Objective The number of adolescents and young adults (AYA) being identified with depressive symptoms is increasing. Unfortunately, there is a paucity of behavioral health (BH) care options for this population, and obtaining care is more challenging in underserved areas. Digital cognitive–behavioral interventions (dCBIs) have been effective in decreasing self-reported depressive symptoms in pediatric patients. We examined the effectiveness of augmenting therapy with dCBI as compared to therapy alone in a multi-site randomized controlled trial (RCT). Method A multi-site RCT was conducted among patients 16 to 22 years of age who were being treated for depressive symptoms within BH collaborative care provided in pediatric primary care settings in Pittsburgh, PA, Boston, MA, and San Diego, CA. Patients were randomized to treatment as usual (TAU) or TAU+dCBI. Data obtained from the dCBI app included the number and type of sessions completed, and engagement with an asynchronous coach within the dCBI. Outcomes of interest were scores on the Patient Health Questionnaire (PHQ-9), the Children’s Depression Rating Scale—Revised (CDRS-R), the Generalized Anxiety Disorder (GAD-7), the Satisfaction with Life Scale (SWLS), and Children’s Global Assessment Scale (CGAS), obtained at baseline, 6 weeks, and 12 weeks. Intent-to-treat analyses used linear mixed-effects models to test the effect of treatment group, adjusting for gender, race, and other treatment (antidepressants, behavioral therapy) at baseline. Additional per protocol analyses examined treatment differences when the analysis was restricted to engaged users. Sensitivity analyses further examined the effect among those without other BH treatment at baseline. Results A total of 185 participants were randomized and enrolled: 73 in TAU and 112 in TAU+dCBI. Mean age was 17.8 (1.66) years; 57% were White, 75% were female, and 48% had public insurance. Among participants randomized to TAU+dCBI, the mean number of techniques used was 5.5 ± 5.7. A total of 61% (n = 68) used at least 3 techniques and were considered engaged users. In intent-to-treat (n = 112) and per protocol (n = 107) analyses, there were no statistically significant differences between TAU and TAU+dCBI on any of the outcome measurements. However, among those without other treatment at baseline (n = 36), those randomized to TAU+dCBI had a significantly greater decrease in CDRS-R over 12 weeks relative to TAU. In this subgroup of 36 participants, the estimated within-person change for TAU+dCBI was d (95% CI) = 0.86 (0.59, 1.13) vs only 0.19 (−0.20, 0.58) for TAU (β = −0.21, 95% CI = −0.35, −0.06, p = .01, for the group-by-time interaction term). Conclusion We did not find a significantly different change in depressive symptoms between patients randomized to TAU+dCBI vs TAU. However, sensitivity analyses suggested that the app may be more effective among subgroups without other treatment options for behavioral health. As only 60.7% of those randomized to the TAU+dCBI study arm engaged with the app, future studies should include ways to promote engagement. The potential effects of dCBI should be further explored, as apps offer a convenient, non-stigmatizing means of accessing therapy techniques to supplement traditional therapy. Given the digital acceptance and familiarity among AYAs, this could be a promising means of providing needed access to therapy at a time when therapy options are scarce. Clinical trial registration information Study to Compare the Use of a Behavioral Health App Versus Care and Usual for 16-22 Year Olds with Depression; https://clinicaltrials.gov/study/NCT05159713

We identified 3 centrally mediated disorders of gastrointestinal pain in the context of epidemiology, pathophysiology, clinical evaluation, and treatment, including pharmacotherapy, brain-gut behavioral therapy and neuromodulation, with an emphasis on the importance of the physician-patient relationship. Centrally mediated abdominal pain syndrome is characterized by chronic abdominal pain. It has 2 main categories: category A, when the pain occurs without association with physiological events, and category B, when there is a variable association of pain with physiological events. Centrally mediated abdominal pain is thought to be predominantly a result of central sensitization with altered processing of visceral pain by spinal and brain networks rather than heightened peripheral afferent nerve excitability. Abdominal migraine is newly recognized in adults with paroxysmal, stereotypical episodes of intense abdominal pain. Narcotic bowel syndrome, or opioid-induced gastrointestinal hyperalgesia, is characterized by the paradoxical development of, or increases in, abdominal pain associated with continuous or increasing dosages of opioids.

