Toward Greater Accountability in Mental Health Care.

Lack of accountability contributes to the gap between best practices and potential outcomes. Few mental health providers routinely practice evidence-based care. In fact, within the mental health field, there is significant controversy over the use of evidence-based practices. Lack of accountability affects individuals receiving care at the patient level, provider level, and systems level. The authors identify several impediments to accountability in behavioral health care. These include failure to develop a diverse, well-trained workforce; challenges in measurement; misalignment of payment incentives; and misguided regulations. Accountability arrangements typically consist of several elements: a clear articulation of goals, objectives, or standards; metrics so that progress toward achieving goals can be tracked; and consequences for insurers, providers, and professionals for achieving or failing to achieve objectives. To advance system goals, the full complement of accountability tools should be consistently applied to all sources of behavioral health care and supports. The authors focus on three sets of accountability tools-performance metrics, payment incentives, and regulatory standards-that when implemented thoughtfully can help move the field toward more positive outcomes in behavioral health.

Organizations in science and medicine must hold each other accountable for discriminatory practices.

Many organizations persist in working with others that engage in known, remediable structural discrimination. We name this practice interorganizational structural discrimination (ISD) and argue it is a pivotal contributor to inequities in science and medicine. We urge organizations to leverage their relationships and demand progress from collaborators.

Social Determinants of Health, Structural Racism, and the Impact on Child and Adolescent Mental Health.

In recent years, there has been a greater emphasis on examining the factors, particularly the social factors, that affect health outcomes and contribute to population health inequities. The social determinants of health, as defined by the World Health Organization, are "the conditions in which people are born, grow, work, live, and develop, and the wider set of forces, including economic policies, social norms, and political systems, that shape the conditions of daily life and impact health outcomes."1 The social determinants of mental health (SDoMH) are similar, but include the added societal stigma associated with mental health and substance use disorders. The SDoMH often receive less focus and study, particularly in youth. Table 1 lists several examples of social determinants of mental health for children and adolescents and examples of how to address them in the clinical setting.1 The SDoMH are particularly relevant for children, as they are reliant on the adults who care for them and have even less control over these societal factors. Additionally, the physical, cognitive, emotional, and social development that occurs during this critical time lays the foundation for mental health and well-being into adulthood. It is important that mental health providers recognize these SDoMH, as they invariably impact the clinical presentation of the children they treat. However, to truly address the SDoMH and improve outcomes for all children, clinicians must understand the major driving force behind them-structural racism.

Online Psychosis Screening: Characterizing an Underexamined Population to Improve Access and Equity.

OBJECTIVE: Online resources represent an important avenue to identify and support individuals who may be experiencing symptoms of psychosis but have yet to engage in care. Understanding the experiences and needs of this group is critical to inform outreach for early psychosis and improve outcomes by addressing barriers to early treatment. METHODS: The authors conducted a retrospective, explorative, cross-sectional analysis by using data collected by Mental Health America as part of their online psychosis screening and support program. Data included scores from the Prodromal Questionnaire-Brief, basic demographic information, and respondents' plans for next steps. RESULTS: Of 120,937 respondents, most (82.1%) reported distressing psychosis-like experiences at levels sufficient to merit a referral to specialty care for additional evaluation. However, only 17.1% planned to seek treatment as a next step, with most (53.6%) wanting instead more information. Higher distress was only weakly associated with the plan to seek treatment. In the multivariable analysis, respondents who were younger; lesbian, gay, bisexual, transgender, or queer; or Native American or who had lower income reported the greatest symptom-related distress. Younger and higher-income respondents were less likely to plan to seek treatment next. Across race-ethnicity, African Americans were most likely to plan to seek treatment. CONCLUSIONS: Most respondents reported that psychosis-like experiences caused significant distress, but they did not plan to seek treatment next. Addressing this treatment gap requires careful consideration regarding what services individuals want, how services should be presented, and what barriers may limit help seeking. These steps are critical to improve access to early intervention for individuals with psychosis spectrum disorders.

