Collaborative Care for Depression and Anxiety: Racial-Ethnic Differences in Treatment Engagement and Outcomes.

OBJECTIVE: This study aimed to examine racial-ethnic differences in engagement with and clinical outcomes of a collaborative care model (CoCM) implemented in primary care outpatient clinics in an urban academic medical center. METHODS: Adult patients (N=4,911) who screened positive for symptoms of depression, anxiety, or both on the Patient Health Questionnaire-9 or the Generalized Anxiety Disorder-7 scale and who identified as non-Hispanic Black, Hispanic, or non-Hispanic White were offered participation in a CoCM implementation. The primary outcome was treatment engagement, defined as receipt of any follow-up visit, minimally adequate 4-week follow-up (at least one visit), and minimally adequate 16-week follow-up (at least three visits) after initial assessment. Secondary outcomes were response and remission of depression or anxiety. RESULTS: After adjustment of analyses for sociodemographic covariates, Black and Hispanic participants were significantly less likely than White participants to have received any or minimally adequate follow-up. Black and Hispanic participants who received any or minimally adequate 16-week follow-up were more likely than White participants to demonstrate depression symptom response and remission of anxiety symptoms. CONCLUSIONS: This CoCM implementation appears to have been effective in treating depression and anxiety among Black and Hispanic patients. However, significant disparities in receipt of follow-up care were observed. Efforts must be made to improve the retention of patients from racial-ethnic minority groups in collaborative care.

Collaborative Care for Low-Income Patients From Racial-Ethnic Minority Groups in Primary Care: Engagement and Clinical Outcomes.

OBJECTIVE: To assess model impact and opportunities for improvement, this study examined collaborative care model (CoCM) engagement and clinical outcomes among low-income patients from racial-ethnic minority groups with depression and anxiety. METHODS: Starting in 2015, the CoCM was implemented in seven primary care practices of an urban academic medical center serving patients from racial-ethnic minority backgrounds, predominantly Medicaid beneficiaries. Eligible individuals scored positive for depressive or anxiety symptoms (or both) on the Patient Health Questionnaire-2 (PHQ-2) and PHQ-9 and the Generalized Anxiety Disorder Scale-2 (GAD-2) and GAD-7 during systematic screening in primary care settings. Screening rates and yield, patient characteristics, and CoCM engagement and outcomes were examined. Clinical improvement was measured by the difference in PHQ-9 and GAD-7 scores at baseline and at 10-to-14-week follow-up. RESULTS: High rates of screening (87%, N=88,236 of 101,091) and identification of individuals with depression or anxiety (13%, N=11,886) were observed, and 58% of 3,957 patients who engaged in minimally adequate CoCM treatment had significant clinical improvement. Nevertheless, only 56% of eligible patients engaged in the model, and 25% of those individuals did not return for at least one follow-up appointment. Being female with clinically significant comorbid anxiety and depressive symptoms and having Medicaid or commercial insurance increased the likelihood of CoCM engagement. CONCLUSIONS: CoCM can help engage vulnerable patients in behavioral health care and improve clinical symptoms. However, significant opportunity exists to advance the model's impact in treating depressive and anxiety disorders and decreasing health disparities by addressing engagement barriers.

Enhancing the scalability of the collaborative care model for depression using mobile technology.

The collaborative care model (CoCM) has substantial support for improving behavioral health care in primary care. However, large-scale CoCM adoption relies on addressing operational and financial implementation challenges across health care settings with varying resources. An academic medical center serving socioeconomically and racially diverse patients implemented the CoCM in seven practices. A smartphone application was introduced to facilitate CoCM care management during depression treatment (app-augmented CoCM). App features included secure texting, goal/appointment reminders, symptom monitoring, and health education material. A nonrandomized convenience patient sample (N = 807) was enrolled in app-augmented CoCM and compared with patients in standard CoCM (N = 3,975). Data were collected on clinical contact frequency, engagement, and clinical outcomes. App-augmented CoCM patients received more health care team contacts (7.9 vs. 4.9, p < .001) and shorter time to follow up compared with the standard CoCM sample (mean = 11 vs. 19 days, p < .001). App-augmented CoCM patients had clinical outcomes similar to the standard CoCM group (47% vs. 46% with ≥50% depression improvement or score <10), despite app-augmented patients having more prior depression treatment episodes. Further, the app-augmented group with greater app engagement demonstrated increased behavioral health appointment compliance, including more completed appointments and fewer no shows, and greater depression symptom improvement than those with less app engagement. App-augmented CoCM may improve patient engagement in treatment and provide opportunities to implement key CoCM elements without overburdening practice resources. CoCM sustainability and scalability in primary care may be enhanced by using this technology.

Comparison of Collaborative Care and Colocation Treatment for Patients With Clinically Significant Depression Symptoms in Primary Care.

