A Cluster Randomized Trial of Primary Care Practice Redesign to Integrate Behavioral Health for Those Who Need It Most: Patients With Multiple Chronic Conditions.

PURPOSE: Patient outcomes can improve when primary care and behavioral health providers use a collaborative system of care, but integrating these services is difficult. We tested the effectiveness of a practice intervention for improving patient outcomes by enhancing integrated behavioral health (IBH) activities. METHODS: We conducted a pragmatic, cluster randomized controlled trial. The intervention combined practice redesign, quality improvement coaching, provider and staff education, and collaborative learning. At baseline and 2 years, staff at 42 primary care practices completed the Practice Integration Profile (PIP) as a measure of IBH. Adult patients with multiple chronic medical and behavioral conditions completed the Patient-Reported Outcomes Measurement Information System (PROMIS-29) survey. Primary outcomes were the change in 8 PROMIS-29 domain scores. Secondary outcomes included change in level of integration. RESULTS: Intervention assignment had no effect on change in outcomes reported by 2,426 patients who completed both baseline and 2-year surveys. Practices assigned to the intervention improved PIP workflow scores but not PIP total scores. Baseline PIP total score was significantly associated with patient-reported function, independent of intervention. Active practices that completed intervention workbooks (n = 13) improved patient-reported outcomes and practice integration (P ≤ .05) compared with other active practices (n = 7). CONCLUSION: Intervention assignment had no effect on change in patient outcomes; however, we did observe improved patient outcomes among practices that entered the study with greater IBH. We also observed more improvement of integration and patient outcomes among active practices that completed the intervention compared to active practices that did not. Additional research is needed to understand how implementation efforts to enhance IBH can best reach patients.

Practice-Level Documentation of Alcohol-Related Problems in Primary Care.

Importance: Rates of alcohol-associated deaths increased over the past 20 years, markedly between 2019 and 2020. The highest rates are among individuals aged 55 to 64 years, primarily attributable to alcoholic liver disease and psychiatric disorders due to use of alcohol. This study investigates potential geographic disparities in documentation of alcohol-related problems in primary care electronic health records, which could lead to undertreatment of alcohol use disorder. Objective: To identify disparities in documentation of alcohol-related problems by practice-level social deprivation. Design, Setting, and Participants: A cross-sectional study using secondary data from the Integrating Behavioral Health and Primary Care clinical trial (September 21, 2017, to January 8, 2021) was performed. A national sample of 44 primary care practices with co-located behavioral health services was included in the analysis. Patients with 2 primary care visits within 2 years and at least 1 chronic medical condition and 1 behavioral health condition or at least 3 chronic medical conditions were included. Exposure: The primary exposure was practice-level Social Deprivation Index (SDI), a composite measure based on county income, educational level, employment, housing, single-parent households, and access to transportation (scores range from 0 to 100; 0 indicates affluent counties and 100 indicates disadvantaged counties). Main Outcomes and Measures: Documentation of an alcohol-related problem in the electronic health record was determined by International Classification of Diseases, 9th Revision, Clinical Modification and International Statistical Classification of Diseases and Related Health Problems, Tenth Revision, Clinical Modification codes or use of medications for alcohol use disorder in past 2 years. Multivariable models adjusted for alcohol consumption, screening for a substance use disorder, urban residence, age, sex, race and ethnicity, income, educational level, and number of chronic health conditions. Results: A total of 3105 participants (mean [SD] age, 63.7 [13.0] years; 64.1% female; 11.5% Black, 7.0% Hispanic, 76.7% White, and 11.9% other race or chose not to disclose; 47.8% household income <$30 000; and 80.7% urban residence). Participants had a mean (SD) of 4.0 (1.7) chronic conditions, 9.1% reported higher-risk alcohol consumption, 4% screened positive for substance use disorder, and 6% had a documented alcohol-related problem in the electronic health record. Mean (SD) practice-level SDI score was 45.1 (20.9). In analyses adjusted for individual-level alcohol use, demographic characteristics, and health status, practice-level SDI was inversely associated with the odds of documentation (odds ratio for each 10-unit increase in SDI, 0.89; 95% CI, 0.80 to 0.99; P = .03). Conclusions and Relevance: In this study, higher practice-level SDI was associated with lower odds of documentation of alcohol-related problems, after adjusting for individual-level covariates. These findings reinforce the need to address primary care practice-level barriers to diagnosis and documentation of alcohol-related problems. Practices located in high need areas may require more specialized training, resources, and practical evidence-based tools that are useful in settings where time is especially limited and patients are complex.

