QuestionDoes a 6-month collaborative care intervention, tailored for low-resource settings, improve clinical outcomes for adults with opioid use disorder and co-occurring depression and/or posttraumatic stress disorder more so than enhanced usual care?FindingsIn this randomized clinical trial of 797 participants, collaborative care showed no evidence of improved outcomes compared to enhanced usual care. Both groups improved over the 6-month follow-up.MeaningThe findings suggest that for clinically complex patients, collaborative care may not be more effective than enhanced usual care; explanations include the potential for spillover, spontaneous improvement, and the fit of collaborative care for this population and setting. ImportanceAdults with opioid use disorder (OUD), co-occurring with depression and/or posttraumatic stress disorder (PTSD), may benefit from collaborative care. Although collaborative care is an evidence-based model to treat behavioral health conditions in primary care, it has not been widely tested for OUD with co-occurring mental illness.ObjectiveTo determine whether collaborative care, tailored for low-resource settings, improves outcomes for patients with OUD and co-occurring depression and/or PTSD more so than enhanced usual care (EUC).Design, Setting, and ParticipantsThis 2-group single-masked pragmatic randomized clinical trial was conducted in 18 primary care clinics in California and New Mexico from January 8, 2021, to December 5, 2023, and included adult participants with probable OUD as well as major depression and/or PTSD. Data analysis was performed August 2024 to May 2025.InterventionsSix months of a care manager and addiction psychiatrist working with a primary care practitioner to deliver evidence-based treatments for OUD, major depression, and PTSD; care managers were community health workers who monitored and addressed biopsychosocial symptoms and referred patients for psychotherapy.Main Outcomes and MeasuresPrimary outcomes at 6 months were time to first filled buprenorphine prescription for participants entering the study not taking medication for OUD; cumulative days of prescribed buprenorphine for participants entering the study while not taking methadone, obtained from the state Prescription Drug Program; and Patient Health Questionnaire-9 and PTSD Checklist for DSM-5 scores from participant surveys. Secondary outcomes included days of opioid and other drug use, the Patient-Reported Outcomes Measurement Information System's substance use short form, and the Veterans RAND 12-item health survey.ResultsOf 2396 participants assessed for eligibility, 797 were randomized (397 to EUC; 400 to intervention); 433 (54.3%) were female and 364 (45.7%) male, with a mean (SD) age of 40.2 (11.9) years. Six-month survey retention was 68% for EUC and 64% for collaborative care. Adjusted mean (SD) differences on primary outcomes for collaborative care vs EUC were: 7.0 (95% CI, -3.4 to 17.4; P = .19) for days until first buprenorphine prescription; 4.3 (95% CI, -7.4 to 16.0; P = .47) for cumulative days of prescribed buprenorphine; -1.0 (95% CI, -2.3 to 0.3; P = .13) for Patient Health Questionnaire-9 score; and -0.9 (95% CI, -4.6 to 2.8; P = .63) for PTSD Checklist for the DSM-5 score; none were statistically significant. There were also no observed differences between groups for any secondary or exploratory outcomes; both groups improved over baseline. As-treated exploratory analyses showed evidence for improvements in OUD outcomes in the as-treated population.Conclusions and RelevanceThis randomized clinical trial found that among participants with OUD co-occurring with depression and/or PTSD, collaborative care did not demonstrate evidence of greater improvements in outcomes compared with EUC. Explanations include a possible spillover effect, spontaneous improvement, or the fit of collaborative care for clinically complex patients and settings with few behavioral health practitioners.Trial RegistrationClinicalTrials.gov Identifier: NCT04559893 and NCT04634279 This randomized clinical trial investigates whether collaborative care, tailored for patients with opioid use disorder and co-occurring depression and/or posttraumatic stress disorder, improves outcomes more so than enhanced usual care.

