Behavioral Health Specialists Research Articles

The relationship between self-reported poor mental health and complete tooth loss among the US adult population in 2019.

Very little is known about the association between poor mental health and poor oral health outcomes in the United Sates. This study investigated the prevalence of complete tooth loss among those with and without perceived poor mental health in a nationally representative sample of noninstitutionalized U.S. adults. Using a cross-sectional study design, we analyzed the 2019 Medical Expenditures Panel Survey to determine the unweighted and weighted prevalence of complete tooth loss among adults. Chi-squared and multivariate logit regression with marginal effects were used to measure the association between complete tooth loss and perceived poor mental health, controlling for respondent characteristics. The prevalence of adults (ages 18 and older) experiencing complete tooth loss was 6% (95% CI: 5.6-6.4). Individuals who have perceived poor mental health were 1.90 percentage points (pps) more likely to report missing all their natural teeth (P = 0.006: 95% CI: 0.5-3.3). Other relevant predictors of complete tooth loss included current smoking status (5.9 pps; 95% CI: 4.5 to 7.2) and secondary education (-6.4 pps (95% CI: -7.0 to -4.8). Overall, self-reported poor mental health was found to be associated with a greater likelihood of reporting complete tooth loss. Findings from this study underscore the need for greater integration of care delivery between behavioral health specialists and dental providers.

Depression Screening in Pediatric Orthopedic Surgery Clinics and Identifying Patients At-Risk.

Up to 25% of youth experience a depressive episode by 18 years of age, leading the US Preventive Services Task Force to recommend depression screening within this population. This study aimed to understand the prevalence of depression identified within pediatric orthopedic clinics compared with primary care clinics after the implementation of a screening program and present data on the prevalence of moderate-severe depression across specific pediatric orthopedic clinics, characterizing and identifying specific populations at higher risk. A retrospective review was performed to identify all patients screened using the 2-item and 9-item versions of the Patient Health Questionnaire (PHQ-2/PHQ-9) and the Columbia-Suicide Severity Rating Scale over a 2-year period (October 2018 to January 2021) within pediatric primary care and orthopaedic clinics. Demographic and clinical characteristics were collected. Statistical analysis was performed to compare scores between orthopedic and primary care clinics, as well as between the different pediatric orthopedic subspecialties and included χ 2 test, ANOVA, and logistic regression. There were 32,787 unique adolescent patients screened in primary care clinics, with an additional 14,078 unique adolescent patients screened in orthopaedic clinics, leading to a 30% increase in the overall number of patients receiving depression screening. 5.2% of patients in primary care pediatric clinics screened positive for moderate-severe depression versus 2.0% in pediatric orthopaedic clinics ( P <0.001). 2.7% of primary care patients were at risk of self-harm compared with 0.8% of orthopedic patients ( P <0.001). Within orthopaedic subspecialty clinics, the spine patients were at the highest risk of moderate-severe depression (3.5%), significantly higher than both the sports (1.4%, P =0.006) and patients with acute fracture (1.3%, P <0.001). This study demonstrates the high incidence of patients screening positive for depression in pediatric and adolescent orthopaedic clinics. By identifying high-risk clinics and patient groups, health care systems can apply a more practical approach and appropriately deploy behavioral health specialists for timely counseling and treatment discussions. Level-III.

Perspectives of clinical stakeholders and patients from four VA liver clinics to tailor practice facilitation for implementing evidence-based alcohol-related care

