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Objectives: Previous research has documented a stigma associated with mental health problems that interferes with the decision to seek treatment. This study assesses the feasibility of an intervention designed to increase treatment initiation among veterans reporting mental health problems.Methods: Participants were 27 Operation Iraqi Freedom National Guard soldiers who screened positive for 1 of the following disorders as assessed by the Mini International Neuropsychiatric Interview: depression, posttraumatic stress disorder, generalized anxiety disorder, panic disorder and/or at-risk drinking. An intervention was administered using a cognitive-behavioral model to modify beliefs that may interfere with treatment-seeking behavior. Beliefs and treatment-seeking behavior were assessed post-intervention.Results: Participants were significantly more likely to report that they intended to seek mental health treatment post-intervention (p < 0.012), suggesting that a cognitive-behavioral model focusing on modifying treatment-interfering beliefs holds promise for increasing mental health treatment-seeking among returning Veterans in need.Conclusions: Given the high rates of mental health symptoms post-deployment and the low likelihood of treatment-seeking among Veterans, interventions designed to increase treatment-initiation such as those explored in this article are critically needed. [ABSTRACT FROM AUTHOR]

OBJECTIVE: This study assessed beliefs about mental health treatment in a group of soldiers newly returning from the war in Iraq. METHODS: Participants were 20 National Guard soldiers who had served in Operation Iraqi Freedom. Soldiers who in phone interviews screened positive for a mental disorder were asked about advantages and disadvantages of seeking treatment, who would or would not support treatment seeking, and facilitators and barriers to treatment seeking. RESULTS: Stigma was portrayed as a major disadvantage to treatment seeking. Yet most participants indicated that people would be supportive of treatment seeking. Reducing symptoms was a major advantage of care. Barriers, especially those viewed as 'self-induced,' such as pride, not being able to ask for help, and not being able to admit to having a problem, were considered major impediments. CONCLUSIONS: The findings suggest that interventions developed to engage veterans in care must be directed toward cognitive factors that motivate treatment seeking. [ABSTRACT FROM AUTHOR]

Objective: This study examined the impact of comorbid anxiety disorders-posttraumatic stress disorder (PTSD), generalized anxiety disorder, and panic disorder-on health-related quality of life among primary care patients enrolled in a collaborative care depression intervention study for the Department of Veterans Affairs (VA).Methods: Baseline data were used from 324 participants in the Telemedicine Enhanced Antidepressant Management (TEAM) Study, a multisite randomized effectiveness trial targeting VA primary care patients with depression. Health-related quality of life was measured by using the Quality of Well-Being Scale, self-administered version (QWB-SA) and the mental component summary (MCS-12V) and physical component summary (PCS-12V) of the 12-item Short Form Health Survey for Veterans (SF-12V).Results: A majority of participants (69 percent) had at least one anxiety disorder. Generalized anxiety disorder and PTSD predicted scores on the QWB-SA. PTSD predicted scores on the PCS-12V, but none of the comorbid anxiety disorders predicted scores on the MCS-12V. In addition, social support, depression severity, and the number of chronic medical conditions significantly predicted QWB-SA scores; the number of self-reported chronic physical health conditions and the number of depression episodes significantly predicted PCS-12V scores; and social support and depression severity significantly predicted MCS-12V scores.Conclusions: According to scores on the QWB-SA, generalized anxiety disorder and PTSD comorbid with major depressive disorder impair health-related quality of life above and beyond major depressive disorder alone. [ABSTRACT FROM AUTHOR]

BACKGROUND: To reduce travel burdens, patients may coordinate outpatient services to receive multiple encounters during a single day. Unmeasured visit 'chaining' may bias estimates of the impact of accessibility barriers when utilization volume is measured using visit days. No studies have evaluated differential encounter chaining by distance. OBJECTIVES: We sought to evaluate the prevalence and predictors of visit chaining among patients with serious mental illnesses (SMIs), to evaluate whether patients living farther from providers are more likely to chain encounters, and to assess distance barriers using alternative measures of utilization volume. DATA SOURCES: We used the Veterans Affairs (VA) National Psychosis Registry, including Fiscal Year 2000 diagnosis and utilization data for 141,275 VA patients with SMI diagnoses. STUDY DESIGN: Random intercepts hierarchical regression to examine the relationship between distance to nearest VA provider and encounters/visit day, adjusting for age, gender, race/ethnicity, marital status, service-connection, previous hospitalization, and treatment setting and comorbidities at initial use. Negative binomial regressions to evaluate distance effects on visit day and encounter volume. Analyses adjusted for patient clustering within facilities. PRINCIPAL FINDINGS: With increased distance, patients had more encounters/visit day. Patients with bipolar disorder were more likely than patients with schizophrenia or other psychoses to chain treatments in association with greater distances. CONCLUSIONS: When utilization volume is measured in terms of visit days, analyses may overestimate distance barriers, because remote patients are more likely to chain encounters within visit days. However, distance remains a substantial barrier limiting total outpatient visit volume. Enhanced services coordination may reduce accessibility barriers for remote patients. [ABSTRACT FROM AUTHOR]

This cross-sectional study examines sociodemographic, clinical and func tional correlates of comorbid depression in a community sample of 268 individuals with alcohol dependence. Results of analyses comparing drinkers with either current or past depression to never-depressed drinkers showed that respondents in the former two groups were more likely to be female and report more comorbid drug use disorders. In addition to marked functional impairment for currently depressed drinkers, we also found that respondents with past depression were significantly less likely to have health insurance coverage. This lack of insurance for previously depressed persons calls for future work examining the potential influence of this barrier to access care on both clinical and functional outcomes. [ABSTRACT FROM AUTHOR]

