Prevalence of antenatal suicidal ideation among racially and ethnically diverse WIC enrolled women receiving care in a Midwestern public health clinic.

BACKGROUND: Suicidal ideation (SI) during pregnancy is a major maternal health concern, however few examinations report findings on the burden of SI among low-income women. The aim of this study is to estimate the prevalence and correlates of suicidal ideation among a sample of low-income women. METHODS: A cross-sectional analysis of 736 low-income pregnant women enrolled in a Women Infant and Children supplemental nutrition program and a perinatal depression registry between 2013 and 2015. All participants provided informed consent. SI was captured from Edinburgh Postnatal Depression Scale (EPDS) screens administered during standard clinic visits. RESULTS: The prevalence of suicidal ideation was 4.6%. After adjusting for smoking, women with depression were 13 times as likely to report SI. LIMITATIONS: SI was measured using a single item from the EPDS during pregnancy. CONCLUSIONS: This study indicates that most, but not all, women with SI reported elevated depressive symptoms.

Value-based payment in implementing evidence-based care: the Mental Health Integration Program in Washington state.

OBJECTIVES: To assess the role of value-based payment (VBP) in improving fidelity and patient outcomes in community implementation of an evidence-based mental health intervention, the Collaborative Care Model (CCM). STUDY DESIGN: Retrospective study based on a natural experiment. METHODS: We used the clinical tracking data of 1806 adult patients enrolled in a large implementation of the CCM in community health clinics in Washington state. VBP was initiated in year 2 of the program, creating a natural experiment. We compared implementation fidelity (measured by 3 process-of-care elements of the CCM) between patient-months exposed to VBP and patient-months not exposed to VBP. A series of regressions were estimated to check robustness of findings. We estimated a Cox proportional hazard model to assess the effect of VBP on time to achieving clinically significant improvement in depression (measured based on changes in depression symptom scores over time). RESULTS: Estimated marginal effects of VBP on fidelity ranged from 9% to 30% of the level of fidelity had there been no exposure to VBP (P <.05 for every fidelity measure). Improvement in fidelity in response to VBP was greater among providers with a larger patient panel and among providers with a lower level of fidelity at baseline. Exposure to VBP was associated with an adjusted hazard ratio of 1.45 (95% confidence interval, 1.04-2.03) for achieving clinically significant improvement in depression. CONCLUSIONS: VBP improved fidelity to key elements of the CCM, both directly incentivized and not explicitly incentivized by the VBP, and improved patient depression outcomes.

Prescription Opioid Taper Support for Outpatients With Chronic Pain: A Randomized Controlled Trial.

Patients receiving long-term opioid therapy for chronic pain and interested in tapering their opioid dose were randomly assigned to a 22-week taper support intervention (psychiatric consultation, opioid dose tapering, and 18 weekly meetings with a physician assistant to explore motivation for tapering and learn pain self-management skills) or usual care (N = 35). Assessments were conducted at baseline and 22 and 34 weeks after randomization. Using an intention to treat approach, we constructed linear regression models to compare groups at each follow-up. At 22 weeks, adjusted mean daily morphine-equivalent opioid dose in the past week (primary outcome) was lower in the taper support group, but this difference was not statistically significant (adjusted mean difference = -42.9 mg; 95% confidence interval, -92.42 to 6.62; P = .09). Pain severity ratings (0-10 numeric rating scale) decreased in both groups at 22 weeks, with no significant difference between groups (adjusted mean difference = -.68; 95% confidence interval, -2.01 to .64; P = .30). The taper support group improved significantly more than the usual care group in self-reported pain interference, pain self-efficacy, and prescription opioid problems at 22 weeks (all P-values < .05). This taper support intervention is feasible and shows promise in reducing opioid dose while not increasing pain severity or interference. PERSPECTIVE: In a pilot randomized trial comparing a prescription opioid taper support intervention to usual care, lower opioid doses and pain severity ratings were observed at 22 weeks in both groups. The groups did not differ significantly at 22 weeks in opioid dose or pain severity, but the taper support group improved significantly more in pain interference, pain self-efficacy, and perceived opioid problems. These results support the feasibility and promise of this opioid taper support intervention.