BACKGROUND AND AIMS:Individuals with opioid use disorder (OUD) frequently present with co-occurring mental health conditions such as depression and posttraumatic stress disorder (PTSD), along with other mental health substance use disorders, physical health conditions and social determinants that together comprise 'clinical complexity.' Collaborative care (CC), a primary care-based behavioral health integration model, aims to improve outcomes through coordinated, patient-centered treatment. This study examined heterogeneity in baseline clinical complexity among participants in the CLARO (Collaboration Leading to Addiction Treatment and Recovery from Other Stresses) trial and assessed whether the effects of CC versus enhanced usual care (EUC) differed across clinical complexity groups. METHODS:Secondary analysis of CLARO, a pragmatic randomized clinical trial (n = 797) of CC versus EUC for adults with OUD and depression and/or PTSD, conducted in 18 low-resourced primary care clinics in New Mexico and California, USA. Latent class analysis of baseline data identified subgroups defined by mental health and substance use as the main characteristics along with physical health and social challenges. Six-month treatment effects were estimated using one-step models that jointly estimated latent class membership and class-specific outcomes, incorporating class × treatment interactions. Outcomes included depression symptom severity, PTSD symptom severity, and buprenorphine utilization and prescribing duration. RESULTS:Three subgroups were identified: (1) low complexity (43%), with relative clinical and social stability; (2) mental health complexity (34%), with high psychiatric symptoms but lower substance use and moderate social adversity; and (3) high dual complexity (23%). Compared with EUC, CC was associated with lower depression severity at follow-up for the low-complexity class, but not for other classes. CC and EUC did not differ statistically significantly with respect to PTSD outcomes in any class. Buprenorphine utilization and prescribing duration outcomes were similar across CC and EUC treatment arms. CONCLUSIONS:The effects of collaborative care may vary according to patients' baseline clinical complexity. Collaborative care appears to be associated with more favorable depression outcomes than enhanced usual care among participants with lower clinical complexity but not among those with higher clinical complexity.

OBJECTIVE:The authors aimed to examine the relationship between characteristics of patients and health systems and receipt of mental health treatment among patients assigned to collaborative care (CC) for opioid use disorder co-occurring with depression, posttraumatic stress disorder (PTSD), or both. METHODS:This secondary analysis used data from the intervention arm (N=400 participants) of a randomized clinical trial of CC, implemented in 18 low-resourced clinics, for patients with opioid use disorder co-occurring with depression, PTSD, or both. Outcomes were receipt of psychiatric medication or counseling during the 6-month intervention, as obtained from the electronic health records data or a caseload tracking tool. Baseline characteristics were assessed by using t tests for continuous variables and chi-square tests for categorical and binary measures. Adjusted logistic regression was used to identify associations between treatment receipt and characteristics; predicted probabilities for covariates were used to demonstrate effect size. RESULTS:Of the patients, 51% received psychiatric medication and 44% received counseling. In the adjusted models, co-use of stimulants was associated with less likelihood of receiving psychiatric medication (adjusted odds ratio [AOR]=0.95) or counseling (AOR=0.92), as was lower education. Male sex and health system characteristics were associated with a lower likelihood of receiving counseling; non-Hispanic ethnicity and more severe depression and PTSD symptoms were associated with a greater likelihood of receiving counseling. CONCLUSIONS:Even within CC settings, substantial unmet need for mental health treatment remained, particularly among individuals co-using stimulants. Future research should examine additional support to increase mental health treatment among individuals with co-occurring disorders.

