Primary Care Behavioral Health Research Articles

"Integrated behavioral health plus": The best of the worlds of collaborative care management, primary care behavioral health, and primary care.

Discussions comparing the components and virtues of models of integrated behavioral health (IBH), that is, collaborative care management and primary care behavioral health, have been ongoing. In this conceptual article, we recommend shifting the focus to a broader set of components we have found essential to serve the needs of our patients, and hopefully the broader aims of dissemination and implementation of IBH. We detail our 20-year experience including the personnel, program components, challenges, successes, and plans for the future that will meet our patients' behavioral health needs and serve primary care. We compare our "IBH Plus" approach using the central tenets of primary care known as the "six Cs" (6Cs) to two dominant models, illustrating differences and similarities among them. The "6Cs" are first contact/accessibility, continuity, comprehensiveness, coordination, context-based, and accountability. We detail how each of these "6Cs" guides the structure and functioning of IBH Plus in the team-based patient-centered medical home setting. We believe IBH Plus more clearly relates to and supports the rest of the primary care transformation movement while integrating components of the most popular models of IBH and may support greater implementation of IBH. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Non-communicable diseases and the prospects of integrated behavioral health in India: current status and future directions

PurposeContextual to the recognition of the complex interplay between health and behavioral aspects, integrated behavioral health (IBH) has emerged. Although this model is becoming popular in the Western world, its presence in the global context is not promising. This paper aims to explore the need for IBH in India and address its barriers to implementation and possible solutions.Design/methodology/approachWe analyzed the case of IBH and its potential implications for India using the current evidence base, authors' reflections and experience of implementing similar programs.FindingsThis paper identifies contextual factors, including increased instances of non-communicable diseases and psychosocial and cultural determinants of health, that necessitate the implementation of IBH programs in India. The key features of different IBH models and their applicability are outlined. The current status of IBH and potential challenges in implementation in India in terms of human resources and other factors are delineated. We also discuss the potential models for implementing IBH in India.Originality/valueIntegrating behavioral health in primary care is considered an effective and sustainable model to promote health and well-being across various target populations. Towards this end, this paper is the first to discuss the contextual factors of IBH in India. It is a significant addition to the knowledge base on IBH and its possible implementation barriers and strategies in low- and middle-income countries.

Integrating Behavioral Health and Primary Care

Osteopathic family physicians embody the philosophy of whole-person care, including using a biopsychosocial approach to incorporate mental health into patient care. The creation of the Behavioral Health Integration Collaborative increased support for a system-level adoption of whole-person care in primary care settings. With the increase in both mental health symptoms and diagnoses among Americans, and the increasing support for integrated physical and behavioral healthcare in the primary care setting, this paper shares various approaches, as well as challenges to, adapting integrated care in the primary care office. This includes reviewing best practices for implementing this care approach. The two leading models for integrated care are the Primary Care Behavioral Health (PCBH) model and Collaborative Care model (CoCM). Both models include clinically embedding licensed mental health professionals into the primary care setting, thus increasing access to colleagues with this specialized approach. The PCBH model utilizes a warm hand-off approach, resulting in a collaboration between physician and mental health provider in the care of the patient. The CoCM focuses on a registry of patients who are overseen by a behavioral health manager with treatment decisions guided by a consulting psychiatrist. Blended models are also emerging to better suit the needs for different practices and the patient populations they serve. Challenges to full implementation include acquiring buy-in from practice leadership, hiring appropriately trained mental health providers, and defining billing and coding procedures.

Embedding Counselors in Student Health Centers: Exploring Challenges to Implementing the Primary Care Behavioral Health Model

ABSTRACT Embedding counselors in various campus locations has been one strategy to address the student mental health crisis. The aim of this study was to evaluate challenges to implementing the primary care behavioral health (PCBH) model, in which behavioral health counselors (BHCs) are embedded within the college health center, and to explore characteristics associated with differing levels of PCBH fidelity. Seventy-one BHCs working in college health centers completed the online fidelity survey. Most respondent scores denoted moderate or strong fidelity to the PCBH model. Psychologists showed better adherence to autonomous clinical aspects of PCBH while social workers/counselors showed better adherence to collaborative aspects of PCBH. Overall findings suggest fidelity to PCBH by BHCs in college health is driven by independent clinical activity more than interdisciplinary collaboration. Strategies for developing and evaluating a PCBH program that complements the specialty mental health services offered through counseling centers are discussed.

