PurposeRural areas persistently face a shortage of mental health specialists. Task shifting, or task sharing, is an approach in global mental health that may help address unmet mental health needs in ...rural and other low‐resource areas. This review focuses on task‐shifting approaches and highlights future directions for research in this area.MethodsSystematic review on task sharing of mental health care in rural areas of high‐income countries included: (1) PubMed, (2) gray literature for innovations not yet published in peer‐reviewed journals, and (3) outreach to experts for additional articles. We included English language articles published before August 31, 2013, on interventions sharing mental health care tasks across a team in rural settings. We excluded literature: (1) from low‐ and middle‐income countries, (2) involving direct transfer of care to another provider, and (3) describing clinical guidelines and shared decision‐making tools.FindingsThe review identified approaches to task sharing focused mainly on community health workers and primary care providers. Technology was identified as a way to leverage mental health specialists to support care across settings both within primary care and out in the community. The review also highlighted how provider education, supervision, and partnerships with local communities can support task sharing. Challenges, such as confidentiality, are often not addressed in the literature.ConclusionsApproaches to task sharing may improve reach and effectiveness of mental health care in rural and other low‐resource settings, though important questions remain. We recommend promising research directions to address these questions.
A Tipping Point for Measurement-Based Care Fortney, John C; Unützer, Jürgen; Wrenn, Glenda ...
Psychiatric services (Washington, D.C.),
02/2017, Volume:
68, Issue:
2
Journal Article
Peer reviewed
Open access
Objective:Measurement-based care involves the systematic administration of symptom rating scales and use of the results to drive clinical decision making at the level of the individual patient. This ...literature review examined the theoretical and empirical support for measurement-based care.Methods:Articles were identified through search strategies in PubMed and Google Scholar. Additional citations in the references of retrieved articles were identified, and experts assembled for a focus group conducted by the Kennedy Forum were consulted.Results:Fifty-one relevant articles were reviewed. There are numerous brief structured symptom rating scales that have strong psychometric properties. Virtually all randomized controlled trials with frequent and timely feedback of patient-reported symptoms to the provider during the medication management and psychotherapy encounters significantly improved outcomes. Ineffective approaches included one-time screening, assessing symptoms infrequently, and feeding back outcomes to providers outside the context of the clinical encounter. In addition to the empirical evidence about efficacy, there is mounting evidence from large-scale pragmatic trials and clinical demonstration projects that measurement-based care is feasible to implement on a large scale and is highly acceptable to patients and providers.Conclusions:In addition to the primary gains of measurement-based care for individual patients, there are also potential secondary and tertiary gains to be made when individual patient data are aggregated. Specifically, aggregated symptom rating scale data can be used for professional development at the provider level and for quality improvement at the clinic level and to inform payers about the value of mental health services delivered at the health care system level.
Post-traumatic Stress Disorder by Gender and Veteran Status Lehavot, Keren; Katon, Jodie G.; Chen, Jessica A. ...
American journal of preventive medicine,
January 2018, 2018-Jan, 2018-01-00, 20180101, Volume:
54, Issue:
1
Journal Article
Peer reviewed
Open access
Population-based data on the prevalence, correlates, and treatment utilization of post-traumatic stress disorder by gender and veteran status are limited. With changes in post-traumatic stress ...disorder diagnostic criteria in 2013, current information from a uniform data source is needed.
This was a secondary analysis of the 2012–2013 National Epidemiologic Survey on Alcohol and Related Conditions-III, which consisted of in-person interviews that were conducted with a representative sample of U.S. adults. The Alcohol Use Disorder and Associated Disabilities Interview Schedule-DSM-5 Version was used to assess past-year and lifetime post-traumatic stress disorder among veterans (n=3,119) and civilians (n=32,982). Data were analyzed from January to March 2017.
