Literature Collection

BACKGROUND: Pain and mental disorders frequently co-occur, yet the direction and specificity of their relationship remain uncertain due to limitations of observational studies. Mendelian randomization (MR) provides an opportunity to clarify causal links between distinct pain phenotypes and psychiatric outcomes. METHODS: We performed a comprehensive bidirectional MR analysis to investigate causal relationships between multiple pain conditions and mental and personality disorders. Multivariable MR was applied to assess the independence of these associations while accounting for common comorbidities. Robustness was evaluated using complementary sensitivity analyses. RESULTS: Forward analyses showed that several pain phenotypes - including back pain, headaches, neck or shoulder pain, stomach or abdominal pain, migraine, and trigeminal neuralgia-were associated with increased risk of specific mental disorders. Reverse analyses indicated that mental disorders also predispose individuals to certain pain conditions. Most associations remained robust after multivariable adjustment, although some were attenuated by obesity or substance use. CONCLUSION: These findings demonstrate structured, pain - type - specific bidirectional relationships between pain and mental disorders. Clinically, they support phenotype-informed screening and management strategies, including targeted assessment of depression and anxiety in patients with high-risk pain conditions and proactive evaluation of pain symptoms in patients with mental disorders, to facilitate earlier risk stratification and integrated care.

In recent years, research on TB multimorbidity has increasingly focused on integrated care delivery, particularly concerning common mental disorders (CMDs). Engagement with relevant stakeholders, including service users and providers, has highlighted the critical intersection of TB and CMD, which affects a substantial percentage of individuals. Studies have found that depression affects approximately 45% of TB patients, and anxiety affects around 40%. Moreover, there is a significant evidence and service gap in delivering CMD care, which emphasises the need for a comprehensive approach to address the dual burden of these health challenges.

At a time of ever increasing mental health problems in Australian society, the nursing profession is beset by problems of an insufficient workforce specialising in this area. Not only is there a shortage of suitable trained specialist mental health nurses, but undergraduate nursing programs inadequately prepare students for practical mental health nursing. Fewer students are enrolling in mental health nursing, and many nurses are leaving the workforce. A particular problem in rural Australia is that there is a lack of specialist mental health services, and nurses are being increasingly relied upon to perform the role of mental health nurse despite lacking the necessary qualifications and experience.This paper aims to describe the development, implementation and evaluation of a mental health continuing education program for nurses employed in rural and remote areas of New South Wales (NSW), Australia. This was a collaborative educational initiative mounted by the NSW Health Department (who funded the project), a rural university and a number of regional health service partners. The paper includes information on how this program was conceived, developed and conducted through distance education mode. It also evaluates the efficacy of this program as perceived by 202 out of 303 participants. Overall the project was rated very favourably, and represents a cost-effective, convenient method of enabling rural and regional nurses to update and improve their skills in mental health nursing.

OBJECTIVE: General medical conditions among patients with mental and substance use disorders are often not adequately detected and managed in behavioral health settings. The project described in this study sought to investigate how behavioral health clinics used a new general health integration (GHI) framework to assess integration efforts. METHODS: Eleven community behavioral health clinics were introduced to a new continuum-based framework for use in GHI assessment. A multidisciplinary team in each clinic was tasked with identifying current GHI interventions according to several framework stages (preliminary, intermediate 1, intermediate 2, and advanced) among eight domains and 15 related subdomains. The clinics provided feedback on the framework's utility for GHI planning and advancement. RESULTS: The clinics could readily identify distinct integration interventions within each domain and subdomain. Clinics reported strengths in the domains of trauma-informed care, self-management support, social service linkages, and quality improvement. Opportunities for future advancement in integration of general health services were identified in the major domains of screening and referral, evidence-based treatments, care teams, and sustainability. The clinics also described potential benefits of the framework to further advance and implement GHI best practices. CONCLUSIONS: The clinics could use the framework as a practice assessment of integration efforts with minimal guidance and identify several evidence-based integration interventions. Some GHI interventions were seen as strengths and as opportunities for further advancement. Longitudinal evaluation among a larger number of and more geographically diverse behavioral health clinics seeking to advance their GHI practices will improve the GHI framework's generalizability and potential for dissemination.

To address the high demand for youth anxiety treatment, researchers have begun to evaluate stepped care approaches to use limited resources efficiently. Quantifying cost savings can inform policy decisions about optimal ways to use limited resources. This study presents a cost analysis of a stepped care treatment approach for anxiety disorders in youth. Youths (N = 112) completed an 8-session computer-administered attention bias modification treatment (Step 1), and families were given the option to "step up" to cognitive behavioral therapy (CBT; Step 2). Stepped care treatment cost estimates were based on (a) resources used in treatment (i.e., clinician/paraprofessional time, equipment/materials) and (b) Medicaid reimbursement rates for clinician and paraprofessional time. We compared these two cost estimates with a hypothetical standard treatment approach for youth anxiety disorders: CBT only. We also tested predictive models to determine whether they could guide decisions about which youths, based on baseline characteristics, should be assigned to stepped care or directly to CBT only to avoid the costs associated with Step 1. Compared to a hypothetical standard CBT approach, the stepped care treatment was associated with an overall cost savings of 44.4% for the Medicaid reimbursement model and 47.7% for the resource cost model. The predictive models indicated that assigning all youths to stepped care would be more cost-effective than assigning certain youths directly to CBT only. This study provides the first evidence that a stepped care treatment approach for youth anxiety is associated with substantial cost savings compared with a standard CBT.