COVID-19, Structural Racism, and Mental Health Inequities: Policy Implications for an Emerging Syndemic.

The complex interactions between the 2019 coronavirus disease (COVID-19) pandemic, structural racism, and mental health inequities have led to devastating health, economic, and social consequences. The intersection of these three conditions, which meets criteria for a syndemic (synergistic epidemics), presents numerous policy challenges-and opportunities. Addressing these issues in a unified manner, using a syndemic theory approach, can lead to significant progress and effective solutions for otherwise intransigent problems in society. This article proposes steps that can be taken to protect "essential workers" and other "vulnerable" populations; engage and empower communities; optimize community-led crisis response interventions; improve data collection about the intersection of COVID-19, structural racism, and mental health inequities; support school-based interventions; expand financial supports for mental health service delivery; expand health care insurance coverage to increase access and lower out-of-pocket costs; and promote workforce diversity. Emphasis on local, state, and federal policy interventions that prioritize equity and justice and focus on collective health and well-being will ultimately lead us on a more sustainable and equitable path.

Transforming Mental Health And Addiction Services.

Even with great advances in behavioral health policy in the last decade, the problems of mental illness and addiction persist in the United States-so more needs to be done. In this article, which is part of the National Academy of Medicine's Vital Directions for Health and Health Care: Priorities for 2021 initiative, we describe the steps needed to improve outcomes, focusing on three strategies. We argue for transforming the behavioral health system to meet people where they are, decriminalizing mental illness and substance use disorders to facilitate recovery, and raising awareness of social context and social needs as essential to effective care. We call for supporting structures in the workforce and structures of accountability, outcome measurement, and more generous financing of behavioral health care. These steps have costs, but the enormous benefits of a major transformation in behavioral health policy far outweigh the expenses.

Racism and Mental Health Equity: History Repeating Itself.

With a growing understanding of how racism negatively affects the mental health of patients, mental health professionals are as anxious to act as they are uncertain about the best path forward. This uncertainty persists even though thoughtful, actionable antiracist recommendations in psychiatry were made 50 years ago. Mental health professionals can take several antiracist actions, including acknowledging individual and structural racism through an examination of racist policies, to achieve mental health equity. The mental health field must take these actions collectively so that history does not continue to repeat itself.

Mental Illness Prevention and Mental Health Promotion: When, Who, and How.

Classification as primary, secondary, or tertiary prevention is based on when during the course of disease the intervention is provided. Another approach to classification-as universal, selective, or indicated preventive interventions-relates to who receives the intervention. The social determinants of health framework also provides a guide to prevention, which requires changing both public policies and social norms. It also addresses the weaknesses of the first two approaches, such as persistent health inequities regarding who has access to preventive services. The social determinants framework is a guide to providing timely and targeted preventive interventions in a way that ensures equal access.

Dismantling Structural Racism in Academic Medicine: A Skeptical Optimism.

Structural racism is pervasive in U.S. society, and academic medicine is not immune to the effects of this disease. The social determinants of health have been implicated as the main drivers of health disparities and inequities in society, and racism has been well established as a social determinant of health. Research consistently highlights poor health outcomes for Black populations and other communities of color compared with White populations across a variety of conditions. Medical students, residents, and faculty of all backgrounds regularly experience the destructive effects of structural racism in medicine. Renewed attention to the problem is encouraging, but, if it is consistent with history, transient. If academic medicine can arrive at a place of discarding the shackles of biological determinism, perhaps the field can begin to take initial steps toward dismantling the structural racism that drives health inequities. To make true headway, academic medicine must be willing to make bold strategic and financial commitments to do more. This work will not be easy, and there will be great resistance to the type of change that is needed. It is time to ask whether the leaders of academic institutions have the will to act and to continue to push forward in the face of opposition. The author is skeptical-because of the scope of the work that needs to be done and because it feels as if society has been here many times before-and, yet, remains optimistic.