Specialty Mental Health Care Research Articles

Patient and Clinician Perspectives on Two Telemedicine Approaches for Treating Patients with Mental Health Disorders in Underserved Areas.

Primary care practices in underserved and/or rural areas have limited access to mental health specialty resources for their patients. Telemedicine can help address this issue, but little is known about how patients and clinicians experience telemental health care. This pragmatic randomized effectiveness trial compared telepsychiatry collaborative care, where telepsychiatrists provided consultation to primary care teams, to a referral approach, where telepsychiatrists and telepsychologists assumed responsibility for treatment. Twelve Federally Qualified Health Centers in rural and/or underserved areas in 3 states participated. Patients and clinicians reported that both interventions alleviated barriers to accessing mental health care, provided quality treatment, and offered improvements over usual care. Telepsychiatry collaborative care was identified as better for patients with difficulty developing trust with new providers. This approach also required more primary care involvement than referral care, creating more opportunities for clinician learning related to mental health diagnosis and treatment. The referral approach was identified as better suited for patients with higher complexity or desiring specific psychotherapies. Both approaches addressed patient needs and provided access to specialty mental health care. Each approach better aligned with different patients' needs, suggesting that having both approaches available to practices is optimal for supporting patient-centered care.

Referring Providers’ Perception of a Tele-geropsychiatry Consult Model of Care

<h3>Introduction</h3> To bridge the gap between limited access to geriatric psychiatry expertise and the high psychiatric needs of rural Veterans, a tele-geropsychiatry consultation model of care was developed to serve a 5-state rural region. This consultation program, led by a geriatric psychiatrist, delivers tele-consultation services via video, phone, and e-consultation to Veterans and their health care teams across the Veterans Health Administration continuum of care (e.g., outpatient, in-home, Community Living Centers). This abstract aims to (1) ascertain referring providers' frequency of using the service and common referral reasons, (2) elicit barriers to following through with recommendations, and (3) examine perceptions of whether the service increased access to specialty care. An exploratory aim examined differences in reasons for referrals and barriers to following through with recommendations between providers with prescription privileges and those without. <h3>Methods</h3> Eighty referring providers were sent an electronic survey comprised of multiple-choice and text response questions. Open-ended questions asked respondents to indicate their discipline, the main reason(s) for requesting the consult(s), general feedback, and barriers to following through with recommendations. Descriptive statistics were used to summarize quantitative responses. Qualitative content analysis was employed to categorize the open-ended data and compare responses by provider group (i.e., prescriber versus non-prescribers). <h3>Results</h3> The response rate for the surveys was 58.75% (n = 47). Twenty-eight referring providers were prescribers (physicians, mid-level providers, pharmacists; 74%); 10 were non-prescribers (psychologists, social workers, a registered nurse; 26%); nine did not indicate their discipline. About 60% of respondents described their level of comfort in working with geriatric mental health-related presenting problems as "comfortable" (36%) or "very comfortable" (23%). Seventy-nine percent of referring providers placed 2 or more consults in the last fiscal year, 17% placed one. Most respondents strongly agreed that they followed through with the geriatric psychiatry consultant's recommendations (78%), and that the consult(s) increased access to geriatric psychiatry care that would not have otherwise been available (87%). Reasons for consultation were categorized into three groups: (1) assistance with diagnostic clarification (18%), (2) medication recommendations to treat behavioral and/or psychiatric disturbances (29%), and (3) geropsychiatry expertise (53%). Access to geropsychiatry expertise included requests related to managing dementia-related behaviors (25%), psychiatric symptoms such as anxiety, depression, and paranoia (31%), complexity due to several reasons including co-morbidities and social situations (22%), and non-specific requests for assistance (22%). General feedback highlighted the importance of timely response to consult, collaboration with local teams, individualized medication and behavioral plans, and establishing strong rapport with patients and families via tele-health. Twenty-eight percent of respondents (n = 13) reported barriers related to following through with recommendations. Of those, seven indicated that the main barrier was the need to put in orders as the consultant does not place orders due to covering multiple healthcare systems. Variations in qualitative response patterns by prescribers and non-prescribers will be presented. <h3>Conclusions</h3> Providers requesting this tele-geropsychiatry consultation service span a wide range of disciplines. More than half indicated some level of comfort in working with geriatric mental health-related presenting problems, yet the majority of respondents placed two or more consults in the past year, thus supporting the merit for specialty geriatric mental health care to address complex neuropsychiatric issues and behavioral disturbances. This consultation supplements the consistent coverage provided by the core healthcare team that includes non-prescribing and prescribing providers. The main barrier to following through with recommendations was related to placing orders as a non-prescribing provider; however, this is a main component of the program that allows for broader reach. The key finding that the telehealth service increases access to geropsychiatry expertise that would not otherwise be available highlights the feasibility, acceptability and potential for tele-health consultation to support teams in managing patients with complex needs. This model of tele-geropsychiatry consultation across multiple health care systems is a highly scalable solution that increases access to specialized expertise for providers caring for older Veterans residing in rural areas. <h3>This research was funded by</h3> Office of Rural Health Salt Lake City team (VRHRC-SLC).

