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OBJECTIVE: The COVID-19 pandemic prompted a significant shift to delivering early psychosis services using telehealth. Little is known about the experience of using telehealth in early psychosis services. This quality improvement qualitative project investigated the experiences of program participants and family members with telehealth services in OnTrackNY, an early intervention program for psychosis in New York State during the COVID-19 pandemic. METHODS: The project team conducted individual interviews and focus groups. Data analyses used a matrix approach. RESULTS: Nineteen OnTrackNY program participants and nine family members participated in five focus groups and nine individual interviews. Data were organized into five themes (a) accessibility: most individuals had a device and internet access and challenges were related to connectivity, such as image freezing and sound breaking; (b) convenience/flexibility: benefits included the reduced commute and costs; (c) levels of comfort/privacy with telehealth: program participants felt less judged and less anxiety leading up to in-person appointments while also expressing privacy concerns; (d) sense of connectedness: in-person social connections were deemed important and not replaceable by telehealth; and (e) suggestions: program participants expressed a preference for in-person group activities and suggested hybrid options, highlighting the importance of in-person visits to establish rapport at the beginning of treatment before transitioning to telehealth. CONCLUSIONS: Telehealth services were generally well accepted. Suggestions for future service delivery include offering a combination of telehealth and in-person services based on program participants' preferences and prioritizing in-person services during the early phase of treatment.
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Despite the potential of digital mental health interventions to aid recovery for people with serious mental illness, access to these digital tools remains a key barrier. In this column, the authors discuss three key assumptions that shape the integration of digital mental health tools into community health settings: clinical context, digital literacy, and financial burden. Clinical contexts have shifted with the increased use of telehealth, altering intervention environments; access to a mobile device is not the same as digital literacy; and digital mental health care is not necessarily affordable. Context-centered study design through ethnography will facilitate transfer of digital resources to real-world settings.
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Salud Mental , Telemedicina , Humanos , Salud Digital , Tecnología , Computadoras de ManoRESUMEN
Individuals with obsessive-compulsive disorder (OCD), a chronic and disabling psychiatric disorder, experience high rates of occupational impairment. OCD symptoms commonly affect individuals' vocational aspirations and result in disability and the need for financial support, problems that are not addressed by current clinical practice guideline recommendations for treating OCD. This Open Forum highlights the need to address occupational impairment caused by OCD and makes the case for formally evaluating whether evidence-based supported employment can help individuals with OCD find and succeed in meaningful work.
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Empleos Subvencionados , Trastorno Obsesivo Compulsivo , HumanosAsunto(s)
COVID-19 , Personal Militar , Veteranos , Humanos , Veteranos/psicología , Salud Mental , Pandemias , Personal Militar/psicologíaRESUMEN
Individual Placement and Support (IPS) has been shown to effectively help people with serious mental illness obtain competitive employment, and IPS programs have been established in over 40 U.S. states and at least 20 other countries. As this expansion continues, the field needs data describing IPS implementation, clients, fidelity, and outcomes in real-world, non-research settings, specifically regarding racial and ethnic disparities and young adults. The goal of this study was to observe the initial three years of IPS implementation, measuring fidelity, client characteristics, and employment outcomes in three mental health agencies in one California county. In 2018, officials in one California county contracted with the IPS Center to provide training and measure IPS program fidelity at three mental health agencies in a large urban area. The goal was to establish and maintain IPS programs with good fidelity and effectiveness. After an initial year of preparation, three mental health programs recruited unemployed clients with interest in employment and implemented IPS. An IPS trainer provided initial training, ongoing consultation, and measured program fidelity. The program clinicians documented client characteristics, IPS service use, and quarterly employment throughout 13 quarters. The project followed 351 mental health clients as they participated in three new supported employment programs over a three-year period. The average client age was 36 years, including 107 (31%) young adults (ages 18-25) and 244 older adults (ages 26+); 177 (50%) identified their gender as female, 173 as male, and 1 as other or declined to answer; 119 (36%) identified as Hispanic, 116 (35%) as non-Hispanic White, 42 (13%) as non-Hispanic Asian, 35 (11%) as non-Hispanic Black, and 20 (6%) as other non-Hispanic. Most clients (78%) had diagnoses of non-psychotic conditions such as anxiety or depression, and 22% had diagnoses of schizophrenia, schizoaffective, or other psychotic disorder. During the project, 312 (87%) engaged in supported employment services, 206 (58%) attained competitive employment, and 177 (50%) found their first job within nine months of enrolling. Hispanics (64%), Asians (57%), and non-Hispanic Blacks (77%) achieved higher employment rates than non-Hispanic Whites (49%). Young adults (73%) achieved higher employment rates than older adults (51%). Engaging in new IPS supported employment programs over several months led to high rates of competitive employment across all groups in real-world, non-research settings, typically within nine months. Hispanics, Asians, and non-Hispanic Blacks achieved higher rates of competitive employment than non-Hispanic Whites, and young adults achieved higher rates than older adults. Further research may explain these differences.
