Managing substance use for clients with serious mental illnesses: Knowledge, attitude, and training challenges among outpatient behavioral health providers in California, Ohio, and New York.

PURPOSE: Individuals with serious mental illness have high rates of substance use. The most commonly used substances among this population are alcohol and cannabis, and whether clinical providers delivering mental health services feel adequately prepared to address substance use is unclear. While information about the effects of alcohol are well established, the effects of cannabis are less well known and staff may feel less confident in their abilities to assess its use and may rely on more informal sources to learn about it. METHODS: Mental health agencies in three states (California, Ohio, and New York) surveyed their staff (n =717) to explore their knowledge, training, and expertise in assessment of substance use generally as well as cannabis and alcohol specifically. RESULTS: Overall, providers felt more prepared to address their clients' alcohol use than cannabis use. In between-state comparisons, California providers felt significantly less well prepared to assess, discuss, and refer their clients to treatment compared to Ohio and New York providers. Using a series of multi-categorical mediation models, we confirmed that deficits in training for these specific substances largely accounted for between-state differences in assessment, capacity, and treatment. CONCLUSIONS: Substance use training to address the service needs of individuals with co-occurring disorders is insufficient and a significant need exists for systemic changes to workforce training of community mental health providers.

Service Use by Medicaid Recipients With Serious Mental Illness During an RCT of the Bridge Peer Health Navigator Intervention.

OBJECTIVE: Integration of general medical care and mental health care is a high priority for individuals with serious mental illnesses because of their high risk of morbidity and early mortality. The Bridge is a peer-led, health navigator intervention designed to improve access to and use of health care and self-management of medical services by individuals with serious mental illnesses. This study expands on a previous study in which the authors examined participants' self-reported outcomes from a 12-month randomized controlled trial of the Bridge. In the study reported here, Medicaid data were used to assess the impact of the intervention on service use during that trial. METHODS: Medicaid data on use of general medical services (emergency room, outpatient, and inpatient) for 6 months were compared for 144 individuals with serious mental illnesses-Bridge participants (N=72) and a waitlist control group (N=72). An intent-to-treat approach was used, with regression models controlling for general medical services in the 6 months before baseline. RESULTS: Zero-inflated negative binomial analyses, controlling for service use 6 months before baseline, found that the intervention group used the emergency room significantly less frequently, compared with the control group (adjusted mean±SD number of visits, 0.72±0.19 versus 1.59±0.42). No between-group differences were found in use of general medical inpatient or outpatient services. CONCLUSIONS: The Bridge was effective in decreasing emergency room use among individuals with serious mental illnesses.

Recovery in Context: Thirty Years of Mental Health Policy in California.

Over the past quarter century, Recovery has become the hegemonic model guiding mental health policy. Advocates presented Recovery as a radical departure from the past, with the promise of dramatically improved outcomes for those with serious mental illness. This article looks at the implementation of Recovery-based policies in California from the 1990s to the present and interrogates the ways these policies emerged out of and reinforced many of the problems they were intended to solve. Against the backdrop of welfare reform, managed care, and a growing belief in market forces and individual responsibility, California policymakers pivoted from rigorously studied pilot programs that were intended to provide intensive, long-term treatment to Recovery-oriented programs that, while initially intensive, promised to "flow" increasingly independent and self-sufficient patients to less-intensive services. Moreover, these new programs promised to produce cost savings by reducing homelessness, hospitalization, and incarceration. Reported outcomes from these programs have been overwhelmingly positive but are based on flawed evaluations that lean more heavily on belief than on evidence. While proclaiming a comprehensive, patient-centered approach, Recovery's embrace of independence over long-term care and social supports has justified a system of care that systematically fails the sickest patients by abandoning them to the streets and jails.

Definitions of Community for Individuals with Serious Mental Illnesses: Implications for Community Integration and Recovery.

