Literature Collection

IMPORTANCE: Federal emergency authorities were invoked during the COVID-19 pandemic to expand clinical telehealth for opioid use disorder (OUD). OBJECTIVE: To examine the association of the receipt of telehealth services and medications for OUD (MOUD) with fatal drug overdoses before and during the pandemic. DESIGN, SETTING, AND PARTICIPANTS: This cohort study used exploratory longitudinal data from 2 cohorts (prepandemic cohort: September 1, 2018, to February 29, 2020; pandemic cohort: September 1, 2019, to February 28, 2021) of Medicare Fee-for-Service beneficiaries aged 18 years or older initiating an episode of OUD-related care using Medicare Fee-for-Service data from the Centers for Medicare & Medicaid Services and National Death Index data from the Centers for Disease Control and Prevention. Data analysis was performed from September 19 to October 17, 2022. EXPOSURES: Prepandemic vs pandemic cohort demographic, medical, substance use, and psychiatric characteristics. MAIN OUTCOMES AND MEASURES: Receipt of OUD-related telehealth services, receipt of MOUD, and fatal drug overdose. RESULTS: The prepandemic cohort comprised 105 162 beneficiaries (58.1% female; 67.6% aged 45-74 years). The pandemic cohort comprised 70 479 beneficiaries (57.1% female; 66.3% aged 45-74 years). The rate of all-cause mortality was higher in the pandemic cohort (99.9 per 1000 beneficiaries; 7041 deaths) than in the prepandemic cohort (76.8 per 1000; 8076 deaths) (P < .001). The rate of fatal drug overdoses was higher in the pandemic cohort (5.1 per 1000 beneficiaries; n = 358) than in the prepandemic cohort (3.7 per 1000; n = 391) (P < .001). The percentage of deaths due to a fatal drug overdose was similar in the prepandemic (4.8%) and pandemic (5.1%) cohorts (P = .49). In multivariable analysis of the pandemic cohort, receipt of OUD-related telehealth was associated with a significantly lower adjusted odds ratio (aOR) for fatal drug overdose (aOR, 0.67; 95% CI, 0.48-0.92) as was receipt of MOUD from opioid treatment programs (aOR, 0.41; 95% CI, 0.25-0.68) and receipt of buprenorphine in office-based settings (aOR, 0.62; 95% CI, 0.43-0.91) compared with those not receiving MOUD; receipt of extended-release naltrexone in office-based settings was not associated with lower odds for fatal drug overdose (aOR, 1.16; 95% CI, 0.41-3.26). CONCLUSIONS AND RELEVANCE: This cohort study found that, among Medicare beneficiaries initiating OUD-related care during the COVID-19 pandemic, receipt of OUD-related telehealth services was associated with reduced risk for fatal drug overdose, as was receipt of MOUD from opioid treatment programs and receipt of buprenorphine in office-based settings. Strategies to expand provision of MOUD, increase retention in care, and address co-occurring physical and behavioral health conditions are needed.

BACKGROUND: Living alone has been associated with cognitive impairment; however, findings have been inconsistent. Social isolation among older adults who live alone may contribute to cognitive impairment. This study was carried out to examine the association of social isolation and living alone with cognitive impairment in community-dwelling older adults. METHODS: In this cross-sectional study, data from the Integrated Research Initiative for Living Well with Dementia Cohort Study, which comprises pooled data from five community-based geriatric cohorts, was used. Social isolation was defined as infrequent interactions with others. Participants were categorized into four groups based on their social isolation and living alone statuses. Cognitive function was assessed using the Mini-Mental State Examination, with a score <24 indicating cognitive impairment. The association between social isolation combined with living alone and cognitive impairment was analyzed using logistic regression. RESULTS: Of the 4362 participants included in the analysis (mean age 75.6 years, 44.3 % male), 11 % had cognitive impairment. Regardless of living alone, social isolation was associated with cognitive impairment (no social isolation x not living alone: reference, social isolation x not living alone; odds ratio (OR): 1.74, 95 % confidence interval (CI): 1.29-2.33, social isolation x living alone; OR: 2.10, 95 % CI: 1.46-3.01). CONCLUSIONS: Social isolation is associated with cognitive impairment; however, living alone is not intrinsically associated with cognitive impairment in older adults. Healthcare providers must focus on social interactions to prevent cognitive impairment in older adults rather than simply focusing on living arrangements.

