Mental Health Visits Research Articles

Outcomes of two quality improvement implementation interventions for depression services in adults with substance use problems

ABSTRACTBackground: Comorbid depression and substance use disorders (SUDs) are associated with poor health and social outcomes disproportionately affecting under-resourced communities.Objectives: To test the hypothesis that a coalition approach to collaborative care (CC) for depression would improve outcomes of hazardous drinking and behavioral health hospitalizations, relative to technical assistance, for individuals with comorbid substance use problems. Substance use problems were defined by meeting criteria for DSM-IV substance abuse or dependence, hazardous drinking by AUDIT-C, or treatment in a SUD program within the prior 6 months.Methods: Two depression CC implementation approaches were compared: Resources for Services (RS) provided expert technical support for CC toolkits to individual programs. Community engagement and planning (CEP) supported multi-sector coalitions in collaborating in planning, adapting, implementing and monitoring CC toolkits. One thousand eighteen individuals with depression (PHQ-8 ≥10) enrolled. Regression analyses estimated intervention effects in participants with comorbid substance use problems (n = 588, 281 females, 307 males). Substance use problems were defined by meeting criteria for DSM-IV substance abuse or dependence, hazardous drinking by AUDIT-C, or treatment in a SUD program within the prior 6 months.Results: There were no significant baseline differences by intervention status among participants with depression and substance use problems. Intervention effects on primary outcomes including depression were not significant at 6 months. Compared to RS, CEP significantly reduced alcohol consumption (CEP = 1.6, RS = 2.1, p = .038), probability of behavioral health hospitalizations (OR = 0.50, p = .036), and use of specialty mental health visits (IRR = 0.52, p = .027), while increasing use of faith-based depression services (IRR = 3.4, p = .001).Conclusions: Given feasibility and possible benefits, CEP should be considered a promising approach to implementing depression CC with potential benefits to adults with comorbid substance use problems.

Cultural Appropriation and Substance Use Disorder: A Case Report

A 16 year old Caucasian male presented for initial mental health visit at an outpatient community psychiatry clinic. Two years prior, he found his father dead after overdosing on heroin. Since this time, he has been involved in numerous altercations with peers. He began using high doses of alprazolam daily after his father’s death. He adopted an urban culture and changed his body language, style of clothing and vernacular. His behavioral changes and substance use after his father’s death is due to psychological, sociological and biological factors, which are explored in this case report. Psychosocial factors include peer and parental mimicry along with attachment styles and biological causes include epigenetics relationship to post traumatic stress disorder responses.

Taking a Closer Look at Mental Health Treatment Differences: Effectiveness of Mental Health Treatment by Provider Type in Racial and Ethnic Minorities.

Objectives:To estimate racial/ethnic differences in the extent to which mental health treatment is obtained from mental health providers, primary care physicians (PCPs), or both and to examine the effects of provider type on change in mental component scores (MCS) of the SF-12 on different race/ethnic groups.Methods:Secondary data analysis of 2008 to 2015 Medical Expenditure Panel Survey (MEPS). Non-institutionalized civilian US population, aged 18 to 64 (N = 62 558). Based on counts of all mental health visits in a calendar year, we identified patients who obtained care from PCPs, mental health provider, PCP and mental health providers and other providers and examined changes in MCS by type of care.Results:9.9% of Non-Hispanic Whites obtained mental health treatment, compared to 5.0% for Hispanics, 5.3% for Blacks and 5.5% for Other Races (P < .001). Non-Hispanic Blacks and non-Hispanic “Other” were more likely than other groups to obtain care from mental health providers only (P = .017). All obtaining care solely from PCP had better mental health (mean (se)) MCS: 43.2(0.28)) than those obtaining care solely from mental health provider (39.8 (0.48)), which in turn was higher than for those obtaining care from both PC and MH providers (38.5 (0.31), (P < .001).Conclusion:Even when diagnosed with a mental health disorder, Hispanics and Blacks were less likely to seek mental health treatment than Whites, highlighting the continuing disparity. Future research should focus on understanding how and what aspects of integrated care models and other mental health delivery models that reduce disparities and provide greater accessibility.

National trends in mental health-related emergency department visits by children and adults, 2009-2015.

