General Mental Health Clinics Research Articles

The influence of patient, provider, and system level characteristics on anxiety diagnostic specificity in the Veterans Health Administration

This retrospective study sought to identify patient-, provider-, and system-level characteristics associated with anxiety diagnostic specificity in mental health clinics in the Veterans Health Administration. It used administrative data extracted from Veteran Health Administration outpatient records to identify patients with a new anxiety or trauma-related diagnosis in fiscal year 2019 (N = 383,418). Logistic regression was used to model the probability of receiving an unspecified anxiety diagnosis as a function of patient-, provider-, and system-level characteristics. Unspecified anxiety disorder was diagnosed in 27% of the sample, with higher rates in primary care mental health integration clinics (42.6%) than in general mental health clinics (22.4%). Patient demographic and clinical characteristics including gender and comorbid diagnoses; provider type; provider use of an anxiety screening instrument; and facility size, complexity, and location were significant predictors of unspecified anxiety diagnosis. Anxiety diagnosis is a complex process influenced by multiple patient-, provider-, and system-level characteristics. Additional assessment tools and guidance for differential diagnosis are needed to support mental health providers in busy clinical settings to facilitate accurate and timely diagnosis of anxiety disorders.

Comparison of medical treatment of patients with schizophrenia in general practitioners' clinics versus mental health clinics: A cohort study

ObjectivesIndividuals with schizophrenia have more cardiometabolic comorbidities than the general population, live about twenty years less and consume more medical services. They are treated at general practitioners' clinics (GPCs) or at mental health clinics (MHCs). In this cohort study we investigated the association between patients' main treatment setting, cardiometabolic comorbidities and medical services utilization. MethodsDemographics, healthcare services utilization, cardiometabolic comorbidities and medication prescriptions of patients with schizophrenia were retrieved from an electronic database for the period 1.1.2011 to 31.12.2012 and compared between patients treated mostly in MHCs (N = 260) and those treated mostly in GPCs (N = 115). ResultsGPC patients tended to be older (mean age 39.8 ± 13.7 vs. 34.6 ± 12.3 yrs., p < 0.0001), of lower socioeconomic status (42.6% vs 24.6%, p = 0.001) and have more cardiometabolic diagnoses (hypertension: 19.1% vs 10.8%, diabetes mellitus: 25.2% vs 17.0%, p < 0.05) than MHC patients. The former received more cardiometabolic disorder medications and utilized more secondary and tertiary medical services. Charlson Comorbidity Index (CCI) was higher in the GPC group than in the MHC group (1.8 ± 1.9 vs.1.2 ± 1. 6, p < 0.0001). A multivariate binary logistic regression analysis, adjusted for age, sex, SES and CCI found lower adjusted odds ratio for the MHC group versus the GPC group, of visiting an EMD, a specialist or to be hospitalized. ConclusionsThe current study highlights the critical importance of integrating GPCs and MHCs, thus offering patients combined physical and mental care at a single location. More studies on the potential benefits of such integration to patients' health are warranted.

One-Year All-Cause Mortality and Delivery of the Collaborative Chronic Care Model in General Mental Health Clinics.

This study aimed to determine whether the evidence-based collaborative chronic care model (CCM) is associated with reduced all-cause mortality among adult patients treated in general mental health clinics. Data came from a stepped-wedge, cluster-randomized CCM implementation trial across nine U.S. Department of Veterans Affairs medical centers. Survival analysis was used to estimate the relative effect of the treatment (N=5,570) compared with a control group (N=46,443) over 1 year. After adjustment for site-level and individual-level acute care utilization factors, analyses indicated that patients treated with the CCM experienced a reduction in all-cause mortality relative to patients in the control cohort (hazard ratio=0.76, 95% CI=0.60-0.95). This study is the first in which CCM has been shown to reduce all-cause mortality for patients treated in general mental health clinics. Care delivery models should be considered part of efforts to reduce the life expectancy gap between individuals with psychiatric conditions and those without such conditions.

