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1.
Am J Addict ; 32(3): 244-253, 2023 05.
Artigo em Inglês | MEDLINE | ID: mdl-36470641

RESUMO

BACKGROUND: A mindfulness-based intervention that reduces comorbid pain, anxiety, and substance use during office-based opioid treatment (OBOT) could enhance retention and prevent overdose. We conducted a pilot study of the Mindful Recovery OUD Care Continuum (M-ROCC), a 24-week trauma-informed program with a motivationally-sensitive curriculum. METHODS: Patients prescribed buprenorphine (N = 18) enrolled in M-ROCC. We collected urine toxicology biweekly. At 0, 4, and 24 weeks, participants completed PROMIS-Pain, PROMIS-Anxiety, Mindfulness (FFMQ), Experiential Avoidance (BEAQ), Interoceptive Awareness (MAIA), and Self-Compassion (SCS-SF) scales. We estimated changes over time using mixed models. Participants completed qualitative interviews at 4 and 24 weeks. RESULTS: Positive urine toxicology decreased over time for cocaine (ß = -.266, p = .008) and benzodiazepines (ß = -.208, p = .028). M-ROCC reduced PROMIS-Pain (Z = -2.29; p = .022), BEAQ (Z = -2.83; p = .0005), and increased FFMQ (Z = 3.51; p < .001), MAIA (Z = 3.40; p = .001), and SCS-SF (Z = 2.29; p = .022). Participants with co-morbid anxiety had decreased PROMIS-Anxiety (Z = -2.53; p = .012). Interviewed participants commonly used mindfulness practices for stress and anxiety (12/12, 100%), and to reduce pain catastrophizing and rumination (7/12, 58%). CONCLUSION AND SCIENTIFIC SIGNIFICANCE: This is the first study to report the effects of a 24-week mindfulness program during buprenorphine treatment on common comorbidities, including pain interference, anxiety, cocaine, and benzodiazepine use. The findings that M-ROCC is associated with reduced experiential avoidance, as well as increased interoceptive awareness and self-compassion, align with proposed mechanisms that are now extended to OUD treatment. Future larger randomized controlled trials are needed before effectiveness can be established and the role of these mechanisms can be confirmed.


Assuntos
Buprenorfina , Cocaína , Atenção Plena , Transtornos Relacionados ao Uso de Substâncias , Humanos , Buprenorfina/uso terapêutico , Projetos Piloto , Ansiedade/complicações , Ansiedade/tratamento farmacológico , Dor/complicações , Dor/tratamento farmacológico , Transtornos Relacionados ao Uso de Substâncias/complicações , Transtornos Relacionados ao Uso de Substâncias/tratamento farmacológico , Atenção Primária à Saúde
2.
Arch Womens Ment Health ; 23(3): 421-428, 2020 06.
Artigo em Inglês | MEDLINE | ID: mdl-31222621

RESUMO

Few studies have examined the association between maternal and youth mental health among US Latinos, or its variation by nativity, country of origin, ethnic subgroup, and time in the mainland US. Using 2007-2014 Medical Expenditure Panel Survey data linking Latino youth (N = 15,686 aged 5-17 years) and their mothers, we estimated multivariate models of the relationship between probable maternal mental illness (a composite of measures) and youth mental health impairment (Columbia Impairment Scale). Children of mothers with probable mental illness were more than three times as likely to have impairment as children of mothers without mental illness (p < 0.01). In adjusted models, there was an 8.5-point (95% CI 5.1, 11.8) increased prevalence of child impairment associated with mother's probable mental illness among mainland US-born youth and mothers and a 6.0-point (95% CI 3.7, 8.3) increased prevalence among US-born youth of foreign/island-born mothers. There was no significant difference in the prevalence of youth impairment associated with maternal mental illness when both youth and mother were born outside of the mainland US. For the Puerto Rican subgroup, the association between maternal and youth mental health was greatest among island-born mothers and mainland US-born youth; for the Mexican subgroup, the link was strongest among US-born mothers and youth. While there were large point differences between those groups, the difference was not statistically significant. This study suggests a protective effect of island/foreign-born nativity on symptom association between Latino mothers and children. Considerations for future research and practice stemming from this finding are discussed.


Assuntos
Emigrantes e Imigrantes/psicologia , Hispânico ou Latino/psicologia , Transtornos Mentais/etnologia , Saúde Mental/etnologia , Mães/psicologia , Transtornos do Neurodesenvolvimento/etnologia , Adolescente , Adulto , Criança , Pré-Escolar , Etnicidade/psicologia , Feminino , Humanos , Masculino , México/etnologia , Pessoa de Meia-Idade , Prevalência , Porto Rico/etnologia , Inquéritos e Questionários , Estados Unidos/epidemiologia , Adulto Jovem
3.
Qual Health Res ; 30(12): 1833-1850, 2020 10.
Artigo em Inglês | MEDLINE | ID: mdl-32713258

RESUMO

As a part of a larger, mixed-methods research study, we conducted semi-structured interviews with 21 adults with depressive symptoms to understand the role that past health care discrimination plays in shaping help-seeking for depression treatment and receiving preferred treatment modalities. We recruited to achieve heterogeneity of racial/ethnic backgrounds and history of health care discrimination in our participant sample. Participants were Hispanic/Latino (n = 4), non-Hispanic/Latino Black (n = 8), or non-Hispanic/Latino White (n = 9). Twelve reported health care discrimination due to race/ethnicity, language, perceived social class, and/or mental health diagnosis. Health care discrimination exacerbated barriers to initiating and continuing depression treatment among patients from diverse backgrounds or with stigmatized mental health conditions. Treatment preferences emerged as fluid and shaped by shared decisions made within a trustworthy patient-provider relationship. However, patients who had experienced health care discrimination faced greater challenges to forming trusting relationships with providers and thus engaging in shared decision-making processes.


