Identifying Challenges and Solutions for Improving Access to Mental Health Services for Rural Youth: Insights from Adult Community Members.

In the rural United States, provider shortages, inadequate insurance coverage, high poverty rates, limited transportation, privacy concerns, and stigma make accessing mental healthcare difficult. Innovative, localized strategies are needed to overcome these barriers, but little is known about what strategies may be feasible in, or acceptable to, rural communities. We aimed to identify barriers youth face in accessing mental healthcare in rural Washington State and to generate ideas to improve access. METHODS: Semi-structured, key informant interviews were conducted by telephone with adult community members, including parents, teachers, and healthcare providers. Participants answered questions related to barriers to mental healthcare access that confront youth and approaches to improving access. Detailed, de-identified field notes were analyzed using conventional content analysis. RESULTS: Limited resources and stigma were the two primary barriers to accessing mental healthcare that youth encounter in the community. Limited resources included lack of services and transportation, inconsistent funding and mental health programming, and workforce shortages. Stigma associated with seeking mental healthcare was of particular concern for youth with diverse identities who experience additional stigma. CONCLUSIONS: Improving access to mental healthcare for rural youth will require building a strong mental health workforce and championing efforts to reduce stigma associated with help-seeking.

Dissociation training and symptom identification accuracy among Australian psychologists.

OBJECTIVE: Dissociation is a common but underrecognized sequelae of trauma exposure. We investigated Australian psychologists' training in dissociation, assessment practices, and accuracy in identifying dissociation symptoms. METHOD: Participants in this cross-sectional study of Australian psychologists (N = 280) were recruited through publicly available email addresses, graduate psychology programs, and social media. Participants estimated the percentages of their clients who had experienced trauma and had dissociative symptoms, their confidence in assessing and treating trauma and dissociation, their training in trauma and dissociation, and their dissociation screening practices. Participants were also asked to identify dissociation symptoms (per the Dissociative Experiences Scale-II and Somatic Dissociation Questionnaire-5) from a list of trauma-related symptoms. RESULTS: Although 99% of participants reported treating trauma-exposed clients, only 59.6% and 41.1% reported formal training in trauma or dissociation during their psychology qualification, respectively. One in five participants correctly identified all psychoform and somatoform symptoms as dissociation. Accurately identifying psychoform dissociation symptoms was associated with confidence in treating dissociation (p = .048) and having informal peer consultation on dissociation (p = .032). Accurately identifying somatoform dissociation was associated with confidence assessing (p = .006) and treating (p = .009) dissociation and having completed professional development on dissociation (p = .047). CONCLUSIONS: Most psychologists demonstrated inaccuracies in their knowledge of dissociation, which raises concern that dissociation may not be recognized in clinical practice and thus go untreated. Training on dissociation should be incorporated into psychology curricula, particularly at the graduate level, and accessible, cost-effective professional development programs for practicing clinicians are needed. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Design and implementation of clinical decision support systems in mental health helpline Services: A systematic review.

BACKGROUND: Clinical Decision Support Systems (CDSSs) are electronic systems used to conduct assessments based on patient characteristics and to offer treatment recommendations for clinicians to consider during their decision-making processes. CDSSs are needed by mental health helpline services to optimise service delivery for clients and counsellors, while also collecting the data needed for the administration of the service. The aim of this systematic review was to provide a comprehensive overview of the design and implementation of CDSSs in mental health helpline services, to identify current issues in their design and implementation, and to provide recommendations that may address any identified issues. MATERIALS AND METHODS: Keywords related to mental health, helplines and CDSS were searched in three databases in April 2022 and September 2023. In total, 21 articles published between 1987 and 2023 met the inclusion criteria. RESULTS: The objectives of the mental health helplines services included in this study included suicide risk reduction, diagnosis, treatment and monitoring of mental health disorders, and support of clinicians or counsellors in making better and more accurate decisions by incorporating real-time data analysis. All included studies demonstrated co-design activities, however, the level and degree of end-user involvement differed across the studies. The factors that impact CDSS implementation success depend on the design and implementation approach, user experience and context. CDSS evaluations in the included studies assessed reliability, utility, user friendlessness, cost-effectivenessand participant satisfaction. Few studies considered data privacy and integration issues. CONCLUSION: More interactive methods should be adopted during the design of CDSSs for mental health helpline services. Increased frequency and intensity of user participation in system design, that goes beyond providing feedback on research materials, enables user opinions to be fully understood and addressed. Comprehensive frameworks should be developed to guide requirements gathering, system design and system evaluation practices. These factors are interrelated and may impact implementation success. From the outset therefore, the design of a CDSS in the mental health helpline domain should consider the full system development cycle.

