The COVID-19 pandemic was a prolonged period of traumatic stress with potentially lasting health impacts, especially for vulnerable groups including pregnant individuals. Prenatal stress has been associated with greater risk of neurodevelopmental disorders (NDD), warranting investigation of prenatal pandemic-related traumatic stress (PTS) as a risk factor for NDD. We surveyed Kaiser Permanente Northern California (KPNC) members who were ≥ 12 weeks pregnant between June 2020 and September 2022. PTS was measured using the 10-item PTS Scale and modeled as a continuous total symptom score (range: 0–10) and binary exposure (high, ≥ 9; low, < 9). We prospectively followed children through July 2025 and linked to sociodemographic and medical characteristics, including NDD diagnoses, in KPNC electronic records. We fit Cox regression models adjusted for maternal age, race and ethnicity, insurance type, SARS-CoV-2 infection, pre-pregnancy BMI, pre-pregnancy depression, child birthyear and sex to estimate hazard ratios (HR) for any NDD and separately for autism spectrum disorder (ASD) associated with PTS and evaluated effect modification by child sex. Of 13,859 mothers, 21.1

BACKGROUND:Even after recognition of depression in primary care, rates of treatment initiation remain low, particularly among some racial and ethnic groups. This pilot randomized controlled trial examined the feasibility and preliminary efficacy of a tailored outreach intervention to improve depression treatment initiation. METHODS:Across two health systems, 309 adults from Asian, Native Hawaiian, Other Pacific Islander, Black or African American, and Hispanic backgrounds who received a new depression diagnosis in primary care but failed to initiate treatment within 30 days were randomized 1:1 to usual care or the outreach intervention. The intervention utilized patient portal messages or telephone contact based on depression severity, employing motivational interviewing techniques. The primary outcome was treatment initiation within 60-days post-randomization. RESULTS:Nearly three quarters (72%) of intervention participants were successfully reached. The intervention group demonstrated significantly higher treatment initiation rates compared to usual care (24.2% vs. 5.9%, p < .001), representing a four-fold increase. Participants who were reached were more likely to initiate treatment than those not reached (31.9% vs. 4.5%, p < .001). Both groups showed significant reductions in PHQ-9 scores at follow-up. CONCLUSIONS:This pilot trial demonstrates that a staged outreach intervention using patient portals and telephone contact is feasible and shows promise for improving depression treatment initiation in racial and ethnic groups historically less likely to initiate treatment.

BACKGROUND:Postpartum depression affects 1 in 7 women in the U.S. and antidepressant medications during pregnancy are recommended by obstetric and psychiatric professional societies for select patients with a history of depressive disorders. However, prenatal antidepressant medication use remains controversial, and current evidence does not allow conclusions regarding prenatal antidepressant medication effectiveness in preventing postpartum depression. OBJECTIVE:To determine postpartum depression risk in women stopping versus continuing antidepressant medications during pregnancy and examine if risk varies by race, ethnicity, age, and prenatal depressive symptoms. We hypothesized continuing prenatal antidepressant medications would be associated with lower postpartum depression risk. STUDY DESIGN:This retrospective cohort study, conducted in a large, diverse, integrated community-based health care system, included patients ≥18 years old with a live birth between 2010-2019 and depression taking antidepressant medication in the year prior to their last menstrual period. Exclusion criteria included bipolar, psychotic, or active substance use disorders. Based on medication fill history, patients were classified as continuing, stopping then restarting, or stopping antidepressant medications during pregnancy. Postpartum depression was defined as an international classification of diseases diagnostic code or a patient health questionnaire (PHQ)-9 score of ≥10 up to a year after delivery. PHQ-9 scores of 0-4 define none-minimal, 5-9 mild, 10-14 moderate, 15-19 moderately-severe, and ≥20 severe symptoms. RESULTS:Of 6,552 patients who continued (n=2,216), stopped then restarted (n=1,258), or stopped (n=3,078) antidepressant medications during pregnancy, 37.7% (n=2,469) developed postpartum depression. Compared to continuing, stopping then restarting or stopping antidepressant medications during pregnancy was associated with a higher risk of postpartum depression (adjusted relative risk (aRR)=1.14, 95%CI:1.05-1.24 and 1.14, 95%CI:1.06-1.22 moderate-severe depression and 1.33, 95%CI:1.09-1.62 severe depression for stopping). Risk was higher for patients with at least mild depressive symptoms at the first pregnancy depression screening (50.8% of patients; aRR=1.55; 95%CI 1.45-1.65), and highest for women with symptoms and stopping their antidepressant during pregnancy (aRR=2.72, 95%CI 1.94-3.82) compared to patients continuing antidepressants with none-minimal depressive symptoms. There were no statistically significant interactions by race, ethnicity, or age. CONCLUSIONS:Antidepressant medications during pregnancy may benefit patients with past depressive disorders to prevent postpartum depression. Depressive symptom severity during pregnancy may inform shared treatment decision-making between patients and prescribers.

