Three things we learned along the way: lessons for training in psychiatric epidemiology.

The coronavirus disease 2019 (COVID-19) pandemic, and its associated mortality, morbidity, and deep social and economic impacts, was a global traumatic stressor that challenged population mental health and our de facto mental health care system in unprecedented ways. Yet, in many respects, this crisis is not new. Psychiatric epidemiologists have recognized for decades the need and unmet need of people in distress and the limits of the public mental health services in the United States. We argue that psychiatric epidemiologists have a critical role to play as we endeavor to address population mental health and draw attention to 3 areas of consideration: elevating population-based solutions; engaging equitably with lived experience; and interrogating recovery. Psychiatric epidemiology has a long history of both responding to and shaping our understanding of the relationships among psychiatric disorders and society through evolving methods and training, and the current sociohistorical moment again suggests that shifts in our practice can strengthen our field and its impact. This article is part of a Special Collection on Mental Health.

Intervention recommendations to improve uptake of breast, cervical, and colorectal cancer screening among individuals living with serious mental illness.

PURPOSE: Few efforts have been made to inform intervention design for increasing the uptake of cancer screening in individuals living with serious mental illness (ILSMI), who have lower cancer screening rates than the general population. This qualitative study explored ILSMI's and their care team member's (CTM) recommendations on the design of a breast, colorectal, and cervical cancer screening intervention for ILSMI. METHODS: Twenty-five ILSMI (mean age: 71.4 years; 60% female) and 15 CTM (mean age: 45.3 years; 80% female) were recruited through purposive sampling. Semi-structured in-depth interviews were used to collect participants' intervention suggestions. Interviews were recorded, transcribed verbatim, and imported into NVivo. Content analysis and the constant comparison method were used to analyze interview data. RESULTS: ILSMI and CTMs provided several salient recommendations. ILSMI should receive disease-specific, logistical, and screening education, and primary care staff should receive education on psychopathology. Mental health providers and patient navigators should be considered as the primary interventionist. The intervention should be delivered where ILSMI receive medical or mental health services, receive community and government services, and/or via various digital media. The intervention should improve the collaboration, communication, and coordination between primary and mental health care. Findings also pointed to the implementation of trauma-informed cancer care and integrated care models comprising mental health care and primary cancer care. CONCLUSION: These findings bring the skills, knowledge, and expertise of ILSM and their care team to intervention design for increasing colorectal, breast, and cervical cancer screening in ILSMI attending an intensive outpatient program.

A phenomenological inquiry into the costs and consequences of insomnia for veterans with serious mental illness.

Many individuals with serious mental illness (i.e. schizophrenia spectrum, bipolar or major depressive disorders, with serious functional impairments) have insomnia symptoms. Insomnia is a common reason for mental health referrals in the Veterans Health Administration. The primary aim of this study was to explore the costs (what participants lose or what trade-offs they make due to insomnia) and consequences (how insomnia impacts functioning) of insomnia for veterans with serious mental illness. Semi-structured interviews of 20 veterans with insomnia and serious mental illness were collected as data using an inductive phenomenological approach. Two main themes were identified: Sleep Affects Mental Health and Functioning; and Compromising to Cope. Results illuminate pathways by which sleep effort destabilizes functional recovery, and illustrate how sleep has multiplicative positive impacts on functioning and mood. Researchers and clinicians alike must explore supporting people with serious mental illness in replacing sleep effort with the recovery of meaningful identity-driven, values-based experiences formerly conceded due to serious mental illness, insomnia or both.

Clinician Perspectives on Palliative Care for Older Adults With Serious Mental Illnesses: A Multisite Qualitative Study.

