Feasibility of an Open Dialogue-Inspired Approach for Young Adults with Psychosis in a Public Hospital System.

The objective was to determine the feasibility of an Open Dialogue-inspired approach in a metropolitan, public hospital setting with predominately African American participants. Participants were ages 18-35, experienced psychosis within the past month, and involved at least one support person in their care. We evaluated domains of feasibility including implementation, adaptation, practicality, acceptability, and limited-efficacy. An organizational change model (Addressing Problems Through Organizational Change) facilitated implementation. Clinicians received three trainings and ongoing supervision. Network meetings were successfully implemented with good self-reported fidelity to principles of dialogic practice. Some adaptations (less frequent meetings and no home visits) were necessary. A subset of individuals completed research assessments over 12 months. Qualitative interviews with participants suggested the intervention was acceptable. Symptom and functional outcomes were preliminary but trended toward improvement. Implementation was feasible with relatively brief training, organizational change processes, and context-specific adaptations. Lessons learned can assist in planning a larger research study.

A Comparison of Attitudes, Comfort, and Knowledge of Clozapine Among Two Diverse Samples of US Psychiatrists.

Considerable variation in clozapine utilization exists across the United States, and little is known about the perspective of psychiatrists in states with low clozapine use. To better understand clozapine practices, attitudes, and barriers, a survey was administered to a group of southeastern state conference attendees (SSCA; N = 86). The same survey was administered to psychiatrists belonging to a national community psychiatry organization (AACP; N = 57), and differences were analyzed across the two samples. In comparison to the AACP, the SSCA group felt less comfortable, perceived clozapine as less safe and effective, had fewer patients on clozapine, and were more likely to prefer antipsychotic polypharmacy to clozapine use. Across the sample, use of a myocarditis screening protocol was rare (N = 14/76; 18%) and less than half used plasma antipsychotic levels to guide dosage (N = 60/129; 47%). Continuing professional education on clozapine are needed for psychiatrists who see individuals with psychotic disorders.

Using the Theory of Planned Behavior to Understand How Crisis Intervention Team (CIT) Training Facilitates Police Officers' Mental Health Referrals.

The Theory of Planned Behavior posits that behaviors are predicted by one's intention to perform them; intention is driven by attitude toward the behavior, subjective norm, and perceived behavioral control. We used this theory to predict Crisis Intervention Team (CIT)-trained and non-CIT officers' intention to facilitate referral of persons with suspected mental illnesses to mental health services. CIT-trained (n = 251) and non-CIT (n = 335) officers from six law enforcement agencies participated. CIT-trained officers had significantly greater scores on all constructs. Theory constructs fit the data well, and fit did not differ meaningfully between the two groups. Direct and indirect predictors together accounted for 28% and 21%, respectively, of variance in behavioral intention. Attitude was the strongest predictor. Intentions to facilitate mental health referrals may be driven by the same factors among CIT-trained and non-CIT officers, but CIT officers, even at a median of 22 months after training, have significantly higher scores on those factors.

Associations Between Two Domains of Social Adversity and Recovery Among Persons with Serious Mental Illnesses Being Treated in Community Mental Health Centers.

As mental health services are increasingly embracing the recovery model, we conducted a study to better understand how social adversity impacts recovery. We also examined how associations between social adversity and recovery are influenced (moderated or mediated) by symptom severity. Data on seven social adversity measures, eight recovery measures, and symptom severity were collected from 300 English-speaking participants, ages 18-65 years, with a diagnosis of a psychotic or mood disorder, from five community mental health agencies in diverse neighborhoods in Washington, D.C. We employed standard correlation, exploratory factor analyses, analysis of variance, and hierarchic regression procedures. Diagnostic category and gender impacted Home Environment Adversities (e.g., food insecurity, perceived neighborhood disorder), the diagnostic category-by-gender interaction influenced Social and Economic Adversities (e.g., years of education and income), and gender affected Recovery. Controlling for diagnostic category and gender, Social and Economic Adversities accounted for 1.7% of variance in Recovery, while Home Environment Adversities accounted for 8.6% (their joint influence was 3.4%). Although symptom severity did not moderate these associations, it partially mediated the effect of Social and Economic Adversities on Recovery, and substantially mediated the effect of Home Environment Adversities on Recovery. The extent to which patients with serious mental illnesses experience recovery may be meaningfully influenced not only by symptoms, but by their social and environmental circumstances.

