Factors Influencing Turnover and Attrition in the Public Behavioral Health System Workforce: Qualitative Study.

Many states are experiencing a behavioral health workforce crisis, particularly in the public behavioral health system. An understanding of the factors influencing the workforce shortage is critical for informing public policies to improve workforce retention and access to care. The aim of this study was to assess factors contributing to behavioral health workforce turnover and attrition in Oregon. Semistructured qualitative interviews were conducted with 24 behavioral health providers, administrators, and policy experts with knowledge of Oregon's public behavioral health system. Interviews were transcribed and iteratively coded to reach consensus on emerging themes. Five key themes emerged that negatively affected the interviewees' workplace experience and longevity: low wages, documentation burden, poor physical and administrative infrastructure, lack of career development opportunities, and a chronically traumatic work environment. Large caseloads and patients' high symptom acuity contributed to worker stress. At the organizational and system levels, chronic underfunding and poor administrative infrastructure made frontline providers feel undervalued and unfulfilled, pushing them to leave the public behavioral health setting or behavioral health altogether. Behavioral health providers are negatively affected by systemic underinvestment. Policies to improve workforce shortages should target the effects of inadequate financial and workplace support on the daily work environment.

The Color of Autonomy: Examining Racial Inequity in Coercive Institutional Practices.

Two articles recently published in this journal identified racial inequities in routine psychiatric practice. This Open Forum discusses the need for a paradigm shift in inequities research. The two articles reviewed here, one by Shea and colleagues on racial-ethnic inequities in inpatient psychiatric civil commitment and one by Garrett and colleagues on racial-ethnic disparities in psychiatric decisional capacity consultations, are examples of the new research gaze. Four topics are identified for enhancing understanding of racism and other forms of structural exclusion in psychiatric practice: medical authority and power imbalance between providers and patients, involuntary psychiatric commitment and requests for decisional capacity consultations as strategic research events, limited use of theory, and limitations of the literature on psychiatric inequities.

Mental Health Services in Colombia: A National Implementation Study.

Laws in Latin American countries are based on scientific evidence that calls for mental health services to move to the community. These care modalities have implementation problems. The objective of this article is to describe the implementation of the services proposed in Law 1616 of 2013 of Colombia (Mental Health Law): emergencies, hospitalization, community-based rehabilitation, pre-hospital care, day hospital for children and adults, Drug Addiction Care Center, groups support and mutual aid, telemedicine, and home and outpatient care. We used a mixed study, with a cross-sectional descriptive quantitative component, where an instrument was used to determine the level of implementation of these services, consisting of a scale that established the availability and use of these services, in addition to the climate of implementation of the services and community mental health strategies, in addition to a qualitative determination of barriers and facilitators of implementation. We found a low availability of all services in departments such as Amazonas, Vaupés, Putumayo, and Meta and an implementation of services in Bogotá and Caldas. The least implemented services are the community ones, and those with the greatest presence at the territorial level are emergencies and hospitalization. We conclude that low- and middle-income countries have few community models and invest a large part of their technical and economic effort in emergencies and hospitalization. There are difficulties in the implementation of most of the services proposed by Colombian legislation related to mental health.

Identifying Core Competencies for Remote Delivery of Psychological Interventions: A Rapid Review.

OBJECTIVE: The COVID-19 pandemic led to a rapid shift toward remote delivery of psychological interventions and transition to voice-only and video communication platforms. However, agreement is lacking on key competencies that are aligned with equitable approaches for standardized training and supervision of remote psychological intervention delivery. A rapid review was conducted to identify and describe competencies that could inform best practices of remote services delivery during and after the COVID-19 pandemic. METHODS: Scopus, MEDLINE, and PsycINFO were searched for literature published in English (2015-2021) on competencies for synchronous, remote psychological interventions that can be measured through observation. RESULTS: Of 135 articles identified, 12 met inclusion criteria. Studies targeted populations in high-income countries (11 in the United States and Canada, one in Saudi Arabia) and focused on specialist practitioners, professionals, or trainees in professional or prelicensure programs working with adult populations. Ten skill categories were identified: emergency and safety protocols for remote services, facilitating communication over remote platforms, remote consent procedures, technological literacy, practitioner-client identification for remote services, confidentiality during remote services, communication skills during remote services, engagement and interpersonal skills for remote services, establishing professional boundaries during remote services, and encouraging continuity of care during remote services. CONCLUSIONS: These 10 skills domains can offer a foundation for refinement of discrete, individual-level competencies that can be aligned with global initiatives promoting use of observational competency assessment during training and supervision programs for psychological interventions. More research is needed on identification of and agreement on remote competencies and on their evaluation.

