Literature Collection

OBJECTIVES: This study identified profiles of outpatient physician follow-up care and other practice features, mostly after detection of incident mental disorders (MD), and associated these profiles with patient characteristics and subsequent adverse outcomes. METHODS: A cohort of 170,957 patients age 12 + with a new or recurrent MD detected in 2019-20 was investigated based on data from the Quebec Integrated Chronic Disease Surveillance System. Latent class analysis was performed to identify follow-up care profiles, mostly within one year of MD detection. Bivariate analyses tested associations between profiles and patient characteristics; logistic regressions examined relationships between profiles and adverse outcomes after one year. RESULTS: Five profiles were identified: Profiles 2 and 5 (64%) offered low mental health (MH) outpatient follow-up care, while the others dispensed higher MH follow-up care. Profiles differed in patient characteristics and related outcomes. Labelled "Follow-up care by usual psychiatrist", Profile 1 (1% of sample) included younger patients with the most health and social issues. Profile 2 (50%), "Low MH follow-up care but high prior consultations for physical reasons", mostly integrated older patients with chronic physical illnesses. Profile 3 (11%), "Follow-up care by general practitioners (GP) and psychiatrists", referred to physicians other than the usual ones (e.g., walk-in practice) and encompassed patients with severe MD conditions. Profile 4 (23%), "High follow-up care by usual GP and prior consultations for physical reasons", showed the typical characteristics of patients treated in primary care (more common MD, women, less materially and socially deprived). Profile 5 (15%), "Low MH follow-up care and prior consultations for physical reasons", integrated more younger men, materially deprived patients, and with substance-related disorders (SRD) or co-occurring MD-SRD. More Profile 1 and 3 patients lived in university regions - those of Profile 4 were the least numerous in such regions. More Profile 5 patients lived in metropolitan and rural areas. Risk of death was higher in Profiles 5, 2, 3, and risk of frequent ED use and hospitalization higher in Profiles 1, 3, and 5 - patients with severe health and social issues. CONCLUSION: The study confirmed the need to improve prompt, adequate and continuous follow-up care for patients with incident MD.

People with serious mental illness (SMI) are more likely to smoke and less likely to quit than the general population. More effective and accessible cessation treatments are needed to promote health and prevent disease in this disparity population. To this end, we optimized a multicomponent health promotion intervention tailored for people with SMI, Breathe Well, Live Well, and conducted a quasi-experimental program evaluation to assess program feasibility and effectiveness compared with a usual care comparison condition consisting of "The 3 As." Community mental health center staff trained as health coaches delivered eight telehealth Breathe Well, Live Well sessions over 4 months to individuals. Breathe Well, Live Well content included cognitive behavioral therapy (CBT)-based counseling, pharmacotherapy support, incentivized app use (National Cancer Institute's quitSTART), and social support person coaching. Participants were 170 integrated mental health and primary care service recipients with SMI who smoked daily; 53 Breathe Well, Live Well and 117 comparison participants were enrolled during February 2020 through July 2022. Effectiveness was measured via biologically verified abstinence; feasibility was measured via Breathe Well, Live Well intervention engagement. Participants of Breathe Well, Live Well were about three times more likely to be abstinent at follow-up compared with comparison participants. Among those still smoking, Breathe Well, Live Well participants were about five times more likely to have decreased their daily cigarette consumption by at least half. Intervention engagement was strong for pharmacotherapy, counseling, and incentivized quitSTART app use, indicating that these components were feasible to deliver by community mental health center staff.

Many women receive their regular check-ups and preventive care through a women's health clinic, including their behavioral health needs. Most of these clinics have not yet developed the capacity to adequately manage behavioral health concerns. We describe our clinical experience integrating behavioral health services into a women's health clinic. In one year, 108 women (54% White, Mage= 35) were referred for behavioral health treatment 47% were identified using a screening questionnaire, 51% were referred by their women's health provider and 2% were self-referred. The most common presenting concerns were anxiety (52%) and depressive symptoms (48%). Sixty-one (56%) patients completed an intake assessment, of whom 33 (54%) engaged in follow-up treatment (M = 3.7 treatment sessions, SD = 3.0). Behavioral health screening and treatment appears to be feasible and effective within a women's health setting. Further research is needed to overcome barriers to referrals and treatment engagement in this population.

Many women receive their regular check-ups and preventive care through a women's health clinic, including their behavioral health needs. Most of these clinics have not yet developed the capacity to adequately manage behavioral health concerns. We describe our clinical experience integrating behavioral health services into a women's health clinic. In one year, 108 women (54% White, M(age)= 35) were referred for behavioral health treatment 47% were identified using a screening questionnaire, 51% were referred by their women's health provider and 2% were self-referred. The most common presenting concerns were anxiety (52%) and depressive symptoms (48%). Sixty-one (56%) patients completed an intake assessment, of whom 33 (54%) engaged in follow-up treatment (M = 3.7 treatment sessions, SD = 3.0). Behavioral health screening and treatment appears to be feasible and effective within a women's health setting. Further research is needed to overcome barriers to referrals and treatment engagement in this population.