Can the electronic medical record provide reliable indicators of primary care behavioral health fidelity? Comparison of accessibility and productivity indicators assessed through observational coding.

The primary care behavioral health (PCBH) model is one of the most widely implemented integrated care approaches. However, research on the model has been limited by inconsistent measurement and reporting of model fidelity. One way of making measurement of PCBH model fidelity more routine is to incorporate fidelity indicators into the electronic medical record (EMR), though research regarding the accuracy of EMR data is mixed. In this study, we aimed to assess the reliability of EMR data as a PCBH fidelity measurement tool by comparing key EMR indicators of PCBH fidelity to those recorded by an observational coder. Over an 8-month period (October 2021-May 2022), 12 behavioral health consultants (BHCs; 92% White, 75% female) across five primary care clinics recorded indicators of PCBH fidelity in the EMR as part of their routine charting of behavioral health visits. During that same period, one observational coder completed seven 4-hr visits per clinic to obtain multiple samples of data from each over time and recorded the same variables (i.e., percentage of visits prompted by warm handoffs, number of warm handoffs, and number of patient visits). We used bivariate correlations to test the associations between the EMR variables and the observer-coded variables. Correlations between EMR and observer-coded variables were moderate to strong, ranging from r = .46 to r = .97. Leveraging EMR data appears to be a fairly reliable approach to capturing indicators of PCBH model fidelity in the key domains of accessibility and high productivity. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Supplemental Material for Can the Electronic Medical Record Provide Reliable Indicators of Primary Care Behavioral Health Fidelity? Comparison of Accessibility and Productivity Indicators Assessed Through Observational Coding

Supplemental Material for Can the Electronic Medical Record Provide Reliable Indicators of Primary Care Behavioral Health Fidelity? Comparison of Accessibility and Productivity Indicators Assessed Through Observational Coding

Brief conjoint visits between an embedded behavioral health provider and primary care team member: When are they used and what are the barriers and facilitators?

Conjoint visits utilize the expertise of primary care providers (PCPs) and behavioral health providers (BHPs) to address complex comorbidities in patients. The objectives were to describe the use and features of conjoint visits and identify barriers and facilitators as described by BHPs in integrated settings. Three hundred and forty-five BHPs who worked in integrated primary care, a majority identifying as female and white, completed an online survey between October 2018 and July 2019. Results indicated common reasons for conjoint visits were for mental or behavioral health concerns. Though they reported high comfort using conjoint visits (M = 4.3/5), 56.5% of BHPs participated in them less than monthly or never. Using a constant comparison approach, qualitative data were coded to reveal six categories of barriers and five categories of facilitators to conjoint visits. The most common barriers were a result of a lack of systemic support, such as 73.5% reporting lack of time, while the most common facilitators were coordination (60.7%) and interprofessional communication (39.3%). Although conjoint visits are used infrequently, findings suggest it is not because they are unhelpful as providers generally found this type of appointment favorable. Rather, they and their teams lack time, training, and support needed for implementation. This research provides an introduction for researchers or clinicians to better understand the use of conjoint visits for patients with high needs and complexities. Future work focused on addressing barriers cited by providers regarding conjoint visits would increase providers' ability to use this form of care when it is needed. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Open to interpretation: An integrated primary care behavioral health training approach for treating linguistically diverse patients.

Integrated primary care settings serve an increasingly high volume of linguistically diverse patients. In English language-dominant countries, limited English proficiency (LEP) is associated with disparities in access and quality of behavioral health (BH) care. Interpretive services (IS) aim to address these disparities by assisting in the delivery of clinical care between patients and providers who speak different languages. Yet, there is a need for greater emphasis on the utilization of IS in clinical training for BH professionals (e.g., psychology, social work, counseling, and family therapy). In this conceptual article, we describe a BH practicum rotation for predoctoral psychology trainees in a free, student-run integrated primary care clinic that largely serves uninsured adults with LEP. First, we discuss our training model which includes a 90-min didactic lecture on IS for BH and supervised applied clinical experiences (e.g., psychotherapy, warm handoffs, and consultation). Then, we present vignettes prepared by trainees about the challenges and benefits associated with delivering BH care with IS at the predoctoral level of training. From the practicum experience, clinical psychology trainees reported improved knowledge and competencies in utilizing IS as well as generalizable skills for delivering BH care with a focus on multicultural practice. We recommend that other integrated primary care BH training sites consider emphasizing training in IS. This article concludes with recommendations for implementation and dissemination of our training model on other sites. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

“Death by a Thousand Cuts”: Agriculture Producer Resiliency in the Western United States

