Primary Care Mental Health Research Articles

Survey of GP registrars' training experience and confidence in managing children and adolescents with mental health conditions in primary care.

The aim of thisstudy is to assess General Practitioner (GP) trainees' training experience, and confidence in assessing and managing children and adolescents with common mental health conditions in primary care in Ireland. An online anonymous questionnaire was distributed to third and fourth year GP registrars enrolled in the Irish College of General Practitioners training schemes. The online questionnaire evaluated participants' training experiences and confidence levels in key areas of child and adolescent mental health in primary care. Sixty participants completed the survey out of 406, yielding a response rate of 14.8%. The majority (88%) reported no formal training or experience working in Child and Adolescent Mental Healthcare Services (CAMHS) during their GP training scheme. Responses indicated that many participants rated their competency, skills, and knowledge in essential areas of Child and Adolescent Mental Health as needing improvement. Similarly, their awareness of referral pathways and specialty services was below expectations, with poor perceived access to services. A large proportion (91.7%) expressed a definite need for further training in child and adolescent mental health disorders. The results highlight the need for enhanced training and support for GP trainees in the field of Child and Adolescent Mental Health, ensuring their ability to effectively and confidently address these common issues in primary care.

A Qualitative Examination of Clinician Anxiety about Suicide Prevention and Its Impact on Clinical Practice.

Clinician distress about working with patients at risk for suicide is well documented in the literature, yet little work has examined its pervasiveness across clinical settings. We conducted a secondary analysis of qualitative data gathered from 26 clinicians in primary care and outpatient mental health clinics serving both adult and child clients on their perception of evidence-based practice use for suicide screening, assessment, and brief intervention. Qualitative data were coded for any mentions of clinician anxiety or emotional response, and brief quantitative measures were collected to characterize our sample. When discussing broader barriers to implementation, 85% of participants spontaneously mentioned anxiety or heightened emotional responses related to delivering suicide prevention practices to those at risk for suicide. Common themes included low self-efficacy in suicide prevention skills, distress related to escalating care, efforts to alleviate such distress, and difficulty related to tolerating the uncertainty inherent in suicide prevention work. Similarly, while standardized anxiety ratings for participants were consistent with those of non-clinical norming samples, clinicians reported mild to moderate anxiety when screening for suicide risk (M = 3.64, SD = 2.19, Range = 0-8) and engaging in safety planning (M = 4.1, SD = 2.88, Range = 1-7) on post-interview surveys. In contrast, survey responses reflected generally high self-efficacy in their ability to screen for suicide risk (M = 7.66, SD = 1.29, Range = 5.25-10) and engage in safety planning (M = 8.25, SD = 0.87, Range = 7-9.5). Findings highlight pervasiveness of clinician distress when implementing suicide prevention practices and can inform future suicide prevention implementation efforts.

Mental Health In Primary Care: Development Of An Educational Guide For Health Professionals

This article presents the creation of an educational guide aimed at health professionals, focusing on mental health care in primary care in a municipality in southwest Paraná, Brazil. The guide aims to provide clear and accessible guidance on mental health care practices, addressing topics such as Psychiatric Reform, the stigma associated with mental disorders, and management strategies in the context of primary care. The development of the guide was based on a literature review and national guidelines, resulting in a practical tool for health professionals' daily work.

Implementing Task Substitution for Doctors and Nurses as a Key Element of Healthcare Reform

The ongoing global shortage of healthcare professionals, particularly doctors and nurses, presents a critical challenge to the efficiency and accessibility of healthcare systems. This manuscript reviews the concept of task substitution between doctors and nurses, emphasizing the role of Advanced Nursing Practitioners (ANPs) in addressing workforce deficits. Drawing on examples from the United States, Canada, the United Kingdom, and Australia, the study explores how ANPs have been integrated into various healthcare settings, including primary care, geriatrics, mental health, and emergency care. The manuscript also discusses the potential for implementing similar practices in Poland, offering a strategic framework for enhancing nursing education, expanding ANP roles, and improving patient outcomes through healthcare reform. By examining the educational requirements, scope of practice, and existing models of ANP integration, this article provides a comprehensive analysis of how advanced nursing roles can alleviate pressures on healthcare systems and suggests actionable steps for policymakers.

