Can the electronic medical record provide reliable indicators of primary care behavioral health fidelity? Comparison of accessibility and productivity indicators assessed through observational coding.

INTRODUCTION: The primary care behavioral health (PCBH) model is one of the most widely implemented integrated care approaches. However, research on the model has been limited by inconsistent measurement and reporting of model fidelity. One way of making measurement of PCBH model fidelity more routine is to incorporate fidelity indicators into the electronic medical record (EMR), though research regarding the accuracy of EMR data is mixed. In this study, we aimed to assess the reliability of EMR data as a PCBH fidelity measurement tool by comparing key EMR indicators of PCBH fidelity to those recorded by an observational coder. METHOD: Over an 8-month period (October 2021-May 2022), 12 behavioral health consultants (BHCs; 92% White, 75% female) across five primary care clinics recorded indicators of PCBH fidelity in the EMR as part of their routine charting of behavioral health visits. During that same period, one observational coder completed seven 4-hr visits per clinic to obtain multiple samples of data from each over time and recorded the same variables (i.e., percentage of visits prompted by warm handoffs, number of warm handoffs, and number of patient visits). We used bivariate correlations to test the associations between the EMR variables and the observer-coded variables. RESULTS: Correlations between EMR and observer-coded variables were moderate to strong, ranging from r = .46 to r = .97. DISCUSSION: Leveraging EMR data appears to be a fairly reliable approach to capturing indicators of PCBH model fidelity in the key domains of accessibility and high productivity. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Leveraging the electronic medical record to measure fidelity to the primary care behavioral health model: Implications for clinical and research pursuits.

INTRODUCTION: The primary care behavioral health (PCBH) model of integration has been widely implemented across a number of noteworthy health care systems. However, lack of consistent measurement and reporting of the degree to which the PCBH model has been implemented as developers intended has resulted in two disadvantages in the field. First, clinical quality improvement efforts are hampered by lack of clear guidance on what elements are central to PCBH implementation. Second, the dearth of empirical studies reporting model fidelity impedes cross-study comparisons and limits the rigor of PCBH-focused research. Efforts to expand measurement of PCBH model fidelity would benefit from identification of accessible, unbiased metrics that could complement existing self-report measures. METHOD: In this article, we describe how we partnered with our clinical informatics team to incorporate PCBH fidelity metrics into the electronic medical record (EMR), allowing for monthly extraction and review of these data. RESULTS: Next, we describe how we have used monthly fidelity monitoring to inform clinical quality improvement efforts in the context of a developing integrated care program and provide an example of how PCBH fidelity data might be reported in a research article. DISCUSSION: Leveraging EMR data to support PCBH fidelity measurement has the potential to strengthen clinical quality improvement efforts and enable more consistent measurement and reporting of PCBH fidelity data in research. Future efforts should aim to parse out the relative contribution of different variables to the success of PCBH integration and evaluate the effectiveness of implementation strategies at supporting high fidelity. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Patient perceptions of trauma-focused telemental health services using the Telehealth Satisfaction Questionnaire (TSQ).

Telehealth services can address many barriers to traditional office-based mental health services. Few studies have assessed youth and caregiver perceptions of and satisfaction with trauma-focused interventions delivered via telemental health. The present study reports data collected using the Telehealth Satisfaction Questionnaire (TSQ), which was developed to measure child and caregiver satisfaction with services, comfort with the telehealth equipment, and barriers to traditional office-based services. Thirteen clinicians delivered home- and school-based Trauma-Focused Cognitive Behavioral Therapy (TF-CBT) via videoconferencing on tablets and computers to 60 child patients (71.7% Latinx, 18.3% Black, and 10.0% non-Hispanic White). Patients and caregivers completed the TSQ at treatment discharge via telephone, videoconferencing, or in-person interviews. There was a high level of satisfaction among patients and caregivers receiving TF-CBT via telemental health. Furthermore, most youth and caregivers felt comfortable using the telehealth equipment from the outset of therapy, and all participants who were not initially comfortable using the equipment reported feeling more comfortable over time. The most common barriers to traditional office-based services were caregiver work schedule (57.7%), distance to mental health clinic (55.8%), and lack of transportation (44.2%). Patients and caregivers expressed a preference for telemental health services if given the option between receiving therapy via videoconferencing versus going to an office-based clinic. Findings indicated telemental health treatment addressed barriers that would have otherwise prevented families from accessing office-based services. The TSQ can be used to help clinics and providers assess patient and caregiver satisfaction with telehealth services in various settings. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Interprofessional microteaching: An innovation to strengthen the behavioral health competencies of the primary care workforce.

