Comparing behavioral health models for reducing risky drinking among older male veterans.

BACKGROUND: Screening older veterans in Veterans Affairs Medical Center (VAMC) primary care clinics for risky drinking facilitates early identification and referral to treatment. OBJECTIVE: This study compared two behavioral health models, integrated care (a standardized brief alcohol intervention co-located in primary care clinics) and enhanced referral care (referral to specialty mental health or substance abuse clinics), for reducing risky drinking among older male VAMC primary care patients. VAMC variation was also examined. METHOD: A secondary analysis of longitudinal data from the Primary Care Research in Substance Abuse and Mental Health for Elderly (PRISM-E) study, a multisite randomized controlled trial, was conducted with a sample of older male veterans (n = 438) who screened positive for risky drinking and were randomly assigned to integrated or enhanced referral care at five VAMCs. RESULTS: Generalized estimating equations revealed no differences in either behavioral health model for reducing risky drinking at a 6-month follow-up (AOR: 1.46; 95% CI: 0.42-5.07). Older veterans seen at a VAMC providing geriatric primary care and geriatric evaluation and management teams had lower odds of risky drinking (AOR: 0.24; 95% CI: 0.07-0.81) than those seen at a VAMC without geriatric primary care services. CONCLUSIONS: Both integrated and enhanced referral care reduced risky drinking among older male veterans. However, VAMCs providing integrated behavioral health and geriatric specialty care may be more effective in reducing risky drinking than those without these services. Integrating behavioral health into geriatric primary care may be an effective public health approach for reducing risky drinking among older veterans.

Enhancing Social Support Postincarceration: Results From a Pilot Randomized Controlled Trial.

OBJECTIVE: Over 50% of released prisoners are reincarcerated within 3 years. Social support from loved ones postincarceration significantly reduces the likelihood of reincarceration. Increasingly, intervention developers aim to implement interventions that will enhance the stability of support available. This study responds to gaps in knowledge. METHOD: The current efficacy study reports findings from a randomized controlled trial (n = 57) of a social support intervention. A priori power analysis indicated moderate effect sizes could be detected. Participants were men, average age was 25 years, and over 90% were African American. Preliminary effects on social support, cognitions, substance use, and rearrest were assessed. Recruitment and consent occurred in prison; the intervention and 4 follow-ups occurred postrelease. RESULTS: Findings converge with research indicating declines in social support (b = -.70, p < .05) and perceived quality of support (b = .05, p < .01) over time. Age showed inverse relationships with support (b = -1.77, p < .05). There were no statistically significant group effects for social support, cognitions, substance use (with the exception of marijuana), or recidivism. Clinical implications are discussed. CONCLUSION: This study advances research on intervention dosage, potency, and measurement considerations.

Violent Death Rates and Risk for Released Prisoners in North Carolina.

Released prisoners face high risk of early mortality. The risk of violent death, specifically homicide and suicide, are addressed in this study. Data on inmates released from the North Carolina Division of Adult Corrections (N = 476) matched to the Violent Death Reporting System are analyzed to estimate rates and demographic and criminal justice-related predictors. Violent death rates for persons released from prison were more than 7 times higher than for the general adult population. Results from multinomial logistic regression indicate decreased homicide risk for every year of age, whereas male gender and minority race increased risk. For suicide, minority race, release without supervision, and substance abuse treatment in prison decreased fatality risk. By contrast, a history of mental illness increased suicide risk. Implications for practice and research are discussed.

Multilevel challenges to engagement in HIV care after prison release: a theory-informed qualitative study comparing prisoners' perspectives before and after community reentry.

