Facilitating Prompt Mental Health Care adoption in primary care: a qualitative study of experiences with external implementation support

Health Care Reform and Care at the Behavioral Health--Primary Care Interface

The epidemic within the pandemic: Behavioral health and substance use in the face of COVID-19

The Effects of the COVID-19 Pandemic on the Risk of Youth Substance Use

The current study utilizes in-depth interviews with inner city African-American and Latino adolescents to understand how they negotiate initial substance use. We applied the social norms approach to explore the role of peers, family, and neighborhood on adolescents’ initial substance use. Utilizing data from 36 interview participants, our analysis revealed that extended family members were pivotal in providing adolescents with their initial alcohol; however, female adolescents were more likely than male adolescents to acquire marijuana from their male peers, for free. Understanding situational contexts underlying initial substance use is imperative for future interventions with this population.

Objective-The federal government boosted support for community health centers in medically underserved areas in 2002-2007.This investigation compared trends in behavioral health services provided by community health centers nationwide during the first several years of that initiative with immediately prior trends.Methods-Data were extracted from the Health Resources and Services Administration's Uniform Data System on community health centers for 1998-2007 (2007, N=1,067).Regression analyses revealed trends in individual community health centers' likelihood of providing on-site specialty mental health care, crisis services, and substance abuse treatment.Aggregate data were used to show national trends in numbers of behavioral health encounters, patients, and encounters per patient.Results-The number of federally funded community health centers increased 43% between 2001 and 2007, from 748 to 1,067, over twice the annual growth rate between 1998 and 2001.However, trends in individual community health centers' likelihood of providing different types of behavioral health care were generally consistent across the two time periods.In 2007, 77% of community health centers offered specialty mental health services, 20% offered 24-hour crisis intervention services, and 51% offered substance abuse treatment.The mean number of mental health encounters per mental health patient at community health centers in 2007 was 2.9.Conclusions-The behavioral health care safety net has widened through rapid recent growth in the number of community health centers as well as a continuing increase in the proportion offering specialty mental health services.Access to behavioral health care remains a major public health concern in the United States (1-4), most acutely affecting people who have low income or are uninsured (5-7).One

BackgroundMental health and/or substance use issues are associated with significant disparities in morbidity and mortality. The aim of this study was to identify the mechanisms underlying poor primary care access for this population.MethodThis was a community-based participatory action qualitative study, in which 85 adults who self-identified as having a serious mental health and/or substance use issue and 17 service providers from various disciplines who worked with this population participated in a semi-structured interview.ResultsClient, service provider and health system barriers to access were identified. Client factors, including socioeconomic and psychological barriers, make it difficult for clients to access primary care, keep appointments, and/or prioritize their own health care. Provider factors, including knowledge and personal values related to mental health and substance use, determine the extent to which clients report their specific needs are met in the primary care setting. Health system factors, such as models of primary care delivery, determine the context within which both client and service provider factors operate.ConclusionsThis study helps elucidate the mechanisms behind poor primary health care access among people with substance use and/or mental health issues. The results suggest that interdisciplinary, collaborative models of primary healthcare may improve accessibility and quality of care for this population, and that more education about mental health and substance use issues may be needed to support service providers in providing adequate care for their clients.

Third and fourth grade students () completed measures of psychosocial development, substance use, and intentions to use in January, and again in May, 1998. A revised Erikson Psychosocial Inventory Scale (EPSI) was employed to assess psychosocial development while estimates of substance use and intentions were obtained from anonymous self-reports. The sample was split on the basis of change in substance use and intentions from January to May. Using this grouping scheme as an independent variable, scores on the EPSI subscales (trust, autonomy, initiative, industry, and identity) were compared over time. Interestingly, no differences in psychosocial development were evident for the initial substance use comparisons, but differences were evident five months later. Respondents who initiated substance use and/or increased intentions during the five-month interval exhibited small gains (averaging less than 2.0%) on measures of trust, autonomy, and initiative and modest declines in industry and identity (−1.2%). Respondents who neither initiated substance use nor increased intentions during the five-month interval experienced significant gains (averaging 6.0%) on all five of the EPSI subscales. These findings suggest that early substance use may impede psychosocial development, thus justifying prevention efforts in the earlier grades as well as efforts to delay onset.