Depression and/or posttraumatic stress disorder (PTSD) commonly co-occur with opioid use disorder (OUD), and such co-occurring disorders (COD) are especially common among patients in primary care settings. Therefore, addressing the mental health needs of people with COD in primary care is essential. We compared the characteristics of three groups of patients who screened positive for OUD and depression and/or PTSD: (OUD + depression, OUD + PTSD, and OUD + depression + PTSD) and examined how membership in these groups was associated with suicidality and treatment. We analyzed cross-sectional baseline survey data from a larger study of collaborative care for COD. 797 adult patients were seen in 17 primary care clinics that provide care for diverse uninsured and underinsured patients in New Mexico and California. Our key independent variable was COD group. Dependent variables were suicidal ideation and behavior; and receipt of treatments for COD 30 days prior to baseline. The patient group with all three conditions was larger than the other groups with only two disorders (OUD + PTSD (no depression) or OUD + depression (no PTSD). Patients with all three disorders reported more severe OUD, depression, and PTSD symptoms and higher probability of suicidality. Patients with PTSD (with or without depression) were more likely to report receiving medication for OUD and mental health counseling compared to those with no PTSD, and those with OUD, PTSD, and depression were more likely to report receiving medication for mental health problems than those with just two disorders. Higher probabilities of suicidality and of receiving mental health treatment among those with all three disorders point to the need for identifying these individuals in primary care. Clinicaltrials.gov, Identifiers, Registration Dates: NCT0455989; NCT04559893, September 8, 2020.

Importance:Adults with opioid use disorder (OUD), co-occurring with depression and/or posttraumatic stress disorder (PTSD), may benefit from collaborative care. Although collaborative care is an evidence-based model to treat behavioral health conditions in primary care, it has not been widely tested for OUD with co-occurring mental illness. Objective:To determine whether collaborative care, tailored for low-resource settings, improves outcomes for patients with OUD and co-occurring depression and/or PTSD more so than enhanced usual care (EUC). Design, Setting, and Participants:This 2-group single-masked pragmatic randomized clinical trial was conducted in 18 primary care clinics in California and New Mexico from January 8, 2021, to December 5, 2023, and included adult participants with probable OUD as well as major depression and/or PTSD. Data analysis was performed August 2024 to May 2025. Interventions:Six months of a care manager and addiction psychiatrist working with a primary care practitioner to deliver evidence-based treatments for OUD, major depression, and PTSD; care managers were community health workers who monitored and addressed biopsychosocial symptoms and referred patients for psychotherapy. Main Outcomes and Measures:Primary outcomes at 6 months were time to first filled buprenorphine prescription for participants entering the study not taking medication for OUD; cumulative days of prescribed buprenorphine for participants entering the study while not taking methadone, obtained from the state Prescription Drug Program; and Patient Health Questionnaire-9 and PTSD Checklist for DSM-5 scores from participant surveys. Secondary outcomes included days of opioid and other drug use, the Patient-Reported Outcomes Measurement Information System's substance use short form, and the Veterans RAND 12-item health survey. Results:Of 2396 participants assessed for eligibility, 797 were randomized (397 to EUC; 400 to intervention); 433 (54.3%) were female and 364 (45.7%) male, with a mean (SD) age of 40.2 (11.9) years. Six-month survey retention was 68% for EUC and 64% for collaborative care. Adjusted mean (SD) differences on primary outcomes for collaborative care vs EUC were: 7.0 (95% CI, -3.4 to 17.4; P = .19) for days until first buprenorphine prescription; 4.3 (95% CI, -7.4 to 16.0; P = .47) for cumulative days of prescribed buprenorphine; -1.0 (95% CI, -2.3 to 0.3; P = .13) for Patient Health Questionnaire-9 score; and -0.9 (95% CI, -4.6 to 2.8; P = .63) for PTSD Checklist for the DSM-5 score; none were statistically significant. There were also no observed differences between groups for any secondary or exploratory outcomes; both groups improved over baseline. As-treated exploratory analyses showed evidence for improvements in OUD outcomes in the as-treated population. Conclusions and Relevance:This randomized clinical trial found that among participants with OUD co-occurring with depression and/or PTSD, collaborative care did not demonstrate evidence of greater improvements in outcomes compared with EUC. Explanations include a possible spillover effect, spontaneous improvement, or the fit of collaborative care for clinically complex patients and settings with few behavioral health practitioners. Trial Registration:ClinicalTrials.gov Identifier: NCT04559893 and NCT04634279.