Examine trends in mental health-related emergency department (ED) visits, changes in disposition and length of stay (LOS), describe disposition by age and estimate proportion of ED treatment hours dedicated to mental health-related visits. Retrospective analysis of ED encounters in the National Hospital Ambulatory Medical Care Visit Survey with a mental health primary, secondary or tertiary discharge diagnosis from 2009 to 2015. We report survey-weighted estimates of the number and proportion of ED visits that were mental health-related and disposition by age and survey year. We estimate the proportion of ED treatment hours dedicated to mental health-related visits. We analyze trends in disposition and LOS for mental health and non-mental health-related visits using multivariate regression analysis. Mental health-related ED visits increased by 56.4% for pediatric patients and 40.8% for adults, accounting for over 10% of ED visits by 15-64 year-olds and nearly 9% by 10-14 year-olds in 2015. Mental health-related visit disposition of admission or transfer declined from 29.8% to 20.4% (p < .001); predicted median ED LOS for admissions or transfers increased from 6.5 to 9.0 hours while median LOS for discharges was stable at 4.4 hours. During the study period, mental health-related visits accounted for 5.0% (95% CI 4.6-5.3) of all pediatric and 11.1% (95% CI 11.0-11.3) of adult ED treatment hours. Mental health-related visits account for an increasing proportion of ED visits and a considerable proportion of treatment hours. A decreasing proportion of mental health-related visits resulted in inpatient disposition and ED LOS increased for admissions and transfers.

Social connectedness, depression symptoms, and health service utilization: a longitudinal study of Veterans Health Administration patients.

Our study explored whether aspects of veterans' social connectedness (social support, interpersonal conflict, loneliness, social norms, number of confidants) are associated with change in their depression symptoms and health services utilization over 1year. We conducted a prospective, longitudinal study of 262 military veterans who obtained primary care and other services at a Veterans Health Administration (VHA) facility and screened positive for depression. Participants completed surveys at baseline and 12-month follow-up. We measured social connectedness variables using the NIH Toolbox Adult Social Relationship Scales. We used the Patient Health Questionnaire to assess depression symptoms and suicidal ideation and administrative medical record data for health services utilization. We calculated change scores to model outcomes over time using multivariable regressions. We found that higher levels of baseline loneliness were associated with decreased depression severity over 1year (B = - 1.55, 95% CI [- 2.53, - .56], p < .01). We found a similar association for suicidal ideation. In contrast, higher baseline number of confidants was associated with increased depression (B = .55, 95% CI [.18, .92], p < .01). Higher levels of emotional support were associated with decreased mental health visits (B = - 3.88, 95% CI [- 6.80, - .96], p < .01). No significant associations were found between social connectedness variables and primary care visits. Emotional support may play an important role in reducing mental health treatment utilization among VHA-using veterans. Additional investigation as to how and why loneliness and number of confidants might be paradoxically associated with depression symptoms remains necessary.

Frequent Emergency Department Users: Focusing Solely On Medical Utilization Misses The Whole Person.

Frequent emergency department (ED) users often have complex behavioral health and social needs. However, policy makers often focus on this population's medical system use without examining its use of behavioral health and social services systems. To illuminate the wide-ranging needs of frequent ED users, we compared medical, mental health, substance use, and social services use among nonelderly nonfrequent, frequent, and superfrequent ED users in San Francisco County, California. We linked administrative data for fiscal years 2013-15 for beneficiaries of the county's Medicaid managed care plan to a county-level integrated data system. Compared to nonfrequent users, frequent users were disproportionately female, white or African American/black, and homeless. They had more comorbidities and annual outpatient mental health visits (11.93 versus 4.16), psychiatric admissions (0.73 versus 0.07), and sobering center visits (0.17 versus <0.01), as well as disproportionate use of housing and jail health services. Our findings point to the need for shared knowledge across domains, at the patient and population levels. Integrated data can serve as a systems improvement tool and help identify patients who might benefit from coordinated care management. To deliver whole-person care, policy makers should prioritize improvements in data sharing and the development of integrated medical, behavioral, and social care systems.