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Empleos Subvencionados , Trastornos Mentales , Esquizofrenia , Adulto Joven , Humanos , Masculino , Femenino , Anciano , Adolescente , Adulto , Centros Comunitarios de Salud Mental , California , Salud Mental , Rehabilitación VocacionalRESUMEN
Background: Participatory research denotes the engagement and meaningful involvement of the community of interest across multiple stages of investigation, from design to data collection, analysis, and publication. Traditionally, people with first-hand experience of psychiatric diagnoses, services users and those living with a psychosocial disability have been seen objects rather than agents of research and knowledge production. This, despite the ethical and practical benefits of their involvement. The state of the art of knowledge about participatory research in mental health Brazil is poorly understood outside of its local context. The purpose of this article was to conduct a scoping review of participatory and user-led research in mental health in Brazil. Findings: We identified 20 articles that met eligibility criteria. Participation in research was not treated as separate from participation in shaping mental health policy, driving care, or the broader right to fully participate in societal life and enjoy social and civil rights. Studies identified several obstacles to full participation, including the biomedical model, primacy of academic and scientific knowledge, and systemic barriers. Our extraction, charting, and synthesis yielded four themes: power, knowledge, autonomy, and empowerment. Implications of the work: Participation in this context must address the intersecting vulnerabilities experienced by those who are both Brazilian and labeled as having a mental illness. Participatory research and Global South leadership must foreground local epistemologies that can contribute to the global debate about participation and mental health research.
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OBJECTIVE: Co-occurrence of substance use disorder and mental illness complicates treatment and is associated with increased disability. However, identification of substance use disorder in populations recently engaged in treatment can be challenging. This study aimed to examine traditional screening tools for substance use disorder and proxy characteristics (i.e., demographic characteristics, behaviors, and diagnoses) as predictors of clinician-observed substance use disorder. METHODS: The Supported Employment Demonstration, funded by the Social Security Administration, studied 2,960 adults whose applications for disability benefits because of mental illness were recently denied. In a subsample (N=1,354) for whom substance use disorder was determined by community-based teams during follow-up, the authors used logistic regression to identify baseline predictors of observed substance use disorder and compared the sensitivity and specificity of detection by using standardized screening tools (Alcohol Use Disorder Identification Test [AUDIT], 10-item Drug Abuse Screening Test [DAST-10]) with detection via decision trees based on proxy characteristics. RESULTS: Using decision trees based on a combination of personal characteristics (sensitivity=0.47, specificity=0.83, area under the curve [AUC]=0.71) or personal characteristics including diagnostic data (sensitivity=0.54, specificity=0.81, AUC=0.72) provided more accurate identification of substance use disorder than using a combination of the AUDIT and DAST-10 (sensitivity=0.34, specificity=0.88, AUC=0.61). Adding the combined AUDIT and DAST-10 substance use disorder indicator to either tree negligibly improved accuracy. CONCLUSIONS: In populations recently engaged in treatment, for whom standardized substance use disorder screening tools are less accurate than expected, consideration of personal characteristics could improve the detection of substance use disorder essential for treatment planning.
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Tamizaje Masivo , Trastornos Relacionados con Sustancias , Adulto , Estados Unidos , Humanos , United States Social Security Administration , Trastornos Relacionados con Sustancias/diagnóstico , Trastornos Relacionados con Sustancias/terapia , Sensibilidad y EspecificidadRESUMEN
Individual placement and support (IPS) is a robust evidence-based model of supported employment for people with mental health conditions that has been implemented in high-income countries. The model is now being extended to new populations and settings, often with modifications. Current evidence indicates that minor modifications may increase fit, major alterations of core principles generally reduce effectiveness, and augmentations have mixed success. The authors recommend that those who implement IPS adhere to its core principles whenever possible, use standardized methods to document and assess modifications, and follow basic scientific procedures to develop, measure, and evaluate modifications before recommending policy changes.
