Women experiencing homelessness and mental illness in a Housing First multi-site trial: Looking beyond housing to social outcomes and well-being.

OBJECTIVE: There is scant research on the effectiveness of permanent supportive housing for homeless women with mental illness. This study examines the effectiveness of Housing First with an unprecedentedly large sample of homeless women from five Canadian cities, and explore baseline risk factors that predict social, health and well-being outcomes over a 24 month-period. METHODS: The At Home/Chez Soi multi-site randomized controlled Housing First trial recruited over 600 women between October 2009 and July 2011. This is a post-hoc subgroup exploratory analysis of self-identified women with at least one follow-up interview who were randomized to Housing First (HF) (n = 374) or treatment-as-usual (TAU) (n = 279) and had at least one follow-up interview. Linear mixed models and generalized estimating equations were used after multiple imputation was applied to address missing data. RESULTS: At the end of follow-up, the mean percentage of days spent stably housed was higher for women in the intervention 74.8% (95%CI = 71.7%-77.8%) compared with women in the treatment-as-usual group, 37.9% (95%CI = 34.4%-41.3%), p<0.001. With few exceptions, social and mental health outcomes were similar for both groups at 6-, 12-, 18- and 24-months post-enrollment. Suicidality was a consistent predictor of increased mental health symptoms (beta = 2.85, 95% CI 1.59-4.11, p<0.001), decreased quality of life (beta = -3.99, 95% CI -6.49 to -1.49, p<0.001), decreased community functioning (beta = -1.16, 95% CI -2.10 to -0.22, p = 0.015) and more emergency department visits (rate ratio = 1.44, 95% CI 1.10-1.87, p<0.001) over the study period. Lower education was a predictor of lower community functioning (beta = -1.32, 95% CI -2.27 to -0.37, p = 0.006) and higher substance use problems (rate ratio = 1.27, 95% CI 1.06-1.52, p = 0.009) during the study. CONCLUSIONS: Housing First interventions ensured that women experiencing homelessness are quickly and consistently stably housed. However, they did not differentially impact health and social measures compared to treatment as usual. Ensuring positive health and social outcomes may require greater supports at enrolment for subgroups such as those with low educational attainment, and additional attention to severity of baseline mental health challenges, such as suicidality. TRIAL REGISTRATION: International Standard Randomized Control Trial Number Register Identifier: ISRCTN42520374.

Validating the Danish version of the Eating Disorder Quality of Life Scale (EDQLS) in anorexia nervosa.

PURPOSE: The aim of this study was to explore the factor structure of the Danish translation of the eating disorder quality of life scale and evaluate the internal reliability and convergent validity of the scale in a Danish cohort of women with AN. METHODS: The total sample comprised 211 patients diagnosed with anorexia nervosa age 13-40 years. Patients completed questionnaires assessing eating disorder psychopathology, physical and social functioning, and well-being. RESULTS: Factor analyses were not able to support the current division of the scale into 12 factors. We found excellent internal consistency of the eating disorder quality-of-life scale total score. We found relevant associations between quality of life and pre-determined variables. CONCLUSION: This study supports the use of the total score of the eating disorder quality of life scale in assessing quality of life in patients with anorexia nervosa. However, future studies should explore the factor structure of the scale further. LEVEL OF EVIDENCE: III: Evidence obtained from cohort or case-control analytic studies.

Priority Given to Technology in Government-Based Mental Health and Addictions Vision and Strategy Documents: Systematic Policy Review.

