Even mild internalized stigma merits attention among adults with serious mental illness.

Internalized or self-stigma can be damaging to psychological and social functioning and recovery, especially for people with serious mental illness. Most studies have focused on the effects of high self-stigma, which has included both moderate and high self-stigma, versus low levels of self-stigma which has included no, minimal, or mild self-stigma. Therefore, little is known about the variation within these categories (e.g., minimal versus mild self-stigma) and its impact on recovery. This article examines differences in the demographic, clinical, and psychosocial variables associated with different levels of self-stigma severity. Baseline data (N = 515) from two concurrent randomized controlled trials of a psychosocial intervention aimed at reducing internalized stigma, and its effects among adults with serious mental illnesses were examined. We found that participants with greater psychological sense of belonging, and greater perceived recovery were significantly less likely to have mild or moderate/high internalized stigma than minimal stigma. Those reporting a greater frequency of stigma experiences, however, were more likely to have mild or moderate/high internalized stigma than minimal stigma. Our findings further underscore the multifaceted nature and impact of self-stigma, particularly in interpersonal relationships and interactions, and demonstrate the importance of attending to even mild levels of self-stigma endorsement. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Barriers and Enablers to Implementing Peer Specialists in Veterans Health Administration Primary Care: a Qualitative Study.

BACKGROUND: Peer specialists (PSs) are increasingly deployed in a variety of settings to provide patient-centered care. In the Veterans Health Administration (VHA), efforts are underway to integrate PSs into primary care settings. Little is known about the barriers and enablers to implementing PS services in primary care. OBJECTIVE: To characterize barriers and enablers to implementing PSs in primary care. DESIGN: Qualitative study using semi-structured interviews. PARTICIPANTS: PSs and their supervisors from 25 VHA primary care settings. APPROACH: PSs and supervisors were interviewed about their experiences integrating PSs in primary care. Rapid analysis was conducted to identify barriers and enablers to PS integration, as well as to examine the role of external facilitation in implementation experiences. KEY RESULTS: Fifty-two interviews were completed (25 PSs from 19 sites and 27 supervisors from 24 sites). Barriers and enablers to PS integration in VHA primary care settings included PS role clarity and constraints, provider buy-in, supervision, leadership support, and primary care culture. The barriers and enablers were consistent across both external facilitation and control sites. CONCLUSIONS: Results describe how the characteristics of the innovation, the recipients, and the context impact successful implementation of PSs in primary care settings. The identification of barriers and enablers holds promise for improving future efforts to embed PSs in primary care. TRIAL REGISTRATION: This project is registered at ClinicalTrials.gov with number NCT02732600 (URL: https://clinicaltrials.gov/ct2/show/NCT02732600 ).

Photoredox-Ni Dual Catalysis: Chelation-Free Hydroacylation of Terminal Alkynes.

Hydroacylation of alkynes is undoubtedly the simplest and most atom-efficient approach for the synthesis of enones with diverse synthetic applications. Despite significant progress in hydroacylations, no hydroacylations exist that make use of aldehydes without a chelating group, especially when combined with terminal alkynes. Here we report a synergistic nickel-photocatalytic system that allows for the highly regio- and stereoselective hydroacylation of unactivated aldehydes and alkynes in milder conditions without the use of chelating groups.

Between and within race differences in patient-centeredness and activation in mental health care.

OBJECTIVES: The aim of this study was to compare Black and White mental health care patients' perceptions of their providers' and their own participation in patient-centered mental health care. Perceptions of patient-centered care (PCC) in relation to the Multidimensional Model of Racial Identity were explored. METHODS: Black and White veterans receiving mental health care (n = 82) completed surveys assessing patient activation, involvement in care, perceptions of PCC, and therapeutic alliance. Black participants (n = 40) also completed the Multidimensional Inventory of Black Identity. RESULTS: There were no differences by race in perceived PCC, though Black participants had lower levels of therapeutic alliance with their mental health care provider and were less activated. Black identity centrality, private regard, and public regard were positively related to PCC and elements of PCC such as patient information seeking/sharing. CONCLUSIONS: Intragroup identity variables such as racial centrality, regard, and ideology influenced perceived PCC among Black participants. Race identity variables should be explored in future research on racial disparities and PCC. PRACTICE IMPLICATIONS: Mental health care providers serving Black patients should create opportunities to discuss racial identity and race-related experiences as part of their efforts to improve therapeutic alliance and increase the patient-centeredness of care.