Background: The gold-standard treatment for opioid use disorder (OUD) is medication for OUD (MOUD). However, less than a quarter of people with OUD initiate MOUD. Expanding the Collaborative Care Model (CoCM) to include primary care patients with OUD could improve access to and initiation of MOUD. This paper presents the methods and baseline sample characteristics of a Hybrid Type 2a trial comparing the effectiveness of CoCM for OUD and co-occurring mental health symptoms (MHS) to CoCM for MHS only., Method: 42 primary care clinics were cluster randomized and 254 primary care patients with OUD and elevated MHS were enrolled. Recruitment was terminated early by the Data and Safety Monitoring Board for futility. Participants completed research assessments at baseline, 3 months, and 6 months. The multiple primary outcomes were past-month number of days of nonmedical opioid use and SF12 Mental Health Component Summary (MCS) scores., Results: MCS scores were over a standard deviation below the national mean (M = 34.5). Nearly half (47.6 %) of participants had previously overdosed in their lifetimes. Three quarters (76.0 %) were already being prescribed MOUD at baseline, only 30.4 % reported non-medical use of opioids, and only 33.9 % reported being bothered by opioid cravings., Conclusion: The unexpectedly high proportion of enrollees already prescribed MOUD at baseline indicates that most patients were in the maintenance rather than acute phase of treatment. Challenges identifying and enrolling patients in the acute phase of OUD treatment implies that intervention effectiveness will depend on its success preventing the discontinuation of MOUD rather than initiating MOUD., Competing Interests: Declaration of competing interest The authors do not have any personal, professional, or financial conflicts of interest to disclose for this work. Dr. Saxon has received travel support from Alkermes, Inc., consulting fees from Indivior, Inc., and royalties from UpToDate, Inc. Dr. Ratzliff receives royalties from Wiley for her book on integrated care., (Published by Elsevier Inc.)

Introduction: Engagement is a critical component of successful treatment for opioid use disorder (OUD). However, rates of patient engagement in OUD treatment, especially in outpatient settings, are variable and often low. Little is known about the specific strategies members of primary care teams use to initiate and encourage ongoing participation in OUD treatment. In a national cohort of primary care clinics in the U.S., we explored the perspectives of primary care team members on the meaning of and approaches to OUD treatment engagement., Methods: We conducted semi-structured interviews with 35 providers from multidisciplinary primary care teams in an existing national cohort of 13 clinics across seven states. Teams were delivering OUD treatment via the Collaborative Care Model, a model that combines primary care providers (PCP), behavioral health care managers (BHCM) and consulting psychiatric providers (CPP) in a structured way to provide patient-centered, team-based, and measurement-based care. Interview participants included 14 PCPs, 13 BHCMs, and 8 CPPs. Interviews asked open-ended questions about provider experiences and practices that aided or hindered patient engagement in OUD treatment. Interview transcripts were double-coded by trained qualitative researchers and analyzed using a combination of deductive and inductive approaches to identify themes., Results: Two themes emerged that describe provider perspectives on the meaning of engagement: 1) qualifying engagement by the volume of contact with patients, and 2) the need for more multidimensional measures of engagement. Six themes emerged that characterized provider engagement practices: 1) creating an environment of disclosure, 2) normalizing OUD treatment, 3) offering gentle but persistent outreach, 4) providing human connection and encouragement, 5) tailoring treatment to patient needs, and 6) avoiding stigmatizing responses. Analysis identified multiple replicable strategies that providers used to support these engagement practices., Conclusions: Providers consistently apply a range of strategies when trying to engage patients in OUD treatment. Specific engagement strategies used embodied compassion and pragmatism, hallmarks of patient-centered care. Further research is needed to understand the impact of scaling engagement approaches across all care settings., Competing Interests: Declaration of competing interest The authors do not have any personal, professional, or financial conflicts of interest to disclose for this work. The authors did not work with or were otherwise influenced by any external sponsors for this work. Dr. Saxon has received travel support from Alkermes, Inc., consulting fees from Indivior, Inc., and royalties from UpToDate, Inc. Anna Ratzliff, MD, PhD receives royalties from Wiley for her book on integrated care., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background: There have only been two efficacy trials reporting a head-to-head comparison of medications and psychotherapy for PTSD, and neither was conducted in primary care. Therefore, this protocol paper describes a pragmatic trial that compares outcomes of primary care patients randomized to initially receive a brief trauma-focused psychotherapy or a choice of three antidepressants. In addition, because there are few trials examining the effectiveness of subsequent treatments for patients not responding to the initial treatment, this pragmatic trial also compares the outcomes of those switching or augmenting treatments., Method: Patients screening positive for PTSD (n = 700) were recruited from the primary care clinics of 7 Federally Qualified Health Centers (FQHC) and 8 Department of Veterans Affairs (VA) Medical Centers and randomized in the ratio 1:1:2 to one of three treatment sequences: 1) selective serotonin reuptake inhibitor (SSRI) followed by augmentation with Written Exposure Therapy (WET), 2) SSRI followed by a switch to serotonin-norepinephrine reuptake inhibitor (SNRI), or 3) WET followed by a switch to SSRI. Participants complete surveys at baseline, 4 months, and 8 months. The primary outcome is PTSD symptom severity as measured by the PTSD Checklist (PCL-5)., Results: Average PCL-5 scores (M = 52.8, SD = 11.1) indicated considerable severity. The most common bothersome traumatic event for VA enrollees was combat (47.8%), and for FQHC enrollees was other (28.2%), followed by sexual assault (23.4%), and child abuse (19.8%). Only 22.4% were taking an antidepressant at baseline., Conclusion: Results will help healthcare systems and clinicians make decisions about which treatments to offer to patients., Competing Interests: Declaration of competing interest The authors do not have any personal, professional, or financial conflicts of interest to disclose for this work., (Published by Elsevier Inc.)

