Unmet health needs and barriers to health care among people experiencing homelessness in San Francisco's Mission District: a qualitative study.

BACKGROUND: People experiencing homelessness have unique health needs and barriers to medical and behavioral health care (mental health, substance use disorder, and overall well-being) compared to housed people. It remains unclear why many people experiencing homelessness do not access care when community-based homeless health care resources are available at low or no cost. This qualitative study examined perspectives of people experiencing homelessness and staff members at community-based homeless health and service organizations in San Francisco's Mission District on unmet medical and behavioral health needs and barriers to accessing care. METHODS: We conducted 34 interviews between September and November 2020: 23 with people experiencing homelessness and 11 with staff at community-based homeless health and service organizations in the Mission District. Qualitative interviews were transcribed, coded, and analyzed using the Framework Method on NVivo Qualitative Data Analysis Software. RESULTS: Both staff and homeless participants reported unmet and common health needs of mental illness, physical injury and disability, food and nutrition insecurity, and substance use disorder. Barriers to care included negative prior health care experiences, competing priorities, and provider turnover. Recommendations for improving services included building more trust with people experiencing homelessness by training clinic staff to treat patients with respect and patience and expanding clinical outreach and health education programs. CONCLUSIONS: People experiencing homelessness face many different health needs and barriers to care, some of which community-based organizations have the ability to address. These findings can help inform future strategies for homeless health care programs to identify and target the specific unmet health needs and barriers to care of people experiencing homelessness in their communities.

A Behavioral Addiction Model of Revenge, Violence, and Gun Abuse.

Data from multiple sources point to the desire for revenge in response to grievances or perceived injustices as a root cause of violence, including firearm violence. Neuroscience and behavioral studies are beginning to reveal that the desire for revenge in response to grievances activates the same neural reward-processing circuitry as that of substance addiction, suggesting that grievances trigger powerful cravings for revenge in anticipation of experiencing pleasure. Based on this evidence, the authors argue that a behavioral addiction framework may be appropriate for understanding and addressing violent behavior. Such an approach could yield significant benefits by leveraging scientific and public health-oriented drug abuse prevention and treatment strategies that target drug cravings to spur development of scientific and public-health-oriented "gun abuse" prevention and treatment strategies targeting the revenge cravings that lead to violence. An example of one such "motive control" strategy is discussed. Approaching revenge-seeking, violence, and gun abuse from the perspective of compulsion and addiction would have the added benefit of avoiding the stigmatization as violent of individuals with mental illness while also acknowledging the systemic, social, and cultural factors contributing to grievances that lead to violent acts.

Citizenship and Community Mental Health Care.

Citizenship is an approach to supporting the social inclusion and participation in society of people with mental illnesses. It is receiving greater attention in community mental health discourse and literature in parallel with increased awareness of social determinants of health and concern over the continued marginalization of persons with mental illness in the United States. In this article, we review the definition and principles of our citizenship framework with attention to social participation and access to resources as well as rights and responsibilities that society confers on its members. We then discuss our citizenship research at both individual and social-environmental levels, including previous, current, and planned efforts. We also discuss the role of community psychology and psychologists in advancing citizenship and other themes relevant to a citizenship perspective on mental health care and persons with mental illness.

[Evaluation of a citizenship-oriented intervention: The Citizens' Project of the University of Recovery]. / Évaluation d'une intervention de promotion de la citoyenneté : le Projet citoyen de l'Université du rétablissement.

Objectives The Global Model of Public Mental Health is "global" not only in the sense of having an international perspective, but in regarding service users as actors at all levels of public mental health exerting collective and organized influence on the social determinants of health, in addition to being recipients of care. Having access to appropriate health and mental health care when needed is a fundamental human right. Having a say over the manner in which care is provided, including partnership in decision making in care planning and ongoing care, has gained increasing support among recipients and providers of care. Over the past few decades in the Canadian province of Quebec, patient participation and partnership in decision-making has been promoted through successive Mental Health Action Plans (MHAP) and other policies. In these documents, participation and partnership are associated with the exercise of citizenship and the promotion of service users' rights, including the rights to participate in one's own care. In this article, using the case example of a citizenship-oriented intervention, namely the Projet citoyen, we discuss the results to a new measure of citizenship, which was developed from a service users' perspective.Methods Employing a mixed methods approach, two types of data were collected from users of mental health care. Quantitative data were generated from administration of a 23-item measure of citizenship with service users in the province of Quebec (N=802), and qualitative data were collected from four focus groups with another sample of 18 service users. They were presented with results from the administration of the measure, and asked to comment on them in regard to their own experience of citizenship.Results Among the five dimensions of the measure of citizenship, participants scored lowest on the 'involvement in the community' dimension, and higher on the other dimensions of 'basic needs,' 'respect by others,' 'self-determination,' and 'access to services.' In focus groups, participants said that there is still prejudice in society and discrimination towards people with mental illnesses that limit their right to participate in public debate and mental health programming. Public health interventions at this level may help to change attitudes and social representations, as they are inclusive of persons with lived experience of mental illness. Public discussion of citizenship issues in relation to mental health also represent an opportunity for participants to confront existing problems, as a first step toward collective action.Conclusion People's lived experience of regaining a sense of citizenship and of belonging to their local neighborhoods and communities, including the scientific micro-community, can help to foster an evolution of public health from disease management to health promotion and community inclusion. More research is needed to compare the sense of citizenship to the rest of the population and to see if specific interventions can have an enduring impact (e.g.: pre/post design).

