Center for Mental Health Services Research Dissemination Activities

Introduction The University of Massachusetts Medical School (UMMS) Center for Mental Health Services Research (CMHSR) conducts research to enhance services, improve the quality of life, and promote recovery for people with behavioral health conditions. The Center was founded in 1993 as a Massachusetts Department of Mental Health Research Center of Excellence. Center faculty receive funding from a variety of federal, state and foundation sources. The Center’s focus on community-based research and engagement with providers, consumers and families also carries the message of hope for the many adults, children, adolescents and families living with mental illness. The Mental Health Agency Research Network (MHARN) expands on the dissemination and research functions of CMHSR to reach providers serving DMH clients across the Commonwealth of Massachusetts. The goals of the MHARN include Dissemination, Engagement and Collaboration as a way to facilitate the translation of research findings into practice and bring together providers with researchers to engage in new research on services provided in the community. Four Research Subject Areas: Child, Youth & Family Mental Health Law, Ethics & Mental Health Multicultural Research Rehabilitation, Recovery & Wellness The Dissemination Series Products for a diverse audience including clinicians/providers, mental health service users and their families, and researchers. Psychiatry Issue Briefs Issue briefs focus on translating research findings into concise, user-friendly information that is accessible to all Research You Can Use A one-page summary of research findings and recommendations specifically developed for busy providers Research in the Works Summarizes current and ongoing research project

Barriers and Facilitators to Addressing Perinatal Depression in Obstetric Settings

Background: Perinatal depression is common and can cause suffering for mother, fetus/child and family. The perinatal period is an ideal time to detect and treat depression due to regular contact between mothers and health professionals. Despite the opportune time and setting, depression is under-diagnosed and under-treated in the obstetric setting. Caring and committed providers are frustrated and confused, and mothers do not feel heard or understood by their providers. Objectives: (1) Identify postpartum women’s perspective on how perinatal depression is addressed in obstetric settings; (2) Identify strategies for improvement of the delivery of depression care in OB/Gyn settings; and, (3) Inform the development of interventions aimed to improve the delivery of perinatal depression care in obstetric settings. Methods: Four, two hour focus groups were conducted women 3 months – 3 years postpartum (n=27), who identified experiencing symptoms of perinatal depression. Focus group data were analyzed using a grounded theory approach. Results: Participants reported individual, provider and systems-level barriers and facilitators to seeking perinatal depression treatment. Women reported feeling stigmatized, afraid of losing parental rights, and described negative experiences with medical providers, including feeling dismissed by providers and uncomfortable discussing mental health concerns. A lack of provider knowledge and skill sets to address depression was noted by participants. Participants recommended an integrated approach, including psycho-education, peer-support, and provider education/training to improve perinatal depression care in the obstetric setting. Conclusion: Individual, provider and systems-level barriers hinder women from addressing issues of perinatal depression and receiving appropriate care. These data suggest strategies that integrate depression and obstetric care to support OB/Gyns providers and staff in their roles as front line providers to perinatal women. Future efforts could focus on the development of multidisciplinary treatment strategies that utilize patient psychoeducation and provider training and education to overcome barriers and engage women in depression treatment

Relationships as Key to Recovery for Perinatal Women Living with Depression

Findings from a study of women with lived experience of depression during and after pregnancy, specific to what is helpful, what are barriers and how to affect change

Why Are Outcomes Different for Registry Patients Enrolled Prospectively and Retrospectively? Insights from the Global Anticoagulant Registry in the FIELD-Atrial Fibrillation (GARFIELD-AF).

