Collaborative care model versus usual care for the management of musculoskeletal and co-existing mental health conditions: a randomised feasibility mixed-methods study.

OBJECTIVE: This study aimed to assess the feasibility of a future trial comparing the collaborative care model with usual care for patients with musculoskeletal conditions and co-existing symptoms of anxiety and depression. DESIGN: A single-centre, parallel-arm, one-to-one, randomised controlled trial design using a mixed-methods approach was used. semistructured interviews and focus groups were conducted post intervention with all participants and staff respectively to explore acceptability towards the model and identify recommendations for improvements. SETTING: An orthopaedic rehabilitation outpatient tertiary hospital. PARTICIPANTS: Adult patients with musculoskeletal conditions and co-existing moderate or severe symptoms of anxiety and depression attending outpatient therapy appointments. INTERVENTION: The collaborative care model consisted of a tailored management programme to facilitate the integration of care provided by physical and mental healthcare professionals. A case manager screened and coordinated targeted mental health support for participants. Participants allocated to usual care had no support from the case manager. MAIN OUTCOMES MEASURE: Feasibility indicators (rates of recruitment, randomisation and retention), acceptability of clinical outcome measures, usage of additional resources and cost of intervention implementation. RESULTS: Of the 89 patients who provided consent to take part, 40 participants who matched the eligibility criteria were randomised to either the intervention (n=20) or usual care arm (n=20). Overall adherence to the intervention was 58.82%, while the withdrawal rate was 37.5% at 6 months. All of the 27 participants who were retained completed self-reported outcomes. Qualitative data highlighted that integrated mental health support was favourably perceived. In addition to prenegotiating protected psychology time, the need for operationalised communication between the case manager and clinicians was identified as a recommendation for a future trial. CONCLUSIONS: The trial and intervention were acceptable to patients and healthcare professionals. While the findings demonstrate the feasibility of trial recruitment, a future trial will require optimised retention strategies to improve adherence and withdrawal rates. TRIAL REGISTRATION NUMBER: NCT05018039.

Collaborative care model versus usual care for people with musculoskeletal conditions and co-existing anxiety and depression: protocol for a feasibility mixed-methods randomised controlled trial.

BACKGROUND: In the UK 17.8 million people have musculoskeletal pathophysiology, which becomes universal with age. Levels of discomfort and incapability correlate with symptoms of anxiety and depression. People with sufficient symptoms who seek care can benefit from collaborative diagnosis and treatment of mental and physical health organised by a case manager. This paper presents the protocol for a feasibility trial of collaborative care in an orthopaedic setting. AIMS: To determine the feasibility and acceptability of providing collaborative care for patients with musculoskeletal conditions and co-existing symptoms of anxiety and depression identified on a screening tool in a physical and occupational therapy out-patient setting. METHOD: A two-arm parallel-group randomised controlled trial will recruit 40 adult out-patients with at least moderate anxiety and depression, who have been referred for physiotherapy and occupational therapy. Participants will be allocated on a 1:1 ratio to collaborative care or to usual care. Co-primary outcomes will be key feasibility indicators collected at baseline and at 6 months. A qualitative study will be conducted post-intervention to explore the acceptability and potential improvements to the collaborative care model. RESULTS: This study will investigate the use of the collaborative care model for patients with musculoskeletal and co-existing moderate or severe levels of anxiety or depression. CONCLUSIONS: The results will provide important evidence to determine a future trial.

Vaccine-preventable hospitalisations in adult mental health service users: a population study.

BACKGROUND: Vaccine-preventable conditions cause preventable illness and may increase mortality in people living with mental illness. We examined how risks of hospitalisation for a wide range of vaccine-preventable conditions varied by age and sex among mental health (MH) service users. METHODS: Linked population data from New South Wales (NSW), Australia were used to identify vaccine-preventable hospitalisations (VPH) for 19 conditions from 2015 to 2020. Adult MH service users (n = 418 915) were compared to other NSW residents using incidence rates standardised for age, sex and socioeconomic status. Secondary analyses examined admissions for COVID-19 to September 2021. RESULTS: We identified 94 180 VPH of which 41% were influenza, 33% hepatitis B and 10% herpes zoster. MH service users had more VPH admissions [adjusted incidence rate ratio (aIRR) 3.2, 95% CI 3.1-3.3]. Relative risks were highest for hepatitis (aIRR 4.4, 95% CI 4.3-4.6), but elevated for all conditions including COVID-19 (aIRR 2.0, 95% CI 1.9-2.2). MH service users had a mean age of 9 years younger than other NSW residents at first VPH admission, with the largest age gap for vaccine-preventable pneumonias (11-13 years younger). The highest relative risk of VPH was among MH service users aged 45-65. CONCLUSIONS: MH service users have increased risk of hospitalisation for many vaccine-preventable conditions. This may be due to reduced vaccination rates, more severe illness requiring hospitalisation, greater exposure to infectious conditions or other factors. People living with mental illness should be prioritised in vaccination strategies.

