Employment of Certified Peer Specialists in Mental Health Professional Shortage Areas.

The current demand for mental health services is exacerbated by an ongoing shortage of behavioral health care providers in the United States. The Health Resources and Services Administration has identified 5,833 Mental Health Professional Shortage Areas (MHPSAs), many of which are rural, and could be served by Certified Peer Specialists (CPSs). This paper examines the relationship between CPS employment and MHPSA residency. Data are from a 2020 survey of 572 CPS certified in one of four states. Random effects logistic regression models were used to test the relationship between MHPSA residence and employment outcomes. Of 166 unique counties identified by participant zip codes, 47 were characterized as being MHPSAs with 14% of participants residing in one of these counties. A higher proportion of those living in MHPSAs were employed in peer support jobs (rather than other job types or unemployed) compared to those living in non-MHPSAs (68% vs. 54%, p = .020). MHPSA residential status was not a significant predictor of employment status (OR = 1.14, p = .728) but was significantly associated with greater likelihood of employment in peer support compared to other jobs, both for the entire sample (OR = 2.13, p = .026), and among those currently employed (OR = 2.90, p = .032). The greater likelihood of working in peer support among those residing in MHPSAs suggests that CPSs may leverage their credential to address shortages. As a result, peer support may become a more necessary part of the traditional service array. Policies that enable CPS to practice in MHPSAs should be encouraged.

Trauma Across the Life Span and Multisystem Morbidity in Women With HIV.

OBJECTIVE: Sexual and physical abuse are highly prevalent among women living with HIV (WLWH) and are risk factors for the development of mental health and substance use disorders (MHDs, SUDs), and cognitive and medical comorbidities. We examined empirically derived patterns of trauma, MHD, and SUD, and associations with later cognitive and health outcomes. METHODS: A total of 1027 WLWH (average age = 48.6 years) in the Women's Interagency HIV Study completed the World Mental Health Composite International Diagnostic Interview from 2010 to 2013 to identify MHDs, SUDs, and age at onset of sexual and physical abuse. Then, cognitive impairment, cardiovascular/metabolic conditions, and HIV disease outcomes were assessed for up to 8.8 years. Latent class analysis identified patterns of co-occurring trauma, MHDs, and/or SUDs. Generalized estimating equations determined associations between these patterns and midlife cognitive and medical outcomes. RESULTS: Six distinct profiles emerged: no/negligible sexual/physical trauma, MHD, or SUD (39%); preadolescent/adolescent sexual trauma with anxiety and SUD (22%); SUD only (16%); MHD + SUD only (12%); early childhood sexual/physical trauma only (6%); and early childhood sexual/physical trauma with later MHD + SUD (4%). Profiles including early childhood trauma had the largest number of midlife conditions (i.e., cognitive, cardiovascular, HIV-related). Preadolescent/adolescent sexual trauma with anxiety and SUD predicted both global and domain-specific cognitive declines. Only SUD without trauma predicted lower CD4, whereas childhood trauma with MHD + SUD predicted increased CD8. CONCLUSIONS: WLWH have complex multisystem profiles of abuse, MHD, and/or SUD that predict midlife cognitive, metabolic/cardiovascular, and HIV outcomes. Understanding the interplay between these factors over time can identify risks and personalize preventative and treatment interventions.

Prevalence, Comorbidity, and Correlates of Psychiatric and Substance Use Disorders and Associations with HIV Risk Behaviors in a Multisite Cohort of Women Living with HIV.

We used the World Health Organization's Composite International Diagnostic Interview to determine the prevalence, comorbidity, and correlates of lifetime and 12-month behavioral health disorders in a multisite cohort of 1027 women living with HIV in the United States. Most (82.6%) had one or more lifetime disorders including 34.2% with mood disorders, 61.6% with anxiety disorders, and 58.3% with substance use disorders. Over half (53.9%) had at least one 12-month disorder, including 22.1% with mood disorders, 45.4% with anxiety disorders, and 11.1% with substance use disorders. Behavioral health disorder onset preceded HIV diagnosis by an average of 19 years. In multivariable models, likelihood of disorders was associated with women's race/ethnicity, employment status, and income. Women with 12-month behavioral health disorders were significantly more likely than their counterparts to engage in subsequent sexual and substance use HIV risk behaviors. We discuss the complex physical and behavioral health needs of women living with HIV.