OBJECTIVE:To evaluate whether adverse childhood experiences (ACEs) and resilience assessed during routine prenatal care were associated with same-day mental health referral. METHODS:We conducted a retrospective cohort study of 52,527 pregnant individuals aged ≥18 years in Kaiser Permanente Northern California whose pregnancies began between January 1, 2022, and June 1, 2024, lasted ≥20 weeks, and included ACEs screening. All data were accessed via the electronic health record (EHR). ACEs were categorized as zero, one, two-three, or ≥ four; Road to Resilience scores as low (<15) or normal/high (≥15). The primary outcome was same-day EHR-documented referral; sensitivity analyses assessed referral within 14 days. Modified Poisson regression estimated adjusted prevalence ratios (aPRs) and confidence intervals (CIs), controlling for patient, clinician, and facility characteristics. RESULTS:Overall, 1.4% received same-day referral. Same-day referral increased with one ACE (aPR = 1.45, 95% CI:1.14,1.84), two-three ACEs (aPR = 2.08, 95% CI:1.67,2.59), and ≥ four ACEs (aPR = 3.39, 95% CI:2.78,4.13; p-trend<0.0001). Low resilience was also associated with referral (aPR = 2.28, 95% CI:1.93,2.68). CONCLUSIONS:ACE and resilience scores were associated with prenatal mental health referral even after adjusting for existing mental health risk factors.

Objective: The objective was to identify demographic and clinical characteristics associated with postpartum depression (PPD) risk in patients with depressive disorder histories. Method: This retrospective cohort study used electronic health records from a US health care system including patients aged >= 18 years with a live birth and International Classification of Diseases (/CD)-coded depression in the year before their last menstrual period between January1, 2010, and December 31, 2019. Modified Poisson regression evaluated associations, with PPD defined as an ICD code or a Patient Health Questionnaire-9 (PHQ-9) score of >= i 0 in the year after delivery. A PHQ-9 score of >= 20 defined severe PPD. Results: Of 6,552 patients, 37.7% screened positive for PPD. Asian/Pacific Islander, Black, and LatinX patients had significantly higher PPD risk (adjusted risk ratio [aRR]=1.54; 95% CI, 1.18-2.01; aRR =1.65; 95% CI, 1.25-2.17; and aRR =1.29; 95% CI, 1.06-1.58, respectively, for severe symptoms). Patients with low median incomes (aRR =1.33; 95% CI, 1.02-1.73) or Medicaid insurance (aRR =1.09; 95% CI, 1.02-1.28) had higher PPD risk. Higher antidepressant dosing before pregnancy, PPD history, stopping antidepressants during pregnancy, and moderate-severe depressive symptoms early in pregnancy were associated with severe PPD risk (aRR =1.34; 95% CI, 1.02-1.76; aRR =1.31; 95% CI, 1.21-1.41; aRR =1.14; 95% CI, 1.08-1.20; aRR =3.58; 95% CI, 2.77-4.61, respectively). Higher parity was associated with lower PPD risk (aRR = 0.90; 95% CI, 0.84-0.98 for land aRR = 0.90; 95% CI, 0.83-0.99 for 2+). Age, multiple gestations, or delayed prenatal care start were not associated with risk. Conclusions: Patients with a depressive disorder history have specific characteristics associated with PPD risk, which differ from the general pregnant population. These findings can help improve PPD screening and personalized care delivery.

