Literature Collection

OBJECTIVE: The time during which adolescents and young adults (AYAs) living with Type 1 Diabetes (T1D) transition from pediatric to adult care is associated with blood sugar levels outside of target ranges, care gaps, and an increased risk of acute diabetes complications. The aim of this study was to understand (1) the perspectives of AYAs and providers about the strengths, challenges, and opportunities of transition care and (2) the role of digital technologies in supporting the transition to adult care. Research Design and Methods. We conducted a qualitative descriptive study that involved 43 semistructured interviews in French or English with AYA living with T1D (aged 16-25; n = 22) and pediatric or adult diabetes health care providers (HCPs) (n = 21). RESULTS: We identified three themes. First, transition care is not standardized and varies widely, and there is a lack of awareness of transition guidelines. Second, virtual care can simultaneously hinder and help relationship-building between providers and AYA. Third, AYAs value a holistic approach to care; both HCPs and AYA highlighted the opportunity to better support overall mental wellbeing. CONCLUSIONS: The design of digital technologies to support T1D transition care should consider methods for standardizing holistic care delivery and integrating hybrid diabetes care visits to support access to transition care. These findings can inform future transition intervention development that leverages existing transition guidelines, targets holistic care model integration, and considers quantitative diabetes metrics in conjunction with broader life experiences of AYA when providing transition care.

Public health emergencies, including climate-related and manmade disasters such as active shooter incidents, occur regularly in the United States. A comprehensive approach is needed to ensure that children's mental health needs are adequately addressed following disasters. This article summarizes the latest evidence on how health systems can effectively address children's unique developmental, social, emotional, and behavioral needs in the context of disasters. To do so requires the integration of mental health considerations throughout all disaster phases, including preparedness, response, and recovery. We discuss the role of traditional emergency response systems and emerging models for responding to mental health crises. These include the national children's disaster mental health concept of operations and specific resources such as crisis lines, mobile crisis units, and telemental health. To achieve a broader reach in addressing children's mental health needs during disasters, health systems can foster a "pediatric disaster system of care" by partnering with community touch points such as schools, faith-based organizations, public health, and law enforcement. Unique considerations during disasters are required to maintain access to care for children with preexisting behavioral health conditions. During disasters, attention is needed to promote equitable identification of mental health needs and linkage to services, particularly for minoritized groups and children living in rural, frontier, and high-poverty areas. Strategies to address children's mental health needs during disasters include the provision of psychological first aid, screening for and triaging mental health needs, and stepped care approaches that progressively allocate higher-intensity evidence-based treatments to children with greater and enduring needs.

While the future of college student mental health is leaning towards systemic-level integrated behavioral health care models, existing mental health support for science, technology, engineering, and mathematics (STEM) students remains highly individual. The REDFLAGS Model is a mental health resource comprising an acronym of warning signs that suggest a college student might be struggling with mental distress. The aim of this study was to test the utility of The REDFLAGS Model, with a large sample of STEM students (N = 358). Results revealed support for the latent dimensionality of The REDFLAGS Model among a large sample of STEM students. Results also demonstrated that higher recognition of the items on The REDFLAGS Model as warning signs for mental distress was a significant predictor of peer-to-peer referrals to counseling among STEM students. Additionally, STEM students with help-seeking histories and those who identified as female were more likely to recognize the items on The REDFLAGS Model as warning signs of mental distress than those without help-seeking histories and men, respectively. Collectively, results indicated that The REDFLAGS Model has potential to provide college counselors with an empirically supported framework for supporting STEM student mental health. It is available at no cost and can be shared in print or digital formats.

