Primary Behavioral Health Research Articles

Chronic Occupational Stress and Health Outcomes: A Systematic Review of Recent Findings

Chronic occupational stress has become an increasingly prevalent issue in modern workplaces, impacting employees across various sectors. Prolonged exposure to stress in professional settings is associated with numerous health risks, including both physical and mental health issues. Understanding these health outcomes is essential for developing effective strategies to mitigate workplace stress and promote employee well-being.This systematic review aims to synthesize recent findings on the health outcomes of chronic occupational stress, examining studies published within the last decade. By evaluating evidence from diverse occupational settings, this review seeks to identify the primary physical, mental, and behavioral health impacts of long-term workplace stress.A systematic literature search was conducted across major academic databases, including PubMed, Scopus, and PsycINFO. Studies were included if they focused on chronic occupational stress and reported on specific health outcomes. Data extraction focused on study design, population characteristics, stress measurement methods, and reported health effects. Studies were critically appraised for quality and relevance. Analysis of the selected studies revealed significant associations between chronic occupational stress and several health outcomes. Physical health consequences frequently included cardiovascular disease, hypertension, and metabolic disorders, while mental health impacts commonly involved anxiety, depression, and burnout. Behavioral outcomes, such as substance use and poor sleep quality, were also prevalent. Variations were observed across different job types and demographic factors, with certain high-risk sectors showing elevated levels of stress-related health issues.Chronic occupational stress is linked to a wide array of adverse health outcomes, underscoring the need for organizational interventions and policies to address long-term stress in the workplace. Future research should focus on longitudinal studies and targeted interventions to mitigate these health risks and improve employee well-being.

Engaging primary care patients at risk for suicide in mental health treatment: user insights to inform implementation strategy design

BackgroundGiven that the majority of suicide decedents visit primary care in the year preceding death, primary care has been identified as a key setting in which to engage patients at risk for suicide in mental health services. The objective of this research was to identify barriers and facilitators to engagement in mental health services among primary care patients at risk for suicide to inform the development of strategies to increase engagement.MethodsSeventy-four semi-structured qualitative interviews were conducted with primary care patients (n = 20), primary care (n = 18) and behavioral health (n = 12) clinicians, mental health intake coordinators (n = 4), and health system and clinic leaders (n = 20). Patients who had been referred for mental health services from primary care and reported an elevated score (≥ 1) on item 9 on the Patient Health Questionnaire at the time of referral were eligible to participate. Eligible clinicians and leaders were employed in a primary care or behavioral health setting in a single large health system with an integrated mental health program. Interviews typically lasted 30–60 min, were completed over video conference or phone, and were coded by members of the research team using a rapid qualitative analysis procedure.ResultsParticipants were primarily female (64.9%), white (70.3%) and non-Hispanic/Latine (91.9%). The most identified barriers to mental health care engagement were waitlists, capacity limits, insurance, patient characteristics, communication, collaboration, and/or difficulties surrounding travel. The most commonly cited facilitators of engagement included telehealth, integrated care models, reminders, case management support, psychoeducation, motivational enhancement, and scheduling flexibility. Concrete suggestions for improving engagement in mental health services included increasing communication between providers, streamlining referral and intake processes, providing reminders and follow ups, and advocacy for increased reimbursement for suicide risk assessment.ConclusionsResults underscore the myriad barriers patients at risk for suicide encounter when attempting to engage in mental health care in a primary care setting. Facilitators of engagement and suggestions for improving connections to care were also identified, which can inform the design of implementation strategies to improve engagement in mental health services among primary care patients at risk for suicide.Trial registrationClinicalTrials.gov Identifier: NCT05021224 (Registered August 19, 2021).

Assessing the use of unstructured electronic health record data to identify exposure to firearm violence.