The patient-centered medical home (PCMH) model is increasingly being recognized as the standard of care in primary care settings. Emerging evidence from large academic hospitals found supports for extending the concepts behind the PCMH to specialist-led integrated care models such as the specialty medical home (SMH), where a team of multidisciplinary specialists work together to care for patients with specific conditions. To explore the scalability of the SMH model to other medical conditions and clinical settings. We conducted semi-structured interviews with 10 patients and 11 providers of chronic and costly, immuno-inflammatory conditions (rheumatologic conditions and endometriosis) to understand relevance and feasibility of scaling the SMH model. Two coders iteratively analyzed the interview transcripts using a codebook, then summarized codes into themes. All patients found the SMH model to be relevant to their care, while providers believed the resource-intensive model may only be necessary for a subset of patients. Patients and providers discussed disease complexity, specialists involved, social determinants of health, and disease/life stages as factors they would consider when deciding the relevance of the model to other conditions. Providers and patients also discussed practical implementation factors such as strength of evidence, cost of care, need for specialty staff, geographical access, and technology as factors that would influence the scaling the SMH model. The SMH model is of interest to patients and providers. Findings illustrate key factors that needed to be addressed by future research to build a case for scaling the SMH model.

Introduction:Digital mental health treatments (DMHTs) have begun to be implemented in some healthcare systems across the United States. These implementations are conducted as business arrangements. Thus, information on successful or unsuccessful implementations is not published or disseminated. This slows progress, as experiences and learnings are siloed within each organization, hindering or preventing learning across implementations and slowing the progress. To address this, the Society for Digital Mental Health established a DMHT Implementation Workgroup, with the goal of developing a DMHT Playbook that describes current best practices in DMHT implementation in American healthcare settings. Methods:The workgroup was comprised of representatives from 7 healthcare systems and 10 DMHT companies that have conducted implementations, along with other stakeholders and technical experts. The workgroup met virtually to discuss implementation of effective DMHT implementation processes and inform the development of an interview guide, which was then administered to another 20 key opinion leaders with DMHT implementation experience. Concepts and thematic constructs were extracted by experts in qualitative data analysis. These findings were discussed and refined by the Workgroup based on the Workgroup's experience. Results:The resulting playbook includes detailed methods, processes and procedures, representing practices that have been successful for implementing DMHTs in healthcare settings. Discussion:The workgroup recognizes that DMHT implementation is a rapidly evolving field. The successful practices for DMHT implementation described in this playbook may be useful for improving the efficiency of future DMHT implementations in American healthcare systems. However, the authors caution that as the field rapidly evolves, successful implementation practices will likely evolve as well.

Approximately 1.4 million Americans struggle with inflammatory bowel disease (IBD),1 and 25% of cases are diagnosed during childhood.2 The peak age of incidence is adolescence and young adulthood, although patients frequently develop IBD later in life as well.3 Certain ethnicities, particularly Whites and Ashkenazi Jews, have higher rates of IBD; however, IBD is seen in numerous different ethnic groups, and rates of diagnosis as a whole are rising.4,5 It is unknown whether this increase in diagnosis is secondary to better detection methods or to an actual increase in numbers of affected patients.

Background Studies have found a higher risk of comorbid anxiety and depression among patients with inflammatory bowel disease (IBD) compared with healthy individuals. If left untreated, comorbid depression and anxiety in patients with IBD can lead to poorer health outcomes and an increased healthcare utilization. The goal of this work was to develop a consensus statement to begin to address patient and provider needs and responsibilities related to screening and treatment of depression and anxiety symptoms among patients with IBD.Methods A literature scan was conducted to gather evidence-based background information and recommendations on the screening, diagnosis, and treatment of anxiety and depression in patients with IBD. This was followed by the engagement of a panel of IBD and mental health experts and patient advocates using a modified Delphi process to synthesize the literature and distill the information into a core set of statements to support provider actions and care delivery.Results Six statements were distilled from the literature and consensus process that link to the general management, screening, and treatment of anxiety and depression in patients with IBD.Conclusions Mental healthcare and support for IBD patients is critical; the statements included in this article represent practical considerations for IBD healthcare professionals in addressing key issues on provider awareness, knowledge and behaviors, screening and treatment resources, and patient education. This work aimed to develop a consensus statement on screening and treatment of anxiety and depression in individuals with inflammatory bowel disease. A literature scan was conducted, and an expert panel developed practical statements to guide inflammatory bowel disease healthcare professionals. Graphical Abstract

