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In March 2020, Veterans Health Administration (VHA) enacted policies to expand treatment for Veterans with opioid use disorder (OUD) during COVID-19. In this study, we evaluate whether COVID-19 and subsequent OUD treatment policies impacted receipt of therapy/counseling and medication for OUD (MOUD).Using VHA's nationwide electronic health record data, we compared outcomes between a comparison cohort derived using data from prior to COVID-19 (October 2017-December 2019) and a pandemic-exposed cohort (January 2019-March 2021). Primary outcomes included receipt of therapy/counseling or any MOUD (any/none); secondary outcomes included the number of therapy/counseling sessions attended, and the average percentage of days covered (PDC) by, and months prescribed, each MOUD in a year.Veterans were less likely to receive therapy/counseling over time, especially post-pandemic onset, and despite substantial increases in teletherapy. The likelihood of receiving buprenorphine, methadone, and naltrexone was reduced post-pandemic onset. PDC on MOUD generally decreased over time, especially methadone PDC post-pandemic onset, whereas buprenorphine PDC was less impacted during COVID-19. The number of months prescribed methadone and buprenorphine represented relative improvements compared to prior years. We observed important disparities across Veteran demographics.Receipt of treatment was negatively impacted during the pandemic. However, there was some evidence that coverage on methadone and buprenorphine may have improved among some veterans who received them. These medication effects are consistent with expected COVID-19 treatment disruptions, while improvements regarding access to therapy/counseling via telehealth, as well as coverage on MOUD during the pandemic, are consistent with the aims of MOUD policy exemptions. more...

Objectives. To assess the impact of the 2008 Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act (MHPAEA) on mental and substance use disorder services in the private, large group employer–sponsored insurance market in the United States. Methods. We analyzed data from the IBM MarketScan Commercial Database from January 2005 through September 2015 by using population-level interrupted time series regressions to determine whether parity implementation was associated with utilization and spending outcomes. Results. MHPAEA had significant positive associations with utilization of mental and substance use disorder outpatient services. A spending decomposition analysis indicated that increases in utilization were the primary drivers of increases in spending associated with MHPAEA. Analyses of opioid use disorder and nonopioid substance use disorder services found that associations with utilization and spending were not attributable only to increases in treatment of opioid use disorder. Conclusions. MHPAEA is positively associated with utilization of outpatient mental and substance use disorder services for Americans covered by large group employer–sponsored insurance. Public Health Implications. These trends continued over the 5-year post-MHPAEA period, underscoring the long-term relationship between this policy change and utilization of behavioral health services. more...

Objectives: We used data from the 2015 National Association of State Alcohol and Drug Abuse Directors Web-based questionnaire and other sources to demonstrate the range and scope of state initiatives being used to deal with the opioid crisis in the United States. Methods: State alcohol and drug agency directors and designated senior agency managers responded to the questionnaire, which asked respondents about recent opioid-related state-level public health initiatives at their agencies. Results: State alcohol and drug agencies in all 50 states and the District of Columbia responded, all of which reported that prescription drug misuse was a high priority or the highest priority area for their agencies. Of the 51 respondents, states reported initiatives to educate the general public (n = 48), prescribers (n = 31), patients and families (n = 24), and pharmacists (n = 22) about the risks of opioids. In addition, 29 states had increased funding for medication-assisted treatment of opioid addiction, 28 had expanded the availability of naloxone (an opioid antidote), 26 had established guidelines for safe opioid prescribing, 23 had launched requirements for prescriber use of prescription monitoring programs, 23 had passed Good Samaritan laws to protect those helping treat overdoses, and 14 had enacted legislation to regulate pain clinics. Conclusions: US state alcohol and drug agencies demonstrated a robust response to the opioid crisis in the United States. They have pursued and expanded on an array of evidence-based initiatives aimed at the opioid crisis. Future public health efforts should focus on maintenance and further expansion of high-quality, evidence-based practices, policies, and programs. more...