BackgroundUnhealthy alcohol use (UAU) is particularly dangerous for people with chronic liver disease. Liver clinics may be an important setting in which to provide effective alcohol-related care by integrating evidence-based strategies, such as brief intervention and medications for alcohol use disorder. We conducted qualitative interviews with clinical stakeholders and patients at liver clinics in four Veterans Health Administration (VA) medical centers to understand barriers and facilitators of integrating alcohol-related care and to support tailoring of a practice facilitation implementation intervention.MethodsData collection and analysis were guided by the Consolidated Framework for Implementation Research (CFIR). Interviews were transcribed and qualitatively analyzed using a Rapid Assessment Process (RAP) guided by the CFIR.ResultsWe interviewed 46 clinical stakeholders and 41 patient participants and analyzed findings based on the CFIR. Clinical stakeholders described barriers and facilitators that ranged from operations/clinic resource-based (e.g., time and capacity, desire for additional provider types, referral processes) to individual perspective and preference-based (e.g., supportiveness of leadership, individual experiences/beliefs). Patient participants shared barriers and facilitators that ranged from relationship-based (e.g., trusting the provider and feeling judged) to resource and education-based (e.g., connection to a range of treatment options, education about impact of alcohol). Many barriers and facilitators to integrating alcohol-related care in liver clinics were similar to those identified in other clinical settings (e.g., time, resources, role clarity, stigmatizing beliefs). However, some barriers (e.g., fellow-led care and lack of integration of liver clinics with addictions specialists) and facilitators (e.g., presence of quality improvement staff in clinics and integrated pharmacists and behavioral health specialists) were more unique to liver clinics.ConclusionsThese findings support the possibility of integrating alcohol-related care into liver clinics but highlight the importance of tailoring efforts to account for variation in provider beliefs and experiences and clinic resources. The barriers and facilitators identified in these interviews were used to tailor a practice facilitation implementation intervention in each clinic setting.

Providing Behavioral Health Care in PACE – A Review of Federal and State Manual Regulations

ObjectivesPresent analysis of the federal and state regulations that guide The Program of All-Inclusive Care for the Elderly (PACE) operations and core clinical features for direction on behavioral health (BH). DesignReview and synthesize the federal (Centers for Medicare and Medicaid Services [CMS]) and all publicly available state manuals according to the BH–Serious Illness Care (SIC) model domains. Setting and ParticipantsThe 155 PACE organizations operating in 32 states and the District of Columbia. MethodsA multipronged search was conducted to identify official state and federal manuals guiding the implementation and functions of PACE organizations. The CMS PACE website was used to identify the federal PACE manual. State-level manuals for 32 states with PACE programs were identified through several sources, including official PACE websites, contacts through official websites, the National PACE Association (NPA), and public and academic search engines. The manuals were searched according to the BH-SIC model domains that pertain to integrating BH care with complex care individuals. ResultsAccording to the CMS Manual, the interdisciplinary team is responsible for holistic care of PACE enrollees, but a BH specialist is not a required member. The CMS Manual includes information on BH clinical functions, BH workforce, and structures for outcome measurement, quality, and accountability. Eight of 32 PACE-participating states offer publicly available state PACE manuals; of which 3 offer information on BH clinical functions. Conclusions and ImplicationsRegarding BH, federal and state manual regulations establish limited guidance for comprehensive care service delivery at PACE organizations. The absence of clear directives weakens BH care delivery due to a limiting the ability to develop quality measures and accountability structures. This hinders incentivization and accountability to truly all-inclusive care. Clearer guidelines and regulatory parameters regarding BH care at federal and state levels may enable more PACE organizations to meet rising BH demands of aging communities.

BEhavioral Health Stratified Treatment (B.E.S.T.) to optimize transition to adulthood for youth with intellectual and/or developmental disabilities

Youth with intellectual and/or developmental disabilities (IDD) often struggle with depression and anxiety, which adversely impacts transition to adulthood. Integrated behavioral health care coordination, wherein care coordinators and behavioral health specialists collaborate to provide systematic, cost-effective, patient-centered care, is a promising strategy to improve access to behavioral health services and address factors that impact transition to adulthood, including depression/anxiety symptoms. Current care coordination models (e.g., Title V Maternal and Child Health Bureau [MCHB]) do not include behavioral health services. The CHECK (Coordinated HealthCarE for Complex Kids) mental health model, hereby refined and renamed BEhavioral Health Stratified Treatment (B.E.S.T.), is a behavioral health intervention delivery program designed for integration into care coordination programs. This study aims to determine whether an integrated behavioral health care coordination strategy (i.e., MCHB care coordination plus B.E.S.T.) would be more acceptable and lead to better youth health and transition outcomes, relative to standard care coordination (i.e., MCHB care coordination alone). Results would guide future investment in improving outcomes for youth with IDD.This study is a two-arm randomized clinical trial of 780 transition-aged youth with IDD (13–20 years) to evaluate the comparable efficacy of MCHB Care Coordination alone vs. MCHB Care Coordination plus B.E.S.T. on the following outcomes: 1) decreased symptoms and episodes of depression and anxiety over time; 2) improved health behaviors, adaptive functioning and health related quality of life; 3) increased health care transition (HCT) readiness; and 4) improved engagement and satisfaction with care coordination among stakeholders.