BACKGROUND: The use of information and communication technologies (ICTs) to deliver mental health and addictions (MHA) services is a global priority, especially considering the urgent shift towards virtual delivery of care in response to the COVID-19 pandemic. It is important to monitor the evolving role of technology in MHA services. Given that MHA policy documents represent the highest level of priorities for a government's vision and strategy for mental health care, one starting point is to measure the frequency with which technology is mentioned and the terms used to describe its use in MHA policy documents (before, during, and after COVID-19). Yet, to our knowledge, no such review of the extent to which ICTs are referred to in Canadian MHA policy documents exists to date. OBJECTIVE: The objective of this systematic policy review was to examine the extent to which technology is addressed in Canadian government-based MHA policy documents prior to the COVID-19 pandemic to establish a baseline for documenting change. METHODS: We reviewed 22 government-based MHA policy documents, published between 2011 and 2019 by 13 Canadian provinces and territories. We conducted content analysis to synthesize the policy priorities addressed in these documents into key themes, and then systematically searched for and tabulated the use of 39 technology-related keywords (in English and French) to describe and compare jurisdictions. RESULTS: Technology was addressed in every document, however, to a varying degree. Of the 39 searched keywords, we identified 22 categories of keywords pertaining to the use of technology to deliver MHA services and information. The 6 most common categories were tele (n=16/22), phone (n=12/22), tech (n=11/22), online (n=10/22), line (n=10/22), and web (n=10/22), with n being the number of policy documents in which the category was mentioned out of 22 documents. The use of terms referring to advanced technologies, such as virtual (n=6/22) and app (n= 4/22), were less frequent. Additionally, policy documents from some provinces and territories (eg, Alberta and Newfoundland and Labrador) mentioned a diverse range of ICTs, whereas others described only 1 form of ICT. CONCLUSIONS: This review indicates that technology has been given limited strategic attention in Canadian MHA policy. Policy makers may have limited knowledge on the evidence and potential of using technology in this field, highlighting the value for knowledge translation and collaborative initiatives among policy makers and researchers. The development of a pan-Canadian framework for action addressing the integration and coordination of technology in mental health services can also guide initiatives in this field. Our findings provide a prepandemic baseline and replicable methods to monitor how the use of technology-supported services and innovations emerge relative to other priorities in MHA policy during and after the COVID-19 pandemic.

Explanatory Factors for Disease-Specific Health-Related Quality of Life in Women with Anorexia Nervosa.

A better understanding of explanatory factors for disease-specific health-related quality of life (HRQoL) in anorexia nervosa (AN) could help direct treatment providers to aspects of the most relevance for patient wellbeing and recovery. We aimed to investigate whether factors associated with HRQoL are the same for women with AN and normal-weight controls. The participants in this study were women with AN recruited from specialized eating disorder centers in Denmark and healthy, normal-weight controls invited via online social media. Participants completed online questionnaires on medical history, disease-specific HRQoL (Eating Disorders Quality of Life Scale, EDQLS) and generic HRQoL (SF-36), eating disorder symptomatology, depression, psychological wellbeing, and work and social adjustment. Questionnaires were fully completed by 211 women with AN (median age 21.7 years) and 199 controls (median age 23.9 years). Women with AN had poorer scores on all measures, i.e., worse HRQoL, psychological health, and work/social functioning. Eating disorder symptomatology affected EDQLS score in both groups, but poorer HRQoL in women with AN was also significantly associated with worse scores on bulimia, maturity fears, depression, vitality, and with older age. The factors investigated together explained 79% of the variance in EDQLS score. Management of disordered self-assessment and thought processes may be of particular importance to women with AN. Greater emphasis on these aspects alongside weight gain could enhance patient-clinician alliance and contribute to better treatment outcomes.

Effectiveness of Housing First for Homeless Adults with Mental Illness Who Frequently Use Emergency Departments in a Multisite Randomized Controlled Trial.

Frequent emergency department (ED) users experiencing homelessness are associated with high costs for healthcare systems yet interventions for this group have been minimally investigated. This study used 24-month data from a multisite randomized controlled trial of Housing First (HF) to examine how effective the intervention is in helping frequent ED users with a mental illness to achieve housing stability, improve behavioural health and functioning, and reduce their ED use. Findings showed that HF is effective in stably housing frequent ED users despite their complex health needs. Reductions in ED use and substance use problems, and improvements in mental health symptoms and community functioning were found for frequent ED users in both the HF and treatment as usual conditions.

Prevalence of Mental Disorders and Suicidality in Canadian Provinces.