Objective To characterise subphenotypes of self-reported symptoms and outcomes (SRSOs) in postacute sequelae of COVID-19 (PASC).Design Prospective, observational cohort study of subjects with PASC.Setting Academic tertiary centre from five clinical referral sources.Participants Adults with COVID-19 ≥20 days before enrolment and presence of any new self-reported symptoms following COVID-19.Exposures We collected data on clinical variables and SRSOs via structured telephone interviews and performed standardised assessments with validated clinical numerical scales to capture psychological symptoms, neurocognitive functioning and cardiopulmonary function. We collected saliva and stool samples for quantification of SARS-CoV-2 RNA via quantitative PCR.Outcomes measures Description of PASC SRSOs burden and duration, derivation of distinct PASC subphenotypes via latent class analysis (LCA) and relationship with viral load.Results We analysed baseline data for 214 individuals with a study visit at a median of 197.5 days after COVID-19 diagnosis. Participants reported ever having a median of 9/16 symptoms (IQR 6–11) after acute COVID-19, with muscle-aches, dyspnoea and headache being the most common. Fatigue, cognitive impairment and dyspnoea were experienced for a longer time. Participants had a lower burden of active symptoms (median 3 (1–6)) than those ever experienced (p<0.001). Unsupervised LCA of symptoms revealed three clinically active PASC subphenotypes: a high burden constitutional symptoms (21.9%), a persistent loss/change of smell and taste (20.6%) and a minimal residual symptoms subphenotype (57.5%). Subphenotype assignments were strongly associated with self-assessments of global health, recovery and PASC impact on employment (p<0.001) as well as referral source for enrolment. Viral persistence (5.6% saliva and 1% stool samples positive) did not explain SRSOs or subphenotypes.Conclusions We identified three distinct PASC subphenotypes. We highlight that although most symptoms progressively resolve, specific PASC subpopulations are impacted by either high burden of constitutional symptoms or persistent olfactory/gustatory dysfunction, requiring prospective identification and targeted preventive or therapeutic interventions.

Journal of Clinical Gastroenterology ():10.1097/MCG.0000000000001970, January 29, 2024. | DOI: 10.1097/MCG.0000000000001970

DESCRIPTION:Pain is a common symptom among patients with inflammatory bowel disease (IBD). Although pain typically occurs during episodes of inflammation, it is also commonly experienced when intestinal inflammation is quiescent. Many gastroenterologists are at a loss how to approach pain symptoms when they occur in the absence of gut inflammation. We provide guidance in this area as to the evaluation, diagnosis, and treatment of pain among patients with IBD. METHODS:This CPU was commissioned and approved by the AGA Institute Clinical Practice Updates Committee (CPUC) and the AGA Governing Board to provide timely guidance on a topic of high clinical importance to the AGA membership and underwent internal peer review by the CPUC and external peer review through standard procedures of Gastroenterology. This expert commentary incorporates important as well as recently published studies in this field, and it reflects the experiences of the authors. Formal ratings regarding the quality of evidence or strength of the presented considerations were not included because systematic reviews were not performed.

Introduction Despite promising outcomes, lack of engagement and poor adherence are barriers to treating mental health using digital CBT, particularly in minority groups. After conducting guided focus groups, a current mental health app was adapted to be more inclusive for minorities living with SCD. Methods Patients between the ages of 16–35 with SCD who reported experiencing anxiety or depression symptoms were eligible for this study. Once enrolled, participants were randomly assigned to receive one of two versions of a mental health app: 1) the current version designed for the general population or 2) the adapted version. Baseline measures for depression, anxiety, pain, and self-efficacy were completed at the start of the study and again at post-intervention (minimum 4 weeks). Results Compared to baseline, mean scores for pain decreased an average of 3.29 ( p = 0.03) on a 10-point scale, self-efficacy improved 3.86 points ( p = 0.007) and depression symptoms decreased 5.75 points ( p = 0.016) for the group that received the adapted app. On average, control participants engaged with the app 5.64 times while the participants in the experimental group engaged 8.50 times ( p = 0.40). Regardless of group assignment, a positive relationship ( r = 0.47) was shown between app engagement and a change in depression symptoms ( p = 0.042). Discussion Target enrollment for this study sought to enroll 40 participants. However, after difficulties locating qualified participants, enrollment criteria were adjusted to expand the population pool. Regardless of these efforts, the sample size for this study was still smaller than anticipated ( n = 21). Additionally, irrespective of group approximately 40% of participants did not engage with the app. However, despite a small sample size and poor engagement, this study 1) demonstrated the feasibility of implementing socially relevant changes into a mental health app and 2) indicated that participants in the intervention group displayed better outcomes and showed trends for greater app interaction. Conclusion These promising results should encourage future researchers to continue exploring ideal adaptations for implementing digital CBT in minority populations. Future studies should also consider implementing post-intervention surveys to help identify common factors relating to a lack of engagement. Trial registration This trial (NCT04587661) was registered on August 12th, 2020.

