Racial-Ethnic Disparities in Outpatient Mental Health Care in the United States

Variation in Hospital Admission Rates for Schizophrenia Spectrum Disorder Emergency Department Visits in 11 States

OBJECTIVE

The authors examined patterns in hospital admission rates for patients with a schizophrenia spectrum disorder (SSD)-related visit to an emergency department (ED).

METHODS

The authors identified 116,928 ED visits for SSD across 1,071 hospitals in an 11-state sample drawn from the 2020 State Emergency Department Databases and State Inpatient Databases. The distribution of hospital-level admission rates was described by using a finite mixture model. Hospital- and county-level characteristics were compared across hospitals with low, medium, or high SSD admission shares.

RESULTS

Admission shares for patients with an SSD ED visit were highly variable and multimodal across hospitals. Although the overall mean admission share for patient ED visits with a primary SSD diagnosis was 56.6% (95% CI=53.0%-60.2%), the mean admission share was 5.6% (95% CI=4.8%-6.4%) in the lowest quintile and was 95.4% (95% CI=94.6%-96.3%) in the highest quintile. The presence of psychiatric beds in a hospital was associated with increased odds of admission (OR=2.56, 95% CI=1.83-3.59). A hospital's size, mental health visit volume, urbanicity, availability of psychiatric consultation, emergency mental health services, and outpatient mental health services, as well as county-level inpatient beds, were not significantly associated with admission rates.

CONCLUSIONS

Hospital admission rates for patients with an SSD ED visit varied widely, and the presence of inpatient psychiatric beds was positively associated with admission. These findings raise equity concerns by suggesting that variation in inpatient psychiatric bed availability contributes to ED disposition of patients with an SSD-related visit.

Emerging Trends in Research on Assisted Outpatient Treatment in the United States: A Narrative Review

OBJECTIVE

The use of court-ordered mental health treatment through programs such as assisted outpatient treatment (AOT) carries substantial ramifications for the welfare of individuals with serious mental health conditions.

METHODS

In this review, the authors used a narrative methodology and performed an interpretive synthesis of existing U.S.-based literature (2008-2023) on AOT implementation and outcomes.

RESULTS

The search yielded 21 peer-reviewed articles published between 2009 and 2022 that assessed various aspects and outcomes of AOT. Although many of these studies generally supported the use of AOT, most used a limited data set (i.e., AOT program data from New York or Ohio between 1999 and 2007). Much of the latest research on AOT did not include attention to possible mechanisms to explain observed outcomes. The emerging literature suggests that increased outreach and less coercive tactics may lead to better outpatient treatment outcomes. However, more research, especially from the point of view of individuals enrolled in AOT programs, is needed.

CONCLUSIONS

The authors strongly recommend that research into these interventions be broadened and include more geographic locations. A greater emphasis should be placed on identifying potential disparities, developing a better understanding of AOT-specific mechanisms of change, and continuing efforts to identify and use high-quality comparison groups.

Protocol for socioecological study of autism, suicide risk, and mental health care: Integrating machine learning and community consultation for suicide prevention

INTRODUCTION

Autistic people experience higher risk of suicidal ideation (SI) and suicide attempts (SA) compared to non-autistic people, yet there is limited understanding of complex, multilevel factors that drive this disparity. Further, determinants of mental health service receipt among this population are unknown. This study will identify socioecological factors associated with increased risk of SI and SA for autistic people and evaluate determinants of mental health care receipt.

METHODS

This study will link information for individuals aged 12-64 years in healthcare claims data (IBM® MarketScan® Research Database and CMS Medicaid) to publicly available databases containing community and policy factors, thereby creating a unique, multilevel dataset that includes health, demographic, community, and policy information. Machine learning data reduction methods will be applied to reduce the dimensionality prior to nested, multilevel empirical estimation. These techniques will allow for robust identification of clusters of socioecological factors associated with 1) risk of SI and SA and 2) receipt of mental health services (type, dose, delivery modality). Throughout, the research team will partner with an established group of autistic partners to promote community relevance, as well as receive input and guidance from a council of policy and practice advisors.