OBJECTIVE: There is limited information to guide health-care service providers and policy makers on the burden of mental disorders and addictions across the Canadian provinces. This study compares interprovincial prevalence of major depressive disorder (MDD), bipolar disorder, generalized anxiety disorder (GAD), alcohol use disorder, substance use disorders, and suicidality. METHOD: Data were extracted from the 2012 Canadian Community Health Survey-Mental Health (n = 25,113), a representative sample of Canadians over the age of 15 years across all provinces. Cross tabulations and logistic regression were used to determine the prevalence and odds of the above disorders for each province. Adjustments for provincial sociodemographic factors were performed. RESULTS: The past-year prevalence of all measured mental disorders and suicidality, excluding GAD, demonstrated significant interprovincial differences. Manitoba exhibited the highest prevalence of any mental disorder (13.6%), reflecting high prevalence of MDD and alcohol use disorder compared to the other provinces (7.0% and 3.8%, respectively). Nova Scotia exhibited the highest prevalence of substance use disorders (2.9%). Quebec and Prince Edward Island exhibited the lowest prevalence of any mental disorder (8.5% and 7.7%, respectively). Manitoba also exhibited the highest prevalence of suicidal ideation (5.1%); however, British Columbia and Ontario exhibited the highest prevalence of suicidal planning (1.4% and 1.3%, respectively), and Ontario alone exhibited the highest prevalence of suicide attempts (0.7%). CONCLUSIONS: Significant interprovincial differences were found in the past-year prevalence of mental disorders and suicidality in Canada. More research is necessary to explore these differences and how they impact the need for mental health services.

Cost-effectiveness of Housing First Intervention With Intensive Case Management Compared With Treatment as Usual for Homeless Adults With Mental Illness: Secondary Analysis of a Randomized Clinical Trial.

Importance: In the At Home/Chez Soi trial for homeless individuals with mental illness, the scattered-site Housing First (HF) with Intensive Case Management (ICM) intervention proved more effective than treatment as usual (TAU). Objective: To evaluate the cost-effectiveness of the HF plus ICM intervention compared with TAU. Design, Setting, and Participants: This is an economic evaluation study of data from the At Home/Chez Soi randomized clinical trial. From October 2009 through July 2011, 1198 individuals were randomized to the intervention (n = 689) or TAU (n = 509) and followed up for as long as 24 months. Participants were recruited in the Canadian cities of Vancouver, Winnipeg, Toronto, and Montreal. Participants with a current mental disorder who were homeless and had a moderate level of need were included. Data were analyzed from 2013 through 2019, per protocol. Interventions: Scattered-site HF (using rent supplements) with off-site ICM services was compared with usual housing and support services in each city. Main Outcomes and Measures: The analysis was performed from the perspective of society, with days of stable housing as the outcome. Service use was ascertained using questionnaires. Unit costs were estimated in 2016 Canadian dollars. Results: Of 1198 randomized individuals, 795 (66.4%) were men and 696 (58.1%) were aged 30 to 49 years. Almost all (1160 participants, including 677 in the HF group and 483 in the TAU group) contributed data to the economic analysis. Days of stable housing were higher by 140.34 days (95% CI, 128.14-153.31 days) in the HF group. The intervention cost $14 496 per person per year; reductions in costs of other services brought the net cost down by 46% to $7868 (95% CI, $4409-$11 405). The incremental cost-effectiveness ratio was $56.08 (95% CI, $29.55-$84.78) per additional day of stable housing. In sensitivity analyses, adjusting for baseline differences using a regression-based method, without altering the discount rate, caused the largest change in the incremental cost-effectiveness ratio with an increase to $60.18 (95% CI, $35.27-$86.95). At $67 per day of stable housing, there was an 80% chance that HF was cost-effective compared with TAU. The cost-effectiveness of HF appeared to be similar for all participants, although possibly less for those with a higher number of previous psychiatric hospitalizations. Conclusions and Relevance: In this study, the cost per additional day of stable housing was similar to that of many interventions for homeless individuals. Based on these results, expanding access to HF with ICM appears to be warranted from an economic standpoint. Trial Registration: isrctn.org Identifier: ISRCTN42520374.

