Colleen T. Fogarty

Mental Health Conditions are Associated With Increased Health Care Utilization Among Urban Family Medicine Patients

Purpose: To assess the relationship between the presence of a mental health condition and health care utilization among family medicine patients. Methods: We used the Patient Health Questionnaire plus a posttraumatic stress disorder screen to measure 6 common mental health conditions. In a sample of 367 patients recruited from 3 urban family medicine practices affiliated with Boston University Medical Center, we measured self-reported health care utilization of primary care provider visits, emergency department visits, nonpsychiatric hospitalizations, and outpatient mental health visits. We determined the association between screening positive for the mental health conditions and health care utilization using both multivariable logistic regression and Poisson regression methods while controlling for sex, age, race, income, insurance status, marital status, educational level, and the presence of chronic medical conditions. Results: After controlling for potential confounders, generalized anxiety disorder, panic disorder, and posttraumatic stress disorder were statistically significantly associated with more PCP visits, ED visits, and nonpsychiatric hospitalizations. Neither major nor minor depression were associated with more PCP visits, ED visits, or nonpsychiatric hospitalizations, except that minor depression was associated with 103% increase in PCP visits (P < .001). Alcohol use disorder was associated with 16% fewer PCP visits (P = .01) but 238% more nonpsychiatric hospitalizations (P < .001). Conclusions: After controlling for confounders we found that mental health conditions among a sample of family medicine patients were associated with increased use of ED services, nonpsychiatric hospitalizations, and, to a lesser extent, PCP visits.

“They Get a C-Section . . . They Gonna Die”: Somali Women’s Fears of Obstetrical Interventions in the United States

The authors explore sources of resistance to common prenatal and obstetrical interventions among 34 Somali resettled adult women in Rochester, New York. Results of individual interviews and focus groups with these women revealed aversion to or outright fear of cesarean sections because of fear of death and substantial resistance regarding other obstetrical interventions. Because Somali women expressed resistance to many common U.S. prenatal/obstetrical care practices, educating health professionals about Somali women’s fears and educating Somali women about common obstetrical practices are both necessary to improve maternity care for non-Bantu and Bantu Somali women.

Synergistic effects of child abuse and intimate partner violence on depressive symptoms in women.

OBJECTIVE Few population-based studies have examined the association of both child abuse (i.e., physical and sexual abuse) and intimate partner violence (IPV) with depressive symptoms in women. This study estimated the odds of depressive symptoms over the prior week among women exposed to child abuse or IPV alone, and both child abuse and IPV. METHOD Cross-sectional analysis of 7918 women respondents to the 1995 National Violence Against Women Survey (NVAWS). RESULTS The prevalence of self-reported depressive symptoms was 50.2% in women reporting both child abuse and IPV, followed by women reporting IPV (35.7%) or child abuse alone (34.9%), and 25.2% in those with no reported abuse. Multivariable logistic regression found that women who reported both child abuse and IPV had over twice the odds of depressive symptoms than women reporting no abuse (adjusted odds ratio, OR=2.80 95% confidence interval, CI=2.35, 3.32). Smaller, though significantly elevated odds of depression were found among respondents with child abuse only (OR=1.63, 95% CI 1.42, 1.86) and IPV only (OR=1.55, 95% CI 1.30, 1.84). CONCLUSION The results demonstrate a super-additive risk of depressive symptoms in women exposed to both child abuse and IPV, and underscore the adverse psychological effects of these exposures.

They told me to leave: how health care providers address intimate partner violence.