Background: Retrospective and prospective observational studies are designed to reflect real-world evidence on clinical practice, but can yield conflicting results. The GARFIELD-AF Registry includes both methods of enrolment and allows analysis of differences in patient characteristics and outcomes that may result. Methods and Results: Patients with atrial fibrillation (AF) and ≥1 risk factor for stroke at diagnosis of AF were recruited either retrospectively (n = 5069) or prospectively (n = 5501) from 19 countries and then followed prospectively. The retrospectively enrolled cohort comprised patients with established AF (for a least 6, and up to 24 months before enrolment), who were identified retrospectively (and baseline and partial follow-up data were collected from the emedical records) and then followed prospectively between 0-18 months (such that the total time of follow-up was 24 months; data collection Dec-2009 and Oct-2010). In the prospectively enrolled cohort, patients with newly diagnosed AF (≤6 weeks after diagnosis) were recruited between Mar-2010 and Oct-2011 and were followed for 24 months after enrolment. Differences between the cohorts were observed in clinical characteristics, including type of AF, stroke prevention strategies, and event rates. More patients in the retrospectively identified cohort received vitamin K antagonists (62.1% vs. 53.2%) and fewer received non-vitamin K oral anticoagulants (1.8% vs . 4.2%). All-cause mortality rates per 100 person-years during the prospective follow-up (starting the first study visit up to 1 year) were significantly lower in the retrospective than prospectively identified cohort (3.04 [95% CI 2.51 to 3.67] vs . 4.05 [95% CI 3.53 to 4.63]; p = 0.016). Conclusions: Interpretations of data from registries that aim to evaluate the characteristics and outcomes of patients with AF must take account of differences in registry design and the impact of recall bias and survivorship bias that is incurred with retrospective enrolment. Clinical Trial Registration: - URL: http://www.clinicaltrials.gov . Unique identifier for GARFIELD-AF (NCT01090362)

Improved risk stratification of patients with atrial fibrillation: an integrated GARFIELD-AF tool for the prediction of mortality, stroke and bleed in patients with and without anticoagulation.

OBJECTIVES: To provide an accurate, web-based tool for stratifying patients with atrial fibrillation to facilitate decisions on the potential benefits/risks of anticoagulation, based on mortality, stroke and bleeding risks. DESIGN: The new tool was developed, using stepwise regression, for all and then applied to lower risk patients. C-statistics were compared with CHA2DS2-VASc using 30-fold cross-validation to control for overfitting. External validation was undertaken in an independent dataset, Outcome Registry for Better Informed Treatment of Atrial Fibrillation (ORBIT-AF). PARTICIPANTS: Data from 39 898 patients enrolled in the prospective GARFIELD-AF registry provided the basis for deriving and validating an integrated risk tool to predict stroke risk, mortality and bleeding risk. RESULTS: The discriminatory value of the GARFIELD-AF risk model was superior to CHA2DS2-VASc for patients with or without anticoagulation. C-statistics (95% CI) for all-cause mortality, ischaemic stroke/systemic embolism and haemorrhagic stroke/major bleeding (treated patients) were: 0.77 (0.76 to 0.78), 0.69 (0.67 to 0.71) and 0.66 (0.62 to 0.69), respectively, for the GARFIELD-AF risk models, and 0.66 (0.64-0.67), 0.64 (0.61-0.66) and 0.64 (0.61-0.68), respectively, for CHA2DS2-VASc (or HAS-BLED for bleeding). In very low to low risk patients (CHA2DS2-VASc 0 or 1 (men) and 1 or 2 (women)), the CHA2DS2-VASc and HAS-BLED (for bleeding) scores offered weak discriminatory value for mortality, stroke/systemic embolism and major bleeding. C-statistics for the GARFIELD-AF risk tool were 0.69 (0.64 to 0.75), 0.65 (0.56 to 0.73) and 0.60 (0.47 to 0.73) for each end point, respectively, versus 0.50 (0.45 to 0.55), 0.59 (0.50 to 0.67) and 0.55 (0.53 to 0.56) for CHA2DS2-VASc (or HAS-BLED for bleeding). Upon validation in the ORBIT-AF population, C-statistics showed that the GARFIELD-AF risk tool was effective for predicting 1-year all-cause mortality using the full and simplified model for all-cause mortality: C-statistics 0.75 (0.73 to 0.77) and 0.75 (0.73 to 0.77), respectively, and for predicting for any stroke or systemic embolism over 1 year, C-statistics 0.68 (0.62 to 0.74). CONCLUSIONS: Performance of the GARFIELD-AF risk tool was superior to CHA2DS2-VASc in predicting stroke and mortality and superior to HAS-BLED for bleeding, overall and in lower risk patients. The GARFIELD-AF tool has the potential for incorporation in routine electronic systems, and for the first time, permits simultaneous evaluation of ischaemic stroke, mortality and bleeding risks. CLINICAL TRIAL REGISTRATION: URL: http://www.clinicaltrials.gov. Unique identifier for GARFIELD-AF (NCT01090362) and for ORBIT-AF (NCT01165710)