Assuntos
Atenção à Saúde , Depressão , Racismo , Adulto , Negro ou Afro-Americano , Depressão/terapia , Etnicidade , Hispânico ou Latino , Humanos , Aceitação pelo Paciente de Cuidados de Saúde
4.
J Gen Intern Med ; 34(2): 293-302, 2019 02.
Artigo em Inglês | MEDLINE | ID: mdl-30511291

RESUMO

BACKGROUND: Self-management of health is important for improving health outcomes among primary care patients with chronic disease. Anxiety and depressive disorders are common and interfere with self-regulation, which is required for disease self-management. An insurance-reimbursable mindfulness intervention integrated within primary care may be effective for enhancing chronic disease self-management behaviors among primary care patients with anxiety, depression, trauma, and stress-related and adjustment disorders compared with the increasingly standard practice of referring patients to outside mindfulness resources. OBJECTIVE: Mindfulness Training for Primary Care (MTPC) is an 8-week, referral-based, insurance-reimbursable program integrated into safety-net health system patient-centered medical homes. We hypothesized that MTPC would be more effective for catalyzing chronic disease self-management action plan initiation within 2 weeks, versus a low-dose comparator (LDC) consisting of a 60-min mindfulness introduction, referral to community and digital resources, and addition to a 6-month waitlist for MTPC. PARTICIPANTS: Primary care providers (PCPs) and mental health clinicians referred 465 patients over 12 months. All participants had a DSM-V diagnosis. DESIGN AND INTERVENTIONS: Participants (N = 136) were randomized in a 2:1 allocation to MTPC (n = 92) or LDC (n = 44) in a randomized controlled comparative effectiveness trial. MTPC incorporates mindfulness, self-compassion, and mindfulness-oriented behavior change skills and is delivered as insurance-reimbursable visits within primary care. Participants took part in a chronic disease self-management action planning protocol at week 7. MAIN MEASURES: Level of self-reported action plan initiation on the action plan initiation survey by week 9. KEY RESULTS: Participants randomized to MTPC, relative to LDC, had significantly higher adjusted odds of self-management action plan initiation in an intention-to-treat analysis (OR = 2.28; 95% CI = 1.02 to 5.06, p = 0.025). CONCLUSIONS: An 8-week dose of mindfulness training is more effective than a low-dose mindfulness comparator in facilitating chronic disease self-management behavior change among primary care patients.


Assuntos
Comportamentos Relacionados com a Saúde , Atenção Plena/métodos , Atenção Primária à Saúde/métodos , Autocuidado/métodos , Autocuidado/psicologia , Autocontrole/psicologia , Adulto , Feminino , Comportamentos Relacionados com a Saúde/fisiologia , Humanos , Masculino , Pessoa de Meia-Idade , Método Simples-Cego , Resultado do Tratamento
5.
Adm Policy Ment Health ; 44(6): 967-977, 2017 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-28646242

RESUMO

Health plan policies can influence delivery of integrated behavioral health and general medical care. This study provides national estimates for the prevalence of practices used by health plans that may support behavioral health integration. Results indicate that health plans employ financing and other policies likely to support integration. They also directly provide services that facilitate integration. Behavioral health contracting arrangements are associated with use of these policies. Delivery of integrated care requires systemic changes by both providers and payers thus health plans are key players in achieving this goal.


Assuntos
Seguro Saúde/organização & administração , Transtornos Mentais/terapia , Serviços de Saúde Mental/organização & administração , Administração de Caso/organização & administração , Continuidade da Assistência ao Paciente/organização & administração , Prática Clínica Baseada em Evidências , Humanos , Seguro Saúde/economia , Reembolso de Seguro de Saúde , Serviços de Saúde Mental/economia , Políticas , Atenção Primária à Saúde/organização & administração , Transtornos Relacionados ao Uso de Substâncias/terapia , Integração de Sistemas , Estados Unidos
6.
J Ment Health Policy Econ ; 18(4): 165-73, 2015 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-26729008

