A microcosting approach for planning and implementing community-based mental health prevention program: what does it cost?

BACKGROUND: Estimating program costs when planning community-based mental health programs can be burdensome. Our aim was to retrospectively document the cost for the first year of planning and implementing Healthy Minds Healthy Communities (HMHC), a mental health promotion and prevention multi-level intervention initiative. This Program is among the first to use the Community Initiated Care (CIC) model in the US and is aimed at building community resilience and the capacity for communities to provide mental health support, particularly among those disproportionately impacted by COVID-19. Our objective is to share our methods for costing a program targeting 10 zip codes that are ethnically and linguistically diverse and provide an example for estimating the cost of a mental health prevention and promotion programs consisting of multiple evidence-based interventions. METHODS: We used a semi-structured interview process to collect cost data through the first year of program planning, start-up and initial implementation from key staff. We calculated costs for each activity, grouped them by major project categories, and identified the cost drivers of each category. We further validated cost estimates through extensive literature review. The cost analysis was done from the provider's perspective, which included the implementing agency and its community partners. We delineated costs that were in-kind contributions to the program by other agency, and community partners. Sensitivity analyses were conducted to estimate uncertainty around parameters. RESULTS: For the first year of the development and implementation of the program, (funded through program and in-kind) is estimated at $1,382,669 (2022 US$). The costs for the three main activity domains for this project are: project management $135,822, community engagement $364,216 and design and execution $756,934. Overall, the cost drivers for the first year of this intervention were: hiring and onboarding staff, in-person community building/learning sessions, communications and marketing, and intervention delivery. CONCLUSION: Implementation of community-based mental health promotion and prevention programs, when utilizing a participatory approach, requires a significant amount of upfront investment in program planning and development. A large proportion of this investment tends to be human capital input. Developing partnerships is a successful strategy for defraying costs.

Coping during the COVID-19 pandemic among young adults experiencing homelessness and unstable housing: A qualitative study.

BACKGROUND: Young adults experiencing homelessness (YAEH) experience more stressors compared to housed peers, yet little is known about the impact of the COVID-19 pandemic on these youth. The purpose of this qualitative study was to explore how YAEH perceived the pandemic's impact on their well-being and coping. METHODS: YAEH were recruited from those participating in an HIV prevention study. Semi-structured interviews were conducted and analysis was guided by Lazarus and Folkman's transactional theory of stress and coping. RESULTS: Four major themes were identified from interviews with 40 youth: (1) ongoing harms, (2) COVID-19 as a stressor, (3) mental health impacts, and (4) coping strategies. Participants described unmet basic needs, emotions of frustration and anxiety, and several coping strategies including substance use. CONCLUSION: Many YAEH reported experiencing continued challenges that were compounded by the stressors related to the COVID-19 pandemic. Special considerations are needed to address pandemic-related exacerbations of mental health symptoms and substance use among YAEH.

Experiences of discrimination among young adults experiencing homelessness: Relationship to mental health outcomes.

Young adults experiencing homelessness (YAEH) are at high risk for discrimination. Limited research has documented the extent of discrimination experiences and their relationship to mental health outcomes among this group. This study used data from YAEH who completed self-administered surveys across seven U.S. cities (N = 1,426) to examine the rates and correlates of discrimination experiences and their association with psychological distress and suicidal ideation. Chi-square and multivariate logistic regressions were used to examine the relations between perceived discrimination and race, gender identity, sexual orientation, foster care history, criminal justice history, reasons for homelessness, and length of time homeless. Then, logistic regression was used to examine whether discrimination increased the odds of psychological distress and suicidal ideation, controlling for other factors. Three-fourths (75.8%) of the sample (n = 1,055) reported experiencing at least one of the five forms of everyday discrimination experiences at least a few times a year, with the most common reason attributed to their housing situation (46%). Sexual orientation, juvenile justice involvement, and having been homeless for 2 years or more were associated with increased odds of experiencing discrimination. Discrimination was a strong predictor of psychological distress but was significant only at the bivariate level for suicidal ideation. Study results suggest that experiences of discrimination are common among YAEH and that these experiences increase risk for psychological distress. Providers working with YAEH need to validate and acknowledge the impact of these experiences on mental health. And, communities need to work to reduce discrimination experiences by targeting stigma against YAEH. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

The intersection of housing and mental well-being: Examining the needs of formerly homeless young adults transitioning to stable housing.

