Literature Collection

Physicians and advanced practice providers often lack structured opportunities to develop personal and professional skills, critical for reducing burnout and enhancing job satisfaction. To address this, Brown Medicine's Division of General Internal Medicine introduced the Personal Development Empowerment Series, a cost- effective faculty development initiative integrated into the existing schedule. The series includes sessions that focus on topics like imposter syndrome, assertiveness, and time management, blending education with interactive activities to promote practical application. Facilitated by psychologists and motivated peers, the lectures have been well received, with faculty appreciating its emphasis on reflection and cognitive-behavioral strategies. This replicable initiative fosters a supportive work culture, boosts morale, and highlights the importance of personal growth. This program demonstrates that affordable, home-grown interventions can significantly impact well-being and organizational culture.

OBJECTIVES: Primary care behavioral health (PCBH) is a patient care model in which a behavioral health consultant (BHC) works alongside the primary care provider to address behavioral components of health conditions. PCBH is well received in the primary care setting; however, little is known about acceptability of the service among prenatal patients. The study was designed to explore the acceptability of PCBH among pregnant patients in a resident obstetrics and gynecology clinic. METHODS: A survey designed to assess different components of acceptability was administered to eligible pregnant patients who received prenatal care at the resident obstetrics and gynecology clinic. RESULTS: The majority of patients wanted to receive education on pregnancy-relevant topics from the BHC: healthy weight gain (68.4%), healthy eating (70.4%), healthy exercise (73.5%), and mood disorders (63.3%). The majority of participants wanted help from the BHC in managing coexisting conditions affecting pregnancy: stress (63.3%), depression (75.5%), or anxiety (73%). The majority of patients (55.6%) preferred to work with a BHC for mental health concerns rather than an outside psychiatrist or counselor. PCBH service was perceived to be easy to understand (78%). Barriers to engaging in the PCBH service included time (41.4%), lack of perceived need (13.8%), unavailability (6.9%), and others (13.8%). Despite the perceived benefit, there was an implication of stigma among prenatal patients seeking PCBH or mental health care. CONCLUSIONS: Overall, the PCBH model had high acceptability among a prenatal care population in a resident obstetrics and gynecology clinic and offers potential to improve prenatal outcomes.

BACKGROUND: Depression is pervasive, and rates are rising in the United States. Most people with depression receive care from primary care clinicians, but gaps in the quality of care exist. Team-based approaches to depression care have been shown to aid in treatment and management; yet, challenges exist in implementation. Digital health apps have been shown to be effective in improving depression symptoms and enhancing patient engagement in some populations. Many, however, do not share data with clinical care teams. OBJECTIVE: This study aimed to understand the barriers to and facilitators for implementation of a digital health program that supports coordinated use by clinical care teams and patients, via a mobile app and care team-facing web interface, for depression in primary care. METHODS: This study was part of a larger intervention study that included 4 primary care practices: 2 intervention and 2 control sites. The intervention sites used a patient-facing mobile app and a care team-facing web interface, and the control sites continued usual care. The study team conducted interviews from May to October 2021. Patient and care team participants were recruited toward the end of their study involvement. Separate semistructured interview guides were developed for patient and care team participants. Interviews were recorded and transcribed. Data were coded using Atlas.ti.9, and data analysis was completed using a grounded theory approach. RESULTS: Interviews with patient (n=8) and care team (n=8) participants revealed 3 main topics for program implementation: app/interface usability, tracking, and program recommendations. For app/interface usability, overall, navigation for both patient and care team participants was simple and straightforward. Although app content was relevant, patient participants desired additional educational resources and information to aid in their depression treatment and management. In terms of tracking, care team participants indicated that data obtained via the interface enabled them to monitor patients in between visits; and in some circumstances, these data facilitated conversations with patients about treatment plans. Tracking medication adherence differed among patient participants due to established routines of taking medications consistently, lack of motivation to track, or lack of interest in tracking. Care team participants reported the ability to respond more quickly to side effects. Patients commented on tracking difficulties: confusing response options, insufficient goal attainment response options, not being able to provide details or write notes, and no ability to change goals. Some patient and care team participants perceived that tracking encouraged communication with one another; others perceived tracking as having no impact on shared decision-making. CONCLUSIONS: Results suggest implementation of a digital health program for depression treatment and management in primary care practices could impact patient medication adherence, produce faster turnaround time for medication optimization, encourage goal setting, and foster communication between patients and care team members. Program enhancements could optimize patient and care team member engagement.

