Primary Care Mental Health Research Articles

A qualitative exploration of the health system responses to the screening and management of comorbid mental illness and chronic physical illness in Jamaica

Background People with comorbid mental illness (MI) and chronic physical illness (CPI) face a range of health and quality of life challenges. The appropriate screening and management of comorbid MI and CPI are crucial to improving outcomes for this population. Despite this, there is a dearth of research exploring the health system response to the screening and management of patients with these comorbidities in public primary care settings, in several jurisdictions including Jamaica. This study explored and described the attitudes, perspectives, experiences, and practices of policymakers, primary care physicians, psychiatrists, and mental health nurses regarding screening and management of comorbid MI and CPI. Method Twenty-nine participants representing policymakers, primary care physicians, psychiatrists, and mental health nurses took part in semi-structured interviews. Data was collected over the period April to November 2020 and subject to thematic analysis. Results Three overarching themes emerged from the data related to: 1) Policies and Protocols; 2) Clinical Practice; and 3) Personnel. The interplay of these themes illustrated fragmentation and gaps between national policies and guidelines and clinical practice. The findings also identified factors related to personnel, including barriers that limit clinicians’ abilities to adequately screen and manage this patient population. Conclusion There is a need for the continued development and revision of policies and protocols that support integrated care for patients with comorbid MI and CPI in primary care settings in Jamaica. Additionally, programs and strategies to improve clinicans knowledge, skills and access to resources are necessary to help them offer improved quality of care around screening and management for this patient population.

Identifying eating disorders at the earliest opportunity: Testing the reliability of an online eating disorder screener (IOI‐S) in primary care and youth mental health settings

AbstractAimEating disorders (EDs) are associated with significant disease burden and unacceptably high mortality rates. Early intervention significantly improves prognosis and can prevent chronic suffering; however, large numbers of people with the illness are not being identified or managed in primary healthcare. The current study aimed to test the reliability of the face‐to‐face, clinician delivery of a previously validated, co‐designed, online screening tool for eating disorders.MethodsIndividuals aged 14 and over who read, English were recruited from the community in either primary care (general practice) settings or headspace youth mental health centres. They completed the InsideOut Institute Screener (IOI‐S) face‐to‐face, delivered verbally by the study researcher clinician and then online by self‐report. The primary outcome was test‐retest reliability as measured by two‐way mixed effects model Intraclass Correlation Coefficient (ICC) with absolute agreement.ResultsA total of 83 participants aged 14–81 (M 36.2) completed the study in New South Wales and the Northern Territory, Australia, between April and November 2022. The ICC between successive iterations of the test was significantly positive (0.980), demonstrating strong internal validity and test–retest reliability of the scale.ConclusionsThe IOI‐S is an adaptive 6‐item screening tool designed to ‘start a conversation’ and determine risk using gentle language conceived by individuals with lived experience. Originally designed for online use, the current study broadens its versatility to clinical settings. The screener performs equally well when delivered face‐to‐face in clinical practice. In conjunction with increased practitioner education and improved treatment referral pathways, broad implementation of the screener in early healthcare settings can support timely identification and intervention for those with EDs.

Characteristics of Hospitals by Graduate Medical Education Expense Category: Implications for Rural Residency Program Expansion.

To describe how the characteristics of the hospitals and communities they serve vary across the 4 hospital graduate medical education (GME) expense categories (according to Section 131 of the Consolidated Appropriations Act of 2021) and identify the rurally located never claimer hospitals that are most similar to teaching hospitals, signaling that they might be good candidates for new rural GME programs. Hospital categories and characteristics were gathered from the March 2022 Medicare Cost Reports; 2022 County Health Rankings & Roadmaps data were used for community characteristics. Each acute hospital was classified into 1 of the following 4 mutually exclusive hospital categories: category A, category B, established teaching hospital (ETH), and never claimer. Multinomial logistic regressions were conducted to estimate the adjusted associations of hospital characteristics with hospital categories and to identify the never claimer hospitals in rural locations that have characteristics similar to teaching hospitals (category A, category B, and ETHs). Out of 3,590 hospitals, 2,075 (57.8%) were never claimer hospitals. After adjusting for multiple characteristics, rural hospitals had a similar probability of being in each hospital category to that of urban hospitals. Never claimer hospitals served an older population and were located in communities with more uninsured adults and children and less availability of primary care physicians, dentists, and mental health professionals. This study demonstrated that most hospitals in every category, but especially teaching hospitals (i.e., category A hospitals, category B hospitals, and ETHs), were concentrated in urban areas. Larger hospitals (measured by net patient revenue) were more likely to report GME expenses (i.e., be a category A hospital, a category B hospital, or an ETH). The study suggests that there are roughly 145 rural never claimer hospitals that might be strong candidates for initiating new residency programs.

