Integrated Treatment Group Curriculum for People with Serious Mental Health Conditions Who Use Substances.

Without proper treatment, people with co-occurring mental health and substance use problems are at great risk for poor outcomes and high treatment costs in multiple domains. Intermediary organizations can provide support to programs implementing integrated treatment and other evidence-based practices; this includes developing practical tools for programs built to encourage fidelity to a particular practice. In this paper, we describe a group curriculum workbook designed to help practitioners provide integrated treatment with fidelity and a pilot learning collaborative to evaluate whether this workbook is a helpful tool for programs to support people with serious mental health conditions and substance use in identifying and achieving personal goals. Results of the pilot found that nearly all participants demonstrated progress with respect to their identified goals, and group facilitators reported that the workbook was easy to use, that participants enjoyed the material, and that they intended to continue offering the group as part of their regular programming.

Video intervention to increase treatment-seeking by healthcare workers during the COVID-19 pandemic: randomised controlled trial.

BACKGROUND: Many healthcare workers do not seek help, despite their enormous stress and greater risk for anxiety, depression and post-traumatic stress disorder (PTSD). AIMS: This study screened for psychopathology and evaluated the efficacy of a brief, social contact-based video intervention in increasing treatment-seeking intentions among healthcare workers (trial registration: NCT04497415). We anticipated finding high rates of psychopathology and greater treatment-seeking intentions post-intervention. METHOD: Healthcare workers (n = 350) were randomised to (a) a brief video-based intervention at day 1, coupled with a booster video at day 14; (b) the video at day 1 only; or (c) a non-intervention control. In the 3 min video, a female nurse described difficulty coping with stress, her anxieties and depression, barriers to care and how therapy helped her. Assessments were conducted pre- and post-intervention and at 14- and 30-day follow-ups. RESULTS: Of the 350 healthcare workers, 281 (80%) reported probable anxiety, depression and/or PTSD. Participants were principally nurses (n = 237; 68%), physicians (n = 52; 15%) and emergency medical technicians (n = 30; 9%). The brief video-based intervention yielded greater increases in treatment-seeking intentions than the control condition, particularly among participants in the repeat-video group. Exploratory analysis revealed that in both video groups, we found greater effect among nurses than non-nurses. CONCLUSIONS: A brief video-based intervention increased treatment-seeking intention, possibly through identification and emotional engagement with the video protagonist. A booster video magnified that effect. This easily disseminated intervention could increase the likelihood of seeking care and offer employers a proactive approach to encourage employees to search for help if needed.

Patient-, Hospital-, and System-Level Factors Associated With 30-Day Readmission After a Psychiatric Hospitalization.

ABSTRACT: Readmission after inpatient care for a psychiatric condition is associated with a range of adverse events including suicide and all-cause mortality. This study estimated 30-day readmission rates in a large cohort of inpatient psychiatric admissions in New York State and examined how these rates varied by patient, hospital, and service system characteristics. Data were obtained from Medicaid claims records, and clinician, hospital, and region data, for individuals with a diagnosis of any mental disorder admitted to psychiatric inpatient units in New York State from 2012 to 2013. Psychiatric readmission was defined as any unplanned inpatient stay with a mental health diagnosis with an admission date within 30 days of being discharged. Unadjusted and adjusted odds ratios of being readmitted within 30 days were estimated using logistic regression analyses. Over 15% of individuals discharged from inpatient units between 2012 and 2013 were readmitted within 30 days. Patients who were readmitted were more likely to be homeless, have a schizoaffective disorder or schizophrenia, and have medical comorbidity. Readmission rates varied in this cohort mainly because of individual-level characteristics. Homeless patients were at the highest risk of being readmitted after discharge.

Structural Racism and Psychiatric Practice: A Call for Sustained Change.

ABSTRACT: Structural racism has received renewed focus over the past year, fueled by the convergence of major political and social events. Psychiatry as a field has been forced to confront a legacy of systemic inequities. Here, we use examples from our clinical and supervisory work to highlight the urgent need to integrate techniques addressing racial identity and racism into psychiatric practice and teaching. This urgency is underlined by extensive evidence of psychiatry's long-standing systemic inequities. We argue that our field suffers not from a lack of available techniques, but rather a lack of sustained commitment to understand and integrate those techniques into our work; indeed, there are multiple published examples of strategies to address racism and racial identity in psychiatric clinical practice. We conclude with recommendations geared toward more firmly institutionalizing a focus on racism and racial identity in psychiatry, and suggest applications of existing techniques to our initial clinical examples.

