Complex Mental Health Conditions Research Articles

Character Strength-Focused Positive Psychotherapy on Acute Psychiatric Wards: A Feasibility and Acceptability Study.

A manualized single-session positive psychotherapy intervention was developed and tested on acute psychiatric wards. Participants were invited in 2018-2019 to identify positive experiences, link them to a personal character strength, and plan a strengths-based activity. The intervention's feasibility was evaluated through fidelity to session components, character strengths identification, and activity completion. Acceptability was evaluated with self-reported pre- and postsession mood ratings, a postsession helpfulness rating, and narrative feedback. Participants (N=70) had complex and severe mental health conditions. In 18 group sessions, 89% of components were delivered with fidelity; 80% of the participants identified a character strength, of whom 71% identified a strengths-based activity, and 58% completed the activity. The mean±SD helpfulness rating (N=23) was 8.5±1.5 (on a 10-point Likert scale), and positive mood significantly increased postsession (5.9 presession vs. 7.2 postsession). Positive psychotherapy is feasible in challenging inpatient settings, and service users with severe and complex mental health conditions find it helpful.

Council tenancies and hoarding behaviours: A study with a large social landlord in England.

Hoarding behaviours are highly stigmatised and often hidden. People with problematic hoarding behaviours have a higher rate of mental health and other healthcare and social services utilisation. Hoarding is a community health problem, one factor being housing insecurity. Hoarding behaviours represent significant burden to housing providers, impact the community and dealing with it involves multiple community agencies. This study with a city council in England with a large housing stock (over 14,000 properties) in summer 2021 sought to understand the nature, circumstances and extent that hoarding presents. We developed a reporting system and conducted 11 interviews with housing officers in which they described a case to explain their involvement. Our report details the nature of 38 people who hoard: 47% had a known disability or vulnerability, 34% presented a fire and environmental risk, 87% lived alone and 60% were resident in flats. Our qualitative themes are: Working with others, Balancing an enforcement approach, Feeling conflicted, Complex needs of people who hoard and Staff needs. The cases described by the housing officers are combined into six case studies and illustrate the complex, multi-agency circumstances around decision making and risk stratification. Our findings point to housing officers as frontline professionals dealing with a public health and social care issue which is often the manifestation of complex life histories and mental health conditions. We suggest a greater focus on risk stratification and a more holistic approach to hoarding cases to effectively deal with this most complex of community health and social care issues.

A Transitional Care Model for Veterans With Complex Needs During COVID: The Behavioral Recovery Outreach (BRO) Team

The Veterans Health Administration’s Care for Patients with Complex Problems (CP)2 Program developed a national infrastructure to disseminate promising practice models to improve care for Veterans with complex medical, mental health, and/or neurocognitive conditions, who may also have behaviors disruptive to care. A strategic priority is improving safe and effective transitions to community care for Veterans with complex care needs, many of whom have historically been limited to VA settings as a result of behavioral concerns. The Behavioral Recovery Outreach (BRO) Team was the first model identified for national dissemination and evaluation at partner sites. Developed at VA Central Iowa, BRO is an interdisciplinary team model that identifies Veterans in long-term VA care settings with complex care needs to engage in individualized behavioral programing to manage/stabilize behaviors and safely transition them to more appropriate and less costly community settings. This symposium will describe the BRO team model, highlight the facilitators and barriers to nationally disseminating the BRO model with VA partner facilities, discuss adaptations in continuing community transitions following the COVID-19 pandemic, and describe program outcomes. The first speaker will discuss development of the BRO model and outcomes of a regional dissemination. The second speaker will present results from the program evaluation of the national dissemination. The final speaker will describe BRO Team expansion and lessons learned from the perspective of a VA partner facility. The (CP)2 Program Director will integrate findings and highlight implications for scaling and evaluating promising models for national dissemination for policy, practice, and future research.

Characteristics of Pediatric Frequent Users of Emergency Departments in Alberta and Ontario.

