Behavioral Health Clinicians Research Articles

How one Kansas CMHC aims to address workforce challenges

Amid increased demand for mental health services and workforce shortages, the CEO of a rural Kansas‐based community mental health center (CMHC), said they have reason to be encouraged about addressing the challenges. Pawnee Mental Health Services in Manhattan, Kansas, recently received a provisional certification for the CMHC to become a Certified Community Behavioral Health Clinic (CCBHC).

Formative evaluation prior to implementation of a brief treatment for posttraumatic stress disorder in primary care

BackgroundSuccessful implementation of evidence-based treatments (EBT) for posttraumatic stress disorder (PTSD) in primary care may address treatment access and quality gaps by providing care in novel and less stigmatized settings. Yet, PTSD treatments are largely unavailable in safety net primary care. We aimed to collect clinician stakeholder data on organizational, attitudinal, and contextual factors relevant to EBT implementation.MethodsOur developmental formative evaluation was guided by the Consolidated Framework for Implementation Research (CFIR), including (a) surveys assessing implementation climate and attitudes towards EBTs and behavioral health integration and (b) semi-structured interviews to identify barriers and facilitators to implementation and need for augmentation. Participants were hospital employees (N = 22), including primary care physicians (n = 6), integrated behavioral health clinicians (n = 8), community wellness advocates (n = 3), and clinic leadership (n = 5). We report frequency and descriptives of survey data and findings from directed content analysis of interviews. We used a concurrent mixed-methods approach, integrating survey and interview data collected simultaneously using a joint display approach. A primary care community advisory board (CAB) helped to refine interview guides and interpret findings.ResultsStakeholders described implementation determinants of the EBT related to the CFIR domains of intervention characteristics (relative advantage, adaptability), outer setting (patient needs and resources), inner setting (networks and communication, relative priority, leadership engagement, available resources), and individuals involved (knowledge and beliefs, cultural considerations). Stakeholders described strong attitudinal support (relative advantage), yet therapist time and capacity restraints are major PTSD treatment implementation barriers (available resources). Changes in hospital management were perceived as potentially allowing for greater access to behavioral health services, including EBTs. Patient engagement barriers such as stigma, mistrust, and care preferences were also noted (patient needs and resources). Recommendations included tailoring the intervention to meet existing workflows (adaptability), system alignment efforts focused on improving detection, referral, and care coordination processes (networks and communication), protecting clinician time for training and consultation (leadership engagement), and embedding a researcher in the practice (available resources).ConclusionsOur evaluation identified key CFIR determinants of implementation of PTSD treatments in safety net integrated primary care settings. Our project also demonstrates that successful implementation necessitates strong stakeholder engagement.

Bidirectional effects of parental and adolescent symptom change in trauma-focused cognitive behavioral therapy.

The current study examines dynamic, bidirectional associations between parent and adolescent symptom improvement in response to children's therapy for posttraumatic stress disorder (PTSD). Data were collected from a racially and ethnically heterogeneous sample of 1,807 adolescents (age 13-18 years old; 69% female) and a parent participating in Trauma-Focused Cognitive Behavioral Therapy (TF-CBT) at a community outpatient behavioral health clinic. Parents self-reported their depressive symptoms and youth self-reported their PTSD and depressive symptoms at the onset of treatment and every three months for up to nine months. Using a bivariate dual change score model (BDCSM) we examine: (a) individual dyad members' change in symptoms and (b) the bidirectional associations between changes in the parent's and youth's symptoms across treatment. Parents' and adolescents' symptoms at the start of treatment were correlated and both parents' and adolescents' symptoms decreased over the course of treatment. Parents' elevated depressive symptoms at each time point contributed to smaller decreases in their children's PTSD and depressive symptoms at the subsequent time point. Adolescents' elevated symptoms at each time point contributed to greater decreases in their parents' symptoms at the subsequent time point. These findings highlight the impact that parents and children have on each other's response to children's trauma-focused psychotherapy. Notably, parents' depressive symptoms appeared to slow their children's progress in treatment, suggesting that attending to parents' symptoms and providing them with supportive services may be an important adjunct to children's interventions. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