Cohort profile: Mental Health Living Longer: a population-wide data linkage to understand and reduce premature mortality in mental health service users in New South Wales, Australia.

PURPOSE: Health systems must move from recognition to action if we are to address premature mortality in people with mental illness. Population data registers are an essential tool for planning and monitoring improvement efforts. The Mental Health Living Longer (MHLL) programme establishes a population-wide data linkage to support research translation and service reform in New South Wales (NSW), Australia. PARTICIPANTS: A total of 8.6 million people who have had contact with NSW public and private health services between July 2001 and June 2018 are currently included in the study. Data include more than 120 million linked records from NSW data collections covering public and private hospital care, emergency departments, ambulance, community mental health services, cancer notifications and care, and death registrations. Linkage is occurring with population-wide breast and cervical cancer screening programmes. Data will be updated 6 monthly. FINDINGS TO DATE: The cohort includes 970 145 people who have received mental healthcare: 79% have received community mental healthcare, 35% a general hospital admission with a primary mental health diagnosis and 25% have received specialist mental health inpatient care. The most frequent pattern of care is receipt of community mental healthcare only (50%). The median age of the mental health cohort is 34 years, and three-quarters are younger than 53 years. Eleven per cent of the mental health cohort had died during the observation period. Their median age at death was 69 years, which was younger than the median age at death for people accessing other health services. FUTURE PLANS: The MHLL programme will examine (i) all-cause mortality, (ii) suicide, (iii) cancer mortality and (iv) medical mortality. Within each theme, the programme will quantify the problem in mental health service users compared with the NSW population, describe the people most affected, describe the care received, identify predictors of premature mortality, and identify variation and opportunities for change.

Depression in primary care: part 1-screening and diagnosis.

Depression is a common and heterogeneous condition with a chronic and recurrent natural course that is frequently seen in the primary care setting. Primary care providers play a central role in managing depression and concurrent physical comorbidities, and they face challenges in diagnosing and treating the condition. In this two part series, we review the evidence available to help to guide primary care providers and practices to recognize and manage depression. In this first of two reviews, we outline an approach to screening and diagnosing depression in primary care that evaluates current evidence based guidelines and applies the recommendations to clinical practice. The second review presents an evidence based approach to the treatment of depression in primary care, detailing the recommended lifestyle, drug, and psychological interventions at the individual level. It also highlights strategies that are being adopted at an organizational level to manage depression more effectively in primary care.

Depression in primary care: part 2-management.

Depression is a common and heterogeneous condition with a chronic and recurrent natural course that is frequently seen in the primary care setting. Primary care providers play a central role in managing depression and concurrent physical comorbidities, and they face challenges in diagnosing and treating the condition. In this two part series, we review the evidence available to help to guide primary care providers and practices to recognize and manage depression. The first review outlined an approach to screening and diagnosing depression in primary care. This second review presents an evidence based approach to the treatment of depression in primary care, detailing the recommended lifestyle, drug, and psychological interventions at the individual level. It also highlights strategies that are being adopted at an organizational level to manage depression more effectively in primary care.

Collaborative care: enough of the why; what about the how?

The clinical and cost-effectiveness of collaborative care for improving outcomes in people with mental and physical comorbidities is well established. However, translating these models into enduring change in routine care has proved difficult. In this editorial we outline how to shift the conversation on collaborative care from 'what are we supposed to do?' to 'how we can do this'.Declaration of interestP.P.R. has received honoraria from Publicis LifeBrands and the Institute for Healthcare Improvement outside of the submitted work. H.A.P. reports personal fees from the BIND Health Plan outside of the submitted work; and is a Member of the Council on Quality of Care of the American Psychiatric Association.

Bearing the cost of the American dream: reflecting on street homelessness in America.