Objective:Prenatal cannabis use is associated with adverse pregnancy and neonatal outcomes, but research on its association with child anxiety and depressive disorders is limited. This study aimed to test the hypothesis that prenatal cannabis use is associated with child anxiety or depressive disorder diagnoses. Method:Population-based retrospective birth cohort study of children (N = 115,553) born between 1/1/2011-12/31-2017 to pregnant individuals (N = 97,376) universally screened for prenatal cannabis use. Cox proportional hazards regression models examined associations between cannabis use during early pregnancy (at ∼8-10 weeks gestation based on self-reported use or a positive urine toxicology test for delta-9-tetrahydrocannabinol [THC]) and child anxiety and depressive disorders from ages 6 to 13 years based on diagnosis codes, adjusting for maternal sociodemographic and clinical characteristics. Results:The median age at pregnancy onset was 31 (inter quartile range [IQR] = 6) years. Most pregnancies (61.4%) were to non-White individuals; 4.4% screened positive for any cannabis use; 3.7% had a positive toxicology test and 1.9% self-reported use. Overall, 9,230 children were diagnosed with an anxiety disorder at median age of 8 (IQR = 3) years and 1,224 with depressive disorder at median age of 9 (IQR = 3) years. Prenatal cannabis use was associated with a lower risk of child anxiety disorders (aHR:0.84, 95%CI: 0.75-0.95), which remained significant when defined by a toxicology test but not by self-report. Maternal prenatal cannabis use was not associated with child depressive disorders (aHR:1.15, 95%CI: 0.85-1.54). Conclusions:Prenatal cannabis use during early pregnancy was not associated with an increased risk of offspring early onset anxiety or depressive disorders.

BACKGROUND:Posttraumatic stress disorder (PTSD) is often underdiagnosed based on medical records. This study aimed to estimate the prevalence and health care utilization of individuals with PTSD and other trauma-related disorders in a large, integrated health care system. METHODS:Adults (between the ages of 18 and 65) with Kaiser Permanente Northern California membership and ≥ 1 outpatient visit in 2022 were eligible. Unspecified/other specified trauma and stressor-related disorder, acute stress disorder, and PTSD were based on diagnosis codes from the International Classification of Diseases, 10th Revision, Clinical Modification. The Primary Care PTSD (PC-PTSD) Scale was used as a screening tool. Prevalence was assessed overall and among the subset of patients seen in primary care, psychiatry, and addiction medicine. To contextualize health care utilization, the authors compared patients with trauma-related disorders to those with major depressive disorder. RESULTS:Of the 2,128,670 eligible adults, the overall prevalence of trauma-related diagnoses and positive screening on PC-PTSD was 4.9% (103,947); 1.3% (n = 27,670) had PTSD, 1.9% (n = 41,205) had unspecified/other specified trauma and stressor-related disorder, 0.1% (n = 1818) had acute stress disorder, and 1.6% (n = 33,254) screened positive on PC-PTSD without a trauma-related International Classification of Diseases code. Prevalence of trauma-related diagnoses by department was 18.3% (n = 47,516) in psychiatry, 16.5% (n = 3816) in addiction medicine, and 3.4% (n = 67,469) in primary care. There were no clinically meaningful differences in health care utilization between those with trauma-related diagnoses compared with major depressive disorder. CONCLUSION:Broadly defining trauma-related disorders and substantial symptoms may provide a more accurate representation of the actual prevalence of PTSD in a health care system. These data may help health care leaders plan treatment options for this diverse group of individuals.

This was a retrospective cohort study of pregnant individuals in the Kaiser Permanente Northern California system who were screened for adverse childhood experiences and resilience as part of standard prenatal care at about 16 weeks of gestation. Overall, 14,625 pregnancies were included; 17.0% had newly identified depression; 9.8% had newly identified depression symptoms; and 8.9% had newly identified anxiety during the pregnancy with no known preexisting diagnosis. We found that adverse childhood experiences and low resilience were independently associated with newly identified depressive disorders, depression symptoms, and anxiety disorders during pregnancy. When adverse childhood experiences and resilience were modeled in combination, the greatest odds of each outcome occurred in individuals with a combination of four or more adverse childhood experiences and low resilience (vs no adverse childhood experiences and high resilience): depression adjusted odds ratio (aOR) 6.43 (95% CI, 5.23–7.90), depression symptoms aOR 9.49 (95% CI, 7.50–12.0), and anxiety disorder aOR 4.79 (95% CI, 3.81–6.02). Routine screening for adverse childhood experiences and resilience may identify individuals at risk of developing prenatal depression and anxiety, allowing faster resource linkage and potentially improved maternal and child outcomes.