Enhancing Use of Medications for Opioid Use Disorder Through External Coaching.

OBJECTIVE: This randomized controlled trial tested whether external coaching influences addiction treatment providers' utilization of medications to treat opioid use disorder (MOUDs). METHODS: This study recruited 75 unique clinical sites in Florida, Ohio, and Wisconsin, including 61 sites in specialty treatment agencies and 14 behavioral health sites within health systems. The trial used external coaching to increase use of MOUDs in the context of a learning collaborative and compared it with no coaching and no learning collaborative (control condition). Outcome measures of MOUD capacity and utilization were monthly tabulations of licensed buprenorphine slots (i.e., the number of patients who could be treated based on the buprenorphine waiver limits of the site's providers), buprenorphine use, and injectable naltrexone administration. RESULTS: The coaching and control arms showed no significant difference at baseline. Although buprenorphine slots increased in both arms during the 30-month trial, growth increased twice as fast at the coaching sites, compared with the control sites (average monthly rate of 6.1% vs. 3.0%, respectively, p<0.001). Buprenorphine use showed a similar pattern; the monthly growth rate in the coaching arm was more than twice the rate in the control arm (5.3% vs. 2.4%, p<0.001). Coaching did not have an impact on injectable naltrexone, which grew less than 1% in both arms over the trial period. CONCLUSIONS: External coaching can increase organizational capacity for and growth of buprenorphine use. Future research should explore the dimensions of coaching practice, dose, and delivery modality to better understand and enhance the coaching function.

Traducción y adaptación de la Escala de Continuidad de Servicios de Salud Mental de Alberta en un contexto latinoamericano

Introducción: La continuidad de atención es considerada como un proceso que involucra una atención ordenada, un movimiento ininterrumpido de personas entre los diversos elementos del sistema de prestación de servicios. No existe evidencia suficiente en cuanto a instrumentos de medición en Iberoamérica. Por lo anterior, el objetivo del presente estudio consiste en describir el proceso de traducción, adaptación cultural a un contexto latinoamericano, así como la consistencia interna y validez de constructo de la Escala de Continuidad de Servicios de Salud Mental de Alberta (ACSS-MH). Método: Este instrumento fue sometido a la evaluación de validez de contenido por expertos y este fue aplicado a una población rural en un contexto colombiano. Se realizaron pruebas de consistencia interna y validez de constructo para cada una de las partes de la escala. Resultados: Bajo el consenso del experto, se realizan cambios en algunos ítems, buscando una mejor adaptabilidad del instrumento a las características lingüísticas del español, sin perder de vista el objetivo de evaluación de cada uno de los ítems del cuestionario original. El resultado del análisis de la parte A convergió en 5 componentes que explican el 69,69% de la varianza con 24 ítems; de igual forma, el análisis de la parte B agrupó 13 ítems en cuatro componentes, los cuales explican el 72.02% de la varianza. Conclusiones: este instrumento podría ser implementado para mejorar la prestación de los servicios en salud mental en contextos latinoamericanos, donde la continuidad del cuidado ha presentado importantes dificultades.

Objective: Describe the process of translation, cultural adaptation to Colombia, as well as the internal consistency and construct validity of the Alberta Continuity of Services Scale for Mental Health (ACSS-MH). Methods: This instrument was subdued to the evaluation of validity of the content by experts and this was applied to a rural population in a Colombian context. Were performed tests of internal consistency and construct validity for each of the parts of the scale. Results: Under the consensus of the expert, it is made changes on some items, looking for a better adaptability of the instrument to the linguistic characteristics of Spanish, without losing sight of the evaluation objective of each one of the items on the original questionnaire. The result of the analysis of part A converged in 5 components that explain the 69.69% of the variance with 24 Items; Similarly, the analysis of part B grouped 13 items into four components, which explain the 72.02% of the variance. Discussion: This scale could be implemented to improve the provision of mental health services in Latin American contexts, where continuity of care has presented significant difficulties.