Two-year outcomes of patients with newly diagnosed atrial fibrillation: results from GARFIELD-AF.

AIMS: The relationship between outcomes and time after diagnosis for patients with non-valvular atrial fibrillation (NVAF) is poorly defined, especially beyond the first year. METHODS AND RESULTS: GARFIELD-AF is an ongoing, global observational study of adults with newly diagnosed NVAF. Two-year outcomes of 17 162 patients prospectively enrolled in GARFIELD-AF were analysed in light of baseline characteristics, risk profiles for stroke/systemic embolism (SE), and antithrombotic therapy. The mean (standard deviation) age was 69.8 (11.4) years, 43.8% were women, and the mean CHA2DS2-VASc score was 3.3 (1.6); 60.8% of patients were prescribed anticoagulant therapy with/without antiplatelet (AP) therapy, 27.4% AP monotherapy, and 11.8% no antithrombotic therapy. At 2-year follow-up, all-cause mortality, stroke/SE, and major bleeding had occurred at a rate (95% confidence interval) of 3.83 (3.62; 4.05), 1.25 (1.13; 1.38), and 0.70 (0.62; 0.81) per 100 person-years, respectively. Rates for all three major events were highest during the first 4 months. Congestive heart failure, acute coronary syndromes, sudden/unwitnessed death, malignancy, respiratory failure, and infection/sepsis accounted for 65% of all known causes of death and strokes for <10%. Anticoagulant treatment was associated with a 35% lower risk of death. CONCLUSION: The most frequent of the three major outcome measures was death, whose most common causes are not known to be significantly influenced by anticoagulation. This suggests that a more comprehensive approach to the management of NVAF may be needed to improve outcome. This could include, in addition to anticoagulation, interventions targeting modifiable, cause-specific risk factors for death. CLINICAL TRIAL REGISTRATION: http://www.clinicaltrials.gov. Unique identifier: NCT01090362

Risk profiles and one-year outcomes of patients with newly diagnosed atrial fibrillation in India: Insights from the GARFIELD-AF Registry.

BACKGROUND: The Global Anticoagulant Registry in the FIELD-Atrial Fibrillation (GARFIELD-AF) is an ongoing prospective noninterventional registry, which is providing important information on the baseline characteristics, treatment patterns, and 1-year outcomes in patients with newly diagnosed non-valvular atrial fibrillation (NVAF). This report describes data from Indian patients recruited in this registry. METHODS AND RESULTS: A total of 52,014 patients with newly diagnosed AF were enrolled globally; of these, 1388 patients were recruited from 26 sites within India (2012-2016). In India, the mean age was 65.8 years at diagnosis of NVAF. Hypertension was the most prevalent risk factor for AF, present in 68.5% of patients from India and in 76.3% of patients globally (P < 0.001). Diabetes and coronary artery disease (CAD) were prevalent in 36.2% and 28.1% of patients as compared with global prevalence of 22.2% and 21.6%, respectively (P < 0.001 for both). Antiplatelet therapy was the most common antithrombotic treatment in India. With increasing stroke risk, however, patients were more likely to receive oral anticoagulant therapy [mainly vitamin K antagonist (VKA)], but average international normalized ratio (INR) was lower among Indian patients [median INR value 1.6 (interquartile range {IQR}: 1.3-2.3) versus 2.3 (IQR 1.8-2.8) (P < 0.001)]. Compared with other countries, patients from India had markedly higher rates of all-cause mortality [7.68 per 100 person-years (95% confidence interval 6.32-9.35) vs 4.34 (4.16-4.53), P < 0.0001], while rates of stroke/systemic embolism and major bleeding were lower after 1 year of follow-up. CONCLUSION: Compared to previously published registries from India, the GARFIELD-AF registry describes clinical profiles and outcomes in Indian patients with AF of a different etiology. The registry data show that compared to the rest of the world, Indian AF patients are younger in age and have more diabetes and CAD. Patients with a higher stroke risk are more likely to receive anticoagulation therapy with VKA but are underdosed compared with the global average in the GARFIELD-AF. CLINICAL TRIAL REGISTRATION-URL: http://www.clinicaltrials.gov. Unique identifier: NCT01090362

