Three Things We Learned Along the Way: lessons for training in psychiatric epidemiology.

The COVID-19 pandemic, and its associated mortality, morbidity, deep social and economic impacts was a global traumatic stressor that challenged population mental health and our de-facto mental health care system in unprecedented ways. Yet in many respects, this 'crisis' is not new. Psychiatric epidemiologists have recognized for decades the need and unmet need of people in distress and the limits of the public mental health services in the United States. We argue that psychiatric epidemiologists have a critical role to play as we endeavor to address population mental health and draw attention to three areas of consideration: the need to elevate population based solutions; engaging equitably with lived experience; and interrogating recovery. Psychiatric epidemiology has a long history of both responding to and shaping our understandings of the relationships among psychiatric disorders and society through evolving methods and training, and the current socio-historical moment again suggests that shifts in our practice can strengthen our field and its impact.

Social Support and Associated Factors Among Men and Women in Pre-COVID Substance Use Treatment.

Low levels of social support are related to negative health outcomes, representing further obstacles to recovery from substance use disorder (SUD). This study examined relationships among stressors, symptoms and social support in 124 women and 102 men engaged in two outpatient public sector substance use treatment programs. Multiple linear regression analyses were utilized to assess relationships between variables of interest and social support. Men reported significantly lower social support than women. Food insecurity was associated with lower social support for men (ß= -13.6 [95% CI -26.7, -0.4], p = 0.04). When examining emotional support and tangible aid, victimization history was related to lower support (both types) for women while food insecurity was associated with lower support (both types) for men. Depression was related to lower emotional support among both men and women. Substance use treatment programs should explicitly target social support and related stressors to facilitate recovery for the individuals they serve.

Messaging inclusion with consequence: U.S. sanctuary cities and immigrant wellbeing.

In the United States (U.S.), sanctuary cities have increasingly garnered public attention as places dedicated to increasing immigrant safety, inclusion, and health. These cities primarily rely on limiting local police cooperation with federal immigration enforcement to deter immigrant detention and deportation. However, sanctuary policies' inability to extend immigrants' legal rights and their reliance on police as ushers of sanctuary may complicate how these spaces attend to their stated goals. In this paper, we examine how organizational workers conceptualize sanctuary, safety, and immigrant health and wellbeing within sanctuary cities. We draw on interviews with organizational workers in two sanctuary cities: Boston, Massachusetts and Seattle, Washington collected between February and August 2018. Our findings reveal that immigrants continue to face structural barriers to housing, safe employment, education, and healthcare within sanctuary cities with consequences to wellbeing. Workers' definitions of safety draw on interconnected structural exclusion that prevent immigrants from accessing basic needs and fail to account for historically rooted forms of racism and nativism. Organizational workers identified tensions between messages of sanctuary and what local sanctuary policies offer in practice, providing insight into consequences of institutionalizing a grassroots social movement. As organizational workers negotiate these tensions, they must develop everyday sanctuary practices to extend immigrant inclusion, safety, health, and wellbeing.

Spatializing stigma-power: Mental health impacts of spatial stigma in a legally-excluded settlement in Mumbai, India.

In disadvantaged neighborhoods such as informal settlements (or "slums" in the Indian context), infrastructural deficits and social conditions have been associated with residents' poor mental health. Within social determinants of health framework, spatial stigma, or negative portrayal and stereotyping of particular neighborhoods, has been identified as a contributor to health deficits, but remains under-examined in public health research and may adversely impact the mental health of slum residents through pathways including disinvestment in infrastructure, internalization, weakened community relations, and discrimination. Based on analyses of individual interviews (n = 40) and focus groups (n = 6) in Kaula Bandar (KB), an informal settlement in Mumbai with a previously described high rate of probable common mental disorders (CMD), this study investigates the association between spatial stigma and mental health. The findings suggest that KB's high rate of CMDs stems, in part, from residents' internalization of spatial stigma, which negatively impacts their self-perceptions and community relations. Employing the concept of stigma-power, this study also reveals that spatial stigma in KB is produced through willful government neglect and disinvestment, including the denial of basic services (e.g., water and sanitation infrastructure, solid waste removal). These findings expand the scope of stigma-power from an individual-level to a community-level process by revealing its enactment through the actions (and inactions) of bureaucratic agencies. This study provides empirical evidence for the mental health impacts of spatial stigma and contributes to understanding a key symbolic pathway by which living in a disadvantaged neighborhood may adversely affect health.

