2) Reimbursement rates, and (3) Buy-in to CoCM.

CONCLUSIONS

Survey data align with what we would expect to see demographically in NYS primary care clinics. Qualitative data indicated that CoCM billing requirements/structure and reimbursement rates were perceived as barriers to providing CoCM, particularly with New York State Medicaid, and that buy-in, which included active involvement from organizational leaders and providers that understand the Collaborative Care model were facilitators. Having dedicated staff to manage billing and data reporting is one way clinics minimize barriers, however, there appeared to be a disconnect between what clinics can bill for and the reimbursed amount several clinics are receiving, illustrating the need for stronger billing workflows and continued refinement of billing options across different payers.

Step away from depression-results from a multicenter randomized clinical trial with a pedometer intervention during and after inpatient treatment of depression

Evidence for the effectiveness of physical activity (PA) in the treatment of depression prevails for outpatients with mild and moderate symptom levels. For inpatient treatment of severe depression, evidence-based effectiveness exists only for structured and supervised group PA interventions. The Step Away from Depression (SAD) study investigated the effectiveness of an individual pedometer intervention (PI) combined with an activity diary added to inpatient treatment as usual (TAU). In this multicenter randomized controlled trial, 192 patients were randomized to TAU or TAU plus PI. The two primary outcomes at discharge were depression-blindly rated with the Montgomery-Åsberg Depression Rating Scale (MADRS)-and average number of daily steps measured by accelerometers. Secondary outcomes were self-rated depression and PA, anxiety, remission and response rates. Multivariate analysis of variance (MANOVA) revealed no significant difference between both groups for depression and daily steps. Mean MADRS scores at baseline were 29.5 (SD = 8.3) for PI + TAU and 28.8 (SD = 8.1) for TAU and 16.4 (SD = 10.3) and 17.2 (SD = 9.9) at discharge, respectively. Daily steps rose from 6285 (SD = 2321) for PI + TAU and 6182 (SD = 2290) for TAU to 7248 (SD = 2939) and 7325 (SD = 3357). No differences emerged between groups in secondary outcomes. For severely depressed inpatients, a PI without supervision or further psychological interventions is not effective. Monitoring, social reinforcement and motivational strategies should be incorporated in PA interventions for this population to reach effectiveness.

Core Components and Implementation Determinants of Multilevel Service Delivery Frameworks Across Child Mental Health Service Settings

Multilevel service delivery frameworks are approaches to structuring and organizing a spectrum of evidence-based services and supports, focused on assessment, prevention, and intervention designed for the local context. Exemplar frameworks in child mental health include positive behavioral interventions and supports in education, collaborative care in primary care, and systems of care in community mental health settings. Yet, their high-quality implementation has lagged. This work proposes a conceptual foundation for multilevel service delivery frameworks spanning diverse mental health service settings that can inform development of strategic implementation supports. We draw upon the existing literature for three exemplar multilevel service delivery frameworks in different child mental health service settings to (1) identify core components common to each framework, and (2) to highlight prominent implementation determinants that interface with each core component. Six interrelated components of multilevel service delivery frameworks were identified, including, (1) a systems-level approach, (2) data-driven problem solving and decision-making, (3) multiple levels of service intensity using evidence-based practices, (4) cross-linking service sectors, (5) multiple providers working together, including in teams, and (6) built-in implementation strategies that facilitate delivery of the overall model. Implementation determinants that interface with core components were identified at each contextual level. The conceptual foundation provided in this paper has the potential to facilitate cross-sector knowledge sharing, promote generalization across service settings, and provide direction for researchers, system leaders, and implementation intermediaries/practitioners working to strategically support the high-quality implementation of these frameworks.

Development of a competency framework for the Assistant Wellbeing Practitioner (Renal) role

BACKGROUND

Many people with kidney disease experience comorbid mental health difficulties that result in worse physical health outcomes alongside greater personal, treatment and societal costs.

PROBLEM

Workforce expansion to treat comorbid mental health difficulties has focussed on psychological practitioners. This fails to capitalise on benefits arising from embedding roles to address biopsychosocial outcomes directly within the renal specialty. A competency framework to inform development and training for such a role has not been developed.

METHODS

Five-phase process to develop a competency framework for an Assistant Wellbeing Practitioner (Renal) role. Following identification of competency frameworks for roles in psychological practice, health and social care, relevant competencies were synthesised to create a draft competency framework. This framework was revised through consultation events with professionals associated with the renal specialty and Kidney Patient Involvement Network with the framework informing a competency map.

RESULTS

The competency map comprised three categories-Knowledge, Values and Principles, Core Skills and Meta-Competencies with specific competencies for an assistant practitioner role to work within the renal specialty identified. Core knowledge and skills included awareness of kidney treatments and common psychosocial difficulties, collaborative care and supporting evidence-based prevention approaches.

CONCLUSIONS

Competencies associated with the Assistant Wellbeing Practitioner (Renal) role have the potential to promote mental wellbeing, better physical health and generate social and economic benefits. The competency map can inform training and role evaluation, although addressing implementation issues associated with commissioning physical and mental healthcare is required.