Core Competencies to Promote Consistency and Standardization of Best Practices for Digital Peer Support: Focus Group Study.

BACKGROUND: As digital peer support is quickly expanding across the globe in the wake of the COVID-19 pandemic, standardization in the training and delivery of digital peer support can advance the professionalism of this field. While telehealth competencies exist for other fields of mental health practice, such as social work, psychiatry, and psychology, limited research has been done to develop and promote digital peer support competencies. OBJECTIVE: The goal of this study is to introduce the coproduction of core competencies that can guide digital peer support. METHODS: Peer support specialists were recruited through an international listserv and participated in a 1-hour virtual focus group. A total of four focus groups were conducted with 59 peer support specialists from 11 US states and three countries. RESULTS: Analysis was conducted using the rigorous and accelerated data reduction (RADaR) technique, and 10 themes were identified: (1) protecting the rights of service users, (2) technical knowledge and skills in the practice of digital peer support, (3) available technologies, (4) equity of access, (5) digital communication skills, (6) performance-based training, (7) self-care, (8) monitoring digital peer support and addressing digital crisis, (9) peer support competencies, and (10) health literacy (emerging). The authors present recommendations based on these themes. CONCLUSIONS: The introduction of digital peer support core competencies is an initial first step to promote the standardization of best practices in digital peer support. The established competencies can potentially act as a guide for training and skill development to be integrated into US state peer support specialist competencies and to enhance competencies endorsed by the Substance Abuse and Mental Health Services Administration (SAMHSA).

Implementation of peer specialist services in VA primary care: a cluster randomized trial on the impact of external facilitation.

BACKGROUND: Over 1100 veterans work in the Veterans Health Administration (VHA) as peer specialists (PSs)-those with formal training who support other veterans with similar diagnoses. A White House Executive Action mandated the pilot reassignment of VHA PSs from their usual placement in mental health to 25 primary care Patient Aligned Care Teams (PACTs) in order to broaden the provision of wellness services that can address many chronic illnesses. An evaluation of this initiative was undertaken to assess the impact of outside assistance on the deployment of PSs in PACTs, as implementation support is often needed to prevent challenges commonly experienced when first deploying PSs in new settings. METHODS: This study was a cluster-randomized hybrid II effectiveness-implementation trial to test the impact of minimal implementation support vs. facilitated implementation on the deployment of VHA PSs in PACT over 2 years. Twenty-five Veterans Affairs Medical Centers (VAMCs) were recruited to reassign mental health PSs to provide wellness-oriented care in PACT. Sites in three successive cohorts (n = 7, 10, 8) over 6-month blocks were matched and randomized to each study condition. In facilitated implementation, an outside expert worked with site stakeholders through a site visit and regular calls, and provided performance data to guide the planning and address challenges. Minimal implementation sites received a webinar and access to the VHA Office of Mental Health Services work group. The two conditions were compared on PS workload data and veteran measures of activation, satisfaction, and functioning. Qualitative interviews collected information on perceived usefulness of the PS services. RESULTS: In the first year, sites that received facilitation had higher numbers of unique veterans served and a higher number of PS visits, although the groups did not differ after the second year. Also, sites receiving external facilitation started delivering PS services more quickly than minimal support sites. All sites in the external facilitation condition continued in the pilot into the second year, whereas two of the sites in the minimal assistance condition dropped out after the first year. There were no differences between groups on veterans' outcomes-activation, satisfaction, and functioning. Most veterans were very positive about the help they received as evidenced in the qualitative interviews. DISCUSSION: These findings demonstrate that external facilitation can be effective in supporting the implementation of PSs in primary care settings. The lack of significant differences across conditions after the second year highlights the positive outcomes associated with active facilitation, while also raising the important question of whether longer-term success may require some level of ongoing facilitation and implementation support. TRIAL REGISTRATION: This project is registered at ClinicalTrials.gov with number NCT02732600 (URL: https://clinicaltrials.gov/ct2/show/NCT02732600 ).