Measurement-based care (MBC) comprises collecting patient-reported outcomes data using validated assessments and using that information to support treatment. The Veterans Health Administration (VHA) has developed technology platforms to support MBC, including the Mental Health Checkup (MHC) mobile health application (app). Our objective was to examine VHA mental health provider perspectives on the MHC app. We completed a mixed-methods, sequential explanatory evaluation of MHC. We surveyed 284 VHA mental health providers who used MHC, then conducted semistructured telephone interviews with a purposefully selected subset of survey respondents ( n = 20). Approximately half of survey respondents agreed that MHC allowed them to collect assessment data from veterans more frequently than before (51%) and that they more frequently discussed assessment results with veterans because of MHC (50%) and used those results to inform goal-setting discussions (50%) and treatment decision making (51%). Bivariate analyses indicated a positive relationship between frequency of MHC use and the aforementioned impacts on care. Interview data conveyed both advantages (e.g., increased treatment efficiency, improved treatment decision making) and challenges (e.g., limited assessment availability, difficulties engaging veterans in completing assessments through the app) to using MHC. This evaluation demonstrated how MHC supported providers working to implement MBC. The app enhanced their ability to reach and engage veterans and incorporate assessment data into clinical encounters. Still, many did not perceive that MHC was impactful on mental health care delivery; given that providers who used MHC more frequently reported more positive impressions of MHC, this may be related to how frequently they used the app. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Background: There is a growing interest in practice-based implementation research, yet too often research prioritizes and is most successful in academic settings. During a national implementation trial to evaluate the effectiveness of Collaborative Care for co-occurring opioid use and mental health disorders, we lost three of our 11 participating implementation sites, all representing community sites., Method: To better understand needed supports for implementation trial participation, we conducted exit interviews ( n  = 5) with key staff at these community sites. Interview transcripts were double-coded and analyzed using Rapid Assessment Process. Qualitative themes were iteratively reviewed by the study team., Results: Three themes emerged characterizing challenges for community sites, including that: (1) research threatens sites' most precious resource-staff; (2) staff lack comfort with and skills for research; and (3) research participation in its current form does not offer a clear return on investment., Conclusions: Learnings from this work illuminate some of the barriers community sites face when trying to participate in multisite implementation research. An undercurrent of participant perspectives was the belief that community sites like theirs are just not set up to successfully participate in clinical trial research, including population-based implementation trials. Future implementation trials should consider strategies that disrupt traditional approaches, increasing the equitable inclusion of diverse practice settings in implementation research., Competing Interests: The authors declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: The authors do not have any personal, professional, or financial conflicts of interest to disclose for this work. The authors did not work with or were otherwise influenced by any external sponsors for this work. Andrew J. Saxon has received travel support from Alkermes, Inc., consulting fees from Indivior, Inc., and royalties from UpToDate, Inc. Anna D. Ratzliff, MD, PhD, receives royalties from Wiley for her book on integrated care., (© The Author(s) 2024.)

Background: Opioid use disorder (OUD) care engagement rates in primary care (PC) settings are often low. Little is known about PC team experiences when delivering OUD treatment and potential factors that influence their capacity to engage patients in treatment. Exploring PC team experiences may inform needed supports that can optimize OUD care delivery and improve outcomes for patients with OUD., Objective: We explored multidisciplinary PC team perspectives on barriers and facilitators to engaging patients in OUD treatment., Design: Qualitative study using in-depth interviews., Participants: Primary care clinical teams., Approach: We conducted semi-structured interviews (n = 35) with PC team members involved in OUD care delivery, recruited using a combination of criterion and maximal variation sampling. Data collection and analysis were informed by existing theoretical literature about patient engagement, specifically that patient engagement is influenced by factors across individual (patient, provider), interpersonal (patient-provider), and health system domains. Interviews were professionally transcribed and doubled-coded using a coding schema based on the interview guide while allowing for emergent codes. Coding was iteratively reviewed using a constant comparison approach to identify themes and verified with participants and the full study team., Key Results: Analysis identified five themes that impact PC team ability to engage patients effectively, including limited patient contact (e.g., phone, text) in between visits, varying levels of provider confidence to navigate OUD treatment discussions, structural factors (e.g., schedules, productivity goals) that limited provider time, the role of team-based approaches in lessening discouragement and feelings of burnout, and lack of shared organizational vision for reducing harms from OUD., Conclusions: While the capacity of PC teams to engage patients in OUD care is influenced across multiple levels, some of the most promising opportunities may involve addressing system-level factors that limit PC team time and collaboration and promoting organizational alignment on goals for OUD treatment., (© 2024. The Author(s), under exclusive licence to Society of General Internal Medicine.)

Pragmatism in clinical trials is focused on increasing the generalizability of research findings for routine clinical care settings. Hybridism in clinical trials (i.e., assessing both clinical effectiveness and implementation success) is focused on speeding up the process by which evidence-based practices are developed and adopted into routine clinical care. Even though pragmatic trial methodologies and implementation science evolved from very different disciplines, Pragmatic Trials and Hybrid Effectiveness-Implementation Trials share many similar design features. In fact, these types of trials can easily be conflated, creating the potential for investigators to mislabel their trial type or mistakenly use the wrong trial type to answer their research question. Blurred boundaries between trial types can hamper the evaluation of grant applications, the scientific interpretation of findings, and policy-making. Acknowledging that most trials are not pure Pragmatic Trials nor pure Hybrid Effectiveness-Implementation Trials, there are key differences in these trial types and they answer very different research questions. The purpose of this paper is to clarify the similarities and differences of these trial types for funders, researchers, and policy-makers. In addition, recommendations are offered to help investigators choose, label, and operationalize the most appropriate trial type to answer their research question. These recommendations complement existing reporting guidelines for clinical effectiveness trials (TIDieR) and implementation trials (StaRI)., (© 2024. This is a U.S. Government work and not under copyright protection in the US; foreign copyright protection may apply.)

Purpose: Social support is a treatment target for individuals with post-traumatic stress disorder (PTSD) but is not systematically assessed in clinical care. This review evaluated the quality of patient-reported social support instruments used in PTSD research to identify candidates for measurement-based care (MBC) with this population., Method: A systematic review identified all validated measures of social support used in research with traumatized populations after 1990. Instrument development/validation studies were then evaluated using components of the updated COSMIN guidelines. Instruments were rated for clinical utility and evidence of their psychometric properties in use with traumatized individuals was synthesized., Results: Twenty-nine instruments were identified across 231 studies. Evaluation of development articles found 14 instruments with sufficient evidence of content validity and internal consistency reliability that could be considered for clinical use. Of these, nine had comparable properties in traumatized samples and could be preliminarily included in MBC of social support in the treatment of PTSD. Additional studies on measures' responsiveness and test-retest reliability are needed., Conclusions: Existing measures of social support could improve clinical care of PTSD when used routinely to provide feedback on this critical component of health. MBC of social support may also improve clinical care of other psychiatric conditions., Competing Interests: This work was supported by a grant from United States Department of Veterans Affairs, Health Services Research and Development (CDA 19-208) to SBC. The authors have no relevant financial or non-financial interests to disclose.

Over 80% of adults in the general population experience trauma. Rates of patients with posttraumatic stress disorder (PTSD) are high in primary care settings and are likely to be even higher in federally qualified health centers (FQHCs). Trauma exposure has been linked to psychiatric symptoms and physical health comorbidities, though little research has focused on FQHC patients. This study addresses this by examining clinical and sociodemographic correlates of specific trauma types among FQHC patients. We analyzed secondary data from patients who screened positive for PTSD and were receiving health care in FQHCs in a clinical trial (N = 978). Individuals who did versus did not experience a specific trauma type were compared using between-group tests. In the sample, 91.3% of participants were exposed to a DSM-5 Criterion A traumatic event, with 79.6% experiencing two or more trauma types. Witnessing a life-threatening event (57.3%) and physical assault (55.7%) were the most common traumatic experiences. Physical health comorbidities and worse physical health functioning were associated with a higher likelihood of exposure to all trauma types, with effect sizes larger than PTSD, ds = 0.78-1.35. Depressive and anxiety symptoms were also associated with a higher likelihood of experiencing nearly all trauma types to a lesser magnitude. People of color, OR = 2.45, and individuals experiencing financial inequities, OR = 1.73, had higher odds of experiencing serious accidents as well as other trauma types. The findings highlight the need for trauma-informed care, including routine trauma and PTSD screening, for FQHC patients., (© 2024 International Society for Traumatic Stress Studies.)

