Literature Collection

OBJECTIVE: The objective of this Clinical Update is to review the principles, structures, processes, and outcomes of collaborative mental health care in the pediatric primary care setting. METHOD: A search of the literature on this topic from 2001was conducted initially in 2016, yielding 2,279 English-language citations. These citations were supplemented by references suggested by topic experts and identified through Web searches, increasing the yield to 2,467 total citations, of which 1,962 were unduplicated. After sequential review by Update authors at title/abstract and then full-text levels, the citations were winnowed to 219 based on topic relevance. A follow-up search from 2016 was conducted in 2021, yielding 2 additional citations based on nonduplication from initial search and topic relevance. RESULTS: The collaborative care approach, arising in the 1990s and gaining momentum in the 2000s, aims to extend behavioral health care to the primary care setting. The goal of collaborative care is to conserve the sparse specialty care workforce for severe and complex psychiatric disorders through shifting certain specialty mental health tasks (eg, assessment; patient self-management; brief psychosocial intervention; basic psychopharmacology; care coordination) to primary care. Collaborative care can be delivered on a spectrum ranging from coordinated to co-located to integrated care. Although each of these models has some empirical support, integrated care-a multidisciplinary team-based approach-has the strongest evidence base in improving clinical outcomes and patient satisfaction while constraining costs. Challenges to integrated care implementation include insufficient mental health education and insufficient specialist consultative and care coordination support for primary care practitioners; space, time, and reimbursement constraints in the primary care setting; discomfort among primary care practitioners in assuming mental health tasks previously undertaken by specialists; and continuing need for and unavailability of ongoing specialty mental health care for severe and complex cases. Essential supporting activities for effective collaborative care include patient and family engagement, professional education and training, evaluation/demonstration of impact, fiscal sustainability, and advocacy for model dissemination. CONCLUSION: Health professionals who are educated in the collaborative care approach can improve access to and quality of behavioral health care for children and adolescents with behavioral health needs.

BACKGROUND: While the number of digital therapeutics (DTx) has proliferated, there is little real-world research on the characteristics of providers recommending DTx, their recommendation behaviors, or the characteristics of patients receiving recommendations in the clinical setting. OBJECTIVE: The aim of this study was to characterize the clinical and demographic characteristics of patients receiving DTx recommendations and describe provider characteristics and behaviors regarding DTx. METHODS: This retrospective cohort study used electronic health record data from a large, integrated health care delivery system. Demographic and clinical characteristics of adult patients recommended versus not recommended DTx by a mental health provider between May 2020 and December 2021 were examined. A cross-sectional survey of mental health providers providing these recommendations was conducted in December 2022 to assess the characteristics of providers and recommendation behaviors related to DTx. Parametric and nonparametric tests were used to examine statistical significance between groups. RESULTS: Of 335,250 patients with a mental health appointment, 53,546 (16%) received a DTx recommendation. Patients recommended to DTx were younger, were of Asian or Hispanic race or ethnicity, were female, were without medical comorbidities, and had commercial insurance compared to those without a DTx recommendation (P<.001). More patients receiving a DTx recommendation had anxiety or adjustment disorder diagnoses, but less had depression, bipolar, or psychotic disorder diagnoses (P<.001) versus matched controls not recommended to DTx. Overall, depression and anxiety symptom scores were lower in patients recommended to DTx compared to matched controls not receiving a recommendation, although female patients had a higher proportion of severe depression and anxiety scores compared to male patients. Provider survey results indicated a higher proportion of nonprescribers recommended DTx to patients compared to prescribers (P=.008). Of all providers, 29.4% (45/153) reported using the suggested internal electronic health record-based tools (eg, smart text) to recommend DTx, and of providers recommending DTx resources to patients, 64.1% (98/153) reported they follow up with patients to inquire on DTx benefits. Only 38.4% (58/151) of respondents report recommending specific DTx modules, and of those, 58.6% (34/58) report following up on the impact of these specific modules. CONCLUSIONS: DTx use in mental health was modest and varied by patient and provider characteristics. Providers do not appear to actively engage with these tools and integrate them into treatment plans. Providers, while expressing interest in potential benefits from DTx, may view DTx as a passive strategy to augment traditional treatment for select patients.

OBJECTIVE: Posttraumatic stress disorder (PTSD) and bipolar disorder are common in primary care. Evidence supports collaborative care in primary care settings to treat depression and anxiety, and recent studies have evaluated its effectiveness in treating complex conditions such as PTSD and bipolar disorder. This study aimed to examine how primary care clinicians experience collaborative care for patients with these more complex psychiatric disorders. METHODS: The authors conducted semistructured interviews with 22 primary care clinicians participating in a pragmatic trial that included telepsychiatry collaborative care (TCC) to treat patients with PTSD or bipolar disorder in rural or underserved areas. Analysis utilized a constant comparative method to identify recurring themes. RESULTS: Clinicians reported that TCC improved their confidence in managing medications for patients with PTSD or bipolar disorder and supported their ongoing learning and skill development. Clinicians also reported improvements in patient engagement in care. Care managers were crucial to realizing these benefits by fostering communication within the clinical team while engaging patients through regular outreach. Clinicians valued TCC because it included and supported them in improving the care of patients' mental health conditions, which opened opportunities for clinicians to enhance care and address co-occurring general medical conditions. Overall, benefits of the TCC model outweighed its minimal burdens. CONCLUSIONS: Clinicians found that TCC supported their care of patients with PTSD or bipolar disorder. This approach has the potential to extend the reach of specialty mental health care and to support primary care clinicians treating patients with these more complex psychiatric disorders.

INTRODUCTION: Cannabis use among adolescents is prevalent, and clinicians who work with adolescents have unique insights about how to treat cannabis use in this population. METHODS: This qualitative study interviewed 32 clinicians from addiction medicine recovery services (AMRS), the emergency department (ED), mental health (MH), and pediatrics in an integrated healthcare system to understand their perspectives and experiences regarding barriers and facilitators to treating adolescent cannabis use. The analysis was developed using thematic analysis of interviews. RESULTS: Thirty-two clinicians (Mean age = 45.9, SD =7.6; 56.3 % Female; 56.3 % White) were recruited from AMRS (n = 13; 41.6 %), the ED (n = 7; 21.9 %), MH (n = 7; 21.9 %) and pediatrics (n = 5; 15.6 %). Clinicians discussed several key barriers and facilitators of treating adolescent cannabis use. Facilitators include the use of multiple screening tools for adolescent cannabis use (i.e., self-report and toxicology testing) which provide more comprehensive information; patient-centered treatment approaches; and discussing cannabis use in the context of adolescents' mental health. Barriers discussed included adolescents' and parents' minimization of adolescent cannabis use risks. Several factors were discussed as potential facilitators or barriers, depending on context, including the influence of peers, virtual treatment, and parental involvement or lack thereof in treatment. CONCLUSIONS: Interviews with clinicians who work with adolescents across settings highlighted factors that serve as barriers and facilitators to treating adolescent cannabis use. These findings have important implications for guiding future research and intervention efforts, including the inclusion of universal screening practices, addressing stigma, reducing adolescents' and parents' minimization of cannabis use-related harms, and improving adolescent and parent engagement in treatment.