Theory, Measurement, and Psychometric Properties of Risk and Protective Factors for Drug Misuse Among Adolescents Living on or near the Cherokee Nation Reservation

A team of tribe-based behavioral health specialists and university-based researchers partnered to implement a cluster randomized trial for the prevention of drug misuse among adolescents attending public high schools on or near the Cherokee Nation Reservation in northeastern Oklahoma. The conceptual framework, which guided intervention and measurement design for the trial, incorporates indigenous knowledge and worldviews with empirically-based frameworks and evidence-based practices. Our goal is to serve multicultural youth, families, and schools and to provide a model of effective strategies for wide dissemination. This paper presents the conceptual model, survey design, and psychometric properties of scales to measure risk and protective factors for substance misuse. The survey includes common measures drawn from the PhenX Toolkit on substance use patterns—adolescent module, measured with standard items from the Monitoring the Future (MTF) study and items harmonized across ten NIH-funded research projects with diverse samples of youth. In our trial, brief (20-minute) self-report questionnaires were administered to 10th grade students in fall 2021 (n = 919, 87% response rate) and spring 2022 (n = 929, 89% response rate) in 20 participating high schools on or near the Cherokee Nation Reservation. The sample primarily fell into the following three categories of race/ethnicity identification: only American Indian (AI-only, 29%), AI and another race/ethnicity (AI+, 27%), and only White (35%). Results indicate that risk and protective factor scales were reliably and validly measured with 10 scales and 10 subscales. There were minimal differences between youth who identified as AI only, AI+, and White only, especially for the main scales, which provide confidence in the interpretation of trial outcomes across demographic groups. Study results may not be generalizable to AI/AN youth who live and attend school in more homogenous reservation lands, or alternatively, live in large diverse metropolitan areas.

Interprofessional Education in a Psychiatry Clerkship.

The purpose of this initiative was to encourage medical students to develop collaborative relationships with healthcare team members during a required psychiatry clerkship and reflect upon their demonstration of interprofessional competencies. During the clerkship, third year medical students were required to complete two interprofessional activities (from a menu of 18 potential options) in conjunction with nurses, therapists, care coordinators, behavioral health specialists, peer specialists, unit secretaries, or unit managers during care of mutual patients. After completing these activities, students completed a reflection in which they self-reported how they had accomplished specific interprofessional competencies (quantitative and qualitative); the healthcare team members with whom the students collaborated also completed a corresponding reflection (quantitative) of students' interprofessional competence, based upon their interactions. Quantitative feedback from students and staff was paired to look for correlations. Paired responses produced a dataset that included 67 students' self-reflections and 110 feedback submissions from staff. Overall, there was much similarity between students' self-assessment ratings and ratings provided by staff members. Qualitative analysis of students' written feedback indicated they took initiative to take on new roles to support the care team and intentionally sought out healthcare teammates to learn about their roles and to better care for patients. Reflections highlight examples of student advocacy and empathy for patients they served. Results demonstrate that clerkship-based interprofessional education initiatives, designed with intentionality, promote interprofessional collaborative practices and prepare medical students for achieving residency milestones related to interprofessional collaboration.

Integrated care and the behavioral health primary care provider.

Primary care remains the main setting for delivery of psychiatric care. An integrated approach improves the ability of primary care providers (PCPs) to care for complex patients with behavioral health needs. This article describes integrated care and how physician associates/assistants can gain additional training to become behavioral health specialists.

Ethnic Determinants of Health and Medication Use for Depression Among US Latinx Adults.

