Literature Collection

ABSTRACTObjectives:Recent research has demonstrated the challenges to self-identity associated with dementia, and the importance of maintaining involvement in decision-making while adjusting to changes in role and lifestyle. This study aimed to understand the lived experiences of couples living with dementia, with respect to healthcare, lifestyle, and "everyday" decision-making. DESIGN: Semi-structured qualitative interviews using Interpretative Phenomenological Analysis as the methodological approach. SETTING: Community and residential care settings in Australia. PARTICIPANTS: Twenty eight participants who self-identified as being in a close and continuing relationship (N = 13 people with dementia, N = 15 spouse partners). Nine couples were interviewed together. RESULTS: Participants described a spectrum of decision-making approaches (independent, joint, supported, and substituted), with these approaches often intertwining in everyday life. Couples' approaches to decision-making were influenced by "decisional," "individual," "relational," and "external" factors. The overarching themes of "knowing and being known," "maintaining and re-defining couplehood" and "relational decision-making," are used to interpret these experiences. The spousal relationship provided an important context for decision-making, with couples expressing a history and ongoing preference for joint decision-making, as an integral part of their experience of couplehood. However, the progressive impairments associated with dementia presented challenges to maintaining joint decision-making and mutuality in the relationship. CONCLUSIONS: This study illustrates relational perspectives on decision-making in couples with dementia. Post-diagnostic support, education resources, proactive dyadic interventions, and assistance for spouse care partners may facilitate more productive attempts at joint decision-making by couples living with dementia.

Primary care systems are a mainstay for how many Americans seek health and behavioral health care. It is estimated that almost a quarter of behavioral health conditions are diagnosed and/or treated in primary care. Many clinics treat the whole person through integrated models of care such as the Primary Care Behavioral Health (PCBH) model. COVID-19 has disrupted integrated care delivery and traditional PCBH workflows requiring swift adaptations. This paper synthesizes how COVID-19 has impacted clinical services at one federally qualified health center and describes how care has continued despite the challenges experienced by frontline behavioral health providers.

Mental disorders are widespread, debilitating and associated with high costs. In Germany, usual care (UC) for mental disorders is afflicted by poor coordination between providers and long waiting times. Recently, the primary alternative to UC-the gatekeeping-based general practitioners (GP) program-was extended by the collaborative Psychiatry-Neurology-Psychotherapy (PNP) program, which is a selective contract designed to improve mental health care and the allocation of resources. Here, we assess the effects of the GP program and the PNP program on costs for mental health care. We analyzed claims data from 2014 to 2016 of 55,472 adults with a disorder addressed by PNP to compare costs and sick leave days between PNP, the GP program and UC. The individuals were grouped and balanced via entropy balancing to adjust for potentially confounding covariates. We employed a negative binomial model to compare sick leave days and two-part models to compare sick pay, outpatient, inpatient and medication costs over a 12-month period. The PNP program significantly reduced sick pay by 164€, compared to UC, and by 177€, compared to the GP program. Consistently, sick leave days were lower in PNP. We found lower inpatient costs in PNP than in UC (-194€) and in the GP program (-177€), but no reduction in those shares of inpatient costs that accrued in psychiatric or neurological departments. Our results suggest that integrating collaborative care elements in a gatekeeping system can favourably impact costs. In contrast, we found no evidence that the widely implemented GP program reduces costs for mental health care.

The United States is experiencing an unprecedented opioid crisis, with a record of about 93,000 opioid-involved overdose deaths in 2020, which requires rapid and substantial scaling up of access to effective treatment for opioid use disorder. Only 18% of individuals with opioid use disorder receive evidence-based treatment, and strategies to increase access are hindered by a lack of treatment providers. Using a case study from the largest municipal hospital system in the United States, the authors describe the effects of a workforce shortage on health system responses to the opioid crisis. This national problem demands a multipronged approach, including federal programs to grow and diversify the pipeline of addiction providers, medical education initiatives, and enhanced training and mentorship to increase the capacity of allied clinicians to treat patients who have an opioid use disorder. Workforce development should be combined with structural reforms for integrating addiction treatment into mainstream medical care and with new treatment models, including telehealth, which can lower patient barriers to accessing treatment.