This paper is a British psychiatrist's personal reflection of the treatment of homeless people in American societies. Drawing upon theories of social distance, exclusion, discrimination and internalised stigma, this reflective piece suggests that homelessness is one price that certain societies pay to invest in the notion of individualised success and self-sufficiency. In reflecting on his own dissonance, the author argues that these societal processes exert a powerful influence on us as individuals, even if we as psychiatrists might think that our understanding confers on us a certain level of understanding.

Evolving Models of Integrated Behavioral Health and Primary Care.

PURPOSE OF REVIEW: Mental and physical disorders commonly co-occur leading to higher morbidity and mortality in people with mental and substance use disorders (collectively called behavioral health disorders). Models to integrate primary and behavioral health care for this population have not yet been implemented widely across health systems, leading to efforts to adapt models for specific subpopulations and mechanisms to facilitate more widespread adoption. RECENT FINDINGS: Using examples from the UK and USA, we describe recent advances to integrate behavioral and primary care for new target populations including people with serious mental illness, people at the extremes of life, and for people with substance use disorders. We summarize mechanisms to incentivize integration efforts and to stimulate new integration between health and social services in primary care. We then present an outline of recent enablers for integration, concentrating on changes to funding mechanisms, developments in quality outcome measurements to promote collaborative working, and pragmatic guidance aimed at primary care providers wishing to enhance provision of behavioral care. Integrating care between primary care and behavioral health services is a complex process. Established models of integrated care are now being tailored to target specific patient populations and policy initiatives developed to encourage adoption in particular settings. Wholly novel approaches to integrate care are significantly less common. Future efforts to integrate care should allow for flexibility and innovation around implementation, payment models that support delivery of high value care, and the development of outcome measures that incentivize collaborative working practices.

Measuring Efficiency at the Interface of Behavioral and Physical Health Care.

BACKGROUND: Measures of efficiency in healthcare delivery, particularly between different parts of the healthcare system could potentially improve health resource utilization. We use a typology adapted from the Agency for Healthcare Research and Quality to characterize current measures described in the literature by stakeholder perspective (payer, provider, patient, policy-maker), type of output (reduced utilization or improved outcomes) and input (physical, financial or both). AIMS OF THE STUDY: To systematically describe measures of healthcare efficiency at the interface of behavioral and physical healthcare and identify gaps in the literature base that could form the basis for further measure development. METHODS: We searched the Medline database for studies published in English in the last ten years with the terms 'efficiency', 'inefficiency', 'productivity', 'cost' or 'QALY' and 'mental' or 'behavioral' in the title or abstract. Studies on healthcare resource utilization, costs of care, or broader healthcare benefits to society, related to the provision of behavioral health care in physical health care settings or to people with physical health conditions or vice versa were included. RESULTS: 85 of 6,454 studies met inclusion criteria. These 85 studies described 126 measures of efficiency. 100 of these measured efficiency according to the perspective of the purchaser or provider, whilst 13 each considered efficiency from the perspective of society or the consumer. Most measures counted physical resources (such as numbers of therapy sessions) rather than the costs of these resources as inputs. Three times as many measures (95) considered service outputs as did quality outcomes (31). DISCUSSION: Measuring efficiency at the interface of behavioral and physical care is particularly difficult due to the number of relevant stakeholders involved, ambiguity over the definition of efficiency and the complexity of providing care for people with multimorbidity. Current measures at this interface concentrate on a limited range of outcomes. LIMITATIONS: We only searched one database and did not review the gray literature, nor solicit a call for relevant but unpublished work. We did not assess the methodological quality of the studies identified. IMPLICATION FOR HEALTH CARE PROVISION AND USE: Most measures of healthcare efficiency are currently viewed from the perspective of payers and providers, with very few studies addressing the benefits of healthcare to society or the individual interest of the consumer. One way this imbalance could be addressed is through much stronger involvement of consumers in measurement-development, for example, by an expansion in patient-reported outcome measures in assessing quality of care. IMPLICATIONS FOR HEALTH POLICIES: Integrating behavioral and physical care is a major area of implementation as health systems in high income countries move from volume to value based care delivery. Measuring efficiency at this interface has the potential to incentivize and also evaluate integration efforts. IMPLICATIONS FOR FURTHER RESEARCH: There has been only one previous systematic review of efficiency measurement and none at the interface of behavioral and physical care. We identify gaps in the evidence base for efficiency measurement which could inform further research and measurement development.

