Bipolar Disorder.

Bipolar disorder (BD) affects approximately 2% of U.S. adults and is the most costly mental health condition for commercial insurers nationwide. Rates of BD are elevated among persons with depression, anxiety disorders, and substance use disorders-conditions frequently seen by primary care clinicians. In addition, antidepressants can precipitate manic or hypomanic symptoms or rapid cycling in persons with undiagnosed BD. Thus, screening in these high-risk groups is indicated. Effective treatments exist, and many can be safely and effectively administered by primary care clinicians.

Utilizing Digital Storytelling to Develop a Public Health Professions Pathway for Native American High School Students.

Digital storytelling is a decentering methodology in health promotion that positions the storyteller as an expert to create a narrative of their lived experiences. This article describes using a two-phase digital storytelling process within the Diné (Navajo) Educational Philosophy framework to guide the development of a culturally grounded curriculum plan that actively engages Diné youth in exploring health professions pathways in their community. The first phase consisted of developing a high school digital storytelling team by training three Diné youth attending high school on the Navajo Nation located in southwest United States, in digital storytelling. In the second phase, the high school digital storytelling team worked collaboratively with seven Diné students enrolled at the local tribal college to develop digital stories about navigating from high school to college. Data from seven completed digital stories were analyzed with assistance from a community advisory board to identify asset-based themes that contributed to positively transitioning from high school to a tribal college. The results revealed several strategies for successful transitions from high school to a public health college major. The culturally relevant strategies and stories were incorporated into a school-based health professions pathway curriculum plan for Diné youth.

Provider Perceptions of Virtual Care During the Coronavirus Disease 2019 Pandemic: A Multispecialty Survey Study.

BACKGROUND: The coronavirus disease 2019 (COVID-19) pandemic has led to a dramatic increase in virtual care (VC) across outpatient specialties, but little is known regarding provider acceptance of VC. OBJECTIVE: The objective of this study was to assess provider perceptions of the quality, efficiency, and challenges of VC versus in-person care with masks. DESIGN: This was a voluntary survey. PARTICIPANTS: Mental health (MH), primary care, medical specialty, and surgical specialty providers across the 8 VA New England Healthcare System medical centers. MEASURES: Provider ratings of: (1) quality and efficiency of VC (phone and video telehealth) compared with in-person care with masks; (2) challenges of VC; and (3) percentage of patients that providers are comfortable seeing via VC in the future. RESULTS: The sample included 998 respondents (49.8% MH, 20.6% primary care, 20.4% medical specialty, 9.1% surgical specialty; 61% response rate). Most providers rated VC as equivalent to or higher in quality and efficiency compared with in-person care with masks. Quality ratings were significantly higher for video versus phone (χ2=61.4, P<0.0001), but efficiency ratings did not differ significantly. Ratings varied across specialties (highest in MH, lowest in SS; all χ2s>24.1, Ps<0.001). Inability to conduct a physical examination and patient technical difficulties were significant challenges. MH providers were comfortable seeing a larger proportion of patients virtually compared with the other specialties (all χ2s>12.2, Ps<0.01). CONCLUSIONS: Broad provider support for VC was stratified across specialties, with the highest ratings in MH and lowest ratings in SS. Findings will inform the improvement of VC processes and the planning of health care delivery during the COVID-19 pandemic and beyond.

Rapid Increase in Telemental Health Within the Department of Veterans Affairs During the COVID-19 Pandemic.

Background: The use of telemental health via videoconferencing (TMH-V) became critical during the Coronavirus disease 2019 (COVID-19) pandemic due to restriction of non-urgent in-person appointments. The current brief report demonstrates the rapid growth in TMH-V appointments in the weeks following the pandemic declaration within the Department of Veterans Affairs (VA), the largest healthcare system in the United States. Methods: COVID-19 changes in TMH-V appointments were captured during the six weeks following the World Health Organization's pandemic declaration (March 11, 2020-April 22, 2020). Pre-COVID-19 TMH-V encounters were assessed from October 1, 2017 to March 10, 2020. Results: Daily TMH-V encounters rose from 1,739 on March 11 to 11,406 on April 22 (556% growth, 222,349 total encounters). Between March 11-April 22, 114,714 patients were seen via TMH-V, and 77.5% were first-time TMH-V users. 12,342 MH providers completed a TMH-V appointment between March 11-April 22, and 34.7% were first-time TMH-V users. The percentage growth of TMH-V appointments was higher than the rise in telephone appointments (442% growth); in-person appointments dropped by 81% during this time period. Discussion and Conclusions: The speed of VA's growth in TMH-V appointments in the wake of the COVID-19 pandemic was facilitated by its pre-existing telehealth infrastructure, including earlier national efforts to increase the number of providers using TMH-V. Longstanding barriers to TMH-V implementation were lessened in the context of a pandemic, during which non-urgent in-person MH care was drastically reduced. Future work is necessary to understand the extent to which COVID-19 related changes in TMH-V use may permanently impact mental health care provision.