Closing the Referral Loop: Piloting a Clinical Pathway Between Primary Care and Community-Based Mental Health and Addictions Services

Findings from a novel Primary Care (PC) Mental Health (MH) pathway for children and young people in Northern Ontario, Canada are presented. Overall, 166 MH referrals from PC to a community-based child and youth MH and addictions agency (CB-CYMHA) occurred, with outstanding PC uptake (100%) and faxing referral outcomes (99%) from the CB-CYMHA to the PC provider. Half of referral outcomes (50%) were returned within 2 weeks and 83% of contacted clients reported satisfaction with services received. This successful pilot serves as an example for care pathway improvements and mobilizes knowledge for other pathway sites across Ontario.

Developing an innovative pediatric integrated mental health care program: interdisciplinary team successes and challenges.

Children and adolescents often do not receive mental healthcare when they need it. By 2021, the complex impact of the COVID-19 pandemic, structural racism, inequality in access to healthcare, and a growing shortage of mental health providers led to a national emergency in child and adolescent mental health in the United States. The need for effective, accessible treatment is more pressing than ever. Interdisciplinary, team-based pediatric integrated mental healthcare has been shown to be efficacious, accessible, and cost-effective. In response to the youth mental health crisis, Rady Children's Hospital-San Diego's Transforming Mental Health Initiative aimed to increase early identification of mental illness and improve access to effective treatment for children and adolescents. A stakeholder engagement process was established with affiliated pediatric clinics, community mental health organizations, and existing pediatric integrated care programs, leading to the development of the Primary Care Mental Health Integration program and drawing from established models of integrated care: Primary Care Behavioral Health and Collaborative Care. As of 2023, the Primary Care Mental Health Integration program established integrated care teams in 10 primary care clinics across San Diego and Riverside counties in California. Measurement-based care has been implemented and preliminary results indicate that patient response to therapy has resulted in a 44% reduction in anxiety symptoms and a 62% decrease in depression symptoms. The program works toward fiscal sustainability via fee-for-service reimbursement and more comprehensive payor contracts. The impact on patients, primary care provider satisfaction, measurement-based care, funding strategies, as well as challenges faced and changes made will be discussed using the lens of the Reach, Effectiveness, Adoption, Implementation and Maintenance framework. Preliminary results suggest that the Primary Care Mental Health Integration is a highly collaborative integrated care model that identifies the needs of children and adolescents and delivers brief, evidence informed treatment. The successful integration of this model into 10 primary care clinics over 3 years has laid the groundwork for future program expansion. This model of care can play a role addressing youth mental health and increasing access to care. Challenges, successes, and lessons learned will be reviewed.

Severe mental illness and the perimenopause

Hormonal fluctuations in the perimenopause are associated with an array of physical and psychological symptoms. Those with pre-existing mental disorders may experience changes to their symptoms and response to treatment during the perimenopausal and postmenopausal periods and may also be at risk of poorer longer-term physical health outcomes in menopause. The transition towards menopause may be compounded by the oestradiol-suppressing effect of many psychotropics on the hypothalamopituitary–gonadal axis. A collaborative approach between primary care and secondary mental health services is an opportunity for proactive discussion of symptoms and support with management of the perimenopause. This may involve lifestyle measures and/or hormone replacement therapy, which can both lead to improvements in well-being and mental and physical health.