DISCUSSION

We hypothesize that nested individual (co-occurring conditions, age, sex), community (healthcare availability, social vulnerabilities), and policy factors (state mental health legislation, state Medicaid expansion) will be associated with heightened risk of SI and SA, and that receipt, dose, and delivery of mental health services will be associated with interdependent factors at all three levels. The approach will lead to identification of multilevel clusters of risk and factors that facilitate or impede mental health service delivery. The study team will then engage the community partners, and policy and practice advisors to inform development of recommendations to reduce risk and improve mental health for the autistic population.

Racial and Ethnic Disparities in EMS Use of Restraints and Sedation for Patients With Behavioral Health Emergencies

Importance

Emergency medical services (EMS) clinicians commonly care for patients with behavioral health emergencies (BHEs), including acute agitation. There are known racial and ethnic disparities in the use of physical restraint and chemical sedation for BHEs in emergency department settings, but less is known about disparities in prehospital use of restraint or sedation.

Objective

To investigate the association of patient race and ethnicity with the use of prehospital physical restraint and chemical sedation during EMS encounters for BHEs.

Design, Setting, and Participants

This nationwide retrospective cohort study used data from EMS agencies across the US that participated in the 2021 ESO Data Collaborative research dataset. Emergency medical services encounters among patients aged 16 to 90 years with a primary or secondary impression, sign or symptom, or protocol use associated with a BHE from January 1 to December 31, 2021, were included. Statistical analysis was conducted from July 2023 to March 2024.

Exposures

Patient race and ethnicity, which was categorized as Hispanic, non-Hispanic Black, non-Hispanic White, non-Hispanic other (American Indian or Alaska Native, Asian, Hawaiian Native or Other Pacific Islander, other, or multiracial), and unknown.

Main Outcomes and Measures

The primary outcome was administration of any physical restraint and/or chemical sedation (defined as any antipsychotic medication, benzodiazepine, or ketamine).

Results

A total of 661 307 encounters (median age, 41 years [IQR, 30-56 years]; 56.9% male) were included. Race and ethnicity were documented as 9.9% Hispanic, 20.2% non-Hispanic Black, 59.5% non-Hispanic White, 1.9% non-Hispanic other, and 8.6% unknown race and ethnicity. Restraint and/or sedation was used in 46 042 (7.0%) of encounters, and use differed across racial and ethnic groups (Hispanic, 10.6%; non-Hispanic Black, 7.9%; non-Hispanic White, 6.1%; non-Hispanic other, 10.9%; unknown race and ethnicity, 5.9%; P < .001). In mixed-effects logistic regression models accounting for clustering by EMS agency and adjusted for age, gender, urbanicity, and community diversity, patients who were non-Hispanic Black had significantly greater odds of being restrained or sedated across all categories compared with non-Hispanic White patients (eg, any restraint and/or sedation: adjusted odds ratio [AOR], 1.17 [95% CI, 1.14-1.21]; physical restraint: AOR, 1.22 [95% CI, 1.18-1.26]). There was no significant difference in adjusted odds of any restraint and/or sedation use for the remaining racial and ethnic groups compared to non-Hispanic White patients. Clustering was associated with agency-level variation in restraint or sedation use (intraclass correlation coefficient, 0.16 [95% CI, 0.14-0.17]).

Conclusions and Relevance

This nationwide retrospective cohort study of EMS encounters for patients with BHEs found differences in the use of prehospital restraint and/or sedation by patient race and ethnicity and an agency-level association with variation in restraint and/or sedation use. These data may inform improvements to protocols and training aimed at equitable care for BHEs.