Roles of Key Ion Channels and Transport Proteins in Age-Related Hearing Loss.

The auditory system is a fascinating sensory organ that overall, converts sound signals to electrical signals of the nervous system. Initially, sound energy is converted to mechanical energy via amplification processes in the middle ear, followed by transduction of mechanical movements of the oval window into electrochemical signals in the cochlear hair cells, and finally, neural signals travel to the central auditory system, via the auditory division of the 8th cranial nerve. The majority of people above 60 years have some form of age-related hearing loss, also known as presbycusis. However, the biological mechanisms of presbycusis are complex and not yet fully delineated. In the present article, we highlight ion channels and transport proteins, which are integral for the proper functioning of the auditory system, facilitating the diffusion of various ions across auditory structures for signal transduction and processing. Like most other physiological systems, hearing abilities decline with age, hence, it is imperative to fully understand inner ear aging changes, so ion channel functions should be further investigated in the aging cochlea. In this review article, we discuss key various ion channels in the auditory system and how their functions change with age. Understanding the roles of ion channels in auditory processing could enhance the development of potential biotherapies for age-related hearing loss.

An Economic Analysis of the Implementation of Team-based Collaborative Care in Outpatient General Mental Health Clinics.

BACKGROUND: Collaborative Chronic Care Models represent an evidence-based way to structure care for chronic conditions, including mental health conditions. Few studies, however, have examined the cost implications of collaborative care for mental health. OBJECTIVE: We aimed to conduct an economic analysis of implementing collaborative care in 9 outpatient general mental health clinics. RESEARCH DESIGN: Analyses were derived from a stepped wedge hybrid implementation-effectiveness trial. We conducted cost-minimization analyses from the health system perspective, incorporating implementation costs, outpatient costs, and inpatient costs for the year before collaborative care implementation and the implementation year. We used a difference-in-differences approach and conducted 1-way sensitivity analyses to determine the robustness of results to variations ±15% in model parameters, along with probabilistic sensitivity analysis using Monte Carlo simulation. SUBJECTS: Our treatment group included 5507 patients who were initially engaged in care within 9 outpatient general mental health teams that underwent collaborative care implementation. We compared costs for this group to 45,981 control patients who received mental health treatment as usual at the same medical centers. RESULTS: Collaborative care implementation cost about $40 per patient and was associated with a significant decrease in inpatient costs and a nonsignificant increase in outpatient mental health costs. This implementation was associated with $78 in cost savings per patient. Monte Carlo simulation suggested that implementation was cost saving in 78% of iterations. CONCLUSIONS: Collaborative care implementation for mental health teams was associated with significant reductions in mental health hospitalizations, leading to substantial cost savings of about $1.70 for every dollar spent for implementation.

Nonpharmacological Treatment of Army Service Members with Chronic Pain Is Associated with Fewer Adverse Outcomes After Transition to the Veterans Health Administration.

