Psychologists and Integrated Behavioral Health Simulation Training: A Survey of Medical Educators and Perspectives of Directors of Clinical Training.

It is well established that the integration of behavioral healthcare into the medical home model improves patient outcomes, reduces costs, and increases resident learning. As academic health centers increasingly integrate behavioral healthcare, targeted training for interprofessional collaboration around behavioral healthcare is needed. Simulation educational approaches potentially can provide this training. Health service psychologists are well-poised to support this because of their specialized training in integrated healthcare. The present exploratory study aimed to evaluate existing simulation programs and develop recommendations for integrated behavioral health training and evaluation. Directors of ACGME accredited residency programs that are high utilizers of the medical home model (Pediatrics, Internal Medicine, Medicine/Pediatrics, Family Medicine) as well as Psychiatry residencies and medical schools with membership in the Society for Simulation in Healthcare were recruited to complete a 26-item survey to assess program usage of psychologists as part of simulation training for integrated behavioral healthcare services. Of 79 participants who completed initial items describing their training program, only 32 programs completed the entire survey. While many academic health centers offered integrated team and behavioral health simulations, few utilized psychology faculty in design, implementation, and evaluation. Other behavioral health providers (psychiatrists, social workers) were often involved in medical school and pediatric residency simulations. Few institutions use standardized evaluation. Qualitative feedback and faculty-written questionnaires were often used to evaluate efficacy. Survey responses suggest that psychologists play limited roles in integrated behavioral healthcare simulation despite their expertise in interdisciplinary training, integrated behavioral healthcare, and program evaluation.

Financial stress and debt in clinical psychology doctoral students.

INTRODUTION: Few studies examine the financial burden of clinical psychology doctoral programs and its impact on achievements, stress, and mental health. OBJECTIVES: The current study sought to better understand students' financial stress and debt, and how financial stress may impact their mental health and the attainment of personal and professional milestones. METHOD: Students (N = 912) completed an online survey assessing demographics, sources of income and expenditures, mental health, and milestones. RESULTS: After accounting for yearly inflation, stipends have not kept pace with the average cost of living in the United States. Over one-third of students indicated that they had no expendable pretax income after paying for their education and typical living expenses. Additionally, over 80% reported acquiring additional debt in graduate school to offset their living expenses. Financial concerns were associated with delays in major life milestones (e.g., buying a car/house, getting married/starting a family, having children), as well as avoiding medical (34.2%) or mental (41.4%) health care, with 17.5% of participants experiencing a health crisis they could not afford while in graduate school. Financial stress was associated with an increase in time spent thinking about finances, higher rates of depression and anxiety symptoms, and decreased sleep. CONCLUSION: Many clinical psychology doctoral students experience financial stress and are often unable to afford basic educational, personal living, and health care expenses, likely worsening mental health. Academic programs and leadership are encouraged to increase student stipends, improve financial transparency, provide access to health care, and alleviate financial stress and debt.

The differential impact of COVID-19 across health service psychology students of color: An embedded mixed-methods study.

OBJECTIVES: Communities of color in the United States systematically experience inequities in physical and mental health care compared to individuals who identify as non-Hispanic White. The coronavirus disease 2019 (COVID-19) pandemic exacerbated these structural drivers of inequity to disproportionate and devastating effects for persons of color. In addition to managing the direct effects of COVID-19 risk, persons of color were also navigating increased racial prejudice and discrimination. For mental health professionals and trainees of color, the effects of COVID-19 racial health disparities and the increase in acts of racism may have been compounded by their work responsibilities. The current study used an embedded mixed-methods approach to examine the differential impact of COVID-19 on health service psychology (HSP) students of color as compared to their non-Hispanic White peers. METHOD: Using quantitative and qualitative data from the Epidemic-Pandemic Impacts Inventory, measures of perceived support and of discrimination, and open-ended questions about students' experiences with racism and microaggressions, we examined the extent to which different racial/ethnic HSP student groups experienced COVID-19-related discrimination, the impacts of COVID-19 felt by students of color, and how these experiences differed from those of their non-Hispanic White peers. RESULTS: HSP students of color endorsed greater impacts of the pandemic on both self and others in the home, perceived themselves as less supported by others, and reported more experiences of racial discrimination than non-Hispanic White HSP students. CONCLUSION: Throughout the graduate experience, HSP students of color and their experiences of discrimination need to be addressed. We provided recommendations to HSP training program directors and students both during and after the COVID-19 pandemic.

Role Distinctions and Role Overlap Among Behavioral Health Providers.

