Specialty addiction and psychiatry treatment initiation and engagement: Results from an SBIRT randomized trial in pediatrics

Abstract

Objective Many adolescents needing specialty addiction or psychiatry treatment never access care. We examined initiation and engagement with addiction and/or psychiatry treatment among adolescents referred to treatment from a trial comparing two different modalities of delivering Screening, Brief Intervention and Referral to Treatment (SBIRT) to Usual Care in pediatric primary care. We hypothesized that both intervention arms would have higher initiation and engagement rates than usual care. Methods We randomized all pediatricians (n=52) in a pediatric primary care clinic to three arms: 1) pediatrician-only arm, in which pediatricians were trained to deliver SBIRT for substance use and/or mental health problems; 2) embedded-behavioral health clinician (embedded-BHC arm), in which pediatricians referred adolescents who endorsed substance use and/or mental health problems to a BHC; and 3) Usual Care (UC). We used electronic health record (EHR) data to examine specialty addiction and psychiatry treatment initiation and engagement rates after referral. Results Among patients who screened positive for substance use and/or mental health problems and were referred to specialty addiction and/or psychiatry (n=333), those in the embedded-BHC arm had almost four times higher odds of initiating treatment than those in the pediatrician-only arm, OR=3.99, 95% CI=[1.99-8.00]. Compared to UC, those in the pediatrician-only arm had lower odds of treatment initiation (OR=0.53, 95% CI=[0.28-0.99]), while patients in the embedded-BHC arm had marginally higher odds (OR=1.83, 95% CI=[0.99-3.38]). Black patients and those with other/unknown race/ethnicity had lower odds of treatment initiation compared with white adolescents; there were no gender or age differences. We found no differences in treatment engagement across the three arms. Conclusions Embedded BHCs can have a significant positive impact on facilitating treatment initiation for pediatric primary care adolescents referred to addiction and/or psychiatry services.

Psychiatric Comorbidity and Healthcare Effectiveness Data and Information Set (HEDIS) Measures of Alcohol and other Drug Treatment Initiation and Engagement across 7 Health Care Systems

“…21 Our findings underscore the importance of regular screening for both psychiatric and AOD use disorders in outpatient settings and providing immediate brief intervention, such as screening, brief intervention, and referral to treatment (SBIRT), which can improve access to specialty AOD care. 22 Importantly, although identification of a comorbid psychiatric disorder may increase the chances that an individual will initiate AOD treatment, rates of initiation and engagement in AOD treatment remain low overall. Nonetheless, special focus may be needed to enhance initiation and engagement in AOD treatment, especially for individuals without a comorbid psychiatric disorder, given the lower treatment uptake among this group.…”

Effect of Computer-Based Substance Use Screening and Brief Behavioral Counseling vs Usual Care for Youths in Pediatric Primary Care

“…30 Additionally, we found that pediatric practitioners were able to deliver the brief intervention in only a few minutes, which bodes well for widespread adoption of the approach. Other studies of brief interventions in youth primary care have relied on standalone computer programs or trained therapists to deliver the intervention, 31,32 which may be financially impractical for smaller pediatric group practices to implement.…”

Implementing SBIRT for adolescents within community mental health organizations: A mixed methods study

“…Although there is limited comparable research, one study examining the efficacy of SBIRT among patients with depression in an integrated behavioral health program found a similar rate of positive screenings, although the sample population was adults (Chan, Huang, Bradley, & Unützer, 2014). Another three-arm randomized trial testing the effectiveness of SBIRT among adolescents using two different modalities – embedded behavioral health clinicians versus pediatric clinicians – compared to usual care in a pediatric primary care clinic found that 36% of youth screened positive to either a substance use or mental health condition (Sterling et al, 2017). The high rates of positive screenings also align with previously reported prevalence estimates of co-occurring substance use and mental health conditions among adolescents in clinical settings, ranging from 55% to 64% (Grella, Hser, Joshi, & Rounds-Bryant, 2001; Sterling & Weisner, 2006), suggesting the importance of screening in mental health settings.…”

“…For example, a study implementing a BI to adolescents at risk for SUDs in an emergency department reported that 47% and 32% of those receiving a BI at the 4- and 12-month follow ups, respectively, attended treatment in the community (Tait, Hulse, & Robertson, 2004; Tait, Hulse, Robertson, & Sprivulis, 2005). A recent study of SBIRT implementation in a pediatric primary care setting found that approximately 36% of all adolescents screened were considered for further assessment, BI, or RT (Sterling et al, 2017). Rates of treatment initiation were highest among patients who received SBIRT delivered by a behavioral health clinician versus pediatrician only or usual care (Sterling et al, 2017) demonstrating the value of integrated care models.…”