BACKGROUND: Potential protective effects of nonpharmacological treatments (NPT) against long-term pain-related adverse outcomes have not been examined. OBJECTIVE: To compare active duty U.S. Army service members with chronic pain who did/did not receive NPT in the Military Health System (MHS) and describe the association between receiving NPT and adverse outcomes after transitioning to the Veterans Health Administration (VHA). DESIGN AND PARTICIPANTS: A longitudinal cohort study of active duty Army service members whose MHS healthcare records indicated presence of chronic pain after an index deployment to Iraq or Afghanistan in the years 2008-2014 (N = 142,539). Propensity score-weighted multivariable Cox proportional hazard models tested for differences in adverse outcomes between the NPT group and No-NPT group. EXPOSURES: NPT received in the MHS included acupuncture/dry needling, biofeedback, chiropractic care, massage, exercise therapy, cold laser therapy, osteopathic spinal manipulation, transcutaneous electrical nerve stimulation and other electrical manipulation, ultrasonography, superficial heat treatment, traction, and lumbar supports. MAIN MEASURES: Primary outcomes were propensity score-weighted proportional hazards for the following adverse outcomes: (a) diagnoses of alcohol and/or drug disorders; (b) poisoning with opioids, related narcotics, barbiturates, or sedatives; (c) suicide ideation; and (d) self-inflicted injuries including suicide attempts. Outcomes were determined based on ICD-9 and ICD-10 diagnoses recorded in VHA healthcare records from the start of utilization until fiscal year 2018. KEY RESULTS: The propensity score-weighted proportional hazards for the NPT group compared to the No-NPT group were 0.92 (95% CI 0.90-0.94, P < 0.001) for alcohol and/or drug use disorders; 0.65 (95% CI 0.51-0.83, P < 0.001) for accidental poisoning with opioids, related narcotics, barbiturates, or sedatives; 0.88 (95% CI 0.84-0.91, P < 0.001) for suicide ideation; and 0.83 (95% CI 0.77-0.90, P < 0.001) for self-inflicted injuries including suicide attempts. CONCLUSIONS: NPT provided in the MHS to service members with chronic pain may reduce risk of long-term adverse outcomes.

Weaving the Strands of Life (Iiná Bitl'ool): History of Genetic Research Involving Navajo People.

To date, some genetic studies offer medical benefits but lack a clear pathway to benefit for people from underrepresented backgrounds. Historically, Indigenous people, including the Diné (Navajo people), have raised concerns about the lack of benefits, misuse of DNA samples, lack of consultation, and ignoring of cultural and traditional ways of knowing. Shortly after the Navajo Nation Human Research Review Board was established in 1996, the Navajo Nation recognized growing concerns about genetic research, and in 2002 they established a moratorium on human genetic research studies. The moratorium effectively has protected their citizens from potential genetic research harms. Despite the placement of the moratorium, some genetic research studies have continued using blood and DNA samples from Navajo people. To understand the history of genetic research involving Navajo people, the authors conducted a literature review of genetic or genetics-related research publications that involved Navajo people, identifying 79 articles from the years 1926 to 2018. To their knowledge, no known literature review has comprehensively examined the history of genetic research in the Navajo community. This review divides the genetic research articles into the following general classifications: bacteria or virus genetics, blood and human leukocyte antigens, complex diseases, forensics, hereditary diseases, and population genetics and migration. The authors evaluated the methods reported in each article, described the number of Navajo individuals reported, recorded the academic and tribal approval statements, and noted whether the study considered Diné cultural values. Several studies focused on severe combined immunodeficiency disease, population history, neuropathy, albinism, and eye and skin disorders that affect Navajo people. The authors contextualize Diné ways of knowing related to genetics and health with Western scientific concepts to acknowledge the complex philosophy and belief system that guides Diné people and recognizes Indigenous science. They also encourage researchers to consider cultural perspectives and traditional knowledge that has the potential to create stronger conclusions and better-informed, ethical, and respectful science.

External facilitators' perceptions of internal facilitation skills during implementation of collaborative care for mental health teams: a qualitative analysis informed by the i-PARIHS framework.

