Insomnia in primary care: Considerations for screening, assessment, and management.

Insomnia, including insomnia disorder, is a common but often overlooked complaint in primary care settings. It is a risk factor for various medical and psychiatric diagnoses and is associated with substantial health care costs. While cognitive behavioral therapy for insomnia (CBT-I) is the first-line treatment for insomnia disorder, access to CBT-I is limited. This article provides a pragmatic approach to screening, assessment, and treatment of insomnia in the primary care setting, promoting a population health approach. The authors review the role of CBT-I, treatment of comorbid conditions, and pharmacologic recommendations in working with primary care patients with insomnia. In addition, the authors highlight the potential utility of technology in improving access to insomnia care.

Demystifying borderline personality disorder in primary care.

Borderline personality disorder (BPD) is a common mental health diagnosis observed in the primary care population and is associated with a variety of psychological and physical symptoms. BPD is a challenging disorder to recognize due to the limitations of accurate diagnosis and identification in primary care settings. It is also difficult to treat due to its complexity (e.g., interpersonal difficulties and patterns of unsafe behaviors, perceived stigma) and healthcare professionals often feel overwhelmed when treating this population. The aim of this article is to describe the impact of BPD in primary care, review current state of knowledge, and provide practical, evidence-based treatment approaches for these patients within this setting. Due to the lack of evidence-based pharmacological treatments, emphasis is placed on describing the framework for treatment, identifying psychotherapeutic opportunities, and managing responses to difficult clinical scenarios. Furthermore, we discuss BPD treatment as it relates to populations of special interest, including individuals facing societal discrimination and adolescents. Through this review, we aim to highlight gaps in current knowledge around managing BPD in primary care and provide direction for future study.

Treating Bipolar Disorder in Primary Care: Diagnosis, Pharmacology, and Management.

Bipolar disorder is a chronic mental illness associated with early mortality, elevated risk of comorbid cardiovascular disease, enormous burden of disability, and large societal costs. Patients often seek treatment for symptoms of bipolar disorder in the primary care setting but are frequently misdiagnosed. This article provides primary care providers with an evidence-based approach to the screening, diagnosis, and pharmacological management of bipolar disorder. Guidance is also provided for helping patients connect with higher levels of specialty psychiatric care when clinically indicated.

Improving Suicide Prevention in Primary Care for Differing Levels of Behavioral Health Integration: A Review.

Importance: Suicide prevention implementation in primary care is needed due to the increasing rate of suicide in the past few decades, particularly for young and marginalized people. Primary care is the most likely point of contact for suicidal patients in the healthcare system. Attention to the level of medical integration with behavioral health is vital to suicide prevention and is applied throughout this review. Methods: A narrative review was performed. Observations: Many interventions help improve suicide prevention care. PCP education, screening, safety planning/lethal means reduction, care transitions, psychotherapy, and medication management are all evidence-based strategies. Additionally, the pragmatic topics of financing suicide prevention, supporting providers, enacting suicide postvention, and preparing for future directions in the field at each level of primary care/behavioral health integration are discussed. Conclusions and Relevance: The findings are clinically relevant for practices interested in implementing evidence-based suicide prevention strategies by attending to the behavioral health/medical interface. Leveraging the patient/provider relationship to allow for optimal suicide prevention care requires clinics to structure provider time to allow for emotionally present care. Defining clear roles for staff and giving attention to provider well being are also critical factors to supporting primary care-based suicide prevention efforts.

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

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

Approach to Evaluating and Managing Adult Attention-Deficit/Hyperactivity Disorder in Primary Care.

Requests for the evaluation of potential adult attention-deficit/hyperactivity disorder (ADHD) is on the rise across primary care clinics. Many health care providers, however, may feel ill equipped to diagnose and manage adults presenting with inattention and impulsivity. The diagnosis of ADHD is often complicated by medical and psychiatric conditions that can contribute to inattention symptoms. In this article, the authors provide a pragmatic clinical approach for evaluating and managing adult ADHD in the primary care setting.

Posttraumatic Stress Disorder in the Primary Care Setting: Summary of Recommended Care.

Posttraumatic stress disorder (PTSD) occurs following acute threatening events in approximately 12.5% of the primary care population. OBJECTIVE: The aim of this article is to advance evidence-based clinical practice and collaborative care approaches to PTSD by summarizing targeted-care guidelines. METHOD: This narrative literature review addresses important aspects of PTSD and management options, in conjunction with expert opinion when indicated. Guidelines were included if they targeted treatment of PTSD in the primary care setting or if the treatments described could be provided in the primary care setting. RESULTS: The implications regarding PTSD, comorbidities, differential diagnosis, screening tools, and treatment are presented. CONCLUSION: Primary care providers can diagnose and offer initial management of PTSD. Future research should delineate therapies helpful for complex PTSD, including group therapies, those increasing self-compassion, and other optimally effective collaborative care interventions.

The Prevalence of Posttraumatic Stress Disorder in Primary Care: A Systematic Review.