Unpacking Collaborative Care for Depression: Examining Two Essential Tasks for Implementation.

OBJECTIVE: This study examined how two key process-of-care tasks of the collaborative care model (CCM) predict patient depression outcomes. METHODS: Registry data were from a large implementation of the CCM in Washington State and included 5,439 patient-episodes for patients age 18 or older with a baseline Patient Health Questionnaire-9 (PHQ-9) score of ≥10 and at least one follow-up contact with the CCM care manager within 24 weeks of initial contact. Key CCM tasks examined were at least one care manager follow-up contact within four weeks of initial contact and at least one psychiatric consultation between weeks 8 and 12 for patients not responding to treatment by week 8. Clinically significant improvement in depression symptoms was defined as achieving a PHQ-9 score of <10 or a 50% or more reduction in PHQ-9 score compared with baseline. Bivariate and multivariate (logistic and proportional hazard models) analyses were conducted to examine how fidelity with either task predicted outcomes. All analyses were conducted with the original sample and with a propensity score-matched sample. RESULTS: Four-week follow-up was associated with a greater likelihood of achieving improvement in depression (odds ratio [OR]=1.63, 95% confidence interval [CI]=1.23-2.17) and a shorter time to improvement (hazard ratio=2.06, CI=1.67-2.54). Psychiatric consultation was also associated with a greater likelihood of improvement (OR=1.44, CI=1.13-1.84) but not with a shorter time to improvement. Propensity score-matched analysis yielded very similar results. CONCLUSIONS: Findings support efforts to improve fidelity to the two process-of-care tasks and to include these tasks among quality measures for CCM implementation.

Screening and Follow-Up Monitoring for Substance Use in Primary Care: An Exploration of Rural-Urban Variations.

BACKGROUND: Rates of substance use in rural areas are close to those of urban areas. While recent efforts have emphasized integrated care as a promising model for addressing workforce shortages in providing behavioral health services to those living in medically underserved regions, little is known on how substance use problems are addressed in rural primary care settings. OBJECTIVE: To examine rural-urban variations in screening and monitoring primary care- based patients for substance use problems in a state-wide mental health integration program. DESIGN: This was an observational study using patient registry. SUBJECTS: The study included adult enrollees (n = 15,843) with a mental disorder from 133 participating community health clinics. MAIN OUTCOMES: We measured whether a standardized substance use instrument was used to screen patients at treatment entry and to monitor symptoms at follow-up visits. KEY RESULTS: While on average 73.6 % of patients were screened for substance use, follow-up on substance use problems after initial screening was low (41.4 %); clinics in small/isolated rural settings appeared to be the lowest (13.6 %). Patients who were treated for a mental disorder or substance abuse in the past and who showed greater psychiatric complexities were more likely to receive a screening, whereas patients of small, isolated rural clinics and those traveling longer distances to the care facility were least likely to receive follow-up monitoring for their substance use problems. CONCLUSIONS: Despite the prevalent substance misuse among patients with mental disorders, opportunities to screen this high-risk population for substance use and provide a timely follow-up for those identified as at risk remained overlooked in both rural and urban areas. Rural residents continue to bear a disproportionate burden of substance use problems, with rural-urban disparities found to be most salient in providing the continuum of services for patients with substance use problems in primary care.

The Role of the Integrated Care Psychiatrist in Community Settings: A Survey of Psychiatrists' Perspectives.