Background and Hypothesis Long-acting injectable (LAI) antipsychotics improve patient outcomes and are recommended by treatment guidelines for patients with limited medication adherence in schizophrenia spectrum, bipolar, and other psychotic disorders. Reports of LAI antipsychotic use in these disorders and if use aligns with treatment guidelines are lacking. This study aimed to report patient characteristics associated with LAI antipsychotic use in these disorders. Study Design Retrospective observational study of patients >= 18-years-old with bipolar or psychotic disorders at a large, integrated, community-based health system. Patient demographic and clinical characteristics served as exposures for the main outcome of adjusted odds ratio (aOR) for LAI versus oral antipsychotic medication use from January 1, 2017 to December 31, 2023. Study Results There were N = 2685 LAI and N = 31 531 oral antipsychotic users. Being non-white (aOR = 1.3-2.0; P < .0001), non-female (aOR = 1.5; P < .0001), from a high deprivation neighborhood (NDI, aOR = 1.3; P < .0007), having a higher body mass index (BMI, aOR = 1.3-1.7; P < .0009), having a schizophrenia/schizoaffective (aOR = 5.8-6.8; P < .0001), psychotic (aOR = 1.6, P < .0001), or substance use disorder (aOR = 1.4; P < .0001), and outpatient psychiatry (aOR = 2.3-7.5; P < .0001) or inpatient hospitalization (aOR = 2.4; P < .0001) utilization in the prior year with higher odds and age >= 40 (aOR = 0.4-0.7; P < .0001) or bipolar disorder (aOR = 0.9; P < .05) were associated with lower odds of LAI use. Non-white, non-female, age 18-39, and high NDI patients had higher LAI use regardless of treatment adherence markers. Smoking and cardiometabolic markers were also associated with LAI use. Conclusions Demographic and clinical factors are associated with increased LAI use irrespective of treatment adherence. Research on utilization variation informing equitable formulation use aligned with treatment guideline recommendations is warranted.

Background: While the number of digital therapeutics (DTx) has proliferated, there is little real-world research on characteristics of providers recommending DTx, their recommendation behaviors, or the characteristics of patients receiving recommendations in the clinical setting. Objective: The aim of this study was to characterize the clinical and demographic characteristics of patients receiving recommendations and describe provider characteristics and behaviors regarding DTx. Methods: This retrospective cohort study used electronic health record data from a large, integrated health care delivery system. Demographic and clinical characteristics of adult patients recommended versus not recommended DTx by a mental health provider between May 2020 and December 2021 were examined. A cross-sectional survey of mental health providers providing these recommendations was conducted in December 2022 to assess the characteristics of providers and recommendation behaviors related to DTx. Parametric and nonparametric tests were used to examine statistical significance between groups. Results: Of 335,250 patients with a mental health appointment, 53,546 (16%) received a DTx recommendation. Patients recommended to DTx were younger, were of Asian or Hispanic race or ethnicity, were female, were without medical comorbidities, and had commercial insurance compared to those without a DTx recommendation (P<.001). P <.001). More patients receiving a DTx recommendation had anxiety or adjustment disorder diagnoses, but less had depression, bipolar, or psychotic disorder diagnoses (P<.001) P <.001) versus matched controls not recommended to DTx. Overall, depression and anxiety symptom scores were lower in patients recommended to DTx compared to matched controls not receiving a recommendation, although female patients had a higher proportion of severe depression and anxiety scores compared to male patients. Provider survey results indicated a higher proportion of nonprescribers recommended DTx to patients compared to prescribers (P=.008). P =.008). all providers, 29.4% (45/153) reported using the suggested internal electronic health record-based tools (eg, smart text) recommend DTx, and of providers recommending DTx resources to patients, 64.1% (98/153) reported they follow up patients to inquire on DTx benefits. Only 38.4% (58/151) of respondents report recommending specific DTx modules, and those, 58.6% (34/58) report following up on the impact of these specific modules. Conclusions: DTx use in mental health was modest and varied by patient and provider characteristics. Providers do not appear to actively engage with these tools and integrate them into treatment plans. Providers, while expressing interest in potential benefits from DTx, may view DTx as a passive strategy to augment traditional treatment for select patients.

Clinical mental health researchers may understandably struggle with how to incorporate biological assessments in clinical research. The options are numerous and are described in a vast and complex body of literature. Here we provide guidelines to assist mental health researchers seeking to include biological measures in their studies. Apart from a focus on behavioral outcomes as measured via interviews or questionnaires, we advocate for a focus on biological pathways in clinical trials and epidemiological studies that may help clarify pathophysiology and mechanisms of action, delineate biological subgroups of participants, mediate treatment effects, and inform personalized treatment strategies. With this paper we aim to bridge the gap between clinical and biological mental health research by (1) discussing the clinical relevance, measurement reliability, and feasibility of relevant peripheral biomarkers; (2) addressing five types of biological tissues, namely blood, saliva, urine, stool and hair; and (3) providing information on how to control sources of measurement variability.