Racial and Ethnic Differences in Psychotropic Prescription Receipt Among Pediatric Patients Enrolled in North Carolina Medicaid.

OBJECTIVE: The authors aimed to examine racial-ethnic differences in filled psychotropic prescriptions among a pediatric Medicaid population. METHODS: This retrospective cohort study included patients ages 0-21 with at least one North Carolina Medicaid claim from October 1, 2017, through September 30, 2018 (N=983,886). The primary outcome was a filled psychotropic prescription. Separate multivariable modified Poisson regression models generated adjusted risk ratios (ARRs) and 95% confidence intervals (CIs), adjusted for patient demographic characteristics. RESULTS: Black and Hispanic patients were significantly less likely to receive any filled psychotropic prescription (ARR=0.61, 95% CI=0.60-0.62; ARR=0.29, 95% CI=0.28-0.29, respectively) compared with White and non-Hispanic patients. Furthermore, Black and Hispanic patients were less likely to receive filled prescriptions in the four included drug classes compared with White and non-Hispanic patients. CONCLUSIONS: Future studies should focus on understanding the factors contributing to racial and ethnic differences among pediatric patients receiving filled psychotropic prescriptions.

Use of North Carolina Medicaid Collaborative Care Billing Codes After Statewide Approval for Reimbursement.

Effective October 2018, North Carolina Medicaid approved reimbursement for collaborative care model (CoCM) billing codes. From October 2018 through December 2019, only 915 of the estimated two million eligible Medicaid beneficiaries had at least one CoCM claim, and the median number of claims per patient was two. Availability of reimbursement for CoCM Medicaid billing codes in North Carolina did not immediately result in robust utilization of CoCM. Furthermore, the low median number of claims per patient suggests lack of fidelity to CoCM. A better understanding of barriers to CoCM implementation is necessary to expand utilization of this evidence-based model.

Intensive Perinatal Mental Health Programs in the United States: A Call to Action.

Despite the growth of intensive perinatal mental health programs in the United States, too few programs serve women with perinatal mood and anxiety disorders (PMADs). Furthermore, little is known about program operations, services, the women served, and the methods of collecting outcome data. With this Open Forum, the authors aimed to share their investigation of intensive perinatal mental health programs in the United States and offer recommendations to improve services for women with PMADs. The authors recommend forming a national consortium that can foster collaboration to expand existing services and establish a national database to inform program development, evaluation, policies, and funding.

Connecting Research and Practice: Implementation of Suicide Prevention Strategies in Learning Health Care Systems.

The health care systems affiliated with the Mental Health Research Network strive to be learning health care systems that identify and address evidence gaps of importance to clinicians, patients, and funders. This column describes how research guides clinical care and clinical care guides research in the area of suicide prevention as well as some of the challenges of conducting embedded research.

Trends in Mental Health Concerns Reported to Two Pediatric Mental Health Care Access Programs During the COVID-19 Pandemic.

OBJECTIVE: Pediatric Mental Health Care Access (PMHCA) programs increase access to mental health care by providing training, consultation, and resource-referral support to primary care providers (PCPs). The authors compared trends in services provided by two PMHCA programs during the COVID-19 pandemic. METHODS: Maryland and Mississippi PMHCA programs had 2,840 contacts with PCPs from January 2019 to March 2021. Descriptive trends on PMHCA program utilization, service type, clinical severity, diagnostic complexity, and PCP contact reasons were reported. RESULTS: Both programs observed significant increases in call volume during the COVID-19 pandemic compared with before COVID-19. Increases were observed in calls regarding patients with multiple diagnoses (Maryland, 20% to 37%; Mississippi, 0% to 11%) as well as patients with mood and anxiety symptoms. CONCLUSIONS: Changes in PMHCA program usage suggest that PCPs identified more complex mental health concerns, particularly regarding mood and anxiety, during the pandemic than before COVID-19. Trends underscore the importance of PMHCA programs in supporting PCPs with managing pediatric mental health concerns.

