Personal Recovery Among People at Risk for Developing Serious Mental Health Problems: A Qualitative Systematic Review.

OBJECTIVE: Personal recovery refers to a person's pursuit of a full, meaningful life despite the potentially debilitating impact of a mental illness. An evidence base describing personal recovery among people at risk for developing a mental illness is lacking, limiting the potential for mental health services to support personal recovery. To address this gap, the authors synthesized the extant research describing personal recovery among people at risk for developing a mental illness. METHODS: A systematic search of several literature databases (MEDLINE, Embase, APA PsycInfo, Web of Science Core Collection, and Cochrane Library) was conducted to retrieve qualitative and case studies and first-person accounts. The Joanna Briggs Institute guidelines for systematic reviews were followed. Included studies reported on participants at variable risk for developing a schizophrenia spectrum, bipolar, major depressive, or borderline personality disorder. Articles were retrieved through a librarian-assisted search and through use of additional strategies (e.g., expert consultation). Abstracts were screened by the research team, and themes were developed by using thematic synthesis. RESULTS: The 36 included articles were synthesized, and six themes were generated: difficulties and challenges; establishing an understanding of, and finding ways to cope with, one's mental health challenges; reestablishing a sense of agency and personhood; receiving support from people and services, as well as restoring relationships; reestablishing hope, meaning, and purpose; and overcoming stigma and destigmatizing mental illness in others. CONCLUSIONS: These findings provide a conceptual foundation that can guide future research on personal recovery and clinical interventions that foster it among people at risk for mental illness.

State of the Art of Participatory and User-led Research in Mental Health in Brazil: A Scoping Review.

Background: Participatory research denotes the engagement and meaningful involvement of the community of interest across multiple stages of investigation, from design to data collection, analysis, and publication. Traditionally, people with first-hand experience of psychiatric diagnoses, services users and those living with a psychosocial disability have been seen objects rather than agents of research and knowledge production. This, despite the ethical and practical benefits of their involvement. The state of the art of knowledge about participatory research in mental health Brazil is poorly understood outside of its local context. The purpose of this article was to conduct a scoping review of participatory and user-led research in mental health in Brazil. Findings: We identified 20 articles that met eligibility criteria. Participation in research was not treated as separate from participation in shaping mental health policy, driving care, or the broader right to fully participate in societal life and enjoy social and civil rights. Studies identified several obstacles to full participation, including the biomedical model, primacy of academic and scientific knowledge, and systemic barriers. Our extraction, charting, and synthesis yielded four themes: power, knowledge, autonomy, and empowerment. Implications of the work: Participation in this context must address the intersecting vulnerabilities experienced by those who are both Brazilian and labeled as having a mental illness. Participatory research and Global South leadership must foreground local epistemologies that can contribute to the global debate about participation and mental health research.

How clinicians can support posttraumatic growth following psychosis: a perspective piece.

Psychosis is often a traumatic experience that can lead to significant suffering. However, people may also experience posttraumatic growth following psychosis. Posttraumatic growth refers to the positive changes that people experience following a struggle with an adversarial event and has been shown to occur in at least five domains, including a greater appreciation for life; improved relationships with others; greater personal strengths; new life possibilities and spiritual/existential growth. Studies have shown that mental health services can play a key role in facilitating posttraumatic growth. However, there are no recommendations that clinicians can follow to best support posttraumatic growth following psychosis specifically. Without guidance, clinicians risk invalidating people's experiences of, or providing improper support for, posttraumatic growth. To address this knowledge gap, we reflect on current research and clinical guidelines to recommend ways that clinicians can support posttraumatic growth following psychosis.

A Mixed Methods Study Examining Citizenship Among Youth With Mental Health Challenges.

