Brief conjoint visits between an embedded behavioral health provider and primary care team member: When are they used and what are the barriers and facilitators?

INTRODUCTION: Conjoint visits utilize the expertise of primary care providers (PCPs) and behavioral health providers (BHPs) to address complex comorbidities in patients. The objectives were to describe the use and features of conjoint visits and identify barriers and facilitators as described by BHPs in integrated settings. METHOD: Three hundred and forty-five BHPs who worked in integrated primary care, a majority identifying as female and white, completed an online survey between October 2018 and July 2019. RESULTS: Results indicated common reasons for conjoint visits were for mental or behavioral health concerns. Though they reported high comfort using conjoint visits (M = 4.3/5), 56.5% of BHPs participated in them less than monthly or never. Using a constant comparison approach, qualitative data were coded to reveal six categories of barriers and five categories of facilitators to conjoint visits. The most common barriers were a result of a lack of systemic support, such as 73.5% reporting lack of time, while the most common facilitators were coordination (60.7%) and interprofessional communication (39.3%). DISCUSSION: Although conjoint visits are used infrequently, findings suggest it is not because they are unhelpful as providers generally found this type of appointment favorable. Rather, they and their teams lack time, training, and support needed for implementation. This research provides an introduction for researchers or clinicians to better understand the use of conjoint visits for patients with high needs and complexities. Future work focused on addressing barriers cited by providers regarding conjoint visits would increase providers' ability to use this form of care when it is needed. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Can Alcohol Use Disorder Recovery Include Some Heavy Drinking? A Replication and Extension up to 9 Years Following Treatment.

BACKGROUND: Recent research indicates some individuals who engage in heavy drinking following treatment for alcohol use disorder fare as well as those who abstain with respect to psychosocial functioning, employment, life satisfaction, and mental health. The current study evaluated whether these findings replicated in an independent sample and examined associations between recovery profiles and functioning up to 6 years later. METHODS: Data were from the 3-year and 7- to 9-year follow-ups of subsamples initially recruited for the COMBINE study (3-year follow-up: n = 694; 30.1% female, 21.0% non-White; 7- to 9-year follow-up: n = 127; 38.9% female, 27.8% non-White). Recovery at 3 years was defined by latent profile analyses including measures of health functioning, quality of life, employment, alcohol consumption, and cannabis and other drug use. Functioning at the 7- to 9-year follow-up was assessed using single items of self-rated general health, hospitalizations, and alcohol consumption. RESULTS: We identified 4 profiles at the 3-year follow-up: (i) low-functioning frequent heavy drinkers (13.9%), (ii) low-functioning infrequent heavy drinkers (15.8%), (iii) high-functioning heavy drinkers (19.4%), and (iv) high-functioning infrequent drinkers (50.9%). At the 7- to 9-year follow-up, the 2 high-functioning profiles had the best self-rated health, and the high-functioning heavy drinking profile had significantly fewer hospitalizations than the low-functioning frequent heavy drinking profile. CONCLUSIONS: Previous findings showing heterogeneity in recovery outcomes were replicated. Most treatment recipients functioned well for years after treatment, and a subset who achieved stable recovery engaged in heavy drinking and reported good health outcomes up to 9 years after treatment. Results question the long-standing emphasis on drinking practices as a primary outcome, as well as abstinence as a recovery criterion in epidemiologic and treatment outcome research and among stakeholder groups and funding/regulatory agencies. Findings support an expanded recovery research agenda that considers drinking patterns, health, life satisfaction, and functioning.

Integrated stepped alcohol treatment for patients with HIV and at-risk alcohol use: a randomized trial.