Prescriptions of Psychotropic Medications by Providers Treating Children of Military Service Members.

There are approximately 1.5 million U.S. military-dependent children. However, little is known about mental health referrals for these youths. This study sought to examine the type of mental health treatment referrals made by primary care providers for child military-dependent beneficiaries receiving care in the direct (within Military Treatment Facilities) and private care (civilian-fee-for service facilities) sectors of the Military Health System. A between-subjects, cross-sectional study was performed on children aged 5-18 years old in fiscal years 2011-2015 and enrolled in TRICARE Prime. Study analyses examined specialty ("talk therapy") mental health care and psychotropic medication referrals from TRICARE Prime (the Defense Health Agency-managed health care program) providers for beneficiary children diagnosed with attention-, mood-, anxiety-, or behavior-related disorders in direct versus private sector care. Of 1,533,630 children enrolled in TRICARE Prime (50.03% female), 8.6% (n = 131,393) were diagnosed with a psychological disorder during FY 2011-2015. Most were attention-related (5.2%, n = 79,770), followed by mood (1.7%, n = 25,314), anxiety (1.1%, n = 16,155), and conduct-related diagnoses (0.7%, n = 10,154). Adjusting for age, sex, and sponsor rank, children within direct care diagnosed with attention-related disorders were 1.7 times more likely to receive a prescription for psychotropic medication than those in private sector care, odds ratio (OR) = 1.72, 95% confidence interval (CI): [1.66, 1.77]. Children diagnosed with mood-related disorders in direct care were 2.1 times more likely to receive a prescription for psychotropic medication than those in private sector care, OR = 2.08, 95% CI: [1.96, 2.21]. Across disorders, children who received private sector care were more likely to have a referral specialty mental health ("talk therapy") follow-up (ps < 0.0001). For attention- and mood-related disorders, but not anxiety- or conduct-related disorders, direct care providers were more likely than private sector care providers to prescribe psychotropic medications. Inconsistencies of provider referrals within and outside of the Military Health System should be elucidated to determine the impact on outcomes.

Providers must step up to meet mental health needs of new mothers

Wide socioeconomic and racial disparities remain in new mothers’ access to mental health care, and both specialty mental health and primary care providers can help remedy the problem, says a leading health scientist with the federal government.

Anticipating VA/non-VA care coordination demand for Veterans at high risk for hospitalization.

U.S. Veterans Affairs (VA) patients’ multi-system use can create challenges for VA clinicians who are responsible for coordinating Veterans’ use of non-VA care, including VA-purchased care (“Community Care”) and Medicare.To examine the relationship between drive distance and time—key eligibility criteria for Community Care—and VA reliance (proportion of care received in VA versus Medicare and Community Care) among Veterans at high risk for hospitalization. We used prepolicy data to anticipate the impact of the 2014 Choice Act and 2018 Maintaining Internal Systems and Strengthening Integrated Outside Networks Act (MISSION Act), which expanded access to Community Care.Cross-sectional analysis using fractional logistic regressions to examine the relationship between a Veteran's reliance on VA for outpatient primary, mental health, and other specialty care and their drive distance/time to a VA facility.Thirteen thousand seven hundred three Veterans over the age of 65 years enrolled in VA and fee-for-service Medicare in federal fiscal year 2014 who were in the top 10th percentile for hospitalization risk.Key explanatory variables were patients’ drive distance to VA > 40 miles (Choice Act criteria) and drive time to VA ≥ 30 minutes for primary and mental health care and ≥60 minutes for specialty care (MISSION Act criteria).Veterans at high risk for hospitalization with drive distance eligibility had increased odds of an outpatient specialty care visit taking place in VA when compared to Veterans who did not meet Choice Act eligibility criteria (odds ratio = 1.10, 95% confidence interval 1.05–1.15). However, drive time eligibility (MISSION Act criteria) was associated with significantly lower odds of an outpatient specialty care visit taking place in VA (odds ratio = 0.69, 95% confidence interval 0.67, 0.71). Neither drive distance nor drive time were associated with reliance for outpatient primary care or mental health care.VA patients who are at high risk for hospitalization may continue to rely on VA for outpatient primary care and mental health care despite access to outside services, but may increase use of outpatient specialty care in the community in the MISSION era, increasing demand for multi-system care coordination.