Palliative Care Psychiatry: Building Synergy Across the Spectrum

PURPOSE OF REVIEW

Palliative care (PC) psychiatry is a growing subspecialty focusing on improving the mental health of those with serious medical conditions and their caregivers. This review elucidates the current practice and ongoing evolution of PC psychiatry.

RECENT FINDINGS

PC psychiatry leverages training and clinical practices from both PC and psychiatry, addressing a wide range of needs, including enhanced psychiatric care for patients with serious medical illness, PC access for patients with medical needs in psychiatric settings, and PC-informed psychiatric approaches for individuals with treatment-refractory serious mental illness. PC psychiatry is practiced by a diverse workforce comprising hospice and palliative medicine-trained psychiatrists, psycho-oncologists, geriatric psychiatrists, other mental health professionals, and non-psychiatrist PC clinicians. As a result, PC psychiatry faces challenges in defining its operational scope. The manuscript outlines the growth, current state, and prospects of PC psychiatry. It examines its roles across various healthcare settings, including medical, integrated care, and psychiatric environments, highlighting the unique challenges and opportunities in each. PC psychiatry is a vibrant and growing subspecialty of psychiatry that must be operationalized to continue its developmental trajectory. There is a need for a distinct professional identity for PC psychiatry, strategies to navigate administrative and regulatory hurdles, and greater support for novel clinical, educational, and research initiatives.

Collaborative care model versus usual care for the management of musculoskeletal and co-existing mental health conditions: a randomised feasibility mixed-methods study

OBJECTIVE

This study aimed to assess the feasibility of a future trial comparing the collaborative care model with usual care for patients with musculoskeletal conditions and co-existing symptoms of anxiety and depression.

DESIGN

A single-centre, parallel-arm, one-to-one, randomised controlled trial design using a mixed-methods approach was used. semistructured interviews and focus groups were conducted post intervention with all participants and staff respectively to explore acceptability towards the model and identify recommendations for improvements.

SETTING

An orthopaedic rehabilitation outpatient tertiary hospital.

PARTICIPANTS

Adult patients with musculoskeletal conditions and co-existing moderate or severe symptoms of anxiety and depression attending outpatient therapy appointments.

INTERVENTION

The collaborative care model consisted of a tailored management programme to facilitate the integration of care provided by physical and mental healthcare professionals. A case manager screened and coordinated targeted mental health support for participants. Participants allocated to usual care had no support from the case manager.

MAIN OUTCOMES MEASURE

Feasibility indicators (rates of recruitment, randomisation and retention), acceptability of clinical outcome measures, usage of additional resources and cost of intervention implementation.

RESULTS

Of the 89 patients who provided consent to take part, 40 participants who matched the eligibility criteria were randomised to either the intervention (n=20) or usual care arm (n=20). Overall adherence to the intervention was 58.82%, while the withdrawal rate was 37.5% at 6 months. All of the 27 participants who were retained completed self-reported outcomes. Qualitative data highlighted that integrated mental health support was favourably perceived. In addition to prenegotiating protected psychology time, the need for operationalised communication between the case manager and clinicians was identified as a recommendation for a future trial.

CONCLUSIONS

The trial and intervention were acceptable to patients and healthcare professionals. While the findings demonstrate the feasibility of trial recruitment, a future trial will require optimised retention strategies to improve adherence and withdrawal rates.

TRIAL REGISTRATION NUMBER

NCT05018039.

Effects of intervention stage completion in an integrated behavioral health and primary care randomized pragmatic intervention trial

Purpose

A pragmatic, cluster-randomized controlled trial of a comprehensive practice-level, multi-staged practice transformation intervention aimed to increase behavioral health integration in primary care practices and improve patient outcomes. We examined association between the completion of intervention stages and patient outcomes across a heterogenous national sample of primary care practices.

Methods

Forty-two primary care practices across the U.S. with co-located behavioral health and 2,426 patients with multiple chronic medical and behavioral health conditions completed surveys at baseline, midpoint and two year follow-up. Effects of the intervention on patient health and primary care integration outcomes were examined using multilevel mixed-effects models, while controlling for baseline outcome measurements.

Results

No differences were found associated with the number of intervention stages completed in patient health outcomes were found for depression, anxiety, fatigue, sleep disturbance, pain, pain interference, social function, patient satisfaction with care or medication adherence. The completion of each intervention stage was associated with increases in Practice Integration Profile (PIP) domain scores and were confirmed with modeling using multiple imputation for: Workflow 3.5 (95% CI: 0.9-6.1), Integration Methods 4.6 (95% CI: 1.5-7.6), Patient Identification 2.9 (95% CI: 0.9-5.0), and Total Integration 2.7 (95% CI: 0.7-4.7).

Conclusion

A practice-centric flexible practice transformation intervention improved integration of behavioral health in primary care across heterogenous primary care practices treating patients with multiple chronic conditions. Interventions that allow practices to flexibly improve care have potential to help complex patient populations. Future research is needed to determine how to best target patient health outcomes at a population level.

