Culturally Adapted Cognitive Behaviour Therapy (CaCBT) to Improve Community Mental Health Services for Canadians of South Asian Origin: A Qualitative Study.

BACKGROUND: South Asian (SA) Canadians are disproportionately affected by higher rates of mood and anxiety disorders. SA Canadians with depression report significant barriers to accessing mental health care and the highest proportion of unmet mental health needs. The Mental Health Commission of Canada (MHCC) advocates for culturally and linguistically relevant services for SA Canadians. Culturally adapted cognitive behavior therapy (CaCBT) has shown to be more effective than standard cognitive behavior therapy (CBT). Adapting CBT for the growing SA population in Canada will ensure equitable access to effective, culturally-appropriate mental health interventions. METHOD: The study used a qualitative design to elicit stakeholder consultation via in-depth interviews. This study is reported using the criteria included in Consolidated Criteria for Reporting Qualitative Studies (COREQ). The analysis follows an ethnographic approach and was informed by the principles of emergent design. RESULTS: Five themes were identified from the analysis, (i) Awareness and preparation: factors that impact the individual's understanding of therapy and mental illness. (ii) Access and provision: SA Canadians' perception of barriers, facilitators, and access to treatment. (iii) Assessment and engagement: experiences of receiving helpful treatment. (iv) Adjustments to therapy: modifications and suggestions to standard CBT. (v) Ideology and ambiguity: racism, immigration, discrimination, and other socio-political factors. CONCLUSIONS: Mainstream mental health services need to be culturally appropriate to better serve SA Canadians experiencing depression and anxiety. Services must understand the family dynamics, cultural values and socio-political factors that impact SA Canadians to reduce attrition rates in therapy.

Rethinking narratives about youth experiencing homelessness: The influence of self-determined motivation and peer relations on coping.

Using the cognitive appraisal theory of coping and the self-determination theory of motivation, we examined the shared variance of motivational orientations, attachment relationships, and gender on adaptive and maladaptive coping among youth experiencing homelessness. Several scales including The Global Motivation Scale (assessing motivational orientations; i.e., autonomous and controlled motivation), the Brief Cope (adaptive and maladaptive coping strategies), and the Inventory of Parent and Peer Attachment (self-perceptions of relationships with mothers, fathers, and peers) were administered to 102 youth aged between 16 and 24 (Mage = 20, SD = 2.07) years recruited from an evening program for youth experiencing homelessness in Montreal, Canada. Autonomous motivation was positively associated with engagement in effective coping strategies, while controlled motivation was positively linked to maladaptive coping. Moderation analyses were used to examine whether gender and relationships with attachment figures moderated the relationship between motivation and coping. A significant main effect of peer attachment on adaptive coping emerged, in which greater peer attachment was related to more adaptive coping among the youth. No interaction effects resulted. Although no significant moderating effects were associated with essential relationships and gender, further research implementing a more nuanced approach to assessing the interaction between these constructs may be warranted. Overall, the findings highlight the importance of intervention programs for youth experiencing homelessness, that focus on enhancing autonomous motivation and utilizing peer support to optimize the use of adaptive coping strategies.

Ambient Temperature and Emergency Hospital Admissions in People Experiencing Homelessness: London, United Kingdom, 2011-2019.

Objectives. To assess the impacts of ambient temperature on hospitalizations of people experiencing homelessness. Methods. We used daily time-series regression analysis employing distributed lag nonlinear models of 148 177 emergency inpatient admissions with "no fixed abode" and 20 804 admissions with a diagnosis of homelessness in London, United Kingdom, in 2011 through 2019. Results. There was a significantly increased risk of hospitalization associated with high temperature; at 25°C versus the minimum morbidity temperature (MMT), relative risks were 1.359 (95% confidence interval [CI] = 1.216, 1.580) and 1.351 (95% CI = 1.039, 1.757) for admissions with "no fixed abode" and admissions with a homelessness diagnosis, respectively. Between 14.5% and 18.9% of admissions were attributable to temperatures above the MMT. No significant associations were observed with cold. Conclusions. There is an elevated risk of hospitalization associated with even moderately high temperatures in individuals experiencing homelessness. Risks are larger than those reported in the general population. Public Health Implications. Greater emphasis should be placed on addressing homeless vulnerabilities during hot weather rather than cold. Activation thresholds for interventions such as the Severe Weather Emergency Protocol (SWEP) could be better aligned with health risks. Given elevated risks at even moderate temperatures, our findings support prioritization of prevention-oriented measures, rather than crisis response, to address homelessness. (Am J Public Health. 2023;113(9):981-984. https://doi.org/10.2105/AJPH.2023.307351).