Research on firearm violence is largely limited to people who experienced acute bodily trauma and death which is readily gathered from Inpatient and Emergency Department settings and mortality data. Exposures to firearm violence, such as witnessing firearm violence or losing a loved one to firearm violence, are not routinely collected in health care. As a result, the true public health burden of firearm violence is underestimated. Clinical notes from electronic health records (EHRs) are a promising source of data that may expand our understanding of the impact of firearm violence on health. Pilot work was conducted on a sample of clinical notes to assess how firearm terms present in unstructured clinical notes as part of a larger initiative to develop a natural language processing (NLP) model to identify firearm exposure and injury in ambulatory care data. We used EHR data from 2012 to 2022 from a large multistate network of primary care and behavioral health clinics. A text string search of broad, gun-only, and shooting terms was applied to 9,598 patients with either/both an ICD-10 or an OCHIN-developed structured data field indicating exposure to firearm violence. A sample of clinical notes from 90 patients was reviewed to ascertain the meaning of terms. Among the 90 clinical patient notes, 13 (14%) notes reflect documentation of exposure to firearm violence or injury from firearms. Results from this study identified refinements that should be considered for NLP text classification. Unstructured clinical notes from primary and behavioral health clinics have potential to expand understanding of firearm violence.

Toward a Comprehensive Model of Medical-Dental-Behavioral Integration.

Existing models of medical-dental integration, as well as those from behavioral health care integrated with primary medical treatment, provide a basis for a truly synthesized and expanded model incorporating medical, dental, and behavioral components. Such a comprehensive model allows for collaborative health care serving patients seamlessly without disciplinary silos, promoting optimal whole-person health. This innovative approach is consistent with recent developments in the behavioral and social oral health sciences that include an imperative for their full inclusion in dental health care, research, and education. Existing models of medical-dental integration are described, along with current models from integrated primary medical and behavioral health care. Using these existing approaches as a basis, a new multilevel model is proposed to include social and cultural determinants of health. Contemporary approaches to providing health care across disciplines include referral to a geographically separate entity, co-location of services, and integrated, side-by-side care. Integration of electronic health records and interoperability are necessary (but not sufficient) factors that affect transdisciplinary health care. Effective communication among health care providers and the need for interprofessional education, comprehensive training, and ongoing cross-disciplinary consultation also are noted as crucial factors in truly collaborative care. Evidence for existing models varies greatly depending on the target population and type of services provided. A fully integrated, transdisciplinary model of health care is possible, theoretically and practically. Combining aspects of extant integrated models and extending them provides opportunity for a greater focus on systemic factors and more emphasis on prevention. Consistent with this new model, medical and dental home concepts can be expanded to that of a person-centered health care home that includes interprofessional practice. This transdisciplinary approach contributes to greater health equity given the multilevel approach. Multidirectional integration of diverse disciplines representing the various realms of medicine, dentistry, and behavioral health care is essential for optimal health of all. This article can be used by clinicians, scientists, administrators, and policy makers in developing and implementing integrated systems of care that provide for patients' medical, dental, and behavioral health needs.

Unhoused patients admitted to inpatient psychiatry at an academic, safety-net hospital: a cross-sectional study

ABSTRACT Introduction: There is a lack of data regarding unhoused patients admitted to inpatient psychiatry in the United States. The authors describe demographic and diagnostic features of unhoused patients admitted to an acute psychiatric inpatient unit (PIU) at an academic, safety net hospital. Methods: This is a cross-sectional, retrospective chart review of 57,902 adult patients admitted to the hospital between January 1, 2018 and May 31, 2023. Eleven percent (n = 6304) were admitted to the PIU and were part of further subgroup analysis examining housing status and primary behavioral health diagnoses. Chi-square tests of independence were used to determine associations between categorical variables. Results: The proportion of patients admitted to the PIU who were unhoused (33%, n = 2065) was 3 times greater than the proportion of patients admitted to non-psychiatric inpatient units who were unhoused (11%, n = 5450). On the PIU, unhoused patients compared to housed patients were more likely to be male (67 and 51%), have a psychotic disorder (35 and 19%) or a substance-related disorder (19 and 8%), and were less likely to have a mood disorder (22 and 44%). Conclusion: Understanding demographic and diagnostic factors is important to develop effective interventions to address the needs of unhoused patients on a PIU.