Anticipating mental health needs after chemotherapy in early-stage breast cancer using patient-reported symptom screening.

Many patients with breast cancer experience depression and anxiety for years after completing systemic chemotherapy, which negatively impact overall symptom burden, quality of life, and treatment outcomes. The objective of this study was to examine the utility of patient-reported outcome (PRO) measures to predict mental health needs in patients with breast cancer during post-chemotherapy follow-up care. In a sample of women with non-metastatic breast cancer, associations between patient-reported depression and anxiety at end of chemotherapy and post-chemotherapy mental health needs were evaluated using log-binomial regression adjusted for functional status, social activity limitations, and time from chemotherapy. In a sample of 149 women, 40% reported at least mild depressive symptoms and 52% reported at least mild anxiety at the end of chemotherapy. Over an average 3.2years post-chemotherapy (range: 0.7-5.6years), 23% received new psychiatric diagnoses, 21% engaged in mental health specialty care, and 62% were prescribed psychotropic medications. End of chemotherapy depression and anxiety were associated with future prescription of psychotropic medications (RR 1.52; 95% CI 1.14-2.03), as well as greater number of psychotropics. Associations were strongest with serotonin-norepinephrine reuptake inhibitors [(depression: RR 4.75; 95% CI 2.06-10.95); (anxiety: RR 3.68; 95% CI 1.62-8.36); (depression and anxiety: RR 2.98; 95% CI 1.65-5.36)]. Diagnosis of and treatment for depression and anxiety are common among women with breast cancer after completing chemotherapy. Prescriptions for psychotropic medications during the initial years after systemic chemotherapy can be anticipated by depression and anxiety screening at end of chemotherapy.

Does Primary Care Fill the Gap in Access to Specialty Mental Health Care? A Mixed Methods Study.

BackgroundBroad consensus supports the use of primary care to address unmet need for mental health treatment.ObjectiveTo better understand whether primary care filled the gap when individuals were unable to access specialty mental health care.Design2018 mixed methods study with a national US internet survey (completion rate 66%) and follow-up interviews.ParticipantsPrivately insured English-speaking adults ages 18–64 reporting serious psychological distress that used an outpatient mental health provider in the last year or attempted to use a mental health provider but did not ultimately use specialty services (N = 428). Follow-up interviews were conducted with 30 survey respondents.Main MeasuresWhether survey respondents obtained mental health care from their primary care provider (PCP), and if so, the rating of that care on a 1 to 10 scale, with ratings of 9 or 10 considered highly rated. Interviews explored patient-reported barriers and facilitators to engagement and satisfaction with care provided by PCPs.Key ResultsOf the 22% that reported they tried to but did not access specialty mental health care, 53% reported receiving mental health care from a PCP. Respondents receiving care only from their PCP were less likely to rate their PCP care highly (21% versus 48%; p = 0.01). Interviewees reported experiences with PCP-provided mental health care related to three major themes: PCP engagement, relationship with the PCP, and PCP role.ConclusionsPrimary care is partially filling the gap for mental health treatment when specialty care is not available. Patient experiences reinforce the need for screening and follow-up in primary care, clinician training, and referral to a trusted specialty consultant when needed.Supplementary InformationThe online version contains supplementary material available at 10.1007/s11606-021-07260-z.

Association Between Virtual Care Use and Same-Day Primary Care Access in VA Primary Care-Mental Health Integration.

