Unmet need for mental health and addictions care in urban community health clinics: frontline provider accounts.

OBJECTIVE: To facilitate planning to improve care delivery in community health clinics, this study provides an in-depth description of the social, cultural, and organizational factors that create the context for mental health and addictions treatment delivery in this setting. METHODS: Seventeen community health clinic providers and personnel were interviewed for 45-90 minutes with open-ended questions to elicit the context of their frontline provider experiences. Major themes and subthemes of responses were identified with content analysis. RESULTS: Issues that create significant barriers to care included complex patient comorbidity and demographic characteristics; clinic organization, resources, and funding shortfalls; communication barriers with specialty mental health and addictions agencies; and stigmatizing aspects of mental health, addictions, and disadvantaged status. CONCLUSIONS: The unique barriers to care in the community health care setting, as well as the unique characteristics of patients served, are likely to require context-specific solutions. These solutions will determine the viability of existing chronic disease management models, such as collaborative care, when applied to this setting.

Adherence to treatment among economically disadvantaged patients with panic disorder.

OBJECTIVE: The purpose of this study was to examine the feelings of disadvantaged patients about and experiences of treatment for anxiety disorders in primary care settings. METHODS: The patients had participated in the Collaborative Care for Anxiety and Panic study, which tested the effectiveness of an intervention to help primary care providers treat panic disorder. The treatment comprised cognitive behavioral therapy (CBT) combined with pharmacotherapy administered by primary care physicians with the expert advice of a psychiatrist. Post hoc semistructured interviews were conducted with 21 intervention participants who were classified according to adherence or nonadherence to treatment. The interview focused on reactions to CBT; reactions to the different features of the intervention, such as therapy sessions, demonstration videotapes, exercises, and a workbook; and comfort with the therapist. Two members of the research team independently coded, analyzed, and interpreted the data. RESULTS: Three themes emerged: information was empowering and reduced the sense of isolation experienced by participants, participants engaged in a dynamic and iterative personalized assessment of the intervention, and barriers to adherence were predominantly logistical. CONCLUSIONS: Results indicate that the extent to which patients chose to remain in treatment and follow treatment recommendations was rarely an all-or-nothing phenomenon. In a disadvantaged population such decisions seem to be influenced by the beliefs of the patient about what will and will not be effective in his or her individual case, an ongoing self-assessment of well-being, and the logistical barriers that come into play.