GOAL:Solutions to address healthcare worker well-being since the COVID-19 pandemic have been tested with varying acceptance and effectiveness. Little is known about how the values underpinning medical professionalism might be leveraged to support healthcare workers during a public health emergency. We sought to characterize the experiences of frontline physicians and nurses during the pandemic through the lens of medical professionalism and identify potential levers that could be activated in future emergencies to better protect the healthcare workforce. METHODS:We conducted semistructured interviews with 23 physicians and nurses who worked in emergency departments, ICUs, or other acute care settings at two urban teaching hospitals at the start of the pandemic. Interviews were conducted in spring and summer 2022, and were audio recorded, transcribed, and thematically analyzed. PRINCIPAL FINDINGS:Three themes emerged reflecting different orientations of professionalism that helped clinicians persevere through the pandemic but were also threatened by the most challenging stages of the pandemic: (1) the call of duty to a greater good (service orientation); (2) a shared identity as a specialized professional (team orientation); and (3) the ability to maintain a human connection with their patients (humanistic orientation). These central orientations of professionalism helped healthcare workers to continue providing care during the pandemic by focusing on achieving a greater good in the face of unprecedented challenges, accessing a shared identity with other healthcare workers to find peer support and maintain a sense of pride in their work, and finding ways to connect on a personal level with patients and families despite strict isolation requirements and fear for personal safety. When these values were not realized, or when they were noticeably absent, healthcare workers felt discouraged, abandoned or alone, and burned out. PRACTICAL APPLICATIONS:Leveraging common aspects of medical professionalism during a public health emergency may help healthcare workers find meaning in their work and mitigate feelings of burnout. Simple actions, such as maintaining a leadership presence on the floors, encouraging peer-to-peer activities or huddles, and acknowledging the need for human connection, are likely feasible to implement during an emergency and effective at fostering a sense of professional community that could buoy healthcare workers during extremely challenging times.

Opioid use disorder, mental health conditions, and housing instability are frequently intertwined and have a profound impact on health outcomes. While past research has focused on the opioid use and mental health of people experiencing homelessness, less is known about those experiencing housing instability. We examined the cross-sectional associations between housing status (currently unhoused, unstably housed, and stably housed) and mental health and substance use severity among primary care patients with co-occurring disorders. Data are from a randomized controlled trial, Collaboration Leading to Addiction Treatment and Recovery from other Stresses, which tests the Collaborative Care Model for primary care patients with opioid use disorder and co-occurring depression and/or post-traumatic stress disorder (PTSD). We defined being unhoused as not living in stable housing in the past 3 months and being unstably housed as living in stable housing but being worried or concerned about loss of housing in the next 3 months. We assessed differences in baseline characteristics across the housing groups using ANOVA for continuous variables and chi-squared tests for categorical and binary measures. Adjusted linear regression models were used to assess associations between housing status and mental health and substance use symptom severity scores. Among the 797 patients randomized, 13

Introduction Low-income and underserved populations, especially racial and ethnic minorities, experience health disparities linked to social determinants. The COVID-19 pandemic amplified these disparities, necessitating effective strategies to address structural racism and related factors. Vaccination, crucial for mitigating infectious diseases, including COVID-19 and influenza, remains challenging among underserved populations. Community health worker (CHW) interventions show promise in addressing these disparities but have not undergone rigorous evaluation with a randomized controlled trial to increase vaccination uptake among underserved populations. This study develops and evaluates a CHW vaccination behavior (CHW-VB) intervention to increase COVID-19 and influenza vaccination among adult patients in primary care settings. Methods Tailoring of the Boost Your Health (Refuerza tu Salud) intervention is grounded in behavior change theory and integrates input from a Community Advisory Board. The study employs a patient randomized controlled trial design to test the effectiveness the CHW-VB intervention compared with usual care across six Federally Qualified Health Centers (FQHCs) in New York. Patients are being screened for eligibility (vaccinated but not up to date with the COVID-19 vaccine and have at least one of seven common chronic illnesses) and 800 are assessed at baseline and three months. Outcomes include COVID-19 vaccine (primary) and influenza vaccine (secondary) uptake. The study also evaluates intervention implementation using the RE-AIM model. Conclusion Boost Your Health aims to increase COVID-19 and influenza vaccination among racially/ethnically diverse, underserved populations with chronic illness through the CHW-VB intervention, targeting critical gaps in vaccination uptake to reduce health disparities and increase health equity.Trial registration: (ClinicalTrials.gov NCT06156254).

