Screening and Follow-Up Monitoring for Substance Use in Primary Care: An Exploration of Rural-Urban Variations.

BACKGROUND: Rates of substance use in rural areas are close to those of urban areas. While recent efforts have emphasized integrated care as a promising model for addressing workforce shortages in providing behavioral health services to those living in medically underserved regions, little is known on how substance use problems are addressed in rural primary care settings. OBJECTIVE: To examine rural-urban variations in screening and monitoring primary care- based patients for substance use problems in a state-wide mental health integration program. DESIGN: This was an observational study using patient registry. SUBJECTS: The study included adult enrollees (n = 15,843) with a mental disorder from 133 participating community health clinics. MAIN OUTCOMES: We measured whether a standardized substance use instrument was used to screen patients at treatment entry and to monitor symptoms at follow-up visits. KEY RESULTS: While on average 73.6 % of patients were screened for substance use, follow-up on substance use problems after initial screening was low (41.4 %); clinics in small/isolated rural settings appeared to be the lowest (13.6 %). Patients who were treated for a mental disorder or substance abuse in the past and who showed greater psychiatric complexities were more likely to receive a screening, whereas patients of small, isolated rural clinics and those traveling longer distances to the care facility were least likely to receive follow-up monitoring for their substance use problems. CONCLUSIONS: Despite the prevalent substance misuse among patients with mental disorders, opportunities to screen this high-risk population for substance use and provide a timely follow-up for those identified as at risk remained overlooked in both rural and urban areas. Rural residents continue to bear a disproportionate burden of substance use problems, with rural-urban disparities found to be most salient in providing the continuum of services for patients with substance use problems in primary care.

Prevalence of symptoms of depression and anxiety in adults with cystic fibrosis based on the PHQ-9 and GAD-7 screening questionnaires.

OBJECTIVE: To examine the prevalence of symptoms of depression and anxiety among patients with cystic fibrosis (CF) who were followed up at the University of Washington Adult CF clinic and to identify sociodemographic and clinical factors associated with symptoms. METHODS: A total of 178 adults with CF were asked to complete the Patient Health Questionnaire-9 for depression and General Anxiety Disorder-7 for anxiety when clinically stable. Clinically significant symptoms of depression and anxiety were defined in the following 2 ways: (1) symptom definition-presence of moderate-to-severe symptoms based on the questionnaires and (2) composite definition-symptom definition or the use of psychiatric medications to manage symptoms. Associations between Patient Health Questionnaire-9 and General Anxiety Disorder-7 scores with sociodemographic (gender, age, age of CF diagnosis, vocation, and spousal status) and clinical factors (forced expiratory volume in 1 second, body mass index, and CF-related diabetes on insulin) were examined. RESULTS: Of 178 patients, 153 (85%) completed the screening questionnaires. Based on the symptom definition, 7% of patients had symptoms of depression and 5% had symptoms of anxiety. Using the composite definition, 22% of patients had symptoms of depression and 10% had symptoms of anxiety. Based on the Patient Health Questionnaire-9, 5% of patients reported suicidal thoughts. In multiple linear regression analysis, only forced expiratory volume in 1 second % predicted was independently associated with Patient Health Questionnaire-9 depression scores, and no sociodemographic or clinical factors were associated with General Anxiety Disorder-7 anxiety scores. CONCLUSIONS: We conclude that all adults with CF should be screened for symptoms of depression and anxiety given the difficulty in identifying strong clinical risk factors and the unexpected high rates of suicidal ideation.

Ethnic differences in tobacco use during pregnancy: findings from a primary care sample in São Paulo, Brazil.