OBJECTIVES: Approximately 5.5% of the population live with serious mental illnesses (SMI). Older adults with SMI experience a high burden of serious medical illnesses and disparities in advance care planning, symptom management, and caregiver support. The objectives of this study are to explore interdisciplinary clinician perspectives on the palliative care needs of older adults with SMI and serious medical illnesses. DESIGN, SETTING, AND PARTICIPANTS: This qualitative study utilized thematic analysis of semi-structured interviews of interdisciplinary clinicians practicing palliative care, geriatrics, or geriatric/consultation-liaison psychiatry at four hospitals within an urban health system. MEASUREMENTS: Themes related to care of older adults with serious mental illness and serious medical illness with respect to clinician experiences, challenges in care, and opportunities to improve care. RESULTS: The authors interviewed 45 clinicians. Major themes identified were: (1) Current paradigms of palliative care do not meet the needs of patients with SMI; (2) Clinicians are motivated to care for this population but require more training and interdisciplinary practice; (3) There is a need for structural integration of psychiatric and palliative care services. CONCLUSIONS: The study underscores the inadequacy of current palliative care models in meeting the unique needs of older adults with SMI. Models of integrated psychiatric and serious illness care and enhanced training are needed to improve the delivery of palliative care. Integrated care models and workforce development at the interface of serious illness care and psychiatric have the potential to improve outcomes for this vulnerable population.

Targeted learning in observational studies with multi-valued treatments: An evaluation of antipsychotic drug treatment safety.

We investigate estimation of causal effects of multiple competing (multi-valued) treatments in the absence of randomization. Our work is motivated by an intention-to-treat study of the relative cardiometabolic risk of assignment to one of six commonly prescribed antipsychotic drugs in a cohort of nearly 39 000 adults with serious mental illnesses. Doubly-robust estimators, such as targeted minimum loss-based estimation (TMLE), require correct specification of either the treatment model or outcome model to ensure consistent estimation; however, common TMLE implementations estimate treatment probabilities using multiple binomial regressions rather than multinomial regression. We implement a TMLE estimator that uses multinomial treatment assignment and ensemble machine learning to estimate average treatment effects. Our multinomial implementation improves coverage, but does not necessarily reduce bias, relative to the binomial implementation in simulation experiments with varying treatment propensity overlap and event rates. Evaluating the causal effects of the antipsychotics on 3-year diabetes risk or death, we find a safety benefit of moving from a second-generation drug considered among the safest of the second-generation drugs to an infrequently prescribed first-generation drug known for having low cardiometabolic risk.

Integrated Physical-Mental Healthcare Services in Specialist Settings to Improve Outcomes for Older People Living With Mental Health Diagnoses: A Systematic Review.

BACKGROUND: Many older people are now living with co-occurring physical and mental health disorders, but these often managed separately. The aim of this systematic review was to explore integrated physical-mental health care services available internationally for older people living with mental health diagnoses, and whether these result in improved health outcomes. METHODS: Medline, Embase, CINAHL, PsycINFO and Scopus were searched with a predefined search strategy (PROSPERO: CRD42022383824), generating 6210 articles. Studies were included where an integrated physical-mental health care service model was utilised in a population of older people (aged >60 years) with a mental health diagnosis (including dementia or cognitive impairment) and at least one concomitant physical health condition requiring physical health care input. All studies were assessed for risk of bias (ROB 2.0, ROBINS-I) and results were synthesised narratively. RESULTS: Nine studies were included across inpatient (n = 6, 1262 patients) and community (n = 3, 466 patients) settings. Studies were rated as low-moderate risk of bias. These covered joint physical-mental health wards, liaison services, embedded physicians in mental health wards, and joint multidisciplinary teams. Services with greater integration (e.g., joint wards) had more benefits for patients and carers. There were few benefits to traditional outcomes (e.g., hospital admissions, mortality), but greater care quality, carer satisfaction, and improved mood and engagement were demonstrated. CONCLUSIONS: Multidisciplinary integrated care resulted in improvement of a range of health outcomes for older people with combined physical and mental health needs. Larger and more robust studies are needed to explore the development of these service models further, with cost-effectiveness analyses.

Mental health interventions for individuals with serious mental illness in the criminal legal system: a systematic review.