OBJECTIVE:Concern about psychiatric injuries for first responders has grown. We examine alternatives to workers' compensation (WC). METHOD:We conducted 15 interviews across five California departments contracted with non-WC mental health (MH) providers. We performed content analysis. RESULTS:MH support outside of WC most often was a dedicated contract with outside MH providers for assessment, diagnosis, and treatment. Departments had formal financing mechanisms with union and city support designating funding for MH care. Frustration and past WC experiences drove the desire for WC alternatives. First responders reported high levels of stigma associated with MH care. Compared to WC, these alternatives allowed more comprehensive services to injured workers along with ease of accessing care, expediting the healing process. CONCLUSIONS:Contracting culturally competent MH providers outside of WC for first responders has potential and needs formal evaluation.

PURPOSE:To describe the well-being supports provided to health care workers (HCWs) during the COVID-19 pandemic in health centers and hospitals. DESIGN:Cross-sectional qualitative interviews before and after implementation of a peer-based support intervention. SETTING:Purposively sampled hospitals and health centers across the US. PARTICIPANTS:28 site leaders and 56 HCWs sampled from 16 hospitals and 12 health centers. METHOD:Site leaders and HCWs were asked to describe supports available to HCWs during the COVID-19 pandemic. Thematic and content coding and analysis of interview responses were conducted using Dedoose. RESULTS:Both site leaders and HCWs identified a range of support resources available. Communication resources were the most frequently cited in both groups. Health care workers reported bi-directional communication, while one-way communication was emphasized by site leaders. Hospitals highlighted counseling support, particularly Employee Assistance Programs (EAP), while health centers prioritized community support. Wellness activities were more prevalent in hospital settings, while health centers offered specific workplace-provided training for HCWs. Health care workers encountered barriers when accessing support, including limited time, fear of stigma, and disruptions to their existing support networks attributable to the pandemic. CONCLUSION:While there are resources for HCWs, the available supports may not align with their needs and barriers to access may limit the effectiveness of these supports. Continued engagement between leaders and HCWs could help better align resources with needs.

Health care workers (HCW) faced chronic stress during the COVID-19 pandemic and were at high risk of illness, death and burnout. To understand the experiences of and assess the acceptability and usability of the “Stress First Aid” (SFA) intervention for HCWs. We used a mixed methods approach to conduct: (1) a quantitative post-intervention survey of experiences with the SFA intervention within a cluster randomized controlled trial (cRCT); and (2) a qualitative descriptive analysis. The intervention was rolled out over three waves from March 2021 – October 2022 simultaneously with the sites’ COVID-19 response. Our team engaged and recruited eight pairs of hospitals and six pairs of Federally Qualified Health Centers (FQHCs), balanced across region, including nine states, and matched on size, type, and COVID-19 burden. A total of 862 HCWs received the SFA intervention and completed both the pre- and post-intervention surveys (FQHC n = 245 and hospital n = 617). For the qualitative analysis, among HCWs who agreed to be contacted for a post-intervention interview, we purposively sampled a subset of 35 HCWs balanced by site, gender, age, race/ethnicity and HCW type. SFA is an evidence-informed intervention adapted to mitigate the psychosocial impact of COVID-19 on HCWs through individual peer support actions. Quantitative measures are binary indicators of agreement with 6 questions about experiences with the SFA intervention. For the qualitative analysis, we utilized a semi-structured interview protocol to provide additional context on experience with SFA and how SFA affects HCW well-being. Between 48.2 and 59.4