While recent work on community integration for individuals with serious mental illnesses (SMIs) has focused on the multi-dimensionality of community integration, it has not been fully rooted in how consumers define and experience communities for themselves. Guided by symbolic interactionism theory, the goal of the present study is to explore definitions of community as provided by individuals with SMIs, and to incorporate those definitions into a theoretical framework of community to inform community integration efforts in the context of mental health services and recovery. Semi-structured interviews were conducted between November 2017 and September 2018 with 90 racially/ethnically diverse participants who were 18 years and older with an SMI and receiving community mental health services. Interviews were audio-recorded, transcribed, and analyzed using ResearchTalk's "Sort and Sift, Think and Shift" methodology. Themes derived from participants' definitions of community included a structural aspect of people and places; a functional aspect of socializing, helping and receiving resources; and an experiential aspect of shared struggles and experiences, finding safety, and identifying with others. To this end, we propose a Structural, Functional and Experiential (SFE) model of community. The SFE model of community provides a conceptual framework and guidance for clinicians, researchers, policy makers and service stakeholders regarding the complexity and variability of community for their consumers, which is essential to their recovery. Application of the SFE framework for assessment and intervention is discussed.

Sources of Social Support After Patient Assault as Related to Staff Well-Being.

Patient assault is a serious issue for the well-being of staff in psychiatric hospitals. To guide workplace responses to patient assault, more information is needed about social support from different sources and whether those supports are associated with staff well-being. The present study examines social support after patient assault from work-based and nonwork-based sources, and whether inpatient psychiatric staff desires support from them and perceive the support received as being effective. Received support across sources was examined in relations to staff well-being (physical health, mental health, anger, sleep quality) and perceptions of safety. Survey data was collected from 348 clinical staff in a large public forensic mental hospital. Among the 242 staff who reported an assault in the last year, 71% wanted support and 72% found effective support from at least one source. Generally, effective support from supervisors, coworkers, and their combination was associated with better well-being. Support from nonwork sources was related to less concerns about safety, but not to other well-being measures. However, 28% of staff did not receive effective support from any source postassault. Gaps in support as reported in this study and as found by other investigators call for systematic programming by hospital organizations to enhance the well-being of clinical staff, which in turn has implications for patient care.

Provider and consumer perspectives of community mental health services: Implications for consumer-driven care.

Public mental health services in the community are broad and continue to expand to address the multiple issues faced by those with serious mental illnesses. However, few studies examine and contrast how helpful consumers and providers find the spectrum of services. The present study examines the services at community mental health service clinics (CMHCs) from the perspectives of providers and consumers. There were 351 consumers and 147 providers from 15 CMHCs who rated and ranked the helpfulness of 24 types of common services. All of the agencies were participating in a Practice-Based Research Network (PBRN). Social support was the highest rated service by both types of respondents, and the creation of a welcoming environment was the highest ranked service by both. There were also areas of disagreement. Consumers identified traditional mental health services (individual therapy and medication services) as being most helpful to them whereas providers selected longer-term services that promote self-reliance (e.g., securing housing, and promoting self-sufficiency) as the most helpful. Understanding how consumers and providers perceive the range of CMHC services provided in usual care is important to develop new targets for intervention. A welcoming milieu and providing social support appear important to both, but significant differences exist between these groups regarding other aspects of services. This holds implications for the design and implementation of consumer-driven services. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Using Electronic Health Records to Enhance a Peer Health Navigator Intervention: A Randomized Pilot Test for Individuals with Serious Mental Illness and Housing Instability.

Individuals with serious mental illnesses have high rates of comorbid physical health issues and have numerous barriers to addressing their health and health care needs. The present pilot study tested the feasibility of a modified form of the "Bridge" peer-health navigator intervention delivered in a usual care setting by agency personnel. The modifications concerned the use of an electronic personal health record with individuals experiencing with housing instability. Twenty participants were randomized to receive the intervention immediately or after 6 months. Health navigator contacts and use of personal health records were associated with improvements in health care and self-management. This pilot study demonstrated promising evidence for the feasibility of adding personal health record use to a peer-led intervention.

Mental illness disclosure decision making.