Novel Machine Learning HIV Intervention for Sexual and Gender Minority Young People Who Have Sex With Men (uTECH): Protocol for a Randomized Comparison Trial.

Sexual and gender minority (SGM) young people are disproportionately affected by HIV in the United States, and substance use is a major driver of new infections. People who use web-based venues to meet sex partners are more likely to report substance use, sexual risk behaviors, and sexually transmitted infections. To our knowledge, no machine learning (ML) interventions have been developed that use web-based and digital technologies to inform and personalize HIV and substance use prevention efforts for SGM young people. This study aims to test the acceptability, appropriateness, and feasibility of the uTECH intervention, a SMS text messaging intervention using an ML algorithm to promote HIV prevention and substance use harm reduction among SGM people aged 18 to 29 years who have sex with men. This intervention will be compared to the Young Men's Health Project (YMHP) alone, an existing Centers for Disease Control and Prevention best evidence intervention for young SGM people, which consists of 4 motivational interviewing-based counseling sessions. The YMHP condition will receive YMHP sessions and will be compared to the uTECH+YMHP condition, which includes YMHP sessions as well as uTECH SMS text messages. In a study funded by the National Institutes of Health, we will recruit and enroll SGM participants (aged 18-29 years) in the United States (N=330) to participate in a 12-month, 2-arm randomized comparison trial. All participants will receive 4 counseling sessions conducted over Zoom (Zoom Video Communications, Inc) with a master's-level social worker. Participants in the uTECH+YMHP condition will receive curated SMS text messages informed by an ML algorithm that seek to promote HIV and substance use risk reduction strategies as well as undergoing YMHP counseling. We hypothesize that the uTECH+YMHP intervention will be considered acceptable, appropriate, and feasible to most participants. We also hypothesize that participants in the combined condition will experience enhanced and more durable reductions in substance use and sexual risk behaviors compared to participants receiving YMHP alone. Appropriate statistical methods, models, and procedures will be selected to evaluate primary hypotheses and behavioral health outcomes in both intervention conditions using an α<.05 significance level, including comparison tests, tests of fixed effects, and growth curve modeling. This study was funded in August 2019. As of June 2024, all participants have been enrolled. Data analysis has commenced, and expected results will be published in the fall of 2025. This study aims to develop and test the acceptability, appropriateness, and feasibility of uTECH, a novel approach to reduce HIV risk and substance use among SGM young adults. ClinicalTrials.gov NCT04710901; https://clinicaltrials.gov/study/NCT04710901. DERR1-10.2196/58448.

The Role of Street Medicine and Mobile Clinics for Persons Experiencing Homelessness: A Scoping Review.

An estimated 5800 to 46,500 lives are lost due to homelessness each year. Experiencing homelessness and poor health are cyclically related, with one reinforcing the other. Mobile programs, which include vehicles that travel to deliver care, and street medicine, the act of bringing care to spaces where PEH live, may play a role in alleviating this burden by providing trusted, affordable, and accessible care to this community. We conducted a scoping review of peer-reviewed literature on the role of mobile clinics and street medicine in providing care for PEH by searching PubMed, Embase, and Web of Science on 10 August 2023. Articles from 2013 to 2023 specific to programs in the United States were included. The protocol was developed following the PRISMA-ScR guidelines. The primary outcome was the role of mobile programs for persons experiencing homelessness. A total of 15 articles were included in this review. The descriptive findings emphasized that street medicine and mobile clinics provide primary care, behavioral health, and social services. The utilization findings indicate that street medicine programs positively impact the health system through their ability to defer emergency department and hospital visits, providing financial benefits. The comparative findings between mobile programs and office-based programs indicate current successes and areas for improvement. Mobile clinics and street medicine programs that serve PEH provide a wide range of services. While more significant structural change is needed to address healthcare costs and housing policies in the United States, mobile clinics and street medicine teams can improve healthcare access and the healthcare system.

Factors to Improve Reverse Integration: A Mixed Method Embedded Design Study.