Service Users’ Descriptions of Recovery-Oriented Elements of a Rural Mental Health Service

ABSTRACT Recovery-oriented practice is the dominant framework for mental health services in Australia. However, evidence demonstrating recovery processes outside public services is scant. This study explores how key processes from the Connectedness, Hope, Identity, Meaning, and Empowerment (CHIME) personal recovery conceptual framework related to service-user experiences of a rural mental health service during the COVID-19 pandemic. Qualitative telephone or video-conference interviews were conducted with 19 service users. Deductive and inductive data analysis was employed, applying the CHIME framework as a predetermined organisational structure. Themes were constructed according to the CHIME framework categories. The data reflected all five categories; connectedness and empowerment were salient. Participants’ service-delivery experiences could either enhance or hinder connectedness, the cultivation of hope, a positive identity, meaning in life, and empowerment. Nonclinical aspects of their experience were viewed as an extension of treatment. Opportunities exist for mental health practitioners to intentionally prioritise and strengthen recovery-oriented practice. Trauma-informed approaches are consistent with and complement personal recovery principles. Accountability structures are needed to monitor recovery-oriented practice in mental health settings. Family-focused interventions also need strengthening to build connectedness, meaning, and hope. IMPLICATIONS Recovery can be promoted and enhanced within primary care mental health services through intentional focus on the key processes. Trauma-informed principles and care are congruent with a recovery-oriented approach and support connectedness and empowerment. Social workers are well placed to lead and drive recovery-oriented practices in private settings that move beyond an individualistic focus to include holistic care and family-focused practice.

Approaches to Integrate Mental Health Services in Primary Care: A Scoping Review of System-Level Barriers and Enablers to Implementation

Collaborative care models offer an evidence-based approach to address mental health in primary care, yet in Canada its implementation seldom conforms to evidence-based practice. Therefore, we conducted a scoping review to address the question: What are the system-level barriers and enablers to implementing collaborative care models to integrate mental health services in primary care? Inclusion criteria comprised peer-reviewed studies published from 1990–2020. We utilized an implementation science framework to inform our analysis. Our themes included funding; health practitioner workforce/training; and relationships with initiatives, organizations, and communities. This review informs the scaling of collaborative care initiatives that integrate mental health services into primary care.

Too late for early intervention? The Healthy Ageing Service's mental health response.

This paper describes the rationale for and development of an innovative mental health service for people aged over 65years living in Northern and Eastern Melbourne, Victoria, Australia. The Healthy Ageing Service (HAS) was established in July 2020 to provide care for people aged over 65years experiencing mild-to-moderate mental health concerns. It embraces a prevention and early intervention model of care. It provides primary consultation and brief intervention, secondary consultation, and capacity building to the primary healthcare sector. This innovative service is a Commonwealth-funded partnership between two tertiary mental health service providers that incorporates the recommendations from two major Royal Commissions. It demonstrates a service that acts as a bridge between primary and specialist mental health care, thereby extending mental health services to target the 'missing middle' and is potentially a model for mental health service provision throughout Victoria and Australia.

Treatment of posttraumatic stress disorder with prolonged exposure for primary care (PE-PC): Effectiveness and patient and therapist factors related to symptom change and retention.

