To go or not go: Patient preference in seeking specialty mental health versus behavioral consultation within the primary care behavioral health consultation model

Current Practices in Clinical Supervision in Primary Care

The purpose of this study was to examine current clinical supervision practices within primary care settings. We used a descriptive survey design, which blends quantitative and qualitative data, and examined the current state of clinical supervision practices and approaches in primary care and the type of training the behavioral health consultants received to provide supervision to pre-licensure level behavioral health trainees. Ninety-four participants completed the survey in 2022. Seventy-one percent of respondents felt they had adequate training to be an effective integrated behavioral health (IBH) supervisor; however, most training came from sources, such as workshops, continuing education, or supervision of supervision. Further efforts to establish universal competencies and formal training programs are needed to meet the growing need for IBH services in primary care.

Development and Evaluation of a Health Behavior Change Clinic in Primary Care: An Interdisciplinary Partnership

Providing effective healthy behavior change interventions within primary care presents numerous challenges. Obesity, tobacco use, and sedentary lifestyle negatively impact the health quality of numerous medical patients, particularly in underserved patient populations with limited resources. Primary Care Behavioral Health (PCBH) models, which incorporate a Behavioral Health Consultant (BHC), can offer point-of-contact psychological consultation, treatment, and also provide opportunities for interdisciplinary psychologist-physician clinical partnerships to pair a BHC's health behavior change expertise with the physician's medical care. Such models can also enhance medical training programs by providing resident physicians with live, case-based learning opportunities when partnered with a BHC to address patient health behaviors. We will describe the development, implementation, and preliminary outcomes of a PCBH psychologist-physician interdisciplinary health behavior change clinic within a Family Medicine residency program. Patient outcomes revealed significant reductions (p < .01) in weight, BMI, and tobacco use. Implications and future directions are discussed.

Primary Care Behavioral Health in Sweden - a protocol of a cluster randomized trial evaluating outcomes related to implementation, organization, and patients (KAIROS)

BACKGROUND

Providing comprehensive and continuous care for patients whose conditions have mental or behavioral components is a central challenge in primary care and an important part of improving universal health coverage. There is a great need for high and routine availability of psychological interventions, but traditional methods for delivering psychotherapy often result in low reach and long wait times. Primary Care Behavioral Health (PCBH) is a method for organizing primary care in which behavioral health staff provide brief, flexible interventions to a large part of the population in active collaboration with other providers. While PCBH holds promise in addressing important challenges, it has not yet been thoroughly evaluated.

METHODS

This cluster randomized trial will assess 17 primary care centers (PCCs) that are starting a PCBH implementation process. The PCCs will be divided into two groups, with one starting immediate implementation and the other acting as a control, implementing six months later. The purpose of the study is to strengthen the evidence base for PCBH regarding implementation-, organization-, and patient-level outcomes, taking into consideration that there is a partially dependent relationship between the three levels. Patient outcomes (such as increased daily functioning and reduction of symptoms) may be dependent on organizational changes (such as availability of treatment, waiting times and interprofessional teamwork), which in turn requires change in implementation outcomes (most notably, model fidelity). In addition to the main analysis, five secondary analyses will compare groups based on different combinations of randomization and time periods, specifically before and after each center achieves sufficient PCBH fidelity.

DISCUSSION

A randomized comparison of PCBH and traditional primary care has, to our knowledge, not been made before. While the naturalistic setting and the intricacies of implementation pose certain challenges, we have designed this study in an effort to evaluate the causal effects of PCBH despite these complex aspects. The results of this project will be helpful in guiding decisions on how to organize the delivery of behavioral interventions and psychological treatment within the context of primary care in Sweden and elsewhere.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT05335382. Retrospectively registered on March 13th, 2022.

Pediatric Primary-Care Integrated Behavioral Health: A Framework for Reducing Inequities in Behavioral Health Care and Outcomes for Children

Nearly half of US children and adolescents will suffer a behavioral health (BH) disorder, with substantially higher rates among more disadvantaged children such as racial/ethnic minorities, LGBTQ + youth, and poor children. The current specialty pediatric BH workforce is inadequate to meet the need and the uneven distribution of specialists as well as other barriers to care, such as insurance coverage and systemic racism/bias, further exacerbate disparities in BH care and outcomes. Integrating BH care into the pediatric primary care medical home has the potential to expand access to BH care and reduce the disparities inherent in the current system.