Managing high-risk behaviours and challenges to prevent housing loss in permanent supportive housing: a rapid review.

Permanent supportive housing is an effective intervention for stably housing most people experiencing homelessness and mental illness who have complex support needs. However, high-risk behaviours and challenges are prevalent among this population and have the potential to seriously harm health and threaten housing tenures. Yet, the research on the relationship between high-risk issues and housing stability in permanent supportive housing has not been previously synthesized. This rapid review aimed to identify the housing-related outcomes of high-risk behaviours and challenges in permanent supportive housing settings, as well as the approaches used by agencies and residents to address them. A range of high-risk behaviours and challenges were examined, including risks to self (overdose, suicide/suicide attempts, non-suicidal self-injury, falls/fall-related injuries), and risks to multiple parties and/or building (fire-setting/arson, hoarding, apartment takeovers, physical/sexual violence, property damage, drug selling, sex trafficking). The search strategy included four components to identify relevant academic and grey literature: (1) searches of MEDLINE, APA PsycINFO, and CINAHL Plus; (2) hand searches of three journals with aims specific to housing and homelessness; (3) website browsing/searching of seven homelessness, supportive housing, and mental health agencies and networks; and (4) Advanced Google searches. A total of 32 articles were eligible and included in the review. Six studies examined the impacts of high-risk behaviours and challenges on housing tenancies, with overdose being identified as a notable cause of death. Twenty-six studies examined approaches and barriers to managing high-risk behaviours and challenges in PSH programs. These were categorized into eight types of approaches: (1) clinical, (2) relational/educational, (3) surveillant, (4) restrictive, (5) strategic, (6) design-based, (7) legal, and (8) self-defence. Consistent across all approaches was a lack of rigorous examination of their effectiveness. Further, some approaches that are legal, restrictive, surveillant, or strategic in nature may be used to promote safety, but may conflict with other program objectives, including housing stability, or resident empowerment and choice. Research priorities were identified to address the key evidence gaps and move toward best practices for preventing and managing high-risk behaviours and challenges in permanent supportive housing.

Workplace trauma and chronic stressor exposure among direct service providers working with people experiencing homelessness.

BACKGROUND: Service providers working with people experiencing homelessness can be directly and indirectly exposed to trauma and other chronic stressors in their work. The types of individuals that are most at-risk of problematic outcomes from traumatic event exposure are unknown. AIM: This study examined exposure to and effects of workplace traumas and stressors among service providers working with people experiencing homelessness in Canada. METHODS: A cross-sectional survey was completed by 701 direct service providers working in the homeless service, supportive housing, and harm reduction sectors. Descriptive statistics, hierarchical multiple regression, and double moderation models were used in the analysis. RESULTS: Employment in homeless service settings, service provision to single adults, and more time in direct contact with service users were each positively associated with the frequency of exposure to critical events and chronic stressors. Younger age, lived experience of behavioural health problems, more frequent exposure to chronic stressors, and less social support from coworkers were significantly correlated with post-traumatic stress and general psychological distress. Emotional support from supervision moderated the relationship between direct exposure to workplace critical events and post-traumatic stress. CONCLUSIONS: More trauma-informed psychosocial supports tailored to the needs of direct service providers working with people experiencing homelessness are needed.

Shelter Bans Among People Experiencing Homelessness: an Exploratory Study of Predictors in Two Large Canadian Datasets.

Emergency shelters are a core component of homeless service systems that address immediate basic needs. Service bans, which refer to temporary or permanent disallowances from a program or organization, are an underresearched phenomenon that can leave people experiencing homelessness without needed supports. This exploratory study examined the factors associated with shelter bans among people experiencing homelessness using secondary data from two Canadian studies: (1) a multisite randomized controlled trial of Housing First (At Home/Chez Soi Demonstration Project) and (2) a cross-sectional survey of youth experiencing homelessness across Canada (2019 Without a Home-National Youth Homelessness Survey). The two datasets were analyzed separately using logistic regression models with similar predictors to maximize the comparability of the results. Participants who experienced homelessness at an earlier age and had recent criminal justice system involvement were more likely to have shelter bans in both datasets. Impaired impulse control, more chronic medical conditions and living in Toronto were associated with increased likelihood of shelter bans in the At Home/Chez Soi dataset, whereas more adverse childhood experiences, physical violence victimization, engagement in survival sex behaviours and longer current episodes of homelessness were significant predictors of bans in the Without A Home dataset. Overall, the findings suggest that victimization and criminalization during homelessness may increase the risk of shelter loss from bans and further exclusion. The observed regional differences also highlight the potential limits of individual-level predictors. Further research is needed on shelter ban outcomes, as well as how capacity limits and organizational policies affect banning decisions.