Understanding healthcare professionals’ responses to patient complaints in secondary and tertiary care in the UK: A systematic review and behavioural analysis using the Theoretical Domains Framework

BackgroundThe path of a complaint and patient satisfaction with complaint resolution is often dependent on the responses of healthcare professionals (HCPs). It is therefore important to understand the influences shaping HCP behaviour. This systematic review aimed to (1) identify the key actors, behaviours and factors influencing HCPs’ responses to complaints, and (2) apply behavioural science frameworks to classify these influences and provide recommendations for more effective complaints handling behaviours.MethodsA systematic literature review of UK published and unpublished (so-called grey literature) studies was conducted (PROSPERO registration: CRD42022301980). Five electronic databases [Scopus, MEDLINE/Ovid, Embase, Cumulated Index to Nursing and Allied Health Literature (CINAHL) and Health Management Information Consortium (HMIC)] were searched up to September 2021. Eligibility criteria included studies reporting primary data, conducted in secondary and tertiary care, written in English and published between 2001 and 2021 (studies from primary care, mental health, forensic, paediatric or dental care services were excluded). Extracted data included study characteristics, participant quotations from qualitative studies, results from questionnaire and survey studies, case studies reported in commentaries and descriptions, and summaries of results from reports. Data were synthesized narratively using inductive thematic analysis, followed by deductive mapping to the Theoretical Domains Framework (TDF).ResultsIn all, 22 articles and three reports met the inclusion criteria. A total of 8 actors, 22 behaviours and 24 influences on behaviour were found. Key factors influencing effective handling of complaints included HCPs’ knowledge of procedures, communication skills and training, available time and resources, inherent contradictions within the role, role authority, HCPs’ beliefs about their ability to handle complaints, beliefs about the value of complaints, managerial and peer support and organizational culture and emotions. Themes mapped onto nine TDF domains: knowledge, skills, environmental context and resources, social/professional role and identity, social influences, beliefs about capability, intentions and beliefs about consequences and emotions. Recommendations were generated using the Behaviour Change Wheel approach.ConclusionsThrough the application of behavioural science, we identified a wide range of individual, social/organizational and environmental influences on complaints handling. Our behavioural analysis informed recommendations for future intervention strategies, with particular emphasis on reframing and building on the positive aspects of complaints as an underutilized source of feedback at an individual and organizational level.

Peer-led intervention for individuals with major depression: study protocol for a randomized controlled trial (SUPEERMood)

BackgroundMajor Depressive Disorder (MDD) is one of the most disabling mental health problems worldwide. The Recovery Model emphasizes peer support to empower individuals with MDD, improve self-management, and patients' quality of life. Despite the demonstrated efficacy of peer-led interventions, further research is needed due to methodological limitations and variability in interventions across studies. Therefore, the objective of this trial is to evaluate the effectiveness of an adjuvant peer-led intervention for the reduction of depressive symptoms in individuals diagnosed with MDD attended in primary care mental health units.MethodsA controlled, parallel, randomized clinical trial will be conducted. The intervention group (n = 35) will receive 6 weeks of peer-led sessions based on a peer support program drive whilst supervised by nurses, while the control group (n = 35) will use a mobile Health (mHealth) application for emotional wellness based on CBT for 6 weeks. Measurements will be collected at baseline, at 6 weeks, at 6 and 12 months after the intervention to evaluate post-intervention effects. The primary outcome is the reduction of depressive symptoms through the Beck Depression Inventory (BDI-II) after the intervention. Secondary outcomes will involve measures such as adherence to psychiatric treatment, quality of life, adherence to mediterranean diet, alcohol consumption and physical activity.DiscussionWe hypothesize that this peer-led intervention, in contrast to the mHealth, will show improvement in BDI-II score reduction of 6 points after six weeks, 6 and 12 months. Standardized peer-led programs can benefit patients and professionals in terms of efficacy and feasibility of clinical treatment of depression, healthy habits, self-care and quality of life. In addition, they can provide recovery and relapse reduction, improved psychosocial support, minimization of intensive care use, and support for patient autonomy through self-management.Trial registrationThe trial protocol is prospectively registered with ClinicalTrials.gov under protocol registration number NCT06398561. Date of registration: May 01, 2024. Recruitment is ongoing.