RESUMO

BACKGROUND: Private health insurance plays a large role in the U.S. health system, including for many individuals with depression. Private insurers have been actively trying to influence pharmaceutical utilization and costs, particularly for newer and costlier medications. The approaches that insurers use may have important effects on patients' access to antidepressant medications. AIMS OF THE STUDY: To report which approaches (e.g., tiered copayments, prior authorization, and step therapy) commercial health plans are employing to manage newer antidepressant medications, and how the use of these approaches has changed since 2003. METHODS: Data are from a nationally representative survey of commercial health plans in 60 market areas regarding alcohol, drug abuse and mental health services in 2010. Responses were obtained from 389 plans (89% response rate), reporting on 925 insurance products. For each of six branded antidepressant medications, respondents were asked whether the plan covered the medication and if so, on what copayment tier, and whether it was subject to prior authorization or step therapy. Measures of management approach were constructed for each medication and for the group of medications. Bivariate and multivariate analyses were used to test for association of the management approach with various health plan characteristics. RESULTS: Less than 1% of health plan products excluded any of the six antidepressants studied. Medications were more likely to be subjected to restrictions if they were newer, more expensive or were reformulations. 55% of products used placement on a high cost-sharing tier (3 or 4) as their only form of restriction for newer branded antidepressants. This proportion was lower than in 2003, when 71% of products took this approach. In addition, only 2% of products left all the newer branded medications unrestricted, down from 25% in 2003. Multivariate analysis indicated that preferred provider organizations were more likely than other product types to use tier 3 or 4 placement. DISCUSSION: We find that U.S. health plans are using a variety of strategies to manage cost and utilization of newer branded antidepressant medications. Plans appear to be finding that approaches other than exclusion are adequate to meet their cost-management goals for newer branded antidepressants, although they have increased their use of administrative restrictions since 2003. Limitations include lack of information about how administrative restrictions were applied in practice, information on only six medications, and some potential for endogeneity bias in the regression analyses. CONCLUSION: This study has documented substantial use of various restrictions on access to newer branded antidepressants in U.S. commercial health plans. Most of these medications had generic equivalents that offered at least some substitutability, reducing access concerns. At the same time, it is worth noting that high copayments and administrative requirements can nonetheless be burdensome for some patients. IMPLICATIONS FOR HEALTH POLICY: Health plans' pharmacy management approaches may concern policymakers less than in the early 2000s, due to the lesser distinctiveness of today's branded medications. This may change depending on future drug introductions. IMPLICATIONS FOR FURTHER RESEARCH: Future research should examine the impact of plans' pharmacy management approaches, using patient-level data.


Assuntos
Antidepressivos/economia , Antidepressivos/uso terapêutico , Custos de Medicamentos/estatística & dados numéricos , Planos de Seguro com Fins Lucrativos/economia , Seguro de Serviços Farmacêuticos/economia , Setor Privado/economia , Citalopram/economia , Citalopram/uso terapêutico , Controle de Custos/economia , Custo Compartilhado de Seguro/economia , Succinato de Desvenlafaxina/economia , Succinato de Desvenlafaxina/uso terapêutico , Uso de Medicamentos , Cloridrato de Duloxetina/economia , Cloridrato de Duloxetina/uso terapêutico , Fluvoxamina/economia , Fluvoxamina/uso terapêutico , Pesquisas sobre Atenção à Saúde , Acessibilidade aos Serviços de Saúde/economia , Humanos , Cobertura do Seguro/economia , Organizações de Prestadores Preferenciais/economia , Selegilina/economia , Selegilina/uso terapêutico , Estados Unidos , Cloridrato de Venlafaxina/economia , Cloridrato de Venlafaxina/uso terapêutico
7.
J Racial Ethn Health Disparities ; 11(1): 326-338, 2024 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-36795291

RESUMO

CONTEXT: Homelessness is a public health crisis affecting millions of Americans every year, with severe consequences for health ranging from infectious diseases to adverse behavioral health outcomes to significantly higher all-cause mortality. A primary constraint of addressing homelessness is a lack of effective and comprehensive data on rates of homelessness and who experiences homelessness. While other types of health services research and policy are based around comprehensive health datasets to successfully evaluate outcomes and link individuals with services and policies, there are few such datasets that report homelessness. METHODS: Gathering archived data from the US Department of Housing and Urban Development, we created a unique dataset of annual rates of homelessness, nationally, as measured by persons accessing homeless shelter systems, for 11 years (2007-2017, including the Great Recession and prior to the start of the 2020 pandemic). Responding to the need to measure and address racial and ethnic disparities in homelessness, the dataset reports annual rates of homelessness across HUD selected, Census-based racial and ethnic categories. FINDINGS: Between 2007 and 2017, across all types of sheltered homelessness, whether individual, family, or total, Black, American Indian or Alaska Native, and Native Hawaiian and Pacific Islander individuals and families were far more likely to experience homelessness than non-Hispanic White individuals and families. Particularly concerning about the rates of homelessness among these populations is the persistent and increasing nature of these disparities across the entire study period. CONCLUSIONS: While homelessness is a public health problem, the hazard of experiencing homelessness is not uniformly distributed across different populations. Because homelessness is such a strong social determinant of health and risk factor across multiple health domains, it deserves the same careful annual tracking and evaluation by public health stakeholders as other areas of health and health care.


Assuntos
Atenção à Saúde , Pessoas Mal Alojadas , Humanos , Estados Unidos/epidemiologia , Etnicidade , Grupos Raciais , Habitação
8.
Psychol Trauma ; 2024 Jun 27.
Artigo em Inglês | MEDLINE | ID: mdl-38934934

RESUMO

OBJECTIVE: Demand for trauma-focused therapy continues to increase, especially in community mental health care settings where group treatment models can be cost-effective and increase access to care. The Internal Family Systems (IFS) model for posttraumatic stress disorder (PTSD) may offer an effective therapeutic approach. The purpose of this proof-of-concept study was to evaluate the feasibility and acceptability of a novel, trauma-focused, group-based treatment approach and investigate potential mechanisms of action. METHOD: Study participants completed the Program for Alleviating and Resolving Trauma and Stress (PARTS), an online-delivered program including 16 weeks of 90-min IFS-based groups with eight 50-min individual IFS counseling sessions. Participants completed assessments including clinician-administered and self-report measures of PTSD, common comorbid conditions (e.g., complex PTSD [disturbances in self-organization], depression, anxiety, and suicidality), and potential mechanisms (e.g., decentering, self-compassion, and emotion regulation). RESULTS: Most participants (n = 11/15; 73%) attended 12+ group sessions, with 92% (12/13 responders) reporting they would recommend PARTS to a friend. All respondents reported the program was helpful (13/13; 100%). PTSD symptom severity was reduced from baseline to Weeks 16 (d = -0.7, p = .005) and 24 (d = -0.9, p < .001). A clinically meaningful response (i.e., 10+ point reduction on the Clinician-Administered PTSD Scale for Diagnostic and Statistical Manual of Mental Disorders [5th ed.]) was demonstrated in 53% of participants (8/15) by Week 24. Decentering, self-compassion, and emotion regulation all improved (p < .05). CONCLUSIONS: PARTS was feasible and acceptable as a group-based, online intervention in an urban, public community health care system. While PARTS showed promise in reducing overall PTSD symptom severity, well-controlled efficacy research is needed. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