NeuroPathways: A Novel, Population-Specific Information and Support Intervention for Patients with Newly Diagnosed Primary Malignant Brain Tumors (P3-13.003)

<h3>Objective:</h3> To develop a targeted intervention aimed at helping patients with newly diagnosed primary malignant brain tumors (PMBT) process and cope with their diagnosis and illness trajectory. <h3>Background:</h3> Patients with newly diagnosed PMBT contend not only with the physical and emotional impact of their cancer but also with the task of absorbing and assimilating an overwhelming amount of information about their diagnosis and treatment, often in the midst of significant cognitive and communicative deficits. As few resources exist to address these particular challenges, we sought to develop an intervention targeting the specific educational and supportive needs of patients with PMBT. <h3>Design/Methods:</h3> We interviewed patients with recently diagnosed PMBT (n=14) and their caregivers (n=11) to explore their cancer-related experiences and needs. Common themes included difficulties processing information, communicating with loved ones and clinicians, coping with uncertainty, and navigating life with a brain tumor. Drawing on these themes and a prior framework for information and support provision in cancer, we developed the NeuroPathways intervention for patients with newly diagnosed PMBT. With input from our multidisciplinary team, we tailored intervention content and delivery for patients with cognitive and/or communication limitations. <h3>Results:</h3> NeuroPathways consists of two components: 1) a comprehensive but accessible information guide containing details about the diagnosis, treatment modalities, practical aspects of living with a PMBT, coping strategies, and techniques for working through cognitive and communication challenges and 2) four one-on-one coaching sessions with a behavioral health clinician designed to help each patient cultivate a unique plan for learning and coping. We will evaluate feasibility and acceptability of NeuroPathways in a forthcoming pilot study and subsequent randomized controlled trial. <h3>Conclusions:</h3> NeuroPathways represents a novel approach to meeting the information and supportive care needs of patients with newly diagnosed PMBT, with potential application towards helping patients with other life-changing neurologic illnesses absorb and process information about their diagnosis. <b>Disclosure:</b> Ms. Strander has nothing to disclose. Miss Podgurski has nothing to disclose. Miss Psenka has nothing to disclose. Dr. Traeger has nothing to disclose. The institution of Jennifer Temel has received research support from Blue Note Therapeutics. Dr. Forst has received stock or an ownership interest from Eli Lilly. Dr. Forst has received research support from Conquer Cancer Foundation of the American Society of Clinical Oncology. Dr. Forst has received research support from Palliative Care Research Cooperative Group. Dr. Forst has received research support from American Cancer Society Institutional Research Grant.

Correlation of Warm Handoffs Versus Electronic Referrals and Engagement With Mental Health Services Co-located in a Pediatric Primary Care Clinic

ObjectiveTo analyze the correlation of referral mechanism—warm handoff or electronic referral and attendance at behavioral health appointments in an outpatient pediatric primary care setting. MethodsA retrospective cohort study was conducted in an inner-city pediatric primary care clinic from January 2019 to December 2019. Adolescent patients who screened positive for depression or anxiety were referred to a Licensed Master Social Worker (LMSW) either via a warm handoff (WH group, n = 148) or an electronic referral (EF group, n = 180). The EF group was contacted by the LMSW via telephone to schedule an appointment. Multiple logistic regression was used to analyze the correlation of type of referral, age, gender, race/ethnicity, primary language, and time between referral and first contact with attendance at three appointments. ResultsThe WH group was more likely to engage with mental health services compared to the EF group (odds ratio = 3.301, 95% confidence interval = 1.850–5.902, p = .002) while age, gender, race/ethnicity, and primary language had no correlation. Within the EF group, those who were contacted by the LMSW within 3 days (1–3 days group) were more likely to attend appointments (odds ratio = 2.680, 95% confidence interval = 0.414–8.219, p = .040). There was no difference in attendance in the WH group and the 1–3 days group (p = .913) DiscussionA warm handoff between primary care providers and behavioral health clinicians is significantly correlated with engagement with behavioral health services for adolescents who screen positive for depression or anxiety. Contact with the family within 3 days of referral is significantly correlated with engagement compared to a longer duration between referral and family contact.