Emergency department (ED) volumes have drawn attention to frequent users but less attention has been paid to children. This study examined sociodemographic and ED presentation characteristics of pediatric high-system ED users (HSUs) in 2 provinces in Canada. Cohorts of HSUs were created from the National Ambulatory Care Reporting System in 2015/2016 for children with the top 10% of ED presentations. Controls were random samples of non-HSU patients. Factors were explored in multivariable logistic regression models. There were 151,497 HSUs (51.7% girls, average age, 6.4 years) and 591,545 controls (53.1% girls; average age, 7.4 years). High-system ED users were more likely to be younger (adjusted odds ratio [aOR], 0.89 per 5 years; 95% confidence interval [CI], 0.88-0.89), live in less populated areas (aOR, 1.85; 95% CI, 1.82-1.88), and from lowest income neighborhoods (aOR, 1.51; 95% CI, 1.48-1.54) than controls. High-system ED users had higher proportions of presentations for pediatric complex chronic (aOR, 1.25 per 0.25 increase; 95% CI, 1.21-1.29), respiratory (aOR, 1.14 per 0.25; 95% CI, 1.12-1.15), and mental health (aOR, 1.14 per 0.25; 95% CI, 1.13-1.16) conditions than controls. Complex factors underlie pediatric health care utilization decisions. Findings identified conditions to target in interventions to improve health care access and utilization. Future work should engage children and families to design interventions.

Organizational attributes of interprofessional primary care for adults with intellectual and developmental disabilities in ontario, Canada: a multiple case study

BackgroundAccess to high-quality primary care has been identified as a pressing need for adults with intellectual and developmental disabilities (IDD). Adults with IDD live with complex physical and mental health conditions, use health services differently than the general population and continue to face challenges when accessing health services. Interprofessional primary care teams offer comprehensive and coordinated approaches to primary care delivery and are well-positioned to address the needs of adults with IDD and other vulnerable populations. Although interprofessional primary care teams are recommended, there is currently limited understanding of how interprofessional care is delivered and how access to a team of providers improves the health of this population. The aim of this paper is to describe the organizational attributes of interprofessional primary care for adults with IDD within and across models of team-based care in one local health service context.MethodsA multiple case study was conducted with five interprofessional primary care teams in Ontario, Canada. Multiple methods were used to generate data including: a survey, document review, electronic medical record report and qualitative interviews. Pattern matching was the primary analytic approach for the within and across case analysis.ResultsAdults with IDD were found to be a small part of the patient population served and this group was poorly identified in three of five teams. Key organizational attributes that support the delivery of interprofessional primary care for adults with IDD were identified. Two examples of targeted programs of care for this group were also found. Despite the presence of interprofessional health providers in all teams, there were limited organizational processes to engage a wide-range of interprofessional services in the care of this group. There was no consistent reporting of outcomes or processes in place to measure the impact of interprofessional services for this population.ConclusionsThis study provides important insights into the current state of interprofessional primary care for adults with IDD in Ontario and highlight a critical need for further work in the field to develop organizational structures and processes to engage in team-based care and demonstrate the value of the approach for this population.

An Emotional Black Hole: Representations of Mental Illness in Television’s You’re the Worst

Abstract Television comedy You’re the Worst (2014–19) traverses unusual territory by exploring mental health disorders in a sustained manner. Rather than introducing short-term and unpredictable characters to explore the impact of mental health disorders, two of the ensemble cast’s four lead characters have on-screen diagnoses of mental illness. Gretchen has clinical depression and Edgar, a veteran, has Post-Traumatic Stress Disorder (PTSD). The interplay of two characters with complex mental health conditions living in the one household is inarguably rare in popular television. This article explores the accuracy of these onscreen representations of episodic mental health challenges, as well as examining the responses of those around them as they try to understand and support these characters during periods when they are markedly unwell.

Association Between Medicaid Prescription Drug Limits and Access to Medications and Health Care Use Among Young Adults With Disabilities.