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Empleos Subvencionados , Trastornos Mentales , Humanos , Trastornos Mentales/terapia , Trastornos Mentales/psicología , Rehabilitación Vocacional , Salud Mental , RentaRESUMEN
ABSTRACT: The nucleus of the solitary tract (NTS) contains pro-opiomelanocortin (POMC) neurons that are 1 of the 2 major sources of ß-endorphin in the brain. The functional role of these NTS POMC neurons in nociceptive and cardiorespiratory function is debated. We have shown that NTS POMC optogenetic activation produces bradycardia and transient apnoea in a working heart-brainstem preparation and chemogenetic activation with an engineered ion channel (PSAM) produced opioidergic analgesia in vivo. To better define the role of the NTS POMC neurons in behaving animals, we adopted in vivo optogenetics (ChrimsonR) and excitatory/inhibitory chemogenetic DREADD (hM3Dq/hM4Di) strategies in POMC-Cre mice. We show that optogenetic activation of NTS POMC neurons produces time-locked, graded, transient bradycardia and bradypnoea in anaesthetised mice that is naloxone sensitive (1 mg/kg, i.p.), suggesting a role of ß-endorphin. Both optogenetic and chemogenetic activation of NTS POMC neurons produces sustained thermal analgesia in behaving mice that can be blocked by naloxone. It also produced analgesia in an inflammatory pain model (carrageenan) but not in a neuropathic pain model (tibial nerve transection). Inhibiting NTS POMC neurons does not produce any effect on basal nociception but inhibits stress-induced analgesia (unlike inhibition of arcuate POMC neurons). Activation of NTS POMC neuronal populations in conscious mice did not cause respiratory depression, anxiety, or locomotor deficit (in open field) or affective preference. These findings indicate that NTS POMC neurons play a key role in the generation of endorphinergic endogenous analgesia and can also regulate cardiorespiratory function.
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Analgesia , Proopiomelanocortina , Ratones , Animales , Proopiomelanocortina/genética , Proopiomelanocortina/metabolismo , Proopiomelanocortina/farmacología , Núcleo Solitario , Bradicardia , betaendorfina , Neuronas , Naloxona/farmacología , DolorRESUMEN
OBJECTIVE: A few clients in every mental health center present challenging behaviors, have difficulty engaging in services, and create stress within the treatment team. The authors provided consultations on clients with these characteristics over 4 years in the Social Security Administration's Supported Employment Demonstration (SED). METHODS: Four experienced community mental health leaders provided consultations on 105 of nearly 2,000 clients receiving team-based behavioral health and employment services in the SED. Using document analysis, consultants coded their notes and identified themes that described barriers to client engagement and strategies teams used to overcome them. RESULTS: Clients who were difficult to engage experienced complex and interacting behavioral health, medical, and social conditions, which made it hard for therapists to develop therapeutic relationships and help clients find employment. Faced with engagement barriers, staff were often discouraged and felt hopeless about achieving success. To address these barriers, consultants and teams developed several strategies: using supervisors and teammates for support, providing persistent outreach, pursuing referrals and consultations to help with complex conditions, and developing realistic goals. CONCLUSIONS: Supervisors, team leaders, and consultants in community mental health settings should help staff develop realistic strategies to manage the small number of clients whose behaviors present the greatest challenges. Effective strategies involve providing team-based outreach and support, fostering staff morale, obtaining specialist consultations regarding complex conditions, and calibrating realistic goals.
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Empleos Subvencionados , Trastornos Mentales , Humanos , Salud Mental , Trastornos Mentales/terapia , Trastornos Mentales/psicologíaRESUMEN
Young adults with mental health conditions want to work and advance their education, but many need help attaining these goals. Individual Placement and Support (IPS), originally developed for working-age adults with serious mental illness, is an evidence-based employment model that may benefit young adults. This study is the first systematic review and meta-analysis of randomized controlled trials (RCTs) of IPS for this population. We conducted a systematic review of the effectiveness of IPS for young adults with mental health conditions, supplementing our electronic search of the published literature with secondary analyses of two published RCTs. Using meta-analysis, we evaluated employment rate, job duration, and education rate. Seven studies met the inclusion criteria. Four evaluated IPS for young adults with early psychosis and three evaluated IPS for other young adult subgroups. All found a significantly higher employment rate for IPS than the control group. Overall, 208 (58.3%) of 357 IPS participants and 110 (32.4%) of 340 control participants were competitively employed during follow-up, yielding an overall risk ratio of 1.69 (95% CI 1.43, 1.99), z = 6.24, p < 0.001. Six of the seven studies also reported longer job duration for IPS than the control group, yielding an overall g = 0.34 (95% CI 0.09, 0.58), z = 2.72, p < 0.01. None of four RCTs examining education outcomes found a significant difference favoring IPS, but the overall risk ratio was significant: 1.33 (95% CI 1.06, 1.66), z = 2.51, p < 0.01. Although the empirical literature is limited, IPS appears to be effective in helping young adults with serious mental illness or early psychosis gain and keep competitive jobs. The impact of IPS on education outcomes is unclear. Future research should evaluate the generalizability of these findings to the broad range of young adults with mental health conditions needing help with their employment goals.
