A Collaborative-Care Telephone-Based Intervention for Depression, Anxiety, and at-Risk Drinking in Primary Care: The PARTNERs Randomized Clinical Trial.

BACKGROUND: Collaborative care (CC) could improve outcomes in primary care patients with common mental conditions. We assessed the effectiveness of a transdiagnostic model of telephone-based CC (tCC) delivered by lay providers to primary care patients with depression, anxiety, or at-risk drinking. METHODS: PARTNERS was a pragmatic trial in 502 primary care adults presenting with depressive symptoms, anxiety symptoms, or at-risk drinking randomized to (1) usual care by primary care providers (PCPs) enhanced with the results of computer-assisted telephone-based assessments (at baseline and 4, 8, and 12 months later) (enhanced usual care [eUC]) or (2) tCC consisting of eUC plus frequent telephone coaching and psychoeducation provided by mental health technicians who also communicated to the PCP recommendations from a psychiatrist for evidence-based pharmacotherapy, psychotherapy, or, when indicated, referrals to mental health services. The primary analysis compared the change on the 9-item Patient Health Questionnaire (PHQ-9) in participants presenting with depression (n = 366) randomized to tCC versus eUC. Secondary analyses compared changes on the Generalized Anxiety Disorder-7 scale (GAD-7) in those presenting with anxiety (n = 298); or change in the number of weekly drinks in those presenting with at-risk drinking (n = 176). RESULTS: There were no treatment or time×treatment effects between tCC and eUC on PHQ-9 scores for patients with depression during the 12-month follow-up. However, there was a treatment effect (tCC > eUC) on GAD-7 scores in those with anxiety and a time×treatment interaction effect on the number of weekly drinks (tCC > eUC) in those with at-risk drinking. CONCLUSION: Implementing transdiagnostic tCC for common mental disorders using lay providers appears feasible in Canadian primary care. While tCC was not better than eUC for depression, there were some benefits for those with anxiety or at-risk drinking. Future studies will need to confirm whether tCC differentially benefits patients with depression, anxiety, or at-risk drinking.

Primary care for individuals with serious mental illness (PriSMI): protocol for a convergent mixed methods study.

INTRODUCTION: People with serious mental illness (SMI) have poor health outcomes, in part because of inequitable access to quality health services. Primary care is well suited to coordinate and manage care for this population; however, providers may feel ill-equipped to do so and patients may not have the support and resources required to coordinate their care. We lack a strong understanding of prevention and management of chronic disease in primary care among people with SMI as well as the context-specific barriers that exist at the patient, provider and system levels. This mixed methods study will answer three research questions: (1) How do primary care services received by people living with SMI differ from those received by the general population? (2) What are the experiences of people with SMI in accessing and receiving chronic disease prevention and management in primary care? (3) What are the experiences of primary care providers in caring for individuals with SMI? METHODS AND ANALYSIS: We will conduct a concurrent mixed methods study in Ontario and British Columbia, Canada, including quantitative analyses of linked administrative data and in-depth qualitative interviews with people living with SMI and primary care providers. By comparing across two provinces, each with varying degrees of mental health service investment and different primary care models, results will shed light on individual and system-level factors that facilitate or impede quality preventive and chronic disease care for people with SMI in the primary care setting. ETHICS AND DISSEMINATION: This study was approved by the University of Ottawa Research Ethics Board and partner institutions. An integrated knowledge translation approach brings together researchers, providers, policymakers, decision-makers, patient and caregiver partners and knowledge users. Working with this team, we will develop policy-relevant recommendations for improvements to primary care systems that will better support providers and reduce health inequities.

Opioid safety recommendations in adult palliative medicine: a North American Delphi expert consensus.

