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INTRODUCTION: Despite the benefits of measurement-based care (MBC) in the behavioral health setting, there have been difficulties in implementation and low saturation. Although barriers and facilitators to MBC implementation have been identified, research has generally only included the perspective of one stakeholder group. The current study aims to examine the similarities and differences-by stakeholder group-in the identified barriers to and facilitators of implementing MBC in the behavioral health setting. METHOD: A purposeful sampling approach was used to recruit and conduct interviews and focus groups with stakeholders (clinicians, clinic leaders, and administrative staff) from four behavioral health clinics at an academic medical center that is part of a larger healthcare system. The data coding process included a directed content analytic approach whereby the coding team used an iterative process to analyze deidentified transcripts starting with a codebook based on the Consolidated Framework for Implementation Research (CFIR) constructs. RESULTS: A total of 31 clinicians, 11 clinic leaders, and 8 administrative staff participated in the interviews and focus groups. There was convergence among all stakeholder regarding which CFIR constructs were identified as barriers and facilitators, but there were differences in the specific thematic factors identified by stakeholders as barriers and facilitators within each of these implementation constructs. The barriers and facilitators that stakeholders identified within each CFIR construct were often connected to their specific role in implementing MBC. CONCLUSION: Collecting information on barriers and facilitators to MBC implementation from the multiple stakeholders involved in the process may enhance successful implementation of MBC given the variation between groups in identified thematic factors. Administrative staff perspectives, which have not been reported in the literature, may be of particular importance in planning for successful MBC implementation.
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Atención a la Salud , Humanos , Investigación Cualitativa , Grupos FocalesRESUMEN
BACKGROUND AND OBJECTIVES: Transitional age youth experiencing homelessness (TAY-EH) bear a disproportionate burden of morbidity and mortality related to psychopathology, substance use disorders (SUD), and neuropsychological dysfunction. Prior reviews examining these conditions are now nearly a decade old, have focused on younger adolescent populations, or have utilized nonsystematic approaches. To our knowledge, no prior reviews have reported on all three of these domains in an integrated fashion. Here, we provide a contemporary, critical synthesis of the literature on the functioning of TAY-EH in North America within these three domains. METHODS: Based upon PRISMA guidelines, a search of PubMed, Medline, and PsycInfo databases was conducted, including literature published between January 2015 and June 2021. RESULTS: The initial search yielded 2024 citations; 104 underwent full text review and 32 met inclusion criteria, with a final aggregate sample size of 13,516. Studies revealed elevated rates of mood disorders, PTSD, anxiety disorders, and alcohol misuse. There is insufficient data to draw generalizable conclusions regarding neuropsychological functioning, other SUD, or other psychiatric diagnoses. No studies reported on co-occurrence of disorders among or between the domains of psychopathology, SUD, and neuropsychological dysfunction. Four studies used structured interviews for diagnoses, with the remainder relying upon brief screeners or self-report measures. CONCLUSIONS AND SCIENTIFIC SIGNIFICANCE: To our knowledge, this is the first systematic review to provide integrated findings on psychopathology, SUD, and neuropsychological dysfunction among TAY-EH. Further research using structured, DSM-based tools is needed to characterize rates of single and co-occurring conditions to inform tailored treatment interventions.
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Personas con Mala Vivienda , Trastornos Mentales , Trastornos Relacionados con Sustancias , Adolescente , Humanos , Personas con Mala Vivienda/psicología , Trastornos Mentales/epidemiología , Trastornos Mentales/psicología , Psicopatología , Problemas Sociales , Trastornos Relacionados con Sustancias/psicologíaRESUMEN
OBJECTIVE: Dramatic changes in state-level cannabis laws (CL) over the past 25 years have shifted societal beliefs throughout the United States, with unknown implications for youth. In the present study, we conducted an updated systematic review and meta-analysis examining estimated effects of medical cannabis legalization (MCL) and recreational cannabis legalization (RCL) on past-month cannabis use among US youth. METHOD: A systematic review was conducted following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, followed by a subsequent meta-analysis investigating the associations between state-level cannabis laws (ie, MCL vs non-MCL, and RCL vs non-RCL) and past-month cannabis use prevalence among US adolescents and young adults. Supplemental analyses examined age-group effects and design-related factors. RESULTS: Our search identified 4,604 citations, 34 and 30 of which were included in qualitative and quantitative analyses, respectively. Meta-analysis of MCL studies identified no significant association between MCL and change in past-month youth cannabis use (odds ratio [OR] = 0.981, 95% CI = 0.960, 1.003). Meta-analysis of RCL studies showed significantly increased odds of past-month cannabis use (OR = 1.134, 95% CI = 1.116-1.153). Meta-analysis of more recent studies, however, showed a significantly increased odds of past-month cannabis use among both adolescents and young adults (OR = 1.089, 95% CI = 1.015,1.169, and OR = 1.221, 95% CI = 1.188,1.255, respectively). CONCLUSION: Cannabis legalization has complex and heterogenous effects on youth use that may differ across law types. Our meta-analytic results showed modest positive effects of RCL on past-month cannabis use (more so in young adults than in adolescents) and minimal effects of MCL on these outcomes in US youth. Given the shift toward recreational legalization, additional focus on RCL effects is warranted.