Prolonged exposure (PE) is a first-line treatment for posttraumatic stress disorder (PTSD) available in specialty mental health. PE for primary care (PE-PC) is a brief version of PE adapted for primary care mental health integration, composed of four-eight, 30-min sessions. Using retrospective data of PE-PC training cases from 155 Veterans Health Administration (VHA) providers in 99 VHA clinics who participated in a 4- to 6-month PE-PC training and consultation program, we examined patients' PTSD and depression severity across sessions via mixed effects multilevel linear modeling. Additionally, hierarchical logistic regression analysis was conducted to assess predictors of treatment dropout. Among 737 veterans, medium-to-large reductions in PTSD (intent-to-treat, Cohen's d = 0.63; completers, Cohen's d = 0.79) and small-to-medium reductions in depression (intent-to-treat, Cohen's d = 0.40; completers, Cohen's d = 0.51) were observed. The modal number of PE-PC sessions was five (SD = 1.98). Providers previously trained in both PE and cognitive processing therapy (CPT) were more likely than providers who were not trained in either PE or CPT to have veterans complete PE-PC (OR = 1.54). Veterans with military sexual trauma were less likely to complete PE-PC than veterans with combat trauma (OR = 0.42). Asian American and Pacific Islander veterans were more likely than White veterans to complete treatment (OR = 2.93). Older veterans were more likely than younger veterans to complete treatment (OR = 1.11). (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Home-based primary care-mental health integration in the Veterans Health Administration: An updated evaluation of practice patterns.

Starting in 2008, the U.S. Veterans Health Administration required the integration of mental health providers (MH providers) in Home-Based Primary Care (HBPC) programs to promote access to and quality of mental health services for veterans enrolled in HBPC. Surveys were administered in both 2010 and 2019 to HBPC program directors and MH providers to evaluate the status of mental health practice in HBPC programs and inform the continued development of program resources. Findings reported here summarize responses to the 2019 survey and highlight changes compared to 2010 in key areas (e.g., mental health staffing and workload, services provided, training needs, and integration with and impact on the HBPC team). In 2019, approximately half of invited HBPC program directors (n = 66) and MH providers (n = 136) completed the voluntary, anonymous, and confidential surveys. Descriptive and bivariate analyses of quantitative data, and thematic analyses of open-text responses, were conducted. Comparisons of survey responses were made between the 2019 surveys and those collected in 2010 from MH providers (n = 132) and program directors (n = 112), and indicated similar patterns of variability in program staffing and practices across sites, with ongoing behavioral/mental health education and training needs reported for both MH providers and teams. The perceived degree and value of mental health integration in HBPC also remained high. Survey responses suggest integration of mental health services into HBPC continues to be feasible and improves access to key services. Findings may inform the expansion of home-based mental health services for meeting the needs of an aging population. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Assessment of adherence to treatment with injectable extended-release antipsychotics within a pharmacotherapeutic follow-up program

ObjectiveTo describe an injectable extended-release antipsychotic pharmacotherapeutic follow-up program and to assess adherence among patients included in the program. MethodA coordinated program is described involving hospital and primary care pharmacy, which included electronic prescription, reviewing, and dispensing of injectable antipsychotic agents in mental health and primary health care centers. Adherence to treatment was assessed in a 1-month prospective observational cross-sectional study which included all patients under treatment with injectable extended-release antipsychotics in a health area of more than 500,000 inhabitants. The variables collected were: medication administered, frequency of administration, administration center, and whether or not the patient attended the center. Patients were considered to have adhered to treatment if they had attended their appointments within a margin of ± 7 days. ResultsA total of 919 patients and 1,073 appointments were included. Eleven mental health units and 40 primary health care centers participated in data collection. In 95.7 % (1,027) of cases, the patients attended the appointment. No differences were found in adherence between drugs or administration frequency. However, differences were found between mental health units and primary health care centers. Patient adherence was slightly higher in mental health units (97.6% vs 91.1%; P < 0.001). ConclusionsThe high adherence rate shows that the described follow-up program is effective. Further long-term studies are needed to confirm this trend.

Management of Lumbar Disc Herniation: A Systematic Review.