9.
Health Serv Res ; : e14373, 2024 Aug 27.
Artigo em Inglês | MEDLINE | ID: mdl-39192536

RESUMO

OBJECTIVE: To understand whether and how primary care providers and staff elicit patients' past experiences of healthcare discrimination when providing care. DATA SOURCES/STUDY SETTING: Twenty qualitative semi-structured interviews were conducted with healthcare staff in primary care roles to inform future interventions to integrate data about past experiences of healthcare discrimination into clinical care. STUDY DESIGN: Qualitative study. DATA COLLECTION/EXTRACTION METHODS: Data were collected via semi-structured qualitative interviews between December 2018 and January 2019, with health care staff in primary care roles at a hospital-based clinic within an urban safety-net health system that serves a patient population with significant racial, ethnic, and linguistic diversity. PRINCIPAL FINDINGS: Providers did not routinely, or in a structured way, elicit information about past experiences of healthcare discrimination. Some providers believed that information about healthcare discrimination experiences could allow them to be more aware of and responsive to their patients' needs and to establish more trusting relationships. Others did not deem it appropriate or useful to elicit such information and were concerned about challenges in collecting and effectively using such data. CONCLUSIONS: While providers see value in eliciting past experiences of discrimination, directly and systematically discussing such experiences with patients during a primary care encounter is challenging for them. Collecting this information in primary care settings will likely require implementation of multilevel systematic data collection strategies. Findings presented here can help identify clinic-level opportunities to do so.

10.
Psychiatry Res ; 325: 115248, 2023 07.
Artigo em Inglês | MEDLINE | ID: mdl-37207543

RESUMO

The early months of the COVID-19 pandemic saw a decline in psychotropic medication use; however, little is known about how this trend evolved as the pandemic progressed and how it varied across different payers in the United States. Using a national multi-payer pharmacy claims database and adopting a quasi-experimental research design, this study examines trends in psychotropic medication prescriptions dispensed from July 2018 - June 2022. The study finds that the number of patients with dispensed psychotropic medications and the number of psychotropic medications dispensed declined during the early months of the pandemic but experienced a statistically significant growth in later periods compared to the pre-pandemic rate. Average days supply of psychotropic medications dispensed increased significantly throughout the pandemic. Commercial insurance remained the primary payer for psychotropic medication during the pandemic, but there was a significant increase in the number of prescription fills covered under Medicaid. This implies that public insurance programs played an increasing role in financing psychotropic medication use during the COVID-19 pandemic.


Assuntos
COVID-19 , Pandemias , Humanos , Estados Unidos/epidemiologia , Psicotrópicos/uso terapêutico , Prescrições de Medicamentos , Medicaid
11.
J Subst Abuse Treat ; 144: 108923, 2023 01.
Artigo em Inglês | MEDLINE | ID: mdl-36334383

RESUMO

OBJECTIVE: Recent studies have shown that early in the COVID-19 pandemic, rates of buprenorphine prescription dispensing for opioid use disorder (OUD) were relatively stable. However, whether that pattern continued later in the pandemic is unclear. This study examines the monthly rate of dispensed buprenorphine prescriptions during the early period and the later period of the pandemic. METHODS: The study uses interrupted time series analysis to examine buprenorphine prescription dispensed, average day's supply, payment source, and the number of patients with a dispensed buprenorphine prescription. The study utilized January 2019-April 2021 data from IQVIA National Prescription Audit, PayerTrack and Total Patient Tracker databases. RESULTS: After an initial increase in the number of patients prescribed buprenorphine in the early period of the pandemic, the monthly rate of patients prescribed buprenorphine increased at a lower rate compared to the pre-pandemic period (6100 vs 4600/month). The study observed a decline in the number of buprenorphine prescriptions dispensed both in levels and growth rate during the pandemic, but an increase occurred in the average day's supply of buprenorphine prescriptions (17 days pre-pandemic vs 18.6 day during the pandemic). Medicaid became the primary payer of buprenorphine prescriptions as the pandemic continued, while buprenorphine prescriptions paid for by private insurance declined. DISCUSSION: Expanding and maintaining access to treatment for OUD were key priorities in federal and state responses to the COVID-19 pandemic. The results of our study underscore the importance of policy efforts to help increase buprenorphine prescribing for OUD.