Predicting mental health disparities using machine learning for African Americans in Southeastern Virginia

This study examined mental health disparities among African Americans using AI and machine learning for outcome prediction. Analyzing data from African American adults (18-85) in Southeastern Virginia (2016-2020), we found Mood Affective Disorders were most prevalent (41.66%), followed by Schizophrenia Spectrum and Other Psychotic Disorders. Females predominantly experienced mood disorders, with patient ages typically ranging from late thirties to mid-forties. Medicare coverage was notably high among schizophrenia patients, while emergency admissions and comorbidities significantly impacted total healthcare charges. Machine learning models, including gradient boosting, random forest, neural networks, logistic regression, and Naive Bayes, were validated through 100 repeated 5-fold cross-validations. Gradient boosting demonstrated superior predictive performance among all models. Nomograms were developed to visualize risk factors, with gender, age, comorbidities, and insurance type emerging as key predictors. The study revealed higher mental health disorder prevalence compared to national averages, suggesting a potentially greater mental health burden in this population. Despite the limitations of its retrospective design and regional focus, this research provides valuable insights into mental health disparities among African Americans in Southeastern Virginia, particularly regarding demographic and clinical risk factors.

High Out-of-Pocket Cost Burden of Mental Health Care for Adult Outpatients in the United States

OBJECTIVE

This report describes characteristics of patients who had high out-of-pocket (OOP) spending on mental health care relative to income.

METHODS

A sample of 8,923 U.S. adults with outpatient mental health visits was drawn from the 2018-2021 Medical Expenditure Panel Survey. Respondents who spent ≥10% of their disposable family incomes on OOP mental health visits were defined as having a high OOP cost burden.

RESULTS

Using weighted percentages, the authors found that 2.4% of psychiatric outpatients had a high OOP burden; among those below the federal poverty level, 12.8% had a high OOP burden. Patients with a high (vs. low) OOP burden were statistically significantly more likely to be uninsured (7.5% vs. 2.4%) or diagnosed as having a substance use disorder (8.7% vs. 2.8%) or bipolar disorder (14.5% vs. 8.0%).

CONCLUSIONS

Despite federal policies extending the availability of insurance for mental health care, many low-income psychiatric outpatients experience high OOP cost burden.

Technology for advancing behavioral health integration: implications for behavioral health practice and policy

Behavioral health integration (BHI) encompasses the integration of general health, mental health, and substance use care. BHI has promise for healthcare improvement, yet several challenges limit its uptake and successful implementation. Translational Behavioral Medicine published the Continuum-Based Framework by Goldman et al., 2020 to create comprehensive guidance for BHI within primary care settings. Technology can help advance BHI and provide evidence to support it. This commentary describes challenges and illustrative use cases in which technology solutions help organizations achieve BHI through the Continuum-Based Framework domains. Two rounds of semi-structured interviews with field leaders, practice sites, and technology stakeholders identified key barriers in BHI amenable to technology solutions, applications of technologies, and how they facilitate BHI. Findings showed that technology can facilitate the implementation and scaling of BHI by reducing care fragmentation and improving patient engagement, accountability and financial sustainability, provider experience and support, and equitable access to culturally competent care. Continued efforts by stakeholders to address legacy policy and implementation issues (e.g. incentives, investment, privacy, and workforce) are needed to optimize the impact of technology on BHI.

A systematic review of participant diversity in psychedelic-assisted psychotherapy trials

A lack of diverse and representative participant samples in mental health intervention research perpetuates mental health disparities. This issue has become a salient concern in studies of psychedelic-assisted psychotherapy (PAT), which is emerging as a promising mental health intervention. This systematic review evaluates the reporting, representation, and analysis of participant sociodemographic characteristics in randomized controlled trials (RCTs) of PAT. A total of 21 RCTs of psilocybin- and 3,4-methylenedioxy methamphetamine (MDMA)-assisted therapies (N = 1034) are summarized. Participants' gender (100%) and race or ethnicity (76%) were frequently reported, with socioeconomic status (SES) sometimes (57%) reported using heterogeneous metrics. Sexual orientation (9.5%) and immigration status (4.8%) were rarely reported, and no studies reported gender identity. Compared to their representation in the US population and non-psychedelic clinical trials, Black/African-American participants (2.2%) and Hispanic/Latino participants (7.2%) were significantly underrepresented in PAT RCTs. MDMA trials enrolled more diverse participant samples than psilocybin trials. Analyses on treatment effects based on demographic variables were virtually nonexistent. These findings underscore the need for more inclusive recruitment strategies, along with more rigorous reporting, to improve the generalizability of PAT research.