177 Disparities in Admission or Transfer for Inpatient Treatment after Emergency Mental Health Visits

While it is widely recognized that disparities exist in access to mental health (MH) care, the emergency department (ED) should serve as the safety net where all patients can access necessary care. We examine whether there are disparities based on patient race/ethnicity and insurance status in disposition to inpatient settings (admission or transfer) for adolescents and young adults with MH ED visits. We perform multivariate regression analysis of all MH ED visits from 2010 to 2014 reported to the Healthcare Cost and Utilization Project’s State emergency department and State Inpatient Discharge Databases for Arizona, Florida, New York, New Jersey, North Carolina, Maryland, Nevada, Kentucky, Rhode Island, and Iowa for 10-29 year olds. MH ED visits were defined as visits with a primary MH or substance abuse diagnosis or a secondary or tertiary diagnosis of suicidal ideation or attempt. We examine the probability that a MH ED visit results in an admission or transfer for further treatment and report predicted probabilities by primary payer and race/ethnicity. Regressions also control for age, sex, year, hospital location, and median income of the patient’s home address. We also perform diagnosis-specific regressions for encounters related to suicide, serious mental illness, substance use, or alcohol use. We report comparisons of predicted probabilities using Bonferroni-corrected critical values. 2.6 million MH ED visits were analyzed. For MH ED visits, the probability of admission or transfer for MH ED visits varied by the patient’s insurance and race/ethnicity (see Table). When all MH ED visits were analyzed, significantly more visits by privately insured (33.1%) than self-pay patients (25.8%) resulted in an inpatient disposition (p<0.01). Disposition after MH ED visits also varied by patient race/ethnicity. A significantly higher proportion of MH ED visits by white patients (34.0%) than black (30.8%, p<0.01), Native American (30.7%, p<0.01) or Hispanic (30.4%, p<0.01) patients resulted in admission or transfer. Differences in disposition were seen for all MH disorders analyzed, including for suicide-related visits. When compared with suicide-related visits by whites, a significantly smaller proportion of suicide-related visits by blacks, Hispanics and Native Americans resulted in admission or transfer (p<0.01 for all comparisons). Suicide-related visits by uninsured patients were significantly less likely than those by patients with private insurance, Medicaid or Medicare to result in admission or transfer (p<0.01 for all comparisons). We demonstrate sizeable disparities in disposition to inpatient settings after MH ED visits based on patient race/ethnicity and insurance status. Psychiatric inpatient beds are limited and socioeconomic disparities in access to this resource are concerning, particularly in ED patients who may have limited access to outpatient psychiatric care. Future research should focus on identifying and mitigating the underlying causes of these disparities.TablePredicted probabilities of ED disposition of admission or transfer.All Mental Health % (95% CI)Suicide-Related % (95% CI)Serious Mental Illness % (95% CI)Alcohol Use % (95% CI)Substance Use % (95% CI)PayerPrivate Insurance33.1 (33.0-33.2)66.4 (66.2-66.7)58.3 (58.0-58.6)7.2 (7.0-7.4)22.8 (22.5-23.0)Medicare36.5 (36.3-36.8)70.9 (70.2-71.6)58.7 (58.2-59.3)11.7 (10.9-12.6)25.9 (24.8-26.9)Medicaid35.7 (35.6-35.8)67.9 (67.7-68.1)58.1 (57.9-58.3)14.6 (14.3-14.9)25.5 (25.2-25.7)Self-Pay25.8 (25.7-25.9)55.2 (54.9-55.5)45.1 (44.7-45.4)5.4 (5.3-5.5)15.3 (15.1-15.6)Race/EthnicityWhite34.0 (33.9-34.0)65.8 (65.6-66.0)57.0 (56.7-57.2)9.5 (9.4-9.7)22.8 (22.6-23.0)Black30.8 (30.7-30.9)62.4 (62.0-62.7)54.6 (54.4-54.9)6.1 (6.0-6.3)15.2 (14.8-15.6)Hispanic30.4 (30.2-30.5)63.2 (62.8-63.6)54.7 (54.4-55.1)7.1 (6.9-7.3)18.8 (18.4-19.3)Asian33.5 (33.1-33.9)67.2 (66.1-68.2)61.6 (60.6-62.6)5.3 (4.7-6.0)19.1 (17.6-20.6)Native American30.7 (30.2-31.3)60.6 (59.3-62.0)57.5 (55.5-59.5)6.1 (5.6-6.5)21.2 (19.4-22.9) Open table in a new tab

Determinants of pathways to care among young adults with early psychosis entering a coordinated specialty care program.