Purpose: To examine changes in addiction medicine treatment utilization during the COVID-19 pandemic among adolescents (aged 13-17 years) and differences by race/ethnicity. (March to December 2019, n = 1,770) and COVID-19 (March to December 2020, n = 1,177) using treatment utilization across both periods. Changes in utilization over time did not differ by race/ the pandemic, especially via telehealth. Although racial/ethnic disparities in treatment utilization (c) 2024 Society for Adolescent Health and Medicine. All rights reserved.

Objective: While collaborative care is known to improve depressive and anxiety symptoms in primary care, comparative effectiveness studies of virtual collaborative care versus virtual specialty psychiatry treatment in real world settings are lacking. This study examined patient depressive and anxiety symptoms over 6 months in collaborative care versus specialty psychiatry. Methods: This was an observational study with target trial emulation in a large, community-based, integrated health care system. Participants were ≥18 years old with mild-moderate depressive or anxiety symptoms measured by the Patient Health Questionnaire-9 or Generalized Anxiety Disorder-7 Scale. Exclusion criteria included acute suicide risk. Patients were assigned to collaborative care or specialty psychiatry, and symptoms were measured 6 months after treatment initiation using linear mixed-effects regression with inverse probability of treatment weighting. Results: There were N = 10,380 patients (n = 1,607 in collaborative care; n = 8,773 in specialty psychiatry) with depressive disorders and N = 2,935 (n = 570 in collaborative care; n = 2,365 in specialty psychiatry) with anxiety disorders. Model effects at 6 months showed significant symptom improvement for patients in collaborative care (adjusted mean difference [AMD] = -9.0, 95% CI, -9.7, -8.4 for depression; -5.4, 95% CI, -6.2, -4.7 for anxiety) and in specialty psychiatry (AMD = -5.0, 95% CI, -5.6, -4.5 for depression; -2.8, 95% CI, -3.6, -2.1 for anxiety), with patients in collaborative care showing significantly greater improvement compared to those in specialty psychiatry (AMD = -4.0, 95% CI, -4.7, -3.3, P < .0001 for depression; AMD = -2.6, 95% CI, -3.4, -1.8, P < .0001 for anxiety). Conclusions: Virtual collaborative care was at least as effective as specialty psychiatry for depression and anxiety. Collaborative care implementation can support national guidelines regarding depression and anxiety screening and treatment.

BACKGROUND:People with HIV (PWH) are at elevated risk for suicidal ideation (SI), yet few studies have examined how substance use, clinical and sociodemographic factors are associated with SI among PWH. METHOD:We used substance use (Tobacco, Alcohol, Prescription Medication, and Other Substance Use [TAPS]) and depression (PHQ-9) data from computerized screening of adult PWH in primary care clinics in Northern California, combined with health record data on psychiatric diagnoses, HIV diagnosis, treatment, and control (HIV RNA, CD4), insurance, and neighborhood deprivation index (NDI) to examine factors associated with SI (PHQ-9 item 9 score > 0). Adjusted odds ratios (aOR) for SI were obtained from logistic regression models. RESULTS:Among 2829 PWH screened (92 % male; 56 % white; mean (SD) age of 54 (13) years; 220 (8 %) reported SI. Compared with no problematic use, SI was higher among those reporting one (aOR = 1.65, 95 % CI = 1.17, 2.33), two (aOR = 2.23, 95 % CI = 1.42, 3.49), or ≥ 3 substances (aOR = 4.49, 95 % CI = 2.41, 8.39). SI risk was higher for those with stimulant use (aOR = 3.55, 95 % CI = 2.25, 5.59), depression (aOR = 4.18, 95 % CI = 3.04, 5.74), and anxiety diagnoses (aOR = 1.67, 95 % CI = 1.19, 2.34), or Medicaid (aOR = 2.11, 95%CI = 1.24, 3.60) compared with commercial/other insurance. SI was not associated with HIV-related measures or NDI. LIMITATIONS:SI was assessed with a single PHQ-9 item. Simultaneous SI and exposure data collection restricts the ability to establish substance use as a risk factor. CONCLUSIONS:HIV care providers should consider multiple substance use, stimulant use, depression or anxiety, and public insurance as risk factors for SI and provide interventions when needed.

