Evidence-based Mental Health Care Research Articles

Mental health literacy in Pakistan: a narrative review

PurposeThe term “Mental health literacy” is defined as knowledge and beliefs about mental disorders which aid their recognition, management or prevention. The importance of health literacy for physical health is widely studied; however, the area of mental health literacy in Pakistan has been comparatively neglected. The purpose of this paper is to address the knowledge about mental health in people living in Pakistan.Design/methodology/approachRelevant literature relating to mental health literacy was identified through various database searches. The databases searched included: PubMed, Cochrane database of Systemic Reviews, PsycINFO using the terms mental health, mental health literacy, mental health education, Pakistan.FindingsLiterature suggests that there is dearth of knowledge about mental illnesses and their treatment among public. This review also highlights the importance of mental health literacy among professionals working in the field of health care. In Pakistan, due to low literacy rate, a high percentage of poverty and dearth of trained professionals warrants an emendation in approaches established for attaining the goal of public health and psychiatric care.Practical implicationsFindings have implications for practitioners in the field of mental health care as well as designing targeted interventions for enhancing mental health literacy and help-seeking behavior in the future.Originality/valueA limited understanding and lack of improvement in mental health literacy may interfere with society’s acceptance of evidence-based mental health care which may hamper the delivery of adequate mental health services to the needy.

Reflections on "Building Back Better" Child and Adolescent Mental Health Care in a Low-Resource Postemergency Setting: The Case of Sierra Leone.

Over the past three decades, Sierra Leone has experienced two major humanitarian crises: an armed conflict (1991–2002) and an Ebola virus disease outbreak (2014–2015). In addition to these country-wide crises, the capital Freetown experienced a mudslide affecting thousands of people in 2017. In response to these emergencies, donors and aid organizations showed an increased interest in supporting and implementing mental health and psychosocial support interventions. Despite these efforts, the mental health infrastructure of the country remains frail. Specifically, systemic improvements in the implementation of evidence-based mental health care for children and adolescents appear to be lacking. In this article, the Interactive Systems Framework for Dissemination and Implementation is used as a tool to analyze issues related to the development of a sustainable, contextually relevant child and adolescent mental health-care delivery system. The author draws on her long-term experience as a child mental health specialist in Sierra Leone. Observations and hypotheses are tested and supplemented by formal and informal reports and national and international literature. The three systems described by the Interactive Systems Framework are explored in the context of Sierra Leone: (1) Synthesis and Translation, (2) Support, and (3) Delivery. Interaction between the three Systems is discussed as critical to the successful dissemination and implementation of interventions. Ample attention is given to contextual factors that are believed to be paramount to the development of child and adolescent mental health care in Sierra Leone. The article concludes with a reflection on the usefulness of the Interactive Systems Framework in the dissemination and implementation of child and adolescent mental health-care interventions in low-resource, postemergency settings. It is suggested that, in addition to funding and policies, the child and adolescent mental health system in Sierra Leone could benefit from the development of contextually relevant interventions, improvement of capacity-building efforts, and acknowledgment of the role of community-based practitioners in the delivery of services. Local mental health experts, especially those trained in child and adolescent mental health, should be empowered to work together with culturally competent expatriate professionals to improve child and adolescent mental health care in Sierra Leone.

Applying lessons from task sharing in global mental health to the opioid crisis.

The current opioid crisis in the United States has been considered an "epidemic of poor access to care." Similar to the shortage of trained providers to prescribe medications to treat opioid use disorder (OUD), there is a severe shortage of trained providers to meet the mental health needs of patients with OUD. These workforce shortages are evident nationwide, yet are particularly salient in rural areas. In this commentary in response to the article "Integrating Addiction Medicine into Rural Primary Care: Strategies and Initial Outcomes (Logan et al., 2019)," we propose that we can apply lessons learned from working in resource-constrained settings globally to improve access to mental health care for patients with OUD in rural areas in the United States. We expand upon Logan et al. (2019) by discussing how non-specialist health workers, including community health workers and peer providers, under the supervision of psychologists and other specialists, can expand access to evidence-based mental health care for patients with OUD, particularly those receiving medications for opioid use disorder (MOUD). We draw from established models in global mental health that rely on "task sharing" mental health care to discuss ways in which lessons learned from scaling up evidence-based interventions with lay health workers in low and middle-income countries can directly inform efforts to increase access to mental health care to address the opioid crisis. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Professionalism and Evidence-Based Mental Health Care: The Roadblocks and New Ways