OBJECTIVES: Tobacco use during pregnancy is a global health concern. To date the majority of research originates in developed countries, thus we have a need to better understand factors related to maternal health in developing countries. We examine the prevalence and correlates of smoking by ethnicity in a sample of pregnant primary care patients in São Paulo, Brazil. DESIGN: Data were obtained from completed surveys during perinatal care visits in primary care clinics. We examine a sample of 811 pregnant women surveyed during 20-30 weeks of pregnancy. Multiple logistic regression was used to obtain odds ratios (OR) and 95% confidence intervals (95% CI). RESULTS: We found significant ethnic differences in smoking during pregnancy. Compared to White women, Black women were more likely to use tobacco during pregnancy (OR: 1.95; 95% CI: 1.16-3.27). In the fully adjusted model, when accounting for common mental disorders, differences in smoking during pregnancy by ethnicity remained (OR: 1.96; 95% CI: 1.14-3.36). CONCLUSIONS: There are ethnic differences in tobacco use during pregnancy. Clinical implications including universal screening for tobacco use during pregnancy and culturally relevant approaches to smoking cessation are suggested.

The experience of primary care providers with an integrated mental health care program in safety-net clinics.

Primary care providers participating in a statewide implementation of an integrated mental health care program for "safety-net" patients in primary care clinics were surveyed to elicit their experiences and level of satisfaction. Quantitative analyses were performed to identify respondent characteristics and satisfaction with the program. Qualitative analyses were done to identify common themes in response to the question "How could psychiatric consultation [in the program] be improved?" Primary care providers were generally satisfied with the integrated mental health care program and raised several concerns that suggest important principles for successful future implementations of these types of programs.

Perceived Educational Needs of the Integrated Care Psychiatric Consultant.

OBJECTIVE: With the increased implementation of models that integrate behavioral health with other medical care, there is a need for a workforce of integrated care providers, including psychiatrists, who are trained to deliver mental health care in new ways and meet the needs of a primary care population. However, little is known about the educational needs of psychiatrists in practice delivering integrated care to inform the development of integrated care training experiences. METHOD: The educational needs of the integrated care team were assessed by surveying psychiatric consultants who work in integrated care. RESULTS: A convenience sample of 52 psychiatrists working in integrated care responded to the survey. The majority of the topics included in the survey were considered educational priorities (>50% of the psychiatrists rated them as essential) for the psychiatric consultant role. Psychiatrists' perspectives on educational priorities for behavioral health providers (BHPs) and primary care providers (PCPs) were also identified. Almost all psychiatrists reported that they provide educational support for PCPs and BHPs (for PCP 92%; for BHP 96%). CONCLUSIONS: The information provided in this report suggests likely educational needs of the integrated care psychiatric consultant and provides insight into the learning needs of other integrated care team members. Defining clear priorities related to the three roles of the integrated care psychiatric consultant (clinical consultant, clinical educator, and clinical team leader) will be helpful to inform residency training programs to prepare psychiatrists for work in this emerging field of psychiatry.

The relationship between sleep disturbance in pregnancy and persistent common mental disorder in the perinatal period (sleep disturbance and persistent CMD).

BACKGROUND: Common mental disorder (CMD) and sleep disturbance are two common conditions among women in late pregnancy, affecting up to 20% and 63% of women, respectively, and may adversely affect their quality of life. AIM: The aim of this study is to examine the relationship between sleep disturbance in pregnancy and persistent CMD among low-income pregnant women living in Brazil. METHODS: This was a prospective cohort study conducted with pregnant women recruited from public primary care clinics in São Paulo, Brazil. We performed a longitudinal analysis of 219 women who had CMD from the Self-Report Questionnaire during the 20-30 weeks of pregnancy. Two groups were examined: (1) those who had CMD remission in the postpartum and (2) those who had persistent CMD in the postpartum (measured once in the postpartum period). Poisson regression was used to estimate the degree of association between sleep disturbance in pregnancy and the risk for persistent CMD postpartum. RESULTS: After adjusting for sociodemographic and clinical factors, sleep disturbance during pregnancy is associated with persistent CMD (RR = 1.36, 95% confidence interval: 1.01-1.84). CONCLUSION: In this sample of low-income pregnant women living in Brazil, the presence of sleep disturbance during pregnancy was associated with persistent common mental disorder in the postpartum period. Identification of sleep disturbance in pregnant women with CMD will be important in order to recognize those women at higher risk of persistent CMD in the postpartum period.

Pharmacologic management of bipolar disorder in a Medicare Advantage population.