Women\u27s perspectives on postpartum depression screening in pediatric settings: a preliminary study

This preliminary study is the first to identify mothers\u27 perspectives on barriers and facilitators to addressing postpartum depression (PPD) in pediatric settings. We conducted four 90-min focus groups with women (n = 27) who self-identified a history of perinatal depression and/or emotional complications. Barriers reported included stigma and fear among women and lack of provider knowledge/skills regarding depression. Participants recommended non-stigmatizing approaches to depression screening/referral. Future PPD screening efforts should leverage the pediatrician-mother relationship to mitigate mothers\u27 fears and encourage help-seeking

Patient\u27s views on depression care in obstetric settings: how do they compare to the views of perinatal health care professionals

OBJECTIVES: The objectives were to examine patients\u27 perspectives on patient-, provider- and systems-level barriers and facilitators to addressing perinatal depression in outpatient obstetric settings. We also compare the views of patients and perinatal health care professionals. METHOD: Four 90-min focus groups were conducted with women 3-36 months after delivery (n=27) who experienced symptoms of perinatal depression, anxiety or emotional distress. Focus groups were transcribed, and resulting data were analyzed using a grounded theory approach. RESULTS: Barriers to addressing perinatal depression included fear of stigma and loss of parental rights, negative experiences with perinatal health care providers and lack of depression management knowledge/skills among professionals. Facilitators included psychoeducation, peer support and training for professionals. CONCLUSIONS: Patients perceive many multilevel barriers to treatment that are similar to those found in our previous similar study of perinatal health care professionals\u27 perspectives. However, patients and professionals do differ in their perceptions of one another. Interventions would need to close these gaps and include an empathic screening and referral process that facilitates discussion of mental health concerns. Interventions should leverage strategies identified by both patients and professionals, including empowering both via education, resources and access to varied mental health care options

Patient, provider, and system-level barriers and facilitators to addressing perinatal depression

Objective: To explore perinatal health care professionals’ perspectives on barriers and facilitators to addressing perinatal depression. Background: Perinatal depression is common and associated with deleterious effects on mother, foetus, child and family. Although the regular contact between mothers and perinatal health care professionals may make the obstetric setting ideal for addressing depression, barriers persist, and depression remains under-diagnosed and under-treated. Methods: Four 90-minute focus groups were conducted with perinatal health care professionals, including obstetric resident and attending physicians, licensed independent practitioners, nurses, patient care assistants, social workers and administrative support staff. Focus groups were transcribed, and resulting data were analysed using a grounded theory approach. Results: Participants identified patient-, provider- and system-level barriers and facilitators to addressing perinatal depression. Provider-level barriers included lack of resources, skills and confidence needed to diagnose, refer and treat perinatal depression. Limited access to mental health care and resources were identified as system-level barriers. Facilitators identified included targeted training for perinatal health care professionals’, structured screening and referral processes, and enhanced support and guidance from mental health providers. Conclusion: A complex set of interactions between women and perinatal health care professionals contributes to perinatal depression being untreated. Service gaps could be closed by addressing identified barriers through integrated obstetric and depression care and enhanced collaborations. Future intervention testing could include targeted training, improved access, and mental health provider support to empower perinatal health care professionals’ to address perinatal depression, and thereby improve delivery of depression treatment in obstetric settings