Using Photovoice to Explore Determinants of Health among Homeless and Unstably Housed Women.

The lived experiences of homeless and unstably housed women, including their health-related priorities, are understudied in smaller metropolitan and rural communities. In this study, we partnered with a day center for women who experience homelessness in Spokane, Washington. We used Photovoice, a community-based participatory action research method, to explore the health-related concerns, needs, and behavior of women who are homeless or unstably housed. Participant-generated photographs and group interview data were analyzed using thematic analysis. Three themes were generated: "These are my supports", "I'm trying to make my health better", and "[My] choices are very limited". The themes illustrated individual, interpersonal, community, and societal strengths and vulnerabilities aligned with the social ecological model. Participants demonstrated resourcefulness, creativity, and hope as they strived toward health improvement. Trauma-informed, strengths-based approaches that respect the autonomy of homeless and unstably housed women and that amplify their voices are needed to minimize power imbalances in research, policy, and practice. This includes an imperative for healthcare and social work programs to ready graduates to deliver effective, empathic services by increasing their knowledge of social determinants of health and of the stigma faced by marginalized communities. Moreover, collaborating with these communities when designing, implementing, and evaluating services is critical.

Shame and Emotion Dysregulation as Pathways to Posttraumatic Stress Symptoms Among Women With a History of Interpersonal Trauma.

Women who have survived interpersonal trauma are at elevated risk of developing posttraumatic stress disorder (PTSD), and potentially modifiable factors that may be targeted in treatment warrant further investigation. This study examined a pathway from interpersonal trauma to PTSD symptoms via emotion dysregulation and shame in a large non-clinical sample of women. The sample comprised 380 women, aged 18 to 59 years (M = 31.70, standard deviation = 10.06), all of whom had a history of interpersonal trauma. Participants completed the Experience of Shame Scale, the Difficulties in Emotion Regulation Scale-Short Form, and the Life Events Checklist for DSM-5. A serial and parallel process model with interpersonal trauma as a predictor of PTSD symptoms, emotional dysregulation and facets of shame as intermediary variables, was analyzed using Statistical Package for Social Sciences Statistics PROCESS Model 81with bias-corrected bootstrap tests of indirect effects. Non-interpersonal trauma was included as a covariate. Interpersonal trauma, emotion dysregulation, and characterological and bodily shame were significantly and directly associated with PTSD symptoms, together explaining 59% of the variation in PTSD symptoms. While emotion dysregulation was associated with behavioral shame, interpersonal trauma was not associated with behavioral shame, nor was behavioral shame associated with PTSD symptoms. Tests of indirect effects supported a pathway from interpersonal trauma to PTSD symptoms via emotion dysregulation and characterological and bodily shame. These findings suggest interventions that are particularly effective at reducing emotion dysregulation and characterological and bodily shame, such as compassion and acceptance-based approaches, may complement evidence-based PTSD interventions when working with women who have survived interpersonal trauma.

Dissociative Symptoms in Complex Posttraumatic Stress Disorder: A Systematic Review.

The 11th revision of the International Classification of Diseases (ICD-11) introduced Complex Posttraumatic Stress Disorder (CPTSD) as a sibling disorder to PTSD. Dissociative symptoms have been implicated in the severity of ICD-11 CPTSD; however, no reviews have investigated how dissociation has been measured in studies investigating CPTSD, nor the relationship between CPTSD and dissociation. This systematic review aimed to identify measures used to assess dissociative symptoms in studies that have assessed CPTSD according to ICD-11 criteria and to synthesize the relationship between these constructs. PsycINFO, PubMed, Scopus and Web of Science were searched on March 31, 2021. Seventeen articles met inclusion criteria. CPTSD was most frequently measured by a version of the International Trauma Questionnaire. Twelve measures were used to assess for dissociative symptoms, the most common being the Dissociative Symptoms Scale and the Dissociative Experiences Scale. The relationship between CPTSD and dissociative symptoms was moderate-to-strong, but inconsistently reported. Further research is needed to determine the most appropriate measure(s) of dissociation in CPTSD.