Recent reports reinforce the widespread interest in complementary and alternative medicine (CAM), not only among military personnel with combat-related disorders, but also among providers who are pressed to respond to patient demand for these therapies. However, an understanding of utilization of CAM therapies in this population is lacking.The goals of this study are to synthesize the content of self-report population surveys with information on use of CAM in military and veteran populations, assess gaps in knowledge, and suggest ways to address current limitations.The research team conducted a literature review of population surveys to identify CAM definitions, whether military status was queried, the medical and psychological conditions queried, and each specific CAM question. Utilization estimates specific to military/veterans were summarized and limitations to knowledge was classified.Seven surveys of CAM utilization were conducted with military/veteran groups. In addition, 7 household surveys queried military status, although there was no military/veteran subgroup analysis. Definition of CAM varied widely limiting cross-survey analysis. Among active duty and Reserve military, CAM use ranged between 37% and 46%. Survey estimates do not specify CAM use that is associated with a medical or behavioral health condition.Comparisons between surveys are hampered due to variation in methodologies. Too little is known about reasons for using CAM and conditions for which it is used. Additional information could be drawn from current surveys with additional subgroup analysis, and future surveys of CAM should include military status variable. more...

BACKGROUND: Mounting evidence indicates that early recognition and treatment of behavioral health disorders can prevent complications, improve quality of life, and help reduce health care costs. The aim of this systematic literature review was to identify and evaluate publicly available, psychometrically tested tools that primary care physicians (PCPs) can use to screen adult patients for common mental and substance use disorders such as depression, anxiety, and alcohol use disorders. METHODS: We followed the Institute of Medicine (IOM) systematic review guidelines and searched PubMed, PsycINFO, Applied Social Sciences Index and Abstracts, Cumulative Index to Nursing and Allied Health Literature, and Health and Psychosocial Instruments databases to identify literature addressing tools for screening of behavioral health conditions. We gathered information on each tool’s psychometrics, applicability in primary care, and characteristics such as number of items and mode of administration. We included tools focused on adults and the most common behavioral health conditions; we excluded tools designed for children, youth, or older adults; holistic health scales; and tools screening for serious but less frequently encountered disorders, such as bipolar disorder. RESULTS: We identified 24 screening tools that met the inclusion criteria. Fifteen tools were subscales stemming from multiple-disorder assessments or tools that assessed more than one mental disorder or more than one substance use disorder in a single instrument. Nine were ultra-short, single-disorder tools. The tools varied in psychometrics and the extent to which they had been administered and studied in primary care settings. DISCUSSION: Tools stemming from the Patient Health Questionnaire had the most testing and application in primary care settings. However, numerous other tools could meet the needs of primary care practices. This review provides information that PCPs can use to select appropriate tools to incorporate into a screening protocol. more...

Understanding the relationship between obesity and fast food consumption encompasses a broad range of individual level and environmental factors. One theoretical approach, the health capability framework, focuses on the complex set of conditions allowing individuals to be healthy. This qualitative study aimed to identify factors that influence individual level health agency with respect to healthy eating choices in uniformly constrained environments (e.g., fast food restaurants). We used an inductive qualitative research design to develop an interview guide, conduct open-ended interviews with a purposive sample of 14 student fast food workers (aged 18–25), and analyze the data. Data analysis was conducted iteratively during the study with multiple coders to identify themes. Emergent themes included environmental influences on eating behaviors (time, cost, restaurant policies, social networks) and internal psychological factors (feelings associated with hunger, food knowledge versus food preparation know-how, reaction to physical experiences, perceptions of food options, delayed gratification, and radical subjectivity). A localized, embedded approach to analyzing the factors driving the obesity epidemic is needed. Addressing contextual interactions between internal psychological and external environmental factors responds to social justice and public health concerns, and may yield more relevant and effective interventions for vulnerable communities. more...