OBJECTIVE: The study compared clinical outcomes of depression treatment in primary care with a colocation model versus a collaborative care model (CoCM). METHODS: Patients (N=240) with Patient Health Questionnaire-9 (PHQ-9) scores of ≥10 treated for clinically significant depression symptoms in primary care sites implementing the CoCM or a colocation model were compared. PHQ-9 scores were collected at baseline and 12 weeks. RESULTS: From baseline to follow-up, reductions in PHQ-9 scores were 33% for the CoCM sites and 14% for the colocation sites, with an unadjusted mean difference in scores of 2.81 (p=.001). CONCLUSIONS: More patients treated in sites that used the CoCM experienced a significantly greater reduction in depression symptoms, compared with patients in sites with the colocation model. As greater adoption of integration models in primary care occurs, it will be important to consider potential implications of these results for promoting adoption of CoCM elements. Further replication of these findings is warranted.

A Survey of American and Canadian Psychiatry Residents on Their Training, Teaching Practices, and Attitudes Toward Teaching.

OBJECTIVE: Formal training for residents-as-teachers in psychiatry is increasingly emphasized. However, little is known about the quantity and content of residents' teaching, their attitudes toward teaching, or the training received on how to teach. METHODS: An online survey was disseminated to American and Canadian psychiatry residents. RESULTS: Three hundred eighty-two residents from all postgraduate years (PGY) responded, representing about 7 % of all trainees. About half of PGY-1 have not received residents-as-teachers training, but by PGY-3 most have. The majority of respondents reported teaching, most commonly 1-5 h. Most found teaching enjoyable or rewarding (n = 304; 87 %); however, 40 % (n = 138) found teaching burdensome, 43 % (n = 151) lacked sufficient time to teach, and many (n = 226; 64 %) reported insufficient feedback from supervisors. CONCLUSIONS: Although the sampling methodology and low response rate limit the generalizability of findings, respondents typically seemed to value teaching, though the majority felt that they lacked feedback on their teaching skills.

The Tarrytown Chief Residents Leadership Conference: a long-term follow-up.

OBJECTIVE: Creating training opportunities for the development of effective leaders is an increasingly important goal in psychiatry residency training programs. This article examines the long-term perceived impact of the Tarrytown Chief Residents Leadership Conference on preparing psychiatric residents for future leadership positions. METHODS: Self-report surveys from attendees who participated in the conference between 1998 and 2011 were examined. RESULTS: Five hundred and forty-one completed surveys were returned (43 % response rate). Eighty-six percent of respondents reported moderate to extreme improvement in leadership confidence post-conference. Most respondents indicated at least moderate improvement in self-awareness (93 %), understanding of group process (92 %), and willingness to address conflict (89 %). Ninety percent felt the conference was important to their residency training, and 80 % indicated increased interest in leadership post-conference. CONCLUSIONS: Responders reported lasting improvements in their confidence in and perceived ability to utilize skills necessary for effective leadership, demonstrating the value of this experiential learning opportunity.

A cognitive behavioral workshop for subclinical obsessions and compulsions.

The present study investigates the effectiveness of a 3-h cognitive behavioral workshop for individuals, ages 18-22, with subclinical obsessions and compulsions. It was hypothesized that, compared to individuals in an assessment-only waitlist group (n = 42), individuals assigned to the workshop group (n = 43) would experience a significant decrease in obsessive-compulsive (OC) symptomatology, comorbidity, and thought action fusion endorsement at 1-month and 5-month follow-up assessments. An additional outcome of interest was the number of incident cases of obsessive-compulsive disorder (OCD) over the course of the study. The results indicated that the workshop group reported a significantly fewer number of OC symptoms at 5-month follow-up and endorsed significantly less thought action fusion at both follow-up points. However, there were no differences between groups in severity of OC symptoms and number of comorbid diagnoses endorsed. Only one incident case of OCD was observed during the study, from a participant in the waitlist group. These results are discussed in reference to treatment of subclinical anxiety symptoms.

Modulation of an activity response with associative and nonassociative fear in the rat: a lighting differential influences the form of defensive behavior evoked after fear conditioning.

Rats confronted with the onset of a light gradient display a transient increase in locomotion called the activity response (AR) and a dark preference (Godsil & Fanselow, 2004). These experiments demonstrate that the magnitude of the AR can be blunted with Pavlovian fear-conditioning procedures via associative and nonassociative fear. Although manifested in decreased locomotion, the blunted AR effect was not due to increased freezing or immobility behaviors. Instead, rats displayed reduced rearing and an increase in a class of behaviors called stationary activity. These results suggest that the lighting differential supplied by the cue influences the topography of defensive behavior and reduces the expression of freezing. This procedure provides a means by which to examine learned and unlearned defensive responses to the same stimulus.