ABSTRACT Objective Agricultural producers face a wide array of stress triggers, shocks, and long-term pressures such as drought, flooding, fire, government policies, financial insecurity, and physical injuries. Extant research has revealed that mental health stigma, lack of access to care in rural areas, and negative coping responses (alcohol abuse, suicide, prescription drugs use) exacerbate the challenge of producer responses to short and long-term adversity. Resilience, the traits, processes, and capacities of producers to adapt and transform their approach to farming or ranching, when necessary, in response to stress triggers or long-term pressures, has received less research attention, particularly in the Western United States. The purpose of the study was to apply an interactionist occupational resilience theoretical perspective to the investigation of contextual factors contributing to resilience in Western United States agricultural producers. Methods Qualitative interviews (45 to 90 minutes) were conducted with agricultural producers (n=51) from Western states and territories. Applied thematic analysis with a phenomenological lens was utilized to analyze interview transcriptions. First and second level coding were conducted to derive themes. Results The analysis revealed that resilience is based upon the interactions between traits of producers and the context of agriculture. Four themes were generated (Agricultural Life, External Stressors, Traits and Adaptations, and Supports and Resources), supported by subthemes. The themes and subthemes are depicted in an agricultural producer resiliency model. The findings shed light on the equivocal role of neighbors in providing support for each other and the double-edged sword of co-working with family. Conclusions The findings underscore that social capital is an important mechanism for supporting farmers and ranchers, as those with stronger social resources are more resilient. We recommend more funding to tailor stress and mental health programming to the specifics of agriculture, integration of behavioral health in primary care as a mechanism to increase access to care, and more intentional technical assistance for farmers and ranchers on strategic planning and problem solving.

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.

Primary Care Behavioral Health in Sweden – a protocol of a cluster randomized trial evaluating outcomes related to implementation, organization, and patients (KAIROS)

BackgroundProviding comprehensive and continuous care for patients whose conditions have mental or behavioral components is a central challenge in primary care and an important part of improving universal health coverage. There is a great need for high and routine availability of psychological interventions, but traditional methods for delivering psychotherapy often result in low reach and long wait times. Primary Care Behavioral Health (PCBH) is a method for organizing primary care in which behavioral health staff provide brief, flexible interventions to a large part of the population in active collaboration with other providers. While PCBH holds promise in addressing important challenges, it has not yet been thoroughly evaluated.MethodsThis cluster randomized trial will assess 17 primary care centers (PCCs) that are starting a PCBH implementation process. The PCCs will be divided into two groups, with one starting immediate implementation and the other acting as a control, implementing six months later. The purpose of the study is to strengthen the evidence base for PCBH regarding implementation-, organization-, and patient-level outcomes, taking into consideration that there is a partially dependent relationship between the three levels. Patient outcomes (such as increased daily functioning and reduction of symptoms) may be dependent on organizational changes (such as availability of treatment, waiting times and interprofessional teamwork), which in turn requires change in implementation outcomes (most notably, model fidelity). In addition to the main analysis, five secondary analyses will compare groups based on different combinations of randomization and time periods, specifically before and after each center achieves sufficient PCBH fidelity.DiscussionA randomized comparison of PCBH and traditional primary care has, to our knowledge, not been made before. While the naturalistic setting and the intricacies of implementation pose certain challenges, we have designed this study in an effort to evaluate the causal effects of PCBH despite these complex aspects. The results of this project will be helpful in guiding decisions on how to organize the delivery of behavioral interventions and psychological treatment within the context of primary care in Sweden and elsewhere.Trial registrationClinicalTrials.gov: NCT05335382. Retrospectively registered on March 13th, 2022.

Update on Identifying and Evaluating Quality Measures for Adult Attention-Deficit/Hyperactivity Disorder

The limited recognition and treatment of attention-deficit/hyperactivity disorder (ADHD) in adults has been studied in the research setting and addressed in the clinical education setting during recent years. Despite these efforts, health care professionals continue to struggle with the management of adult ADHD in everyday practice. To better evaluate and measure meaningful practice metrics, a set of 10 key quality measures (QMs) that can help improve health care outcomes in adult ADHD was identified using a combination of evidence-based literature reviews and expert consensus. Subsequently, these QMs were field-tested in a sample of 71,310 adult ADHD patients in the primary care setting and behavioral health clinics over the course of a decade to assess whether these measures were attained. The results allowed us to understand how the clinician approach to diagnosing and treating ADHD has evolved in the past few years and highlighted the ongoing challenges in practice variation by clinicians caring for patients with adult ADHD. In turn, this information also guides our understanding of the next steps needed to improve the quality of care provided to adults with ADHD in different care settings. Accordingly, the American Professional Society of ADHD and Related Disorders (APSARD) assembled a guidelines committee to create a set of clinical practice guidelines to provide practitioners with a standardized, evidence-based approach to diagnosing and treating ADHD in adults. [ Psychiatr Ann . 2023;53(10):444–448.]