Predictive Validity of the MINI Suicidality Subscale for Suicide Attempts in a Homeless Population With Mental Illness.

OBJECTIVE: Suicide is a leading cause of death, yet the accurate prediction of suicidal behavior is an elusive target for clinicians and researchers. The current paper examines the predictive validity of the Mini Neuropsychiatric Interview (MINI) Suicidality subscale for suicide attempts (SAs) for a homeless population with mental illness. METHODS: Two thousand two hundred and fifty-five homeless individuals with mental illness across five Canadian cities enrolled in the At Home/Chez Soi Housing First trial interviewed at baseline using the MINI Suicidality subscale with 2-year follow-up of self-reported SAs. RESULTS: Two thousand two hundred and twenty-one participants were included in the analysis. High rates of mood and substance use disorders were present (56.5% and 67.4%, respectively). The mean MINI Suicidality subscale score was 7.71. Among 1,700 participants with follow-up data, 11.4% reported a SA over the 2-year study period. MINI Suicidality subscale scores were predictive of SAs (AUC ≥ 0.70) among those with and without a history of SAs, even among those with missing answers. A positive predictive value of 0.20 and a negative predictive value of 0.95 were demonstrated, with a relatively low number needed to assess of 4.5-5. CONCLUSION: The MINI Suicidal subscale shows promise as an easy to use and accurate suicide risk prediction tool among homeless individuals with mental illness.

Mental health and addictions policy priorities and performance measurement frameworks.

To inform the future development of a pan-Canadian Mental Health and Addictions (MHA) performance measurement framework, we undertook a review and comparison of current provincial/territorial MHA policies and performance measurement frameworks. Most did not have performance measurement approaches that were explicitly linked to policy actions but eleven acknowledged the importance of performance measurement. Among the provinces with a framework, there were few performance domains in common. The common policy priorities and areas of convergence in current performance measurement practices may provide a useful starting point for the development of a pan-Canadian MHA performance measurement framework.

Key steps for a mental health and addictions performance measurement framework for Canada.

To inform the development of a pan-Canadian Mental Health and Addictions (MHA) performance measurement framework, we undertook a rapid review of the recent Performance Measurement (PM) literature and solicited input from 20 MHA policy and measurement experts. Six key steps for framework development were identified: recognizing and acknowledging key issues, developing shared language and understanding of key concepts, defining overall scope, defining framework dimension/domains, selecting indicators and using systematic engagement and consultation processes with stakeholders. Subject matter experts underscored the need for a comprehensive engagement process which would honour multiple stakeholder viewpoints and attend to key issues in the codesign of features of the PM framework. Findings from this analysis may be used to inform a comprehensive stakeholder consultation process for the development of a pan-Canadian PM framework for MHA.

Sharing longitudinal, non-biological birth cohort data: a cross-sectional analysis of parent consent preferences.

BACKGROUND: Mandates abound to share publicly-funded research data for reuse, while data platforms continue to emerge to facilitate such reuse. Birth cohorts (BC) involve longitudinal designs, significant sample sizes and rich and deep datasets. Data sharing benefits include more analyses, greater research complexity, increased opportunities for collaboration, amplification of public contributions, and reduced respondent burdens. Sharing BC data involves significant challenges including consent, privacy, access policies, communication, and vulnerability of the child. Research on these issues is available for biological data, but these findings may not extend to BC data. We lack consensus on how best to approach these challenges in consent, privacy, communication and autonomy when sharing BC data. We require more stakeholder engagement to understand perspectives and generate consensus. METHODS: Parents participating in longitudinal birth cohorts completed a web-based survey investigating consent preferences for sharing their, and their child's, non-biological research data. Results from a previous qualitative inquiry informed survey development, and cognitive interviewing methods (n = 9) were used to improve the question quality and comprehension. Recruitment was via personalized email, with email and phone reminders during the 14-day window for survey completion. RESULTS: Three hundred and forty-six of 569 parents completed the survey in September 2014 (60.8%). Participants preferred consent processes for data sharing in future independent research that were less-active (i.e. no consent or opt-out). Parents' consent preferences are associated with their communication preferences. Twenty percent (20.2%) of parents generally agreed that their child should provide consent to continue participating in research at age 12, while 25.6% felt decision-making on sharing non-biological research data should begin at age 18. CONCLUSIONS: These finding reflect the parenting population's preference for less project-specific permission when research data is non-biological and de-identified and when governance practices are highly detailed and rigourous. Parents recognize that children should become involved in consent for secondary data use, but there is variability regarding when and how involvement occurs. These findings emphasize governance processes and participant notification rather than project-specific consent for secondary use of de-identified, non-biological data. Ultimately, parents prefer general consent processes for sharing de-identified, non-biological research data with ultimate involvement of the child.