HIV Pre-exposure Prophylaxis (PrEP) Care in Belgium: A mixed-methods Study on PrEP Users' Experiences and Service Delivery Preferences

In Belgium, HIV pre-exposure prophylaxis (PrEP) services are mainly provided through specialised HIV clinics. To optimise PrEP uptake and retention in care, we require insights into users' perspectives on PrEP care. We aimed to elicit experiences with, and preferences for, PrEP service delivery among PrEP users in Belgium, including willingness to involve their family physician (FP) in PrEP care. We adopted a sequential mixed-methods design. We used a web-based longitudinal study among 326 PrEP users that consisted of two questionnaires at six-month intervals, and complemented this with 21 semi-structured interviews (September 2020-January 2022). We conducted descriptive analyses and logistic regression to examine factors associated with willingness to involve their FP in PrEP care. Interviews were analysed using thematic analysis. Survey respondents reported high satisfaction with care received in HIV clinics [median score 9 (IQR 8-10), 10='very satisfied']. Interviews revealed the importance of regular HIV/STI screening, and the expertise and stigma-free environment of HIV clinics. Yet, they also contextualised service delivery barriers reported in the questionnaire, including the burden of cost and challenges integrating PrEP visits into their private and professional lives. Although 63.8% (n = 208/326) of baseline respondents preferred attending an HIV clinic for PrEP follow-up, 51.9% (n = 108/208) of participants in the follow-up questionnaire reported to be willing to have their FP involved in PrEP care. Participants reporting trust in FPs' PrEP and sexual health expertise, or who didn't feel judged by their FP, were more likely to be willing to involve them in PrEP care. Therefore, we recommend a differentiated PrEP service delivery approach, including involving FPs, to make PrEP care more client-centred.

Effectiveness of care models for chronic disease management: A scoping review of systematic reviews

OBJECTIVE

To conduct a scoping review of models of care for chronic disease management to identify potentially effective components for management of chronic traumatic brain injury (TBI).

METHODS

Information sources: Systematic searches of three databases (Ovid MEDLINE, Embase, and Cochrane Database of Systematic Reviews) from January 2010 to May 2021.

ELIGIBILITY CRITERIA

Systematic reviews and meta-analyses reporting on the effectiveness of the Chronic Care Model (CCM), collaborative/integrated care, and other chronic disease management models.

DATA

Target diseases, model components used (n = 11), and six outcomes (disease-specific, generic health-related quality of life and functioning, adherence, health knowledge, patient satisfaction, and cost/health care use).

SYNTHESIS

Narrative synthesis, including proportion of reviews documenting outcome benefits.

RESULTS

More than half (55%) of the 186 eligible reviews focused on collaborative/integrated care models, with 25% focusing on CCM and 20% focusing on other chronic disease management models. The most common health conditions were diabetes (n = 22), depression (n = 16), heart disease (n = 12), aging (n = 11), and kidney disease (n = 8). Other single medical conditions were the focus of 22 reviews, multiple medical conditions of 59 reviews, and other or mixed mental health/behavioral conditions of 20 reviews. Some type of quality rating for individual studies was conducted in 126 (68%) of the reviews. Of reviews that assessed particular outcomes, 80% reported disease-specific benefits, and 57% to 72% reported benefits for the other five types of outcomes. Outcomes did not differ by the model category, number or type of components, or target disease.

CONCLUSIONS

Although there is a paucity of evidence for TBI per se, care model components proven effective for other chronic diseases may be adaptable for chronic TBI care.

Bring It Up: An Adapted Collaborative Care Model for Depression in a Safety-Net Primary Care Clinic

Objective

Over 90 clinical trials demonstrate the efficacy of the collaborative care model (CoCM) to treat depression in primary care but there is significant variability in real-world CoCM implementation and scalability. This study aimed to determine the feasibility and effectiveness of an adapted CoCM in a safety-net primary care setting.

Methods

Bring It Up! (BIU) is a pilot trial comparing an adapted CoCM (intervention group) to usual care (historical controls) for primary care safety-net clinic patients with depression. Inclusion criteria: (1) age ≥18; (2) Patient Health Questionnaire-9 (PHQ-9) score ≥10; and (3) major depressive disorder diagnosis. Patients who completed ≥6 months of treatment upon rolling enrollment (April 1, 2018-October 31, 2019) were included. Historical controls completed ≥6 months of usual care in 2017. BIU included all aspects of CoCM except accountable care and leveraged existing staff rather than a dedicated care manager. The primary outcome was depression remission (PHQ-9 <5) within 6 months. Secondary outcomes included depression response, adherence to treatment guidelines and care coordination process. Data were extracted from the electronic health record.

Results

Thirty-six patients received the intervention; 41 controls received usual care. Depression remission was achieved in 33.3% of intervention patients and 0% of controls (p = 0.001). Of intervention patients, 44.4% achieved ≥50% reduction in PHQ-9 compared to 4.9% of controls (p = 0.003). Further, 66.7% of intervention patients had guideline-recommended antidepressant medication titration compared to 26.9% of controls (p = 0.003); 94.4% of intervention patients had PHQ-9 repeated compared to 53.7% of controls (p < 0.001).

