Availability of behavioral health crisis care and associated changes in emergency department utilization.

OBJECTIVE: To determine whether availability of behavioral health crisis care services is associated with changes in emergency department (ED) utilization. DATA SOURCES AND STUDY SETTING: We used longitudinal panel data (2016-2021) on ED utilization from the Healthcare Cost and Utilization Project's State ED Databases and a novel dataset on crisis care services compiled using information from the Substance Abuse and Mental Health Services Administration's National Directories of Mental Health Treatment Facilities. A total of 1002 unique zip codes from Arizona, Florida, Kentucky, Maryland, and Wisconsin were included in our analyses. STUDY DESIGN: To estimate the effect of crisis care availability on ED utilization, we used a linear regression model with zip code and year fixed effects and standard errors accounting for clustering at the zip code-level. ED utilization related to mental, behavioral, and neurodevelopmental (MBD) disorders served as our primary outcome. We also examined pregnancy-related ED utilization as a nonequivalent dependent variable to assess residual bias in effect estimates. DATA COLLECTION/EXTRACTION METHODS: We extracted data on crisis care services offered by mental health treatment facilities (n = 14,726 facility-years) from the National Directories. MBD-related ED utilization was assessed by applying the Clinical Classification Software Refined from the Healthcare Cost and Utilization Project to the primary ICD-10-CM diagnosis code on each ED encounter (n = 101,360,483). All data were aggregated to the zip code-level (n = 6012 zip-years). PRINCIPAL FINDINGS: The overall rate of MBD-related ED visits between 2016 and 2021 was 1610 annual visits per 100,000 population. Walk-in crisis stabilization services were associated with reduced MBD-related ED utilization (coefficient = -0.028, p = 0.009), but were not significantly associated with changes in pregnancy-related ED utilization. CONCLUSIONS: Walk-in crisis stabilization services were associated with reductions in MBD-related ED utilization. Decision-makers looking to reduce MBD-related ED utilization should consider increasing access to this promising alternative model.

Social anhedonia in the daily lives of people with schizophrenia: Examination of anticipated and consummatory pleasure.

Social anhedonia is a hallmark symptom of schizophrenia. Discrepancies in anticipated versus consummatory pleasure for non-social stimuli are well-documented. Thus, a similar emotional paradox may underlie social anhedonia. If so, our understanding of social anhedonia-including how to treat it in schizophrenia-could be enhanced. This project used a 5-day experience sampling method (ESM) to measure discrepancies between anticipated and consummatory pleasure for real-world social activities in people with schizophrenia and healthy controls (n = 30/group). ESM results were compared to laboratory assessments of negative symptoms and neurocognition. The schizophrenia group exhibited similar levels of anticipated and consummatory social pleasure as controls throughout daily life, and both groups were accurate in their short-term predictions of pleasure. Clinical interviews revealed those with schizophrenia showed significant deficits in long-term social pleasure prediction (i.e., a 1-week timeframe). Thus, people with schizophrenia may exhibit differences in ability to predict pleasure in the short-term versus the long-term. Negative symptoms and neurocognition were related to anticipated, but not consummatory, social pleasure, suggesting anhedonia is driven by deficits in thinking about pleasure, rather than inability to experience pleasure. Clinical implications include focusing on building upon short-term ability to predict pleasure in therapy to increase social motivation in schizophrenia.

Market Factors Associated with Comprehensive Behavioral Health Crisis Care Availability: A Resource Dependence Theory Study.

Behavioral health crisis care (BHCC) is a care delivery model for individuals experiencing acute distress related to a mental health or substance use disorder. We examined market factors associated with comprehensive BHCC availability using 2022 data on mental health treatment facilities (n = 9385) obtained from the Substance Abuse and Mental Health Services Administration. We aggregated facility-level data by county (n = 3142) and merged with county-level market factors. Logistic regression models were used to examine the adjusted associations between market factors and BHCC availability. We found that 468 (14.9%) counties had at least one mental health treatment facility offering comprehensive BHCC services. Specifically, counties with more mental health providers (Adjusted Odds Ratio = 2.26, Confidence Interval = 1.32-3.86) and metropolitan counties (AOR = 3.26, CI = 1.95-5.43) had higher odds of having a comprehensive BHCC facility. Our findings highlight the importance of developing the mental health workforce to increase BHCC availability and a need to address disparities in rural counties.

