Care integration goes Beyond Co-Location: Creating a Medical Home.

How to successfully integrate mental health and primary care remains a critically important question given the continued morbidity and early mortality of people with serious mental illness. This study investigated integration in a community mental health center (MHC) primarily treating people with SMI in a large, urban northeastern city where an on-site primary care center (PCC) was opened resulting in co-located mental health and primary care services being provided. Using focus groups and online surveys this study asked participants about their thoughts and interactions with the on-site PCC. Participants included staff from clinical, non-clinical, and leadership roles in the mental health center (MHC; PCC staff; and MHC clients who did not use the on-site PCC). MHC staff also offered their thoughts about and experiences with the on-site PCC one year and two years after the on-site PCC opened through an on-line survey. In both methods, staff reported limited awareness and expectations of the PCC in the first year. Staff indicated that successful care integration goes beyond co-location and peer health navigation can enhance integration. Finally, staff discussed desires for enhancing care integration and co-located services into a medical home that included communicating across medical records and providers at different agencies. Our results suggest that, in addition to the previously researched three C's of care integration (consultation, coordination, and collaboration), two more C's were essential to successful care integration: co-location and communication. Communication across medical records and providers at different agencies was an essential component of care integration, and co-location added increased ability to communicate across providers.

The Organizational Multicultural Competence Assessment (OMCA): A tool to assess an organization's multicultural competence and adherence to the National Standards for Culturally and Linguistically Appropriate Services in Health and Healthcare (the National CLAS Standards).

Objective: Behavioral health organizations must respond to the needs of increasing numbers of multicultural populations, as the world population continues to diversify. The goal of this research was to develop a measure to assess the multicultural competence of a behavioral health agency using a quick and efficient but comprehensive strategy that utilizes input from multiple staff members. Method: The Organizational Multicultural Competence Assessment (OMCA) was developed through a review of existing cultural competence assessment measures and item generation from researchers and policy makers. 469 staff from all departments of a U.S. state-operated and funded behavioral health facilities were asked by the CEO of their agency to complete the 45-item survey. Findings: Principal components analysis revealed seven factors that accounted for 64% of the variance in item responses: Governance, Policies, and Procedures; Staff Training and Service Delivery; Addressing Stigma and Discrimination; Accessibility of Services; Community Relationships; Quality, Monitoring, and Evaluation; and Human Resource Development. Items within factors showed high internal reliability. Conclusions and Implications for Practice: This measure may be used on an ongoing basis as a quality improvement tool to assess an agency or system's multicultural competence and adherence to the CLAS standards. Future research can investigate the relationship between scores on this measure and organization-level recovery oriented, client health, and person-centered outcomes. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Enhancing outcomes for persons with co-occurring disorders through skills training and peer recovery support.

Background: "Recovery supports", often provided by persons in recovery themselves, have emerged over the last decade as important components of recovery-oriented systems of care for persons with substance use disorders.Aims: This study assesses the benefit of adding peer recovery supports to the care of adults with co-occurring psychosis and substance use.Method: 137 adults with both disorders who had at least one prior admission within the past year were recruited during an index hospitalization into a randomized trial of standard care vs skills training with and without a peer-led social engagement program. Participants were assessed at admission and at three and nine months post-discharge on symptoms, functioning, substance use, and other factors.Results: At three months, skills training was effective in reducing alcohol use and symptoms, with the addition of peer-led support resulting in higher levels of relatedness, self-criticism, and outpatient service use. At nine months, skills training was effective in decreasing symptoms and inpatient readmissions and increasing functioning, with the addition of peer support resulting in reduced alcohol use.Conclusions: Adding peer-led support may increase engagement in care over the short term and reduce substance use over the longer-term for adults with co-occurring disorders.

A Pilot Study of Motive Control to Reduce Vengeance Cravings.

Violence is a serious public health problem in the United States, and a common risk factor for many forms of violence is the perpetrator's motivation to achieve personal justice for past wrongs and injustices. Using a fictional transgression scenario to stimulate revenge feelings, we studied the preliminary efficacy of an intervention designed to mitigate revenge desires among victims of perceived injustice. The intervention consisted of a guided role-play of key figures in the justice system (e.g., victim, prosecutor, defendant, judge, etc.) in an imaginary mock trial of the offender. Study participants' revenge desires toward the perpetrator decreased significantly immediately after the intervention and at a 2-week follow-up interview. Benevolence toward the offender increased immediately postintervention and at a 2-week follow-up interview. These results suggest that the intervention has promise to decrease revenge desires in people who have been victimized, and it potentially opens the door to behavioral health motive control approaches to violence prevention. Findings on the roles of vengeance and the desire for retaliation in relation to violent acts, as well as neuroscience research that suggests a connection between retaliatory aggression and the neural circuitry of anticipated reward and cravings, are discussed. Limitations of this pilot study are also discussed, and recommendations for future research are provided.