BACKGROUND: At-risk levels of alcohol use threaten the health of patients with HIV (PWH), yet evidence-based strategies to decrease alcohol use and improve HIV-related outcomes in this population are lacking. We examined the effectiveness of integrated stepped alcohol treatment (ISAT) on alcohol use and HIV outcomes among PWH and at-risk alcohol use. METHODS: In this multi-site, randomized trial conducted between January 28, 2013 through July 14, 2017, we enrolled PWH and at-risk alcohol use [defined as alcohol consumption of ≥ 14 drinks per week or ≥ 4 drinks per occasion in men ≤ 65 years old or ≥ 7 drinks per week or ≥ 3 drinks per occasion in women or men > 65 years old]. ISAT (n = 46) involved: Step 1- Brief Negotiated Interview with telephone booster, Step 2- Motivational Enhancement Therapy, and Step 3- Addiction Physician Management. Treatment as usual (TAU) (n = 47) involved receipt of a health handout plus routine care. Analyses were conducted based on intention to treat principles. RESULTS: Despite a multi-pronged approach, we only recruited 37% of the target population (n = 93/254). Among ISAT participants, 50% advanced to Step 2, among whom 57% advanced to Step 3. Participants randomized to ISAT and TAU had no observed difference in drinks per week over the past 30 days at week 24 (primary outcome) [least square means (Ls mean) (95% CI) = 8.8 vs. 10.6; adjusted mean difference (AMD) (95% CI) = - 0.4 (- 3.9, 3.0)]. CONCLUSION: An insufficient number of patients were interested in participating in the trial. Efforts to enhance motivation of PWH with at-risk alcohol use to engage in alcohol-related research and build upon ISAT are needed. Trial registration Clinicaltrials.gov: NCT01410123, First posted August 4, 2011.

Integrated stepped alcohol treatment for patients with HIV and liver disease: A randomized trial.

BACKGROUND: There is no known safe level of alcohol use among patients with HIV and liver disease. We examined the effectiveness of integrated stepped alcohol treatment (ISAT) on alcohol use, HIV, and liver outcomes among patients with HIV and liver disease. METHODS: In this multi-site, randomized trial conducted between January 28, 2013 through July 15, 2016, we enrolled 95 patients with HIV and liver disease [defined as having active hepatitis C infection or FIB-4 score > 1.45]. ISAT (n = 49) involved: Step 1- Brief Negotiated Interview with telephone booster, Step 2- Motivational Enhancement Therapy, and Step 3- Addiction Physician Management. Treatment as usual (TAU) (n = 46) involved receipt of a health handout plus routine care. Analyses were conducted based on intention to treat. RESULTS: Among ISAT participants, 55% advanced to Step 2, among whom 70% advanced to Step 3. Participants randomized to ISAT and TAU increased abstinence (primary outcome) over time. Abstinence rates were non-significantly higher by self-report (38% vs. 23%, adjusted odds ratio [AOR] [95% CI] = 2.6 [0.8, 9.0]) and phosphatidylethanol (43% vs. 32%, AOR [95% CI] = 1.8 [0.5, 6.3] among those randomized to ISAT vs. TAU at week 24. VACS Index scores (AMD [95% CI] = 1.1 [-3.2, 5.5]) and the proportion with an undetectable HIV viral load (AOR [95% CI] = 0.3 [0.1, 1.3]) did not differ by group at week 24 (p values >0.05). ISAT had non-significantly lower FIB-4 scores (adjusted mean difference [AMD] [95% CI] = -0.2 [-0.9, 0.5]), ALT (AMD [95% CI] = -7 [-20, 7]) and AST (AMD [95% CI] = -4 [-15, 7]) at week 24 compared to TAU. CONCLUSION: ISAT is feasible and potentially effective at enhancing delivery of evidence-based alcohol treatment to promote alcohol abstinence and improve liver biomarkers among patients with HIV and liver disease.

Motivation Precedes Goal Setting in Prediction of Cannabis Treatment Outcomes in Adolescents.

Studies have shown that motivation to change is related to better substance use outcomes among treatment-seeking adolescents. Goal setting, which may be related to motivation, also has been shown to be associated with positive treatment outcomes. However, relationships between motivation and goal setting as mediators of change in cannabis use over time among treated youth have not been investigated. This study tested direct and indirect associations of motivation and goal setting with cannabis use frequency over 12 month follow-up among treated adolescents. A longitudinal study of 163 adolescents enrolled in intensive outpatient substance use treatment (mean age = 16.69, 34% female, 87% Caucasian) provided repeated assessment of motivation, goal setting, and cannabis use. Path analysis tested direct and indirect effects of motivation and goal setting on cannabis use. A comparison of two path models that tested motivation and goal setting independently showed that goal setting had better model fit and accounted for more of the variance in 6-month (R2 = .35) and 12-month (R2 = .46) cannabis use frequency than motivation (R2 = .28, .44, respectively). When both mediators were included in the same model, better model fit was found for motivation preceding goal setting in the context of double mediation. Overall, results suggest that goal setting, or the combination of motivation preceding goal setting in a double mediation model, predicted lower cannabis use in treated adolescents.