Alabama, Kansas provider communities looking forward to new CCBHC funding

Mental Health Weekly last week interviewed two behavioral health care leaders representing Alabama and Kansas, two of 15 states recently awarded $1 million, one‐year Certified Community Behavioral Health Clinic (CCBHC) planning grants, courtesy of the Substance Abuse and Mental Health Services Administration (SAMHSA).

Association of Patients’ Direct Addition of Buprenorphine to Urine Drug Test Specimens With Clinical Factors in Opioid Use Disorder

The direct addition of buprenorphine to urine drug test specimens to mimic results suggestive of adherence is a clinically significant result, yet little is known about the phenomenon. To characterize factors associated with the direct addition of buprenorphine to urine specimens among patients prescribed buprenorphine for opioid use disorder. This cross-sectional study of urine drug test specimens was conducted from January 1, 2017, to April 30, 2022, using a national database of urine drug test specimens ordered by clinicians from primary care, behavioral health, and substance use disorder treatment clinics. Urine specimens with quantitative norbuprenorphine and buprenorphine concentrations from patients with opioid use disorder currently prescribed buprenorphine were analyzed. Nonprescribed opioid or stimulant co-positive, clinical setting, collection year, census division, patient age, patient sex, and payor. Norbuprenorphine to buprenorphine ratio less than 0.02 identified direct addition of buprenorphine. Unadjusted trends in co-positivity for stimulants and opioids were compared between specimens consistent with the direct addition of buprenorphine. Factors associated with the direct addition of buprenorphine were examined with generalized estimating equations. This study included 507 735 urine specimens from 58 476 patients. Of all specimens, 261 210 (51.4%) were obtained from male individuals, and 137 254 (37.7%) were from patients aged 25 to 34 years. Overall, 9546 (1.9%) specimens from 4550 (7.6%) patients were suggestive of the direct addition of buprenorphine. The annual prevalence decreased from 2.4% in 2017 to 1.2% in 2020. Opioid-positive with (adjusted odds ratio [aOR], 2.01; 95% CI, 1.85-2.18) and without (aOR, 2.02; 95% CI, 1.81-2.26) stimulant-positive specimens were associated with the direct addition of buprenorphine to specimens, while opioid-negative/stimulant-positive specimens were negatively associated (aOR, 0.78; 95% CI, 0.71-0.85). Specimens from patients aged 35 to 44 years (aOR, 1.59; 95% CI, 1.34-1.90) and primary care (aOR, 1.60; 95% CI, 1.44-1.79) were associated with the direct addition of buprenorphine. Differences by treatment setting decreased over time. Specimens from the South Atlantic census region had the highest association (aOR, 1.4; 95% CI, 1.25-1.56) and New England had the lowest association (aOR, 0.54; 95% CI, 0.46-0.65) with the direct addition of buprenorphine. In this cross-sectional study, the direct addition of buprenorphine to urine specimens was associated with other opioid positivity and being collected in primary care settings. The direct addition of buprenorphine to urine specimens is a clinically significant finding, and best practices specific for this phenomenon are needed.

Impacts of the Certified Community Behavioral Health Clinic Demonstration on Emergency Department Visits and Hospitalizations.

The Certified Community Behavioral Health Clinic (CCBHC) demonstration is designed to increase access to comprehensive ambulatory care and crisis services, which may reduce emergency department (ED) visits and hospitalizations. This study examined whether the demonstration had an impact on ED visits and hospitalizations in Missouri, Oklahoma, and Pennsylvania. This difference-in-differences analysis used Medicaid claims data from 2015 to 2019 to examine service use during a 12-month baseline period and the first 24 months of the demonstration for beneficiaries who received care from CCBHCs and beneficiaries who received care from other behavioral health clinics in the same state, representing care as usual. Propensity score methods were used to develop treatment and comparison groups with similar characteristics. In Pennsylvania and Oklahoma, beneficiaries who received care from CCBHCs had a statistically significant reduction in the average number of behavioral health ED visits, relative to the comparison group (13% and 11% reductions, respectively); no impact on ED visits in Missouri was observed. The demonstration was associated with a statistically significant reduction in all-cause hospitalizations in Oklahoma, when the analysis used a 2-year rather than a 1-year baseline period, and also in Pennsylvania, when hospitalizations were truncated at the 98th percentile to exclude beneficiaries with outlier hospitalization rates. The CCBHC demonstration reduced behavioral health ED visits in two states, and the study also revealed some evidence of reductions in hospitalizations.