Racial and Ethnic Differences in Use of State-Operated Inpatient Substance Abuse Services, 2004-2005 Versus 2010-2011.

OBJECTIVE: This study examined ethnic-racial differences in referral source, length of stay, legal status, and diagnosis in state-operated substance abuse inpatient treatment in Connecticut. METHODS: Data from 2004-2005 (N=1,484) and from 2010-2011 (N=4,529) were investigated with regression analyses. RESULTS: At both time points, African Americans were more likely than other groups to be referred by criminal justice sources, Hispanics were more likely than whites to be referred by other sources, and whites were more likely than African Americans to have emergency-crisis admissions; length of stay was shorter for Hispanics than for whites and longer for African Americans than for whites and Hispanics; and Hispanics were less likely than other groups to have an alcohol use disorder, more likely than other groups to have a drug use disorder, and more likely than whites to receive a discharge diagnosis of a personality disorder from cluster B. CONCLUSIONS: Targeted interventions to address racial-ethnic differences in inpatient addiction treatment are needed.

An Evaluation of Racial and Ethnic Health Differences in State Mental Health Inpatient Services: 2002-2005 Versus 2010-2011.

This study analyzed racial-ethnic differences previously documented in the Connecticut Department of Mental Health and Addiction Services mental health inpatient system across two time periods (2002-2005 and 2010-2011). Comparisons of logistic regression analyses from the two time periods showed that, at time 1, significant racial-ethnic differences were found for referral by other sources (e.g., outpatient), length of stay, discharge against medical advice, and some diagnostic differences (e.g., schizophrenia, other psychotic disorders, cluster B discharge diagnosis), but these differences were not significant at time 2. Other diagnostic differences remained significant at time 2 (e.g., mood disorders, substance use disorders, other axis I disorders, mental retardation) as well as racial-ethnic differences in self-referral. These results suggest that the multiple national and state cultural competence initiatives between time 1 and time 2 could have resulted in decreases in racial-ethnic differences. Targeted interventions to alleviate the remaining differences are needed.

Development of a Response Inconsistency Scale for the Personality Inventory for DSM-5.

The advent of a dimensional model of personality disorder included in DSM-5 has necessitated the development of a new measurement scheme, specifically a self-report questionnaire termed the Personality Inventory for DSM-5 (PID-5; Krueger, Derringer, Markon, Watson, & Skodol, 2012 ). However, there are many threats to the validity of a self-report measure, including response inconsistency. This study outlines the development of an inconsistency scale for the PID-5. Across both college student and clinical samples, the inconsistency scale was able to reliably differentiate real from random responding. Random responses led to increased scores on the PID-5 facets, indicating the importance of detecting inconsistent responding prior to test interpretation. Thus, this inconsistency scale could be of use to researchers and clinicians in detecting inconsistent responses to this new personality disorder measure.

"Recovery Speaks": A Photovoice Intervention to Reduce Stigma Among Primary Care Providers.

OBJECTIVE: Preliminary findings are reported from a photovoice intervention, "Recovery Speaks," to reduce primary care provider stigma in regard to people with mental illness and addiction. METHODS: Twenty-seven primary care providers were recruited through a practice-based research network. Participants were randomly assigned to the intervention-attending a one-hour performance followed by discussion-or to no intervention. Provider stigma was evaluated by using established measures of stigma and recovery and qualitative responses. Linear mixed models controlling for baseline differences compared changes in provider stigma across time and groups. RESULTS: Providers who attended Recovery Speaks demonstrated significantly decreased negative stereotypes, attribution of dangerousness, fear, desire to coerce people into treatment, desire to segregate people from the community, and desire for avoidance. More desire to help and more hope for recovery were also found. CONCLUSIONS: Witnessing people's unique recovery stories and how they contribute to their communities may reduce provider stigma.

Learning from those we serve: Piloting a culture competence intervention co-developed by university faculty and persons in recovery.