Gone Too Soon: priorities for action to prevent premature mortality associated with mental illness and mental distress.

Globally, too many people die prematurely from suicide and the physical comorbidities associated with mental illness and mental distress. The purpose of this Review is to mobilise the translation of evidence into prioritised actions that reduce this inequity. The mental health research charity, MQ Mental Health Research, convened an international panel that used roadmapping methods and review evidence to identify key factors, mechanisms, and solutions for premature mortality across the social-ecological system. We identified 12 key overarching risk factors and mechanisms, with more commonalities than differences across the suicide and physical comorbidities domains. We also identified 18 actionable solutions across three organising principles: the integration of mental and physical health care; the prioritisation of prevention while strengthening treatment; and the optimisation of intervention synergies across social-ecological levels and the intervention cycle. These solutions included accessible, integrated high-quality primary care; early life, workplace, and community-based interventions co-designed by the people they should serve; decriminalisation of suicide and restriction of access to lethal means; stigma reduction; reduction of income, gender, and racial inequality; and increased investment. The time to act is now, to rebuild health-care systems, leverage changes in funding landscapes, and address the effects of stigma, discrimination, marginalisation, gender violence, and victimisation.

'Let Others Love You Back to Health': The Role of Performance-based Support Groups for People in Recovery.

Peer support groups have become widely utilized among those in recovery from problematic substance use. Yet, these peer-based programs vary and research examining their effectiveness has yielded mixed results. Relatively less is known about the impacts of arts-based peer recovery programs. Some research suggests that theatre may offer a powerful tool to address biopsychosocial changes among individuals in recovery. To explore the role of arts-based peer support programs, we draw on qualitative interviews with performers in two arts-based recovery programs. Our findings suggest that arts-based peer recovery programs may aid individuals in recovery in four main ways. Performing allowed participants to build relationships with others in recovery, channel experiences creatively while challenging stigma, foster confidence and recovery-identity formation, aiding participants in working through emotional impacts of prior substance use. These findings support emerging scholarship examining the role of performance in challenging stereotypes about substance use to aid those in recovery.

Social support over time for men and women veterans with and without complex trauma histories.

Social support is closely linked to health, but little is known about United States (U.S.) veterans' social support over time and factors that may influence their support trajectories. This study investigates social support over time for U.S. men and women Post-9/11 veterans in relation to trauma history and gender. A secondary analysis of longitudinal cohort data from the Survey of Experiences of Returning Veterans (SERV), which employed a repeated-measures longitudinal design using five waves of data (baseline, 3, 6, 9, 12 months) with 672 combat veterans. Results from random intercept multilevel models found no significant gender differences in social support over time. Veterans with complex trauma histories were at risk for lower social support across waves. A stability trend was also observed; specifically, at baseline, veterans who started with high support maintained their level over time whereas veterans who started with deficits in social support remained low over time. Veterans identifying as African American or Latinx, and those with lower annual incomes, reported lower support compared to White and higher-income veterans. Furthermore, low social support was significantly associated with severe posttraumatic stress symptoms and active suicidal ideation across 12 months. SERV utilized a nonrandom sampling method that may reduce generalizability of findings. There is also potential for residual confounding by factors related to both social support levels and time since discharge that were not available in this data set. Findings have implications for developing clinical and community interventions intended to support veterans as they transition back to the community. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Distinct groups of firearm owners with differential risk for suicide in the United States: A latent class analysis.