Medication use for depression among US Latinx adults is low (34%) and commonly associated with systems-related and individual-related cultural factors. Social determinants of health (SDH) include economic, environmental, educational, community, and healthcare systems factors. Ethnic determinants of health (EDH) are SDH factors specific to an ethnic group and described by an ethnic and disparities framework. To assess relationships between EDH factors and depression medication use among non-Latinx White (NLW) and Latinx adult populations using data from a weighted national sample for hypothesis building. Weighted responses to 2015-2018 National Survey on Drug Use and Health surveys from NLW, Latinx, and Latinx adult respondents from Puerto Rico, Mexico, and other Latinx countries were compared. Bivariate analyses were conducted using 2-way cross tabulation and a Wald chi-square test of association. EDH variables were characterized within the construct domains of systems-related geographic location, education, and economic stability, and individual-related cultural factors. Prescription medication use for depressive symptoms is 16.6% (P < 0.05) lower among a national sample of Latinx compared with NLW adults with major depressive episode (MDE). Many differences among systems-level EDH variables between Latinx and NLW populations with MDE were also found between populations with depression medication use. Of note, seeing a primary care provider or psychologist or social worker was significantly different among populations with MDE but not for those with depression medication use. Individual-related cultural EDH variables of overall health and serious psychological distress were significantly worse for Latinx than NLW populations with depression medication use. However, stigma, healing beliefs, and religious beliefs were not different between populations with MDE or depression medication use. Differences between certain Latinx populations with depression medication use were found with limited English proficiency and living in poverty. EDH variables for environment-physical characteristics or community and interpersonal levels of analysis were not represented within the NSDUH survey. Seeing a primary care provider or behavioral health specialist, depression severity, and overall health status appear to be important factors related to depression medication use among Latinx adults. Given the limitations of these analyses, multivariate analyses of EDH factors and other Latinx populations are warranted.

Year one review: Staff perception on the implementation of the chair restraint on an adolescent psychiatric inpatient unit.

The purpose of this project was to assess perceptions, thoughts, and feelings of psychiatric mental health nursing staff when utilizing the chair restraint on an adolescent unit. Furthermore, to explore decision making related to choosing the chair restraint verses choosing to use the six-point board as a safety management intervention. This was a phenomenological qualitative study, utilizing semistructured interviews to explore the experiences of nursing staff, consisting of behavioral health specialists, and direct-care staff nurses who work on an adolescent psychiatric unit utilizing both chair restraint and the six-point board. Ten nursing staff were interviewed. Using thematic analysis, staff perceptions, thoughts, and feelings when using mechanical restraints for safety management were explored. Demographics were collected however, there was no variability in the responses and saturation was reached. Five themes emerged from the interviews. The Five themes that emerged were: Restraint chair was less traumatic and preferred, feelings of defeat when de-escalation was not successful, pushing away emotions as protection, units were short staffed, and patient behaviors were seen as a potential barrier to eliminating the six-point board. The results of this study will be used to guide to further develop behavioral health education, orientation for new staff, and to understand ways to support staff through their experiences in managing a patient's unsafe behaviors.

Virtual Collaborative Behavioral Health Model in a Community Pediatric Network: Two-Year Outcomes.

Due to the pervasive shortage of behavioral health (BH) specialists, collaborative partnerships between pediatric primary care practitioners (PPCPs) and BH specialists can enhance provision of BH services by PPCPs. We aimed to create a new model of collaborative care that was mostly virtual, affordable, and scalable. The pilot program was implemented in 18 practices (48 PPCPs serving approximately 150 000 patients) in 2 consecutive cohorts. Outcomes were assessed by administering pre-program and post-program surveys. Across the 18 practices, PPCPs reported significantly increased confidence in their BH knowledge and skills, and significantly increased their provision of target BH services. Barriers to BH service provision (resources, time, and staff) were unchanged. This compact, mostly virtual model of BH collaboration appears to be beneficial to PPCPs while also offering convenience to patients and affordability and scalability to the practice network.

Collaborative Care Model Gaining Traction in North Carolina

Collaborative Care Model Gaining Traction in North Carolina

Connecting Behavioral Health Specialists With Schools: Adapting a Telementoring Series During COVID-19.