The Association Between Depression and Substance Use Among Primary Care Patients With Comorbid Medical and Behavioral Health Conditions.

INTRODUCTION: The scope of primary care increasingly encompasses patient behavioral health problems, manifest typically through depression screening and treatment. Although substance use is highly comorbid with depression, it is not commonly identified and addressed in the primary care context. This study aimed to examine the association between the likelihood of substance use disorder and increased depression severity, both cross-sectionally and longitudinally, among a sample of 2409 patients from 41 geographically dispersed and diverse primary care clinics across the US. METHODS: This is secondary analysis of data obtained from a multi-site parent study of integrated behavioral health in primary care, among patients with both chronic medical and behavioral health conditions. Patient reported outcome surveys were gathered from patients at 3 time points. The primary care practices were blind to which of their patients completed surveys. Included were standardized measures of depression severity (Patient Health Questionnaire-9) [PHQ-9] and substance use disorder likelihood (Global Appraisal of Individual Needs-Short Screener [GSS]). RESULTS: Four percent of the study population screened positive for substance use disorder. PHQ-9 scores indicated depression among 43% of all patients. There was a significant association between the likelihood of substance use disorder and depression initially, at a 9-month follow-up, and over time. These associations remained significant after adjusting for age, gender, race, ethnicity, education, income, and other patient and contextual characteristics. CONCLUSIONS: The findings suggest that substance use disorder is associated with depression severity cross-sectionally and over time. Primary care clinics and health systems might consider implementing substance use screening in addition to the more common screening strategies for depression. Especially for patients with severe depression or those who do not respond to frontline depression treatments, the undermining presence of a substance use disorder should be explored.

Lessening the Impact of Opioid Misuse at a Federally Qualified Health Center in New York: Outcomes of an Integrated Workforce Training Program.

The COVID-19 pandemic has placed an unprecedented burden on patients, health care providers, and communities and has been particularly challenging for medically underserved populations impacted by the social determinants of health, as well as people with co-occurring mental health and substance use risks. This case study examines outcomes and lessons learned from a multisite low-threshold medication-assisted treatment (MAT) program at a federally qualified health center in partnership with a large suburban public university in New York to integrate and train Health Resources & Services Administration Behavioral Health Workforce Education and Training-funded graduate student trainees in social work and nursing in screening, brief intervention, and referral to treatment and patient care coordination, including social determinants of health and medical and behavioral comorbidities. The MAT program for the treatment of opioid use disorder has a low threshold for entry that is accessible and affordable, reduces barriers to care, and uses a harm reduction approach. Outcome data showed an average 70% retention rate in the MAT program and reductions in substance use. And, while more than 73% of patients reported being somewhat or definitely impacted by the pandemic, most patients endorsed the effectiveness of telemedicine and telebehavioral health, such that 86% indicated the pandemic did not affect the quality of their health care. The main implementation lessons learned were the importance of increasing the capacity of primary care and health care centers to deliver integrated care, using cross-disciplinary practicum experiences to enhance trainee competencies, and addressing the social determinants of health among populations with social vulnerabilities and chronic medical conditions.

Integrating behavioral health & primary care for multiple chronic diseases: Clinical trial of a practice redesign toolkit.

Context: Most patients in need of behavioral health (BH) care are seen in primary care, which often has difficulty responding. Some practices integrate behavioral health care (IBH), with medical and BH providers at the same location, working as a team. However, it is difficult to achieve high levels of integration. Objective: Test the effectiveness of a practice intervention designed to increase BH integration. Study Design: Pragmatic, cluster-randomized controlled trial. Setting: 43 primary care practices with on-site BH services in 13 states. Population: 2,460 adults with multiple chronic medical and behavioral conditions. Intervention: 24-month practice change process including an online curriculum, a practice redesign and implementation workbook, remote quality improvement coaching services, and an online learning community. Outcomes: Primary outcomes were changes in the 8 Patient-Reported Outcomes Measurement Information System (PROMIS-29) domain scores. Secondary outcomes were changes in medication adherence, self-reported healthcare utilization, time lost due to disability, cardiovascular capacity, patient centeredness, provider empathy, and several condition-specific measures. A sample of practice staff completed the Practice Integration Profile at each time point to estimate the degree of BH integration in that site. Practice-level case studies estimated the typical costs of implementing the intervention. Results: The intervention had no significant effect on any of the primary or secondary outcomes. Subgroup analyses showed no convincing patterns of effect in any populations. COVID-19 was apparently not a moderating influence of the effect of the intervention on outcomes. The intervention had a modest effect on the degree of practice integration, reaching statistical significance in the Workflow domain. The median cost of the intervention was $18,204 per practice. In post-hoc analysis, level of BH integration was associated with improved patient outcomes independent of the intervention, both at baseline and longitudinally. Conclusions: The specific intervention tested in this study was inexpensive, but had only a small impact on the degree of BH integration, and none on patient outcomes. However, practices that had more integration at baseline had better patient outcomes, independent of the intervention. Although this particular intervention was ineffective, IBH remains an attractive strategy for improving patient outcomes.