We examine the challenges formerly homeless young adults (FHYAs) face after they transition out of homelessness. Considering the adversities FHYAs face, it is unclear how transitioning to stable housing may affect their mental well-being or what types of stressors they may experience once housed. This study investigates the social environment young adults encounter in their transition to stable housing and examines trauma and social coping predictors of mental health symptoms in a sample of FHYAs to generate new knowledge for better intervening to meet their needs. Data were obtained from REALYST, a national research collaborative comprised of interdisciplinary researchers investigating young adults' (ages 18-26) experiences with homelessness. Cross-sectional data for 1426 young adults experiencing homelessness were collected from 2016 to 2017 across seven cities in the United States (i.e., Los Angeles, Phoenix, Denver, Houston, San Jose, St. Louis, and New York City). The analytical sub-sample for this study consisted of 173 FHYAs who were housed in their own apartment (via voucher from Housing and Urban Development or another source) or in transitional living programs during their participation in the study. Ordinary Least Squares regression was used to examine the influence of trauma and social coping strategies on indicators of mental well-being. Findings indicated that higher adversity scores and higher mental health help-seeking intentions were positively associated with higher levels of stress, psychological distress, and depression severity. Higher level of social coping was associated with lower levels of depression severity. Logistic regression results showed that young adults with higher adversity scores had higher odds of reporting clinical levels of post-traumatic symptoms. The study implications suggest that FHYAs who transition to stable housing continue to need support navigating and coping with stressful life events; and interventions that help FHYAs develop strong networks of social supports are needed to promote positive mental well-being.

A mixed-methods investigation into the perspectives on mental health and professional treatment among former system youth with mood disorders.

Research has shown that how people think about their health (or illnesses) shapes their help-seeking behavior. In this mixed-methods study, we employed a simultaneous concurrent design to explore the perceptions of mental illness among an understudied population: marginalized young adults. Participants were 60 young adults (ages 18-25) who had experienced mood disorders and used multiple public systems of care during their childhoods. Semistructured interviews were conducted to understand participants' illness and treatment experiences during the transition to adulthood. A team of analysts used constant comparison to develop a codebook of the qualitative themes, and quantitative data were examined using SAS 9.3. Findings suggest that some theoretical categories identified in past illness-perceptions frameworks are salient to marginalized young adults (e.g., identity, management-or control-of symptoms), but both the developmental transition to adulthood and experiences with public systems of care add nuanced variations to illness and treatment perceptions. Our study demonstrates that young adults possess a set of beliefs and emotions about their mental health and help-seeking options that need to be better understood to improve engagement and quality of mental health care for this population. Implications for practice, research, and policy are discussed. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Prior Experiences of Behavioral Health Treatment among Uninsured Young Adults Served in a Psychiatric Crisis Setting.

This study qualitatively explored the past treatment experiences of uninsured young adults who sought public emergency psychiatric care. Qualitative interviews were conducted with a racially diverse sample of 55 young adults (ages 18-25) using a semi-structured interview guide, and analyzed using a team-based open coding approach. Findings emerged in three broad areas-provider-related factors, treatment-related factors, and environmental factors. Young adults talked about the importance of providers respecting and listening to them, the perceived advantages and disadvantages of therapy and medication treatment, and aspects of the environment that resulted in positive and negative experiences, particularly in inpatient settings. Providers need to convey respect and caring that transcends job duties and provide tangible skills and supports.

Relations between mental health diagnoses, mental health treatment, and substance use in homeless youth.

BACKGROUND: Youth experiencing homelessness have elevated rates of mental illness and substance use compared to the general population. However, the extent to which underlying mental health issues may contribute to substance use as a way to manage symptoms and whether mental health treatment may reduce risk for substance use is unclear. This paper investigated these relations in a community sample of homeless youth. METHODS: Youth ages 13-24 (N=416) were interviewed as part of a community count and survey of homeless youth in Houston, Texas. A path analysis examined relations among lifetime diagnoses of ADHD, bipolar disorder, and depression; past-month marijuana, alcohol, and synthetic marijuana use, and hypothesized mediators of past-year mental health treatment and perceived unmet need for treatment. RESULTS: Rates of prior mental disorder diagnoses were high, with extensive comorbidity across the three diagnoses (n=114, 27.3% had all three diagnoses). Relations varied by diagnoses and substances. ADHD was positively related to current marijuana use (ß=0.55 (0.16), p<0.001), a relation that mental health treatment did not mediate. Depression was positively related to synthetic marijuana use through unmet need (ß=0.25 (0.09), p=0.004) and to alcohol use through unmet need (ß=0.20 (0.10), p=0.04) CONCLUSIONS: This study provides new information about relations between prior mental health diagnoses and substance use in homeless youth. Findings support the need to consider prior mental disorder diagnoses in relation to current substance use and to assess for whether youth perceive they have unmet needs for mental health treatment.