BACKGROUND: Knowledge acquisition and knowledge update through research remains an important factor to ensure quality and cost-effective care, which is the hallmark of professionalism and evidence-based care. Knowledge is vital in nursing due to the centrality of nursing to health care. More importantly is mental health because mental health is primary to general health, just as nursing is the heartbeat of health care. This makes the issue of mental health care, a necessary service that cannot be overemphasised. The World Health Organisation declares mental health as the essential form of health that needs to be acquired without which all others form of health may not be achieved. Further to this, the global emphasis on care and recovery of lost mental health is on the increase. This, therefore, makes evidence-based mental health care, a necessity and not a choice. 
 
 AIM: To discuss evidence-based nursing, the benefits, challenges and opportunities.
 
 METHODOLOGY: This article adopts the traditional review method to assess the concept of discussion on mental health care, evidence-based practice and professionalism. 
 
 FINDINGS: The term evidence-based care Is gaining recognition in a variety of professions and organisations. The use of evidence in nursing care is influenced by policies, knowledge of time management, availability of human resources, practice autonomy and attitude of professionals. However, the use of evidence-based practice is not debatable. 
 
 CONCLUSION: The use of scientific evidence for validating nursing care is germane. This article exposed the barriers to evidence-based mental health nursing and the way forward. 

Understanding of evidence-based mental health care and the perceived importance of scientific information in a sample of U.S. adults.

This online survey sought to qualitatively ascertain the extent to which a sample of U.S. adults understood the concept of evidence-based mental health care (EBMHC). Additional goals included assessing the perceived importance of scientific information in EBMHC, and examining whether understanding EBMHC and science values varied as a function of participant factors. Participants (N = 221) defined EBMHC and rated the importance of scientific information. Open-ended EBMHC definitions were content-coded, and binomial logistic and linear regressions examined predictors of accurately defining EBMHC and of the perceived importance of scientific information. Participants endorsed seven definitions of EBMHC, and only 20% defined it accurately. Having greater knowledge about mental health conditions was associated with understanding EBMHC and with the higher perceived importance of scientific information. Greater help-seeking efficacy also predicted higher perceived importance of scientific information. Results support customized strategies to promote basic EBMHC education among U.S. adults.

Mental health problems and socioeconomic disadvantage: a controlled household study in rural Ethiopia

BackgroundThere is a lack of high quality population-based studies from low- and middle-income countries examining the relative economic status of households with and without a member with a mental health problem. The aim of the study was to explore the socio-economic status of households with a person with severe mental disorder (SMD; psychosis or bipolar disorder) or depression compared to households without an affected person.MethodsA population-based, comparative, cross-sectional household survey was conducted in Sodo district, south Ethiopia, between January and November 2015. Two samples were recruited, each with its own comparison group. Sample (1): households of 290 community-ascertained persons with a clinician-confirmed diagnosis of SMD and a comparison group of 289 households without a person with SMD. Sample (2): households of 128 people who attended the primary health care centre and who were identified by primary care staff as having a probable diagnosis of depressive disorder; and comparison households of 129 patients who attended for other reasons and who did not receive a diagnosis of depression. Household socioeconomic status (household income, consumption and asset-based wealth) was assessed using a contextualized version of theWorld Health Organization (WHO) Study on global Ageing and adult health (SAGE) questionnaire. Each disorder group (SMD and depression) was further divided into higher and lower disability groups on the basis of median score on the WHO Disability Assessment Schedule.ResultsHouseholds of a person with SMD who had higher disability were more likely to have a poorer living standard (no toilet facility; p < 0.001). Having a reliable source of regular income was significantly lower in households of a person with SMD (p = 0.008) or depression (p = 0.046) with higher disability than the comparison group. Households of persons with SMD with higher disability earned less (p = 0.005) and owned significantly fewer assets (p < 0.001) than households without SMD. Households including persons with depression who had higher disability had lower income (p = 0.042) and reduced consumption (p = 0.048).ConclusionsHouseholds with a member who had either SMD or depression were socioeconomically disadvantaged compared to the general population. Moreover, higher disability was associated with worse socio-economic disadvantage. Prospective studies are needed to determine the direction of association. This study indicates a need to consider households of people with SMD or depression as a vulnerable group requiring economic support alongside access to evidence-based mental healthcare.