Similarities and Differences in Associations Between Duration of Untreated Psychosis (DUP) and Demographic, Premorbid, and Symptom Severity Measures in Two Samples of First-Episode Psychosis Patients from Mexico and the United States.

Early-psychosis researchers have documented that duration of untreated psychosis (DUP) is an important predictor of outcomes in first-episode psychosis. Very few cross-national studies have been conducted, and none have been carried out involving patients from both Mexico and the U.S. We collaborated to answer three questions: (1) Are DUP estimates similar in two very different settings and samples? (2) Are demographic variables, premorbid adjustment, and symptom severity similarly related to DUP in the two different settings? (3) Does the same set of variables account for a similar proportion of variance in DUP in the two settings? Data on sociodemographic characteristics, premorbid adjustment, symptom severity, and DUP were available for 145 Mexican and 247 U.S. first-episode psychosis patients. DUP was compared, and bivariate analyses and multiple linear regressions were carried out in each sample. DUP estimates were similar (medians of 35 weeks in Mexico and 38 weeks in the U.S.). In the Mexican sample, DUP was associated with gender, employment status, premorbid social adjustment, and positive symptom severity (explaining 18% of variance). In the U.S. sample, DUP was associated with age, employment status, premorbid social adjustment, and positive symptom severity (but in the opposite direction of that observed in the Mexican sample), accounting for 25% of variance. Additional cross-national collaborations examining key facets of early-course psychotic disorders, including DUP, will clarify the extent of generalizability of findings, strengthen partnerships for more internationally relevant studies, and support the global movement to help young people struggling with first-episode psychosis and their families.

Coping with Food Insecurity Among African American in Public-Sector Mental Health Services: A Qualitative Study.

While there are high rates of food insecurity among individuals with serious mental illnesses, and among African Americans, there is very little research on the ways African Americans in public-sector mental health services cope with food insecurity. This research paper presents qualitative data from a mixed methods study on the prevalence and management of food insecurity among African Americans using public sector mental health services. We interviewed 21 people about their everyday experiences of food insecurity and strategies they used to cope. While participants reported experiencing high levels of food insecurity, they also described the use of communal strategies to help them cope, including sharing food and cooking meals jointly, which seemed to reduce the negative effects of living with high levels of food insecurity as well as a serious mental illness. Policy innovations like communal gardens and kitchens provided through public mental health services may be particularly helpful.

Police officers' volunteering for (rather than being assigned to) Crisis Intervention Team (CIT) training: Evidence for a beneficial self-selection effect.

Officers' volunteering for Crisis Intervention Team (CIT) training-rather than being assigned-is assumed to be an important, beneficial self-selection bias. This bias remains poorly characterized, though CIT officers are more likely to be female and to have had exposure to the mental health field. We determined whether or not self-selection is beneficial with regard to knowledge, attitudes, and skills, as well as level of force used (i.e., no or low force versus any form of physical force) and disposition of subjects, in actual encounters. We compared CIT-trained officers who had volunteered with those who had been assigned using data from two prior, linked studies that compared CIT-trained and non-CIT officers on knowledge, attitudes, and skills (251 CIT-trained officers; 68% had volunteered), as well as behaviors (517 actual encounters provided by 91 CIT-trained officers; 70% had volunteered). Of 28 scores on knowledge, attitudes, and skills compared, six were statistically significantly different (p < .01) and another eight were marginally significant (.01 < p < .05). Furthermore, although CIT officers who had volunteered were more likely to report use of some form of physical force as we had defined it (which included the use of handcuffs), when they did so they were more likely to refer to treatment services and less likely to make an arrest. These effects were apparent even when taking into account effects of gender, having had exposure to the mental health field, empathy, and other covariates. In conclusion, we found evidence for benefits of self-selection/volunteering that should be further characterized, as it appears to be associated with better outcomes with regard to key attitudes, skills, and behaviors.

