Specialty Mental Health Settings Research Articles

The 10-item Adverse Childhood Experience International Questionnaire (ACE-IQ-10): psychometric properties of the Dutch version in two clinical samples

ABSTRACT Background: Childhood trauma has been associated with adult mental disorders, physical illness, and early death. The World Health Organization (WHO) supported the development of the Adverse Childhood Experiences International Questionnaire (ACE-IQ) to explore childhood trauma in adults. We report the psychometric properties of the Dutch version of the Adverse Childhood Experiences International Questionnaire 10 items version (ACE-IQ-10) in the Netherlands. Methods: Confirmatory factor analysis was performed in two convenience samples of consecutive patients presenting at an outpatient specialty mental health setting between May 2015 and September 2018: Sample A (N = 298), patients with anxiety and depressive disorders; and sample B (N = 234), patients with Somatic Symptom and Related Disorders (SSRD). Criterion validity of the scales of the ACE-IQ-10 was explored by their correlation with the PHQ-9, the GAD-7, and the SF-36. The correlation between reporting sexual abuse on the ACE-IQ-10 and in a face-to-face interview was assessed as well. Results: We found support for a two-factor structure in both samples: one for directly experiencing childhood abuse and another for household dysfunction, but also support for using the total score. The correlation between reporting a sexual trauma in childhood at face-to-face interview and the sexual abuse item of the ACE-IQ-10 was r = .98 (p < .001). Conclusions: The current study provides evidence on the factor structure, reliability, and validity of the Dutch ACE-IQ-10 in two Dutch clinical samples. It shows clear potential of the ACE-IQ-10 for further research and clinical use. Further studies are needed to assess the ACE-IQ-10 in the Dutch general population.

Care transitions from the specialty to the primary care setting: A scoping literature review of potential barriers and facilitators with implications for mental health care.

This scoping review aimed to understand potential barriers and facilitators in transitioning patients from specialty to primary care settings, to inform the implementation of an intervention to promote active consideration of psychiatrically stable patients for transition from the specialty mental health setting back to primary care. Guided by Levac and colleagues' six-stage methodological framework for conducting scoping studies, we systematically searched electronic article databases for peer-reviewed literature from January 2000 to May 2016. We included identified articles that discuss findings related to potential barriers and facilitators in transitioning patients from specialty to primary care settings. We performed descriptive and thematic analyses of results to generate emergent codes and their categorizations. Our database search yielded 906 unique articles, 23 of which we included in our scoping review. All but one of the included studies were conducted in North America. Identified potential barriers and facilitators spanned eight emergent themes-(i) primary care accessibility, especially in terms of timely availability of appointments, (ii) clarity in respective roles of specialty care and primary care in managing a patient, (iii) timely exchange of information, (iv) transition process management, (v) perceived ability of primary care providers to manage specialty conditions, (vi) perceived ability of patients to self-manage, (vii) leadership support and (viii) support for implementing initiatives to promote transitions. Findings from this scoping review enable an increased understanding of current practices and considerations regarding care transitions from specialty to primary care settings. The importance of role clarification, shared clinical information systems, confidence in care competency, and adequate organizational support to promote appropriate transitions were themes most widely reported across the reviewed studies. Few studies specifically examined the transition from specialty mental health to primary care. Future studies should account for mental health-specific symptomatic patterns and recovery trajectories, such as prevalent chronicity and frequency of relapse, in planning and conducting transitions from specialty mental health back to primary care.

Innovations in Care Delivery for Patients With Serious Mental Illness Among Accountable Care Organizations.

This study examined whether and how organizations participating in accountable care organization (ACO) contracts integrate primary care and treatment for patients with serious mental illness. This study used responses to the 2017–2018 National Survey of ACOs (55% response rate) to measure ACO-reported use of three integrated care strategies: care manager to address physical health treatment coordination or nonmedical needs (e.g., job support and housing), patient registries to track physical health conditions, and primary care clinician colocated in a specialty mental health setting. Logistic regression was used to determine associations between ACO characteristics and strategy use. Of 399 respondents who answered questions on integration, 303 (76%) reported using at least one integrated care strategy in at least one location. Use of care managers (defined by the respondent) was most common (N=281, 70%), followed by use of a patient registry (N=146, 37%) and colocation of a primary care clinician in a specialty mental health setting (N=118, 30%). Respondents reporting that their largest Medicaid contract or largest commercial contract included quality measures specific to serious mental illness (e.g., antipsychotic adherence) were more likely to use each integrated care delivery strategy. Self-reported use of three collaborative care strategies (care management, patient registry, or mental health consulting clinician) for treatment of depression or anxiety was associated with use of integrated primary care and treatment for serious mental illness. In a national survey of ACOs, few respondents reported using either patient registries or primary care colocation to integrate primary care and treatment for serious mental illness.

