Bridging the divide between epilepsy and mental health to drive solutions.

Since its establishment in 2000, Epilepsy & Behavior has published more than 1000 papers on mental health issues among people with epilepsy, including about 200 reviews. These studies on prevalence, treatment, and guidance for future research are important contributions to the field, and they offer great promise. Yet these papers and the multitude published in other journals over the years have failed to result in systematic, scaled changes in how the epilepsy field in the United States addresses mental health issues. The mental health assessment and management gap is especially notable given decades-old, as well as more recent, recommendations from national initiatives on epilepsy, consensus statements, and other expert appeals to reduce psychiatric burden. Selected or comprehensive elements of emerging models and latest approaches from behavioral health (e.g., peer support) and public health (e.g., community-clinical linkages) highlight current opportunities to engage multiple community partners and sectors to bridge the epilepsy and behavioral health fields to implement solutions for improved mental healthcare for people with epilepsy. In honor of the 20th anniversary of Epilepsy & Behavior and its contribution to the literature and the field, we seek to build public health roadmaps to bridge the epilepsy and behavioral health divide-with new epilepsy partners who can expand community-based partnerships that may help facilitate systematic changes to close mental health treatment gaps. Special Issue: Epilepsy & Behavior's 20th Anniversary.

Behavioral Health, Local Health Department Accreditation, and Public Health 3.0: Leveraging Opportunities for Collaboration.

The rise of the opioid epidemic and the increasing rate of suicides have drawn attention to mental health and addiction and have highlighted the need for collaboration between public health and behavioral health. However, these 2 fields have had limited engagement with one another. The introduction of Public Health 3.0 and population-based financing models that promote prevention and value in health care have created opportunities and incentives for local health departments and behavioral health agencies and providers to work together. New undertakings include the creation of accountable care organizations, community health needs assessment requirements for all non-profit hospitals, local health department requirements to conduct community Health Assessments (CHA), and increasing numbers of public health departments that are pursing accreditation. We argue that by taking advantage of these opportunities and others, local health departments can play a vital role in addressing critical challenges in mental health and addiction facing their communities.

Openness to adopting evidence-based practice in public substance use treatment in South Africa using task shifting: Caseload size matters.

BACKGROUND: In response to the lack of coverage for substance use treatment in the Western Cape province of South Africa, the local government expanded funding for evidence-based practices (EBPs) for treating substance use. Yet, little is known about provider and staff attitudes towards adopting EBPs in this setting, which is particularly relevant in this context where task shifting clinical care increases demands on paraprofessional providers. This study aimed to (1) assess attitudes towards adopting EBPs among a range of staff working in substance use treatment in Cape Town using a task shifting model; and (2) evaluate factors associated with openness towards adopting EBPs in this setting. METHODS: Staff (n = 87) were recruited from 11 substance use treatment clinics. Demographics and job-related characteristics were assessed. Staff perceptions of organizational factors were assessed using the TCU Organizational Readiness for Change (ORC) scale. The dependent variable, attitudes towards adopting EBPs, was assessed using the Evidence-Based Practice Attitude Scale (EBPAS). RESULTS: This study is one of the first to administer the EBPAS in South Africa and found good internal consistency (total score: α = .82). In a multivariable model adjusting for site and factors associated with EBPAS total score at the bivariate level, only smaller caseload size was associated with greater openness to adopting EBPs (B = 1.61, SE = .73; t = 2.21; p<.05). CONCLUSIONS: As pressure to scale up implementation of EBPs in South African substance use treatment services intensifies, additional efforts are needed to understand barriers to adopt EBPs in this setting. Supporting staff adoption of EBPs in resource-limited settings may require additional resources to limit staff caseloads in the context of task shifting.

Fostering sustainable, integrated medical and behavioral health services in medical settings.

The integration of behavioral health (BH) and primary care services has been the subject of considerable attention for almost a decade. Such work has been motivated by the prevalence of chronic health problems in persons with BH conditions and correspondingly high rates of early death. Service integration efforts typically included cross-referral or bidirectional efforts to add some features of primary care to specialty BH settings or the reverse. This article proposes a third approach based on full service and financial integration and shows how it differs substantially from the other 2 models. This new model has the potential to bring much-needed BH services to persons served in primary care settings who have these conditions, while fostering integrated services in specialty settings for those with the most severe mental or substance use conditions. The Patient Protection and Affordable Care Act could provide a valuable opportunity to implement this third model.

Identifying perceived barriers to monitoring service quality among substance abuse treatment providers in South Africa.

