Stakeholder and Equity Data-Driven Implementation: a Mixed Methods Pilot Feasibility Study.

We conducted a mixed methods pilot feasibility study of a Stakeholder and Equity Data-Driven Implementation (SEDDI) process to facilitate using healthcare data to identify patient groups experiencing gaps in the use of evidence-based interventions (EBIs) and rapidly adapt EBIs to achieve greater access and equitable outcomes. We evaluated the feasibility and acceptability of SEDDI in a pilot hybrid type 2 effectiveness-implementation trial of a paired colorectal cancer (CRC) and social needs screening intervention at four federally qualified community health centers (CHCs). An external facilitator partnered with CHC teams to support initial implementation, followed by the SEDDI phase focused on advancing health equity. Facilitation sessions were delivered over 8 months. Preliminary evaluation of SEDDI involved convergent mixed methods with quantitative survey and focus group data. CHCs used data to identify gaps in outreach and completion of CRC screening with respect to race/ethnicity, gender, age, and language. Adaptations to improve access and use of the intervention included cultural, linguistic, and health literacy tailoring. CHC teams reported that facilitation and systematic review of data were helpful in identifying and prioritizing gaps. None of the four CHCs completed rapid cycle testing of adaptations largely due to competing priorities during the COVID-19 response. SEDDI has the potential for advancing chronic disease prevention and management by providing a stakeholder and data-driven approach to identify and prioritize health equity targets and guide adaptations to improve health equity. ClinicalTrials.gov Identifier: NCT04585919.

Advancing the Science of Recovery: The Utility of the Recovery Assessment Scale in the Prediction of Self-Directed Health and Wellness Outcomes in Adults with a Diagnosis of a Serious Mental Illness.

Adults with serious mental illness commonly experience comorbid chronic physical conditions and experience a reduced life expectancy of 10-25 years compared to the general population (Saha et al. in Arch Gen Psychiatry 64(10):1123-31.  2007; Hayes et al. in Acta Psychiatr Scand 131(6):417-25. 2015; Walker et al. in JAMA Psychiatry 72(4):334-41. 2015). Dimensions of personal recovery may have real-world implications that extend beyond functional and mental health outcomes to impact the self-directed health and wellness of adults with serious mental illness. This study examined the predictive utility of the Recovery Assessment Scale with respect to medical self-efficacy, self-management, psychiatric symptoms, and community functioning for adults with serious mental illness. Data were derived from a secondary analysis of baseline and 10-month data collected from a randomized control trial with adults aged 18 years and older with a diagnosis of bipolar disorder, schizoaffective disorder, schizophrenia, or major depressive disorder (N=56). A linear regression was conducted to examine the predictive value of total baseline RAS scores on self-efficacy at 10 months while controlling for study group. This model significantly predicted self-efficacy (F (2, 53) = 13.28, p < .001) and accounted for 36.1% of the variance. Total baseline RAS scores significantly predicted self-efficacy (ß = 059, p < .001); specifically, higher baseline RAS scores were associated with greater self-efficacy. A greater degree of recovery may facilitate greater medical self-efficacy in managing chronic disease in people diagnosed with a serious mental illness. Future intervention approaches may consider recovery-focused therapeutic targets such as peer support to promote self-efficacy to manage chronic diseases in people with serious mental illness.

Assessing a digital peer support self-management intervention for adults with serious mental illness: feasibility, acceptability, and preliminary effectiveness.