IMPORTANCE: Women veterans increasingly seek care yet continue to face barriers in the Veterans Health Administration (VA), which predominantly cares for men. Evidence-based collaborative care models can improve patient access to treatment of depression, which is experienced at higher rates by women. While the VA has implemented these care models nationally, it is not known whether access improvements occur equitably across genders in primary care. OBJECTIVE: To examine whether the VA's national Primary Care-Mental Health Integration (PC-MHI) initiative (beginning 2007) expanded realized access to mental health care similarly for men and women. DESIGN, SETTING, AND PARTICIPANTS: This cohort study included 5 377 093 million primary care patients assigned to 396 VA clinics that provided integrated mental health services nationally between October 2013 and September 2016. Data analysis occurred between May 2017 and July 2020. EXPOSURES: Clinic PC-MHI penetration, calculated as the proportion of clinic patients who saw an integrated specialist per fiscal year. MAIN OUTCOMES AND MEASURES: Estimates of mean VA health care utilization (mental health, primary care, other specialty care, telephone, hospitalizations) and median total costs for men and women. Multilevel models adjusted for year, clinic, patient characteristics, and interactions between patient-defined gender and clinic PC-MHI penetration. RESULTS: This study examined 5 377 093 veterans (448 455 [8.3%] women; 3 744 140 [69.6%] White) with a mean (SD) baseline age 62.0 (16.6) years. Each percentage-point increase in the proportion of clinic patients who saw an integrated specialist was associated with 38% fewer mental health visits per year for women (incidence rate ratio [IRR], 0.62; 95% CI, 0.60-0.65), but 39% more visits for men (IRR, 1.39; 95% CI, 1.34-1.44; P < .001). Both men and women had more primary care visits (men: IRR, 1.40; 95% CI, 1.36-1.45; women: IRR, 1.22; 95% CI, 1.17-1.28; P < .001) and total costs (men: β [SE], 2.23 [0.10]; women: β [SE], 1.24 [0.15]; P = .06), but women had 74% fewer hospitalizations than men related to clinics with mental health integration (IRR, 0.26; 95% CI, 0.19-0.36 vs IRR, 1.02; 95% CI, 0.83-1.24; P < .001). CONCLUSIONS AND RELEVANCE: While greater outpatient service use for men was observed in this study, PC-MHI was associated with a decrease in mental health specialty visits (and hospitalizations) for women veterans, potentially signifying a shift of services to primary care. With increasing patient choice for where veterans receive care, the VA must tailor medical care to the needs of rising numbers of women patients. Differences in health care utilization by gender highlight the importance of anticipating policy impacts on and tailoring services for patients in the numerical minority in the VA and other health systems.

Evidence describing the association between sleep quality and trauma-focused therapy is mixed. This secondary analysis of a primary care sample examined whether (a) baseline sleep quality moderated posttraumatic stress disorder (PTSD) symptom severity over time across groups receiving different doses of cognitive processing therapy (CPT) and (b) sleep quality improved over time with CPT. Participants were 227 adults who screened positive for PTSD and were participating in a clinical trial comparing two models of PTSD treatment delivery in primary care. The Pittsburgh Sleep Quality Index (PSQI) and PTSD Checklist for DSM-5 (PCL-5) were used to assess sleep disturbance and PTSD symptom severity, respectively. Multiple linear regression was used to assess whether baseline PSQI scores moderated 12-month PCL-5 scores across CPT dosage groups (0 sessions: 51.1%, 1-7 sessions: 31.7%; ≥ 8 sessions [adequate dose]: 17.2%) and whether PSQI scores differed by group at 12-month follow-up. Post hoc analyses examined changes in PCL-5 sleep disturbance items. Baseline sleep disturbance did not moderate the effect of CPT on PTSD severity among participants with an adequate CPT dose, p > .112. Sleep quality improved with adequate dose, B  = -2.63, SE = 0.75, p < .001. Differences in change scores across groups for PCL-5 Item 2, F(2, 435) = 11.34, and Item 20, H(2) = 32.04, indicated that participants with an adequate CPT dose had greater reductions in trauma-related sleep symptoms than those who received 0-7 sessions, ps < .001. Residual post-CPT sleep impairment despite adequate PTSD improvement warrants further interventions.