To address the daunting behavioral and mental health needs of Kansas' rural and underserved communities, Telehealth ROCKS (Rural Outreach for the Children of Kansas) Schools project partnered with school-based health centers, school districts, and special education cooperatives to provide a range of telebehavioral health intervention services and teletraining. This project used the Project Extension for Community Healthcare Outcomes (ECHO) telementoring framework to connect specialty providers with school/community providers for web-based continuing education and case consultation to support students with special education needs. Our team created the Function Friday for Better Behavior ECHO series to address challenging behaviors in schools, based on the concept of functional behavior assessment and function-based treatment. Part of the ECHO series came into being after the onset of the COVID-19 pandemic. This article describes how our ECHO series provided an effective mechanism for supporting school and community providers during the pandemic, and participating educators utilized skills as they transitioned from onsite education to the virtual learning environment with students.

Improving First-Year Family Medicine Residents' Confidence in Safe Opioid Prescribing Through a Multiactivity Educational Program.

It is documented that some of the opioids prescribed to manage chronic pain are diverted and used for nonmedical purposes. We investigated whether a skill-based, chronic pain management (CPM) educational program could improve first-year family medicine residents' comfort, knowledge, and concerns in assessing and managing patients who use opioids for chronic noncancer pain. A total of 72 first-year residents (four cohorts of 18) participated in a 3-month CPM training intervention that consisted of didactic lectures, objective structured clinical examination (OSCE) activities, and post-OSCE debriefing with faculty, one being a behavioral health specialist, between 2017 and 2020. We used a single-sample, pre/post design. At three points in time (baseline, 3-months, and 6-months postintervention), participants completed a set of measures assessing comfort, knowledge, and concern. We used repeated measures analyses to assess changes in outcome measures. Participants reported improvements compared with baseline at both follow-up time points. At 6 months postintervention, the participants had significantly better scores on measures of comfort (F[1, 71]=65.22;P<.001), knowledge (F[1, 71]=22.38,P<.001), and concern (F[1, 71]=37.89,P<.001) in prescribing opioids for chronic noncancer pain. A multiactivity CPM educational program for first-year residents was associated with improvement in perceived sense of comfort, knowledge, and concerns in assessing and managing patients who use opioids for chronic noncancer pain. CPM training interventions may be an effective tool to educate first-year residents to implement best practices for pain management with the goal of reducing the chances of inappropriately prescribing controlled substances or denying analgesia.

Team Approach: Management of Mental Health in Orthopaedic Patients.

Mental health evaluation should be considered an essential part of the routine preoperative assessment and should be managed by a multidisciplinary team composed of the primary care physician, orthopaedic provider, and behavioral health specialist. The scientific literature indicates that patients without comorbid psychiatric symptoms and adaptive coping strategies, resilience, and well-managed expectations have improved functional outcomes and satisfaction after orthopaedic procedures. Psychological issues are multifaceted and require treatment tailored to each individual patient. Therefore, close communication between all members of the care team is required to create and execute the perioperative plan.

What does it take to get a diagnosis? Dementia recognition and diagnosis pathways among Indigenous peoples

AbstractBackgroundPatients, caregivers, and providers face an oftentimes‐confusing healthcare terrain around dementia diagnostics and care given the lack of standardization for screening and evaluation of neurocognitive disorders. This can be further compounded by systemic healthcare inequalities and historical and present‐day marginalization faced by Indigenous populations.MethodWe present a segment of a pilot study (NIH R56 AG 62307) which sought to explore the impact of Alzheimer’s disease and related dementias (ADRDs) in Indigenous populations across four diverse settings, three in the United States and one in Canada. Community‐based researchers conducted key informant interviews with healthcare providers (n = 20) and sequential focus groups (SFGs) with local health care staff and formal caregivers (14 sessions, n = 17). Data were coded based on research questions and objectives in consultation with project leaders, coders, and community‐based researchers.ResultIn recognizing a cognitive change, all participants identified the importance of family members who often brought their concerns to the attention of a healthcare provider. Additionally, participants in the US and Canada identified events like hospital admissions as a “catastrophic event” (e.g., injury, missed medication, physical decline) as another route for diagnosis. A unique pathway that Canadian participants identified was the role of personal support workers (PSWs) and community nurses in noticing cognitive changes among individuals they served. Finally, providers mentioned various pathways for receiving a dementia diagnosis. While all providers mentioned taking steps to rule out other reasons for cognitive decline, the specific next step for the diagnosis varied widely. The possible professionals to see for a diagnosis included social workers, family doctors, tribal dementia care specialists, behavioral health specialists, psychiatrists, and neurologists.ConclusionFamily members are crucial in recognizing the changes associated with ADRDs. A strength of the Canadian healthcare system is that PSWs and community nurses can also help identify changes, potentially before hazardous “catastrophic events” bring people to the hospital. Once a cognitive change has been identified, the diagnostic pathway is complicated, non‐standardized, and irregular – in other words difficult to navigate. Policies and procedures need to be put in place, delineating standardized protocols to better help family caregivers and patients dealing with ADRDs.