Integrating Behavioral Health and Primary Care Services for People with Serious Mental Illness: A Qualitative Systems Analysis of Integration in New York.

People with co-occurring behavioral and physical conditions receive poorer care through traditional health care services. One solution has been to integrate behavioral and physical care services. This study assesses efforts to integrate behavioral health and primary care services in New York. Semi-structured interviews were conducted with 52 professionals in either group or individual settings. We aimed to identify factors which facilitate or hinder integration for people with serious mental illness and how these factors inter-relate. Content analysis identified structural, process, organizational ("internal") and contextual ("external") themes that were relevant to integration of care. Network analysis delineated the interactions between these. We show that effective integration does not advance along a single continuum from minimally to fully integrated care but along several, parallel pathways reliant upon consequential factors that aid or hinder one another.

Measuring and improving the quality of mental health care: a global perspective.

Mental disorders are common worldwide, yet the quality of care for these disorders has not increased to the same extent as that for physical conditions. In this paper, we present a framework for promoting quality measurement as a tool for improving quality of mental health care. We identify key barriers to this effort, including lack of standardized information technology-based data sources, limited scientific evidence for mental health quality measures, lack of provider training and support, and cultural barriers to integrating mental health care within general health environments. We describe several innovations that are underway worldwide which can mitigate these barriers. Based on these experiences, we offer several recommendations for improving quality of mental health care. Health care payers and providers will need a portfolio of validated measures of patient-centered outcomes across a spectrum of conditions. Common data elements will have to be developed and embedded within existing electronic health records and other information technology tools. Mental health outcomes will need to be assessed more routinely, and measurement-based care should become part of the overall culture of the mental health care system. Health care systems will need a valid way to stratify quality measures, in order to address potential gaps among subpopulations and identify groups in most need of quality improvement. Much more attention should be devoted to workforce training in and capacity for quality improvement. The field of mental health quality improvement is a team sport, requiring coordination across different providers, involvement of consumer advocates, and leveraging of resources and incentives from health care payers and systems.

Bringing Recovery and Consumers' Views Into the Mainstream of Mental Health Quality Measurement.

Health policies in the United States and elsewhere are moving to increase accountability of health care systems and providers for providing high-quality, efficient care and driving application of evidence-based improvement strategies. To support these efforts, a "quality measurement industrial complex" has been created to develop, endorse, and apply quality measures that incentivize these behaviors. Parallel to this development in mental health care is an emerging commitment to include recovery orientation approaches in treating serious mental illness. However, consumers have been only tangentially involved in quality assessment and improvement strategies of the mental health services that they are receiving. This Open Forum aims to advance the conversation about how to integrate recovery into mental health care quality assessment cohesively and how to involve consumers in this process in a more meaningful way.

Prioritizing quality measure concepts at the interface of behavioral and physical healthcare.

OBJECTIVE: Integrated healthcare models can increase access to care, improve healthcare quality, and reduce cost for individuals with behavioral and general medical healthcare needs, yet there are few instruments for measuring the quality of integrated care. In this study, we identified and prioritized concepts that can represent the quality of integrated behavioral health and general medical care. DESIGN: We conducted a literature review to identify candidate measure concepts. Experts then participated in a modified Delphi process to prioritize the concepts for development into specific quality measures. SETTING: United States. PARTICIPANTS: Expert behavioral health and general medical clinicians, decision-makers (policy, regulatory and administrative professionals) and patient advocates. MAIN OUTCOME MEASURES: Panelists rated measure concepts on importance, validity and feasibility. RESULTS: The literature review identified 734 measures of behavioral or general medical care, which were then distilled into 43 measure concepts. Thirty-three measure concepts (including a segmentation strategy) reached a predetermined consensus threshold of importance, while 11 concepts did not. Two measure concepts were 'ready for further development' ('General medical screening and follow-up in behavioral health settings' and 'Mental health screening at general medical healthcare settings'). Among the 31 additional measure concepts that were rated as important, 7 were rated as valid (but not feasible), while the remaining 24 concepts were rated as neither valid nor feasible. CONCLUSIONS: This study identified quality measure concepts that capture important aspects of integrated care. Researchers can use the prioritization process described in this study to guide healthcare quality measures development work.

Carrots and Sticks on Opposite Sides of the Atlantic: Integration Incentives for People With Serious Mental Illness in England.