BACKGROUND: Facilitation is a key strategy that may contribute to successful implementation of healthcare innovations. In blended facilitation, external facilitators (EFs) guide and support internal facilitators (IFs) in directing implementation processes. Developers of the i-PARIHS framework propose that successful facilitation requires project management, team/process, and influencing/negotiating skills. It is unclear what IF skills are most important in real-world settings, which could inform recruitment and training efforts. As prior qualitative studies of IF skills have only interviewed IFs, the perspectives of their EF partners are needed. Furthermore, little is known regarding the distribution of implementation tasks between IFs and EFs, which could impact sustainability once external support is removed. In the context of an implementation trial, we therefore: 1) evaluated IFs' use of i-PARIHS facilitation skills, from EFs' perspectives; 2) identified attributes of IFs not encompassed within the i-PARIHS skills; and 3) investigated the relative contributions of IFs and EFs during facilitation. METHODS: Analyses were conducted within a hybrid type II trial utilizing blended facilitation to implement the collaborative chronic care model within mental health teams of nine VA medical centers. Each site committed one team and an IF to weekly process design meetings and additional implementation activities over 12 months. Three EFs worked with three sites each. Following study completion, the EFs completed semi-structured qualitative interviews reflecting on the facilitation process, informed by the i-PARIHS facilitation skill areas. Interviews were analyzed via directed content analysis. RESULTS: EFs emphasized the importance of IFs having strong project management, team/process, and influencing/negotiating skills. Prior experience in these areas and a mental health background were also benefits. Personal characteristics (e.g., flexible, assertive) were described as critical, particularly when faced with conflict. EFs discussed the importance of clear delineation of EF/IF roles, and the need to shift facilitation responsibilities to IFs. CONCLUSIONS: Key IF skills, according to EFs, are aligned with i-PARIHS recommendations, but IFs' personal characteristics were also emphasized as important factors. Findings highlight traits to consider when selecting IFs and potential training areas (e.g., conflict management). EFs and IFs must determine an appropriate distribution of facilitation tasks to ensure long-term sustainability of practices. TRIAL REGISTRATION: Clinicaltrials.gov, September 7, 2015, #NCT02543840.

Change in Patient Outcomes After Augmenting a Low-level Implementation Strategy in Community Practices That Are Slow to Adopt a Collaborative Chronic Care Model: A Cluster Randomized Implementation Trial.

BACKGROUND: Implementation strategies are essential for promoting the uptake of evidence-based practices and for patients to receive optimal care. Yet strategies differ substantially in their intensity and feasibility. Lower-intensity strategies (eg, training and technical support) are commonly used but may be insufficient for all clinics. Limited research has examined the comparative effectiveness of augmentations to low-level implementation strategies for nonresponding clinics. OBJECTIVES: To compare 2 augmentation strategies for improving uptake of an evidence-based collaborative chronic care model (CCM) on 18-month outcomes for patients with depression at community-based clinics nonresponsive to lower-level implementation support. RESEARCH DESIGN: Providers initially received support using a low-level implementation strategy, Replicating Effective Programs (REP). After 6 months, nonresponsive clinics were randomized to add either external facilitation (REP+EF) or external and internal facilitation (REP+EF/IF). MEASURES: The primary outcome was patient 12-item short form survey (SF-12) mental health score at month 18. Secondary outcomes were patient health questionnaire (PHQ-9) depression score at month 18 and receipt of the CCM during months 6 through 18. RESULTS: Twenty-seven clinics were nonresponsive after 6 months of REP. Thirteen clinics (N=77 patients) were randomized to REP+EF and 14 (N=92) to REP+EF/IF. At 18 months, patients in the REP+EF/IF arm had worse SF-12 [diff, 8.38; 95% confidence interval (CI), 3.59-13.18] and PHQ-9 scores (diff, 1.82; 95% CI, -0.14 to 3.79), and lower odds of CCM receipt (odds ratio, 0.67; 95% CI, 0.30-1.49) than REP+EF patients. CONCLUSIONS: Patients at sites receiving the more intensive REP+EF/IF saw less improvement in mood symptoms at 18 months than those receiving REP+EF and were no more likely to receive the CCM. For community-based clinics, EF augmentation may be more feasible than EF/IF for implementing CCMs.

The Collaborative Chronic Care Model for Mental Health Conditions: From Evidence Synthesis to Policy Impact to Scale-up and Spread.