Dialectical behaviour therapy skills training: A feasibility study with active duty military

LAY SUMMARYThis study looked at the use of dialectical behaviour therapy (DBT) skills group training with military personnel. DBT skills group training teaches coping skills to manage emotions; it has been well researched and used effectively with civilians and Veterans, but less is known about its use with military personnel. The General Mental Health (GMH) clinic receives a large volume of referrals for military personnel who have difficulty with coping skills and managing emotions. On the basis of previous research, a modified DBT skills group therapy program was developed for the clinic to offer an efficient, effective treatment program for these clients in this busy clinic. Military personnel may be a particularly good fit for this type of group-based treatment because they are familiar with working in small group settings. This treatment can also allow for a timelier return to work, minimizing interruptions to military deployments and operations. Study results showed that program participants had lower levels of depression and a greater ability to manage emotions and cope more effectively after the program. Treatment gains were largely maintained at six-month follow-up. This research suggests that DBT skills group training may be an effective treatment for military personnel.

Progress toward a performance measure for mental health based on a generic patient- reported outcome measure: Findings from the Veterans Outcome Assessment survey

We report on studies conducted to develop outcome-based performance measures (PROM-PMs) based on generic patient-reported outcome measures (PROMs) that could support strategies for quality improvement applicable to all patients in a mental health system. Data were from the Veterans Outcome Assessment Survey at baseline and three months for the Mental Component Score (MCS-12), a widely used measure of mental health-related quality of life, for 15,540 outpatients beginning treatment in General Mental Health clinics in 140 Veterans Affairs (VA) facilities. Mental health diagnoses from medical records were coded using hierarchical categories. Mental health staffing levels and quality measures were from administrative data. Changes in MCS-12 scores were associated with demographics, baseline scores, and diagnostic categories; in fully adjusted models, differences between facilities accounted for only 0.5% of the total variance between patients. There were small but significant associations of both baseline and changes in MCS-12 scores with staffing levels and administrative measures of the quality of care that support the potential value of adjusted measures of changes in MCS-12 as a PROM-PM. Remaining issues include the low proportion of variability that can be attributed to differences between facilities and the associations of staffing and quality with possible case-mix adjustment variables.

Interpreting patient reports of perceived change during treatment for depression: Findings from the Veterans Outcome Assessment survey

This study addressed ongoing questions about the meaning of patients’ perceptions of change during treatment. The study used data from the Veterans Outcome Assessment survey for patients with a depressive disorder, without mental health comorbidities, treated in Department of Veterans Affairs general mental health clinics (n = 694). Perceived changes in problems/symptoms, other domains, and the quality of communication with providers were evaluated with items from the Experience of Care & Health Outcomes (ECHO) survey. Depressive symptoms were measured with the Patient Health Questionnaire-9 (PHQ-9). Linear regression models evaluated associations of perceived change at 3-months post-baseline with observed change in PHQ-9 scores, scores on other patient-reported outcome measures (PROMs), and ratings of communication with providers. Patients’ reports of their clinical condition at follow-up together with ratings of communication accounted for approximately one-third of the variance in patients’ perceptions of change. Adding change-scores based on baseline and follow-up scores on the PHQ-9 and other PROMs did not improve model fit. The findings suggest that patient reports of perceived change during treatment reflect their current clinical state and their experience of care more closely than actual changes in the PHQ-9 or other PROMs.

Time-motion analysis of external facilitation for implementing the Collaborative Chronic Care Model in general mental health clinics: Use of an interval-based data collection approach.

Background: Facilitation is an effective strategy to implement evidence-based practices, often involving external facilitators (EFs) bringing content expertise to implementation sites. Estimating time spent on multifaceted EF activities is complex. Furthermore, collecting continuous time-motion data for facilitation tasks is challenging. However, organizations need this information to allocate implementation resources to sites. Thus, our objectives were to conduct a time-motion analysis of external facilitation, and compare continuous versus noncontinuous approaches to collecting time-motion data. Methods: We analyzed EF time-motion data from six VA mental health clinics implementing the evidence-based Collaborative Chronic Care Model (CCM). We documented EF activities during pre-implementation (4-6 weeks) and implementation (12 months) phases. We collected continuous data during the pre-implementation phase, followed by data collection over a 2-week period (henceforth, "a two-week interval") at each of three time points (beginning/middle/end) during the implementation phase. As a validity check, we assessed how closely interval data represented continuous data collected throughout implementation for two of the sites. Results: EFs spent 21.8 ± 4.5 h/site during pre-implementation off-site, then 27.5 ± 4.6 h/site site-visiting to initiate implementation. Based on the 2-week interval data, EFs spent 2.5 ± 0.8, 1.4 ± 0.6, and 1.2 ± 0.6 h/week toward the implementation's beginning, middle, and end, respectively. Prevalent activities were preparation/planning, process monitoring, program adaptation, problem identification, and problem-solving. Across all activities, 73.6% of EF time involved email, phone, or video communication. For the two continuous data sites, computed weekly time averages toward the implementation's beginning, middle, and end differed from the interval data's averages by 1.0, 0.1, and 0.2 h, respectively. Activities inconsistently captured in the interval data included irregular assessment, stakeholder engagement, and network development. Conclusions: Time-motion analysis of CCM implementation showed initial higher-intensity EF involvement that tapered. The 2-week interval data collection approach, if accounting for its potential underestimation of irregular activities, may be promising/efficient for implementation studies collecting time-motion data.