Correlates of Current Smoking Among Adults Served by the Public Mental Health System.

OBJECTIVE: As part of a study of health status among 457 adults with diagnostically heterogeneous serious mental illnesses served by the public mental health system in four U.S. states, we assessed predictors of current cigarette smoking. METHODS: We examined bivariate relationships between smoking status and risks for drug and alcohol use disorders, residential setting, parental status, and employment. Finally, we used multivariable logistic regression to predict current smoking, controlling for significant confounds. RESULTS: Of the total sample, 44% of participants reported that they currently smoked and most (62%) were moderately to severely nicotine-dependent. Those at high risk for drug use disorders were more than three times as likely and those at high risk for alcohol use disorders were more than twice as likely to smoke, compared to their counterparts with little or no drug or alcohol use disorder risk. Controlling for all other model variables including drug and alcohol disorder risk, current smokers were less likely to be parents and more likely to reside in supervised settings than nonsmokers. Younger people and those without a college degree were more likely to smoke, controlling for all other model variables. CONCLUSIONS: Given the high degree of comorbidity of smoking, alcohol disorders, and drug use disorders, the authors highlight the need for integrated interventions that address these issues simultaneously.

Post-traumatic stress is associated with verbal learning, memory, and psychomotor speed in HIV-infected and HIV-uninfected women.

The prevalence of post-traumatic stress disorder (PTSD) is higher among HIV-infected (HIV+) women compared with HIV-uninfected (HIV-) women, and deficits in episodic memory are a common feature of both PTSD and HIV infection. We investigated the association between a probable PTSD diagnosis using the PTSD Checklist-Civilian (PCL-C) version and verbal learning and memory using the Hopkins Verbal Learning Test in 1004 HIV+ and 496 at-risk HIV- women. HIV infection was not associated with a probable PTSD diagnosis (17% HIV+, 16% HIV-; p = 0.49) but was associated with lower verbal learning (p < 0.01) and memory scores (p < 0.01). Irrespective of HIV status, a probable PTSD diagnosis was associated with poorer performance in verbal learning (p < 0.01) and memory (p < 0.01) and psychomotor speed (p < 0.001). The particular pattern of cognitive correlates of probable PTSD varied depending on exposure to sexual abuse and/or violence, with exposure to either being associated with a greater number of cognitive domains and a worse cognitive profile. A statistical interaction between HIV serostatus and PTSD was observed on the fine motor skills domain (p = 0.03). Among women with probable PTSD, HIV- women performed worse than HIV+ women on fine motor skills (p = 0.01), but among women without probable PTSD, there was no significant difference in performance between the groups (p = 0.59). These findings underscore the importance of considering mental health factors as correlates to cognitive deficits in women with HIV.

Abstinence and Use of Community-Based Cessation Treatment After a Motivational Intervention Among smokers with Severe Mental Illness.

Motivational interventions help people with mental illness try to quit smoking, but few studies have evaluated factors associated with this groups' cessation with community treatment. We examined predictors of abstinence after a brief motivational intervention among smokers with severe mental illness. Education, stage of change post intervention, and use of cessation treatment predicted any 1-week period of self-reported abstinence over 6 months (29%). Cessation treatment mediated the relationship between stage of change and abstinence. Because treatment was the key modifiable predictor of abstinence, future research should establish strategies that improve motivation for, access to, and retention in cessation treatment. Clinical Trials Identifier NCT01412866.

Associations Between Gender and Obesity Among Adults with Mental Illnesses in a Community Health Screening Study.

The prevalence of obesity and its associations with gender, clinical factors, and medical co-morbidities were examined among 457 adults attending public mental health programs in 4 U.S. states. BMI was measured directly and other information was gathered by interview. Over half (59%, n = 270) were obese including 18% (n = 83) who were morbidly obese. In hierarchical ordinary least squares regression analysis controlling for demographic, psychiatric, medical, smoking, and health insurance statuses, women were significantly more likely to be obese than men. Obesity also was more likely among those who were younger and not high school graduates, those with diabetes or hypertension, and those who did not smoke tobacco. Interaction effects were found between gender and diabetes, hypertension, tobacco smoking, education, race, and age. The high prevalence of obesity among women, coupled with interactions between gender and other factors, suggest that targeted approaches are needed to promote optimal physical health in this population.