To describe the characteristics of the pathway to coordinated specialty care for young adults with early psychosis in the United States, to examine how various factors correlate with the duration of untreated psychosis (DUP), and to explore factors associated with time from onset of symptoms to first mental health service contact (help-seeking DUP). The sample included 779 individuals ages 16 to 30 with recent-onset non-affective psychosis enrolled in OnTrackNY. Domains assessed included demographics, clinical characteristics, mental health service utilization and characteristics of the pathway to care. Primary outcomes included the time from onset of psychotic symptoms to admission to OnTrackNY (DUP) and time from onset of psychotic symptoms to first mental health service contact (help-seeking DUP). The mean DUP was 231.2 days (SD = 87.7, median = 169) and mean help-seeking DUP was 73.7 days (SD = 110.8, median = 27). Being in school, better social functioning, and greater number of ER visits or hospitalizations were associated with shorter DUP. Violent ideation or behaviour and having an outpatient mental health visit as the first service contact or hallucinations as the reason for first service contact were significantly associated with longer DUP. Only the type of first service contact (outpatient mental health treatment or other non-mental health service provider) and having hallucinations as the clinical reason for the first service contact were associated with help-seeking DUP. Referral delays were longer than help-seeking delays. Strategies to reduce treatment referral delays through systems-level interventions may be most likely to reduce the overall DUP in this population.

Association of Primary Care Continuity With Outcomes Following Transition to Adult Care for Adolescents With Severe Mental Illness

Adolescents with severe mental illness often age out of pediatric care without a clear transfer of care to adult services. The extent to which primary care provides stability during this vulnerable transition period is not known. To analyze the association between primary care continuity during the transition from pediatric to adult care and need for acute mental health services in young adulthood. This population-based cohort study used linked health and demographic administrative data for all adolescents aged 12 to 16 years with severe mental illness ascertained by hospitalization for schizophrenia, eating disorder, or mood disorder between April 1, 2002, and April 1, 2014, in Ontario, Canada. Participants were followed up through March 31, 2017. Data were analyzed from July 2018 to January 2019. Continuous primary care (same physician as baseline [age 12-16 years] always or sometimes), discontinuous primary care (visits to a primary care physician during the transition period who was not the patient's usual physician), and no primary care during the transition period (age 17-18 years). Mental health-related hospitalizations and emergency department visits in young adulthood (age 19-26 years) adjusted for sex, rurality, neighborhood income, mental illness type, and health service use before transition. Among 8409 adolescents with severe mental illness (5720 [68.0%] female; mean [SD] age, 14.8 [1.2] years), 5478 (65.1%) had continuous primary care, 2391 (28.4%) had discontinuous primary care, and 540 (6.4%) had no primary care during the transition period. Youths with no primary care during transition were more likely to be male (57.2%), have lower socioeconomic status (31.5%), and have no usual primary care practitioner at baseline (25.6%). Compared with continuous care, patients with discontinuous and no primary care had an increased rate of mental health-related hospitalization in young adulthood (adjusted relative rate, 1.20; 95% CI, 1.10-1.30; and adjusted relative rate, 1.30; 95% CI, 1.08-1.56, respectively). In the context of decreasing outpatient specialist mental health visit rates following transition to adult care, ensuring adequate access to primary care during this vulnerable period may improve mental health outcomes in young adulthood.

Veterans Health Administration Investments In Primary Care And Mental Health Integration Improved Care Access.

Aiming to increase care access, the national Primary Care-Mental Health Integration (PC-MHI) initiative of the Veterans Health Administration (VHA) embedded specialists, care managers, or both in primary care clinics to collaboratively care for veterans with psychiatric illness. The initiative's effects on health care use and cost patterns were examined among 5.4million primary care patients in 396 VHA clinics in 2013-16. The median rate of patients who saw a PC-MHI provider was 6.3percent. Each percentage-point increase in the proportion of clinic patients seen by these providers was associated with 11percent more mental health and 40percent more primary care visits but also with 9percent higher average total costs per patient per year. At the mean, 2.5 integrated care visits substituted for each specialty-based mental health visit that did not occur. PC-MHI was associated with improved access to outpatient care, albeit at increased total cost to the VHA. Successful implementation of integrated care necessitates significant investment and multidisciplinary partnership within health systems.

