Work-Related Cognitive Behavioral Therapy for racially and economically diverse unemployed persons with social anxiety: A randomized clinical trial.

Individuals with Social Anxiety Disorder (SAD) are at risk for employment problems. This multi-site trial examined the efficacy of Work-Related Cognitive Behavioral Therapy provided alongside vocational services as usual (WCBT+VSAU), a group-based treatment designed to improve mental health and employment outcomes for individuals with SAD. Vocational service-seeking participants with SAD (N = 250) were randomized to either WCBT+VSAU or VSAU-alone. Hypotheses were that participants randomized to WCBT+VSAU would report less social anxiety, less depression, and more hours worked than participants randomized to VSAU-alone. WCBT+VSAU participants had significantly greater improvements on the Liebowitz Social Anxiety Scale (LSAS; d=-.25, CI=-0.49 to -0.02, p = .03) at post-assessment compared to VSAU-alone. The conditions did not differ on any variable at later time points or on secondary outcomes. Unexpectedly, participants randomized to VSAU-alone experienced LSAS improvements, similar to WCBT+VASU at later timepoints. Baseline psychological flexibility (beta=-.098 [-0.19-0.008]) and depression (beta=-0.18 [-0.34-0.009]) moderated change in social anxiety. Participants with lower psychological flexibility and higher depression responded more strongly to WCBT+VSAU than VSAU-alone over the duration of the study, suggesting that WCBT+VSAU may particularly benefit those with greater psychopathology. Results indicate that vocational centers are promising settings for treating SAD and employment-focused refinements are likely needed to improve work outcomes.

The impact of the affordable care act on perinatal mood and anxiety disorder diagnosis and treatment rates among Michigan Medicaid enrollees 2012-2018.

BACKGROUND: Perinatal Mood and Anxiety Disorders (PMADs) affect one in five birthing individuals and represent a leading cause of maternal mortality. While these disorders are associated with a variety of poor outcomes and generate significant societal burden, underdiagnosis and undertreatment remain significant barriers to improved outcomes. We aimed to quantify whether the Patient Protection Affordable Care Act (ACA) improved PMAD diagnosis and treatment rates among Michigan Medicaid enrollees. METHODS: We applied an interrupted time series framework to administrative Michigan Medicaid claims data to determine if PMAD monthly diagnosis or treatment rates changed after ACA implementation for births 2012 through 2018. We evaluated three treatment types, including psychotherapy, prescription medication, and either psychotherapy or prescription medication. Participants included the 170,690 Medicaid enrollees who had at least one live birth between 2012 and 2018, with continuous enrollment from 9 months before birth through 3 months postpartum. RESULTS: ACA implementation was associated with a statistically significant 0.76% point increase in PMAD diagnosis rates (95% CI: 0.01 to 1.52). However, there were no statistically significant changes in treatment rates among enrollees with a PMAD diagnosis. CONCLUSION: The ACA may have improved PMAD detection and documentation in clinical settings. While a higher rate of PMAD cases were identified after ACA Implementation, Post-ACA cases were treated at similar rates as Pre-ACA cases.

Racial Disparities in Diagnosis of Postpartum Mood and Anxiety Disorders Among Symptomatic Medicaid Enrollees, 2012-2015.

OBJECTIVE: This study quantified the prevalence of postpartum mood and anxiety disorder (PMAD) diagnoses among symptomatic Michigan Medicaid enrollees and explored factors associated with receiving a diagnosis. METHODS: Data sources comprised Michigan Medicaid administrative claims and Phase 7 Michigan Pregnancy Risk Assessment Monitoring System (MI-PRAMS) survey responses, linked at the individual level. Participants were continuously enrolled in Michigan Medicaid, delivered a live birth (2012-2015), responded to the survey, and screened positive for PMAD symptoms on the adapted two-item Patient Health Questionnaire. Unadjusted and adjusted weighted logistic regression analyses were used to predict the likelihood of having a PMAD diagnosis (for the overall sample and stratified by race). RESULTS: The weighted analytic cohort represented 24,353 deliveries across the 4-year study. Only 19.8% of respondents with symptoms of PMAD had a PMAD diagnosis between delivery and 3 months afterward. Black respondents were less likely to have PMAD diagnoses (adjusted odds ratio [AOR]=0.23, 95% CI=0.11-0.49) compared with White respondents. Among White respondents, no covariates were significantly associated with having a diagnosis. However, among Black respondents, more comorbid conditions and more life stressors were statistically significantly associated with having a diagnosis (AOR=3.18, 95% CI=1.27-7.96 and AOR=3.12, 95% CI=1.10-8.88, respectively). CONCLUSIONS: Rate of PMAD diagnosis receipt differed by race and was low overall. Black respondents were less likely than White respondents to receive a diagnosis. Patient characteristics influencing diagnosis receipt also differed by race, indicating that strategies to improve detection of these disorders require a tailored approach.