BACKGROUND: Extensive evidence indicates that Collaborative Chronic Care Models (CCMs) improve outcome in chronic medical conditions and depression treated in primary care. Beginning with an evidence synthesis which indicated that CCMs are also effective for multiple mental health conditions, we describe a multistage process that translated this knowledge into evidence-based health system change in the US Department of Veterans Affairs (VA). EVIDENCE SYNTHESIS: In 2010, recognizing that there had been numerous CCM trials for a wide variety of mental health conditions, we conducted an evidence synthesis compiling randomized controlled trials of CCMs for any mental health condition. The systematic review demonstrated CCM effectiveness across mental health conditions and treatment venues. Cumulative meta-analysis and meta-regression further informed our approach to subsequent CCM implementation. POLICY IMPACT: In 2015, based on the evidence synthesis, VA Office of Mental Health and Suicide Prevention (OMHSP) adopted the CCM as the model for their outpatient mental health teams. RANDOMIZED IMPLEMENTATION TRIAL: In 2015-2018 we partnered with OMHSP to conduct a 9-site stepped wedge implementation trial, guided by insights from the evidence synthesis. SCALE-UP AND SPREAD: In 2017 OMHSP launched an effort to scale-up and spread the CCM to additional VA medical centers. Seventeen facilitators were trained and 28 facilities engaged in facilitation. DISCUSSION: Evidence synthesis provided leverage for evidence-based policy change. This formed the foundation for a health care leadership/researcher partnership, which conducted an implementation trial and subsequent scale-up and spread effort to enhance adoption of the CCM, as informed by the evidence synthesis.

Assessing Collaborative Care in Mental Health Teams: Qualitative Analysis to Guide Future Implementation.

The Collaborative Care Model (CCM) is an evidence-based approach for structuring care for chronic health conditions. Attempts to implement CCM-based care in a given setting depend, however, on the extent to which care in that setting is already aligned with the specific elements of CCM-based care. We therefore interviewed staff from ten outpatient mental health teams in the US Department of Veterans Affairs to determine whether care delivery was consistent or inconsistent with CCM-based care in those settings. We discuss implications of our findings for future attempts to implement CCM-based outpatient mental health care.

Adjunctive thyroid hormone treatment in rapid cycling bipolar disorder: A double-blind placebo-controlled trial of levothyroxine (L-T4 ) and triiodothyronine (T3 ).

OBJECTIVES: This report describes the first comparative double-blind, placebo-controlled trial of levothyroxine (L-T4 ) and triiodothyronine (T3 ) as adjunctive treatments in rapid cycling bipolar disorder. METHODS: Thirty-two treatment-resistant, rapid cycling patients who had failed a trial of lithium were randomized into three treatment arms: L-T4 , T3 , or placebo. They were followed for ≥4 months with weekly clinical and endocrine assessments. RESULTS: There were no statistically significant differences between the groups in age, gender, duration of illness, or thyroid status. Markov chain analyses were employed to assess treatment effects on cycling patterns among mood states (euthymia, depression, mania, and mixed). Within groups, post-treatment the L-T4 group spent significantly less time depressed or in a mixed state and greater time euthymic. The T3 and placebo groups did not differ significantly pre- and post-treatment in any mood state, although the pattern of effects was the same for the T3 group as for the L-T4 group. Between groups, the L-T4 group had a significantly greater increase in time euthymic and decrease in time in the mixed state than the placebo group. Other group differences were not significant, although they were in the expected direction. CONCLUSIONS: The findings in this first double-blind study directly comparing the effects of L-T4 and T3 therapy against placebo provide evidence for the benefit of adjunctive L-T4 in alleviating resistant depression, reducing time in mixed states and increasing time euthymic. Adjunctive T3 did not show statistically significant evidence of benefit over placebo in reducing the time spent in disturbed mood states.

Factor structure of the Q-LES-Q short form in an enrolled mental health clinic population.

PURPOSE: The Quality of Life, Enjoyment, and Satisfaction Questionnaire-Short Form (Q-LES-Q-SF) is a recovery-oriented, self-report measure with an uncertain underlying factor structure, variously reported in the literature to consist of either one or two domains. We examined the possible factor structures of the English version in an enrolled mental health population who were not necessarily actively engaged in care. METHODS: As part of an implementation trial in the U.S. Department of Veterans Affairs mental health clinics, we administered the Q-LES-Q-SF and Veterans RAND 12-Item Health Survey (VR-12) over the phone to 576 patients across nine medical centers. We used a split-sample approach and conducted an exploratory factor analysis (EFA) and multi-trait analysis (MTA). Comparison with VR-12 assessed construct validity. RESULTS: Based on 568 surveys after excluding the work satisfaction item due to high unemployment rate, the EFA indicated a unidimensional structure. The MTA showed a single factor: ten items loaded on one strong psychosocial factor (α = 0.87). Only three items loaded on a physical factor (α = 0.63). Item discriminant validity was strong at 92.3%. Correlations with the VR-12 were consistent with the existence of two factors. CONCLUSIONS: The English version of the Q-LES-Q-SF is a valid, reliable self-report instrument for assessing quality of life. Its factor structure can be best described as one strong psychosocial factor. Differences in underlying factor structure across studies may be due to limitations in using EFA on Likert scales, language, culture, locus of participant recruitment, disease burden, and mode of administration.