A herniated disc in the spine is a condition during which a nucleus pulposus is displaced from intervertebral space. It is a common cause of back pain. The patients who experience pain related to a herniated disc often remember an inciting event that caused their pain. This activity reviews the evaluation and management of lumbar disc herniation and discusses the role of the healthcare team in evaluating and improving care for patients with this condition. Data sources were PubMed/Medline and Embase. Our review investigated English-language articles (from 2010 to 2023) according to the PRISMA guidelines.Overall, there were seven articles. Surveys and analyses of national databases were the most widely used methods (n=7). The search identified 777 studies; 7 were eligible for inclusion in the analysis. Further understanding of spinal disc herniationand treatment protocols may help improve evaluation and management in the future. Our research covered a range of management options. Disc herniation is a frequent problem for internists, emergency department doctors, nurse practitioners, and primary care physicians. To manage efficiently, an interprofessional team is needed. The first course of treatment is conservative, with paracetamol and anti-inflammatories being frequently used to relieve pain. A chemist must supervise the use of opioid analgesics in certain situations. Although surgery is sometimes the final option, patients frequently have neurological damage and lingering discomfort. In circumstances where physical treatment is not working, MRI interpretation becomes necessary. Primary care physicians or mental health professionals should handle back pain as it is frequently linked to mental health issues. Results can be enhanced by regular exercise and preserving a healthy body weight.

Expectant fathers' worries and needs: data from a primary mental health care setting in Greece

Expectant fathers' worries and needs: data from a primary mental health care setting in Greece

Intervention recommendations to improve uptake of breast, cervical, and colorectal cancer screening among individuals living with serious mental illness.

Few efforts have been made to inform intervention design for increasing the uptake of cancer screening in individuals living with serious mental illness (ILSMI), who have lower cancer screening rates than the general population. This qualitative study explored ILSMI's and their care team member's (CTM) recommendations on the design of a breast, colorectal, and cervical cancer screening intervention for ILSMI. Twenty-five ILSMI (mean age: 71.4years; 60% female) and 15 CTM (mean age: 45.3years; 80% female) were recruited through purposive sampling.Semi-structured in-depth interviews were used to collect participants' intervention suggestions. Interviews were recorded, transcribed verbatim, and imported into NVivo. Content analysis and the constant comparison method were used to analyze interview data. ILSMI and CTMs provided several salient recommendations. ILSMI should receive disease-specific, logistical, and screening education, and primary care staff should receive education on psychopathology. Mental health providers and patient navigators should be considered as the primary interventionist. The intervention should be delivered where ILSMI receive medical or mental health services, receive community and government services, and/or via various digital media. The intervention should improve the collaboration, communication, and coordination between primary and mental health care. Findings also pointed to the implementation of trauma-informed cancer care and integrated care models comprising mental health care and primary cancer care. These findings bring the skills, knowledge, and expertise of ILSM and their care team to intervention design for increasing colorectal, breast, and cervical cancer screening in ILSMI attending an intensive outpatient program.

Structural racism and health: Assessing the mediating role of community mental distress and health care access in the association between mass incarceration and adverse birth outcomes

Research has linked spatial concentrations of incarceration with racial disparities in adverse birth outcomes. However, little is known about the specific mechanisms of this association. This represents an important knowledge gap in terms of intervention. We theorize two pathways that may account for the association between county-level prison rates and adverse birth outcomes: (1) community-level mental distress and (2) reduced health care access. Examining these mechanisms, we conducted a cross-sectional study of county-level prison rates, community-level mental distress, health insurance, availability of primary care physicians (PCP) and mental health providers (MHP), and adverse birth outcomes (preterm birth, low birth weight, infant mortality). Our data set included 475 counties and represented 2,677,840 live U.S. births in 2016. Main analyses involved between 170 and 326 counties. All data came from publicly available sources, including the U.S. Census and the Centers for Disease Control and Prevention. Descriptive and regression results confirmed the link between prison rates and adverse birth outcomes and highlighted Black-White inequities in this association. Further, bootstrap mediation analyses indicated that the impact of spatially concentrated prison rates on preterm birth was mediated by PCP, MHP, community-level mental distress, and health insurance in both crude and adjusted models. Community-level mental distress and health insurance (but not PCP or MHP) similarly mediated low birthweight in both models. Mediators were less stable in the effect on infant mortality with only MHP mediating consistently across models. We conclude that mass incarceration, health care access, and community mental distress represent actionable and urgent targets for structural-, community-, and individual-level interventions targeting population inequities in birth outcomes.