Introduction:Same-day referrals from primary care to mental health increase subsequent mental health treatment engagement. VA Primary Care-Mental Health Integration (PC-MHI) clinics offer integrated mental health services embedded in primary care clinics, providing a key entry point to mental health care. Although telehealth use expanded rapidly after the onset of COVID-19, the impact of telehealth on same-day primary care access among new PC-MHI mental health patients is unknown. To address this knowledge gap, we examined associations between telehealth use and same-day primary care access in VA PC-MHI.Methods:We examined electronic health record data to identify same-day primary care appointments among PC-MHI patients who initiated care during 3/1/2018 to 10/29/2021. We used logistic regression analyses to evaluate the effect of telehealth on same-day primary care access. Time, demographic characteristics, mental health diagnoses (PTSD and depression), and substance use disorder diagnosis were evaluated as covariates.Results:New PC-MHI patients who were seen via telehealth were less likely to receive same-day primary care access than patients seen in person (OR: 0.54; 95% CI: 0.41-0.71; P < .001).Conclusions:Despite the potential advantages of using telehealth to increase access, VA patients with an initial PC-MHI visit via telehealth were less likely than patients seen in person to be referred from primary care. Telehealth may adversely affect primary care referrals to mental health services, an outcome that could ultimately reduce specialty mental health care continuity. There is an urgent need to identify strategies to facilitate PC-MHI care coordination in the telehealth context.

Collaborative Care Model Promotes Justice and Equity

Collaborative Care Model Promotes Justice and Equity

Health Service Utilization Among Children and Adolescents with Posttraumatic Stress Disorder: A Case-Control Study.

Trauma exposure is widely prevalent, with more than 60% of adolescents having experienced at least 1 traumatic event and a third of those at high risk to develop posttraumatic stress disorder (PTSD). Data are scarce and out of date on the services children and adolescents with PTSD receive, impeding efforts to improve care and outcomes. This study examines health service use for a large and diverse sample of children and adolescents with and without a diagnosis of PTSD. Using a matched case-control study, we gathered information from 4 large health care systems participating in the Mental Health Research Network. Data from each site's electronic medical records on diagnoses, health care encounters, and demographics were analyzed. Nine hundred fifty-five 4- to 18-year-olds with a diagnosis of PTSD were identified and matched on a 1:5 ratio to 4770 controls. We compared cases with controls on frequency of service use in outpatient primary care, medical specialty care, acute care, and mental health care. We also assessed psychotropic medication use. Children and adolescents diagnosed with PTSD used nearly all physical and mental health service categories at a higher rate than controls. However, one-third of children and adolescents did not receive even 1 outpatient mental health visit (36.86%) during the year-long sampling window. Our findings suggest that children and adolescents diagnosed with PTSD may have unmet mental health needs. They are high utilizers of health services overall, but lower utilizers of the sectors that may be most helpful in resolving their symptoms.

Psychopharmacoepidemiology of antidepressant medications among homeless and unstably housed service users in theVeterans Affairs healthcare system.

This study conducted a pharmacoepidemiologic examination of antidepressant prescription patterns in homeless and unstably housed (HUH) populations. Data were analyzed on over 2.6 million veterans from the U.S. Department of Veterans Affairs (VA), the largest provider of healthcare for HUH veterans and a system that does not require healthcare insurance. Multivariable analyses revealed that HUH veterans with depression and PTSD were less likely to receive an antidepressant Rx compared to their stably housed (SH) counterparts with these conditions (OR=0.77, 99% CI=0.74-0.79; and OR=0.87, 99% CI=0.84-0.90, respectively). Antidepressants were mostly prescribed in specialty mental health care settings, but HUH veterans were less likely to be prescribed antidepressants in primary care settings than SH veterans. Inthe total sample, the 40-49 age group, female sex, VA service-connected disability,outpatient mental health visits, and emergency department visits were positively associated with any antidepressant Rx. Nearly all psychiatric diagnoses weremoreassociated with prescription of selective serotonin reuptake inhibitors/serotonin and norepinephrine reuptake inhibitors (SSRIs/SNRIs) than tricyclic antidepressants. These findings highlight socioeconomic disparities in antidepressant Rx in a healthcare system that does not rely on insurance and suggest clinical challenges with antidepressant prescriptions in HUH populations.