Introduction: Multiple stakeholders have recently called for greater research on the barriers to citizenship and community belonging faced by people with mental health challenges. Citizenship has been defined as a person's access to the rights, roles, responsibilities, resources and relationships that help people feel a sense of belonging. Factors that may impact citizenship include financial precarity; intersecting forms of marginalization and oppression (e.g., racism); and the mental health care people receive. Research has yet to examine experiences of citizenship among youth with mental health challenges. To address this gap, this study will examine how youth experience citizenship; predictors of citizenship; how citizenship shapes recovery; and the degree to which youth are receiving citizenship-oriented care. Methods: The research objectives will be evaluated using a multiphase mixed methods research design. Quantitative data will be collected cross-sectionally using validated self-report questionnaires. Qualitative data will be collected using a hermeneutic phenomenological method using semi-structured interviews and focus groups. Analyses: Multiple stepwise regression analyses will be used to determine predictors of citizenship and if of citizenship predict recovery. Pearson correlations will be computed to determine the relationship between participants' perceived desire for, and receipt of citizenship-oriented care. Phenomenological analysis will be used to analyze qualitative data. Findings will then be mixed using a weaving method in the final paper discussion section. Conclusion: Findings from this study may support the development of citizenship-oriented healthcare in Canada.

Generativity among people with lived experience of mental illness and distress.

Generativity refers to the contributions that people make toward the betterment of others, communities, and future generations. Engaging in generativity may add purpose and meaning to one's life, elements which people with mental illness often feel is relevant for their recovery. Despite its importance, what is known about how people with mental health problems engage in generativity, and the relationship between generativity and recovery is unclear. Addressing this knowledge gap may inform recovery-oriented interventions; and may help shift stigmatizing views that people with mental illnesses are a burden on society. This study explored generativity and its relationship to recovery among people with mental illnesses. The objectives were evaluated using a mixed methods sequential explanatory design over two phases. During the quantitative phase, participants completed questionnaires measuring generativity, recovery, and distress. During the qualitative phase, participants interpreted and elaborated upon the quantitative results. Phase one participants endorsed many items reflecting generativity. Generativity was correlated with overall recovery scores, as well as with domains reflecting no domination by symptoms (r = .32), a willingness to ask for help (r = .46), and personal confidence and hope (r = .48). Phase two participants discussed how the quantitative results resonated with their own experiences; their own generative behaviors, which included ephemeral and concrete forms of generativity; and how engaging in generativity improved their recovery. People with lived experience of mental illness make important contributions to the lives of other people and their communities; and these contributions can support recovery. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Generativity among persons providing or receiving peer or mutual support: A scoping review.

OBJECTIVE: People with lived experience of mental illness or distress can help others recover through peer or mutual support. One way they may help others recover is by fostering generativity, which refers to one's concern for and contributions toward the betterment of others, including future generations (e.g., through caregiving, engaging in civics). Generativity may add purpose to one's life, benefit society, and improve areas which persons with lived experience feel are important for their recovery. Despite its importance, the state of knowledge on experiences and facilitators of generativity, as well as the impact that engaging in generativity has on the lives of persons engaged in peer or mutual support, is unclear. METHOD: A librarian-assisted scoping review of the literature was conducted in five steps: identifying the research question and relevance; selecting studies; charting data; and coding and summarizing the results. RESULTS: Out of 11,862 articles that were screened, only 18 met eligibility criteria. Most studies were conducted in the United States and included White/Caucasian participants. Our synthesis produced themes related to generative actions, which included helping others, changing organizations and systems, and sharing personal stories. Themes describing facilitators of generativity included individual-level and organizational-level factors. One theme reflecting the positive psychosocial impact of engaging in generativity was produced. CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: Findings from this study point to several knowledge gaps to be investigated in future research and can facilitate the implementation of peer support initiatives aimed at fostering generativity, which may in turn promote recovery. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Post-traumatic growth in psychosis: a systematic review and narrative synthesis.

BACKGROUND AND OBJECTIVE: People with psychosis report experiences of highly traumatic events. Positive change or post-traumatic growth (PTG) can occur as a result of traumatic experiences. Yet there is limited attention on PTG in psychosis, possibly due to the negative impact of psychotic symptoms on functioning and quality of life. The aim of this review was to identify significant correlates and mediators of PTG in psychosis, and to develop a conceptual framework synthesising facilitators of PTG in psychosis. METHOD: Ten electronic databases were searched in seven languages, and five journals and grey literature were searched in English. Quantitative studies were eligible if examining correlates, mediators, or the temporal relationship between PTG and one or more variables. Qualitative studies were eligible if describing PTG arising from experiences of psychosis. Findings from quantitative papers were grouped by analysis method, with significant correlates, mediators, and temporal relationships descriptively reported upon. Narrative synthesis was conducted on findings in qualitative papers. RESULTS: Thirty-seven papers were included. Significant correlates and mediators of PTG were identified. Mediators of PTG in psychosis included meaning in life, coping self-efficacy, core beliefs, and self-reported recovery. No studies describing the temporal relationship between PTG and psychosis were identified. The narrative synthesis identified seven facilitators of PTG in psychosis: Personal identity and strength, Receiving support, Opportunities and possibilities, Strategies for coping, Perspective shift, Emotional experience, and Relationships, giving the acronym PROSPER. CONCLUSIONS: Individuals with psychosis can be supported to grow from traumatic experiences. Clinicians can support PTG through the provision of trauma-informed care that supports positively valued identity changes. For researchers, the findings provide an evidence-based theoretical framework for conceptualising PTG, which can be validated through longitudinal cohort studies and underpin the development of new clinical interventions.