Collaborative implementation of an evidence-based package of integrated primary mental healthcare using quality improvement within a learning health systems approach: Lessons from the Mental health INTegration programme in South Africa.

The treatment gap for mental health disorders persists in low- and middle-income countries despite overwhelming evidence of the efficacy of task-sharing mental health interventions. Key barriers in the uptake of these innovations include the absence of policy to support implementation and diverting of staff from usual routines in health systems that are already overstretched. South Africa enjoys a conducive policy environment; however, strategies for operationalizing the policy ideals are lacking. This paper describes the Mental health INTegration Programme (MhINT), which adopted a health system strengthening approach to embed an evidence-based task-sharing care package for depression to integrate mental health care into chronic care at primary health care (PHC). The MhINT care package consisting of psycho-education talks, nurse-led mental health assessment, and a structured psychosocial counselling intervention provided by lay counsellors was implemented in Amajuba district in KwaZulu-Natal over a 2-year period. A learning health systems approach was adopted, using continuous quality improvement (CQI) strategies to facilitate embedding of the intervention.MhINT was implemented along five phases: the project phase wherein teams to drive implementation were formed; the diagnostic phase where routinely collected data were used to identify system barriers to integrated mental health care; the intervention phase consisting of capacity building and using Plan-Do-Study-Act cycles to address implementation barriers and the impact and sustaining improvement phases entailed assessing the impact of the program and initiation of system-level interventions to sustain and institutionalize successful change ideas. Integrated planning and monitoring were enabled by including key mental health service indicators in weekly meetings designed to track the performance of noncommunicable diseases and human immunovirus clinical programmes. Lack of standardization in mental health screening prompted the validation of a mental health screening tool and testing feasibility of its use in centralized screening stations. A culture of collaborative problem-solving was promoted through CQI data-driven learning sessions. The province-level screening rate increased by 10%, whilst the district screening rate increased by 7% and new patients initiated to mental health treatment increased by 16%. The CQI approach holds promise in facilitating the attainment of integrated mental health care in resource-scarce contexts. A collaborative relationship between researchers and health system stakeholders is an important strategy for facilitating the uptake of evidence-based innovations. However, the lack of interventions to address healthcare workers' own mental health poses a threat to integrated mental health care at PHC.

Seasonal trends in antidepressant prescribing, depression, anxiety and self-harm in adolescents and young adults: an open cohort study using English primary care data

BackgroundThere is an increasing demand for mental health services for young people, which may vary across the year.ObjectiveTo determine whether there are seasonal patterns in primary care antidepressant prescribing and...

Development of an Integrated Telehealth Primary Care and Mental Health Training Program for Nurse Practitioner Students: Review of the Literature

Nurse practitioners (NPs) are well equipped to meet the growing mental and primary health care needs of patients through telehealth. Training programs that integrate primary care and mental health care delivery through telehealth for NPs are needed in advanced practice education. A review of the literature was completed to guide the development and determine the best education practices for an integrated telehealth primary care and mental health training program for NP students. This review highlights 4 themes: confidence and competency, collaboration and consultation, applicability to practice, and technology use.

Integration of Mental Health in Primary Care: Insights for Enhanced Program Delivery

The integration of mental health in primary care was considered one of the best strategies to address the increasing incidence of mental health disorders. This study determined the level of mental health integration in primary care in the province of Capiz and the level of challenges of primary health workers in the process of integration in terms of knowledge, skills, and health system constraints encountered. The 381 primary health workers were surveyed using a validated and reliability-tested researcher-made questionnaire. The results revealed that the level of mental health integration in the province of Capiz based on primary health practice was only slightly integrated. Primary health workers were highly challenged in the process of integration in terms of their knowledge and skills, which therefore needs enhancement. They were also highly challenged by the health system constraints encountered in the different areas of the current health system, which necessitates support from the Local Government Unit (LGU). The mental health integration level and the challenges of primary health worker respondents when grouped according to profile disclosed a significant difference. Moreover, their level of challenges as to their knowledge, skills, and health system constraints encountered did not significantly affect the level of mental health integration.