Patient perspectives for improving treatment initiation for new episodes of depression in historically minoritized racial and ethnic groups

OBJECTIVE

Depression is one of the costliest and most prevalent health conditions in the U.S. with 21 million adults having experienced at least one major depressive episode. Despite the availability of evidence-based treatments for depression, a large proportion of people with new diagnoses fail to initiate formal mental health treatment. Although individuals across all racial and ethnic groups fail to initiate treatment for depression, historically minoritized racial/ethnic groups are at even greater risk.

METHOD

Thirty-four participants representing historically underserved racial and ethnic populations from two large health care systems in the U.S. participated in qualitative interviews or focus group to identify factors that impede and facilitate depression treatment initiation in primary care settings.

RESULTS

Participants identified individual and systemic barriers and facilitators of treatment initiation for depression and suggested several ideas for increasing treatment engagement (i.e., increased communication and education from providers, community events, information on social media).

CONCLUSION

Novel interventions are needed to improve treatment initiation following initial diagnosis of depression in primary care settings. Findings from this study offer suggestions for improving treatment initiation in traditionally underserved communities.

Factors Associated With Interest in Engaging in Psychological Interventions for Pain Management

OBJECTIVE

Engagement in evidence-based psychological interventions for pain management is low. Identifying characteristics associated with interest in interventions can inform approaches to increase uptake and engagement. The purpose of this study was to examine factors associated with interest in psychological interventions among persons with chronic noncancer pain receiving prescription opioids.

METHODS

Participants with chronic noncancer pain and a new 30 to 90 day opioid prescription were recruited from 2 health systems. Participants (N=845) completed measures regarding pain, opioid use, psychiatric symptoms, emotional support, and interest in psychological interventions for pain management.

RESULTS

There were 245 (29.0%) participants who reported a high interest in psychological interventions for pain management. In bivariate analyses, variables associated with interest included younger age, female sex, greater pain severity, greater pain interference, greater number of pain sites, lower emotional support, depression, anxiety, and post-traumatic stress disorder ( P <0.05). In a multivariate model, greater pain severity (odds ratio [OR]=1.17; CI: 1.04-1.32), depression (OR=2.10; CI: 1.39-3.16), post-traumatic stress disorder (OR=1.85; CI: 1.19-2.95), and lower emotional support (OR=0.69; CI: 0.5-0.97) remained statistically significant.

DISCUSSION

The rate of interest in psychological interventions for pain management was low, which may indicate that patients initiating opioid treatment of chronic noncancer pain have low interest in psychological interventions. Greater pain severity and psychiatric distress were related to interest, and patients with these characteristics may especially benefit from psychological interventions. Providers may want to refer to psychological interventions before or when opioids are initiated. Additional work is needed to determine whether this would reduce long-term opioid use.

A patient activation intervention in primary care for patients with chronic pain on long term opioid therapy: results from a randomized control trial

BACKGROUND

Given significant risks associated with long-term prescription opioid use, there is a need for non-pharmacological interventions for treating chronic pain. Activating patients to manage chronic pain has the potential to improve health outcomes. The ACTIVATE study was designed to evaluate the effectiveness of a 4-session patient activation intervention in primary care for patients on long-term opioid therapy.

METHODS

The two-arm, pragmatic, randomized trial was conducted in two primary care clinics in an integrated health system from June 2015-August 2018. Consenting participants were randomized to the intervention (n = 189) or usual care (n = 187). Participants completed online and interviewer-administered surveys at baseline, 6- and 12- months follow-up. Prescription opioid use was extracted from the EHR. The primary outcome was patient activation assessed by the Patient Activation Measure (PAM). Secondary outcomes included mood, function, overall health, non-pharmacologic pain management strategies, and patient portal use. We conducted a repeated measure analysis and reported between-group differences at 12 months.

RESULTS

At 12 months, the intervention and usual care arms had similar PAM scores. However, compared to usual care at 12 months, the intervention arm demonstrated: less moderate/severe depression (odds ratio [OR] = 0.40, 95%CI 0.18-0.87); higher overall health (OR = 3.14, 95%CI 1.64-6.01); greater use of the patient portal's health/wellness resources (OR = 2.50, 95%CI 1.42-4.40) and lab/immunization history (OR = 2.70, 95%CI 1.29-5.65); and greater use of meditation (OR = 2.72; 95%CI 1.61-4.58) and exercise/physical therapy (OR = 2.24, 95%CI 1.29-3.88). At 12 months, the intervention arm had a higher physical health measure (mean difference 1.63; 95%CI: 0.27-2.98).