BACKGROUND: There is significant variability in how residency programs prepare the primary care workforce in behavioral health competencies. One approach that warrants further exploration is to have integrated behavioral health consultants (BHCs) capitalize on in vivo clinical teaching opportunities in the context of team-based care. This article presents preliminary results from the implementation of a pilot program wherein BHCs use warm handoffs and other clinical interactions to provide brief, targeted education to medical residents. METHOD: Twelve BHCs from five resident training clinics participated in a 1-hr training on "microteaching" skills that could be used in clinical teaching interactions. BHCs were asked to track instances of microteaching using an Excel spreadsheet. After 3 months, BHCs and residents responded to electronic surveys that assessed the acceptability and feasibility of this process. RESULTS: In 3 months, BHCs provided 269 instances of microteaching with 66 residents (66.7%) across five clinics. These microteachings occurred within the context of various interactions, including warm handoffs (n = 138, 51.3%), curbside consultations (n = 78, 29.0%), debriefs (n = 46, 17.1%), and team huddles (n = 7, 2.6%). Roughly half (n = 149, 55.4%) of these encounters involved Level 1 microteaching (i.e., lasting 2 min or less), while half (n = 120, 44.6%) involved Level 2 (i.e., lasting 3-10 min). BHCs and residents rated the microteaching interactions as acceptable and feasible. DISCUSSION: Leveraging embedded BHCs as clinical educators in integrated care environments may hold value for increasing behavioral health competencies among medical residents. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Does Group Size Matter? Group Size and Symptom Reduction Among Incarcerated Women Receiving Psychotherapy Following Sexual Violence Victimization.

Survivors Healing from Abuse: Recovery through Exposure (SHARE) is an eight-week therapy group for incarcerated women who have experienced sexual violence victimization. SHARE requires each member to complete an imaginal exposure and to listen when others share their experiences of victimization. While trauma-focused group interventions including SHARE are associated with reductions in internalizing symptoms, little work has examined how group characteristics predict symptom decreases. The purpose of this study was to examine whether group size was associated with symptom changes pre- to post-treatment. Participants (n=140 across 29 groups) completed self-report measures of posttraumatic stress symptoms before and after completing SHARE. Multilevel modeling revealed the majority of the variance in post-treatment symptoms was attributed to individual factors rather than group factors. Symptom change was comparable for groups of two to eight women; declines in symptom improvement were observed at a group size of ten participants.

Clinician's commentary to accompany "Clinical, operational, and financial evaluation practices in integrated behavioral health care".

Presents a clinician's commentary to accompany the article "Clinical, operational, and financial practices in integrated behavioral health care" by A. R. Muse et al (see record 2022-60013-001). In this commentary, the authors address four questions: (1) How does this article, written by researchers, resonate with your experience as a clinician? (2) What Is one thing you might do differently in your practice after reading this article? (3) What factors might facilitate or hinder the uptake/implementation of ideas in this piece? What is one unanswered question that you would like to see pursued as a follow-up to this article? (5) (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Trauma-focused cognitive behavioral therapy with Puerto Rican youth in a post-disaster context: Tailoring, implementation, and program evaluation outcomes.