Research on the Tufts Be Well at Work Program for Employees With Depression: 2005-2020.

OBJECTIVE: Although depression is a prevalent and costly health problem exacting a large toll on work productivity, interventions targeting occupational functioning are rare. This article describes the development of the Tufts Be Well at Work intervention, a brief telephonic program designed to improve occupational functioning among employees with depression and reduce depression symptom severity. Results from 15 years of research are summarized evaluating the occupational, clinical, and economic impact of Be Well at Work. METHODS: The design, methods, and results of all six Tufts Be Well at Work studies are reported. Studies included an initial workplace pilot study, two workplace randomized clinical trials (RCTs), one RCT in a health care system, and two pilot implementation studies conducted in a workplace and in an academic medical center. RCTs compared Tufts Be Well at Work to usual care. RESULTS: Tufts Be Well at Work consistently and significantly improved occupational functioning, work productivity, and depression symptom severity. Employees randomly assigned to usual care experienced smaller gains. The program also delivered a positive return on investment. CONCLUSIONS: Evidence suggests that Tufts Be Well at Work is an effective intervention for improving occupational and clinical functioning. Its relatively low cost and its impact on work productivity contribute to its positive economic impact.

Access to Care for Veterans With Serious Mental Illness During the COVID-19 Pandemic.

OBJECTIVE: The authors examined access to care among persons with serious mental illness during the pandemic and disparities in use of virtual care among this population versus among individuals with other psychiatric diagnoses. METHODS: Data from the Veterans Health Administration were used to examine whether the number of visits for serious mental illness differed for January-September 2019 versus the same period in 2020. Mixed-effects regression analyses tested whether the post-COVID-19 rate of growth in virtual care differed for people with serious mental illnesses versus those with other diagnoses. RESULTS: Fewer visits for serious mental illnesses occurred during the initial weeks of the pandemic but not subsequently. The rate of growth in video visits during 2020 was slower for serious mental illnesses than for other psychiatric diagnoses. CONCLUSIONS: Several months after the pandemic's start, the total number of visits for serious mental illnesses was similar to 2019; however, adoption of video care was slower than for other psychiatric diagnoses.

Service User Participation Within the Mental Health System: Deepening Engagement.

Over the past decade, there has been a marked uptick in interest in increasing service user participation in the U.S. mental health care system, including clinical practice, research, and policy. Too often, however, these efforts remain superficial and unlikely to bring about the deeper transformation of systems long called for by grassroots activists. This Open Forum-addressed to mental health administrators, researchers, and clinicians-highlights the importance of considering diverse, critical perspectives and engaging in ways that move beyond purely intellectual rapprochement.

U.S. Health Care Reform and Enduring Barriers to Mental Health Care Among Low-Income Adults With Psychological Distress.

OBJECTIVE: The author aimed to assess changes in mental health service use, unmet need for mental health care, and barriers to obtaining care among low-income adults after the implementation of the Affordable Care Act in 2014. METHODS: Data on 15,968 adults with psychological distress and family income <100% of the federal poverty level were drawn from the National Survey on Drug Use and Health, 2009-2018. Health insurance coverage, contact with mental health services, unmet need for mental health care, and self-reported barriers to care were compared between 2009-2013 and 2014-2018. RESULTS: Health insurance coverage increased between 2009-2013 and 2014-2018. However, mental health service use did not change, and unmet need for care modestly decreased. Financial barriers were common and did not change significantly over time. Attitudinal and structural barriers increased. CONCLUSIONS: Further efforts are needed to address the enduring barriers to mental health care among low-income adults.

Development and Validation of an Instrument to Measure Staff Perceptions of Recovery Climate and Culture in Mental Health Programs.