Prescription drugs are necessary for managing complex physical and mental health conditions for more than 10 million Medicaid beneficiaries with disabilities. However, some state Medicaid programs limit the number of prescription drugs that beneficiaries can obtain monthly, which may decrease access to essential medications. To examine the association between exposure to the 3-drug limit at age 21 years in Arkansas and Texas and prescription drug and health care use among beneficiaries with disabilities enrolled in Medicaid. In this cohort study of 28 046 young adults with disabilities, difference-in-differences analysis was performed using Medicaid Analytic eXtract claims data from January 1, 2007, to December 31, 2012. Analyses were completed December 1, 2020. The analyses included Medicaid beneficiaries with disabilities in Arkansas and Texas (ie, drug cap states) or 15 comparison states without drug cap policies who became age 21 years during the study period and were continuously enrolled in fee-for-service Medicaid in the year before and after that point. Exposure to the 3-drug prescription limit at age 21 years in 2 drug cap states. Monthly total prescriptions and prescriptions for drugs to treat mental health conditions, total prescription drug spending, and inpatient and emergency department visits and spending in the 12 months before and after becoming age 21 years. Among 28 046 young adults with disabilities, 8214 (29.3%) resided in drug cap states and were subject to the 3-drug limit at age 21 years. Most individuals were male (drug cap states: 61.4%, comparison states: 60.6%), and the minority were White individuals (drug cap states: 36.7%, comparison states: 49.4%). More than one-half of individuals with disabilities were diagnosed with a mental health condition before age 21 years (drug cap states: 57.0%, comparison states: 60.0%). In the year before the analyzed individuals became aged 21 years, the mean (SD) number of prescriptions per beneficiary per month was 1.58 (2.16) in drug cap states vs 1.82 (1.91) in comparison states. The drug cap policy was associated with 19.6% (95% CI, -21.3% to -17.8%; P < .001) fewer monthly prescriptions and 16.5% (95% CI, -21.9% to -10.8%; P < .001) fewer prescriptions for drugs for mental health conditions but was not associated with total prescription drug spending. The drug cap policy was associated with 13.6% (95% CI, 1.9% to 26.6%; P = .02) more inpatient admissions. In this cohort study of young adults with disabilities, drug cap policies were associated with lower rates of access to important medications and higher rates of hospitalization among individuals in states with drug cap policies vs those without these policies.

Contextualising Eating Disorder Concerns for Paediatric Obesity Treatment

Eating disorders are complex mental health conditions that share risk factors with obesity. This review outlines the context for concerns that paediatric obesity treatment presents a risk for eating disorder development. Most children and adolescents undergoing professionally supervised obesity treatment will have improvements or no change to eating disorder risk profiles. However, some may subsequently develop a clinical eating disorder, and this is proposed to relate to weight-focussed dietary interventions that are standard in paediatric obesity treatment. Nevertheless, dietary restraint may not be a strong predictor of eating disorder risk in the context of paediatric obesity treatment. Most international guidelines recommend weight maintenance or weight loss as a treatment goal, and weight loss is related to improvements in cardiometabolic health but not eating disorder risk in the short term. The risk of inducing or exacerbating an eating disorder during paediatric weight management is likely to be low; however, the serious consequences combined with increasing scale of obesity treatment, and lack of empirical evidence, are of concern. There is a need for further research to identify long-term predictors of eating disorder development for children and adolescents who seek treatment for their obesity.

Design Considerations for the Development and Implementation of a Medical Respite for Older Adults Experiencing Homelessness in Metro Vancouver.