Health Behavior Change Processes Among Adults With Serious Mental Illness Engaged in Illness Self-Management.

Self-management interventions promote illness management among adults with chronic health conditions. Little is known regarding the processes by which these interventions have their effects. The present study examined how Living Well, an effective self-management intervention for adults with serious mental illness, led to health behavior change in a randomized controlled trial. A convenience subset (N = 15) of participants completed qualitative interviews regarding the feasibility/acceptability of Living Well. An inductive secondary qualitative analysis, using a combination of interpretive phenomenological and social constructivist approaches, was conducted to examine processes of change. Results indicate that Living Well provided information and knowledge, opportunities for learning from others and real-world practice, and an interpersonally supportive environment. These active ingredients led to enhanced self-awareness, confidence, sense of control, and behavior and health status changes among participants. These findings are considered in the context of prominent behavior change theories such as social cognitive theory and self-regulation.

Peer and Non-Peer Co-Facilitation of a Health and Wellness Intervention for Adults with Serious Mental Illness.

Peer specialists, or individuals with lived experience of mental health conditions who support the mental health recovery of others, often work side-by-side with traditional providers (non-peers) in the delivery of treatment groups. The present study aimed to examine group participant and peer provider experiences with peer and non-peer group co-facilitation. Data from a randomized controlled trial of Living Well, a peer and non-peer co-facilitated intervention for medical illness management for adults with serious mental illness, were utilized. A subset of Living Well participants (n = 16) and all peer facilitators (n = 3) completed qualitative interviews. Transcripts were coded and analyzed using a general inductive approach and thematic analysis. The complementary perspectives of the facilitators, teamwork between them, skillful group pacing, and peer facilitator self-disclosure contributed to a warm, respectful, and interactive group atmosphere, which created an environment conducive to social learning. Guidelines for successful co-facilitation emerging from this work are described.

Certified Peer Specialists' Perspective of the Barriers and Facilitators to Mobile Health Engagement.

This study examined certified peer specialists' perceptions of the barriers and facilitators to mobile health (mHealth) engagement. A total of 267 certified peer specialists from 38 states completed an online survey. Of this sample, 74 certified peer specialists completed open-ended questions. Data were analyzed from the 74 respondents who responded to open-ended questions. Certified peer specialists identified previously unidentified facilitators including the augmented use of certified peer specialists in combination with mHealth to improve engagement. One emerging theme identified was the belief that mHealth interventions may promote social isolation if not designed appropriately. Certified peer specialists appear to prefer using tablets instead of smartphones. Integrating certified peer specialists' perspectives of barriers and facilitators to mHealth engagement may promote initial and sustained mHealth engagement among consumers with serious mental illness. Future research using implementation science frameworks should examine these previously identified barriers and facilitators to mHealth engagement as correlates and/or predictors of engagement among service users.

Digital Peer Support Mental Health Interventions for People With a Lived Experience of a Serious Mental Illness: Systematic Review.

BACKGROUND: Peer support is recognized globally as an essential recovery service for people with mental health conditions. With the influx of digital mental health services changing the way mental health care is delivered, peer supporters are increasingly using technology to deliver peer support. In light of these technological advances, there is a need to review and synthesize the emergent evidence for peer-supported digital health interventions for adults with mental health conditions. OBJECTIVE: The aim of this study was to identify and review the evidence of digital peer support interventions for people with a lived experience of a serious mental illness. METHODS: This systematic review was conducted using Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) procedures. The PubMed, Embase, Web of Science, Cochrane Central, CINAHL, and PsycINFO databases were searched for peer-reviewed articles published between 1946 and December 2018 that examined digital peer support interventions for people with a lived experience of a serious mental illness. Additional articles were found by searching the reference lists from the 27 articles that met the inclusion criteria and a Google Scholar search in June 2019. Participants, interventions, comparisons, outcomes, and study design (PICOS) criteria were used to assess study eligibility. Two authors independently screened titles and abstracts, and reviewed all full-text articles meeting the inclusion criteria. Discrepancies were discussed and resolved. All included studies were assessed for methodological quality using the Methodological Quality Rating Scale. RESULTS: A total of 30 studies (11 randomized controlled trials, 2 quasiexperimental, 15 pre-post designs, and 2 qualitative studies) were included that reported on 24 interventions. Most of the studies demonstrated feasibility, acceptability, and preliminary effectiveness of peer-to-peer networks, peer-delivered interventions supported with technology, and use of asynchronous and synchronous technologies. CONCLUSIONS: Digital peer support interventions appear to be feasible and acceptable, with strong potential for clinical effectiveness. However, the field is in the early stages of development and requires well-powered efficacy and clinical effectiveness trials. TRIAL REGISTRATION: PROSPERO CRD42020139037; https://www.crd.york.ac.uk/PROSPERO/display_record.php?RecordID= 139037.