A systematic review of team-building interventions in non-acute healthcare settings.

BACKGROUND: Healthcare is increasingly delivered in a team-based format emphasizing interdisciplinary coordination. While recent reviews have investigated team-building interventions primarily in acute healthcare settings (e.g. emergency or surgery departments), we aimed to systematically review the evidence base for team-building interventions in non-acute settings (e.g. primary care or rehabilitation clinics). METHODS: We conducted a systematic review in PubMed and Embase to identify team-building interventions, and conducted follow-up literature searches to identify articles describing empirical studies of those interventions. This process identified 14 team-building interventions for non-acute healthcare settings, and 25 manuscripts describing empirical studies of these interventions. We evaluated outcomes in four domains: trainee evaluations, teamwork attitudes/knowledge, team functioning, and patient impact. RESULTS: Trainee evaluations for team-building interventions were generally positive, but only one study associated team-building with statistically significant improvement in teamwork attitudes/knowledge. Similarly mixed results emerged for team functioning and patient impact. CONCLUSIONS: The evidence base for healthcare team-building interventions in non-acute healthcare settings is much less developed than the parallel literature for short-term team function in acute care settings. Only one intervention we identified has been tested in multiple non-acute settings by distinct research teams. Positive findings regarding the utility of team-building interventions are tempered by a lack of control conditions, inconsistency in outcome measures, and high probability of bias. Considering these results alongside the well-recognized costs of poor healthcare teamwork suggests that additional research is sorely needed to develop the evidence base for team-building in non-acute settings.

Implementing and Sustaining Team-Based Telecare for Bipolar Disorder: Lessons Learned from a Model-Guided, Mixed Methods Analysis.

BACKGROUND: Telemental health interventions have empirical support from clinical trials and structured demonstration projects. However, their implementation and sustainability under less structured clinical conditions are not well demonstrated. INTRODUCTION: We conducted a follow-up analysis of the implementation and sustainability of a clinical video teleconference-based collaborative care model for individuals with bipolar disorder treated in the Department of Veterans Affairs to (a) characterize the extent of implementation and sustainability of the program after its establishment and (b) identify barriers and facilitators to implementation and sustainability. MATERIALS AND METHODS: We conducted a mixed methods program evaluation, assessing quantitative aspects of implementation according to the Reach, Efficacy, Adoption, Implementation, and Maintenance implementation framework. We conducted qualitative analysis of semistructured interviews with 16 of the providers who submitted consults, utilizing the Integrated Promoting Action on Research Implementation in the Health Services implementation framework. RESULTS: The program demonstrated linear growth in sites (n = 35) and consults (n = 915) from late 2011 through mid-2016. Site-based analysis indicated statistically significant sustainability beyond the first year of operation. Qualitative analysis identified key facilitators, including consult content, ease of use via electronic health record, and national infrastructure. Barriers included availability of telehealth space, equipment, and staff at the sites, as well as the labor-intensive nature of scheduling. DISCUSSION: The program achieved continuous growth over almost 5 years due to (1) successfully filling a need perceived by providers, (2) developing in a supportive context, and (3) receiving effective facilitation by national and local infrastructure. CONCLUSION: Clinical video teleconference-based interventions, even multicomponent collaborative care interventions for individuals with complex mental health conditions, can grow vigorously under appropriate conditions.

Explication and Definition of Mental Health Recovery: A Systematic Review.

This review assessed the concordance of the literature on recovery with the definition and components of recovery developed by the Substance Abuse and Mental Health Services Administration (SAMHSA). Each SAMHSA identified recovery component was first explicated with synonyms and keywords and made mutually exclusive by authors. Inter-rater reliability was established on the coding of the presence of 17 recovery components and dimensions in 67 literature reviews on the recovery concept in mental health. The review indicated that concordance varied across SAMHSA components. The components of recovery with greatest concordance were: individualized/person centered, empowerment, purpose, and hope.

Staff perceptions implementing interprofessional team-based behavioural healthcare.