"It Makes us Realize that We Have Been Heard": Experiences with Open Dialogue in Vermont.

The Open Dialogue approach was developed in Finland as a form of psychotherapy and a way to organize mental health systems. Open Dialogue has drawn global interest leading to adaptations worldwide, including in Vermont-US where it is called Collaborative Network Approach. Our study aimed to investigate the experiences of families who received Collaborative Network Approach in two agencies in Vermont. Qualitative interviews were conducted with 17 persons receiving services. Seven themes emerged: 1) network focus, 2) decision-making, 3) structure of care, 4) use of reflections, 5) medications, 6) hospitalizations, 7) challenges. Our study provides evidence that CNA is well-received, appreciated, and for many people an empowering form of mental health care. The findings suggest that elements of Open Dialogue are highly consistent with the vision for recovery-oriented care, in that they are flexible, person-centered, encourage processes of negotiation, and highlight the importance of family and social supports in care.

Impact of childhood trauma on positive and negative symptom remission in first episode psychosis.

OBJECTIVE: Early life adversity is suspected to play an important role for onset and course of psychosis, but its relationship with longer-term clinical outcome is not entirely clear. In this longitudinal study, we investigated the impact of childhood trauma (CT) on positive and negative symptom remission in first episode psychosis (FEP) patients over two years. METHODS: A total of 210 FEP patients were assessed with the Childhood Trauma Questionnaire. Patients reporting moderate to severe trauma (CT; N = 114; 54.3%) were compared to those without trauma (N-CT; N = 96; 45.7%). Positive (PSR) and negative symptom remission (NSR) were determined monthly over 24 months following established criteria using the Scale for Assessment of Positive Symptoms and the Scale for Assessment of Negative Symptoms. Global Functioning was evaluated at baseline and 24 months of follow-up. RESULTS: Compared to N-CT patients, CT patients had achieved significantly lower rates of PSR at 12 months and significantly lower rates of NSR at 24 months. A dose-response relationship was observed between the number of trauma categories fulfilled and the number of patients not achieving PSR and NSR at these time points. Higher trauma scores were significantly associated with poor functioning and higher positive and negative symptom severity at 24 months, but not at baseline and 12 months of follow-up. CONCLUSION: Differential effects of CT on clinical outcome may not be apparent at psychosis onset, but only become evident through poor symptomatic remission and general functioning over time. Targeted diagnostic and therapeutic efforts after illness onset might limit these detrimental consequences.

Perceived facilitators and predictors of positive change and posttraumatic growth following a first episode of psychosis: a mixed methods study using a convergent design.

BACKGROUND: This study aimed to identify predictors and perceived facilitators of positive change and posttraumatic growth in persons with a first episode of psychosis using a mixed methods convergent design. METHODS: In the quantitative component, 94 participants completed measures of posttraumatic growth and predictors of posttraumatic growth. The qualitative component involved in-depth interviews with 12 participants. RESULTS: Quantitative results revealed that being hospitalized for psychosis, spiritual coping, positive reframing and subjective recovery were significant predictors of posttraumatic growth. Qualitative findings revealed that positive change was perceived to be facilitated by the psychosis itself; receiving mental health services; drawing on personal and social resources and strategies; healing and recovering; a meaning-making and knowledge gaining process; and normative developmental processes. CONCLUSIONS: Posttraumatic growth following a first episode of psychosis may therefore be facilitated by complex person-environment interactions.