Conclusions

An adapted CoCM was feasible and improved depression care in a safety-net clinic.

Effectiveness of a coordinated ambulatory care program for patients with mental disorders or multiple sclerosis: results of a prospective non-randomized controlled trial in South Germany

Background

The Psychiatry, Neurology, Psychosomatics and Psychotherapy (PNP) program of the German statutory health insurance AOK BW promotes coordinated and evidence-based specialist care with the aim of providing individualized, guideline-based outpatient care, strengthening the collaboration between health care providers, as well as reducing care costs. The purpose of this study was to evaluate its effectiveness regarding patient-reported outcomes compared to the less specialized general practitioner program (GP) and usual care (UC).

Materials and methods

AOK insured patients, who were on sick leave due to a mental disorder (affective disorder, anxiety disorder, adjustment disorder, somatoform disorder, alcohol abuse disorder, schizophrenia) or multiple sclerosis were included in the prospective non-randomized controlled study. All patients either participated in the PNP program (intervention group, IG-PNP), the general practitioner program (control group, CG-GP) or usual care (control group, CG-UC). Entropy balancing was used to adjust for baseline imbalance between groups. Primary outcome was health-related quality of life, assessed by the Short-form health survey (SF-36) 12 months after diagnosis. Secondary outcomes included symptom severity, functional health, and treatment satisfaction.

Results

Of the 14,483 insured patients who were contacted, 1,104 patients participated at baseline and 725 at follow-up. The adjusted mean differences of SF-36 sum score did not significantly differ between groups: -1.89 (95%-CI = -4.60; 0.81, p = 0.170) between IG-PNP and CG-GP, and -1.42 (95%-CI = -4.05; 1.22, p = 0.293) between PNP and CG-UC. The adjusted mean differences of secondary outcomes did not differ between groups, except for a slightly higher increase of functional health in CG-UC.

Conclusion

We found no evidence that the PNP program is superior to the GP program or to usual care in terms of patient-reported outcomes or treatment satisfaction. The results are limited by the low response rate. Accordingly, future studies should strive for more representative samples. To improve the program, an integration of further collaborative care elements and guideline recommendations might be useful.

Clinical trial registration

DRKS (German Clinical Trials Register https://drks.de/search/en); identifier (DRKS00013114).

Reduction of anxiety symptoms among women within a collaborative care model and women's health settings

AIM

The purpose of this study is to focus on changes in anxiety symptoms among women treated in women's health practices and under a collaborative care model.

BACKGROUND

Research on collaborative care has largely focused on improving depressive and anxiety symptoms among adults in primary care settings. The applicability of collaborative care in other healthcare settings is underreported with limited research investigating if collaborative care has advantages in subpopulations treated in both traditional primary care settings and other healthcare settings, such as women's health practices.

METHODS

This study, completed through secondary data analysis of the electronic record of N = 219 women across three women's healthcare centers, evaluated if instituting a collaborative care model is associated with reduced anxiety symptoms and which factors (eg, primary diagnosis, duration of care, and use of psychotropic medications) are associated with anxiety outcomes. Anxiety symptoms were assessed using the Generalized Anxiety Disorder 7-item scale (GAD-7) at entry into and at termination from collaborative care services.

RESULTS

Overall, there was a significant reduction in average anxiety scores from baseline to termination of collaborative care (t(218) = 12.41, P < 0.001). There was a main effect for the duration of time receiving collaborative care services on anxiety score reduction (β = -0.28, SE = 0.06, P < 0.001) with a significant reduction in anxiety symptoms at the 90-day mark (t(218) = 10.58, P < 0.001). Therefore, collaborative care can be useful in women's health practices in reducing anxiety symptoms over a 90-day time period.

"We want to be heard": A Qualitative Study of Mental Health Care Access among Patients of an Urban Federally Qualified Health Center

Introduction

Although depression is common in primary care, challenges to timely intervention exist, particularly for communities of color and lower socioeconomic status. Our objective was to understand barriers and facilitators to mental healthcare access among a sample of patients receiving care at a federally qualified health center (FQHC) in Minnesota, United States.

Methods

We qualitatively interviewed 34 patients of an urban FQHC, purposively sampled on race/ethnicity, insurance status, language, and depression symptom status (based on Patient Health Questionnaire-9 responses). We inductively and deductively analyzed interview data, leveraging theory in both the codebook development and analysis processes.

Results

Participants, who were predominantly English-speaking, female, not privately insured, and people of color, shared numerous barriers and facilitators to accessing mental healthcare. Prominent barriers primarily concerned healthcare providers, including perceived dismissal of mental health concerns and challenges with provider continuity. Additional barriers included the costs of mental health care, communication breakdowns, the patient portal, and community-specific perceptions of mental health. Prominent facilitators included clinic organizational factors (internal and external) and staff friendliness and warmth. Other factors including consideration of patients' financial situation, integrated management of behavioral and physical health conditions, language concordant staff, the telehealth visit modality, and the clinic's social mission were also raised as facilitating access.