Adjusting for age and race/ethnicity, women veterans reported the highest rates of lifetime and past-year post-traumatic stress disorder (13.4%, 95% CI=8.8%, 17.9%, and 11.7%, 95% CI=7.1%, 16.4%) compared with women civilians (8.0%, 95% CI=7.4%, 8.6%, and 6.0%, 95% CI=5.5%, 6.6%); men veterans (7.7%, 95% CI=6.5%, 8.8%, and 6.7%, 95% CI=5.7%, 7.8%); and men civilians (3.4%, 95% CI=3.0%, 3.9%, and 2.6%, 95% CI=2.2%, 2.9%). Traumatic event exposure, correlates of lifetime post-traumatic stress disorder, and treatment seeking varied across subgroups. Men and women veterans were more likely than civilians to use a variety of treatment sources, with men civilians being least likely to seek treatment and men veterans exhibiting the longest delay in seeking treatment.
Post-traumatic stress disorder is a common mental health disorder that varies by gender and veteran status. Women veterans’ high rates of post-traumatic stress disorder highlight a critical target for prevention and intervention, whereas understanding treatment barriers for men veterans and civilians is necessary.
Using telemedicine technologies, off-site mental health specialists collaborating with on-site primary care physicians yielded better depression outcomes than practice-based care with staff available ...on-site. In this study of mostly rural, unemployed, and uninsured patients with treatment-resistant depression and numerous comorbidities, those patients assigned to a telemedicine-based group had significantly and substantially greater treatment response rates, remission rates, reductions in depression severity, and increases in mental health status and quality of life than patients assigned to the practice-based care group.
ObjectivePractice-based collaborative care is a complex evidence-based practice that is difficult to implement in smaller primary care practices that lack on-site mental health staff. Telemedicine-based collaborative care virtually co-locates and integrates mental health providers into primary care settings. The objective of this multisite randomized pragmatic comparative effectiveness trial was to compare the outcomes of patients assigned to practice-based and telemedicine-based collaborative care.MethodFrom 2007 to 2009, patients at federally qualified health centers serving medically underserved populations were screened for depression, and 364 patients who screened positive were enrolled and followed for 18 months. Those assigned to practice-based collaborative care received evidence-based care from an on-site primary care provider and a nurse care manager. Those assigned to telemedicine-based collaborative care received evidence-based care from an on-site primary care provider and an off-site team: a nurse care manager and a pharmacist by telephone, and a psychologist and a psychiatrist via videoconferencing. The primary clinical outcome measures were treatment response, remission, and change in depression severity.ResultsSignificant group main effects were observed for both response (odds ratio=7.74, 95% CI=3.94–15.20) and remission (odds ratio=12.69, 95% CI=4.81–33.46), and a significant overall group-by-time interaction effect was observed for depression severity on the Hopkins Symptom Checklist, with greater reductions in severity over time for patients in the telemedicine-based group. Improvements in outcomes appeared to be attributable to higher fidelity to the collaborative care evidence base in the telemedicine-based group.ConclusionsContracting with an off-site telemedicine-based collaborative care team can yield better outcomes than implementing practice-based collaborative care with locally available staff.
Abstract Objective Millions of disadvantaged youth and returning veterans are enrolled in community colleges. Our objective was to determine the prevalence of mental disorders and help-seeking ...behaviors among community college students. Methods Veterans ( n = 211) and non-veterans ( n = 554) were recruited from 11 community colleges and administered screeners for depression (PHQ-9), generalized anxiety (GAD-7), posttraumatic stress disorder (PC-PTSD), non-lethal self-injury, suicide ideation and suicide intent. The survey also asked about the perceived need for, barriers to and utilization of services. Regression analysis was used to compare prevalence between non-veterans and veterans adjusting for non-modifiable factors (age, gender and race/ethnicity). Results A large proportion of student veterans and non-veterans screened positive and unadjusted bivariate comparisons indicated that student veterans had a significantly higher prevalence of positive depression screens (33.1% versus 19.5%, P < .01), positive PTSD screens (25.7% versus 12.6%, P < .01) and suicide ideation (19.2% versus 10.6%, P = .01). Adjusting for age, gender and race/ethnicity, veterans were significantly more likely than non-veterans to screen positive for depression (OR=2.10, P = .01) and suicide ideation (OR=2.31, P = .03). Student veterans had significantly higher odds of perceiving a need for treatment than non-veterans (OR=1.93, P = .02) but were more likely to perceive stigma (beta=0.28, P = .02). Despite greater need among veterans, there were no significant differences between veterans and non-veterans in use of psychotropic medications, although veterans were more likely to receive psychotherapy (OR=2.35, P = .046). Conclusions Findings highlight the substantial gap between the prevalence of probable mental health disorders and treatment seeking among community college students. Interventions are needed to link community college students to services, especially for student veterans.