Assessment of Perceptions of Mental Health vs Medical Health Plan Networks Among US Adults With Private Insurance

Ten years after the Mental Health Parity and Addiction Equity Act, patients continue to report insurance-related barriers to specialty mental health care. To assess privately insured patients' perceptions of the adequacy of their health plan's provider network (provider network includes physicians, clinicians, other health care professionals, and their institutions that constitute the network), whether practitioners frequently leave plans, and whether practitioner plan participation affected patients' plan choice. A nationally representative, population-based internet survey study of English-speaking US adults participating in KnowledgePanel, an online research panel, was conducted from August to September 2018. Data analysis was performed from November 12, 2020, to May 12, 2021. From a sample of 29 854 panelists aged 18 to 64 years, 19 602 initiated the screener (completion rate of 66%), and 728 met study criteria: adults with private insurance receiving both specialty mental health and medical care in the past year. Health plan's provider network. Self-report of plan inadequacy, whether a practitioner left the plan and the participant's responses (stopped treatment, switched practitioner, or continued treatment), and whether participation of a specific practitioner was considered when a health plan was chosen. Experiences with both mental health and medical provider networks were assessed. Analyses were weighted to match the sample to the US population. Weights provided by KnowledgePanel were also adjusted for panel recruitment, attrition, oversampling, and survey nonresponse. Of a total of 728 study participants, 204 (39%) were aged 18 to 34 years, 504 (61%) were women, 82 (17%) were Hispanic, and 551 (66%) were non-Hispanic White individuals. Serious psychological distress was reported by 262 participants (36%), and 214 participants (29%) also received mental health treatment from a primary care practitioner. Participants rated their mental health provider network as inadequate more frequently than their medical provider network (163 [21%] vs 70 [10%]; odds ratio [OR], 2.69; 95% CI, 1.64-4.40; P < .001). However, among the 193 participants also receiving mental health treatment from a primary care practitioner, there was no significant difference in the ratings of mental health and medical provider networks (44 [14%] vs 18 [9%]; OR, 1.55; 95% CI, 0.65-3.67; P = .32). Sixty participants (8%) reported that a mental health practitioner had left their plan's insurance network in the past 3 years. Of the 523 participants with a choice of plan, 98 (20%) considered whether a specific mental health practitioner was in network before choosing a plan. This study's findings suggest that more participants perceived their mental health networks to be inadequate compared with their medical networks. Increasing the availability of mental health treatment in primary care practices may aid plans in constructing adequate mental health provider networks and improve patient access to mental health care.

Increasing Depression Treatment for Safety‐Net Patients: A Five‐Year Evaluation of Integrated Mental Health Services in Primary Care across Los Angeles County

Research ObjectiveSocioeconomic disparities in mental health care use can be mitigated by interventions to systematically improve disease diagnosis and treatment. Beginning 2010, Los Angeles County Departments of Health Services (DHS) and Mental Health (DMH) collaborated to increase access to effective mental health treatment. Implemented in staggered fashion among select safety‐net clinics, the Mental Health Integration Program (MHIP) embedded behavioral health specialists to co‐manage primary care patients (e.g., psychiatric consultation support for medication prescription, brief problem‐focused psychotherapy). This study examined whether clinic MHIP implementation was associated with higher treatment initiation (medication receipt and/or specialist follow‐up [for psychotherapy]) in safety‐net clinic sites.Study DesignThis retrospectively cohort study examined 33,537 primary care patients who were newly diagnosed with depression from June 30, 2009 to July 1, 2014 (n = 39,066 person‐years), using merged medical and pharmacy records from DHS and DMH. Patients were seen in one of 19 clinics that were either: (1) before, (2) after, or (3) had never implemented MHIP. We followed patients for 90 days after a new diagnosis, defined as having no diagnoses in the prior year. Then, we determined whether patients received antidepressant medication (prescription filled per pharmacy records) and/or mental health specialist follow‐up (completed referral documented in medical records). In multilevel regression models, we used MHIP implementation status to predict odds of treatment initiation, controlling for time and patient demographic and clinical characteristics (e.g., comorbidity).Population Studied255,840 safety‐net patients seen in LA County.Principal FindingsIn 30.1% of episodes, primary care patients received any treatment within 90 days of a new depression diagnosis (38.7% [after] vs 36.2% [before] vs 25.0% [never implemented MHIP in clinic]). 27.9% received medication within 90 days, while only 3% reached specialists. In multivariate analyses (n = 30,347 person‐years), we found that there was 2.35‐times odds of treatment initiation among patients in clinics after MHIP implementation (odds ratio [OR] = 2.35; 95% confidence interval [CI] = 2.18–2.55; p &lt; 0.001), compared to patients in clinic before implementation. This program effect was driven by medication treatment (OR = 2.42; CI = 2.24–2.63; p &lt; 0.001), as opposed to specialist follow‐up (OR = 1.14; CI = 0.88–1.47; p = 0.32). Odds of treatment initiation were higher among minority (Asian &gt; Latino &gt; Black) than White patients, Spanish‐ than English‐speaking patients, and uninsured than insured patients in the study sample.ConclusionsCollaboration between two large, distinct health systems and its resulting integrated care programs were associated with greater odds of treatment initiation among patients newly diagnosed with depression, compared to patients in clinics before implementation or in clinics that did not implement. Findings suggest potential positive effects of targeted outreach (to minority and Spanish‐speaking patients) and possible leakage of insured patients to private sectors for depression treatment.Implications for Policy or PracticeThis evaluation is one of few to document effects from widescale implementation of integrated mental health care, in particular within the country's second largest public health system. Observed mental health integration programs may need further innovation to address current access gaps in mental health specialty care, such that evidence‐based psychotherapy options are also available to safety‐net primary care patients.Primary Funding SourceDepartment of Veterans Affairs.