BACKGROUND: A performance measurement system is planned for South African substance abuse treatment services. Provider-level barriers to implementing these systems have been identified in the United States, but little is known about the nature of these barriers in South Africa. This study explored the willingness of South African substance abuse treatment providers' to adopt a performance measurement system and perceived barriers to monitoring service quality that would need to be addressed during system development. METHODS: Three focus group discussions were held with treatment providers from two of the nine provinces in South Africa. These providers represented the diverse spread of substance abuse treatment services available in the country. The final sample comprised 21 representatives from 12 treatment facilities: eight treatment centres in the Western Cape and four in KwaZulu-Natal. Content analysis was used to extract core themes from these discussions. RESULTS: Participants identified barriers to the monitoring of service quality that included outdated modes of collecting data, personnel who were already burdened by paperwork, lack of time to collect data, and limited skills to analyse and interpret data. Participants recommended that developers engage with service providers in a participatory manner to ensure that service providers are invested in the proposed performance measurement system. CONCLUSION: Findings show that substance abuse treatment providers are willing to adopt a performance measurement system and highlight several barriers that need to be addressed during system development in order to enhance the likelihood that this system will be successfully implemented.

Health disparities and health equity: the issue is justice.

Eliminating health disparities is a Healthy People goal. Given the diverse and sometimes broad definitions of health disparities commonly used, a subcommittee convened by the Secretary's Advisory Committee for Healthy People 2020 proposed an operational definition for use in developing objectives and targets, determining resource allocation priorities, and assessing progress. Based on that subcommittee's work, we propose that health disparities are systematic, plausibly avoidable health differences adversely affecting socially disadvantaged groups; they may reflect social disadvantage, but causality need not be established. This definition, grounded in ethical and human rights principles, focuses on the subset of health differences reflecting social injustice, distinguishing health disparities from other health differences also warranting concerted attention, and from health differences in general. We explain the definition, its underlying concepts, the challenges it addresses, and the rationale for applying it to United States public health policy.

A Mixed-Methods Evaluation of the Implementation of a Performance Measurement System for South Africa's Substance Use Treatment Services.

OBJECTIVE: Minimal knowledge exists on the factors that affect implementation of performance measurement systems, particularly in low- and middle-income countries (LMICs). To address this, we describe the implementation of a performance measurement system for South Africa's substance abuse treatment services known as the Service Quality Measures (SQM) initiative. METHOD: We conducted a mixed-methods evaluation of system implementation. We surveyed 81 providers about the extent of system implementation within their agencies and the factors that facilitated implementation. We conducted 26 in-depth interviews of providers' perceived barriers and facilitators to implementation. RESULTS: The overall penetration of this system was high. Almost all providers viewed the system as feasible to implement, acceptable, appropriate for use in their context, and useful for guiding service improvements. However, the extent of implementation varied significantly across sites (p < .05). Leadership support (p < .05) was associated with increased implementation in multivariable analyses. Providers reflected that high rates of patient attrition, variability in willingness to implement the system, and limited capacity for interpreting performance feedback affected the extent of system implementation. CONCLUSIONS: It is feasible to implement a performance measurement system in LMICs if the system is acceptable, appropriate, and useful to providers. To ensure the utility of this system for treatment service strengthening, system implementation must be optimized. Efforts to enhance target population coverage, strengthen leadership support for performance measurement, and build capacity for performance feedback utilization may enhance the implementation of this performance measurement system.

South African service users' perceptions of patient-reported outcome and experience measures for adolescent substance use treatment: A qualitative study.

INTRODUCTION AND AIMS: Patient-reported outcome measures (PROM) and experience measures (PREM) for substance use disorder (SUD) treatment exist for adults but have unknown relevance for adolescents. This study aimed to explore adolescents' perceptions of effective SUD treatment and possible barriers to completing PROMs and PREMs to guide efforts to adapt the South African Addiction Treatment Services Assessment (SAATSA) for adolescents. DESIGN AND METHODS: Five focus groups were conducted with 38 adolescent service users recruited from residential and outpatient SUD treatment facilities in South Africa. Group discussions explored perceptions of treatment components necessary for desired SUD treatment outcomes, treatment experiences that support engagement in care, and perceptions of PROM and PREM completion. RESULTS: Participants viewed treatment elements that enhance motivation for change, coping and emotional regulation; provide recreational alternatives to substance use; and improve family relationships and home environments as critical to positive treatment outcomes. They reflected that provider characteristics and developmentally and culturally appropriate services facilitated engagement in treatment. PROM and PREM completion seemed acceptable, with participants suggesting ways to enhance their appeal. DISCUSSION AND CONCLUSION: Findings confirm that adult-oriented PROMs and PREMs require adaptation for adolescents. Service user inputs identified ways to expand the content of the SAATSA to better reflect adolescents' treatment priorities. These inputs have also guided changes to item formulation and administration procedures to enhance the SAATSA's acceptability for adolescents. Ensuring the SAATSA addresses treatment outcomes and experiences that matter to adolescents is vital for generating information to guide improvements to adolescent SUD services.

