Reconsidering culturally competent approaches to American Indian healing and well-being.

There is an urgent need to eliminate mental health disparities experienced by American Indians and Alaska Natives (AI/ANs). Service providers and researchers often address these disparities by focusing on low rates of participation in Western mental health services. In part, this reflects limited understandings of the sociopolitical and historical context of AI/AN mental health problems. Furthermore, this emphasis fails to recognize the importance of emic understandings of locally resonant coping strategies, healing, and treatment. In this article, we describe (a) a study designed to address these gaps, (b) findings related to the importance of land and place, and (c) a community-university collaboration to translate these findings into meaningful change within one Diné community. Connections to the land were an important cultural strength on which to build efforts to promote mental health. Thus, effective treatment might involve more in-depth understanding of cultural processes through which healing occurs and well-being is maintained.

Parental etiological explanations and longitudinal medication use for youths with attention deficit hyperactivity disorder.

Due to the need to increase understanding of factors associated with medication usage for youth with ADHD, this study examined parental explanatory etiologies in relationship to psychotropic medication use in a sample of youth who met criteria for ADHD and utilized outpatient specialty mental health services in the previous year. When examined cross-sectionally, medication usage was positively associated with parental explanatory etiologies related to physical causes and negatively associated with those involving sociological causes. Longitudinal analyses did not show a significant effect of Time 1 parental explanatory etiologies on the slope of medication use, suggesting that the relationship between Time 1 parental explanatory etiologies and medication usage remains stable over time for those who have had past year involvement with outpatient specialty mental health services.

"An Old Way to Solve an Old Problem": Provider Perspectives on Recovery-Oriented Services and Consumer Capabilities in New Mexico.

The goal of recovery has emerged as a core value in the reformation of public and private mental health services in the last twenty years. However, definitions of recovery remain as varied as methods of implementation. Through an ethnographic lens, we examine meanings of recovery in the context of a major statewide reform of mental health services in New Mexico, focusing specifically on provider-voiced concerns regarding recovery and recovery-oriented care. We argue that the concept of recovery functions as a symbol that seemingly reconciles the long-standing tension between biological and social explanations of mental illness. Drawing upon provider perspectives, we also discuss concerns that popular rhetoric about recovery may mask some needed fundamental changes to transform the mental health system to a recovery orientation. Finally, we consider recovery from a capabilities standpoint and discuss how this view lends itself to addressing both individual and social components of mental illness.

Suicidal Behaviour Among Youth in Five Public Sectors of Care.

BACKGROUND: Rates of suicidal ideation and behaviours as well as associated risk factors are examined among youth recruited from five public sectors of care (i.e. child welfare, juvenile justice, special education services, alcohol and drug services, and county mental health). METHOD: 1057 youth (ages 11-18) completed a diagnostic interview and questionnaires assessing relevant suicide risk factors at baseline and 2-year follow-up. RESULTS: While past year thoughts about death (28%) and talking about killing oneself (7.1%) were comparable to community norms, rates of lifetime suicide attempts (20.1%) were considerably higher in this sample. However, youth in the special education sector reported significantly more suicidal thoughts and behaviours relative to the other sectors. In multivariate analyses, longitudinal predictors of suicidality included major depression, female gender, and involvement in the special education sector. CONCLUSIONS: Efforts to implement screening and evidence based interventions for depression and suicide in the public sector, particularly special education services, are necessary.

Child maltreatment profiles and adjustment problems in high-risk adolescents.

The purpose of this article is to identify profiles of maltreatment experiences in a sample of high-risk adolescents and to investigate the relationship between the derived profiles and psychological adjustment. Participants are 1,131 youth between the ages of 12 and 18 years involved with publicly funded mental health and social services. Information on physical, sexual, and emotional maltreatment and psychological symptoms are obtained in interviews with adolescents and their primary caregivers. Using latent profile analysis, three maltreatment profiles are identified: "sexual+physical+emotional maltreatment," "physical+emotional maltreatment," and "low maltreatment." Adolescents in the two maltreatment profiles generally have significantly higher scores on symptom scales compared with those in the "low maltreatment" profile, but scores in the two maltreatment profiles do not differ. Findings highlight the need for agencies to identify and provide appropriate intervention for youth who experience multiple types of maltreatment.