Influences of Aging on PTSD Prevalence, Neurobiology, and Clinical Course

Posttraumatic stress disorder (PTSD) affects 6.8% of adults in the United States and is associated with high rates of disability, comorbid medical and psychiatric disorders, and suicide. Recent studies report increasing prevalence rates of PTSD among older adults, and this pattern is anticipated to accelerate as the population skews older and Veterans from recent conflicts age. Most older adults suffer from chronic PTSD, which is associated with at least one disability in nearly 80% of cases. Compared to those without PTSD, individuals with chronic PTSD have exceedingly high rates of Major Depressive Disorder (MDD), triple the rates of drug abuse, and significant functional impairment. Prompt diagnosis and treatment of PTSD in later life is complicated by its differing phenomenology in older compared to younger adults and age-related changes in treatment seeking. Whereas overall symptom severity, intrusive thoughts, and avoidance behaviors are lower among older adults with PTSD, they more frequently report somatic problems (e.g., pain, insomnia, gastrointestinal upset) relative to emotional issues (e.g., specific aspects of the trauma). Older patients may not spontaneously report traumatic experiences or minimize their importance, use generic terms such as “stress”, and generally present to primary medical doctors rather than specialty mental health settings. In terms of treatment, few studies of exposure-based psychotherapies are randomized, older adults are rarely enrolled, and almost none evaluate the most evidence-based psychotherapy for PTSD, Prolonged Exposure therapy. Analyses of prescribing trends using Veterans Affairs (VA) databases suggest that only about half of veterans (all ages) with PTSD receive first-line pharmacotherapy agents such as selective serotonin reuptake inhibitors (SSRIs), with even lower medication prescription in older compared to younger adults.In this symposium the influence of age-related factors will be discussed on the prevalence, development of PTSD given a traumatic stimulus, clinical presentation in terms of symptom profiles, underlying neurobiology, treatment responsivity, and illness course. Speakers will engage the audience in a discussion of what makes PTSD different in older adults compared to younger adults and what are the implications of these differences on clinical evaluation and treatment. Dr. Joan Cook will present data comparing characteristics of younger vs. older sexual assault survivors in order to discuss clinical and research implications. Next, Dr. Vanessa Simiola will present electronic health record and utilization data and discuss age-based differences between diagnoses made in primary care versus specialty mental health, differences in mental health treatment receipt, as well as clinical characteristics of the samples. Then, Dr. Xi Zhu will delve into data suggesting higher rates of MDD in older adults with PTSD and present her analyses of network connectivity differences discriminating PTSD from comorbid PTSD/MDD. Finally, Dr. Bret Rutherford will present data from an ongoing NIMH study in which older adults with PTSD are compared to trauma-exposed healthy controls (TEHCs) on cognitive, physical functioning, and neuroimaging indices. Two-year follow up data will be reviewed to consider the differing cognitive and physical functioning trajectories experienced over time between PTSD and TEHC participants. Finally, an audience discussion synthesizing all three of the talks will be held, with ample opportunity for audience members to ask questions of each speaker.

Identifying Common and Unique Barriers and Facilitators to Implementing Evidence-Based Practices for Suicide Prevention across Primary Care and Specialty Mental Health Settings