Suicide is a leading cause of mortality and firearm suicide accounts for the majority of fatalities. Firearm owners are a diverse population and firearm-specific suicide prevention programs should be tailored to distinct at-risk firearm-owning groups. This study set out to identify groups of firearm owners with differential suicide risk having unique characteristics that could be used to customize suicide prevention efforts. We conducted a nationally-representative survey of 2646 firearm owners to assess individual suicide risk, suicide risk factors, and demographic characteristics. A Latent Class Analysis identified unique segments of firearm owners at increased risk of suicide with similar underlying suicide risk factors and demographic characteristics. We found almost one in ten (9.6%) of firearm owners were at increased risk of suicide with 25% reporting suicide ideation, 6.6% reporting suicide planning, and 1.8% reporting previous suicide attempts. We identified three unique groups of firearm owners with higher than average suicide risk. Relative to other groups of firearm owners, one at-risk group were more affluent with a history of adverse experiences and mental health challenges, a second group had more male veterans with high levels of alcohol consumption, and third group had more non-heterosexual women who experienced trauma. We conclude that there are three unique groups of firearm owners with higher than average suicide risk with very different characteristics. In addition to broad suicide prevention efforts, customized firearm suicide prevention programs should be developed individually for these different firearm-owning populations, taking into consideration the unique suicide risk factors and demographics of each group.

Performing an Organizational Health Literacy Assessment in a Shelter Serving People with Mental Illness.

BACKGROUND: Health literacy research and practice are constantly evolving. Recent inquiry has highlighted the burdensome literacy demands faced by people with serious mental illness (SMI). Systems, organizational operations, and structures can play a role in decreasing literacy demand, thereby reducing unnecessary challenges for people with SMI. Brief Description of Activity: An organizational health literacy assessment was conducted to explore literacy demands in one mental health shelter and revealed best practice action steps for improving the literacy environment. IMPLEMENTATION: The assessment included an exploration of the shelter environment using The Health Literacy Environment Activity Packet, First Impressions & Walking Interview, and a commonly used shelter document using the Simple Measure of Gobbledygook (SMOG), Suitability Assessment of Materials (SAM), and Centers for Disease Control and Prevention (CDC) Index. RESULTS: The literacy demands of the shelter environment and a frequently used document exceeded the literacy skills of people with SMI. Environment assessment revealed environmental facilitators (e.g., welcoming atmosphere) and barriers (e.g., unclear signage). Document assessment also revealed facilitating factors and barriers. SMOG scores ranged from 11.25 to 11.80 (median: 11.38), meaning 11th to 12th grade-level reading skills are required to understand, use, and take action on the document's content. A SAM score of 50% (adequate) and a CDC Index score of 42.1 (revise and improve) reveal materials contain both facilitating factors (e.g., chunked sections) and barriers (e.g., jargon, mismatched graphics) to use. LESSONS LEARNED: The mismatch between system demands and the literacy skills of people with SMI is more profound than that of the general United States population. Organizational health literacy assessments are achievable and useful for both immediate and long-term action aimed at understanding and improving the organizational health literacy of mental health spaces. Further work is needed to explore the role of behavioral health services in addressing the institutional and programmatic literacy demands that inhibit treatment and recovery. [HLRP: Health Literacy Research and Practice. 2022;6(3):e167-e174.] Plain Language Summary: An organizational health literacy assessment reveals how system demands can be changed to better serve intended users. Engaging in mental health, recovery, and treatment services requires complex literacy skills. Generally, the U.S. adult population does not have the skills to meet such demands, and this is especially true among public mental health service users.

Challenging federal exclusion: Immigrant safety, health, and healthcare access in sanctuary cities.

As the United States (U.S.) continues to prioritize federal immigration enforcement, subnational localities increasingly enact their own immigration policies. Cities limiting cooperation with federal immigration enforcement are commonly referred to as sanctuary cities, which aim to improve immigrant safety and wellbeing. Yet, little is known about how these cities accomplish this beyond immigration enforcement non-cooperation. We draw from qualitative interviews with 54 organizational workers in Seattle, Washington and Boston, Massachusetts. Our findings illuminate lingering challenges immigrants face within sanctuary cities and demonstrate how organizational workers mitigate the shortcomings of sanctuary policies to addressing broad definitions of safety and health by enacting their own sanctuary practices.

Associations between health literacy, cognitive function and general literacy in people with schizophrenia attending community mental health clinics in Australia.