Frontline healthcare workers (HCWs) have experienced increased levels of stress and burnout during and after the pandemic, resulting in healthcare worker shortages and diminished quality of care for patients. Originally piloted in combat environments, Stress First Aid (SFA) is an evidence-informed intervention that has shown promising results in helping mitigate stress reactions in other high-stress work environments. This article details the adaptation of an SFA intervention using a train-the-trainer model for use in hospitals and healthcare clinics for HCWs during the pandemic. The origins of the principles of SFA, how they were adapted for use with HCWs, and how barriers such as lack of time were addressed by further modifications during the intervention are discussed. These findings may help inform future SFA interventions in healthcare settings during public health crises.

BackgroundThe COVID-19 pandemic has taken a toll on frontline health care workers (HCWs), leading to poor mental and physical well-being. We conducted a large, cluster randomized controlled trial to implement an adapted Stress First Aid (SFA) intervention to support HCW well-being using a train-the-trainer (TTT) approach for rapid deployment in the United States and collected qualitative data through interviews to understand implementation. The goal of this study is to understand barriers and facilitators to deploying SFA using a TTT model, with particular emphasis on the acceptability, uptake, and barriers from the implementation.MethodsWe conducted seven individual and seven group semi-structured qualitative interviews with 28 trainers (i.e., site champions) who delivered SFA training to their local HCWs from Spring 2021 to Winter 2022 in hospitals and health care centers within the United States. We utilized both inductive and deductive approaches to coding transcripts. All transcripts were coded in Dedoose. We used the Consolidated Framework for Implementation Research (CFIR) to rigorously assess implementation experiences.ResultsSite champions highlighted leadership buy-in, protected time and incentives, and teams as implementation facilitators, while implementation barriers included unhelpful training materials and content, time constraints and scheduling difficulties, and pandemic-related factors, such as COVID-19 surges. SFA implementation processes varied: some champions had virtual SFA presentations, while others held informal discussions about SFA material in person. Champions also differed on their perceptions of SFA sustainability: some indicated it would be difficult to sustain SFA in their organization due to limited structure and time, while others stated they would continue to utilize it.ConclusionLimited research has examined the implementation of HCW well-being interventions using a TTT approach in a changing environment. Site champions were able to implement SFA during a period of rapid and frequent change and shared several implementation facilitators and barriers related to the SFA intervention. In the future, addressing the implementation barriers proactively and prioritizing the implementation facilitators may prove to be useful for large-scale interventions implemented during disease outbreaks and pandemics.

Introduction: Posttraumatic stress disorder (PTSD) results in substantial costs to society. Prevalence of PTSD among adults is high, especially among those presenting to primary care settings. Evidence-based psychotherapies (EBPs) for PTSD are available but dissemination and implementation within primary care settings is challenging. Building Experience for Treating Trauma and Enhancing Resilience (BETTER) examines the effectiveness of integrating Written Exposure Therapy (WET) within primary care collaborative care management (CoCM). WET is a brief exposure-based treatment that has the potential to address many challenges of delivering PTSD EBPs within primary care settings. Methods: The study is a hybrid implementation effectiveness cluster-randomized controlled trial in which 12 Federally Qualified Health Centers (FQHCs) will be randomized to either CoCM plus WET (CoCM+WET) or CoCM only with 60 patients within each FQHC. The primary aim is to evaluate the effectiveness of CoCM+WET to improve PTSD and depression symptom severity. Secondary treatment outcomes are mental and physical health functioning. The second study aim is to examine implementation of WET within FQHCs using FQHC process data and staff interviews pre- and post-intervention. Exploratory aims are to examine potential moderators and mediators of the intervention. Assessments occur at baseline, and 3- and 12-month follow-up. Conclusion: The study has the potential to impact practice and improve clinical and public health outcomes. By establishing the effectiveness and feasibility of delivering a brief trauma-focused EBP embedded within CoCM in primary care, the study aims to improve PTSD outcomes for underserved patients. Trial registration: (Clinicaltrials.gov NCT05330442).