Objective We identified common and unique barriers and facilitators of evidence-based suicide prevention practices across primary care practices with integrated behavioral health services and specialty mental health settings to identify generalizable strategies for enhancing future implementation efforts. Method Twenty-six clinicians and practice leaders from behavioral health (n = 2 programs) and primary care (n = 4 clinics) settings participated. Participation included a semi-structured qualitative interview on barriers and facilitators to implementing evidence-based suicide prevention practices. Within that interview, clinicians participated in a chart-stimulated recall exercise to gather additional information about decision making regarding suicide screening. Interview guides and qualitative coding were informed by leading frameworks in implementation science and behavioral science, and an integrated approach to interpreting qualitative results was used. Results There were a number of similar themes associated with implementation of suicide prevention practices across settings and clinician types, such as the benefits of inter-professional collaboration and uncertainties about managing suicidality once risk was disclosed. Clinicians also highlighted barriers unique to their settings. For primary care settings, time constraints and competing demands were consistently described as barriers. For specialty mental health settings, difficulties coordinating care with schools and other providers in the community made implementation of suicide prevention practices challenging. Conclusion Findings can inform the development and testing of implementation strategies that are generalizable across primary care and specialty mental health settings, as well as those tailored for unique site needs, to enhance use of evidence-based suicide prevention practices in settings where individuals at risk for suicide are especially likely to present. HIGHLIGHTS We examined barriers and facilitators to suicide prevention across health settings. Common and unique barriers and facilitators across health-care settings emerged. Findings can enhance suicide prevention implementation across health-care settings.

Are Veterans Getting Their Preferred Depression Treatment? A National Observational Study in the Veterans Health Administration

BackgroundPhysician responsiveness to patient preferences for depression treatment may improve treatment adherence and clinical outcomes.ObjectiveTo examine associations of patient treatment preferences with types of depression treatment received and treatment adherence among Veterans initiating depression treatment.DesignPatient self-report surveys at treatment initiation linked to medical records.SettingVeterans Health Administration (VA) clinics nationally, 2018–2020.ParticipantsA total of 2582 patients (76.7% male, mean age 48.7 years, 62.3% Non-Hispanic White)Main MeasuresPatient self-reported preferences for medication and psychotherapy on 0–10 self-anchoring visual analog scales (0=“completely unwilling”; 10=“completely willing”). Treatment receipt and adherence (refilling medications; attending 3+ psychotherapy sessions) over 3 months. Logistic regression models controlled for socio-demographics and geographic variables.Key ResultsMore patients reported strong preferences (10/10) for psychotherapy than medication (51.2% versus 36.7%, McNemar χ21=175.3, p<0.001). A total of 32.1% of patients who preferred (7–10/10) medication and 21.8% who preferred psychotherapy did not receive these treatments. Patients who strongly preferred medication were substantially more likely to receive medication than those who had strong negative preferences (odds ratios [OR]=17.5; 95% confidence interval [CI]=12.5–24.5). Compared with patients who had strong negative psychotherapy preferences, those with strong psychotherapy preferences were about twice as likely to receive psychotherapy (OR=1.9; 95% CI=1.0–3.5). Patients who strongly preferred psychotherapy were more likely to adhere to psychotherapy than those with strong negative preferences (OR=3.3; 95% CI=1.4–7.4). Treatment preferences were not associated with medication or combined treatment adherence. Patients in primary care settings had lower odds of receiving (but not adhering to) psychotherapy than patients in specialty mental health settings. Depression severity was not associated with treatment receipt or adherence.ConclusionsMismatches between treatment preferences and treatment type received were common and associated with worse treatment adherence for psychotherapy. Future research could examine ways to decrease mismatch between patient preferences and treatments received and potential effects on patient outcomes.

Treatment Differences in Primary and Specialty Settings in Veterans with Major Depression.

The Veterans Health Administration (VHA) supports the nation's largest primary care-mental health integration (PC-MHI) collaborative care model to increase treatment of mild to moderate common mental disorders in primary care (PC) and refer more severe-complex cases to specialty mental health (SMH) settings. It is unclear how this treatment assignment works in practice. Patients (n = 2610) who sought incident episode VHA treatment for depression completed a baseline self-report questionnaire about depression severity-complexity. Administrative data were used to determine settings and types of treatment during the next 30 days. Thirty-four percent (34.2%) of depressed patients received treatment in PC settings, 65.8% in SMH settings. PC patients had less severe and fewer comorbid depressive episodes. Patients with lowest severity and/or complexity were most likely to receive PC antidepressant medication treatment; those with highest severity and/or complexity were most likely to receive combined treatment in SMH settings. Assignment of patients across settings and types of treatment was stronger than found in previous civilian studies but less pronounced than expected (cross-validated AUC = 0.50-0.68). By expanding access to evidence-based treatments, VHA's PC-MHI increases consistency of treatment assignment. Reasons for assignment being less pronounced than expected and implications for treatment response will require continued study.

