Literature Collection

BACKGROUND: The integration of mental health services within primary care settings is a growing priority in Canada, driven by the need to improve access and ensure comprehensive patient-centred care. This year-long pilot quality improvement (QI) project was conducted to examine the feasibility and impact of introducing monthly telephone consultations between primary care physicians (PCPs) and psychiatrists working at a secondary care regional hospital in Ontario, Canada. METHODS: PCPs were connected with a team of psychiatrists via email on a voluntary basis. Once connected, PCPs were encouraged to contact psychiatrists by text or email to book monthly telephone consultation for patient care. RESULTS: A total of seven PCPs and five psychiatrists participated in this project. A total of 66 patients were discussed via telephone consultations between PCPs and psychiatrists and 11 of these patients were referred to psychiatry for further assessment. The number of referrals to psychiatry O-P service from the seven PCPs involved in this pilot decreased from 83 for the period of November 2021 to October 2022 to 53 for the period of this project, that is, November 2022 to October 2023.There were initial challenges in scheduling consultations due to busy practices. After the first few months of regular monthly contact, three psychiatrists reported fewer ongoing contacts with PCPs and that PCPs email them on an as needed basis. Two psychiatrists continued to have ongoing 4-6 weeks contact with their assigned PCP, discussing on average 3-4 patients, after 1 year.Psychiatrists found the telephone meetings productive and the PCPs were appreciative of the support provided and were willing to take over the primary care of some patients under the care of the psychiatrists, who had medical needs but no PCP. CONCLUSION: This pilot QI project confirms the feasibility and successful collaborations between PCPs and psychiatrists through monthly phone calls.

Abbreviated psychotherapies for chronic pain improve access to care by reducing length of treatment and reaching patients outside of chronic pain clinics, such as primary care. However, the evidence for these approaches is limited. We conducted a randomized controlled trial of brief cognitive behavioral therapy for chronic pain (ie, 6, 30-minute sessions of psychoeducation, behavioral and cognitive skills, and relapse prevention delivered individually) with 184 primary care patients with moderate to severe chronic musculoskeletal pain from a Veterans Health Administration medical center. Mean age of the sample was 59 years (SD = 13.3), 84.8% were male, and 77.2% were White. Following baseline, patients were randomized to either brief cognitive behavioral therapy for chronic pain plus usual pain care or usual pain care alone. Assessments were conducted at baseline plus 6 weeks (mid-treatment), 12 weeks (treatment completion), and 24 weeks (3 month post-treatment follow-up) to gather information regarding pain interference (primary outcome), pain intensity, mental health symptoms, quality of life, and social role participation. Results indicated that relative to usual pain care alone, participants who also received behavioral treatment showed statistically greater improvement in pain interference at each time point. Clinically significant improvement in pain interference was reached by mid-treatment with continued improvement at treatment completion and 3-month follow-up among the behavioral treatment group but not the usual pain care group. Behavioral treatment was also associated with improved physical quality of life and sleep quality. This significantly abbreviated behavioral treatment designed for scalability can lead to rapid and sustained improvements in pain outcomes.

OBJECTIVES: Although cognitive behavioral therapy is an effective intervention for chronic pain, it is a lengthy treatment typically applied only in specialty care settings. The aim of this project was to collect preliminary effectiveness data for Brief Cognitive Behavioral Therapy for Chronic Pain (Brief CBT-CP), an abbreviated, modular form of treatment designed for use in primary care. METHODS: A clinical demonstration project was conducted in which Brief CBT-CP was delivered to primary care patients by 22 integrated care providers practicing in the Primary Care Behavioral Health model of Veterans Health Administration primary care clinics. Brief measures were used at each appointment to collect patient-reported clinical outcomes. RESULTS: One hundred eighteen patients provided sufficient data for analysis (male, 75%; mean age, 51.4 y). Multilevel modeling suggested that a composite measure of pain intensity and functional limitations showed statistically significant improvements by the third appointment (Cohen's d=0.65). Pain-related self-efficacy outcomes showed a similar pattern of results but of smaller effect size (Cohen's d=0.22). The exploratory analysis identified that Brief CBT-CP modules addressing psychoeducation and goal setting, pacing, and relaxation training were associated with the most significant gains in treatment outcomes. DISCUSSION: These findings provide early support for the effectiveness of Brief CBT-CP when delivered by providers in every day Primary Care Behavioral Health settings. Results are discussed in relation to the need for additional research regarding the potential value of employing safe, population-based, nonpharmacological approaches to pain management in primary care.

BACKGROUND: Z-hypnotics are commonly prescribed for insomnia, but their use in older adults is associated with an increased risk of adverse events. AIM: We examined the long-term effect of brief intervention (BI) for inappropriate z-hypnotic use, where the control group crossed over to receive the BI 6 months after baseline. DESIGN AND SETTING: A before-and-after intervention study was conducted in general practice. Older patients received the BI from trained general practitioners. METHOD: The BI group and the business-as-usual (BAU) group received the intervention with a six-month delay. The primary outcome: proportion of participants without inappropriate z-hypnotic use (≥4 weeks of use, ≥3 times per week). Secondary outcomes: the Global Sleep Assessment Questionnaire (GSAQ), pain visual analogue scale (VAS), Montreal Cognitive Assessment (MOCA), and Hospital Anxiety and Depression Scale (HADS). Patients were assessed at baseline, 6 weeks, 6 months, and 12 months. RESULTS: We included 45 patients (31 female, mean age 69.4 years) and 21 GPs in the study. We found a significant reduction in inappropriate z-hypnotic use from baseline (68.9%) to post-treatment (27.78%), OR = 0.16, 95% CI: 0.04, 0.65, p = 0.01. GSAQ-insomnia score stayed low throughout the study. At 6 months, no participant reported insomnia. HADS was significantly reduced from baseline (mean 10.1) to post-intervention (mean 7.3, Cohen's d = -0.44, p < 0.01), whereas MOCA and VAS pain did not change significantly from baseline to post-intervention. CONCLUSION: The proportion of patients with inappropriate z-hypnotic use decreased after BI without negatively affecting sleep, mood, pain, or cognitive function.. TRIAL REGISTRATION: clinicaltrials.gov (NCT06032715).