The US Veterans Health Administration (VHA) in 2013 mandated a nationwide implementation of interprofessional team-based care in the general mental health setting and officially endorsed the collaborative care model in 2015 to guide the coordinated and anticipatory care to be delivered by these teams. Front-line clinic staff are major stakeholders whose practices are most directly affected by this implementation and may or may not view teams as useful or feasible for their practice. Our objective was to examine their perspectives on delivering team-to-patient care in order to understand what system-level efforts can best support the transition to such care from the more conventional provider-to-patient care. We conducted 14 semi-structured interviews with staff from general mental health clinics across three different VHA medical facilities. The interview questions focused on asking how care is organised and delivered at their clinic, their experiences in collaborating with other staff, and how the clinic handles changes. Four recurrent themes were identified: navigating workplace supervision, organisation, and role structures; continuing professional growth and relationships; delivering patient-focused care through education and connection to resources; and utilising information technology for communication and panel-based management. Quality improvement efforts were rarely discussed during the interviews. Our results indicate that staff's endorsement of the implementation of interprofessional care teams in general mental health settings may be strengthened through associated efforts targeted at enhancing their experiences aligned to these emergent themes.

A population-based study of the comparative effectiveness of second-generation antipsychotics vs older antimanic agents in bipolar disorder.

OBJECTIVES: Numerous antimanic treatments have been introduced over the past two decades, particularly second-generation antipsychotics (SGAs). However, it is not clear whether such newer agents provide any advantage over older treatments. METHODS: A historical cohort design investigated the nationwide population of outpatients with bipolar disorder treated in the Department of Veterans Affairs who were newly initiated on an antimanic agent between 2003 and 2010 (N=27 727). The primary outcome was likelihood of all-cause hospitalization during the year after initiation, controlling for numerous demographic, clinical, and treatment characteristics. Potential correlates of effect were explored by investigating time to initiation of a second antimanic agent or antidepressant. RESULTS: After control for covariates, those initiated on lithium or valproate monotherapy, compared to those beginning SGA monotherapy, were significantly less likely to be hospitalized, had a longer time to hospitalization, and had fewer hospitalizations in the subsequent year. Those on combination treatment had a significantly higher likelihood of hospitalization, although they also had a longer time to addition of an additional antimanic agent or antidepressant. CONCLUSIONS: The present analysis of a large and unselected nationwide population provides important complementary data to that from controlled trials. Although various mechanisms may be responsible for the results, the data support the utilization of lithium or valproate, rather than SGAs, as the initial antimanic treatment in bipolar disorder. A large-scale, prospective, randomized, pragmatic clinical trial comparing the initiation of SGA monotherapy to that of lithium or valproate monotherapy is a logical next step.

Interest in Use of Technology for Healthcare Among Veterans Receiving Treatment for Mental Health.

INTRODUCTION: There is great interest in leveraging technology, including cell phones and computers, to improve healthcare. A range of e-health applications pertaining to mental health such as messaging for prescription refill or mobile device videoconferencing are becoming more available, but little is known about the mental health patient's interest in using these newer applications. METHODS: We mailed a survey to 300 patients seen in the general mental health clinic of a local Veterans Affairs Medical Center. Survey questions focused on interest in use of cell phones, tablets, and other computers in patients' interactions with the healthcare system. RESULTS: A total of 74 patients, primarily treated for depression, post-traumatic stress disorder, or anxiety disorders, returned completed surveys. Nearly all reported having a cell phone (72/74, 97%), but fewer than half reported having a smartphone (35/74, 47%). Overall, a substantial majority (64/74, 86%) had access to an Internet-capable device (smartphone or computer, including tablets). Respondents appeared to prefer computers to cell phones for some health-related communications, but did not express differential interest for other tasks (such as receiving appointment reminders). Interest in use was higher among younger veterans. DISCUSSION: Most veterans with a mental health diagnosis have access to technology (including cell phones and computers) and are interested in using that technology for some types of healthcare-related communications. CONCLUSIONS: While there is capacity to utilize information technology for healthcare purposes in this population, interests vary widely, and a substantial minority does not have access to relevant devices. Although interest in using computers for health-related communication was higher than interest in using cell phones, single-platform technology-based interventions may nonetheless exclude crucial segments of the population.