Capacity for delivering culturally competent mental health services in New Mexico: results of a statewide agency survey.

The Federal government has promoted National Standards for Culturally and Linguistically Appropriate Services (CLAS) to reduce mental health disparities among Hispanic and Native American populations. In 2005, the State of New Mexico embarked upon a comprehensive reform of its behavioral health system with an emphasis on improving cultural competency. Using survey methods, we examine which language access services (i.e., capacity for bilingual care, interpretation, and translated written materials) and organizational supports (i.e., training, self-assessments of cultural competency, and collection of cultural data) mental health agencies in New Mexico had at the onset of a public sector mental health reform (Office of Minority Health 2001).

Public-academic partnerships: improving care for older persons with schizophrenia through an academic-community partnership.

Translating evidence-based mental health interventions designed in research settings into community practice is a priority for multiple stakeholders. Partnerships between academic and public institutions can facilitate this translation. To improve care for middle-aged and older adults with schizophrenia, the authors developed a collaboration between a university research center and a public mental health service system using principles from community-based participatory research and cultural exchange theory. They describe the process that has led to a number of mutually beneficial products. Despite the challenges involved, building and maintaining academic-public collaborations will be essential for improving mental health care for persons with schizophrenia.

The shifting subtypes of ADHD: classification depends on how symptom reports are combined.

Research on the correlates of ADHD subtypes has yielded inconsistent findings, perhaps because the procedures used to define subtypes vary across studies. We examined this possibility by investigating whether the ADHD subtype distribution in a community sample was sensitive to different methods for combining informant data. We conducted a study to screen all children in grades 1-5 (N = 7847) in a North Carolina County for ADHD. Teachers completed a DSM-IV behavior rating scale and parents completed a structured telephone interview. We found substantial differences in the distribution of ADHD subtypes depending on whether one or both sources were used to define the subtypes. When parent and teacher data were combined, the procedures used substantially influenced subtype distribution. We conclude the ADHD subtype distribution is sensitive to how symptom information is combined and that standardization of the subtyping process is required to advance our understanding of the correlates of different ADHD subtypes.

Substance involvement among youths in child welfare: the role of common and unique risk factors.

This study examines risk factors for substance involvement for youths involved with the child welfare (CW) system. In addition to common risk factors examined in general population studies; this research examines risk factors unique to youths in the CW system, including age at entry into CW and number of out-of-home placements. Participants included 214 youths ages 13 to 18, randomly sampled from youths active to CW in San Diego County, California. Severity of substance involvement was assessed through structured diagnostic interviews determining lifetime substance use, abuse, and dependence. Hierarchical regression analyses including demographics, psychosocial variables, maltreatment history, CW placement variables, and the interaction of age at entry into CW and number of out-of-home placements revealed that both common and CW-specific risk factors were associated with the severity of youth substance involvement. Multiple-placement changes, later entry into the CW system, and multiple-placement changes at an older age are associated with higher risk for more serious substance involvement for youths in CW.

A longitudinal study of the use of mental health services by persons with serious mental illness: do Spanish-speaking Latinos differ from English-speaking Latinos and Caucasians?