Reducing Barriers to Mental Health Care: Bringing Evidence-Based Psychotherapy Home.

Barriers to treatment for depression and anxiety are prevalent among older adults and caregivers living in the community. We designed and implemented an evidence-based psychotherapy program to reduce obstacles to care. A practice improvement initiative providing no-fee evidence-based mental health care at home in clients' primary languages. Independence at Home, a community service of SCAN Health Plan in Southern California. Diverse older adults and adult caregivers of older people with age-related disability (mainly dementia). Redesign of an existing supportive counseling program to improve access to validated models of psychotherapy for depression and anxiety. We describe program content, phases of development, equity in participation from referral to program completion, clinical outcomes, and estimated direct program delivery costs. Insights successfully served demographically diverse clients experiencing a broad range of barriers to mental health care. A total of 211 clients completed therapy using one of three evidence-based approaches in the first 33 months of operation (2015-2018). Clinical efficacy was high and equivalent across demographic groups and therapy models. Depression, anxiety, quality of life, self-rated disability, and patient activation all improved significantly. We supported therapists' transition to the new model, modified workflows, and used clinical outcome data and therapist focus groups to improve referral, selection, and enrollment processes and simplify treatment assignment. With program maturation, treatment duration and direct costs both declined. The Insights model could add value to healthcare organizations seeking to provide effective, equitable mental health services for older adults and caregivers who have difficulty accessing care for depression, anxiety, or difficult life challenges. J Am Geriatr Soc 67:2174-2179, 2019.

Internet-Based Cognitive Therapy for Social Anxiety Disorder in Hong Kong: Therapist Training and Dissemination Case Series.

BackgroundGuided internet-based psychological interventions show substantial promise for expanding access to evidence-based mental health care. However, this can only be achieved if results of tightly controlled studies from the treatment developers can also be achieved in other independent settings. This dissemination depends critically on developing efficient and effective ways to train professionals to deliver these interventions. Unfortunately, descriptions of therapist training and its evaluation are often limited or absent within dissemination studies.ObjectiveThis study aimed to describe and evaluate a program of therapist training to deliver internet-based Cognitive Therapy for social anxiety disorder (iCT-SAD). As this treatment was developed in the United Kingdom and this study was conducted in Hong Kong with local therapists, an additional objective was to examine the feasibility, acceptability, and initial efficacy of iCT-SAD in this cultural context, based on data from a pilot case series.MethodsTraining in iCT-SAD was provided to 3 therapists and included practice of the face-to-face format of therapy under clinical supervision, training workshops, and treating 6 patients with the iCT-SAD program. Training progress was evaluated using standardized and self-report measures and by reviewing patient outcomes. In addition, feedback from patients and therapists was sought regarding the feasibility and acceptability of the program.ResultsThe training program was effective at increasing therapists’ iCT-SAD knowledge and skills, resulting in levels of competence expected of a specialist Cognitive Behavioral Therapy practitioner. The 6 patients treated by the trainees all completed their treatment and achieved a mean pre- to posttreatment change of 53.8 points (SD 39.5) on the primary patient outcome measure, the Liebowitz Social Anxiety Scale. The within-group effect size (Cohen d) was 2.06 (95% CI 0.66-3.46). There was evidence to suggest that the patients’ clinical outcomes were sustained at 3-month follow-up. These clinical results are comparable to those achieved by UK patients treated by the developers of the internet program. Patient and therapist feedback did not identify any major cultural barriers to implementing iCT-SAD in Hong Kong; some modest language suggestions were made to assist understanding.ConclusionsThe therapist training implemented here facilitated the successful dissemination of an effective UK-developed internet intervention to Hong Kong. The treatment appeared feasible and acceptable in this setting and showed highly promising initial efficacy. A randomized controlled trial is now required to examine this more robustly. As therapist training is critical to the successful dissemination of internet interventions, further research to develop, describe, and evaluate therapist training procedures is recommended.