The association of perceived stress and verbal memory is greater in HIV-infected versus HIV-uninfected women.

In contrast to findings from cohorts comprised primarily of HIV-infected men, verbal memory deficits are the largest cognitive deficit found in HIV-infected women from the Women's Interagency HIV Study (WIHS), and this deficit is not explained by depressive symptoms or substance abuse. HIV-infected women may be at greater risk for verbal memory deficits due to a higher prevalence of cognitive risk factors such as high psychosocial stress and lower socioeconomic status. Here, we investigate the association between perceived stress using the Perceived Stress Scale (PSS-10) and verbal memory performance using the Hopkins Verbal Learning Test (HVLT) in 1009 HIV-infected and 496 at-risk HIV-uninfected WIHS participants. Participants completed a comprehensive neuropsychological test battery which yielded seven cognitive domain scores, including a primary outcome of verbal memory. HIV infection was not associated with a higher prevalence of high perceived stress (i.e., PSS-10 score in the top tertile) but was associated with worse performance on verbal learning (p < 0.01) and memory (p < 0.001), as well as attention (p = 0.02). Regardless of HIV status, high stress was associated with poorer performance in those cognitive domains (p's < 0.05) as well as processing speed (p = 0.01) and executive function (p < 0.01). A significant HIV by stress interaction was found only for the verbal memory domain (p = 0.02); among HIV-infected women only, high stress was associated with lower performance (p's < 0.001). That association was driven by the delayed verbal memory measure in particular. These findings suggest that high levels of perceived stress contribute to the deficits in verbal memory observed in WIHS women.

Do HIV-positive women receive depression treatment that meets best practice guidelines?

This study addressed whether psychopharmacologic and psychotherapeutic treatment of depressed HIV+ women met standards defined in the best practice literature, and tested hypothesized predictors of standard-concordant care. 1,352 HIV-positive women in the multi-center Women's Interagency HIV Study were queried about depressive symptoms and mental health service utilization using standards published by the American Psychiatric Association and the Agency for Healthcare Research and Quality to define adequate depression treatment. We identified those who: (1) reported clinically significant depressive symptoms (CSDS) using Centers for Epidemiological Studies-Depression Scale scores of ≥16; or (2) had lifetime diagnoses of major depressive disorder (MDD) assessed by World Mental Health Composite International Diagnostic Interviews plus concurrent elevated depressive symptoms in the past 12 months. Adequate treatment prevalence was 46.2 % (n = 84) for MDD and 37.9 % (n = 211) for CSDS. Multivariable logistic regression analysis found that adequate treatment was more likely among women who saw the same primary care provider consistently, who had poorer self-rated role functioning, who paid out-of-pocket for healthcare, and who were not African American or Hispanic/Latina. This suggests that adequate depression treatment may be increased by promoting healthcare provider continuity, outreaching individuals with lower levels of reported role impairment, and addressing the specific needs and concerns of African American and Hispanic/Latina women.

Psychiatric symptoms moderate the effects of mental illness self-management in a randomized controlled trial.

Depression has been shown to moderate the effects of physical illness self-management (ISM) programs. We attempted to replicate these findings for a mental ISM intervention. Outpatients with serious mental illness (N = 428) from eight Tennessee communities were randomly assigned to receive a peer-led self-management intervention called Building Recovery of Individual Dreams and Goals Through Education and Support or services as usual. Psychiatric symptoms were assessed with the Brief Symptom Inventory; the outcome of personal empowerment was measured by the Empowerment Scale. Intent-to-treat analysis using mixed-effects random regression found significant interaction effects between study condition and three moderating symptom profiles. Empowerment was greater for the intervention participants with high levels of depressive symptoms, anxiety symptoms, and general symptom distress than for the experimental participants with low symptom levels and the control subjects with high or low levels of symptoms. These results shed light on how mental ISM programs operate and ways these can be improved.