OBJECTIVE: To assess the feasibility, acceptability, and preliminary effectiveness of digital peer support integrated medical and psychiatric self-management intervention ("PeerTECH") for adults with a serious mental illness. METHODS: Twenty-one adults with a chart diagnosis of a serious mental illness (i.e., schizophrenia, schizoaffective disorder, bipolar disorder, or treatment-refractory major depressive disorder) and at least one medical comorbidity (i.e., cardiovascular disease, obesity, diabetes, chronic obstructive pulmonary disease, hypertension, and/or high cholesterol) aged 18 years and older received the PeerTECH intervention in the community. Nine peer support specialists were trained to deliver PeerTECH. Data were collected at baseline and 12-weeks. RESULTS: This pilot study demonstrated that a 12-week, digital peer support integrated medical and psychiatric self-management intervention for adults with serious mental illness was feasible and acceptable among peer support specialists and patients and was associated with statistically significant improvements in self-efficacy to manage chronic disease and personal empowerment. In addition, pre/post non-statistically significant improvements were observed in psychiatric self-management, medical self-management skills, and feelings of loneliness. CONCLUSIONS: This single-arm pre/post pilot study demonstrated preliminary evidence peer support specialists could offer a fidelity-adherent digital peer support self-management intervention to adults with serious mental illness. These findings build on the evidence that a digital peer support self-management intervention for adults with serious mental illness designed to improve medical and psychiatric self-management is feasible, acceptable, and shows promising evidence of improvements in clinical outcomes. The use of technology among peer support specialists may be a promising tool to facilitate the delivery of peer support and guided evidence-based self-management support.People with serious mental illness (SMI; defined as individuals diagnosed with schizophrenia spectrum disorder, bipolar disorder, or treatment-refractory major depressive disorder) are increasingly utilizing peer support services to support their health and recovery. Peer support is defined as shared knowledge, experience, emotional, social, and/or practical assistance to support others with similar lived experiences (Solomon, 2004). Most recently the definition also includes the provision of evidence-based peer-supported self-management services (Fortuna et al., 2020). Mental health peer support can augment the traditional mental health treatment system through providing support services to maintain recovery between clinical encounters (Solomon, 2004) and is classified by the World Health Organization as an essential element of recovery (World, Health, and Organization, About social determinants of health, 2017).

Virtual Learning Collaborative Compared to Technical Assistance as a Strategy for Implementing Health Promotion in Routine Mental Health Settings: A Hybrid Type 3 Cluster Randomized Trial.

BACKGROUND: Despite widespread use of learning collaboratives, few randomized trials have evaluated their effectiveness as a strategy for implementing evidence based practices. This randomized trial evaluated the effectiveness of a virtual learning collaborative (VLC) in the implementation of a health promotion program for persons with serious mental illness (SMI) aimed at reducing cardiovascular risk reduction in routine mental health settings, compared to routine technical assistance (TA). METHODS: Fifty-five mental health provider organizations were recruited to participate in a Hybrid Type 3 cluster randomized implementation-effectiveness trial of the InSHAPE health promotion program for persons with SMI. Sites were stratified by size and randomized prior to implementation to an 18-month group-based VLC with monthly learning sessions or individual site TA with four scheduled conference calls over 18 months. Primary implementation and service outcomes were InSHAPE program fidelity, participation, and reach. Primary clinical outcomes were weight loss, cardiorespiratory fitness, and cardiovascular risk reduction (≥ 5% weight loss or > 50 m increase on the 6-Minute Walk Test). Program fidelity was assessed at 6, 12, and 24 months; program participation and participant-level outcomes were assessed at 3, 6, 9, and 12 months. RESULTS: VLC (N = 27) and TA (N = 28) sites were similar in organizational characteristics (all p > 0.05). At 12-month follow-up mean program fidelity score was higher in VLC compared to TA (90.5 vs. 79.1; p = 0.002), with over double the proportion with good fidelity (VLC = 73.9% vs. TA = 34.8%; p = 0.009). Over half of individuals in both VLC and TA achieved cardiovascular risk-reduction at 6-month follow-up (VLC: 51.0%; TA: 53.5%; p = 0.517) and at 12-month follow-up (62% VLC and TA; p = 0.912). At 12-month follow-up VLC compared to TA was associated with greater participation (VLC 69.5% vs. TA 56.4% attending at least 50% of sessions, p = 0.002); larger caseloads (VLC = 16 vs. TA = 11; p = 0.024); greater reach consisting of 45% greater number of participants receiving InSHAPE (VLC = 368 vs. TA = 253), and 58% greater number of participants achieving cardiovascular risk reduction (VLC = 150 vs. TA = 95). CONCLUSION: Virtual learning collaboratives compared to routine technical assistance as an implementation strategy for evidence-based health promotion promote greater intervention fidelity, greater levels of intervention participation, greater reach, and a greater number of participants achieving clinically significant risk reduction outcomes, while achieving similarly high levels of intervention effectiveness for participants who completed at least 6 months of the program.