Increasing Access to CBT for Psychosis: Development, Feasibility, and Acceptability of a Specialized Outpatient Service.

Despite the increasing demand for cognitive behavioural therapy for psychosis (CBTp), the existing literature is lacking in terms of models for sustainable implementation. The aims of this study were to: (a) describe the development of a specialized CBTp Service; (b) report demographic characteristics and referral patterns over 1 year to examine feasibility; and (c) review feedback from participants in group-based CBTp to examine acceptability. Data were analyzed from 126 referrals (M = 35.52, SD = 13.06, 59.5% men) to an outpatient CBTp Service at the Centre for Addiction and Mental Health (Toronto, Ontario) between January 2019 to January 2020. Anonymous feedback was obtained from 54 individuals who completed group-based CBTp. Positive symptoms and distressing emotions were the main reasons for referral. Over half of eligible referrals scheduled an intake assessment and 70% of individuals who completed this assessment attended further treatment. Primary reasons for service refusal were scheduling conflicts and illness-related barriers. The total service wait-time was two months, with the longest delay between dates of referral and initial contact. Satisfaction with the quality of CBTp and its components was rated high among group members. Although variable wait-times and engagement levels were identified across stages of the referral process, the CBTp Service demonstrates preliminary feasibility and acceptability, and provides a model of service delivery to incorporate within future CBTp implementation efforts in Canada.

Global Climate Implications for Homelessness: A Scoping Review.

Homelessness is a persistent global challenge with significant health impacts on those affected. Homeless people are by definition the most exposed to weather conditions and the social and economic problems caused by extreme weather and climate change and variability. This systematic review was designed to synthesize the academic literature that addresses the health and social implications of global climate change for homelessness. The question examined in this systematic scoping review is the following: What is the current state of knowledge in the scientific literature on the health and social implications of global climate change for homelessness? A systematic scoping review method was used to identify and synthesize the peer-reviewed literature relevant to this question. The databases searched were PsycINFO, Medline, Scopus, and Google Scholar. Of the 26 papers identified in this review, 20 employed original data analyses with conclusions largely inferred from cross-sectional associations. Themes included the potential influence of climate change on homelessness prevalence, climate impacts that exacerbate specific vulnerabilities of homeless populations (e.g., chronic illness, exposure, stigmatization), and health and social outcomes. Service use and design implications were also addressed. Given the scale of the impacts of climate change on homelessness, the literature on this topic poses promising directions but is under-developed in its current state to adequately inform risk mitigation and response planning. A systems framework is proposed here to inform future research and service design.

The Second National Canadian Homeless Youth Survey: Mental Health and Addiction Findings: La Deuxième Enquête Nationale Auprès des Jeunes Sans Abri : Résultats en Matière De Santé Mentale et de Toxicomanie.

OBJECTIVE: Youth experiencing homelessness represent a major social problem in Canada and, as demonstrated in the first national survey of this population conducted in 2015, are experiencing significant mental health challenges. The present study examines the findings of a second national survey completed in 2019. These findings afford the opportunity to examine the reliability of the findings of the first study with another large, representative sample and to attempt to articulate the unique characteristics of youth experiencing the greatest distress among this at-risk population. METHODS: This study analyzed the mental-health-related data from the 2019 Without a Home-National Youth Homelessness Survey that was administered through convenience sampling at 98 agencies serving homeless youth in 49 communities across Canada. The survey was cross-sectional and self-administered, assessing a range of demographic information, pre- and post-homelessness variables, and mental health indicators. Multinomial logistic regression and linear regression were implemented to evaluate associations with distress level. RESULTS: Survey data were obtained from 1,375 youth accessing Canadian homeless services in 9 provinces. Thirty-five percent reported at least 1 suicide attempt, and 33.1% reported a drug overdose requiring hospitalization. The findings of this survey replicated most of the key findings from the 2015 survey. The current findings emphasized, for this high-risk population, the heightened adversity faced by young women, Lesbian, Gay, Bisexual, Transgender, Queer, Two-Spirit (LGBTQ2S), and Indigenous subpopulations, as well as the centrality of violence exposure in determining risk and distress. Sexual violence, in particular, emerged as a key factor in the identification of youth experiencing the greatest distress with risk buffered by contact with family. CONCLUSIONS: These findings can inform prevention and intervention policies and services and reinforce the importance of attending to violence exposure and trauma as central to the mental health trajectories of youth who have experienced homelessness.

INNOVATE Research: Impact of a workshop to develop researcher capacity to engage youth in research.

