Psychiatric services最新文献

Objective: This mixed-methods study explored providers' perceptions of the value of using pharmacogenetic (PGx) testing in depression treatment after they had used the test during a pragmatic clinical trial.

Methods: Data were drawn from baseline and follow-up surveys (mental health and primary care providers; N=217) of and qualitative interviews (N=61) with trial participants. Pre-post changes in agreement with statements about PGx testing's value in depression care were examined with a generalized estimating equations cumulative logit ordinal regression model with two time points and robust standard errors. Interviews were analyzed via rapid qualitative analysis.

Results: Analyses showed greater agreement at follow-up with statements about comfort with PGx testing, feeling well informed about PGx testing, and the strength of the evidence base. Mental health providers had stronger levels of agreement compared with primary care providers. Interview data indicated that although providers found value in PGx testing, they also thought that the test was useful only for some patients. Several providers felt that the main value may be in facilitating patient buy-in to trying medication.

Conclusions: Overall, this mixed-methods study demonstrated that, after using PGx testing during a clinical trial, primary care and mental health providers have overall positive perceptions of its potential value and utility in depression treatment.

A national and global focus on expanding identification and treatment of youths who are at clinical high risk for psychosis (CHR-P) highlights an urgent need to develop clinical services for this population; however, questions remain regarding program structures and treatment approaches in CHR-P clinics. The authors of this Open Forum expand on previous recommendations and argue that a focus on enhancing developmentally informed care should serve as a central principle for structuring macrolevel service policies and programs as well as person-specific treatment approaches. The authors discuss developmental considerations in program planning and service provision and offer recommendations for providers and other stakeholders to enhance developmentally informed care for individuals at CHR-P.

Objective: The Clear Answers to Louisiana Mental Health (CALM) campaign's objective is to reduce the duration of untreated psychosis (DUP) of patients experiencing first-episode psychosis in the New Orleans community.

Methods: CALM used mass transit and digital marketing and local community engagement strategies to reduce DUP in referrals to the Early Psychosis Intervention Clinic-New Orleans. DUP measures were collected for clinic referrals pre- and post-CALM launch (N=116). Analytics from marketing strategies were used to evaluate campaign success.

Results: In the first 12 months of CALM, the mean DUP from onset of psychotic symptoms to clinic entry decreased from a median of 6.6 (interquartile range [IQR]=2.5-14.9) to 2.1 (IQR=1.1-10.7) months. Time from onset of psychotic symptoms to first antipsychotic treatment decreased from a median of 2.0 (IQR=0.5-8.6) to 0.2 (IQR=0.0-0.7) months.

Conclusions: The CALM campaign produced promising results for reducing DUP in referrals to a coordinated specialty care program.

To advance diversity, equity, and inclusion (DEI) initiatives within community organizations, more attention is needed to how community-engaged research can contribute to the effectiveness of such initiatives. The authors describe their experiences of participating in an academic-community partnership to conduct a DEI evaluation of an evidence-based program implemented through the public mental health system. Elements of this successful partnership included valuing community-initiated research, building connections and learning together, including multiple perspectives, finding shared goals in different contexts, leaning into problem solving, and using feedback to move forward. The lessons learned may inform continued collaborative efforts to support DEI in mental health services contexts.

Objective: A significant number of patients in psychiatric emergency departments (PEDs) are brought in by police. The authors sought to identify the weighted global rate of police referrals to PEDs, to compare the characteristics of police-referred patients with those of patients not referred by police, and to assess possible effects of the COVID-19 pandemic on referral rates.

Methods: A systematic review was conducted by searching medical databases according to PRISMA guidelines. Multivariate and pairwise meta-regression analyses were performed.

Results: Overall, 1,374 articles were screened, and 34 samples comprising 542,143 patients (61,647 of whom were referred by police) from 28 articles were included. On average, 13.7% of PED admissions were referred by police, a rate that was higher in the United States (22.8%). Compared with patients not referred by police, police-referred patients were significantly more likely to show aggressive behavior (relative risk [RR]=4.73), to be homeless (RR=1.84), and to have a diagnosis of a substance use (RR=1.33) or psychotic (RR=1.45) disorder but were less likely to have depressive (RR=0.31) or adjustment (RR=0.58) disorders. Police-referred patients were also more likely to be admitted to inpatient care (RR=1.35) and involuntarily (RR=4.38). The pandemic had no apparent effect on police-referral rates to PEDs.

Conclusions: A substantial proportion of psychiatric patients is referred to PEDs by police. Police-referred patients had characteristics that were similar to those of incarcerated individuals with mental disorders. Early treatment may prevent later incarceration of police-referred PED patients. Interventions to reduce homelessness among psychiatric patients might help reduce police referrals to PEDs.

Objective: The purpose of this study was to examine how inner-context (organizational) and outer-context (system) variables affect implementation outcomes for wraparound care coordination, an evidence-based strategy for youths with complex behavioral health needs.

Methods: This study focused on data from 1,178 providers in 10 states that used one of two state-level administrative structures to implement wraparound care coordination; four states used care management entities (CMEs), and six used community mental health centers (CMHCs). Implementation completeness and duration were assessed with the Stages of Implementation Completion tool, and practice fidelity was assessed with the Coaching Observation Measure for Effective Teams. Multilevel models were used to compare CMEs with CMHCs at the state level in terms of implementation completeness, duration, and fidelity.