Integrated behavioral health care (IBHC) models are a growing trend for health care delivery, particularly in the primary setting. Clinicians working within IBHC contexts provide a spectrum of behavioral health services, including screening, prevention and health promotion, assessment, and treatment services. Integration of behavioral health providers into primary and specialty medical settings addresses the significant need for behavioral health services, improves care quality, improves patient experience, and reduces costs of care, access issues, and delays in service provision. While benefits are clear, what type of model to implement and which behavioral health care providers to include in that model remain elusive. This is partly due to the failure of IBHC models to include all behavioral health providers in their design, a lack of clarity of the expertise of each provider, and how providers work together. IBHC models are also complicated by contextual issues such as the relative availability of each profession, population health needs in different clinic populations, and financial factors. The purpose of this manuscript is to the clarify roles and responsibilities of different behavioral health professions including similarities and differences in their training, areas of unique expertise (role distinctions), shared responsibilities (role overlap), and relative cost and availability in the United States.

Characterizing changes in mental health-related outcomes for health service psychology graduate students during the first year of the COVID-19 pandemic.

OBJECTIVES: Health service psychology (HSP) graduate students experienced adverse mental health outcomes during COVID-19. However, little is known about how mental health outcomes changed in this population after the onset of COVID-19. METHODS: N = 496 HSP graduate students reported onset or worsening of mental health outcomes, inability to access mental health care, worry about COVID-19, and stress at two different timepoints during the first year of the COVID-19 outbreak (timepoint 1: May 1 to June 25, 2020; timepoint 2: September 2 to October 17, 2020). This study tested whether mental health outcomes improved, worsened, or stayed stable during this timeframe. The study also examined whether rising COVID-19 case rates in the state where a participant lived moderated changes in mental health outcomes. RESULTS: Overall, HSP graduate students endorsed adverse mental health outcomes at a higher rate during the first survey relative to the second survey. Even still, 62.68% of students reported worsened mental health symptoms, 49.84% reported worsened sleep, and 23.92% reported increased alcohol and substance use in the 2 months leading up to the second survey. CONCLUSION: HSP programs should monitor graduate students' evolving mental health, provide wellness resources, and adopt flexible approaches to support graduate students navigating training during periods of immense disruption.

Clinical psychology PhD students' admission experiences: Implications for recruiting racial/ethnic minority and LGBTQ students.

AIM: The purpose of this study was to explore differences in the clinical psychology PhD program admissions experience (i.e., interviewing and decision-making) by race/ethnicity and lesbian, gay, bisexual, transgender, and queer (LGBTQ) identity. METHODS: Participants were 803 students (24% racial/ethnic minority; 19% LGBTQ) enrolled in US clinical psychology PhD programs. Two-group comparisons tested for differences in admission experiences by race/ethnicity and LGBTQ identity. RESULTS: Racial/ethnic minority and LGBTQ students considered a programmatic commitment to diversity as more important in application decisions compared to non-Hispanic White and cisgender heterosexual students, respectively. LGBTQ students were more likely to be advised to not discuss personal information (e.g., sexual orientation) than cisgender heterosexual students. Racial/ethnic minority and LGBTQ students identified financial considerations and program outcomes as more important in their decision-making compared with non-Hispanic White and cisgender heterosexual students, respectively. CONCLUSION: Increasing funding and fostering authentic training environments should be prioritized in institutional conversations around recruiting racial/ethnic minority and LGBTQ trainees.

Mental health concerns and barriers to care among future clinical psychologists.

Few studies have examined the mental health of clinical psychology doctoral students, a unique group given their education and training in psychopathology, assessment, and intervention. Students (N = 912) completed an online survey assessing demographics, mental health, mental healthcare utilization, and barriers to care during graduate school. Nearly 25% of participants reported moderate to severe symptoms of anxiety, 20% reported moderate to severe symptoms of depression or suicidal intent (SI), and more than 10% reported a high risk of alcohol abuse or moderate to severe drug use during graduate school. In comparison to peers, ethnic minority and lesbian, gay, bisexual, transgender, and queer (LGBTQ+) participants reported more symptoms of depression and SI. LGBTQ+ participants reported more nonsuicidal self-injury and drug use. Participants also experienced significant barriers to receiving mental healthcare (e.g., financial difficulties, limited availability, insufficient time). Leadership is encouraged to prioritize the mental health of clinical psychology doctoral students, which may have implications on their service provision.

Psychologists' Leadership Roles and Leadership Training Needs in Academic Health Centers.