CONCLUSION

This trial evaluated the effectiveness of a primary care intervention in improving patient activation and patient-reported outcomes among adults with chronic pain on long-term opioid therapy. Despite a lack of improvement in patient activation, a brief intervention in primary care can improve outcomes such as depression, overall health, non-pharmacologic pain management, and engagement with the health system.

TRIAL REGISTRATION

The study was registered on 10/27/14 on ClinicalTrials.gov (NCT02290223).

An innovative model of psychological service delivery in primary healthcare: the Single-Session Intervention

BACKGROUND

In Canada, the demand for mental health care exceeds the provision of services. This exploratory study aimed to assess the feasibility and impact of a new service delivery model for psychological consultations in primary care settings: the Single-Session Intervention (SSI), inspired by Advanced Access (AA) principles for appointment scheduling. The specific objectives were to examine whether the SSI increases accessibility to psychological consultations, to measure the effects of the intervention on different self-reported measures, and to assess users' consultation experiences.

METHODS

Participants were recruited in a University Family Medicine Group in Quebec (Canada), and the SSI was delivered by the on-site psychologist. No referral or formal diagnosis was needed to attend, and participants could promptly obtain an appointment. Participants rated the intensity of their problem, their level of psychological distress and their well-being, before and after the SSI. They also rated their satisfaction with their consultation experience. There was a follow-up 4 to 6 weeks later.

RESULTS

Of the N = 69 participants who received SSI, 91% were able to obtain an appointment in less than 7 working days. The number of patients who were able to benefit from a psychological consultation was about 7 times higher after the implementation of SSI compared to previous years, when a traditional model of service delivery was in place. After SSI, participants felt that the intensity of their problem and psychological distress were lower, and that their well-being was increased, as indicated by significant pre-post test clinical measures (p < 0.0001). The observed effects seemed to be sustained at follow-up. Moreover, 51% of participants said that one session was sufficient to help them with their problem. Participants rated SSI as a highly satisfying and helpful consultation experience (92,9% overall satisfaction).

CONCLUSIONS

SSI, offered in a timely manner, could be an innovative and cost-effective intervention to provide mental health services on a large scale in primary healthcare. Further research is needed to replicate the results, but these preliminary data seem to indicate that psychological distress may be quickly addressed by SSI, thereby preventing further deteriorations in patients' mental health.

TRIAL REGISTRATION

2019-393, 26 March 2019.

Piloting a Dementia Caregiver Intervention in a Primary Care Setting

OBJECTIVES

The purpose of this pilot study is to examine the efficacy of a theoretically based, 6-week dementia caregiver support group in a primary care setting.

METHODS

Using a quasi-experimental design, 22 participants completed the caregiver support group. Participants were mostly in their mid-60 s (M = 63 years old), female (n = 19), Caucasian (n = 14), and identified as either the care recipient's child or spouse (n = 19). At baseline and 6 weeks, participants completed self-report measures related to demographic information, caregiver preparedness, strain, and depressive symptoms, and care recipient's neuropsychiatric symptoms. Participants also completed a satisfaction survey. Within-subjects t-tests were run to determine if participants' scores changed over time.

RESULTS

Results revealed that participants demonstrated a significant increase in mean caregiver preparedness scores. No significant effects were found for caregiver strain, depressive symptoms, and distress related to neuropsychiatric symptoms. Participants rated being largely satisfied with the program.

CONCLUSIONS

Results suggest that this 6-week caregiver support group may be a promising caregiver intervention in primary care clinics.

CLINICAL IMPLICATIONS

Findings support the importance of caregiver support for persons with dementia in primary care.

