Literature Collection

Interventional psychiatric procedures (IPPs) such as electroconvulsive therapy (ECT), transcranial magnetic stimulation (TMS), and ketamine intravenous treatments (KIT) are widely used for treatment resistant depression (TRD), but we lack studies of their real-world impact compared to standard outpatient medication management (MM). Longitudinal electronic health records of 22,481 patients in a large integrated healthcare system during 2018-2022 were examined to describe depression improvement via 9-item Patient Health Questionnaire (PHQ-9), changes in psychiatric admissions, and use of continuation/maintenance (C/M) treatments. Overall, each IPP group had significantly greater depression improvement at 6 weeks compared to MM: adjusted estimates TMS:1.64 (p < 0.001), KIT:2.02 (p < 0.001), and ECT:2.16 (p < 0.001). Patient characteristics were associated with symptom worsening within treatment groups, for example: (1) non-white race for ECT (2.33, p < 0.01) and MM (0.29, p < 0.001); (2) anxiety disorder for TMS (1.73, p < 0.001); and (3) personality disorder for all treatment groups, with significant coefficients found for KIT (3.27, p < 0.05) and MM (1.27, p < 0.001). Some examples of correlations with improved symptom response include: (1) psychotic disorder for ECT (-3.57, p < 0.01); and (2) bipolar disorder for KIT (-2.19; p < 0.05). For the KIT group, C/M treatment versus no C/M treatment was associated with lower risk for 12-month psychiatric hospitalization (adjusted relative risk: 0.25). This is the first study to show a protective association for maintenance ketamine on psychiatric hospitalization risk. Treatment-specific predictors of response should be confirmed in future comparative effectiveness studies.

BACKGROUND: Unmet social needs are common among individuals with multiple chronic health conditions (MCC). OBJECTIVE: To evaluate the acceptability of proactive outreach to assess and follow up on social health needs among patients with MCC. DESIGN: Qualitative study using semi-structured interviews. PARTICIPANTS: We interviewed 25 patients with 2 or more chronic health conditions in three integrated care settings in Washington, Colorado, and California that experienced proactive outreach offering assessment and follow-up for social health risks. All patients had a higher likelihood of social health risks based on a predictive model using health plan and electronic health record data. Patients received initial outreach from clinical pharmacists at the Northern California site, licensed practical nurses in primary care at the Washington site, and Community Specialists at the Colorado site. APPROACH: Transcripts were analyzed using a mixed deductive and inductive thematic approach informed by the Theoretical Framework of Acceptability. KEY RESULTS: Mean age across the groups was 66 years. We identified five themes common across all three healthcare sites. Participants appreciated the outreach, stating they felt understood and cared for by their providers; recognized how their social needs were intertwined with their physical and mental health; and found that uncomfortable social health conversations were easier with known healthcare providers. Assessment of social health needs and referral to community resources provided some participants with hope that their needs would be met, while others felt discouraged by prior experience. Following referral to community resources, participants had uneven experiences receiving resources to address their needs. CONCLUSIONS: Our results suggest proactive outreach by healthcare team members to assess and address social health needs is valued by patients with MCC despite challenges with accessing some social health resources. Future work is needed to support access to community resources and evaluate the outcomes of outreach to those with MCC who have social needs.

IMPORTANCE: Addiction treatment rapidly transitioned to a primarily telehealth modality (telephone and video) during the COVID-19 pandemic, raising concerns about disparities in utilization. OBJECTIVE: To examine whether there were differences in overall and telehealth addiction treatment utilization after telehealth policy changes during the COVID-19 pandemic by age, race, ethnicity, and socioeconomic status. DESIGN, SETTING, AND PARTICIPANTS: This cohort study examined electronic health record and claims data from Kaiser Permanente Northern California for adults (age ≥18 years) with drug use problems before the COVID-19 pandemic (from March 1, 2019, to December 31, 2019) and during the early phase of the COVID-19 pandemic (March 1, 2020, to December 31, 2020; hereafter referred to as COVID-19 onset). Analyses were conducted between March 2021 and March 2023. EXPOSURE: The expansion of telehealth services during COVID-19 onset. MAIN OUTCOMES AND MEASURES: Generalized estimating equation models were fit to compare addiction treatment utilization during COVID-19 onset with that before the COVID-19 pandemic. Utilization measures included the Healthcare Effectiveness Data and Information Set of treatment initiation and engagement (including inpatient, outpatient, and telehealth encounters or receipt of medication for opioid use disorder [OUD]), 12-week retention (days in treatment), and OUD pharmacotherapy retention. Telehealth treatment initiation and engagement were also examined. Differences in changes in utilization by age group, race, ethnicity, and socioeconomic status (SES) were examined. RESULTS: Among the 19 648 participants in the pre-COVID-19 cohort (58.5% male; mean [SD] age, 41.0 [17.5] years), 1.6% were American Indian or Alaska Native; 7.5%, Asian or Pacific Islander; 14.3%, Black; 20.8%, Latino or Hispanic; 53.4%, White; and 2.5%, unknown race. Among the 16 959 participants in the COVID-19 onset cohort (56.5% male; mean [SD] age, 38.9 [16.3] years), 1.6% were American Indian or Alaska Native; 7.4%, Asian or Pacific Islander; 14.6%, Black; 22.2%, Latino or Hispanic; 51.0%, White; and 3.2%, unknown race. Odds of overall treatment initiation increased from before the COVID-19 pandemic to COVID-19 onset for all age, race, ethnicity, and SES subgroups except for patients aged 50 years or older; patients aged 18 to 34 years had the greatest increases (adjusted odds ratio [aOR], 1.31; 95% CI, 1.22-1.40). Odds of telehealth treatment initiation increased for all patient subgroups without variation by race, ethnicity, or SES, although increases were greater for patients aged 18 to 34 years (aOR, 7.17; 95% CI, 6.24-8.24). Odds of overall treatment engagement increased (aOR, 1.13; 95% CI, 1.03-1.24) without variation by patient subgroups. Retention increased by 1.4 days (95% CI, 0.6-2.2 days), and OUD pharmacotherapy retention did not change (adjusted mean difference, -5.2 days; 95% CI, -12.7 to 2.4 days). CONCLUSIONS: In this cohort study of insured adults with drug use problems, there were increases in overall and telehealth addiction treatment utilization after telehealth policies changed during the COVID-19 pandemic. There was no evidence that disparities were exacerbated, and younger adults may have particularly benefited from the transition to telehealth.