Patient and Clinician Satisfaction with the Early Implementation of Telemental Health Services in an Urban Behavioral Health Clinic During the COVID-19 Pandemic.

Objective: The COVID-19 pandemic served as an impetus for the rapid expansion of telehealth. In this study, we examined the experience of rapid transition to telemental health (TMH) within The Family Health Centers at NYU Langone, a large, urban, Federally Qualified Health Center, in the 3 months after the onset of the COVID-19 pandemic. Methods: We administered surveys to clinicians and patients who utilized TMH between March 16, 2020 and July 16, 2020. Patients were sent a web-based survey via email or received a phone survey (for those without email) with four languages choices: English, Spanish, Traditional Chinese, or Simplified Chinese. Results: The majority (79%) of clinicians (n = 83) rated the experience of TMH as "excellent" or "good," and felt that they could establish and maintain the patient relationship through TMH. Four thousand seven hundred seventy-two survey invitations were sent out to patients, and 654 (13.7%) responded. Ninety percent reported that they were satisfied with the service they received and rated TMH as better or the same as in-person care (81.6%) with a high mean satisfaction score (4.5 out of 5). Patients were more likely to rate TMH as better or the same as in-person care relative to the clinicians. Conclusions: These results are consistent with several recent studies that have explored patient satisfaction with TMH during the COVID-19 pandemic and demonstrate that both clinicians and patients experienced a high degree of satisfaction with mental health care delivered virtually compared with face-to-face encounters.

Clinician-rated outcomes of patients with functional neurological disorders treated in an outpatient clinic

BackgroundPatients with functional neurological (conversion) disorder (FND) have historically been difficult to treat. Outcomes have been studied in research trials, documenting improvements; however, limited information is available from a community-treated FND cohort. ObjectivesWe aimed to examine clinical outcomes in outpatients with FND treated with the Neuro-Behavioral Therapy (NBT) approach. These uncontrolled setting treatment data could complement more structured clinical studies results. MethodsWe conducted a retrospective chart review of consecutive patients diagnosed with FND, ages 17 to 75, who were treated with the NBT workbook at the Rhode Island Hospital Behavioral Health clinic between 2014 and 2022. NBT consisted of 45-minute, individual, outpatient sessions, in clinic or via telehealth with one clinician. Global Assessment of Functioning (GAF), and Clinical Global Impression (CGI) –Severity, and –Improvement were scored for every appointment. ResultsBaseline characteristics are available for 107 patients. Mean age at FND symptom onset was 37 years. Patients had a mix of FND semiologies, which included Psychogenic Nonepileptic Seizures (71%), Functional Movement Disorder (24.3%), Functional Sensory Disorder (14%), Functional Weakness (6.5%), and Functional Speech Disorder (5.6%). Clinical evaluation scores revealed improvements over time. ConclusionsWe describe a well-characterized sample of patients with various and mixed FND semiologies, who received manualized therapy, NBT, in an outpatient clinic. Patients had similar psychosocial profiles to those in clinical studies and displayed improvement in clinical measures. These results demonstrate the practicability of NBT for motor FND semiologies and for PNES, in a “real-world” outpatient practice, extending care beyond structured clinical trials.

Maryland lawmakers aim to ‘modernize’ MH, improve access

Maryland Senate lawmakers announced last month an ambitious effort to create a “world‐class mental health system” to include the establishment of more certified community behavioral health clinics (CCBHCs), integrated wraparound services and the expansion of intensive and in‐home behavioral health care for youth.