A Brief Psychological Intervention for Chronic Pain in Primary Care: Examining Long-term Effects from a Pilot Randomized Clinical Trial

BACKGROUND

Despite the existence of evidence-based psychological interventions for pain management, there are barriers that interfere with treatment engagement. A brief intervention integrated into primary care reduced barriers and showed promising benefits from pre- to post-intervention. However, it is unknown whether a brief intervention can provide long-term effects. The purpose of this study was to examine whether a brief psychological intervention offered benefits in pain severity, pain interference, pain catastrophizing, and depressive symptoms at 1- and 6-month follow-ups.

METHODS

The majority of participants who enrolled in a pilot randomized clinical trial of a 5-session psychological intervention for chronic pain in primary care completed the 1-month (n= 54; 90%) and 6-month follow-ups (n= 50; 83.3%). Participants completed measures of pain severity, pain interference, pain catastrophizing, and depressive symptoms.

RESULTS

From baseline to the 6-month follow-up, those in the intervention group had significantly better outcomes for pain severity (p= .01) and pain catastrophizing (p= .003) compared to the control group. There were no significant differences between the intervention and control groups for pain interference and depression. The percentage of patients in the intervention experiencing clinically significant improvement across all outcomes was higher than the control group.

CONCLUSIONS

Findings suggest that a brief psychological intervention for chronic pain in primary care may offer longer-term benefits similar to that of lengthier interventions. Future studies should examine this through a randomized clinical trial with a larger sample size.

Development of evidence-informed bridge programming to support an increased need for eating disorder services during the COVID-19 pandemic

Over the course of the COVID-19 pandemic, rates of eating disorders have increased, further straining systems of care that were already overburdened. The current paper describes novel interventions, largely informed by Family-Based Treatment (FBT), that were implemented by a tertiary specialist adolescent eating disorders service. In response to the pandemic, programming was designed to bridge access to care while waiting for availability of evidence-based therapy. The Brief Psychology Consultation Clinic provides several sessions to patients and families, focused on psychoeducation and problem-solving informed by FBT and other evidence-based therapies. Two groups, the FBT Caregiver Workshop Series and FBT Caregiver Support Group, provide psychoeducation and support for caregivers of youth with eating disorders. Perceived strengths and benefits of these services, as well as barriers to implementation and future research directions are discussed.

Utilizing Primary Care to Engage Patients on Opioids in a Psychological Intervention for Chronic Pain

INTRODUCTION

Given the risks of opioids for pain management, we need nonpharmacological interventions that patients will engage in and that can reduce opioid use. The purpose was to examine whether offering a psychological intervention in primary care can engage patients receiving opioids for pain management and to explore whether the intervention influences opioid use.

METHODS

This was a secondary analysis of a pilot randomized controlled trial (RCT) of a 5-session psychological intervention in primary care for chronic pain. Patients with chronic pain (N = 220) were approached to enroll in the RCT. Electronic health records were reviewed to determine whether patients were prescribed opioids or pain medications at the time they were approached about the RCT and the 6-months following the intervention.

RESULTS

Enrollees and non-enrollees had similar rates of opioid prescriptions, morphine milligram equivalent dose of opioids, and rates of other pain medication prescriptions (p> .05). However, no males with an opioid prescription enrolled. Though not significant, those in the intervention had lower odds of having an opioid prescription 6 months following the intervention (p= .09, OR= .32). Those randomized to the intervention had lower odds of having a non-opioid pain medication prescription (p= .01, OR= .17).

CONCLUSIONS

Having an opioid prescription did not interfere with enrollment, suggesting that primary care may be useful for engaging patients on opioids in a psychological treatment for chronic pain. However, this may be true for women, and not men. This intervention also showed promise for decreasing opioid use and warrants further study.

A Brief Psychological Intervention for Chronic Pain in Primary Care: A Pilot Randomized Controlled Trial

OBJECTIVE

Although evidence-based psychological interventions improve chronic pain, many patients do not engage in behavioral health services. Offering a brief intervention in a medical setting may provide benefits to patients with chronic pain. The purpose of this study was to examine preliminary outcomes of a brief psychological intervention for chronic pain delivered in primary care.

DESIGN

Pilot randomized controlled trial.

SETTING

Primary care clinic.

SUBJECTS

Sixty participants with chronic pain were randomized to a 5-session psychological intervention or treatment-as-usual control group.

METHODS

Participants completed pre- and post-intervention measures assessing pain severity, pain interference, pain catastrophizing, depression, and anxiety.