The association of depression and anxiety with obesity and unhealthy behaviors among community-dwelling US adults.

OBJECTIVE: The aim of this study was to examine the extent to which depression and anxiety are associated with smoking, obesity, physical inactivity and alcohol consumption in the US population using the Patient Health Questionnaire 8 (PHQ-8) and two questions on lifetime diagnosis of anxiety and depression. METHODS: Data were analyzed in 38 states, the District of Columbia and two territories using the 2006 Behavioral Risk Factor Surveillance System (n=217,379), a large state-based telephone survey. RESULTS: Overall, adults with current depression or a lifetime diagnosis of depression or anxiety were significantly more likely than those without each diagnosis to smoke, to be obese, to be physically inactive, to binge drink and drink heavily. There was a dose-response relationship between depression severity and the prevalence of smoking, obesity and physical inactivity and between history of depression (never depressed, previously depressed, currently depressed) and the prevalence of smoking, obesity, physical inactivity, binge drinking and heavy drinking. Lifetime diagnosis of depression and anxiety had an additive association with smoking prevalence. CONCLUSION: The associations between depression, anxiety, obesity and unhealthy behaviors among US adults suggest the need for a multidimensional and integrative approach to health care.

Substance abuse treatment engagement, completion and short-term outcomes in the Western Cape province, South Africa: Findings from the Service Quality Measures Initiative.

BACKGROUND: Optimizing the effectiveness of substance use disorder (SUD) treatment is critical in low-and middle-income countries (LMICs) with limited opportunities for SUD treatment. This is the first study to identify targets for interventions to improve the quality of SUD treatment in a LMIC. METHOD: We explored correlates of three indicators of treatment quality (treatment engagement, completion and abstinence at treatment exit) using data from a SUD performance measurement system implemented in the Western Cape Province of South Africa. The sample included data from 1094 adult treatment episodes representing 53% of the treatment episodes in 2016. Using multivariate logistic regression analyses, we modeled socio-demographic, substance use and program correlates of treatment engagement, completion, and abstinence at treatment exit. RESULTS: Overall, 59% of patients completed treatment (48% of patients from outpatient services). Treatment completion was associated with greater likelihood of abstinence at treatment exit. Patients were more likely to complete treatment if they engaged in treatment, were older, and had more severe drug problems (characterized by daily drug use and heroin problems) and attended programs of shorter duration. Residential treatment was associated with greater likelihood of treatment engagement, completion, and abstinence at treatment exit. CONCLUSION: Improving rates of outpatient treatment completion will enhance the effectiveness of South Africa's SUD treatment system. Interventions that promote engagement in treatment, particularly among younger patients; reduce program length through referral to step-down continuing care; and ensure better matching of drug problem to treatment level and type could improve rates of treatment completion.

What Does Mental Health Parity Really Mean for the Care of People with Serious Mental Illness?

Parity of mental health and substance abuse insurance benefits with medical care benefits, as well as parity in their management, are major ongoing concerns for adults with serious mental illness (SMI). The Mental Health Parity and Addiction Equity Act of 2008 guaranteed this parity of benefits and management in large private insurance plans and privately managed state Medicaid plans, but only if the benefits were offered at all. The Patient Protection and Affordable Care Act of 2010 extended parity to all persons receiving insurance through the state health insurance marketplaces, through the state Medicaid Expansions, and through new individual and small group plans. This article presents an analysis of how accessible parity has become for adults with SMI at both the system and personal levels several years after these legislative changes have been implemented.

Providers' perceptions of the implementation of a performance measurement system for substance abuse treatment: A process evaluation of the Service Quality Measures initiative.

BACKGROUND: In South Africa, concerns exist about the quality of substance abuse treatment. We developed a performance measurement system, known as the Service Quality Measures (SQM) initiative, to monitor the quality of treatment and assess efforts to improve quality of care. In 2014, the SQM system was implemented at six treatment sites to evaluate how implementation protocols could be improved in preparation for wider roll-out. OBJECTIVE: To describe providers' perceptions of the feasibility and acceptability of implementing the SQM system, including barriers to and facilitators of implementation. METHODS: We conducted 15 in-depth interviews (IDIs) with treatment providers from six treatment sites (two sites in KwaZulu-Natal and four in the Western Cape). Providers were asked about their experiences in implementing the system, the perceived feasibility of the system, and barriers to implementation. All IDIs were audio-recorded and transcribed verbatim. A framework approach was used to analyse the data. RESULTS: Providers reported that the SQM system was feasible to implement and acceptable to patients and providers. Issues identified through the IDIs included a perceived lack of clarity about sequencing of key elements in the implementation of the SQM system, questions on integration of the system into clinical care pathways, difficulties in tracking patients through the system, and concerns about maximising patient participation in the process. CONCLUSION: Findings suggest that the SQM system is feasible to implement and acceptable to providers, but that some refinements to the implementation protocols are needed to maximise patient participation and the likelihood of sustained implementation.