OBJECTIVE: The objective of this study was to describe the work and experiences of psychiatrists practicing integrated care in the community. METHODS: Consulting psychiatrists working in integrated care participated in an online survey about their experiences, opinions, and advice. Results were analyzed with quantitative and qualitative methods. RESULTS: A convenience sample of 52 psychiatrists from around the country who were working in integrated care responded. Respondents reported that they address a wide variety of clinical problems with a range of treatment strategies. Most reported positive experiences, which were summarized in four themes: working in a patient-centered care model, working with a team, the psychiatrist's role as educator, and opportunities for growth and innovation. CONCLUSIONS: The survey documented the experiences of psychiatrists working in integrated care. Findings suggest that integrated care teams allow consulting psychiatrists to leverage their expertise to reach a large number of patients in a variety of practice settings.

The relationship between sleep disturbance in pregnancy and persistent common mental disorder in the perinatal period (sleep disturbance and persistent CMD).

BACKGROUND: Common mental disorder (CMD) and sleep disturbance are two common conditions among women in late pregnancy, affecting up to 20% and 63% of women, respectively, and may adversely affect their quality of life. AIM: The aim of this study is to examine the relationship between sleep disturbance in pregnancy and persistent CMD among low-income pregnant women living in Brazil. METHODS: This was a prospective cohort study conducted with pregnant women recruited from public primary care clinics in São Paulo, Brazil. We performed a longitudinal analysis of 219 women who had CMD from the Self-Report Questionnaire during the 20-30 weeks of pregnancy. Two groups were examined: (1) those who had CMD remission in the postpartum and (2) those who had persistent CMD in the postpartum (measured once in the postpartum period). Poisson regression was used to estimate the degree of association between sleep disturbance in pregnancy and the risk for persistent CMD postpartum. RESULTS: After adjusting for sociodemographic and clinical factors, sleep disturbance during pregnancy is associated with persistent CMD (RR = 1.36, 95% confidence interval: 1.01-1.84). CONCLUSION: In this sample of low-income pregnant women living in Brazil, the presence of sleep disturbance during pregnancy was associated with persistent common mental disorder in the postpartum period. Identification of sleep disturbance in pregnant women with CMD will be important in order to recognize those women at higher risk of persistent CMD in the postpartum period.

Visualizing Anomalies in Electronic Health Record Data: The Variability Explorer Tool.

As Electronic Health Record (EHR) systems are becoming more prevalent in the U.S. health care domain, the utility of EHR data in translational research and clinical decision-making gains prominence. Leveraging primay· care-based. multi-clinic EHR data, this paper introduces a web-based visualization tool, the Variability Explorer Tool (VET), to assist researchers with profiling variability among diagnosis codes. VET applies a simple statistical method to approximate probability distribution functions for the prevalence of any given diagnosis codes to visualize between-clinic and across-year variability. In a depression diagnoses use case, VET outputs demonstrated substantial variability in code use. Even though data quality research often characterizes variability as an indicator for data quality, variability can also reflect real characteristics of data, such as practice-level, and patient-level issues. Researchers benefit from recognizing variability in early stages of research to improve their research design and ensure validity and generalizability of research findings.

Perceived Educational Needs of the Integrated Care Psychiatric Consultant.

OBJECTIVE: With the increased implementation of models that integrate behavioral health with other medical care, there is a need for a workforce of integrated care providers, including psychiatrists, who are trained to deliver mental health care in new ways and meet the needs of a primary care population. However, little is known about the educational needs of psychiatrists in practice delivering integrated care to inform the development of integrated care training experiences. METHOD: The educational needs of the integrated care team were assessed by surveying psychiatric consultants who work in integrated care. RESULTS: A convenience sample of 52 psychiatrists working in integrated care responded to the survey. The majority of the topics included in the survey were considered educational priorities (>50% of the psychiatrists rated them as essential) for the psychiatric consultant role. Psychiatrists' perspectives on educational priorities for behavioral health providers (BHPs) and primary care providers (PCPs) were also identified. Almost all psychiatrists reported that they provide educational support for PCPs and BHPs (for PCP 92%; for BHP 96%). CONCLUSIONS: The information provided in this report suggests likely educational needs of the integrated care psychiatric consultant and provides insight into the learning needs of other integrated care team members. Defining clear priorities related to the three roles of the integrated care psychiatric consultant (clinical consultant, clinical educator, and clinical team leader) will be helpful to inform residency training programs to prepare psychiatrists for work in this emerging field of psychiatry.