Behavioral Health Workforce Development in the era of COVID-19: Examples From a State-Funded Intermediary Organization.

Intermediary and purveyor organizations (IPOs) play a key role in disseminating and implementing behavioral health evidence-based practices. The COVID-19 pandemic created a time of crisis and disruption to behavioral health care delivery. Using the conceptual framework of basic, targeted, and intensive technical assistance (TA) from the Training and Technology Transfer Centers, case studies are used to describe how programs at The Center for Practice Innovations a state funded-intermediary organization, adapted its training and technical assistance to be delivered entirely remotely, to include content related to COVID-19 and to provide guidance on telehealth-based behavioral health care.

Feasibility and Utility of Different Approaches to Violence Risk Assessment for Young Adults Receiving Treatment for Early Psychosis.

This pilot study examined violence risk assessment among a sample of young adults receiving treatment for early psychosis. In this study, thirty participants were assessed for violence risk at baseline. Participants completed follow-up assessments at 3, 6, 9 and 12 months to ascertain prevalence of violent behavior. Individuals were on average 24.1 years old (SD = 3.3 years) and predominantly male (n = 24, 80%). In this sample, six people (20%) reported engaging in violence during the study period. Individuals who engaged in violence had higher levels of negative urgency (t(28) = 2.21, p = 0.035) This study sought to establish the feasibility, acceptability, and clinical utility of violence risk assessment for clients in treatment for early psychosis. Overall, this study found that most individuals with early psychosis in this study (who are in treatment) were not at risk of violence. Findings suggest that violent behavior among young adults with early psychosis is associated with increased negative urgency.

"Everything Changed, Would You Like Me to Elaborate?": A Qualitative Examination of the Impact of the COVID-19 Pandemic on Community Participation Among Young Adults with Early Psychosis and Their Families.

OnTrackNY provides early intervention services to young people with early psychosis throughout New York State. This report describes the impact of the COVID-19 pandemic on community participation of OnTrackNY program participants and their families. Thirteen participants and nine family members participated in five focus groups and three individual semi-structured interviews. Data were analyzed using a summary template and matrix analysis approach. Major themes highlight the negative impacts of the pandemic with reports of decreased socializing or using online means to connect, unemployment, challenges with online learning and a decrease in civic engagement. Positive impacts include more time to deepen connections with family and valued friendships and engage in activities that promote wellness and goal attainment. Implications for coordinated specialty care programs include adapting services to promote mainstream community integration and creating new strategies for community involvement of young people within a new context brought forth by the pandemic.

COVID-19 Case Rates After Surveillance and Vaccinations in a Statewide Psychiatric Hospital System.

Individuals with serious mental illness are particularly vulnerable to COVID-19. The New York State (NYS) Office of Mental Health implemented patient and staff rapid testing, quarantining, and vaccination to limit COVID-19 spread in 23 state-operated psychiatric hospitals between November 2020 and February 2021. COVID-19 infection rates in inpatients and staff decreased by 96% and 71%, respectively, and the NYS population case rate decreased by 6%. Repeated COVID-19 testing and vaccination should be priority interventions for state-operated psychiatric hospitals. (Am J Public Health. 2021;111(10):1780-1783. https://doi.org/10.2105/AJPH.2021.306444).

Increasing treatment-seeking intentions of US veterans in the Covid-19 era: A randomized controlled trial.

BACKGROUND: Veterans have higher rates of anxiety, depression, and posttraumatic stress disorder (PTSD), and may be vulnerable to mental health consequences of the Covid-19 pandemic. More than half of veterans who meet mental illness criteria do not seek help. This study screened for clinical symptoms and evaluated the efficacy of a brief, online social-contact-based video intervention in increasing treatment-seeking intentions among veterans. We hypothesized that the video-based intervention would increase treatment-seeking intentions more than written vignette and control conditions. METHODS: One hundred seventy-two veterans were randomized to either a (a) brief video-based intervention; (b) written vignette intervention, or (c) nonintervention control group. In the 3-min video, a veteran previously diagnosed with PTSD described his symptom reactivation by Covid-19, his barriers to care, and how therapy helped him to cope. Assessments were conducted at baseline, postintervention, and at 14- and 30-day follow-ups. RESULTS: A total of 91 (53%) veterans reported high levels of clinical symptoms, especially those self-reporting Covid-19 exposure. The brief video-based intervention yielded greater increase in treatment-seeking intentions among veterans. Within the video group, women showed an increase in treatment-seeking intentions from baseline to postintervention only, whereas men showed a more sustained effect, from baseline to Day 14. CONCLUSIONS: Surveyed veterans reported high symptoms levels. A brief video intervention increased treatment-seeking intention, likely through identification and emotional engagement with the video protagonist. This easily disseminable video-based intervention has the potential to increase likelihood of seeking care. Future research should examine longer term sustainability and changes in help-seeking behavior.

