Sexual health services in urban, suburban, and rural outpatient mental healthcare settings in New York: findings from a survey of practices and gaps.

We surveyed all licensed outpatient mental health programs in New York to examine sexual health services and training needs of providers. Gaps were found in processes for assessing whether patients were sexually active, engaging in sexual risk behaviours, and in need of HIV testing and pre-exposure prophylaxis. Significant differences between urban, suburban, and rural settings statewide were found in how the following sexual health services were delivered: education; on-site sexually transmitted infection screenings; and condom distribution and barriers to distribution. Staff training in sexual health services delivery is critically needed for optimal sexual health and recovery of patients in community mental healthcare.

Challenges and Opportunities in Global Mental Health: a Research-to-Practice Perspective.

PURPOSE OF REVIEW: Globally, the majority of those who need mental health care worldwide lack access to high-quality mental health services. Stigma, human resource shortages, fragmented service delivery models, and lack of research capacity for implementation and policy change contribute to the current mental health treatment gap. In this review, we describe how health systems in low- and middle-income countries (LMICs) are addressing the mental health gap and further identify challenges and priority areas for future research. RECENT FINDINGS: Common mental disorders are responsible for the largest proportion of the global burden of disease; yet, there is sound evidence that these disorders, as well as severe mental disorders, can be successfully treated using evidence-based interventions delivered by trained lay health workers in low-resource community or primary care settings. Stigma is a barrier to service uptake. Prevention, though necessary to address the mental health gap, has not solidified as a research or programmatic focus. Research-to-practice implementation studies are required to inform policies and scale-up services. Four priority areas are identified for focused attention to diminish the mental health treatment gap and to improve access to high-quality mental health services globally: diminishing pervasive stigma, building mental health system treatment and research capacity, implementing prevention programs to decrease the incidence of mental disorders, and establishing sustainable scale up of public health systems to improve access to mental health treatment using evidence-based interventions.

Building a Diverse Psychiatric Workforce for the Future and Helping Them Thrive: Recommendations for Psychiatry Training Directors.

The COVID-19 pandemic and murder of Mr George Floyd served as catalysts for examining antiracism efforts in psychiatry training programs and health care systems. Our recruitment and retention of Black, Indigenous, and other racial/ethnic minority psychiatry trainees has not met the demand for care and does not represent the communities served. Training directors at a critical juncture in creating systemic changes to recruitment, retention, policies, and curricular competencies to address ongoing inequities and disparities in health care. We describe several strategies and considerations for training directors in supporting a diverse psychiatric workforce.

Statement of Partnership and Humility: A Structural Intervention to Improve Equity and Justice in Medical Education.

PROBLEM: Due to generational exposure to the Black Lives Matter movement, other anti-bias social movements, and diverse peer advocacy groups, health professions students are often more knowledgeable than their teachers about ways in which systemic racism and bias have led to scientific inaccuracies that contribute to health inequities. However, traditional hierarchies and concerns about retaliation may limit educational communities from benefiting maximally from students' contributions. APPROACH: In spring 2021, faculty and students at the Vagelos College of Physicians and Surgeons, Columbia University, designed a structural innovation to engage faculty and students in partnership toward decreasing bias in medical education. This article discusses development and implementation of a Statement of Partnership and Humility (SPH) disclosure slide on which faculty acknowledge consideration of potential teaching biases and invite student feedback. OUTCOMES: The initial primary goal of the SPH slide was to increase faculty awareness and engagement in anti-bias topics; however, the unexpected dividends of decreasing faculty anxiety about receiving student feedback and promoting student engagement have proven equally powerful in promoting a healthy, inclusive learning environment. NEXT STEPS: Next steps include gathering qualitative and quantitative data to elicit both faculty and student perspectives on the use of the SPH slide, particularly with regard to psychological safety and openness to feedback.

Building a Diverse Psychiatric Workforce for the Future and Helping Them Thrive: Recommendations for Psychiatry Training Directors.