LEARNING OBJECTIVES: After participating in this activity, learners should be better able to:• Determine the prevalence of clinician-diagnosed posttraumatic stress disorder (PTSD) in primary care patients• Identify the prevalence of questionnaire-ascertained PTSD symptoms in primary care patients OBJECTIVE: Determine the prevalence of clinician-diagnosed PTSD and questionnaire-ascertained PTSD symptoms in primary care patients. METHODS: A systematic review of the literature using the PRISMA method, searching MEDLINE, CINAHL, Cochrane Database, PsycINFO, EMBASE, Google Scholar, and relevant book chapter bibliographies. Studies that reported on the prevalence, including point or lifetime prevalence, of PTSD ascertained using diagnostic interviews or self-report questionnaires, or from administrative data, among patients seen in primary care were deemed eligible for inclusion. We abstracted data on the PTSD assessment tool, the mean questionnaire scores/cutoff scores, the time period of PTSD symptoms, and PTSD prevalence reported. RESULTS: Of 10,614 titles screened, 41 studies were eligible for inclusion. The included studies assessed PTSD in a total of 7,256,826 primary care patients. The median point prevalence of PTSD across studies was 12.5%. The median point prevalence in the civilian population was 11.1%; in the special-risk population, 12.5%; and in veterans, 24.5%. The point prevalence of diagnostic interview-ascertained PTSD ranged from 2% to 32.5%, and the point prevalence of questionnaire-based substantial PTSD symptoms ranged from 2.9% to 39.1%. Lifetime prevalence of diagnostic interview-ascertained PTSD ranged from 14.5% to 48.8%. The prevalence of PTSD in administrative data-based studies ranged from 3.5% to 29.2%. CONCLUSIONS: PTSD is common in primary care settings. Additional research on effective and generalizable interventions for PTSD in primary care is needed.

Availability of Outpatient Mental Health Care by Pediatricians and Child Psychiatrists in Five U.S. Cities.

The authors sought to assess the availability of outpatient mental health care through pediatrician and child psychiatrist offices in the United States and to characterize differences in appointment availability by location, provider type, and insurance across five cities. To do so, the authors posed as parents of a 12-year-old child with depression, gave a predetermined insurance type, and asked to make the first available appointment with the specified provider. They called the offices of 601 individual pediatricians and 312 child psychiatrists located in five U.S. cities and listed as in-network by Blue Cross Blue Shield, one of the largest private insurers in the United States. Appointments were obtained with 40% of the pediatricians and 17% of the child psychiatrists. The mean wait time for psychiatry appointments was 30 days longer than for pediatric appointments. Providers were less likely to have available appointments for children on Medicaid, which is public insurance for low-income people. The most common reason for being unable to make an appointment was that the listed phone number was incorrect. Pediatricians were twice as likely to see new patients and to see them sooner than child psychiatrists. Increasing the number of both types of providers may be necessary to increase access to mental health care for children.

Using Shared Medical Appointments to Increase Access to Buprenorphine Treatment.

INTRODUCTION: This study examines patient experiences with shared medical appointments for buprenorphine treatment at a safety net primary care clinic. METHODS: This is a cross-sectional observational study of 28 participants in a primary care buprenorphine shared medical appointments program. RESULTS: Participants reported appreciating the group visit format, gaining increased coping skills, and having more stable housing and less legal difficulty after starting the program. CONCLUSION: The implementation of shared medical appointments for buprenorphine treatment benefits clinicians and patients. The nurse care manager and buprenorphine prescriber can efficiently attend to the clinical needs of multiple patients.

Cortical thickness maturation and duration of music training: health-promoting activities shape brain development.

OBJECTIVE: To assess the extent to which playing a musical instrument is associated with cortical thickness development among healthy youths. METHOD: Participants were part of the National Institutes of Health (NIH) Magnetic Resonance Imaging (MRI) Study of Normal Brain Development. This study followed a longitudinal design such that participants underwent MRI scanning and behavioral testing on up to 3 separate visits, occurring at 2-year intervals. MRI, IQ, and music training data were available for 232 youths (334 scans), ranging from 6 to 18 years of age. Cortical thickness was regressed against the number of years that each youth had played a musical instrument. Next, thickness was regressed against an "Age × Years of Playing" interaction term. Age, gender, total brain volume, and scanner were controlled for in analyses. Participant ID was entered as a random effect to account for within-person dependence. False discovery rate correction was applied (p ≤ .05). RESULTS: There was no association between thickness and years playing a musical instrument. The "Age × Years of Playing" interaction was associated with thickness in motor, premotor, and supplementary motor cortices, as well as prefrontal and parietal cortices. Follow-up analysis revealed that music training was associated with an increased rate of thickness maturation. Results were largely unchanged when IQ and handedness were included as covariates. CONCLUSION: Playing a musical instrument was associated with more rapid cortical thickness maturation within areas implicated in motor planning and coordination, visuospatial ability, and emotion and impulse regulation. However, given the quasi-experimental nature of this study, we cannot rule out the influence of confounding variables.

Global health education in U.S. medical schools.

Interest in global health (GH) among medical students worldwide is measurably increasing. There is a concomitant emphasis on emphasizing globally-relevant health professions education. Through a structured literature review, expert consensus recommendations, and contact with relevant professional organizations, we review the existing state of GH education in US medical schools for which data were available. Several recommendations from professional societies have been developed, along with a renewed emphasis on competencies in global health. The implementation of these recommendations was not observed as being uniform across medical schools, with variation noted in the presence of global health curricula. Recommendations for including GH in medical education are suggested, as well as ways to formalize GH curricula, while providing flexibility for innovation and adaptation.