Aging and Engaging: A Pilot Randomized Controlled Trial of an Online Conversational Skills Coach for Older Adults

Communication difficulties negatively impact relationship quality and are associated with social isolation and loneliness in later life. There is a need for accessible communication interventions offered outside specialty mental health settings. Pilot randomized controlled trial. Assessments in the laboratory and intervention completed in-home. Twenty adults age 60 and older from the community and a geriatric psychiatry clinic. A web-based communication coach that provides automated feedback on eye contact, facial expressivity, speaking volume, and negative content (Aging and Engaging Program, AEP), delivered with minimal assistance in the home (eight brief sessions over 4-6 weeks) or control (education and videos on communication). System Usability Scale and Social Skills Performance Assessment, an observer-rated assessment of social communication elicited through standardized role-plays. Ninety percent of participants completed all AEP sessions and the System Usability Scale score of 68 was above the cut-off for acceptable usability. Participants randomized to AEP demonstrated statistically and clinically significant improvement in eye contact and facial expressivity. The AEP is acceptable and feasible for older adults with communication difficulties to complete at home and may improve eye contact and facial expressivity, warranting a larger RCT to confirm efficacy and explore potential applications to other populations, including individuals with autism and social anxiety.

Treatment for Adolescent Depression: National Patterns, Temporal Trends, and Factors Related to Service Use Across Settings

PurposeUntreated major depression can lead to various negative health and social consequences among adolescents. This study aimed to examine national patterns, temporal trends, and factors related to U.S. adolescents' mental health service use for 12-month major depression across service settings. MethodsData on adolescents aged 12–17 years who received treatment for their 12-month major depression were drawn from the National Survey on Drug Use and Health, 2011–2018. Patterns, trends, and factors related to adolescents' service use in specialty mental health, educational, and general medical settings and multiple settings were examined using bivariate and multivariate logistic regression. ResultsAcross the survey years, service use in specialty mental health settings was the most common, followed by educational and general medical settings. A significant increase was observed in adolescents' specialty mental health service use (p < .001) over time, whereas the rates of service use in educational and general medical settings remained stable. Approximately 40% of adolescents who were treated for 12-month depression received services in multiple settings each year, with no significant change over time. Among multisetting service users, combined service use in specialty mental health and educational settings was the most common. Adolescents' age, race, gender, insurance status, family income, and school experiences significantly influenced their service use across settings. ConclusionsContinued efforts are needed to improve service provision for adolescents with depression, especially in educational and general medical settings. Strengthened funding and policy support are warranted to expand safety-net mental health services for uninsured, low-income, and racial/ethnic minority adolescents.

Perceived barriers and facilitators to implementation of peer support in Veterans Health Administration Primary Care-Mental Health Integration settings.

Peer support is increasingly recognized as consistent with the goals of integrated primary care and is being implemented in primary care settings as a patient-centered approach that increases patient activation and access to care. Within the Veterans Health Administration (VHA), peer support specialists (PSSs) have traditionally worked in specialty mental health settings and only recently started working in Primary Care-Mental Health Integration (PC-MHI) settings. Prior research has identified implementation challenges, such as role confusion, when integrating peer support into new settings. In this qualitative descriptive study, we conducted semistructured interviews on perceived barriers and facilitators to implementing peer support in PC-MHI with 25 key stakeholders (7 PSSs, 6 PSS supervisors, 6 PC-MHI providers, and 6 primary care providers). We used conventional content analysis to code responses within four a priori implementation categories: barriers, initial facilitators, long-term facilitators, and leadership support. Perceived barriers included poor program functioning, inadequate administrative support, role confusion, and negative stakeholder attitudes. Key perceived facilitators of initializing and maintaining peer support were similar; administrative support was emphasized followed by program functioning and team cohesion. Stakeholder buy-in and access/visibility were perceived to facilitate initial implementation, whereas evidence of success was believed to facilitate maintenance. Stakeholder buy-in and administrative support were considered key elements of leadership support. Results were consistent with prior research from specialty mental health settings, but identified unique considerations for PC-MHI settings, particularly clarifying the PSS role based on local PC-MHI needs, obtaining buy-in, and facilitating integration of PSSs into the primary care team. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Screening Older Adults for Depression: Barriers Across Clinical Discipline Training.