BACKGROUND: Globally, individuals with mental illness get in contact with the law at a greater rate than the general population. The goal of this review was to identify and describe: (1) effectiveness of mental health interventions for individuals with serious mental illness (SMI) who have criminal legal involvement; (2) additional outcomes targeted by these interventions; (3) settings/contexts where interventions were delivered; and (4) barriers and facilitating factors for implementing these interventions. METHODS: A systematic review was conducted to summarize the mental health treatment literature for individuals with serious mental illness with criminal legal involvement (i.e., bipolar disorder, schizophrenia, major depressive disorder). Searches were conducted using PsychINFO, Embase, ProQuest, PubMed, and Web of Science. Articles were eligible if they were intervention studies among criminal legal involved populations with a mental health primary outcome and provided description of the intervention. RESULTS: A total of 13 eligible studies were identified. Tested interventions were categorized as cognitive/behavioral, community-based, interpersonal (IPT), psychoeducational, or court-based. Studies that used IPT-based interventions reported clinically significant improvements in mental health symptoms and were also feasible and acceptable. Other interventions demonstrated positive trends favoring the mental health outcomes but did not show statistically and clinically significant changes. All studies reported treatment outcomes, with only 8 studies reporting both treatment and implementation outcomes. CONCLUSION: Our findings highlight a need for more mental health research in this population. Studies with randomized design, larger sample size and studies that utilize non-clinicians are needed.

Factors Associated with Transition to Serious Mental Illness.

OBJECTIVE: There is increasing interest in early intervention and detection strategies for youth at-risk of developing a serious mental illness (SMI). Little is known about early factors that may be related to the later development of a SMI; thus, the aim of this study was to determine what clinical factors might relate to the development of in this study psychosis, bipolar disorder and severe or recurrent major depression in at-risk youth. METHOD: The sample consisted of 162 youth aged 12-26 years at different stages of risk. Thirty-one participants developed a SMI during the study. Those who made a transition were compared on a range of baseline clinical and functional measures with those who did not make the transition. A Cox regression model was used to assess the association between measures and later development of a SMI. RESULTS: Female sex, attenuated psychotic symptoms as assessed with the Scale of Psychosis-Risk Symptoms (SOPS) and ratings on the K-10 Distress Scale, were found to be significantly associated with the later transition to mental illness. Females were 2.77 times more likely to transition compared to males. For the SOPS and K-10 scales, there is a 14% increase in the transition rate relative to a one-scale increase in SOPS and a 7% increase in the transition rate relative to a one-point increase in the K-10. CONCLUSIONS: Results from these longitudinal data provide further insight into the specific clinical measures that may be pertinent in early detection of mental illnesses.

Tailored vs. General COVID-19 prevention for adults with mental disabilities residing in group homes: a randomized controlled effectiveness-implementation trial.