Digital Technology for Building Capacity of Nonspecialist Health Workers for Task Sharing and Scaling Up Mental Health Care Globally.

Workforce shortages pose major obstacles to delivering adequate mental health care and scaling up services to address the global treatment gap. Mounting evidence demonstrates the clinical effectiveness of having nonspecialist health workers, such as community health workers, lay health workers, midwives, or nurses, deliver brief psychosocial treatments for common mental disorders in primary care settings. With rapidly increasing access to, and use of, digital technology worldwide, new opportunities are available to leverage these emerging digital technologies to support nonspecialist health workers and increase mental health workforce capacity. This Perspectives article considers the potential that digital technology holds for supporting nonspecialist health workers in delivering evidence-based mental health care. Specifically, from our search of the academic literature, we identified seven promising examples from primary care settings in different low- and middle-income countries (India, Pakistan, Zimbabwe, Peru, China, and Nigeria) where digital platforms are being used to support delivery of mental health care from a variety of nonspecialist providers by offering training, providing digital tools for diagnosis, guiding treatment, facilitating supervision, and integrating services. We summarize these examples and discuss future opportunities to use digital technology for supporting the development of a trained, effective, and sustainable mental health workforce. We also consider the potential to leverage these technologies for integrating mental health care into existing health systems in low-resource settings.

Improving the mental health of low- and middle-income countries.

Although low- and middle-income countries experience more adversity, and this is associated with higher rates of mental health problems, most people in these countries cannot access evidence-based mental health care. There are opportunities to implement affordable evidence-based programs in ways that are sustainable in low- and middle-income countries.

Psychology across cultures: Challenges and opportunities.

Large variations of inequalities in rates of mental health disorders and access to mental health care exist within and between countries. Globally, disparities range from countries where there is little provision to those where, despite the availability of evidence-based mental health care, service access and outcomes are mediated by social factors such as socio-economic status, race/ethnicity, and culture. This is salient because increasingly diverse populations are inevitably created with globalization. We posit that in multicultural contexts, effective therapeutic engagement requires therapists who are competent and confident to work with diversity and difference, utilizing insights into their own as well as their clients' internal and external worlds. Although there are many reasons why psychotherapies can be insensitive and harmful, for example, the inherent power imbalance in therapeutic relationships, a lack of awareness of cultural and ethnic variation and needs are among them. Acquisition of 'cultural competence' and increasing availability of culturally-adapted interventions should, in theory, enable practitioners to work with a range of individuals with whom they might have little in common. However, whilst cultural adaptation appears promising, there are concerns regarding its viability as a strategy for tackling disparities in access to psychological care. Evidence for cultural competency is patchy at best. We show how and why delivering effective psychotherapy in the twenty-first century requires a paradigm shift from current approaches to truly integrated models, developed in collaboration with recipients of care. Coproducing interventions, training, and means of evaluating them with clients necessitates taking into consideration social contexts, alternative conceptualizations of mental health and disorders and difficulties, and what constitutes appropriate helpful interventions for psychological distress. PRACTITIONER POINTS: Upskilling therapists to work with diversity and difference is essential for effective delivery of psychological treatments. Increasing the availability of culturally-adapted interventions together with therapists who are sufficiently competent and confident to deliver them should enable practitioners to work with a range of individuals with whom they might have little in common. Coproducing culturally appropriate means of responding to mental health difficulties, staff training and development, and service evaluation methods with clients necessitates taking into consideration social contexts, alternative explanatory models of mental health and 'illness', and what constitutes helpful interventions for psychological distress.

Integration of Traditional Birth Attendants into Mental Healthcare: A Multistakeholder Qualitative Study Exploration.