Assuntos
Buprenorfina , COVID-19 , Transtornos Relacionados ao Uso de Opioides , Estados Unidos , Humanos , Buprenorfina/uso terapêutico , Pandemias , Transtornos Relacionados ao Uso de Opioides/tratamento farmacológico , Transtornos Relacionados ao Uso de Opioides/epidemiologia , Medicaid , Analgésicos Opioides/uso terapêutico
12.
Pediatrics ; 151(2)2023 02 01.
Artigo em Inglês | MEDLINE | ID: mdl-36710646

RESUMO

OBJECTIVES: To examine whether Supplemental Nutrition Assistance Program (SNAP) participation is associated with emergency department use among low-income children and whether any such association is mediated by household food hardship and child health status and/or moderated by special health care needs (SHCN) status. We hypothesized SNAP to be associated with reduced likelihoods of emergency department use, with greater effect sizes for children with SHCN and mediation by food hardship and health status. METHODS: In this secondary analysis, we estimated a bivariate probit model (with state-level SNAP administrative policies as instruments) within a structural equation modeling framework using pooled cross-sectional samples of children in low-income households from the 2016 to 2019 iterations of the National Survey of Children's Health (n = 24 990). RESULTS: Among children with and without SHCN, respectively, SNAP was associated with: 22.0 percentage points (pp) (95% confidence interval [CI] 12.2-31.8pp) and 17.1pp (95% CI 7.2-27.0pp) reductions in the likelihood of household food hardship exposure (4.8pp difference-in-differences, 95% CI 2.3-7.4pp), 9.7pp (95% CI 3.9-15.5pp) and 7.9pp (95% CI 2.2-13.6) increases in the likelihood of excellent health status (1.9pp difference-in-differences, 95% CI 0.7-3.0pp), and 7.7pp (95% CI 2.9-12.5pp) and 4.3pp (95% CI 1.0-7.6pp) reductions in the likelihood of emergency department use (3.4pp difference-in-differences, 95% CI 1.8-5.1pp). CONCLUSIONS: We found SNAP participation was associated with lower likelihoods of emergency department use, that better food hardship and health statuses mediated this association, and that effect sizes were larger among children with SHCN. Food hardship relief may improve outcomes for vulnerable children and the health systems serving them.


Assuntos
Assistência Alimentar , Criança , Humanos , Estudos Transversais , Características da Família , Pobreza , Nível de Saúde , Abastecimento de Alimentos
13.
Addiction ; 118(2): 353-364, 2023 02.
Artigo em Inglês | MEDLINE | ID: mdl-36385708

RESUMO

AIMS: To estimate recent trends in cigarette use and health insurance coverage for United States adults with and without mental health and substance use disorders (MH/SUD). DESIGN: Event study analysis of smoking and insurance coverage trends among US adults with and without MH/SUD using 2008-19 public use data from the National Survey on Drug Use and Health, an annual, cross-sectional survey. SETTING: USA. PARTICIPANTS: A nationally representative sample of non-institutionalized respondents aged 18-64 years (n = 448 762). MEASUREMENTS: Outcome variables were three measures of recent cigarette use and one measure of past-year health insurance coverage. We compared outcomes between people with and without MH/SUD (MH disorder: past-year mental illness, predicted from Kessler-6 and the World Health Organization-Disability Assessment Schedule impairment scale; SUD: met survey-based DSM-IV criteria for past-year alcohol, cannabis, cocaine or heroin use disorder) and over time. FINDINGS: Comparing pooled data from 2008 to 2009 and from 2018 to 2019, current smoking rates of adults with MH/SUD decreased from 37.9 to 27.9% while current smoking rates of adults without MH/SUD decreased from 21.4 to 16.3%, a significant difference in decrease of 4.9 percentage points (pts) [95% confidence interval (CI) = 3.3-6.6 pts]. Daily smoking followed similar patterns (difference in decrease of 3.9 pts (95% CI = 2.3-5.4 pts). Recent smoking abstinence rates for adults with MH/SUD increased from 7.4 to 10.9%, while recent smoking abstinence rates for adults without MH/SUD increased from 9.6 to 12.0%, a difference in increase of 1.0 pts (95% CI = -3.0 to 0.9 pts). In 2018-19, 11% of net reductions in current smoking, 12% of net reductions in daily smoking and 12% of net increases in recent smoking abstinence coincided with greater gains in insurance coverage for adults with MH/SUD compared to those without MH/SUD. CONCLUSIONS: Improvements in smoking and abstinence outcomes for US adults with mental health and substance use disorders appear to be associated with increases in health insurance coverage.


Assuntos
Transtornos Mentais , Transtornos Relacionados ao Uso de Substâncias , Produtos do Tabaco , Adulto , Humanos , Estados Unidos/epidemiologia , Saúde Mental , Estudos Transversais , Transtornos Relacionados ao Uso de Substâncias/epidemiologia , Transtornos Mentais/epidemiologia , Cobertura do Seguro
14.
Health Psychol ; 42(10): 699-711, 2023 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-37410421

RESUMO

OBJECTIVE: To determine the effects of mindfulness training for primary care (MTPC), an integrated warm mindfulness training program, on emotion regulation and its relationship with health behavior change. Interventions that improve self-regulation, particularly emotion regulation, are needed for the self-management of comorbid chronic physical and mental illnesses. Mindfulness-based interventions (MBIs) may impact self-regulation and facilitate health behavior change. METHOD: A randomized controlled comparative effectiveness trial was conducted in a population of adult primary care patients to evaluate the impact of MTPC versus a low-dose mindfulness comparator (LDC) on self-reported difficulties in emotion regulation (DERS) total score and other assays of self-regulation at baseline, Weeks 8 and 24. Self-reported action plan initiation was reported between Weeks 8 and 10. Participants had diagnoses of anxiety, depression, or stress-related disorders. MTPC is an 8-week insurance-reimbursable warm MBI designed to cultivate mindfulness and self-compassion and to catalyze chronic illness self-management related health behavior change. RESULTS: Compared to LDC, MTPC participants had statistically significant reductions in DERS total score at 8 weeks (d = -0.59, ß = -12.98, 95% CI [-23.3 to -2.6]; p = .01) and 24 weeks (d = -0.61, ß = -13.35, [-24.3, -2.4]; p = .02). Compared to 38% for LDC, 63% of MTPC participants successfully initiated their action plan within 3 weeks (OR = 2.87, [1.1, 7.9]; p = .04). CONCLUSIONS: This randomized controlled trial demonstrated MTPC enhanced emotion regulation and facilitated initiation of chronic illness self-management and health behavior change among primary care patients with anxiety, depression, and stress-related disorders, replicating previous reports. (PsycInfo Database Record (c) 2023 APA, all rights reserved).