Key Considerations in Integrating a Peer Support Model Within Psychiatric Emergency Services at a Canadian Pediatric Emergency Department: A Qualitative Study.

Difficulties accessing primary care and community-based mental health supports has contributed toyouth (aged < 18years) with mental health concerns presenting to Emergency Departments (EDs). Peer support services in community-based mental health settings areassociated with improved outcomes; research exploring this in pediatric EDs is lacking. Determinefeasibility and acceptability of integrating peer support services into a pediatric ED. 13 peer support workers (PSWs) and 30 mental health providers andstakeholders participated in interviews or focus groups. Using codebookthematic analysis,recommendations for integrationwere identified. Key recommendations were:clear conceptualization of youth and family peer support, effective communication pathways between the multidisciplinary team and PSWs, provision of training for ED staff to ensure workplace readiness for peer support, and consistent support for PSWs. Integration of peer support into pediatric EDs offers a feasible andacceptable way to support youth experiencing mental health crises.

Transitioning an implementation research intervention to a sustained clinical service: Telehealth primary care mental health integration implementation in Veterans Health Administration.

Often in implementation science efforts, an intervention originated by research funding does not continue in clinical practice after funding ends, or if it does, the process by which it was sustained remains known only to the implementation research or clinical teams. From 2018 to 2020, we implemented a complex telehealth interdisciplinary behavioral health program supported by research funding. The intervention was Primary Care Mental Health Integration (PCMHI) delivered via televideo from a large parent medical facility to rural satellite clinics (tele-PCMHI) within the Veterans Health Administration. Two implementation facilitators worked closely with clinical leaders and staff to plan, launch, and sustain tele-PCMHI across four sites. The intervention is still maintained by the clinical service and has spread to eight sites. Based on ethnographic and qualitative data collected weekly over 2 years, we categorized sustainment strategies across distinct time periods for this complex program, theoretically grounded in the Dynamic Sustainability Framework, emphasizing changes to adapt intervention fit to rapidly changing context. To contextualize, we identified barriers and strengths, such as difficulty training staff to use new equipment, restructuring clinic workflow, and determining suicide risk management remotely. New barriers arose, and, thus, new strategies were needed to continue implementing at the onset of the COVID-19 pandemic in 2020. Different strategies at different stages of implementation allowed sustainment to be a dynamic and evolving process. Plus, proactive and persistent planning for sustainment early in the effort, along with alignment with performance metrics and national policy, supported continued delivery in real-world organized care. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

National Addiction Workshop: A Virtual Adaptation to Support Competency Development in Opioid Use Disorder Management.

Accessible, manualized, skill-based training ready for wide dissemination is needed to prepare healthcare staff to meet the needs of people impacted by the opioid epidemic. A 2-day workshop and simulation training was designed by an interprofessional substance use disorder (SUD) specialty care team, adapted to a virtual platform, manualized, and offered to healthcare staff and trainees from a large healthcare system. The workshop was offered 6 times over the course of 10 months with a total of 177 participants from across the United States enrolled in the training. Interactive experiential learning strategies including games designed to test knowledge, small-group case discussions, video demonstrations of skills, patient panels, and 3 simulations of a patient with chronic pain who developed opioid use disorder in the context of long-term opioid therapy were utilized in efforts to build skills and confidence managing SUDs in primary care and general mental health settings. Of those who completed the post-workshop survey, most found both content and training structure useful, particularly content related to medication management, stigma, and collaborative care. In addition, overall confidence scores in assessing, diagnosing, and treating SUD increased. Skill building exercises, such as interprofessional team simulations, were highlighted as most beneficial. The workshop received national attention leading to a partnership with the healthcare system's simulation center for wider dissemination. Expanding access to SUD treatment requires training healthcare staff to effectively change attitudes, increase knowledge, and improve key skills. This 2-day interprofessional workshop was well-received by participants who reported high acceptability and satisfaction scores and demonstrated improved confidence in the management of SUDs. This type of manualized, collaborative, skill-based learning experience can foster staff preparedness and willingness to conceptualize SUD as a chronic condition amenable to treatment in different healthcare settings.

