Literature Collection

IMPORTANCE: Emerging evidence suggests that integrated care models are associated with improved mental health care access and outcomes for youths (children ≤12 years and adolescents 12-21 years) served in pediatric primary care settings. However, the key components of these complex models remain unexamined. OBJECTIVE: To identify and describe the key components of effective pediatric integrated mental health care models. EVIDENCE REVIEW: The PubMed, Embase, PsycINFO, and Cochrane Controlled Register of Trials electronic databases were searched for relevant peer-reviewed articles published between January 1, 1985, and April 30, 2019. Articles were restricted to those published in the English language. Eligible articles reported original data on youths 17 years or younger, implemented an integrated mental health care model in a pediatric primary care setting, and assessed the model's association with primary outcomes (eg, mental health symptom severity) and secondary outcomes (eg, functional impairment and patient satisfaction). Articles that specified some degree of systematic coordination or collaboration between primary care and mental health professionals were included in the final review. Two independent reviewers extracted data on study design, model type, model components, level of integration, and outcomes. Study quality was assessed using the Jadad scale. Data were analyzed between January 1, 2018, and May 31, 2019. FINDINGS: Eleven randomized clinical trials involving 2190 participants were included. Three studies focused on youths with depression, 3 on youths with attention-deficit/hyperactivity disorder, and 5 on youths with behavioral disorders. Most studies (9 of 11) implemented either the collaborative care model (n = 3), a slightly modified version of the collaborative care model (n = 2), or colocated care (n = 4). The most commonly reported components of effective pediatric integrated mental health care models were population-based care, measurement-based care, and delivery of evidence-based mental health services; all 3 components were present in studies reporting clinical improvement of mental health symptoms. Other model components, such as treatment-to-target or team-based care, were common in studies reporting specific outcomes, such as functional impairment. CONCLUSIONS AND RELEVANCE: This review is the first to date to systematically search and qualitatively synthesize information on the key components of effective pediatric integrated mental health care models. This knowledge may be especially useful for pediatric primary care administrators in the selection of an integrated care model for their setting.

OBJECTIVES: Many patients with major depressive disorder must try multiple antidepressants before they identify a drug that is both effective and tolerable. Pharmacogenomic (PGx) testing may provide clinicians with guidance around medication choice based on a patient's drug response-related genetic variants. However, this technology is not routinely used in clinical care in Canada, and the views of key actors in the implementation process are largely unknown. The objective of this study was to qualitatively elicit the perspectives and attitudes of clinicians, scientists, policy actors and members of industry about PGx testing to guide antidepressant prescribing in primary care via interviews to help inform implementation policies for this technology. DESIGN: We conducted a qualitative description study. Data analysis proceeded in parallel with data collection and consisted of an inductive qualitative content analysis. SETTING: The focus of this study was implementation of PGx testing in primary care in Ontario, Canada. PARTICIPANTS: We conducted semistructured interviews with 28 individuals who had professional experience relevant to the implementation of PGx testing for depression care ('key informants'). Geographical limits for recruitment were applied based on the transferability of key informants' expertise to the Ontario setting; included participants worked in Canada, the USA and Europe. RESULTS: Participants described views about PGx testing relating to benefits and harms of this technology; their interpretation of the evidence base; implementation-oriented considerations and industry involvement. Overall, participants spoke enthusiastically about PGx testing, but emphasised genetic information is only one component of decision-making about medication prescription. Most endorsed implementation in primary care and felt a pre-emptive approach to testing would be ideal. CONCLUSIONS: Key informants consider the use of PGx testing to guide antidepressant prescribing in primary care as having both patient-level and system-level benefits. Concerns raised centred primarily around clinician education and barriers to access. Future research should focus on questions relating to feasibility of system-wide implementation.