Individuals with serious mental illness face inequity in receiving primary care services. The Substance Abuse and Mental Health Services Administration (SAMHSA) granted funds to Certified Community Behavioral Health Clinics (CCBHC) to integrate primary care and behavioral health specialties to increase access to care. This mixed method study aimed to measure the SAMHSA-defined levels of reverse integration at a CCBHC at one point in time. Providers and patients provided feedback through semi-structured interviews. Qualitative data was investigated for themes, while the quantitative data was run through inferential analysis with the Kruskal Wallis H test. Clinically meaningful results showed people using primary care at the integrated clinic were more satisfied and were more apt to continue seeing their current providers than those receiving non-integrated care. The CCBHC achieved level 4 integration; factors investigated confirmed proximity alone does not necessitate integration without effective communication and implementation of practice changes.

Care Delivery in Community Health Centers Before, During, and After the COVID-19 Pandemic (2019-2022).

Health centers provide primary and behavioral health care to the nation's safety net population. Many health centers served on the frontlines of the COVID-19 pandemic, which brought major changes to health center care delivery. To elucidate primary care and behavioral health service delivery patterns in health centers before and during the COVID-19 public health emergency (PHE). We compared annual and monthly patients from 2019 to 2022 for new and established patients by visit type (primary care, behavioral health) and encounter visits by modality (in-person, telehealth) across 218 health centers in 13 states. There were 1581,744 unique patients in the sample, most from health disparate populations. Review of primary care data over 4 years show that health centers served fewer pediatric patients over time, while retaining the capacity to provide to patients 65+. Monthly data on encounters highlights that the initial shift in March/April 2020 to telehealth was not sustained and that in-person visits rose steadily after November/December 2020 to return as the predominant care delivery mode. With regards to behavioral health, health centers continued to provide care to established patients throughout the PHE, while serving fewer new patients over time. In contrast to primary care, after initial uptake of telehealth in March/April 2020, telehealth encounters remained the predominant care delivery mode through 2022. Four years of data demonstrate how COVID-19 impacted delivery of primary care and behavioral health care for patients, highlighting gaps in pediatric care delivery and trends in telehealth over time.

Stakeholder perspectives on a telemedicine referral and coordination model to expand medication treatment for opioid use disorder in rural primary care clinics

IntroductionOpioid overdose deaths are increasing rapidly in the United States. Medications for opioid use disorder (MOUD) are effective and can be delivered in primary care, but uptake has been limited in rural communities. Referral to and coordination with an external telemedicine (TM) vendor by rural primary care clinics for MOUD (TM-MOUD) may increase MOUD access for rural patients, but we know little about perspectives on this model among key stakeholders. As part of a TM-MOUD feasibility study, we explored TM-MOUD acceptability and feasibility among personnel and patients from seven rural primary care clinics and a TM-MOUD vendor. MethodsWe conducted virtual interviews or focus groups with clinic administrators (n = 7 interviews), clinic primary care and behavioral health providers (8 groups, n = 30), other clinic staff (9 groups, n = 37), patients receiving MOUD (n = 16 interviews), TM-MOUD vendor staff (n = 4 interviews), and vendor-affiliated behavioral health and prescribing providers (n = 17 interviews). We asked about experiences with and acceptability of MOUD (primarily buprenorphine) and telemedicine (TM) and a TM-MOUD referral and coordination model. We conducted content analysis to identify themes and participants quantitatively rated acceptability of TM-MOUD elements on a 4-item scale. ResultsPerceived benefits of vendor-based TM-MOUD included reduced logistical barriers, more privacy and less stigma, and access to services not available locally (e.g., counseling, pain management). Barriers included lack of internet or poor connectivity in patients' homes, limited communication and trust between TM-MOUD and clinic providers, and questions about the value to the clinic of TM-MOUD referral to external vendor. Acceptability ratings for TM-MOUD were generally high; they were lowest among frontline staff. ConclusionsRural primary care clinic personnel, TM-MOUD vendor personnel, and patients generally perceived referral from primary care to a TM-MOUD vendor to hold potential for increasing access to MOUD in rural communities. Increasing TM-MOUD uptake requires buy-in and understanding among staff of the TM-MOUD workflow, TM services offered, requirements for patients, advantages over clinic-based or TM services from clinic providers, and identification of appropriate patients. Poverty, along with patient hesitation to initiate treatment, creates substantial barriers to MOUD treatment generally; insufficient internet availability creates a substantial barrier to TM-MOUD.