Barriers, facilitators, and opportunities to optimize care engagement in a diverse sample of older low-income women: A qualitative study.

The growing population of aging women in the United States is disproportionately at-risk for adverse physical, behavioral, mental, and psychosocial health conditions. Engagement with preventive care is critical to address these risk factors. A qualitative descriptive approach was used to explore patterns of healthcare use, facilitators, barriers, and opportunities to optimize primary/preventive care engagement among low-income midlife and older women. Themes were deductively derived from the Behavioral Model for Vulnerable Populations. Categories were inductively determined: barriers to care engagement; facilitators of care engagement; opportunities to optimize primary/preventive care engagement. Themes emerging from this study suggest that experiences related to discrimination, psychological health, trauma, and prioritizing care of others negatively influence care engagement; while respect, continuity, and clinician gender and racial/ethnic concordance enhance care participation. Efforts aiming to engage low-income aging women in care should focus on addressing barriers, building on facilitators, and leveraging contemporary telehealth-outreach solutions.

Opportunities to Improve a Mobile Obesity Wellness Intervention for Rural Older Adults with Obesity.

Older adults with obesity are at a high risk of decline, particularly in rural areas. Our study objective was to gain insights into how a potential Mobile Health Obesity Wellness Intervention (MOWI) in rural older adults with obesity, consisting of nutrition and exercise sessions, could be helpful to improve physical function. A qualitative methods study was conducted in a rural community, community-based aging center. Four community leaders, 7 clinicians and 29 patient participants underwent focus groups and semi-structured interviews. All participants had a favorable view of MOWI and saw its potential to improve health and create accountability. Participants noted that MOWI could overcome geographic barriers and provided feedback about components that could improve implementation. There was expressed enthusiasm over its potential to improve health. The use of technology in older adults with obesity in rural areas has considerable promise. There is potential that this intervention could potentially extend to distant areas in rural America that can surmount accessibility barriers. If successful, this intervention could potentially alter healthcare delivery by enhancing health promotion in a remote, geographically constrained communities. MOWI has the potential to reach older adults with obesity using novel methods in geographically isolated regions.

Advanced Research Institute (ARI): An Effective Model for Career Development and Transition to Independence.

The vitality of geriatric mental health research requires an ongoing infusion of new investigators into the career pipeline. This report examines outcomes of the NIMH-funded, Advanced Research Institute (ARI) in Geriatric Mental Health, a national mentoring program supporting the transition of early career researchers to independent investigators. Outcome data for 119 ARI Scholars were obtained from the NIH Reporter database, CVs, and PubMed: 95.0% continue in research, 80.7% had obtained federal grants, and 45.4% had achieved an NIH R01. Among all NIMH mentored K awardees initially funded 2002-2014 (n=901), 60.4% (32/53) of ARI participants vs. 42.0% (356/848) of nonparticipants obtained an R01. Controlling for funding year, ARI participants were 1.9 times more likely to achieve R01 funding than nonparticipants. These data suggest that ARI has helped new generations of researchers to achieve independent funding, become scientific leaders, and conduct high impact research contributing to public health and patient care.

A Future Research Agenda for Digital Geriatric Mental Healthcare.

The proliferation of mobile, online, and remote monitoring technologies in digital geriatric mental health has the potential to lead to the next major breakthrough in mental health treatments. Unlike traditional mental health services, digital geriatric mental health has the benefit of serving a large number of older adults, and in many instances, does not rely on mental health clinics to offer real-time interventions. As technology increasingly becomes essential in the everyday lives of older adults with mental health conditions, these technologies will provide a fundamental service delivery strategy to support older adults' mental health recovery. Although ample research on digital geriatric mental health is available, fundamental gaps in the scientific literature still exist. To begin to address these gaps, we propose the following recommendations for a future research agenda: 1) additional proof-of-concept studies are needed; 2) integrating engineering principles in methodologically rigorous research may help science keep pace with technology; 3) studies are needed that identify implementation issues; 4) inclusivity of people with a lived experience of a mental health condition can offer valuable perspectives and new insights; and 5) formation of a workgroup specific for digital geriatric mental health to set standards and principles for research and practice. We propose prioritizing the advancement of digital geriatric mental health research in several areas that are of great public health significance, including 1) simultaneous and integrated treatment of physical health and mental health conditions; 2) effectiveness studies that explore diagnostics and treatment of social determinants of health such as "social isolation" and "loneliness;" and 3) tailoring the development and testing of innovative strategies to minority older adult populations.