BACKGROUND: Health literacy (HL) has been defined as the ability of individuals to access, understand, and utilise basic health information. HL is crucial to patient engagement in treatment through supporting patient autonomy, informed consent and collaborative care. In people with physical disorders, poor HL is associated with poor health outcomes, but less is known about HL in people with severe mental illness. This study aimed to assess HL and investigate the associations between education, cognitive function, general literacy, and HL in participants with schizophrenia attending community mental health clinics. METHOD: Fifty-two outpatients with schizophrenia attending a public community mental health clinic in Adelaide, Australia completed the Test of Functional Health Literacy in Adults-Short Form (S-TOFHLA) along with tests of cognition, aural and reading literacy and numeracy including Digit Symbol Coding (DSC), verbal fluency, the Wechsler Adult Intelligence Scale (WAIS-IV), Woodcock-Johnson III (Part 4 and 9) and the Lipkus numeracy scale. Sixty-one percent of participants were male. Participants had a mean age of 41.2 (SD 9.9) years and a mean of 11.02 (SD 1.5) years of education. RESULTS: The majority of participants had very poor aural and verbal literacy and poorer literacy correlated with fewer years of education. On the S-TOFHLA, 81% of participants had adequate HL; 6% were marginal and 13% were inadequate. There was a positive correlation between education and HL, with those with more years of education scoring higher for HL. There was also a significant association between better HL and better working memory and attention. CONCLUSIONS: Consistent with previous research in schizophrenia, our participants had reduced educational attainment, aural and reading literacy and cognitive function compared to population norms. However, HL was better than expected given that previous research has found that people with psychiatric disorders tend to have lower HL, compared to the general population. This may reflect effective case management of our participants whilst attending the community clinics and supports ongoing research and intervention regarding HL in people living with mental illness.

Sexual and physical revictimization in U.S. military veterans.

The present study examined revictimization, defined as sexual or physical assault in adulthood that followed a history of childhood maltreatment. We aimed to identify factors associated with revictimization over time in a group of U.S. military veterans deployed following the September 11, 2001, terrorist attacks (9/11). As revictimization is associated with multiple negative mental health outcomes in the literature, identifying risk and protective factors can aid in the prevention of revictimization and associated poor health outcomes among veterans. In this sample, the proportion of adult revictimization was 2.7% for men, 95% CI [2.0, 3.6] and 22.9% for women, 95% CI [20.5, 25.8]. Using multilevel logistic models, we found that women, ß = 2.2, p < .001; Navy veterans, ß = 1.5, p < .001; and participants who reported posttraumatic stress symptoms, ß = 0.2, p = .028, were at significantly higher risk of revictimization across time compared to nonrevictimized counterparts. Social support while in the military was protective, ß = -0.1, p < .001, against revictimization. In addition, childhood abuse experiences combined with characteristics such as female gender were related to an increased risk of revictimization during and following military service. The findings highlight opportunities for intervention and areas of strength within this population; social connection garnered during military service may serve as a protective factor against revictimization. Future research is needed to examine the role of social support in possibly lowering veterans' risk of revictimization over time, particularly for post-9/11 veterans struggling with transitioning from military to civilian life.

Discrimination and mental health of Somali immigrants in North America: a longitudinal study from 2013 to 2019.

PURPOSE: Immigrant mental health is closely linked to the context of reception in the receiving society, including discrimination; past research has examined this relationship only cross-sectionally. This longitudinal study examines the relationships between discrimination and mental health among Somali immigrants living in North America from 2013 to 2019. METHODS: Data for 395 participants (mean age 21 years at Time 1) were collected through the four-wave Somali Youth Longitudinal Study in four cities: Boston, MA, Minneapolis, MN, Lewiston/Portland, ME, and Toronto, ON. Latent linear and quadratic growth models were used to predict mental health symptoms over time and discrimination's role in these changes. RESULTS: PTSD and anxiety symptoms decreased from 2013 to 2015 and subsequently increased. Depression was static from 2013 to 2015, worsening thereafter. Increases in discrimination predicted increases in mental health symptomatology at all timepoints. CONCLUSION: This study provides support for discrimination's toxic impact on mental health and suggests that recent increases in discrimination may have contributed to worsening mental health among Somali immigrants living in North America.

Chipped or Whole? Listening to Survivors' Experiences With Disclosure Following Sexual Violence.