Virtual health care: Meeting patients where they are

There's no getting around one simple fact about the health care system: We are staring down a shortage of thousands of behavioral health care and primary care providers. More than three‐quarters of U.S. counties are currently experiencing a severe behavioral health clinician shortage. By 2025, we are projected to need an additional 30,000 psychiatrists and up to 48,000 primary care providers just to keep pace with demand.

Progress and Pitfalls in the Provision of Quality Care for Adults With Attention Deficit Hyperactivity Disorder in Primary Care

Objective: Quality care for attention deficit hyperactivity disorder (ADHD) in adults has lagged behind other psychiatric disorders. We sought to assess how the achievement of quality measures (QMs) for diagnosing and treating ADHD in adults has changed over time. Method: We assessed 10 QMs in electronic health records (EHRs) from primary care and behavioral health clinics from 2010 to 2020 for 71,310 patients diagnosed with ADHD. Results: The achievement of QMs increased over time (p < .001). Some showed increases to high levels; others remained low throughout the observation period. No patients achieved more than six of 10 QMs in any year. Small but significant effects for sex, race, ethnicity, practice ownership, practice type, and age. Conclusion: Increase in quality care from 2010 to 2020 along with clear evidence that more efforts are needed to improve quality of care for adults with ADHD seen in primary care.

Policy Recommendations for Increasing the Use of Evidence-Based Psychotherapy for Posttraumatic Stress Disorder in the Military Health System.

Few service members with posttraumatic stress disorder (PTSD) receive evidence-based psychotherapy (EBP) in the military health system (MHS). Efforts to increase EBP implementation have focused on provider training but have not adequately addressed organizational barriers. Thus, although behavioral health providers are trained in EBPs, clinic-, facility-, and system-level barriers preclude widespread EBP implementation. Building on work examining barriers to EBP use for PTSD across eight military treatment facilities, we propose recommendations for increasing the implementation of EBPs for PTSD and improving the quality of behavioral health care in MHS outpatient behavioral health clinics. Increasing the use of EBPs for PTSD will require that their use is supported and prioritized through MHS policy. We recommend that psychotherapy appointments are scheduled at least once weekly, as clinically indicated, as this frequency of care is prerequisite for EBP delivery. We propose several recommendations designed to increase system capacity for weekly psychotherapy, including improved triaging of potential patients, incentivizing and supporting group psychotherapy, matching the modality (i.e., group vs. individual) and frequency of treatment to patients' needs, and using behavioral health technicians as clinician extenders. Additional recommendations include providing ongoing support for EBP implementation (e.g., protected time to participate in EBP consultation) and matching patients to providers based on patient's clinical needs and treatment preferences. The barriers to EBP implementation that these recommendations target are interrelated. Therefore, adopting multiple policy recommendations is likely necessary to yield a meaningful and sustained increase in the implementation of EBPs for PTSD in the MHS.

Supplemental Material for Whole Person Care: Outcomes From a 5-Year Care Model Integrating Primary Care Into a Behavioral Health Clinic

Supplemental Material for Whole Person Care: Outcomes From a 5-Year Care Model Integrating Primary Care Into a Behavioral Health Clinic

Evaluating the Implementation of a Model of Integrated Behavioral Health in Primary Care: Perceptions of the Healthcare Team.

This study aims to compare primary care providers and medical assistants in degrees of comfort, confidence, and consistency when addressing behavioral health concerns with patients before and after the implementation of a model of integrated behavioral health in primary care (IBHPC), and evaluate whether these perceptions differ based on increased access to behavioral health clinicians. This longitudinal study was conducted at 2 primary care clinics in Northern California while implementing an IBHPC model. The Integrated Behavioral Health Staff Perceptions Survey was administered to assess the comfort, confidence, and consistency of behavioral health practices. Confidential online surveys were distributed to primary care faculty and staff members before and post-implementation. Responses from providers and medical assistants were compared between pre- and post-implementation with linear regression analyses. The relationships between accessibility to behavioral health clinicians and a change in comfort, confidence, and consistency of behavioral health practices were explored using a linear mixed-effects model. A total of 35 providers and medical assistants completed the survey both before and post-implementation of IBHPC. Over time, there were increasingly positive perceptions about the consistency of behavioral health screening (P = .03) and overall confidence in addressing behavioral health concerns (P = .005). Comfort in addressing behavioral health concerns did not significantly change for either providers or staff over time. Medical assistants were initially more confident and comfortable addressing behavioral health concerns than providers, but providers' attitudes increased post-IBHPC implementation. Improved access to behavioral health clinicians was associated with greater consistency of screening and referral to specialty mental health care (P < .001). The present study is the first to explore differences in provider and medical assistant perceptions during the course of an IBHPC implementation. Findings underscore the importance of integrating medical assistants, along with providers, into all phases of the implementation process.