The experience of primary care providers with an integrated mental health care program in safety-net clinics.

Primary care providers participating in a statewide implementation of an integrated mental health care program for "safety-net" patients in primary care clinics were surveyed to elicit their experiences and level of satisfaction. Quantitative analyses were performed to identify respondent characteristics and satisfaction with the program. Qualitative analyses were done to identify common themes in response to the question "How could psychiatric consultation [in the program] be improved?" Primary care providers were generally satisfied with the integrated mental health care program and raised several concerns that suggest important principles for successful future implementations of these types of programs.

Cyberbullying, depression, and problem alcohol use in female college students: a multisite study.

Cyberbullying and its effects have been studied largely in middle and high school students, but less is known about cyberbullying in college students. This cross-sectional study investigated the relationship between involvement in cyberbullying and depression or problem alcohol use among college females. Two hundred and sixty-five female students from four colleges completed online surveys assessing involvement in cyberbullying behaviors. Participants also completed the Patient Health Questionnaire-9 (PHQ-9) to assess depressive symptoms and the Alcohol Use Disorder Identification Test (AUDIT) to assess problem drinking. Logistic regression tested associations between involvement in cyberbullying and either depression or problem drinking. Results indicated that 27% of participants had experienced cyberbullying in college; 17.4% of all participants met the criteria for depression (PHQ-9 score ≥10), and 37.5% met the criteria for problem drinking (AUDIT score ≥8). Participants with any involvement in cyberbullying had increased odds of depression. Those involved in cyberbullying as bullies had increased odds of both depression and problem alcohol use. Bully/victims had increased odds of depression. The four most common cyberbullying behaviors were also associated with increased odds for depression, with the highest odds among those who had experienced unwanted sexual advances online or via text message. Findings indicate that future longitudinal study of cyberbullying and its effects into late adolescence and young adulthood could contribute to the prevention of associated comorbidities in this population.

Prevalence of symptoms of depression and anxiety in adults with cystic fibrosis based on the PHQ-9 and GAD-7 screening questionnaires.

OBJECTIVE: To examine the prevalence of symptoms of depression and anxiety among patients with cystic fibrosis (CF) who were followed up at the University of Washington Adult CF clinic and to identify sociodemographic and clinical factors associated with symptoms. METHODS: A total of 178 adults with CF were asked to complete the Patient Health Questionnaire-9 for depression and General Anxiety Disorder-7 for anxiety when clinically stable. Clinically significant symptoms of depression and anxiety were defined in the following 2 ways: (1) symptom definition-presence of moderate-to-severe symptoms based on the questionnaires and (2) composite definition-symptom definition or the use of psychiatric medications to manage symptoms. Associations between Patient Health Questionnaire-9 and General Anxiety Disorder-7 scores with sociodemographic (gender, age, age of CF diagnosis, vocation, and spousal status) and clinical factors (forced expiratory volume in 1 second, body mass index, and CF-related diabetes on insulin) were examined. RESULTS: Of 178 patients, 153 (85%) completed the screening questionnaires. Based on the symptom definition, 7% of patients had symptoms of depression and 5% had symptoms of anxiety. Using the composite definition, 22% of patients had symptoms of depression and 10% had symptoms of anxiety. Based on the Patient Health Questionnaire-9, 5% of patients reported suicidal thoughts. In multiple linear regression analysis, only forced expiratory volume in 1 second % predicted was independently associated with Patient Health Questionnaire-9 depression scores, and no sociodemographic or clinical factors were associated with General Anxiety Disorder-7 anxiety scores. CONCLUSIONS: We conclude that all adults with CF should be screened for symptoms of depression and anxiety given the difficulty in identifying strong clinical risk factors and the unexpected high rates of suicidal ideation.