Older persons with lived or living experience of homelessness (PWLEs) often live with complex physical and/or mental health conditions which are challenged by poor access to health services, especially primary care. To fill the gap in the continuum of care following hospital discharge for PWLEs, medical respite provides health and shelter support for PWLEs who do not have acute care needs that qualify for a stay in a hospital bed, yet are too sick or frail to recover on the streets or in a traditional shelter. This study examines how a medical respite could be designed for older PWLEs in Metro Vancouver, BC. Using a community-based participatory research approach, in-depth interviews and focus groups were conducted with PWLE (n=15) and service provider (n=11) participants. Participants offered rich suggestions about (a) the culture of the medical respite, (b) the physical design of a medical respite, (c) individuals who should be involved in medical respite delivery, (d) services a medical respite should provide, and (e) who the medical respite should serve. When designing a medical respite for older PWLEs, considerations include providing an environment where patients can rest, but also feel safe and be surrounded by persons who they trust and who care for them. Developing a medical respite that adheres to the tenets of trauma-informed and patient-centered care acknowledges the mistrust and traumatization that often accompanies homeless patients presenting to health care.

A Brief Breathing Space: Experiences of Brief Admission by Self-Referral for Self-Harming and Suicidal Individuals with a History of Extensive Psychiatric Inpatient Care

Individuals with severe self-harm and experiences of lengthy psychiatric admissions often have complex mental health conditions and are at risk of suicide. In this qualitative study, self-harming individuals with >180 days of psychiatric admission over 12 months shared their experiences of Brief Admission (BA), a standardized crisis-management intervention encouraging self-admission and autonomy. Phenomenological hermeneutic analysis formulated BA as a worthy respite, replacing an old system of having to prove need ‘in blood’ or wait and get worse. Successes and struggles in early help-seeking, interpreted in the light of human rights and person-centered care, suggested that individual development of autonomy depended on perceived focus on recovery and compassion. Future research may consider ethical and health-economic aspects of BA in a broader perspective.

Foregrounding the perspectives of mental health services users during the COVID-19 pandemic

PurposeThis paper aims to highlight the critical importance of the perspectives of mental health service-users during the COVID-19 pandemic.Design/methodology/approachThis viewpoint is based on a review of recent research and literature and draws on consultations with experts by experience, including the lead author.FindingsThe authors argue that expertise-by-experience is critical to policy, service development and research; but there is a risk it will be neglected at a time of rapid and reactive clinical development.Research limitations/implicationsUnderstanding and responding to the nuances of individual need can only be achieved through coproducing service strategy design, delivery and research with mental health service users. The consultation outlined in this viewpoint gives some indication of the type of valuable insights that can be gained through seeking and listening to the perspectives of experts by experience.Originality/valueThe discussions revealed that experience of managing severe and complex mental health conditions can actually be advantageous when facing a crisis such as COVID-19.

Social prescribing for frequent attenders: findings from an innovative pilot intervention

BackgroundSocial prescribing and use of local resources is emerging as a complementary prescription in meeting health-care demands to address public needs. Frequent attenders are individuals who have, on average, 30 face-to-face consultations with general practitioners (GPs) over 2 years. There is growing evidence of the positive health outcomes of social prescribing, although less is known about the patients that are referred and the economic impact on the health-care system. We aimed to explore whether the participation of frequent attenders in a pilot social prescribing intervention affected their health and wellbeing outcomes and use of health-care resources as a consequence of the intervention. MethodsThis pilot evaluation took a mixed method approach using focus groups, in-depth interviews, and quantitative health and wellbeing data gathered before and after the intervention via self-reported questionnaires (Warwick-Edinburgh Mental Wellbeing Scale). The intervention was delivered via two social prescribers across three GP practices in south Wales, with patients identified as frequent attenders referred to structured volunteering interventions. Participants received time credits in exchange for volunteering. 1 h of volunteering equalled one credit, which could be exchanged for various leisure activities and other opportunities (eg, cinema vouchers). We did a cost analysis to estimate cost variances based on health-care unit usage before, during, and after the intervention. FindingsBetween Sept 1, 2017, and Jan 31, 2018, 78 patients were recruited to the intervention over 5 months, with 21 identified as frequent attenders. Thematic analysis of social prescriber's case notes showed that all patients presented with complex psychosocial, mental, and physical health conditions. Post-intervention, frequent attenders had improved health and wellbeing outcomes and were less reliant on health-care resources (decreased usage of health-care units, GP consultations, and prescriptions issued). Cost variance results show a direct cost saving of £8109 or £77·22 per frequent attender over the 5 months. InterpretationAlthough frequent attenders often have complex, chronic health issues, participating in this innovative intervention had a positive effect on their health and wellbeing outcomes, improved social support, and reduced isolation. Our findings show that social prescribing interventions are a key part of a social model of health and wellbeing in non-clinical support policy development in line with legislative changes. FundingInnovate to Save, Welsh Government.