Conclusion

Patient voices from a single FQHC illustrate the challenges and possibilities of providing mental healthcare in safety net settings. Clinical, strategy, and policy solutions can be tailored to minimize barriers and optimize facilitators documented herein.

Access, Utilization, and Quality of Behavioral Health Integration in Medicaid Managed Care

Importance

Many states have moved from models that carve out to those that carve in or integrate behavioral health in their Medicaid managed care organizations (MCOs), but little evidence exists about the effect of this change.

Objective

To assess the association of the transition to integrated managed care (IMC) in Washington Medicaid with health services use, quality, health-related outcomes, and measures associated with social determinants of health.

Design, Setting, and Participants

This cohort study used difference-in-differences analyses of Washington State's 2014 to 2019 staggered rollout of IMC on claims-based measures for enrollees in Washington's Medicaid MCO. It was supplemented with interviews of 24 behavioral health agency leaders, managed care administrators, and individuals who were participating in the IMC transition. The data were analyzed between February 1, 2023, and September 30, 2023.

Main Outcomes and Measures

Claims-based measures of utilization (including specialty mental health visits and primary care visits); health-related outcomes (including self-harm events); rates of arrests, employment, and homelessness; and additional quality measures.

Results

This cohort study included 1 454 185 individuals ages 13 to 64 years (743 668 female [51.1%]; 14 306 American Indian and Alaska Native [1.0%], 132 804 Asian American and Pacific Islander [9.1%], 112 442 Black [7.7%], 258 389 Hispanic [17.8%], and 810 304 White [55.7%] individuals). Financial integration was not associated with changes in claims-based measures of utilization and quality. Most claims-based measures of outcomes were also unchanged, although enrollees with mild or moderate mental illness experienced a slight decrease in cardiac events (-0.8%; 95% CI, -1.4 to -0.2), while enrollees with serious mental illness experienced small decreases in employment (-1.2%; 95% CI -1.9 to -0.5) and small increases in arrests (0.5%; 95% CI, 0.1 to 1.0). Interviews with key informants suggested that financial integration was perceived as an administrative change and did not have substantial implications for how practices delivered care; behavioral health agencies lacked guidance on how to integrate care in behavioral health settings and struggled with new contracts and regulatory policies that may have inhibited the ability to provide integrated care.

Conclusions and Relevance

The results of this cohort study suggest that financial integration at the MCO level was not associated with significant changes in most measures of utilization, quality, outcomes, and social determinants of health. Additional support, including monitoring, training, and funding, may be necessary to drive delivery system changes to improve access, quality, and outcomes.

Prevention of psychosocial distress consequences in somatic hospital inpatients via a stepped and collaborative care model: protocol of SomPsyNet, a stepped wedge cluster randomised trial

INTRODUCTION

Approximately 30% of somatic hospital inpatients experience psychosocial distress, contributing to increased (re-)hospitalisation rates, treatment resistance, morbidity, and direct and indirect costs. However, such distress often remains unrecognised and unaddressed. We established 'SomPsyNet', a 'stepped and collaborative care model' (SCCM) for somatic hospital inpatients, aiming at alleviating this issue through early identification of distress and provision of appropriate care, providing problem-focused pathways and strengthening collaborative care. We report the protocol of the 'SomPsyNet' study, aiming to evaluate implementation and impact of the SCCM on distressed patients' health-related quality of life. Secondary objectives include assessing efficacy of the screening procedures, influence of SCCM on other health outcomes and associated costs.

METHODS AND ANALYSIS

Our stepped wedge cluster randomised trial conducted at three tertiary hospitals comprises three conditions: treatment as usual (TAU) without screening for distress (phase 0), TAU with screening but without consequences (phase I, main comparator) and TAU with screening and psychosomatic-psychiatric consultations for those distressed (phase II). The time-of-transition between phases I and II was randomised. Sample size target is N=2200-2500 participants, with 6 month follow-up for distressed (anticipated n=640-700) and a subsample of non-distressed (anticipated n=200) patients. Primary outcome is mental health-related quality of life (SF-36 'Mental Health Component Summary score'); secondary outcomes include psychosocial distress, anxiety, depressive and somatic symptoms, symptom burden and distress, resilience, social support and qualitative of life, assessed by internationally accepted instruments, with good psychometric properties. Further, health claims data will be used to assess SCCM's impact on direct and indirect costs.

ETHICS AND DISSEMINATION

SomPsyNet adheres to the Helsinki Declaration and is approved by the 'Ethikkommission Nordwest- und Zentralschweiz' (2019-01724). Findings will be published in peer-reviewed journals and communicated to participants, healthcare professionals and the public.

TRIAL REGISTRATION NUMBER

Swiss National Clinical Trials Portal; ClinicalTrials.gov (NCT04269005, updated 19.09.2023).