RESULTS

Most participants (76.7%) randomized to the intervention completed all sessions. Compared to the control group, those in the intervention had decreases in pain severity (P = .048), pain catastrophizing (P = .04), and depression (P = .01) from pre- to post-intervention. Within the intervention group, there was a significant improvement in pain interference scores (P = 0.02). Within the intervention group, effect sizes were medium to large for changes in pain severity, pain interference, pain catastrophizing, and depression scores. There were no significant changes in anxiety scores.

CONCLUSION

Results suggest that delivery of a brief psychological intervention for chronic pain in primary care appears to offer improvements in pain severity, pain interference, pain catastrophizing, and depression. Findings suggest that shorter-term psychological interventions may offer similar benefits as longer-term ones. Furthermore, offering a brief intervention in primary care may increase access and engagement in behavioral pain management services. Future research should examine this through a fully-powered trial with longer-term outcomes.

The Behavioral Health Consultant: Roles and Responsibilities

With the scarcity of mental health services, integration of behavioral health into pediatric primary care increases the accessibility and availability to mental health services to a broad range of patients and their families while bridging the gap of physical and mental health. Encouraging whole-person care, the role of the behavioral health consultant serves as a proactive and preventative means fostering early intervention and detection, as 50% of all lifetime mental health disorders begin by the age of 14 years.

Comparative Effectiveness of Embedded Mental Health Services in Pain Management Clinics vs Standard Care

OBJECTIVE

Embedded behavioral medicine services are a common component of multidisciplinary chronic pain treatment programs. However, few studies have studied whether these services are associated with improved treatment outcomes.

METHODS

Using a retrospective, matched, two-cohort study design, we examined patient-reported outcomes (PROs), including Patient-Reported Outcomes Measurement Information System pain, mental health, and physical function measures, collected at every clinic visit in every patient. Changes from baseline through 12 months were compared in those receiving embedded Behavioral Medicine in addition to usual care to a Standard Care group seen in the same pain practice and weighted via propensity scoring.

RESULTS

At baseline, Behavioral Medicine patients had worse scores on most pain, mental health, and physical health measures and were more likely to be female, a member of a racial minority, and have lower socioeconomic status. Regardless of having a worse clinical pain syndrome at baseline, at follow-up both Behavioral Medicine (N = 451) and Standard Care patients (N = 8,383) showed significant and comparable improvements in pain intensity, physical function, depression, and sleep disturbance. Behavioral Medicine patients showed significantly greater improvements in their global impressions of change than the Standard Care patients.

CONCLUSIONS

Despite worse pain and physical and psychological functioning at baseline, Behavioral Medicine patients showed improvements comparable to patients not receiving these services. Further, Behavioral Medicine patients report higher global impressions of change, indicating that embedded mental health services appear to have the additive value of amplifying the benefits of multimodal pain care.

Emotional stress and reproduction: what do fertility patients believe?

PURPOSE

To better understand the beliefs about a causal role of emotional stress maintained by women seeking fertility care.

METHODS

A cross-sectional, self-administered survey was distributed to fertility care patients at an academic fertility center in Illinois. Of 5000 consecutive patients, 1460 completed the survey and were included in the study sample.

RESULTS

Members of our sample (N = 1460) were between 20 and 58 years (mean = 36.2, SD = 4.4). Most respondents were White (72.2%), were in a heterosexual relationship (86.8%), and felt that their physician understood their cultural background (79.4%). Of the sample, 28.9% believed emotional stress could cause infertility, 69.0% believed emotional stress could reduce success with fertility treatment, and 31.3% believed that emotional stress could cause a miscarriage, with evidence of significant racial differences. Less than a quarter (23.8%) of the sample believed emotional stress had no impact on fertility. Lower household income and educational attainment were associated with a greater belief in emotional stress as a causative factor in reproduction with regard to infertility, fertility treatment, and miscarriage.

CONCLUSION

The majority of women seeking fertility care believe emotional stress could reduce the success of fertility treatment. Furthermore, beliefs about emotional stress and reproduction significantly differ based on race/ethnicity, income, and education. Particular attention should be paid to specific groups of women who may more likely not be aware of the lack of a proven biological relationship between emotional stress and reproduction.