Mitigating the Stigma of Mental Illness: The Impact of Story-Telling in the Black Community

Racial/ethnic minorities, including the Black community, experience stigma as a significant barrier to mental health care, with fears of being devalued or discriminated against deterring individuals from seeking help. Racial stigma further exacerbates mental health issues and negatively influences perceptions of service utilization. To address this, our research team partnered with a national non-profit storytelling organization to develop and evaluate a virtual narrative storytelling intervention series that amplifies the voices and experiences of Black Americans living with mental illness and addiction. We randomly assigned 193 participants to either the intervention (n = 102) or an active control condition (n = 91) and used a pre-post survey design to assess the changes in the outcome variables. Contrary to our hypothesis, there were no race-based interactions; instead, the results show significant reductions in public stigma and perceived discrimination and increased positive attitudes toward seeking treatment universally among all the intervention participants. This study provided preliminary evidence that a virtual storytelling intervention is instrumental across varied demographic cohorts, transcending potential cultural barriers in the discourse and understanding of mental health to effectively mitigate stigma and improve attitudes toward mental health treatment.

Mobile Mindfulness Intervention for Psychological Distress Among Intensive Care Unit Survivors: A Randomized Clinical Trial

Importance

Although psychological distress is common among survivors of critical illness, there are few tailored therapies.

Objective

To determine the optimal method for delivering a mindfulness intervention via a mobile app for critical illness survivors.

Design, Setting, and Participants

This randomized clinical trial used a 2 × 2 × 2 factorial design and was conducted at 3 sites among survivors of critical illness with elevated postdischarge symptoms of depression. The study was conducted between August 2019 and July 2023.

Interventions

Participants were randomized to 1 of 8 different groups as determined by 3 two-level intervention component combinations: intervention introduction method (mobile app vs therapist call), mindfulness meditation dose (once daily vs twice daily), and management of increasing symptoms (mobile app vs therapist call).

Main Outcomes and Measures

The primary outcome was the 9-item Patient Health Questionnaire (PHQ-9) depression scale score (range, 0-27) at 1 month. Secondary outcomes included anxiety (7-item Generalized Anxiety Disorder) and posttraumatic stress disorder (Posttraumatic Stress Scale) symptoms at 1 and 3 months, adherence, and feasibility. General linear models were used to compare main effects and interactions of the components among intervention groups. A formal decisional framework was used to determine an optimized intervention version.

Results

A total of 247 participants (mean [SD] age, 50.2 [15.4] years; 104 [42.1%] women) were randomized. Twice-daily meditation compared with once-daily meditation was associated with a 1.2 (95% CI, 0.04-2.4)-unit lower mean estimated PHQ-9 score at 1 month and a 1.5 (95% CI, 0.1-2.8)-unit lower estimated mean score at 3 months. The other 2 intervention components had no main effects on the PHQ-9. Across-group adherence was high (217 participants [87.9%] using the intervention at trial conclusion) and retention was strong (191 [77.3%] and 182 [73.7%] at 1 and 3 months, respectively).

Conclusions and Relevance

A mindfulness intervention for survivors of critical illness that included an app-based introduction, twice-daily guided meditation, and app-based management of increasing depression symptoms was optimal considering effects on psychological distress symptoms, adherence, and feasibility.

Trial Registration

ClinicalTrials.gov Identifier: NCT04038567.

Mobile App-Based Mindfulness Intervention for Addressing Psychological Distress Among Survivors of Hospitalization for COVID-19 Infection

BACKGROUND

Psychological distress symptoms are present and persistent among many patients who survive a critical illness like COVID-19.

RESEARCH QUESTION

Could a self-directed mobile app-delivered mindfulness intervention be feasibly and rapidly implemented within a clinical trials network to reduce distress symptoms?