Assuntos
Regulação Emocional , Atenção Plena , Autogestão , Adulto , Humanos , Ansiedade/terapia , Transtornos de Ansiedade
15.
JAMA Health Forum ; 4(7): e231982, 2023 07 07.
Artigo em Inglês | MEDLINE | ID: mdl-37477926

RESUMO

Importance: In April 2021, the US Department of Health and Human Services (HHS) released practice guidelines exempting educational requirements to obtain a Drug Addiction Treatment Act (DATA) waiver to treat up to 30 patients with opioid use disorder with buprenorphine. Objective: To compare demographic and practice characteristics of clinicians who received traditional DATA waivers before and after release of the education-exempted HHS practice guidelines and those who were approved under the guidelines. Design, Setting, and Participants: This survey study was conducted electronically from February 1 to March 1, 2022. Eligible survey recipients were US clinicians who obtained an initial DATA waiver between April 2020 and November 2021. Exposure: DATA waiver approval pathway. Main Outcome and Measures: The outcomes were clinician demographic and practice characteristics, buprenorphine prescribing barriers, and strategies to treat patients with opioid use disorder, measured using χ2 tests and z tests to assess for differences among the waivered groups. Results: Of 23 218 eligible clinicians, 4519 (19.5%) responded to the survey. This analysis was limited to 2736 respondents with a 30-patient limit at the time of survey administration who identified their DATA waiver approval pathway. Among these respondents, 1365 (49.9%; female, 831 [61.9%]; male, 512 [38.1%]) received their DATA waiver prior to the education-exempted practice guidelines (prior DATA waiver), 550 (20.1%; female, 343 [63.4%]; male, 198 [36.6%]) received their waiver after guidelines were released but met education requirements (concurrent DATA waiver), and 821 (30.0%; female, 396 [49.2%]; male, 409 [50.8%]) received the waiver under the education-exempted guidelines (practice guidelines). Among practice guidelines clinicians, 500 (60.9%) reported that traditional DATA waiver educational requirements were a reason for not previously obtaining a waiver. Demographic and practice characteristics differed by waiver approval type. Across all groups, a large minority had not prescribed buprenorphine since obtaining a waiver (prior DATA waiver, 483 [35.7%]; concurrent DATA waiver, 226 [41.2%]; practice guidelines, 359 [44.3%]; P < .001). Clinicians who prescribed buprenorphine in the past 6 months reported treating few patients in an average month: 27 practice guidelines clinicians (6.0%) prescribed to 0 patients and 338 (75.1%) to 1 to 4 patients compared with 16 (2.2%) and 435 (59.9%) for prior and 11 (3.6%) and 166 (55.0%) for concurrent DATA waiver clinicians, respectively (P < .001). Across waiver types, clinicians reported multiple challenges to buprenorphine prescribing. Conclusions and Relevance: In this survey of DATA-waivered clinicians, clinician- and systems-level challenges that limit buprenorphine prescribing were observed, even among clinicians approved under the education-exempted guidelines pathway. The findings suggest that as implementation of legislation removing the DATA waiver begins, addressing these barriers could be essential to increasing buprenorphine access.


Assuntos
Buprenorfina , Transtornos Relacionados ao Uso de Opioides , Humanos , Masculino , Feminino , Buprenorfina/uso terapêutico , Tratamento de Substituição de Opiáceos , Transtornos Relacionados ao Uso de Opioides/tratamento farmacológico , Inquéritos e Questionários , Escolaridade
16.
JAMA Netw Open ; 5(4): e229401, 2022 04 01.
Artigo em Inglês | MEDLINE | ID: mdl-35471567

