Literature Collection

BACKGROUND: Individuals with serious mental illness (SMI) die significantly earlier and experience disproportionately higher rates of physical health issues compared with non-SMI groups. Despite advances in care, this mortality gap persists. One factor that contributes to this discrepancy is inadequate access to healthcare, as individuals with SMI are less likely to receive appropriate medical care. METHODS: To better understand this, we completed a narrative review synthesizing existing literature on common barriers to care faced by the SMI community. We reviewed 34 articles and identified three primary barriers to receiving healthcare. RESULTS: These included structural and logistical barriers (geographic location, access to technology and internet, disjointed medical and mental healthcare); intrapersonal- and patient-level barriers (symptoms and psychological impact of SMI, lack of awareness or prioritization of medical issues, medical mistrust, and limited health literacy); and provider- and system-level barriers (lack of knowledge or support for integrated care, lack of knowledge of SMI, stigma, and diagnostic overshadowing). CONCLUSIONS: We argue that addressing these issues requires a reorientation toward person-centered approaches that prioritize continuity, integration, and dignity in care for individuals with SMI, and we offer specific recommendations in service of these aims.

BACKGROUND: Nearly 9 out of 10 youth who die by suicide visit health care settings in the year prior to their death. Given the opportunity of primary care to screen for youth suicide risk, past research has focused on understanding provider attitudes toward screening and barriers to screening implementation. However, research has not robustly examined how providers utilize information gathered from screening tools. Therefore, the aim of this qualitative study was to outline existing suicide protocols and characterize attitudes and practices toward youth suicide risk screening and subsequent triage. METHODS: Youth-serving primary care providers and clinic staff working at clinics in one Midwest health network participating in a randomized control trial implementing integrated behavioral health care were contacted via email by a research assistant. Nineteen individuals participated in 30-minute, semi-structured interviews regarding attitudes and practices toward youth suicide risk screening in primary care. Interviews were transcribed and analyzed using consensus deductive and inductive coding. RESULTS: Existing clinic workflow largely pertained to screening administration. Participants discussed the intention to universally screen pediatric patients using the Patient Health Questionnaire (PHQ)-2 for sick visits, which served as gate questions for the PHQ-9. For well child visits, clinics implemented universal PHQ-9 screeners. Participants were largely not aware of standardized processes, including brief suicide risk assessment, use of consultation services, or risk triage decision-making. Interviews described themes of attitudes toward youth suicide screening, primary care protocols, risk triage decision-making, and barriers and facilitators to youth suicide risk screening. Overall, providers and clinic staff expressed overwhelming confidence in administering screens, which was considered within their scope of practice. Confidence, however, wavered when providers discussed their ability and/or comfort determining follow-up steps, providing brief interventions, and connecting youth to behavioral health services. CONCLUSIONS: Results emphasize that without adequate behavioral health assessment and intervention post-screening, primary care providers face significant burden managing suicide risk, which was often felt outside their scope of practice. Developing and adapting intervention models within primary care (e.g., integrated care models) are crucial next steps.

BACKGROUND: Co-prescribing benzodiazepines to patients in opiate substitution treatment is controversial and often alleged to increase mortality. In an inner-London general practice, patients with problematic benzodiazepine co-dependence were allowed benzodiazepine maintenance treatment (BMT) since 1994, providing an opportunity for analysis. METHOD: 1) Case-note review of all 278 opiate substitution treatment patients, accruing 1289 patient treatment years; 46% had concurrent BMT. 2) National Health Service database search for patients who died after leaving accrued a further 883 years of information; only patients who left the UK were unaccounted for (4%). Three groups were studied: 1) never obtained benzodiazepine prescription (NOB): n=80); 2) briefly/occasionally prescribed benzodiazepines (BOP): n=71; 3) BMT: n=127. OUTCOMES MEASURED: Treatment retention (months); deaths/100 patient treatment years; deaths after leaving the service/100 years of information. RESULTS: Treatment retention: NOB: 34 months; BOP: 51 months; BMT: 72 months. In-treatment mortality: NOB: 1.79/100 patient treatment years; BOP: 0.33/100 patient treatment years; BMT: 1.31/100 patient treatment years. Deaths after leaving service: NOB: 2.24/100 years of information, BOP: 0.63/100 years of information. However, mortality for previously BMT-patients increased by 450% to 5.90/100 years of information. DISCUSSION: BMT patients had longer treatment retention than NOB or BOP and lower mortality than NOB patients. It is unlikely that patients had access to prescribed benzodiazepines on leaving the service because of restrictions in the national guidelines but co-dependent patients are a high-risk group who may stand to gain most benefit from opiate substitution treatment if combined with benzodiazepine-maintenance.