Psychologists are increasingly called upon to become more involved in academic health centers (AHCs) as leaders across a range of leadership roles in areas such as the clinical, teaching, and research missions, and in the administration thereof. Similarly, expansion of psychologists' service in national associations, boards, and other forums is increasing. This paper attempts to delineate the nature and extent of psychologists' involvement in leadership roles and their needs for professional leadership development to assist them in securing and succeeding in these positions. Members of the Association of Psychologists in Academic Health Centers (APAHC) were invited to complete a survey to identify current leadership roles and training needed to enhance leadership capabilities. Most (75%) of the respondents (total n = 105; 42% of APAHC full members; 70% female) were currently serving in leadership roles (range 1 to ≥ 10 positions). Years since degree conferred was positively associated with the number of leadership positions. Diversity of roles was delineated across AHC missions including psychology training (49.5%), clinical service (33.3%), and research (26.7%). An important subgroup (11.5%) served in upper-level administrative leadership positions. Leadership roles external to AHCs were common, particularly service ion committees (30.5%) and boards (27.6%) in state and national professional organizations. Half (51.4%) of survey respondents endorsed at least one leadership development need, with approximately 10% endorsing leadership development needs in all areas. The most common leadership development need was financial management skills, endorsed by nearly two-thirds of the sample. Early career respondents recognized more needs than advanced career respondents. AHC psychologists are expanding their leadership roles and distinguishing themselves as important contributors in AHCs. Despite this, many identified needs for further leadership training.

Patterns of Psychologists' Interprofessional Collaboration Across Clinical Practice Settings.

Healthcare increasingly emphasizes collaborative treatment by multidisciplinary teams. This is the first research focusing on psychologists' participation in team-based care, the mix of professionals with whom psychologists collaborate, and how these collaborations vary across practice settings. Data are from 1607 respondents participating in the American Psychological Association Center for Workforce Studies' 2015 on-line Survey of Psychology Health Service Providers. Practice settings differed markedly in systemic organizational support for interprofessional collaboration and in psychologists' participation in collaborative activities. Psychologists in individual private practice reported least support for and least occurrence of interprofessional collaboration. Psychologists' collaboration with non-behavioral health professionals, such as non-psychiatrist physicians and nurses, was more frequent in general hospitals and VA medical centers. Across settings, greater contact with another health profession was generally associated with psychologists being more confident about working with that profession. However, for work with psychiatrists, that association was attenuated. A collaborative practice model is presented for psychotherapy patients also treated by physicians or other professionals who manage a patient's psychotropic medication.

Moderators of treatment outcomes in a partial hospitalization and intensive outpatient program for eating disorders.

Eating disorders cause a number of severely impairing symptoms that may require more intensive intervention that is available through outpatient therapy services. The PHP/IOP level of care may be an effective mode of treatment in these cases, but few studies have examined overall outcomes or treatment moderators for this level of care. Using a large sample from a PHP/IOP specifically designed for the treatment of eating disorders, the current study examines a variety of symptoms (eating disorder severity, quality of life, depression, etc.) from admission to discharge, as well as potential moderators of treatment, including demographic and clinical factors. Overall, the PHP/IOP level of care was found to improve treatment outcomes. Age, race, gender, and depression were found to moderate the change in quality of life and functional impairment. Additionally, patients diagnosed with anorexia nervosa had significantly lowered quality of life and greater eating disorder symptomatology than all other diagnoses. The results of this study can help to inform clinical practice and help guide in treatment decisions at the partial hospitalization level of care.

Characterizing gender differences in nonsuicidal self-injury: Evidence from a large clinical sample of adolescents and adults.

While nonsuicidal self-injury (NSSI) is common in both men and women, research exploring the intersection of NSSI and gender has been limited by the use of small samples of males drawn primarily from non-clinical populations. To address these limitations, we analyzed data from a large sample of patients enrolled in an NSSI partial hospitalization program (PHP) to compare males and females across several variables, including NSSI characteristics, correlates, and pre-post treatment outcomes. Results indicated similar NSSI characteristics and treatment outcomes for males and females, with few exceptions. Males notably reported lower severity levels for most NSSI correlates (e.g., psychopathology, suicidality), highlighting the need to screen males for NSSI even when reporting comparatively less impairment. Finally, our results also suggest that PHP treatment for NSSI can be beneficial for both males and females. These findings have implications for the assessment, diagnosis, conceptualization, and treatment of NSSI in males and females.

Health Disparities in Drug- and Alcohol-Use Disorders: A 12-Year Longitudinal Study of Youths After Detention.