IMPORTANCE: Posttraumatic stress disorder (PTSD) is prevalent, persistent, and disabling. Although psychotherapy and pharmacotherapy have proven efficacious in randomized clinical trials, geographic ...barriers impede rural veterans from engaging in these evidence-based treatments. OBJECTIVE: To test a telemedicine-based collaborative care model designed to improve engagement in evidence-based treatment of PTSD. DESIGN, SETTING, AND PARTICIPANTS: The Telemedicine Outreach for PTSD (TOP) study used a pragmatic randomized effectiveness trial design with intention-to-treat analyses. Outpatients were recruited from 11 Department of Veterans Affairs (VA) community-based outpatient clinics serving predominantly rural veterans. Inclusion required meeting diagnostic criteria for current PTSD according to the Clinician-Administered PTSD Scale. Exclusion criteria included receiving PTSD treatment at a VA medical center or a current diagnosis of schizophrenia, bipolar disorder, or substance dependence. Two hundred sixty-five veterans were enrolled from November 23, 2009, through September 28, 2011, randomized to usual care (UC) or the TOP intervention, and followed up for 12 months. INTERVENTIONS: Off-site PTSD care teams located at VA medical centers supported on-site community-based outpatient clinic providers. Off-site PTSD care teams included telephone nurse care managers, telephone pharmacists, telepsychologists, and telepsychiatrists. Nurses conducted care management activities. Pharmacists reviewed medication histories. Psychologists delivered cognitive processing therapy via interactive video. Psychiatrists supervised the team and conducted interactive video psychiatric consultations. MAIN OUTCOMES AND MEASURES: The primary outcome was PTSD severity as measured by the Posttraumatic Diagnostic Scale. Process-of-care outcomes included medication prescribing and regimen adherence and initiation of and adherence to cognitive processing therapy. RESULTS: During the 12-month follow-up period, 73 of the 133 patients randomized to TOP (54.9%) received cognitive processing therapy compared with 16 of 132 randomized to UC (12.1%) (odds ratio, 18.08 95% CI, 7.96-41.06; P < .001). Patients in the TOP arm had significantly larger decreases in Posttraumatic Diagnostic Scale scores (from 35.0 to 29.1) compared with those in the UC arm (from 33.5 to 32.1) at 6 (β = −3.81; P = .002) and 12 (β = −2.49; P = .04) months. Patients in the TOP arm also had significantly larger decreases in Posttraumatic Diagnostic Scale scores (from 35.0 to 30.1) compared with those in the UC arm (from 33.5 to 29.1) at 12 months (β = −2.49; P=.04). There were no significant group differences in the number of PTSD medications prescribed and adherence to medication regimens were not significant. Attendance at 8 or more sessions of cognitive processing therapy significantly predicted improvement in Posttraumatic Diagnostic Scale scores (β = −3.86 95% CI, −7.19 to −0.54; P = .02) and fully mediated the intervention effect at 12 months. CONCLUSIONS AND RELEVANCE: Telemedicine-based collaborative care can successfully engage rural veterans in evidence-based psychotherapy to improve PTSD outcomes. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT00821678
ABSTRACT
BACKGROUND
Implementing new programs and practices is challenging, even when they are mandated. Implementation Facilitation (IF) strategies that focus on partnering with sites show promise ...for addressing these challenges.
OBJECTIVE
Our aim was to evaluate the effectiveness of an external/internal IF strategy within the context of a Department of Veterans Affairs (VA) mandate of Primary Care–Mental Health Integration (PC-MHI).
DESIGN
This was a quasi-experimental, Hybrid Type III study. Generalized estimating equations assessed differences across sites.