INTRODUCTION: This study examines associations between a young adult's visit to a designated primary care physician (PCP) in the 18 months after transitioning from pediatrics and their completion of preventive healthcare screenings. The period from 18 to 25 years is marked by transition and continued brain development, making it an ideal period for impactful intervention on healthy behaviors and outcomes. METHODS: Completion of screening for alcohol use, mental health issues, exercise habits, and tobacco use was measured in members upon turning 18 during 2020-2021. These members had transitioned from pediatrics to adult medicine at an integrated healthcare system at Kaiser Permanente Northern California. Associations of sex, race and ethnicity, need of interpreter, insurance type, neighborhood deprivation, pediatric PCP visit, and chronic conditions were compared for members with or without a visit with their new PCP during the 18 months of transition. RESULTS: A multivariate model showed that young adults with a visit to their PCP had increased likelihood of completion of screening: 21% for alcohol use, 12% for mental health issues, 18% for exercise, and 16% for tobacco use. Several characteristics were associated with a reduced likelihood of a visit with a PCP: 15% reduced likelihood for residence in more deprived neighborhoods (incidence rate ratio=0.85, 95% CI=0.82, 0.88); between a 6% and 3% reduced likelihood for individuals who were Asian, Black or Hispanic (incidence rate ratio=0.96, 95% CI=0.93, 0.99), (incidence rate ratio=0.94, 95% CI=0.90, 0.98), (incidence rate ratio=0.97, 95% CI=0.94, 0.99) respectively; 55% reduced likelihood for those requiring an interpreter (incidence rate ratio=0.45, 95% CI=0.37, 0.53); and 16% reduced likelihood for males (incidence rate ratio=0.84, 95% CI=0.82, 0.86). Individuals who had a visit to their pediatric PCP, and individuals with chronic conditions, were 20% and 29% more likely, respectively, to have had a visit with their adult PCP (incidence rate ratio=1.20, 95% CI=1.18, 1.23) and (incidence rate ratio=1.29, 95% CI=1.27, 1.32). CONCLUSION: Promotion of PCP visits and outreach to individuals with a reduced likelihood of visiting their PCP during this transition could provide opportunities for preventive health interventions among young adults.

INTRODUCTION: Integrated Behavioral Health (IBH) clinics in primary care offer cost-effective options for receiving mental health (MH) support for Black patients. By tracking specific aspects of social determinants of health (SDOH), more commonly assessed in primary care, IBH programs can provide helpful insights to both MH and primary care providers. METHODS: This retrospective study examined the impact of IBH care delivery on MH and social needs variables in a Black adult patient population. MH outcomes were assessed using the PHQ9 and GAD7, with a positive score being greater than 5. RESULTS: There were N = 119 Black patients included in analysis. The sample was 83% female and the average age at first visit was 41. There was a significant reduction in both GAD7 (change = -1.8, P < .001) and PHQ9 (change = -2.3, P < .001) scores for patients receiving IBH services. There were no significant differences between those who had a SDOH screen and having an initial elevated GAD7/PHQ9 score. CONCLUSION: More culturally inclusive research on the impact of IBH implementation where Black patients receive their primary care is needed to maximize treatment possibilities among this group.

BACKGROUND: Behavioral health services (BHS) can help improve and treat mental and emotional health problems. Yet, attitudinal and/or structural barriers often prevent individuals from accessing and benefiting from these services. Positive provider-patient interactions in healthcare, encompassing patient comfort with a primary care provider (PCP), which is often enhanced by shared decision-making, may mitigate the stigma associated with seeing a mental health professional; this may improve BHS utilization among patients who need these services. However, few studies have examined how patient comfort with a PCP, often through shared decision-making, may influence patients' BHS utilization in the real world. This study sought to address this gap in practice. METHOD: Multivariable regression analyses, using weighted data from an internet panel survey of Los Angeles County adults (n = 749), were carried out to examine the associations between patient comfort with a PCP and three measures of BHS utilization. Subsequent analyses were conducted to explore the extent to which shared decision-making moderated these associations. RESULTS: Participants who reported an intermediate or high comfort level with a provider had higher odds of reporting that they were likely to see (aOR = 2.10 and 3.84, respectively) and get advice (aOR = 2.75 and 4.76, respectively) from a mental health professional compared to participants who reported a low comfort level. Although shared decision-making influenced participants' likelihood of seeing and getting advice from a mental health professional, it was not a statistically significant moderator in these associations. CONCLUSION: Building stronger relationships with patients may improve BHS utilization, a provider practice that is likely underutilized.

OBJECTIVE: To investigate associations between the percentage and severity of mental disorders (MD) and three different primary health care (PHC) strategies in Brazil: traditional care (TC), the Family Health Strategy (FHS), and FHS with shared mental health care (FHS+SC). METHODS: Random samples were selected from three different areas of a Brazilian city. Each area was served by a different PHC strategy (TC, FHS, or FHS+SC). Five mental health professionals, blinded to the type of PHC strategy delivered in each area, conducted interviews using the Mini International Neuropsychiatric Interview (MINI) and other specific instruments to assess the prevalence and severity of MD. RESULTS: 530 subjects were interviewed. The TC strategy was significantly associated with a higher percentage of MD when compared to FHS and FHS+SC. These results were not affected by adjustment for sociodemographic variables. The difference in prevalence of MD between the two FHS areas (with and without SC) was not statistically significant. No significant differences in MD severity were observed across the three PHC strategies. CONCLUSION: Areas covered by FHS showed a lower percentage of MD than those covered by TC. Presence of SC did not influence the prevalence of MD, suggesting that mental-health training of FHS teams may have minimized the influence of SC.