OBJECTIVE: To assess patient and family outcomes of psychological interventions provided by behavioral health clinicians (BHCs) integrated into community-based pediatric primary care practices. Little is known about the feasibility, acceptability, and effectiveness of this treatment strategy in real-world settings. METHODS: The sample comprised 5487 patients in ∼80 practices who received psychological interventions from ∼100 integrated BHCs over 2 years. Patients of all ages identified by universal screening or verbal patient/family report as having a developmental or behavioral health (BH) problem of any kind were eligible for intervention. Post-intervention patient clinical improvement was assessed using a clinician-completed standardized clinical global impressions scale. Family satisfaction was assessed using a family-completed standardized patient experience survey. RESULTS: Patients receiving intervention were predominantly >age 7 and had BH problems (predominantly stress-related, anxiety, depressive, attention, or behavior) that were predominantly mild-moderate in severity. The mean number of intervention visits was 5.6 (range: 3-41; mode: 3). Post-intervention, 72.9% of patients with >3 intervention visits were improved and 28.9% were much or very much improved. After adjusting for potential moderators, lesser odds of improvement were significantly associated with age <7 or 12 to 15 years; symptomatic illness at initial presentation; a disorder other than anxiety; SSRI medication; complex chronic medical disease; and only 3 BHC visits. Overall, 79.3% of families responding to a survey were highly likely to recommend the services to family/friends. CONCLUSION: The findings suggest that psychological interventions delivered in the context of integrated BH in a community-based pediatric primary care setting were feasible, valued, and effective.

BACKGROUND: Digital mental health applications (DMHAs) are emerging, novel solutions to address gaps in behavioral health care. Accordingly, Kaiser Permanente Mid-Atlantic States (KPMAS) integrated referrals for 6 unique DMHAs into clinical care in 2019. OBJECTIVE: This study investigated patient and health care professional (HCP) experiences with DMHA referral; DMHA use; and perceived importance of engagement, functionality, design, and information attributes in real-world practice. METHODS: Separate cross-sectional surveys were developed and tested for patients and HCPs. Surveys were administered to KPMAS participants through REDCap (Research Electronic Data Capture), and completed between March 2022 and June 2022. Samples included randomly selected patients who were previously referred to at least 1 DMHA between April 2021 and December 2021 and behavioral health and primary care providers who referred DMHAs between December 2019 and December 2021. RESULTS: Of the 119 patients e-mailed a survey link, 58 (48.7%) completed the survey and 44 (37%) confirmed receiving a DMHA referral. The mean age of the sample was 42.21 (SD 14.08) years (29/44, 66%); 73% (32/44) of the respondents were female, 73% (32/44) of the respondents had at least a 4-year college degree, 41% (18/44) of the respondents were Black or African American, and 39% (17/44) of the respondents were White. Moreover, 27% (12/44) of the respondents screened positive for anxiety symptoms, and 23% (10/44) of the respondents screened positive for depression. Overall, 61% (27/44) of the respondents reported DMHA use for ≤6 months since referral, 36% (16/44) reported use within the past 30 days, and 43% (19/44) of the respondents reported that DMHAs were very or extremely helpful for improving mental and emotional health. The most important patient-reported DMHA attributes by domain were being fun and interesting to use (engagement); ease in learning how to use (functionality); visual appeal (design); and having well-written, goal- and topic-relevant content (information). Of the 60 sampled HCPs, 12 (20%) completed the survey. Mean HCP respondent age was 46 (SD 7.75) years, and 92% (11/12) of the respondents were female. Mean number of years since completing training was 14.3 (SD 9.94) years (10/12, 83%). Of the 12 HCPs, 7 (58%) were physicians and 5 (42%) were nonphysicians. The most important HCP-reported DMHA attributes by domain were personalized settings and content (engagement); ease in learning how to use (functionality); arrangement and size of screen content (design); and having well-written, goal- and topic-relevant content (information). HCPs described "typical patients" referred to DMHAs based on perceived need, technical capability, and common medical conditions, and they provided guidance for successful use. CONCLUSIONS: Individual patient needs and preferences should match the most appropriate DMHA. With many DMHA choices, decision support systems are essential to assist patients and HCPs with selecting appropriate DMHAs to optimize uptake and sustained use.