BACKGROUND: Quality integrated care, which involves primary care and mental health clinicians working together, can help identify and treat adolescent depression early. We explored systemic barriers to quality integrated care at the provincial level in Ontario, Canada using a learning system approach. METHODS: Two Ontario Health Teams (OHTs), regional networks designed to support integrated care, completed the Practice Integration Profile (PIP) and participated in focus groups. RESULTS: The OHTs had a median PIP score of 69 out of 100. Among the PIP domains, the lowest median score was case identification (50), and the highest one was workspace (100). The focus groups generated 180 statements mapped to the PIP domains. Workflow had the highest number of coded statements (59, 32.8%). DISCUSSION: While the primary care practices included mental health clinicians on-site, the findings highlighted systemic barriers with adhering to the integrated care pathway for adolescent depression. These include limited access to mental health expertise for assessment and diagnosis, long wait times for treatment, and shortages of clinicians trained in evidence-based behavioral therapies. These challenges contributed to the reliance on antidepressants as the first line of treatment due to their accessibility rather than evidence-based guidelines. CONCLUSION: Primary care practices, within regional networks such as OHTs, can form learning systems to continuously identify the strategies needed to support quality integrated care for adolescent depression based on real-world data.

Pregnant people with comorbid posttraumatic stress disorder (PTSD) and substance use disorder (SUD) constitute a highly vulnerable population. PTSD and SUD confer risks to both the pregnant person and the fetus, including a host of physical and mental health consequences. When PTSD and SUD co-occur, potential negative impacts are amplified, and the symptoms of each may exacerbate and maintain the other. Pregnancy often increases engagement in the healthcare system, presenting a unique and critical opportunity to provide PTSD and SUD treatment to birthing people motivated to mitigate risks of losing custody of their children. This paper presents implementation process outcomes of Written Exposure Therapy (WET), a brief, scalable, and sustainable evidence-based PTSD treatment delivered to pregnant persons receiving care in an integrated obstetrical-addiction recovery program at Boston Medical Center. Trial participants (N = 18) were mostly White, non-Hispanic (61.1%), not currently working (77.8%), had a high school or lower level of education (55.5%), had an annual household income less than $35,000 (94.4%), and were living in a substance use residential program (55.6%). We examined intervention feasibility, acceptability, appropriateness, adoption; barriers and facilitators to implementation; and feedback on supporting uptake and sustainability of the intervention using coded qualitative sources (consultation field notes [N = 47] and semi-structured interviews [N = 5]) from providers involved in trial planning and treatment delivery. Results reflected high acceptability, appropriateness, and adoption of WET. Participants described system-, provider-, and patient-level barriers to implementation, offered suggestions to enhance uptake, but did not raise concerns about core components of the intervention. Findings suggest that WET is an appropriate and acceptable PTSD treatment for this difficult-to-reach, complex population, and has the potential to positively impact pregnant persons and their children.

BACKGROUND: Unhealthy substance use (USU) is common and ranges from use above guideline-recommended levels to severe substance use disorder. USU results in substantial morbidity and mortality yet primary care practices rarely systematically screen, diagnose, and treat USU. Supporting Unhealthy Substance use care Through a whole person Approach and user centered INtegration into primary care (SUSTAIN) tests whether the implementation of a co-designed change package for USU improves patient function. The protocol for SUSTAIN is presented here. METHODS: SUSTAIN is a cluster randomized controlled implementation trial of a customized approach to identify and treat USU in primary care. The sample includes 24 primary care clinics in two practice-based research networks (PBRNs). In phase one, primary care practice champions and patients with lived USU experience co-design a change package to identify and treat USU. In phase two, we test the effectiveness of the change package versus usual care and evaluate the implementation of the change package. Data will be collected from 24 clinics (50 patients per clinic for total of 1200 patients) through patient surveys and the electronic health record. Patients surveyed must be 18 or older and screen positive for USU using the Tobacco, Alcohol, Prescription medication and other Substance use part one (TAPS-1) tool. Primary outcomes include mental and physical health patient function scales measured using Patient Reported Outcomes Measurement Information System (PROMIS-29-v2). Secondary outcomes are prevalence of USU, recovery, health care utilization, USU screening rates, provision/referral to behavioral health services and prescription of appropriate medications. We will also evaluate implementation outcomes by surveying 96 practice representatives (4 at each clinic) and conduct qualitative interviews with 20 patients and 20 practice leaders to assess their experience with the intervention and its implementation. CONCLUSIONS: The SUSTAIN trial creates and tests an implementation package approach to address USU in diverse primary care settings. The SUSTAIN change package aims to transform how primary care practices care for individuals with USU to improve patient outcomes and enhance community well-being.