Population Health Management Approach to Depression Symptom Monitoring in Primary Care via Patient Portal: A Randomized Controlled Trial.

Depression is undertreated in primary care. Using patient portals to administer regular symptom assessments could facilitate more timely care. At an urban academic medical center outpatient clinic, patients with active portal accounts and depression on their problem list or a positive screen in the past year were randomized to assessment during triage at visits (usual care) versus usual care plus assessment via portal (population health care). Portal invitations were sent regardless of whether patients had scheduled appointments. More patients completed assessments in the population health care arm than usual care: 59% versus 18%, P < 0.001. Depression symptoms were more common among patients who completed their initial assessment via the portal versus in the clinic. In the population health care arm, 57% (N = 80/140) of patients with moderate-to-severe symptoms completed at least 1 follow-up assessment versus 37% (N = 13/35) in usual care. A portal-based population health approach could improve depression monitoring in primary care.

Association between wait time and behavioral health appointment attendance across patient characteristics.

Adequate access to behavioral health (BH) services is a critical issue. Many patients who are referred to BH care miss their appointments. One barrier to BH care is that longer wait times decrease the likelihood of appointment attendance. The present study examines the relationship between the wait time for BH services and appointment attendance, overall and by multiple patient characteristics. Logistic regression was performed to analyze the association between wait time and patient attendance for BH referrals made from March 1, 2016, to February 28, 2019, at an urban academic medical center. In total, 1,587 referrals were included. Most patients were female (72%) and of non-Hispanic/Latinx Black race (55%). Each additional week of waiting between the referral and scheduled appointment was associated with a 5% decrease in odds of attendance. In adjusted race/ethnicity-stratified analyses, Hispanic/Latinx patients had a 9% lower odds of attendance per week of waiting. Non-Hispanic/Latinx White and Black patients had a 5% lower odds of attendance per week of waiting. Patients with private insurance had a 7% lower odds of attendance per week of waiting, and patients with Medicare had a 6% lower odds of attendance per week of waiting. Limiting scheduling may improve BH care utilization by decreasing the rate of "no shows." (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Pragmatic Clinical Trial of Population Health, Portal-Based Depression Screening: the PORTAL-Depression Study.

BACKGROUND: A population health approach to depression screening using patient portals may be a promising strategy to proactively engage and identify patients with depression. OBJECTIVE: To determine whether a population health approach to depression screening is more effective than screening during clinic appointments alone for identifying patients with depression. DESIGN: A pragmatic clinical trial at an adult outpatient internal medicine clinic at an urban, academic, tertiary care center. PATIENTS: Eligible patients (n = 2713) were adults due for depression screening with active portal accounts. Patients with documented depression or bipolar disorder and those who had been screened in the year prior to the study were excluded. INTERVENTION: Patients were randomly assigned to usual (n = 1372) or population healthcare (n = 1341). For usual care, patients were screened by medical assistants during clinic appointments. Population healthcare patients were sent letters through the portal inviting them to fill out an online screener regardless of whether they had a scheduled appointment. The same screening tool, the Computerized Adaptive Test for Mental Health (CAT-MH™), was used for clinic- and portal-based screening. MAIN MEASURES: The primary outcome was the depression screening rate. KEY RESULTS: The depression screening rate in the population healthcare arm was higher than that in the usual care arm (43% (n = 578) vs. 33% (n = 459), p < 0.0001). The rate of positive screens was also higher in the population healthcare arm compared to that in the usual care (10% (n = 58) vs. 4% (n = 17), p < 0.001). CONCLUSION: Findings suggest depression screening via a portal as part of a population health approach can increase screening and case identification, compared to usual care. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT03832283.

Improving Primary Care Behavioral Health Integration in an Academic Internal Medicine Practice: 2-Year Follow-Up.

This report details ongoing efforts to improve integration in the 2 years following implementation of the Primary Care Behavioral Health model at a general internal medicine clinic of an urban academic medical center. Efforts were informed by a modified version of the validated Level of Integration Measure, sent to all faculty and staff annually. At baseline, results indicated that the domains of systems integration, training, and integrated clinical practices had the greatest need for improvement. Over the 2 years, the authors increased availability of behavioral medicine appointments, improved depression screening processes, offered behavioral health training for providers, disseminated clinical decision support tools, and provided updates about integration progress during clinic meetings. Follow-up survey results demonstrated that physicians and staff perceived improvements in integration overall and in targeted domains. However, the main ongoing barrier to integration was insufficient behavioral health staff to meet patient demand for behavioral health services.

Measuring Perceived Level of Integration During the Process of Primary Care Behavioral Health Implementation.

Provider- and staff-perceived levels of integration were measured during implementation of a primary care behavioral health clinic; these data were used to tailor and evaluate quality improvement strategies. Providers and staff at an urban, academic, adult primary care clinic completed the 32-item Level of Integration Measure (LIM) at baseline and 7 months. The LIM assesses 6 domains of integrated care. Overall and domain scores were calibrated from 0 to 100, with ≥80 representing a highly integrated clinic. Response rate was 79% (N = 46/58) at baseline and 83% (N = 52/63) at follow-up. Overall, LIM score increased from 64.5 to 70.1, P = .001. The lowest scoring domains at baseline were targeted for quality improvement and increased significantly: integrated clinical practice, 60.0 versus 68.4, P < .001; systems integration, 57.0 versus 63.8, P = .001; and training, 56.7 versus 65.3, P = .001. Ongoing quality improvement, including organizational and financial strategies, is needed to achieve higher levels of integration.

Strategic self-presentation may enhance effects of interdisciplinary chronic pain treatment.

