Clinic-Level Process of Care for Depression in Primary Care Settings

Multi-component models for improving depression care target primary care (PC) clinics, yet few studies document usual clinic-level care. This case comparison assessed usual processes for depression management at 10 PC clinics. Although general similarities existed across sites, clinics varied on specific processes, barriers, and adherence to practice guidelines. Screening for depression conformed to guidelines. Processes for assessment, diagnosis, treatment, and follow-up varied to different degrees in different clinics. This individuality of usual care should be defined prior to quality improvement interventions, and may provide insights for introducing or tailoring changes, as well as improving interpretation of evaluation results. Presentation  This work has been presented as a poster of the same title at the Annual Meeting of Academy Health in Orlando, FL, June 2007.     

Crossing The Divide: Primary Care And Mental Health Integration

This paper describes the views of primary care providers about treating depression among adult Medicaid patients and their experiences with managed behavioral health care. It also shows the outcomes of an intervention project that provides a care manager to facilitate connections among PCPs, patients, and behavioral health providers. Despite widespread initiatives to improve depression management in primary care and to manage behavioral health services, it appears that links between the two systems and the use of evidence-based approaches to managing patients are rare. A pilot project to initiate practice redesign, the use of a care manager to assist in patient support, and compliance with both medical and behavioral health treatment has been shown to improve communication and results in positive patient outcomes. Managed behavioral health care can result in incentive structures that create gaps between primary care and behavioral health systems. This project illustrates an initiative co-sponsored by the Massachusetts behavioral health program designed to strengthen links between behavioral health and primary care, and increase rates and effectiveness of depression treatment.     

Addressing the Population Burden of Child and Adolescent Mental Health Problems: A Primary Care Model

A model for primary care child and adolescent mental health (CAMH) services is presented, the overall goal of which is to reduce population burden of CAMH problems. The theoretical orientation of the model is based on ecological systems theories. Features of the model include: local population outcome measures; small area service focus; primary-care-based CAMH specialists; a locally comprehensive service framework based in primary care (schools and general practices); and an explicit process of community engagement. The model is illustrated by reference to a primary care CAMH service (currently the subject of a controlled trial) in Flintshire, North Wales.     

Primary care and mental health: Where do we go from here?

Primary care has been dubbed the “de facto” mental health system of the United States since the 1970s. Since then, various forms of mental health delivery models for primary care have proven effective in improving patient outcomes and satisfaction and reducing costs. Despite increases in collaborative care implementation and reimbursement, prevalence rates of major depression in the United States remain unchanged while anxiety and suicide rates continue to climb. Meanwhile, primary care task forces in countries like the United Kingdom and Canada are recommending against depression screening in primary care altogether, citing lack of trials demonstrating improved outcomes in screened vs unscreened patients when the same treatment is available, high false-positive results, and small treatment effects. In this perspective, a primary care physician and two psychiatrists address the question of why we are not making headway in treating common mental health conditions in primary care. In addition, we propose systemic changes to improve the dissemination of mental health treatment in primary care.     

Predictors of anxiety recurrence in the Coordinated Anxiety Learning and Management (CALM) trial

Few studies have examined anxiety recurrence after symptom remission in the primary care setting. We examined anxiety recurrence in the Coordinated Anxiety Learning and Management (CALM) trial. From 2006 to 2009, CALM randomized adults with anxiety disorders (generalized anxiety disorder, panic disorder, social anxiety disorder, and post-traumatic stress disorder) in primary care clinics to usual care (UC) or a collaborative care (CC) intervention of pharmacotherapy and/or cognitive behavioral therapy. We examined 274 patients who met criteria for anxiety remission (Brief Symptom Inventory for anxiety and somatization (BSI-12) < 6) after 6 months of randomized treatment and completed a follow-up of 18 months. Logistic regression and receiver operating characteristics (ROC) were used to identify predictors of anxiety recurrence (BSI-12 ≥ 6 and 50% increase from 6-month ratings) during the year following remission. Recurrence was lower in CC (29%) compared to UC (41%) (p = 0.04). Patients with comorbid depression or lower self-perceived socioeconomic status particularly benefited (in terms of reduced recurrence) if assigned to CC instead of UC. In the multivariable logistic regression model, smoking, being single, Anxiety Sensitivity Index score, functional impairment at month 6 due to residual anxiety (measured with the Sheehan Disability Scale), and treatment with benzodiazepines were associated with subsequent anxiety recurrence. ROC identified prognostic subgroups based on the risk of recurrence. Our study was exploratory, and our findings require replication. Future studies should also examine the effectiveness of relapse prevention programs in patients at highest risk for recurrence.     