The COVID-19 pandemic and murder of Mr George Floyd served as catalysts for examining antiracism efforts in psychiatry training programs and health care systems. Our recruitment and retention of Black, Indigenous, and other racial/ethnic minority psychiatry trainees has not met the demand for care and does not represent the communities served. Training directors at a critical juncture in creating systemic changes to recruitment, retention, policies, and curricular competencies to address ongoing inequities and disparities in health care. We describe several strategies and considerations for training directors in supporting a diverse psychiatric workforce.

Developing a theoretical framework for persistent cannabis use among young adults with first episode psychosis.

AIM: Cannabis use is common among individuals with first episode psychosis (FEP) and persistent use is associated with worse outcomes. The purpose of this qualitative study is to identify factors pertaining to onset of cannabis use and persistent use among young adults with early psychosis receiving coordinated specialty care (CSC) in the United States and begin to develop a theoretical framework to drive further study and hypothesis testing and inform the approach to treatment of cannabis use disorder in this setting. METHODS: Participants were ages 16-30 years with early psychosis attending a CSC program in New York State. Interviews were conducted in December 2018. Coding and analysis was conducted in Atlas.ti and themes were identified via a thematic analysis approach. RESULTS: Thirteen individuals completed the interview. The mean age in years was 20.7 and the majority were male (n = 10). Almost half (46%) were Black, non-Hispanic and 39% were Hispanic. Seven participants indicated they were currently using cannabis and six participants indicated they had stopped for at least 6 months at the time of the interview. Several themes emerged including the influence of family and social norms, motivating factors for persistent use and for reduced use or abstinence, and ambivalence regarding the impact of cannabis use on mental health. CONCLUSION: A theoretical framework emerged which may help identify future research in this area and inform the approach to treatment of cannabis use disorder in this setting.

Violence risk assessment for young adults receiving treatment for early psychosis.

AIM: Although the absolute risk of violence is small for individuals with mental illnesses, a specific subgroup of individuals who appear to be at increased risk for violence includes young people experiencing emerging or early psychosis. Prior research has identified risk factors for violence in this population, though no prior studies using a formal risk assessment tool have been identified. This study used the Historical Clinical Risk Management-20, version 3 (HCR-20) to identify risk of future violence among a sample of young adults with early psychosis and relevant predictors of risk unique to this population. METHODS: The HCR-20 was administered to a sample of young adults with early psychosis (N = 53) enrolled at one OnTrackNY site, part of a statewide program providing early intervention services to young adults presenting with a first episode of non-affective psychosis. A Confirmatory Factor Analysis (CFA) was conducted to explore the relative importance of the HCR-20 items for this population. RESULTS: The average age of participants was 21.9 years (SD 3.6 years) and most were male (69.8%, n = 37). Most patients were assessed to be at low risk for future violence based on the Case Prioritization summary risk rating (67.9%, n = 36). The CFA identified 4 items that were not of relative predictive value in identifying the risk of violence in this sample: history of substance use (item H5), history of major mental disorder (item H6), living situation (item R2), and personal support (item R3). CONCLUSION: This study presents a formal approach to assessing violence risk in a population at elevated risk of violence, demonstrates the feasibility of using a standardized risk assessment tool in early intervention services, and identifies factors of particular importance associated with predicting violence in this population. Future research should implement violence risk assessment with a structured tool such as the HCR-20 and assess its accuracy in predicting future violent behavior in this setting.

Sociodemographic, clinical and help-seeking characteristics of homeless young people with recent onset of psychosis enrolled in specialized early intervention services.

AIM: To examine differences in demographic, clinical, social, functional and help-seeking characteristics of homeless vs housed individuals enrolled in specialized early intervention teams in the United States. METHODS: Participants comprised 1349 individuals enrolled across 21 teams. Teams report individual-level data including homelessness status at admission. Bivariate differences between homeless and housed participants were analysed using Wilcoxon-rank, chi-square, Fisher-exact and t tests, as appropriate. RESULTS: Approximately 5% of participants were homeless at admission. Homeless participants were less likely to be enrolled in school and/or employed (12.2% vs 43.4%); to have more involvement in the legal system (23.0% vs 6.2%); and to have had a more restrictive pathway to care, than housed participants. CONCLUSIONS: Homeless young people with recent-onset psychosis have a substantially greater need for a diversity of services for psychosocial needs. Homeless individuals may also have a more adverse pathway to care and directed outreach to engage this population may be needed.