Psychiatric symptoms and moral injury among US healthcare workers in the COVID-19 era.

BACKGROUND: Emerging cross-sectional data indicate that healthcare workers (HCWs) in the COVID-19 era face particular mental health risks. Moral injury - a betrayal of one's values and beliefs, is a potential concern for HCWs who witness the devastating impact of acute COVID-19 illness while too often feeling helpless to respond. This study longitudinally examined rates of depression, generalized anxiety disorder (GAD), posttraumatic stress disorder (PTSD), and moral injury among United States HCWs in the COVID-19 era. We anticipated finding high levels of clinical symptoms and moral injury that would remain stable over time. We also expected to find positive correlations between clinical symptoms and moral injury. METHODS: This three-wave study assessed clinical symptoms and moral injury among 350 HCWs at baseline, 30, and 90 days between September and December 2020. Anxiety, depression, PTSD, and moral injury were measured using the Generalized Anxiety Disorder-7 (GAD-7), Patient Health Questionnaire-9 (PHQ-9), Primary Care PTSD Screen (PC-PTSD), and Moral Injury Events Scale (MIES). RESULTS: Of the 350 HCWs, 72% reported probable anxiety, depression, and/or PTSD disorders at baseline, 62% at day 30, and 64% at day 90. High level of moral injury was associated with a range of psychopathology including suicidal ideation, especially among healthcare workers self-reporting COVID-19 exposure. CONCLUSIONS: Findings demonstrate broad, persisting, and diverse mental health consequences of the COVID-19 pandemic among United States HCWs. This study is the first to longitudinally examine the relationships between moral injury and psychopathology among HCWs, emphasizing the need to increase HCWs' access to mental healthcare.

Violence in Psychiatric Settings: Demographic and Clinical Characteristics of Patients Who Were Targets of Aggression.

ABSTRACT: Violence is a serious concern in the psychiatric inpatient and emergency setting. Much of the research on victims of inpatient violence has focused on identifying and supporting staff who are at risk of being victimized when working in psychiatric settings. This article presents an analysis of 72 patients who were targeted during incidents of patient-on-patient physical aggression in hospital-based psychiatric settings (both inpatient and emergency) from 2014 to 2018. Results suggest that patients who are at risk of being targeted by another patient while in the hospital tend to be younger, are more likely to be male, and present with manic symptoms and recent cannabis use. These variables have all been identified as risk factors for perpetration of violence by patients with mental illness. This study adds to a literature demonstrating a consistent overlap between individuals with mental illness who are victimized and those who initiate violence.

Telehealth and the Community SMI Population: Reflections on the Disrupter Experience of COVID-19.

The novel coronavirus pandemic and the resulting expanded use of telemedicine have temporarily transformed community-based care for individuals with serious mental illness (SMI), challenging traditional treatment paradigms. We review the rapid regulatory and practice shifts that facilitated broad use of telemedicine, the literature on the use of telehealth and telemedicine for individuals with SMI supporting the feasibility/acceptability of mobile interventions, and the more limited evidence-based telemedicine practices for this population. We provide anecdotal reflections on the opportunities and challenges for telemedicine drawn from our daily experiences providing services and overseeing systems for this population during the pandemic. We conclude by proposing that a continued, more prominent role for telemedicine in the care of individuals with SMI be sustained in the post-coronavirus landscape, offering future directions for policy, technical assistance, training, and research to bring about this change.

Acceptability, feasibility and outcome of a screening programme for complicated grief in integrated primary and behavioural health care clinics.