Sexual violence is a prevalent crime but vastly underreported and with serious long-term health consequences for survivors. Disclosure of sexual violence represents a social experience that may offer support towards healing or further traumatization depending on the response received. Although current research suggests that process of disclosure itself is important, as are social responses, there is a dearth of research examining the perceived impact of initial responses to disclosure on healing and relationships, particularly over time. The current study used data from nine focus groups with 45 survivors to explore the impact of initial disclosure reactions on recovery, from the survivors' perspectives. Constant comparative analysis identified several themes, including subtypes of positive and negative responses to disclosure and long-term impacts on healing and relationships. Survivors disclosed to informal and formal support persons and although many identified responses as positive or negative, some also experienced mixed responses. Survivors identified perceived long-term impacts on healing, interpersonal relationships, and social justice. Our findings suggest disclosures are a critical point for potential intervention after sexual violence. It is through the disclosure process that survivors can be supported and empowered to connect with others and move further along in their journey towards healing and recovery. Public awareness and promotion of positive responses could be designed to reach children and youth, so that the next generation is equipped with the tools to support each other in difficult times, particularly in the aftermath of sexual violence.

A Qualitative Examination of How Somali Young Adults Think About and Understand Violence in Their Communities.

Violence prevention efforts must take into consideration the potentially stigmatizing labels associated with violence, and how youth perceive different types of violence in their communities. Somali communities and individuals in North America have at times been labeled as at-risk for violence, with two notable examples being gang violence and ideologically motivated violence, or violent radicalization. Little is known, however, about how the youth themselves think about and understand these types of violence in their communities. In this article, we seek to answer the following questions: How do Somali immigrants think about violence in their communities, and the stigma related to this violence? and What are the implications of these perceptions/beliefs for violence prevention? Data are drawn from two qualitative studies conducted as part of an ongoing community-based participatory research (CBPR) collaboration between academic partners and Somali communities in three cities in North America. Study 1 consists of nine focus groups (n = 36, male only), and Study 2 consists of in-depth interviews (n = 40, male and female). All participants are Somali young adults living in North America. Overall, radicalization to violence is seen as a remote and irrelevant issue in the Somali community. Participants distance themselves from the idea of radicalization to violence and from those who participate in radical acts or held such beliefs. In contrast, gang involvement is characterized as a major problem for Somali communities, and a product of the marginalization associated with being a refugee in Canada or the United States. Findings suggest that prevention efforts focused on gangs are more likely to be acceptable to communities than those focused on violent extremism.

Evidence to Practice for Mental Health Task-Sharing: Understanding Readiness for Change among Accredited Social Health Activists in Sehore District, Madhya Pradesh, India.

Involvement of community health workers (CHWs) within task-sharing to bridge the mental health treatment gap has been proven to be efficacious in randomized controlled trials. The impact of mental health programs based on task-sharing paradigm greatly depends on the performance of CHWs which, in-turn, is influenced by their readiness for change. However, there is dearth of literature assessing the role of readiness for change as an important predicator of CHW performance. The aim of this study is to examine the applicability of the readiness for change model and investigate its cultural and contextual nuances among Accredited Social Health Activists (ASHAs), a cadre of CHWs in India, to understand their engagement in mental health task-sharing. We conducted in-depth, semi-structured interviews with a purposive sample of n = 12 key informants including ASHAs and other healthcare professionals in Sehore district, India. The interview guide consisted of open-ended questions based on the readiness for change factors including ASHAs' attitudes towards their role in mental health care, perception of capability to implement mental health task-sharing, of support from the public health system, etc. Framework analysis with a combined inductive-deductive approach was employed to code the data and generate themes. Participants endorsed three readiness for change themes relevant to task-sharing among ASHAs including change valence or value ascribed to task-sharing, change-efficacy or the perceived ability to implement task-sharing, and job valence or value ascribed to their regular job role. In addition, they provided insights into the culturally and contextually salient aspects of these factors. Themes of personal empowerment, gaining respect and trust from community, professional duty, relationship with supervisors, and lack of resources availability were majorly highlighted. This is the first study to qualitatively investigate the applicability of the readiness for change model and its culture- and context-specific nuances among a cadre of non-specialist health workers in India. Our findings posit that implementation science models should strongly consider the culture and context within which they are being applied to enhance fit and relevance. Further, our results should be taken into consideration to adapt and validate measurement tools and build readiness for change in this population.

Associations Between Work-Related Factors and Psychological Distress Among Construction Workers.