Surgical management and outcomes of adult acquired buried penis with and without lichen sclerosus: a comparative analysis.

PURPOSE: Adult acquired buried penis (AABP) can present with concomitant Lichen Sclerosus (LS), a chronic dermatosis that may affect surgical outcomes. Our aim was to evaluate outcomes of patients undergoing AABP repair with and without LS. METHODS: A retrospective cohort study was performed for AABP repair patients at a single institution from 1/1991 to 12/2017. Patient characteristics and surgical and peri-operative outcomes, including success, erectile function, and complications, were collected. RESULTS: Sixty-seven AABP patients with mean follow-up of 16.1 ± 20.4 months were identified. Overall surgical success was 91%. Overall surgical complication rate was 50.7% (23.9% Clavien-Dindo ≥ 3). Forty-two (62.7%) patients had concomitant LS. A higher proportion of patients with LS required a STSG (90% vs 60%, p = 0.005). There was no difference in surgical success (90.5% vs 92.0%, p = 0.999), overall complication rate (57.1% vs 40.0%, p = 0.212), Clavien-Dindo ≥ 3 complications (23.8% vs 24.0%, p = 0.999) or early complications (35.7% vs 32.0%, p = 0.797) between patients with and without LS, respectively. However, a higher proportion of patients with LS experienced late complications (33.3% vs 8.0%, p = 0.020), which were mainly related to wound healing. Satisfaction with erectile function was higher among patients with LS (59.5% vs 320%, p = 0.043). CONCLUSION: AABP patients with LS behave somewhat differently than their non LS counterparts. They are more likely to require skin graft during surgical treatment. Though surgical success and complications are similar, they do experience a higher rate of late complications from impaired wound healing. Work on improving wound healing in this population should be considered.

ShareDisk: A novel visual tool to assess perceptions about who should be responsible for supporting persons with mental health problems.

OBJECTIVES: Views on who bears how much responsibility for supporting individuals with mental health problems may vary across stakeholders (patients, families, clinicians) and cultures. Perceptions about responsibility may influence the extent to which stakeholders get involved in treatment. Our objective was to report on the development, psychometric properties and usability of a first-ever tool of this construct. METHODS: We created a visual weighting disk called 'ShareDisk', measuring perceived extent of responsibility for supporting persons with mental health problems. It was administered (twice, 2 weeks apart) to patients, family members and clinicians in Chennai, India (N = 30, 30 and 15, respectively) and Montreal, Canada (N = 30, 32 and 15, respectively). Feedback regarding its usability was also collected. RESULTS: The English, French and Tamil versions of the ShareDisk demonstrated high test-retest reliability (rs = .69-.98) and were deemed easy to understand and use. CONCLUSION: The ShareDisk is a promising measure of a hitherto unmeasured construct that is easily deployable in settings varying in language and literacy levels. Its clinical utility lies in clarifying stakeholder roles. It can help researchers investigate how stakeholders' roles are perceived and how these perceptions may be shaped by and shape the organization and experience of healthcare across settings.

Implanting Rhizomes in Vermont: a Qualitative Study of How the Open Dialogue Approach was Adapted and Implemented.

The Open Dialogue approach was developed in Finland in the 1980s as a form of psychotherapy and a way to organize mental health systems. It has been adapted and implemented in several countries in recent years. This qualitative study sought to explore staff and developers' experiences with one adaptation of the Open Dialogue approach in the state of Vermont called the Collaborative Network Approach. In total twenty two staff members from two agencies participated in focus groups and three developers of the approach were interviewed. Three dominant topics emerged in the analysis process: impact of training; buy-in across levels; and shift in organizational culture. Findings revealed that 1) participants experienced the Collaborative Network Approach as positively impacting their clinical work, relationship with clients and families, and with colleagues; 2) buy-in across levels - colleagues, management and department of mental health - was perceived as crucial to the development and implementation of the approach; 3) the main challenges to full implementation were: inadequate billing structures, costly and lengthy training, and resistance to shift organizational culture to integrate the Collaborative Network Approach into agencies. We hope to have contributed to the field in a way that will support further efforts to develop and implement Open Dialogue-informed approaches by pointing to potential successes and challenges future program developers may face.

"It's Brought Me a Lot Closer to Who I Am": A Mixed Methods Study of Posttraumatic Growth and Positive Change Following a First Episode of Psychosis.