BACKGROUND: Although prison provides the opportunity for HIV diagnosis and access to in-prison care, following release, many HIV-infected inmates experience clinical setbacks, including nonadherence to antiretrovirals, elevations in viral load, and HIV disease progression. HIV-infected former inmates face numerous barriers to successful community reentry and to accessing healthcare. However, little is known about the outcome expectations of HIV-infected inmates for release, how their post-release lives align with pre-release expectations, and how these processes influence engagement in HIV care following release from prison. METHODS: We conducted semi-structured interviews (24 pre- and 13 post-release) with HIV-infected inmates enrolled in a randomized controlled trial of a case management intervention to enhance post-release linkage to care. Two researchers independently coded data using a common codebook. Intercoder reliability was strong (kappa = 0.86). We analyzed data using Grounded Theory methodology and Applied Thematic Analysis. We collected and compared baseline sociodemographic and behavioral characteristics of all cohort participants who did and did not participate in the qualitative interviews using Fisher's Exact Tests for categorical measures and Wilcoxon rank-sum tests for continuous measures. RESULTS: Most participants were heterosexual, middle-aged, single, African American men and women with histories of substance use. Substudy participants were more likely to anticipate living with family/friends and needing income assistance post-release. Most were taking antiretrovirals prior to release and anticipated needing help securing health benefits and medications post-release. Before release, most participants felt confident they would be able to manage their HIV. However, upon release, many experienced intermittent or prolonged periods of antiretroviral nonadherence, largely due to substance use relapse or delays in care initiation. Substance use was precipitated by stressful life experiences, including stigma, and contact with drug-using social networks. As informed by the Social Cognitive Theory and HIV Stigma Framework, findings illustrate the reciprocal relationships among substance use, experiences of stigma, pre- and post-release environments, and skills needed to engage in HIV care. CONCLUSION: These findings underscore the need for comprehensive evidence-based interventions to prepare inmates to transition from incarceration to freedom, particularly those that strengthen linkage to HIV care and focus on realities of reentry, including stigma, meeting basic needs, preventing substance abuse, and identifying community resources.

What Do Farmers Need for Suicide Prevention: Considerations for a Hard-to-Reach Population.

Purpose: Farmers have suicide rates much higher than the general population, with elevated mental health symptoms and high stress levels. Farmers are a hard-to-reach population due to occupational demands and a culture where conversations about mental health are often stigmatizing. This study explored ways to tailor suicide prevention strategies to unique characteristics of farmers by speaking with groups close to farmers who were open to discussing stress and suicide prevention: women married to farmers and agricultural Extension agents. Methods: Focus groups with women married to farmers (N=29) and interviews with agricultural agents from the university's local Cooperative Extension offices (N=13) from rural Georgia counties explored effective ways outreach and education about suicide prevention, mental health, and coping could be provided to farmers. Using a thematic analysis approach, qualitative coding was completed by two researchers (Cohens kappa=0.86), with initial codes collapsed into common themes. Results: Four themes were identified: 1) Barriers due to the nature of farming, including time demands of farming and cultural stigma in help-seeking; 2) Acceptable messaging, including framing conversations as part of general health; 3) Make information accessible by making it brief, clear, and omnipresent through multiple media; and 4) Elements of effective information and education, including emphasizing "you're not alone" and connection, how to access supports and crisis services, educating people close to farmers, and motivating farmers by emphasizing that they could help another farmer with the information. Conclusion: Due to farmers' stoic identities and reluctance to admit mental health struggles, speaking with those close to farmers may help us better understand what is needed to tailor farmer suicide prevention strategies. The insights shared by participants suggest that culturally responsive outreach and education strategies, strengthening relationships through peer support, and gatekeeper training with specific trusted others are important ways to tailor suicide prevention strategies for this hard-to-reach group.

Intensive case management before and after prison release is no more effective than comprehensive pre-release discharge planning in linking HIV-infected prisoners to care: a randomized trial.

