Standardizing Fidelity to Evidence-Based Practice in the Early Psychosis Intervention Network.

OBJECTIVE: This study investigated variations in the measurement of fidelity to coordinated specialty care (CSC) within the Early Psychosis Intervention Network (EPINET), a learning health system that consists of 101 CSC programs within eight hubs. The study investigated the degree to which five fidelity scales could be mapped onto a standard scale. METHODS: The investigators identified six fidelity scales in use by EPINET participants; examined their item content, scoring, and data sources; and mapped five scales onto the First Episode Psychosis Services Fidelity Scale (FEPS-FS), which is the most widely used scale. RESULTS: Mapping five fidelity scales onto the FEPS-FS showed that the percentage of FEPS-FS components successfully mapped ranged from 42% to 81%. CONCLUSIONS: Mapping five scales onto one that uses dichotomous scoring identified the degree of variation in measures and reduced the amount and quality of usable fidelity data. Identifying variations in fidelity measurement is a core function of a learning health system.

Assessing the Evidence Base for School-Based Promotion and Prevention Interventions: Introduction to the Series.

Schools are an important component in the mental health system of care for youths. Teachers and other school staff have unique opportunities to promote emotional wellness and prevent mental health conditions. Although numerous programs are available, identifying evidence-based and effective options is a significant challenge. This introduction lays out the rationale and methodology of the Assessing the Evidence Base (AEB) Series, a collection of systematic reviews of school-based mental health promotion and prevention approaches recommended by the National Academies of Sciences, Engineering, and Medicine for students in kindergarten through grade 12. Authors of the current AEB Series used the rating criteria derived from the 2014 AEB Series, which provided systematic reviews of a wide spectrum of interventions for mental and substance use disorders. Like its predecessor, the current series upholds a high standard of scientific rigor while ensuring that the information is easily accessible to various stakeholders in education, behavioral health, and communities. It describes the universal features included in each systematic review, such as a rating of the level of evidence for interventions, intervention program components, identification of interventions that have yielded positive outcomes for students from underserved populations, and a review of cost data. The AEB systematic reviews will serve as an important tool for decision makers involved in managing limited resources for various programs in school-based mental health services by synthesizing large bodies of research for use by leaders in education and behavioral health.

Community- and Program-Level Predictors of Funding Streams Used by Coordinated Specialty Care Programs.

OBJECTIVE: Although coordinated specialty care (CSC) is an effective service model to address first-episode psychosis, CSC is not widely accessible in the United States, and funding for this service model often remains challenging. The authors examined whether community- or program-level factors predict the use of public and private funding streams in a national sample of 34 CSC programs in 22 U.S. states and territories. METHODS: As part of a larger mixed-methods study, CSC program leaders completed a brief questionnaire regarding funding sources. Statistical modeling was used to examine program- and community-level predictors of the use of funding sources. RESULTS: Most CSC programs (20 of 34, 59%) reported that Mental Health Block Grant (MHBG) set-aside funds accounted for more than half of their total funding, and 11 of these programs reported that these funds contributed to >75% of their funding. Programs ≤5 years old were more likely to rely on MHBG set-aside funds. Programs in Medicaid expansion states were more likely to rely on Medicaid funding than programs in nonexpansion states. Programs in higher-income service catchment areas used more state funds than did those in lower-income areas, and among programs in lower-income service catchment areas, those that were >4 years old were more likely than those ≤4 years old to rely on state funds other than Medicaid. CONCLUSIONS: CSC programs remain largely dependent on MHBG set-aside funding. Some programs have diversified their funding streams, most notably by including more Medicaid and other state funding. A more comprehensive funding approach is needed to reduce reliance on the MHBG set-aside funds.

Informatics Research on Mental Health Functioning: Decision Support for the Social Security Administration Disability Program.

The disability determination process of the Social Security Administration's (SSA's) disability program requires assessing work-related functioning for individual claimants alleging disability due to mental impairment. This task is particularly challenging because the determination process involves the review of a large file of information, including objective medical evidence and self-reports from claimants, families, and former employers. To improve this decision-making process, SSA entered an interagency agreement with the Rehabilitation Medicine Department, Epidemiology and Biostatistics Section, in the Clinical Center of the National Institutes of Health, intending to use data science and informatics to develop decision support tools. This collaborative effort over the past decade has led to the development of the Work Disability-Functional Assessment Battery and has initiated an approach to applying natural language processing to the review of claimants' files for information on mental health functioning. This informatics research collaboration holds promise for improving the process of disability determination for individuals with mental impairments who make claims at the SSA.