OBJECTIVE: The purpose of this study was to examine patterns of pharmacotherapy for beneficiaries in a high-risk Medicare Advantage program who were diagnosed with bipolar disorder. METHODS: This was a cross-sectional study of 2338 Medicare Advantage beneficiaries diagnosed with bipolar disorder. Pharmacotherapy treatment was assessed via receipt of (1) a mood stabilizer or antipsychotic or both (i.e., guideline concordant bipolar care) and (2) unopposed antidepressant (i.e., without prescription of a mood stabilizer or an antipsychotic). Logistic regression was used to examine correlates of bipolar disorder care. RESULTS: Among those younger than 65 years of age (n = 1395), 54% received guideline concordant therapy and 29% received unopposed antidepressant therapy. Among those 65 years and older (n = 943), 40% received guideline concordant therapy and 33% received unopposed antidepressant therapy. CONCLUSION: Overall, about half of beneficiaries in this Medicare Advantage plan received guideline concordant pharmacotherapy for bipolar disorder, while approximately one-third received an unopposed antidepressant prescription. Antipsychotic medications accounted for most of the monotherapy observed. This study identifies opportunities for further improvements in the pharmacotherapy of bipolar disorder in high-risk Medicare patients.

Characteristics, management, and depression outcomes of primary care patients who endorse thoughts of death or suicide on the PHQ-9.

BACKGROUND: With increasing emphasis on integrating behavioral health services, primary care providers play an important role in managing patients with suicidal thoughts. OBJECTIVE: To evaluate whether Patient Health Questionnaire-9 (PHQ-9) Item 9 scores are associated with patient characteristics, management, and depression outcomes in a primary care-based mental health program. DESIGN: Observational analysis of data collected from a patient registry. PARTICIPANTS: Eleven thousand fifteen adults enrolled in the Mental Health Integration Program (MHIP). INTERVENTIONS: MHIP provides integrated mental health services for safety-net populations in over 100 community health centers across Washington State. Key elements of the team-based model include: a disease registry; integrated care management; and organized psychiatric case review. MAIN MEASURES: The independent variable, suicidal ideation (SI), was assessed by PHQ-9 Item 9. Depression severity was assessed with the PHQ-8. Outcomes included four indicators of depression treatment process (care manager contact, psychiatric case review, psychotropic medications, and specialty mental health referral), and two indicators of depression outcomes (50 % reduction in PHQ-9 score and PHQ-9 score < 10). KEY RESULTS: SI was common (45.2 %) at baseline, with significantly higher rates among men and patients with greater psychopathology. Few patients with SI (5.4 %) lacked substantial current depressive symptoms. After adjusting for age, gender, and severity of psychopathology, patients with SI received follow-up earlier (care manager contact HR = 1.05, p < 0.001; psychiatric review HR = 1.02, p < 0.05), and were more likely to receive psychotropic medications (OR = 1.11, p = 0.001) and specialty referral (OR = 1.23, p < 0.001), yet were less likely to achieve a PHQ-9 score < 10 (HR = 0.87, p < 0.001). CONCLUSIONS: Suicidal thoughts are common among safety-net patients referred by primary care providers for behavioral health care. Scores on Item 9 of the PHQ-9 are easily obtainable in primary care, may help providers initiate conversations about suicidality, and serve as useful markers of psychiatric complexity and treatment-resistance. Patients with positive scores should receive timely and comprehensive psychiatric evaluation and follow-up.

The presentation, recognition and management of bipolar depression in primary care.

Bipolar disorder is a mood disorder characterized by episodes of major depression and mania or hypomania. Most patients experience chronic symptoms of bipolar disorder approximately half of the time, most commonly subsyndromal depressive symptoms or a full depressive episode with concurrent manic symptoms. Consequently, patients with bipolar depression are often misdiagnosed with major depressive disorder. Individual patient characteristics and population screening tools may be helpful in improving recognition of bipolar depression in primary care. Health risk behaviors including tobacco use, sedentary activity level and weight gain are highly prevalent in patients with bipolar disorder, as are the comorbid chronic diseases such as diabetes mellitus and cardiovascular disease. Patients with bipolar illness have about an eight-fold higher risk of suicide and a two-fold increased risk of death from chronic medical illnesses. Recognition of bipolar depression and its associated health risk behaviors and chronic medical problems can lead to the use of appropriate interventions for patients with bipolar disorder, which differ in important ways from the treatments used for major depressive disorder. The above topics are reviewed in detail in this article.