Background: A first episode of psychosis is often a traumatic experience that may also lead to positive change, a phenomenon that has received little attention. This knowledge gap may impede service providers' capacity to foster positive change among service users. Objective: To investigate aspects of positive change among persons receiving early intervention services for psychosis. Design: The study objective was addressed using a mixed methods convergent design, which entailed simultaneously employing qualitative and quantitative methods. Setting: This study was conducted at a specialized early intervention service for psychosis based in Montreal, Quebec, Canada. Participants: Participants included service users receiving services at an early intervention service for psychosis. Participants had to be fluent in English or French, be clinically stable enough to take part in the study, and have received at least 6 months of treatment. Participants were conveniently sampled in the quantitative component and purposefully sampled in the qualitative component. The quantitative component was carried out using a cross-sectional survey design. Ninety-four participants completed the Posttraumatic Growth Inventory, a widely used measure of positive change. Data on the extent and domains of posttraumatic growth were summarized using descriptive statistics. The qualitative component was carried out using a qualitative descriptive approach. Semistructured interviews were conducted with 12 participants. Data were analyzed using thematic analysis. Findings from both components were integrated using a weaving method in the discussion section. Results: Quantitative results indicated that most participants reported a moderate amounts of posttraumatic growth. A greater appreciation of life was the most commonly endorsed domain, whereas spiritual growth was the least commonly endorsed domain. The qualitative results revealed that in addition to suffering, participants experienced positive changes, such as improved health and personality, and a stronger sense of self; stronger, more balanced religiosity and spirituality; improved relationships with others; and improved lifestyles, goals, and expectations for the future. Conclusions: Positive change may be a common phenomenon in the aftermath of first episode psychosis. The study findings may provide hope to those who have experienced a first episode of psychosis and can inform efforts by early intervention services to provide recovery-oriented, growth-focused care.

Gaming With Stigma: Analysis of Messages About Mental Illnesses in Video Games.

BACKGROUND: Video game playing is a daily activity for many youths that replaces other media forms (eg, television); it serves as an important source of knowledge and can potentially impact their attitudes and behaviors. Researchers are, thus, concerned with the impact of video gaming on youth (eg, for promoting prosocial or antisocial behavior). Studies have also begun to explore players' experience of gameplay and video game messages about violence, sexism, and racism; however, little is known about the impact of commercial video games in the sharing and shaping of knowledge, and messages about mental illness. OBJECTIVE: The aim of this review was to identify how mental illness, especially psychosis, is portrayed in commercial video games. METHODS: We performed keyword searches on games made available between January 2016 and June 2017 on Steam (a popular personal computer gaming platform). A total of 789 games were identified and reviewed to assess whether their game content was related to mental illness. At the end of the screening phase, a total of 100 games were retained. RESULTS: We used a game elements framework (characters, game environment/atmosphere, goals, etc) to describe and unpack messages about mental health and illness in video games. The majority of the games we reviewed (97%, 97/100) portrayed mental illness in negative, misleading, and problematic ways (associating it with violence, fear, insanity, hopelessness, etc). Furthermore, some games portrayed mental illness as manifestations or consequences of supernatural phenomena or paranormal experiences. Mental illness was associated with mystery, the unpredictable, and as an obscure illness; its treatment was also associated with uncertainties, as game characters with mental illness had to undergo experimental treatment to get better. Unfortunately, little or no hope for recovery was present in the identified video games, where mental illness was often presented as an ongoing struggle and an endless battle with the mind and oneself. CONCLUSIONS: The game elements of the identified commercial video games included mental illness, about which many perpetuated well-known stereotypes and prejudices. We discuss the key findings in relation to current evidence on the impact of media portrayals of mental illness and stigma. Furthermore, we reflect on the ability of serious video games to promote alternative messages about mental illness and clinical practices. Future research is needed to investigate the impact that such messages have on players and to explore the role that video games can play in fostering alternative messages to reduce the stigma associated with mental illness.

"Everyone Has a Role": Perspectives of Service Users With First-Episode Psychosis, Family Caregivers, Treatment Providers, and Policymakers on Responsibility for Supporting Individuals With Mental Health Problems.