Background: Mental health conditions are highly prevalent among US veterans. The Veterans Health Administration (VHA) is committed to enhancing mental health care through the integration of measurement-based care (MBC) practices, guided by its Collect-Share-Act model. Incorporating the use of remote mobile apps may further support the implementation of MBC for mental health care., Objective: This study aims to evaluate veteran experiences with Mental Health Checkup (MHC), a VHA mobile app to support remote MBC for mental health., Methods: Our mixed methods sequential explanatory evaluation encompassed mailed surveys with veterans who used MHC and follow-up semistructured interviews with a subset of survey respondents. We analyzed survey data using descriptive statistics. We then compared responses between veterans who indicated having used MHC for ≥3 versus <3 months using χ 2 tests. We analyzed interview data using thematic analysis., Results: We received 533 surveys (533/2631, for a 20% response rate) and completed 20 interviews. Findings from these data supported one another and highlighted 4 key themes. (1) The MHC app had positive impacts on care processes for veterans: a majority of MHC users overall, and a greater proportion who had used MHC for ≥3 months (versus <3 months), agreed or strongly agreed that using MHC helped them be more engaged in their health and health care (169/262, 65%), make decisions about their treatment (157/262, 60%), and set goals related to their health and health care (156/262, 60%). Similarly, interviewees described that visualizing progress through graphs of their assessment data over time motivated them to continue therapy and increased self-awareness. (2) A majority of respondents overall, and a greater proportion who had used MHC for ≥3 months (versus <3 months), agreed/strongly agreed that using MHC enhanced their communication (112/164, 68% versus 51/98, 52%; P=.009) and rapport (95/164, 58% versus 42/98, 43%; P=.02) with their VHA providers. Likewise, interviewees described how MHC helped focus therapy time and facilitated trust. (3) However, veterans also endorsed some challenges using MHC. Among respondents overall, these included difficulty understanding graphs of their assessment data (102/245, 42%), not receiving enough training on the app (73/259, 28%), and not being able to change responses to assessment questions (72/256, 28%). (4) Interviewees offered suggestions for improving the app (eg, facilitating ease of log-in, offering additional reminder features) and for increasing adoption (eg, marketing the app and its potential advantages for veterans receiving mental health care)., Conclusions: Although experiences with the MHC app varied, veterans were positive overall about its use. Veterans described associations between the use of MHC and engagement in their own care, self-management, and interactions with their VHA mental health providers. Findings support the potential of MHC as a technology capable of supporting the VHA's Collect-Share-Act model of MBC., (©Robin T Higashi, Bella Etingen, Eric Richardson, Jennifer Palmer, Mark S Zocchi, Felicia R Bixler, Bridget Smith, Nicholas McMahon, Kathleen L Frisbee, John C Fortney, Carolyn Turvey, Jennifer Evans, Timothy P Hogan. Originally published in JMIR Mental Health (https://mental.jmir.org), 10.05.2024.)

Rationale: Cognitive and emotional responses associated with care seeking for chronic obstructive pulmonary disease (COPD) exacerbations are not well understood. Objectives: We sought to define care-seeking profiles based on whether and when U.S. veterans seek care for COPD exacerbations and compare cognitive and emotional responses with exacerbation symptoms across the profiles. Methods: This study analyzes data from a 1-year prospective observational cohort study of individuals with COPD. Cognitive and emotional responses to worsening symptoms were measured with the Response to Symptoms Questionnaire, adapted for COPD. Seeking care was defined as contacting or visiting a healthcare provider or going to the emergency department. Participants were categorized into four care-seeking profiles based on the greatest delay in care seeking for exacerbations when care was sought: 0-3 days (early), 4-7 days (short delay), >7 days (long delay), or never sought care for any exacerbation. The proportion of exacerbations for which participants reported cognitive and emotional responses was estimated for each care-seeking profile, stratified by the timing of when care was sought. Results: There were 1,052 exacerbations among 350 participants with Response to Symptoms Questionnaire responses. Participants were predominantly male (96%), and the mean age was 69.3 ± 7.2 years. For the 409 (39%) exacerbations for which care was sought, the median delay was 3 days. Those who sought care had significantly more severe COPD (forced expiratory volume in 1 s, modified Medical Research Council dyspnea scale) than those who never sought care. Regardless of the degree of delay until seeking care at one exacerbation, participants consistently reported experiencing serious symptoms if they sought care compared with events for which participants did not seek care (e.g., among early care seekers when care was sought, 36%; when care was not sought, 25%). Similar findings were seen in participants' assessment of the importance of getting care (e.g., among early care seekers when care was sought, 90%; when care was not sought, 52%) and their assessment of anxiety about the symptoms (e.g., among early care seekers when care was sought, 33%; when care was not sought, 17%). Conclusions: Delaying or not seeking care for COPD exacerbations was common. Regardless of care-seeking profile, cognitive and emotional responses to symptoms when care was sought differed from responses when care was not sought. Emotional and cognitive response to COPD exacerbations should be considered when developing individualized strategies to encourage seeking care for exacerbations.Clinical trial registered with www.clinicaltrials.gov (NCT02725294).