Partnerships in Research to Implement and Disseminate Sustainable and Scalable Evidence-Based Practices (PRIDE) in Mozambique.

BACKGROUND: Mental health conditions impose a major burden worldwide, especially in low- and middle-income countries (LMICs), where health specialists are scarce. A challenge to closing LMICs' mental health treatment gap is determining the most cost-effective task-shifting pathway for delivering mental health services using evidence-based interventions (EBIs). This article discusses the protocol for the first study implementing comprehensive mental health services in LMICs. METHODS: In partnership with the Mozambican Ministry of Health, this cluster-randomized, hybrid implementation effectiveness type-2 trial will evaluate implementation, patient, and service outcomes of three task-shifting delivery pathways in 20 Mozambican districts (population 4.7 million). In pathway 1 (usual care), community health workers (CHWs) and primary care providers (PCPs) refer patients to district-level mental health clinics. In pathway 2 (screen, refer, and treat), CHWs screen and refer patients to PCPs for behavioral and pharmacological EBIs in community clinics. In pathway 3 (community mental health stepped care), CHWs screen patients and deliver behavioral EBIs in the community and refer medication management cases to PCPs in clinics. Mixed-methods process evaluation will be used to examine factors affecting pathway implementation, adoption, and sustainability. Clinical activities will occur without research team support. Ministry of Health personnel will coordinate training and supervision. RESULTS: The most cost-effective pathway will be scaled up in all districts for 12 months. NEXT STEPS: This novel study integrating comprehensive mental health services into primary care will inform a toolkit to help the Mozambican Ministry of Health scale up the most cost-effective pathway for mental health services and can be a template for other LMICs.

Technology and implementation science to forge the future of evidence-based psychotherapies: the PRIDE scale-up study.

OBJECTIVE: To report the interim results from the training of providers inevidence-based psychotherapies (EBPs) and use of mobile applications. DESIGN AND SETTING: The Partnerships in Research to Implement and Disseminate Sustainable and Scalable Evidence (PRIDE) study is a cluster-randomised hybrid effectiveness-implementation trial comparing three delivery pathways for integrating comprehensive mental healthcare into primary care in Mozambique. Innovations include the use of EBPs and scaling-up of task-shifted mental health services using mobile applications. MAIN OUTCOME MEASURES: We examined EBP training attendance, certification, knowledge and intentions to deliver each component. We collected qualitative data through rapid ethnography and focus groups. We tracked the use of the mobile applications to investigate early reach of a valid screening tool (Electronic Mental Wellness Tool) and the roll out of the EBPs PARTICIPANTS: Psychiatric technicians and primary care providers trained in the EBPs. RESULTS: PRIDE has trained 110 EBP providers, supervisors and trainers and will train 279 community health workers in upcoming months. The trainings improved knowledge about the EBPs and trainees indicated strong intentions to deliver the EBP core components. Trained providers began using the mobile applications and appear to identify cases and provide appropriate treatment. CONCLUSIONS: The future of EBPs requires implementation within existing systems of care with fidelity to their core evidence-based components. To sustainably address the vast mental health treatment gap globally, EBP implementation demands: expanding the mental health workforce by training existing human resources; sequential use of EBPs to comprehensively treat mental disorders and their comorbid presentations and leveraging digital screening and treatment applications.

Mental Health Equity in the Twenty-First Century: Setting the Stage.

Significant mental health disparities persist in screening, diagnosis, and treatment for racial and ethnic minorities compared with non-Latinx white people. Reducing mental health disparities, and ultimately achieving mental health equity, requires understanding the wide range of factors that influence health outcomes at multiple levels. Components of an effective strategy to achieve mental health equity include increasing population-based care; increasing community-based health care services; addressing the social determinants of health; engaging the community; enhancing the pipeline; and supporting a diverse, structurally competent workforce.

Persistent cannabis use among young adults with early psychosis receiving coordinated specialty care in the United States.