A Facility-Wide Plan to Increase Access to Medication for Opioid Use Disorder in Primary Care and General Mental Health Settings.

The opioid epidemic in the United States has generated a pressing need to enhance access to medications for opioid use disorder (MOUD). This program description illustrates a quality-improvement effort to extend MOUD to primary care and general mental health clinics within the US Department of Veterans Affairs (VA) Connecticut Healthcare system (VACHS), and to examine barriers and facilitators to implementation of MOUD in target clinics. As part of the national VA Stepped Care for Opioid Use Disorder Train the Trainer (SCOUTT) initiative to improve MOUD access, a VACHS team identified and resolved barriers to MOUD in target clinics. Key interventions were to obtain leadership support, increase waivered prescribers, and develop processes and tools to enhance prescribing. New initiatives included quarterly educational sessions, templated progress notes, and instant messaging for addiction specialist electronic consultations. MOUD receipt and prescriber characteristics were evaluated before and 1 year after implementation. There was a 4% increase in eligible patients receiving MOUD, from 552 (44%) to 582 (48%) (P = .04). The number of waivered prescribers increased from 67 to 131, and the number of buprenorphine prescribers increased from 35 to 52 over a 6-month span, and the percentage of health care practitioners capable of prescribing within the electronic health record increased from 75% to 89% (P = .01). An interdisciplinary team approach to identifying and overcoming barriers to MOUD target clinics expands access. Key interventions include interdisciplinary leadership engagement, proactive education and incentivization of target prescribers, removal of procedural barriers, and development of tools to facilitate and support prescribing. These concrete interventions can help inform other institutions interested in expanding MOUD access.

Services Delivered by the Department of Paediatric Neuroscienc at Walk- in Clinic: A Study in Tertiary Care Children Hospital in Bangladesh

Introduction: Outpatient services usually cost less, because you don't need to stay overnight. Staff members at outpatient centers are well trained in the service they provide. Neurodevelopmental Disorders (NDDs) are a heterogeneous group of conditions that share a commonality of abnormal development and functioning of the brain. Paediatric Neurscience Department of Dhaka Shishu Hospiatal provides outpatient services for the children having neurodevelopmental problem without an overnight stay. Aim of the study: The aim of the study was to evaluate the clinical patterns of neurological and neurodevelopmental disorders of children attending in the OPD in the clinic. Materials and methodology: This retrospective study was conducted in the Outpatient department of Neuroscience Department of Dhaka Shishu (Children) Hospital where a multi-disciplinary team comprising a physician, developmental therapist and child psychologist used to give service. Patients were contacted in Outpatient department of Neuroscience Department who were enrolled in OPD registration from March’2019 to August’2019. A total 3632 out patients were selected for the study. Data were organized and prepared on a spreadsheet. All statistical tests were run on SPSS for Windows version 16.0 software. Results: Total 3632 patients attended the OPD clinic. Nine hundred and two (902) patients were referred to other clinics. Most of the patients (400) were referred for general assessment and ( 400) mental health clinic, Ninety (90) for psychological assessment, Seventy nine(79)for admission, Seventy one (71) to SAHIC for hearing assessment and the lest fifty five(55) patients were referred to SLC(speech, language clinic) respectively. From the patients most of them (24.59%) had motor delay. Then 21.28% had cerebral palsy. After that20.76% had epilepsy/seizure, 14.84% had other neurological disease, 8.89% had speech problem, 6.53% had mental health problem (ASD/ ADHD/ Behavoural problem). 0.85% had ...........