PURPOSE: Trauma-Focused Cognitive Behavioral Therapy (TF-CBT) has not yet been systematically evaluated in the Caribbean context, particularly with Hispanic youth exposed to multiple disasters. The objective of this project was twofold: 1) to train mental health providers in Puerto Rico in TF-CBT as part of a clinical implementation project within the largest managed behavioral health organization (MBHO) on the island, and 2) to conduct a program evaluation to determine the feasibility of implementation and the effectiveness of the treatment. METHOD: Fifteen psychologists were trained in TF-CBT. These psychologists then provided TF-CBT to 56 children and adolescents, ages 5-18, in community-based mental health clinics and one primary care clinic with a co-located psychologist in Puerto Rico. The mean number of traumatic events reported by youth referred for TF-CBT was 4.11. RESULTS: Thirty-six out of 56 children enrolled in the project (64.3%) successfully completed all components of TF-CBT. Results demonstrated large effect sizes for reduction in youth-reported posttraumatic stress symptoms (PTSS) (Cohen's d = 1.32), depressive symptoms (Cohen's d = 1.32), and anxiety symptoms (Cohen's d = 1.18). CONCLUSIONS: These results suggest that it was feasible to train providers in TF-CBT, that providers were able to deliver TF-CBT in community-based settings both in person and via telehealth (due to the COVID-19 pandemic), and that TF-CBT was an effective treatment option to address trauma-related concerns for youth in Puerto Rico in a post-disaster context. This project is an important first step in the dissemination and implementation of evidence-based trauma-focused treatment for Hispanic youth and disaster-affected youth in the Caribbean.

Implementation of an Evidence-Based Psychotherapy for Trauma-Exposed Children in a Lower-Middle Income Country: the Use of Trauma-Focused Cognitive Behavioral Therapy in El Salvador.

Central American youth are at a high risk for experiencing trauma and related psychosocial problems. Despite this, few studies of evidence-based trauma-focused interventions with this population exist. The objective of this project was twofold: 1) to train providers in El Salvador in Trauma-Focused Cognitive Behavioral Therapy (TF-CBT) as part of a clinical implementation project within a non-governmental organization, and 2) to conduct program evaluation to determine the feasibility of implementation and the effectiveness of the treatment. Fifteen Salvadoran psychologists were trained in TF-CBT who then provided TF-CBT to 121 children and adolescents ages 3-18 in community-based locations. The mean number of traumas reported by youth was 4.39. Results demonstrated large effect sizes for reduction in youth-reported trauma symptoms (Cohen's d = 2.04), depressive symptoms (Cohen's d = 1.68), and anxiety symptoms (Cohen's d = 1.67). Our program evaluation results suggest that it was feasible to train providers in TF-CBT, that providers were in turn able to deliver TF-CBT in community-based settings, and that TF-CBT was an effective treatment option to address trauma-related concerns for youth in El Salvador. This project is an important first step in the dissemination and implementation of evidence-based trauma-focused treatment for youth in Latin American countries.

A Pilot Trial of Universal School-Based Mental Health Screening in El Salvador: Traumatic Stress in an Underresourced School Environment.

Salvadoran youth have an elevated risk of trauma exposure and related mental health problems. However, investigations of childhood trauma exposure and mental health sequelae in El Salvador are limited. The present study aimed to (a) explore the prevalence of exposure to potentially traumatic events and symptoms of posttraumatic stress, anxiety, and depression and (b) evaluate the associations between specific trauma types and emotional functioning among Salvadoran youth. A total of 1,296 youth aged 8-21 years from seven public schools completed self-report measures of trauma exposure, posttraumatic stress symptoms (PTSS), anxiety, and depression. Participants reported high levels of trauma exposure, endorsing an average of 3.62 (SD = 2.32) trauma types. In total, 34.5% of participants reported clinically elevated PTSS; fewer youths reported elevated depressive (8.7%) and anxiety symptoms (8.6%). Although boys reported exposure to more trauma types than girls, d = 0.22, girls were more likely to endorse elevated PTSS, V = .11; anxiety, V = .06; and depression, V = .10. Adolescents reported exposure to more trauma types than younger children, d = 0.23, and were more likely to endorse elevated PTSS, V = .07; anxiety, V = .13; and depression, V = .16. Undergoing a frightening medical procedure, OR = 2.30; female sex, OR = 1.92; witnessing domestic violence, OR = 1.70; and experiencing war between gangs, OR = 1.61, were strong predictors of elevated PTSS. This broad, school-based screening was a critical step toward better understanding the rate of trauma exposure and trauma-related symptoms among Salvadoran youth.