OBJECTIVE: Strategic self-presentation (SSP) is rooted in cognitive dissonance and self-perception theories, and holds that when a person presents him/herself as having certain attributes and publicly commits to having these attributes, then he or she may then begin to behave consistently with that presentation. SSP principles were integrated into an interdisciplinary chronic pain program to test whether self-presentation as a "good coper" made in a public context would increase pre- to posttreatment gains on measures of pain severity, interference, activity level, depression, pain self-efficacy, and coping. METHOD: Eighty-nine patients with chronic pain were assigned to either claim that they are coping well with pain (SSP-positive) or that they are having problems coping with pain (SSP-negative). This condition was crossed with public or private commitments. RESULTS: Significant 2 SSP (positive, negative) × 2 Commitment (public, private) interactions were found for most pre- to posttreatment change scores such that the participants in the SSP-positive/Public condition reported greater improvements than other conditions on interference, depression, self-efficacy and positive coping. These effects were not accounted for by participant level of social desirability. CONCLUSION: Results imply that publicly committing to coping well with chronic pain enhances adjustment to pain relative to other commitment conditions.

Who benefits from emotional expression? An examination of personality differences among gynaecological cancer patients participating in a randomized controlled emotional disclosure intervention trial.

The present study examined the role of neuroticism and extraversion in the effects of written emotional disclosure in patients diagnosed with gynaecological cancer. It was hypothesized that high levels of neuroticism would be associated with an increase in distress after emotional disclosure as mediated by heightened negative affect and avoidance post-disclosure. Conversely, we expected high extraversion to be associated with decreased distress as mediated by heightened positive moods and a decrease in avoidance. Eighty-eight participants were randomly assigned to participate in an expressive writing task versus a control writing task. Distress and avoidance were assessed at baseline and 6 months post-writing. Negative and positive mood were assessed immediately following writing. Multiple regression confirmed that neuroticism but not extraversion moderates the effects of emotional disclosure on distress, however no significant mediating relationships were found.

Within-subject comparison of the subjective and psychomotor effects of a gaseous anesthetic and two volatile anesthetics in healthy volunteers.

Inhalant abuse is a serious public health problem throughout the world. The present study compared the states of intoxication produced by three inhaled anesthetics that represent two of the three major classes of abused inhalants, as classified by [Balster, R.L., 1998. Neural basis of inhalant abuse. Drug Alcohol Depend 51, 207-214.]. Isoflurane and sevoflurane represent the class of volatile substances, and nitrous oxide (N2O) comprises a class of its own. Fourteen healthy volunteers inhaled the vehicle (100% O2) and two concentrations each of isoflurane (0.1 and 0.2%), sevoflurane (0.2 and 0.4%), and N2O (15 and 30%) for 40 min each, across seven separate sessions. Drug concentrations were chosen to produce similar ratings of drug effect strength and similar impairment on a psychomotor test, the digit-symbol substitution test (DSST). Ratings of drug effect strength and performance on the DSST were similar across drugs; however, the volatile anesthetics produced greater sedation and greater impairment on three other psychomotor tests than N2O, whereas N2O produced a greater magnitude of putatively pleasant and psychedelic-like subjective effects. These results are consistent with the drugs' putative receptor mechanisms of action and confirm Balster's classification of the volatile anesthetics into a class distinct from N2O.

Reinforcing and subjective effects of the volatile anesthetic, sevoflurane.

Sevoflurane is a volatile anesthetic that is chemically similar to volatile substances of abuse and can be safely administered to humans in laboratory research. In this study, the reinforcing and subjective effects of five concentrations of sevoflurane (0, 0.2, 0.4, 0.6, 0.8% sevoflurane in O2) were studied in 20 non-drug-abusers. During each of five sessions, subjects sampled a concentration of sevoflurane and 100% O2 (placebo) for 10 min each. Later, within the session, they chose nine times, once every 5 min, among sevoflurane (e.g. "Agent A"), placebo (e.g. "Agent B"), or neither (and were administered 100% O2, identified as "drug-free air"). Although "neither" was selected most frequently, mean preference ratios (sevoflurane choices/[sevoflurane choices+placebo choices]) and total sevoflurane choice peaked at the 0.4% concentration. Choice patterns varied across subjects, with some subjects never choosing sevoflurane and other subjects showing monotonic increasing or bitonic concentration-choice functions. Concentration-related increases in subjective effects were observed, including effects that are putatively associated with abuse liability. Ratings of drug liking and of wanting to inhale the drug again were positively correlated with sevoflurane choice. This study shows that sevoflurane can function as a reinforcer and produce abuse liability-related subjective effects in some healthy volunteers.

The effects of a cold-water stimulus on butorphanol effects in males and females.

Using a crossover, randomized, double-blind, cumulative-dosing procedure, we examined whether a painful stimulus modulated subjective and psychomotor effects of butorphanol in eight male and eight female volunteers. During each session, volunteers received four intravenous injections of either butorphanol (0, 0.5, 1, and 2 mg/70 kg) or saline (placebo) at hourly intervals. Saline and butorphanol were tested in two conditions, forearm immersion 30 min after each injection into either 2 or 37 degrees C water. During the 180-s immersion, volunteers completed a visual analog scale (VAS), psychomotor test, and pain ratings. VAS ratings of "Coasting ('spaced out')", "heavy or sluggish feeling," and "sleepy" were lower in the 2 degrees C than in the 37 degrees C condition during butorphanol administration, but only in females. Modulation by a painful stimulus of sleepy ratings was confined to the third immersion (i.e., a dose effect). The cold-water stimulus significantly decreased butorphanol-induced impairment during the third immersion for males, and females showed a similar trend. Overall, pain ratings were higher in females, and although not significant, males reported a greater degree of analgesia. The differences in pain ratings and degree of analgesia between the sexes are discussed as a possible mechanism for the sex differences in modulatory effects.