Background A significant number of people with common mental disorders are undiagnosed or undetected at primary healthcare facilities. The experience of traditional birth attendants (TBAs) in reassuring perinatal mothers could be utilized in maternal mental healthcare. The aim of this study was to gain insight into the feasibility of integrating TBAs into maternal mental healthcare using multiple stakeholder views. Methods We conducted an exploratory qualitative study in September 2017 using focus group discussions (FGDs) and in depth interviews in Makueni County, Kenya. A total of 246 participants (TBAs, community health volunteers (CHVs), healthcare workers (HCWs), antenatal and postnatal mothers seeking care from TBAs and those seeking both hospital and TBA services, mothers in law and/or husbands of perinatal mothers, and opinion leaders based in the county) were purposively selected to participate in the discussions. Transcribed data was analyzed using NVivo version 10. Results Four major themes emerged from the qualitative data and were identified as follows; (a) involving TBAs in perinatal mental healthcare by assigning them roles, (b) utilizing TBAs' patient rapport and counseling experience, (c) recognition and appreciation of TBAs by the healthcare system, and (d) training and collaboration of TBAs with healthcare workers. Discussion The findings of this study reveal that although TBAs informally provide psychosocial interventions to pregnant mothers, their roles in mental health are not clearly defined. The importance of TBAs sharing their experience and being recognized as important stakeholders in mental healthcare for perinatal mothers was highlighted. Inclusion of TBAs in dialogue and training them to offer evidence-based mental healthcare were identified as important steps towards improving the mental wellbeing of mothers and the future generation.

Evaluating transdiagnostic, evidence-based mental health care in a safety-net setting serving homeless individuals.

Homeless individuals experience higher rates of mental illness than the general population, though this group is less likely to receive evidence-based psychological treatment for these difficulties. One explanation for this science-to-service gap may be that most empirically supported interventions are designed to address a single disorder, which may not map on to the substantial comorbidity present in safety-net samples, and create a high training burden for often underresourced clinicians who must learn multiple protocols to address the needs of their patients. One solution may be to prioritize the dissemination of transdiagnostic interventions that can reduce therapist burden and simultaneously address comorbid conditions. The purpose of the present article is to describe the process of conducting a pilot study administering the Unified Protocol (UP), a transdiagnostic treatment for the range of emotional disorders, at a community-based organization that provides health care and other services to homeless individuals and families in Boston, Massachusetts. Therapists on a specialized behavioral health unit received didactic training in the intervention, followed by weekly consultation while they provided the UP to patients on their caseload. Qualitative and quantitative data were collected from both patients and therapists. Barriers to use of the UP by therapists, as well as to conducting research in this setting, will be discussed, along with the solutions that were used. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Who Wants Feedback? Effects of Transformational Leadership and Leader-Member Exchange on Mental Health Practitioners' Attitudes Toward Feedback.

The purpose of this study was to identify the mechanisms through which different aspects of leadership affect mental health practitioners' attitudes toward supervisory feedback. Data were collected from 363 practitioners nested in 68 treatment teams in public-sector mental health organizations. A multilevel path analysis was conducted to examine the associations of transformational leadership (supervisor's ability to inspire others to follow a course of action) and leader-member exchange (quality of the supervisor-practitioner relationship) with practitioner attitudes toward feedback. Transformational leadership and leader-member exchange were directly and positively associated with practitioners' attitudes toward feedback. Transformational leadership was also indirectly associated with practitioners' attitudes toward feedback through the quality of supervisor-practitioner relationships. Study results contribute to the growing body of evidence suggesting that leaders play a key role in shaping mental health service delivery. Both leadership behavior and high-quality supervisor-practitioner relationships are important in supporting practitioners in delivering evidence-based mental health care. Policymakers, administrators, and researchers should consider an integrative approach when developing leadership training interventions.

The Influence of Team Functioning and Workload on Sustainability of Trauma-Focused Evidence-Based Psychotherapies.

