Literature Collection

OBJECTIVE: This study aimed to examine racial-ethnic differences in engagement with and clinical outcomes of a collaborative care model (CoCM) implemented in primary care outpatient clinics in an urban academic medical center. METHODS: Adult patients (N=4,911) who screened positive for symptoms of depression, anxiety, or both on the Patient Health Questionnaire-9 or the Generalized Anxiety Disorder-7 scale and who identified as non-Hispanic Black, Hispanic, or non-Hispanic White were offered participation in a CoCM implementation. The primary outcome was treatment engagement, defined as receipt of any follow-up visit, minimally adequate 4-week follow-up (at least one visit), and minimally adequate 16-week follow-up (at least three visits) after initial assessment. Secondary outcomes were response and remission of depression or anxiety. RESULTS: After adjustment of analyses for sociodemographic covariates, Black and Hispanic participants were significantly less likely than White participants to have received any or minimally adequate follow-up. Black and Hispanic participants who received any or minimally adequate 16-week follow-up were more likely than White participants to demonstrate depression symptom response and remission of anxiety symptoms. CONCLUSIONS: This CoCM implementation appears to have been effective in treating depression and anxiety among Black and Hispanic patients. However, significant disparities in receipt of follow-up care were observed. Efforts must be made to improve the retention of patients from racial-ethnic minority groups in collaborative care.

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.

IMPORTANCE: Adults with opioid use disorder (OUD), co-occurring with depression and/or posttraumatic stress disorder (PTSD), may benefit from collaborative care. Although collaborative care is an evidence-based model to treat behavioral health conditions in primary care, it has not been widely tested for OUD with co-occurring mental illness. OBJECTIVE: To determine whether collaborative care, tailored for low-resource settings, improves outcomes for patients with OUD and co-occurring depression and/or PTSD more so than enhanced usual care (EUC). DESIGN, SETTING, AND PARTICIPANTS: This 2-group single-masked pragmatic randomized clinical trial was conducted in 18 primary care clinics in California and New Mexico from January 8, 2021, to December 5, 2023, and included adult participants with probable OUD as well as major depression and/or PTSD. Data analysis was performed August 2024 to May 2025. INTERVENTIONS: Six months of a care manager and addiction psychiatrist working with a primary care practitioner to deliver evidence-based treatments for OUD, major depression, and PTSD; care managers were community health workers who monitored and addressed biopsychosocial symptoms and referred patients for psychotherapy. MAIN OUTCOMES AND MEASURES: Primary outcomes at 6 months were time to first filled buprenorphine prescription for participants entering the study not taking medication for OUD; cumulative days of prescribed buprenorphine for participants entering the study while not taking methadone, obtained from the state Prescription Drug Program; and Patient Health Questionnaire-9 and PTSD Checklist for DSM-5 scores from participant surveys. Secondary outcomes included days of opioid and other drug use, the Patient-Reported Outcomes Measurement Information System's substance use short form, and the Veterans RAND 12-item health survey. RESULTS: Of 2396 participants assessed for eligibility, 797 were randomized (397 to EUC; 400 to intervention); 433 (54.3%) were female and 364 (45.7%) male, with a mean (SD) age of 40.2 (11.9) years. Six-month survey retention was 68% for EUC and 64% for collaborative care. Adjusted mean (SD) differences on primary outcomes for collaborative care vs EUC were: 7.0 (95% CI, -3.4 to 17.4; P = .19) for days until first buprenorphine prescription; 4.3 (95% CI, -7.4 to 16.0; P = .47) for cumulative days of prescribed buprenorphine; -1.0 (95% CI, -2.3 to 0.3; P = .13) for Patient Health Questionnaire-9 score; and -0.9 (95% CI, -4.6 to 2.8; P = .63) for PTSD Checklist for the DSM-5 score; none were statistically significant. There were also no observed differences between groups for any secondary or exploratory outcomes; both groups improved over baseline. As-treated exploratory analyses showed evidence for improvements in OUD outcomes in the as-treated population. CONCLUSIONS AND RELEVANCE: This randomized clinical trial found that among participants with OUD co-occurring with depression and/or PTSD, collaborative care did not demonstrate evidence of greater improvements in outcomes compared with EUC. Explanations include a possible spillover effect, spontaneous improvement, or the fit of collaborative care for clinically complex patients and settings with few behavioral health practitioners. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT04559893 and NCT04634279.