OBJECTIVE: This article describes the development and piloting of a bilevel intervention codeveloped by persons in recovery from mental illness and addiction and university faculty with expertise in cultural competence to improve the cultural competence of a community mental health center in the northeastern United States. METHOD: Two faculty and 5 persons in recovery met for 6 months to develop the bilevel training intervention. They discussed experiences of culturally responsive care and developed experiential activities and case examples for the 2-day training. Forty-five community mental health service providers attended the 2-day training. Trainees' self-reported awareness, knowledge, and skills in cultural competence were measured pre and post training and analyzed with repeated measure t tests. Next, faculty and persons in recovery provided follow-up training and helped to establish an infrastructure supported to support the agency cultural competence plan. One hundred twenty-five providers completed the Organizational Multicultural Competence Survey and between-subjects t tests measured increases in organizational cultural competence. RESULTS: Significant increases were found in providers' multicultural knowledge, awareness, and skills. Qualitative responses demonstrated the contribution of the experiences of persons in recovery to the training. Ratings of the organizational-level cultural competence intervention showed significant improvements in the agency's cultural competence policies (e.g., implementation of strategies to hire and retain a diverse workforce). CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: These data suggest that bilevel interventions codeveloped by persons in recovery and researchers may be effective in increasing provider and organizational-level cultural competence. Future research should evaluate the effect of these interventions on consumers and health outcomes.

Racial-ethnic differences in access, diagnosis, and outcomes in public-sector inpatient mental health treatment.

This study investigated inequities in access, diagnosis, and treatment for African Americans and Hispanic Americans receiving treatment in northeast, public sector, inpatient mental health settings as part of a Department of Mental Health and Addiction Services Health Disparities Initiative. Data from 1,484 adults were obtained through a random extract of patients admitted to state inpatient facilities between 2002 and 2005. After controlling for demographic variables and symptom severity, logistic and linear regression showed that Hispanic Americans were significantly more likely to enter inpatient care through crisis/emergency sources and were significantly less likely to self-refer or come to inpatient care through other sources (e.g., family, outpatient). After admission, Hispanic Americans were more likely to be diagnosed with other psychotic disorders (e.g., schizoaffective disorder, delusional disorder), were less likely to receive an Axis II diagnosis at discharge, and had a shorter length of stay than non-Hispanic White Americans. African Americans were more likely than other groups to be diagnosed with schizophrenia, drug-related, and Cluster B diagnoses (discharge only), and they were less likely to be diagnosed with mood disorders and other nonpsychotic disorders. Although African Americans were more likely than other groups to come to inpatient units from numerous routes, including self-referral and referral from other sources (e.g., family, outpatient), they were more likely to terminate treatment against medical advice and displayed shorter length of stay despite receiving ratings of greater symptom severity at discharge. These findings highlight the need for policies, programs, and system interventions designed to eliminate disparities and improve the quality and cultural responsiveness of behavioral health services.

Functional impairment and the DSM-5 dimensional system for personality disorder.

The DSM-5 has included for further research a new dimensional measure of personality disorder, operationalized in the Personality Inventory for DSM-5 (PID5). It is important to investigate if extreme variants of these traits are associated with functional impairment, because functional impairment is a key aspect of the definition of personality disorder. The current study investigated this relationship in 989 college students and 91 clinical patients. The PID5 facets were meaningfully associated with measures of functional impairment in both samples, although the clinical sample evidenced more pathological levels of most traits, as might be expected. Overall, the PID5 appears to be a useful measure for the new DSM-5 system of personality disorder diagnosis.

The cycle of classification: DSM-I through DSM-5.

The Diagnostic and Statistical Manual of Mental Disorders (DSM) was created in 1952 by the American Psychiatric Association so that mental health professionals in the United States would have a common language to use when diagnosing individuals with mental disorders. Since the initial publication of the DSM, there have been five subsequent editions of this manual published (including the DSM-III-R). This review discusses the structural changes in the six editions and the research that influenced those changes. Research is classified into three domains: (a) issues related to the DSMs as measurement systems, (b) studies of clinicians and how clinicians form diagnoses, and (c) taxonomic issues involving the philosophy of science and metatheoretical ideas about how classification systems function. The review ends with recommendations about future efforts to revise the DSMs.

Toward an endgame: finding and engaging people unaware of their HIV-1 infection in treatment and prevention.

Epidemic modeling suggests that a major scale-up in HIV treatment could have a dramatic impact on HIV incidence. This has led both researchers and policymakers to set a goal of an "AIDS-Free Generation." One of the greatest obstacles to achieving this objective is the number of people with undiagnosed HIV infection. Despite recent innovations, new research strategies are needed to identify, engage, and successfully treat people who are unaware of their infection.