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Empleos Subvencionados , Trastornos Mentales , Trastornos Psicóticos , Adulto Joven , Humanos , Salud Mental , Trastornos Mentales/psicología , Rehabilitación VocacionalRESUMEN
Over the past three decades, Individual Placement and Support (IPS) has emerged as a robust evidence-based approach to helping people with severe mental illnesses, such as schizophrenia, bipolar disorder, and major depression, to obtain and succeed in competitive employment. This review addresses the history, principles, research, and future directions of IPS. It covers current evidence on employment outcomes, cost-effectiveness, and nonvocational outcomes. It also describes current attempts to extend IPS to new populations. The authors provide an overview of numerous systematic reviews and meta-analyses of randomized controlled trials involving people with serious mental illness. For studies addressing nonvocational outcomes and new populations, the review uses best available evidence. Published reviews agree that IPS enables patients with serious mental illness in high-income countries to succeed in competitive employment at a higher rate than patients who receive other vocational interventions. Within IPS programs, quality of implementation, measured by standardized fidelity scales, correlates with better outcomes. Employment itself leads to enhanced income, psychosocial outcomes, clinical improvements, and decreased mental health service use. As IPS steadily spreads to new populations and new settings, research is active across high-income countries and spreading slowly to middle-income countries. IPS is an evidence-based practice for people with serious mental illness in high-income countries. It shows promise to help other disability groups also, and emerging research aims to clarify adaptations and outcomes.
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This Viewpoint discusses the benefits of psychiatrists using individual placement and support to help patients find and maintain employment.
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Empleos Subvencionados , Trastornos Mentales , Humanos , Rehabilitación Vocacional , Trastornos Mentales/terapia , Trastornos Mentales/psicologíaRESUMEN
BACKGROUND: Military personnel face numerous challenges transitioning from military jobs to meaningful civilian employment. Many veterans seek help finding employment, but few veteran employment programs have been rigorously studied. Transitioning veterans generally have access to Local Community Resources (LCR), which include the Veterans Health Administration vocational rehabilitation services, the state-federal Vocational Rehabilitation program, and the Department of Labor's American Job Centers. By contrast, the innovative National Career Coach Program (NCCP) offers intensive career coaching and financial incentives for working. METHODS: This study used a randomized controlled design to compare the NCCP and LCR approaches for 208 transitioning service members (recent or pending transition). Researchers conducted interviews by telephone every four months for two years. Outcomes included earnings, months worked, and standardized self-report measures of health and well-being. Findings At two-year follow-up, significantly more NCCP participants had worked in paid employment than LCR participants (95% vs. 83%). NCCP participants averaged $2568 in monthly earnings compared to $1865 for LCR participants, thus averaging $16,872 more total income per participant over the two-year period. Employment outcomes significantly improved between Year 1 and Year 2. NCCP participants also reported significantly greater improvements in both physical and mental health compared to LCR participants. Average monthly earnings correlated with changes in health outcomes. CONCLUSIONS: Veterans receiving multi-faceted employment services early in the transition from the military showed sustained benefit over a two-year period with increased earnings over time and improved mental and physical outcomes. Positive employment outcomes may have contributed to improved health outcomes.