The impact of socioeconomic status on mental health and health-seeking behavior across race and ethnicity in a large multiple sclerosis cohort

BACKGROUND

Psychiatric symptoms are common in multiple sclerosis (MS) and may contribute to worse MS outcomes. Previous studies suggest the burden of symptoms may vary by race, ethnicity and socioeconomic status (SES). Our objective was to expand upon this previous work and explore the associations between SES, race, and ethnicity, as predictors of psychiatric symptoms, mental health attitudes, and health-seeking behavior in patients with MS.

METHODS

Persons with MS answered a national web-based survey including demographic characteristics (including race, ethnicity and measures of SES), mental health attitudes, the Patient Health Questionnaire-9 (PHQ-9), the Generalized Anxiety Disorder 7-item (GAD-7) scale, the Modified Fatigue Impact Scale 5-item version (MFIS-5), and the Alcohol Use Disorders Identification Test (AUDIT). The survey also queried mental health availability and perceptions of care. We measured neighborhood-level SES (nSES) of each participant using the Agency for Healthcare Research and Quality (AHRQ) index that was calculated from 5-digit postal codes. Other indicators of participant-level SES included education level and self-reported household income. We assessed the association between race, ethnicity, and neighborhood/participant-level SES indicators and affective symptom burden using generalized linear models that were adjusted for age, sex, and MS characteristics.

RESULTS

2095 participants answered the survey (mean AHRQ index 54.6 ± 5.4, age 51.3 ± 12.2 years, 7% Black/African American, 5.4% Hispanic/Latino, and 81.8% female). Those in the lowest quartile of nSES (most disadvantaged) were more likely to be either Black/African American or Hispanic/Latino as compared to those in highest quartile (least disadvantaged). Those in the lowest quartile of nSES had higher mean MFIS-5 (1.02 points; 95% CI: 0.39, 1.43), PHQ-9 (1.24 points; 95% CI: 0.49, 1.98), and GAD-7 (0.69 points; 95% CI: -0.01, 1.38) scores relative to those in the highest quartile. Of those who consumed alcohol (n = 1489), participants in the lowest AHRQ quartile had lower mean AUDIT scores (-0.73 points; 95% CI: -1.18, -0.29) as compared to those in higher quartiles. Race and ethnicity were not associated with self-reported psychiatric symptom burden in this cohort. SES was also associated with self-reported improvement of symptoms after receiving mental health care. A higher proportion of Black/African American (44.1% vs 30.2%, p = 0.003) and Hispanic/Latino (49.1% vs 30.6%, p<0.001) participants were more likely to report they would "definitely go" receive mental health care if services were co-located with their MS care as compared to white and Non-Hispanic/Latino participants, respectively.

CONCLUSION

Higher SES was associated with a lower burden of psychiatric symptoms and with a higher likelihood of self-reported symptom recovery after receiving mental health treatment. Attitudes regarding mental health care delivery in MS varied according to racial and ethnic background. Future longitudinal studies in more diverse populations should assess whether co-location of mental health services with MS care helps to reduce the gap between access and need of mental health care in MS.

Quality Perceptions and Choice of Public Health Facilities: A Mediation Effect Analysis of Outpatient Experience in Rural China

PURPOSE

Outpatients have choices of providers in the hierarchical health service delivery system of China. Understanding how quality perceptions and outpatient experience affect the choice of health facility would help inform decisions about priorities for action aimed at guiding the use of primary care. This study examines how quality perceptions of outpatient service affect the facility level choice in rural China.

METHODS

Household surveys were conducted in 2011, 2012 and 2015 in Ningxia Hui Autonomous Region, China. We selected 968 respondents as the study sample, who had at least two outpatient visits to the public health facilities during each survey period. Prior quality perceptions of the outpatient service at the village clinics, township centers, and county hospitals were reported on an 8-item Quality Indicator questionnaire. Experienced quality perception from the first outpatient visit was also reported. The outcome of interest was outpatients' facility level choices. We used regression and mediation analysis to explore whether and how outpatient experience at a specific health facility would mediate the relationship between prior quality perceptions and the facility level choice.

RESULTS

Overall, the quality perception was positively and significantly associated with outpatients' staying at the same or lower levels of care (β=0.265, P=0.007). This effect was fully mediated by experienced quality perception (z=2.985, P=0.003). The indirect effect was significant for three particular dimensions, including quality perceptions of the environment (β=0.075, P=0.025), doctor-patient communication (β=0.065, P=0.022), and physician ability (β=0.062, P=0.021).