Multi-province epidemiological research using linked administrative data: a case study from Canada.

BACKGROUND: Canada has a publicly-funded universal healthcare system with information systems managed by 13 different provinces and territories. This context creates inconsistencies in data collection and challenges for research or surveillance conducted at the national or multi-jurisdictional level. OBJECTIVE: Using a recent Canadian research project as a case study, we document the strengths and challenges of using administrative health data in a multi-jurisdictional context. We discuss the implications of using different health information systems and the solutions we adopted to deal with variations. Our goal is to contribute to better understanding of these challenges and the development of a more integrated and harmonized approach to conducting multi-jurisdictional research using administrative data. CONTEXT AND MODEL: Using data from five separate provincial healthcare data systems, we sought to create and report on a set of provincially-comparable mental health and addiction services performance indicators. In this paper, we document the research process, challenges, and solutions. Finally, we conclude by making recommendations for investment in national infrastructure that could help cut costs, broaden scope, and increase use of administrative health data that exists in Canada. CONCLUSIONS: Canada has an incredible wealth of administrative data that resides in 13 territorial and provincial government systems. Navigating access and improving comparability across these systems has been an ongoing challenge for the past 20 years, but progress is being made. We believe that with some investment, a more harmonized and integrated information network could be developed that supports a broad range of surveillance and research activities with strong policy and program implications.

Changes in quality of life from a homelessness intervention: true change, response shift, or random variation.

BACKGROUND AND OBJECTIVE: Participants experiencing homelessness and mental illness who received housing and support through the At Home/Chez Soi trial showed modest gains in quality of life (QOL) compared to treatment as usual participants. Participants' QOL ratings over time may have been affected by either response shift triggered by new life circumstances or by random variation in the meaning of QOL ratings. This study seeks to identify both phenomena to estimate the intervention's effect on true change in QOL. METHODS: Using the residuals from a regression model of the global item of Lehman's 20-item quality of life interview (QOLI-20), latent trajectory analysis was used to identify response shift, while a measure of overall variability in residuals identified random variation of QOL. The latter was used to adjust group comparisons of QOLI-20 total scores and the global item. RESULTS: Equivalent distributions of both groups' participants across latent trajectory classes (χ2 = 2.97, p = .397) suggest that the intervention did not trigger response shift. However, random variation interacted significantly with the treatment effect on global item ratings. For every increase of one standard deviation of residuals, treatment odds ratios decreased by a factor of 0.70 (SE 1.18, p = .036, 95% CI 0.50-0.98). CONCLUSIONS: Measuring random variation in QOL ratings from the standard deviation of residuals offers the ability to approximate, although indirectly, how participants' QOL is truly affected by a housing intervention. Specifically, we found that QOL improvement is more evident when QOL ratings have a consistent meaning over time.

Outcome Trajectories among Homeless Individuals with Mental Disorders in a Multisite Randomised Controlled Trial of Housing First.