Background: Implementing evidence-based practices (EBPs) within service systems is critical to population-level health improvements, but also challenging, especially for complex behavioural health interventions in low-resource settings. 'Mis-implementation' refers to poor outcomes from an EBP implementation effort; mis-implementation outcomes are an important, but largely untapped, source of information about how to improve knowledge exchange. Aims and objectives: We present mis-implementation cases from three pragmatic trials of behavioural health EBPs in US Federally Qualified Health Centers (FQHCs).Methods: We adapted the Consolidated Framework for Implementation Research and its Outcomes Addendum into a framework for mis-implementation and used it to structure the case summaries with information about the EBP and trial, mis-implementation outcomes, and associated determinants (barriers and facilitators). We compared the three cases to identify shared and unique mis-implementation factors.Findings: Across cases, there was limited adoption and fidelity to the interventions, which led to eventual discontinuation. Barriers contributing to mis-implementation included intervention complexity, low buy-in from overburdened providers, lack of alignment between providers and leadership, and COVID-19-related stressors. Mis-implementation occurred earlier in cases that experienced both patient-and provider-level barriers, and that were conducted during the COVID19 pandemic. Discussion and conclusion: Multilevel determinants contributed to EBP mis-implementation in FQHCs, limiting the ability of these health systems to benefit from knowledge exchange. To minimise mis-implementation, knowledge exchange strategies should be designed around common, core barriers but also flexible enough to address a variety of site-specific contextual factors, and should be tailored to relevant audiences such as providers, patients, and/or leadership.

ObjectivesTo understand the impact of public discourse and reaction around the COVID-19 pandemic on healthcare worker (HCW) experiences and well-being caring for patients with COVID-19.MethodsWe conducted 60 min in-depth interviews with 11 physicians and 12 nurses who were providing care to patients with COVID-19 in acute care settings at two health systems in the Western USA. Interviews were conducted in Spring-Summer 2022 using a semi-structured interview protocol that guided respondents through different stages of the pandemic.ResultsThree themes emerged from the data around providing care in the unique social context of the COVID-19 pandemic including: (1) public polarisation and disagreement with science; (2) feelings of hope and optimism during the pandemic and (3) the compounded strain of providing care within this unique social context of the pandemic.ConclusionsTo prepare for future pandemics, improved public health communications and social-emotional supports for HCWs are critical to ameliorate the physical and emotional impacts related to the social context of modern US pandemic response.