STUDY DESIGN AND METHODS

A randomized clinical trial was conducted between January 2021 and May 2022 at 29 US sites and included survivors of hospitalization due to COVID-19-related illness with elevated symptoms of depression at discharge. Participants were randomized to intervention or usual care control. The intervention consisted of four themed weeks of daily audio, video, and text content. All study procedures were virtual. The primary outcome was depression symptoms assessed with the Patient Health Questionnaire 9 at 3 months. Secondary outcomes included anxiety (Generalized Anxiety Disorder 7-item scale), quality of life (EQ-5D), and adherence. We used general linear models to estimate treatment arm differences in outcomes over time.

RESULTS

Among 56 randomized participants (mean age ± SD, 51.0 ± 13.2 years; 38 female [67.9%]; 14 Black participants [25%]), 45 (intervention: n = 23 [79%]; control: n = 22 [81%]) were retained at 6 months. There was no difference in mean improvement between intervention and control participants at 3 months in Patient Health Questionnaire 9 (-0.5 vs 0.1), Generalized Anxiety Disorder 7-item scale (-0.3 vs 0.1), or EQ-5D (-0.03 vs 0.02) scores, respectively; 6-month results were similar. Only 15 participants (51.7%) initiated the intervention, whereas the mean number ± SD of the 56 prescribed intervention activities completed was 12.0 ± 15.2. Regulatory approvals delayed trial initiation by nearly a year.

INTERPRETATION

Among survivors of COVID-19 hospitalization with elevated psychological distress symptoms, a self-directed mobile app-based mindfulness intervention had poor adherence. Future psychological distress interventions mobilized at broad scale should focus efforts on patient engagement and regulatory simplification to enhance success.

TRIAL REGISTRATION

ClinicalTrials.gov; No.: NCT04581200; URL: www.clinicaltrials.gov.

Editorial: Pandemics Interact With and Amplify Child Mental Health Disparities: Further Lessons From COVID-19

Infectious diseases change our world. It is a simple understanding that history has consistently shown but it is a set of lessons that are routinely forgotten. From cholera1 to smallpox,2 pandemics amplify and run along societal fractures that form in the context of disparities. As of early September 2023, COVID-19 had caused nearly 7 million deaths worldwide, and there have been over 1.1 million deaths in the United States.3 The scale of this impact on children and families is only beginning to become clear.

Mental Health-Related Outpatient Visits Among Adolescents and Young Adults, 2006-2019

Importance

Concerns over the mental health of young people have been increasing over the past decade, especially with the rise in mental health burden seen during the COVID-19 pandemic. Examining trends in mental health-related outpatient visits provides critical information to elucidate contributing factors, identify vulnerable populations, and inform strategies to address the mental health crisis.

Objective

To examine characteristics and trends in mental health-related outpatient visits and psychotropic medication use among US adolescents and young adults.

Design, Setting, and Participants

A retrospective cross-sectional analysis of nationally representative data from the National Ambulatory Medical Care Survey, an annual probability sample survey, was conducted from January 2006 to December 2019. Participants included adolescents (age 12-17 years) and young adults (age 18-24 years) with office-based outpatient visits in the US. Data were analyzed from March 1, 2023, to September 15, 2023.

Main Outcomes and Measures

Mental health-related outpatient visits were identified based on established sets of diagnostic codes for psychiatric disorders. Temporal trends in the annual proportion of mental health-related outpatient visits were assessed, including visits associated with use of psychotropic medications. Analyses were stratified by age and sex.

Results

From 2006 to 2019, there were an estimated 1.1 billion outpatient visits by adolescents and young adults, of which 145.0 million (13.1%) were associated with a mental health condition (mean [SD] age, 18.4 [3.5] years; 74.0 million females [51.0%]). Mental health-related diagnoses were more prevalent among visits by male (16.8%) compared with female (10.9%) patients (P < .001). This difference was most pronounced among young adults, with 20.1% of visits associated with a psychiatric diagnosis among males vs 10.1% among females (P < .001). The proportion of mental health-related visits nearly doubled, from 8.9% in 2006 to 16.9% in 2019 (P < .001). Among all outpatient visits, 17.2% were associated with the prescription of at least 1 psychotropic medication, with significant increases from 12.8% to 22.4% by 2019 (P < .001).