The COVID-19 pandemic resulted in increased feelings of emotional distress and disruptions in care across diverse patients subgroups, including those with chronic medical conditions such as inflammatory bowel diseases (IBD). We sought to understand the impact of the pandemic on the physical and emotional well-being of individuals with IBD and concurrent depression and/or anxiety symptoms. We conducted qualitative interviews after the beginning of the pandemic with 46 adults with IBD. Participants reported increased levels of emotional distress, feelings of social isolation, and uncertainty over whether IBD medications put them at increased risk. Young adults discussed feeling as if their lives had been disrupted. In addition, several individuals demonstrated resiliency and emphasized positives about the pandemic, including increased connectivity with family and friends, the convenience of being able to work from home despite their IBD symptoms, and lessened feelings of “missing out.” Our findings highlight several opportunities to improve the health and well-being of individuals with IBD and beyond including increased support for combatting social isolation, enhanced counseling about medication risks and benefits, and the incorporation of resiliency skills building.

Adolescents and young adults frequently experience anxiety and depression. The authors evaluated engagement in and effects of a coach-enhanced digital cognitive-behavioral intervention (dCBI; RxWell) targeting emotional distress in this age group. The dCBI app was prescribed to 506 adolescents and young adults at 35 pediatric practices; 278 enrolled in the app, of whom 58% engaged and 63% messaged their coach. Patients completed monthly General Anxiety Disorder-7 and eight-item Patient Health Questionnaire assessments, and a subset completed qualitative interviews. The dCBI app was associated with a significant reduction in anxiety and depression at 1 and 3 months. A dCBI is feasible as part of routine pediatric care and associated with reduced emotional distress.

Mood disorders (anxiety, depression), sleep disorders, and catastrophizing lead to increased post-operative pain perception, increase in postoperative opioid consumption, decreased engagement with physical activity, and increased resource utilization in surgical patients. Psychosocial disorders significantly affect postoperative outcome. Unfortunately, studies focused on perioperative psychological assessment and treatment are scarce. We propose to test whether digital cognitive behavioral intervention (dCBI) can help surgical patients. dCBI such as RxWell™ is a proven treatment for mood disorders in medical patients such as reducing depression in patients with inflammatory bowel disease. We hypothesize that RxWell™ will also be effective in surgical patients. This study aims to test whether RxWell™ can improve preoperative mood disorders and subsequently reduce postoperative pain and opioid requirement in patients scheduled for primary total hip and knee arthroplasty (THA, TKA). We named the trial as the SuRxgWell trial. This is a randomized, controlled trial that will enroll primary and unilateral THA or TKA patients with anxiety and/or depression symptoms before surgery to receive the SuRxgWell dCBI program and investigate its impact on postoperative outcomes including postoperative pain, anxiety, depression, sleep disorder, and catastrophizing. After signing an informed consent, subjects will be screened using the PROMIS questionnaires, and subjects with a T-score of ≥ 60 on the short Patient-Reported Outcomes Measurement Information System (PROMIS) 4a Anxiety and/or short PROMIS 4a Depression questionnaires will be randomized to either usual care (control group) or the cognitive behavioral intervention, RxWell™, plus usual care (intervention group). The control group will receive information on how to locate tools to address anxiety and depression, whereas the intervention group will have access to SuRxgWell 1 month prior to surgery and up to 3 months after surgery. The allocation will be 3:1 (intervention to control). Investigators will be blinded, but research coordinators approaching patients and research subjects will not. The primary outcome will be day of surgery anxiety or depression symptoms measured with the PROMIS Short Form v1.0 -Anxiety 4a/Depression and Generalized Anxiety Disorder Measure (GAD-7) and Patient Health Questionnaire (PHQ-8). Secondary end points include measuring other health-related quality of life outcomes including sleep disturbance, fatigue, ability to participate in social roles, pain interference, cognitive function, pain catastrophizing, and physical function. Other secondary outcomes include collecting data about preoperative and postoperative pain scores, and pain medication usage, and orthopedic functional recovery at baseline, day of surgery, and 1, 2, and 3 months after the surgery with the Pain Catastrophizing Scale, the Knee injury and Osteoarthritis Outcome Score (KOOS), and Hip injury and Osteoarthritis Outcome Score (HOOS). In addition, subjects will be asked to complete a GAD-7 and PHQ-8 questionnaires bi-weekly (via the RxWell™ app for the interventional group or REDCAP for the control group). Data about postsurgical complications, and resource utilization will also be recorded. We will also receive monthly reports measuring the usage and engagement of RxWell use for each participant randomized to that arm. The primary hypotheses will be assessed with intention-to-treat estimates, and differences in primary outcome will be tested using independent two sample t-tests. This trial is registered to the ClinicalTrials.gov database (NCT05658796) and supported by the DAPM, UPMC Health Plan, and the NIH. Our trial will evaluate the feasibility of digital cognitive behavioral intervention as a perioperative tool to improve anxiety and depression before and after major orthopedic surgery in comparison to education. If digital cognitive behavioral intervention proves to be effective, this might have important clinical implications, reducing the incidence of chronic postsurgical pain and improving outcomes.