A Mental Health Innovation for Nurse Home Visiting Program Shows Effectiveness in Reducing Depressive Symptoms and Anxiety.

The objective of this paper is to report on the effectiveness of a mental health addition to a national nurse-delivered home visiting program. The methods are as follows: analysis of pre/post-launch of the standard Mental Health Intervention and comparison of 356 teams randomized to standard versus enhanced implementation. Stepwise regression controlled for significant client characteristics that were related to relevant outcomes. These characteristics were used in generalized mixed effect models comparing pre/post implementation and intervention and control groups. Pre/post analysis showed that only clients with no elevated mental health screening scores or mental health diagnoses at enrollment showed a significant decrease in depressive symptoms. Clients enrolled with and without mental health needs at enrollment significantly decreased on anxiety scores while referrals to mental health care increased. Teams receiving enhanced implementation enrolled more clients with mental health needs and clients completed more well-child visits and use of safe sleep practices. By integrating mental health care into maternal, infant, and early childhood home visiting programs, a new equitable model of primary mental health care can reach populations in need. This example provides a new paradigm of accessible and equitable mental health care for the future that can be implemented in a variety of home visiting programs.

The role of social adversity on emotional dysregulation during infancy and early childhood.

PURPOSE: The purpose of this study was to investigate if social adversity is associated with mother reported emotional dysregulation behaviors and trajectories during infancy and early childhood. DESIGN & METHODS: A secondary data analysis from the Durham Child Health and Development study study included 206 child-mother dyads. Three models were used to explore the relationship between social adversity and mother reported emotional dysregulation during infancy (Infant Behavior Questionnaire-Revised) and early childhood (Child Behavior Checklist - Dysregulation Profile). Linear mixed effects models were adopted to investigate if social adversity was associated with mother reported emotional dysregulation longitudinally. Regression analysis was conducted to explore if social adversity was associated with maternal reported emotional dysregulation trajectory slope scores and maternal reported emotional dysregulation trajectory class. Maternal psychological distress and the child's sex assigned at birth were included as covariates in each analysis. RESULTS: Infants with greater social adversity scores had significantly higher maternal reported fear responses across the first year of life. Social adversity was associated with maternal reported distress to limitations trajectory, dysregulated recovery class, and dysregulated distress to limitations class. During early childhood social adversity was significantly associated with maternal reported emotional dysregulation but not trajectories which showed little variability. CONCLUSION & PRACTICAL IMPLICATIONS: Our results indicate that social adversity is associated with maternal reported emotional dysregulation during infancy and early childhood. Nursing and other professionals can participate in early screening to determine risk and provide intervention.

Developing a multicomponent implementation strategy for mental health interventions within the Nurse-Family Partnership: An application of the EPIS framework.

PURPOSE: The purpose of this article is to describe the process used to create the Mental Health Innovation (MHI), a multicomponent implementation strategy that integrates evidence-based mental health interventions into the Nurse-Family Partnership (NFP), a national home visiting program delivered by nurses to low-income mothers. ORGANIZING CONSTRUCT: The Exploration, Preparation, Implementation, Sustainment (EPIS) framework outlines the multistep, stakeholder-engaged process used to develop the MHI. CONCLUSION: Engaging stakeholders provided an in-depth understanding of NFP infrastructure and the needs of NFP nurses and their clients. This understanding was key to designing a multicomponent implementation strategy to integrate mental health interventions within national and local NFP infrastructure and existing care processes. CLINICAL RELEVANCE: Application of implementation frameworks such as EPIS provides a guide to integrating evidence-based interventions in a systematic, intentional, and rigorous manner, which in turn may promote their wide scale use and long-term sustainability.

Interpersonal Theory of Nursing for Anxiety Management in People with Substance Use Disorder (ITASUD): A Feasibility Study.