Veterans' mental health beliefs: Facilitators and barriers to primary care-mental health use.

INTRODUCTION: The Veterans Health Administration (VA) Primary Care-Mental Health Integration (PC-MHI) program aims to increase availability and acceptability of mental health (MH) care by integrating these services into primary care. Little is known about veterans' perceptions of this of method MH care delivery. This study explored the range of veterans' beliefs and perceptions of MH and MH services with the aim of describing potential facilitators and barriers to the uptake of PC-MHI services. METHOD: Team-based qualitative analysis of proceedings from focus groups. Participants included 41 veterans from across service eras. Focus groups were organized by service era and use of PC-MHI services. Codes pertaining to beliefs about MH and MH treatment were identified, grouped into subthemes, and then larger organizing themes. Barriers and facilitators to treatment seeking were identified. RESULTS: Although our study was focused on veteran perceptions of PC-MHI, participants did not appear to discriminate between PC-MHI and other MH services when discussing their decisions to seek services. Facilitators and barriers to MH treatment-seeking included systems, personal and social influences. Stigma was mentioned infrequently relative to other beliefs. DISCUSSION: Veterans with and without experience of PC-MHI services described a variety of beliefs about MH without regard to whether this service location. These findings suggest that while integration increases access, it may not in itself decrease some barriers to seeking treatment. These findings suggest that more work is needed to address the way potential PC-MHI patients decide whether or not to engage in care. (PsycINFO Database Record

Time-varying associations between confidence and motivation to abstain from marijuana during treatment among adolescents.

INTRODUCTION: An important goal of addictions treatment is to develop a positive association between high levels of confidence and motivation to abstain from substance use. This study modeled the time-varying association between confidence and motivation to abstain from marijuana use among youth in treatment, and the time-varying effect of pre-treatment covariates (marijuana abstinence goal and perceived peer marijuana use) on motivation to abstain. METHOD: 150 adolescents (75% male, 83% White) in community-based intensive outpatient treatment in Pennsylvania completed a pre-treatment assessment of abstinence goal, perceived peer marijuana use, and motivation and confidence to abstain from marijuana. Ratings of motivation and confidence to abstain also were collected after each session. A time-varying effect model (TVEM) was used to characterize changes in the association between confidence and motivation to abstain (lagged), and included covariates representing pre-treatment abstinence goal and perceived peer marijuana use. RESULTS: Confidence and motivation to abstain from marijuana generally increased during treatment. The association between confidence and motivation strengthened across sessions 1-4, and was maintained through later sessions. Pre-treatment abstinence goal had an early time-limited effect (through session 6) on motivation to abstain. Pre-treatment perception of peer marijuana use had a significant effect on motivation to abstain only at session 2. CONCLUSIONS: Early treatment sessions represent a critical period during which the association between confidence and motivation to abstain generally increased. The time-limited effects of pre-treatment characteristics suggest the importance of early sessions in addressing abstinence goal and peer substance use that may impact motivation to abstain from marijuana.

Personal Network Characteristics of Youth in Substance Use Treatment: Motivation for and Perceived Difficulty of Positive Network Change.