Comparison of Teleintegrated Care and Telereferral Care for Treating Complex Psychiatric Disorders in Primary Care

Only one-third of patients with complex psychiatric disorders engage in specialty mental health care, and only one-tenth receive adequate treatment in primary care. Scalable approaches are critically needed to improve access to effective mental health treatments in underserved primary care settings. To compare 2 clinic-to-clinic interactive video approaches to delivering evidence-based mental health treatments to patients in primary care clinics. This pragmatic comparative effectiveness trial used a sequential, multiple-assignment, randomized trial (SMART) design with patient-level randomization. Adult patients treated at 24 primary care clinics without on-site psychiatrists or psychologists from 12 federally qualified health centers in 3 states who screened positive for posttraumatic stress disorder and/or bipolar disorder and who were not already receiving pharmacotherapy from a mental health specialist were recruited from November 16, 2016, to June 30, 2019, and observed for 12 months. Two approaches were compared: (1) telepsychiatry/telepsychology-enhanced referral (TER), where telepsychiatrists and telepsychologists assumed responsibility for treatment, and (2) telepsychiatry collaborative care (TCC), where telepsychiatrists provided consultation to the primary care team. TER included an adaptive intervention (phone-enhanced referral [PER]) for patients not engaging in treatment, which involved telephone outreach and motivational interviewing. Survey questions assessed patient-reported outcomes. The Veterans RAND 12-item Health Survey Mental Component Summary (MCS) score was the primary outcome (range, 0-100). Secondary outcomes included posttraumatic stress disorder symptoms, manic symptoms, depressive symptoms, anxiety symptoms, recovery, and adverse effects. Of 1004 included participants, 701 of 1000 (70.1%) were female, 660 of 994 (66.4%) were White, and the mean (SD) age was 39.4 (12.9) years. Baseline MCS scores were 2 SDs below the US mean; the mean (SD) MCS scores were 39.7 (14.1) and 41.2 (14.2) in the TCC and TER groups, respectively. There was no significant difference in 12-month MCS score between those receiving TCC and TER (β = 1.0; 95% CI, -0.8 to 2.8; P = .28). Patients in both groups experienced large and clinically meaningful improvements from baseline to 12 months (TCC: Cohen d = 0.81; 95% CI, 0.67 to 0.95; TER: Cohen d = 0.90; 95% CI, 0.76 to 1.04). For patients not engaging in TER at 6 months, there was no significant difference in 12-month MCS score between those receiving PER and TER (β = 2.0; 95% CI, -1.7 to 5.7; P = .29). In this comparative effectiveness trial of patients with complex psychiatric disorders randomized to receive TCC or TER, significantly and substantially improved outcomes were observed in both groups. From a health care system perspective, clinical leadership should implement whichever approach is most sustainable. ClinicalTrials.gov Identifier: NCT02738944.