Factors associated with mental health treatment among Michigan medicaid enrollees with perinatal mood and anxiety disorders, 2012-2015.

OBJECTIVE: Perinatal mood and anxiety disorders (PMADs) represent the most prevalent pregnancy-related comorbidity and a leading cause of maternal mortality. Effective treatments exist, but remain underutilized. We sought to identify factors associated with receipt of prenatal and postpartum mental health treatment. METHODS: This observational, cross-sectional analysis used self-reported survey data from the Michigan Pregnancy Risk Assessment Monitoring System linked to Michigan Medicaid administrative claims for births from 2012 to 2015. We used survey-weighted multinomial logistic regression to predict prescription medication and psychotherapy utilization among respondents with PMADs. RESULTS: Only 28.0% of respondents with prenatal PMAD and 17.9% of respondents with postpartum PMAD received both prescription medication and psychotherapy. During pregnancy, Black respondents were 0.33 (95%CI: 0.13-0.85, p = 0.022) times less likely to receive both treatments while more comorbidities were associated with receipt of both treatments (adjRR = 1.31, 95%CI: 1.02-1.70, p = 0.036). In the first three months postpartum, respondents with four or more stressors were 6.52 times more likely to receive both treatments (95%CI: 1.62-26.24, p = 0.008) and those satisfied with prenatal care were 16.25 times more likely to receive both treatments (95%CI: 3.35-78.85, p = 0.001). DISCUSSION: Race, comorbidities, and stress are critical factors in PMAD treatment. Satisfaction with perinatal healthcare may facilitate access to care.

Implementation beyond the clinic: Community-driven utilization of research evidence from PC CARES, a suicide prevention program.

While implementation and dissemination of research is a rapidly growing area, critical questions remain about how, why, and under what conditions everyday people integrate and utilize research evidence. This mixed-methods study investigates how participants of Promoting Community Conversations About Research to End Suicide (PC CARES) make sense of and use research evidence about suicide prevention in their own lives. PC CARES is a health intervention addressing the need for culturally responsive suicide prevention practices in rural Alaska through a series of community Learning Circles. We analyzed PC CARES transcripts and surveys for 376 participants aged 15+ across 10 Northwest Alaska Native villages. Quantitative analysis showed significant correlations between five utilization of research evidence (URE) factors and participants' intent to use research evidence from PC CARES Learning Circles. Key qualitative themes from Learning Circle transcripts expanded upon these URE constructs and included navigating discordant information, centering relationships, and Indigenous worldviews as key to interpreting research evidence. We integrate and organize our findings to inform two domains from the Consolidated Framework for Research Implementation: (1) intervention characteristics and (2) characteristics of individuals, with emphasis on findings most relevant for community settings where self-determined, evidence-informed action is especially important for addressing health inequities.

A systematic review of rural-specific barriers to medication treatment for opioid use disorder in the United States.

BACKGROUND: Opioid-related deaths have risen dramatically in rural communities. Prior studies highlight few medication treatment providers for opioid use disorder in rural communities, though literature has yet to examine rural-specific treatment barriers. OBJECTIVES: We conducted a systematic review to highlight the state of knowledge around rural medication treatment for opioid use disorder, identify consumer- and provider-focused treatment barriers, and discuss rural-specific implications. METHODS: We systematically reviewed the literature using PsycINFO, Web of Science, and PubMed databases (January 2018). Articles meeting inclusion criteria involved rural samples or urban/rural comparisons targeting outpatient medication treatment for opioid use disorder, and were conducted in the U.S. to minimize healthcare differences. Our analysis categorized consumer- and/or provider-focused barriers, and coded barriers as related to treatment availability, accessibility, and/or acceptability. RESULTS: Eighteen articles met inclusion, 15 which addressed consumer-focused barriers, while seven articles reported provider-focused barriers. Availability barriers were most commonly reported across consumer (n = 10) and provider (n = 5) studies, and included the lack of clinics/providers, backup, and resources. Acceptability barriers, described in three consumer and five provider studies, identified negative provider attitudes about addiction treatment, and providers' perceptions of treatment as unsatisfactory for rural patients. Finally, accessibility barriers related to travel and cost were detailed in four consumer-focused studies whereas two provider-focused studies identified time constraints. CONCLUSIONS: Our findings consistently identified a lack of medication providers and rural-specific implementation challenges. This review highlights a lack of rural-focused studies involving consumer participants, treatment outcomes, or barriers impacting underserved populations. There is a need for innovative treatment delivery for opioid use disorder in rural communities and interventions targeting provider attitudes.

Adolescent opioid use: Examining the intersection of multiple inequalities.