Addressing Adolescent Suicidality in Pediatric Primary Care.

This study examines prevalence rates of reported suicidal ideation (SI) in 2107 adolescents, characterizes recommendations and interventions given by primary care providers (PCPs) and behavioral health clinicians (BHCs) in response to SI on the Patient Health Questionnaire 9-Item Modified for Adolescents (PHQ-9A) for 140 adolescents, and identifies factors associated with a decrease in the frequency of SI at follow-up visits for 85 adolescents. A retrospective mixed-method approach was taken. Clinical informatics was used to extract visit data, demographics, and PHQ-9A scores for all visits between January 3, 2017, and August 31, 2018. Conventional content analysis of electronic medical records was used to examine qualitative results, and qualitative codes were then analyzed using point-biserial correlations. The setting includes a fully integrated behavioral health team within the primary care clinic. Of the 2107 adolescents, 140 (7%) endorsed SI within the past 2 weeks. Content analysis yielded 40 actions (17 PCP codes and 23 BHC codes) used in response to SI. Significant correlations were found between decreased SI frequency and the PCP referring to integrated behavioral health ( r = 0.24) and family navigators ( r = 0.26) and BHCs conducting a risk assessment ( r = 0.24), completing a safety plan ( r = 0.21), involving caregivers ( r = 0.29), sending the adolescent to the emergency department ( r = 0.28), and referring to family navigators ( r = 0.21; all p values < 0.05). The findings from this study support screening for SI and highlight specific multidisciplinary and family-centered interventions and recommendations to address adolescent endorsement of SI in pediatric primary care settings.

Patient Acceptance of Primary Care Behavioral Health in a Resident Obstetrics and Gynecology Clinic.

Primary care behavioral health (PCBH) is a patient care model in which a behavioral health consultant (BHC) works alongside the primary care provider to address behavioral components of health conditions. PCBH is well received in the primary care setting; however, little is known about acceptability of the service among prenatal patients. The study was designed to explore the acceptability of PCBH among pregnant patients in a resident obstetrics and gynecology clinic. A survey designed to assess different components of acceptability was administered to eligible pregnant patients who received prenatal care at the resident obstetrics and gynecology clinic. The majority of patients wanted to receive education on pregnancy-relevant topics from the BHC: healthy weight gain (68.4%), healthy eating (70.4%), healthy exercise (73.5%), and mood disorders (63.3%). The majority of participants wanted help from the BHC in managing coexisting conditions affecting pregnancy: stress (63.3%), depression (75.5%), or anxiety (73%). The majority of patients (55.6%) preferred to work with a BHC for mental health concerns rather than an outside psychiatrist or counselor. PCBH service was perceived to be easy to understand (78%). Barriers to engaging in the PCBH service included time (41.4%), lack of perceived need (13.8%), unavailability (6.9%), and others (13.8%). Despite the perceived benefit, there was an implication of stigma among prenatal patients seeking PCBH or mental health care. Overall, the PCBH model had high acceptability among a prenatal care population in a resident obstetrics and gynecology clinic and offers potential to improve prenatal outcomes.

Leveraging the electronic medical record to measure fidelity to the primary care behavioral health model: Implications for clinical and research pursuits.

The primary care behavioral health (PCBH) model of integration has been widely implemented across a number of noteworthy health care systems. However, lack of consistent measurement and reporting of the degree to which the PCBH model has been implemented as developers intended has resulted in two disadvantages in the field. First, clinical quality improvement efforts are hampered by lack of clear guidance on what elements are central to PCBH implementation. Second, the dearth of empirical studies reporting model fidelity impedes cross-study comparisons and limits the rigor of PCBH-focused research. Efforts to expand measurement of PCBH model fidelity would benefit from identification of accessible, unbiased metrics that could complement existing self-report measures. In this article, we describe how we partnered with our clinical informatics team to incorporate PCBH fidelity metrics into the electronic medical record (EMR), allowing for monthly extraction and review of these data. Next, we describe how we have used monthly fidelity monitoring to inform clinical quality improvement efforts in the context of a developing integrated care program and provide an example of how PCBH fidelity data might be reported in a research article. Leveraging EMR data to support PCBH fidelity measurement has the potential to strengthen clinical quality improvement efforts and enable more consistent measurement and reporting of PCBH fidelity data in research. Future efforts should aim to parse out the relative contribution of different variables to the success of PCBH integration and evaluate the effectiveness of implementation strategies at supporting high fidelity. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Brief, modular, transdiagnostic, cognitive-behavioral intervention for anxiety in veteran primary care: Development, provider feedback, and open trial.