BACKGROUND: Complicated grief, a syndrome of persistent grief diagnosed >6 months following the loss of someone close is expected to be included in the 11th revision of the International Classification of Diseases as a new diagnosis called prolonged grief disorder. Complicated grief is associated with impaired functioning and health comorbidity and does not respond to treatments for depression. Individuals may seek help in primary care where providers need to be familiar with the syndrome. OBJECTIVE: This study examines the acceptability, feasibility and outcome of a screening programme for complicated grief among diverse adults receiving behavioural health services in integrated primary care. METHODS: Behavioural health providers (n = 14) administered the Brief Grief Questionnaire and the Inventory of Complicated Grief during routine assessment and completed an acceptability survey. Descriptive statistics described rates of complicated grief symptoms and sample demographics, health and service use. RESULTS: Most providers (71%) reported the Brief Grief Questionnaire to be a moderate to very useful assessment instrument and the Inventory of Complicated Grief moderate to very useful for developing a treatment plan (57%). Of the 2425 patients screened, 1015 reported a loss over 6 months ago. Of these 1015, 28% (n = 282) screened positive on the Brief Grief Questionnaire and 22% (n = 228) endorsed symptoms of complicated grief (Inventory of Complicated Grief score ≥25), considered at high risk for needing clinical care. CONCLUSIONS: A screening programme for identifying complicated grief was acceptable to providers, feasible to implement and useful in identifying complicated grief in integrated primary care clinics.

How the DSM Is Used in Clinical Practice.

Despite widespread use, how clinicians use the DSM in psychiatric practice is not well understood. Recognizing public and professional attitudes toward the DSM are integral to future DSM development, to assess a commonly held assumption such as that the DSM is used primarily for coding, and to assess its clinical utility. A convenience sample of Psychiatric Times readers was surveyed to assess the DSM's use in clinical practice. A total of 394 behavioral health care practitioners fully completed the online survey. Results suggest that the DSM, beyond administrative and billing use, is used for communication with health care providers, for teaching diagnoses to trainees, and, importantly, as an educational tool to inform patients and caregivers alike.

Supported Education and Employment Services for Young People with Early Psychosis in OnTrackNY.

BACKGROUND: Psychosis onset commonly occurs at ages 16-30 when individuals are typically developing their education, employment and career trajectories. Coordinated specialty care (CSC) programs provide access to team-based early invention services for psychosis, including supported education and employment (SEE) services. AIMS OF STUDY: We examine factors associated with the use of SEE services and whether use of SEE services (for supported education, supported employment, or both) is associated with education and employment participation within New York's CSC program, OnTrackNY. METHODS: Participants (n=779) enrolled in OnTrackNY from October 2013-September 2017. Assessments were collected by clinical staff at admission, quarterly, and at discharge. Logistic regression models were specified to identify factors associated with the probability of use of SEE specialist services during the first year of program participation, using generalized estimating equations with an autoregressive covariance structure to account for within-subject correlations over time. Logistic models were also used to predict whether use of SEE services in the prior quarter predict the probability of work and school participation in the subsequent quarter, respectively; these were analyzed cross-sectionally for each time period. Models controlled for other factors associated with work/school outcomes for young people with early psychosis. RESULTS: Participants who were younger, and who had lower rates of work/school participation had greater odds of SEE service use. Use of SEE services for education support in the first quarter among clients under age 23 is significantly associated with school enrollment in the second quarter and this continued through the first year. Use of SEE services for employment support in the first quarter is significantly associated with employment in the second quarter, but significant associations for employment were not found at later periods of participation. Use of SEE services for both education and employment support was inconsistently associated with subsequent school enrollment or employment in the subsequent quarter. Results were upheld when limiting the sample to those not receiving other SEE services. DISCUSSION: Rates of school and work participation increased over the duration of OnTrackNY participation. Clients with lower work/school participation were more likely to use SEE services. Supported education services are associated with greater school participation during the first year for clients under age 23. However, this association is only significant in the first quarter for supported employment services, and is inconsistent when examining those who used both simultaneously. It is possible that we may find significant associations for employment as the program continues. It is also possible that clients may end supported employment services after obtaining employment, while those in school may require ongoing services (e.g. to renew educational accommodations). Additionally, it is possible that OnTrackNY's supported education model, designed to adhere to Individual Placenment and Support (IPS) principles, may be helping clients stay in school. However, as this is an observational study with no control condition, we cannot say that OnTrackNY, or SEE services participation, caused the observed outcomes. IMPLICATIONS FOR FURTHER RESEARCH: Future research should continue to develop the evidence base for supported education services.

Transforming the Treatment of Schizophrenia in the United States: The RAISE Initiative.