This study aim to evaluate the feasibility, based on six feasibility study criteria, of using a one-week intervention of interpersonal theory of nursing for anxiety management in people who are taking part in a substance use disorders (ITASUD). The study adopted a feasibility mixed methods approach. The ITASUD was implemented with 39 male users of cocaine/crack as their principal drug with high levels of anxiety. The outcome (anxiety) was assessed by the Beck anxiety inventory. To address the feasibility criteria, data were gathered during appointments. Additionally, qualitative open-ended interviews were conducted in the final appointment. The assessment of the six feasibility criteria indicated the following: (1) demand: there was high demand among eligible participants; (2) acceptability: the ITASUD had better acceptability until the 3rd appointment; (3) implementation: the ITASUD's complexity and design was acceptable for participants; (4) practicality: 61.54% of participants used strategies from the ITASUD to manage their anxiety; (5) adaptation: there was no contamination and cointervention; and (6) safety: the ITASUD was safe. The exploratory analysis showed a relation between the level of anxiety and ITASUD (p < 0.0001). The ITASUD appears to be feasible. The participants reported positive experiences with the implementation of the ITASUD. The findings support the design of a powered larger trial to evaluate the effectiveness of the ITASUD.

Integrating Maternal Depression Screening Into an Early Intervention Program: An Implementation Evaluation.

BACKGROUND: In all 50 states, early intervention (EI) services to improve long-term child cognitive and academic outcomes are provided to infants and toddlers with suspected or diagnosed developmental delays. When mothers of EI-enrolled children experience depressive symptoms, uptake of EI services can be compromised. AIMS: The purpose of the article is to present a depressive symptom screening intervention for mothers consisting of toolkit development for EI staff and families, symptom screening for mothers and follow-up protocol. To formally evaluate the implementation of the intervention, our research team followed the consolidated framework for implementation research (CFIR). METHODS: Participants were 12 EI service coordinators across two offices. Focus groups and individual interviews were used to develop the toolkit and education module. Through the five CFIR domains, we evaluated the implemented intervention in order to allow other teams to learn from our experiences. RESULTS: Our team successfully partnered with SCs to develop the intended deliverables. Still, the SCs found it challenging to conduct the screenings and reported mixed success. CONCLUSIONS: Preparation of EI SCs to integrate mental health screenings into their existing skillsets requires a high level of support from the research team, resulting in a rich understanding of the barriers-and potential rewards-for staff and families.

A Preliminary Investigation of Psychoneurological Symptoms in Low-Income Mothers.

BACKGROUND: Exposure to chronic stressors may contribute to the development of psychoneurological symptoms (i.e., fatigue, cognitive dysfunction, sleep disturbance, depressed mood, and pain) that can compromise maternal function. OBJECTIVES: In two studies of low-income mothers, we investigated the presence of psychoneurological symptoms and explored associations between mothers' stressors and psychoneurological symptoms as well as between symptoms and function. We also considered the possible mediating role of the symptoms between stressors and function. METHODS: We conducted secondary analyses of psychoneurological symptoms in two studies of low-income mothers of infants and toddlers in the United States. Study 1 sampled Latina women with limited English proficiency, whereas Study 2 was conducted with English-speaking women from diverse backgrounds. In both studies, symptoms were measured using items from the Center for Epidemiological Studies Depression Scale and the Medical Outcomes Study Short-Form Health Survey. Maternal function was measured through self-report and researcher observation. In Study 2, stressors were measured using the Everyday Stressors Index. Multiple linear regressions were used to investigate associations while controlling for relevant covariates. RESULTS: In both studies, mothers endorsed a wide range of psychoneurological symptoms. In Study 1, psychoneurological symptoms had significant negative associations with role function, social function, and developmental stimulation. In Study 2, psychoneurological symptoms had significant negative associations with role function, social function, and physical function. Using Aroian test for mediation, we found that psychoneurological symptoms mediated all significant relationships between stressors and maternal functions in Study 2. DISCUSSION: In two samples of low-income mothers, psychoneurological symptoms were prevalent and associated with chronic stressors and with maternal function and may mediate the association between those two factors. These findings extend prior research on depressive symptoms in mothers by investigating pain as an additional key symptom. The studies advance symptom science by highlighting psychoneurological symptoms in a heterogeneous sample without known health conditions.