A large-scale retrospective study of opioid poisoning in New York State with implications for targeted interventions.

Opioid overdose related deaths have increased dramatically in recent years. Combating the opioid epidemic requires better understanding of the epidemiology of opioid poisoning (OP). To discover trends and patterns of opioid poisoning and the demographic and regional disparities, we analyzed large scale patient visits data in New York State (NYS). Demographic, spatial, temporal and correlation analyses were performed for all OP patients extracted from the claims data in the New York Statewide Planning and Research Cooperative System (SPARCS) from 2010 to 2016, along with Decennial US Census and American Community Survey zip code level data. 58,481 patients with at least one OP diagnosis and a valid NYS zip code address were included. Main outcome and measures include OP patient counts and rates per 100,000 population, patient level factors (gender, age, race and ethnicity, residential zip code), and zip code level social demographic factors. The results showed that the OP rate increased by 364.6%, and by 741.5% for the age group > 65 years. There were wide disparities among groups by race and ethnicity on rates and age distributions of OP. Heroin and non-heroin based OP rates demonstrated distinct temporal trends as well as major geospatial variation. The findings highlighted strong demographic disparity of OP patients, evolving patterns and substantial geospatial variation.

Integrating Behavioral Health and Primary Care (IBH-PC) to improve patient-centered outcomes in adults with multiple chronic medical and behavioral health conditions: study protocol for a pragmatic cluster-randomized control trial.

BACKGROUND: Chronic diseases that drive morbidity, mortality, and health care costs are largely influenced by human behavior. Behavioral health conditions such as anxiety, depression, and substance use disorders can often be effectively managed. The majority of patients in need of behavioral health care are seen in primary care, which often has difficulty responding. Some primary care practices are providing integrated behavioral health care (IBH), where primary care and behavioral health providers work together, in one location, using a team-based approach. Research suggests there may be an association between IBH and improved patient outcomes. However, it is often difficult for practices to achieve high levels of integration. The Integrating Behavioral Health and Primary Care study responds to this need by testing the effectiveness of a comprehensive practice-level intervention designed to improve outcomes in patients with multiple chronic medical and behavioral health conditions by increasing the practice's degree of behavioral health integration. METHODS: Forty-five primary care practices, with existing onsite behavioral health care, will be recruited for this study. Forty-three practices will be randomized to the intervention or usual care arm, while 2 practices will be considered "Vanguard" (pilot) practices for developing the intervention. The intervention is a 24-month supported practice change process including an online curriculum, a practice redesign and implementation workbook, remote quality improvement coaching services, and an online learning community. Each practice's degree of behavioral health integration will be measured using the Practice Integration Profile. Approximately 75 patients with both chronic medical and behavioral health conditions from each practice will be asked to complete a series of surveys to measure patient-centered outcomes. Change in practice degree of behavioral health integration and patient-centered outcomes will be compared between the two groups. Practice-level case studies will be conducted to better understand the contextual factors influencing integration. DISCUSSION: As primary care practices are encouraged to provide IBH services, evidence-based interventions to increase practice integration will be needed. This study will demonstrate the effectiveness of one such intervention in a pragmatic, real-world setting. TRIAL REGISTRATION: ClinicalTrials.gov NCT02868983 . Registered on August 16, 2016.

Past Experiences of Getting Bullied and Assaulted and Posttraumatic Stress Disorder (PTSD) After a Severe Traumatic Event in Adulthood: A Study of World Trade Center (WTC) Responders.