It has been over a decade since the U.S. Department of Veterans Affairs (VA) began formal dissemination and implementation of two trauma-focused evidence-based psychotherapies (TF-EBPs). The objective of this study was to examine the sustainability of the TF-EBPs and determine whether team functioning and workload were associated with TF-EBP sustainability. This observational study used VA administrative data for 6,251 patients with posttraumatic stress disorder (PTSD) and surveys from 78 providers from 10 purposefully selected PTSD clinical teams located in nine VA medical centers. The outcome was sustainability of TF-EBPs, which was based on British National Health System Sustainability Index scores (possible scores range from 0 to 100.90). Primary predictors included team functioning, workload, and TB-EBP reach to patients with PTSD. Multiple linear regression models were used to examine the influence of team functioning and workload on TF-EBP sustainability after adjustment for covariates that were significantly associated with sustainability. Sustainability Index scores ranged from 53.15 to 100.90 across the 10 teams. Regression models showed that after adjustment for patient and facility characteristics, team functioning was positively associated (B=9.16, p<.001) and workload was negatively associated (B=-.28, p<.05) with TF-EBP sustainability. There was considerable variation across teams in TF-EBP sustainability. The contribution of team functioning and workload to the sustainability of evidence-based mental health care warrants further study.

Advances in Asynchronous Telehealth Technologies to Improve Access and Quality of Mental Health Care for Children and Adolescents

Although mental health (MH) disorders are common among children and adolescents, most youth in need of services do not receive care. Among those who do access the mental health care system, quality of care remains poor. Telehealth technologies have the potential to improve access and quality of MH care for this population. In this article, we provide an overview of several promising asynchronous telemental health (A-TMH) technologies that target one or more dimensions of access to MH care, the quality of MH care, or both: (1) patient registries and tracking systems, (2) store and forward telehealth, (3) mobile health (mHealth) interventions, and (4) internet self-administered therapies. Next, we draw on two conceptual frameworks to identify key dimensions of health care access and quality that may be targeted by these A-TMH technologies. There are, however, a number of major challenges to the broader dissemination of these tools including a dearth of available research on their efficacy and effectiveness; the monetary cost associated with developing, acquiring, implementing, and maintaining these technologies; and the time cost associated with training on and implementation of these technologies. As researchers, practitioners, and policymakers may pursue strategies to overcome these challenges, A-TMH technologies have the potential to help create a more accessible, equitable, evidence-based, and patient-centered mental health care system for youth.

A structured approach to integrating mental health services into primary care: development of the Mental Health Scale Up Nigeria intervention (mhSUN)

BackgroundThe treatment gap for mental illness in Nigeria, as in other sub-Saharan countries, is estimated to be around 85%. There is need to prioritise mental health care in low and middle income countries by providing a strong body of evidence for effective services, particularly with a view to increasing international and government confidence in investment in scaling up appropriate services. This paper lays out the processes by which a programme to integrate evidence-based mental health care into primary care services in Nigeria was designed, including a research framework to provide evidence from a robust evaluation.MethodsThis paper forms the first step in the overall process evaluation of the mhSUN intervention, where standard research practice indicates that the intervention, and its development, is clearly documented prior to subsequent evaluation. The report covers the period of programme development and evaluation design, and study site and design was chosen to allow generalisability and practical conclusions to be drawn for service development in Nigeria. In order to design an intervention that was informed by evidence and took into account local context and input of stakeholders, a structured process was followed, including: (1) Engagement of relevant stakeholders for information gathering and buy-in; (2) Literature review and gathering of pertinent evidence; (3) Situation analysis at a national and local level; (4) Model development (using Theory of Change); (5) Ongoing consultation, recognising the iterative nature of Theory of Change, and need for ongoing refinement of complex interventions.ResultsThe different sections of the structured approach resulted in outputs that built the necessary components (literature review, situation analysis) for informing the Theory of Change. A Theory of Change map is presented, which includes transparent documentation of the assumptions and logic behind the activities to drive the desired change. In addition, it documents the indicators necessary to measure fidelity and draw conclusions as to hypothesised effects of different mechanisms of action in subsequent evaluation.ConclusionIn addition to the details of ensuring robust evaluation design, there are a number of considerations that are particular to the context that must be taken into account in programme development, including the relationships between ultimate beneficiaries, implementers, host government and institutions, donors, and programme evaluators. Structured methods from existing frameworks can be drawn upon to use and collate relevant information to maximise the local applicability of a generic evidence base. Theory of Change, with its documented assumptions can form the basis of subsequent evaluation and iterative programme refinement, contributing to a more scientifically valid means of developing mental health programmes for scale up.