A Refined Model of Stress-Diathesis Relationships in Mothers With Significant Depressive Symptom Severity.

BACKGROUND: Mothers' depressive symptoms affect their children's growth as well as physical and mental well-being. Moreover, mothers of young children with developmental delay or disability (DD) tend to have higher depressive symptoms. AIMS: The purpose of this study was to examine associations between maternal depressive symptoms and number of children with DD among mothers with significant levels of depressive symptoms, while accounting for maternal diathesis factors and family stress factors. METHODS: This study was a secondary analysis of pooled baseline data collected from 2004 to 2012 in the northeastern and southeastern United States from three intervention studies to reduce depressive symptoms of mothers with young children (n = 364). Multiple regression analyses were conducted to examine associations between maternal depressive symptoms and number of children with DD, followed by the post hoc pairwise comparison. RESULTS: In the model including family stress factors, we found a significant test for linear trend in the mean for maternal depressive symptoms across the number of children with DD (F[1] = 4.3, p = .0388). CONCLUSIONS: Mothers who have multiple children with DD tend to experience higher depressive symptoms; thus, interventions are needed to help prevent these mothers from experiencing higher depressive symptoms or to reduce their current depressive symptoms. Both theory-based and strength-based interventions can target conflict management at the family level, reducing maternal depressive symptoms while improving mothers' self-efficacy, which would help mothers care for their own health, manage family conflict, and seek appropriate support to manage the children's medical and developmental needs.

Two Methods for Calculating Symptom Cluster Scores.

BACKGROUND: Symptom clusters are conventionally distilled into a single score using composite scoring, which is based on the mathematical assumption that all symptoms are equivalently related to outcomes of interest; this may lead to a loss of important variation in the data. OBJECTIVES: This article compares two ways of calculating a single score for a symptom cluster: a conventional, hypothesis-driven composite score versus a data-driven, reduced rank regression score that weights the symptoms based on their individual relationships with key outcomes. METHODS: We conducted a secondary analysis of psychoneurological symptoms from a sample of 356 low-income mothers. Four of the psychoneurological symptoms (fatigue, cognitive dysfunction, sleep disturbance, and depressed mood) were measured with the Center for Epidemiological Studies Depression Scale; the fifth (pain) was measured using an item from the Medical Outcomes Study 12-item Short Form Health Survey (SF-12). Mothers' function was measured using the 12-item Short Form Health Survey. The composite score was calculated by summing standardized scores for each individual psychoneurological symptom. In contrast, reduced rank regression weighted the individual symptoms using their respective associations with mothers' function; the weighted individual symptom scores were summed into the reduced rank regression symptom score. RESULTS: The composite score and reduced rank regression score were highly correlated at .93. The cluster of psychoneurological symptoms accounted for 53.7% of the variation in the mothers' function. Depressed mood and pain accounted for almost all the explained variation in mothers' function at 37.2% and 15.0%, respectively. DISCUSSION: The composite score approach was simpler to calculate, and the high correlation with the reduced rank regression score indicates that the composite score reflected most of the variation explained by the reduced rank regression approach in this data set. However, the reduced rank regression analysis provided additional information by identifying pain and depressed mood as having the strongest association with a mother's function, which has implications for understanding which symptoms to target in future interventions. Future studies should also explore composite versus reduced rank regression approaches given that reduced rank regression may yield different insights in other data sets.

Exploring a broader context of the home environment and its relationship with asthma control in American Indian children.

In this cross-sectional study of 60 American Indian mother-child dyads from Southeastern North Carolina, we examined whether childhood asthma control was related to household-level factors, such as environmental tobacco smoke and family management behaviors. We also examined the relationships among family management behaviors and maternal depressive symptoms. We used logistic regression to assess the relationships among childhood asthma control, the presence of environmental tobacco smoke, and family management behaviors, specifically condition management ability (CMA) and condition management effort (CME). We used linear regression to evaluate the relationships between both CMA and CME and maternal depressive symptoms. Better asthma control in children was associated with the absence of environmental tobacco smoke in the home and the maternal perception of asthma as a manageable condition. Mothers perceived an increase in effort to manage their child's asthma as their depressive symptoms increased. These findings emphasize the importance of environmental triggers, perceptions of condition management, and maternal mental health in controlling asthma in American Indian children. Interventions to reduce environmental triggers, treat maternal depressive symptoms, and support mothers in their ability to manage childhood asthma may yield better asthma control and help to reduce existing racial disparities in this population.