Persistent cannabis use among young adults with first episode psychosis (FEP), even those receiving early intervention services, has been associated with poor outcomes. In the United States (US), Coordinated Specialty Care (CSC) has been shown to be more effective at reducing symptoms, improving quality of life and increasing involvement in work or school, compared to typical care for FEP. However, little is known about the prevalence, course and outcomes for cannabis use in this real-world, clinical setting. This study examined the prevalence, course and outcomes of cannabis use categorized into three groups: no use, reduced use, and persistent use, among a sample of 938 CSC participants enrolled for at least 1 year. Prevalence of cannabis use was 38.8% at admission and 32.8% of the sample had persistent cannabis use at 1 year. At baseline, persistent cannabis users were more likely to be male (p < .001), white, non-Hispanic and black non-Hispanic (p = .001), have worse symptoms as measured by the GAF (p < .001), increased suicidality (p = .024), violent ideation (p = .008), and legal trouble (p = .006) compared with non-users. At 1 year, persistent users maintained worse symptoms compared with non-users (p = .021) while those who reduced use had significant improvement in symptoms compared with persistent users (p = .008). This study suggests that cannabis use is common among young adults enrolled in a CSC program in the US and that persistent cannabis users may have worse outcomes while reducing cannabis use may improve outcomes. These findings highlight the potential impact of secondary prevention in this population through reduction in cannabis use.

Three Decades and Counting: HIV Service Provision in Outpatient Mental Health Settings.

OBJECTIVE: People with serious mental illness in the United States have higher human immunodeficiency virus (HIV) infection rates than the general U.S. population. This study aimed to assess delivery of HIV services in New York State's outpatient mental health programs. Greater access would enhance efforts to improve HIV prevention and care outcomes. METHODS: The authors surveyed directors of licensed outpatient mental health care programs statewide to investigate their HIV service delivery. Data were compared with surveys conducted in 1997 and 2004 in order to examine differences in services between geographic regions and time periods. RESULTS: Outpatient mental health programs have improved in the volume and range of HIV services offered, but their provision of preexposure prophylaxis, condoms, HIV testing, and HIV antiretroviral treatment monitoring has lagged. CONCLUSIONS: New York's initiative to end the HIV epidemic is not optimized to reach people with serious mental illness in settings designed for their care.

Perspectives of Individuals With Serious Mental Illness on a Reverse-Colocated Care Model: A Qualitative Study.

OBJECTIVE: Individuals with serious mental illness experience excess mortality related to general medical comorbidities. Reverse-integrated and reverse-colocated models of care have been proposed as a system-level solution. Such models integrate primary care services within behavioral health settings. Further understanding of consumer perspectives on these models is needed to ensure that models adequately engage consumers on the basis of their expressed needs. This qualitative study examined the perspectives of English- and Spanish-speaking individuals with serious mental illness on their current experience with the management of their medical care and on a hypothetical reverse-colocated care model. METHODS: Semistructured interviews were conducted in a purposive sample of 30 individuals with serious mental illness recruited from two outpatient mental health clinics affiliated with a comprehensive community-based program. The interview assessed the participant's current experience with the management of their health care, followed by a vignette describing a reverse--colocated care model and questions to elicit the participant's reaction to the vignette. An inductive thematic analysis was employed. RESULTS: Consumers expressed positive views of the potential for working with trusted staff, increased communication, and access to care through reverse colocation. Reflections on current health management experience were notable for an emphasis on self-efficacy and receipt of support for self-management strategies from mental health clinicians. CONCLUSIONS: Study findings add to prior literature indicating support for assistance with management of general medical health in the mental health setting among individuals with serious mental illness. Key themes similar to those in previous studies generate hypotheses for further evaluation.

The Washington Heights Community Service model: positive outcomes and implications for reimbursement under the ACA.

Medicare and the Affordable Care Act (ACA) base reimbursement partly on hospital readmission rates, but there is little guidance for providers to reduce these rates. This column describes a model of care used by Washington Heights Community Service (WHCS) in New York City. Without benefit of external funding, WHCS has implemented practices, such as family involvement at all treatment levels, community outreach, effective medication prescribing, shared electronic medical records, and proactive provider communication, that have led to lower rates of readmission in addition to low rates of admission and emergency room use and a high rate of outpatient follow-up--all particularly relevant in this era of ACA mandates.