Background The objective was to analyze disparities in unmet need for substance use treatment and to observe variation across different definitions of need for treatment. Methods Data were analyzed from the 2002 to 2005 National Survey of Drug Use and Health and the National Epidemiologic Survey on Alcohol and Related Conditions. Logistic regressions estimated the likelihood of specialty substance use treatment across the two data sets. Parallel variables for specialty, informal and any substance abuse treatment were created. Perceived need and normative need for substance use treatment were defined, with normative need stratified across lifetime disorder, past twelve month disorder, and heavy alcohol/any illicit drug use. Treatment rates were analyzed, comparing Blacks, Asians and Latinos to non-Latino whites across need definitions, and adjusting for age, sex, household income, marital status, education and insurance. Results Asians with past year substance use disorder had a higher likelihood of unmet need for specialty treatment than whites. Blacks with past year disorder and with heavy drinking/illicit drug use had significantly lower likelihood of unmet need. Latinos with past year disorder had a higher likelihood of unmet need for specialty substance abuse treatment. Asians with heavy drinking/illicit drug use had lower likelihood of unmet need. Conclusions The findings suggest that pathways to substance abuse treatment differ across groups. Given high rates of unmet need, a broad approach to defining need for treatment is warranted. Future research to disentangle social and systemic factors from factors based on diagnostic criteria is necessary in the identification of need for treatment. more...

Experimental philosophers advocate expansion of philosophical methods to include empirical investigation into the concepts used by ordinary people in reasoning and action. We propose also including methods of qualitative social science, which we argue serve both moral and epistemic goals. Philosophical analytical tools applied to interdisciplinary research designs can provide ways to extract rich contextual information from subjects. We argue that this approach has important implications for bioethics; it provides both epistemic and moral reasons to use the experiences and perspectives of diverse populations to better identify underlying concepts as well as to develop effective interventions within particular communities. more...

This qualitative study examines the experience of racial and ethnic minorities receiving behavioral health care in a safety net setting during the early process of health insurance reform in Massachusetts. Three rounds of interviews were conducted between August 2007 and May 2009, collecting information from patients (n=65) on the experience of health reform and delivery of mental health care. Four categories of enrollees transitioning into health reform emerged over the course of the study that grouped into a typology of experiences with reform: early enrollees, middle enrollees, late enrollees, and multiple switchers. With support, a majority of the sample transitioned smoothly to the new health insurance mechanisms. However, some experienced administrative confusion and disruption in mental health care during the transition. Administrative policies providing special accommodations for individuals with mental health disorders and other vulnerable populations may be important to consider during the transition to health insurance reform. more...

Limited research in health valuation analyzes samples with high proportions of racial/ethnic minorities within the United States. The primary objective was to explore patterns of health valuation across race/ethnicity using the Collaborative Psychiatric Epidemiology Surveys. A secondary objective was to analyze whether mental health disorder and immigrant status were associated with these estimates.Health valuation questions using different metrics (time and money) were analyzed. Ordered logit models stratified across poor and moderate health tested differences by race/ethnicity, with mental health disorder and immigrant status as covariates.Asians in moderate health and Latinos were willing to pay more for health than non-Latino whites. Asians in moderate health were willing to trade more time for health. Latinos in poor health were less willing to trade time and gave disproportionate zero-trade responses. Lifetime history of anxiety disorder was positively associated with both metrics. Immigrant status confounded money valuation for Asians in moderate health, and time valuation for Latinos in poor health.Health valuation estimates vary across race/ethnicity depending upon the metric. Time valuation scenarios appear less feasible for Latinos in poor health. More research is necessary to understand these differences and the role of immigrant status in health valuation. more...

Obesity is a public health problem influenced by behavioral patterns that span an ecological spectrum of individual-level factors, social network factors and environmental factors. Both individual and environmental approaches necessarily include significant influences from social networks, but how and under what conditions social networks influence behavior change is often not clearly mapped out either in the obesity literature or in many intervention designs. In this paper, we provide an analysis of recent empirical work in obesity research that explicates social network influences on eating behaviors. We argue that a relational rather than individualistic view of personhood should help us better understand the content and context of social network relations that inform health behavior choices. We introduce the concept of ‘identity-constitutive affiliations’ as the glue that binds these social relationships together. Finally, we outline the implications for public health ethics in the development of effective interventions to address overweight and obesity, leveraging the content and context of social network ties to reinforce healthy (or alter unhealthy) eating. More complex treatment of positive and negative behaviors stemming from social network connections should lead to more comprehensive theoretical models of health behavior change and more effective public health interventions. more...