BACKGROUND AND AIMS: Individuals living with severe mental illness such as schizophrenia and bipolar can have significant emotional, cognitive, physical and social challenges. Most people with severe mental illness in the United Kingdom do not receive specialist mental health care. Collaborative care is a system of support that combines clinical and organisational components to provide integrated and person-centred care. It has not been tested for severe mental illness in the United Kingdom. We aimed to develop and evaluate a primary care-based collaborative care model (PARTNERS) designed to improve quality of life for people with diagnoses of schizophrenia, bipolar or other psychoses when compared with usual care. METHODS: Phase 1 included studies to (1) understand context: an observational retrospective study of primary and secondary care medical records and an update of the Cochrane review ‘Collaborative care approaches for people with severe mental illness’; (2) develop and formatively evaluate the PARTNERS intervention: a review of literature on collaborative care and recovery, interviews with key leaders in collaborative care and recovery, focus groups with service users and a formative evaluation of a prototype intervention model; and (3) develop trial science work in this area: a core outcome set for bipolar and recruitment methods. In phase 2 we conducted a cluster randomised controlled trial measuring quality of life using the Manchester Short Assessment of Quality of Life and secondary outcomes including time use, recovery and mental well-being; a cost-effectiveness study; and a mixed-methods process evaluation. Public involvement underpinned all of the workstream activity through the study Lived Experience Advisory Panel and the employment of service user researchers in the project team. RESULTS PHASE 1: The study of records showed that care for individuals under secondary care is variable and substantial and that people are seen every 2 weeks on average. The updated Cochrane review showed that collaborative care interventions were highly variable, and no reliable conclusions can be drawn about effectiveness. The PARTNERS model incorporated change at organisational, practitioner and individual levels. Coaching was selected as the main form of support for individuals’ personal goals. In the formative evaluation, we showed that more intensive supervision and ‘top-up’ training were needed to achieve the desired shifts in practice. A core outcome set was developed for bipolar, and measures were selected for the trial. We developed a stepped approach to recruitment including initial approach and appointment. RESULTS PHASE 2: The trial was conducted in four areas. In total, 198 participants were recruited from 39 practices randomised. Participants received either the PARTNERS intervention or usual care. The follow-up rate was 86% at 9–12 months. The mean change in overall Manchester Short Assessment Quality of Life score did not differ between the groups [0.25 (standard deviation 0.73) for intervention vs. 0.21 (standard deviation 0.86) for control]. We also found no difference for any secondary measures. Safety outcomes (e.g. crises) did not differ between those receiving and those not receiving the intervention. Although the costs of intervention and usual care were similar, there is insufficient evidence to draw conclusions about the overall cost-effectiveness of PARTNERS. The mixed-methods process evaluation demonstrated that a significant proportion of individuals did not receive the full intervention. This was partly due to care partner absence and participant choice. The in-depth realist informed case studies showed that participants generally appreciated the support, with some describing having a ‘professional friend’ as very important. For some people there was evidence that delivery of the intervention had led to specific personal changes. STRENGTHS AND LIMITATIONS: The phase 1 records study provided insights into usual care that had not been previously documented. The realist informed complex intervention development was both theoretical and pragmatic. The trial continued through the COVID-19 pandemic with high levels of follow-up. The process evaluation had the depth to explore individual changes in participants’ response to the intervention. Weaknesses in the trial methodology included suboptimal implementation, outcome measures that may not have been sensitive to changes patients most appreciated and difficulties collecting some outcomes. CONCLUSIONS: While PARTNERS was not shown to be superior to usual care, the change to PARTNERS care was not shown to be unsafe. Full intervention implementation was challenging, but this is to be expected in studies of care that include those with psychosis. Some individuals responded well to the intervention when psychological support in the form of individualised goal setting was flexibly deployed, with evidence that having access to a ‘professional friend’ was experienced as particularly helpful for some individuals. FUTURE WORK: Key components of the PARTNERS model could be developed further and tested, along with improved supervision in the context of ongoing community mental health care change. TRIAL REGISTRATION: This trial is registered as ISRCTN95702682. FUNDING: This award was funded by the National Institute for Health and Care Research (NIHR) Programme Grants for Applied Research programme (NIHR award ref: NIHR200625) and is published in full in Programme Grants for Applied Research; Vol. 12, No. 6. See the NIHR Funding and Awards website for further award information.; Over 7 years, the PARTNERS2 research programme co-developed and evaluated a new way of working to support people with schizophrenia, bipolar or other psychoses in order to fill the gap in provision between primary care and secondary mental health services. The intervention involved a ‘care partner’ and followed a collaborative care approach. We completed several studies, including a full randomised controlled trial, in four sites: Birmingham, Cornwall, Plymouth and Somerset. We found the following: Analysis of secondary care records showed that many individuals received a lot of specialist care contacts that are not visible in primary care records. Our outcomes work for bipolar identified several themes, including personal recovery, connectedness, clinical recovery and mental health/well-being. These helped us choose quality of life as the primary outcome for the PARTNERS2 trial. Our preliminary work developing the ‘care partner’ collaborative care coaching approach was well received but showed problems with delivery, including supervision. The full trial was completed despite the COVID-19 pandemic but with fewer participants (a total of 198) than intended. No differences were found between those receiving and those not receiving PARTNERS care. Some participants received little or no intervention, partly due to care partner absences. The care partner approach was appreciated by some service users whom we interviewed for feedback. They described positive benefits of working with a ‘professional friend’ but only more limited examples of longer-term impact. Care partners sometimes appeared to take time to learn to put joined-up individualised care into practice. Although the PARTNERS2 trial produced a neutral result – meaning that people were no worse or no better as a result of receiving primary-care-based collaborative care – there are both practical and theoretical reasons that are likely to explain this. As the PARTNERS approach aligns well with current mental health policy, we are continuing to test the approach in practice.; eng