Background and ObjectivesDepressed older adults are more likely to be seen in primary care than in specialty mental health settings, but research shows that physicians may not routinely screen for depression. Other clinical disciplines are also in a position to screen for depression, but have not been studied. This study examined barriers to screening older adults for depression, and disciplinary differences in clinical trainees’ likelihood of screening.Research Design and MethodsWe used a cross-sectional, online survey with experimental manipulation of vignettes. A four-way mixed analysis of variance explored the effects of clinical discipline (between subjects) and time pressure, patient difficulty, and level of symptoms (within subjects) on trainees’ likelihood of screening.ResultsParticipants were 229 trainees in medicine (83), psychology (51), nursing (49), and social work (46). Lower time pressure and greater symptom severity increased likelihood of screening. There was a significant three-way interaction among discipline, patient difficulty, and symptom level that was driven by social work graduate trainees’ greater likelihood of screening for depression when there were more symptoms present, which was diminished if the patient was being difficult. There was a two-way interaction between patient difficulty and level of symptoms: more symptoms resulted in increased likelihood of screening, an effect that diminished with greater patient difficulty.Discussion and ImplicationsThe study holds implications for identifying and addressing gaps in education on depression screening to minimize the effects of barriers. Interventions could address education about older adults and depression, including practice-based screening, time management, and behavior management skills.

Need for Cardiovascular Risk Reduction in Persons With Serious Mental Illness: Design of a Comprehensive Intervention.

Persons with serious mental illness (SMI) comprise a high-risk group for cardiovascular disease (CVD)-related mortality with rates at least twice those of the overall US. Potentially modifiable CVD risk behaviors (tobacco smoking, obesity, physical inactivity, unhealthy diet) and risk factors (hypertension, diabetes, dyslipidemia) are all markedly elevated in persons with SMI. Evaluations of programs implementing integrated medical care into specialty mental health settings have not shown meaningful effects on CVD risk factor reduction. Rigorously tested, innovative interventions are needed to address the large burden of CVD risk in populations with SMI. In this article, we describe the design of a comprehensive 18-month intervention to decrease CVD risk that we are studying in a randomized clinical trial in a community mental health organization with psychiatric rehabilitation programs. The individual-level intervention incorporated health behavior coaching and care coordination/care management to address all seven CVD risk behaviors and risk factors, and is delivered by a health coach and nurse. If successful, the intervention could be adopted within current integrated care models and significantly improve the physical health of persons with SMI.

Caseworker assessment of child risk and functioning and their relation to service use in the child welfare system

Children within the child welfare system are more likely to experience emotional and behavioral problems than children not involved with the system. Many states have adopted standardized risk and assessment measures to inform decision-making on appropriate levels of care related to placement or service intensity for children within the system. This study examined the relationship of caseworker ratings of risk across multiple domains to youth functioning and service use for a sample of children open to the child welfare system. The study identified a stratified random sample of youth who were between the ages of five and 21 and open to the child welfare system (n = 184). Stratification was based on current placement (i.e., in-home, foster home, congregate care, and juvenile justice placements). Administrative data was used to access caseworker ratings of risk across child, parent, and family domains using a standardized risk assessment tool. Children's caseworkers (n = 103) completed a standardized measure of child functioning and reported on youth utilization of services across multiple sectors including specialty mental health, school-based, juvenile justice, and medical settings. Regression analyses using variance-corrected estimation for clustered data (by caseworker) revealed higher levels of child risk were associated with poorer child functioning, which, in turn, were associated with higher rates of multi-sector service use. Recommendations and future directions are discussed.

To go or not go: Patient preference in seeking specialty mental health versus behavioral consultation within the primary care behavioral health consultation model.

Much of behavioral health care takes place within primary care settings rather than in specialty mental health settings. Access to specialty mental health care can be difficult due to limited access to mental health providers and wait times to receive mental health care. The purpose of this study is to determine patient satisfaction with behavioral health consultation visits that take place within the context of the primary care behavioral health consultation model. Patient likelihood to seek out specialty mental health care services if behavioral health consultation services were not provided was also examined. Two primary care clinic systems were examined in this study. The first was a primary care clinic predominately serving low-income patients: 100 individuals participated. The second was primary care in the context of military treatment centers: 539 individuals participated. Results show that 61% of the patients in the low-income primary care clinic would not attend a specialty mental health appointment versus 30% in the military population. This study suggests that primary care behavioral health is a patient-centered approach to care and reaches populations that otherwise may not receive behavioral health services. (PsycINFO Database Record (c) 2018 APA, all rights reserved).