Community Treatment Orders and Supported Decision-Making.

This paper presents findings from an interdisciplinary project undertaken in Victoria, Australia, investigating the barriers and facilitators to supported decision-making (SDM) for people living with diagnoses including schizophrenia, psychosis, bipolar disorder, and severe depression; family members supporting them; and mental health practitioners, including psychiatrists. We considered how SDM can be used to align Australian laws and practice with international human rights obligations. The project examined the experiences, views, and preferences of consumers of mental health services, including people with experiences of being on Community Treatment Orders (CTOs), in relation to enabling SDM in mental health service delivery. It also examined the perspectives of informal family members or carers and mental health practitioners. Victoria currently has high rates of use of CTOs, and the emphasis on SDM in the Mental Health Act, 2014, is proposed as one method for reducing coercion within the mental health system and working towards more recovery-oriented practice. Our findings cautiously suggest that SDM may contribute to reducing the use of CTOs, encouraging less use of coercive practices, and improving the experience of people who are subject to these orders, through greater respect for their views and preferences. Nonetheless, the participants in our study expressed an often ambivalent stance towards CTOs. In particular, the emphasis on medication as the primary treatment option and the limited communication about distressing side effects, alongside lack of choice of medication, was a primary source of concern. Fears, particularly among staff, about the risk of harm to self and others, and stigma attached to complex mental health conditions experienced by consumers and their families, represent important overarching concerns in the implementation of CTOs. Supporting the decision-making of people on CTOs, respecting their views and preferences about treatment, and moving towards reducing the use of CTOs require system-wide transformation and a significant shift in values and practice across mental health service delivery.

Strengthening care for children with complex mental health conditions: Views of Australian clinicians.

ObjectivesImproving mental health outcomes for children and young people has become a priority for policy makers in the developed world. In Australia, up to half of all children and adolescents meeting criteria for mental health disorders receive suboptimal levels of treatment (or no treatment at all) despite the availability of effective treatments. Children with complex mental health conditions are particularly at risk of inadequate treatment as optimal care requires coordination from medical, educational and social services. In Australia, clinicians including pediatricians, psychologists and child and adolescent psychiatrists deliver the bulk of mental health care for children with complex mental health conditions. We aimed to determine perspectives of these Australian clinicians on barriers and enablers within the current system and components of an optimal model of care.MethodsInductive content analysis was used to analyse 30 semi-structured interviews with key clinicians managing the care of children with complex mental health conditions across Australia. Interviews were conducted using vignettes with Attention Deficit Hyperactivity Disorder (ADHD) and Autism as exemplars.FindingsMultiple barriers to optimal care exist at a systemic, clinician and family level. However, regional health systems provide an enabling environment from which metropolitan models could learn. Transitioning to adult services was highlighted as the most compromised area of care. Clinicians identified short (e.g. empowering parents to advocate for and deliver their child’s care, case conferencing with schools) and long term (e.g. co-locating disciplines to deliver care, workforce training) solutions.ConclusionsWhilst multiple barriers to optimal care for children with complex mental health conditions exist, clinicians identify several enablers including developing networks with other disciplines and empowering parents to advocate for and co-ordinate care. Systemic changes based on multidisciplinary, co-located and integrated care services should be developed as longer term solutions.