Nonsuicidal Self-Injury: Management on the Inpatient Psychiatric Unit[Formula: see text].

BACKGROUND. Between 4% to 70% of inpatients engage in self-harming behaviors and effective interventions are needed to address this population. AIM. This article reviews literature from 2007 to 2017 to address treatment and management strategies specific for the treatment of nonsuicidal self-injury in the inpatient psychiatric setting. METHODS. Cochrane, PsycINFO, PubMed, and CINAHL were searched for relevant articles with 34 studies reviewed for applicability to the question, and 9 parsed into a summary of Findings table. RESULTS. Therapeutic approaches that show promise include cognitive behavioral therapy, dialectical behavior therapy, and mentalization as well as medications that act on the serotonergic, dopaminergic, and opioid systems. Effective models of care aim toward enhancing therapeutic relationships with staff, providers, and most important, encouraging the internal shift toward recovery within the patient. CONCLUSIONS. More research with controlled designs in the inpatient setting is needed, however, regardless of which approach is used, the impact of the individual caregiver on the patient's recovery is key.

A community-engaged approach to investigate cardiovascular-associated inflammation among American Indian women: A research protocol.

American Indian women are more likely to die from cardiovascular disease (CVD) than White or African American women. Inflammatory processes may underlie CVD disparities by gender and race and may be critical to understanding population-specific drivers and potential buffers. Exposure to environmental air pollutants, especially particulate matter (PM), is known to be an important catalyst in CVD-associated inflammation. Positive psychological states, associated with low levels of inflammatory gene expression, could serve to moderate the inflammatory response to environmental air pollutants and ultimately lead to better cardiovascular health outcomes. The aim of the ongoing community-engaged and NIH-funded study described in this study protocol is to address the racial and gender gaps in CVD mortality by investigating the contextually relevant and culturally important determinants of health among American Indian women. In this paper we describe the procedures used to examine the relationship between environmental air pollutant exposures (PM10-2.5 and PM 2.5 ), psychological factors (e.g., depressive symptoms, posttraumatic stress symptoms, eudemonic well-being, and positive emotions), and cardiovascular-associated inflammation (hs-CRP, IL-6, Amyloid A, CBCs with differentials) in a sample of 150 women 18-50 years of age from the Lumbee Tribe in southeastern North Carolina. We describe lessons learned and strategies used in developing a community-engaged approach to enhance recruitment of American Indian women in biomedical research. The empirical data and community infrastructure resulting from this study will be foundational in designing and testing future interventions to reduce CVD-associated morbidity and mortality in American Indian women.

Mental Health Issues and Substance Use in the United States: Pulling the Power Levers.

BACKGROUND: Promising treatment avenues have been developed and studied that align well with the skills of psychiatric-mental health (PMH) nurses. The treatments are relationship-driven, nimble and accessible, and recovery-guided. They emphasize a whole-person approach with care delivered by a team of experts working in a contextually coordinated way. AIMS: To describe the challenges facing the United States with regard to mental illness and substance use disorders and the ways in which PMH nurses can use their skills to mitigate these challenges. METHOD: Published research and government reports were reviewed to obtain current mental health and substance use data. RESULTS: The number of people not being treated for mental illnesses-particularly serious mental illness, major depressive episode, and suicidal thoughts-has not improved since 2009. Although inroads have been made in reducing the rate of smoking in the United States, we are facing an opioid crisis. There are limited data on marijuana use, but it is apparent that many Americans use cannabis routinely. According to the Substance Abuse and Mental Health Administration, approximately 44.7 million people need mental health treatment and 20.1 million Americans need substance use treatment, but only 10% to 30% receive it. CONCLUSIONS: PMH nurses must take a leading role in retooling the therapeutic relationship and partnering with clients, families, and caregivers to improve the quality of life and well-being of those dealing with mental illness and substance use disorders. To accomplish this essential task, the PMH nursing workforce must be robust and distributed throughout the United States.