Implementing electronic substance use disorder and depression and anxiety screening and behavioral interventions in primary care clinics serving people with HIV: Protocol for the Promoting Access to Care Engagement (PACE) trial

BACKGROUND

Substance use disorders (SUDs) and psychiatric disorders are common among people with HIV (PWH) and lead to poor outcomes. Yet these conditions often go unrecognized and untreated in primary care.

METHODS

The Promoting Access to Care Engagement (PACE) trial currently in process examines the impact of self-administered electronic screening for SUD risk, depression and anxiety in three large Kaiser Permanente Northern California primary care clinics serving over 5000 PWH. Screening uses validated measures (Tobacco, Alcohol, Prescription medication, and other Substance use [TAPS]; and the Adult Outcomes Questionnaire [AOQ], which includes the Patient Health Questionnaire [PHQ-9] and Generalized Anxiety Disorder [GAD-2]) delivered via three modalities (secure messaging, tablets in waiting rooms, and desktop computers in exam rooms). Results are integrated automatically into the electronic health record. Based on screening results and physician referrals, behavioral health specialists embedded in primary care initiate motivational interviewing- and cognitive behavioral therapy-based brief treatment and link patients to addiction and psychiatry clinics as needed. Analyses examine implementation (screening and treatment rates) and effectiveness (SUD, depression and anxiety symptoms; HIV viral control) outcomes using a stepped-wedge design, with a 12-month intervention phase implemented sequentially in the clinics, and a 24-month usual care period prior to implementation in each clinic functioning as sequential observational phases for comparison. We also evaluate screening and treatment costs and implementation barriers and facilitators.

DISCUSSION

The study examines innovative, technology-facilitated strategies for improving assessment and treatment in primary care. Results may help to inform substance use, mental health, and HIV services.

TRIAL REGISTRATION

NCT03217058.

Integrated primary care: patient perceptions and the role of mental health stigma

Some patients are more willing to see a behavioral health provider within primary care. The purpose of this study was to evaluate the patients’ perspectives of having access to a psychologist within primary care and to investigate whether mental health stigma affected preferences. In total, 36 patients completed questionnaires after seeing a psychologist in primary care. Patients were satisfied with having a primary care psychologist involved in their care. Most patients were more likely to see the psychologist in primary care and those who preferred this indicated higher levels of mental health stigma. The overarching theme for why patients saw a psychologist in primary care was convenience. Mental health stigma may also have played a role. Results suggest that providing integrated services may reach patients who may not have otherwise sought services in a behavioral health clinic. Findings from this study encourage the continued integration of behavioral health services.

Pediatrician and Behavioral Clinician-Delivered Screening, Brief Intervention and Referral to Treatment: Substance Use and Depression Outcomes

PURPOSE

Early intervention for adolescent substance use and mental health problems may mitigate potential harm. We examined patient outcomes from a pragmatic trial of two modalities of delivering screening, brief intervention, and referral to treatment (SBIRT) and usual care (UC) in pediatric primary care.

METHODS

All clinic pediatricians (n = 52) were randomized to three arms: (1) pediatrician-only, in which pediatricians were trained to deliver SBIRT; (2) embedded behavioral clinician (BC), in which pediatricians were trained to refer eligible adolescents to a BC who administered SBIRT; and (3) UC. Using electronic health record data, changes in past year substance use and depression symptoms between the index visit and next screening visit were examined across treatment arms.

RESULTS

Among patients who endorsed substance use and/or depression symptoms or were eligible for further assessments, brief interventions, and referrals based on clinician assessment at the index visit, 648 patients (mean age = 15.2 [standard deviation = 1.2]) were rescreened at a follow-up visit between 6 months and 2 years later. Among all patients, self-reported substance use rates did not differ over time or across arms, and depression symptoms increased over time. The embedded BC arm had lower odds of having depression symptoms at follow-up than the physician-only arm, and lower odds than the UC arm although not significant; we found no differences between the pediatrician-only and UC arms.

CONCLUSIONS

The increase in depression symptoms over time highlights this population's vulnerability and the importance of developing appropriate interventions. An embedded BC in pediatric primary care trained in SBIRT may benefit patients with depression symptoms.