Illnesses in siblings of US patients with bipolar disorder relate to multigenerational family history and patients severity of illness.

BACKGROUND: Patients with bipolar disorder from the US have more early-onset illness and a greater familial loading for psychiatric problems than those from the Netherlands or Germany (abbreviated here as Europe). We hypothesized that these regional differences in illness burden would extend to the patients siblings. METHODS: Outpatients with bipolar disorder gave consent for participation in a treatment outcome network and for filling out detailed questionnaires. This included a family history of unipolar depression, bipolar disorder, suicide attempt, alcohol abuse/dependence, drug abuse/dependence, and "other" illness elicited for the patients' grandparents, parents, spouses, offspring, and siblings. Problems in the siblings were examined as a function of parental and grandparental problems and the patients' adverse illness characteristics or poor prognosis factors (PPFs). RESULTS: Each problem in the siblings was significantly (p<0.001) more prevalent in those from the US than in those from Europe. In the US, problems in the parents and grandparents were almost uniformly associated with the same problems in the siblings, and sibling problems were related to the number of PPFs observed in the patients. LIMITATIONS: Family history was based on patient report. CONCLUSIONS: Increased familial loading for psychiatric problems extends through 4 generations of patients with bipolar disorder from the US compared to Europe, and appears to "breed true" into the siblings of the patients. In addition to early onset, a variety of PPFs are associated with the burden of psychiatric problems in the patients' siblings and offspring. Greater attention to the multigenerational prevalence of illness in patients from the US is indicated.

Environment-Level Strategies to Support Independent Control of Finances: A Response to the SSA Review of Financial Capability Determination Review.

The Social Security Administration (SSA) recently completed an evaluation of the process by which representative payees are assigned. The SSA report is welcome, particularly for its focus on developing more accurate, real-world assessments of a person's financial capability and its recognition of the need for more flexible options for people with disabilities. Crucially, the report discusses the impact of the broader environment-specifically, conditions related to living in poverty. However, it provides no guidance about environmental interventions that could enable more beneficiaries to manage their funds without a payee. Innovative financial products could be offered to beneficiaries, and the retail industry could develop processes to support responsible financial management by people with mental illness. Changes to SSA benefits systems, including raising benefits levels and asset limits, could enable more beneficiaries to manage their funds independently.

Age at Onset of Bipolar Disorder Related to Parental and Grandparental Illness Burden.

OBJECTIVE: The age at onset of bipolar disorder varies greatly in different countries and continents. The association between load of family history of psychiatric illness and age at onset has not been adequately explored. METHODS: 979 outpatients with bipolar disorder (from 4 sites in the United States and 3 in the Netherlands and Germany) gave informed consent and completed a questionnaire about their demographics, age at onset of illness, and family history of unipolar and bipolar disorder, alcohol and substance abuse comorbidity, suicide attempts, and "other" illnesses in their parents, 4 grandparents, and any offspring. We examined how the parental and grandparental burden of these illnesses related to the age at onset of the patients' bipolar disorder. RESULTS: The burden of family psychiatric history was strongly related to an earlier age at onset of illness in both US and European patients (F3,906 = 35.42, P < .0001). However, compared to the Europeans, patients in the United States had both more family history of most difficulties and notably earlier age at onset. Earlier age at onset was associated with a greater illness burden in the patient's offspring (t568 = 4.1, P < .0001). CONCLUSIONS: More parental and grandparental psychiatric illness was associated with an earlier age at onset of bipolar disorder, which is earlier in the United States compared with Europe and is strongly related to a poor long-term prognosis. This apparent polygenic contribution to early onset deserves further study and therapeutic attempts at ameliorating the transgenerational impact.

Mental Health Outreach to Persons Who are Homeless: Implications for Practice from a Statewide Study.