Psychiatric-related Revisits to the Emergency Department Following Rapid Expansion of Community Mental Health Services.

Repeat visits (revisits) to emergency departments (EDs) for psychiatric care reflect poor continuity of care and impose a high financial cost. We test whether rapid expansion of community health centers (CHCs)-which provide regional, low-cost primary care-correspond with fewer repeat psychiatric-related ED visits (PREDVs). We obtained repeated cross-sectional time-series data for 7.8 million PREDVs from the State Emergency Department Database for four populous U.S. states (California, Florida, North Carolina, and New York) from 2006 to 2011. We specified as the outcome variable the count of repeat visits per ED visitor with a psychiatric diagnosis. We retrieved aggregate-level mental health visits at CHCs from the Uniform Data System. Negative binomial regression methods controlled for individual-level confounders, county health system and sociodemographic attributes, year fixed effects, and county fixed effects. The risk of a repeat PREDV decreased with a county-level increase in mental health patients seen at CHCs (incidence rate ratio= 0.986, 95% confidence interval= 0.98 to 0.99). Conversion of this rate ratio to the number of revisits averted indicated 34,000 fewer repeat PREDVs in these four states statistically associated with a 1% expansion in CHC mental health visits. Exploratory analyses found that revisits decline for relatively mild/moderate illnesses (e.g., mood, anxiety disorders) but not for severe illnesses (e.g., schizophrenia/psychoses). An increase in mental health services at CHCs corresponds with a modest decline in repeat PREDVs. This decline concentrates among those with less severe mental illnesses.

Veterans' Prospective Attitudes About Mental Health Treatment Using Telehealth.

The current study examined Veterans' attitudes about the potential use of telepsychiatry for mental health treatment in routine clinical settings. Data were collected from Veteran outpatients (N = 253) who completed a series of self-report screening measures as part of their initial evaluation at an outpatient clinic providing care to Veterans with deployment-related mental health problems. Using a de-identified data repository, symptoms of post-traumatic stress disorder (PTSD), depression, anxiety, and stress, as well as attitudes and level of comfort with receiving treatment through telehealth were assessed. Overall interest in telepsychiatry was mixed, with 25.7% of patients being "not at all comfortable" and 13.4% being "extremely comfortable" using telepsychiatry from home. Approximately one third (32.8%) of participants indicated a clear preference for telepsychiatry compared to in-person mental health visits. There were no differences in telepsychiatry preferences by symptom severity, demographic variables, rural versus urban location, or endorsed barriers to care. Although telepsychiatry may be a viable means of increasing access, patient preference should be considered, as a substantial percentage of Veterans in this study preferred in-person visits. [Journal of Psychosocial Nursing and Mental Health Services, 57(9), 38-43.].

Changing Rates of Self-Harm and Mental Disorders by Sex in Youths Presenting to Ontario Emergency Departments: Repeated Cross-Sectional Study.

To document the rates of intentional self-harm and mental disorders among youths aged 13 to 17 years visiting Ontario emergency departments (EDs) from 2003-2017. This was a repeated cross-sectional observational design. Outcomes were rates of adolescents with (1) at least 1 self-harm ED visit and (2) a visit with a mental disorder code. Rates of youths with self-harm visits fell 32% from 2.6/1000 in 2003 to 1.8 in 2009 but rose 135% to 4.2 by 2017. The slope of the trend in self-harm visits changed from -0.18 youths/1000/year (confidence interval [CI], -0.24 to -0.13) during 2003 to 2009 to 0.31 youths/1000/year (CI, 0.27 to 0.35) during 2009 to 2017 (P < 0.001). Rates of youths with mental health visits rose from 11.7/1000 in 2003 to 13.5 in 2009 (15%) and to 24.1 (78%) by 2017. The slope of mental health visits changed from 0.22 youths/1000/year (CI, 0.02 to 0.42) during 2003 to 2009 to 1.84 youths/1000/year (CI, 1.38 to 2.30) in 2009 to 2017 (P < 0.001). Females were more likely to have self-harm (P < 0.001) and mental health visits (P < 0.001). Rates of increase after 2009 were greater for females for both self-harm (P < 0.001) and mental health (P < 0.001). Rates of adolescents with self-harm and mental health ED visits have increased since 2009, with greater increases among females. Research is required on the determinants of adolescents' self-harm and mental health ED visits and how they can be addressed in that setting. Sufficient treatment resources must be supplied to address increased demands for services.