Objective: The Veterans Choice Program (VCP) of the Veterans Health Administration (VHA) allowed eligible veterans to use their benefits with participating providers outside the VHA. The authors aimed to identify characteristics of veterans with depression who used or did not use mental health care through the VCP., Methods: In this cross-sectional study, the authors analyzed secondary data from the national VHA Corporate Data Warehouse. VHA administrative data were linked with VCP claims to examine characteristics of VCP-eligible veterans with depression. The study sample included 595,943 unique veterans who were enrolled in the VHA before 2013, were eligible for the VCP in 2016, were alive in 2018, and had an assessed Patient Health Questionnaire-9 (PHQ-9) score or depressive disorder diagnosis documented in the VHA between 2016 and 2018., Results: Veterans who used the VCP had lower medical comorbidity scores and lived in less socioeconomically disadvantaged counties, compared with veterans who received only VHA care. VCP veterans were also more likely to have a PHQ-9 score assessment and to have higher mean depression scores. Mean counts of annual mental health visits per 1,000 veterans were markedly higher for direct VHA care than for care provided via the VCP. As a percentage of the total counts of visits per 1,000 veterans across the VCP and VHA, residential programs and outpatient procedures were the services that were most frequently delivered through the VCP., Conclusions: Between 2016 and 2018, the VCP was used primarily to augment mental health care provided by the VHA, rather than to fill a gap in care., Competing Interests: Dr. Carlo reports receiving consulting fees from Otsuka Pharmaceutical. The other authors report no financial relationships with commercial interests.

Objective: To determine the perceived acceptability and helpfulness of bipolar disorder symptom measures and rank the measures in order of preference among individuals with bipolar disorder., Methods: We recruited 20 participants 18 years of age or older with any type of bipolar disorder from a primary care clinical site and a national advocacy organization. We used a simultaneous complementary mixed-method design involving completion of symptom measures, a semistructured interview, and numerical ranking of measures. Participants completed three symptom measures or combination of measures: 1) Affective Self-Rating Scale; 2) combination Patient Mania Questionnaire-9 (PMQ-9) and Patient Health Questionnaire-9 (PHQ-9); and 3) combination Altman Self-Rating Mania Rating Scale and PHQ-9. A semistructured interview was conducted, and participants ranked their preferences for measures. Interviews focused on participants' rationale for measuring preferences. Interviews were analyzed by two psychiatrist-investigators using content analysis, and themes were determined. Average rank of each measure was determined., Results: The average rank for each measure was 1.48 for the combination PMQ-9 and PHQ-9, 1.68 for the Affective Self-Rating Scale, and 2.85 for the combination Altman Self-Rating Mania Rating Scale and PHQ-9, indicating that the combination PMQ-9 and PHQ-9 (top-ranked measure by 55% of participants) was the most preferred among the three measures. Major themes that emerged from the data were: 1) measure format; 2) patient experience; 3) clinical practice; and 4) therapeutic effects., Conclusions: Individuals with bipolar disorder preferred the combination PMQ-9 and PHQ-9 for use in monitoring treatment due to perceived strengths such as format, ease of completion and interpretation, accurate description of experiences, and feasibility of use in practice., (Copyright © 2023 Academy of Consultation-Liaison Psychiatry. Published by Elsevier Inc. All rights reserved.)

The importance of patients' trust in health care is well known. However, identifying actionable access barriers to trust is challenging. The goal of these exploratory analyses is to identify actionable access barriers that correlate with and predict patients' lack of trust in providers and in the health care system. This article combines existing data from three studies regarding perceived access to mental health services to explore the relationship between provider and system trust and other access barriers. Data from the Perceived Access Inventory (PAI) were analyzed from three studies that together enrolled a total of 353 veterans who screened positive for a mental health problem and had a VA mental health encounter in the previous 12 months. The PAI includes actionable barriers to accessing VA mental health services. The data are cross-sectional, and analyses include Spearman rank correlations of PAI access barriers and provider and system trust, and linear regressions examining the effect of demographic, clinical, and PAI barriers on lack of trust in VA mental health providers and in the VA health care system. Age, depression, and anxiety symptoms and PAI items demonstrated statistically significant bivariate correlations with provider and system trust. However, in multivariate linear regressions, only PAI items remained statistically significant. The PAI items that predicted provider and system trust could be addressed in interventions to improve provider- and system-level trust. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

The PTSD Checklist for DSM-5 (PCL-5) is a measure of posttraumatic stress disorder (PTSD) symptom severity that is widely used for clinical and research purposes. Although previous work has examined metrics of minimal important difference (MID) of the PCL-5 in veteran samples, no work has identified PCL-5 MID metrics among adults in primary care in the United States. In this secondary analysis, data were evaluated from primary care patients (N = 971) who screened positive for PTSD and participated in a large clinical trial in federally qualified health centers in three U.S. states. Participants primarily self-identified as women (70.2%) and White (70.3%). We calculated test-retest reliability using clinic registry data and multiple distribution- and anchor-based metrics of MID using baseline and follow-up survey data. Test-retest reliability (Pearson's r, Spearman's ρ, intraclass correlation coefficient) ranged from adequate to excellent (.79-.94), with the shortest time lag demonstrating the highest reliability estimate. The MID for the PCL-5 was estimated using multiple approaches. Distribution-based approaches indicated an MID range of 8.5-12.5, and anchor-based approaches indicated an MID range of 9.8-11.7. Taken together, the MID metrics indicate that PCL-5 change scores of 9-12 likely reflect real change in PTSD symptoms and indicate at least an MID for patients, whereas PCL-5 change scores of 5 or less likely are not reliable. These findings can help inform clinicians using the PCL-5 in similar populations to track patient responses to treatment and help researchers interpret PCL-5 score changes in clinical trials., (© 2023 International Society for Traumatic Stress Studies.)