In order to help states establish best practice standards for mental health outreach and engagement teams for persons who are homeless, this study aimed to identify key functional elements needed to effectively address the multiple needs of these persons. A statewide survey across six representative outreach programs was initiated in Connecticut. Focus groups with staff and clients, interviews with program administrators, shadowing of outreach workers on their rounds, and review of relevant written materials were conducted. Four main functional themes regarding optimal outreach work-constructive outreach team characteristics; availability of a wide range of services and resources for clients; navigation of multiple service systems; and favorable work demands and training opportunities-were identified through thematic analysis. The article concludes with recommendations for incorporating these four essential functional elements into mental health outreach and engagement practice to effectively meet the varied needs of the target group.

Financial Health and Mental Health Among Clients of a Community Mental Health Center: Making the Connections.

OBJECTIVES: This study evaluated financial challenges, satisfaction with financial-management supports, and interest in additional or alternative supports among clients of a mental health center. METHODS: Six focus groups were held with 39 clients of an urban community mental health center who reported having difficulty with their finances. Five focus groups were held with direct-care staff who provided services to the clients. Investigators used an inductive analytical approach to distill themes from notes taken during the focus groups. RESULTS: Clients emphasized the challenges of living in poverty and described using complex strategies to sustain themselves, including negotiating benefits systems, carefully planning purchases, and developing and relying on social relationships. They spoke of having uneven access to tools and services for managing their money, such as advice from direct-care staff, representative payees, and bank accounts, and had varying opinions about their value. Noting concerns similar to those of clients, direct-care staff expressed frustration at the lack of support services for helping clients manage their finances. Both clients and staff expressed the need for more services to help clients with their finances. CONCLUSIONS: Findings suggest a need for more services to support people with mental illness to manage their finances, particularly a more flexible and broader range of options than are provided by current representative-payee mechanisms.

Financial motivation to work among people with psychiatric disorders.

BACKGROUND: Supported employment is an effective intervention for people with serious mental illnesses (SMI) but is underutilized. Clients' desire to work might be heightened by programs that provide counseling about managing one's funds, since money management helps people become more aware of the advantages of having money. AIM: To analyze the thoughts of recently homeless or hospitalized persons with SMI concerning their personal finances and employment. METHODS: We interviewed 49 people with SMI about their finances, reviewed transcripts and analyzed their baseline characteristics. RESULTS: Twenty of the 49 participants spontaneously expressed a desire to work in order to earn more money. Those who expressed a desire to work managed their money significantly better than those who did not. CONCLUSION: Discussion of finances, such as that fostered by money management programs, may promote engagement in vocational rehabilitation and working for pay.

Pathways to assignment of payees.

How clients come to be assigned representative payees and/or conservators to manage their funds is not well understood. We compared clients assigned a payee during a clinical trial of a money management-based intervention to those not assigned payees and examined antecedents to payee assignment. One year after randomization, significantly more clients assigned to the advisor teller money manager (ATM) money management intervention were assigned payees than participants in the control condition (10 of 47 vs. 2 of 43; p = .02); those assigned payees had lower baseline GAF scores and participated more in study therapies. Several ATM clients were assigned payees after third parties paid more attention to clients' finances, and others after having negotiated storage of their funds with the ATM money manager during the study. Assignment of payees appears to be influenced by whether third parties critically attend to how clients' manage funds and by clients' receptiveness to having a payee.

Recovery and money management.

OBJECTIVE: Social recovery and external money management are important approaches in contemporary mental health care, but little research has been done on the relationship between the two or on application of recovery principles to money management for people at risk of being assigned a representative payee or conservator. METHOD: Out of 49 total qualitative interviews, 25 transcripts with persons receiving Social Security insurance or Social Security disability insurance who were at risk of being assigned a money manager were analyzed to assess the presence of recognized recovery themes. RESULTS: The recovery principles of self-direction and responsibility were strong themes in participant comments related to money management. CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: Money management interventions should incorporate peoples' recovery-related motivations to acquire financial management skills as a means to direct and assume responsibility for one's finances. Staff involved in money management should receive training to support client's recovery-related goals.

Going to the source: creating a citizenship outcome measure by community-based participatory research methods.

OBJECTIVE: This study used participatory methods and concept-mapping techniques to develop a greater understanding of the construct of citizenship and an instrument to assess the degree to which individuals, particularly those with psychiatric disorders, perceive themselves to be citizens in a multifaceted sense (that is, not in a simply legal sense). METHODS: Participants were persons with recent experience of receiving public mental health services, having criminal justice charges, having a serious general medical illness, or having more than one of these "life disruptions," along with persons who had not experienced any of these disruptions. Community-based participatory methods, including a co-researcher team of persons with experiences of mental illness and other life disruptions, were employed. Procedures included conducting focus groups with each life disruption (or no disruption) group to generate statements about the meaning of citizenship (N = 75 participants); reducing the generated statements to 100 items and holding concept-mapping sessions with participants from the five stakeholder groups (N = 66 participants) to categorize and rate each item in terms of importance and access; analyzing concept-mapping data to produce citizenship domains; and developing a pilot instrument of citizenship. RESULTS: Multidimensional scaling and hierarchical cluster analysis revealed seven primary domains of citizenship: personal responsibilities, government and infrastructure, caring for self and others, civil rights, legal rights, choices, and world stewardship. Forty-six items were identified for inclusion in the citizenship measure. CONCLUSIONS: Citizenship is a multidimensional construct encompassing the degree to which individuals with different life experiences perceive inclusion or involvement across a variety of activities and concepts.

