Literature Collection

BACKGROUND: Approximately 20% of Canadian youth (12-25 years) experience mental health and substance use (MHSU) concerns, with the majority not receiving timely evidence-informed care. The YouthCan IMPACT study was a pragmatic randomized controlled trial (pRCT) of an integrated youth services model. The pRCT compared integrated collaborative care teams (the intervention) to youth outpatient hospital psychiatric services (the treatment as usual control). We embedded a qualitative study within the pRCT to explore youth's perceptions and experiences of the intervention and the control services. METHODS: Youth participants (14-17 years) were recruited to the study within an ongoing pRCT from hospitals. Youth were purposively sampled from the broader pRCT sample based on sex assigned at birth and pRCT arm (intervention or control group). To capture service experience across a range of follow-up intervals, youth were eligible to participate in the study if they had completed a six-month or a 12-month assessment within the pRCT. Semi-structured interviews were conducted with n = 44 youth between January 2018 and December 2019 (n = 22 intervention and n = 22 control participants). The interview focused on access; needs and preferences; decision-making; and satisfaction, among other domains. Two coders thematically analyzed the groups separately. Coding differences were resolved through discussion with the research team. RESULTS: Participants in both study arms articulated their service experiences around the themes of dignity, respect, and autonomy in care. Participants felt valued and respected when they receive tailored, consistent services; comprehensive information; were able to develop a supportive, collaborative relationship with the service provider; and used their voice in their care plan. They reported improved satisfaction, improvement in mental health status, and usefulness of services. Some youth within the hospital setting experienced services that were inappropriate, inefficient, and poorly coordinated. These experiences adversely affected youth's dignity, respect, and autonomy. CONCLUSIONS: This study is the first embedded qualitative study globally within a pRCT that explores experiences of an integrated collaborative care team model and standard hospital care. The study adds to the limited evidence base on dignity, respect, and autonomy within youth MHSU services. Determining how youth experience services in community-based and hospital settings is critical as it helps reduce treatment gaps. TRIAL REGISTRATION: Clinicaltrials.gov NCT02836080. Registration date 2016-07-14.

BACKGROUND: Posttraumatic stress disorder (PTSD) and substance use disorder (SUD) co-occur frequently and have deleterious impact. Seeking Safety (SS) - an evidence-based, present-focused, coping skills model - lends itself to mobile app delivery. OBJECTIVES: A novel SS mobile app is compared to a control app that lacks the interactivity, social engagement, and feature-richness of the SS app. We hypothesized that the SS app would outperform the control on primary outcome variables (substance use, trauma symptoms) and at least two secondary variables. METHODS: Outpatients with current PTSD and SUD (n = 116) were randomized to the apps; assessed were pre, post (12 weeks), and 3-month follow-up in this online study. RESULTS: The SS app outperformed the control on the primary outcomes, but not on secondary outcomes. Also both conditions evidenced significant change over time from pre to post, with gains sustained at follow-up. External medication and supports during the trial did not differ by condition. CONCLUSION: This first RCT on a SS mobile app had positive results for reduction in substance use and trauma symptoms compared to a control app. This is noteworthy as mental health mobile apps, in general, evidence few positive outcomes. Our substance use finding is also notable as psychosocial interventions in PTSD/SUD populations find it harder to achieve reduction in SUD than trauma symptoms. Our control app may have represented too strong a comparison and weakened our ability to find results on secondary outcomes by condition.

OBJECTIVE: To examine the feasibility, acceptability, and potential health effects of computerized cognitive behavioral therapy-enhanced collaborative care (cCBT-CC) versus usual primary care (UC). BACKGROUND: Internet-based cCBT can effectively treat depression but is not widely used, including in the Veterans Health Administration where it was freely available for veterans. We adapted pre-existing depression collaborative care models using implementation and user-centered design strategies to facilitate cCBT implementation. METHODS: This pilot randomized controlled trial (RCT) included 57 VA primary care patients to cCBT-CC or UC. Participants had Patient Health Questionnaire (PHQ-9) scores of 10+. Those with serious mental illness (e.g., bipolar depression, schizophrenia) and active suicidality were excluded. Intervention patients received tailored Vets Prevail cCBT accompanied by collaborative care manager support, overseen by psychiatry and primary care. UC offered collaborative care services and digital mental health tools at baseline. Feasibility (patient reach, provider adoption, intervention implementation), acceptability (CSQ-8), and potential effectiveness (PHQ-9) data was collected at baseline and 3-months by a blinded study team member. RESULTS: Participants (cCBT-CC n = 29, UC n = 28) were 50 years old (mean); 70 % men; 32 % White, 32 % Hispanic, 25 % Black; 21 % homeless-experienced. Mean baseline PHQ-9 scores were 15.1 (SD = 5.0); 39 % reported suicidal thoughts/behaviors. 72 % of 94 primary care providers, from 6 out of the 8 participating clinics, helped support their patients' participation. cCBT-CC participants received 4 care manager check-ins over 33 days totaling 113 min (64 % clinical; 36 % technical), on average. They completed mean 6.7 out of 11 cCBT lessons. Participants in the cCBT-CC arm experienced a statistically (not clinically) significant decline in the primary outcome of depression (Δ = -2.5; p = 0.02) symptoms from pretreatment to posttreatment. There was a greater, albeit non-significant, decrease in PHQ-9 scores among cCBT-CC participants over 3-months, compared to UC participants (Δ = -2.8; 95 % CI = -5.6, -0.01; p = 0.05). CONCLUSIONS: cCBT-enhanced collaborative care appeared feasible, acceptable, and possibly effective in treating primary care patients with depression.

BACKGROUND: Health policy in many countries directs treatment to the lowest effective care level and encourages collaboration between primary and specialist mental health care. A number of models for collaborative care have been developed, and patient benefits are being reported. Less is known about what enables and prevents implementation and sustainability of such models regarding the actions and attitudes of stakeholders on the ground. This article reports from a qualitative sub-study of a cluster-RCT testing a model for collaborative care in Oslo, Norway. The model involved the placement of psychologists and psychiatrists from a community mental health centre in each intervention GP practice. GPs could seek their input or advice when needed and refer patients to them for assessment (including assessment of the need for external services) or treatment. METHODS: We conducted in-depth qualitative interviews with GPs (n = 7), CMHC specialists (n = 6) and patients (n = 11) in the intervention arm. Sample specific topic guides were used to investigate the experience of enablers and barriers to the collaborative care model. Data were subject to stepwise deductive-inductive thematic analysis. RESULTS: Participants reported positive experiences of how the model improved accessibility. First, co-location made GPs and CMHC specialists accessible to each other and facilitated detailed, patient-centred case collaboration and learning through complementary skills. The threshold for patients' access to specialist care was lowered, treatment could commence early, and throughput increased. Treatment episodes were brief (usually 5-10 sessions) and this was too brief according to some patients. Second, having experienced mental health specialists in the team and on the front line enabled early assessment of symptoms and of the type of treatment and service that patients required and were entitled to, and who could be treated at the GP practice. This improved both care pathways and referral practices. Barriers revolved around the organisation of care. Logistical issues could be tricky but were worked out. The biggest obstacle was the funding of health care at a structural level, which led to economic losses for both the GP practices and the CMHC, making the model unsustainable. CONCLUSIONS: Participants identified a range of benefits of collaborative care for both patients and services. However, the funding system in effect penalises collaborative work. It is difficult to see how policy aiming for successful, sustainable collaboration can be achieved without governments changing funding structures. TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT03624829.