Engaging national and regional partners to accelerate broad-scale implementation of nurse-developed interventions.

Only a small proportion of research-tested interventions translate into broad-scale implementation in real world practice, and when they do, it often takes many years. Partnering with national and regional organizations is one strategies that researchers may apply to speed the translation of interventions into real-world practice. Through these partnerships, researchers can promote and distribute interventions to the audiences they want their interventions to reach. In this paper, we describe five nurse scientists' programs of research and their partnerships with networks of national, regional, and local organizations, including their initial formative work, activities to engage multi-level network partners, and lessons learned about partnership approaches to speeding broad-scale implementation.

Mothers' Perspectives on Managing the Developmental Delay of a Child With Considerations for Contextual Influences and Maternal Functioning.

Developmental delay in very young children is trending upward. Maternal depressive symptoms are known to negatively impact child development and may also impact family management of the child's condition. Research on family management guided this second phase of a sequential mixed methods study. The purpose of this study was to explore mothers' perceptions of family management of their children's developmental delays. Mothers of very young children who received early intervention services were interviewed. A team-based content analysis approach revealed key findings: (a) views of the child that were not holistic, (b) condition management ability was informed by what the mother thought her child needed, (c) views of condition impact were related to adapting to possible child outcomes and experiences of isolation, and (d) parental/caregiver mutuality was impaired by conflict. Understanding perceptions of family management and influence of depressive symptoms in this context is essential to extend assessment and intervention.

Green Care as Psychosocial Intervention for Depressive Symptoms: What Might Be the Key Ingredients?

BACKGROUND: Green care is an umbrella term for psychosocial interventions that integrate biotic and abiotic elements of nature to promote an individual's health and well-being. Green care decreases depressive symptoms but the parts of the interventions that lead to this effect are unknown. OBJECTIVES: Review of literature to evaluate perceived social support, behavioral activation, and self-efficacy as key ingredients to decrease depressive symptoms in psychosocial interventions and extrapolate those mediators, or key ingredients, to green care. DESIGN: A literature search of three databases was conducted to find relevant studies examining a psychosocial intervention for adults, the mediator of interest, and depressive symptoms. RESULTS: Evidence supports behavioral activation, social support, and self-efficacy as mediators of psychosocial interventions to improve depressive symptoms. CONCLUSIONS: Green care offers a portal for individuals with different depressive symptoms and severities to be treated alongside each other while receiving targeted interventions to meet the needs of each individual participant. Additionally, it offers the opportunity for psychiatric nurses to concurrently target all three active key ingredients.

Recognizing Maternal Depressive Symptoms: An Opportunity to Improve Outcomes in Early Intervention Programs.

Objective A higher rate of depressive symptoms is found among mothers of children with disabilities compared to other parents. However, there is a lack of study of mothers with children <3 years of age participating in Early Intervention (EI) programs. This study aims to more fully describe the extent of mood disorders in these mothers including estimated prevalence, severity and factors associated with maternal mental health, using gold standard clinical diagnostic and symptom measures, and test models associating depressive symptoms with contextual factors and child behavior. Methods A cross-sectional study was conducted with 106 women who had at least one child enrolled in EI. Mothers were interviewed and completed reliable, valid measures to evaluate mental health, health status, family conflict, parent-child interaction, self-efficacy, social support, child behavioral problems, hardship, endangerment, and child disability. Descriptive statistics and multivariate analyses were performed. Results We found 8 % of participants met all criteria for a Major Depressive Episode (MDE) with 44 % of the sample reporting a past episode and 43 % endorsing recurrent episodes. Using the CES-D to assess depressive symptom severity approximately 34 % of mothers screened in a clinically significant range. Using linear regression to predict severity of current depressive symptoms demonstrated that current depression severity was primarily predicted by poorer maternal health status, lower self-efficacy and past MDE (p < 0.05). Conclusions for practice A brief assessment of maternal mood, health and self-efficacy are important factors to assess when evaluating how to support mothers of children in EI.