BACKGROUND: Among youth in substance use treatment, peer substance use consistently predicts worse treatment outcomes. This study characterized personal (egocentric) networks of treated youth and examined predictors of adolescents' motivation and perceived difficulty in making changes in the peer network to support recovery. METHODS: Adolescents (aged 14-18; N = 155) recruited from substance use treatment reported on substance use severity, motivation to abstain from substance use, abstinence goals such as "temporary abstinence," motivation and perceived difficulty in reducing contact with substance-using peers, and personal network characteristics. Personal network variables included composition (proportion of abstinent peers) and structure (number of network members, extent of ties among members) for household and nonhousehold (peer) members. RESULTS: Although a majority of peer network members were perceived as using alcohol or marijuana, youth in treatment had relatively high motivation to abstain from substance use. However, treated youths' motivation to reduce contact with substance-using peers was relatively low. In particular, a goal of temporary abstinence was associated with lower motivation to change the peer network. For marijuana, specifically, network composition features (proportion of abstinent peers) were associated with motivation and perceived difficulty to change the peer network. For marijuana, in particular, network structural variables (extent of ties among members) were associated only with perceived difficulty of changing the peer network. CONCLUSIONS: Despite high motivation to abstain from substance use during treatment, adolescents reported low motivation to reduce contact with substance-using peers. Personal motivation to abstain and abstinence goal predicted motivation to reduce contact with substance-using peers. In contrast, particularly for marijuana, network structure predicted perceived difficulty of network change. Results highlight the potential utility of addressing motivation and perceived difficulty to change the peer network as part of youth network-based interventions.

Serotonin Transporter Genotype Linked to Adolescent Substance Use Treatment Outcome through Externalizing Behavior.

Meta-analyses suggest that the serotonin transporter linked polymorphic region (5-HTTLPR) short (S) allele, relative to the long (L) allele, is associated with risk for alcohol dependence, particularly among individuals with early onset antisocial alcoholism. Youth in substance use treatment tend to show antisocial or externalizing behaviors, such as conduct problems, which predict worse treatment outcome. This study examined a pathway in which 5-HTTLPR genotype is associated with externalizing behavior, and the intermediate phenotype of externalizing behavior serves as a link between 5-HTTLPR genotype and substance use treatment outcome in youth. Adolescents (n = 142) who were recruited from addictions treatment were genotyped for 5-HTTLPR polymorphisms (S and LG carriers vs. LALA), assessed for externalizing and internalizing behaviors shortly after starting treatment, and followed over 6-months. 5-HTTLPR genotype was not associated with internalizing behaviors, and was not directly associated with 6-month substance use outcomes. However, 5-HTTLPR genotype was associated with externalizing behaviors (S and LG > LALA), and externalizing behaviors predicted alcohol and marijuana problem severity at 6-month follow-up. Results indicated an indirect (p < 0.05) and non-specific (i.e., both alcohol and marijuana severity) effect of 5-HTTLPR genotype on youth substance use treatment outcomes, with externalizing behaviors as an important linking factor. Adolescents in substance use treatment with low expressing (S and LG) 5-HTTLPR alleles and externalizing behavior might benefit from intervention that addresses serotonergic functioning, externalizing behaviors, and substance use to improve outcomes.

Provider practices in the primary care behavioral health (PCBH) model: an initial examination in the Veterans Health Administration and United States Air Force.

The goals of this study were to identify characteristics of both behavioral health providers (BHPs) and the patients seen in a primary care behavioral health (PCBH) model of service delivery using prospective data obtained from BHPs. A secondary objective was to explore similarities and differences between these variables within the Veterans Health Administration (VHA) and United States Air Force (USAF) primary care clinics. A total of 159 VHA and 23 USAF BHPs, representing almost every state in the United States, completed the study, yielding data from 403 patient appointments. BHPs completed a web-based questionnaire that assessed BHP and setting characteristics, and a separate questionnaire after each patient seen on one day of clinical service. Data demonstrated that there are many similarities between the VHA and USAF BHPs and practices. Both systems tend to use well-trained psychologists as BHPs, had systems that support the BHP being in close proximity to the primary care providers, and have seamless operational elements (i.e., shared record, one waiting room, same-day appointments, and administrative support for BHPs). Comorbid anxiety and depression was the most common presenting problem in both systems, but overall rates were higher in VHA clinics, and patients were significantly more likely to meet diagnostic criteria for mental health conditions. This study provides the first systematic, prospective examination of BHPs and practices within a PCBH model of service delivery in two large health systems with well over 5 years of experience with behavioral health integration. Many elements of the PCBH model were implemented in a manner consistent with the model, although some variability exists within both settings. These data can help guide future implementation and training efforts.

Behavioral health interventions being implemented in a VA primary care system.