The relationship between depressive/anxiety symptoms during pregnancy/postpartum and sexual life decline after delivery.

INTRODUCTION: Several factors have been found to be independently associated with decline in sexual activity after delivery. However, the association between depression in pregnancy/postpartum and sexual problems is less clear. AIM: To prospectively evaluate the relationship between depressive/anxiety symptoms (DAS) during the perinatal period and sexual life in the postpartum period. METHODS: A prospective cohort study conducted between May 2005 and March 2007 included 831 pregnant women recruited from primary care clinics of the public sector in São Paulo, Brazil. Four groups with DAS during antenatal and postpartum periods were identified using the Self Report Questionnaire (SRQ-20): absence of both antenatal and postpartum DAS; presence of antenatal DAS only; presence of postpartum DAS only; and presence of both antenatal and postpartum DAS. The primary outcome was perception of sexual life decline (SLD) before and after pregnancy/delivery. Crude and adjusted risk ratios (RR), with 95% confidence intervals (95% CI), were calculated using Poisson regression to examine the associations between DAS and SLD. MAIN OUTCOME MEASURE: The main outcome measure of this study is the perception of SLD before and after pregnancy/delivery. RESULTS: SLD occurred in 21.1% of the cohort. In the multivariable analysis, the following variables were independently associated with SLD: DAS during both pregnancy and postpartum (RR: 3.17 [95% CI: 2.18-4.59]); DAS during only the postpartum period (RR: 3.45 [95% CI: 2.39-4.98]); a previous miscarriage (RR: 1.54 [95% CI: 1.06-2.23]); and maternal age (RR: 2.11 [95% CI: 1.22-3.65]). CONCLUSIONS: Postpartum women with DAS have an increased likelihood for SLD up to 18 months after delivery. Efforts to improve the rates of recognition and treatment of perinatal depression/anxiety in primary care settings have the potential to preserve sexual functioning for low-income mothers.

Care managers' experiences in a collaborative care program for high risk mothers with depression.

OBJECTIVES: The aim of this study was to understand care managers' experiences in caring for depressed mothers in an integrated behavioral health program. METHODS: As part of a quality improvement project, we conducted a focus group interview with six care managers caring for low income mothers with behavioral health needs in a safety net program in King County, WA. Using thematic analysis, codes were organized into themes that described the care managers' experiences. RESULTS: Two organizing themes along with associated themes emerged: (1) Assets for improving depression outcomes: patient-provider interactions, including the importance of engagement; program resources such as care coordination and (2) Barriers to improved depression outcomes: patient-provider interactions, including difficulty engaging patient; patient-related factors such as multiple stressors; program resources such as need for more psychiatric support; and difficulty accessing outside resources. CONCLUSIONS: Numerous potentially modifiable factors including levels of engagement, motivational interviewing, and increased psychiatric support were identified by care managers as affecting depression care and outcomes. Implications for care management training and approaches to psychiatric consultations are discussed.

Specialty behavioral health service use among chronically ill medicare advantage patients with substance use problems.

OBJECTIVE: This study examines the use of substance abuse and mental health services among older adults with substance use disorders. METHODS: Participants were members of Humana Cares, a subsidiary of Humana, Inc., a care management program for chronically ill Medicare Advantage members, between 2008 and 2010. All adults aged 65 and older with a substance use disorder identified with International Classification of Diseases-9 codes were included. We compared utilization of substance abuse and mental health services among participants with no psychiatric comorbidity (n = 585), with comorbid depression (n = 605), and with comorbid severe and persistent mental illness (severe and persistent mental illness, n = 95). RESULTS: Twenty-eight percent utilized substance abuse services and 36% utilized mental health services. After adjusting for covariates, comorbid depression (odds ratio = 4.27, 95% confidence interval: 3.22-5.65) and severe and persistent mental illness (odds ratio = 10.75, 95% confidence interval: 5.22-20.13) were independently associated with specialty service use (either substance abuse or mental health services). CONCLUSION: Although few chronically ill older adults with substance use disorders in this Medicare Advantage program received any specialty substance abuse or mental health services, utilization was higher among those who had concurrent psychiatric disorders.