Disclosure related to mental illness has been linked to various positive outcomes, including better mental health. However, many individuals with serious mental illness (SMI) continue to practice non-disclosure. Even though disclosure inherently occurs within the context of one's social relationships, research has generally conceptualized mental illness disclosure as an individual level phenomenon and neglected to consider preferences concerning to whom an individual discloses and the factors that influence this decision. The current study uses the disclosure decision-making model (DD-MM) by Greene (2009) to better understand the processes of mental illness disclosure preference and selective disclosure for individuals with SMI (n = 60) using multivariate random intercept logistic regression with an emphasis on the constituent factors of disclosure preference at both individual and relational levels. The majority of participants were found to practice selective disclosure, with 68% of the participants identifying at least 1 network member to whom they could disclose. Family members and friends were central to the selective disclosure process, comprising the greatest proportion of network members who, both were and were not identified as preferred confidants. Women were found to show higher odds of preference for mental illness disclosure than men. Having lower perceived social support was associated with lower odds of disclosure preference. Among relational factors, greater relationship availability and lower dyadic tangible social support were associated with lower odds of disclosure preference. Practice and research implications of using social network analysis to get a deeper understanding of disclosure and disclosure preference are discussed, including implications for future interventions targeting stigma reduction. (PsycINFO Database Record

System Transformation Under the California Mental Health Services Act: Implementation of Full-Service Partnerships in L.A. County.

OBJECTIVE: The study evaluated the effect of California's Mental Health Services Act (MHSA) on the structure, volume, location, and patient centeredness of Los Angeles County public mental health services. METHODS: This prospective mixed-methods study (2006-2013) was based in five Los Angeles County public mental health clinics, all with usual care and three with full-service partnerships (FSPs). FSPs are MHSA-funded programs designed to "do whatever it takes" to provide intensive, recovery-oriented, team-based, integrated services for clients with severe mental illness. FSPs were compared with usual care on outpatient services received (claims data) and on organizational climate, recovery orientation, and provider-client working alliance (surveys and semistructured interviews), with regression adjustment for client and provider characteristics. RESULTS: In the first year after admission, FSP clients (N=174) received significantly more outpatient services than did usual care clients (N=298) (5,238 versus 1,643 minutes, p<.001), and a larger proportion of these services were field based (22% versus 2%, p<.001). Compared with usual care clients, FSP clients reported more recovery-oriented services (p<.001) and a better provider-client working alliance (p=.01). Compared with usual care providers (N=130), FSP providers (N=42) reported more stress (p<.001) and lower morale (p<.001). CONCLUSIONS: Los Angeles County's public mental health system was able to transform service delivery in response to well-funded policy mandates. For providers, a structure emphasizing accountability and patient centeredness was associated with greater stress, despite smaller caseloads. For clients, service structure and volume created opportunities to build stronger provider-client relationships and address their needs and goals.

How Occupationally High-Achieving Individuals With a Diagnosis of Schizophrenia Manage Their Symptoms.

OBJECTIVE: The study objective was to elucidate coping strategies utilized by individuals recovered from schizophrenia. METHODS: This qualitative study enrolled individuals with schizophrenia who had reached a level of recovery defined by their occupational status. Diagnosis of schizophrenia was confirmed with the Structured Clinical Interview for DSM-IV. Current symptoms were objectively rated by a clinician. Surveys gathered information on demographic characteristics, occupation, salary, psychiatric history, treatment, and functioning. Audio-recorded person-centered qualitative interviews gathered accounts of coping strategies. Transcripts were summarized and coded with a hybrid deductive-inductive approach. RESULTS: Twenty individuals were interviewed, including ten men. The average age was 40 years. Sixty percent of participants were either currently in a master's-level program or had completed a master's or doctoral degree. Eight categories of coping strategies were identified: avoidance behavior, utilizing supportive others, taking medications, enacting cognitive strategies, controlling the environment, engaging spirituality, focus on well-being, and being employed or continuing their education. Some strategies were used preventively to keep symptoms from occurring; others were used to lessen the impact of symptoms. Strategies were flexibly utilized and combined depending on the context. CONCLUSIONS: Use of strategies in a preventive fashion, the effectiveness of the identified strategies, and the comfort individuals expressed with using several different strategies supported these individuals in achieving their occupational goals. The findings contribute to an overall shift in attitudes about recovery from schizophrenia and highlight the importance of learning from people with lived experience about how to support recovery.

Integrating behavioral healthcare for individuals with serious mental illness: A randomized controlled trial of a peer health navigator intervention.

