Building an Integrated Data Infrastructure to Examine the Spectrum of Suicide Risk Factors in Philadelphia Medicaid.

While there are many data-driven approaches to identifying individuals at risk of suicide, they tend to focus on clinical risk factors, such as previous psychiatric hospitalizations, and rarely include risk factors that occur in nonclinical settings, such as jails or emergency shelters. A better understanding of system-level encounters by individuals at risk of suicide could help inform suicide prevention efforts. In Philadelphia, we built a community-level data infrastructure that encompassed suicide death records, behavioral health claims, incarceration episodes, emergency housing episodes, and involuntary commitment petitions to examine a broader spectrum of suicide risk factors. Here, we describe the development of the data infrastructure, present key trends in suicide deaths in Philadelphia, and, for the Medicaid-eligible population, determine whether suicide decedents were more likely to interact with the behavioral health, carceral, and housing service systems compared to Medicaid-eligible Philadelphians who did not die by suicide. Between 2003 and 2018, there was an increase in the number of annual suicide deaths among Medicaid-eligible individuals, in part due to changes in Medicaid eligibility. There were disproportionately more suicide deaths among Black and Hispanic individuals who were Medicaid-eligible, who were younger on average, compared to suicide decedents who were never Medicaid-eligible. However, when we accounted for the racial and ethnic composition of the Medicaid population at large, we found that White individuals were four times as likely to die by suicide, while Asian, Black, Hispanic, and individuals of other races were less likely to die by suicide. Overall, 58% of individuals who were Medicaid-eligible and died by suicide had at least one Medicaid-funded behavioral health claim, 10% had at least one emergency housing episode, 25% had at least one incarceration episode, and 22% had at least one involuntary commitment. By developing a data infrastructure that can incorporate a broader spectrum of risk factors for suicide, we demonstrate how communities can harness administrative data to inform suicide prevention efforts. Our findings point to the need for suicide prevention in nonclinical settings such as jails and emergency shelters, and demonstrate important trends in suicide deaths in the Medicaid population.

Guidance for Handling the Increasing Prevalence of Drugs Adulterated or Laced With Fentanyl.

The use of fentanyl and its analogs is the primary driver of deaths related to the opioid overdose crisis. In fall 2021, the U.S. Drug Enforcement Administration issued its first public safety alert in 6 years to raise awareness of the escalating prevalence of fentanyl in counterfeit pills and in other opioids, such as heroin, and nonopioids, such as methamphetamine. In addition to increased public awareness, specific actions are needed to remediate the risk for fentanyl overdose. The authors endorse four principles to address the opioid overdose crisis and provide guidance for remediating its impacts: an incremental approach to behavior change or harm reduction; engagement strategies for individuals with substance use disorder; an integrated care approach to ensure better access to treatment programs and effective interventions; and vigilance among clinicians, program staff, and patients to the threat of fentanyl-adulterated drugs. The authors offer specific recommendations on how to apply these principles effectively within health care systems, communities, and law enforcement agencies across the United States.

Understanding therapists' perceived determinants of trauma narrative use.

BACKGROUND: Trauma narratives are a critical, exposure-based component of trauma-focused cognitive-behavioral therapy, yet community therapists rarely use them. Given evidence that intentions to deliver elements of cognitive behavioral therapy vary by component, and that intentions to deliver exposure are the weakest, this study focused specifically on trauma narratives. We drew on a social psychology causal theory (Theory of Planned Behavior (TPB)) and an implementation science framework (the Consolidated Framework for Implementation Research (CFIR)) to glean insight into multilevel influences on trauma narrative use. While the CFIR offers a broad list of factors potentially affecting implementation, the TPB offers causal pathways between individual-level constructs that predict behavior, including the uptake of an evidence-based intervention. The integration of these approaches may provide a more complete understanding of factors affecting therapists' use of TNs. METHODS: Therapists (n=65) trained in trauma-focused cognitive behavioral therapy completed a survey about their use of and beliefs about trauma narratives. Content analysis was used to identify common beliefs about trauma narratives. A subset of participants (n=17) completed follow-up qualitative interviews, which were analyzed using an integrated approach informed by the CFIR. RESULTS: While most participants reported high intentions to use TNs, nearly half reported that they did not use TNs in the last 6 months. Survey data indicate a number of TPB-related determinants related to using trauma narratives. Qualitative interviews identified CFIR-relevant contextual factors that may influence constructs central to TPB. CONCLUSIONS: These results highlight the importance of integrating approaches that address multiple theoretical determinants of therapist behavior, including therapist, organizational, and client factors with causal explanations to explain implementation behavior.