Quality improvement with pay-for-performance incentives in integrated behavioral health care.

OBJECTIVES: We evaluated a quality improvement program with a pay-for-performance (P4P) incentive in a population-focused, integrated care program for safety-net patients in 29 community health clinics. METHODS: We used a quasi-experimental design with 1673 depressed adults before and 6304 adults after the implementation of the P4P program. Survival analyses examined the time to improvement in depression before and after implementation of the P4P program, with adjustments for patient characteristics and clustering by health care organization. RESULTS: Program participants had high levels of depression, other psychiatric and substance abuse problems, and social adversity. After implementation of the P4P incentive program, participants were more likely to experience timely follow-up, and the time to depression improvement was significantly reduced. The hazard ratio for achieving treatment response was 1.73 (95% confidence interval=1.39, 2.14) after the P4P program implementation compared with pre-program implementation. CONCLUSIONS: Although this quasi-experiment cannot prove that the P4P initiative directly caused improved patient outcomes, our analyses strongly suggest that when key quality indicators are tracked and a substantial portion of payment is tied to such quality indicators, the effectiveness of care for safety-net populations can be substantially improved.

Variations in depression care and outcomes among high-risk mothers from different racial/ethnic groups.

UNLABELLED: PURPOSE. To examine variations in depression care and outcomes among high-risk pregnant and parenting women from different racial/ethnic groups served in community health centres. METHODS: As part of a collaborative care programme that provides depression treatment in primary care clinics for high-risk mothers, 661 women with probable depression (Patient Health Questionnaire-9 ≥ 10), who self-reported race/ethnicity as Latina (n = 393), White (n = 126), Black (n = 75) or Asian (n = 67), were included in the study. Primary outcomes include quality of depression care and improvement in depression. A Cox proportional hazard model adjusting for sociodemographic and clinical characteristics was used to examine time to treatment response. RESULTS: We observed significant differences in both depression processes and outcomes across ethnic groups. After adjusting for other variables, Blacks were found to be significantly less likely to improve than Latinas [hazard ratio (HR): 0.53, 95% confidence interval (CI): 0.44-0.65]. Other factors significantly associated with depression improvement were pregnancy (HR: 1.52, 95% CI: 1.27-1.82), number of clinic visits (HR: 1.26, 95% CI: 1.17-1.36) and phone contacts (HR: 1.45, 95% CI: 1.32-1.60) by the care manager in the first month of treatment. After controlling for depression severity, having suicidal thoughts at baseline was significantly associated with a decreased likelihood of depression improvement (HR: 0.75, 95% CI: 0.67-0.83). CONCLUSIONS: In this racially and ethnically diverse sample of pregnant and parenting women treated for depression in primary care, the intensity of care management was positively associated with improved depression. There was also appreciable variation in depression outcomes between Latina and Black patients.

Suicidal ideation during pregnancy: prevalence and associated factors among low-income women in São Paulo, Brazil.

The aim of this study was to estimate the prevalence and correlates of suicidal ideation among low-income pregnant women living in Brazil. We performed a cross-sectional analysis of 831 women surveyed during 20 to 30 weeks of pregnancy using the Self-Report Questionnaire-20. The prevalence of suicidal ideation was 6.3%. The factors associated with suicidal ideation were common mental disorders, single partner status, past psychiatric history, and smoking tobacco. All cases of suicidal ideation were associated with common mental disorders.

HIV risk behaviors: risky sexual activities and needle use among adolescents in substance abuse treatment.