OBJECTIVES: Mobile integrated health programs have emerged as a means to reduce avoidable emergency department (ED) visits and optimize healthcare resource utilization. Such models are estimated to cost less than ED encounters but may be more costly than traditional ambulatory services. However, mobile integrated health is not reimbursed by most payors, and its operational costs are poorly understood. Our objective if this study was to estimate the costs of delivering acute care services through a mobile integrated health program. METHODS: This study was performed at an urban academic tertiary care center with a hospital-affiliated emergency medical services agency in which a mobile integrated health program is embedded. Home visits are conducted by paramedics who collaborate with a remotely located, actively engaged physician to evaluate and treat patients. We compiled cost data derived from real-world mobile integrated health patient encounters to account for all the resources needed to perform acute care visits. Mobile integrated health visits were categorized as basic, involving lower complexity evaluations with limited diagnostics, or advanced, which include higher acuity care with intravenous medications and multiple diagnostic studies. We used Monte Carlo simulations to provide probabilistic estimates of the cost per visit of mobile integrated health-facilitated care. RESULTS: Using a Monte Carlo simulation with 1,000 iterations, we established cost estimates for basic and advanced service categories of mobile integrated health services. The median cost of a basic call is $550 (90% CI [$512-$676]), and $1400.00 for an advanced call (90% CI [$810-$1,813]). CONCLUSION: This project, which generated real-world cost estimates for mobile integrated health programs delivering acute care services, offers essential context for policymakers and payors evaluating sustainable reimbursement models. We estimate that mobile integrated health services cost more than the mean cost of most outpatient clinic visits ($160) but remain substantially less expensive than emergency department visits ($2,715) or inpatient admissions ($24,680). These findings should be interpreted with caution, given the limitations of simulation-based estimates in a single system. They highlight the ongoing need to prospectively and rigorously assess the cost-effectiveness of mobile integrated health models.

BACKGROUND: Major depressive disorder (MDD) is a chronic condition with high relapse rates affecting patients and health systems. Cognitive behavioral therapy (CBT) and mindfulness-based cognitive therapy (MBCT) are strategies for relapse prevention, but their comparative long-term cost-effectiveness remains unclear. METHODS: We developed a cohort-based Markov model with three health states, depressive episode, remission, and death, to compare MBCT and CBT in adults with MDD. The model used a lifetime horizon, six-month cycles, with healthcare payer and societal perspectives. Costs included direct medical and productivity losses discounted at 1.5%. Health-state utilities were drawn from published sources. Incremental cost-effectiveness ratios (ICERs) and net monetary benefit (NMB) were estimated at willingness-to-pay (WTP) thresholds of $50,000 and $100,000 per quality-adjusted life-year (QALY). Deterministic and probabilistic sensitivity analyses, plus scenario analyses with alternative horizons and discount rates, assessed uncertainty. RESULTS: In the base case, MBCT was associated with 14.71 QALYs at a cost of $543,861, while CBT yielded 15.07 QALYs at $549,487. CBT provided an incremental 0.37 QALYs at $5625 higher cost, producing an ICER of $15,266 per QALY gained, well below both thresholds. NMB favored CBT ($204,242 vs. $191,443 at $50,000; $957,971 vs. $926,746 at $100,000). Sensitivity analyses highlighted remission- and depression-related costs as main drivers. Probabilistic analyses showed CBT optimal in 56% of simulations at $50,000 and 61% at $100,000, with MBCT preferred at lower thresholds. CONCLUSION: CBT may be more cost-effective relative to MBCT for relapse prevention in MDD, though differences are modest. MBCT remains a competitive alternative where CBT access is limited.

OBJECTIVE: To explore the experiences of providers from two community behavioral health agencies involved in the implementation of Certified Community Behavioral Health Clinics (CCBHCs). STUDY SETTING AND DESIGN: This qualitative study was conducted as part of a larger evaluation of CCBHC implementation outcomes in two community-based behavioral health agencies. Ninety-one participants, including case managers, counselors, care coordinators, and leadership teams from both agencies, participated in focus group discussions to share their experiences regarding the implementation of the CCBHC model within their organizations. DATA SOURCES AND ANALYTIC SAMPLE: Three rounds of focus group discussions were held between 2021 and 2023. A total of 24 focus groups were audio-recorded and transcribed by one of the researchers. Qualitative data was analyzed by two researchers using the systematic text condensation method. PRINCIPAL FINDINGS: Six themes emerged from the focus groups reflecting both positive impacts and implementation challenges. Providers reported the implementation of CCBHCs improved service accessibility and effective care coordination; however, staff noted difficulties connecting clients with essential community resources, including housing and transportation. Both agencies underwent significant organizational transformation, although communication strategies varied by agency size. Finally, providers observed improved communication, client benefits (e.g., reduced hospitalizations), and positive organizational change. Despite these successes, agencies expressed significant concerns about long-term program viability due to reliance on temporary grant funding. CONCLUSION: The CCBHC model of integrated care has expanded significantly in recent years. Most participants reported a positive cultural shift within their agencies following CCBHC implementation. However, limited community resources continue to restrict agencies' ability to address clients' basic needs. Since the CCBHC model was implemented through temporary grant funding, sustainability remains a concern. Both issues underscore the need for policies that increase the availability of community resources and ensure the long-term viability of CCBHCs.