Background: Preventing suicide among adolescents is an urgent global public-health challenge, especially in Africa. Accordingly, the aim of this study was to examine the relationship between the early initiation (< 12 years old) of substance use (cigarette smoking, alcohol use, and drug use) and attempted suicide among in-school adolescents in seven African countries.Methods: Data on the early initiation of substance use and on attempted suicide among in-school adolescents over the previous 12 months in Benin, Liberia, Mauritius, Mozambique, Namibia, Seychelles, and the United Republic of Tanzania were collected from Global School-based Student Health Surveys and were pooled to determine the overall prevalence of these behaviors in adolescents. Univariate and multivariate logistic regressions were then performed to evaluate country-specific associations between the early initiation of substance use and attempted suicide in these adolescents, followed by meta-analyses to evaluate overall pooled associations.Results: In the abovementioned seven African low- or middle-income countries (LMICs), overall weighted prevalences of attempted suicide and early initiation of cigarette smoking, alcohol use, and drug use among in-school adolescents were 16.05, 7.76, 17.68, and 3.48%, respectively. Multivariate logistic regression analyses revealed that relative to non-smoking, the early initiation of smoking was significantly associated with attempted suicide in these adolescents [OR (95% CI) = 1.783 (1.219–2.348)]. Additionally, the relationship between early initiation of cigarette smoking and attempted suicide is mostly driven by a higher association in girls [OR (95% CI) = 1.867 (1.031–2.703)] than boys [OR (95% CI) = 1.392 (0.995−1.789)]. Moreover, relative to not using other drugs, the early and later initiation of other drug use were also significantly associated with attempted suicide in these adolescents [ORs (95% CIs) = 2.455 (1.701–3.208) and 1.548 (1.198–1.898)].Conclusion: Programs that can eliminate or decrease the early initiation of substance use among adolescents should be implemented in African LMICs to prevent subsequent suicide attempts, especially among adolescent girls.

Changes in medicine domestically and globally are transforming primary care in the United States. Many have suggested that primary care is in crisis or at least at a crossroads in the United States. The Annals of Internal Medicine recently devoted much of one issue to this topic.1 Primary care for children and adolescents, however, was not addressed specifically. This article focuses on pediatrics and identifies potential roles and new models for primary care pediatrics. The Institute of Medicine has defined primary care as “the provision of integrated, accessible health care services by clinicians who are accountable for addressing a large majority of personal health care needs, developing a sustained partnership with patients, and practicing in the context of family and community.”2 Starfield3 has defined 4 attributes of primary care including first-contact care, longitudinality, comprehensiveness, and coordination. September 11, 2001, the anthrax scare, and emerging threats such as severe acute respiratory syndrome (SARS) have brought a new focus on the importance of individual-level contacts in addressing population-level threats. Before these world events, however, primary care pediatrics was already grappling with its identity and responding to significant changes in medical systems, science, and family needs. The pace and scope of these changes are such that primary care pediatricians of the future will not be performing the same role as today. Historically, American medicine has tended to be reactive rather than proactive in defining its roles in society. However, dynamic change demands collective reflection; it is time to be proactive in assessing the needs of patients, exploring potential roles as health care providers, and developing the mechanisms to redefine the primary care pediatrician of the future. Projecting future trends requires reflection on the history of the profession of preventive pediatrics. In the 1800s, few physicians in the United States routinely … Address correspondence to Tina L. Cheng, MD, MPH, Johns Hopkins University Department of Pediatrics, 600 N Wolfe St, Park 392, Baltimore, MD 21287. E-mail: tcheng2{at}jhmi.edu