In this study, the authors identify three guiding principles or relational strategies for developing successful community partnerships and building an alliance for systemic change. These principles were derived from their work over 4 years with an urban public school system, which was focused on generating a series of interventions for improving the behavioral and academic functioning of immigrant students. In their process, they developed an analysis and monitoring system of students’ progress, which allowed for earlier targeted effective support. more...

This study seeks to identify risk factors for psychiatric disorders that may explain differences in nativity effects among adult Latinos in the USA. We evaluate whether factors related to the processes of acculturation and enculturation, immigration factors, family stressors and supports, contextual factors, and social status in the US account for differences in 12-month prevalence of psychiatric disorders for eight subgroups of Latinos. We report results that differentiate Latino respondents by country of origin and age at immigration (whether they were US-born or arrived before age 6: In-US-as-Child [IUSC]; or whether they arrived after age 6: later-arrival immigrants [LAI]). After age and gender adjustments, LAI Mexicans and IUSC Cubans reported a significantly lower prevalence of depressive disorders than IUSC Mexicans. Once we adjust for differences in family stressors, contextual factors and social status factors, these differences are no longer significant. The risk for anxiety disorders appears no different for LAI compared to IUSC Latinos, after age and gender adjustments. For substance use disorders, family factors do not offset the elevated risk of early exposure to neighborhood disadvantage, but coming to the US after age 25 does offset it. Family conflict and burden were consistently related to the risk of mood disorders. Our findings suggest that successful adaptation into the US is a multidimensional process that includes maintenance of family harmony, integration in advantageous US neighborhoods, and positive perceptions of social standing. Our results uncover that nativity may be a less important independent risk factor for current psychiatric morbidity than originally thought. more...

Objectives. We examined the prevalence of depressive, anxiety, and substance use disorders among Latinos residing in the United States. Methods. We used data from the National Latino and Asian American Study, which included a nationally representative sample of Latinos. We calculated weighted prevalence rates of lifetime and past-year psychiatric disorders across different sociodemographic, ethnic, and immigration groups. Results. Lifetime psychiatric disorder prevalence estimates were 28.1% for men and 30.2% for women. Puerto Ricans had the highest overall prevalence rate among the Latino ethnic groups assessed. Increased rates of psychiatric disorders were observed among US-born, English-language-proficient, and third-generation Latinos. Conclusions. Our results provide important information about potential correlates of psychiatric problems among Latinos that can inform clinical practice and guide program development. Stressors associated with cultural transmutation may exert particular pressure on Latino men. Continued attention to environmental influences, especially among third-generation Latinos, is an important area for substance abuse program development. more...

Objective Effective patient–provider communication is essential to improve health care delivery and satisfaction and to minimize disparities in care for minorities. The objective of our study was to evaluate the impact of a patient–provider communication program, the Patient Passport Program, to improve communication and satisfaction for hospitalized minority children. Methods This was a qualitative evaluation of a communication project for families with hospitalized children. Families were assigned to either the Patient Passport Program or to usual care. The Passport Program consisted of a personalized Passport book and additional medical rounds with medical providers. Semistructured interviews at the time of patient discharge were conducted with all participants to measure communication quality and patient/family satisfaction. Inductive qualitative methods were used to identify common themes. Results Of the 40 children enrolled in the Passport Program, 60% were boys; the mean age was 9.7 years (range, 0.16–19 years). The most common themes in the qualitative analysis of the interviews were: 1) organization of medical care; 2) emotional expressions about the hospitalization experience; and 3) overall understanding of the process of care. Spanish- and English-speaking families had similar patient satisfaction experiences, but the Passport families reported improved quality of communication with the medical care team. Conclusions The Patient Passport Program enhanced the quality of communication among minority families of hospitalized children with some common themes around the medical care expressed in the Passport book. more...