OBJECTIVE: Reports of mental health care use by Latinos compared to Caucasians have been mixed. To the authors' knowledge, no large-scale studies have examined the effects of language on mental health service use for Latinos who prefer Spanish compared to Latinos who prefer English and to Caucasians. Language is the most frequently used proxy measure of acculturation. The authors used the administrative database of a mental health system to conduct a longitudinal examination of mental health service use among Spanish-speaking versus English-speaking Latinos and Caucasians with serious mental illness. METHOD: There were 539 Spanish-speaking Latinos, 1,144 English-speaking Latinos, and 4,638 Caucasians initiating treatment for schizophrenia, bipolar disorder, or major depression during 2001-2004. Using multivariate regressions, the authors examined the differences among the groups in the type of service first used. The authors also examined the probability of use of each of four types of mental health services and the intensity of outpatient treatment. RESULTS: Spanish-speaking Latinos differed from both English-speaking Latinos and Caucasians on most measures. Compared to patients in the other groups, the Spanish-speaking Latinos were less likely to enter care through emergency or jail services and more likely to enter care through outpatient services. There were no group differences in the proportion that stayed in treatment or used inpatient hospitalization. CONCLUSIONS: This study suggests that for Latinos, preferred language may be more important than ethnicity in mental health service use. Future studies comparing mental health use may need to differentiate between Spanish- and English-speaking Latinos.

Anxiety disorders in a public mental health system: clinical characteristics and service use patterns.

BACKGROUND: Anxiety disorders are among the most common forms of psychiatric disorder, yet few investigations have examined the prevalence or service use of clients with anxiety disorders in the public mental health sector. METHODS: We examined demographics, clinical information, and service use in clients with anxiety disorders enrolled in San Diego County Adult and Older Adult Mental Health Services in fiscal 2002-2003. RESULTS: Almost 15% of the sample had a diagnosis of an anxiety disorder based on administrative billing data. Most anxiety disorder clients had additional psychiatric diagnoses, most commonly depression. Clients with both anxiety disorders and depression were more likely than those with anxiety or depression alone to use emergency psychiatric services and outpatient services than those with depression alone. Those with anxiety disorders alone used more outpatient services than those with depression alone. LIMITATION: Data were taken from an administrative database. CONCLUSIONS: Data indicate that anxiety disorders are not uncommon in public mental health settings and are associated with higher utilization of outpatient mental health services.

Caregiver depression and medication use by youths with ADHD who receive services in the public sector.

OBJECTIVE: This study examined caregiver depression and medication use by youths with attention-deficit hyperactivity disorder (ADHD) in the public sector. METHODS: Multivariate logistic regression models were created for 390 youths six to 17 years of age who met ADHD criteria on the Diagnostic Interview Schedule for Children (DISC) and were enrolled in a prospective study of youths served in public-sector service systems. The dependent variable was caregiver report of youth medication use for ADHD in the 12 months before the 24-month interview. RESULTS: Only 38% of youths with DISC diagnoses of ADHD were using medication. Youths whose caregivers had depression (41% of the sample) were half as likely as other youths to use medication. Younger age, public insurance, caregiver report of diagnosis, and receipt of medical, mental health, or school services also predicted use. CONCLUSIONS: Caregiver depression and its association with medication use warrant further exploration.

"We never used to do things this way": behavioral health care reform in New Mexico.

This column describes the first year of efforts in New Mexico to reform the behavioral health system. The process, guided by principles of cultural exchange theory, seeks to establish a "collaborative culture" among all stakeholders involved, including state agencies, consumers, families, advocates, and providers. Challenges have included inadequate system funding; insufficient development of skill sets among state personnel; underestimation of time and labor needed to address complex tasks; varying federal statutory and funder requirements for individual agencies; lack of a solid infrastructure for data collection, management, and dissemination; and clear definitions of the roles and relationships of local stakeholders to the state leadership group.

Measures and predictors of community-based employment and earnings of persons with schizophrenia in a multisite study.