OBJECTIVE: Identify work-related factors associated with the mental health and well-being of construction workers. METHODS: We completed eight key informant interviews, six worker focus groups, and a survey, informed by the interviews and focus groups, of 259 construction workers on five construction sites. Negative binomial regressions examined associations between psychological distress and work-related factors including safety climate, work-to-family conflict, psychological demands, social support, harassment, and job security. RESULTS: Three themes emerged from the interviews and focus groups, job demands and structure, social support and workplace relations, and job precarity. From the survey higher psychological demands, higher work-to-family conflict, lower supervisor support, higher discrimination, and higher likelihood of losing a job were associated with higher psychological distress. When combined into a single model job demands and work-to-family conflict remained significant. CONCLUSIONS: Work-related factors were associated with high levels of distress.

You Have to Pay to Live: Somali Young Adult Experiences With the U.S. Health Care System.

There is increasing documentation that refugees face experiences of interpersonal or structural discrimination in health care and employment. This study examines how Somali refugees understand various forms of discrimination in employment and health care related to their health, utilization of, and engagement with the health care system in the United States. We draw on semistructured qualitative interviews (N = 35) with Somali young adults in three U.S. states-Minnesota, Massachusetts, and Maine. Using modified grounded theory analysis, we explore how experiences of discrimination in employment and health care settings impact health care access, utilization, and perceptions of health among Somali young adults. Discrimination was identified as a major barrier to using health services and securing employment with employer-sponsored insurance coverage. These findings highlight how interpersonal and structural discrimination in employment and health care are mutually reinforcing in their production of barriers to health care utilization among Somali refugees.

Similarities in client-clinician perceptions of subjective social status and its association to similarities in the quality of working alliance and client anxiety symptoms.

Subjective social status (SSS) has largely been ignored within psychotherapy literature. We investigated the association between similarities in client-clinician perceptions of SSS, similarities in their report of the quality of working alliance, and resultant anxiety symptoms.Participants represented a primarily low-income, culturally diverse sample of 312 clients receiving care from 68 clinicians at 13 outpatient mental health clinics in the Northeastern United States between September 2013 and August 2016. As part of a larger randomized controlled trial, clients and clinicians completed the MacArthur Scale of subjective social status and the Working Alliance Inventory (WAI), and clients completed the Generalized Anxiety Disorder 7-item Scale (GAD-7).At the within-clinician level, client-clinician dyads with less similar perceptions of the client's SSS were characterized by less similar perceptions of their alliance, which in turn resulted in worsening anxiety symptoms.Clinicians' correct perception of their clients' social status might be important for sharing a similar view of the client-clinician level of alliance, which can, in turn, contribute to lowering the client's anxiety symptoms.

Barriers to and Facilitators of Implementing Peer Support Services for Criminal Justice-Involved Individuals.

OBJECTIVE: This study sought to examine perceived barriers to and facilitators of the adoption, implementation, and sustainability of community-based mental health peer support services for criminal justice-involved individuals, also known as "forensic peer support" (FPS). METHODS: Qualitative interviews were conducted with stakeholders (N=14) and peer specialists (N=37) to better understand delivery of peer support services for justice-involved individuals in Pennsylvania. Thematic analysis followed by directed content analysis was used to identify factors in three a priori implementation categories based on the RE-AIM (Reach, Effectiveness, Adoption, Implementation, Maintenance) model: initial facilitators (adoption), barriers (implementation), and facilitators (maintenance) to long-term sustainability. RESULTS: Initial service adoption was facilitated by buy-in from recovery-oriented gatekeepers in the criminal justice system. Unique implementation barriers included the chasm between the orientations of the two systems (recovery vs. punitive) and formal and informal limitations on the employment of individuals with criminal justice system exposure. For services to be sustainable and have an impact over the long term, FPS advocates and workers must develop rapport with on-the-ground employees of the criminal justice system. Funding barriers specific to the criminal justice system limited the adoption, implementation, and maintenance of FPS services. CONCLUSIONS: Although many of the factors that affect FPS service implementation were similar to those identified in the broader peer support literature, important differences must be addressed for successful FPS service delivery. Within the criminal justice system, both policies and norms presented barriers to the expansion of peer support services for justice-involved individuals.