Literature Collection

A significant percentage of patients with psychiatric disorders are exclusively seen for health-care services by primary care physicians. To address the mental health needs of such patients, collaborative models of care were developed including the embedded psychiatry consult model which places a consultant psychiatrist on-site to assist the primary care physician to recognize psychiatric disorders, prescribe psychiatric medication, and develop management strategies. Outcome studies have produced ambiguous and inconsistent findings regarding the impact of this model. This review examines a primary care-embedded psychiatric consultation service in place for nine years in a family medicine residency program. Psychiatric consultants, family physicians, and residents actively involved in the service participated in structured interviews designed to identify the clinical and educational value of the service. The benefits and limitations identified were then categorized into physician, consultant, patient, and systems factors. Among the challenges identified were inconsistent patient appointment-keeping, ambiguity about appropriate referrals, consultant scope-of-practice parameters, and delayed follow-up with consultation recommendations. Improved psychiatric education for primary care physicians also appeared to shift referrals toward more complex patients. The benefits identified included the availability of psychiatric services to underserved and disenfranchised patients, increased primary care physician comfort with medication management, and improved interprofessional communication and education. The integration of the service into the clinic fostered the development of a more psychologically minded practice. While highly valued by respondents, potential benefits of the service were limited by residency-specific factors including consultant availability and the high ratio of primary care physicians to consultants.

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: In 2019, Pennsylvania established a voluntary financial incentive program designed to increase the engagement in addiction treatment for Medicaid patients with opioid use disorder after emergency department (ED) encounters. In this qualitative study involving hospital leaders, the authors examined decisions leading to participation in this program as well as barriers and facilitators that influenced its implementation. METHODS: Twenty semistructured interviews were conducted with leaders from a diverse sample of hospitals and health systems across Pennsylvania. Interviews were planned and analyzed following the Consolidated Framework for Implementation Research. An iterative approach was used to analyze the interviews and determine key themes and patterns regarding implementation of this policy initiative in hospitals. RESULTS: The authors identified six key themes that reflected barriers and facilitators to hospital participation in the program. Participation in the program was facilitated by community partners capable of arranging outpatient treatment for opioid use disorder, incentive payments focusing hospital leadership on opioid treatment pathways, multidisciplinary planning, and flexibility in adapting pathways for local needs. Barriers to program participation concerned the implementation of buprenorphine prescribing and the measurement of treatment outcomes. CONCLUSIONS: A financial incentive policy encouraged hospitals to enact rapid system and practice changes to support treatment for opioid use disorder, although challenges remained in implementing evidence-based treatment-specifically, initiation of buprenorphine-for patients visiting the ED. Analysis of treatment outcomes is needed to further evaluate this policy initiative, but new delivery and payment models may improve systems to treat patients who have an opioid use disorder.