BACKGROUND: People with serious mental illness (SMI) and people with intellectual disabilities/developmental disabilities (ID/DD) are at higher risk for COVID-19 and more severe outcomes. We compare a tailored versus general best practice COVID-19 prevention program in group homes (GHs) for people with SMI or ID/DD in Massachusetts (MA). METHODS: A hybrid effectiveness-implementation cluster randomized control trial compared a four-component implementation strategy (Tailored Best Practices: TBP) to dissemination of standard prevention guidelines (General Best-Practices: GBP) in GHs across six MA behavioral health agencies. GBP consisted of standard best practices for preventing COVID-19. TBP included GBP plus four components including: (1) trusted-messenger peer testimonials on benefits of vaccination; (2) motivational interviewing; (3) interactive education on preventive practices; and (4) fidelity feedback dashboards for GHs. Primary implementation outcomes were full COVID-19 vaccination rates (baseline: 1/1/2021-3/31/2021) and fidelity scores (baseline: 5/1/21-7/30/21), at 3-month intervals to 15-month follow-up until October 2022. The primary effectiveness outcome was COVID-19 infection (baseline: 1/1/2021-3/31/2021), measured every 3 months to 15-month follow-up. Cumulative incidence of vaccinations were estimated using Kaplan-Meier curves. Cox frailty models evaluate differences in vaccination uptake and secondary outcomes. Linear mixed models (LMMs) and Poisson generalized linear mixed models (GLMMs) were used to evaluate differences in fidelity scores and incidence of COVID-19 infections. RESULTS: GHs (n=415) were randomized to TBP (n=208) and GBP (n=207) including 3,836 residents (1,041 ID/DD; 2,795 SMI) and 5,538 staff. No differences were found in fidelity scores or COVID-19 incidence rates between TBP and GBP, however TBP had greater acceptability, appropriateness, and feasibility. No overall differences in vaccination rates were found between TBP and GBP. However, among unvaccinated group home residents with mental disabilities, non-White residents achieved full vaccination status at double the rate for TBP (28.6%) compared to GBP (14.4%) at 15 months. Additionally, the impact of TBP on vaccine uptake was over two-times greater for non-White residents compared to non-Hispanic White residents (ratio of HR for TBP between non-White and non-Hispanic White: 2.28, p = 0.03). CONCLUSION: Tailored COVID-19 prevention strategies are beneficial as a feasible and acceptable implementation strategy with the potential to reduce disparities in vaccine acceptance among the subgroup of non-White individuals with mental disabilities. TRIAL REGISTRATION: ClinicalTrials.gov, NCT04726371, 27/01/2021. https://clinicaltrials.gov/study/NCT04726371 .

Mental health care use and quality among Medicaid adults with serious mental illness receiving care at Federally Qualified Health Centers vs. other settings.

BACKGROUND: Federally Qualified Health Centers (FQHCs) are a critical source of care for medically underserved populations and often serve as medical homes for individuals with serious mental illness (SMI). Many FQHCs provide mental health services and could facilitate access to mental health treatment within and outside of FQHCs. This study compared mental health care utilization and acute care events for adult Medicaid enrollees with SMI who receive care at Federally Qualified Health Centers (FQHCs) vs. other settings. METHODS: This study used the 2015-2016 Massachusetts All-Payer Claims Database to examine outpatient mental health care and acute care events for 32,330 Medicaid adults, ages 18-64 and with major depressive, bipolar, or schizophrenia spectrum disorders (SSD), who resided in FQHC service areas and received care from FQHCs vs. other settings in 2015. Multivariable linear regressions assessed associations between receiving care at FQHCs and outpatient mental health visits, psychotropic medication fills, and acute care events in 2016. RESULTS: There were 8,887 (27.5%) adults in the study population (N = 32,330) who had at least one FQHC visit in 2015. Those who received care at FQHCs were more likely to have outpatient mental health visits (73.3% vs. 71.2%) and psychotropic medication fills (73.2% vs. 69.0%, both p < .05), including antidepressants among those with depressive disorders and antipsychotics among those with SSD. They were more likely to have ED visits (74.0% vs. 68.7%), but less likely to be hospitalized (27.8% vs. 31.9%, both p < .05). However, there was no significant difference in the likelihood of having an acute psychiatric hospitalization (9.5% vs. 9.8%, p = .35). CONCLUSIONS: Among Medicaid enrollees with SMIs who had access to care at FQHCs, those receiving care at FQHCs were more likely to have outpatient mental health visits and psychotropic medication fills, with lower rates of hospitalization, suggesting potentially improved quality of outpatient care. Higher ED visit rates among those receiving care at FQHCs warrant additional investigation.

Lived experiences: Growing up with a seriously mentally ill parent.