Why do Stayers Stay? Perceptions of White and Black Long-Term Employees in a Community Mental Health Center.

Previous research has focused on factors influencing turnover of employees in the mental health workforce, yet little research has explored reasons why employees stay. To facilitate retaining a diverse mental health workforce, the current study aimed to elucidate factors that contributed to employees' tenure at a community mental health center (CHMC) as well as compare these perceptions between Black and White employees. Long-term employees (7 years or more) from one urban CMHC (n = 22) completed semi-structured stayer interviews. Using emergent thematic analysis, stayer interviews revealed four major themes for why they have stayed at the organization for 7 years or more: (1) work as a calling, (2) supportive relationships, (3) opportunities for growth or meaningful contribution, and (4) organization mission's alignment with personal attributes or values. Comparison between Black and White stayer narratives revealed differences in their perceptions with work as a calling and opportunities for growth and meaningful contribution. Guided by themes derived from stayer interviews, the current study discusses theoretical (e.g., job embeddedness theory, theory of racialized organizations, self-determination theory) and practical implications (e.g., supporting job autonomy, Black voices in leadership) in an effort to improve employee retention and address structural racism within a mental health organization.

Enhancing patient-clinician collaboration during treatment decision-making: study protocol for a community-engaged, mixed method hybrid type 1 trial of collaborative decision skills training (CDST) for veterans with psychosis.

BACKGROUND: Patient participation in treatment decision making is a pillar of recovery-oriented care and is associated with improvements in empowerment and well-being. Although demand for increased involvement in treatment decision-making is high among veterans with serious mental illness, rates of involvement are low. Collaborative decision skills training (CDST) is a recovery-oriented, skills-based intervention designed to support meaningful patient participation in treatment decision making. An open trial among veterans with psychosis supported CDST's feasibility and demonstrated preliminary indications of effectiveness. A randomized control trial (RCT) is needed to test CDST's effectiveness in comparison with an active control and further evaluate implementation feasibility. METHODS: The planned RCT is a hybrid type 1 trial, which will use mixed methods to systematically evaluate the effectiveness and implementation feasibility of CDST among veterans participating in a VA Psychosocial Rehabilitation and Recovery Center (PRRC) in Southern California. The first aim is to assess the effectiveness of CDST in comparison with the active control via the primary outcome, collaborative decision-making behavior during usual care appointments between veterans and their VA mental health clinicians, and secondary outcomes (i.e., treatment engagement, satisfaction, and outcome). The second aim is to characterize the implementation feasibility of CDST within the VA PRRC using the Practical Robust Implementation and Sustainability Model framework, including barriers and facilitators within the PRRC context to support future implementation. DISCUSSION: If CDST is found to be effective and feasible, implementation determinants gathered throughout the study can be used to ensure sustained and successful implementation at this PRRC and other PRRCs and similar settings nationally. TRIAL REGISTRATION: ClinicalTrials.gov NCT04324944. Registered on March 27, 2020. Trial registration data can be found in Appendix 1.

Narrative Forewarnings: A Qualitative Analysis of the Themes Preceding Disorganized Speech in Schizophrenia.

Disorganized speech is a critical barrier to recovery in schizophrenia, with profound negative impacts on one's ability to engage with the world. Despite the limited efficacy of existing treatments in addressing disorganization, a qualitative analysis of what leads to disorganization in patient narratives has been lacking. This study addresses this gap through inductive thematic analysis of 30 narrative interviews with individuals with schizophrenia, matched based on whether Formal Thought Disorder (FTD) is present. Through this analysis, we identified four core themes (alienation, interpersonal tension, personal benchmarks, and adverse experiences) and eight subthemes. Our findings suggest that disorganization may serve as a protective mechanism against psychological distress and highlight how the severity of FTD influences these themes. Alienation, particularly due to illness-related stigma, emerged more prominently in those with FTD. The themes of personal benchmarks and interpersonal tension pointed towards a heightened sensitivity to social interactions and self-perception among those with schizophrenia. Adverse experiences, encompassing past challenges, suggest a potential link between trauma and symptom exacerbation. Our qualitative analysis of what themes precede disorganized speech has implications for tailoring psychotherapy. By considering an individual's specific triggers and level of disorganization, therapy may be more effectively targeted to improve recovery-based outcomes. By identifying themes within patient narratives, this study advances our understanding of the qualitative aspects preceding disorganized speech in schizophrenia, paving the way for more personalized and effective recovery-focused interventions.