This study aims to compare patterns of ADHD screening before and during the COVID-19 pandemic and to examine comorbid conditions present during the assessment of ADHD. The first hypothesis was that the number of requests for ADHD evaluations increased during the COVID-19 pandemic. The second hypothesis was that the average age at the time of ADHD evaluation request would be higher during the pandemic. The third hypothesis was that there would be an increase in comorbid anxiety and depression during the pandemic. A retrospective analysis was conducted with a cohort study of Kaiser Permanente Northern California South Bay members, under age 18 years, between 9/1/2019 and 3/19/2020 (Cohort 1) and 9/1/2021 and 3/19/2022 (Cohort 2). Electronic health record (EHR) data were used to ascertain patients per cohort for whom the Behavior Assessment System for Children (BASC) evaluation was requested for ADHD screening (age and diagnoses were also extracted). The incidence rate (IR) and IR ratio (IRR) of ADHD screening per 1000 appointments for the cohorts were calculated. Student’s t test was used to compare ages between the 2 cohorts, and the proportions of comorbid depressive and anxiety disorders were determined. The sample included 182 patients (Cohort 1 n = 84 and Cohort 2 n = 98) with a mean age of 8.24 (SD 3.96) and 9.79 (SD 4.95), respectively. Age between the cohorts was not statistically significant (p = .16). The IR for Cohort 1 was 8.13 (95% CI, 7.80-8.46; p < .001). The IR for Cohort 2 was 8.02 (95% CI, 7.67-8.38; p < .001). The IRR was .99 (95% CI, -.16 to 2.13; p = .49). Cohort 1 consisted of 1% of patients with depressive disorders, 7% with anxiety disorders, 2% with both, and 21% with ADHD. Cohort 2 consisted of 7% of patients with depressive disorders, 6% with anxiety disorders, 3% with both, and 11% with ADHD. The results demonstrate no significant changes in the age of patient requesting or the number of ADHD screening requests during the pandemic compared with prepandemic data. There was a slight increase in depressive disorder diagnoses postpandemic. Future studies should include data from primary care, where many youth ADHD evaluations originate, and longitudinal examination of comorbidity patterns with ADHD for fuller assessment of prepandemic and postpandemic trends.

Emotional support animals (ESAs) are different from service animals, therapy animals, and other disability-related assistance animals. Although pet ownership may confer psychological benefits, limited research has supported the use of ESAs to realize such benefits. If clinicians are asked to write a letter of support for use of an ESA, they need to be familiar with relevant federal, state, and local laws that regulate ESAs and with the essential components of an ESA evaluation. This article provides an overview of terminology; federal, state, and local laws related to ESAs; and clinical and ethical considerations for clinicians who decide to write these letters. The authors also review liability issues related to writing these letters, including those related to ESA aggression.

Adverse childhood experiences (ACEs) - defined as abuse, neglect, or household dysfunction before age 18 years - are consistently associated with a higher risk for many chronic health conditions and harmful health behaviors. Many organizations have recommended ACE screening to support preventive medical care and have provided examples of screening strategies. However, despite the consistent evidence linking ACEs with chronic health conditions and harmful health behaviors, routine ACE screening in primary care populations is rarely clinically implemented. The 1998 seminal Kaiser Permanente (KP)-Centers for Disease Control and Prevention ACEs study was born from ACE screening implemented in the Department of Preventive Medicine at KP San Diego in the 1980s. The goal of the 2018 initiative was to build on and advance that earlier work by implementing universal ACE screening in primary care at a KP Northern California site. The KP team included patient service representatives, medical assistants, nurses, physicians, and patients. Team members were first educated about ACEs and screening best practices. The workflow included directions on the ACE screener handout procedure, patient screener completion location, patient screening response documentation, and addressing the results with patients. Hurdles included concerns regarding the time it would take for patients to complete the screening and for providers to review and discuss with the patient, as well as the communication barriers related to topic discomfort among clinicians. Consistent with prior reports, patient resistance or discomfort was not a major hurdle. Metrics to measure implementation focused on ACE screenings completed by clinicians and patient screening refusal rates. Over the course of an 18-month pilot period, only 1% of patients declined screenings and more than 90% of physicians completed the screening process with their primary care patients. Team member education and recognition of ACEs as risk factors for chronic health conditions, a culture of trauma-informed care, and identifying team members who are passionate about ACE screening are necessary preludes to implementation of ACE screening.