INTRODUCTION: Individuals with serious mental illness often have persistent and disruptive symptoms. These can profoundly affect their children's lives, exposing them to adverse social and psychological conditions. Such conditions can result in traumatic lived experiences during childhood, which can carry over into adulthood, influencing their self-perceptions and shaping their attitudes toward themselves and society. To gain insights into this phenomenon, this study explored the lived experiences of adults who grew up with a parent with serious mental illness and their perceptions of their lives in adulthood. DESIGN: This study used an interpretive phenomenological design. METHODS: Participants were invited to voluntarily participate in the study through a call posted on social media. Semi-structured interviews were conducted with 30 adults (age range, 20-55 years) who grew up with a parent with serious mental illness. The interviews were recorded and transcribed, and inductive thematic analysis was used to identify main and overarching themes. RESULTS: The overarching theme of transition from childhood survival to adulthood survival emerged and included four main themes: (1) a traumatic childhood, (2) perceived control, (3) resilience and general self-efficacy, and (4) adult quality of life. A traumatic childhood consisted of experiences of neglect and abuse, while participants used perceived control to achieve personal growth, self-care, and care of others. Resilience and general self-efficacy emerged during the transition to adulthood and helped participants further their social status and strengthen family bonds. Lastly, adult quality of life was described as being disturbed by feelings of loneliness and being burdensome, stemming from an inherent tendency to rely solely on themselves, leading to trust issues and mental health complications. Therefore, these adults found it difficult to reach out and get help or treatment for their concerns, as they initially did not want to appear dysfunctional or in need. CONCLUSION: This study has illuminated the lived experiences of a specific, vulnerable population that has not been intentionally explored until now. To delve into these experiences, we employed a distinctive qualitative approach, merging the interpretive phenomenological perspective with an inductive thematic analysis. This allowed for rich insight with a relatively large group of participants and enabled an in-depth exploration within this methodological framework. Consequently, this study constitutes a notable contribution to the extant body of knowledge, exploring the intricacies of personal growth and its impact on participants' quality of life. It uncovers the essence of resilience and general self-efficacy, revealing how these elements intertwine with the negative results observed. However, the study findings emphasize the need for healthcare professionals, including nurses and other caregivers, to be mindful of the long-lasting effects of the adverse experiences of children of patients with serious mental illness. Prioritizing active clinical assessment and implementing tailored interventions to address such children's specific needs and difficulties across different developmental stages is imperative. Such comprehensive and targeted approaches are crucial in providing appropriate support and promoting the well-being of these individuals. CLINICAL RELEVANCE: Enhanced clinical attention in holistic psychiatric care is crucial for individuals and their relatives, especially children. Comprehensive assessments of children and adults raised by seriously mentally ill parents can enable tailored and preventive interventions, positively impacting overall quality of life.

Family Caregivers' Trajectories of Distress While Caring for a Person With Serious Mental Illness.

Serious mental illness (SMI) can significantly impact the lives of individuals and their families. These families often experience great emotional distress over time due to the early onset of SMI, which in turn leads to long-term trajectories and only partial recovery. However, we do not fully understand the emotional distress of family caregivers. Thus, our aim was to enrich the understanding of the lived experiences of family caregivers' emotional trajectories of distress while caring for persons with SMI. We conducted a secondary analysis using a hermeneutic approach to the narratives of seven family caregivers from a study on living with voices unheard by others. Participants' trajectories of emotional distress came forth as being thrust on an unpredictable, intensely worrisome, and indefinite journey. The following themes highlighted this tumultuous journey: fumbling in the dark trying to grasp the incomprehensible, "on your toes"-enduring unpredictability, facing different forms of fear, and battling waves of sadness and regret. Caregivers face multiple threats to their well-being and sometimes even to their health. Their distress appeared to vary according to their relationship with the person with SMI, whether they lived with the ill person, illness trajectory, and amount of violent or suicidal behavior. The results underscore the need for individualized and timely information, opportunities for dialogue with healthcare providers with and without the person with SMI, and inclusion in care planning. Caregivers who have experienced trauma, threats of violence, and rejection require special attention.

Prevalence, Characteristics, and Reasons for Kratom Use among Psychiatrically Ill Inpatients Who Use Substances.