The effectiveness of collaborative care delivered via telehealth in a pediatric primary care population

Introduction

The prevalence of mental health conditions among children and adolescents in the United States has become a pressing concern, exacerbated by the COVID-19 pandemic. Collaborative care is an evidence-based model for identifying and treating depression and anxiety in healthcare settings, with additional promise for remote healthcare delivery. This study aims to evaluate the impact of a telehealth collaborative care model for adolescents with depression and anxiety in pediatric and primary care settings.

Methods

Secondary analysis was conducted using de-identified national data from Concert Health, a behavioral health medical group offering remote collaborative care across 17 states. Baseline, 90-day, and 120-day assessments of the PHQ-9 and GAD-7 were collected, along with baseline covariates. Stepwise regression analysis was performed to determine the contribution of select covariates to improvement rates.

Results

Among the analyzed data, 263 participants had complete PHQ-9 data, and 230 had complete GAD-7 data. In both the PHQ-9 and GAD-7 groups, over 50% of patients experienced treatment success based on success at discharge, as well as 90- and 120-day improvement rates. Predictors of success at discharge for the GAD-7 group included age at enrollment (OR 1.2258, 95% CI 1.01-1.496), clinical touchpoints (OR 1.1469, 95% CI 1.086-1.218), and lower baseline GAD-7 score (OR 0.9319, 95% CI 0.874-0.992). For the PHQ-9 group, Medicaid was significantly associated with not achieving a 50% reduction in PHQ-9 score at 120 days (OR 0.5874, 95% CI 0.349-0.979).

Discussion

Collaborative care has demonstrated its effectiveness in treating adolescent populations, providing an opportunity to expand access to evidence-based behavioral health treatment for young individuals. Notably, collaborative care is already integrated into the Medicaid fee schedule for 22 states and accepted by all commercial payers. Given that individuals often turn to their trusted primary care providers for behavioral health care, offering collaborative care to adolescents can play a crucial role in addressing the ongoing mental health crisis.

Medicaid Costs and Utilization of Collaborative Versus Colocation Care for Patients With Depression

OBJECTIVE

The authors examined cost and utilization metrics for racially diverse Medicaid primary care patients with depression receiving care through either a collaborative care model (CoCM) of integration or the standard colocation model.

METHODS

Data from a retrospective cohort of Medicaid patients screening positive for clinically significant depression during January 2016-December 2017 were analyzed to assess health care costs and selected utilization measures. Seven primary care clinics providing CoCM were compared with 16 clinics providing colocated behavioral health care. Data for the first year and second year after a patient received an initial Patient Health Questionnaire-9 score ≥10 were analyzed.

RESULTS

In the first year, compared with patients receiving colocated care (N=3,061), CoCM patients (N=4,315) had significantly lower odds of emergency department (ED) visits (OR=0.95) and medical specialty office visits (OR=0.92), with slightly higher odds of primary care provider (PCP) visits (OR=1.03) and behavioral health office visits (OR=1.03). In year 2, CoCM patients (N=2,623) had significantly lower odds of inpatient medical admissions (OR=0.87), ED visits (OR=0.84), medical specialty office visits (OR=0.89), and PCP visits (OR=0.94) than the colocated care patients (N=1,838). The two groups did not significantly differ in total cost in both years.

CONCLUSIONS

Access to CoCM treatment in primary care for racially diverse Medicaid patients with depression was associated with more positive health care utilization outcomes than for those accessing colocated treatment. As organizations continue to seek opportunities to integrate behavioral health care into primary care, consideration of health care costs and utilization may be helpful in the selection and implementation of integration models.

Factors Associated with Implementing the Integrated Behavioral Health Care Model and Iraqi Refugees in the USA

The aim was to identify which factors facilitate providing integrated behavioral health care for Iraqi refugees in nationally recognized community health center in Northern USA. The social-ecological model (SEM) framework guided this qualitative case study exploring the experience of 11 professional staff. Data were collected from June through August 2021 through individual interviews. Eight themes emerged based on the SEM levels: Intrapersonal-gender-driven engagement; interpersonal-the need for discretion and trusting relationship; community-collaboration with community resources and integrator from the community; organizational-holistic care, and long-term care; and policy-insufficient educational preparation. The results highlight components for clinical practice and policymakers regarding a population that is a big consumer of mental health care. Future research should explore other vulnerable populations, the effect of social groups, and the incorporation of community resources as part of the integrated care team.

Relations between clinical characteristics and cognitive deficits among adult patients diagnosed with major depressive disorder

OBJECTIVE

The present study examined the relations between clinical characteristics and cognitive deficits in adult patients with major depressive disorder (MDD) from a local outpatient psychiatric clinic in Malaysia.

METHODS

The present sample included 110 participants aged 20-60 years old. Participants were invited to provide their information on sociodemographic variables (age, gender, and educational level) and clinical characteristics (age at onset of depression and duration of illness) and to complete a series of cognitive performance measures including the Trail Making Tests A (psychomotor speed) and B (executive function), the Digit Symbol Substitution Test (attention), and the Auditory Verbal Learning Test (immediate free recall, acquisition phase, and delayed recall). The Mini International Neuropsychiatric Interview Version 6.0 was used to confirm the diagnosis of MDD and the Montgomery-Åsberg Depression Rating Scale was used to assess illness severity.