OBJECTIVES: To examine sex and racial/ethnic differences in the prevalence of 9 substance-use disorders (SUDs)--alcohol, marijuana, cocaine, hallucinogen or PCP, opiate, amphetamine, inhalant, sedative, and unspecified drug--in youths during the 12 years after detention. METHODS: We used data from the Northwestern Juvenile Project, a prospective longitudinal study of 1829 youths randomly sampled from detention in Chicago, Illinois, starting in 1995 and reinterviewed up to 9 times in the community or correctional facilities through 2011. Independent interviewers assessed SUDs with Diagnostic Interview Schedule for Children 2.3 (baseline) and Diagnostic Interview Schedule version IV (follow-ups). RESULTS: By median age 28 years, 91.3% of males and 78.5% of females had ever had an SUD. At most follow-ups, males had greater odds of alcohol- and marijuana-use disorders. Drug-use disorders were most prevalent among non-Hispanic Whites, followed by Hispanics, then African Americans (e.g., compared with African Americans, non-Hispanic Whites had 32.1 times the odds of cocaine-use disorder [95% confidence interval = 13.8, 74.7]). CONCLUSIONS: After detention, SUDs differed markedly by sex, race/ethnicity, and substance abused, and, contrary to stereotypes, did not disproportionately affect African Americans. Services to treat substance abuse--during incarceration and after release--would reach many people in need, and address health disparities in a highly vulnerable population.

Loss Due to Death and its Association with Mental Disorders in Juvenile Detainees.

This study investigated the prevalence of loss due to death and its association with mental disorders in a random sample of 898 newly detained adolescents in Chicago, Illinois. Nearly 90% of youth experienced the loss of an important person; most had also experienced a "high-risk" loss (e.g., loss due to violence, sudden loss). Minority youth were at particular risk. Youth with any loss or multiple losses were more likely to have mood disorders and ADHD/behavioral disorders, respectively, than youth who had no such losses. Interventions focusing on modifiable protective factors following loss may increase positive outcomes in this vulnerable population.

Aggressive and prosocial behavior: community violence, cognitive, and behavioral predictors among urban African American youth.

We use longitudinal multilevel modeling to test how exposure to community violence and cognitive and behavioral factors contribute to the development of aggressive and prosocial behaviors. Specifically, we examine predictors of self-, peer-, and teacher-reported aggressive and prosocial behavior among 266 urban, African American early adolescents. We examine lagged, within-person, between-person, and protective effects across 2 years. In general, results suggest that higher levels of violence exposure and aggressive beliefs are associated with more aggressive and less prosocial peer-reported behavior, whereas greater self-efficacy to resolve conflict peacefully is associated with less aggression across reporters and more teacher-reported prosocial behavior. Greater knowledge and violence prevention skills are associated with fewer aggressive and more prosocial teacher-reported behaviors. Results also suggest that greater self-efficacy and lower impulsivity have protective effects for youth reporting higher levels of exposure to community violence, in terms of teacher-reported aggressive behavior and peer-reported prosocial behavior. Differences among reporters and models are discussed, as well as implications for intervention.

Eating disorder behaviors as a form of non-suicidal self-injury.

Nonsuicidal Self-Injury (NSSI), the purposeful harming of one's body tissue without suicidal intent. NSSI frequently co-occurs with other self-destructive forms of psychopathology, such as eating disorders (ED); however, it remains unclear if ED behaviors are used as a form of NSSI. This exploratory study examined the occurrence of Self-Injurious Disordered Eating Symptoms (SIDES), as well as differences in clinical correlates and treatment outcomes between NSSI patients with and without SIDES. Participants included 1,327 patients admitted for partial hospitalization or intensive outpatient treatment for NSSI (87.4% female; 75.3% Non-Hispanic White). Data were collected at admission and discharge as part of routine clinical outcome assessment. Results indicate that 29.5% of the sample engaged in SIDES, while most were not diagnosed with an ED. Patients that engaged in SIDES reported greater clinical severity at baseline, including greater general psychopathology, lower quality of life, and worse functional impairment, as well as more clinically severe NSSI (e.g., greater number of methods, higher urge to self-injure, greater intrapersonal functions). No differences in treatment outcomes were found. These findings suggest that some NSSI patients perceive ED behaviors as a form of NSSI and that SIDES may be a marker for a more severe clinical presentation.

Clarifying the Definition of Nonsuicidal Self-Injury.

Background: Challenges and inconsistencies in defining nonsuicidal self-injury (NSSI) have persisted for decades, which significantly impact NSSI conceptualization and assessment in clinical and research settings and impede the field's progress. Aims: The present study aimed to solicit opinions from individuals with NSSI expertise so as to improve the operational definition and conceptualization of NSSI. Method: We asked researchers, clinicians, and graduate students with varying NSSI expertise to provide opinions on six NSSI definitional components (e.g., whether pain should be a required outcome), as well as to review 118 behaviors and indicate whether each is NSSI. Results: Responses (N = 159) revealed good agreement on specific NSSI definitional aspects and the classification of oft-cited NSSI behaviors. However, findings also demonstrated potential discrepancies in how clinicians and researchers define NSSI when compared with specific behaviors that might be classified as NSSI. Limitations: The opinions of the study's sample may not reflect the wider NSSI field. Conclusion: Findings suggest that there is an increased need for a clear and consistent definition of NSSI and specific NSSI behaviors. There is also a need to develop new assessment measures that capture the range of NSSI behaviors that received good-to-excellent agreement among self-injury experts.