The Self-assessment for Modification of Anti-Racism Tool (SMART): Addressing Structural Racism in Community Behavioral Health.

A national dialogue on systemic racism has been reinvigorated by the highly publicized deaths of several unarmed Black Americans, including George Floyd and Breonna Taylor. In response, the AACP Board considered how to promote concrete, meaningful action to support its membership in measurably addressing structures and policies that promote racism. In this article, literature on existing frameworks aimed at addressing health inequity on the organizational level are reviewed. We introduce the Self-assessment for Modification of Anti-Racism Tool (SMART), a quality improvement tool that aims to meet the AACP's needs in facilitating organizational change in community behavioral healthcare. The AACP SMART's development, components, use, and future directions are described. The AACP SMART builds on prior organizational tools supporting equity work in healthcare, providing a quality improvement tool that incorporates domains specific to structural racism and disparities issues in community behavioral healthcare.

Using behavioral insights to design implementation strategies in public mental health settings: a qualitative study of clinical decision-making.

BACKGROUND: Trauma-focused cognitive behavioral therapy (TF-CBT) is an evidence-based intervention for youth with posttraumatic stress disorder. An important component of TF-CBT is the trauma narrative (TN), a phase in the intervention in which youth are guided to process the memories, thoughts, and feelings associated with their traumatic experience(s). Previous work has shown that TF-CBT clinicians complete TNs with only half of their clients, yet little is known about what determines TF-CBT clinicians' use of TNs. The behavioral insights literature-an interdisciplinary field studying judgment and decision-making-offers theoretical and empirical tools to conceptualize what drives complex human behaviors and decisions. Drawing from the behavioral insights literature, the present study seeks to understand what determines clinician use of TNs and to generate strategies that target these determinants. METHODS: Through semi-structured qualitative interviews, we sought the perspectives of trained TF-CBT clinicians working in public mental health settings across the city of Philadelphia (N = 17) to understand their decisions to use TNs with clients. We analyzed the qualitative data using a coding approach informed by the behavioral insights literature. We used an iterative process of structured hypothesis generation, aided by a behavioral insights guide, and rapid validation informed by behavioral insights to uncover the determinants of TN use. We then generated implementation strategies that targeted these determinants using the "Easy Attractive Social Timely" framework, a behavioral insights design approach. RESULTS: We generated and validated three broad themes about what determines clinician implementation of TNs: decision complexity, clinician affective experience, and agency norms. We hypothesized behavioral insights that underlie these implementation determinants and designed a list of nine corresponding behavioral insights strategies that may facilitate TN implementation. CONCLUSIONS: Our study investigated why an effective component of an evidence-based intervention is difficult to implement. We leveraged robust scientific theories and empirical regularities from the behavioral insights literature to understand clinician perspectives on TN implementation. These factors were theoretically linked to implementation strategies. Our work revealed the potential for using behavioral insights in the diagnosis of evidence-based intervention determinants and the design of implementation strategies.

Recommendations for Primary Care Provided by Psychiatrists.

Recent studies have shown that people with severe mental illness have a dramatically lower life expectancy than the general population. Psychiatrists have not traditionally been very attentive to or involved with physical health issues and there has been growing emphasis on integrated care for physical and mental health and access to primary care for all members of the population. This paper examines the role of psychiatrists in the provision of primary care to the patients they treat. Some recommendations are offered for their involvement in the provision of primary care at three levels of complexity: Level 1--Universal Basic Psychiatric Primary Care; Level 2--Enhanced Psychiatric Primary Care; and Level 3--Fully Integrated Primary Care and Psychiatric Management. Some of the obstacles to the provision of primary care by psychiatrists are considered along with some suggestions for overcoming them.

Psychiatry residents' experiences with systems-based practice: a qualitative survey.