CONCLUSION

Outpatient quality perceptions-especially positive perceptions regarding environment, doctor-patient communication, and physician ability-could contribute to minimizing upward referral via improvement in outpatient experience. Policymakers and health care providers may need to therefore optimize outpatient experience as they push to develop a more locally responsive primary care system.

Managing lower urinary tract symptoms in primary care: qualitative study of GPs' and patients' experiences

Background

Lower urinary tract symptoms (LUTS) are common in males aged ≥40 years and have a considerable impact on quality of life. Management can be complex, and although most LUTS could be treated effectively in primary care, referrals to urology outpatients are increasing.

Aim

To explore GPs’ experiences of managing LUTS together with patients’ experiences of and preferences for treatment in primary care.

Design and setting

Telephone interviews were conducted with GPs and male patients presenting to primary care with bothersome LUTS.

Method

Eleven GPs and 25 male patients were purposively sampled from 20 GP practices in three UK regions: Newcastle upon Tyne, Bristol, and South Wales. Interviews were conducted between May 2018 and January 2019, and were analysed using a framework approach.

Results

Difficulty establishing causes and differentiating between prostate and bladder symptoms were key challenges to the diagnosis of LUTS in primary care, often making treatment a process of trial and error. Pharmacological treatments were commonly ineffective and often caused side effects. Despite this, patients were generally satisfied with GP consultations and expressed a preference for treatment in primary care.

Conclusion

Managing LUTS in primary care is a more accessible option for patients. Given the challenges of LUTS diagnosis, an effective diagnostic tool for use by GPs would be beneficial. Ensuring bothersome LUTS are not dismissed as a normal part of ageing is essential in improving patients’ quality of life. Greater exploration of the role of non-pharmacological treatments is needed.

Methodology for task-shifting evidence-based psychological treatments to non-licenced/lay health workers: protocol for a systematic review

INTRODUCTION

'Task-shifting' or 'task-sharing' is an effective strategy for delivering behavioural healthcare in lower resource communities. However, little is known regarding the actual steps (methods) in carrying out a task-shifting project. This paper presents a protocol for a systematic review that will identify steps in adapting an evidence-based psychological treatment for delivery by lay/non-licenced personnel.

METHODS AND ANALYSIS

A systematic review of peer-reviewed, published studies involving a non-licenced, non-specialist (eg, community health worker, promotor/a, peer and lay person) delivering an evidence-based psychological treatment for adults will be conducted. Study design of selected articles must include a statistical comparison (eg, randomised controlled trials, quasiexperimental trials, pre-post designs and pragmatic trials). Study selection will follow the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Databases including PubMed, the Cochrane Library, Cochrane Central Register of Controlled Trials, SCOPUS, Cumulative Index to Nursing and Allied Health Literature, APA PsycInfo and Google Scholar will be searched from 2000 to 2020. Risk of bias will be assessed using the Cochrane Collaboration's Risk of Bias (RoB 2) tool, and publication bias will be evaluated with the Cochrane GRADE approach. A narrative synthesis will be conducted for all included studies, and a summary table following Proctor's framework for operationalising implementation strategies will be included. This protocol was developed following the 2015 guidelines of Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols.

ETHICS AND DISSEMINATION

This review will analyse data from published studies only; thus, it will not require institutional board review. Findings will be presented at conferences, to the broader community via the Community Health Worker Translational Advisory Board and social media, and the final systematic review will be published in a peer-reviewed journal.

Peer delivery of a brief cognitive-behavioral treatment for posttraumatic stress disorder: A hybrid effectiveness-implementation pilot study

OBJECTIVE

Posttraumatic stress disorder (PTSD) treatment delivery by peer specialist providers could increase access to and engagement with PTSD treatment in low resource settings. The current pilot study tested the feasibility, acceptability, and initial effectiveness of a peer-delivered, brief cognitive-behavioral therapy for PTSD.

METHOD

Four certified peer specialists delivered the intervention to 18 participants with probable PTSD. We assessed PTSD symptoms weekly and administered surveys and interviews at baseline and posttreatment.

RESULTS

Our mixed-methods approach suggests that the intervention was feasible and acceptable, demonstrating high client satisfaction. We also found significant improvements in PTSD, depressive, anxiety, and general stress symptoms.