State Policies Associated with Availability of Mobile Crisis Teams.

Mobile crisis teams are comprised of multidisciplinary mental health professionals that respond to mental health crisis calls in community settings. This study identified counties with mobile crisis teams and examined state policies associated with mobile crisis teams. Descriptive statistics and geographic information system software were used to quantify and map counties with mobile crisis teams in the United States. Relationships between state policies and mobile crisis teams were examined using an adjusted logistic regression model, controlling for county characteristics and accounting for clustering by state. Approximately 40% (n = 1,245) of all counties in the US have at least one mobile crisis team. Counties in states with legislation in place to fund the 988 Suicide and Crisis Lifeline were more likely to have a mobile crisis team (Adjusted Odds Ratio (AOR): 2.0; Confidence Interval (CI): 1.23-3.26), whereas counties in states with 1115 waivers restricting Medicaid benefits were less likely to have a mobile crisis team (AOR: 0.43; CI: 0.21-0.86). Additionally, counties with the largest population were more likely to have a mobile crisis team (AOR: 2.20; CI:1.43-3.38) than counties with the smallest population. Having a mobile crisis teams was positively associated with legislation to fund 988. Legislation that encourages expansion of existing crisis care services, specifically funding aimed at mobile crisis teams, may help increase availability of services for people who are experiencing a mental health crisis in the community.

The Impact of Patient Race, Patient Socioeconomic Status, and Cognitive Load of Physician Residents and Fellows on Chronic Pain Care Decisions.

Social stereotypes are more likely to influence decision-making under conditions of high cognitive load (ie, mental workload), such as in medical settings. We examined how patient race, patient socioeconomic status (SES), physician cognitive load, and physician implicit beliefs about race and SES differences in pain tolerance impacted physicians' pain treatment decisions. Physician residents and fellows (N = 120) made treatment decisions for 12 computer-simulated patients with back pain that varied by race (Black/White) and SES (low/high). Half of the physicians were randomized to be interrupted during the decision task to make hypertension medication conversion calculations (high cognitive load group), while the other half completed the task without interruptions (low cognitive load group). Both groups were given equal time to make pain care decisions (2.5 minutes/patient). Results of multilevel ordinal logistic regression analyses indicated that physicians prescribed weaker analgesics to patients with high vs. low SES (odds ratio = .68, 95% confidence interval [.48, .97], P = .03). There was also a patient SES-by-cognitive load interaction (odds ratio = .56, 95% confidence interval [.31, 1.01], P = .05) that is theoretically and potentially practically meaningful but was not statistically significant at P < .05. These findings shed light on physician cognitive load as a clinically-relevant factor in the context of pain care quality and equity. PERSPECTIVE: These findings highlight the clinical relevance of physician cognitive load (eg, mental workload) when providing pain care for diverse patients. This line of work can support the development of interventions to manage physician cognitive load and its impact on pain care, which may ultimately help reduce pain disparities.

Meta-analysis of the relationship between metacognition and disorganized symptoms in psychosis.

OBJECTIVE: Disorganized symptoms show associations with metacognitive deficits in psychosis. However, the magnitude of this relationship is unclear. This meta-analysis aimed to 1) quantify relationships between metacognition and both disorganized symptoms and disorganized speech; and 2) examine moderators of these relationships (e.g., metacognition type, neurocognition). METHOD: A literature search was conducted using PsycINFO, Web of Science, PubMed, and EMBASE databases. English-language studies measuring disorganized symptoms and metacognition (i.e., introspective accuracy, metacognitive beliefs, or metacognitive capacity) in psychosis were included. Random effects meta-analyses were conducted using Pearson's r. RESULTS: Meta-analysis of 20 studies (n = 1490) resulted in a significant negative medium correlation between disorganized symptoms and metacognition (r = -0.332, 95 % CI [-0.423, -0.235]). Magnitude was moderated by metacognition type. A significant negative small correlation between disorganized speech and metacognition (r = -0.173, 95 % CI [-0.254, -0.089], n = 1470) was observed, with no significant moderators. CONCLUSIONS: Results clarify the magnitude of the relationships between metacognition and both disorganized symptoms and disorganized speech. Significant relationships may indicate conceptual links, yet the different magnitudes may reflect a distinction between disorganized symptoms and speech. The moderator finding highlights that metacognitive capacity has an especially strong link to disorganized symptoms and underscores the need for careful distinction between types of metacognition in future work.