State Mental Health Authority Level of Involvement in Coordinated Specialty Care Clinics and Client Outcomes.

OBJECTIVE: State mental health authorities (SMHAs) in all U.S. states and territories administer the Mental Health Block Grant (MHBG) set-aside funding for first-episode psychosis. Funds support implementation of coordinated specialty care (CSC) programs. The authors investigated the relationship between the level of SMHA involvement with CSC programs and clinical outcomes of clients in these programs. METHODS: As part of a mixed-methods study of 34 CSC programs, SMHAs from 21 states and one U.S. territory associated with the 34 CSC programs participated in a 1-hour interview (between November 2018 and May 2019) focused on SMHA involvement in administration of MHBG set-aside funds and the SMHA's ongoing relationship with funded CSC programs. SMHA involvement was rated on a scale of 1 to 5, with 5 indicating the highest involvement. Client outcome data were collected at the 34 study sites over an 18-month period. Multilevel random-effect modeling was used, controlling for response propensity (propensity score), client demographic variables, and program-level covariates (i.e., fidelity score, staff turnover rates, service area urbanicity, and number of clients enrolled). RESULTS: Clients in CSC programs with SMHAs that were the most involved (level 5) had significantly improved symptoms, social functioning, and role functioning, compared with clients in programs with which SMHAs were least involved (level 1). CONCLUSIONS: The findings suggest that increased SMHA involvement in CSC programs is relevant for positive client outcomes. Levels of first-episode psychosis funding doubled in 2021 and 2022, and it is important to identify how SMHAs affect the success of CSC programs and the individuals served.

How Phantom Networks And Other Barriers Impede Progress On Mental Health Insurance Reform.

Phantom networks are but one of many barriers to realizing access to mental health services. The term phantom networks refers to the misleading practice of listing providers as members of a network when they are not actually accepting patients. Inaccurate information on provider availability impedes the implementation of reforms that are designed to improve health insurance coverage of mental health treatment. Some other barriers to improving access to mental health services include low reimbursement rates from Medicaid, hesitancy of psychiatrists and psychologists to participate in networks, and practices of some managed care networks that require prior approval of mental health services such as psychiatric hospitalization. Phantom networks and these other barriers stand in the way of patients finding providers to help them at a time of need for treatment and support.

Client Racial Composition in First-Episode Psychosis Programs Compared With Compositions in Program Service Areas.

OBJECTIVE: The authors examined the extent to which clients served by first-episode psychosis programs reflected the racial composition of the surrounding service area and, to the extent that they did not, explored possible explanatory factors. METHODS: As part of a national study of coordinated specialty care (CSC) sites in the United States, 35 programs documented race for 772 clients. Programs identified a geographic service area for their clients. Using Census data, the authors identified the proportion of clients in this service area who were Black and then examined the extent of disproportionality, calculated as a risk ratio and as a relative difference in racial composition between CSC programs and their service areas. RESULTS: Overall, 71% of CSC programs had a disproportionately greater proportion of Black clients than Black residents within the service area. This disproportionality was still evident after conducting sensitivity analyses that included adjusting for sampling error in the service area population estimates; however, smaller study sites displayed greater fluctuations in disproportionality in the sensitivity analyses. CONCLUSIONS: Using data from diverse CSC programs, the authors illustrate that the odds of Blacks receiving services through a CSC program are much higher than would be expected on the basis of the population living in the area being served by the program. Multiple reasons may explain this finding, but in the absence of clear explanatory factors, this result may be ripe for discussion and further investigation.

Growth of Coordinated Specialty Care in the United States With Changes in Federal Funding Policies: 2014-2018.

OBJECTIVE: In 2014, the number of coordinated specialty care (CSC) programs in the United States greatly expanded. The proliferation of CSC programs was likely due in part to the availability of Mental Health Block Grant (MHBG) set-aside funds for treatment of first-episode psychosis. This study aimed to explore the characteristics of CSC programs across 44 states, the District of Columbia, and three U.S. territories that received funding through the MHBG set-aside program in 2018. METHODS: Leadership at 88% (N=215) of the 244 MHBG-funded CSC programs identified through state mental health authorities participated in an online survey. RESULTS: Overall, 69% of the CSC programs were initiated after 2014. More than 90% of programs included services that were consistent with federal guidance. CSC programs showed variability in training received, program size, and enrollment criteria. CONCLUSIONS: The results of this study emphasize that clear federal guidance can help shape national CSC implementation efforts, although decisions at the state and local levels can influence how implementation occurs. The strategy of states administering federal funds for CSC may be adapted for the rollout of other behavioral health interventions. Future studies could investigate factors that may shape national dissemination efforts, such as leadership within the state, funding, availability of programs established before the influx of funding, and considerations about sustainability after the funding is no longer available.

