Impact of geographic access to primary care providers on pediatric behavioral health screening.

Behavioral Health (BH) screening is critical for early diagnosis and treatment of pediatric mental disorders. The objective of this study was to assess the impact of geographic access to primary care providers (PCP) on pediatric BH screening in children with different race/ethnicity. A retrospective cohort study was conducted using the 2013-2016 administrative claims data from a large pediatric Medicaid Managed Care Plan that have been linked to 2010 US Census data and the 2017 National Provider Identifier (NPI) Registry. Geographic access was defined as the actual travel distance to nearest PCP and the PCP density within 10-mile travel radius from each individual's residence. Stratified multivariate logistic regression was conducted to examine the association between the geographic access to PCP and the likelihood of receiving screening for behavioral disorders within each racial/ethnic group. BH screening rate was 12.6% among 402,655 children and adolescents who met the inclusion criteria. Multivariable analysis stratified by individual race/ethnicity revealed that Hispanic and Black children were more vulnerable to the geographic access barriers than their non-Hispanic White counterparts. The increase in travel distance to the nearest PCP was negatively associated with screening uptake only among Hispanics (10-20 miles vs. 0-10 miles: OR = 0.78, 95% CI [0.71-0.86]; 20-30 miles vs. 0-10 miles: OR = 0.35, 95% CI [0.23-0.54]). In a subgroup that had access to at least one PCP within 10 miles of travel distance, the variation in PCP density had a greater impact on the screening uptake among Hispanics and Blacks than that in non-Hispanic Whites.

The association between geographic access to providers and the treatment quality of pediatric depression.

OBJECTIVE: To examine the association of geographic access to providers with racial/ethnic variations in treatment quality among youth with depression. METHODS: The geographic access to providers who initiated the depression treatment was measured using the travel distance estimated based on Google Maps® and the provider density within a 5-mile radius of each patient residence. Depression treatment quality was measured as treatment engagement, defined as having ≥2 prescriptions or psychotherapy with 2-month following a new depression diagnosis, and treatment completion defined as having ≥8 sessions of psychotherapy within 12 weeks or received ≥84 days of continuous treatment with antidepressants within 114 days following the treatment initiation. RESULTS: The results of multivariate logistic regression analysis have demonstrated that the travel distance to provider was only negatively associated with the treatment engagement of Hispanics (5.0 - 14.9 vs ≤ 4.9 miles: OR=0.74, 95% CI [0.54-0.88]; ≥15 vs ≤ 4.9 miles: OR=0.82, 95% CI [0.56-0.97]), while a higher mental health specialist density was only positively associated with the treatment engagement of Blacks (1.00-1.99 vs < 1.00: OR=1.63, 95% CI [1.03-4.51]; 2.00-4.99 vs < 1.0: OR=2.28, 95% CI [1.21-7.11]). Among those who have engaged in the treatment, travel distance was associated with a lower likelihood of treatment completion in all racial/ethnic groups. LIMITATIONS: The study did not account for types of transportation used by patients. CONCLUSION: Geographic access barriers had a negative association with treatment quality of pediatric depression. Minority children were more sensitive to the barriers than Whites.

Psychosocial assessment and monitoring in the new era of non-interferon-alpha hepatitis C virus treatments.