Referring Adolescent Primary Care Patients to Single-Session Interventions for Anxiety and Depression: Protocol for a Feasibility Study.

Despite the growing prevalence of depression and anxiety among adolescents, fewer than half access appropriate mental health care. Single-session interventions (SSIs) for depression and anxiety offered in primary care are a promising approach to bridging the treatment gap. We aimed to implement a clinical workflow for primary care and behavioral health providers to refer patients aged 13 to 17 years with mild to moderate depression and anxiety symptoms to Project YES (Youth Empowerment and Support), an open-access SSI platform, in a large group medical practice with an integrated behavioral health department. Pediatric primary care and integrated behavioral health providers will be educated on the benefits of Project YES for adolescent anxiety and depression and trained in a workflow integrated within the electronic health record system, Epic, to refer patients during well-child visits and pediatric behavioral health visits. Patients with mild to moderate internalizing symptoms based on the 17-item Pediatric Symptom Checklist or youth Pediatric Symptom Checklist will be invited to try an SSI through Project YES. We will examine provider uptake and perceptions of acceptability, feasibility, and appropriateness over time. The rollout will take place between November 2022 and May 2023, when outcomes will be evaluated. Data analysis and manuscript writing are anticipated to be completed during the summer of 2023. SSIs such as those available through Project YES have the potential to provide low-cost, evidence-based mental health treatment to adolescents with mild to moderate depression and anxiety. If deemed feasible and acceptable, providing SSIs in primary care settings could significantly improve access to mental health care without taxing pediatric primary care and behavioral health providers. DERR1-10.2196/45666.

Findings from an Organizational Context Survey to Inform the Implementation of a Collaborative Care Study for Co-occurring Disorders

Primary care is an opportune setting to deliver treatments for co-occurring substance use and mental health disorders; however, treatment delivery can be challenging due multi-level implementation barriers. Documenting organizational context can provide insight into implementation barriers and the adaptation of new processes into usual care workflows. This study surveyed primary care and behavioral health staff from 13 clinics implementing a collaborative care intervention for opioid use disorders co-occurring with PTSD and/or depression as part of a multisite randomized controlled trial. A total of 323 completed an online survey for a 60% response rate. The Consolidated Framework for Implementation Research guided this assessment of multi-level factors that influence implementation. Most areas for improvement focused on inner setting (organizational level) constructs whereas individual-level constructs tended to be strengths. This work addresses a research gap regarding how organizational analyses can be used prior to implementation and provides practical implications for researchers and clinic leaders.

Results of a national survey of substance use treatment services for youth under community supervision

BackgroundDespite the heightened risk for substance use (SU) among youth in the juvenile justice system, many do not receive the treatment that they need.ObjectivesThe purpose of this study is to examine the extent to which youth under community supervision by juvenile justice agencies receive community-based SU services and the factors associated with access to such services.MethodsData are from a nationally representative sample of Community Supervision (CS) agencies and their primary behavioral health (BH) partners. Surveys were completed by 192 CS and 271 BH agencies.ResultsSU services are more often available through BH than CS for all treatment modalities. EBPs are more likely to be used by BH than by CS. Co-location of services occurs most often in communities with fewer treatment options and is associated with higher interagency collaboration. Youth are more likely to receive services in communities with higher EBP use, which mediates the relationship between the availability of SU treatment modalities and the proportion of youth served.ConclusionFindings identify opportunities to strengthen community systems and improve linkage to care.

Feasibility, Engagement, and Usability of a Remote, Smartphone-Based Contingency Management Program as a Treatment Add-On for Patients Who Use Methamphetamine: Single-Arm Pilot Study.