A potential new form of jail diversion and reconnection to mental health services: I. Stakeholders' views on acceptability.

The most effective point of intervention to prevent unnecessary arrest/incarceration of persons with serious mental illnesses is the initial encounter with police. We piloted a new police-mental health linkage system. When officers run an enrolled participant's name/identifiers, they receive an electronic message that the person has mental health considerations and that they should call for information. The linkage specialist receives the call and assists telephonically. In this qualitative study to examine acceptability of the linkage system, we conducted nine focus groups with diverse stakeholders (e.g., enrolled patients, officers). Focus groups revealed that patients enrolled with the hope that the linkage system would prevent negative interactions with police and minimize risk of arrest. Officers reported preferring not to arrest mental health patients and were genuinely invested in helping them, and felt that the linkage system might be an additional tool during encounters. Findings revealed acceptability of the intervention, and further research is warranted.

A potential new form of jail diversion and reconnection to mental health services: II. Demonstration of feasibility.

Given fragmentation between mental health and criminal justice systems, we tested the feasibility of implementing a potential new form of pre-booking jail diversion. Our "linkage system" consists of three steps: (i) individuals with serious mental illnesses and an arrest history give special consent to be enrolled in a statewide database; (ii) if an officer has an encounter with an enrolled patient and runs a routine background check, he or she receives an electronic message to call; and (iii) the "linkage specialist" provides brief telephonic assistance to the officer. Of 206 eligible individuals, 199 (96.6%) opted in, the database received 679 hits, and the linkage specialist received 31 calls (and in at least three cases an arrest was probably averted). The mean number of arrests was 0.59 ± 0.92 in the year before enrollment (38.7% arrested) and 0.48 ± 0.83 during the 12-month intervention (30.7% arrested). Implementation is feasible, and a signal that the system might reduce incarceration was detected, encouraging development of a larger study.

A Mixed-Methods Study of the Recovery Concept, "A Meaningful Day," in Community Mental Health Services for Individuals with Serious Mental Illnesses.

The recovery concept encompasses overcoming or managing one's illness, being physically and emotionally healthy, and finding meaningful purpose through work, school, or volunteering, which connects one to others in mutually fulfilling ways. Using a mixed-methods approach, we studied the emphasis on "a meaningful day" in the new Opening Doors to Recovery (ODR) program in southeast Georgia. Among 100 participants, we measured the meaningful day construct using three quantitative items at baseline (hospital discharge) and at 4-, 8-, and 12-month follow-up, finding statistically significant linear trends over time for all three measures. Complementary qualitative interviews with 30 individuals (ODR participants, family members, and ODR's Community Navigation Specialists and program leaders) revealed themes pertaining to companionship, productivity, achieving stability, and autonomy, as well as the concern about insufficient resources. The concept of "a meaningful day" can be a focus of clinical attention and measured as a person-centered outcome for clients served by recovery-oriented community mental health services.

Developing visually based, low-literacy health education tools for African Americans with psychotic disorders and their families.

Schizophrenia presents particular challenges to health literacy, partly due to associated neurocognitive deficits. In order to develop engaging, recovery-oriented, visually based psychoeducational tools pertaining to psychotic disorders, thirty-nine individuals, consisting of mental health service users with serious mental illnesses, family members, and mental health professionals, participated in informal discussions. Using suggestions from these groups, the first two psychoeducational booklets of a planned series were developed in collaboration with a graphic designer and visual artist. Content of the booklets was developed addressing four components: knowledge, self-efficacy/self-management, incorporating a workbook format, and planning/contracting. In a follow-up discussion group, mental health service users provided positive feedback on the completed booklets. The finished booklets are practical, accessible, engaging, and low-literacy. These and other innovative approaches are needed to enhance mental health care, promote self-efficacy/empowerment, and encourage communication between service users, family members, and providers, especially in light of limited health literacy, illness-related neurocognitive impairments, and stigma.