The influence of experiences of stigma on recovery: Mediating roles of internalized stigma, self-esteem, and self-efficacy.

OBJECTIVE: Experiencing stigmatization regarding mental illness has harmful effects on recovery from serious mental illness (SMI). Stigma experiences can also lead to internalized stigma, the cognitive and emotional internalization of negative stereotypes, and application of those stereotypes to one's self. Internalized stigma may lead to additional harms, including decrements in self-esteem and self-efficacy. Therefore, this study examined the effects of stigmatization experiences on recovery-related outcomes through internalized stigma, self-esteem, and self-efficacy in a single comprehensive model. METHODS: Adults with SMI (n = 516) completed standardized measures assessing the variables of interest during baseline assessments for 2 randomized controlled trials. In a secondary analysis of the trial data, separate serial mediation models were tested for recovery orientation, perceived quality of life, and social withdrawal as outcomes, with experiences of stigma as the predictor variable and internalized stigma, self-esteem, and self-efficacy as serial mediators in that order. Alternate order and parallel mediation models were also tested to evaluate directionality. RESULTS: The serial mediation model was the best fit, although self-efficacy was not found to be a critical mediator. Experiences of stigma led to internalized stigma, which influenced self-esteem and recovery-related outcomes, consistent with the social-cognitive model of internalized stigma. CONCLUSION: This indicates that internalized stigma is an essential target for reducing the negative impact of stigmatization on recovery. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Stigma and discrimination as correlates of mental health treatment engagement among adults with serious mental illness.

OBJECTIVE: The negative impacts of stigma on mental health treatment initiation are well established, but the relationship of stigma to proactive engagement in mental health treatment (e.g., actively working toward therapy goals) is largely unexamined. This study examined the relationship between mental health treatment engagement and stigma experiences, discrimination experiences, and internalized stigma among adults with serious mental illness. Age, race, gender, and education were tested as moderators of the relationships between stigma-related variables and treatment engagement. METHOD: Data were collected from 167 adults with serious mental illnesses who were receiving services at 5 psychosocial rehabilitation programs. Treatment engagement was assessed by participants' primary mental health care providers, using the Service Engagement Scale. The relationship between treatment engagement, stigma, and discrimination as well as potential demographic moderators were tested with Pearson's correlations and multiple linear regressions. RESULTS: Treatment engagement was not correlated with experiences of stigma, experiences of discrimination, or application of stigmatizing beliefs to self. Gender, race, and age were not significant moderators but education was. Experiences of stigma were associated with greater treatment engagement in those with a higher level of education (p = .007), whereas application of stigma to one's self was associated with poorer treatment engagement in those with a higher level of education (p = .005). CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: Among individuals with higher levels of education, efforts to prevent internalization of public stigma may be crucial to promote proactive mental health treatment. Replication studies are needed to confirm these findings. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Predictors of attendance in health and wellness treatment groups for people with serious mental illness.