OBJECTIVES: Despite the escalating public health emergency related to opioid-related deaths in Canada and the USA, opioids are essential for palliative care (PC) symptom management.Opioid safety is the prevention, identification and management of opioid-related harms. The Delphi technique was used to develop expert consensus recommendations about how to promote opioid safety in adults receiving PC in Canada and the USA. METHODS: Through a Delphi process comprised of two rounds, USA and Canadian panellists in PC, addiction and pain medicine developed expert consensus recommendations. Elected Canadian Society of Palliative Care Physicians (CSPCP) board members then rated how important it is for PC physicians to be aware of each consensus recommendation.They also identified high-priority research areas from the topics that did not achieve consensus in Round 2. RESULTS: The panellists (Round 1, n=23; Round 2, n=22) developed a total of 130 recommendations from the two rounds about the following six opioid-safety related domains: (1) General principles; (2) Measures for healthcare institution and PC training and clinical programmes; (3) Patient and caregiver assessments; (4) Prescribing practices; (5) Monitoring; and (6) Patients and caregiver education. Fifty-nine topics did not achieve consensus and were deemed potential areas of research. From these results, CSPCP identified 43 high-priority recommendations and 8 high-priority research areas. CONCLUSIONS: Urgent guidance about opioid safety is needed to address the opioid crisis. These consensus recommendations can promote safer opioid use, while recognising the importance of these medications for PC symptom management.

Conceptualizing success factors for patient engagement in patient medical homes: a cross-sectional survey.

BACKGROUND: Patient engagement is a priority for health care quality improvement and health system design, but many organizations struggle to engage patients meaningfully. We describe patient engagement activities and success factors that influence organizational decision-making in Ontario's patient medical homes. METHODS: From March to May 2018, we conducted an online survey focused on practice-level patient engagement that targeted primary care organization leaders at all Ontario family health teams, community health centres, nurse practitioner-led clinics and Aboriginal Health Access Centres. We asked questions from the Measuring Organizational Readiness for Engagement (MORE) and Public and Patient Engagement Evaluation Tool (PPEET) questionnaires. We used factor and mediation analysis to identify organizational conditions and activities that are associated with the outcomes of patient engagement, affecting board decisions, program-level decisions and the formation of collaborative partnerships. RESULTS: We achieved a 53% response rate (n = 149/283); after removing missing data, our final sample size was 141 respondents. Most respondents perceived that their organization's patient engagement activities and resources were insufficient. Processes that had a direct effect on outcomes (ß = 0.7, p < 0.0001) included planning, training and supporting employees; identifying, recruiting and supporting relevant patients; and using leaders. Structures - including an organizational mission and vision for patient engagement, and policies, procedures, job positions, training programs and organizational culture that reflect that mission - indirectly affected outcomes, mediated by the aforementioned processes (ß = 0.7, p < 0.0001). INTERPRETATION: Based on the perceptions of primary care leaders, organizational structures and processes are related to successful patient engagement. Organizations that seek to improve patient engagement should assess their commitment and follow-through with associated resources and activities.

What to do with that policy paper (and why).

In this editorial we describe the clinician/administrator/researcher experience of frustration or confusion around how to effectively advocate for policy change in health care. By the end of the piece the reader will (a) understand the importance of health professionals' advocacy; (b) know how to use policy papers to advocate; and (c) understand how policy organizations use policy papers. We also discuss the National Academies of Medicine, Science, & Engineering High Quality Primary Care report as an example of a policy paper, introduce our new coeditors for the Policy and Management Department, and describe the Collaborative Family Health Care Association's new policy principles. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

The relationship between clinician leverage, patient experiences, and and the impact of stigma: a study in academic and community outpatient psychiatry settings.