Background: User modifications are common in evidence-based psychosocial interventions (EBPIs) for mental health disorders. Often, EBPIs fit poorly into clinical workflows, require extensive resources, or pose considerable burden to patients and therapists. Implementation science is increasingly researching ways to improve the usability of EBPIs before implementation. A user-centered design can be used to support implementation methods to prioritize user needs and solutions to improve EBPI usability., Objective: Trauma-focused EBPIs are a first-line treatment for patients with posttraumatic stress disorder (PTSD) in the Department of Veterans Affairs. Written exposure therapy (WET) is a brief, trauma-focused EBPI wherein patients handwrite about trauma associated with their PTSD. Initially developed for in-person delivery, WET is increasingly being delivered remotely, and outcomes appear to be equivalent to in-person delivery. However, there are logistical issues in delivering WET via video. In this evaluation, we explored usability issues related to WET telehealth delivery via videoconferencing software and designed a solution for therapist-facing challenges to systematize WET telehealth delivery., Methods: The Discover, Design and Build, and Test framework guided this formative evaluation and served to inform a larger Virtual Care Quality Enhancement Research Initiative. We used qualitative descriptive methods in the Discover phase to understand the experiences and needs of 2 groups of users providing care within the Department of Veterans Affairs: in-person therapists delivering WET via video because of the COVID-19 pandemic and telehealth therapists who regularly deliver PTSD therapies. We then used user-centered design methods in the Design and Build phase to brainstorm, develop, and iteratively refine potential workflows to address identified usability issues. All procedures were conducted remotely., Results: In the Discover phase, both groups had challenges delivering WET and other PTSD therapies via telehealth because of technology issues with videoconferencing software, environmental distractions, and workflow disruptions. Narrative transfer (ie, patients sending handwritten trauma accounts to therapists) was the first target for design solution development as it was deemed most critical to WET delivery. In the Design and Build phase, we identified design constraints and brainstormed solution ideas. This led to the development of 3 solution workflows that were presented to a subgroup of therapist users through cognitive walkthroughs. Meetings with this subgroup allowed workflow refinement to improve narrative transfers. Finally, to facilitate using these workflows, we developed PDF manuals that are being refined in subsequent phases of the implementation project (not mentioned in this paper)., Conclusions: The Discover, Design and Build, and Test framework can be a useful tool for understanding user needs in complex EBPI interventions and designing solutions to user-identified usability issues. Building on this work, an iterative evaluation of the 3 solution workflows and accompanying manuals with therapists and patients is underway as part of a nationwide WET implementation in telehealth settings., (©Megan Moldestad, Valentina V Petrova, Katie Tirtanadi, Sonali R Mishra, Suparna Rajan, George Sayre, John C Fortney, Heather Schacht Reisinger. Originally published in JMIR Formative Research (https://formative.jmir.org), 06.11.2023.)

Unhealthy alcohol use is common among Operations Enduring and Iraqi Freedom (OEF/OIF) veterans, yet barriers discourage treatment-seeking. Mobile applications (apps) that deliver alcohol interventions have potential to address these barriers and increase treatment receipt. Few studies have qualitatively assessed users' experiences with apps to manage alcohol use. We assessed OEF/OIF veterans' experiences with Step Away, an app to reduce alcohol-related risks, to identify factors that may influence engagement. This single-arm pilot study recruited OEF/OIF veterans with positive alcohol screens nationwide using mail/telephone. Veterans aged 18-55 who exceeded drinking guidelines and owned an iPhone were eligible. Twenty-one (16 men, 5 women) of 55 participants completed interviews. Interviews were analyzed using thematic analysis. Participants found Step Away easy to use, although setup was time consuming. Participants reported increased awareness of alcohol use, highlighting daily assessment, weekly feedback, goal setting, and high-risk notification features as helpful and associated awareness with an intent to decrease use. Participants described Step Away as informative, with over half reporting they would use it outside of the study and most recommending it. Suggestions for improvement included greater personalization and control over features. Step Away features appear to influence engagement and increase users' awareness about alcohol consumed and factors associated with drinking, as well as intent to change. Assessment, feedback, and customization features of apps may facilitate app engagement. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Competing Interests: Disclosures: Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M23-1369.

An effectiveness trial found that telemedicine collaborative care for posttraumatic stress disorder (PTSD) significantly increased engagement in trauma-focused psychotherapy (TFP) and improved PTSD symptoms. However, in a subsequent implementation trial, very few veterans enrolled in collaborative care initiated TFP. We conducted a mixed-methods evaluation to determine why veterans did not initiate TFP in the implementation trial. After conducting chart reviews of 1,071 veterans with PTSD enrolled in collaborative care, patients were categorized into four mutually exclusive TFP groups: TFP not discussed; TFP discussed, declined; TFP discussed, did not decline; and TFP initiated. We conducted semistructured interviews with 43 unique patients and 58 unique providers (i.e., care managers and mental health specialists). Almost half (48.6%) of the veterans had no documentation of discussing TFP with their care manager; another 28.9% discussed it but declined. Most veterans (77.1%) had an encounter with a mental health specialist, 36.8% of whom never discussed TFP, and 35.7% of whom discussed it but declined. Providers reported that many veterans were not able, willing, or ready to engage in TFP and that non-trauma-focused therapies were better aligned with their treatment goals. Veterans gave numerous reasons for not initiating TFP, including having bad prior experiences with TFP and wanting to avoid thinking about past traumatic experiences. Commonly cited reasons for noninitiation were providers never discussing TFP with veterans and veterans declining TFP after discussing it with their provider. Interventions, such as shared decision-making tools, may be needed to engage providers and patients in informed discussions about TFP., (© 2023 The Authors. Journal of Traumatic Stress published by Wiley Periodicals LLC on behalf of International Society for Traumatic Stress Studies.)

Importance: Medication for opioid use disorder (MOUD) (eg, buprenorphine and naltrexone) can be offered in primary care, but barriers to implementation exist., Objective: To evaluate an implementation intervention over 2 years to explore experiences and perspectives of multidisciplinary primary care (PC) teams initiating or expanding MOUD., Design, Setting, and Participants: This survey-based and ethnographic qualitative study was conducted at 12 geographically and structurally diverse primary care clinics that enrolled in a hybrid effectiveness-implementation study from July 2020 to July 2022 and included PC teams (prescribing clinicians, nonprescribing behavioral health care managers, and consulting psychiatrists). Survey data analysis was conducted from February to April 2022., Exposure: Implementation intervention (external practice facilitation) to integrate OUD treatment alongside existing collaborative care for mental health services., Measures: Data included (1) quantitative surveys of primary care teams that were analyzed descriptively and triangulated with qualitative results and (2) qualitative field notes from ethnographic observation of clinic implementation meetings analyzed using rapid assessment methods., Results: Sixty-two primary care team members completed the survey (41 female individuals [66%]; 1 [2%] American Indian or Alaskan Native, 4 [7%] Asian, 5 [8%] Black or African American, 5 [8%] Hispanic or Latino, 1 [2%] Native Hawaiian or Other Pacific Islander, and 46 [4%] White individuals), of whom 37 (60%) were between age 25 and 44 years. An analysis of implementation meetings (n = 362) and survey data identified 4 themes describing multilevel factors associated with PC team provision of MOUD during implementation, with variation in their experience across clinics. Themes characterized challenges with clinical administrative logistics that limited the capacity to provide rapid access to care and patient engagement as well as clinician confidence to discuss aspects of MOUD care with patients. These challenges were associated with conflicting attitudes among PC teams toward expanding MOUD care., Conclusions and Relevance: The results of this survey and qualitative study of PC team perspectives suggest that PC teams need flexibility in appointment scheduling and the capacity to effectively engage patients with OUD as well as ongoing training to maintain clinician confidence in the face of evolving opioid-related clinical issues. Future work should address structural challenges associated with workload burden and limited schedule flexibility that hinder MOUD expansion in PC settings.