OBJECTIVE: People with serious mental illness have dramatically reduced life expectancy that is largely attributed to elevated rates of chronic medical conditions. Several group interventions have been developed and implemented in recent years to improve health and wellness among people with mental health conditions. Unfortunately, attendance in these interventions is often low, and there is limited understanding of factors that influence patient engagement in this treatment modality. METHOD: Participants (N = 242) were enrolled in 1 of 2 group-based health and wellness treatment programs. Using descriptive statistics and regression, we assessed treatment attendance and a range of potential predictors of attendance. RESULTS: We found lower attendance among people who were younger, people with more medical conditions, and people with more emergency room visits in the 6 months prior to the beginning of treatment. Younger age was a particularly strong predictor of low attendance and was the only variable significantly associated with attending zero treatment sessions. CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: These results highlight the need for strategies to improve engagement of patients with poorer objective indicators of medical health and patients with younger age. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Quality of life outcomes of web-based and in-person weight management for adults with serious mental illness.

Adults with serious mental illness have high rates of obesity, with associated negative impacts on health-related quality of life. The present study utilized data from a randomized controlled trial (N = 276) to examine the effectiveness of in-person and online-delivered weight management interventions, compared to usual care, for improving health-related quality of life in this population. Participants completed quality of life assessments at baseline, 3 months, and 6 months. Mixed effects models examined group by time interactions. Compared to usual care, in-person MOVE was associated with improvements in loneliness (t = - 2.76, p = .006) and mental health related quality of life (t = 1.99, p = 0.048) at 6 months, and webMOVE was associated with improvements in weight-related self-esteem at 6 months (t = 2.23, p = .026) and mental health-related quality of life at 3 months (t = 2.17, p = 0.031) and 6 months (t = 2.38, p = .018). Web-based and in-person weight management led to improvements in health-related quality of life for adults with serious mental illness.ClinicalTrials.gov Identifier: NCT00983476.

Unmet Needs of People with Serious Mental Illness: Perspectives from Certified Peer Specialists.

Examine the unmet needs of people with serious mental illness (SMI) from the perspective of certified peer specialists. 267 certified peer specialists from 38 states completed an online survey (female [73%], 50.9 [SD = 12] years, and non-Hispanic White [79.8%]). Many respondents reported a primary mental health diagnoses (n = 200), 22 respondents reported their diagnosis as schizophrenia spectrum disorder (11%), 46 respondents reported bipolar disorder (22.1%), 47 respondents reported major depressive disorder (22.6%), 29 respondents reported post-traumatic stress disorder (13.9%), 27 respondents reported alcohol/substance use disorder (13%), 2 respondents reported personality disorder (1%), and 12 reported "other" (5.8%). A mixed methods convergence analysis integrated quantitative with qualitative data. Social isolation (n = 160, 59.9%) and feeling lonely (n = 159, 59.6%) were the most highly endorsed unmet need, followed by the need to address chronic health conditions (n = 80, 30%), prevent mental health hospitalization (n = 71, 23.6%), and prevent drug use (n = 66, 24.7%). Four themes emerged: need to address basic necessities, loneliness and social isolation, hope, and addiction. Addressing loneliness and social isolation were identified as the primary unmet needs among people with SMI. Addressing co-morbid health conditions may simultaneously impact other unmet needs. Hope is an important intervention target. Initial insights from this study can be used to guide researchers' efforts to incorporate certified peer specialists perspectives in developing programs to meet the needs of people with SMI. Future research using participatory research methods can further examine these initial insights.

Preparing Long-Term Care Staff to Meet the Needs of Aging Persons With Serious Mental Illness.

OBJECTIVES: Individuals with serious mental illness (SMI; schizophrenia spectrum disorders and affective psychoses) are increasingly aging into older adulthood and are overrepresented in residential long-term care settings. The present study aimed to examine the preparedness of staff in these settings to care for individuals with SMI. DESIGN: A multidisciplinary US Department of Veterans Affairs (VA) workgroup of professionals with expertise in geriatric mental health collected voluntary feedback via online questionnaire as part of a quality improvement project. SETTING AND PARTICIPANTS: Respondents were mental health providers (N=51) embedded in VA nursing homes called Community Living Centers (CLCs). MEASURES: The questionnaire contained multiple-choice, Likert-type scale, and open-ended questions regarding the opportunities and challenges associated with caring for Veterans with SMI in CLCs. RESULTS: Respondents identified a lack of training of front-line staff as a key challenge in providing high-quality care to residents with SMI. Specifically, respondents indicated a need to increase staff knowledge about SMI symptoms and diagnoses, to improve staff communication and interactions with residents with SMI, and to decrease mental illness stigma among staff. CONCLUSIONS/IMPLICATIONS: The present study revealed significant areas of training need for front-line staff in nursing homes. Many perceived staff training needs overlap with the knowledge and skill set required to provide high-quality dementia care. Integrating training regarding the care of residents with SMI into dementia care training efforts may be a fruitful future direction. Strategies for this and a suggested curriculum are provided.