RESULTS

At the bivariate level, relations of age and educational level to all cognitive deficit domains were significant. At the multivariate level, only educational level and illness severity consistently and significantly predicted all cognitive deficits domains.

CONCLUSIONS

Therapeutic modalities should be individualised whilst considering the impacts of cognitive deficits in an attempt to prevent further deterioration in psychosocial functioning of MDD patients.KEY POINTSCognitive deficits are an elemental component of Major Depressive Disorder (MDD) persisting during a current major depressive episode or during remission, altering individuals' ability to process information and changes the way they perceive and interact with the environment.Cognitive deficits in MDD are evident among the upper-middle income groups in South-Eastern Asian countries warranting more local research as such deficits could lead to functional decline and work performance such as absenteeism and presenteeism.Therapeutic modalities should be individualised by taking the impacts of cognitive deficits into consideration to promote psychosocial functioning of MDD patients.

Impact of colocated behavioral health on OB-GYN clinicians' rate of perinatal behavioral health diagnosis and psychotropic prescription

OBJECTIVE

To examine the association of colocated behavioral health(BH) care with rates of OB-GYN clinician coding of BH diagnoses and BH medications.

METHOD

Using 2 years of EMR data from perinatal individuals treated across 24 OB-GYN clinics, we tested the hypothesis that colocated BH care would increase rates of OB-GYN BH diagnoses and psychotropic prescription.

RESULTS

Psychiatrist integration(0.1 FTE) was associated with 45.7% higher odds of OB-GYN coding for BH diagnoses and BH clinician integration was associated with 25% lower odds of OB-GYN BH diagnosis and 37.7% lower odds of BH medication prescription. Non-white patients had 28-74% and 43-76% lower odds of having a BH diagnosis and a BH medication ordered, respectively. The most common diagnoses were anxiety and depressive disorders(60%) and the most prescribed BH medications were SSRIs(86%).

CONCLUSIONS

OB-GYN clinicians made fewer BH diagnoses and prescribed fewer psychotropics after 2.0 FTE BH clinician integration, a possible indication of external referrals for BH treatment. Non-white patients received BH diagnoses and medications less often than white patients. Future research in real world implementation of BH integration in OB-GYN clinics should examine fiscal strategies that support BH care manager-OB-GYN collaboration as well as methods to ensure equitable delivery of BH care.

Characteristics of collaborative care networks in functional disorders: A systematic review

OBJECTIVE

Functional disorders (FD) are complex conditions, for which multidisciplinary involvement is often recommended. Collaborative care networks (CCN) may unlock the potential of the multidisciplinary team (MDT) in FD care. To understand what characteristics should be part of CCNs in FD, we studied the composition and characteristics of existing CCNs in FD.

METHODS

We performed a systematic review following PRISMA guidelines. A search of PubMed, WebofScience, PsycInfo, SocINDEX, AMED and CINAHL was undertaken to select studies describing CCNs in FD. Two reviewers extracted characteristics of the different CCNs. Characteristics were classified as relating to structure and processes of networks.

RESULTS

A total of 62 studies were identified representing 39 CCNs across 11 countries. Regarding structural characteristics, we found that most networks are outpatient, secondary-care based, with teams of between two and 19 members. Medical specialists were most commonly involved and the typical team leads as well as main patient contacts were general practitioners (GPs) or nurses. Regarding processes, collaboration was demonstrated mostly during assessment, management and patient education, less often during rehabilitation and follow-up, mostly using MDT meetings. CCNs provided a wide range of treatment modalities, reflecting a biopsychosocial approach, including psychological therapies, physiotherapy and social and occupational therapy.

CONCLUSION

CCNs for FD are heterogeneous, showing a wide variety of structures as well as processes. The heterogeneity of results provides a broad framework, demonstrating considerable variation in how this framework is applied in different contexts. Better development of network evaluation, as well as professional collaboration and education processes is needed.

Pathophysiological mechanisms of post-myocardial infarction depression: a narrative review

Myocardial infarction (MI) can have significant physical and mental consequences. Depression is a prevalent psychiatric condition after MI which can reduce the quality of life and increase the mortality rates of patients. However, the connection between MI and depression has remained under-appreciated. This review examines the potential connection between depression and MI by overviewing the possible pathophysiologic mechanisms including dysregulation of the hypothalamic-pituitary-adrenal axis and autonomic nervous system, coagulation system dysfunction, inflammation, environmental factors, as well as, genetic factors. Furthermore, depression can be an adverse event of medications used for MI treatment including beta-blockers, statins, or anti-platelet agents. The need for early detection and management of depression in patients with MI is, therefore, crucial for improving their overall prognosis. Adherence to treatments and regular follow-up visits can ensure the best response to treatment.