OBJECTIVE: Data from a national study of persons with schizophrenia-related disorders were examined to determine clinical factors and labor-market conditions related to employment outcomes. METHODS: Data were obtained from the U.S. Schizophrenia Care and Assessment Program, a naturalistic study of more than 2,300 persons from organized care systems in six U.S. regions. Data were collected via surveys and from medical records and clinical assessments at baseline and for three years. Outcome measures included any community-based (nonsheltered) employment, 40 or more hours of work in the past month, employment at or above the federal minimum wage, days and hours of work, and earnings. Bivariate and multiple regression analyses of data from more than 7,000 assessments tested relationships between outcomes and sociodemographic, clinical, and local labor market characteristics. RESULTS: The employment rate was 17.2%; only 57.1% of participants who worked reported 40 or more hours of past-month employment. The mean hourly wage was $7.05, and mean monthly earnings were $494.20. Employment rates and number of hours worked were substantially below those found in household surveys or in baseline data from trials of employment programs but substantially higher than those found in a recent large clinical trial. Strong positive relationships were found between clinical factors and work outcomes, but evidence of a relationship between local unemployment rates and outcomes was weak. CONCLUSIONS: Work attachment and earnings were substantially lower than in previous survey data, not very sensitive to labor market conditions, and strongly related to clinical status.

Diagnostic variability for schizophrenia and major depression in a large public mental health care system dataset.

Administrative datasets can provide information about mental health treatment in real world settings; however, an important limitation in using these datasets is the uncertainty regarding psychiatric diagnosis. To better understand the psychiatric diagnoses, we investigated the diagnostic variability of schizophrenia and major depression in a large public mental health system. Using schizophrenia and major depression as the two comparison diagnoses, we compared the variability of diagnoses assigned to patients with one recorded diagnosis of schizophrenia or major depression. In addition, for both of these diagnoses, the diagnostic variability was compared across seven types of treatment settings. Statistical analyses were conducted using t tests for continuous data and chi-square tests for categorical data. We found that schizophrenia had greater diagnostic variability than major depression (31% vs. 43%). For both schizophrenia and major depression, variability was significantly higher in jail and the emergency psychiatric unit than in inpatient or outpatient settings. These findings demonstrate that the variability of psychiatric diagnoses recorded in the administrative dataset of a large public mental health system varies by diagnosis and by treatment setting. Further research is needed to clarify the relationship between psychiatric diagnosis, diagnostic variability and treatment setting.

Racial variation in self-labeled child abuse and associated internalizing symptoms among adolescents who are high risk.

One thousand and ten Non-Hispanic White, African American, Hispanic, and Asian Pacific Islander youth who were high risk and receiving public sector services were interviewed regarding history of child emotional and physical abuse and current internalizing symptoms. The study examined whether race moderated the association between adolescents' reports of specific parent behaviors and their self-labeling as victims of abuse. The study also examined whether reports of parental behaviors or self-labeled abuse better predicted internalizing symptoms, and whether these associations differed by race. When reporting punitive parent behavior, Non-Hispanic White youth were more likely to describe themselves as abused compared to Asian Pacific Islanders. Reported punitive parental behaviors accounted for more variance in internalizing symptoms than did self-labeled abuse. Reports of parent behaviors were more strongly related to concurrent internalizing symptoms among ethnic minority youth than among Non-Hispanic White youth. Results are discussed in the context of cultural competence in identification of child abuse.

Racial and ethnic differences in utilization of mental health services among high-risk youths.

OBJECTIVE: Racial and ethnic disparities in mental health service use have been identified as a major public health problem. However, the extent to which these disparities may be accounted for by other confounding sociodemographic or clinical predictors of service use (e.g., family income, functional impairment, caregiver strain) is relatively unexplored, especially for youth services. The goal of this study was to test for racial/ethnic disparities in use of a variety of outpatient, inpatient, and informal mental health services among high-risk youths, with the effects of other predictive factors controlled. METHOD: Participants were 1,256 youths ages 6-18 years who received services in a large, publicly funded system of care (including the child welfare, juvenile justice, special education, alcohol and drug abuse, and mental health service sectors). Youths and caregivers were interviewed with established measures of mental health service use, psychiatric diagnoses, functional impairment, caregiver strain, and parental depression. RESULTS: Significant racial/ethnic group differences in likelihood of receiving any mental health service and, specifically, formal outpatient services were found after the effects of potentially confounding variables were controlled. Race/ethnicity did not exert a significant effect on the use of informal or 24-hour-care services. CONCLUSIONS: Racial/ethnic disparities in service use remain a public health problem.