PARTICIPANTS
Patients and providers at seven VA primary care clinics receiving the IF intervention and national support and seven matched comparison clinics receiving national support only participated in the study.
INTERVENTION
We used a highly partnered IF strategy incorporating evidence-based implementation interventions.
MAIN MEASURES
We evaluated the IF strategy using VA administrative data and RE-AIM framework measures for two 6-month periods.
KEY RESULTS
Evaluation of RE-AIM measures from the first 6-month period indicated that PC patients at IF clinics had nine times the odds (OR=8.93,
p
<0.001) of also being seen in PC-MHI (Reach) compared to patients at non-IF clinics. PC providers at IF clinics had seven times the odds (OR=7.12, p=0.029) of referring patients to PC-MHI (Adoption) than providers at non-IF clinics, and a greater proportion of providers’ patients at IF clinics were referred to PC-MHI (Adoption) compared to non-IF clinics (β=0.027,
p
<0.001). Compared to PC patients at non-IF sites, patients at IF clinics did not have lower odds (OR=1.34,
p
=0.232) of being referred for first-time mental health specialty clinic visits (Effectiveness), or higher odds (OR=1.90,
p
=0.350) of receiving same-day access (Implementation). Assessment of program sustainability (
Maintenance
) was conducted by repeating this analysis for a second 6-month time period. Maintenance analyses results were similar to the earlier period.
CONCLUSION
The addition of a highly partnered IF strategy to national level support resulted in greater Reach and Adoption of the mandated PC-MHI initiative, thereby increasing patient access to VA mental health care.
Over 80% of adults in the general population experience trauma. Rates of patients with posttraumatic stress disorder (PTSD) are high in primary care settings and are likely to be even higher in ...federally qualified health centers (FQHCs). Trauma exposure has been linked to psychiatric symptoms and physical health comorbidities, though little research has focused on FQHC patients. This study addresses this by examining clinical and sociodemographic correlates of specific trauma types among FQHC patients. We analyzed secondary data from patients who screened positive for PTSD and were receiving health care in FQHCs in a clinical trial (N = 978). Individuals who did versus did not experience a specific trauma type were compared using between-group tests. In the sample, 91.3% of participants were exposed to a DSM-5 Criterion A traumatic event, with 79.6% experiencing two or more trauma types. Witnessing a life-threatening event (57.3%) and physical assault (55.7%) were the most common traumatic experiences. Physical health comorbidities and worse physical health functioning were associated with a higher likelihood of exposure to all trauma types, with effect sizes larger than PTSD, ds = 0.78-1.35. Depressive and anxiety symptoms were also associated with a higher likelihood of experiencing nearly all trauma types to a lesser magnitude. People of color, OR = 2.45, and individuals experiencing financial inequities, OR = 1.73, had higher odds of experiencing serious accidents as well as other trauma types. The findings highlight the need for trauma-informed care, including routine trauma and PTSD screening, for FQHC patients.
Many e-health technologies are available to promote virtual patient–provider communication outside the context of face-to-face clinical encounters. Current digital communication modalities include ...cell phones, smartphones, interactive voice response, text messages, e-mails, clinic-based interactive video, home-based web-cams, mobile smartphone two-way cameras, personal monitoring devices, kiosks, dashboards, personal health records, web-based portals, social networking sites, secure chat rooms, and on-line forums. Improvements in digital access could drastically diminish the geographical, temporal, and cultural access problems faced by many patients. Conversely, a growing digital divide could create greater access disparities for some populations. As the paradigm of healthcare delivery evolves towards greater reliance on non-encounter-based digital communications between patients and their care teams, it is critical that our theoretical conceptualization of access undergoes a concurrent paradigm shift to make it more relevant for the digital age. The traditional conceptualizations and indicators of access are not well adapted to measure access to health services that are delivered digitally outside the context of face-to-face encounters with providers. This paper provides an overview of digital “encounterless” utilization, discusses the weaknesses of traditional conceptual frameworks of access, presents a new access framework, provides recommendations for how to measure access in the new framework, and discusses future directions for research on access.
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