PURPOSE: Housing First (HF) has been shown to improve housing stability, on average, for formerly homeless adults with mental illness. However, little is known about patterns of change and characteristics that predict different outcome trajectories over time. This article reports on latent trajectories of housing stability among 2140 participants (84% followed 24 months) of a multisite randomised controlled trial of HF. METHODS: Data were analyzed using generalised growth mixture modeling for the total cohort. Predictor variables were chosen based on the original program logic model and detailed reviews of other qualitative and quantitative findings. Treatment group assignment and level of need at baseline were included in the model. RESULTS: In total, 73% of HF participants and 43% of treatment-as-usual (TAU) participants were in stable housing after 24 months of follow-up. Six trajectories of housing stability were identified for each of the HF and TAU groups. Variables that distinguished different trajectories included gender, age, prior month income, Aboriginal status, total time homeless, previous hospitalizations, overall health, psychiatric symptoms, and comorbidity, while others such as education, diagnosis, and substance use problems did not. CONCLUSION: While the observed patterns and their predictors are of interest for further research and general service planning, no set of variables is yet known that can accurately predict the likelihood of particular individuals benefiting from HF programs at the outset.

"Housing First" for Homeless Youth With Mental Illness.

BACKGROUND AND OBJECTIVES: "Housing First" has been shown to improve housing stability in homeless individuals with mental illness, but had not been empirically tested in homeless youth. We aimed to evaluate the effect of "Housing First" on housing stability in homeless youth aged 18 to 24 years participating in At Home/Chez Soi, a 24-month randomized trial of "Housing First" in 5 Canadian cities. METHODS: Homeless individuals with mental illness were randomized to receive "Housing First" (combined with assertive community treatment or intensive case management depending on their level of need) or treatment as usual. We defined our primary outcome, housing stability, as the percent of days stably housed as a proportion of days for which residence data were available. RESULTS: Of 2148 participants who completed baseline interviews and were randomized, 7% (n = 156) were youth aged 18 to 24 years; 87 received "Housing First" and 69 received treatment as usual. In an adjusted analysis, youth in "Housing First" were stably housed a mean of 437 of 645 (65%) days for which data were available compared with youth in treatment as usual, who were stably housed a mean of 189 of 582 (31%) days for which data were available, resulting in an adjusted mean difference of 34% (95% confidence interval, 24%-45%; P < .001). CONCLUSIONS: "Housing First" was associated with improved housing stability in homeless youth with mental illness. Future research should explore whether adaptations of the model for youth yield additional improvements in housing stability and other outcomes.

Housing Quality in a Randomized Controlled Trial of Housing First for Homeless Individuals with Mental Illness: Correlates and Associations with Outcomes.

Housing quality (HQ) is associated with mental health, and may mediate outcomes in housing interventions. However, studies of housing interventions rarely report HQ. The purpose of this study was to describe HQ in a multi-site randomized controlled trial of Housing First (HF) in five Canadian cities and to examine possible differences by treatment group (HF recipients and treatment-as-usual (TAU) participants who were able to find housing through other programs or on their own). We also examined the association between HQ and the primary trial outcome: housing stability. The performance of a new multi-dimensional standardized observer-rated housing quality scale (the OHQS) in a relatively large cross-site sample was also of interest. HQ was rated by trained research assistants for 204 HF participants and 228 TAU participants using the OHQS. General linear regression models were used to examine unit/building quality scores by group and site adjusting for other group differences, and as a predictor of housing stability outcomes after 24 months of follow-up. The OHQS was found to have good reliability and validity, but because most of the neighborhood subscale items were negatively correlated with the overall scale, only unit and building items were included in the total HQ score (possible scores ranging from 13.5 to 135). Unit/building HQ was significantly better for the HF group overall (91.2 (95 % CI = 89.6-92.9) vs. 88.3 (95 % CI = 86.1-90.5); p = .036), and in one site. HQ in the TAU group was much more variable than the HF group overall (W (mean) = 24.7; p < .001) and in four of five sites. Unit/building HQ scores were positively associated with housing stability: (73.4 (95 % CI 68.3-78.5) for those housed none of the time; 91.1 (95 % CI 89.2-93.0) for those housed some of the time; and 93.1 (95 % CI 91.4-94.9)) for those housed all of the time (F = 43.9 p < .001). This association held after adjusting for site, housing characteristics, participant ethnocultural status, community functioning, and social support. This study demonstrates that HQ can be as good or better, and less variable, in HF programs in Canada that systematically and predominantly source housing stock from the private sector compared to housing procured outside of an HF program. HQ is also an important predictor of housing stability outcomes.