OBJECTIVE: Various methods are used to induce or pressure patients into being more adherent with treatment; collectively, we can describe them as leverage. Leverage strategies are common in psychiatric services, and may carry unintended, potentially negative effects. We examine their relationships to experiences and impact of stigma. METHODS: Data from 137 researcher-administered surveys with adult general psychiatry patients from hospital and community psychiatric services in Toronto, Canada were analyzed, including socio-demographics, service use history, current level of symptoms, insight into mental illness, and stigma scores. Descriptive and bivariate analyses were performed to guide generalized linear models to examine the relationships between multiple domains of leverage and experiences and impact of stigma. RESULTS: Use of leverage strategies is prevalent, ranging from outpatient commitment (10.2%) to financial (21.2%) to access to children or family (31.2%). Regression analyses show being female, having high psychiatric symptomology, financial leverage, and family and/or child access leverage were significantly correlated with stigma experience; similarly, these same factors, except for being female, were also associated with stigma impact. CONCLUSION: This cross-sectional study shows a significant association between use of some types of leverage and experience and impact of stigma in general psychiatry patients. Care and balance between good intentioned but potentially stigmatizing leveraging practices should be actively considered in clinical decisions to avoid the unintended negative effects.

Patient perspectives on quality of care for depression and anxiety in primary health care teams: A qualitative study.

BACKGROUND: Widespread policy reforms in Canada, the United States and elsewhere over the last two decades strengthened team models of primary care by bringing together family physicians and nurse practitioners with a range of mental health and other interdisciplinary providers. Understanding how patients with depression and anxiety experience newer team-based models of care delivery is essential to explore whether the intended impact of these reforms is achieved, identify gaps that remain and provide direction on strengthening the quality of mental health care. OBJECTIVE: The main study objective was to understand patients' perspectives on the quality of care that they received for anxiety and depression in primary care teams. METHODS: This was a qualitative study, informed by constructivist grounded theory. We conducted focus groups and individual interviews with primary care patients about their experiences with mental health care. Focus groups and individual interviews were recorded and transcribed verbatim. Grounded theory guided an inductive analysis of the data. RESULTS: Forty patients participated in the study: 31 participated in one of four focus groups, and nine completed an individual interview. Participants in our study described their experiences with mental health care across four themes: accessibility, technical care, trusting relationships and meeting diverse needs. CONCLUSION: Greater attention by policymakers is needed to strengthen integrated collaborative practices in primary care so that patients have similar access to mental health services across different primary care practices, and smoother continuity of care across sectors. The research team is comprised of individuals with lived experience of mental health who have participated in all aspects of the research process.

The primary care assessment and research of a telephone intervention for neuropsychiatric conditions with education and resources study: Design, rationale, and sample of the PARTNERs randomized controlled trial.

While most patients with depression, anxiety, or at-risk drinking receive care exclusively in primary care settings, primary care providers experience challenges in diagnosing and treating these common problems. Over the past two decades, the collaborative care model has addressed these challenges. However, this model has been adopted very slowly due to the high costs of care managers; inability to sustain their role in small practices; and the perceived lack of relevance of interventions focused on a specific psychiatric diagnosis. Thus, we designed an innovative randomized clinical trial (RCT), the Primary Care Assessment and Research of a Telephone Intervention for Neuropsychiatric Conditions with Education and Resources study (PARTNERs). This RCT compared the outcomes of enhanced usual care and a novel model of collaborative care in primary care patients with depressive disorders, generalized anxiety, social phobia, panic disorder, at-risk drinking, or alcohol use disorders. These conditions were selected because they are present in almost a third of patients seen in primary care settings. Innovations included assigning the care manager role to trained lay providers supported by computer-based tools; providing all care management centrally by phone - i.e., the intervention was delivered without any face-to-face contact between the patient and the care team; and basing patient eligibility and treatment selection on a transdiagnostic approach using the same eligibility criteria and the same treatment algorithms regardless of the participants' specific psychiatric diagnosis. This paper describes the design of this RCT and discusses the rationale for its main design features.

Inspiring Muslim Minds: Evaluating a Spiritually Adapted Psycho-educational Program on Addiction to Overcome Stigma in Canadian Muslim Communities.