Background: Individuals with bipolar disorder commonly present for treatment in primary care settings. Collaborative care and colocated specialty care models can improve quality of care and outcomes, though it is unknown which model is more effective., Objective: To compare 12-month treatment outcomes for primary care patients with bipolar disorder randomized to treatment with collaborative care or colocated specialty care., Methods: We conducted a secondary analysis of 191 patients diagnosed with bipolar disorder treated for 12 months during a comparative effectiveness trial in 12 Federally Qualified Health Centers in three states. Characteristics and outcomes were assessed at enrollment and 12 months. The primary outcome was mental health quality of life scores (Veterans RAND 12-Item Health Survey Mental Health Component Summary), and secondary outcomes included depression and anxiety symptom scores, euthymic mood state, and recovery. T-tests and multiple linear and logistic regression models were used., Results: Among participants (mean age: 40 years; 73% women), the Veterans RAND 12-Item Health Survey Mental Health Component Summary increased in both arms over 12 months (baseline: collaborative care 21.99, SD 10.78; colocated specialty 24.15, SD 12.05; 12-month collaborative care 30.63, SD 13.33; colocated specialty 34.16, SD 12.65). The mean Mental Health Component Summary change did not differ by arm (collaborative care: MΔ = 9.09; colocated specialty: MΔ = 10.73; t = -0.67, P = 0.50). Secondary outcomes also improved at 12 months compared to baseline measured by the Hopkins Symptoms Checklist (MΔ = -0.75; SD = 0.85), Generalized Anxiety Disorder-7 (MΔ = -3.92; SD = 6.48), and Recovery Assessment Scale (MΔ = 0.37; SD = 0.65) and did not differ significantly by arm. The proportion of participants with euthymic mood state increased from 11% to 25% with no statistically significant difference by arm., Conclusions: The effectiveness of collaborative care and that of colocated specialty care were similar. Both were associated with substantial improvements in mental health quality of life and symptom reduction., (Copyright © 2023 Academy of Consultation-Liaison Psychiatry. Published by Elsevier Inc. All rights reserved.)

Objective: Posttraumatic stress disorder (PTSD) and bipolar disorder are common in primary care. Evidence supports collaborative care in primary care settings to treat depression and anxiety, and recent studies have evaluated its effectiveness in treating complex conditions such as PTSD and bipolar disorder. This study aimed to examine how primary care clinicians experience collaborative care for patients with these more complex psychiatric disorders., Methods: The authors conducted semistructured interviews with 22 primary care clinicians participating in a pragmatic trial that included telepsychiatry collaborative care (TCC) to treat patients with PTSD or bipolar disorder in rural or underserved areas. Analysis utilized a constant comparative method to identify recurring themes., Results: Clinicians reported that TCC improved their confidence in managing medications for patients with PTSD or bipolar disorder and supported their ongoing learning and skill development. Clinicians also reported improvements in patient engagement in care. Care managers were crucial to realizing these benefits by fostering communication within the clinical team while engaging patients through regular outreach. Clinicians valued TCC because it included and supported them in improving the care of patients' mental health conditions, which opened opportunities for clinicians to enhance care and address co-occurring general medical conditions. Overall, benefits of the TCC model outweighed its minimal burdens., Conclusions: Clinicians found that TCC supported their care of patients with PTSD or bipolar disorder. This approach has the potential to extend the reach of specialty mental health care and to support primary care clinicians treating patients with these more complex psychiatric disorders., Competing Interests: The authors report no financial relationships with commercial interests.

Background: Children's Advocacy Centers (CACs) use multidisciplinary teams to investigate and respond to maltreatment allegations. CACs play a critical role in connecting children with mental health needs to evidence-based mental health treatment, especially in low-resourced rural areas. Standardized mental health screening and referral protocols can improve CACs' capacity to identify children with mental health needs and encourage treatment engagement. In the team-based context of CACs, teamwork quality is likely to influence implementation processes and outcomes. Implementation strategies that target teams and apply the science of team effectiveness may enhance implementation outcomes in team-based settings., Methods: We will use Implementation Mapping to develop team-focused implementation strategies to support the implementation of the Care Process Model for Pediatric Traumatic Stress (CPM-PTS), a standardized screening and referral protocol. Team-focused strategies will integrate activities from effective team development interventions. We will pilot team-focused implementation in a cluster-randomized hybrid type 2 effectiveness-implementation trial. Four rural CACs will implement the CPM-PTS after being randomized to either team-focused implementation (n = 2 CACs) or standard implementation (n = 2 CACs). We will assess the feasibility of team-focused implementation and explore between-group differences in hypothesized team-level mechanisms of change and implementation outcomes (implementation aim). We will use a within-group pre-post design to test the effectiveness of the CPM-PTS in increasing caregivers' understanding of their child's mental health needs and caregivers' intentions to initiate mental health services (effectiveness aim)., Conclusions: Targeting multidisciplinary teams is an innovative approach to improving implementation outcomes. This study will be one of the first to test team-focused implementation strategies that integrate effective team development interventions. Results will inform efforts to implement evidence-based practices in team-based service settings., Trial Registration: Clinicaltrials.gov, NCT05679154 . Registered on January 10, 2023., (© 2023. The Author(s).)

Background: Experts recommend that treatment for substance use disorder (SUD) be integrated into primary care. The Digital Therapeutics for Opioids and Other SUD (DIGITS) Trial tests strategies for implementing reSET® and reSET-O®, which are prescription digital therapeutics for SUD and opioid use disorder, respectively, that include the community reinforcement approach, contingency management, and fluency training to reinforce concept mastery. This purpose of this trial is to test whether two implementation strategies improve implementation success (Aim 1) and achieve better population-level cost effectiveness (Aim 2) over a standard implementation approach., Methods/design: The DIGITS Trial is a hybrid type III cluster-randomized trial. It examines outcomes of implementation strategies, rather than studying clinical outcomes of a digital therapeutic. It includes 22 primary care clinics from a healthcare system in Washington State and patients with unhealthy substance use who visit clinics during an active implementation period (up to one year). Primary care clinics implemented reSET and reSET-O using a multifaceted implementation strategy previously used by clinical leaders to roll-out smartphone apps ("standard implementation" including discrete strategies such as clinician training, electronic health record tools). Clinics were randomized as 21 sites in a 2x2 factorial design to receive up to two added implementation strategies: (1) practice facilitation, and/or (2) health coaching. Outcome data are derived from electronic health records and logs of digital therapeutic usage. Aim 1's primary outcomes include reach of the digital therapeutics to patients and fidelity of patients' use of the digital therapeutics to clinical recommendations. Substance use and engagement in SUD care are additional outcomes. In Aim 2, population-level cost effectiveness analysis will inform the economic benefit of the implementation strategies compared to standard implementation. Implementation is monitored using formative evaluation, and sustainment will be studied for up to one year using qualitative and quantitative research methods., Discussion: The DIGITS Trial uses an experimental design to test whether implementation strategies increase and improve the delivery of digital therapeutics for SUDs when embedded in a large healthcare system. It will provide data on the potential benefits and cost-effectiveness of alternative implementation strategies., Clinicaltrials: gov Identifier: NCT05160233 (Submitted 12/3/2021). https://clinicaltrials.gov/ct2/show/NCT05160233., (© 2023. The Author(s).)