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Objective: Transitional age youth experiencing homelessness (TAY-EH) bear a high burden of substance use disorders (SUDs) and psychopathology. However, limited data exist on the co-occurrence and interactions between these diagnoses in this marginalized group. This study sought to identify rates of single and co-occurring SUDs and psychiatric diagnoses among a sample of TAY-EH and to investigate associations between psychopathology and prevalence and severity of SUDs in this group. Method: TAY-EH accessing a low-threshold social service agency in a large metropolitan area completed psychosocial and diagnostic interviews to assess for SUDs and psychopathology. Analyses examined rates of single and co-occurring disorders and associations between burden of psychopathology and presence and severity of SUDs. Results: The assessment was completed by 140 TAY-EH; the majority were youth of color (54% Black/African American, 16% Latinx), and 57% identified as male. Rates of single and co-occurring psychiatric disorders and specific SUDs (cannabis use disorder [CUD] and alcohol use disorder [AUD]) were notably high. An increasing number of psychiatric diagnoses was significantly associated with elevated CUD/AUD prevalence and severity. Mood, anxiety, attention-deficit/hyperactivity, and antisocial personality disorders were significantly associated with elevated CUD/AUD prevalence and severity, as was suicidality (all p < .05). Conclusion: This study reveals a complex overlay of SUDs and psychopathology facing TAY-EH, with a significant association between co-occurring psychopathology and severity of CUD/AUD. To the authors' knowledge, this is the first study to examine associations between specific psychopathology and severity of SUDs among TAY-EH. Further research into the mechanistic and temporal links between these conditions is needed to inform tailored treatment interventions.
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AIM: To assess the empirical evidence for the treatment of attention deficit/hyperactivity disorder (ADHD) in populations with autism spectrum disorder (ASD). METHODS: A systemic PubMed, PsychINFO, Embase, and Medline database search of peer-reviewed literature was conducted. Included in the review were controlled trials published in English with sample sizes ⩾10 participants examining the safety and efficacy of anti-ADHD medication in ASD populations. Data was extracted on relevant variables of study design, demographics, associated psychopathology, medication dose, efficacy, and tolerability. RESULTS: Nine controlled trials met the inclusion and exclusion criteria: five with methylphenidate, three with atomoxetine, and one with guanfacine. Sample sizes ranged from 10 to 128 with 430 children participating across all the trials. In all the trials, treatment response was significantly superior to placebo. However, almost all trials assessed only hyperactivity, and most included only participants with intellectual disability with high levels of irritability. None of the trials distinguished agitation from hyperactivity. The response on hyperactivity for methylphenidate and atomoxetine was less than that observed in the neurotypical population; however, the response for guanfacine surpassed results observed in neurotypical populations. Treatment-emergent mood lability (i.e. mood dysregulation and mood-related adverse events) was frequently associated with methylphenidate and guanfacine treatments. Worse treatment outcomes were associated with individuals with lower intellectual capability compared with those with higher IQs. CONCLUSIONS: here is a scarcity of controlled trials examining ADHD treatments in ASD populations, particularly in intellectually capable individuals with ASD and in adults. Response to ADHD medications in ASD were adversely moderated by the presence of intellectual disability and mood lability.