Ethnic differences in tobacco use during pregnancy: findings from a primary care sample in São Paulo, Brazil.

OBJECTIVES: Tobacco use during pregnancy is a global health concern. To date the majority of research originates in developed countries, thus we have a need to better understand factors related to maternal health in developing countries. We examine the prevalence and correlates of smoking by ethnicity in a sample of pregnant primary care patients in São Paulo, Brazil. DESIGN: Data were obtained from completed surveys during perinatal care visits in primary care clinics. We examine a sample of 811 pregnant women surveyed during 20-30 weeks of pregnancy. Multiple logistic regression was used to obtain odds ratios (OR) and 95% confidence intervals (95% CI). RESULTS: We found significant ethnic differences in smoking during pregnancy. Compared to White women, Black women were more likely to use tobacco during pregnancy (OR: 1.95; 95% CI: 1.16-3.27). In the fully adjusted model, when accounting for common mental disorders, differences in smoking during pregnancy by ethnicity remained (OR: 1.96; 95% CI: 1.14-3.36). CONCLUSIONS: There are ethnic differences in tobacco use during pregnancy. Clinical implications including universal screening for tobacco use during pregnancy and culturally relevant approaches to smoking cessation are suggested.

Pharmacologic management of bipolar disorder in a Medicare Advantage population.

OBJECTIVE: The purpose of this study was to examine patterns of pharmacotherapy for beneficiaries in a high-risk Medicare Advantage program who were diagnosed with bipolar disorder. METHODS: This was a cross-sectional study of 2338 Medicare Advantage beneficiaries diagnosed with bipolar disorder. Pharmacotherapy treatment was assessed via receipt of (1) a mood stabilizer or antipsychotic or both (i.e., guideline concordant bipolar care) and (2) unopposed antidepressant (i.e., without prescription of a mood stabilizer or an antipsychotic). Logistic regression was used to examine correlates of bipolar disorder care. RESULTS: Among those younger than 65 years of age (n = 1395), 54% received guideline concordant therapy and 29% received unopposed antidepressant therapy. Among those 65 years and older (n = 943), 40% received guideline concordant therapy and 33% received unopposed antidepressant therapy. CONCLUSION: Overall, about half of beneficiaries in this Medicare Advantage plan received guideline concordant pharmacotherapy for bipolar disorder, while approximately one-third received an unopposed antidepressant prescription. Antipsychotic medications accounted for most of the monotherapy observed. This study identifies opportunities for further improvements in the pharmacotherapy of bipolar disorder in high-risk Medicare patients.

Bipolar disorder in primary care: clinical characteristics of 740 primary care patients with bipolar disorder.

OBJECTIVE: This study aimed to describe the characteristics of primary care patients with bipolar disorder enrolled in a statewide mental health integration program (MHIP). METHODS: With the Composite International Diagnostic Interview (Version 3.0) and clinician diagnosis, 740 primary care patients with bipolar disorder were identified in Washington State between January 2008 and December 2011. Clinical rating scales were administered to patients at the time of enrollment and during treatment. Quality-of-care outcomes were obtained from a systematic review of the patient disease registry and compared with a previous study of patients with depressive symptoms in an MHIP. Descriptive analysis techniques were used to describe patients' clinical characteristics. RESULTS: Primary care patients with bipolar disorder had high symptom severity on depression and anxiety measures: Patient Health Questionaire-9 (mean±SD score of 18.1±5.9 out of 27) and the seven-item Generalized Anxiety Disorder scale (15.7±4.7 out of 21). Psychosocial problems were common, with approximately 53% reporting concerns about housing, 15% reporting homelessness, and 22% reporting lack of a support person. Only 26% of patients were referred to specialty mental health treatment. Patients with bipolar disorder had a greater amount of contact with clinicians during treatment compared with patients with depressive symptoms from a prior study. CONCLUSIONS: Primary care patients with bipolar disorder enrolled in MHIP had severe depression, symptoms of comorbid psychiatric illnesses, and multiple psychosocial problems. Patients with bipolar disorder received more intensive care compared with patients with depressive symptoms from a prior study. Referral to a community mental health center occurred infrequently even though most patients had persistent symptoms.