Performance of the PHQ-9 across conditions and comorbidities: Findings from the Veterans Outcome Assessment survey

BackgroundThe items of the Patient Health Questionnaire-9 (PHQ-9) represent the criterion symptoms for DSM-IV major depression. This study evaluated the extent to which the PHQ-9 functions as a patient-reported outcome measure (PROM) specific to patients with major depressive disorder. MethodData were from the Veterans Outcome Assessment survey for 8848 patients beginning treatment in VA general mental health clinics, including 5754, re-surveyed after 3 months. The PHQ-9’s performance as a PROM was evaluated by comparing rank order correlations between both initial scores and improvements over 3 months between the PHQ-9 and several transdiagnostic PROMs across a range of diagnoses and comorbidities. Performance of PHQ-9-related patient-reported outcome-based performance measures (PROM-PM) were evaluated by comparing rates of response and remission across patient groups. ResultsCorrelations between the PHQ-9 and transdiagnostic measures were significant and comparable in magnitude across a range of diagnoses and for cases with depression with or without comorbidities. Rates of response and remission were comparable across most patient groups. LimitationsLimitations include use of clinical diagnoses as recorded in health records, and the relatively short time between assessments. ConclusionsIn these settings, the PHQ-9 functions more as a general measure of symptoms or distress than as a disease-specific scale. This supports its use as a PROM for patients beyond those with major depression, including those with related diagnoses and those with comorbidities, and use of related PROM-PMs in clinical settings where diagnoses may not be precise and comorbidities may be common.

Implementing the Collaborative Chronic Care Model in Mental Health Clinics: Achieving and Sustaining Clinical Effects.

Collaborative chronic care models (CCMs) were established with implementation support in nine mental health clinics. This study sought to determine whether their clinical impact was maintained after implementation support ceased. Posttrial data were analyzed from a randomized stepped-wedge CCM implementation trial in general mental health clinics in nine Department of Veterans Affairs medical centers. Sites received 1 year of implementation support, which was associated with reduced mental health hospitalization rates compared with non-CCM clinics in the same medical centers. Hospitalization rates for the year after implementation support were analyzed by using repeated measures logistic regression comparing the same clinics. Hospitalization rates for the postsupport year did not differ from comparison clinics either in the population that initially showed the difference or the population active in the clinics at the end of the year of implementation support. Clinical effects of the CCM may wane after cessation of active implementation support.

Associations between patient experience and clinical outcomes in general mental health clinics: Findings from the veterans outcomes assessment survey

For mental health, evidence linking the patients’ experiences of care with treatment outcomes is limited. We report findings from the Veterans Outcome Assessment (VOA) survey of Veterans beginning treatment in Veterans Health Administration (VHA) mental health programs with follow-up after approximately 3 months. In addition to assessments of symptoms and functioning, it includes key components of the Experience of Care and Health Outcomes (ECHO) survey including patient reports of communication with clinicians and of the overall quality of mental health care. For Veterans treated in VHA general mental health clinics, significant associations between ratings of communication and quality at baseline, and both retention in treatment and patient-reported outcomes assessed at follow-up demonstrate that better patient experience predicts more favorable outcomes. Further research is necessary to determine whether including them in measurement-based care could improve outcomes by facilitating the early identification of problems in providing care.

Critical Foundations for Implementing the VA's Public Health Approach to Suicide Prevention.

Critical Foundations for Implementing the VA's Public Health Approach to Suicide Prevention.

An Economic Analysis of the Implementation of Team-based Collaborative Care in Outpatient General Mental Health Clinics.