OBJECTIVE: Brief non-pharmacologic chronic pain treatments are largely effective and widely recommended for pain self-management. The purpose of this study was to evaluate veteran and provider perceptions of acceptability, appropriateness, and feasibility of Brief Cognitive Behavioral Therapy (Brief CBT-CP) content and materials to inform future implementation efforts in primary care and other integrated settings. DESIGN: Qualitative analysis of data from a pilot randomized controlled trial (RCT). SETTING: Two Veterans Affairs (VA) primary care clinics in the Northeast. SUBJECTS: Veterans (n = 10) who completed Brief CBT-CP treatment, integrated behavioral health providers (IBHPs; n = 3 clinical social workers; n = 4 clinical psychologists), and primary care physicians (PCPs; n = 5). METHOD: Rapid Qualitative Analysis of semi-structured interview data. INTERVENTION: Brief CBT-CP, an adapted intervention for chronic pain intended for use in primary care and other integrated care settings utilizing brief treatment modalities. RESULTS: PCPs and IBHPs described Brief CBT-CP as highly acceptable and clinically useful, particularly in response to its focus on biopsychosocial pain self-management skills. Similarly, veterans pointed to the non-pharmacologic skills as a highly acceptable component of treatment. The intervention was also viewed as highly appropriate by providers who emphasized the treatment's alignment with the tenets of primary care, accessibility, and potential to strengthen stepped care adherence. Some providers suggested minor modifications to the content. Veterans regarded Brief CBT-CP as highly appropriate due to the customizability of the non-pharmacologic skills which helped them achieve their recovery goals while acknowledging that the primary limitation was the intervention's inability to completely eliminate pain. Providers, who viewed the intervention as practical overall, anticipated issues such as patient readiness and logistics as potentially impacting treatment uptake; veterans, however, perceived the intervention as feasible, favoring flexibility with scheduling. CONCLUSIONS: Veterans and providers endorsed Brief CBT-CP as a highly acceptable, highly appropriate, and generally feasible non-pharmacological behavioral pain treatment. Veterans described improvements across behavioral, cognitive, and affective domains including decreased pain levels, increased pain tolerance, improved functioning, and decreased stress related to pain. CLINICAL TRIAL INFORMATION: The Clinical Trials Registration #NCT03490981.; Pain is often first treated in primary care. Despite many patients being interested in alternatives to pain medicine or strategies they can use while taking medicine, self-management practices are not routinely taught. Skills like taking breaks during tasks that increase pain, using special exercises to relax muscles, and changing how we think to avoid going to worst-case scenarios are proven to be helpful for those living with chronic pain. We wanted to know if veterans and providers would be receptive to a brief treatment for chronic pain, Brief Cognitive Behavioral Therapy for Chronic Pain (Brief CBT-CP), grounded in these evidence-based practices. This study is unique because we spoke not only with veterans who received the treatment, but also primary care doctors and mental health providers who would be recommending or delivering it. Veterans overwhelmingly found the treatment helpful because it taught them skills to improve day-to-day functioning and helped reduce pain. The providers felt the treatment would be a good fit for primary care as long as patient factors such as treatment expectations and ability to travel to appointments were considered. Knowing that this provider-backed intervention helped so many veterans will allow us to move forward with offering it in primary care clinics.; eng

