Determinants of remote measurement-based care uptake in a safety net outpatient psychiatry department as part of learning health system transition.

Introduction: Behavioral measurement-based care (MBC) can improve patient outcomes and has also been advanced as a critical learning health system (LHS) tool for identifying and mitigating potential disparities in mental health treatment. However, little is known about the uptake of remote behavioral MBC in safety net settings, or possible disparities occurring in remote MBC implementation. Methods: This study uses electronic health record data to study variation in completion rates at the clinic and patient level of a remote MBC symptom measure tool during the first 6 months of implementation at three adult outpatient psychiatry clinics in a safety net health system. Provider-reported barriers to MBC adoption were also measured using repeated surveys at one of the three sites. Results: Out of 1219 patients who were sent an MBC measure request, uptake of completing at least one measure varied by clinic: General Adult Clinic, 38% (n = 262 of 696); Substance Use Clinic, 28% (n = 73 of 265); and Transitions Clinic, 17% (n = 44 of 258). Compared with White patients, Black and Portuguese or Brazilian patients had lower uptake. Older patients also had lower uptake. Spanish language of care was associated with much lower uptake at the patient level. Significant patient-level disparities in uptake persisted after adjusting for the clinic, mental health diagnoses, and number of measure requests sent. Providers cited time within visits and bandwidth in their workflow as the greatest consistent barriers to discussing MBC results with patients. Conclusions: There are significant disparities in MBC uptake at the patient and clinic level. From an LHS data infrastructure perspective, safety net health systems may need to address the need for possible ways to adapt MBC to better fit their populations and clinical needs, or identify targeted implementation strategies to close data gaps for the identified disparity populations.

Pathways to adolescent internalizing: early attachment insecurity as a lasting source of vulnerability.

Despite theoretical links between attachment quality in early childhood and subsequent internalizing symptoms, there is limited empirical evidence supporting direct effects. In this article, we test whether early attachment insecurity indirectly contributes to adolescent internalizing by increasing the likelihood of certain pathways leading to elevated symptoms (i.e., moderated mediation). Structural equation modeling and bootstrapping were used to test for moderated mediation using longitudinal data from 910 adolescents participating in the National Institute of Child Health and Human Development Study of Early Child Care (M age = 15.1; 50% female, 23% racial/ethnic minority). Among dyads with a history of an insecure attachment in early childhood, mothers' negative emotions during the transition to adolescence significantly predicted less availability during parent-adolescent interactions, which in turn increased adolescents' preoccupation with parental relationships. The same process was not evident in youth with a history of secure attachments. However, the extent to which preoccupation with parental relationships was associated with increases in internalizing symptoms depended on both attachment history and gender. Results highlight one pathway by which early attachment history may indirectly contribute to increased internalizing symptoms for girls during the transition to adolescence.

Group therapy in primary care settings for the treatment of posttraumatic stress disorder: A systematic literature review.

OBJECTIVE: This systematic review aims to summarize existing literature on group therapy for the treatment of post-traumatic stress disorder (PTSD) in primary care. METHOD: A PRISMA systematic literature review was performed through February 26, 2022 identifying existing studies of group trauma therapy in primary care. Articles were included if they discussed group trauma therapy for primary care patients. Bias was assessed based on sample sizes and presence of control groups. Results are presented as a weighted average of the engagement rate and a qualitative description of overlapping study traits. RESULTS: Four studies of group PTSD treatment within primary care were identified with 70 total patients completing group treatment. The weighted treatment engagement rate was 65%. Each utilized distinct group trauma treatment models and reported significant patient improvements in PTSD symptoms on standardized trauma symptom scales. DISCUSSION: Group trauma therapy models are available and can be disseminated within primary care settings. Limitations include both the small number of studies and participants. CONCLUSION: There have been few studies of group therapy for PTSD in primary care, but these could represent a promising and scalable approach to meet the high need for trauma treatment. Further research is needed regarding implementation feasibility and impact.

Gender differences in the longitudinal impact of exposure to violence on mental health in urban youth.