Effectiveness of a Disability Preventive Intervention for Minority and Immigrant Elders: The Positive Minds-Strong Bodies Randomized Clinical Trial.

OBJECTIVE: To test the acceptability and effectiveness of a disability prevention intervention, Positive Minds-Strong Bodies (PMSB), offered by paraprofessionals to mostly immigrant elders in four languages. DESIGN: Randomized trial of 307 participants, equally randomized into intervention or enhanced usual care. SETTING: Community-based organizations in Massachusetts, New York, Florida, and Puerto Rico serving minority elders. Data collected at baseline, 2, 6, and 12 months, between May 2015 and March 2019. PARTICIPANTS: English-, Spanish-, Mandarin-, or Cantonese-speaking adults, age 60+, not seeking disability prevention services, but eligible per elevated mood symptoms and minor to moderate physical dysfunction. INTERVENTIONS: Ten individual sessions of cognitive behavioral therapy (PM) concurrently offered with 36 group sessions of strengthening exercise training (SB) over 6 months compared to enhanced usual care. MEASUREMENTS: Acceptability defined as satisfaction and attendance to >50% of sessions. Effectiveness determined by changes in mood symptoms (HSCL-25 and GAD-7), functional performance (SPPB), self-reported disability (LLFDI), and disability days (WHODAS 2.0). RESULTS: Around 77.6% of intervention participants attended over half of PM Sessions; 53.4% attended over half of SB sessions. Intent-to-treat analyses at 6 months showed significant intervention effects: improved functioning per SPPB and LLFDI, and lowered mood symptoms per HSCL-25. Intent-to-treat analyses at 12 months showed that effects remained significant for LLFDI and HSCL-25, and disability days (per WHODAS 2.0) significantly decreased 6-month after the intervention. CONCLUSIONS: PMSB offered by paraprofessionals in community-based organizations demonstrates good acceptability and seems to improve functioning, with a compliance-benefit effect showing compliance as an important determinant of the intervention response.

Doctor-Diagnosed Arthritis and Self-Reported Physical Health Function Among Middle-Aged and Older Adults With Serious Mental Illness.

Arthritis is one of the most common chronic conditions in aging adults, with both physical and mental health issues and consequences. However, there is insufficient arthritis research among aging adults with serious mental illness (SMI). This study examined rates of doctor-diagnosed arthritis and its cross-sectional associations with self-reported physical health function among adults aged 50 years and older with SMI. Community-based mental health center participants (n = 176) reported clinical and sociodemographic data (e.g., physical health function, sex), whereas diagnostic information (i.e., arthritis, psychiatric, and medical diagnoses) was retrieved from medical records. Arthritis prevalence was high (43.8%) and had an independent, negative association with physical health function. Findings suggest that arthritis evaluations and intervention services need to be prioritized in middle-aged and older adults with SMI. Future research should focus on further testing arthritis self-management programs and other nonpharmacological psychosocial approaches for arthritis in aging adults with SMI.

The role of serious mental illness in motivation, participation and adoption of health behavior change among obese/sedentary Latino adults.

Objective: Serious mental illness (SMI; e.g. schizophrenia, schizoaffective disorder, delusional disorder, bipolar disorder, severe major depressive disorder, and psychotic disorders) and Latino ethnicity can produce a compounded health disparity, placing individuals at particularly high risk for excess morbidity and premature mortality. In this study we sought to identify the role of SMI in motivation, participation, and adoption of health behavior change among overweight Latino adults. Design: Qualitative, semi-structured interviews were conducted with 20 overweight Latinos with SMI who were enrolled in a randomized trial evaluating the effectiveness of a motivational health promotion intervention adapted for persons with SMI, In SHAPE. The interviews explored the complicated role having an SMI had in the lives of the Latino participants. Results: SMI had both positive and negative impact on Latino participants' health behaviors. The nature of their mental illness along with medication side effects (e.g. lethargy, weight gain, etc.) negatively impacted their ability to making lasting health behavior change. However, the regular appointments with various specialists provided them with structure that they otherwise would have lacked and gave them a reason to get out of the house. Conclusions: This exploratory research provides insight into the experience of overweight Latinos with SMI and the ways in which SMI impacts their participation in health behavior change. An understanding of the positive and negative effects of SMI on health behavior change will inform the development of health promotion interventions targeted at Latinos with SMI.