A community-based treatment and rehabilitation pathway for people with mental disorders recently convicted of an offence.

People with mental disorders can receive treatment in the community. Some, however, fall out of services and into the criminal justice system, running the risk of imprisonment and a deteriorating mental health cycle. This editorial describes Mental Health Treatment Requirements (MHTRs), that is court-imposed sentences that enable people in the UK to access treatment in the community and divert them from short custodial sentences. MHTRs have proven successful for people with primary care mental health needs. It remains difficult to secure these sentences for people with secondary care mental health needs. Three new 'proof of concept' sites for secondary care MHTRs may help understand barriers and find solutions.

Using physical health apps to promote healthy lifestyles in youth mental healthcare: A nationwide perspective-gathering exercise of over 400 service users

Digital technologies have presented a myriad of new solutions for improving cardiometabolic and behavioural health in the general population. However, the ways in which such advances could be applied to address the heightened health-risk behaviours and associated diseases in mental healthcare is unknown. To examine this, 492 young people with mental illness (YPMI) were recruited from 27 Primary Care and NHS mental healthcare sites across the UK, covering various diagnoses (excluding eating disorders). Participants were presented with four types of physical health apps, delivering: 1) Health Tracking; 2) Health Coaching; 3) Health Connections; and 4) Instructional Videos, and completed an online perspective-gathering exercise on the preferred utility, features, behavioural targets of these technologies, and barriers/facilitators to uptake. Results showed a high level of perceived utility across each of the four app types, with physical activity, sleep and diet emerging as preferred behavioural targets. Feedback on ideal app features indicated a need for integrated physical-mental health tracking, and expert-led instructional content/coaching, with less interest expressed towards sharing data with clinical teams. These findings can improve the development, future trials, and clinical implementation of digital lifestyle interventions in mental healthcare, through better accounting for the needs and preferences of YPMI.

Linking Community-based Substance Use Disorder Treatment to Health Administrative Data: understanding vulnerable populations.

IntroductionMost substance use disorder (SUD) treatment occurs in community settings. Community-based SUD treatment information is rarely captured or utilized. The objective of this study was to examine the efficiency of a data linkage of community-based SUD treatment to health administrative data holdings in Ontario, Canada, and to describe sociodemographic and clinical characteristics of individuals accessing SUD services. MethodsData from community-based SUD service providers (&gt;180) from April 2015 to March 2022 were linked to administrative data holdings at ICES. Linkage rates were evaluated. Sociodemographic (age, sex, neighbourhood-level income) and clinical (substance use, physician visits, Emergency Department (ED) visits and hospitalizations) characteristics were evaluated. ResultsThe linkage rate of DATIS ICES data holdings was &gt;92% for all years (2015-2022). Of the 234,501 individuals admitted to a DATIS program, 36.1% were female, 46.2% were 25-44 years old, and 51.6% resided in the two lowest neighbourhood income quintiles. Alcohol (33.4%) was the most common substance identified. For outpatient care occurring within 1 year prior to admission, around 56.0% and 23.3% had Mental Health and Addictions (MHA) related primary care and psychiatrist visits, respectively. For acute health services, 29.8% and 14.2% had a MHA- related ED visit or hospitalization, respectively. DiscussionSUD treatment data from community settings can be successfully linked to other health administrative data. Individuals with SUD have a high rate of acute health care use, and a relatively low access to psychiatrists. SUD treatment data linkage should be used to understand how to optimize access to care for vulnerable individuals.

Cultural Adaptation of Skills Training in Affective and Interpersonal Regulation Therapy for Spanish-speaking Caribbean Veterans at the VA Caribbean Healthcare System: A preliminary study of feasibility and acceptability in a Primary Care setting