Anxiety is undertreated in primary care, and most treatment provided is pharmacological rather than behavioral. Integrating behavioral health providers (BHPs) using the Primary Care Behavioral Health (PCBH) model can help address this treatment gap, but brief interventions suitable for use in PCBH practice are needed. We developed a modular, cognitive-behavioral anxiety intervention, Modular Anxiety Skills Training (MAST), that is evidence-based, transdiagnostic, feasible for PCBH, and patient-centered. MAST comprises up to six 30-min sessions emphasizing skills training. This article describes the rationale for and development of MAST as well as pilot work in the Veterans Health Administration (VA) to tailor and refine MAST for delivery to Veterans in VA primary care (MAST-V) to improve feasibility for VA BHPs and acceptability to Veterans. We used a convergent mixed-methods design with concurrent data collection. In phase one, we interviewed five BHPs to obtain feedback on the treatment manual. BHPs assessed MAST-V to be highly compatible with PCBH and provided suggestions to enhance feasibility. In phase two, we conducted an open trial in which six Veterans experiencing clinically significant anxiety received and provided feedback on all nine possible modules; we also assessed changes in mental health symptoms and functioning as well as treatment satisfaction and credibility. Veterans found MAST-V to be highly acceptable, and pre-post clinical outcomes were very promising with large effect sizes. Findings from this initial pilot provide preliminary support for the feasibility, acceptability, and efficacy of MAST-V and suggest further research with a randomized clinical trial is warranted. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Screening for parent and child ADHD in urban pediatric primary care: pilot implementation and stakeholder perspectives

BackgroundADHD commonly co-occurs in children and parents. When ADHD is untreated in parents, it contributes to negative child developmental and treatment outcomes. Screening for parent and child ADHD co-occurrence in pediatric primary care may be an effective strategy for early identification and treatment. There is no data on whether this screening model can be implemented successfully and there exists limited guidance on how to effectively approach parents about their own ADHD in pediatric settings. Even greater sensitivity may be required when engaging with families living in urban, low SES communities due to systemic inequities, mistrust, and stigma.MethodsThe current pilot study described the first 6 months of implementation of a parent and child ADHD screening protocol in urban pediatric primary care clinics serving a large population of families insured through Medicaid. Parents and children were screened for ADHD symptoms at annual well-child visits in pediatric primary care clinics as part of standard behavioral health screening. Independent stakeholder group meetings were held to gather feedback on factors influencing the implementation of the screening and treatment strategies. Mixed methods were used to examine initial screening completion rates and stakeholder perspectives (i.e., parents, primary care office staff, pediatricians, and behavioral health providers) on challenges of implementing the screening protocol within urban pediatric primary care.ResultsScreening completion rates were low (19.28%) during the initial 6-month implementation period. Thematic analysis of stakeholder meetings provided elaboration on the low screening completion rates. Identified themes included: 1) divergence between provider enthusiasm and parent hesitation; 2) parent preference versus logistic reality of providers; 3) centering the experiences of people with marginalized identities; and 4) sensitivity when discussing parent mental health and medication.ConclusionsFindings highlight the importance of developing flexible approaches to screening parent and child ADHD in urban pediatric health settings and emphasize the importance of cultural sensitivity when working with marginalized and under-resourced families.Trial registrationNCT04240756 (27/01/2020).

Using a Delphi Technique to Define Primary Care Behavioral Health Clinical Supervision Competencies.