Background: Asynchronous telepsychiatry (ATP) consultations are a novel form of psychiatric consultation. Studies comparing patient and provider satisfaction for ATP with that for synchronous telepsychiatry (STP) do not exist. Methods: This mixed-methods study is a secondary analysis of patients' and primary care providers' (PCPs) satisfaction from a randomized clinical trial of ATP compared with STP. Patients and their PCPs completed satisfaction surveys, and provided unstructured feedback about their experiences with either ATP or STP. Differences in patient satisfaction were assessed using mixed-effects logistic regression models, and the qualitative data were analyzed using thematic analysis with an inductive coding framework. Results: Patient satisfaction overall was high with 84% and 97% of respondents at 6 months reported being somewhat or completely satisfied with ATP and STP, respectively. Patients in the STP group were more likely to report being completely satisfied, to recommend the program to a friend, and to report being comfortable with their care compared with ATP (all p < 0.05). However, there was no difference between the patients in ATP and STP in perceived change in clinical outcomes (p = 0.51). The PCP quantitative data were small, and thus only summarized descriptively. Conclusions: Patients expressed their overall satisfaction with both STP and ATP. Patients in ATP reported more concerns about the process, likely because feedback after ATP was slower than that after STP consultations. PCPs had no apparent preference for STP or ATP, and reported implementing the psychiatrists' recommendations for both groups when such recommendations were made, which supports our previous findings. Trial Registration: ClinicalTrials.gov NCT02084979; https://clinicaltrials.gov/ct2/show/NCT02084979.

IMPORTANCE: Harm reduction is associated with improved health outcomes among people who use substances. As overdose deaths persist, hospitals are recognizing the need for harm reduction services; however, little is known about the outcomes of hospital-based harm reduction for patients and staff. OBJECTIVE: To evaluate patient and staff perspectives on the impact and challenges of a hospital-based harm reduction program offering safer use education and supplies at discharge. DESIGN, SETTING, AND PARTICIPANTS: This qualitative study consisted of 40-minute semistructured interviews with hospitalized patients receiving harm reduction services and hospital staff at an urban, safety-net hospital in California from October 2022 to March 2023. Purposive sampling allowed inclusion of diverse patient racial and ethnic identities, substance use disorders (SUDs), and staff roles. EXPOSURE: Receipt of harm reduction education and/or supplies (eg, syringes, pipes, naloxone, and test strips) from an addiction consult team, or providing care for patients receiving these services. MAIN OUTCOMES AND MEASURES: Interviews were analyzed using thematic analysis to identify key themes. RESULTS: A total of 40 participants completed interviews, including 20 patients (mean [SD] age, 43 [13] years; 1 American Indian or Alaska Native [5%], 1 Asian and Pacific Islander [5%], 6 Black [30%]; 6 Latine [30%]; and 6 White [30%]) and 20 staff (mean [SD] age 37 [8] years). Patients were diagnosed with a variety of SUDs (7 patients with opioid and stimulant use disorder [35%]; 7 patients with stimulant use disorder [35%]; 3 patients with opioid use disorder [15%]; and 3 patients with alcohol use disorder [15%]). A total of 3 themes were identified; respondents reported that harm reduction programs (1) expanded access to harm reduction education and supplies, particularly for ethnically and racially minoritized populations; (2) built trust by improving the patient care experience and increasing engagement; and (3) catalyzed culture change by helping destigmatize care for individuals who planned to continue using substances and increasing staff fulfillment. Black and Latine patients, those who primarily used stimulants, and those with limited English proficiency (LEP) reported learning new harm reduction strategies. Program challenges included hesitancy regarding regulations, limited SUD education among staff, remaining stigma, and the need for careful assessment of patient goals. CONCLUSIONS AND RELEVANCE: In this qualitative study, patients and staff believed that integrating harm reduction services into hospital care increased access for populations unfamiliar with harm reduction, improved trust, and reduced stigma. These findings suggest that efforts to increase access to harm reduction services for Black, Latine, and LEP populations, including those who use stimulants, are especially needed.