This study estimated prevalence of HIV risk behaviors and its association with substance use and mental health problems among adolescents in treatment. A pooled dataset of 9,519 adolescents admitted to substance abuse treatment programs between 2002 and 2006 was analyzed. HIV risk behaviors, substance use, and mental health problems were assessed at treatment intake. Sixty percent of adolescents were engaged in at least one sexual or needle use risk behavior in the year prior to entering treatment. Sex with multiple partners, sex under the influence of alcohol or drugs, and unprotected sex were the most prevalent HIV risk behaviors. Several gender differences were found for specific types of sexual and needle use behaviors. Adolescents with substance dependence or other comorbid mental health problems were at increased odds for HIV risk. Findings suggest treatment programs may benefit adolescents better by screening them consistently for HIV risk behaviors and incorporating tailored interventions.

Psychometric evaluation of the Hospital Anxiety and Depression Scale in a large community sample of adolescents in Hong Kong.

PURPOSE: The Hospital Anxiety and Depression Scale (HADS) is widely used in adult populations; however, its usefulness with adolescents has been explored less. This study sought to evaluate the reliability, validity, and factor structure of the Chinese version of HADS in a community sample of adolescents residing in Hong Kong. METHODS: A prospective cohort of 5,857 students recruited from 17 secondary schools completed the HADS. Internal consistency and concurrent validity were examined. Confirmatory factor analysis was applied to test the relative fits of six factor structures of the HADS. The best fitting model was further cross-validated by male, female, split-half samples, and age subgroups. RESULTS: The HADS possessed adequate internal consistency, especially for the anxiety subscale. Significant concurrent intercorrelations with self-reported suicidal thoughts and the Youth Self Report Anxious/Depressed subscale were discovered and found to be stronger for females. The cross-validation supported a two-factor model, where anxiety item 7, "I can sit at ease and feel relaxed", was placed in the depression subscale. CONCLUSIONS: The HADS showed satisfactory psychometric properties as a screening instrument in assessing anxious and depressive states as two correlated but distinct factors in adolescents. Study implications and recommendations for future research were discussed.

Prevalence of antenatal suicidal ideation among racially and ethnically diverse WIC enrolled women receiving care in a Midwestern public health clinic.

BACKGROUND: Suicidal ideation (SI) during pregnancy is a major maternal health concern, however few examinations report findings on the burden of SI among low-income women. The aim of this study is to estimate the prevalence and correlates of suicidal ideation among a sample of low-income women. METHODS: A cross-sectional analysis of 736 low-income pregnant women enrolled in a Women Infant and Children supplemental nutrition program and a perinatal depression registry between 2013 and 2015. All participants provided informed consent. SI was captured from Edinburgh Postnatal Depression Scale (EPDS) screens administered during standard clinic visits. RESULTS: The prevalence of suicidal ideation was 4.6%. After adjusting for smoking, women with depression were 13 times as likely to report SI. LIMITATIONS: SI was measured using a single item from the EPDS during pregnancy. CONCLUSIONS: This study indicates that most, but not all, women with SI reported elevated depressive symptoms.

Prevalence and comorbidity of major internalizing and externalizing problems among adolescents and adults presenting to substance abuse treatment.

As the field follows recommendations to introduce standardized assessments on substance, mental, and behavioral problems, a consistent picture has emerged that co-occurring disorders are common, that there is heterogeneity in the type of disorder, and that the pattern varies by age. This study examines the prevalence of self-reported substance use and mental health problems, the pattern of comorbidity, and how both vary by age among people presenting to substance abuse treatment. Data are from 4,930 adolescents and 1,956 adults admitted to substance abuse treatment in multisite studies who were assessed with the Global Appraisal of Individual Needs and categorized into five age groups: <15, 15-17, 18-25, 26-39, and 40+ years. Two thirds of clients had a co-occurring mental health problem in the year prior to treatment admission. Across all ages, clients self-reporting criteria for past-year substance dependence were more likely than those who did not to have other co-occurring mental health problems (odds ratios of 2.9 to 8.8). The prevalence and patterns of co-occurring mental health problems, however, varied by age. Young adults (ages 18-25) were found to be most vulnerable to co-occurring problems.