Collaborative Chronic Care Models represent an evidence-based way to structure care for chronic conditions, including mental health conditions. Few studies, however, have examined the cost implications of collaborative care for mental health. We aimed to conduct an economic analysis of implementing collaborative care in 9 outpatient general mental health clinics. Analyses were derived from a stepped wedge hybrid implementation-effectiveness trial. We conducted cost-minimization analyses from the health system perspective, incorporating implementation costs, outpatient costs, and inpatient costs for the year before collaborative care implementation and the implementation year. We used a difference-in-differences approach and conducted 1-way sensitivity analyses to determine the robustness of results to variations ±15% in model parameters, along with probabilistic sensitivity analysis using Monte Carlo simulation. Our treatment group included 5507 patients who were initially engaged in care within 9 outpatient general mental health teams that underwent collaborative care implementation. We compared costs for this group to 45,981 control patients who received mental health treatment as usual at the same medical centers. Collaborative care implementation cost about $40 per patient and was associated with a significant decrease in inpatient costs and a nonsignificant increase in outpatient mental health costs. This implementation was associated with $78 in cost savings per patient. Monte Carlo simulation suggested that implementation was cost saving in 78% of iterations. Collaborative care implementation for mental health teams was associated with significant reductions in mental health hospitalizations, leading to substantial cost savings of about $1.70 for every dollar spent for implementation.

Depressive symptomatology and alcohol misuse among treatment-seeking military veterans: Indirect associations via ruminative thinking

BackgroundVeterans are particularly vulnerable to experiencing concurrent issues related to depression and alcohol misuse. Despite this well-established susceptibility, research explicating targetable mechanisms that can account for this comorbidity remains limited. The present study sought to examine the explanatory role of ruminative thought processing within the depression and alcohol misuse relationship. MethodThe sample included 230 veterans presenting to a general mental health clinic at a large Veterans Affairs (VA) hospital (83% male, 58% African American, Mage = 50.61, SDage = 13.79). As part of their intake evaluation, veterans completed a brief battery of self-report questionnaires to assist with diagnostic clarification and treatment planning. ResultsA significant total effect was observed between depression and alcohol misuse. An indirect effect between depression and alcohol misuse via rumination was also found. Notably, when examining two subtypes of rumination, an indirect effect between depression and alcohol misuse via reflective pondering but not brooding was evinced. ConclusionsFindings suggest that ruminative thought processing may be an explanatory risk factor within the depression and alcohol misuse relationship. By testing the simultaneous indirect effects of brooding rumination and reflective pondering, the present study also offers novel insights concerning the circumstances under which reflection may become a maladaptive process.

Using patient-reported outcome measures for program evaluation: Design and findings on intention-to-treat outcomes from the Veterans Outcome Assessment survey

The Veterans Outcomes Assessment (VOA) program surveys Veteran Health Administration (VHA) patients when they begin mental health treatment and at follow-up at three months to obtain patient-reported outcomes measures (PROM). It complements VA's evolving program in measurement-based care by providing additional data that can be useful for program evaluation including assessments of patients who have not been seen for ongoing mental health care. In principle, it provides data on intention-to-treat outcomes for program evaluation to complement the outcomes for patients who are receiving ongoing treatment that can be derived from measurement-based care. VOA findings confirm differences in outcomes between patients who have continued to be seen for treatment and those who have not. Patients in general mental health clinics with no encounters between the baseline and follow-up assessments who reported discontinuing care because they did not want or need treatment improved more, and those who discontinued due to problems improved less than those who remained in treatment. Experience with VOA has identified a number of issues that must be addressed before it is possible to use intention-to-treat outcomes for program evaluation.

Examining the Effectiveness of a Group-Based Behavioral Activation Treatment for Depression among Veterans

To date, the utility of behavioral activation (BA) as a treatment for depression has been primarily demonstrated in an individual therapy format, with few empirical investigations exploring group-based delivery. In addition, little is known about the utility of such interventions within veterans, a population known to have increased rates of depression. To this end, the purpose of the proposed study was to examine the potential therapeutic benefits of BA delivered in a group-based format to an outpatient sample of veterans with a primary depressive diagnosis. The sample consisted of 32 veterans presenting for psychological services within a general mental health clinic at a large, Southeastern Veterans Affairs (VA) hospital. Depression and quality of life symptoms were measured pre- and post- delivery of the Brief Behavioral Activation Treatment for Depression-Revised (BATD-R; Lejuez et al. Behavior Modification, 35(2), 111–161, 2011), a 10-session manualized protocol designed to address depressive symptoms by increasing patient contact with reinforcing environmental contingencies. Consistent with prediction, engagement in BATD-R led to reductions in depression symptoms and increases in overall life satisfaction from pre- to post-treatment. The present study provides preliminary support for the effectiveness of BATD-R delivered in a group-based format among an outpatient sample of veterans.