A European Research Agenda for Somatic Symptom Disorders, Bodily Distress Disorders, and Functional Disorders: Results of an Estimate-Talk-Estimate Delphi Expert Study.

Background: Somatic Symptom Disorders (SSD), Bodily Distress Disorders (BDD) and functional disorders (FD) are associated with high medical and societal costs and pose a substantial challenge to the population and health policy of Europe. To meet this challenge, a specific research agenda is needed as one of the cornerstones of sustainable mental health research and health policy for SSD, BDD, and FD in Europe.Aim: To identify the main challenges and research priorities concerning SSD, BDD, and FD from a European perspective.Methods: Delphi study conducted from July 2016 until October 2017 in 3 rounds with 3 workshop meetings and 3 online surveys, involving 75 experts and 21 European countries. EURONET-SOMA and the European Association of Psychosomatic Medicine (EAPM) hosted the meetings.Results: Eight research priorities were identified: (1) Assessment of diagnostic profiles relevant to course and treatment outcome. (2) Development and evaluation of new, effective interventions. (3) Validation studies on questionnaires or semi-structured interviews that assess chronic medical conditions in this context. (4) Research into patients preferences for diagnosis and treatment. (5) Development of new methodologic designs to identify and explore mediators and moderators of clinical course and treatment outcomes (6). Translational research exploring how psychological and somatic symptoms develop from somatic conditions and biological and behavioral pathogenic factors. (7) Development of new, effective interventions to personalize treatment. (8) Implementation studies of treatment interventions in different settings, such as primary care, occupational care, general hospital and specialty mental health settings. The general public and policymakers will benefit from the development of new, effective, personalized interventions for SSD, BDD, and FD, that will be enhanced by translational research, as well as from the outcomes of research into patient involvement, GP-patient communication, consultation-liaison models and implementation.Conclusion: Funding for this research agenda, targeting these challenges in coordinated research networks such as EURONET-SOMA and EAPM, and systematically allocating resources by policymakers to this critical area in mental and physical well-being is urgently needed to improve efficacy and impact for diagnosis and treatment of SSD, BDD, and FD across Europe.

One Size Doesn’t Fit All: Applying Flexibility to the Primary Care Behavioral Health Model with Transient Populations – A Brief Report

Each year, approximately 3.5 million individuals in the United States experience homelessness (“Hunger and Homelessness,” n.d.). Patients experiencing homelessness have negative health outcomes in part due to decreased access to health care (Fitzpatrick et al., 2011). Additionally, the rate of behavioral health disorders (i.e., mental health and substance use disorders) in patients experiencing homelessness is about 66% (“HCH,” 2006; “National Coalition,” 2014). Follow-up rates for behavioral health services embedded within primary care are higher for transient patient populations when compared to specialty mental health services offered off-site: 16% no-show rate in primary care compared to a 35% no-show rate in specialty mental health settings (Reynolds, Chesney, &amp; Capobianco, 2006). This suggests the need for improved primary care behavioral health integration efforts with this population (Miller et al., 2014; Reynolds et al., 2006). Behavioral health providers have varying roles on the primary care team (Collins et al., 2010; “HCH,” 2006; Heath et al., 2013; Miller-Matero et al., 2014; Robinson &amp; Strosahl, 2009) but the Primary Care Behavioral Health (PCBH) consultation role has not been described with this special population as well as quality improvement efforts with practice change.