BackgroundSeveral studies have demonstrated the importance of sense of coherence (SOC), neuroticism (N), extraversion (E), and general self-efficacy (GSE) for health, yet the unique utility of these overlapping constructs remains uncertain. The present research aims at exploring incremental validity when predicting (1) substance use specifically and (2) mental health generally among adolescents.MethodsA prospective and longitudinal design was used to predict (1) initial substance use nine years into the future and (2) mental health one year and four years into the future. Participants were 318 adolescents (age 14 to 15 at the beginning of the study).ResultsStructural equation modeling revealed (1) that SOC had long-term incremental validity over N, E, and GSE for tobacco use and alcohol use, whereas cannabis use was predicted by E and GSE; and (2) that long-term mental health after four years was only predicted by SOC.ConclusionsTwo studies provide further evidence for the importance of considering salutogenic factors when forecasting mental health and health-related behavior beyond classical constructs such as N, E, and GSE. Differences in criterion validity reveal that SOC cannot be equated with reversed neuroticism.

AimTo explore factors that foster positive mental health among adults with type 1 and type 2 diabetes and identify opportunities for more accessible, person‐centred mental health support within diabetes care.MethodsParticipants were purposively sampled from the Mental health IN Diabetes Monitoring And Pathways (MIND‐MAP) cohort study. Semi‐structured online interviews were conducted with 32 adults in Victoria, Australia. Interviews explored factors associated with emotional well‐being and experiences and preferences for mental health support. Data were analysed using reflexive thematic analysis, informed by phenomenology and constructivist grounded theory. The study was co‐designed with guidance from a multidisciplinary Steering Committee and lived experience input through a Community Advisory Group comprising 12 adults with type 1 or type 2 diabetes.ResultsParticipants described internal strengths (e.g. acceptance, perspective‐taking) and external supports (e.g. peer connections, empathetic health professionals, timely access to mental health care) that supported their mental health. Several barriers to accessing mental health support were reported, including limited‐service access, geographic and financial constraints, discomfort discussing emotions, and a lack of diabetes‐specific mental health expertise. Emotional support was often absent at diagnosis and other key transition points. Participants called for support that is empathetic, non‐judgemental, tailored and embedded within diabetes services.ConclusionAdults with type 1 and type 2 diabetes show resilience in managing mental health, yet systemic, practical and attitudinal barriers remain. Care models should build on personal strengths, normalise emotional support and integrate psychological care from diagnosis, as well as harness the value of peer support.

Background and AimsYoung adults with attention deficit/hyperactivity disorder (ADHD) show higher substance use disorder (SUD) prevalence relative to non‐ADHD controls; few longitudinal studies have examined the course of substance use with reference to conduct disorder (CD). We compared initiation and escalation of substance use at 15‐month follow‐up in men screened positive or negative for ADHD (ADHD+ versus ADHD–), controlling for CD presence in early adolescence.DesignParticipants were recruited during August 2010 and November 2011 from the census of all young men who have to pass mandatory army conscription from three of six Swiss Army recruitment centres. A two‐wave data collection was performed via questionnaires at baseline and 15‐month follow‐up as a part of the longitudinal Cohort Study on Substance Use Risk Factors.SettingRecruitment centres in Lausanne, Windisch and Mels, responsible for 21 cantons in German‐ and French‐speaking areas of Switzerland.ParticipantsConsecutive sample of 5103 male Swiss Army conscripts who provided informed consent and responded to questionnaires at baseline and 15‐month follow‐up. Their mean age was 20.0 (standard deviation = 1.21) years at baseline.MeasurementsADHD and CD were assessed using the adult ADHD Self‐Report Scale and the MINI International Neuropsychiatric Interview Plus, respectively, at baseline, and substance use was measured via self‐administered substance use questionnaires at baseline and follow‐up.FindingsCompared with the ADHD– group, the ADHD+ group (n = 215, 4.2%) showed heavier baseline substance use and increased likelihood of alcohol (χ2 = 53.96; P < 0.001), tobacco (χ2 = 21.73; P < 0.001) and cannabis use disorders (χ2 = 48.43; P < 0.001). The extent of alcohol, tobacco and cannabis use in the two groups remained stable from baseline to follow‐up (no escalation). The ADHD+ group was more likely to initiate substance use compared with the ADHD– group (higher initiation rates), particularly with amphetamines [odds ratio (OR) = 3.81; 95% confidence interval (CI) = 2.20–6.60; P < 0.001] and non‐medical use of ADHD medication (OR = 4.45; 95% CI = 2.06–9.60; P < 0.001). CD was associated with initiation of substance use but did not mediate the associations between ADHD and substance use, revealing that the impact of ADHD on substance use was independent of CD.ConclusionsFor men in their early 20s, attention deficit/hyperactivity disorder is a risk factor for continued heavier but not escalating use of alcohol, tobacco and cannabis when already consuming these substances, compared with young men with no ADHD. It is also a risk factor for initiating the use of cannabis, stimulants, hallucinogens and sedatives, independent of conduct disorder in early adolescence.