The U.S. Department of Veterans Affairs has endorsed the Skills Training in Affective and Interpersonal Regulation (STAIR) therapy as an effective intervention for reducing PTSD symptoms, enhancing self-regulation, and improving interpersonal efficacy. However, Spanish-speaking veterans at the VA Caribbean Healthcare System lacked access to STAIR manuals in their preferred language. This study addressed this gap by translating and culturally adapting the STAIR therapy participant manual using the Ecological Validity Model (EVM). The materials were then tested in a randomized intervention with six Caribbean Spanish-speaking male veterans, aged 23-62, diagnosed with PTSD who received mental health services at the Primary Care Mental Health Integration (PC-MHI) level of care. Nonparametric tests were used to evaluate symptom progression, and content analysis was conducted on semi-structured interviews. There were no statistically significant changes in PTSD, emotion regulation, or interpersonal problems within the groups. However, participants in the intervention group reported clinically significant changes regarding PTSD symptoms. Interviews with therapists and STAIR participants highlighted improvements in social engagement and interpersonal boundaries. The intervention was found to be feasible and acceptable at PC-MHI. The culturally adapted Spanish version of the STAIR manual proved to be effective, suggesting that STAIR may be a viable approach for reducing PTSD symptoms and improving interpersonal and self-regulation strategies among Spanish-speaking veterans in primary care settings. A randomized control trial is recommended to further explore its efficacy.

Collaborating to heal addiction and mental health in primary care (CHAMP): A protocol for a hybrid type 2a trial

BackgroundThe gold-standard treatment for opioid use disorder (OUD) is medication for OUD (MOUD). However, less than a quarter of people with OUD initiate MOUD. Expanding the Collaborative Care Model (CoCM) to include primary care patients with OUD could improve access to and initiation of MOUD. This paper presents the methods and baseline sample characteristics of a Hybrid Type 2a trial comparing the effectiveness of CoCM for OUD and co-occurring mental health symptoms (MHS) to CoCM for MHS only. Method42 primary care clinics were cluster randomized and 254 primary care patients with OUD and elevated MHS were enrolled. Recruitment was terminated early by the Data and Safety Monitoring Board for futility. Participants completed research assessments at baseline, 3 months, and 6 months. The multiple primary outcomes were past-month number of days of nonmedical opioid use and SF12 Mental Health Component Summary (MCS) scores. ResultsMCS scores were over a standard deviation below the national mean (M = 34.5). Nearly half (47.6 %) of participants had previously overdosed in their lifetimes. Three quarters (76.0 %) were already being prescribed MOUD at baseline, only 30.4 % reported non-medical use of opioids, and only 33.9 % reported being bothered by opioid cravings. ConclusionThe unexpectedly high proportion of enrollees already prescribed MOUD at baseline indicates that most patients were in the maintenance rather than acute phase of treatment. Challenges identifying and enrolling patients in the acute phase of OUD treatment implies that intervention effectiveness will depend on its success preventing the discontinuation of MOUD rather than initiating MOUD.

The Association Between COVID-fear with Psychological Distress and Substance Use: the Moderating Effect of Treatment Engagement.

The purpose of this brief report was to examine the association between COVID-fear with psychiatric symptoms severity and substance use risk in an outpatient population with co-occurring substance use and mental health disorders and whether these associations were moderated by treatment engagement, especially after providers had shifted from an in-person care model to a telehealth format. A total of 136 patients receiving outpatient treatment for comorbid substance use and mental health disorders completed self-report questionnaires on their psychiatric symptoms, substance use, and treatment engagement (i.e., frequency, length, and helpfulness of phone and video sessions with a mental health counselor, psychiatrist, or primary care provider) in the past month between November 2020 and March 2021. Results showed that COVID-fear was significantly associated with psychiatric symptom severity, but not substance use risk. Additionally, perceived helpfulness of phone counseling sessions moderated the associations between COVID-fear and global psychiatric symptom severity, such that COVID-fear and global psychiatric symptom severity were positively associated when perceived helpfulness was low, and not associated if perceived helpfulness was high. The present results highlight the importance of directly addressing fears specific to a national emergency, as well as for providers to build strong rapport with their clients.

Neglect of older adults living with dementia in family caregiving: A dimensional concept analysis.