In the United States, methamphetamine-related overdoses have tripled from 2015 to 2020 and continue to rise. However, efficacious treatments such as contingency management (CM) are often unavailable in health systems. We conducted a single-arm pilot study to evaluate the feasibility, engagement, and usability of a fully remotely delivered mobile health CM program offered to adult outpatients who used methamphetamine and were receiving health care within a large university health system. Participants were referred by primary care or behavioral health clinicians between September 2021 and July 2022. Eligibility criteria screening was conducted by telephone and included self-reported methamphetamine use on ≥5 out of the past 30 days and a goal of reducing or abstaining from methamphetamine use. Eligible participants who agreed to take part then completed an initial welcome phase that included 2 videoconference calls to register for and learn about the CM program and 2 "practice" saliva-based substance tests prompted by a smartphone app. Participants who completed these welcome phase activities could then receive the remotely delivered CM intervention for 12 consecutive weeks. The intervention included approximately 24 randomly scheduled smartphone alerts requesting a video recording of themselves taking a saliva-based substance test to verify recent methamphetamine abstinence, 12 weekly calls with a CM guide, 35 self-paced cognitive behavioral therapy modules, and multiple surveys. Financial incentives were disbursed via reloadable debit cards. An intervention usability questionnaire was completed at the midpoint. Overall, 37 patients completed telephone screenings, with 28 (76%) meeting the eligibility criteria and consenting to participate. Most participants who completed a baseline questionnaire (21/24, 88%) self-reported symptoms consistent with severe methamphetamine use disorder, and most had other co-occurring non-methamphetamine substance use disorders (22/28, 79%) and co-occurring mental health disorders (25/28, 89%) according to existing electronic health records. Overall, 54% (15/28) of participants successfully completed the welcome phase and were able to receive the CM intervention. Among these participants, engagement with substance testing, calls with CM guides, and cognitive behavioral therapy modules varied. Rates of verified methamphetamine abstinence in substance testing were generally low but varied considerably across participants. Participants reported positive opinions about the intervention's ease of use and satisfaction with the intervention. Fully remote CM can be feasibly delivered within health care settings lacking existing CM programs. Although remote delivery may help reduce barriers to treatment access, many patients who use methamphetamine may struggle to engage with initial onboarding. High rates of co-occurring psychiatric conditions in the patient population may also contribute to uptake and engagement challenges. Future efforts could leverage greater human-to-human connection, more streamlined onboarding procedures, larger incentives, longer durations, and the incentivization of non-abstinence-based recovery goals to increase uptake and engagement with fully remote mobile health-based CM.

Interprofessional Collaborative Practice: Management of Chronic Disease and Mental Health Issues in Primary Care.

This case study describes the process of implementing and evaluating an interprofessional collaborative practice (IPCP) program for primary care and behavioral health integration focused on chronic disease management. The result was a strong IPCP program in a nurse-led federally qualified health center serving medically underserved populations. The IPCP program at the Larry Combest Community Health and Wellness Center at the Texas Tech University Health Sciences Center spanned >10 years of planning, development, and implementation, supported by demonstration, grants, and cooperative grants from the Health Resources and Services Administration. The program launched 3 projects: a patient navigation program, an IPCP program for chronic disease management, and a program for primary care and behavioral health integration. We established 3 evaluation domains to track the outcomes of the program: TeamSTEPPS education outcomes (Team Strategies and Tools to Enhance Performance and Patient Safety), process/service measures, and patient clinical and behavioral measures. TeamSTEPPS outcomes were evaluated before and after training on a 5-point Likert scale (1 = strongly disagree, 5 = strongly agree). Mean (SD) scores increased significantly in team structure (4.2 [0.9] vs 4.7 [0.5]; P < .001), situation monitoring (4.2 [0.8] vs 4.6 [0.5]; P = .002), and communication (4.1 [0.8] vs 4.5 [0.5]; P = .001). From 2014 to 2020, the rate of depression screening and follow-up improved from 16% to 91%, and the hypertension control rate improved from 50% to 62%. Lessons learned include recognizing partner contributions and the worth of each team member. Our program evolved with the help of networks, champions, and collaborative partners. Program outcomes show the positive impact of a team-based IPCP model on health outcomes among medically underserved populations.