Minimum cost of transport in Asian elephants: do we really need a bigger elephant?

Body mass is the primary determinant of an animal's energy requirements. At their optimum walking speed, large animals have lower mass-specific energy requirements for locomotion than small ones. In animals ranging in size from 0.8 g (roach) to 260 kg (zebu steer), the minimum cost of transport (COT(min)) decreases with increasing body size roughly as COT(min)∝body mass (M(b))(-0.316±0.023) (95% CI). Typically, the variation of COT(min) with body mass is weaker at the intraspecific level as a result of physiological and geometric similarity within closely related species. The interspecific relationship estimates that an adult elephant, with twice the body mass of a mid-sized elephant, should be able to move its body approximately 23% cheaper than the smaller elephant. We sought to determine whether adult Asian and sub-adult African elephants follow a single quasi-intraspecific relationship, and extend the interspecific relationship between COT(min) and body mass to 12-fold larger animals. Physiological and possibly geometric similarity between adult Asian elephants and sub-adult African elephants caused body mass to have a no effect on COT(min) (COT(min)∝M(b)(0.007±0.455)). The COT(min) in elephants occurred at walking speeds between 1.3 and ∼1.5 m s(-1), and at Froude numbers between 0.10 and 0.24. The addition of adult Asian elephants to the interspecific relationship resulted in COT(min)∝M (-0.277±0.046)(b). The quasi-intraspecific relationship between body mass and COT(min) among elephants caused the interspecific relationship to underestimate COT(min) in larger elephants.

Is health care a right or a commodity? Implementing mental health reform in a recession.

The Patient Protection and Affordable Care Act, signed into law by President Obama in March 2010, contains elements of two seemingly contradictory positions: health care as a commodity and as a right. The commodity argument posits that the marketplace should govern demand, supply, and costs of care. The law's establishment of state insurance exchanges reflects this position. The argument that health care is a right posits that it is a need, not a choice, and that government should regulate care standards that may be compromised as insurers attempt to minimize costs. The law's requirement for coverage of mental and substance use disorders reflects this position. This Open Forum examines these arguments in light of current state fiscal crises and impending reforms. Despite the federal government's interest in expanding prevention and treatment of mental illness, states may demonstrate varying levels of commitment, based in part on their perception of health care as a right or a commodity. The federal government should outline clear performance standards, with minimum services specified to maximize state commitments to services.

"A life in the community": Italian mental health reform and recovery.

There are remarkable parallels between the vision of the Italian Mental Health Reform of the 1960s and 1970s and the vision of "recovery" being promoted around the globe. Most importantly, they share a fundamental conviction in the right of individuals with mental illnesses to "a life in the community", arguing that the basic rights of social inclusion, self-determination, and citizenship provide the necessary foundation for, rather than follow after, recovery. This article describes four strategies used in the Italian Reform to actualize this vision: creating two-way streets between the mental health system and the broader community, establishing social cooperatives with joining forces with other citizens' groups, and working toward community inclusion on a person-by-person basis. The authors suggest that useful lessons learned from these efforts can be applied to the present challenge of affording all individuals with serious mental illnesses the "life in the community" to which they are entitled.

Spectral estimation of irregularly sampled exponentially decaying signals with applications to RF spectroscopy.

The problem of estimating the spectral content of exponentially decaying signals from a set of irregularly sampled data is of considerable interest in several applications, for example in various forms of radio frequency spectroscopy. In this paper, we propose a new nonparametric iterative adaptive approach that provides a solution to this estimation problem. As opposed to commonly used methods in the field, the damping coefficient, or linewidth, is explicitly modeled, which allows for an improved estimation performance. Numerical examples using both simulated data and data from NQR experiments illustrate the benefits of the proposed estimator as compared to currently available nonparametric methods.

Doctors' responses to medical errors.

Medical error has become a topic of much concern in recent years. Doctors' responses to their own or others' medical errors are important because openness or secrecy has an impact on efforts to reduce iatrogenic injury, on malpractice litigation, and on patient and doctor satisfaction with care. This article reviews doctor's responses to error within the context of contemporary medical care and considers themes that emerge from this review.