Helping People Denied Disability Benefits for a Mental Health Impairment: The Supported Employment Demonstration.

Social Security Administration demonstration projects that are intended to help people receiving disability benefits have increased employment but not the number of exits from disability programs. The Supported Employment Demonstration (SED) is a randomized controlled trial (RCT) of services for individuals with mental health problems before they enter disability programs. The SED aims to provide health, employment, and other support services that help them become self-sufficient and avoid entering disability programs. The target population is people who have been denied Social Security disability benefits for a presumed psychiatric impairment. Thirty community-based programs across the United States serve as treatment sites; inclusion in the SED was based on the existence of high-fidelity employment programs that use the individual placement and support model, the ability to implement team-based care, and the willingness to participate in a three-armed RCT. In the SED trial, one-third of 2,960 participants receive services as usual, one-third receive services from a multidisciplinary team that includes integrated supported employment, and one-third receive services from a similar team that also includes a nurse care coordinator for medication management support and medical care. The goals of the study are to help people find employment, attain better health, and delay or avoid disability program entry. This article introduces the SED.

Effects of ACA Expansion of Dependent Coverage on Hospital-Based Care of Young Adults With Early Psychosis.

OBJECTIVE: Since 2010, the Affordable Care Act has required private health plans to extend dependent coverage to adults up to age 26. Because psychosis often begins in young adulthood, expanded private insurance benefits may affect early psychosis treatment. The authors examined changes in insurance coverage and hospital-based service use among young adults with psychosis before and after this change. METHODS: The study included a national sample (2006-2013) of discharges and emergency department visits. Using a difference-in-differences study design, the authors compared changes in insurance coverage (measured as payer source), per capita admissions, and 30-day readmissions for psychosis before and after ACA dependent coverage expansion among targeted individuals (ages 20-25) and a comparison group (ages 27-29). RESULTS: After dependent coverage expansion, hospitalization for psychosis among young adults was 5.8 percentage points more likely to be reimbursed by private insurance among the targeted age group (ages 20-25), compared with the slightly older age group (ages 27-29). Dependent coverage expansion was not associated with changes in overall insurance coverage, per capita admissions, or 30-day readmission for psychosis. CONCLUSIONS: Although dependent coverage expansion was unrelated to changes in use of hospital-based treatments for psychosis among young adults, care was more likely to be covered by private insurance, and coverage of these hospitalizations by public insurance decreased. This shift from public to private insurance may reduce public spending on young-adult treatments for early-episode psychosis but may leave young adults without coverage for rehabilitation services.

Social Security and Disability Due to Mental Impairment in Adults.

The Social Security Administration (SSA) oversees two disability programs, Social Security Disability Insurance (SSDI) and Supplemental Security Income (SSI). Adults with mental impairments represent a very large component of the programs. Policy makers and SSA are concerned about the accuracy of disability determination and also about low levels of labor force participation among individuals with disabilities. Adults with mental impairments are challenging to assess for work-related functional limitations. They are also a challenge to return to labor force participation. SSA has sponsored several demonstration research programs focusing on improving the accuracy of disability determination and on interventions in supported employment to return individuals with mental impairments to competitive employment. This article reviews the demonstration research focused on both entry into the disability system (at the "front door") and potential exit from it (through the "back door"). All of the research holds promise to "right-size" the SSA disability program.

Communicating about Mental Illness and Violence: Balancing Stigma and Increased Support for Services.

In the ongoing national policy debate about how to best address serious mental illness (SMI), a major controversy among mental health advocates is whether drawing public attention to an apparent link between SMI and violence, shown to elevate stigma, is the optimal strategy for increasing public support for investing in mental health services or whether nonstigmatizing messages can be equally effective. We conducted a randomized experiment to examine this question. Participants in a nationally representative online panel (N = 1,326) were randomized to a control arm or to read one of three brief narratives about SMI emphasizing violence, systemic barriers to treatment, or successful treatment and recovery. Narratives, or stories about individuals, are a common communication strategy used by policy makers, advocates, and the news media. Study results showed that narratives emphasizing violence or barriers to treatment were equally effective in increasing the public's willingness to pay additional taxes to improve the mental health system (55 percent and 52 percent, vs. 42 percent in the control arm). Only the narrative emphasizing the link between SMI and violence increased stigma. For mental health advocates dedicated to improving the public mental health system, these findings offer an alternative to stigmatizing messages linking mental illness and violence.