Development, implementation, and preliminary evaluation of a recovery-based curriculum for community navigation specialists working with individuals with serious mental illnesses and repeated hospitalizations.

A recovery-oriented curriculum for training the Community Navigation Specialists (CNSs) of the new Opening Doors to Recovery in Southeast Georgia program was developed, implemented, and preliminarily evaluated. This new mental health program provides mobile, community-based support services to individuals with serious mental illnesses and a history of psychiatric inpatient recidivism (and commonly past incarcerations and homelessness). Teams of CNSs include a licensed social worker, a family member of an individual with a serious mental illness, and a peer specialist with lived experience. In two courses held in February and June of 2011, 14 newly hired CNSs participated in the new training. A pre-training/post-training evaluation demonstrated statistically significant improvements in pertinent knowledge and self-efficacy for working in a community navigation role. As the recovery paradigm continues to be implemented in diverse real-world mental health treatment settings, recovery-based training curricula should be carefully constructed and evaluated.

Community navigation to reduce institutional recidivism and promote recovery: initial evaluation of opening doors to recovery in Southeast Georgia.

New approaches for preventing repeated inpatient psychiatric stays, detention in jails and prisons, and homelessness among individuals with serious mental illnesses with established histories of such recidivism, while promoting recovery, are direly needed. We present findings from an initial program evaluation of a new community-based, recovery-oriented "community navigation" program in southeast Georgia, called Opening Doors to Recovery. Twenty-three in-depth interviews were conducted with key stakeholders, program participants, community navigation specialist team members, and referring mental health professionals to identify hopes and strengths, challenges and weaknesses, and recommendations pertaining to the new program. Cited strengths included teamwork and pooling of resources from various partners, as well as the novel recovery-based, community navigation team approach. An initial lack of fidelity processes across teams and an ongoing scarcity of safe and affordable housing were identified as weaknesses, with the latter seen as a liability of the overall mental health and social service systems rather than the program itself. Findings from this evaluation highlight strengths and opportunities of this new community navigation approach, including those related to the involvement of certified peer specialists and multiple community partners.

Changes in knowledge, behavioural expectations, self-efficacy, and stigma after an educational campaign about early psychosis for jail correction officers.

AIM: Given a lack of interventions to identify and engage individuals with early psychosis in jail and connect them to specialty care in the community upon release, we designed a Targeted Educational Campaign (TEC) for correction officers working in jails. We report on impacts of the TEC on officers' cognitive and attitudinal outcomes. METHODS: Three different cohorts of officers-totaling n = 451-took part in a survey: 200 at baseline before the TEC began, 123 at 6-months into the TEC, and 128 at 12-months into the TEC. Among each cohort of officers, four constructs were measured: (1) knowledge about early psychosis; (2) self-efficacy around detecting early psychosis and referring to mental health services within the jail; (3) expectations about the benefits of detection and referral to specialty care; and (4) social distance stigma toward detainees with early psychosis. RESULTS: While exposure to TEC elements was as-planned in the first 6-months, exposure diminished substantially at 12-months, coinciding with increasing fatigue among correction officers due to the COVID-19 pandemic as well as serious staffing shortages. Knowledge, behavioural expectations, and self-efficacy scores improved from baseline to 6-months, with greater exposure to roll-call messages driving scores. Knowledge and behavioural expectations at 12-months were associated with having received an information post card. Social distance stigma worsened across timepoints. CONCLUSIONS: An educational campaign for jail staff can enhance knowledge, self-efficacy, and behavioural expectations regarding early psychosis, though only while the campaign elements are active. Further research should investigate whether or not social distance stigma or other types of stigma increase alongside improvements.

Opening Doors to Recovery: A Randomized Controlled Trial of a Recovery-Oriented Community Navigation Service for Individuals With Serious Mental Illnesses and Repeated Hospitalizations.