Referral for substance abuse treatment and depression improvement among patients with co-occurring disorders seeking behavioral health services in primary care.

This study examined the relationship between substance treatment referrals and depression improvement among 2,373 participants with concurrent substance use and depressive disorders enrolled in an integrated behavioral health program. Three groups of substance treatment referral status were identified: accessed treatment (n=780), declined treatment (n=315), and no referral for treatment (n=1278). The primary outcome is improvement in depressive symptoms (PHQ-9<10 or ≥50% reduction). Using propensity score adjustments, patients accessing substance treatment were significantly more likely to achieve depression improvement than those who declined receiving treatment services (hazard ratio (HR)=1.82, 95% confidence interval (CI): 1.50-2.20, p<0.001) and those without a referral for treatment (HR=1.13, 95% CI: 1.03-1.25, p=0.014). Each 1 week delay in initiating a referral was associated with a decreased likelihood of depression improvement (HR=0.97, 95% CI: 0.96-0.98, p<0.001). Study findings highlight the need of enhancing early treatment contact for co-occurring substance use disorders in primary care.

Specialty behavioral health service use among chronically ill medicare advantage patients with substance use problems.

OBJECTIVE: This study examines the use of substance abuse and mental health services among older adults with substance use disorders. METHODS: Participants were members of Humana Cares, a subsidiary of Humana, Inc., a care management program for chronically ill Medicare Advantage members, between 2008 and 2010. All adults aged 65 and older with a substance use disorder identified with International Classification of Diseases-9 codes were included. We compared utilization of substance abuse and mental health services among participants with no psychiatric comorbidity (n = 585), with comorbid depression (n = 605), and with comorbid severe and persistent mental illness (severe and persistent mental illness, n = 95). RESULTS: Twenty-eight percent utilized substance abuse services and 36% utilized mental health services. After adjusting for covariates, comorbid depression (odds ratio = 4.27, 95% confidence interval: 3.22-5.65) and severe and persistent mental illness (odds ratio = 10.75, 95% confidence interval: 5.22-20.13) were independently associated with specialty service use (either substance abuse or mental health services). CONCLUSION: Although few chronically ill older adults with substance use disorders in this Medicare Advantage program received any specialty substance abuse or mental health services, utilization was higher among those who had concurrent psychiatric disorders.

The presentation, recognition and management of bipolar depression in primary care.

Bipolar disorder is a mood disorder characterized by episodes of major depression and mania or hypomania. Most patients experience chronic symptoms of bipolar disorder approximately half of the time, most commonly subsyndromal depressive symptoms or a full depressive episode with concurrent manic symptoms. Consequently, patients with bipolar depression are often misdiagnosed with major depressive disorder. Individual patient characteristics and population screening tools may be helpful in improving recognition of bipolar depression in primary care. Health risk behaviors including tobacco use, sedentary activity level and weight gain are highly prevalent in patients with bipolar disorder, as are the comorbid chronic diseases such as diabetes mellitus and cardiovascular disease. Patients with bipolar illness have about an eight-fold higher risk of suicide and a two-fold increased risk of death from chronic medical illnesses. Recognition of bipolar depression and its associated health risk behaviors and chronic medical problems can lead to the use of appropriate interventions for patients with bipolar disorder, which differ in important ways from the treatments used for major depressive disorder. The above topics are reviewed in detail in this article.