Integrating care pathways between primary and specialist mental health care is seen as integral to improving the health of people with mental illness. Multiple integration initiatives have been implemented, but few have tried to integrate care for people with serious mental illness. This column describes two such initiatives in the United States and in England. The two schemes are compared according to the population they target, payment mechanisms, accountability structures, service delivery, outcomes, and lessons learned.

Increased rates of sequelae post-encephalitis in individuals attending primary care practices in the United Kingdom: a population-based retrospective cohort study.

The true extent of sequelae in encephalitis survivors relative to rates within the general population is not known. This study aimed to quantify increased risks of epilepsy, depressive disorders, anxiety disorders, psychotic disorders, bipolar disorder, cognitive problems, dementia, headache, and alcohol abuse among encephalitis cases. 2460 exposed individuals diagnosed with incident encephalitis in the Clinical Practice Research Datalink and 47,914 unexposed individuals without a history of encephalitis were included. Multivariable Poisson regression was used to estimate adjusted rate ratios in individuals with encephalitis compared to the general population and to estimate whether the effect of these outcomes varied over time. Individuals with encephalitis had an increased risk of all investigated outcomes. The highest RR was seen for epilepsy (adjusted RR 31.9; 95 % confidence interval 25.38-40.08), whereas the lowest was seen for anxiety disorders (1.46, 1.27-1.68). The second highest RRs were for particular psychiatric illnesses, including bipolar disorder (6.34, 3.34-12.04) and psychotic disorders (3.48, 2.18-5.57). The RR was highest in the first year of follow-up for all outcomes except headache; this was particularly true for epilepsy (adjusted RR in first year of follow-up 139.6, 90.62-215.03). This study shows that sequelae are common in survivors of encephalitis. We confirm the presence of outcomes more commonly linked to encephalitis and describe those less commonly identified as being associated with encephalitis. The results of this study have important implications for the management of encephalitis patients and for the design of tertiary prevention strategies, as many of these sequelae are treatable.

A review of mental health recovery programs in selected industrialized countries.

The concept of recovery has gained increasing attention and many mental health systems have taken steps to move towards more recovery oriented practice and service structures. This article represents a description of current recovery-oriented programs in participating countries including recovery measurement tools. Although there is growing acceptance that recovery needs to be one of the key domains of quality in mental health care, the implementation and delivery of recovery oriented services and corresponding evaluation strategies as an integral part of mental health care have been lacking.

Quality Measures at the Interface of Behavioral Health and Primary Care.

The development of quality measures has gained increasing attention as health care reimbursements transition from fee-for-service to value-based payment models. As behavioral health care moves towards integration of services with primary care, specific measures and payment incentives will be needed to successfully expand access. This study uses a keyword search to identify 730 quality indicators that are relevant to behavioral health and general medical health. Measures identified have been coded and grouped into domains based on a taxonomy developed by the authors. The analysis reveals that quality measures focusing on general medical conditions exceed those focused on behavioral health diagnoses for evidence-based treatments, patient safety, and outcomes. Furthermore, measures predominantly concentrate on care during or following hospitalizations, which represents a minority of behavioral health care and does not characterize the outpatient settings that are the focus of many models of integrated care. The authors offer recommendations for future steps to identify the quality measures that can best evaluate the evolving behavioral health care system.

Acute mental health service use by patients with severe mental illness after discharge to primary care in South London.

BACKGROUND: To return the patients to primary care is arguably the desired service outcome for community mental health teams (CMHTs). AIMS: To assess acute mental health service use (hospitalisation or Home Treatment Team) by people with severe mental illness following discharge to primary care. METHOD: Retrospective cohort study comparing receipt and duration of acute care by 98 patients in the two years following discharge to primary care from CMHT, with a cohort of 92 patients transferred to another CMHT. RESULTS: The discharged group was significantly more stable on clinical measures. Fifty-seven (58.2%) patients were re-referred after median 39 weeks, with 35 (60.3%) in crisis. The difference in acute service use between discharged patients (27.9 days/patient) and transferred patients (31.7 days/patient) was not significant. Hospitalisation in the two years prior to discharge or transfer increased the odds of re-referral (OR 3.93, 95% CI 1.44-14.55), subsequent acute service use (OR 1.02, 95% CI 1.01-1.03) and duration of input (0.45 extra days/patient, 95% CI 0.22-0.68). CONCLUSIONS: The majority of the discharged patients were re-referred to mental health services. Although these were more stable, there was no difference from the transferred group on acute service use. Further support may be required in primary care to maintain stability.