Symptoms, circumstances, and service systems: Pathways to psychiatric crisis service use among uninsured young adults.

Young adults have low rates of outpatient service utilization and higher rates of emergency service use compared to older adults. This study explored pathways to crisis service use for uninsured young adults who accessed emergency psychiatric treatment. Participants were 55 young adults (ages 18-25) who were on an inpatient short-term stabilization unit and had qualifying diagnoses for outpatient services (bipolar, major depression, or schizophrenia). Semistructured qualitative interviews were conducted to understand decision-making and the events that led to service use. A team of coders used an open coding approach to develop a codebook and participated in iterative discussions of coded text to generate results presented. Themes across 3 dimensions were identified. Participants formed the intention to seek treatment through the interaction of escalating symptoms, triggering events, and motivating factors. Intention was translated to actualized service use through individual and systemic facilitators. Natural supports and service systems influenced the entire process. Findings highlight the importance of understanding motivating factors to better engage young people in treatment and including their support systems in efforts to increase awareness of problems and treatments. Systemic barriers identified suggest the need for enhanced coordination of care across systems such as drug and alcohol treatment, homeless services, and criminal justice and for ready access to outpatient services to reduce crisis psychiatric service use. (PsycINFO Database Record

Managing and Mentoring: Experiences of Assistant Professors in Working with Research Assistants.

Support from research assistants (RAs) is often framed as a resource to facilitate faculty research productivity, yet most assistant professors have received minimal training on how to effectively make use of this resource. This study collected data from a national sample of assistant professors to examine tasks RAs are asked to perform, satisfaction with RA work, challenges in working with RAs, and lessons learned to be successful. Authors used a sequential mixed-methods design, first conducting a Web-based survey with 109 assistant professors in social work schools with doctoral programs, then qualitative interviews with a subset of 13 respondents who volunteered to talk more about their experiences. Evidence indicated low levels of satisfaction regarding the preparation of students for RA work, particularly among those assistant professors working with first-year doctoral students. Primary challenges included lack of student skills and commitment and sufficient time to supervise and train students. Recommendations include careful assessment of student skills at the start of the relationship and setting clear expectations. Social work programs can improve faculty-RA relationships by training new assistant professors on how to support and manage RAs and training incoming students on basic research skills for their work as RAs.

Perception of Need and Receipt of Mental Health Treatment: A Three-Group Comparison of Young Adults With Psychological Distress.

OBJECTIVE: This study examined mental health service use among three groups of young adults with assessed psychological distress: no perceived need for treatment, reported unmet need, and received treatment. METHODS: Data came from participants ages 18 to 25 in the National Survey on Drug Use and Health (2008-2013) who met criteria for psychological distress (N=19,775). Demographic, access-, and need-related predictors of perceived need and treatment group were examined by using multinomial logistic regression. RESULTS: Half the sample did not perceive a need for treatment (51.0%), and only one-third had received treatment (33.7%). White youths were more likely than those from other racial-ethnic groups to perceive a need and to receive treatment. Men were less likely than women to perceive need but equally likely to receive treatment. Higher education and having insurance also predicted treatment receipt. CONCLUSIONS: Efforts to increase service utilization among young adults should increase awareness of mental health problems and facilitate access, particularly for racial-ethnic minority groups.

Development and piloting of a treatment foster care program for older youth with psychiatric problems.