Utilization of the Behavior Change Wheel framework to develop a model to improve cardiometabolic screening for people with severe mental illness

BackgroundIndividuals with severe mental illness (e.g., schizophrenia, bipolar disorder) die 10–25 years earlier than the general population, primarily from premature cardiovascular disease (CVD). Contributing factors are complex, but include systemic-related factors of poorly integrated primary care and mental health services. Although evidence-based models exist for integrating mental health care into primary care settings, the evidence base for integrating medical care into specialty mental health settings is limited. Such models are referred to as “reverse” integration. In this paper, we describe the application of an implementation science framework in designing a model to improve CVD outcomes for individuals with severe mental illness (SMI) who receive services in a community mental health setting.MethodsUsing principles from the theory of planned behavior, focus groups were conducted to understand stakeholder perspectives of barriers to CVD risk factor screening and treatment identify potential target behaviors. We then applied results to the overarching Behavior Change Wheel framework, a systematic and theory-driven approach that incorporates the COM-B model (capability, opportunity, motivation, and behavior), to build an intervention to improve CVD risk factor screening and treatment for people with SMI.ResultsFollowing a stepped approach from the Behavior Change Wheel framework, a model to deliver primary preventive care for people that use community mental health settings as their de facto health home was developed. The CRANIUM (cardiometabolic risk assessment and treatment through a novel integration model for underserved populations with mental illness) model focuses on engaging community psychiatrists to expand their scope of practice to become responsible for CVD risk, with significant clinical decision support.ConclusionThe CRANIUM model was designed by integrating behavioral change theory and implementation theory. CRANIUM is feasible to implement, is highly acceptable to, and targets provider behavior change, and is replicable and efficient for helping to integrate primary preventive care services in community mental health settings. CRANIUM can be scaled up to increase CVD preventive care delivery and ultimately improve health outcomes among people with SMI served within a public mental health care system.

Trauma of Las Vegas Shooting Likely to Show Up Weeks, Months Later

Trauma of Las Vegas Shooting Likely to Show Up Weeks, Months Later

Cognitive behavioral therapy for somatic symptom disorders in later life: a prospective comparative explorative pilot study in two clinical populations.

BackgroundElderly patients with somatic symptom disorder (SSD) put a great burden on the health care delivery system. Cognitive behavioral therapy (CBT) is effective in adults with SSD. However, no studies have been conducted yet into CBT for SSD in later life.ObjectivesWe explored the feasibility of CBT for SSD in the elderly.MethodsThis is a prospective pilot study comparing two outpatient specialty mental health settings for adults (<60 years; n=13) and for elderly patients (≥60 years; n=9) with SSD. Intervention was 18 structured, protocoled, and supervised CBT sessions. Outcomes were somatic symptoms, pain intensity, pain disability, quality of life, depressive symptoms, and generalized anxiety symptoms. Feasibility of the CBT intervention was explored with self-developed questions, both for the therapists and the patients.ResultsBoth therapists and elderly patients evaluated the treatment as positive. Somatic symptoms improved significantly in the adult group but not in the elderly group. There was a large, significant decrease in pain intensity and pain disability in elderly patients compared to the adults. Social functioning, vitality, and anxiety symptoms improved significantly in the adults. Presence of chronic medical conditions did not influence these results.ConclusionThis study shows that CBT is feasible as a treatment for SSD in older adults and has encouraging results. Replication in an RCT is warranted.

Predictors of Antidepressant Nonadherence Among Older Veterans With Depression.

Most depression among older adults is treated in primary care, and many patients do not adhere to medication treatment. The U.S. Department of Veterans Affairs (VA) has recently introduced initiatives to address such treatment gaps. This study examined patient-reported antidepressant nonadherence during the acute treatment period (first four months after a prescription) and identified predictors of nonadherence in a sample of older veterans. This was a prospective, observational study of 311 participants ages 60 and older who received care at three VA medical centers and who had a diagnosis of clinically significant depression and were given a new outpatient antidepressant prescription. Participants completed an initial interview and a follow-up interview at four months after treatment recommendation. Antidepressant adherence was measured with a well-validated self-report measure. At four months, 29% of participants reported nonadherence to their antidepressant medication. In unadjusted analyses, nonadherence was significantly associated with being African American, having no spouse or significant other, having greater general medical comorbidity, and receiving the prescription in a primary care setting (versus a specialty mental health setting). In logistic regression models controlling for several variables (demographic, illness, and functional status variables; type of antidepressant; contact with a therapist; medical setting; and site of recruitment), two predictors remained significantly associated with nonadherence: African-American race (odds ratio [OR]=4.23, p<.001) and general medical comorbidity (OR=1.33, p=.002). The two main predictors of nonadherence among older adults with depression were African-American race and general medical comorbidity. Results suggest that significant needs remain for important patient subgroups to improve antidepressant adherence.