Interventions to Reduce Repeat Presentations to Hospital Emergency Departments for Mental Health Concerns: A Scoping Review of the Literature.

The number of readmissions to the emergency department (ED) for mental health services each year is significant, which increases healthcare costs and negatively affects the morale and quality of life of patients and their families. This scoping review aimed to establish a better understanding of interventions that have been implemented to reduce psychiatric patient readmission and ED use within the ED, to identify areas for improvement, and therefore to assist in the development of more effective actions in the future. The scoping review was conducted on several bibliographic databases to identify relevant studies. Two researchers independently screened and reviewed titles, abstracts, and full-text articles that met the inclusion criteria. Using Covidence software, 26 out of 6951 studies were eligible for inclusion in this scoping review based on the PRISMA checklist. Data were extracted, collated, summarized, presented, and discussed. This review identified 26 studies which examined interventions aimed to reduce ED visits, such as the High Alert Program (HAP), the Patient-Centered Medical Home (PCMH), the Primary Behavioral Health Care Integration (PBHCI), and the Collaborative Care (CC) Program, etc. Twenty-three of the studies were conducted in North America, while the rest were conducted in Europe and Australia. A total of 16 studies examined interventions directed to any mental health conditions, while the rest addressed specific health conditions, such as substance use disorders, schizophrenia, anxiety, depression. Interventions involved comprehensive and multidisciplinary services, incorporation of evidence-based behavioral and pharmacological strategies, and emphasized the case management that was found to be effective. Additionally, there was a marked consideration for diverse mental health groups, such as those with substance use disorder and of young age. Most interventions showed a positive effect on reducing psychiatric ED visits. Various initiatives have been implemented worldwide to reduce the number of emergency department visits and the associated burden on healthcare systems. This review highlights the greater need for developing more accessible interventions, as well as setting up a comprehensive community health care system aiming to reduce frequent ED presentations.

Implementing Evidence-Based Suicide Prevention Strategies for Greatest Impact.

Suicide remains a leading cause of death in the United States and globally. In this review, epidemiological trends in mortality and suicide risk are presented, with consideration given to the impact of the COVID-19 pandemic. A public health model of suicide prevention with a community and clinical framework, along with advances in scientific discovery, offer new solutions that await widespread implementation. Actionable interventions with evidence for reducing risk for suicidal behavior are presented, including universal and targeted strategies at community, public policy, and clinical levels. Clinical interventions include screening and risk assessment; brief interventions (e.g., safety planning, education, and lethal means counseling) that can be done in primary care, emergency, and behavioral health settings; psychotherapies (cognitive-behavioral, dialectical behavior, mentalization therapy); pharmacotherapy; and systemwide procedures for health care organizations (training, policies, workflow, surveillance of suicide indicators, use of health records for screening, care steps). Suicide prevention strategies must be prioritized and implemented at scale for greatest impact.

Association of Patients’ Direct Addition of Buprenorphine to Urine Drug Test Specimens With Clinical Factors in Opioid Use Disorder