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Trastorno por Déficit de Atención con Hiperactividad/tratamiento farmacológico , Trastorno del Espectro Autista/tratamiento farmacológico , Discapacidad Intelectual/complicaciones , Clorhidrato de Atomoxetina/administración & dosificación , Clorhidrato de Atomoxetina/efectos adversos , Trastorno por Déficit de Atención con Hiperactividad/fisiopatología , Trastorno del Espectro Autista/fisiopatología , Niño , Guanfacina/administración & dosificación , Guanfacina/efectos adversos , Humanos , Metilfenidato/administración & dosificación , Metilfenidato/efectos adversos , Resultado del TratamientoRESUMEN
Importance: Guidelines recommend that adult patients receive screening for alcohol and drug use during primary care visits, but the adoption of screening in routine practice remains low. Clinics frequently struggle to choose a screening approach that is best suited to their resources, workflows, and patient populations. Objective: To evaluate how to best implement electronic health record (EHR)-integrated screening for substance use by comparing commonly used screening methods and examining their association with implementation outcomes. Design, Setting, and Participants: This article presents the outcomes of phases 3 and 4 of a 4-phase quality improvement, implementation feasibility study in which researchers worked with stakeholders at 6 primary care clinics in 2 large urban academic health care systems to define and implement their optimal screening approach. Site A was located in New York City and comprised 2 clinics, and site B was located in Boston, Massachusetts, and comprised 4 clinics. Clinics initiated screening between January 2017 and October 2018, and 93â¯114 patients were eligible for screening for alcohol and drug use. Data used in the analysis were collected between January 2017 and October 2019, and analysis was performed from July 13, 2018, to March 23, 2021. Interventions: Clinics integrated validated screening questions and a brief counseling script into the EHR, with implementation supported by the use of clinical champions (ie, clinicians who advocate for change, motivate others, and use their expertise to facilitate the adoption of an intervention) and the training of clinic staff. Clinics varied in their screening approaches, including the type of visit targeted for screening (any visit vs annual examinations only), the mode of administration (staff-administered vs self-administered by the patient), and the extent to which they used practice facilitation and EHR usability testing. Main Outcomes and Measures: Data from the EHRs were extracted quarterly for 12 months to measure implementation outcomes. The primary outcome was screening rate for alcohol and drug use. Secondary outcomes were the prevalence of unhealthy alcohol and drug use detected via screening, and clinician adoption of a brief counseling script. Results: Patients of the 6 clinics had a mean (SD) age ranging from 48.9 (17.3) years at clinic B2 to 59.1 (16.7) years at clinic B3, were predominantly female (52.4% at clinic A1 to 64.6% at clinic A2), and were English speaking. Racial diversity varied by location. Of the 93,114 patients with primary care visits, 71.8% received screening for alcohol use, and 70.5% received screening for drug use. Screening at any visit (implemented at site A) in comparison with screening at annual examinations only (implemented at site B) was associated with higher screening rates for alcohol use (90.3%-94.7% vs 24.2%-72.0%, respectively) and drug use (89.6%-93.9% vs 24.6%-69.8%). The 5 clinics that used a self-administered screening approach had a higher detection rate for moderate- to high-risk alcohol use (14.7%-36.6%) compared with the 1 clinic that used a staff-administered screening approach (1.6%). The detection of moderate- to high-risk drug use was low across all clinics (0.5%-1.0%). Clinics with more robust practice facilitation and EHR usability testing had somewhat greater adoption of the counseling script for patients with moderate-high risk alcohol or drug use (1.4%-12.5% vs 0.1%-1.1%). Conclusions and Relevance: In this quality improvement study, EHR-integrated screening was feasible to implement in all clinics and unhealthy alcohol use was detected more frequently when self-administered screening was used at any primary care visit. The detection of drug use was low at all clinics, as was clinician adoption of counseling. These findings can be used to inform the decision-making of health care systems that are seeking to implement screening for substance use. Trial Registration: ClinicalTrials.gov Identifier: NCT02963948.
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Alcoholismo/diagnóstico , Tamizaje Masivo/métodos , Tamizaje Masivo/normas , Guías de Práctica Clínica como Asunto , Atención Primaria de Salud/métodos , Atención Primaria de Salud/normas , Trastornos Relacionados con Sustancias/diagnóstico , Adulto , Anciano , Boston , Femenino , Humanos , Masculino , Persona de Mediana Edad , Ciudad de Nueva YorkRESUMEN
Along with general practice burdens, child and adolescent psychiatrists (CAPs) are commonly tasked with completing prior authorizations (PAs) for medications prescribed in clinical practice. CAPs frown in resignation to their PA requirements to allow patients to be initiated onto, or continue with, their medications. PAs are often required for both brand and generic prescription medications, sometimes to confirm if the medication is medically necessary and appropriate for the indication,1 to review medication dosages, or more commonly to review the need in context to the medication cost of the requested agent relative to less expensive alternatives. Some states have implemented policies that leverage PAs to regulate and oversee provider prescribing patterns. Notably, many state Medicaid programs have restrictions on prescription of antipsychotics in children, and adoption of these regulations has led to decreases in their use in children 6 to 12 years old.2.