Moral injury and chronic pain among military veterans in an integrated behavioral health clinic.

Military service may place veterans at increased risk for perpetrating, witnessing, or failing to prevent events that violate deeply held moral values. In some cases, veterans may develop moral injury (MI) symptoms that transcend and/or overlap with mental health conditions such as posttraumatic stress disorder (PTSD) and major depressive disorder (MDD). Further, PTSD and MDD are 2 established risk factors for chronic pain. However, research has not examined the association between MI symptoms and chronic pain. We tested whether MI would emerge as a salient correlate of concurrent reports of chronic pain in the presence of PTSD and MDD symptom severity among 59 veterans seeking integrated behavioral health care. Findings indicated the severity of MI symptoms was significantly linked with veterans' concurrent reports of chronic pain. Self-directed MI symptoms emerged as a correlate of worse pain in the presence of PTSD and MDD. Preliminary findings demonstrate possible associations between MI and chronic pain among veterans with a need for holistic health care. Future research should examine mechanisms for an apparent MI-chronic pain link. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Omnibus bill supports key MH policies, advances service access

The year ended on a high note for the mental health field with the release of the Consolidated Appropriations Act of 2023 (also known as the “Omnibus”). The omnibus appropriations funding package, which passed Dec. 23, 2022 by the House of Representatives and earlier in the week by the U.S. Senate, contains key mental health provisions, including significant increases for the Community Mental Health Services Block Grant and for Certified Community Behavioral Health Clinics (CCBHCs).

Comparative analysis of pediatric anxiety measures in clinical sample: evaluation of the PROMIS pediatric anxiety short forms.

Examine the psychometric properties, validity in relation to a legacy measure, and diagnostic accuracy of the PROMIS Anxiety Short Form 2.0 (PROMIS A-SF) Caregiver and Youth Reports in a clinical sample. Participants were 301 youth and caregivers referred to a behavioral health clinic by their pediatrician. Participants and their caregivers completed PROMIS A-SF (youth and caregiver proxy), SCARED (youth and caregiver proxy), and a semi-structured interview. Descriptive, correlational, test-retest reliability, and receiver operating characteristic (ROC) analyses were conducted for both measures. PROMIS A-SF measures were highly correlated with SCARED total scores and the panic subscale. PROMIS A-SF measures had AUCs ranging from .49-.79 for the detection of any of three primary subtypes of anxiety: Generalized Anxiety, Separation Anxiety, and Social Anxiety. Dimensional anxiety subtypes, such as Social Anxiety may not be well detected on the PROMIS youth measure. Use of the PROMIS A-SF as a part of Evidence Based Assessment process is discussed.

BEFORE A NEUROCOGNITIVE EVALUATION: ROLES AND COMPETENCIES OF BEHAVIORAL HEALTH PROVIDERS

Abstract Neurocognitive disorders are among the most stigmatized medical conditions in the USA and across the globe. Cultural beliefs about cognitive aging also impact how individuals, families and healthcare teams respond to concerns about cognitive impairment. GSA’s revised KAER Toolkit for Primary Care Teams (Fall, 2020) provides useful information for the early stages of this process, including kickstarting the conversation about brain health concerns and conducting screenings. This presentation outlines additional competencies for behavioral health clinicians involved in patient, family, and health care team discussions regarding cognitive health concerns. Culturally responsive strategies and resources are suggested to help clinicians explore the decision for a formal evaluation and shape the nature of the referral question(s).