The direct addition of buprenorphine to urine drug test specimens to mimic results suggestive of adherence is a clinically significant result, yet little is known about the phenomenon. To characterize factors associated with the direct addition of buprenorphine to urine specimens among patients prescribed buprenorphine for opioid use disorder. This cross-sectional study of urine drug test specimens was conducted from January 1, 2017, to April 30, 2022, using a national database of urine drug test specimens ordered by clinicians from primary care, behavioral health, and substance use disorder treatment clinics. Urine specimens with quantitative norbuprenorphine and buprenorphine concentrations from patients with opioid use disorder currently prescribed buprenorphine were analyzed. Nonprescribed opioid or stimulant co-positive, clinical setting, collection year, census division, patient age, patient sex, and payor. Norbuprenorphine to buprenorphine ratio less than 0.02 identified direct addition of buprenorphine. Unadjusted trends in co-positivity for stimulants and opioids were compared between specimens consistent with the direct addition of buprenorphine. Factors associated with the direct addition of buprenorphine were examined with generalized estimating equations. This study included 507 735 urine specimens from 58 476 patients. Of all specimens, 261 210 (51.4%) were obtained from male individuals, and 137 254 (37.7%) were from patients aged 25 to 34 years. Overall, 9546 (1.9%) specimens from 4550 (7.6%) patients were suggestive of the direct addition of buprenorphine. The annual prevalence decreased from 2.4% in 2017 to 1.2% in 2020. Opioid-positive with (adjusted odds ratio [aOR], 2.01; 95% CI, 1.85-2.18) and without (aOR, 2.02; 95% CI, 1.81-2.26) stimulant-positive specimens were associated with the direct addition of buprenorphine to specimens, while opioid-negative/stimulant-positive specimens were negatively associated (aOR, 0.78; 95% CI, 0.71-0.85). Specimens from patients aged 35 to 44 years (aOR, 1.59; 95% CI, 1.34-1.90) and primary care (aOR, 1.60; 95% CI, 1.44-1.79) were associated with the direct addition of buprenorphine. Differences by treatment setting decreased over time. Specimens from the South Atlantic census region had the highest association (aOR, 1.4; 95% CI, 1.25-1.56) and New England had the lowest association (aOR, 0.54; 95% CI, 0.46-0.65) with the direct addition of buprenorphine. In this cross-sectional study, the direct addition of buprenorphine to urine specimens was associated with other opioid positivity and being collected in primary care settings. The direct addition of buprenorphine to urine specimens is a clinically significant finding, and best practices specific for this phenomenon are needed.

Impact of COVID-19 on Trends in Outpatient Clinic Utilization: A Tale of 2 Departments.

The COVID-19 pandemic forced many US health care organizations to shift from mostly in-person care to a hybrid of virtual visits (VV) and in-person visits (IPV). While there was an expected and immediate shift to virtual care (VC) early in the pandemic, little is known about trends in VC use after restrictions eased. This is a retrospective study using data from 3 health care systems. All completed visits from adult primary care (APC) and behavioral health (BH) were extracted from the electronic health record of adults aged 19 years and older from January 1, 2019 to June 30, 2021. Standardized weekly visit rates were calculated by department and site and analyzed using time series analysis. There was an immediate decrease in APC visits following the onset of the pandemic. IPV were quickly replaced by VV such that VV accounted for most APC visits early in the pandemic. By 2021, VV rates declined, and VC visits accounted for <50% of all APC visits. By Spring 2021, all 3 health care systems saw a resumption of APC visits as rates neared or returned to prepandemic levels. In contrast, BH visit rates remained constant or slightly increased. By April 2020, almost all BH visits were being delivered virtually at each of the 3 sites and continue to do so without changes to utilization. VC use peaked during the early pandemic period. While rates of VC are higher than prepandemic levels, IPV are the predominant visit type in APC. In contrast, VC use has sustained in BH, even after restrictions eased.

On the Relationship Between Stakeholder Affiliation and Attitudes Toward Behavioral Health Reform in Kansas.

The lack of access to behavioral health care, trends in behavioral health issues, and the impact of social determinants of health underlie the need for behavioral health reform in Kansas. However, stakeholders may affect progress toward behavioral health reform. This study examined stakeholders' attitudes toward behavioral health reform. The authors analyzed data from a survey administered to elected officials, members of health advocacy groups, state employees, and payers in Kansas. Main outcome measures included attitudes toward the perceived benefit of certain behavioral health and social determinants of health policies and the perceived performance of the primary care and behavioral health care systems in Kansas. Payers perceived legislation to improve insurance coverage for behavioral health issues as less beneficial than state employees and members of health advocacy groups. Elected officials perceived legislation to address various social determinants of health as less beneficial than health advocates. Members of health advocacy groups rated the behavioral health care system more poorly than elected officials did. Preliminary findings reflected both the barriers and facilitators to behavioral health reform in Kansas. However, several limitations undermined the generalizability of these findings. Future studies should consider more representative sample sizes, additional variables in behavioral health and social determinants of health policies, and more comprehensive, validated measures.