Results: Compared with CMHC states, CME states had higher mean fidelity scores among practitioners (0.37 vs. 0.24; t=8.02, df=1,136, p<0.001), completed more implementation activities, and completed most implementation activities faster. Multilevel models found that the duration of the preimplementation phase was positively associated with fidelity (b<0.001, t=3.62, df=10.85, p=0.004) and that the duration of the implementation phase was negatively associated with fidelity (b<-0.001, t=-6.64, df=7.04, p<0.001).

Conclusions: The results reinforce that systems-level strategies such as wraparound care coordination require considerable time to plan and implement and that state-level administrative structures meaningfully influence implementation outcomes and service quality. Taking the time to design hospitable inner and outer contexts is crucial to implementation efficiency, completeness, and quality.

Objective: This study aimed to assess the feasibility of the screening for early emerging mental experiences model, which is designed to screen for psychosis in settings with integrated primary and mental health care.

Methods: Psychosis screening, triage, and engagement processes (July 2021-June 2022) were implemented in four integrated care practices serving approximately 7,000 patients in the targeted age range (14-26 years). Practice and community stakeholders participated in the project's design and development. Psychosis care specialists provided training and case consultation to general medical providers and behavioral health clinicians (BHCs). The BHCs screened all patients referred for selective screening. One practice aimed to universally screen patients ages 14-26 attending well visits.

Results: Training sessions were attended by 100% (N=6) of the BHCs and by 79% (N=27 of 34) of the primary care providers. The BHCs selectively screened and triaged 266 patients (89% of their new patients). Providers conducted universal screening of 606 patients (67% of that site's well visits). The screening samples were >90% White and >55% rural, consistent with the clinics' populations. Rates of positive selective screens were consistent with published rates in similar populations. Of the recorded screening-related activities, 92% (146 of 159) were completed within the billable intake time, and 11% (N=17) of these patients were engaged in a psychosis-relevant discussion. The providers reported that the project was important and positive.

Conclusions: Systematic assessment of psychosis symptoms, followed by triage and engagement, appeared to be feasible and acceptable to patients and providers in integrated care settings.

Objective: This study aimed to evaluate screening strategies for identifying risk for self-harm among adolescents making outpatient health care visits.

Methods: Health system records were used to identify a prospective cohort of adolescents completing the Patient Health Questionnaire-9 (PHQ-9) at outpatient visits between October 1, 2015, and March 15, 2020, and a retrospective cohort of adolescents experiencing self-harm events (ascertained from health records and state mortality data) during the same period. Self-harm risk scores were computed from health records. Analyses of the prospective sample examined the sensitivity and positive predictive value (PPV) of questionnaires and risk scores, separately and in combination. Analyses of the retrospective sample examined the proportion of self-harm events that could have been detected by different screening strategies.

Results: The prospective sample (N=8,929) included 43,548 questionnaires, with 1,045 questionnaires followed by a self-harm event within 180 days. A score of ≥2 on PHQ-9 item 9 had a sensitivity of 0.37 and a PPV of 0.09 for self-harm within 180 days of a mental health specialty visit, with similar results for primary care visits. In the retrospective sample, 89% of adolescents made a mental health specialty visit or a primary care visit with a recorded psychiatric diagnosis in the 180 days before a self-harm event.

Conclusions: Responses to PHQ-9 item 9 and risk scores computed from health records accurately identified adolescents needing additional assessment for risk for self-harm. Over 80% of adolescents experiencing self-harm could have been identified by screening during an outpatient health care visit.

Objective: The authors examined trends in racial and ethnic disparities in youth mental health treatment for internalizing and externalizing conditions in the United States from 2002 to 2019.

Methods: Using data from the Medical Expenditure Panel Survey-Household Component, the authors analyzed trends in mental health treatment between 2002 and 2019 for youths ages 5-21 years (N=139,242). Logistic regression models predicting treatment were adjusted for age and sex and also for health status, household income, insurance coverage, and geographic region.

Results: The treatment rate for internalizing conditions grew faster for White youths than for Hispanic or Black youths, and this difference tripled (from 1.6 to 5.4 percentage points) from 2002 to 2019. For externalizing conditions, the treatment rate grew twice as fast for White youths compared with Hispanic youths and 50% faster relative to Black youths. Uninsured status was significantly and negatively associated with treatment for externalizing conditions (b=-0.928, SE=0.342) but not internalizing conditions (b=-0.440, SE=0.317). Family income was most strongly linked to treatment among Hispanic youths. For internalizing conditions, adjustments for health, household income, insurance status, and region explained 18% of the treatment gap for Hispanic youths but only 6% of the gap for Black youths in 2016-2019.

Conclusions: These findings highlight widening racial and ethnic disparities in youth mental health treatment. The demographic and socioeconomic factors associated with these disparities varied by type of condition. Addressing socioeconomic determinants alone is insufficient to ensure equitable access to mental health services. Tailored approaches considering clinical, cultural, and societal needs are essential to mitigate treatment disparities.