The stigma of addiction in Muslim communities is a significant barrier to accessing mental health services. The objective of this study was to evaluate the impact of a newly developed spiritually-adapted addictions psychoeducational program with adult Muslims in the mosque setting. Ninety-three individuals were recruited from nine different mosques within Toronto, Canada. Ninety-minute seminars were presented. This study used a convergent mixed method design. There was a significant increase in the participants' self-reported knowledge (t = 3.6; p < 0.001), a more positive attitude on two scales (t = 3.7; p < 0.001 and t = 2.9; p = 0.005) and an increase in willingness to seek help from a medical doctor and mental health professional (t = 4.4; p < 0.001 and t = 2.2; p = 0.03, respectively) post-seminar as compared to baseline. Qualitative data confirmed these changes. Evidence-informed spiritually-adapted outreach program in the mosque setting can help reduce addiction related stigma in Muslim communities.

Lessons from the team care playbook: Recommendations for COVID-19 vaccination dissemination and uptake.

For too many of us, the implications of a worldwide pandemic unfolded in graduated stages of understanding that seemed too sluggish for the opponent we faced. For too many of us, even those of us in health care, the unfolding was terrifying; we felt blindsided and unprepared. If coronavirus disease 2019 (COVID-19) were a bully picking a fight, they got the first punch in before we even raised a fist. Now, many rounds in, health care teams will have an opportunity to deploy a new weapon against COVID-19. Vaccines are coming. We do not know when, who will pay for them, or the logistical aspects (e.g., storage and administration). We do not even know how effective they will be. Moreover, we must plan for mass vaccination in a chaotic and politically charged context that bears little resemblance to the ones with which we have experience. Nevertheless, in this fight, vaccines could be our winning blow. We are getting better at working with unknowns and in disrupted environments during COVID-19. We have some time to prepare, and we have some extant knowledge and experience in vaccine distribution and uptake. Health care teams can use these to best their adversary, and we can and should begin now. The aim of this article is to discuss how to mobilize interprofessional teams within systems of care to engage best practices in vaccine dissemination and uptake in the unique COVID-19 context. We begin by discussing challenges to dissemination and uptake and then provide solutions using our experiences in the primary care system. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

A walk on the translational science bridge with leaders in integrated care: Where do we need to build?

Entrepreneurs in integrated care face some of the same challenges in empirically demonstrating impact, regardless of the model of care they espouse. In this editorial, 2 leading model developers reflect on the state of the science in primary care integration, including research gaps and promising research underway. We asked these leaders to discuss conceptual areas of shared concern, and we present those with reference to the metaphor of the translational research bridge. Their insights resonate with one another and suggest a role for collaboration to advance empirical support for the implementation of integrated care. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Understanding the effects of chronic benzodiazepine use in depression: a focus on neuropharmacology.

Benzodiazepines are frequently prescribed on an ongoing basis to individuals with depression, mainly to alleviate anxiety or insomnia, despite current guideline recommendations that continuous use should not exceed 4 weeks. Currently, there are no efficacy trials published beyond 8 weeks. Several antidepressant trials demonstrate that the concomitant use of a benzodiazepine is associated with poorer depressive outcomes and functional status; however, it is unclear why this is the case. Patients with depression receiving a benzodiazepine may reflect a more ill or high anxiety group, although even within anxiety disorders, the use of a benzodiazepine is associated with poorer outcomes. The neuroadaptive consequences of long-term benzodiazepine use may be a factor underlying these findings. Chronic benzodiazepine use results in decreased gamma-aminobutyric acid and monoaminergic function, as well as interference with neurogenesis, which are all purported to play a role in antidepressant efficacy. This review will discuss the oppositional neuropharmacological interactions between chronic benzodiazepine use and antidepressant mechanism of action, which could result in reduced antidepressant efficacy and function in depression.

Urgent Outpatient Care Following Mental Health ED Visits: A Population-Based Study.