OBJECTIVE: The aim of this study is to analyze qualitative data collected during field-testing of an instrument to assess psychiatric residents' experiences with systems-based practice (SBP). METHODS: A total of 237 psychiatry residents from 6 levels of training in 12 different psychiatry residency training programs responded to a 60-item instrument measuring their experiences with SBP during residency. Qualitative techniques adapted from content analysis were used to review narrative responses to open-ended questions on the instrument. RESULTS: Certain themes emerged in the residents' answers reflecting their opinions about the opportunities for (and barriers to) performing SBP in their work. CONCLUSIONS: Psychiatric residents express an eagerness for opportunities to learn about and perform SBP but often feel constrained by the lack of resources, teaching, and supervision. Moreover, many residents desire a better understanding of healthcare economics and how to factor cost consideration into clinical care.

Emergency department utilization among Medicaid beneficiaries with schizophrenia and diabetes: the consequences of increasing medical complexity.

OBJECTIVE: Individuals with both physical and mental health problems may have elevated levels of emergency department (ED) service utilization either for index conditions or for associated comorbidities. This study examines the use of ED services by Medicaid beneficiaries with comorbid diabetes and schizophrenia, a dyad with particularly high levels of clinical complexity. METHODS: Retrospective cohort analysis of claims data for Medicaid beneficiaries with both schizophrenia and diabetes from fourteen Southern states was compared with patients with diabetes only, schizophrenia only, and patients with any diagnosis other than schizophrenia and diabetes. Key outcome variables for individuals with comorbid schizophrenia and diabetes were ED visits for diabetes, mental health-related conditions, and other causes. RESULTS: Medicaid patients with comorbid diabetes and schizophrenia had an average number of 7.5 ED visits per year, compared to the sample Medicaid population with neither diabetes nor schizophrenia (1.9 ED visits per year), diabetes only (4.7 ED visits per year), and schizophrenia only (5.3 ED visits per year). Greater numbers of comorbidities (over and above diabetes and schizophrenia) were associated with substantial increases in diabetes-related, mental health-related and all-cause ED visits. Most ED visits in all patients, but especially in patients with more comorbidities, were for causes other than diabetes or mental health-related conditions. CONCLUSION: Most ED utilization by individuals with diabetes and schizophrenia is for increasing numbers of comorbidities rather than the index conditions. Improving care in this population will require management of both index conditions as well as comorbid ones.

Mental health access to care in Missouri.

Mental illnesses are a significant cause of morbidity and mortality in the United States, affecting, in some estimates, up to one in four adults or 57.7 million people. Severe psychiatric disorders, like schizophrenia, bipolar and major depression occur in one in seventeen Americans. Moreover, serious mental illnesses affect children at rates approaching 10%. Addictive disorders co-occurring with other mental illnesses affect over five million adults. The direct cost of these illnesses is high, totaling 16 billion dollars per year; dwarfed by the indirect costs of loss productivity which is four times as much. Individuals diagnosed with mental disorders have significantly higher rates of school dropout, homelessness, incarceration, and suicide. Embedded in these statistics is a concerning fact; access to care for those with psychiatric disorders is poor, with only one-third of adults and half the children diagnosed receiving care in any given year. These numbers are worse if the person is a racial or ethnic minority. This paper hopes to highlight the state of mental health treatment first in the United States and then in our state of Missouri. The news is sobering but there are pockets of good news as well.

A day in the life of a public psychiatry fellow.

Now in its 29th year, the Public Psychiatry Fellowship of the New York Psychiatric Institute at Columbia Medical Center selects 10 fellows per year for its 1-year program (1). This award-winning fellowship trains future leaders for the public mental health sector. The curriculum (2) employs a combination of a didactic seminar series, management-problem-focused presentations by guest speakers, field trips, and supervision by fellowship faculty to instill the values and skills required for practice and leadership in the public sector. Fellows utilize the framework of the academic curriculum to carry out a series of presentations throughout the year that allow them to organize, implement and evaluate concepts that they learn during the year. The following account, written from bird's eye view, details one fellow's day at his field placement in a State Hospital outpatient clinic setting, with the aim of illustrating how the concepts taught by the fellowship find application in day to day practice.