Although experiencing bullying and other forms of assault is associated with adverse physical, emotional, and psychological consequences, the long-term consequences, especially in the aftermath of a severe trauma in adulthood, is not known. This study examined the relationship between history of being bullied and/or assaulted and posttraumatic stress disorder (PTSD) symptoms among responders to the World Trade Center (WTC) disaster. During 2015-16, a modified life events checklist was administered to responders at Stony Brook WTC Health Program. WTC-related PTSD symptoms were assessed by PTSD checklist (PCL). Longitudinal mixed models examined associations between bullying, other forms of assault, and severity and chronicity of PTSD symptoms. Approximately 13% of 920 responders had probable WTC-PTSD (PCL≥44). Being bullied in childhood was associated with increased odds of WTC-PTSD (adjusted odds ratio [aOR] =7.34; 95% confidence interval [CI] = 2.12-25.34), adjusted for demographics, other stressors, and WTC exposures. PTSD odds decreased over time among those not bullied (aOR 0.82; 95% CI: 0.73-0.92), but not among victims. Experiencing physical, sexual, or verbal assaults during adulthood, also had a significant association with WTC-PTSD (aOR 4.64; 95% CI: 1.98-10.92). Findings suggest being bullied in childhood and/or assaulted in adulthood can increase PTSD risk and progression after mass trauma.

Geographic, Temporal, and Sociodemographic Differences in Opioid Poisoning.

INTRODUCTION: Not enough is known about the epidemiology of opioid poisoning to tailor interventions to help address the growing opioid crisis in the U.S. The objective of this study is to expand the current understanding of opioid poisoning through the use of data analytics to evaluate geographic, temporal, and sociodemographic differences of opioid poisoning- related hospital visits in a region of New York State with high opioid poisoning rates. METHODS: This retrospective cohort study utilized patient-level New York State all-payer hospital data (2010-2016) combined with Census data to evaluate geographic, patient, and community factors for 9,714 Long Island residents with an opioid poisoning-related inpatient or outpatient hospital facility discharge. Temporal, 7-year opioid poisoning rates and trends were evaluated, and geographic maps were generated. Overall, significance tests and tests for linear trend were based upon logistic regression. Analyses were completed between 2017 and 2018. RESULTS: Since 2010, Long Island and New York State opioid poisoning hospital visit rates have increased 2.5- to 2.7-fold (p<0.001). Opioid poisoning hospital visit rates decreased for men, white patients, and self-payers (p<0.001) and increased for Medicare payers (p<0.001). Communities with high opioid poisoning rates had lower median home values, higher percentages of high school graduates, were younger, and more often white patients (p<0.01). Maps displayed geographic patterns of communities with high opioid poisoning rates overall and by age group. CONCLUSIONS: Findings highlight the changing demographics of the opioid poisoning epidemic and utility of data analytics tools to identify regions and patient populations to focus interventions. These population identification techniques can be applied in other communities and interventions.

Parental and Peer Attachment Characteristics: Differentiating Between Youth Sexual and Non-Sexual Offenders and Associations With Sexual Offense Profiles.

Attachment deficits have been suggested as an etiological explanation underlying the development of sexually abusive behaviors and general delinquency among youth. Yet, few researchers have explored the discriminating functions of attachment characteristics or investigated attachments as a stand-alone risk/protective factor explaining offending profiles among youth sexual offenders. This article explored the differences in characteristics of parental and peer attachments between youth sexual ( n = 355) and non-sexual offenders ( n = 150). Furthermore, associations between family and peer attachments and criminal profiles of sexual offenders were tested. The t-test results revealed that the groups of youth differed on various mother and father attachment characteristics, with youth sexual offenders exhibiting greater deficits. Regression models revealed lower levels of mother and peer trust and communication were associated with more severe sexual offenses; low levels of mother trust were associated with more victims; and low levels of mother trust and high father alienation were associated with more non-sexual criminality. Practice implications suggest the need to amalgamate families more consistently into treatment and addressing peer dynamics within groups and community contexts.

The Impact of Types and Extent of Trauma on Depressive Affect Among Male Juvenile Sexual Offenders.

High levels of depression have been found among incarcerated youth, which suggests that mental health problems are associated with delinquent behavior and are part of a constellation of risk factors that contribute to youth entering the juvenile justice system. In this project, we investigated trauma and mental health issues among male youth in residential treatment, and addressed the following questions: (a) Does childhood trauma predict current depression for male juvenile sexual offenders? (b) If so, do different types of traumas predict depressive affect better than others? and, (c) Does extent of trauma exposure predict depression? Data on incarcerated male juvenile sexual offenders were analyzed ( n = 379). Multiple regressions of various types of traumas and cumulative trauma and depression were conducted. Emotional abuse was the strongest predictor of depressive affect for this sample, and multiple exposures to trauma were the second strongest predictor.

Family Experiences and Sexual Victimization Histories: A Comparative Analysis Between Youth Sexual and Nonsexual Offenders.