Prevalence and risk factors for homelessness and utilization of mental health services among 10,340 patients with serious mental illness in a large public mental health system.

OBJECTIVE: The authors examined the prevalence of and risk factors for homelessness among all patients treated for serious mental illnesses in a large public mental health system in a 1-year period. The use of public mental health services among homeless persons was also examined. METHOD: The study included 10,340 persons treated for schizophrenia, bipolar disorder, or major depression in the San Diego County Adult Mental Health Services over a 1-year period (1999-2000). Analytic methods that adjusted for potentially confounding variables were used. Multivariate logistic regression analyses were used to calculate odds ratios for the factors associated with homelessness, including age, gender, ethnicity, substance use disorder, Medicaid insurance, psychiatric diagnosis, and level of functioning. Similarly, odds ratios were computed for utilization of mental health services by homeless versus not-homeless patients. RESULTS: The prevalence of homelessness was 15%. Homelessness was associated with male gender, African American ethnicity, presence of a substance use disorder, lack of Medicaid, a diagnosis of schizophrenia or bipolar disorder, and poorer functioning. Latinos and Asian Americans were less likely to be homeless. Homeless patients used more inpatient and emergency-type services and fewer outpatient-type services. CONCLUSIONS: Homelessness is a serious problem among patients with severe mental illness. Interventions focusing on potentially modifiable factors such as substance use disorders and a lack of Medicaid need to be studied in this population.

Tri-ethnic variations of co-morbid substance and alcohol use disorders in schizophrenia.

OBJECTIVES: This study examined the differential prevalence of substance and alcohol use disorders among European Americans, African Americans, and Latinos with schizophrenia (n = 6424) who received public mental health services in San Diego County during fiscal year 2002-2003. METHODS: Data were obtained from the public mental health database used by the San Diego County Mental Health System. Chi-Square analyses and stepwise logistic regression analyses were used to examine differences regarding the prevalence of substance and alcohol use among clients with schizophrenia and schizoaffective disorder, and to analyze the sociodemographic variables associated with this co-morbidity. RESULTS: Significant differences in the prevalence of diagnosed co-morbidity were found across the ethnic groups. Rates of co-morbid diagnosis among African Americans (25%) were significantly higher than those among European Americans (22%) and Latinos (19%). Logistic regression results revealed ethnicity was a significant predictor of co-morbid substance and alcohol use, as was being homeless and male. Among Latinos, language preference was also a significant predictor. Latinos who denoted English as their primary language were 1.7 times more likely to be diagnosed with co-morbid substance or alcohol use disorders than Latinos who denoted Spanish. CONCLUSIONS: Among people with schizophrenia, there were significant differences in prevalence rates and predictors of diagnosed co-morbid substance and alcohol use disorders. Future research is needed to examine the relationship among language preference, level of acculturation, and subsequent diagnosing barriers for Latinos. Among African Americans, the reasons behind increased co-morbidity rates need to be examined, and homelessness should be carefully addressed among all three ethnic groups.

Why bother with beliefs? Examining relationships between race/ethnicity, parental beliefs about causes of child problems, and mental health service use.

In this study, the authors examined the role of parental beliefs about the causes of child problems in predicting later mental health service use in a large, diverse population of at-risk youths. Study hypotheses were that parental beliefs consistent with biopsychosocial causes would be associated with later mental health service use; sociological, spiritual, or nature disharmony etiologies would be negatively associated with service use; and beliefs would partially mediate the relationship between race/ethnicity and service use. Of the 5 biopsychosocial beliefs, 2 were positively related to later mental health service use. Unexpectedly, of the 6 parental beliefs related to sociological, spiritual, or nature disharmony etiologies, only 1 was negatively associated with later service use patterns. Parental endorsement of etiologies relating to physical causes, relational issues, trauma, and prejudice was found to partially mediate the relationship between race/ethnicity and service use for Asian/Pacific Islander American and Latino youths. ((c) 2005 APA, all rights reserved).