Pain intensity, depressive symptoms, and functional limitations among older adults with serious mental illness.

OBJECTIVE: To examine pain-related activity interference as a mediator for the relationship between pain intensity and depressive symptoms among older adults with serious mental illness (SMI). METHOD: Ordinary least-squares regressions were used to investigate the mediation analysis among older adults with SMI (n = 183) from community mental health centers. Analyses used secondary data from the HOPES intervention study. RESULTS: Higher pain intensity was associated with greater pain-related activity interference. Higher pain intensity and pain-related activity interference were also associated with elevated depressive symptoms. Finally, greater pain-related activity interference significantly mediated the association between higher pain intensity and elevated depressive symptoms. CONCLUSIONS: These findings demonstrate that pain and depressive symptoms may be linked to functional limitations. Clinicians and researchers in the mental health field should better address pain-related activity interference among older adults with SMI, especially among those with higher pain intensity and elevated depressive symptoms.

Self-Reported Pain Intensity and Depressive Symptoms Among Community-Dwelling Older Adults with Schizophrenia Spectrum Disorders.

Older adults with schizophrenia have some of the highest rates of both medical and psychiatric comorbidities. Despite this, little is known about comorbid pain and depressive symptoms in schizophrenia research. This study aimed to examine the associations between levels of pain intensity and depressive symptoms among community-dwelling adults aged 50 years and older with schizophrenia spectrum disorders. Recruited from U.S. community mental health centers, participants reported on pain and depressive symptoms at the onset of the Helping Older People Experience Success (HOPES) study. Unadjusted and adjusted regression analyses were conducted. Higher pain intensity was associated with elevated depressive symptoms in all analyses, which is consistent with other studies in the general population. Given the widespread efforts to manage pain and related mental health complications in older adults without serious mental illnesses, it is likewise important that community-based mental health professionals monitor and address intense pain and related depressive symptoms among older adults with schizophrenia.

Health Through Activity: Initial Evaluation of an In-Home Intervention for Older Adults With Cancer.

OBJECTIVE: The objective of this study was to assess the feasibility of conducting a future full-scale trial to test the efficacy of an in-home occupational therapy intervention designed to reduce disability in older adult cancer survivors. METHOD: Participants reporting activity limitations during or after cancer treatment were enrolled in a Phase 1 pilot randomized controlled trial comparing the 6-wk intervention (n = 30) to usual care (n = 29). Descriptive data on retention rates were collected to assess feasibility of intervention and study procedures. Potential efficacy was explored through participants' self-reported disability, quality of life, activity level, and behavioral activation at 0, 8, and 16 wk after enrollment. RESULTS: Retention rates were high regarding completion of the intervention (90%) and outcome assessments (90% of usual-care participants and 80% of intervention participants). Outcomes consistently favored the intervention group, although group differences were small. CONCLUSION: The procedures were feasible to implement and acceptable to participants.

Qualitative analysis of social network influences on quitting smoking among individuals with serious mental illness.

Objective: The prevalence of cigarette smoking among adults with serious mental illness (SMI) remains high in the United States despite the availability of effective smoking cessation treatment. Identifying social influences on smoking and smoking cessation may help enhance intervention strategies to help smokers with SMI quit. The objective of this qualitative study was to explore social network influences on efforts to quit smoking among adults with SMI enrolled in a cessation treatment program. Methods: Participants were 41 individuals with SMI enrolled in a Medicaid Demonstration Project of smoking cessation at community mental health centers. A convenience sampling strategy was used to recruit participants for social network interviews exploring the influence of family, friends, peers, and significant others on quitting smoking. A team-based analysis of qualitative data involved descriptive coding, grouping coded data into categories, and identifying themes across the data. Results: Social barriers to quitting smoking included pro-smoking social norms, attitudes, and behaviors of social network members, and negative interactions with network members, either specific to smoking or that triggered smoking. Social facilitators to quitting included quitting with network members, having cessation role models, and social support for quitting from network members. Conclusions: Similar to the general population, social factors appear to influence efforts to quit smoking among individuals with SMI enrolled in cessation treatment. Interventions that leverage positive social influences on smoking cessation have the potential to enhance strategies to help individuals with SMI quit smoking.