BACKGROUND: Engaging youth in research provides substantial benefits to research about youth-related needs, concerns and interventions. However, researchers require training and capacity development to work in this manner. METHODS: A capacity-building intervention, INNOVATE Research, was co-designed with youth and adult researchers and delivered to researchers in three major academic research institutions across Canada. Fifty-seven attendees participated in this research project evaluating youth engagement practices, attitudes, perceived barriers, and perceived capacity development needs before attending the intervention and six months later. RESULTS: The intervention attracted researchers across various career levels, roles and disciplines. Participants were highly satisfied with the workshop activities. Follow-up assessments revealed significant increases in self-efficacy six months after the workshop (P = .035). Among possible barriers to youth engagement, four barriers significantly declined at follow-up. The barriers that decreased were largely related to practical knowledge about how to engage youth in research. Significantly more participants had integrated youth engagement into their teaching activities six months after the workshop compared to those who were doing so before the workshop (P = .007). A large proportion (71.9%) of participants expressed the need for a strengthened network of youth-engaged researchers; other future capacity-building approaches were also endorsed. CONCLUSIONS: The INNOVATE Research project provided improvements in youth engagement attitudes and practices among researchers, while lifting barriers. Future capacity-building work should continue to enhance the capacity of researchers to engage youth in research. Researchers notably pointed to the need to establish a network of youth-engaged researchers to provide ongoing, sustainable gains in youth engagement.

Enhancing researcher capacity to engage youth in research: Researchers' engagement experiences, barriers and capacity development priorities.

BACKGROUND: There is increasing emphasis on engaging youth in research about youth, their needs, experiences and preferences, notably in health services research. By engaging youth as full partners, research becomes more feasible and relevant, and the validity and richness of findings are enhanced. Consequently, researchers need guidance in engaging youth effectively. This study examines the experiences, needs and knowledge gaps of researchers. METHODS: Eighty-four researchers interested in youth engagement training were recruited via snowball sampling. They completed a survey regarding their youth engagement experiences, attitudes, perceived barriers and capacity development needs. Data were analysed descriptively, and comparisons were made based on current engagement experience. RESULTS: Participants across career stages and disciplines expressed an interest in increased capacity development for youth engagement. They had positive attitudes about the importance and value of youth engagement, but found it to be complex. Participants reported requiring practical guidance to develop their youth engagement practices and interest in a network of youth-engaged researchers and on-going training. Those currently engaging youth were more likely to report the need for greater appreciation of youth engagement by funders and institutions. CONCLUSIONS: Engaging youth in research has substantial benefits. However, skills in collaborating with youth to design, conduct and implement research have to be learned. Researchers need concrete training and networking opportunities to develop and maximize these skills. They also need mechanisms that formally acknowledge the value of engagement. Researchers and those promoting youth engagement in research are encouraged to consider these findings in their promotion and training endeavours.

The Healthcare Triple Aim in the Recovery Era.

Recovery is the guiding vision of mental health systems and policy. However, skepticism has emerged about whether the paradigm can achieve its sought goals. We argue that embedding recovery within a quality improvement framework, such as the Triple Aim, would increase leverage for systems change and advance recovery practice. The Triple Aim's goals of improving healthcare outcomes, quality, and costs are pertinent to mental health systems, although action is also needed to address the social determinants of health. Accordingly, we propose the recovery-oriented Triple Aim, which could be used to guide policy development and evaluation of mental health services.

Transition Experiences Following Psychiatric Hospitalization: A systematic Review of the Literature.

The period immediately following discharge after inpatient stay for mental illness has been found to be the time of greatest risk for adverse outcomes (e.g., rehospitalization, relapse, suicide). However, the experiences of patients as they transition from the hospital to the community are not well understood. The purpose of the present review was to systematically search and synthesize the literature examining the transition experiences of individuals following inpatient psychiatric stay. A systematic search was conducted for studies examining the experiences of patients as they transition back into their communities, using qualitative or quantitative methods. Qualitative articles were analyzed using thematic content analysis. Quantitative articles were extracted and summarized. The search identified 1614 abstracts, of which 27 (18 qualitative; 9 quantitative) were included in the review. The results of the analysis identified themes necessary for transition including safety, supported autonomy, and the opportunity to engage in a number of reintegration activities. A number of barriers were found that prevent integration, such as poverty, interpersonal difficulties, and stigma. The results highlight the disconnect that occurs for patients as they transition from hospital, pointing to the need for effective transitional interventions that target these challenges.

Thirty-Day and 5-Year Readmissions following First Psychiatric Hospitalization: A System-Level Study of Ontario's Psychiatric Care.