Clinical screening and peer interventions to prevent substance use in at-risk adolescents: A longitudinal single-arm trial protocol

Objectives: The purpose of this study was to identify subgroups of early adolescents based on their history of initiation and recent substance use, examine changes in their subgroup membership across two waves, and evaluate whether sociodemographic characteristics were associated with longitudinal changes in substance use patterns. Methods: Participants were 1,811 early adolescents (72% Black, 53% female) attending middle schools in neighborhoods with high rates of violence and residents with incomes below the federal poverty level. Latent class analysis identified subgroups of adolescents with different substance use patterns at two waves 3 months apart. Latent transition analysis then examined changes in subgroup membership over time and the impact of sex, grade, and time of year on the likelihood of transitioning subgroups. Results: Four patterns were identified: Non-use (76% of sample at wave 1, 73% at wave 2), Initiation (11%, 13%), Alcohol Use (7%, 7%), and Polysubstance Use (6%, 7%). Instability in membership in the Alcohol Use and Polysubstance Use subgroups across waves indicated that early adolescents varied in the number of types of substances they used across 3-month intervals. Female adolescents and eighth grade students were most likely to endorse past 30-day polysubstance use. Conclusions: These findings indicate that membership in substance use subgroups changes even across several months, and that older middle school students are more likely to report polysubstance use. Early adolescence is an important period for early interventions to prevent stability and escalation of use among those who have initiated substance use.

BackgroundAnxiety, depressive and substance use disorders account for three quarters of the disability attributed to mental disorders and frequently co-occur. While programs for the prevention and reduction of symptoms associated with (i) substance use and (ii) mental health disorders exist, research is yet to determine if a combined approach is more effective. This paper describes the study protocol of a cluster randomised controlled trial to evaluate the effectiveness of the CLIMATE Schools Combined intervention, a universal approach to preventing substance use and mental health problems among adolescents.Methods/designParticipants will consist of approximately 8400 students aged 13 to 14-years-old from 84 secondary schools in New South Wales, Western Australia and Queensland, Australia. The schools will be cluster randomised to one of four groups; (i) CLIMATE Schools Combined intervention; (ii) CLIMATE Schools - Substance Use; (iii) CLIMATE Schools - Mental Health, or (iv) Control (Health and Physical Education as usual).The primary outcomes of the trial will be the uptake and harmful use of alcohol and other drugs, mental health symptomatology and anxiety, depression and substance use knowledge. Secondary outcomes include substance use related harms, self-efficacy to resist peer pressure, general disability, and truancy. The link between personality and substance use will also be examined.DiscussionCompared to students who receive the universal CLIMATE Schools - Substance Use, or CLIMATE Schools - Mental Health or the Control condition (who received usual Health and Physical Education), we expect students who receive the CLIMATE Schools Combined intervention to show greater delays to the initiation of substance use, reductions in substance use and mental health symptoms, and increased substance use and mental health knowledge.Trial registrationThis trial is registered with the Australian and New Zealand Clinical Trials registry, ACTRN12613000723785.