A competency framework for domestic violence counselling

ABSTRACT Domestic violence (DV) affects around 20% of the population globally and is linked with complex mental health conditions and difficulties in client therapeutic engagement. Developing therapeutic competency to meet the standards for independent, professional practice is a significant part of counsellor training. A competency framework for DV is a useful addition to the literature. This framework has been systematically developed from a client-informed DV counselling model (grounded theory) and integrates well with existing international publications. It highlights high level and wide-ranging counselling skills, specialist knowledge and specific personal characteristics for working with this client group, beyond the level required for independent practice. This framework could be used as a basis for pre- and post-qualification counsellor training, recruitment and assessment.

The Recovery House in Trieste: rational, participants, intervention as the “work”

PurposeToo often people with complex mental health needs do not find their way out of the mental health system or find satisfactory solutions that enable them to live a full life. In 2015 the Mental Health Department (MHD) of Trieste established the Recovery House pilot project to address this concern. The paper aims to Investigate the project.Design/methodology/approachThe Recovery House was co-created with and for people between 18 and 35 years old with diagnoses of psychosis and other complex mental health conditions. An integral part of the pilot was the organization of the “Recovery Community,” inspired by the Assembly model embraced by Franco Basaglia. The Recovery Community met regularly to both support and learn from the Recovery House and aimed to create a democratic and reflective space where power relationships, self-determination, responsibility and ownership by all the stakeholders, including family members, could be explored together.FindingsOver a period of 31 months, four groups of people have successfully completed their residency at the Recovery House. In total, 89 percent of people who stayed at the Recovery House did so up to six months. After the period of staying at the Recovery House most of them moved to independent living or shared supported accommodation.Originality/valueThis initiative sheds light on the fact that democratic values, approaches and structures can improve both service functioning and the recovery outcomes for people with complex health needs. Further, the Recovery House has had a significant effect on the culture and practice of the MHD in adopting a comprehensive approach to emotional distress.

Providing Mental Health Services in the Primary Care Setting: the Experiences and Perceptions of General Practitioners at a New York City Clinic.

Mental illness is a significant cause of disability worldwide, including here in the United States. Given the shortage of trained mental health professionals, a significant portion of patients needing care are managed in the primary care setting. Accountable Care Organizations (ACOs), for example, are seeking to improve the quality ofcare for this vulnerable population, but many are facing significant challenges relating to integration of new services. We sought to elucidate barriers faced by primary care practitioners (PCPs)-physicians, physician trainees and nurse practitioners-at a New York primary care clinic, which impede delivery of optimal care to those suffering from mental illness. The study was conducted with 32 PCPs in 2016-2017 at Mount Sinai Internal Medicine Associates in New York City. For the quantitative component of the study, a 54-item questionnaire was devised to assess their attitude, behavior and confidence in managing psychiatric patients. For the qualitative component, data was obtained from 3 open-ended questions. Responses were coded for salient themes. Analysis revealed a range of difficulties faced by PCPs. Overall, participants felt that the need to integrate mental health care into primary care was important, however they reported significant barriers in terms of lack of time, lack of resources, low confidence in treating more complex mental health conditions and difficulties with referring patient to mental health specialists. Despite a growing body of evidence that integration of mental health services in primary care leads to improved outcomes, addressing barriers to care will be key to ensuring feasibility of integration measures.

Primary Care-Mental Health Integration in the Veterans Affairs Health System: Program Characteristics and Performance.