OBJECTIVE: Follow-up after psychiatric emergency department (ED) contact is key to optimizing outcomes for vulnerable patients. We aimed to quantify the likelihood of receiving outpatient mental health care after psychiatric ED visits in a population-level sample. METHODS: Among individuals who presented for a psychiatric ED visit in Ontario, Canada (2010-2012) and were not admitted to hospital (N=143,662), the authors estimated the likelihood of outpatient physician mental health care within 14 days post-ED visit and compared this across presenting diagnoses. RESULTS: About 40.2% (N=57,797) had a follow-up mental health visit within 14 days post-ED. Follow-up was lower among individuals presenting with substance use disorders (25.2%) than among those presenting with disorders not primarily related to substance use (44.5%) (χ2=3,784.7, df=1, p<0.001). Follow-up differed among those presenting with schizophrenia (46.4%), bipolar disorder (56.1%), and major depressive disorder (51.1%) (χ2=61.7, df=2, p<0.001). CONCLUSIONS: Post-ED outpatient mental health follow-up is low. Systemwide coordination is needed to connect these high-acuity patients with care, especially those with presentations related to substance use.

Evaluating time in health care: What are we busy about?

At the end of the day, there are both economic and less tangible benefits to having predictable clinic operations in which people's medical and behavioral health needs are met. These different benefits, stemming from changes in how time is used, are relevant to a wide range of stakeholders including administrators, clinicians, and patients. In short, time is one of our most important resources in health care. Therefore, time studies have a crucial role to play in advancing the implementation of integrated care. In this editorial we describe several methods for measuring time and invite readers to consider which of these (or another method you're aware of) balances your needs for precision and feasibility of measurement. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Patient access: How do we measure it?

The aim of this article is to introduce key definitions to patient access and a measurement approach, translated for a clinic-based research study or program evaluation. The authors hope this piece will provide those seeking to improve access with some basic starting points and replace rhetoric with rigor in evaluation. Issues discussed include defining access for measurement, measuring access, starting with the end point in mind, and using a logic model. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Challenges in conducting research on collaborative mental health care: a qualitative study.

BACKGROUND: We sought to understand poor uptake of the Primary Care Assessment and Research of a Telephone Intervention for Neuropsychiatric Conditions with Education and Resources study (PARTNERs), a pragmatic randomized controlled trial of a collaborative care intervention for people experiencing depression, anxiety or at-risk drinking. We explored primary care providers' experience with PARTNERs, and preferences regarding collaborative care models and trials. METHODS: In this qualitative study, we interviewed primary care providers across Ontario who had participated in PARTNERs, using stratified sampling to reach high-, low- and nonreferring providers in urban and rural settings. We audio-recorded, transcribed and thematically analyzed the interviews between May and December 2017, collecting and analyzing data concurrently until achieving saturation. RESULTS: We interviewed 23 primary care providers. They valued the unique availability of telephone-based coaching for patients but desired greater integration of the coach into their practice. They appreciated expert psychiatric recommendations but rarely changed their practices. Sites varied in organizational adoption and implementation of the study, including whether they designated a local champion, proactively identified eligible patients, integrated the study into existing workflows and reflected on (and revised) practices. These behaviours affected continuing awareness of the study and referral rates. INTERPRETATION: Study uptake was influenced by the limited relationship between PARTNERs coaches and primary care providers, and variable attention to leadership, training and quality improvement as vital elements of collaborative care. Study designs focusing on implementation could promote reach and penetration of novel interventions in the practice setting and more successfully advance collaborative care implementation.

A recipe for assessing fidelity in family and health systems.

Following recipes is an analogy for maintaining intervention integrity, or, fidelity. Fidelity is the extent to which an intervention is implemented as intended. This editorial presents a recipe for assessing fidelity in family and health systems. The author discusses the challenges posed by the complex recipes of families and health systems interventions, in both research and clinical practice. The author concludes that increasing the measurement and reporting of fidelity is paramount in the exploding literature around family and health systems research. Researchers and practice improvement champions must find ways to assess fidelity or its proximal indicators and work to innovate new, more efficient methods that allow for ubiquitous fidelity assessment and monitoring systems, ensuring the best care for the families and system stakeholders they serve. (PsycINFO Database Record (c) 2019 APA, all rights reserved).