OBJECTIVE: Individuals with serious mental illness also have high rates of comorbid physical health issues. To address those issues, this population needs interventions that improve self-management of health and healthcare. METHODS: In order to improve the health and healthcare of individuals with serious mental illnesses, 151 consumers with serious mental illness were randomized to receive either usual mental healthcare plus the Bridge intervention (n=76) or usual mental healthcare while on a 6month waitlist (n=75). The waitlist group received the intervention after the waitlist period. RESULTS: Change score comparisons (difference of differences) of the treatment vs the waitlist groups revealed that the treated group showed significantly greater improvement in access and use of primary care health services, higher quality of the consumer-physician relationship, decreased preference for emergency, urgent care, or avoiding health services and increased preference for primary care clinics, improved detection of chronic health conditions, reductions in pain, and increased confidence in consumer self-management of healthcare. CONCLUSIONS: Peer providers using a manualized intervention can be an important part of the efforts to address the general medical care of individuals with serious mental illnesses.

3D Cell Culture in a Self-Assembled Nanofiber Environment.

The development and utilization of three-dimensional cell culture platforms has been gaining more traction. Three-dimensional culture platforms are capable of mimicking in vivo microenvironments, which provide greater physiological relevance in comparison to conventional two-dimensional cultures. The majority of three-dimensional culture platforms are challenged by the lack of cell attachment, long polymerization times, and inclusion of undefined xenobiotics, and cytotoxic cross-linkers. In this study, we review the use of a highly defined material composed of naturally occurring compounds, hyaluronic acid and chitosan, known as Cell-Mate3DTM. Moreover, we provide an original measurement of Young's modulus using a uniaxial unconfined compression method to elucidate the difference in microenvironment rigidity for acellular and cellular conditions. When hydrated into a tissue-like hybrid hydrocolloid/hydrogel, Cell-Mate3DTM is a highly versatile three-dimensional culture platform that enables downstream applications such as flow cytometry, immunostaining, histological staining, and functional studies to be applied with relative ease.

Rapid Induction of Cerebral Organoids From Human Induced Pluripotent Stem Cells Using a Chemically Defined Hydrogel and Defined Cell Culture Medium.

UNLABELLED: Tissue organoids are a promising technology that may accelerate development of the societal and NIH mandate for precision medicine. Here we describe a robust and simple method for generating cerebral organoids (cOrgs) from human pluripotent stem cells by using a chemically defined hydrogel material and chemically defined culture medium. By using no additional neural induction components, cOrgs appeared on the hydrogel surface within 10-14 days, and under static culture conditions, they attained sizes up to 3 mm in greatest dimension by day 28. Histologically, the organoids showed neural rosette and neural tube-like structures and evidence of early corticogenesis. Immunostaining and quantitative reverse-transcription polymerase chain reaction demonstrated protein and gene expression representative of forebrain, midbrain, and hindbrain development. Physiologic studies showed responses to glutamate and depolarization in many cells, consistent with neural behavior. The method of cerebral organoid generation described here facilitates access to this technology, enables scalable applications, and provides a potential pathway to translational applications where defined components are desirable. SIGNIFICANCE: Tissue organoids are a promising technology with many potential applications, such as pharmaceutical screens and development of in vitro disease models, particularly for human polygenic conditions where animal models are insufficient. This work describes a robust and simple method for generating cerebral organoids from human induced pluripotent stem cells by using a chemically defined hydrogel material and chemically defined culture medium. This method, by virtue of its simplicity and use of defined materials, greatly facilitates access to cerebral organoid technology, enables scalable applications, and provides a potential pathway to translational applications where defined components are desirable.

Implementation Status of Assisted Outpatient Treatment Programs: A National Survey.

OBJECTIVE: The authors' objective was to determine how assisted outpatient treatment (AOT) has been implemented in actual practice in the 45 states with AOT statutes. METHODS: A national survey of AOT programs was conducted to examine the extent to which AOT programs have been implemented and variations in implementation models. RESULTS: Although 45 states have current AOT statutes, the most active programs were identified in 20 states. These programs varied considerably in style of implementation, criteria applied, agency responsible, use of a treatment plan, monitoring procedures, and numbers of participants involved. Three implementation models were identified: community gateway, hospital transition, and surveillance (or safety net). Common problems included inadequate resources, lack of enforcement power, inconsistent monitoring, and weakness of interagency collaboration. CONCLUSIONS: AOT is a widely applied and much-discussed mechanism for providing treatment to individuals with serious mental illnesses nationally. The uneven implementation of AOT programs within and across states highlights the ambivalence in the community, by judicial officials, and by mental health clinicians about the role and scope of AOT and the difficulties of implementation under existing funding constraints and statutory limitations.