Imprisonment provides opportunities for the diagnosis and successful treatment of HIV, however, the benefits of antiretroviral therapy are frequently lost following release due to suboptimal access and utilization of health care and services. In response, some have advocated for development of intensive case-management interventions spanning incarceration and release to support treatment adherence and community re-entry for HIV-infected releasees. We conducted a randomized controlled trial of a motivational Strengths Model bridging case management intervention (BCM) beginning approximately 3 months prior to and continuing 6 months after release versus a standard of care prison-administered discharge planning program (SOC) for HIV-infected state prison inmates. The primary outcome variable was self-reported access to post-release medical care. Of the 104 inmates enrolled, 89 had at least 1 post-release study visit. Of these, 65.1% of BCM and 54.4% of SOC assigned participants attended a routine medical appointment within 4 weeks of release (P > 0.3). By week 12 post-release, 88.4% of the BCM arm and 78.3% of the SOC arm had at attended at least one medical appointment (P = 0.2), increasing in both arms at week 24-90.7% with BCM and 89.1% with SOC (P > 0.5). No participant without a routine medical visit by week 24 attended an appointment from weeks 24 to 48. The mean number of clinic visits during the 48 weeks post release was 5.23 (SD = 3.14) for BCM and 4.07 (SD = 3.20) for SOC (P > 0.5). There were no significant differences between arms in social service utilization and re-incarceration rates were also similar. We found that a case management intervention bridging incarceration and release was no more effective than a less intensive pre-release discharge planning program in supporting health and social service utilization for HIV-infected individuals released from prison.

Consumers' perceptions of forensic assertive community treatment.

OBJECTIVE: The evidence for forensic assertive community treatment (FACT) is promising; however, a number of gaps in our knowledge about FACT remain. For example, only one study in the extant literature includes the perspectives of FACT consumers and more information about what consumers like and/or dislike about FACT is needed. METHODS: To address this gap in our knowledge, semi-structured interviews were conducted with 14 FACT consumers from four FACT teams in Ohio. Interviews were audio recorded and transcribed and open coding analysis techniques were used to identify themes. RESULTS: Findings suggest most consumers have no complaints or dislikes about FACT and found housing assistance, access to mental health services, and access to medication and psychiatrists particularly helpful. CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: FACT consumers have profound needs and teams must be prepared to provide a wide array of intensive services, especially in early stages of intervention. Collaborations with local Housing First or other initiatives may be particularly important to facilitate consumer engagement and build therapeutic rapport. This study contributes to the growing literature on FACT; however, more research is needed about how FACT needs to be adapted to serve justice-involved consumers, the critical ingredients of FACT, and FACT's impact on psychiatric functioning and other outcomes.

Assertive community treatment and the physical health needs of persons with severe mental illness: issues around integration of mental health and physical health.

BACKGROUND: Assertive community treatment (ACT) is characterized as a service delivery platform and represents an ideal setting in which mental health and physical health care can be integrated. OBJECTIVE: Little is known about the extent to which ACT integrates physical health care with mental health care or the challenges ACT teams experience. To address this gap, focus groups were conducted with five ACT teams in a Midwestern US state to explore how ACT teams address the physical health care needs of persons with severe mental illness. DESIGN: A qualitative study design was used. RESULTS: Three major themes emerged: ACT teams recognize serious and chronic physical health problems, ACT teams take on a variety of roles to address physical health problems, and there are challenges to integrating primary and mental health care within an ACT setting. CONCLUSIONS: ACT needs to be adapted to incorporate promising practices designed to better integrate physical health care and mental health care.

HIV-infected prison inmates: depression and implications for release back to communities.

High rates of both HIV and depression are seen in prison populations; depression has been linked to disease progression in HIV, risky behaviors, and medication non-adherence. Despite this, few studies have examined HIV-infected inmates with depression. We therefore conducted an exploratory study of a sample of HIV-infected inmates in North Carolina prisons (N = 101) to determine what proportion of this sample screened positive for depression and whether depression was associated with different pre-incarceration characteristics or post-release needs. A high proportion of HIV infected inmates (44.5%) screened positive for depression. Depressed inmates were significantly more likely have low coping self-efficacy scores (180 vs. 214), to report having had resource needs (OR = 2.91) prior to incarceration and to anticipate needing income (OR = 2.81), housing (OR = 4.07), transportation (OR = 9.15), and assistance with adherence (OR = 8.67) post-release. We conclude by discussion the implications of our findings for prison based care and effective prison release planning for HIV infected inmates.

Screening and access to services for individuals with serious mental illnesses in jails.