Nurses' experiences of a screening and associated psychosomatic consultation service for mental comorbidities in somatic care inpatients - a qualitative study

Background

Screening for mental comorbidities and related liaison service can reduce hospital length of stay in somatic hospital care. To develop, test and sustain such health care services, stakeholder feedback is required. One of the most important stakeholders in general hospital care and health care processes are nurses.

Aim

The aim of this study is to explore nurses' experiencess on standardized nurse-led screening for mental comorbidities and associated psychosomatic consultation service in routine somatic inpatient care.

Method

Semi-structured qualitative interviews were conducted with 18 nurses that were involved in a nurse-led screening service for mental comorbidities on internal medicine or dermatological wards. Data were analyzed using thematic analysis.

Results

Eight thematic groups were developed. On the one hand, participants reported benefits of screening: mental health education, general mental health awareness, holistic treatment approach, opportunity to build rapport with patients and reduction in workload. On the other hand, possible psychological effects of the intervention, reasons why patients may not want to be referred and application requirements to facilitate delivery were identified. None of the nurses opposed screening and associated psychosomatic consultation service.

Conclusion

All nurses endorsed the screening intervention and considered it meaningful. Nurses particularly emphasized the potential for holistic patient care and nurses' improved skills and competencies, but partly critizised current application requirements.

Relevance to clinical practice

This study adds on existent evidence on nurse-led screening for mental comorbidities and associated psychosomatic consultation service by emphasizing its potential to improve both patient care as well as nurses' perceived self-efficacy and job satisfaction. To take full advantage of this potential, however, usability improvements, regular supervision, and ongoing training for nurses need to be considered.

The effects of behavioral health integration in Medicaid managed care on access to mental health and primary care services-Evidence from early adopters

OBJECTIVE

To evaluate the impacts of a transition to an "integrated managed care" model, wherein Medicaid managed care organizations moved from a "carve-out" model to a "carve-in" model integrating the financing of behavioral and physical health care.

DATA SOURCES/STUDY SETTING

Medicaid claims data from Washington State, 2014-2019, supplemented with structured interviews with key stakeholders.

STUDY DESIGN

This mixed-methods study used difference-in-differences models to compare changes in two counties that transitioned to financial integration in 2016 to 10 comparison counties maintaining carve-out models, combined with qualitative analyses of 15 key informant interviews. Quantitative outcomes included binary measures of access to outpatient mental health care, primary care, the emergency department (ED), and inpatient care for mental health conditions.

DATA COLLECTION

Medicaid claims were collected administratively, and interviews were recorded, transcribed, and analyzed using a thematic analysis approach.

PRINCIPAL FINDINGS

The transition to financially integrated care was initially disruptive for behavioral health providers and was associated with a temporary decline in access to outpatient mental health services among enrollees with serious mental illness (SMI), but there were no statistically significant or sustained differences after the first year. Enrollees with SMI also experienced a slight increase in access to primary care (1.8%, 95% CI 1.0%-2.6%), but no sustained statistically significant changes in the use of ED or inpatient services for mental health care. The transition to financially integrated care had relatively little impact on primary care providers, with few changes for enrollees with mild, moderate, or no mental illness.

CONCLUSIONS

Financial integration of behavioral and physical health in Medicaid managed care did not appear to drive clinical transformation and was disruptive to behavioral health providers. States moving towards "carve-in" models may need to incorporate support for practice transformation or financial incentives to achieve the benefits of coordinated mental and physical health care.

A patient-centered nurse-supported primary care-based collaborative care program to treat opioid use disorder and depression: Design and protocol for the MI-CARE randomized controlled trial

BACKGROUND

Opioid use disorder (OUD) contributes to rising morbidity and mortality. Life-saving OUD treatments can be provided in primary care but most patients with OUD don't receive treatment. Comorbid depression and other conditions complicate OUD management, especially in primary care. The MI-CARE trial is a pragmatic randomized encouragement (Zelen) trial testing whether offering collaborative care (CC) to patients with OUD and clinically-significant depressive symptoms increases OUD medication treatment with buprenorphine and improves depression outcomes compared to usual care.

METHODS

Adult primary care patients with OUD and depressive symptoms (n ≥ 800) from two statewide health systems: Kaiser Permanente Washington and Indiana University Health are identified with computer algorithms from electronic Health record (EHR) data and automatically enrolled. A random sub-sample (50%) of eligible patients is offered the MI-CARE intervention: a 12-month nurse-driven CC intervention that includes motivational interviewing and behavioral activation. The remaining 50% of the study cohort comprise the usual care comparison group and is never contacted. The primary outcome is days of buprenorphine treatment provided during the intervention period. The powered secondary outcome is change in Patient Health Questionnaire (PHQ)-9 depression scores. Both outcomes are obtained from secondary electronic healthcare sources and compared in "intent-to-treat" analyses.

CONCLUSION

MI-CARE addresses the need for rigorous encouragement trials to evaluate benefits of offering CC to generalizable samples of patients with OUD and mental health conditions identified from EHRs, as they would be in practice, and comparing outcomes to usual primary care. We describe the design and implementation of the trial, currently underway.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT05122676. Clinical trial registration date: November 17, 2021.