RESUMO

Importance: Strong financial incentives are critical to promoting widespread implementation of interventions that prevent postpartum depression. Value-based payment (VBP) approaches could be adapted to capture longer-term value and offer stronger incentives for postpartum depression prevention by sharing the expected future health care savings estimated by reduced postpartum depression incidence with clinicians. Objective: To evaluate whether sharing 5-year expected savings estimated by reduced postpartum depression incidence offers stronger incentives for prevention than traditional VBP under a variety of circumstances. Design, Setting, and Participants: This decision analytic model used a simulated cohort of 1000 Medicaid-enrolled pregnant individuals. Health care costs for individuals receiving postpartum depression preventive intervention or not, over 1 or 5 years post partum, in a variety of scenarios, including varying rates of Medicaid churn (ie, transitions to a new Medicaid managed care plan, commercial insurance plan, or loss of coverage) were estimated for the period 2020 to 2025. The model was developed between March 5 and July 30, 2021. Exposure: Sharing 100% of 1-year actual health care cost saving vs 50% of 5-year estimated health care cost savings associated with reduced postpartum depression incidence. Main Outcomes and Measures: The main outcome was the amount of clinician incentive shared in a VBP model from providing preventive interventions. The likelihood of the health care payer realizing a positive return on investment if it shared 50% of 5-year expected savings with a clinician up front was also measured. Results: The simulated cohort was designed to be reflective of the demographics characteristics of pregnant individuals receiving Medicaid; however, no specific demographic features were simulated. Providing preventive interventions for postpartum depression resulted in an estimated 5-year savings of $734.12 (95% credible interval [CrI], $217.21-$1235.67) per person. Without health insurance churn, sharing 50% of 5-year expected savings could offer more than double the financial incentives for clinicians to prevent postpartum depression compared with traditional VBP ($367.06 [95% CrI, $108.61-$617.83] vs $177.74 [95% CrI, $52.66-$296.60], respectively), with a high likelihood of positive return for the health care payer (91%). As health insurance churn increased, clinician incentives from sharing estimated savings decreased (73% reduction with 50% annual churn). Conclusions and Relevance: In this decision analytic model of VBP approaches to incentivizing postpartum depression prevention, VBP based on 5-year expected savings offered stronger incentives when churn was low. Policy should support health care payers and clinicians to share estimated savings and overcome health insurance churn issues to promote wide-scale implementation of interventions to prevent perinatal mental health conditions.


Assuntos
Depressão Pós-Parto , Depressão Pós-Parto/epidemiologia , Depressão Pós-Parto/prevenção & controle , Feminino , Humanos , Seguro Saúde , Medicaid , Motivação , Período Pós-Parto , Gravidez , Estados Unidos
17.
Front Psychol ; 13: 780383, 2022.
Artigo em Inglês | MEDLINE | ID: mdl-35719537

RESUMO

Background: Opioid-related deaths continue to rise. Psychological trauma is commonly comorbid with Opioid Use Disorder (OUD). Adverse childhood experiences can disrupt the development of emotion regulation, increasing risk of substance use. Self-compassion may reduce OUD risk and outcomes by facilitating emotion regulation, decreasing the toxicity of shame, and reducing internalized stigma that can hinder recovery. Mindfulness practice enhances self-compassion. Methods: This study is part of a pilot (N = 18) of the Mindful Recovery OUD Care Continuum (M-ROCC) during buprenorphine office-based opioid treatment (OBOT). The present study was conducted to gain a deeper understanding of the intervention's effects on self-compassion development, and to explore differential changes in self-compassion during the intervention among participants with varying intensity of trauma exposure measured by high levels of childhood adversity (defined by 4+ adverse childhood experiences (ACEs) at baseline). We conducted secondary analyses of a subset of qualitative interview data (N = 11 unique participants) collected for the pilot study (weeks 4 and 24, 14 total interviews) to elaborate upon changes in Self-Compassion Scale (SCS-SF) scores. Results: In the primary pilot study, participants' mean SCS-SF scores shifted significantly from baseline to week 24, ß = 0.22, p = 0.028. This change is elaborated upon through interviews. Despite pervasive challenges to becoming more self-compassionate (e.g., trauma histories and substance use), participants reported increased compassionate self-responding and decreased uncompassionate self-responding. Mindfulness training was identified as the primary mechanism underlying the shift. Kindness to self and others and-to a lesser extent an increased sense of common humanity-were also identified as key to overall self-compassion. Compared to those in the lower ACEs group, participants in the higher ACEs group tended to have lower baseline self-compassion scores (d = 1.09, p = 0.055). Conclusion: M-ROCC may increase self-compassion among patients with OUD during OBOT by increasing compassionate, and decreasing uncompassionate, self-responding. Patients with OUD with greater childhood adversity tended to have lower levels of self-compassion, which improved with M-ROCC. Future trials with larger samples are needed to confirm these potential outcomes, mechanisms, and differential impacts between ACEs subgroups.

18.
Health Serv Res ; 57 Suppl 2: 183-194, 2022 12.
Artigo em Inglês | MEDLINE | ID: mdl-35811358

RESUMO

OBJECTIVE: To estimate the effects of Affordable Care Act (ACA) Medicaid expansion on insurance and health services use for adults with disabilities who were newly eligible for Medicaid. DATA SOURCES: 2008-2018 Medical Expenditure Panel Survey data. STUDY DESIGN: We used the Agency for Healthcare Research and Quality (AHRQ) PUBSIM model to identify adults aged 26-64 years with disabilities who were newly Medicaid-eligible in expansion states or would have been eligible in non-expansion states had those states opted to expand. Outcomes included insurance coverage; access to care; receipt of primary care, outpatient specialty physician services, and preventive services; and out-of-pocket health care spending. To estimate the effects of Medicaid expansion, we used two-way fixed effects models and a triple differences framework to compare pre-post changes in each outcome in expansion and non-expansion states for adults with and without disabilities. EXTRACTION METHODS: We simulated Medicaid eligibility with the AHRQ PUBSIM model, which uses state-specific Medicaid rules and MEPS data on family relationships, state of residence, and income. PRINCIPAL FINDINGS: Among adults with disabilities who were newly eligible for Medicaid, Medicaid expansion was associated with significant increases in full-year Medicaid coverage (35.9 percentage points [pp], p < 0.001), receipt of primary care (15.5 pp, p < 0.01), and receipt of flu shots (19.2 pp, p < 0.01), and a significant decrease in out-of-pocket spending (-$457, p < 0.01). There were larger improvements for adults with disabilities compared to those without disabilities in full-year Medicaid coverage (11.0 pp, p < 0.01) and receipt of flu shots (18.0 pp, p < 0.05). CONCLUSIONS: Medicaid expansion was associated with improvements in full-year insurance coverage, receipt of primary and preventive care, and out-of-pocket spending for adults with disabilities who were newly eligible for Medicaid. For insurance coverage, preventive care, and some primary care measures, there were differentially larger improvements for adults with disabilities than for those without disabilities.