BACKGROUND: Older youth in out-of-home care often live in restrictive settings and face psychiatric issues without sufficient family support. This paper reports on the development and piloting of a manualized treatment foster care program designed to step down older youth with high psychiatric needs from residential programs to treatment foster care homes. METHODS: A team of researchers and agency partners set out to develop a treatment foster care model for older youth based on Multi-dimensional Treatment Foster Care (MTFC). After matching youth by mental health condition and determining for whom randomization would be allowed, 14 youth were randomized to treatment as usual or a treatment foster home intervention. Stakeholders were interviewed qualitatively at multiple time points. Quantitative measures assessed mental health symptoms, days in locked facilities, employment and educational outcomes. RESULTS: Development efforts led to substantial variations from the MTFC model and a new model, Treatment Foster Care for Older Youth was piloted. Feasibility monitoring suggested that it was difficult, but possible to recruit and randomize youth from and out of residential homes and that foster parents could be recruited to serve them. Qualitative data pointed to some qualified clinical successes. Stakeholders viewed two team roles - that of psychiatric nurse and skills coaches - very highly. However, results also suggested that foster parents and some staff did not tolerate the intervention well and struggled to address the emotion dysregulation issues of the young people they served. Quantitative data demonstrated that the intervention was not keeping youth out of locked facilities. CONCLUSIONS: The intervention needed further refinement prior to a broader trial. Intervention development work continued until components were developed to help address emotion regulation problems among fostered youth. Psychiatric nurses and skills coaches who work with youth in community settings hold promise as important supports for older youth with psychiatric needs.

Pioneering the psychiatric nurse role in foster care.

Older youth served in the foster care system have elevated rates of mental health disorders and are high users of mental health services, yet concerns have been raised about the quality of this care. This paper describes the details of a psychiatric nurse's work within a multidisciplinary team to address gaps in care for older youth with psychiatric disorders. We describe the process, outcomes, and lessons learned in developing and piloting a psychiatric nurse intervention for older youth in the foster care system as part of a multidimensional treatment foster care program. Our experiences support further work to develop a role for nursing to improve the quality of mental health treatment in foster care.

Pregnancy Risk Among Older Youth Transitioning Out Of Foster Care.

Youth served in the foster care system have higher rates of pregnancy than general population youth; yet we have little information about risk and protective factors to target in order to prevent early pregnancy in this population. We assessed early pregnancy risk and protective factors known for general population adolescents for their relevance to youth in the foster care system. Using data from a longitudinal study of 325 older youth from the foster care system, we examined bivariate and multivariate relationships between these factors and pregnancy between age 17 and 19 using logistic regression. Models examined risk for early parenting separately by gender. The pregnancy rate increased by 300% between ages 17 and 19. At 19, 55% of females had been pregnant, while 23% of males had fathered a child. Although this study assessed multiple known factors, few were significant for this high risk group. Females who were not sexually active at age 17 were less likely to become pregnant, but those who reported using birth control were as likely to become pregnant as those who did not. Also, females with a history of arrest were more likely to have a pregnancy between 17 and 19. Males who left the foster care system before their 19th birthday were more likely to make someone pregnant. Youth from the foster care system are at exceptional risk of early pregnancy, no matter their maltreatment history, religiosity, school connectedness, or academic achievement, particularly in the years between 17 and 19. This high risk group needs pregnancy prevention interventions and access to effective birth control.

Postsecondary education and employment among youth with an autism spectrum disorder.

OBJECTIVES: We examined the prevalence and correlates of postsecondary education and employment among youth with an autism spectrum disorder (ASD). METHODS: Data were from a nationally representative survey of parents, guardians, and young adults with an ASD. Participation in postsecondary employment, college, or vocational education and lack of participation in any of these activities were examined. Rates were compared with those of youth in 3 other eligibility categories: speech/language impairment, learning disability, and mental retardation. Logistic regression was used to examine correlates of each outcome. RESULTS: For youth with an ASD, 34.7% had attended college and 55.1% had held paid employment during the first 6 years after high school. More than 50% of youth who had left high school in the past 2 years had no participation in employment or education. Youth with an ASD had the lowest rates of participation in employment and the highest rates of no participation compared with youth in other disability categories. Higher income and higher functional ability were associated with higher adjusted odds of participation in postsecondary employment and education. CONCLUSIONS: Youth with an ASD have poor postsecondary employment and education outcomes, especially in the first 2 years after high school. Those from lower-income families and those with greater functional impairments are at heightened risk for poor outcomes. Further research is needed to understand how transition planning before high school exit can facilitate a better connection to productive postsecondary activities.

Stepping Down and Stepping In: Youth's Perspectives on Making the Transition from Residential Treatment to Treatment Foster Care.

Older youth preparing to emancipate from the foster care system are often served in residential treatment settings where they have limited opportunities to practice skills for independent living in a community setting. Stepping these youth down to less restrictive environments such as treatment foster care is a growing trend, especially for youth with mental health issues. Yet, few studies have explored the youth's perspective on making this transition. This study utilized qualitative interviews with youths who were participating in a treatment foster care intervention study (n=8) to gain their perspectives on the process of transitioning from residential care. Youths were interviewed right before they exited residential care and two months after placement in the new foster home. Youths reported hopes for gaining family in the new home as well as fears of placement disruption. Findings point to the need to enlist youths in discussion and problem solving about difficulties they anticipate in the new home and expectations for their relationship with the new foster parents. In addition, the struggles described after two months in the home point to the need for youths to build specific skills to better manage ongoing relationships with foster parents and for foster parent training on how to help build these skills.