Background: Intimate partner violence (IPV) victims frequently seek medical treatment, though rarely for IPV. Recommendations for health care providers (HCPs) include IPV screening, counseling, and safety referral. The objective of this study was to report womens experiences discussing IPV with HCPs. Methods: This study used structured interviews with women reporting IPV discussions with their HCP; descriptive analyses and bivariate and multivariate analyses were performed, and association with patient demographics and substance abuse was reviewed. We included women from family court; a community-based, inner-city primary care practice; and a tertiary care-based, outpatient psychiatric practice. Results: A total of 142 women participated: 44 from family court (31%), 62 from a primary care practice (43.7%), and 36 from a psychiatric practice (25.4%). Fifty-one percent (n = 72) of patients reported that HCPs knew of their IPV. Of those, 85% (n = 61) told a primary care provider. Regarding IPV attitudes, 85% (n = 61) found their HCP open, and 74% (n = 53) found their HCP knowledgeable. Regarding approaches, 71% (n = 51) believed their HCP advocated leaving the relationship. Whereas 31% (n = 22) received safety information, only 8% (n = 6) received safety information and perceived their HCP as not advocating leaving the abusive relationship. Conclusions: Half of participants disclosed IPV to their HCPs, and most perceived their provider advocated them leaving the relationship. Only 31% reported that HCPs provided safety planning despite increased risks associated with leaving. We suggest HCPs improve safety planning with patients who disclose IPV.

Team huddles: the role of the primary care educator

Background:  The Institute for Healthcare Improvement (USA) has recommended the ‘team huddle’ as one communication strategy to improve health care outcomes.

‘You need a support. When you don’t have that . . . chocolate looks real good’. Barriers to and facilitators of behavioural changes among participants of a Healthy Living Program

BACKGROUND Health behavioural change is complex, especially for underserved patients who have higher rates of obesity and physical inactivity. Behavioural change interventions that show high efficacy in clinical trials may be difficult to disseminate and may not be effective in the office. OBJECTIVE We sought to identify factors that facilitate or hinder behavioural change among past participants of a healthy lifestyle intervention in an urban underserved health centre. METHODS Between March and October 2011, we conducted five focus group sessions with a total of 23 past participants. The focus group transcripts were analysed with a framework approach using the Social Ecological Model as a coding structure. RESULTS We found four interconnected levels of social contexts: individual, interpersonal, programmatic and community levels. Themes of social support and the importance of relationships for making and maintaining behavioural changes were found at all levels. CONCLUSION Social support and relatedness were key facilitators of healthy lifestyle changes and influenced individual motivation and perseverance. Harnessing the power of social support and motivation may be a way for future behavioural change interventions to bridge the gap between efficacy and effectiveness.

Seeking a wider lens for scientific rigor in emerging fields: The case of the primary care behavioral health model.

In response to widespread recognition of the need to blend biomedical and psychosocial health care efforts, the primary care behavioral health (PCBH) model has achieved rapid uptake across the United States. Reports of its application come from military sectors, community health centers, and a variety of health care systems, large and small. Examining the PCBH models appeal, evidence, and design forces us to confront important questions. These questions and much more are addressed in this issue of Families, Systems, & Health. (PsycINFO Database Record

What Can Primary Care Learn From Sports Teams

Teams are familiar to sports but relatively new to primary care. In this perspective, we use sports teams to illustrate key principles from team science and extract practical lessons for primary care teams. The most notable lessons include the need for continuous team learning based on presession planning and postsession debriefing, real-world team training focused on identified teamwork needs, and on-site team coaching. Implementation of these principles requires organizational commitment coupled with alignment of continuing medical education and recertification requirements with primary care teamwork competencies.

How do we know when to celebrate

This editorial presents a brief historical overview of emerging knowledge since the 1970s that led to the birth of a new discipline, Family Practice (now Family Medicine). Family Medicine residencies were required to include training on mental health, family dynamics, communication skills, and other behavioral science topics. The next two decades witnessed an explosion of clinical research. High users of general medical services were found to have a two- to threefold higher prevalence of mental illness. These patients consumed disproportionate amounts of health care dollars, suggesting that cost containment may require mental health treatment. Over the last 30 years researchers have demonstrated that combining biomedical and psychosocial expertise in collaborative treatment models produces better outcomes for patients with mental illness, with physical illness, and for the majority who have a complicated mixture of biopsychosocial ailments. The advent of collaboration between disciplines and the integration of service designs is something to celebrate. In this issue of Families, Systems and Health, representatives of eight organizations, spanning behavioral health, nursing, medicine, and interdisciplinary practice, all endorse behavioral health integration in the health home. (PsycINFO Database Record (c) 2014 APA, all rights reserved).

Call it 'jiffy boob': what's lacking when care has assembly-line efficiency.

Productivity at a breast care center is laudable, but not if interactions with scared or vulnerable patients lose the individualized human touch.