Development and psychometric validation of a novel patient survey to assess perceived quality of substance abuse treatment in South Africa.

BACKGROUND: A hybrid performance measurement system that combines patient-reported outcome data with administrative data has been developed for South African substance abuse treatment services. This paper describes the development and psychometric validation of one component of this system, the South African Addiction Treatment Services Assessment (SAATSA). METHODS: First, a national steering committee identified five domains and corresponding indicators on which treatment quality should be assessed. A decision was made to develop a patient survey to assess several of these indicators. A stakeholder work group sourced survey items and generated additional items where appropriate. The feasibility and face validity of these items were examined during cognitive response testing with 16 patients. This led to the elimination of several items. Next, we conducted an initial psychometric validation of the SAATSA with 364 patients from residential and outpatient services. Exploratory (EFA) and confirmatory factor analyses (CFA) were conducted to assess the latent structure of the SAATSA. Findings highlighted areas where the SAATSA required revision. Following revision, we conducted another psychometric validation with an additional sample of 285 patients. We used EFA and CFA to assess construct validity and we assessed reliability using Cronbach's measure of internal consistency. RESULTS: The final version of the SAATSA comprised 31 items (rated on a four-point response scale) that correspond to six scales. Four of these scales are patient-reported outcome measures (substance use, quality of life, social connectedness and HIV risk outcomes) that together assess the perceived effectiveness of treatment. The remaining two scales assess patients' perceptions of access to and quality of care. The models for the final revised scales had good fit and the internal reliability of these scales was good to excellent, with Cronbach's α ranging from 0.72 to 0.89. CONCLUSION: A lack of adequate measurement tools hampers efforts to improve the quality of substance abuse treatment. Our preliminary evidence suggests that the SAATSA, a novel patient survey that assesses patients' perceptions of the outcomes and quality of substance abuse treatment, is a psychometrically robust tool that can help fill this void.

The Affordable Care Act: overview and implications for county and city behavioral health and intellectual/developmental disability programs.

The author begins by reviewing the 5 key intended actions of the Affordable Care Act (ACA)-insurance reform, coverage reform, quality reform, performance reform, and information technology reform. This framework provides a basis for examining how populations served and service programs will change at the county and city levels as a result of the ACA, and how provider staff also will change over time as a result of these developments. The author concludes by outlining immediate next steps for county and city programs.

Stigma and difficulty accessing medical care in a sample of adults with serious mental illness.

INTRODUCTION: Wellness of people with mental illness is increasingly a public health priority. This study examined factors associated with difficulties receiving medical care in adults with mental illness. METHODS: In a sample of 1,670 adults with mental illness, we assessed difficulties in accessing medical care and stigma. RESULTS: A total of 465 (28%) participants reported difficulties in accessing medical care; 211 (13%) attributed difficulties in access to stigma. Lack of comprehensive medical care coverage and mental health symptoms were associated with increased odds of perceived difficulties in accessing medical care; personal empowerment was negatively associated with perceived difficulties attributed to stigma; education was positively associated. DISCUSSION: The findings highlight unmet need for medical care in this population and the need to recognize stigma as a barrier medical care. Interventions to empower patients and educate medical providers about wellness for people with serious mental illness could help to reduce barriers.

Psychological distress and mental health treatment among persons with and without active duty military experience, Behavioral Risk Factor Surveillance System, United States, 2007.

OBJECTIVES: To examine self-reported psychological distress (K-6 scale) and mental health treatment among persons with and without active duty U.S. military experience (ADME) currently residing in private residences in the U.S. METHODS: Analysis of 2007 Behavioral Risk Factor Surveillance System data from 35 states, District of Columbia, and Puerto Rico (n = 202,029 for those answering all K-6 questions, the treatment question, and the ADME question) RESULTS: Adjusting for age, sex, race/ethnicity, and education, overall mean K-6 scores of those with and without ADME were similar (p = 0.3223); however, more of those with, vs. without, ADME reported current mental health treatment (11.7 % vs. 9.6 %, p = 0.0001). Those with ADME receiving such treatment had a higher mean K-6 score (7.7) than those without ADME receiving such treatment (6.9) (p = 0.0032). CONCLUSIONS: Community-dwelling persons with ADME have similar demographically-adjusted mean K-6 psychological distress scores, but greater likelihood of recent mental health treatment, compared to those without ADME.