Psychometric Properties of the Assessment of Perceived Access to Care (APAC) Instrument.

Valid measures of perceived access are needed to measure whether health care systems are providing adequate access. This research reports on the psychometric properties of the Assessment of Perceived Access to Care (APAC), which was administered to 1004 Community Health Center patients screening positive for psychiatric disorders. Known-group validity was good, with 6 of the 8 hypothesized associations between social determinants of access and perceived access being significant (P < .01). Better access was significantly (P < .01) correlated with more outpatient mental health visits, indicating good convergent validity. The test-retest Pearson correlation coefficient (0.64) was statistically significant (P < .01). The APAC has acceptable psychometric properties.

Study design and implementation of the PRecision Medicine In MEntal health Care (PRIME Care) Trial.

Genomic testing has the potential to improve patient outcomes and reduce patient care costs by personalizing medication selection. Commercial pharmacogenetic (PGx) testing for psychotropic and other medications is widely available and promoted as a means to implement "precision medicine." Despite evidence that genetic variation affects the metabolism of psychotropic medications, the clinical utility of these test results has not been established. Moreover, implementing such testing in routine clinical care is complex, requiring informatics support and a systematic approach to patient and provider education. The PRIME Care program is designed to bridge this gap, applying both clinical trials and implementation science methods to conduct a program of research. It is centered on a large, pragmatic randomized clinical trial (RCT) in which 2000 Veterans with a major depressive disorder (MDD) and their health care providers are randomized together to receive PGx test results at the beginning of an episode of care or 6 months later. We hypothesize that providers who receive the PGx test results will prescribe an antidepressant guided by the PGx findings and Veterans whose care is guided by PGx testing will experience higher rates of remission from MDD. If the results of the trial replicate those of prior PGx studies, which provided preliminary evidence of the utility of PGx guided prescribing, it would strongly support using a precision medicine approach to treat MDD. This program of research is also evaluating dissemination influencers, other biomarkers (e.g., genetic variation associated with depression response), and the health care cost implications of PGx testing. ClinicalTrials.gov Identifier: NCT03170362.

Design and implementation of the telemedicine-enhanced antidepressant management study.

OBJECTIVE: Evidence-based practices designed for large urban clinics are not necessarily transportable into small rural practices. Implementing collaborative care for depression in small rural primary care clinics presents unique challenges because it is typically not feasible to employ on-site mental health specialists. The purpose of the Telemedicine-Enhanced Antidepressant Management (TEAM) study was to evaluate a collaborative care model adapted for small rural clinics using telemedicine technologies. The purpose of this paper is to describe the TEAM study design. METHOD: The TEAM study was conducted in small rural Veterans Administration community-based outpatient clinics with interactive video equipment available for mental health, but no on-site psychiatrists/psychologists. The study attempted to enroll all patients whose depression could be appropriately treated in primary care. RESULTS: The clinical characteristics of the 395 study participants differed significantly from most previous trials of collaborative care. At baseline, 41% were already receiving primary care depression treatment. Study participants averaged 5.5 chronic physical health illnesses and 56.5% had a comorbid anxiety disorder. Over half (57.2%) reported that pain impaired their functioning extremely or quite a bit. CONCLUSIONS: Despite small patient populations in rural clinics, enough patients with depression can be successfully enrolled to evaluate telemedicine-based collaborative care.

Virtual reality graded exposure therapy with arousal control for the treatment of combat related posttraumatic stress disorder: a follow up case series.

Important challenges confronting DOD/military medical care are that of maintaining or increasing quality of care and increasing the effectiveness of treatments for warriors diagnosed with Posttraumatic Stress Disorder (PTSD) secondary to their combat deployments to Iraq and/or Afghanistan. Virtual Reality Graded Exposure Therapy with Arousal Control (VR-GET) has demonstrated a positive treatment effectiveness resulting in significant reductions of PTSD symptom severity. This positive treatment effectiveness has been maintained for up to 22 weeks after VR-GET therapy was completed. A robust methodology for the assessment of Virtual Reality efficacy suggests that the ideal time for follow-up begins at twelve months. Others have suggested that follow-up should occur between two and four years post treatment. In this report we describe the outcome of VR-GET for the treatment of combat-related PTSD with three warriors between five and seven years following their having completed treatment.