Two Studies Investigating Associations Between Sexual Assault Victimization History and Bystander Appraisals of Risk.

Across two studies, we examined sexual assault history and bystander appraisals of risk and the moderating roles of danger cue salience (Study 1) and alcohol intoxication (Study 2) in women. Participants (Study 1 = 148, Study 2 = 64) read vignettes ending with cues of nonconsensual sexual activity and an opportunity to intervene. Participants also completed self-report measures of vignette appraisals and history of sexual assault victimization. Across both studies, sexual assault victimization was unassociated with bystander risk appraisals. Alcohol intoxication and subtlety of nonconsent cues did not interact with sexual assault victimization history to influence appraisals of dangerousness.

Listen, don't tell: Partnership and adaptation to implement trauma-focused cognitive behavioral therapy in low-resourced settings.

Clinical psychological science has developed many efficacious treatments for diverse emotional and behavioral difficulties encountered by children and adolescents, although randomized trials investigating these treatments have disproportionally been conducted by American, university-based research labs. The subsection of the world population involved in these studies, however, represents very few people among those in need of psychological services whose voices, perspectives, and orientations to therapy have not generally been reflected in well-funded research trials. Dissemination and implementation of evidence-based services designed to meet the needs of this broader global population, therefore, may require cultural and contextual adaptation to be successful. The current article describes the implementation of Trauma-Focused Cognitive Behavioral Therapy (TF-CBT) in 3 separate low-resourced settings (rural South Carolina, Puerto Rico, and El Salvador) utilizing the Exploration, Preparation, Implementation, and Sustainment (EPIS) framework and guided by a community-based participatory research framework. Emphasis is placed on description of program development, building collaborative and responsive partnerships, and the use of implementation strategies to guide continuous quality improvement. Program evaluation data comparing baseline to posttreatment trauma symptoms and treatment completion rates for all sites are also presented, which suggests that treatment was associated with a large reduction in symptoms, exceeding that noted in many TF-CBT randomized trials. The implications of attention to context, adaptation, and methods of building partnerships with global communities are discussed, with a particular focus on propelling more refined models and controlled studies in the future. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Relations of friendship experiences with depressive symptoms and loneliness in childhood and adolescence: A meta-analytic review.

Well-established psychological theories indicate that interpersonal relationships and emotional well-being are linked in fundamental ways (Coyne, 1976; Sullivan, 1953). Indeed, difficulties in close relationships can contribute to emotional adjustment problems, and emotional problems can adversely affect close relationships. Moreover, different close relationships are especially significant in terms of development and adjustment at different stages of the life span. The current review focuses on childhood and adolescence, developmental stages at which friendships are particularly important. This article presents the results of 16 meta-analyses including 589 unique effects from 233 studies that examine concurrent and longitudinal associations between youths' friendship experiences (number of friends, positive friendship quality, negative friendship quality) and their emotional adjustment (depressive symptoms and loneliness). Studies examining these associations are mixed in regard to whether significant effects emerge. The current research synthesis provides more stable estimates of the effects. In fact, relatively small but significant concurrent and longitudinal associations emerged between the 3 indices of friendship with depressive symptoms and loneliness. The results also suggest that friendship experiences may be more closely linked with loneliness than depressive symptoms and that negative friendship quality may be related to friendship experiences more strongly than number of friends or positive friendship quality. Interestingly, some of the relations were found to be stronger for younger youth. Implications for prevention and intervention efforts are discussed. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

A Retrospective Examination of Symptom Improvements in Primary Care Patients Receiving Behavior Therapy With and Without Concurrent Pharmacotherapy.