OBJECTIVE: Despite kratom impacting neurobiological systems involved in psychiatric disorders, little is known about the prevalence of use among patients with severe psychopathologies. Here, we investigated the prevalence of kratom use, motives for use, and the clinical associations among inpatients with severe psychiatric disorders. METHODS: A total of 578 patients, aged 18 to 65, were evaluated by New Hampshire Hospital's Addiction Services from January 1, 2020, to February 28, 2022. The study collected demographic information and used chi-square tests, multivariable logistic regression, and subgroup analyses with 95% confidence intervals to examine trends among kratom users. A receiver operating characteristic curve analysis was also conducted. All statistical tests were performed using IBM SPSS Version 28.0.1. RESULTS: Of the patients assessed, 2.2% (n = 13) reported using kratom. The reasons for kratom use were managing withdrawal symptoms (15.4%), maintaining sobriety and reducing cravings for opioids (53.8%), improving focus and concentration (30.8%), alleviating low moods (38.5%), and managing pain (15.4%). Compared to non-kratom users, the only factor with a fair to good association with kratom use is postsecondary education (Area Under Curve, AUC = 0.77). CONCLUSIONS: Prevalence of kratom use among patients with serious mental illness at our site aligns with that reported in the general population. Users often cite self-management of cravings and sobriety from opioids, as well as treatment of low mood states, as motivations for consumption. While observations suggest a possible association between kratom use and individuals with post-secondary education, multiple substance use, and experience of substance-induced psychosis or mood disorders, it is essential to interpret these links cautiously until further rigorous studies are carried out to substantiate these findings.

The Way I See It: Older Adults with Mental Illness Share Their Views of Community Life Using Photovoice.

The importance of community involvement for both older adults and individuals coping with mental illness is well documented. Yet, barriers to community integration for adults with mental illness such as social stigma, discrimination, and economic marginalization are often exacerbated by increased health and mobility challenges among older adults. Using photovoice, nine older adults with mental illness represented their views of community in photographs and group discussions over a six-week period. Participant themes of community life included physical spaces, valued social roles, and access to resources in the community. Themes were anchored by older adults' perceptions of historical and cultural time comparisons between 'how things used to be' and 'how things are now.' Barriers to community integration were often related to factors such as age, mobility, and resources rather than to mental health status. Program evaluation results suggest photovoice can promote self-reflection, learning, and collaboration among older adults with mental illness.

The Role of Acceptance in Everyday Loneliness Among Adults with Serious Mental Illness.

There is a high prevalence of loneliness among adults with serious mental illness (SMI) with most research focusing on stable contributing factors. This study sought to identify the role of dispositional loneliness and internalized stigma, as well as the momentary feelings of acceptance on experiential loneliness among adults with SMI. Data were collected using ecological momentary assessment via smart phones, and 89 adults with a SMI were included. Hierarchical linear modeling was used to identify the role of dispositional and experience factors in experiential loneliness. Findings indicated that (a) dispositional internalized stigma, (b) being at home, (c) being alone and, (d) a cross-level interaction between dispositional loneliness and feelings of acceptance best fit the data. The relationship of acceptance to experiential loneliness was strongest among the most lonely. Supporting people with SMI to develop social connections contributing to their relational value may enhance feelings of acceptance and reduce loneliness.

Factors to Improve Reverse Integration: A Mixed Method Embedded Design Study.

Individuals with serious mental illness face inequity in receiving primary care services. The Substance Abuse and Mental Health Services Administration (SAMHSA) granted funds to Certified Community Behavioral Health Clinics (CCBHC) to integrate primary care and behavioral health specialties to increase access to care. This mixed method study aimed to measure the SAMHSA-defined levels of reverse integration at a CCBHC at one point in time. Providers and patients provided feedback through semi-structured interviews. Qualitative data was investigated for themes, while the quantitative data was run through inferential analysis with the Kruskal Wallis H test. Clinically meaningful results showed people using primary care at the integrated clinic were more satisfied and were more apt to continue seeing their current providers than those receiving non-integrated care. The CCBHC achieved level 4 integration; factors investigated confirmed proximity alone does not necessitate integration without effective communication and implementation of practice changes.