There is an increasing need for Primary Care Behavioral Health (PCBH) workforce development (i.e., increase in well-trained PCBH providers) given the growth of behavioral health (BH) integration into primary care, specifically at a time when behavioral health needs are increasing because of the COVID-19 pandemic (Kanzler and Ogbeide in Psychol Trauma 12(S1):S177-S179, https://doi.org/10.1037/tra0000761 , 2020). Therefore, it is imperative to provide current and future behavioral health clinical supervisors in primary care settings specific competencies, given there are no current competencies specific to clinical supervision within the PCBH Model. Using a Delphi process, the authors identified and reached expert consensus on competencies for BH clinical supervisors in primary care. A purposive sample (in: Patton, Qualitative evaluation and research methods, Sage, Newbury Park, 1990) of fifteen experts (n = 15) in PCBH clinical training and education evaluated quantitative and qualitative domains and specific competencies associated with PCBH supervision gathered during an initial in-depth qualitative interview. This was followed by two subsequent rounds of quantitative Delphi surveys to reach consensus. The response rates from our panel of experts were 100% (15/15) for all stages (interviews, round one and round two surveys). Three domains (Primary Care Knowledge, Clinical Supervisor Development, and Clinical Supervision Skills) were rated as essential for providing clinical supervision with PCBH for pre-licensure level learners. The development of competencies will further support BH clinical supervisor needs, professional development, and provide a concrete way to evaluate progress towards teaching and training excellence. This will also have a great impact on the development of the future BH workforce within primary care.

Medicaid Costs and Utilization of Collaborative Versus Colocation Care for Patients With Depression.

The authors examined cost and utilization metrics for racially diverse Medicaid primary care patients with depression receiving care through either a collaborative care model (CoCM) of integration or the standard colocation model. Data from a retrospective cohort of Medicaid patients screening positive for clinically significant depression during January 2016-December 2017 were analyzed to assess health care costs and selected utilization measures. Seven primary care clinics providing CoCM were compared with 16 clinics providing colocated behavioral health care. Data for the first year and second year after a patient received an initial Patient Health Questionnaire-9 score ≥10 were analyzed. In the first year, compared with patients receiving colocated care (N=3,061), CoCM patients (N=4,315) had significantly lower odds of emergency department (ED) visits (OR=0.95) and medical specialty office visits (OR=0.92), with slightly higher odds of primary care provider (PCP) visits (OR=1.03) and behavioral health office visits (OR=1.03). In year 2, CoCM patients (N=2,623) had significantly lower odds of inpatient medical admissions (OR=0.87), ED visits (OR=0.84), medical specialty office visits (OR=0.89), and PCP visits (OR=0.94) than the colocated care patients (N=1,838). The two groups did not significantly differ in total cost in both years. Access to CoCM treatment in primary care for racially diverse Medicaid patients with depression was associated with more positive health care utilization outcomes than for those accessing colocated treatment. As organizations continue to seek opportunities to integrate behavioral health care into primary care, consideration of health care costs and utilization may be helpful in the selection and implementation of integration models.

Ethnic Determinants of Health and Medication Use for Depression Among US Latinx Adults.

Medication use for depression among US Latinx adults is low (34%) and commonly associated with systems-related and individual-related cultural factors. Social determinants of health (SDH) include economic, environmental, educational, community, and healthcare systems factors. Ethnic determinants of health (EDH) are SDH factors specific to an ethnic group and described by an ethnic and disparities framework. To assess relationships between EDH factors and depression medication use among non-Latinx White (NLW) and Latinx adult populations using data from a weighted national sample for hypothesis building. Weighted responses to 2015-2018 National Survey on Drug Use and Health surveys from NLW, Latinx, and Latinx adult respondents from Puerto Rico, Mexico, and other Latinx countries were compared. Bivariate analyses were conducted using 2-way cross tabulation and a Wald chi-square test of association. EDH variables were characterized within the construct domains of systems-related geographic location, education, and economic stability, and individual-related cultural factors. Prescription medication use for depressive symptoms is 16.6% (P < 0.05) lower among a national sample of Latinx compared with NLW adults with major depressive episode (MDE). Many differences among systems-level EDH variables between Latinx and NLW populations with MDE were also found between populations with depression medication use. Of note, seeing a primary care provider or psychologist or social worker was significantly different among populations with MDE but not for those with depression medication use. Individual-related cultural EDH variables of overall health and serious psychological distress were significantly worse for Latinx than NLW populations with depression medication use. However, stigma, healing beliefs, and religious beliefs were not different between populations with MDE or depression medication use. Differences between certain Latinx populations with depression medication use were found with limited English proficiency and living in poverty. EDH variables for environment-physical characteristics or community and interpersonal levels of analysis were not represented within the NSDUH survey. Seeing a primary care provider or behavioral health specialist, depression severity, and overall health status appear to be important factors related to depression medication use among Latinx adults. Given the limitations of these analyses, multivariate analyses of EDH factors and other Latinx populations are warranted.