Rural-urban prescribing patterns by primary care and behavioral health providers in older adults with serious mental illness

BackgroundOlder adults with serious mental illness (SMI) often have multiple comorbidities and complex medication schedules. Shortages of behavioral health specialists (BHSs), especially in rural areas, frequently make primary care providers (PCPs) the only clinician managing this complex population. The aim of this study was to describe rural/urban psychiatric medication prescribing in older adults with SMI by PCPs and BHSs, and by clinician type.MethodsThis retrospective descriptive analysis used 2018 Medicare data to identify individuals with a bipolar, major depression, schizophrenia, or psychosis diagnosis and examined medication claims for antianxiety, antidepressants, antipsychotics, hypnotics, and anticonvulsants. Descriptive statistics summarized percentage of medications provided by PCPs and BHSs stratified by rural and urban areas and by drug class. Additional analyses compared psychiatric prescribing patterns by physicians, advanced practice registered nurses (APRNs), and physician assistants (PAs).ResultsIn urban areas, PCPs prescribed at least 50% of each psychiatric medication class, except antipsychotics, which was 45.2%. BHSs prescribed 40.7% of antipsychotics and less than 25% of all other classes. In rural areas, percentages of psychiatric medications from PCPs were over 70% for each medication class, except antipsychotics, which was 60.1%. Primary care physicians provided most psychiatric medications, between 36%-57% in urban areas and 47%-65% in rural areas. Primary care APRNs provided up to 13% of prescriptions in rural areas, which was more than the amount prescribed by BHS physicians, expect for antipsychotics. Psychiatric mental health APRNs provided up to 7.5% of antipsychotics in rural areas, but their prescribing contribution among other classes ranged between 1.1%-3.6%. PAs provided 2.5%-3.4% of medications in urban areas and this increased to 3.9%-5.1% in rural areas.ConclusionsResults highlight the extensive roles of PCPs, including APRNs, in managing psychiatric medications for older adults with SMI.

Extreme risk protection orders, race/ethnicity, and equity: Evidence from California

Extreme risk protection orders (ERPOs) provide a civil mechanism to temporarily remove firearm access from individuals at high risk of harming themselves or others. Evidence and theory suggest that ERPOs can prevent firearm-related harm, but the policy's impact on racial/ethnic equity is largely unknown. To examine potential inequities by race/ethnicity in public perceptions and use of California's ERPO law, we drew on two complementary data sources: 1) a 2020 state-representative survey of California adults, and 2) ERPO court documents for the first 3 years of policy implementation (2016–2018). Majorities (54–89%) of all racial/ethnic groups reported that ERPOs are at least sometimes appropriate, and 64–94% were willing to ask a judge for an ERPO for a family member. However, Black and Hispanic/Latinx survey participants less often perceived ERPOs as appropriate and were less willing to serve as petitioners, with Black participants citing lack of knowledge about ERPOs and not trusting the system to be fair as their top reasons for unwillingness. Similarly, review of ERPO court documents revealed that no family or household members served as petitioners for Black and Hispanic/Latinx ERPO respondents. Additionally, Black respondents were the least likely to have documented access to a firearm and legal representation in court. Racial/ethnic equity in ERPO use may be improved by reducing barriers to petitioning, incorporating non-law enforcement intervention professionals like behavioral health specialists into the ERPO process, providing legal assistance to respondents and petitioners, and investing in the social safety net.

Wellness for the Wounded: Mental Health Care in the Diabetic Limb Salvage Team.