Conclusions and Relevance

In this cross-sectional study, there were substantial increases in mental health-related outpatient visits and use of psychotropic medications, with greater overall burden among male patients. These findings provide a baseline for understanding post-pandemic shifts and suggest that current treatment and prevention strategies will need to address preexisting psychiatric needs in addition to the effects of the COVID-19 pandemic.

Trends in Psychological Distress and Outpatient Mental Health Care of Adults During the COVID-19 Era

BACKGROUND

In addition to the physical disease burden of the COVID-19 pandemic, concern exists over its adverse mental health effects.

OBJECTIVE

To characterize trends in psychological distress and outpatient mental health care among U.S. adults from 2018 to 2021 and to describe patterns of in-person, telephone, and video outpatient mental health care.

DESIGN

Cross-sectional nationally representative survey of noninstitutionalized adults.

SETTING

United States.

PARTICIPANTS

Adults included in the Medical Expenditure Panel Survey Household Component, 2018 to 2021 (n = 86 658).

MEASUREMENTS

Psychological distress was measured with the Kessler-6 scale (range of 0 to 24, with higher scores indicating more severe distress), with a score of 13 or higher defined as serious psychological distress, 1 to 12 as less serious distress, and 0 as no distress. Outpatient mental health care use was measured via computer-assisted personal interviews.

RESULTS

Between 2018 and 2021, the rate of serious psychological distress among adults increased from 3.5% to 4.2%. Although the rate of outpatient mental health care increased from 11.2% to 12.4% overall, the rate decreased from 46.5% to 40.4% among adults with serious psychological distress. When age, sex, and distress were controlled for, a significant increase in outpatient mental health care was observed for young adults (aged 18 to 44 years) but not middle-aged (aged 45 to 64 years) and older (aged >65 years) adults and for employed adults but not unemployed adults. In 2021, 33.4% of mental health outpatients received at least 1 video visit, including a disproportionate percentage of young, college-educated, higher-income, employed, and urban adults.

LIMITATION

Information about outpatient mental health service modality (in-person, video, telephone) was first fully available in the 2021 survey.

CONCLUSION

These trends and patterns underscore the persistent challenges of connecting older adults, unemployed persons, and seriously distressed adults to outpatient mental health care and the difficulties faced by older, less educated, lower-income, unemployed, and rural patients in accessing outpatient mental health care via video.

PRIMARY FUNDING SOURCE

None.

Health equity in pediatrics: Current concepts for the care of children in the 21st century (Dis Mon)

This is an analysis of important aspects of health equity in caring for children and adolescents written by a multidisciplinary team from different medical centers. In this discussion for clinicians, we look at definitions of pediatric health equity and the enormous impact of social determinants of health in this area. Factors involved with pediatric healthcare disparities that are considered include race, ethnicity, gender, age, poverty, socioeconomic status, LGBT status, living in rural communities, housing instability, food insecurity, access to transportation, availability of healthcare professionals, the status of education, and employment as well as immigration. Additional issues involved with health equity in pediatrics that are reviewed will include the impact of the COVID-19 pandemic, behavioral health concepts, and the negative health effects of climate change. Recommendations that are presented include reflection of one's own attitudes on as well as an understanding of these topics, consideration of the role of various healthcare providers (i.e., community health workers, peer health navigators, others), the impact of behavioral health integration, and the need for well-conceived curricula as well as multi-faceted training programs in pediatric health equity at the undergraduate and postgraduate medical education levels. Furthermore, ongoing research in pediatric health equity is needed to scrutinize current concepts and stimulate the development of ideas with an ever-greater positive influence on the health of our beloved children. Clinicians caring for children can serve as champions for the optimal health of children and their families; in addition, these healthcare professionals are uniquely positioned in their daily work to understand the drivers of health inequities and to be advocates for optimal health equity in the 21st century for all children and adolescents.