There is evidence of gender differences in psychopathology during adolescence, but little research has investigated gender differences in trauma-related symptoms. Exposure to violence is a commonly experienced potentially traumatic event among urban adolescents, and the few studies examining gender differences in its mental health impact have produced inconsistent findings. The present study examines the moderating effects of gender on the longitudinal association between exposure to violence and a variety of mental health symptoms (externalizing, internalizing, PTSD, dissociation) in a racially diverse urban adolescent sample (N = 615; 50.6% female; Time 1 mean age = 14.15; Time 2 mean age = 16.70). For both genders, exposure to violence prospectively predicted increases in all types of symptoms. Although boys reported more exposure to violence on average, girls experiencing violence were more likely to experience dissociative (but not PTSD, internalizing, or externalizing) symptoms. The results suggest that adolescent girls exposed to potentially traumatic events may be especially vulnerable to experiencing certain trauma-related symptoms and imply gender-specific pathways to trauma-related psychopathology.

Responding to COVID-19 through an integrated primary care/behavioral health program.

Background and Implementation: Novel coronavirus disease 2019 (COVID-19) has presented unique challenges for patients and health care systems, including a surge in behavioral health (BH) needs. A community teaching public hospital system in Massachusetts (MA) whose 13 primary care (PC) clinics serve a diverse patient population, has developed a model for Primary Care Behavioral Health Integration (PCBHI) to provide brief, evidence-based interventions to patients in PC. In response to COVID-19, the system developed an intensive community management strategy to care for patients with COVID-19 outside of the hospital, and its PCBHI program adapted alongside this strategy to provide rapid support to patients in emotional distress. Over a 13-week period, 78 patients were specifically referred to the PCBHI COVID clinic and received rapid therapeutic support and/or care navigation. Recommendations: This article will discuss the development and implementation of the PCBHI COVID clinic, common presenting issues and clinical interventions used, and lessons that informed our adaptation of clinic operations and that can serve as recommendations to other health systems in establishing similar services. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Disorganized Attachment Interactions Among Young Adults With Borderline Personality Disorder, Other Diagnoses, and No Diagnosis.

Theorists have suggested that attachment disorganization contributes to the development of borderline personality disorder (BPD). However, few studies have directly observed attachment-related interactions with parents. This study used a newly developed attachment-based coding system to examine whether individuals with BPD were more likely to exhibit disorganized interactions with their mothers than those with (a) other diagnoses (anxiety, depressive, or substance use diagnoses) or (b) no diagnosis. Results indicated that participants with BPD had a greater likelihood of disorganized attachment interactions than did both comparison groups. The odds ratio for disorganized attachment among BPD participants was almost 8 times that of participants without BPD. These results underscore the utility of observational assessments to capture the interpersonal features of BPD and highlight the potential value of examining the developmental trajectories of disorganized and controlling attachment behavior in order to identify pathways toward BPD.

Prospective risk factors for adolescent PTSD: sources of differential exposure and differential vulnerability.

There are two types of risk factors for developing PTSD: factors that increase the likelihood of experiencing a potentially traumatizing event and factors that increase the likelihood of developing symptoms following such events. Using prospective data over a two-year period from a large, diverse sample of urban adolescents (n = 1242, Mean age = 13.5), the current study differentiates these two sources of risk for developing PTSD in response to violence exposure. Five domains of potential risk and protective factors were examined: community context (e.g., neighborhood poverty), family risk (e.g., family conflict), behavioral maladjustment (e.g., internalizing symptoms), cognitive vulnerabilities (e.g., low IQ), and interpersonal problems (e.g., low social support). Time 1 interpersonal violence history, externalizing behaviors, and association with deviant peers were the best predictors of subsequent violence, but did not further increase the likelihood of PTSD in response to violence. Race/ethnicity, thought disorder symptoms, and social problems were distinctly predictive of the development of PTSD following violence exposure. Among youth exposed to violence, Time 1 risk factors did not predict specific event features associated with elevated PTSD rates (e.g., parent as perpetrator), nor did interactions between Time 1 factors and event features add significantly to the prediction of PTSD diagnosis. Findings highlight areas for refinement in adolescent PTSD symptom measures and conceptualization, and provide direction for more targeted prevention and intervention efforts.