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Empleos Subvencionados , Personal Militar , Veteranos , Humanos , Estados Unidos , Veteranos/psicología , Rehabilitación Vocacional , EmpleoRESUMEN
The pivotal role of the periaqueductal grey (PAG) in fear learning is reinforced by the identification of neurons in male rat ventrolateral PAG (vlPAG) that encode fear memory through signalling the onset and offset of an auditory-conditioned stimulus during presentation of the unreinforced conditioned tone (CS+) during retrieval. Some units only display CS+ onset or offset responses, and the two signals differ in extinction sensitivity, suggesting that they are independent of each other. In addition, understanding cerebellar contributions to survival circuits is advanced by the discovery that (i) reversible inactivation of the medial cerebellar nucleus (MCN) during fear consolidation leads in subsequent retrieval to (a) disruption of the temporal precision of vlPAG offset, but not onset responses to CS+, and (b) an increase in duration of freezing behaviour. And (ii) chemogenetic manipulation of the MCN-vlPAG projection during fear acquisition (a) reduces the occurrence of fear-related ultrasonic vocalisations, and (b) during subsequent retrieval, slows the extinction rate of fear-related freezing. These findings show that the cerebellum is part of the survival network that regulates fear memory processes at multiple timescales and in multiple ways, raising the possibility that dysfunctional interactions in the cerebellar-survival network may underlie fear-related disorders and comorbidities.
Anxiety disorders are a cluster of mental health conditions characterised by persistent and excessive amounts of fear and worry. They affect millions of people worldwide, but treatments can sometimes be ineffective and have unwanted side effects. Understanding which brain regions are involved in fear and anxiety-related behaviours, and how those areas are connected, is the first step towards designing more effective treatments. A region known as the periaqueductal grey (or PAG) sits at the centre of the brain's fear and anxiety network, regulating pain, encoding fear memories and responding to threats and stressors. It also controls survival behaviours such as the 'freeze' response, when an animal is frightened. A more recent addition to the fear and anxiety network is the cerebellum, which sits at the base of the brain. Two-way connections between this region and the PAG have been well described, but how the cerebellum might influence fear and anxiety-related behaviours remains unclear. To explore this role, Lawrenson, Paci et al. investigated whether the cerebellum modulates brain activity within the PAG and if so, how this relates to fear behaviours. Rats had electrodes implanted in their brains to record the activity of nerve cells within the PAG. A common fear-conditioning task was then used to elicit 'freeze' responses: a sound was paired with mild foot shocks until the animals learned to fear the auditory signal. In the rats, a subset of neurons within the PAG responded to the tone, consistent with those cells encoding a fear memory. But when a drug blocked the cerebellum's output during fear conditioning, the timing of the PAG response was less precise and the rats' freeze response lasted longer. Lawrenson, Paci et al. concluded that the cerebellum, through its interactions with the brain's fear and anxiety network, might be responsible for coordinating the most appropriate behavioural response to fear, and how long 'freezing' lasts. In summary, these findings show that the cerebellum is a part of the brain's survival network which regulates fear-memory processes. It raises the possibility that disruption of the cerebellum might underlie anxiety and other fear-related disorders, thereby providing a new target for future therapies.
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Miedo , Sustancia Gris Periacueductal , Animales , Cerebelo/fisiología , Condicionamiento Clásico/fisiología , Condicionamiento Operante/fisiología , Miedo/fisiología , Masculino , Sustancia Gris Periacueductal/fisiología , RatasRESUMEN
Community mental health nurses sometimes join multi-disciplinary teams, but the role has not been defined and studied carefully. This article describes the psychiatric Nurse Care Coordinator (NCC)-a unique position created to support care management, facilitate systematic medication management, and coordinate medical care in the Social Security Administration's 30-site Supported Employment Demonstration. The authors reviewed the study's NCC manual, supervised and consulted with the NCCs weekly over nearly three years, and reviewed data on NCC activities. Although the 984 participants assigned to NCCs experienced numerous mental health, substance use, and chronic medical conditions, only 59% completed intake assessments and engaged over time with NCCs. For those 581 participants, NCCs spent approximately 51% of their time helping with mental health issues, 35% on medical care, and 12% on substance use conditions. The NCC was critically important for complex, high-need individuals.
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Salud Mental , Enfermería Psiquiátrica , Enfermedad Crónica , Humanos , Psicoterapia , Estados UnidosRESUMEN
Transitioning from military service is stressful for veterans with service-connected disabilities seeking civilian employment. This descriptive study examined self-assessed mental health, well-being, and substance use of men and women shortly before or after transition from US military service, compared to norms from community and military samples. As part of a prospective study evaluating an innovative employment program, researchers interviewed 229 current and former service members with service-connected disabilities transitioning from U.S. military service. Compared to published norms, respondents reported significantly poorer outcomes on 5 of 6 standardized measures, indicating less life satisfaction, poorer mental health, more symptoms of depression and posttraumatic stress disorder, and greater financial distress. In the previous year, 42% were prescribed opioid medications, over twice the annual opioid prescription rate of 19% in the general US population. Systematic strategies are needed to ensure access for transitioning veterans with serious behavioral health issues to appropriate evidence-based practices.