The Veterans Health Administration (VHA) has achieved substantial national implementation of primary care-mental health integration (PC-MHI) services. However, little is known regarding program characteristics, variation in characteristics across settings, or associations between program fidelity and performance. This study identified core elements of PC-MHI services and evaluated their associations with program characteristics and performance. A principal-components analysis (PCA) of reports from 349 sites identified factors associated with PC-MHI fidelity. Analyses assessed the correlation among factors and between each factor and facility type (medical center or community-based outpatient clinic), primary care population size, and performance indicators (receipt of PC-MHI services, same-day access to mental health and primary care services, and extended duration of services). PCA identified seven factors: core implementation, care management (CM) assessments and supervision, CM supervision receipt, colocated collaborative care (CCC) by prescribing providers, CCC by behavioral health providers, participation in patient aligned care teams (PACTs) for special populations, and treatment of complex mental health conditions. Sites serving larger populations had greater core implementation scores. Medical centers and sites serving larger populations had greater scores for CCC by prescribing providers, CM assessments and supervision, and participation in PACTs. Greater core implementation scores were associated with greater same-day access. Sites with greater scores for CM assessments and supervision had lower scores for treatment of complex conditions. Outpatient clinics and sites serving smaller populations experienced challenges in integrated care implementation. To enhance same-day access, VHA should continue to prioritize PC-MHI implementation. Providing brief, problem-focused care may enhance CM implementation.

The Role of Healthcare Providers in Return to Work

International research has generated strong evidence that healthcare providers (HCPs) play a key role in the return to work (RTW) process. However, pressure on consultation time, administrative challenges and limited knowledge about a patient's workplace can thwart meaningful engagement. Aim: Our study sought to understand how HCPs interact with workers compensation boards (WCBs), manage the treatment of workers compensation patients and navigate the RTW process. Method: The study involved in-depth interviews with 97 HCPs in British Columbia, Manitoba, Ontario and Newfoundland and Labrador and interviews with 34 case managers (CMs). An inductive, constant comparative analysis was employed to develop key themes. Findings: Most HCPs did not encounter significant problems with the workers compensation system or the RTW process when they treated patients who had visible, acute, physical injuries, but faced challenges when they encountered patients with multiple injuries, gradual-onset or complex illnesses, chronic pain and mental health conditions. In these circumstances, many experienced the workers compensation system as opaque and confusing. A number of systemic, process and administrative hurdles, disagreements about medical decisions and lack of role clarity impeded the meaningful engagement of HCPs in RTW. In turn, this has resulted in challenges for injured workers (IWs), as well as inefficiencies in the workers compensation system. Conclusion: This study raises questions about the appropriate role of HCPs in the RTW process. We offer suggestions about practices and policies that can clarify the role of HCPs and make workers compensation systems easier to navigate for all stakeholders.

Implementing and Sustaining Team-Based Telecare for Bipolar Disorder: Lessons Learned from a Model-Guided, Mixed Methods Analysis.

Telemental health interventions have empirical support from clinical trials and structured demonstration projects. However, their implementation and sustainability under less structured clinical conditions are not well demonstrated. We conducted a follow-up analysis of the implementation and sustainability of a clinical video teleconference-based collaborative care model for individuals with bipolar disorder treated in the Department of Veterans Affairs to (a) characterize the extent of implementation and sustainability of the program after its establishment and (b) identify barriers and facilitators to implementation and sustainability. We conducted a mixed methods program evaluation, assessing quantitative aspects of implementation according to the Reach, Efficacy, Adoption, Implementation, and Maintenance implementation framework. We conducted qualitative analysis of semistructured interviews with 16 of the providers who submitted consults, utilizing the Integrated Promoting Action on Research Implementation in the Health Services implementation framework. The program demonstrated linear growth in sites (n = 35) and consults (n = 915) from late 2011 through mid-2016. Site-based analysis indicated statistically significant sustainability beyond the first year of operation. Qualitative analysis identified key facilitators, including consult content, ease of use via electronic health record, and national infrastructure. Barriers included availability of telehealth space, equipment, and staff at the sites, as well as the labor-intensive nature of scheduling. The program achieved continuous growth over almost 5 years due to (1) successfully filling a need perceived by providers, (2) developing in a supportive context, and (3) receiving effective facilitation by national and local infrastructure. Clinical video teleconference-based interventions, even multicomponent collaborative care interventions for individuals with complex mental health conditions, can grow vigorously under appropriate conditions.