Probabilistic approaches do not invalidate descriptive studies but answer fundamentally different questions: Reply to Loh and Ren (2023).

Loh and Ren (2023) critiqued our study on authorship trends in high-impact psychology journals that publish invited submissions for the use of outcome-dependent sampling. Although they offer a useful perspective, their methodological suggestions would answer a fundamentally different research question from the one we proposed. We thank Loh and Ren (2023) for their constructive contributions to this dialogue. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Premature mortality 16 years after emergency department presentation among homeless and at risk of homelessness adults: a retrospective longitudinal cohort study.

BACKGROUND: People experiencing homelessness have an increased risk of mortality. The association between being at risk of homelessness and premature mortality is unclear. We aimed to determine all-cause and cause-specific mortality in patients who were homeless, at risk of homelessness (marginally housed), or housed. METHODS: This retrospective longitudinal cohort study compared mortality patterns in adult patients identified in 2003/04 by linking data from an Australian metropolitan emergency department to national mortality data. We used Cox proportional hazards models to estimate associations between housing status and mortality. To address competing risks, cause-specific hazards were modelled and transformed into stacked cumulative incidence functions. FINDINGS: Data from 6290 patients (homeless deceased = 382/1050, marginally housed deceased = 259/518, housed deceased = 1204/4722) found increased risk of mortality in homeless [hazard ratio (HR) = 4.0, 95% confidence interval (CI) = 2.0-3.3) and marginally housed (HR = 2.6, 95% CI = 3.4-4.8) patients. Homeless patients had an excess risk from external causes (HR = 6.1, 95% CI = 4.47-8.35), cardiovascular disease (HR = 4.9, 95% CI = 2.78-8.70) and cancer (HR = 1.5, 95% CI = 1.15-2.09). Marginally housed patients had increased risk from external causes (HR = 3.6, 95% CI = 2.36-5.40) and respiratory diseases (HR = 4.7, 95% CI = 1.82-12.05). Taking account of competing risk, marked inequality was observed, with homeless, marginally housed and housed patients having probabilities of death by 55 years of 0.2, 0.1 and 0.02, respectively. CONCLUSIONS: Mortality rates were elevated in patients who were homeless or at risk of homelessness. Increasing numbers of people are at risk of homelessness, and the effect of this on mortality is relatively unrecognized. Marginal housing may assuage some risk of premature mortality associated with homelessness; however, it is not equivalent to stable housing.

Gender disparities in authorship of invited submissions in high-impact psychology journals.

Women comprise the majority of graduates from psychology doctoral programs, but equity is yet to be achieved in the professoriate. Publication drives career advancement, underscoring the need to investigate publication-based metrics of eminence. To our knowledge, authorship of invited submissions-a proxy of research esteem-has not been the focus of any psychology studies. In this cross-sectional study, authorship of invited submission(s) in five elite psychology journals (2015-2019) was investigated: Psychological Science in the Public Interest, Annual Review of Psychology, Trends in Cognitive Sciences, Annual Review of Clinical Psychology, and Annual Review of Organizational Psychology and Organizational Behavior. We hypothesized that women would be underrepresented. Author gender was classified using publicly available details (e.g., pronouns on professional websites). Primary outcomes were the proportion of women solo-, first-, or likely invited authors, relative to the proportion of women full and associate professors in psychology at R1 institutions (42.3%). Of 1,828 authorship positions (713 articles), 35.6% were occupied by women. Relative to the nominated base rate, women were disproportionately underrepresented. When the likely invited author on a multi-author publication was a woman, the first author was a woman on 51.0% of papers; when the likely invited author was a man, the first author was a woman on 34.1% of papers. These findings align with prior studies and extend the research by demonstrating that the gender publication gap in psychology is exacerbated in invited submissions and driven by particular subfields. Continued efforts are needed to redress gender disparities in authorship of invited submissions. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Psychological First Aid principles within a community-led arts initiative: lessons from the Blacksmiths' Tree.