Alcohol-related and mental health care for patients with unhealthy alcohol use and posttraumatic stress disorder in a National Veterans Affairs cohort

ObjectiveUnhealthy alcohol use and posttraumatic stress disorder (PTSD) frequently co-occur. Patients with both conditions have poorer functioning and worse treatment adherence compared to those with either condition alone. Therefore, it is possible that PTSD, when co-occurring with unhealthy alcohol use, may influence receipt of evidence-based alcohol-related care and mental health care. We evaluated receipt of interventions for unhealthy alcohol use and receipt of mental health follow-up care among patients screening positive for unhealthy alcohol use with and without PTSD in a national sample from the Veterans Health Administration (VA). MethodsNational clinical and administrative data from VA's electronic medical record were used to identify all patients who screened positive for unhealthy alcohol use (AUDIT-C score≥5) between 10/1/09–5/30/13. Unadjusted and adjusted Poisson regression models were fit to estimate the relative rate and prevalence of receipt of: brief interventions (advice to reduce or abstain from drinking≤14days after positive screening), specialty addictions treatment for alcohol use disorder (AUD; documented visit≤365days after positive screening), pharmacotherapy for AUD (filled prescription≤365days after positive screening), and mental health care ≤14days after positive screening for patients with and without PTSD (documented with ICD-9 CM codes). In secondary analyses, we tested effect modification by both severity of unhealthy alcohol use and age. ResultsAmong 830,825 patients who screened positive for unhealthy alcohol use, 140,388 (16.9%) had documented PTSD. Of the full sample, 71.6% received brief interventions, 10.3% received specialty AUD treatment, 3.1% received pharmacotherapy for AUD, and 24.0% received mental health care. PTSD was associated with increased likelihood of receiving all types of care. Adjusted relative rates were 1.04 (95% CI 1.03–1.05) for brief interventions, 1.06 (1.05–1.08) for specialty AUD treatment, 1.35 (1.31–1.39) for AUD pharmacotherapy, and 1.82 (1.80–1.84) for mental health care. Alcohol use severity modified effects of PTSD for specialty AUD treatment, AUD pharmacotherapy, and mental health care such that effects were maintained at lower severity but attenuated among patients with severe unhealthy alcohol use. Age modified all effects with the strength of the association between PTSD and care outcomes being strongest for younger (18–29years) and older veterans (65+ years) and weaker or non-significant for middle-aged veterans (30–44 and 45–64years). ConclusionsIn this large national sample of patients with unhealthy alcohol use, PTSD was associated with increased likelihood of receiving alcohol-related and mental health care. PTSD does not appear to be a barrier to care among VA patients with unhealthy alcohol use.

Collaborative Care Model Effective For Addiction Treatment

Collaborative Care Model Effective For Addiction Treatment

Understanding integrated mental health care in "real-world" primary care settings: What matters to health care providers and clients for evaluation and improvement?

The integration of mental health specialists into primary care has been widely advocated to deliver evidence-based mental health care to a defined population while improving access, clinical outcomes, and cost efficiency. Integrated care has been infrequently and inconsistently translated into real-world settings; as a result, the key individual components of effective integrated care remain unclear. This article reports findings from a qualitative study that explored provider and client experiences of integrated care. We conducted in-depth interviews with integrated care providers (n = 13) and clients (n = 9) to understand their perspectives and experiences of integrated care including recommended areas for quality measurement and improvement. The authors used qualitative content and reflexive thematic analytic approaches to synthesize the interview data. Clients and integrated care providers agreed regarding the overarching concepts of the what, how, and why of integrated care including co-location of care; continuity of care; team composition and functioning; client centeredness; and comprehensive care for individuals and populations. Providers and clients proposed a number of dimensions that could be the focus for quality measurement and evaluation, illuminating what is needed for successful context-sensitive spreading and scaling of integrated care interventions. With a mounting gap between the empirical support for integrated care approaches and the implementation of these models, there is a need to clarify the aims of integrated care and the key ingredients required for widespread implementation outside of research settings. This study has important implications for future integrated care research, and health care provider and client engagement in the quality movement. (PsycINFO Database Record