OBJECTIVE: Analyses of representative, system-level data to examine trends in short- and longer-term readmission rates for psychiatric illnesses are largely absent. The objective of this article is to examine key trends and variables with implications for inpatient care as indicated by 30-day readmission and outpatient care as reflected by readmission within 5 years. METHODS: Using OMHRS data from 2005 to 2015, patients who had their first inpatient admission were followed for 5 years to examine their subsequent 30-day and overall admission rates stratified by discharge time and diagnosis. RESULTS: The study cohort consisted of 42,280 patients. The 30-day and 5-year readmission rates for the entire cohort were 7.2% and 35.1%, respectively. Using a time course analysis of readmission for discharges in different years, both 30-day readmission and 5-year readmission rates decreased in a linear manner from 2005 to 2010, primarily because of readmission patterns for patients diagnosed with mood disorders and schizophrenia/other psychotic disorders. It was also evident that both demographic considerations such as age and gender and variables reflective of social determinants such as education level and employment were predictive of rehospitalization risk. CONCLUSIONS: The trends of decreasing readmission rates may be reflective of improvements in the quality of hospital and community-based outpatient care. Such system-level indicators warrant tracking and may inform more effective tertiary prevention.

Gender role strain, core schemas, and psychotic experiences in ethnically diverse women: A role for sex- and gender-based analysis in psychosis research?

Negative -self and -others core schemas have been implicated in the development and maintenance of psychotic experiences. One component of the self-system is gender-role strain (GRS; perceived discrepancy between actual self and gender-role norms). Although the role of gender in the formation of core schemas has been underscored in social and developmental psychology literatures, GRS has not been investigated in relation to psychosis. We examined whether it might be associated with negative schemas and psychotic experiences in women consistent with the trend toward sex- and gender-based analysis (SGBA) in health research. Forty-four women with a schizophrenia spectrum disorder diagnosis and 48 female nonclinical participants completed a series of questionnaires measuring GRS, femininity ideology, core schemas, childhood trauma, and implicit femininity stereotypes (The Gender Stereotype Implicit Association Test). Half the total sample comprised women with minority-ethnic status. Women in the psychosis group reported higher levels of GRS than comparison participants. Differences in endorsement of femininity ideology between the two groups narrowly missed significance with a trend toward greater femininity ideology in the psychosis group and significantly greater endorsement of the sexual purity domain for minority-ethnic women. There was no difference in implicit femininity stereotypes. Analyses suggested that the relationship between GRS and symptoms was mediated by negative -self and -others schemas. Childhood sexual trauma, though higher for women with psychosis, was associated with gender-role strain in the nonclinical sample only. Findings warrant further investigation with larger samples. SGBA has the potential to fill gaps in our current knowledge with regard to psychosis theory, research, and practice.

The 2015 National Canadian Homeless Youth Survey: Mental Health and Addiction Findings.

OBJECTIVE: This study was designed to provide a representative description of the mental health of youth accessing homelessness services in Canada. It is the most extensive survey in this area to date and is intended to inform the development of mental health and addiction service and policy for this marginalized population. METHODS: This study reports mental health-related data from the 2015 "Leaving Home" national youth homelessness survey, which was administered through 57 agencies serving homeless youth in 42 communities across the country. This self-reported, point-in-time survey assessed a broad range of demographic information, pre-homelessness and homelessness variables, and mental health indicators. RESULTS: Survey data were obtained from 1103 youth accessing Canadian homelessness services in the Nunavut territory and all Canadian provinces except for Prince Edward Island. Forty-two per cent of participants reported 1 or more suicide attempts, 85.4% fell in a high range of psychological distress, and key indicators of risk included an earlier age of the first episode of homelessness, female gender, and identifying as a sexual and/or gender minority (lesbian, gay, bisexual, transgender, queer, and 2 spirit [LGBTQ2S]). CONCLUSIONS: This study provides clear and compelling evidence of a need for mental health support for these youth, particularly LGBTQ2S youth and female youth. The mental health concerns observed here, however, must be considered in the light of the tremendous adversity in all social determinants faced by these youth, with population-level interventions best leveraged in prevention and rapid response.

Common Factors in Community Mental Health Intervention: A Scoping Review.

While there is considerable research and commentary devoted to common factors in psychotherapy, their implications for community mental health interventions are much less clear. In response, a scoping review was conducted to answer the question, 'What is the evidence base for common factors in community mental health intervention?' A comprehensive search of MEDLINE, PsycINFO, and Google Scholar was completed. A total of 60 publications were identified in this review with a focus primarily upon therapeutic alliance. Though methodologically diverse, this review supports the likely importance of alliance in the outcomes of community mental health interventions.