The integration of behavioral health and primary care has received much attention in the literature. Behavioral health providers (BHPs) in integrated settings are faced with different treatment constraints than those who work in specialty mental health. The existing literature focuses on what BHPs should do in primary care settings; however, little research exists specifying what BHPs are actually doing. This study provides a glimpse into what types of interventions BHPs are using, and what types of patients they are seeing, in primary care. A chart review was conducted of patients (N = 180) seen by BHPs in five Veterans Affairs primary care clinics. Depression was the most common diagnosis, while less common presenting problems included substance abuse/dependence, psychosis, and bipolar disorder. Common interventions used were medical management, psycho-education, elements of cognitive-behavioral therapy (CBT), and supportive psychotherapy. Future research should examine the efficacy of brief interventions in primary care settings.

The description and evaluation of the implementation of an integrated healthcare model.

Two studies were conducted to examine the practical implementation of an integrated health care model in five primary care clinics in the Upstate New York Veterans Affairs (VA) system. The aims of the studies were: (a) to describe the basic clinical elements of the integrated health care service offered by behavioral health providers (BHPs) in the primary care setting, and (b) to evaluate the perceptions of providers and patients regarding integrated health care practices in their primary care clinics. In Study 1, we reviewed 180 electronic medical records of patients who met with a BHP in primary care. In Study 2, we used semistructured interviews and self-report questionnaires to collect information from 46 primary care providers, 12 BHPs, and 140 patients regarding their perceptions of integrated health care in their primary care clinics. Both studies illustrate a useful method for evaluating the practical implementation of integrated health care models.

Adolescents' thoughts about abstinence curb the return of marijuana use during and after treatment.

Despite evidence showing that readiness to change substance use predicts reductions in substance use among treated adolescents, there is little research on changes in thoughts about abstinence and marijuana use during and after treatment. The current study tested whether time-varying changes in adolescents' motivation to abstain and perceived difficulty to abstain from marijuana use hinder the return of regular marijuana use during and after treatment. Monthly data on thoughts about abstinence, marijuana use, and treatment utilization were collected over 6 months from 142 adolescents recruited from intensive outpatient substance use treatment. Results indicated that higher motivation to abstain (but not perceived difficulty) predicted fewer days of marijuana use, over and above the individual's average trajectory of marijuana use, the initial severity of marijuana involvement, and the effects of treatment utilization. Moreover, past-month marijuana use influenced both motivation to abstain and perceived difficulty to abstain. Findings highlight the importance of abstinence-related cognitions as a target of intervention during and after treatment and underscore the importance of considering recovery from substance use disorders as a dynamic process of change over time.

"What I got from treatment": predictors of treatment content received and association of treatment content with 6-month outcomes in adolescents.

Some adolescents show a greater response to treatment than others. We examined the extent to which amount of treatment content received was associated with certain patient characteristics (e.g., readiness to change) and severity of substance involvement at 6-month follow-up. Adolescents (N = 107) recruited from outpatient addiction treatment reported at follow-up on the extent to which treatment addressed addictive behaviors (e.g., getting motivated to change) and other concerns (e.g., depression). Contrary to prediction, readiness to change did not predict amount of treatment content received, but greater number of inpatient days during follow-up predicted greater endorsement of addictive behaviors content. At 6 months, more addictive behaviors content received was associated with fewer alcohol symptoms. For both alcohol and marijuana, greater endorsement of treatment content related to other concerns was associated with greater substance involvement at 6 months, suggesting the importance of evaluating and addressing other concerns because youth may present with problems in multiple domains.

Rapid relapse generally follows treatment for substance use disorders among adolescents.

This prospective study involved 59 adolescents with drug and alcohol disorders who had just completed outpatient treatment. They participated in a comprehensive baseline assessment, and then participated in monthly telephone assessments of substance use and reasons for use. Despite their recent treatment, two-thirds (66%) of the participants in this study had relapsed to drug use within 6 months. The median time to drug relapse was only 54 days (+/-14 days), or slightly less than 2 months. The three most commonly given reasons for relapse were social pressure, withdrawal, and negative affect. These findings provide a first confirmation of the results of S.A. Brown [Recovery patterns in adolescent substance abuse. (1993). In J. S. Baer, G. A. Marlatt, & R. J. McMahon (Eds.), Addictive behaviors across the life span (pp. 160-183). London: SAGE.] in showing that most adolescents relapse quickly following treatment for substance use disorders.