Trends in Pediatric Emergency Department Visits for Mental Health Conditions and Disposition by Presence of a Psychiatric Unit

ObjectiveTo examine trends in mental health (MH) visits to pediatric emergency departments (EDs) and identify whether ED disposition varies by presence of a hospital inpatient psychiatric unit (IPU). Study DesignCross-sectional study of 8,479,311 ED visits to 35 children's hospitals from 2012 to 2016 for patients aged 3 to 21 years with a primary MH or non-MH diagnosis. Multivariable generalized estimating equations and bivariate Rao-Scott chi-square tests were used to examine trends in ED visits and ED disposition by IPU status, adjusted for clustering by hospital. ResultsFrom 2012 to 2016, hospitals experienced a greater increase in ED visits with a primary MH versus non-MH diagnosis (50.7% vs 12.7% cumulative increase, P < .001). MH visits were associated with patients who were older, female, white non-Hispanic, and privately insured compared with patients of non-MH visits (all P < .001). Forty-four percent of MH visits in 2016 had a primary diagnosis of depressive disorders or suicide or self-injury, and the increase in visits was highest for these diagnosis groups (depression: 109.8%; suicide or self-injury: 110.2%). Among MH visits, presence of a hospital IPU was associated with increased hospitalizations (34.6% vs 22.5%, P < .001) and less transfers (9.2% vs 16.2%, P < .001). ConclusionThe increase in ED MH visits from 2012 to 2016 was 4 times greater than non-MH visits at US children's hospitals and was primarily driven by patients diagnosed with depressive disorders and suicide or self-injury. Our findings have implications for strategic planning in tertiary children's hospitals dealing with a rising demand for acute MH care.

Combining Natural Language Processing of Electronic Medical Notes With Administrative Data to Determine Racial/Ethnic Differences in the Disclosure and Documentation of Military Sexual Trauma in Veterans.

Despite national screening efforts, military sexual trauma (MST) is underreported. Little is known of racial/ethnic differences in MST reporting in the Veterans Health Administration (VHA). This study aimed to compare patterns of MST disclosure in VHA by race/ethnicity. Retrospective cohort study of MST disclosures in a national, random sample of Veterans who served in Afghanistan and Iraq and completed MST screens from October 2009 to 2014. We used natural language processing (NLP) to extract MST concepts from electronic medical notes in the year following Veterans' first MST screen. Any evidence of MST (positive MST screen or NLP concepts) and late MST disclosure (NLP concepts following a negative MST screen). Multivariable logistic regressions, stratified by sex, tested racial/ethnic differences in any MST evidence, and late disclosure. Of 6618 male and 6716 female Veterans with MST screen results, 1473 had a positive screen (68 male, 1%; 1405 female, 21%). Of those with a negative screen, 257 evidenced late MST disclosure by NLP (44 male, 39%; 213 female, 13%). Late MST disclosure was usually documented during mental health visits. There were no significant racial/ethnic differences in MST disclosure among men. Among women, blacks were less likely than whites to have any MST evidence (adjusted odds ratio=0.75). In the subsample with any MST evidence, black and Hispanic women were more likely than whites to disclose MST late (adjusted odds ratio=1.89 and 1.59, respectively). Combining NLP results with MST screen data facilitated the identification of under-reported sexual trauma experiences among men and racial/ethnic minority women.

Using ESSENCE to Meet Local Needs for Mental Health Data: Query &amp; Results

Using ESSENCE to Meet Local Needs for Mental Health Data: Query &amp; Results

Preventing Suicide Begins With Regular Assessments

Preventing Suicide Begins With Regular Assessments

P070: Mental health consultations for emergency department patients in crisis: Insights into quality improvement opportunities from a multicenter analysis