Prevalence and correlates of psychotropic medication use in adolescents with an autism spectrum disorder with and without caregiver-reported attention-deficit/hyperactivity disorder.

BACKGROUND: Many youths with an autism spectrum disorder (ASD) benefit from psychotropic medication treatment of co-morbid symptom patterns consistent with attention-deficit/hyperactivity disorder (ADHD). The lack of clear indications and algorithms to direct clinical practice has led to a very poor understanding of overall medication use for these youths. The present study examined the prevalence of psychotropic medication use compared across individuals with an ASD without a caregiver-reported ADHD diagnosis (ASD-only), ADHD without ASD (ADHD-only), and an ASD with co-morbid ADHD (ASD+ADHD). Correlates of medication use were also examined. METHODS: Data on psychotropic medication from the first wave of the National Longitudinal Transition Study 2, a nationally representative study of adolescents ages 13-17 in special education, were used to compare the prevalence of medication use across the three groups, overall and by class. Separate logistic regression models were constructed for each group to examine the correlates of psychotropic medication use. Poisson regression models were used to examine correlates of the number of medications. RESULTS: Youths with ASD+ADHD had the highest rates of use (58.2%), followed by youths with ADHD-only (49.0%) and youths with ASD-only (34.3%). Youths with an ASD, both ASD-only and ASD+ADHD, used medications across a variety of medication classes, whereas stimulants were dominant among youths with ADHD-only. African American youths with ASD-only and with ASD+ADHD were less likely to receive medication than white youths, whereas race was not associated with medication use in the ADHD-only group. CONCLUSIONS: Clearer practice parameters for ADHD have likely contributed to more consistency in treatment, whereas treatment for ASD reflects a trial and error approach based on associated symptom patterns. Additional studies examining the treatment of core and associated ASD symptoms are needed to guide pharmacologic treatment of these youths. Interventions targeting African American youths with ASD and the physicians who serve them are also warranted.

Mental health service use among adolescents with an autism spectrum disorder.

OBJECTIVE: This study examined prevalence and correlates of mental health service use among adolescents with an autism spectrum disorder. METHODS: Data from the National Longitudinal Transition Study-2 were used to examine mental health service use among 920 youths with this disorder. Estimates are nationally representative of students enrolled in the special education autism category. Regression models examined the association of predisposing, enabling, and need factors with service use overall and with a focus on receiving these services at school. RESULTS: Overall, 46% (weighted) of the youths had used a mental health service in the past year. Of those who had, 49% (weighted) had received it at school. Need variables were the strongest correlates of service use. African-American youths and youths from lower-income families were more likely to receive school-based services. CONCLUSIONS: Schools played a key role in providing services, especially for vulnerable populations. Focused attention on youths with an autism spectrum disorder is needed to ensure continuity of care as youths leave high school.

Knowledge of and Attitudes Towards Behavioral Health Services Among Older Youth in the Foster Care System.

This study examined knowledge of and attitudes toward services among 268 17-year olds with psychiatric diagnoses preparing to exit foster care. A structured interview assessed knowledge of services with vignette scenarios and attitudes with a standardized scale. Descriptive statistics described the extent of knowledge and attitudes among this population and regression analyses examined predictors of these dimensions of literacy. Most youth suggested a help source, but responses often lacked specificity. Gender and depression were the strongest predictors of knowledge and attitudes, respectively. Knowing which aspects of literacy are low, and for whom, can inform education efforts to improve access to care in adulthood.

Diagnosis and medication overload? A nurse review of the psychiatric histories of older youth in treatment foster care.

Prior research has raised concern about the appropriateness of psychotropic medication use and the validity of psychiatric diagnosing for youth in child welfare but has lacked in-depth case information. This study reports results from a psychiatric nurse review conducted with eight youth entering a foster care intervention using case records and multiple key informant interviews. Results revealed extensive histories of unique (nonoverlapping) psychiatric diagnoses (M = 8, range 7-9) and past psychotropic medications (M = 13, range 9-21). The findings highlight the need to improve assessment practices and to create mechanisms that promote greater continuity of psychiatric care.