What Factors Influence the Decision to Share Suicidal Thoughts? A Multilevel Social Network Analysis of Disclosure Among Individuals with Serious Mental Illness.

Nondisclosure of suicidal thoughts limits suicide risk management. Consistent with disclosure models for other stigmatized statuses, understanding suicidal disclosure requires accounting for features of the discloser (individual factors) and the discloser-recipient relationship (relational factors). In a sample of 30 adults with schizophrenia, bipolar disorder, or major depressive disorder (Level 2) who nominated 436 social network members (Level 1), we examined disclosure patterns and identified individual and relational correlates of disclosure intent. Most individuals disclosed in the past (77%; n = 23) and all intended on disclosing (100%; n = 30). Disclosure was highly selective, with 14% (n = 62) of network members identified as prior confidants and 23% (n = 99) identified as intended confidants. Multilevel modeling indicated that relational factors were more central to disclosure than individual factors. Network members who were prior confidants and who provided social support were attractive targets for intended disclosure. Our findings suggest that "targeted" gatekeeper training may be a promising strategy and reveal relational characteristics to identify "high-probability confidants."

Remission of symptoms in community-based psychosocial rehabilitation services for individuals with schizophrenia.

OBJECTIVE: The aims of this study were to determine the prevalence of remission in individuals with schizophrenia at baseline and 6 months after admission to community-based psychosocial rehabilitation and whether baseline intrapersonal and environmental resources predicted remission at 6 months, controlling for relevant demographic and clinical variables. METHOD: The sample featured 187 individuals with schizophrenia spectrum disorder. To determine remission status, consensus-based criteria proposed by the Remission in Schizophrenia Working Group were adapted to identify predictors of remission outcomes, direct binary logistic regression analysis was performed. RESULTS: Findings indicated that 34.57% and 55.61% of the sample was in remission at baseline and 6 months, respectively. Remission at 6 months was predicted by shorter length of illness and being in remission at admission. CONCLUSIONS: Remission of schizophrenia is an achievable outcome in community psychosocial rehabilitation settings. Clinical characteristics exerted a significantly stronger influence on remission outcomes compared with psychosocial factors.

Well-Being and Safety Among Inpatient Psychiatric Staff: The Impact of Conflict, Assault, and Stress Reactivity.

Psychiatric staff are faced with multiple forms of hostility, aggression, and assault at work, collectively referred to as workplace violence, which typically is activated by patients but can also come from coworkers and supervisors. Whether workplace violence adversely affects staff well-being may be related not only to its presence, but also to an individual's stress reactivity. At a large public psychiatric hospital, an online survey was completed by 323 clinical care staff, of whom 69.5 % had experienced physical assault in the previous 12 months. Staff well-being (depression, anger, and physical health) and staff safety concerns were adversely affected by conflicts with other staff members and by individual reactivity to social conflict and to assault. To improve staff well-being, in addition to safety protocols, interventions should target staff relationships, personal health maintenance practices, and individual coping skills for dealing with adverse workplace experiences.

The Recovery-Oriented Care Collaborative: A Practice-Based Research Network to Improve Care for People With Serious Mental Illnesses.

Practice-based research networks (PBRNs) create continuous collaborations among academic researchers and practitioners. Most PBRNs have operated in primary care, and less than 5% of federally registered PBRNs include mental health practitioners. In 2012 the first PBRN in the nation focused on individuals with serious mental illnesses-the Recovery-Oriented Care Collaborative-was established in Los Angeles. This column describes the development of this innovative PBRN through four phases: building an infrastructure, developing a research study, executing the study, and consolidating the PBRN. Key lessons learned are also described, such as the importance of actively engaging direct service providers and clients.