ImportanceStress First Aid is an evidence-informed peer-to-peer support intervention to mitigate the effect of the COVID-19 pandemic on the well-being of health care workers (HCWs).ObjectiveTo evaluate the effectiveness of a tailored peer-to-peer support intervention compared with usual care to support HCWs’ well-being at hospitals and federally qualified health centers (FQHCs) during the COVID-19 pandemic.Design, Setting, and ParticipantsThis cluster randomized clinical trial comprised 3 cohorts of HCWs who were enrolled from March 2021 through July 2022 at 28 hospitals and FQHCs in the US. Participating sites were matched as pairs by type, size, and COVID-19 burden and then randomized to the intervention arm or usual care arm (any programs already in place to support HCW well-being). The HCWs were surveyed before and after peer-to-peer support intervention implementation. Intention-to-treat (ITT) analysis was used to evaluate the intervention’s effect on outcomes, including general psychological distress and posttraumatic stress disorder (PTSD).InterventionThe peer-to-peer support intervention was delivered to HCWs by site champions who received training and subsequently trained the HCWs at their site. Recipients of the intervention were taught to respond to their own and their peers’ stress reactions.Main Outcomes and MeasuresPrimary outcomes were general psychological distress and PTSD. General psychological distress was measured with the Kessler 6 instrument, and PTSD was measured with the PTSD Checklist.ResultsA total of 28 hospitals and FQHCs with 2077 HCWs participated. Both preintervention and postintervention surveys were completed by 2077 HCWs, for an overall response rate of 28% (41% at FQHCs and 26% at hospitals). A total of 862 individuals (696 females [80.7%]) were from sites that were randomly assigned to the intervention arm; the baseline mean (SD) psychological distress score was 5.86 (5.70) and the baseline mean (SD) PTSD score was 16.11 (16.07). A total of 1215 individuals (947 females [78.2%]) were from sites assigned to the usual care arm; the baseline mean (SD) psychological distress score was 5.98 (5.62) and the baseline mean (SD) PTSD score was 16.40 (16.43). Adherence to the intervention was 70% for FQHCs and 32% for hospitals. The ITT analyses revealed no overall treatment effect for psychological distress score (0.238 [95% CI, −0.310 to 0.785] points) or PTSD symptom score (0.189 [95% CI, −1.068 to 1.446] points). Post hoc analyses examined the heterogeneity of treatment effect by age group with consistent age effects observed across primary outcomes (psychological distress and PTSD). Among HCWs in FQHCs, there were significant and clinically meaningful treatment effects for HCWs 30 years or younger: a more than 4-point reduction for psychological distress (−4.552 [95% CI, −8.067 to −1.037]) and a nearly 7-point reduction for PTSD symptom scores (−6.771 [95% CI, −13.224 to −0.318]).Conclusions and RelevanceThis trial found that this peer-to-peer support intervention did not improve well-being outcomes for HCWs overall but had a protective effect against general psychological distress and PTSD in HCWs aged 30 years or younger in FQHCs, which had higher intervention adherence. Incorporating this peer-to-peer support intervention into medical training, with ongoing support over time, may yield beneficial results in both standard care and during public health crises.Trial RegistrationClinicalTrials.gov Identifier: NCT04723576

This cohort study uses data from a randomized clinical trial for opioid use disorder (OUD) co-occurring with mental illness to examine patient characteristics associated with collaborative care model engagement and fidelity.

Interpersonal violence is a common type of trauma experienced by people with opioid use disorder (OUD), especially for people with co-occurring OUD and mental illness (COD). However, little is known about demographic and clinical characteristics of individuals with COD who have experienced an interpersonal violence traumatic event compared to those who have experienced a non-violent trauma, and how experiences of interpersonal violence are associated with treatment utilization. Data presented are from a randomized clinical trial testing collaborative care for COD in primary care. Of the 797 patients enrolled in the larger study, 733 (92%) were included in this analysis because they reported a traumatic event. In this sample, 301 (41%) participants experienced a traumatic event involving interpersonal violence. Participants who experienced interpersonal violence were more likely to be younger and female. Among the 301 people who experienced interpersonal violence, 30% experienced child sexual abuse, 23% experienced physical violence, 19% experienced domestic violence, and 28% experienced sexual assault. Those who experienced physical violence were significantly less likely to be female (28.6% vs 74.2% to 88.2% in other groups). Those who reported domestic violence had significantly fewer days of drug use (4.1 days vs 9.0 to 11.5 in the other groups) and lower opioid use severity scores (mean = 13.0 vs 16.6 to 19.5 in the other groups). Multivariable regression results examining the associations between interpersonal violence experiences on treatment utilization revealed no statistically significant differences. Rates of receipt were high for medication for opioid use disorder (∼80%) in this sample while rates of mental health counseling were around 35% and rates of receiving mental health medication around 48%. These findings make an important contribution to understanding the associations between patient characteristics and traumatic experiences, and receipt of treatment for OUD and mental health problems among a sample of patients with COD. Clinical trial registration clinicalTrials.gov ID: NCT04559893