Varying perceptions of who should be responsible for supporting individuals with mental health problems may contribute to their needs remaining unmet. A qualitative descriptive design was used to explore these perceptions among key stakeholders. Focus groups were conducted with 13 service users, 12 family members, and 18 treatment providers from an early psychosis intervention program in Montreal, Canada. Individual interviews were conducted with six mental health policy-/decision-makers. Participants across stakeholder groups assigned a range of responsibilities to individuals with mental health problems, stakeholders in these individuals' immediate and extended social networks (e.g., families), macro-level stakeholders with influence (e.g., government), and society as a whole. Perceived failings of the health care system and the need for greater sharing of roles and responsibilities also emerged as important themes. Our findings suggest that different stakeholders should collectively assume certain responsibilities and that systems-level failings may contribute to unmet needs for mental health support.

Does an integrated outreach intervention targeting multiple stages of early psychosis improve the identification of individuals at clinical high risk?

AIMS: To explore the impact of a targeted case identification intervention, with training and education regarding first-episode psychosis and clinical high-risk syndromes, on the referral and identification of those at high risk. METHODS: Using a historical control design, referral information from pre-intervention and post-intervention periods was collected via administrative data and clinician notes from a catchment-based early psychosis service. RESULTS: A significant increase in the number of referrals sent to the service's clinical high-risk unit was observed following the intervention (P = 0.01). The proportion of referrals eligible was significantly higher post-intervention (P = 0.03), with the majority (26/44, 59.1%) referred via the first-episode psychosis service unit. CONCLUSIONS: An integrated outreach intervention for both first-episode psychosis and the clinical high-risk state was effective in increasing referrals of eligible cases to the service's at-risk unit. Rather than being stage-specific, targeted case identification strategies and service integration should span across the early stages of psychosis.

Baby or bathwater? Referrals of "non-cases" in a targeted early identification intervention for psychosis.

PURPOSE: To explore the unintended impact of a targeted case identification (TCI) campaign for first episode psychosis (FEP) on people not experiencing FEP ("non-cases") with respect to referral patterns and reasons for being a non-case. METHODS: Sources of referral, reasons for being a non-case, and subsequent referral destinations of non-cases were examined before and after a TCI. RESULTS: Following the TCI, a greater proportion of non-cases lived outside the study catchment area. A smaller proportion was referred by the parent hospital's emergency room or had a substance-induced psychosis. CONCLUSIONS: TCIs for FEP may have unintended effects, with implications for early case identification and early intervention services.

Outcome in patients converting to psychosis following a treated clinical high risk state.

AIM: We explored 2-year outcomes in a sample of clinical high risk (CHR) patients who converted to psychosis despite receiving interventions. METHODS: Of 167 CHR patients, 18 had converted to psychosis and received treatment for their first episode of psychosis in an early intervention service over 2 years. RESULTS: Compared to patients admitted directly to the same early intervention service without having been identified as CHR prior to onset of psychosis, CHR converters were in remission for fewer months (M = 5 vs M = 10); were more likely to be prescribed more than 1 antipsychotic medication (90% vs 68%) and to receive clozapine treatment (38% vs 2%) over 2 years. CONCLUSIONS: CHR patients who convert to psychosis may be inherently more resistant to comprehensive treatment and may have poorer outcomes. Conversion to psychosis from a state of CHR can be reduced to a rate of 10%-12% following interventions, yet outcomes for patients who convert despite such interventions remain unexplored.

Examination of cultural competence in service providers in an early intervention programme for psychosis in Montreal, Quebec: Perspectives of service users and treatment providers.

AIM: To better understand cultural competence in early intervention for psychosis, we compared service users' and service providers' perceptions of the importance of providers being culturally competent and attentive to aspects of culture. METHODS: At a Canadian early intervention programme, a validated scale was adapted to assess service user (N = 51) and provider (N = 30) perceptions of service providers' cultural competence and the importance accorded thereto. RESULTS: Analyses of variance revealed that the importance of service providers being culturally competent was rated highest by service providers, followed by visible minority service users, followed by white service users. Providers rated themselves as being more interested in knowing about service users' culture than service users perceived them to be. CONCLUSIONS: Service users accorded less import to service providers' cultural competence than providers themselves, owing possibly to varied socialization. A mismatch in users' and providers' views on providers' efforts to know their users' cultures may influence mental healthcare outcomes.