Assuntos
Pessoas com Deficiência , Medicaid , Adulto , Estados Unidos , Humanos , Patient Protection and Affordable Care Act , Seguro Saúde , Acessibilidade aos Serviços de Saúde , Cobertura do Seguro , Serviços de Saúde
19.
SSM Ment Health ; 22022 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-36819115

RESUMO

Background: Discrimination is experienced across demographic attributes (e.g., race and gender) and vantage points (e.g., personal and vicarious), yet few studies have classified these different experiences of discrimination within healthcare systems. Moreover, which discriminatory experiences have greater influence on patient-reported quality outcomes remains poorly understood. To address these gaps, we used latent class analysis (LCA) to identify typologies of past experiences with healthcare discrimination among adults with depression-who experience more frequent and stigmatizing healthcare interactions than the general population-and assess the relationship between class membership and current ratings of patient-reported quality outcomes. Methods: We surveyed a nationally representative sample of adults with depression (n = 803) to assess past experiences of discrimination by medical providers in terms of both the characteristics targeted for discrimination and whether healthcare discrimination was experienced personally or by friends and family members. We conducted an LCA to identify discrimination-exposure classes and a modified Poisson regression to identify associations between class membership and patient-reported quality outcomes (e.g., overall medical provider quality, respect, clear communication, and careful listening), while adjusting for covariates. Results: We identified four latent classes of healthcare discrimination: low discrimination (LD; referent class: 72.2% of total sample), vicarious linguistic discrimination (VL; 13.9%), elevated personal and vicarious racial discrimination (EPVR; 10.5%), and high racial/ethnic discrimination (HRE; 3.4%). Compared to those in the LD class, individuals in the EPVR class had higher rates of reporting their current medical provider's respect and careful listening skills as sometimes or never, (Respect aIRR: 1.90, 95% CI: 1.05-3.42; Listening aIRR: 2.18, 95% CI: 1.29-3.66). Those in the HRE class reported higher rates of reporting their medical provider's quality and communication as poor or fair and lower ratings of careful listening (Quality aIRR: 2.06, 95% CI: 1.08-3.93; Communication aIRR: 1.97, 95% CI: 1.00-3.63; Listening aIRR: 2.41, 95% CI: 1.27-4.59), compared to those in the LD class. Those in the VL class had higher rates of reporting that their medical provider never or sometimes respected or carefully listened to them (Respect aIRR: 2.12, 95% CI: 1.20-3.72; Listening aIRR:1.67, 95% CI:1.03-2.71) than those in, the LD class. Conclusions: Healthcare organizations committed to providing equitable patient care should establish more robust quality improvement approaches to prevent discrimination at the medical provider level as well as structures of accountability to reconcile previously embedded social inequities within the healthcare system.

20.
Drug Alcohol Depend ; 221: 108555, 2021 04 01.
Artigo em Inglês | MEDLINE | ID: mdl-33596496

RESUMO

BACKGROUND: It is common for adults with opioid use disorder (OUD) to misuse additional substances, and these individuals may be particularly at risk for adverse events, including mortality. Less is known about how continued receipt of prescription opioids or risk of adverse events (e.g., suicidality, overdose, poisoning) differs for people with co-occurring OUD and additional substance use disorders (SUDs). METHODS: We conducted a retrospective study using IBM® MarketScan® Multi-State Medicaid Database enrollment/claims data. We used logistic regression to measure the association between sample characteristics and our dependent variables. The sample consisted of non-Medicare-eligible adults aged 18-64 years who were continuously enrolled in Medicaid in 2016-2017 with an OUD diagnosis on at least one claim in 2016. RESULTS: Adults with OUD and a co-occurring SUD were more likely than adults with OUD only to have an opioid-related poisoning event (odds ratio [OR] = 1.488, p = .0052), all-cause poisoning (OR = 1.756, p < .0001), or suicidal ideation (OR = 1.796, p < .0001) but not to receive ongoing opioid prescriptions (OR = 0.973, p = .1626). Adverse events varied by OUD-SUD combination. For example, adults with OUD and cocaine use disorder had the highest odds of all-cause (OR = 2.393, p < .0001) or opioid-related (OR = 1.890, p = .0027) poisoning among those with a drug-specific diagnosis and were most likely to be diagnosed with suicidal ideation (OR = 2.465, p < .0001). CONCLUSIONS: This study provides evidence that adults with OUD and a co-occurring additional SUD have increased risk for several adverse events. Multisubstance use should be screened for and identified to determine the most appropriate course of treatment.


Assuntos
Efeitos Colaterais e Reações Adversas Relacionados a Medicamentos/epidemiologia , Medicaid , Transtornos Relacionados ao Uso de Opioides/epidemiologia , Adolescente , Adulto , Idoso , Analgésicos Opioides , Bases de Dados Factuais , Overdose de Drogas/epidemiologia , Feminino , Humanos , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Razão de Chances , Estudos Retrospectivos , Estados Unidos , Adulto Jovem
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