Disruptions in Primary Care among People with Schizophrenia in Ontario,Canada, During the COVID-19 Pandemic

ObjectiveTo investigate how primary care access, intensity and quality of care changed among patients living with schizophrenia before and after the onset of the COVID-19 pandemic in Ontario, Canada.MethodsThis cohort study was performed using primary care electronic medical record data from the University of Toronto Practice-Based Research Network (UTOPIAN), a network of > 500 family physicians in Ontario, Canada. Data were collected during primary care visits from 2643 patients living with schizophrenia. Rates of primary care health service use (in-person and virtual visits with family physicians) and key preventive health indices indicated in antipsychotic monitoring (blood pressure readings, hemoglobin A1c, cholesterol and complete blood cell count [CBC] tests) were measured and compared in the 12 months before and after onset of the COVID-19 pandemic.ResultsAccess to in-person care dropped with the onset of the COVID-19 pandemic. During the first year of the pandemic only 39.5% of patients with schizophrenia had at least one in-person visit compared to 81.0% the year prior. There was a corresponding increase in virtual visits such that 78.0% of patients had a primary care appointment virtually during the pandemic period. Patients prescribed injectable antipsychotics were more likely to continue having more frequent in-person appointments during the pandemic than patients prescribed only oral or no antipsychotic medications. The proportion of patients who did not have recommended tests increased from 41.0% to 72.4% for blood pressure readings, from 48.9% to 60.2% for hemoglobin A1c, from 57.0% to 67.8% for LDL cholesterol and 45.0% to 56.0% for CBC tests during the pandemic.ConclusionsThere were substantial decreases in preventive care after the onset of the pandemic, although primary care access was largely maintained through virtual care. Addressing these deficiencies will be essential to promoting health equity and reducing the risk of poor health outcomes.     

“One Degree of Separation”: A Mixed-Methods Evaluation of Canadian Mental Health Care User and Provider Experiences With Remote Care During COVID-19

ObjectivesThe COVID-19 pandemic has contributed to a shift from in-person to remote mental health care. While remote care methods have long existed, their widespread use is unprecedented. There is little research about mental health care user and provider experiences with this transition, and no published studies to date have compared satisfaction between these groups.MethodsCanadian mental health care users (n = 332) and providers (n = 107) completed an online self-report survey from October 2020 to February 2021 hosted by the Canadian Biomarker Integration Network in Depression. Using a mixed-methods approach, participants were asked about their use of remote care, including satisfaction, barriers to use, helpful and unhelpful factors, and suggestions for improvement.ResultsOverall, 59% to 63% of health care users and 59% of health care providers were satisfied with remote care. Users reported the greatest satisfaction with the convenience of remote care, while providers were most satisfied with the speed of provision of care; all groups were least satisfied with therapeutic rapport. Health care providers were less satisfied with the user-friendliness of remote care (P < 0.001) than users, while health care users were less satisfied than providers with continuity of care (P < 0.001). The use of a video-based platform was associated with remote care satisfaction among health care users (P < 0.02), and qualitative responses support the importance of visual cues in maintaining therapeutic rapport remotely. The majority of users (55%) and providers (87%) reported a likelihood of using remote care after the pandemic.ConclusionsRemote mental health care is generally accepted by both users and providers, and the majority would consider using remote care following the pandemic. Suggestions for improvement include greater use of video, increased attention to body language and eye contact, consistency with in-person care, as well as increased provider training and administrative support.