Utility of functioning measures in the prediction of independent living status in older adults with serious mental illness.

OBJECTIVE: The objective of the study was to compare the predictive utility of three commonly used functioning measures for people with serious mental illness in the prediction of independent living status. METHODS: We conducted a secondary data analysis from the Helping Older People Experience Success study with adults aged 50 years and older with a diagnosis of bipolar disorder, schizoaffective disorder, schizophrenia, or major depressive disorder (N = 183). RESULTS: Total scores for the Independent Living Skills Survey, Multnomah Community Ability Scale, and UCSD Performance-Based Skills Assessment were modestly inter-correlated. For the overall sample, greater independent living status at baseline and 1-year follow-up was predicted by higher baseline functioning scores on both the self-reported Independent Living Skills Survey and the UCSD Performance-Based Skills Assessment. However, by diagnostic subgroup, independent living status at 1-year follow-up was only predicted by the Independent Living Skills Survey for affective disorders and by the UCSD Performance-Based Skills Assessment for schizophrenia-spectrum disorders. For the total sample, the Independent Living Skills Survey was associated with self-efficacy and employment status. Neither the Independent Living Skills Survey nor UCSD Performance-Based Skills Assessment was associated with medical or psychiatric hospitalizations or with subjective physical or mental health status. CONCLUSIONS: These commonly used functioning measures for people with serious mental illness examine different aspects of functioning. The choice of functional measurement should be based on the population under study and intervention goals. Copyright © 2017 John Wiley & Sons, Ltd.

Prevalence rates of arthritis among US older adults with varying degrees of depression: Findings from the 2011 to 2014 National Health and Nutrition Examination Survey.

OBJECTIVE: Arthritis and depressive symptoms often interact and negatively influence one another to worsen mental and physical health outcomes. Better characterization of arthritis rates among older adults with different levels of depressive symptoms is an important step toward informing mental health professionals of the need to detect and respond to arthritis and related mental health complications. The primary objective is to determine arthritis rates among US older adults with varying degrees of depression. METHODS: Using National Health and Nutrition Examination Survey 2011 to 2014 data (N = 4792), we first identified participants aged ≥50 years. Measures screened for depressive symptoms and self-reported doctor-diagnosed arthritis. Weighted logistic regression models were conducted. RESULTS: Prevalence of arthritis was 55.0%, 62.9%, and 67.8% in participants with minor, moderate, and severe depression, respectively. In both unadjusted and adjusted regression models, a significant association between moderate depression and arthritis persisted. There were also significant associations between minor and severe depression with arthritis. CONCLUSIONS: Arthritis is commonly reported in participants with varying degrees of depression. This study highlights the importance of screening for and treating arthritis-related pain in older adults with depressive symptoms and the need for future geriatric psychiatry research on developing integrated biopsychosocial interventions for these common conditions.

Certified Peer Specialists and Older Adults With Serious Mental Illness' Perspectives of the Impact of a Peer-Delivered and Technology-Supported Self-Management Intervention.

We explored the perspectives of certified peer specialists and older adults with serious mental illness on the impact of a peer-delivered medical and psychiatric self-management intervention, "PeerTECH." Transcripts from interviews with consumers with serious mental illness and a focus group with certified peer specialists who were engaged in PeerTECH were analyzed. Consumer participants (n = 8) had a mean age of 68.8 years (SD = 4.9) and included individuals diagnosed with major depressive disorder (five people), schizophrenia spectrum disorders (two people), and bipolar disorder (one person). Certified peer specialists (n = 3) were aged 55 years or more. Themes included internal and external forces of accountability, confidence, internal and external locus of hope, human bonding, and peer support. This exploratory qualitative study found that human support from peers can potentially influence health behavioral change in a combined peer and technology-based medical and psychiatric illness self-management intervention.