Objective: Opening Doors to Recovery (ODR) is a community navigation and recovery support model created in southeast Georgia by diverse, collaborative stakeholders. Following promising results from a quasi-experimental study, this randomized controlled trial hypothesized that, among patients with serious mental illnesses being discharged from inpatient psychiatric settings, compared to those randomized to traditional case management (CM) services, those randomized to ODR would have (1) lower likelihood of hospitalization, fewer hospitalizations, and fewer inpatient days; (2) lower likelihood of arrest, fewer arrests, and longer time to arrest; and, secondarily, (3) greater housing satisfaction and housing stability; and (4) higher scores on several scales measuring recovery-related constructs.Methods: 240 individuals with Structured Clinical Interview for DSM-5 Disorders-based psychotic or mood disorders, functional impairment, and repeated hospitalizations were randomized (December 2014 to June 2018) to ODR or CM. Hospitalization and arrest data were collected from State agencies after 12 months, and housing- and recovery-related measures were collected in person, longitudinally at 4, 8, and 12 months. Intention-to-treat analyses were conducted. Effects of dropout were accounted for, and sensitivity analyses were run.Results: ODR was associated with fewer days hospitalized (RR = 0.86, P = .001), a lower incidence of arrests (OR = 0.35, P < .0005), and longer time to arrest (HR = 0.42, P = .001). In addition, measures of housing satisfaction (Cohen d = 0.45) and recovery (Cohen d = 0.33) were significantly more improved in ODR patients compared to CM patients.Conclusions: The ODR model appears to have advantages over more traditional CM services and could fill a gap in the service array. Studying the mediators of success, cost benefit, dissemination, fidelity, and financing of the model is warranted.Trial Registration: ClinicalTrials.gov identifier: NCT04612777.

Social distance and stigma toward individuals with schizophrenia: findings in an urban, African-American community sample.

Because schizophrenia is arguably among the most stigmatized health conditions, research assessing correlates of stigma is essential. This study examined factors associated with stigma in predominantly Protestant, low-income, urban African Americans in the Southeastern United States. A survey was distributed to 282 patrons of an inner-city food court/farmers' market. Associations were assessed between two measures of stigma--an adapted version of the Social Distance Scale (SDS) and a Semantic Differential Measure (SDM) of attributes such as dangerousness, dirtiness, and worthlessness--and several key variables addressing sociodemographic characteristics and exposure to/familiarity with mental illnesses. Independent predictors of scores on the two measures were identified using linear regression modeling. Higher stigma (as measured by the SDM) was predicted by a family history of psychiatric treatment, whereas lower stigma (as indicated by the SDS) was predicted by personal psychiatric treatment history and higher annual income. The results suggest special considerations when working with disenfranchised populations, especially family members of individuals with mental illnesses, in treatment settings.

A Community Navigation Scale for Persons With Serious Mental Illnesses.

OBJECTIVE: The recovery paradigm in the context of serious mental illnesses pertains to several characteristics of community functioning, adjustment, and integration, among other constructs. Additional rating scales would be beneficial for measuring various facets of community functioning for research that is recovery oriented as opposed to symptom focused. The Community Navigation Scale was developed as part of the Opening Doors to Recovery project to address several aspects of navigating community resources. METHODS: After item development, the 21-item Community Navigation Scale was used across two studies with 340 participants who had serious mental illnesses. Factor analysis revealed three potential factors, and subscales were computed. RESULTS: The social and physical well-being subscale (seven items, Cronbach's α=0.82) addressed community involvement, volunteering, finding enjoyable activities, and engaging in positive health behaviors. The accessing external resources subscale (nine items, Cronbach's α=0.80) tapped one's ability to obtain needed resources, ranging from medications to housing and from small appliances to classes in the community. The home and self-maintenance subscale (five items, Cronbach's α=0.73) measured abilities around shopping, cooking, cell phone use, house cleaning, and personal grooming and hygiene. Initial validity of the subscales was suggested through correlations with the Multnomah Community Ability Scale (r=0.65, 0.55, and 0.41 for social and physical well-being, accessing external resources, and home and self-maintenance, respectively). CONCLUSIONS: The Community Navigation Scale assesses dimensions of community functioning among persons with serious mental illnesses and may add to the array of research and clinical measures pertinent to recovery outcomes. Additional research on its psychometric properties is warranted.

