Literature Collection

BACKGROUND: Generalized anxiety disorder (GAD) is one of the most common mental disorders in primary care (PC). GAD has low remission and high relapse rates over long follow-up periods. Qualitative evidence was synthesized to understand the implementation of care and treatment options for people with GAD in PC. METHODS: Research published from 2008 to September 2020 was searched in five databases (MEDLINE, EMBASE, CINAHL, WOS and PsycArticles). Studies that used qualitative methods for data collection and analysis to investigate the implementation of care and treatment options for people with GAD in PC and outpatient settings were included. Non-qualitative studies, mixed methods studies that did not separately report qualitative findings and studies in languages other than English or Spanish were excluded. We used the Confidence in the Evidence from Reviews of Qualitative Research (CERQual) framework to assess the overall confidence in the findings. RESULTS: The results with a moderate level of confidence showed that the trajectory of care for people with GAD in PC and outpatient settings is long and fluctuates over time, involving multiple difficulties in accessing and maintaining initial treatment or successive treatment options. In addition, there are wide variations in the preferences for and acceptability of different treatment options. The results with a high level of confidence indicated that more information on GAD and its treatment options is needed for PC practitioners, GAD patients and their carers. The results with a low level of confidence suggested that patients use antidepressants for longer than recommended and that the interruption of treatment is not usually planned. CONCLUSIONS: Initial resistance to new treatments among people with GAD can make access and adherence to treatment difficult. Improving care may require patients to be informed of possible trajectories in stepped care pathways before the initiation of treatment so they are aware that they may need to try a number of options until the most effective treatment for them is found. Increased awareness of and information materials on GAD may facilitate both appropriate diagnosis and long-term care.

Frequent emergency department (ED) users often have complex behavioral health and social needs. However, policy makers often focus on this population's medical system use without examining its use of behavioral health and social services systems. To illuminate the wide-ranging needs of frequent ED users, we compared medical, mental health, substance use, and social services use among nonelderly nonfrequent, frequent, and superfrequent ED users in San Francisco County, California. We linked administrative data for fiscal years 2013-15 for beneficiaries of the county's Medicaid managed care plan to a county-level integrated data system. Compared to nonfrequent users, frequent users were disproportionately female, white or African American/black, and homeless. They had more comorbidities and annual outpatient mental health visits (11.93 versus 4.16), psychiatric admissions (0.73 versus 0.07), and sobering center visits (0.17 versus <0.01), as well as disproportionate use of housing and jail health services. Our findings point to the need for shared knowledge across domains, at the patient and population levels. Integrated data can serve as a systems improvement tool and help identify patients who might benefit from coordinated care management. To deliver whole-person care, policy makers should prioritize improvements in data sharing and the development of integrated medical, behavioral, and social care systems.