Primary care providers are the biggest prescribers of psychopharmacological medications. In this non-randomized retrospective examination, we asked whether primary care patients receiving behavioral health interventions with and without concurrent pharmacological treatments showed differential symptom improvement. Participants (79.4% women, 61.5% Hispanic, M age = 41.68, SD = 13.50) were 431 primary care patients referred to behavioral health with a primary concern of depression at one of three federally qualified health centers. Thirty-three percent of patients initiated or had an increase in pharmacotherapy concurrently with behavioral therapy; 26.9% had no change in medication during the episode of care, and 39.7% had no concurrent psychotropic medication prescribed during the episode of care. One-way analyses of variance revealed patients in the no medication group had higher global functioning, as measured by Global Assessment of Functioning (GAF) scores, than patients who were taking medication, or who initated or had an increase in medication. There was a significant main effect of time, where patients had significantly higher GAF scores during their last session in comparison to the first session. All three patient groups experienced comparable improvements in GAF scores, but patients in the initiated/increased medication group were significantly more likely to terminate behavioral health treatment prematurely. Results suggest primary care patients experience improvements in functioning across an episode of behavioral health care, even without concurrent psychotropic medication use.

The impact of anxiety on health care utilization among Hispanic and non-Hispanic youth.

This study examined differences in health service utilization among anxious and non-anxious youth primary care patients. We further examined the moderating role of Hispanic ethnicity on the relation between anxiety and service utilization. Past 4-year health care utilization was examined in a group of 6962 American youth (51.10% male; 53.10% Hispanic). Youth with an anxiety disorder had significantly more medical visits over the prior 4-year period than youth without an anxiety disorder. Hispanic youth utilized health care services at higher rates than non-Hispanic youth; however, ethnicity did not moderate the relation between youth anxiety and health care utilization.

Training Pediatric Primary Care Residents in Trauma-Informed Care: A Feasibility Trial.

This study examined the feasibility and outcomes of a training designed to enhance pediatric residents' trauma-informed practices in primary care. Paired samples t tests examined changes in 33 residents' attitudes, perceived competence, and perceived barriers toward trauma-informed care after a 2-hour training. Fisher's exact tests measured changes in residents' screening and referral behaviors. A subsample (n = 9) of residents were interviewed about the training. Residents reported increases in favorable attitudes (P = .065) and perceived competence (P < .001) and decreases in perceived barriers (P = .001 to .521) to implementing trauma-informed care practices. Chart reviews revealed a significant increase in completed trauma screens (0% to 8.0%, P < .001) but no difference in referrals for psychology/psychiatry services (1.9% to 4.2%, P = .200). Residents reported finding the training helpful. Although residents were willing and understood the utility of assessing for trauma, they faced substantial barriers.

Examining Proximal Risk Factors for Suicide in a Sample of Mexican Adults in Rehabilitation Centers.

The cross-cultural generalizability of the interpersonal theory of suicide was examined in this study. One hundred ninety-nine adults in an inpatient setting in Mexico completed the Personal Resources Questionnaire, Beck Hopelessness Scale, Interpersonal Needs Questionnaire, Acquired Capability for Suicide Scale, and Suicide Behaviors Questionnaire-Revised. Analyses revealed the interaction between perceived burdensomeness and thwarted belongingness did not predict suicide ideation. The interactions between perceived burdensomeness and thwarted belongingness and between perceived burdensomeness and acquired capacity significantly predicted suicidal behaviors, whereas the hypothesized three-way interaction did not. These findings highlight the importance of perceived burdensomeness in the development of suicidal behaviors among Mexican-origin adults.

Inadequacy of the PHQ-2 depression screener for identifying suicidal primary care patients.