To present a concept analysis of neglect, specifically examining its occurrence and implications in the context of family caregiving for older adults living with dementia. A literature search was conducted in Medline, CINAHL, Scopus, and Embase databases in February 2023. Inclusion criteria targeted articles focusing on neglect in dementia family caregiving, leading to the identification of 11 articles for thorough review. Employing Caron and Bowers' dimensional analysis approach, the concept analysis aimed to elucidate neglect as a social construct shaped by diverse contexts, perspectives, and underlying assumptions. Neglect in this context emerged as a multidimensional phenomenon, influenced by contextual elements such as activities of daily living and behavioral symptoms of dementia. It encompasses dimensions including "expectations of unmet needs", "maladaptive behaviors", and "feelings of guilt", considering the perspectives of both caregivers and individuals living with dementia. Recognizing neglect as a dyadic phenomenon emphasizes the significance of interactions between caregivers and individuals living with dementia. A comprehensive understanding of neglect in dementia family caregiving is crucial for effective interventions and support systems. The dyadic perspective is vital for accurate assessment. Primary care physicians, mental health, nurses, and other health professionals play a key role in prevention and supporting family caregivers. Further research is needed to explore the dynamics of dementia caregiving settings strengthening prevention strategies against elder neglect.

Health-related quality of life in psychiatric outpatients: a cross-sectional study of associations with symptoms, diagnoses, and employment status.

This cross-sectional study aimed to explore health-related quality of life (HRQoL) in a large heterogeneous patient sample seeking outpatient treatment at a specialist mental health clinic. A sample of 1947 patients with common mental disorders, including depressive-, anxiety-, personality-, hyperkinetic- and trauma-related disorders, completed the EuroQoL 5-Dimension 5-Level (EQ-5D-5L) to assess HRQoL. We investigated clinical and sociodemographic factors associated with the EQ-5D index and the EQ Visual Analogue Scale (VAS) using regression analyses. The sample reported lower HRQoL compared with the general population and primary mental health care patients. Sick leave, disability pension, work assessment allowance, and more symptoms of anxiety and depression were associated with lower EQ-5D index and EQ VAS scores. Furthermore, being male, use of pain medication and having disorders related to trauma were associated with reduced EQ-5D index scores, while hyperkinetic disorders were associated with higher EQ-5D index scores. HRQoL of psychiatric outpatients is clearly impaired. This study indicated a significant association between employment status, symptom severity, and HRQoL in treatment-seeking outpatients. The findings highlight the importance of assessing HRQoL as part of routine clinical assessment.

Innovations in Preconception Care: Optimizing Health for All Individuals.

Optimizing the overall health of individuals prior to pregnancy can improve both pregnancy and lifelong health outcomes. Despite extremely high financial expenditure on birth in the United States, maternal and infant mortality rates continue to rise. Moreover, significant racial and ethnic disparities persist in perinatal health outcomes. Preconception care, or health care provided before or between pregnancies, has the capacity to meet these challenges. Preconception care can be integrated into every health care visit, including visits with primary care, reproductive health, and mental health care clinicians. Increasing awareness among clinicians of the benefits of preconception care and equipping them with innovative strategies to implement this care into practice, the number of people receiving optimal care could be increased. Recent innovations in preconception care include group care, health applications (apps), reminders in electronic health records, social marketing campaigns, social media movements, community-based partnerships, health care policy and access, and improving public and clinician education on preconception health topics. Ultimately, improving preconception health is best done in partnership between the consumer and clinician. Midwives, whose care is person-centered and partnership-focused, are well positioned to champion the innovation and implementation of equitable preconception care. The purpose of this State of the Science review, therefore, is to synthesize the literature on recent evidence-based innovations that may be used to improve preconception health and counseling.

Integrated primary and community mental health care for young adults with serious mental illness: A program evaluation.

Young adults with serious mental illness (SMI) have poor physical health and high Emergency Department (ED) and hospital utilization. Integrating primary care into community mental health care may be an important form of early intervention. Adjusted multivariable regressions assessed changes in self-reported annual primary care, ED and hospital utilization for 83 young adults with SMI enrolled in integrated care. Participants' mean annual per person utilization changed significantly as follows: primary care visits, from 1.8 to 3.6, p < .001; medical ED visits, from 1.0 to 0.6, p < .01; psychiatric ED visits from 0.6 to 0.2, p < .001; medical inpatient days, from 1.2 to 0.1, p < .001 and psychiatric inpatient days, from 6.3 to 2.6, p < .001. Young adults with SMI receiving integrated care increased primary care and reduced ED and inpatient utilization. Future controlled research is warranted to further assess integrated care for young adults with SMI.

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

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