Developing a Mobile App for Young Adults with Nonsuicidal Self-Injury: A Prototype Feedback Study.

Nonsuicidal self-injury (NSSI) affects approximately 13% of young adults. Though evidence-based treatments for NSSI exist, most young adults do not receive treatment. Digital interventions can provide access to evidence-based treatments for NSSI at scale. Further, preliminary research suggests the acceptability, feasibility, and potential efficacy of digital interventions for NSSI. To date, however, there are few publicly available digital interventions developed specifically for young adults who engage in NSSI. The aim of this study was to solicit young adults' impressions of early app prototypes to identify ways of improving interactive features and content needs. Building on a prior interview study which explored young adults' self-management of NSSI and their use of technology in self-management, this study involved three waves of iterative app prototype feedback sessions with 10 young adults with past month NSSI. In general, participants responded favorably and provided feedback to augment the app to better meet their needs, including adding new features and functionality as well as increasing opportunities for personalization. We discuss two key design challenges related to the roles of tracking and temporality in digital interventions for NSSI, and then frame design considerations related to these challenges within the lived informatics model.

Evidence-Based Strategies Improve Assessment of Pediatric Bipolar Disorder by Community Practitioners.

The misdiagnosis of pediatric bipolar disorder (PBD) has become a major public health concern. Would available evidence-based assessment (EBA) strategies help improve diagnostic accuracy, and are clinicians willing to consider these strategies in practice? The purpose of the present study was to document the extent to which using an EBA decision tool--a probability nomogram--improves the interpretation of family history and test data by clinicians and to examine the acceptability of the nomogram technique to clinicians. Over 600 clinicians across the US and Canada attending continuing education seminars were trained to use the nomogram. Participants estimated the probability that a youth in a clinical vignette had bipolar disorder, first using clinical judgment and then using the nomogram. Brief training of clinicians (less than 30 minutes) in using the nomogram for assessing PBD improved diagnostic accuracy, consistency, and agreement. The majority of clinicians endorsed using the nomogram in practice. EBA decision aids, such as the nomogram, may lead to a significant decrease in overdiagnosis and help clinicians detect true cases of PBD.

Understanding predictors of change in a day treatment setting for non-suicidal self-injury.

OBJECTIVES: To examine change in non-suicidal self-injury (NSSI) frequency, quality of life, and functional impairment from admission to discharge in patients enrolled in partial hospitalization and intensive outpatient programmes (PHP/IOP) designed to treat NSSI. Demographic, clinical, and treatment-related predictors of changes were also examined. DESIGN: Data were collected as part of routine clinical assessment procedures at admission and discharge from patients enrolled in a PHP/IOP programme designed to treat NSSI. The clinical assessment included measures examining quality of life, functional impairment, and NSSI behaviour. METHODS: Paired t-tests were used to examine change in NSSI frequency, quality of life, and functional impairment. Reliable clinical change analyses were used to identify clinically significant change in quality of life and functional impairment. Multilevel mixed-effects regression was used to examine predictors of change for quality of life and functional impairment. Negative binomial regression was used to examine predictors of change for NSSI frequency. RESULTS: From admission to discharge, NSSI frequency significantly decreased and quality of life and functional impairment evidenced clinically significant change. Age, race/ethnicity, and insurance type predicted change in functional impairment, while gender predicted change in quality of life. Urge to self-injure predicted change in NSSI frequency. Borderline symptoms predicted change across all outcome variables. CONCLUSIONS: Patients who completed a day treatment programme for NSSI evidenced significant change in NSSI frequency, functional impairment, and quality of life at discharge; however, several demographic and clinical variables were associated with change. PRACTITIONER POINTS: Patients who engage in NSSI show significant change from admission to discharge in a day treatment programme dedicated to the treatment of NSSI. Quality of life and functional impairment are important outcome variables to consider and evaluate in higher levels of care. It is important to consider demographic and clinical variables when creating a treatment plan for NSSI. Although BPD symptoms may be important to consider in day treatment for NSSI, interpersonal dysfunction, depressive symptoms, and mood lability may also affect change in symptoms.