Psychological First Aid (PFA) is widely used in the early phases of disaster recovery, despite limited empirical evidence supporting its application. PFA aims to reduce distress and encourage adaptive coping and is grounded in five principles: the promotion of hope, self- and collective efficacy, social connectedness, safety, and calm. Drawing on a constructivist perspective, this study analysed interview transcripts from Forged from Fire: The Making of the Blacksmiths' Tree, a documentary film about a community-led arts project initiated after the 2009 bushfires in Victoria, Australia. Using a reflexive process that employed deductive and inductive coding, the research investigated the presence of PFA principles in participants' experiences of the Blacksmiths' Tree project and whether themes not accounted for by PFA were also salient. The findings supported the PFA principles and generated two additional themes: grassroots and community leadership; and healing through creation and expression. The implications for disaster recovery in community settings are also presented.

Substance use and posttraumatic stress disorder: 12-month outcomes among adults experiencing chronic homelessness in Australia.

INTRODUCTION: Substance use disorder and posttraumatic stress disorder (PTSD) are highly prevalent among individuals who experience homelessness. However, evaluations of interventions that combine housing and mental health services have reported inconsistent mental health and substance use outcomes when compared to usual services. We investigated 12-month change in substance use severity and PTSD symptom severity among adults experiencing chronic homelessness and tested whether observed differences were associated with housing, support from mental health services or the Journey to Social Inclusion (J2SI) program. METHODS: A randomised controlled trial compared the J2SI program with standard service provision (N = 135). Secondary analyses compared those who obtained housing or received mental health services with those who did not. Primary outcomes were alcohol and illicit substance use severity (alcohol, smoking and substance involvement screening test) and PTSD symptom severity (six-item PTSD checklist). RESULTS: There was significant improvement at 12 months in alcohol use severity, illicit substance use severity and PTSD symptoms in the overall sample. Having seen a mental health professional in the previous 12 months was associated with a significant reduction in alcohol and illicit substance use severity but was not associated with changes in PTSD symptom severity. Being housed at 12 months was associated with significantly higher alcohol use severity. DISCUSSION AND CONCLUSIONS: Findings highlight the importance of access to mental health care for people with a history of chronic homelessness. Research is needed to develop and test therapeutic and housing approaches to reduce PTSD symptom severity among people with experience of homelessness.

Geographic Disparities in the Availability of Mental Health Services in U.S. Public Schools.

INTRODUCTION: The purpose of this study was to examine geographic variation in the availability of and barriers to school-based mental health services. METHODS: A weighted, nationally representative sample of U.S. public schools from the 2017-2018 School Survey on Crime and Safety was used. Schools reported the provision of diagnostic mental health assessments and/or treatment as well as factors that limited the provision of mental health services. Availability of mental health services and factors limiting service provision were examined across rurality, adjusting for school enrollment and grade level. The analysis was conducted in December 2021. RESULTS: Half (51.2%) of schools reported providing mental health assessments, and 38.3% reported providing treatment. After adjusting for enrollment and grade level, rural schools were 19% less likely, town schools were 21% less likely, and suburban schools were 11% less likely to report providing mental health assessments than city schools. Only suburban schools were less likely than city schools to provide mental health treatment (incidence rate ratio=0.85; 95% CI=0.72, 1.00). Factors limiting the provision of services included inadequate access to professionals (70.9%) and inadequate funding (77.0%), which were most common among rural schools. CONCLUSIONS: Significant inequities in school-based mental health services exist outside of urban areas.

Barriers and facilitators to treatment seeking and engagement amongst women with complex trauma histories.

Complex traumatic experiences, such as childhood sexual and physical abuse, occur in approximately 13% of the Australian population and are more common in women. Despite the prevalence of complex trauma and the need for evidence-based services for survivors, no studies have explored treatment-related experiences of women with complex trauma in Australia. The aim of the current study was to identify barriers and facilitators to treatment seeking and engagement amongst women who have experienced complex trauma in Australia. Semi-structured interviews were conducted with 11 women with complex trauma histories who presented to a university outpatient psychology clinic. Content analysis was used to identify common barriers and facilitators to mental health treatment seeking and engagement amongst these women. Participants faced three key barriers when seeking treatment and engaging in mental health services: systemic issues, dissatisfaction with treatment and intrapersonal barriers (e.g. fear of the healthcare system). Appropriate support from supportive, committed health care workers was a facilitator to engagement and access. Findings from this study suggest that the mental health system in Australia may not be meeting the needs of women with complex trauma histories. Increasing access to affordable, trauma-informed care and bolstering providers' knowledge of complex trauma, may enable some of the barriers identified by participants to be overcome.