OBJECTIVE: Few existing instruments measure recovery-oriented organizational climate and culture. This study developed, psychometrically assessed, and validated an instrument to measure recovery climate and culture. METHODS: Organizational theory and an evidence-based conceptualization of mental health recovery guided instrument development. Items from existing instruments were reviewed and adapted, and new items were developed as needed. All items were rated by recovery experts. A 35-item instrument was pilot-tested and administered to a national sample of mental health staff in U.S. Department of Veterans Affairs Psychosocial Rehabilitation and Recovery Centers (PRRCs). Analysis entailed an exploratory factor analysis (EFA) and inter-item reliability and scale correlation assessment. Blinded site visits to four PRRCs were performed to validate the instrument. RESULTS: The EFA determined a seven-factor solution for the data. The factors identified were staff expectations, values, leadership, rewards, policies, education and training, and quality improvement. Seven items did not meet retention criteria and were dropped from the final instrument. The instrument exhibited good internal consistency (Cronbach's α=0.81; subscales, α=0.84-0.88). Scale correlations were between 0.16 and 0.61, well below the threshold (α=0.9) for indicating overlapping constructs. Site visitors validated the instrument by correctly identifying high-scoring and low-scoring centers. CONCLUSIONS: These findings provide a psychometrically tested and validated instrument for measuring recovery climate and culture in mental health programs. This instrument can be used in evaluation of mental health services to determine the extent to which programs possess the organizational precursors that drive recovery-oriented service delivery.

Clinical Outcomes of Specialized Treatment Units for Patients With Serious Mental Illness in the New York City Jail System.

OBJECTIVE: New York City's (NYC) Correctional Health Services has introduced specialized treatment units for patients with serious mental illness in the NYC jail system. With multidisciplinary mental health staffing and a coordinated approach with NYC's Department of Correction, these units expand therapeutic options for patients vulnerable to clinical instability and physical harm, including those at high risk of psychiatric medication nonadherence and those returning to jail from psychiatric hospitalization. This study evaluated the extent to which these units improve clinical outcomes for this population. METHODS: This retrospective, observational cohort study included adult males with serious mental illness with a length of jail stay of ≥14 days between January 1, 2016, and March 31, 2018. Patients on treatment units were matched with patients of similar characteristics (control group) by using propensity score matching (N=302 pairs). Rates of self-injury, injury due to violence, and psychiatric medication adherence were analyzed. RESULTS: Most patients on treatment units had diagnoses of schizophrenia spectrum and other psychotic disorders (81%), and most had a violent felony as their most severe charge (68%). Compared with patients in a control group, those on the treatment units had lower rates per 100 person-days of injury due to violence at 30 and 60 days (0.04, 95% confidence interval [CI]=0.02-0.07, and 0.03, 95% CI=0.02-0.06, respectively) and higher mean medication adherence (77% versus 55%, p<0.001). They also experienced lower rates of self-injury, although the difference was not statistically significant. CONCLUSIONS: Initial outcomes indicate substantial benefits to patients, demonstrating the value of a rehabilitative approach to psychiatric care in jail.

Perspectives on Mobile Health Versus Clinic-Based Group Interventions for People With Serious Mental Illnesses: A Qualitative Study.

OBJECTIVE: This study built on research comparing a mobile health intervention (FOCUS) and a clinic-based intervention (Wellness Recovery Action Planning [WRAP]) for self-management of serious mental illnesses. Qualitative interviews were conducted to provide additional insight into engagement and satisfaction and augment understanding of clinical outcomes. METHODS: Individuals (N=31) with serious mental illness participating in a comparative effectiveness trial were interviewed. Interviewees were sampled purposively for a range of engagement with the interventions. Interviews inquired into experiences with the interventions and were 45-60 minutes long, audio recorded, and transcribed. Researchers developed qualitative codes based on the research aims, interview domains, and inductively derived categories, aggregating data by code and producing analytic memos to distill main findings. RESULTS: Both FOCUS and WRAP participants described gaining new information about mental illness and new skills for managing symptoms. FOCUS participants emphasized the intervention's accessibility, and WRAP participants highlighted the importance of community and shared experiences. FOCUS participants commenced treatment at higher rates, compared with WRAP participants, which may have been related to the strongly negative views of group interventions expressed by some WRAP participants. FOCUS was generally enthusiastically received. The comparable clinical outcomes of the interventions were reflected in narratives detailing the positive impact of the interventions. CONCLUSIONS: Interviews provided evidence that mobile health and clinic-based illness self-management interventions were well received and offered opportunities to learn new illness management skills. Findings support expanding the range of services and supports for persons with serious mental illness to include traditional and technology-based approaches.