Introduction: Mental health and addiction presentations are on the increase in Canadian Emergency Departments (EDs) and are placing strains on existing resources. The purpose of this study is to examine practice variations and opportunities for improved mental health (MH) consultation practices across four adult EDs. Methods: We conducted a retrospective analysis of administrative data from Alberta Health Services (AHS) at urban Calgary Zone EDs from 2015 to 2018 regarding MH consults requested and patients admitted to inpatient psych. Individual MD and overall referral rates as well as admission rates for patients consulted to MH were considered. Time of day and patient ETOH level were also examined as potential influencing factors. CEDIS codes were used to identify MH complaints. Results: 73,536 MH related visits were included, 29,228 received a MH consult with 10,648 admitted to an inpatient MH unit (36.4%). The admission rate among consults requested varied considerably among the 200 MDs who evaluated more than 50 patients with MH complaints; median 35.9%, IQR – 25.0 to 47.5. The average consultation rate for ETOH positive patients was 28.4% median 26.35%, IQR – 21.2 to 35.0% During regular working hours (08:00-17:00), there were 33,599 MH visits, 15,035 received a psych consult with 5,976 admitted to an inpatient MH unit. The admission rate among consults was 39.8%. For the remaining hours(17:01-07:59) there were 39,939 MH visits, 14,191 received a psych consult with 4,672 admitted to an inpatient MH unit. The admission rate among consults was 32.9%. Conclusion: Varying MD thresholds for MH consultation are reflected in a wide range of admission rates among patients consulted for MH evaluation in the ED. ETOH and timing of presentation are factors which modulate the likelihood of admission. There may be opportunities to improve MH referrals from the ED by providing consultation feedback to providers.

Postpartum mental health service utilization in women with Human Immunodeficiency Virus (HIV): a population-based study

ABSTRACTWomen with HIV have higher rates of psychiatric disorders than HIV-negative women, yet little is known about their postpartum mental health and associated service use. The purpose of this study was to characterize HIV-positive women’s use of ambulatory and acute mental health services in the first year postpartum, relative to HIV-negative women. Using health administrative data, we identified 861,365 women who had a live birth delivery from April 1, 2002 to March 31, 2012 in Ontario, Canada, of whom 530 were identified to be HIV-positive. We described their use of mental health services, including outpatient mental health visits, psychiatric emergency department (ED) visits and hospitalizations using adjusted odds ratios (aORs) and 95% confidence intervals (CIs). HIV-positive women were more likely to access outpatient mental health services (31.5% vs. 21.0%, aOR, 1.26; 95% CI, 1.03–1.55), but more likely to remain engaged in psychiatrist services only (15.6% vs. 6.5%, aOR, 2.35; 95% CI, 1.41–3.72). They were also more likely to require a psychiatric ED visit or hospitalization (3.3% vs. 1.1%, aOR, 2.74; 95% CI, 1.72–4.12). Our findings highlight the importance of considering postpartum mental health as part of comprehensive reproductive health care for women with HIV.

Post-traumatic stress disorder and hypertensive disorders of pregnancy among military women.

Women are more likely to develop post-traumatic stress disorder (PTSD) than men. Limited research exists evaluating the risk of hypertensive disorders of pregnancy (HDP) among military women with PTSD. We conducted a retrospective cohort study using US Department of Defense (DoD) data comprised of all active-duty women giving birth to their first, liveborn singleton infant using DoD-sponsored health insurance from 1 January 2004 to 31 December 2008 (n=34176). Birth hospitalisation records, maternal mental health visits, and Post-Deployment Health Assessment (PDHA) and Reassessment (PDHRA) screenings were included. The HDP outcome (yes vs no) was defined using ICD-9-CM codes in the maternal birth hospitalisation record. Women fit into one of four PTSD exposure categories (confirmed, probable, possible, none). Confirmed cases had a PTSD ICD-9-CM diagnosis code. Probable/possible cases were classified using PDHA screening items. We used multiple log-linear regression to assess PTSD (confirmed, any vs none) and the risk of HDP overall, and then explored effect modification by military service and demographic variables. We assessed the risk of HDP among deployed mothers with PTSD (confirmed, probable/possible vs none) who completed a PDHA, and explored effect modification by race/ethnicity. We also assessed risk of HDP with differing PTSD lead times. Overall, PTSD was not associated with HDP except among mothers whose PTSD was diagnosed ≥1year prior to conception (RR1.42, 95% CI 1.06, 1.90). Post-traumatic stress disorder preceding conception by at least a year appeared to confer an increased risk of HDP, but further research is needed using more thorough PTSD assessment.