Intra-operative point-of-procedure delineation of oral cancer margins using optical coherence tomography.

OBJECTIVES: Surgical margin status is a significant determinant of treatment outcome in oral cancer. Negative surgical margins can decrease the loco-regional recurrence by five-fold. The current standard of care of intraoperative clinical examination supplemented by histological frozen section, can result in a risk of positive margins from 5 to 17 percent. In this study, we attempted to assess the utility of intraoperative optical coherence tomography (OCT) imaging with automated diagnostic algorithm to improve on the current method of clinical evaluation of surgical margin in oral cancer. MATERIALS AND METHODS: We have used a modified handheld OCT device with automated algorithm based diagnostic platform for imaging. Intraoperatively, images of 125 sites were captured from multiple zones around the tumor of oral cancer patients (n = 14) and compared with the clinical and pathologic diagnosis. RESULTS: OCT showed sensitivity and specificity of 100%, equivalent to histological diagnosis (kappa, ĸ = 0.922), in detection of malignancy within tumor and tumor margin areas. In comparison, for dysplastic lesions, OCT-based detection showed a sensitivity of 92.5% and specificity of 68.8% and a moderate concordance with histopathology diagnosis (ĸ = 0.59). Additionally, the OCT scores could significantly differentiate squamous cell carcinoma (SCC) from dysplastic lesions (mild/moderate/severe; p ≤ 0.005) as well as the latter from the non-dysplastic lesions (p ≤ 0.05). CONCLUSION: The current challenges associated with clinical examination-based margin assessment could be improved with intra-operative OCT imaging. OCT is capable of identifying microscopic tumor at the surgical margins and demonstrated the feasibility of mapping of field cancerization around the tumor.

Living Well: An Intervention to Improve Medical Illness Self-Management Among Individuals With Serious Mental Illness.

OBJECTIVE: Many adults with serious mental illness have significant medical illness burden and poor illness self-management. In this study, the authors examined Living Well, a group-based illness self-management intervention for adults with serious mental illness that was cofacilitated by two providers, one of whom has lived experience with co-occurring mental health and medical conditions. METHODS: Adults with serious mental illness (N=242) were randomly assigned to Living Well or an active control condition. Participants completed assessments of quality of life; health attitudes; self-management behaviors; and symptoms at baseline, posttreatment, and follow-up. Emergency room use was assessed by means of chart review. Mixed-effects models examined group × time interactions on outcomes. RESULTS: Compared with the control group, adults in Living Well had greater improvements at posttreatment in mental health-related quality of life (t=2.15, p=.032), self-management self-efficacy (t=4.10, p<.001), patient activation (t=2.08, p=.038), internal health locus of control (t=2.01, p=.045), behavioral and cognitive symptom management (t=2.77, p=.006), and overall psychiatric symptoms (t=-2.02, p=.044); they had greater improvements at follow-up in physical activity-related self-management (t=2.55, p=.011) and relationship quality (t=-2.45, p=.015). No effects were found for emergency room use. The control group exhibited greater increases in physical health-related quality of life at posttreatment (t=-2.23, p=.026). Significant group differences in self-management self-efficacy (t=2.86,p=.004) and behavioral and cognitive symptom management (t=2.08, p= .038) were maintained at follow-up. CONCLUSIONS: Compared with an active control group, a peer-cofacilitated illness self-management group was more effective in improving quality of life and self-management self-efficacy among adults with serious mental illness.