Because Vietnam veterans comprise the majority of all living veterans and most are now older adults, the urgency and potential value of studying the long-term health effects of service in the Vietnam War, including effects on mortality, is increasing. The present study is the first prospective mortality assessment of a representative sample of Vietnam veterans. We used one of the longest follow-up periods to date (spanning older adulthood) and conducted one of the most comprehensive assessments of potential risk factors. Vital status and cause of death were ascertained for the 1,632 veterans who fought in the Vietnam theater (hereafter referred to as theater veterans) and for 716 Vietnam War-era veterans (hereafter referred to as era veterans) who participated in the National Vietnam Veterans Readjustment Study (1987-2011). As of April 2011, 16.0% (95% confidence interval: 13.1, 19.0) of all Vietnam veterans who were alive in the 1980s were deceased. Male theater veterans with a high probability of posttraumatic stress disorder (PTSD) were nearly 2 times more likely to have died than were those without PTSD, even after adjustment for sociodemographic and other characteristics. A high level of exposure to war zone stress was independently associated with mortality for both male and female theater veterans after adjustment for sociodemographic characteristics, PTSD, and physical comorbid conditions. Theater veterans with a high level of exposure to war zone stress and a high probability of PTSD had the greatest mortality risk (adjusted hazard ratio = 2.34, 95% confidence interval: 1.24, 4.43). more...

This article highlights results from the Right Question Project—Mental Health (RQP-MH), an intervention designed to teach skills in question formulation and to increase patients' participation in decisions about mental health treatment. Of participants in the RQP-MH intervention, 83% were from a Latino background, and 75% of the interviews were conducted in Spanish. The authors present the steps participants undertook in the process of becoming “activated” to formulate effective questions and develop decision-making skills in relation to their care. Findings suggest that patient activation and empowerment are interdependent because many of the skills (i.e., question formulation, direct patient—provider communication) required to become an “activated patient” are essential to achieve empowerment. Also, findings suggest that cultural and contextual factors can influence the experience of Latinos regarding participation in health care interactions. The authors provide recommendations for continued research on the patient activation process and further application of this strategy in the mental health field, especially with Latinos. more...

WOS:000335652600006 (Nº de Acesso Web of Science) We compared service outcomes of dedicated language and cultural competency services in adequacy of care, ER, and inpatient care among Portuguese-speaking patients in ethnic- and non-ethnic-specific behavioral health clinics. We assessed adequacy of mental health care, and use of inpatient emergency department among Portuguese-speaking patients, comparing individuals receiving care from a culturally and linguistically competent mental health care setting (the Portuguese Mental Health Program [PMHP]) with usual mental health care in a community health care system in the USA. Propensity score matching was used to balance patients in treatment and control groups on gender, marital status, age, diagnosis of mental disorder, and insurance status. We used de-identified, longitudinal, administrative data of 854 Portuguese-speaking patients receiving care from the PMHP and 541 Portuguese-speaking patients receiving usual care from 2005-2008. Adequate treatment was defined as receipt of at least eight outpatient psychotherapy visits, or at least four outpatient visits of which one was a psychopharmacological visit. PMHP patients were more likely to receive adequate care. No differences were found in rates of ER use or inpatient mental health care. The present study suggests increased quality of care for patients that have contact with a clinic that dedicates resources specifically to a minority/immigrant group. Advantages of this setting include greater linguistic and cultural concordance among providers and patients. Further research is warranted to better understand the mechanisms by which culturally appropriate mental health care settings benefit minority/immigrant patients. more...

Community-based participatory research has the potential to improve implementation of best practices to reduce disparities but has seldom been applied in mental health services research. This article presents the content and lessons learned from a national conference designed to stimulate such an application.Mental health program developers collaborated in hosting a two-day conference that included plenary and break-out sessions, sharing approaches to community-academic partnership development, and preliminary findings from partnered research studies. Sessions were audiotaped, transcribed and analyzed by teams of academic and community conference participants to identify themes about best practices, challenges faced in partnered research, and recommendations for development of the field. Themes were illustrated with selections from project descriptions at the conference.Participants, representing 9 academic institutions and 12 community-based agencies from four US census regions, were academic and community partners from five research centers funded by the National Institute of Mental Health, and also included staff from federal and non-profit funding agencies.Five themes emerged: 1) Partnership Building; 2) Implementing and Supporting Partnered Research; 3) Developing Creative Dissemination Strategies; 4) Evaluating Impact; and 5) Training.Emerging knowledge of the factors in the partnership process can enhance uptake of new interventions in mental health services. Conference proceedings suggested that further development of this field may hold promise for improved approaches to address the mental health services quality chasm and service disparities. more...