Disparities in Technology and Broadband Internet Access Across Rurality: Implications for Health and Education.

Amidst the COVID-19 pandemic, interest in using telehealth to increase access to health and mental health care has grown, and school transitions to remote learning have heightened awareness of broadband inequities. The purpose of this study was to examine access and barriers to technology and broadband Internet service ("broadband") among rural and urban youth. Washington State public school districts were surveyed about youth's access to technology (ie, a device adequate for online learning) and broadband availability in spring 2020. Availability of and barriers to broadband (ie, geography, affordability, and smartphone-only connectivity) were assessed across rurality. Among responding districts, 64.2% (n = 172) were rural and 35.8% (n = 96) were urban. Rural districts reported significantly fewer students with access to an Internet-enabled device adequate for online learning (80.0% vs 90.1%, P < .01). Access to reliable broadband varied significantly across geography (P < .01). Compared with their urban peers, rural youth face more challenges in accessing the technology and connectivity needed for remote learning and telehealth. Given that inadequate broadband infrastructure is a critical barrier to the provision of telehealth services and remote learning in rural areas, efforts to improve policies and advance technology must consider geographical disparities to ensure health and education equity.

Stair-Related Injuries Among Pregnant Women Treated in United States Emergency Departments.

OBJECTIVES: Falls are one of the leading causes of trauma during pregnancy, and most falls occur on stairs. The purpose of this study was to describe stair-related falls among pregnant women who were treated in United States emergency departments during a 10-year period. METHODS: This study utilized a cross-sectional analysis of National Electronic Injury Surveillance System (NEISS) data, 2008-2017. Emergency department visits by pregnant women aged 12 years and older were identified using case narratives. RESULTS: From 2008 to 2017, 1466 cases of pregnant women who had sustained stair-related falls were reported to NEISS, equating to a national estimate of 57,512 over the 10-year study period. Variables examined included age, body part injured, location of injury, discharge disposition, gestation, mechanism of injury, and other fall-associated hazards and symptoms. Most injuries involved contusions or abrasions, other injuries commonly reported were sprains/strains and contusions/abrasions. Wet/icy conditions represented hazards associated with 4.1% of all injuries. Severe obstetric symptoms, such as decreased fetal movement and vaginal bleeding, were described in study narratives. CONCLUSIONS: Falls are a leading cause of injury among women of childbearing age and stair-related falls comprise a large proportion of maternal falls. Physiological changes associated with pregnancy can put gravid women at greater risk for falls. Healthcare providers can provide women anticipatory guidance that may reduce their risk for falls as they progress in pregnancy.

Content Analysis of Health Concerns among Housing First Residents with a History of Alcohol Use Disorder.

Previous research has utilized survey and administrative data to document health problems among Housing First (HF) residents; however, little is known about residents' personal perspectives on their health. The purpose of this study was to utilize conventional content analysis to analyze health-related concerns among HF residents with histories of alcohol use disorder. Between June and December 2013, we interviewed 44 adults who had histories of chronic homelessness and alcohol use disorder and were residing in single-site HF in Seattle, Washington. Responses centered on five primary topics: alcohol-related harm, perceived health vulnerability, concern for fellow residents' health, end of life, and health and safety promotion. HF residents experience complex alcohol-exacerbated health difficulties and existing health services may not meet the needs of those whose health is particularly compromised. Considering that HF facilitates aging in place, end-of-life care and grief counseling should be integrated into HF services.

COVID-19 and emergency care for adults experiencing homelessness.

Homeless individuals face many barriers to accessing healthcare, and EDs are often their primary entry point to the healthcare system. The COVID-19 pandemic has the potential to exacerbate existing social inequities and health disparities, including barriers to accessing social services and healthcare. Addressing the complex social and chronic health issues associated with homelessness can be challenging within the acute care environment. This perspective reflects upon the delivery of emergency healthcare to patients experiencing homelessness, and highlights strategies for optimising health outcomes during and beyond the pandemic.