Guidelines for research recruitment of underserved populations (EERC).

PURPOSE: Despite concerted efforts to establish health equity, significant disparities persist. One roadblock to eliminating health disparities is the inadequate recruitment of underserved populations, which prevents researchers from creating culturally-tailored interventions. To further develop the science of recruitment, we argue that a systematic approach should be applied to research participant recruitment. Given the lack of practical and comprehensive recruitment conceptual frameworks or guidelines in the literature, the authors propose newly synthesized guidelines for research recruitment of underserved populations: EERC (evaluate, engage, reflect, and carefully match). METHODS: The EERC guidelines are delineated, and the application of these guidelines is illustrated through a study recently conducted by the authors. RESULTS: The guidelines consist of the following four components: 1. Evaluate the composition of the research team; 2. Engage fully with the community by working with key informants and cultural insiders; 3. Reflect the unique cultural characteristics of the community in the research conduct; and 4. Carefully use a matching technique. The application component of the article demonstrates concrete examples of how the guidelines can enhance research recruitment for an underserved population. CONCLUSION: The authors intend these guidelines to be broadly applicable for research teams regardless of research design or characteristics of the underserved population. Application of these guidelines in nursing and health science will contribute to increasing research recruitment of underserved populations, with the goal of reducing health disparities and achieving health equity for all persons.

Using Liberating Structures to Increase Engagement in Identifying Priorities for the APNA Research Council.

BACKGROUND: In 2015, the Co-Chairs and Steering Committee of the Research Council members recognized the need to reevaluate the council's priorities. OBJECTIVE: To determine the top priorities for the Research Council. DESIGN: Use of liberating structures: Impromptu Speed Networking, 1-2-4-all, and Crowd Sourcing. RESULTS: Identified Research Council priorities included the following: efforts to increase psychiatric mental health (PMH) research funding; serve as a connector to bring researchers together; foster research through state chapters; increase collaboration between PhDs and DNPs; and develop models for organizational support for PMH staff nurse involvement in research. CONCLUSIONS: The liberating structures used are valuable strategies for engaging groups of people to identify what matters most to the group. Through the use of these novel techniques, the American Psychiatric Nurses Association Research Council has identified priorities for the work of the council. This has led to actions planned for the coming future with the intent to move PMH nursing research forward.

Maternal depressive symptoms and healthcare expenditures for publicly insured children with chronic health conditions.

This study estimated the prevalence of maternal depressive symptoms and tested associations between maternal depressive symptoms and healthcare utilization and expenditures among United States publicly insured children with chronic health conditions (CCHC). A total of 6,060 publicly insured CCHC from the 2004-2009 Medical Expenditure Panel Surveys were analyzed using negative binomial models to compare healthcare utilization for CCHC of mothers with and without depressive symptoms. Annual healthcare expenditures for both groups were compared using a two-part model with a logistic regression and generalized linear model. The prevalence of depressive symptoms among mothers with CCHC was 19 %. There were no differences in annual healthcare utilization for CCHC of mothers with and without depressive symptoms. Maternal depressive symptoms were associated with greater odds of ED expenditures [odds ratio (OR) 1.26; 95 % CI 1.03-1.54] and lesser odds of dental expenditures (OR 0.81; 95 % CI 0.66-0.98) and total expenditures (OR 0.71; 95 % CI 0.51-0.98). Children of symptomatic mothers had lower predicted outpatient expenditures and higher predicted expenditures for total health, prescription medications, dental care; and office based, inpatient and ED visits. Mothers with CCHC were more likely to report depressive symptoms than were mothers with children without chronic health conditions. There were few differences in annual healthcare utilization and expenditures between CCHC of mothers with and without depressive symptoms. However, having a mother with depressive symptoms was associated with higher ED expenditures and higher predicted healthcare expenditures in a population of children who comprise over three-fourths of the top decile of Medicaid spending.