In 2004, Latinos in the United States numbered 41 million, with 31% under the age of 16. Over the period from 2000 to 2004, Latino population growth represented half the total growth in the United States (The National Academies 2007). Part of this considerable increase includes immigration from Latin America, some who confront major challenges in integrating into the country, such as lack of English proficiency and different norms and lifestyle circumstances (Guarnaccia et al. 2007). These new immigrants also sustain strong ties with their home communities, interacting by phone and email, which contributes to the maintenance of language and culture (Levitt et al. 2003; Viruell-Fuentes 2006). These transnational dynamics pose complex challenges of how best to provide services, given Latinos’ circumstances (U.S. Department of Health and Human Services 2001). more...

The goal of this study is to analyze preferences for relational styles in encounters with mental health providers across racial and ethnic groups. Four primary themes describe what patients want from a mental health provider: listening, understanding, spending time, and managing differences. However, using contextual comparative analysis, the findings explicate how these themes are described differently across African Americans, Latinos, and non-Latino Whites, uncovering important qualitative differences in the meaning of these themes across the groups. The article suggests that closer attention to qualitative preferences for style of interaction with providers may help address disparities in mental health care for racial and ethnic minorities. more...

This article presents analyses of a representative sample of U.S. Latinos ( N = 2,540) to investigate whether family cohesion moderates the effects of cultural conflict on psychological distress. The results for the aggregated Latino group suggest a significant association between family cohesion and lower psychological distress, and the combination of strong family cohesion with presence of family cultural conflict is associated with higher psychological distress. However, this association differs by Latino groups. In this study, no association for Puerto Ricans is seen; Cuban results are similar to the aggregate group, family cultural conflict in Mexicans is associated with higher psychological distress whereas family cohesion in other Latinos is associated with higher psychological distress. Implications of these findings are discussed to unravel the differences in family dynamics across Latino subethnic groups. more...

Objectives. We examined correlates and rates of past-year mental health service use in a national sample of Latinos residing in the United States. Methods. We used data from the National Latino and Asian American Study, a national epidemiological household survey of Latinos. Results. Cultural factors such as nativity, language, age at migration, years of residence in the United States, and generational status were associated with whether or not Latinos had used mental health services. However, when the analysis was stratified according to past-year psychiatric diagnoses, these associations held only among those who did not fulfill criteria for any of the psychiatric disorders assessed. Rates of mental health service use among those who did not fulfill diagnostic criteria were higher among Puerto Ricans and US-born Latinos than among non–Puerto Ricans and foreign-born Latinos. Conclusions. Rates of mental health service use among Latinos appear to have increased substantially over the past decade relative to rates reported in the 1990s. Cultural and immigration characteristics should be considered in matching mental health services to Latinos who need preventive services or who are symptomatic but do not fulfill psychiatric disorder criteria. more...

The role of individual versus community level social connections in promoting health is an important factor to consider when addressing Latino health. This analysis examines the relationships between social support, social cohesion, and health in a sample of Latinos in the United States. Using data from the National Latino and Asian American Study, the analysis uses ordered logistic regression to explore the relationships of family support, friend support, family cultural conflict, and neighborhood social cohesion with self-rated physical and mental health, taking into account language proficiency and use, nativity, and sociodemographic variables. Family support, friend support, and neighborhood social cohesion were positively related to self-rated physical and mental health, and family cultural conflict was negatively related when controlled only for sex and age. After controlling for education, income, and other demographic measures, only family support was found to have a weak association with self-rated physical health; however, the relationship seemed to be mediated by language. In contrast, family support and family cultural conflict were strongly associated with self-rated mental health, after controlling for language, education, income, and other demographic measures. The study did not find neighborhood social cohesion to be significantly related to either self-rated physical or mental health, after accounting for the effects of the other social connection variables. Language of interview did not explain the highly significant effects of language proficiency and use. Social connections are important for health and mental health, but language and other sociodemographic factors seem to be related to how Latinos establish these social linkages. Further investigation into the role of language in the development and maintenance of social connections may help unravel the mechanisms by which they promote or decrease health. more...