Youth who commit sexual offenses often have sexual victimization histories that occur in the family context. These victimization experiences can be exacerbated by other risks present in the family environment. This research study uses MANOVAs to explore how family environments including substance use, mental health, physical and emotional victimization experiences, attachment, and parenting styles differentiate subgroups of youth offenders including youth sexual offenders with ( n = 179) and without ( n = 176) sexual victimization histories, and nonsexual offenders without sexual victimization histories ( n = 150). Results reveal that youth sexual offenders with sexual victimization histories had greater risks in family environments relative to youth sexual and nonsexual offenders without sexual victimization histories. Treatment and research implications are discussed.

Part II: differences between sexually victimized and nonsexually victimized male adolescent sexual abusers and delinquent youth: further group comparisons of developmental antecedents and behavioral challenges.

In a recent paper published in the Journal of Child Sexual Abuse, we assessed the differences between sexually victimized and nonsexually victimized male adolescent sexual abusers ( Burton, Duty, & Leibowitz, 2011 ). We found that the sexually victimized group had more severe developmental antecedents (e.g., trauma and early exposure to pornography) and behavioral difficulties (sexual aggression, arousal, pornography use, and nonsexual offenses). The present study compares sexually victimized and nonsexually victimized adolescent sexual abusers with a group of nonsexually victimized delinquent youth. Findings included that delinquent youth had fewer behavioral and developmental problems than the comparison groups. In addition, sexually victimized sexual abusers had the highest mean scores on trauma and personality measures. Implications for research and treatment are offered.

Differences between sexually victimized and nonsexually victimized male adolescent sexual abusers: developmental antecedents and behavioral comparisons.

This study compares sexually victimized and nonsexually victimized male adolescent sexual abusers on a number of variables. Self-report measures were administered to 325 male sexually abusive youth (average age 16) in six residential facilities in the Midwest, 55% of whom reported sexual victimization. The results indicate that the sexually victimized sexual abusers have more severe developmental antecedents (trauma, family characteristics, early exposure to pornography and personality) and recent behavioral difficulties (characteristics of sexual aggression, sexual arousal, use of pornography, and nonsexual criminal behavior) than the nonsexually victimized group. Results are contrasted with recent typological research, which found no relationship between sexual victimization and subtype membership. Treatment, research, and theoretical implications are discussed.

Exploring the relationships between dissociation, victimization, and juvenile sexual offending.

An etiological model of sexually abusive behavior including dissociation could have utility for researchers and treatment providers working with sexually abusive youth with trauma histories. This article explores relationships between dissociation, victimization, and juvenile sexual offending. Self-reported data on dissociation and 5 types of abuse were collected from 2 racially/ethnically diverse groups of sexually abusive and general delinquent male adolescents (n = 502). Bivariate analysis showed significant correlations between all types of child abuse and dissociation with the exception of emotional neglect. Hierarchical logistic regression analysis indicated that dissociation was significant in predicting sexual offender status. Moreover, dissociation, sexual victimization, and physical abuse showed significant effects in predicting membership in the sexual offender group. The results confirm the need for additional research in the areas of assessment and treatment of dissociation among sexually abusive youth.

Mental health needs of people living with HIV/AIDS in India: a literature review.

We describe the global conditions associated with the AIDS pandemic and its socioeconomic and psychological impacts. A systematic review was performed to investigate the literature on the mental health needs of people living with HIV/AIDS (PLHA) in India. The focus is on the prevalence, nature, and sociocultural factors of the epidemic in India. A conceptual framework is offered and the findings of this study are presented across three major domains: (a) prevalence of mental health disorders among the HIV-infected population; (b) mental health needs of PLHA; and (c) gaps in policies and programs addressing these issues. Experiences of HIV stigma and discrimination are also noted in this population. We conclude with implications for future research, interventions, and public policy.

Comparison by crime type of juvenile delinquents on pornography exposure: the absence of relationships between exposure to pornography and sexual offense characteristics.

Previous literature on pornography indicates that pornography use for men at risk for aggression may result in sexually aggressive behavior, but very little research has been reported on juvenile sexual abusers' exposure to pornography. The current study compared pornography exposure between male adolescent sexual abusers (n=283) and male nonsexually offending delinquent youth (n=170). Sexual abusers reported more pre- and post-10 (years of age) exposure to pornography than nonsexual abusers. Yet, for the sexual abusers, exposure is not correlated to the age at which the abusers started abusing, to their reported number of victims, or to sexual offense severity. The pre-10 exposure subscale was not related to the number of children the group sexually abused, and the forceful exposure subscale was not correlated with either arousal to rape or degree of force used by the youth. Finally, exposure was significantly correlated with all of the nonsexual crime scores in the study. Implications for forensic nursing are discussed.