Clinical Predictors of Engagement in Teleintegrated Care and Telereferral Care for Complex Psychiatric Disorders in Primary Care: a Randomized Trial.

BACKGROUND: Telepsychiatry Collaborative Care (TCC) and Telepsychiatry/Telepsychology Enhanced Referral (TER) expand the reach of specialty mental health services to underserved populations. OBJECTIVE: Assess clinical predictors of treatment engagement for complex psychiatric conditions in TCC-in which remote specialists consult with primary care teams via an onsite care manager who also provides brief psychotherapy-and TER, in which remote specialists provide direct telehealth treatment. DESIGN: A randomized pragmatic trial from twenty-four primary care clinics without onsite psychiatrists or psychologists. PARTICIPANTS: A total of 1,004 adult patients screened positive for posttraumatic stress disorder (PTSD)and/or bipolar disorder were randomized to receive TCC or TER for 1 year. MAIN MEASURES: Psychotherapy engagement was measured by the number of sessions completed, and pharmacotherapy engagement by the medication adherence item from the Schizophrenia Care and Assessment Program Health Questionnaire (SCAP-HQ). KEY RESULTS: Engagement in TCC psychotherapy visits was greater compared to TER. There was no association between the PTSD symptom severity and treatment engagement. The internal state scale (ISS) activation subscale, an indicator of mania, was associated with reduced odds of initiating psychotherapy (odds ratio [OR] = 0.70; 95% CI, 0.59 to 0.84) but not the number of sessions attended once psychotherapy started. The Drug Abuse Screening Test-10(DAST-10) score was associated with receipt of fewer psychotherapy sessions (incidence ratio rate [IRR] = 0.88; 95% CI, 0.81 to 0.95). The number of physical health comorbidities was associated with greater engagement in psychotherapy (IRR = 1.11, 95% CI, 1.03 to 1.19) and pharmacotherapy (OR = 1.54; 95% CI, 1.27 to 1.87). None of the findings varied by intervention group. CONCLUSIONS: Both teleintegrated and telereferral care offer an opportunity to treat patients with complex psychiatric conditions. While there was no difference in clinical characteristics predicting engagement, onsite care managers engaged patients in more psychotherapy sessions than remote therapists. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT02738944.

C-L Case Conference: Chronic Psychosis Managed in Collaborative Care.

We present the case of a 60-year-old woman who presented to primary care with chronic mixed depressive and hypomanic symptoms consistent with schizoaffective disorder. Patients with serious mental illness such as psychotic disorders are ideally referred for treatment in specialty psychiatric settings; however, many patients with serious mental illness receive their care in primary care settings due to patient preference or unavailability of psychiatric services. Top experts in the CL field provide guidance for this commonly encountered clinical case based on their experience and a review of the available literature. The Collaborative Care Model (CoCM) can support primary care providers in managing patients with serious mental illness. Key teaching topics include the application of the CoCM to patients with psychotic disorders, clinician- and systems-level facilitators and barriers to CoCM implementation, and quality improvement within the CoCM. Specifically, the differential diagnosis when a patient is not improving should include systems-level considerations.

Definitive test to diagnose median arcuate ligament syndrome: injection of vasodilator during angiography.

The diagnosis of median arcuate ligament (MAL) syndrome and its correlation with symptoms has been controversial since the disease entity was described. The authors describe a technique that will identify patients who will benefit from intervention. Eight patients with isolated celiac artery compression from MAL were identified by the authors. Their technique involved selective cannulation of the superior mesenteric artery (SMA) and injection of a vasodilator during angiography. Symptom reproduction and loss of collateral filling of the celiac territory represented a positive test: 4 of the 8 patients had a positive test and underwent successful surgical treatment of the condition; 3 of them remained asymptomatic at follow-up; 1 patient continues to have mild abdominal discomfort. Of the 4 patients with a negative test, 2 were found to have other conditions causing their symptoms. Vasodilator injection into the SMA is a useful diagnostic test to identify patients with symptomatic MAL syndrome.