Modeling the effects of Crisis Intervention Team (CIT) training for police officers: How knowledge, attitudes, and self-efficacy drive de-escalation skills and referral decisions.

OBJECTIVE: Prior research on Crisis Intervention Team (CIT) training for police officers has demonstrated improvements in knowledge, attitudes, self-efficacy, and stigma, but how these factors work together to influence behavioral outcomes like de-escalation skills and referral decisions remains unstudied. METHOD: 251 CIT-trained and 335 non-CIT officers completed in-depth surveys measuring these six constructs. We used structural equation modeling to test fit of the data to our hypothesized model and made indicated changes to improve fit. RESULTS: An alternate 8-path model (with three paths originally hypothesized being removed) fit reasonably well, and allowing path coefficients to differ for CIT and non-CIT groups resulted in models with similar fit statistics. CONCLUSION: CIT training enhances knowledge and attitudes, both of which have beneficial effects on stigma. Though an important outcome itself, lower stigma does not have an effect on de-escalation skills and referral decisions, though self-efficacy clearly does.

Development, item analysis, and initial reliability and validity of a multiple-choice knowledge of mental illnesses test for lay samples.

The public's level of mental health literacy remains low, despite growing access to information regarding mental illnesses. Because few measures exist to assess the level of knowledge of mental illnesses in lay samples, the Multiple-Choice Knowledge of Mental Illnesses Test (MC-KOMIT) was developed, initially for use in a study involving police officers, some of whom received 40 h of training focused on recognizing mental illnesses, using verbal de-escalation techniques, and making mental health referrals when appropriate. This report details the initial development of the 100 questions in the item bank and the eventual selection of the final 33 items that were retained. For these 33 items, internal consistency was demonstrated, and test-retest reliability was examined among officers not in the mental health-related training who completed the test on Monday morning and again on Friday afternoon. Construct validity was examined by three hypothesis tests: the MC-KOMIT was sensitive to change related to the educational intervention, scores were significantly correlated with years of educational attainment, and officers reporting past or current treatment for a mental health problem scored higher than those without such a history. This initial report suggests that the MC-KOMIT may be useful in quantifying knowledge of mental illnesses in police officers and other diverse lay samples.

Development and initial reliability and validity of four self-report measures used in research on interactions between police officers and individuals with mental illnesses.

There currently exists a dearth of reliable and valid instruments to examine key police officer variables of importance in the growing research on their interactions with individuals with mental illnesses. This study tested reliability and validity of four newly designed measures of the constructs of self-efficacy (Self-Efficacy Scale; SES), referral decisions and de-escalation skills (Behavioral Outcomes Scale; BOS), attitudes toward psychiatric treatment (Opinions about Psychiatric Treatment; OPT), and social distance (Adapted Social Distance Scale; ASDS) in a sample of law enforcement officers. Self-administered, anonymous surveys, which included the measures of interest, were completed by 177 officers-68 of whom were undergoing Crisis Intervention Team (CIT) training and 109 of whom were not-at the beginning and end of week-long trainings. Analyses examined the internal consistency reliability, test-retest reliability, and construct validity of the instruments. The four measures of interest were found to be reliable and valid. Specifically, internal consistency coefficients and test-retest reliability correlations were generally acceptable, all four demonstrated sensitivity to change, and validity correlations were significant and in the expected direction. Findings demonstrated the ability to measure key constructs related to attitudes and intended behaviors in law enforcement officers utilizing psychometrically sound instruments. Further testing and the development of additional reliable and valid instruments focused on attitudinal and behavioral domains among officers who have frequent interactions with individuals with mental illnesses would be of great value.