Breastfeeding difficulties and supports and risk of postpartum depression in a cohort of womenwho have given birth in Calgary: a prospective cohort study.

BACKGROUND: A link exists between breastfeeding difficulties and postpartum depression, and evidence shows that some breastfeeding promotion initiatives may increase maternal stress and contribute to risk of the condition. We conducted a prospective cohort study to determine whether breastfeeding difficulties affect the risk of postpartum depression and whether breastfeeding support modifies the relationship between breastfeeding difficulties and postpartum depression. METHODS: Between June and October 2010, we recruited 442 women who intended to breastfeed from all maternity hospitals in Calgary within 72 hours of giving birth to full-term, singleton infants. We administered questionnaires at birth and 6 weeks and 6 months postpartum, measuring breastfeeding difficulties, exposure to breastfeeding supports and postpartum depression. We used qualitative inquiry to measure breastfeeding support experiences. Postpartum depression was defined as a score of 10 or greater on the Edinburgh Postnatal Depression Scale or a self-reported diagnosis of depression in the first 6 months postpartum. RESULTS: A total of 386 women (87.3%) reported moderate to severe breastfeeding difficulties and 437 (98.9%) received some form of breastfeeding advice, help or support. Among women with breastfeeding difficulties, those who did not report a negative breastfeeding support experience were at decreased risk of postpartum depression (risk ratio 0.36). In the final regression model a negative breastfeeding support experience was a significant effect modifier of the relationship between breastfeeding difficulties and postpartum depression. INTERPRETATION: The quality of breastfeeding support is important not only for breastfeeding promotion but also for maternal mental health. Educating front-line caregivers to ensure that support experiences of breastfeeding women are positive can reduce the risk of postpartum depression.

The Unique Needs of Homeless Youths With Mental Illness: Baseline Findings From a Housing First Trial.

OBJECTIVE: Although youth homelessness presents a significant public health problem, the needs of homeless youths with mental illness, as distinct from adults, are not well understood. This study examined the unique demographic, clinical, and service use characteristics of homeless youths. METHODS: At Home/Chez Soi was a large randomized controlled trial of the Housing First model in five cities in Canada. Of 2,255 participants, 7% (N=164) were youths ages 18 to 24. Youths were compared with older participants on baseline demographic, clinical, and service use characteristics. RESULTS: More youths than adults had not finished high school (76% versus 54%), had a drug use disorder (66% versus 52%), and had been assaulted in the past six months (44% versus 36%) (all p<.05). Fewer than half the youths (49%) had a regular medical doctor, 50% reported unmet need for health care, and 61% visited an emergency department in the past six months. CONCLUSIONS: This sample of homeless youths with mental illness had low education, high rates of substance use disorders and victimization, and problems accessing services. These findings suggest that youths have trajectories to homelessness and service needs that are distinct from adults and may guide future planning for this vulnerable population.

Further Validation of the Pathways Housing First Fidelity Scale.

OBJECTIVE: This study examined whether Housing First fidelity ratings correspond to program operation descriptions from administrative data and predict client outcomes. METHODS: A multisite, randomized controlled trial (At Home/Chez Soi) in five Canadian cities included two assessments of 12 programs over two years. Outcomes for 1,158 clients were measured every six months. Associations between fidelity ratings and administrative data (Spearman correlations) and participant outcomes (mixed-effects modeling) were examined. RESULTS: Fidelity ratings were generally good (mean ± SD=136.6 ± 10.3 out of a possible range of 38-152; 87% of maximum value). Fidelity was significantly associated with three of four measures of program operation, with correlations between .55 and .60. Greater program fidelity was associated with improvement in housing stability, community functioning, and quality of life. CONCLUSIONS: Variation in program fidelity was associated with operations and outcomes, supporting scale validity and intervention effectiveness. These findings reinforced the value of using fidelity monitoring to conduct quality assurance and technical assistance activities.