Chronic hepatitis C virus (HCV) is a global concern. With the 2014 Food and Drug Administration approvals of two direct-acting antiviral (DAA) regimens, ledipasvir/sofosbuvir regimen and the ombitasvir/paritaprevir/ritonavir and dasabuvir regimen, we may now be in the era of all-pill regimens for HCV. Until this development, interferon-alpha along with Ribavirin has remained part of the standard of care for HCV patients. That regimen necessitates psychosocial assessment of factors affecting treatment eligibility, including interferon-alpha-related depressive symptoms, confounding psychiatric conditions, and social aspects such as homelessness affecting treatment eligibility. These factors have delayed as much as 70% of otherwise eligible candidates from interferon-based treatment, and have required treating physicians to monitor psychiatric as well as medical side effects throughout treatment. All-pill DAA regimens with the efficaciousness that would preclude reliance upon interferon-alpha or ribavirin have been anticipated for years. Efficacy studies for these recently approved DAA regimens provide evidence to assess the degree that psychosocial assessment and monitoring will be required. With shorter treatment timelines, greatly reduced side effect profiles, and easier regimens, psychosocial contraindications are greatly reduced. However, current or recent psychiatric comorbidity, and drug-drug interactions with psychiatric drugs, will require some level of clinical attention. Evidence from these efficacy studies tentatively demonstrate that the era of needing significant psychosocial assessment and monitoring may be at an end, as long as a manageable handful of clinical issues are managed.

State mandates regarding postpartum depression.

OBJECTIVE: Postpartum depression continues to be undertreated. This project identified state policies that have been enacted regarding peripartum mental health and assessed how effective they might be. METHODS: A systematic search strategy was used to detect state-level legislative initiatives. Legislative tracking resources were used to determine which were enacted. Policies were sorted into categories. Related evidence was reviewed to gauge the impact of each category. RESULTS: Thirteen states have enacted one or more state-level peripartum mental health policies. Categories include patient education mandates, depression screening mandates, mandated task force, and public awareness campaigns. Those mandating screening include Illinois, Massachusetts, New Jersey, and West Virginia. Related outcomes evidence suggests a very limited impact. CONCLUSIONS: Several states have enacted policies addressing peripartum mental health, but these are probably not influencing clinical outcomes. Home visits with a mental health component are effective for postpartum depression; state policies could support home visits.

Integrating behavioral health and primary care: the Harris County Community Behavioral Health Program.

This column describes and evaluates the Harris County Community Behavioral Health Program, a new integrated care program operating in community health centers serving low-income uninsured residents in Houston, Texas. Patient service data, provider satisfaction, patient outcome data, and appointment waiting periods were obtained to evaluate the initial operation of the program. The integrated care program has been successfully implemented on a large scale at an annual cost of about dollars 800,000, or dollars 268 per patient served. About 3,000 patients were treated for behavioral problems by behavioral health staff during the first 11 months of the program. In addition, efforts were made to expand the scope of behavioral health interventions provided by primary care physicians. Providers were satisfied with the program, improvement was detected among patients treated, and there was an increase in the average number of community-based behavioral health services received per patient since the program was implemented.

Evaluating reactivity to ecological momentary assessment during smoking cessation.

Ecological momentary assessment (EMA) consists of assessing phenomena in real time in the natural environment. EMA allows for more fine-grained analyses of addictive behavior and minimizes threats to internal validity, such as recall biases and errors. However, because of the intensive monitoring involved in EMA, measurement reactivity is a concern. To test whether EMA with palmtop personal computers induces reactivity, the authors compared smoking-related outcomes between smokers using EMA and those not using EMA during a quit attempt. The use of no-EMA control groups has been rare in reactivity investigations to date. The EMA protocol included event-contingent assessments (smoking episodes, urge episodes) and random assessments. Outcomes included biologically confirmed abstinence and self-report measures of withdrawal, self-efficacy, motivation, affect, and temptations. Participants were smokers motivated to quit (N = 96). They were randomized to 1 of 3 groups: EMA for the week preceding a planned quit date, EMA for the week following the quit date, and no EMA. Abstinence rates did not differ between the groups at Day 7 or at Day 28 postcessation. For the 20 subscales assessed at each of 3 assessment times, there were significant differences between participants with and without EMA experience for 3 subscales at the 1st of 3 assessment times, and significant differences for 3 different subscales at the 3rd assessment time. These differences suggest some reactivity to EMA, although the inconsistent pattern across time indicates that further research is needed to definitively conclude that EMA induces reactivity.