High rates of serious mental illnesses (SMI) among jail inmates pose challenges for the criminal justice system and risks for the individual with SMI. Research has identified actions to address these issues; it is unclear to what extent they have been operationalized. This study examines jails in one state, exploring how individuals with SMI are identified and treated, and comparing these with research-based recommendations. Results indicate that jails are not using evidence-based screenings, staff require training in SMI, access to services and medications for jailed individuals with SMI is often slow, and coordination between community providers and jails is limited.

Front line workers' attitudes towards psychiatric advance directives.

Studies have begun to explore provider attitudes' toward psychiatric advance directives (PADs) and how those attitudes are related to provider characteristics. The study gathered attitudinal data from a sample of 193 social workers serving mentally ill adults. Social workers with pro-healthcare power of attorney (HCPA) attitudes were likely to have prior experience with an HCPA and to believe that involuntary treatment violates the NASW Code of Ethics. Social workers are more favorable of HCPAs than advance instructions. The findings suggest that clinical experiences with PADs may positively impact social worker's perceptions of the law.

The interaction of serious mental disorder and race on time to reincarceration.

Individuals with a serious mental disorder (SMD) are disproportionately incarcerated in state prisons, and research has shown that individuals with SMD are more likely to recidivate upon release. Persons of color are also disproportionately incarcerated and at risk for repeat incarcerations. However, minimal research has yet to examine whether the relationship between SMD and recidivism is conditioned on race. This study used proportional hazards Cox regression modeling to investigate the effect of SMD on criminal recidivism over an 8-year period among 22,376 former prisoners in North Carolina. The interaction between race and SMD is explored to test for cross-racial variation in time-to-reincarceration. A significant interaction effect of non-Black minority by SMD was found. Non-Black minority former prisoners with SMD returned to prison significantly quicker than non-Black minorities without SMD. No interaction effect was found for either Black or White former prisoners. Hazard to return to prison was also significantly increased for former prisoners that were younger in age, male, Black, not employed at arrest, and indicated for substance abuse. Those factors contributing to the effect of SMD on criminal recidivism within non-Black minority former prisoners is unclear. Additional research is needed on the interactive effects of racial group and SMD on postprison experiences. (PsycINFO Database Record

Understanding the personal and clinical utility of psychiatric advance directives: a qualitative perspective.

Psychiatric advance directives (PADs) are legal tools that allow competent individuals to declare preferences for future mental health treatment when they may not be capable of doing so as a result of a psychiatric crisis. PADs allow individuals to maintain self-determination during times when they are most vulnerable to loss of autonomy and in need of assistance to make their preferences known and honored. This article describes the content of twenty-eight open-ended, semi-structured qualitative interviews of adults with PADs who have experienced psychiatric crises. The qualitative analysis revealed three major themes from the interviews: (1) PADs as tools for empowerment and self-determination, (2) limited knowledge of PADs among service providers; and (3) difficulties communicating PADs to inpatient staff. In general, many participants expressed enthusiasm of the implementation of PADs but concern regarding clinicians' general lack of awareness about them. Additionally, some consumers discussed discomfort in even mentioning that they had a PAD to clinicians for fear of a negative response from them, or some type of involuntary treatment during their hospitalization. However, participants consistently viewed PADs as a positive tool to promote autonomy with the potential to facilitate stronger patient-provider relationships. Therefore, when working with individuals in psychiatric crisis who have a PAD, and who have never before experienced a sense of control over their own treatment, clinicians must recognize the potential troubling disequilibrium this sense of control may engender. In sum, though the most significant challenges facing the implementation of PADs involve clinicians' familiarity with and education about PADs, much promise for the future growth of PADs lies in the benefits perceived by the patients.

Psychiatric advance directives: a tool for consumer empowerment and recovery.

Individuals with psychiatric disabilities identify choice and self-direction as central elements of recovery. During times of psychiatric crisis people may experience a frightening loss of choice and self-direction, which can be damaging and traumatic. Psychiatric advance directives (PADs) are legal documents created to address this loss of autonomy and choice during crises by allowing individuals to communicate in the present wishes for care during a future crisis. This paper examines the ways in which PADs support and can be a tool for recovery and discusses future recovery-oriented directions for PAD research and intervention.