Birthing people with opioid use disorder (OUD) face unique stressors during the transition from pregnancy to postpartum that can negatively impact the maternal-infant dyad. This study aimed to describe the development of a family-centered, technology-delivered intervention tailored to help pregnant people receiving medication for OUD (MOUD) prepare for this transition. Formative data from patients and providers identified intervention content: (1) recovery-oriented strategies for the pregnancy-to-postpartum transition; (2) guidance around caring for an infant with opioid withdrawal symptoms; and (3) preparation for child welfare interactions. The content was reviewed in successive rounds by an expert panel and modified. Pregnant and postpartum people receiving MOUD pre-tested the intervention modules and provided feedback in semi-structured interviews. The multidisciplinary expert panel members (n = 15) identified strengths and areas for improvement. Primary areas for improvement included adding content, providing more structure to help participants navigate the intervention more easily, and revising language. Pre-testing participants (n = 9) highlighted four themes: reactions to intervention content, navigability of the intervention, feasibility of the intervention, and recommendation of the intervention. All iterative feedback was incorporated into the final intervention modules for the prospective randomized clinical trial. Family-centered interventions tailored for pregnant people receiving MOUD should be informed by patient-reported needs and multidisciplinary perspectives.

Background: Our rural health system sought to (1) increase the number of primary care clinicians waivered to prescribe buprenorphine for treatment of opioid use disorder (OUD) and (2) consequently increase the number of our patients receiving this treatment. Methods: We used the Project for Extension for Community Health Outcomes (ECHO) tele-education model as an implementation strategy. We examined the number of clinicians newly waivered, the number of patients treated with buprenorphine, the relationship between clinician engagement with ECHO training and rates of buprenorphine prescribing, and treatment retention at 180 days. Results: The number of clinicians with a waiver and number of patients treated increased during and after ECHO training. There was a moderate correlation between the number of ECHO sessions attended by a clinician and number of their buprenorphine prescriptions (r = 0.50, p = 0.01). The 180-day retention rate was 80.7%. Conclusions: Project ECHO was highly effective for increasing access to this evidence-based treatment. The high retention rate in this rural context indicates that most patients are increasing their likelihood of favorable outcomes.

Background: There is emerging recognition of the unique benefits of implementing screening, brief intervention, and referral to treatment (SBIRT) in pharmacy settings to identify patients who can benefit from services and connecting them to those services.Objectives: This study describes Project Lifeline - a multipronged public health initiative to provide educational and technical support to rural community pharmacies implementing SBIRT for substance use disorder (SUD) and providing harm reduction support.Methods: Eight community pharmacies were recruited. Patients receiving a Schedule II prescription were invited to engage in SBIRT and offered naloxone. Patient screening data and key informant interviews with pharmacy staff on implementation strategy were analyzed.Results: Between 2018-2020, 4,601 adult patients were offered screens and 3,407 screens were completed on 2,881 unique adult patients (51.3% female; <0.01% nonbinary; 95.7% White). Of these unique screens, 107 patients were indicated for brief intervention, 31 accepted the brief intervention; and 12 were given a referral to SUD treatment. Patients who declined SBIRT or who did not want to reduce their use were offered access to naloxone (n = 372). Key informant interviews highlighted the importance of person-centered staff education, role-playing, anti-stigma training, and integrating activities into existing patient-care processes.Conclusion: While ongoing research is needed to characterize the full impact of Project Lifeline on patient outcomes, the reported findings help reinforce the benefits of multipronged public health initiatives that include community pharmacists to address the SUD crisis.