This study developed and psychometrically evaluated a brief measure of mental health treatment knowledge ( N = 726). Scores from Knowledge about Treatment (KaT) demonstrated a unidimensional measure with good model fit, internal consistency reliability, convergent and predictive validity, test-retest reliability, and measurement invariance across gender, ethnicity, education, and poverty status.

Out-of-home storage of personal firearms is one recommended option for individuals at risk of suicide, and statewide online maps of storage locations have been created in multiple states, including Colorado and Washington. We sought to examine both the extent to which firearm retailers and ranges offer temporary, voluntary firearm storage and the perceived barriers to providing this service. We invited all firearm retailers and ranges in Colorado and Washington to complete an online or mailed survey; eligible sites had to have a physical location where they could provide storage. Between June-July 2021, 137 retailers/ranges completed the survey (response rate = 25.1%). Nearly half (44.5%) of responding firearm retailers/ranges in Colorado and Washington State indicated they had ever provided firearm storage. Among those who had ever offered storage, 80.3% currently offered storage while 19.7% no longer did. The majority (68.6%) of participants had not heard of the Colorado/Washington gun storage maps and 82.5% did not believe they were currently listed on the maps. Respondents indicated liability waivers would most influence their decision about whether to start or continue providing temporary, voluntary storage of firearms. Understanding current practices, barriers, and concerns about providing out-of-home storage by retailers and ranges may support development of more feasible approaches for out-of-home firearm storage during times of suicide risk., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Background: The Veterans Community Care Program (VCCP) aims to address access constraints in the Veterans Health Administration (VA) by reimbursing care from non-VA community providers. Little existing research explores how veterans' choice of VA versus VCCP providers has evolved as a significant VCCP expansion in 2014 as part of the Veterans Access, Choice, and Accountability Act., Objectives: We examined changes in reliance on VA for primary care (PC), mental health (MH), and specialty care (SC) among VCCP-eligible veterans., Research Design: We linked VA administrative data with VCCP claims to retrospectively examine utilization during calendar years 2016-2018., Subjects: 1.78 million veterans enrolled in VA before 2013 and VCCP-eligible in 2016 due to limited VA capacity or travel hardship., Measures: We measured reliance as the proportion of total annual outpatient (VA+VCCP) visits occurring in VA for PC, MH, and SC., Results: Of the 26.1 million total outpatient visits identified, 45.6% were for MH, 29.9% for PC, and 24.4% for SC. Over the 3 years, 83.2% of veterans used any VA services, 23.8% used any VCCP services, and 20.0% were dual VA-VCCP users. Modest but statistically significant declines in reliance were observed from 2016-2018 for PC (94.5%-92.2%), and MH (97.8%-96.9%), and a more significant decline was observed for SC (88.5%-79.8%)., Conclusions: Veterans who have the option of selecting between VA or VCCP providers continued using VA for most of their outpatient care in the initial years after the 2014 VCCP expansion., Competing Interests: The authors declare no conflict of interest.

Purpose: Compared to urban areas, rural populations are less likely to engage in mental health care. Using data from the Study to Promote Innovation in Rural Integrated Telepsychiatry, we examined the effect of rurality on engagement in mental health treatment as well as the role of potential mediators., Methods: Data were obtained from medical records and surveys. We defined rurality using the rural-urban commuting area codes. Baseline mediators included the Endorsed and Anticipated Stigma Inventory and the Assessment of Perceived Access to Care. Engagement outcomes included number of psychotherapy visits and self-reported medication use. We used path analysis to examine the relationship between rurality and engagement and the influence of mediating variables., Findings: Rural participants were less likely to initiate psychotherapy (OR = 0.49; adjusted P = .036), although rurality was not associated with number of psychotherapy sessions or medication use. Rurality was associated with a small elevation in negative beliefs about mental health, but this potential mediator was not associated with engagement. Rurality was negatively associated with lower perceived need for treatment (OR = 0.67, adjusted P = .040), which was in turn positively associated with initiating psychotherapy (OR = 1.99, adjusted P = .001)., Conclusions: Neither rurality itself nor the potential mediators had a large effect on engagement. Federally Qualified Health Centers offering colocated and/or integrated mental health care appear to be mostly mitigating rural-urban disparities in mental health engagement. Improving rates of psychotherapy initiation for rural patients should remain a policy goal., (© 2021 National Rural Health Association.)

Objective: To compare medication treatment of individuals with bipolar disorder in two primary care-based integrated care models., Methods: Participants were randomized to 12-months of treatment with direct care by co-located psychiatrists in primary care, or collaborative care (primary care clinicians supported by psychiatrists). Medication data at initial and last treatment visits were extracted from the clinical registry for 191 patients diagnosed with bipolar disorder., Results: Participants receiving no medication treatment decreased from 28% to 11% (direct co-located) (χ 2  = 10.9, p < .001) and 39% to 17% (collaborative care; χ 2  = 16.9, p < .001). Last visit medication prescriptions for antipsychotic medication (approximately one-half of participants) increased significantly compared to initial visit and did not differ between arms. Anticonvulsant mood-stabilizing medication (approximately one-third of participants in both arms) was higher than lithium prescription (approximately 6% of participants) at last visit., Conclusion: Similar patterns of medication treatment were observed in participants with bipolar disorder receiving either direct care from psychiatrists, or medication treatment by primary care clinicians supported by psychiatrists., (Copyright © 2022 Elsevier Inc. All rights reserved.)