A method to reduce imbalance for site-level randomized stepped wedge implementation trial designs

BackgroundControlled implementation trials often randomize the intervention at the site level, enrolling relatively few sites (e.g., 6–20) compared to trials that randomize by subject. Trials with few sites carry a substantial risk of an imbalance between intervened (cases) and non-intervened (control) sites in important site characteristics, thereby threatening the internal validity of the primary comparison. A stepped wedge design (SWD) staggers the intervention at sites over a sequence of times or time waves until all sites eventually receive the intervention. We propose a new randomization method, sequential balance, to control time trend in site allocation by minimizing sequential imbalance across multiple characteristics. We illustrate the new method by applying it to a SWD implementation trial.MethodsThe trial investigated the impact of blended internal-external facilitation on the establishment of evidence-based teams in general mental health clinics in nine US Department of Veterans Affairs medical centers. Prior to randomization to start time, an expert panel of implementation researchers and health system program leaders identified by consensus a series of eight facility-level characteristics judged relevant to the success of implementation. We characterized each of the nine sites according to these consensus features. Using a weighted sum of these characteristics, we calculated imbalance scores for each of 1680 possible site assignments to identify the most sequentially balanced assignment schemes.ResultsFrom 1680 possible site assignments, we identified 34 assignments with minimal imbalance scores, and then randomly selected one assignment by which to randomize start time. Initially, the mean imbalance score was 3.10, but restricted to the 34 assignments, it declined to 0.99.ConclusionsSequential balancing of site characteristics across groups of sites in the time waves of a SWD strengthens the internal validity of study conclusions by minimizing potential confounding.Trial registrationRegistered at ClinicalTrials.gov as clinical trials # NCT02543840; entered 9/4/2015.

No Trauma, no Problem: Symptoms of Posttraumatic Stress in the Absence of a Criterion A Stressor

Previous research on Posttraumatic Stress Disorder (PTSD) has investigated the sentinel role of Criterion A to the diagnosis. Some researchers have found that PTSD symptom measures are elevated in the absence of a Criterion A stressor. Therefore, the current study sought to extend this research to the Diagnostic and Statistical Manual, fifth edition (DSM-5; American Psychiatric Association 2013) using the PTSD Checklist for DSM-5 (PCL-5; Weathers et al. 2013b). Data from 222 veterans presenting to a general outpatient mental health clinic at a Veterans Health Administration were asked to complete the PCL-5 after indicating the presence of a stressful or traumatic life event. In line with previous research, the current study revealed no differences between veterans with (n = 92) and without (n = 120) a Criterion A stressor on PTSD symptom severity, clinically-indicated levels of PTSD, or symptom clusters. However, these groups differed on empirically-identified core symptoms of PTSD (Brewin et al. Journal of Traumatic Stress 22 (5), 366-373, 2009), such that veterans with a Criterion A stressor reported significantly more core PTSD symptoms. A significant limitation to these findings is that Criterion A status was examined only via self-report on the PCL-5. The findings highlight the need for more research on the definition of a Criterion A stressor, use of the PCL-5, and the current composition of PTSD symptoms that make up the DSM-5 diagnostic criteria. In the future, clinicians are encouraged to conduct a thorough trauma assessment in conjunction with a PTSD screening measure to facilitate diagnostic accuracy and treatment planning.

12.1 The Integration of Child Mental Health Services Into Primary Child Health Care in Barbados

The goal of this session is to review models of integrating child mental health services in primary health care in Barbados. Barbados is a densely populated Caribbean island where 27 percent of the 285,006 islanders are below the age of 20 years. Pediatric mental health services were traditionally provided in a clinic at the mental hospital, which was a deterrent for many families. The World Health Organization (WHO) Mental Health Gap Action Programme (mhGAP), introduced to the Caribbean region in 2015, trains primary care physicians (PCPs) to identify child mental health disorders and provide supportive therapy. In February 2016, to decrease stigma and increase access, youngsters were allowed to be treated in general mental health clinics in the primary health care centers (PHCCs). In June 2016, the Child Guidance Clinc was relocated in one of the central PHCCs.