Predicting clinically significant response to primary care treatment for depression from electronic health records of veterans

ObjectiveTo reduce delays in referral to specialty mental health care, we evaluated clinical prediction models estimating the likelihood of response to primary care treatment of depression in the VA healthcare system. MethodsWe included patients with a primary care depression diagnosis between October 1, 2015 and December 31, 2017, an initial PHQ-9 score ≥ 10 within 30 days, a follow-up PHQ-9 score within 2-8 months, and no specialty mental health care within three months prior to depression diagnosis. We evaluated eight ordinary least squares regression models, each with a different procedure for selecting predictors of percentage change in PHQ-9 score from baseline to follow-up. Predictors included patient characteristics from electronic health records and neighborhood characteristics from US census data. We repeated each modeling procedure 1,000 times, using different training and validation sets of patients. We used R2, RMSE, and MAE to evaluate model performance. ResultsThe final cohort included 3,464 patients. The two best performing models included multiple iterations of backwards stepwise variable selection with R2 of 0.07, RMSE of 41.45, MAE of 33.30; and R2 of 0.07, RMSE of 41.39, MAE of 33.28. LimitationsWide follow-up interval, possibility of misclassification error due to use of EHR data. ConclusionsModel performance did not suggest its use as a guide in clinical decision-making. Future research should explore whether obtaining additional risk factor data from patients (e.g., duration of symptoms) or modeling PHQ-9 scores over a narrower time interval improves performance of clinical risk prediction tools for depression.

Psychiatric comorbidity of eating disorders in children between the ages of 9 and 10.

Eating disorders exhibit high comorbidity with other psychiatric disorders, most notably mood, substance use, and anxiety disorders. However, most studies examining psychiatric comorbidity are conducted in adolescents and adults. Therefore, the comorbidity among children living with eating disorders is unknown. The aim of this study was to characterize co-occurring psychiatric disorders with eating disorders in a US sample of children aged 9-10 years old utilizing the Adolescent Brain Cognitive Development study. The analytic sample included 11,718 children aged 9-10 years. Anorexia nervosa, bulimia nervosa, binge eating disorder, and other specified feeding and eating disorder subtype diagnoses were examined. Statistical analyses were conducted using complex sampling. Odds ratios and 95% confidence intervals were calculated comparing the likelihood of being diagnosed for a psychiatric disorder when having an eating disorder, as compared to children without an eating disorder, children diagnosed with major depressive disorder, and children diagnosed with posttraumatic stress disorder using binary logistic regression. Co-occurring psychiatric disorders were substantially higher in children with eating disorders as compared to children without eating disorders, but not as compared to children diagnosed with major depressive disorder or posttraumatic stress disorder. The most common comorbidities for the eating disorder group were anxiety disorders (71.4%), attention deficit/hyperactivity disorder (47.9%), disruptive/impulse control disorders (45.0%), mood disorders (29.6%), and obsessive-compulsive disorder (28.8%), largely in line with previous research. This study extends prior research finding high rates of comorbidity in eating disorders, specifically with anxiety, mood, and disruptive/impulse control disorders. Clinicians assessing for psychiatric disorders should be aware that eating disorders can occur in children 9 and 10 years old and are associated with severe comorbidity. Referrals for specialty mental health care should be considered.

Predicting suicide attempts and suicide deaths among adolescents following outpatient visits

BackgroundFew studies report on machine learning models for suicide risk prediction in adolescents and their utility in identifying those in need of further evaluation. This study examined whether a model trained and validated using data from all age groups works as well for adolescents or whether it could be improved. MethodsWe used healthcare data for 1.4 million specialty mental health and primary care outpatient visits among 256,823 adolescents across 7 health systems. The prediction target was 90-day risk of suicide attempt following a visit. We used logistic regression with least absolute shrinkage and selection operator (LASSO) and generalized estimating equations (GEE) to predict risk. We compared performance of three models: an existing model, a recalibrated version of that model, and a newly-learned model. Models were compared using area under the receiver operating curve (AUC), sensitivity, specificity, positive predictive value and negative predictive value. ResultsThe AUC produced by the existing model for specialty mental health visits estimated in adolescents alone (0.796; [0.789, 0.802]) was not significantly different than the AUC of the recalibrated existing model (0.794; [0.787, 0.80]) or the newly-learned model (0.795; [0.789, 0.801]). Predicted risk following primary care visits was also similar: existing (0.855; [0.844, 0.866]), recalibrated (0.85 [0.839, 0.862]), newly-learned (0.842, [0.829, 0.854]). LimitationsThe models did not incorporate non-healthcare risk factors. The models relied on ICD9-CM codes for diagnoses and outcome measurement. ConclusionsPrediction models already in operational use by health systems can be reliably employed for identifying adolescents in need of further evaluation.