Nonmedical prescription opioid use in the U.S. has increased, with devastating consequences. Yet, we know little about how multiple inequalities impact adolescent opioid use. Using data from the 2015 Monitoring the Future study, we address this gap by examining adolescent opioid use by residential context, parental education, across race/ethnicity and sex. Bivariate findings demonstrate differential patterns of use by residential context and SES across race/ethnicity and sex. Multi-group logistic regression analyses were used to explore whether associations in parental education, residential context, sex with opioid use differed within race/ethnicity. Our results suggest that intersecting identities lead to different rates of opioid use among adolescents and that multiple identities should be considered when designing treatment interventions for adolescent opioid use. Findings also reveal a need to acknowledge racial/ethnic heterogeneity among rural adolescents and how the rural context relates to opioid use. Implications for community-based approaches for addressing these inequalities are addressed.

Depressive symptoms and psychological distress among rural African Americans: The role of material hardship and self-rated health.

BACKGROUND: Despite experiencing conditions associated with higher risk for depression and psychological distress, the mental health of rural African Americans remains understudied. This brief report examines the association between sociodemographic characteristics, self-rated health, and material hardship, and depressive symptoms and psychological distress among rural African Americans. METHOD: Data are from the rural African American subsample (N = 250) of the National Survey of American Life (NSAL; 2001-2003). The Center for Epidemiological Studies-Depression Scale (CES-D) was used to assess depressive symptoms. Psychological distress was measured using the Kessler 6 (K6). Negative binominal regression analyses were performed. RESULTS: Rural African Americans reporting more material hardship and poorer self-rated physical health had higher levels of depressive symptoms and psychological distress compared to counterparts with less hardship and better self-rated health. Findings also suggest rural African American women had more depressive symptoms compared to male peers. Older rural African Americans and African Americans with fewer years of education had more symptoms of psychological distress than their respective counterparts. LIMITATIONS: Though the NSAL represents the only national probability survey on African Americans' mental health; the timeliness of the data, collected between 2001 and 2003 is a limitation. CONCLUSIONS: Material hardship and worse self-rated health emerged as risk factors for depression and psychological distress among this population. This suggests the need for systems of care and integrated healthcare models across service providers within rural African American communities to promote adequate screening, intervention, and referrals related to economic, physical, and mental health needs.

Mental Health Interventions with Community Health Workers in the United States: A Systematic Review.

Mental health conditions are common in the United States, yet the mental health workforce is limited in its capacity to reach disadvantaged populations. While a number of recent reviews demonstrate that community health worker (CHW)-supported physical health interventions are effective, and increase access to services, there are no recent reviews that systematically assess CHW-supported mental health interventions. To address this gap, the authors conducted a systematic review of mental health interventions with CHWs in the United States, and assessed the methodological rigor of such studies. Nine studies met review criteria. Though most of the studies reviewed showed inadequate methodological rigor, findings suggest CHW-supported mental health interventions show promise, particularly given evidence of feasibility and acceptability with underserved populations. The authors describe the rationale for mental health CHWs in the workforce, offer recommendations to strengthen the evidence base, and discuss implications of mental health interventions with CHWs for underserved populations.

Systematic review of EBPs for SMI in rural America.

This systematic review of the implementation of evidence-based practices (EBPs) for adults with severe mental illnesses (SMI) in rural mental health settings examined peer-reviewed literature, grey literature, and public information. Included articles had to report implementation efforts of EBP(s) for SMI in rural settings or adaptations for rural service delivery. Only three peer-reviewed articles and two publicly available reports met inclusion criteria. Findings suggest little attention is focused on studying factors affecting implementation of EBPs for SMI in rural areas. Adaptations are occurring in rural settings, though rarely documented or tested; their impact on fidelity and consumer outcomes is unclear.

Raising the stakes: assessing the human service response to the advent of a casino.

This article reports the findings of one county's human service network's readiness to treat gambling related problems in anticipation of the opening of a new casino. Using a cross-sectional survey design, questionnaires were mailed to executive directors of all mental health, family counseling, drug and alcohol, and faith-based, addiction-related organizations in the county (N = 248); 137 (55.2%) agency directors responded to the questionnaire. The survey requested information about agency demographics, training, screening, treatment, and public awareness/education. Descriptive statistics and bivariate analyses were used to summarize the findings. The analyses revealed a lack of human service response to the impending start of casino gambling. More than three-quarters of respondents had not sent staff for training in screening or treating gambling disorders, did not screen for problem gambling, did not treat problem gambling, and did not refer clients to other agencies for treatment of gambling-related problems. The most common reason offered for not engaging in prevention and treatment activities was that problem gambling is not considered an issue for the agency. There were differences between mental health and/or substance abuse focused agencies and other service providers. Based on the findings of this study, specific strategies to enhance the service delivery network's capacity to address problem gambling are suggested.