Recipients of Representative Payeeship with Mental Illness: Financial Leverage, Conflict, and Satisfaction.

This study aimed to examine self-report of financial leverage, conflict, and satisfaction pertaining to representative payeeship for persons with mental illness, which research has not examined in the past decade. Sixty representative payee recipients with mental illness residing across the U.S. completed an online survey, with most (n = 50) receiving representative payeeship by family members/friends. Wilcoxon-Mann-Whitney tests and Spearman correlations were computed. One-third of participants reported experiencing financial leverage and conflict "sometimes" or more often and were dissatisfied with their representative payee arrangement. With the exception of use of alcohol and/or drugs, no participant characteristic was associated with financial leverage, conflict, or satisfaction. Financial leverage was reported to be greater when representative payees were family members/friends. Financial leverage and conflict were positively associated with each other and negatively associated with satisfaction. It is advisable that satisfaction with representative payeeship be increased and conflict resulting from representative payeeship be minimized.

'Life Minus Illness = Recovery': A Phenomenological Study About Experiences and Meanings of Recovery Among Individuals with Serious Mental Illness from Southern India.

Traditional medical models have given way to recovery-oriented approaches over the years in the management of individuals with serious mental illnesses. However, very little is known about such recovery-based models in the Indian context. This qualitative study used a phenomenological approach to explore the experiences and meanings of recovery among individuals with serious mental illness in southern India. Purposive sampling with maximum variation was used to recruit participants. In-depth interviews were conducted with ten participants, using a semi-structured interview guide. Thematic analysis resulted in three themes: "The illness journey," "Life minus illness = Recovery," and "It takes a village to recover,". Illness and recovery seemed to be two sides of the same coin with the context playing an influential role in the perceptions of recovery. The term "recovery" seemed to be a misnomer giving the impression that one is expected to return to an illness free state.

Promoting Reflection on the Process of Recovery: Unique Contributions from Literature and the Humanities for Practitioner.

Recovery from serious mental illness requires persons to make their own meaning and deal with evolving challenges and possibilities. Psychiatric rehabilitation thus must offer more than manualized curricula that address symptoms and skills. We suggest that exposure to the humanities and in particular literature may offer practitioners unique avenues for developing interventions that are sensitive to the processes that enable meaning to be made. We suggest that through what the poet Keats called negative capability, reading novels may enhance practitioners? abilities to see and accept uncertainty, tolerate ambiguity without need for complete resolution, and accept the complex and ambiguous nature of persons. As an illustration we described how reading two novels, The Trial and Slaughterhouse-Five enhanced the process of meaning making while supporting the recovery of one prototypical person with serious mental illness during his efforts to make sense of his experience of returning to work.

Prevalence and Predictors of Medical Mistrust Among African Americans with Serious Mental Illness Receiving Care in an Urban Setting.

Patients with serious mental illness are reported to have a 10-25 year reduction in life expectancy. Medical mistrust may influence their willingness to seek care (Bynum, S. A., Davis, J. L., Green, B. L., & Katz, R. V. (2012). Unwillingness to participate in colorectal cancer screening: Examining fears, attitudes, and medical mistrust in an ethnically diverse sample of adults 50 years and older. American Journal of Health Promotion : Ajhp, 26(5), 295-300. https://doi.org/10.4278/ajhp.110113-QUAN-20 ). This cross-sectional study used baseline data from a SAMHSA funded demonstration project to describe the prevalence and of medical mistrust among a sample of African American adults with serious mental illness. Medical mistrust was identified using the Medical Mistrust Scale. One hundred and fifty-four participants completed the medical mistrust scale. Approximately, a third (34.4%) reported medical mistrust. After adjusting for financial stability, those endorsing medical mistrust reported nearly 3 times the odds of lacking support (AOR [95% CI]: 2.84 [1.01-7.97]) compared to those not endorsing medical mistrust. The study is among the first to describe elevated rates of medical mistrust among a sample of African Americans people with serious mental illness. An association between medical mistrust and lack of social support was demonstrated.