Patterns of Mental Health Care Before Initiation of Telemental Health Services.

Use of telemental health has increased among rural Medicare beneficiaries, particularly among individuals with serious mental illness (SMI). Little is known about what leads to the initiation of telemental health. To categorize the different patterns of mental health care use before initiation of telemental health services among individuals with SMI. A cohort of rural beneficiaries with SMI (defined as schizophrenia/related psychotic disorders or bipolar disorder) with an index telemental health visit in 2010-2017 was built using claims for a 20% random sample of fee-for-service Medicare beneficiaries. The authors used latent class analysis to identify classes of mental health care use in the 6 months before the index telemental health visits. Across the classes, the authors also described characteristics of index and subsequent mental health visits. The cohort included 4930 rural Medicare beneficiaries with SMI. Three classes of mental health care use before initiation of telemental health were identified. The largest class (n=3066) had minimal use of primary care provider mental health care and the second largest class (n=1537) had minimal specialty mental health care. The smallest class (n=327) was characterized by recent hospitalization or emergency department care. In the overall cohort, index visits were frequently established visits and were often with specialty prescribers. Our findings highlight 3 distinct patterns of care before telemental health initiation, providing insight into the role that telemedicine may play in mental health care for rural Medicare beneficiaries with SMI. Overall, telemental health was most often used to maintain care with existing providers.

Addressing Common Challenges in the Implementation of Collaborative Care for Mental Health: The Penn Integrated Care Program.

We developed and implemented a new model of collaborative care that includes a triage and referral management system. We present initial implementation metrics using the Reach, Effectiveness, Adoption, Implementation, Maintenance (RE-AIM) framework. Primary care clinicians in 8 practices referred patients with any unmet mental health needs to the Penn Integrated Care program. Assessments were conducted using validated measures. Patients were primarily triaged to collaborative care (26%) or specialty mental health care with active referral management (70%). We conducted 50 qualitative interviews to understand the implementation process and inform program refinement. Our primary outcomes were reach and implementation metrics, including referral and encounter rates derived from the electronic health record. In 12 months, 6,124 unique patients were referred. Assessed patients reported symptoms consistent with a range of conditions from mild to moderate depression and anxiety to serious mental illnesses including psychosis and acute suicidal ideation. Among patients enrolled in collaborative care, treatment entailed a mean of 7.2 (SD 5.1) encounters over 78.1 (SD 51.3) days. Remission of symptoms was achieved by 32.6% of patients with depression and 39.5% of patients with anxiety. Stakeholders viewed the program favorably and had concrete suggestions to ensure sustainability. The Penn Integrated Care program demonstrated broad reach. Implementation was consistent with collaborative care as delivered in seminal studies of the model. Our results provide insight into a model for launching and implementing collaborative care to meet the needs of a diverse group of patients with the full range of mental health conditions seen in primary care.

What Are Patient Preferences for Integrated Behavioral Health in Primary Care?

Background: Behavioral health services, integrated into primary care practices, have become increasingly implemented. Although patient satisfaction has been studied, limited information exists about patient preferences for integrated behavioral health in primary care and how perceptions may vary. Objective: To determine patient preferences for integrated behavioral health within primary care and explore differences across patient groups. Methods: A self-report survey was distributed within a quality improvement initiative in an academic health system. A brief 8-item self-report questionnaire of perceptions and preferences for integrated behavioral health was administered to 752 primary care patients presenting before their visits at two primary care clinics. Participation was voluntary, responses were anonymous, and all patients presenting during a three-week timeframe were eligible. Results: In general, patients preferred to have behavioral health concerns addressed within primary care (n = 301; 41%) rather than referral to a specialist (7.5%; n = 55). There was no evidence of variation in preferences by demographic characteristics. Comfort levels to receive behavioral health services (P < .001) and perceived needs being met were significantly associated with preferences for receiving IBHPC (P < .001). Conclusion: This project provided valuable data to support the implementation of integrated behavioral health services in primary care clinics. In general, patients prefer to have behavioral health issues addressed within their primary care experience rather than being referred to specialty mental health care. This study adds to an expanding pool of studies exploring patient preferences for integrated behavioral health in primary care.