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Personal Militar , Trastornos por Estrés Postraumático , Veteranos , Analgésicos Opioides , Femenino , Humanos , Masculino , Salud Mental , Personal Militar/psicología , Estudios Prospectivos , Trastornos por Estrés Postraumático/epidemiología , Trastornos por Estrés Postraumático/psicología , Trastornos por Estrés Postraumático/terapia , Estados Unidos , Veteranos/psicologíaRESUMEN
Individual placement and support (IPS) was the primary intervention in the United States Social Security Administration's supported employment demonstration (SED), a large randomized trial that sought to increase employment and reduce disability among those whose first application for disability benefits was denied. Researchers developed a measure of participation in IPS services to quantify participation among enrollees assigned to receive IPS. The IPS participation measure, which IPS teams completed monthly for individual clients, recorded clients assigned to IPS as being either out of contact with their IPS treatment teams or, if in contact, according to their employment status (employed or not employed) and receipt of IPS job search services (participating or not participating). The measure also recorded types of IPS activities and reasons for non-participation. IPS teams completed the IPS participation measure at a rate of approximately 95% each month. Between 27 and 35% of enrollees assigned to a treatment condition participated in IPS services each month during the first 24 months of measurement. The most common activities were applying for jobs and attending job interviews. Most of those out of contact were not responding to outreach efforts (58-72%). Those in contact but not participating despite being unemployed were typically either uninterested in employment (20-44%) or difficult to reach (10-16%). As IPS expands to serve new populations, it will be important to document and understand the links between individual characteristics, variance in participation patterns, and employment outcomes. Subsequent analyses of SED data will investigate these relationships among enrollees.
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Personas con Discapacidad , Empleos Subvencionados , Trastornos Mentales , Humanos , Trastornos Mentales/terapia , Rehabilitación Vocacional , Desempleo , Estados UnidosRESUMEN
ABSTRACT: Military personnel face numerous challenges transitioning from military jobs to meaningful civilian employment. The Independence Project compared an innovative employment program (National Career Coach Program) with standard employment services (Local Community Resources) in a randomized controlled trial. Study participants were transitioning veterans with self-reported service-connected disabilities seeking permanent employment. The primary outcomes were paid employment and disability ratings over 1 year. Secondary outcomes included health and well-being. At 1-year follow-up, National Career Coach Program participants were significantly more likely to work, had significantly greater earnings, and reported significantly greater improvements in physical and mental health compared with participants assigned to Local Community Resources. Both groups increased in disability ratings over 12 months, with no difference between groups. Multifaceted supports delivered by the National Career Coach Program increased employment, earnings, mental health, and physical health over 1 year. These significant differences appeared even though control group participants achieved considerable employment success.
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Personas con Discapacidad , Personal Militar , Veteranos , Empleo , Humanos , Salud Mental , Veteranos/psicologíaRESUMEN
OBJECTIVE: Individual placement and support (IPS), an evidence-based supported employment practice, is a core service in community mental health in the United States. Several factors promote the growth of IPS, including a network of 24 states participating in a learning community devoted to expanding IPS services. This study examined growth of IPS in the United States from 2016 to 2019, comparing growth rates for states within and outside the learning community. METHODS: This national survey included telephone interviews with 70 representatives from state mental health and vocational rehabilitation agencies in 50 states and the District of Columbia, replicating methods of a 2016 survey. The primary outcomes were the number of IPS programs and clients served. The survey inquired about four indicators of state-level support for IPS implementation and sustainment: collaboration between state agencies, independent fidelity reviews, technical assistance and training, and funding. RESULTS: In 2019, 41 (80%) of 50 states and the District of Columbia had IPS services, with 857 IPS programs serving an estimated 43,209 clients. Between 2016 and 2019, the number of programs increased from 272 to 486 in 22 learning-community states and two learning-community counties, and from 251 to 371 in 18 states outside the learning community. State-level support for IPS was significantly greater in learning-community states, compared with non-learning-community states. CONCLUSIONS: IPS services expanded substantially in the United States between 2016 and 2019. Learning-community states had more rapid growth and provided greater implementation support, facilitating implementation, expansion, and sustainment of high-fidelity IPS. Nevertheless, access to IPS remains limited.