CONCLUSIONS

Peer-delivered interventions may be a good fit for addressing posttraumatic stress symptoms for people accessing care in low resource settings. Future research should evaluate peer-delivered PTSD treatment as a strategy for both reducing symptoms and improving access and engagement in professional care.

Treating Post-traumatic Stress Disorder with a Prolonged Exposure Protocol Within Primary Care Behavioral Health: A Case Example

Posttraumatic stress disorder (PTSD) is a debilitating condition that impacts anywhere from 2 to 39% of primary care patients. Research suggests overall health, instances of hospitalizations, emergency room visits, and utilization of primary care services are impacted by a diagnosis of PTSD. Evidenced based treatments such as cognitive process therapy and prolonged exposure (PE) are available in specialty mental health but pose many barriers to treatment and implementation into primary care. This case study serves as the first known case example with an ethnic minority civilian, examining the treatment of PTSD within the Primary Care Behavioral Health Model using the brief (5 visits), PE protocol for primary care (PE-PC). PTSD was assessed using the PCL-5. Additional variables were assessed and tracked with the following tools: PHQ-9 (depressive symptoms), GAD-7 (anxiety symptoms), QLES-SF (quality of life), and the AAQ-2 (psychological flexibility) pre/post treatment, 6 months post-treatment and 9 months post-treatment. The patient reported clinically significant decreases in symptoms of PTSD, depression, and anxiety symptoms. Additionally, the patient's scores on quality of life and psychological flexibility improved. Brief, exposure-based treatment for PTSD can be delivered within the PCBH model. This treatment may result in improved quality of life and has the potential to reduce health care costs. This case encourages the treatment of PTSD within primary care, increasing access to care for patients. Future research is needed to further investigate this protocol in primary care with underserved, civilian populations and to explore patient attitudes toward brief treatment for PTSD in a primary care setting.

Reducing the Impacts of Mental Health Stigma Through Integrated Primary Care: An Examination of the Evidence

The reduction of mental health stigma (MHS) was an expected benefit of integrating behavioral health in primary care (IPC). However, unlike other barriers discussed in agency reports on IPC, discussions of MHS lack research support. To fill this gap, the authors conducted a literature review identifying seven studies. Given the dearth of research, we also examine general IPC research on probable indicators of MHS reduction in IPC, as well as, facets of IPC potentially influencing MHS related factors negatively associated with help-seeking. Using the data from these three types of research, the evidence suggests the potential of IPC to reduce MHS impact on care utilization, but indicates it is premature to draw firm conclusions. Given the possible benefits of primary care and the known benefits of decreased MHS, this review highlights the importance of further research examining this question and provides specific research and program development recommendations.

Addressing trauma and stress in the COVID-19 pandemic: Challenges and the promise of integrated primary care

Integrated primary care settings are ideal locations for treatment of posttraumatic stress concerns as primary care is the principal access point for mental health treatment in the United States. The COVID-19 global pandemic will increase the necessity of posttraumatic stress-related psychological care for vulnerable populations and frontline providers through traditional and virtual methods; integrated primary care settings are rapidly adapting to meet this need. Integrating more behavioral health clinicians into primary care clinics will provide better access to whole-person care when it is needed most. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Behavioral health and new models of service delivery for an aging world: Public/private partnerships to develop best practices of care for older adults

Individual and societal initiatives in areas of research, education, and health care policy have resulted in unprecedented gains in life expectancy. It is true that today more people in the world are living longer and have opportunities for higher quality lives than ever before. However, the resulting rapid rise in number of older adults has become a source of concern: Experts of many countries, in anticipation of looming problems, such as overburdened health care and pension systems, are now seeking opportunities to work together to find common solutions for globally-shared problems. The good news is that while all countries are experiencing change brought on by aging populations, the rate of change varies substantially from country to country; differences in historical events have produced differences in demographic profiles. Some countries have relatively large numbers of older adults, comprising large percentages of their populations; others have fewer older adults, with slower growth in numbers and percentages of older adults relative to other age groups. These differences have led to variations for the type and pace of response mounted by individual countries for problems associated with increasingly large older adult populations. In turn, these variations in response provide opportunities for countries to learn from one another. This brief review will outline potential issues associated with aging populations and discuss strengths and challenges for the integration of primary medical care with behavioral health as an innovative, best practices approach to the provision of care for aging persons of the world.