The schizophrenia spectrum disorders are neurodevelopmental illnesses with a lifetime prevalence near 1%, producing extensive functional impairment and low expectations for recovery. Until recently, treatment in the United States has largely attempted to stabilize individuals with chronic schizophrenia. The identification and promotion of evidence-based practices for schizophrenia via the Patient Outcomes Research Team, combined with international studies supporting the value of early intervention, provided the foundation for the Recovery After an Initial Schizophrenia Episode (RAISE) project. The RAISE studies further supported the value of reducing the duration of untreated psychosis and providing a multi-element treatment called coordinated specialty care (CSC) to improve outcomes for patients in usual treatment settings. Although CSC programs have proliferated rapidly in the United States, many challenges remain in the treatment and recovery of individuals with schizophrenia in the aftermath of RAISE.

Giving Back to Families: Evidence and Predictors of Persons with Serious Mental Illness Contributing Help and Support to Families.

Persons with serious mental illness (SMI) often rely on family for significant assistance and support, but the contributions made by persons with SMI to their families have been overlooked. This study assessed the extent to which persons with SMI contribute help or support to their families and identified significant predictors of contribution using an analysis of 1 year of clinicians' electronic health record (EHR) notes. EHR notes with reference to families of 226 Veterans with SMI were extracted and classified as suggesting help being given to and/or received from families. Forty-one percent of the sample contributed to family in a variety of ways. More frequent contact with family and being female were significant predictors of contribution. This study underlines the potential for reciprocal relationships within families of individuals with SMI. Clinicians can help clients and families maximize the support they provide to one another and possibly improve outcomes.

Consumer satisfaction with antipsychotic medication-monitoring appointments: the role of consumer-prescriber communication patterns.

OBJECTIVE: The study was designed to explore patterns of prescriber communication behaviors as they relate to consumer satisfaction among a serious mental illness sample. METHODS: Recordings from 175 antipsychotic medication-monitoring appointments between veterans with psychiatric disorders and their prescribers were coded using the Roter Interaction Analysis System (RIAS) for communication behavioral patterns. RESULTS: The frequency of prescriber communication behaviors (i.e., facilitation, rapport, procedural, psychosocial, biomedical, and total utterances) did not reliably predict consumer satisfaction. The ratio of prescriber to consumer utterances did predict consumer satisfaction. CONCLUSIONS: Consistent with client-centered care theory, antipsychotic medication consumers were more satisfied with their encounters when their prescriber did not dominate the conversation. PRACTICE IMPLICATIONS: Therefore, one potential recommendation from these findings could be for medication prescribers to spend more of their time listening to, rather than speaking with, their SMI consumers.

Patient, Provider, and System Factors Contributing to Patient Safety Events During Medical and Surgical Hospitalizations for Persons With Serious Mental Illness.

This study aimed to explore patient-, provider-, and system-level factors that may contribute to elevated risk of patient safety events among persons with serious mental illness (SMI). We conducted a medical record review of medical/surgical admissions in Maryland hospitals from 1994 to 2004 for a community-based sample of adults with SMI (N = 790 hospitalizations). We estimated the prevalence of multiple patient, provider, and system factors that could influence patient safety among persons with SMI. We conducted a case crossover analysis to examine the relationship between these factors and adverse patient safety events. Patients' mental status, level of consciousness, disease severity, and providers' lack of patient monitoring, delay/failure to seek consultation, lack of trainee supervision, and delays in care were positively associated with adverse patient safety events (p < 0.05). Efforts to reduce SMI-related patient safety risks will need to be multifaceted and address both patient- and provider-level factors.

Why We Need to Enhance Suicide Postvention: Evaluating a Survey of Psychiatrists' Behaviors after the Suicide of a Patient.

Suicide prevention efforts are increasing to enhance capabilities and better understand risk factors and etiologies. Postvention, or how clinicians manage the postsuicide aftermath, strengthens suicide prevention, destigmatizes the tragedy, operationalizes the confusing aftermath, and promotes caregiver recovery. However, studies regarding its efficacy are minimal. The Psychopathology Committee of the Group for the Advancement for Psychiatry surveyed a convenience sample of psychiatrists to better understand postvention activities. Ninety psychiatrists completed the survey; they were predominantly men (72%) with an average of 24.6 years of experience (SD, 16.7 years). Most had contact with the patient's family within 6 months of the suicide, and most psychiatrists sought some form of support. Few psychiatrists used a suicide postvention procedure or toolkit (9%). No psychiatrists stopped clinical practice after a patient suicide, although 10% stopped accepting patients they deemed at risk of suicide. Postvention efforts, therefore, should be improved to better address survivor care.