Managing patients with diabetic foot ulcers mandates coordinated input from multiple disciplines. Our practice has published previously on the value of a multidisciplinary team, incorporating skills from plastic surgery, vascular surgery, podiatry, rheumatology, and hyperbaric oxygen therapy in a single location.1 A relatively underdiscussed and poorly recognized component of the multidisciplinary team is mental health care through psychiatrists and psychosocial support. The effects of acute and chronic wound formation on a patient’s quality of life are well documented. Much of the literature comes from studies on trauma and burn survivors. In these fields, preexisting mental health conditions have been linked to higher rates of reoperation, longer hospital stays, and longer times to return to preinjury activity.2 More recently, validated surveys that assess emotional quality of life, such as the 36-Item Short-Form Health Survey, have been applied to the chronic wound populations.3 Patients with chronic leg ulcers have the highest rates of depression among patients with skin diseases and consistently report lower quality of life, worse physical functioning, and higher levels of pain.4 However, few studies comment on the critical role of psychiatrists, psychologists, and social support in the chronic wound population. In the chronic wound population, the interplay of mental health and wound-related outcomes is critical. Chronic diseases, such as diabetes, require lifelong maintenance therapy and diligent monitoring for acute emergencies. Patients who have difficulty adapting to their intensive medically necessary care face higher disease burden and are at risk for experiencing the extremes of disease progression, such as limb loss. Research shows that patients with high mental illness burden often have difficulty adhering to medication schedules. Patients who are prescribed psychiatric medication take, on average, 58 to 65 percent of all prescribed medications.5 Patients with chronic wounds and diabetic foot ulcers are seen bimonthly to weekly by a team of specialized wound care physicians who are not trained to recognize or manage psychiatric disease. Adding psychiatry or behavioral psychology to the wound team provides critical services that allow for prompt identification of disease. Incorporating providers who are equipped to manage physical and mental aspects of care is essential to improve health outcomes and reduce health care costs. To accomplish this goal, all centers that provide care for patients with diabetic wounds can (1) incorporate a dedicated expert in mental health on their team, (2) consistently refer all diabetic wound patients who are exhibiting signs of mental health distress to a behavioral health specialist, (3) educate existing staff members on the role of mental health in wound healing, and (4) screen patients for depression and anxiety during all stages of care. There is abundant need for research into the relationship between successful chronic wound management and mental health support. More longitudinal analyses of the development of new or progression of preexisting psychiatric conditions as a consequence of chronic wound formation will help guide treatment of coexisting conditions. Quality trials also need to assess which behavioral or pharmacologic treatments yield the greatest benefit to wound healing and functional outcomes. DISCLOSURE The authors have no financial interest to declare in relation to the content of this article.

The Effect of Creative Arts Therapy on Psychological Distress in Health Care Professionals

BackgroundWork-related psychological distress is common among health care professionals. We determined whether 4 creative arts therapy (CAT) programs were acceptable, feasible, and improved psychological distress and job turnover intention in health care professionals with burnout symptoms. MethodsHealth care professionals were enrolled during the coronavirus disease (COVID-19) pandemic from September 2020 until July 2021. Participants attended in-person weekly 90-minute group session for 12 consecutive weeks. Intervention and control subjects completed surveys before the beginning and after the end of their cohort. The study outcomes were session attendance (feasibility), program satisfaction (acceptability), and change in symptoms of anxiety, depression, burnout, posttraumatic stress disorder (PTSD), and job turnover intention. ResultsWe randomized 165 participants into 4 CAT interventions and 1 common control group across 3 sequential cohorts. Thirty-five randomized participants dropped out before the start of the cohort, and 16 were replaced from a waiting list. Therefore, the cohort consisted of 146 participants. On average, participants were 35 years old, white (85%), and female (92%). Overall, 52% were nurses, 10% were doctors, and 16% were behavioral health specialists. Participants attended a median of 9.5 [8-11] sessions. Program satisfaction was high with a median Client Satisfaction Questionnaire (CSQ-8) score of 31 [17-32] out of a possible score of 32. Participants randomized to the intervention had improvements in anxiety (P < .0001) and depression scores (P = .0007), total posttraumatic stress disorder score (P =.0002), burnout scores (P = .001, .003, .008), and turnover intention (P = .001). ConclusionsA CAT program is feasible, acceptable, and may reduce psychological distress and turnover intention for health care professionals.