Slavery and Its Afterlives in US Psychiatry

Antecedents of racist treatments of Black patients by the psychiatric profession in the United States affect the way they view treatment today. Specifically, in this essay, we explore the enduring consequences of racial science on various treatment practices. We examined a range of primary sources on the history of racial theories about the mind, medical and psychiatric publications, and hospitals. We contextualize this analysis by examining the secondary literature in the history and sociology of psychiatry. Through analyzing racial thinking from the antebellum through the Jim Crow periods, we show how US medicine and psychiatry have roots in antebellum racial science and how carceral logics underpinned the past and present politics of Black mental health. Changing this trajectory requires practitioners to interrogate the historical foundations of racist psychiatric concepts. This essay urges them to reject biological racial realism, which bears reminiscences to 19th-century racial science, and embrace the variable of race as a social construct to study social inequalities in health as a first step toward moving away from the legacies of past injustices in medicine. (Am J Public Health. 2024;114(S3):S250-S257. https://doi.org/10.2105/AJPH.2023.307554).

Mental Health Care Access Among Arab Immigrants in the United States: Application of Public Arena Model

Arab immigrants constitute a sizable portion of the US population, and their adjustment and relocation challenges might escalate mental health issues. Nevertheless, mental health care accessibility among such populations is not recognized as policy issue. Hence, it is crucial to explore the political tools that might be employed to improve immigrants' access to mental health treatment. The Public Arenas Model (Hilgartner and Bosk, American Journal of Sociology 94:53-78, 1988) provides better understanding of how access to mental health care is defined in the public sphere, why mental health inaccessibility among Arabs has not received attention, and how stakeholders worked to raise the public's attention to such issue (Smith, Policy, Politics & Nursing Practice 10:134-142, 2009). Ultimately, several policy options are proposed to address Arab immigrants' access to mental health care issue, including increasing mental health service providers' language proficiency and cultural competency, integration of behavioral health and primary care services for immigrant populations, and considering novel modes of mental health delivery.

No Improvement In Mental Health Treatment Or Patient-Reported Outcomes At Medicare ACOs For Depression And Anxiety Disorders

Accountable care organizations (ACOs) have become Medicare's dominant care model because policy makers believe that ACOs will improve the quality and efficiency of care for chronic conditions. Depression and anxiety disorders are the most prevalent and undertreated chronic mental health conditions in Medicare. Yet it is unknown whether ACOs influence treatment and outcomes for these conditions. To explore these questions, this longitudinal study used data from the 2016-19 Medicare Current Beneficiary Survey, linked to validated depression and anxiety symptom instruments, among diagnosed and undiagnosed fee-for-service Medicare patients with these conditions. Among patients not enrolled in ACOs at baseline, those who newly enrolled in ACOs in the following year were 24 percent less likely to have their depression or anxiety treated during the year than patients who remained unenrolled in ACOs, and they saw no relative improvements at twelve months in their depression and anxiety symptoms. Better-designed incentives are needed to motivate Medicare ACOs to improve mental health treatment.

Digital solutions and the future of recovery after critical illness

PURPOSE OF REVIEW

Digital technologies may address known physical and psychological barriers to recovery experienced by intensive care survivors following hospital discharge and provide solutions to care fragmentation and unmet needs. The review highlights recent examples of digital technologies designed to support recovery of survivors of critically illness.

RECENT FINDINGS

Despite proliferation of digital technologies supporting health in the community, there are relatively few examples for intensive care survivors. Those we identified included web-based, app-based or telemedicine-informed recovery clinics or pathways offering services, including informational resources, care planning and navigation support, medication reconciliation, and recovery goal setting. Digital interventions supporting psychological recovery included apps providing adaptive coping skills training, mindfulness, and cognitive behavioural therapy. Efficacy data are limited, although feasibility and acceptability have been established for some. Challenges include difficulties identifying participants most likely to benefit and delivery in a format easily accessible to all, with digital exclusion a resultant risk.

SUMMARY

Digital interventions supporting recovery comprise web or app-based recovery clinics or pathways and digital delivery of psychological interventions. Understanding of efficacy is relatively nascent, although several studies demonstrate feasibility and acceptability. Future research is needed but should be mindful of the risk of digital exclusion.