INTRODUCTION: The Patient Health Questionnaire-2 (PHQ-2) depression screener has been praised for its brevity and ability to identify depressed primary care patients. Additionally, it is often used as the first of a two-step screening process for suicide risk. Despite its decent performance as a depression screener, the PHQ-2 cannot be assumed to be an adequate screener for suicide risk. In the present study, we examine the utility of the PHQ-2 for identifying suicidal patients. METHOD: We examined data from 548 adult primary care patients at a Federally Qualified Health Center in the mid-Southern region of the United States who completed the PHQ-2 as part of the full administration of the Patient Health Questionnaire-9 (PHQ-9). RESULTS: Cross-tabulation analyses revealed 22 of the 157 (14.0%) patients endorsing suicidal ideation fell below the conventional clinical cutoff of 3 on the PHQ-2. Logistic regression analyses indicated a positive screen on the PHQ-2 did not improve explanation of suicidal ideation beyond the base model, and only 3 items from the first 8 PHQ-9 questions (depressed mood, feeling like a failure, and psychomotor retardation/agitation) were significant explanatory variables for suicidal ideation. DISCUSSION: Providers should consider asking about suicide directly, rather than relying on depression screeners to identify suicidal patients. We also recommend providers pay particular attention to any indication that patients feel like a failure or like they have let their loved ones down, in addition to endorsement of depressed mood. (PsycINFO Database Record

Suicide interventions in primary care: A selective review of the evidence.

INTRODUCTION: About half of people who die by suicide visit their primary care provider (PCP) within 1 month of doing so, compared with fewer than 1 in 5 contacting specialty mental health. Thus, primary care is an important setting for improving identification and treatment of suicide risk. This review identifies and summarizes evidence for the effectiveness of intervention components for suicide risk in primary care. METHOD: We searched the PsycINFO database to identify relevant articles. We considered publications reporting the effectiveness of a packaged intervention for management of suicide risk in primary care or any other brief (i.e., single-session) intervention for suicide risk in the present review. RESULTS: Four major components to suicide interventions in primary care emerged: (a) educating practitioners, (b) screening for suicide risk and/or mood disturbance, (c) managing depression symptoms, and (d) assessing and managing suicide risk. Although practitioner education and screening for suicide risk are important, they are insufficient for effective suicide prevention programs. Collaborative treatment of depression by multidisciplinary teams can reduce rates of suicidal ideation in primary care patients. Recent evidence also indicates a single-session crisis response planning intervention may be effective at reducing suicidal ideation and attempts. DISCUSSION: Integration of behavioral health specialists trained in suicide risk assessment and management could be important for improving suicide prevention in primary care patients. This condensed review of the evidence serves as a resource for practitioners who are hoping to implement brief, effective interventions for suicide risk to better serve their patients. (PsycINFO Database Record

Social-Cognitive and Social-Behavioral Correlates of Suicide Risk in College Students: Contributions from Interpersonal Theories of Suicide and Depression.

Joiner's interpersonal-psychological theory of suicide (IPTS) is predated by literature examining maladaptive interpersonal behaviors associated with depression; however, research has not examined the potential relevance of such behaviors for the IPTS. The current study aimed to expand understanding of suicide risk by examining two maladaptive interpersonal behaviors in the context of Joiner's IPTS model. Structural equation modeling examined associations between depressive symptoms, social-cognitive predictors of suicide, maladaptive interpersonal behaviors, and suicide risk in 228 college students (53.9% female; M = 19.5 years, SD = 1.8). Social-cognitive IPTS variables mediated the relation between depressive symptoms and maladaptive interpersonal behavior. Both social-cognition and maladaptive interpersonal behavior mediated the effect of depressive symptoms on suicide risk. Findings have the potential to add to our understanding of the interplay of social-cognitive factors and interpersonal behaviors associated with suicide risk. Directions for future research are discussed.

Can brief behavioral health interventions reduce suicidal and self-harm ideation in primary care patients?

OBJECTIVE: We examined whether brief behavioral health visits reduced suicidal and self-harm ideation among primary care patients and compared the effectiveness of interventions that targeted ideation directly (i.e., safety planning) with those that targeted ideation indirectly through management of underlying mental illness (e.g., behavioral activation). METHOD: We examined first- and last-visit data from 31 primary care patients with suicidal or self-harm ideation seen by behavioral health consultants. RESULTS: Patients reported significantly lower frequencies of suicidal and self-harm ideation at their final visit than at their initial visit. Patients whose ideation was targeted directly showed greater improvements than patients whose ideation was targeted indirectly. DISCUSSION: Although preliminary, results suggest mild to moderate suicidal ideation could be addressed in primary care through integration of behavioral health consultants into the medical team. (PsycINFO Database Record