Mental health professionals' natural taxonomies of mental disorders: implications for the clinical utility of the ICD-11 and the DSM-5.

OBJECTIVE: To examine the conceptualizations held by psychiatrists and psychologists around the world of the relationships among mental disorders in order to inform decisions about the structure of the classification of mental and behavioral disorders in World Health Organization's International Classification of Diseases and Related Health Problems 11th Revision (ICD-11). METHOD: 517 mental health professionals in 8 countries sorted 60 cards containing the names of mental disorders into groups of similar disorders, and then formed a hierarchical structure by aggregating and disaggregating these groupings. Distance matrices were created from the sorting data and used in cluster and correlation analyses. RESULTS: Clinicians' taxonomies were rational, interpretable, and extremely stable across countries, diagnostic system used, and profession. Clinicians' consensus classification structure was different from ICD-10 and the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders 4th Edition (DSM-IV), but in many respects consistent with ICD-11 proposals. CONCLUSIONS: The clinical utility of the ICD-11 may be improved by making its structure more compatible with the common conceptual organization of mental disorders observed across diverse global clinicians.

Seven essential strategies for promoting and sustaining systemic cultural competence.

Racial and ethnic disparities are disturbing facets of the American healthcare system that document the reality of unequal treatment. Research consistently shows that patients of color experience poorer quality of care and health outcomes contributing to increased risks and accelerated mortality rates relative to their white counterparts. While initially conceptualized as an approach for increasing the responsiveness of children's behavioral health care, cultural competence has been adopted as a key strategy for eliminating racial and ethnic health disparities across the healthcare system. However, cultural competence research and practices largely focus on improving provider competencies, while agency and system level approaches for meeting the service needs of diverse populations are given less attention. In this article we offer seven essential strategies for promoting and sustaining organizational and systemic cultural competence. These strategies are to: (1) Provide executive level support and accountability, (2) Foster patient, community and stakeholder participation and partnerships, (3) Conduct organizational cultural competence assessments, (4) Develop incremental and realistic cultural competence action plans, (5) Ensure linguistic competence, (6) Diversify, develop, and retain a culturally competent workforce, and (7) Develop an agency or system strategy for managing staff and patient grievances. For each strategy we offer several recommendations for implementation.

Considering DSM-5: the personal experience of schizophrenia in relation to the DSM-IV-TR criteria.

Previous analyses have suggested that the personal experience of schizophrenia might be different from its depiction in the DSM-IV-TR. In this study, 17 people with schizophrenia or schizoaffective disorder were interviewed about their experiences of the DSM-IV-TR diagnostic criteria for schizophrenia. Descriptive phenomenological analysis was used to analyze the ways in which the personal experiences of the people in this study were similar to or different from the depiction of schizophrenia in the DSM-IV-TR. The personal experience of schizophrenia was similar in some way to each of the five diagnostic criteria for schizophrenia. Participants' personal experiences also went beyond the DSM-IV-TR criteria. Specifically, participants described strong emotional reactions to their symptoms, including fear, sadness, embarrassment, and alienation. Also, participants described intense interest but severe disruptions in goal-directed behavior due to their hallucinations being engrossing, confusing, and distracting. Further, participants described not sharing their experiences in order to avoid social stigma. These findings suggest that the description of schizophrenia in DSM-5 may benefit from a change to DSM-IV-TR criteria to incorporate more of the personal experience of schizophrenia. Further research is needed to establish the representativeness, reliability, and validity of the qualitative findings described here.

How the global call for elimination of pediatric HIV can support HIV-positive women to achieve their pregnancy intentions.

The global call to eliminate new pediatric HIV infections requires a comprehensive approach, including consideration of the pregnancy intentions of HIV-positive women. This paper presents a literature review on the interface between pediatric HIV elimination and the pregnancy intentions of HIV-positive women, focusing on the four prongs of prevention of mother-to-child transmission: primary prevention of HIV infection in women; preventing unintended pregnancies in HIV-positive women; preventing transmission of HIV from infected women to their infants; and providing care, support and treatment to HIV-positive women, their children and their families. The paper describes the role of pregnancy intentions in determining appropriate health services for HIV-positive women - including family planning, reproductive and obstetric care, and HIV-related services - and explains how these essential health services are linked to improving maternal health, reducing child mortality and eliminating pediatric HIV. The paper provides context for the recent UNAIDS-led call to eliminate pediatric HIV, which will require a complete, integrated approach to providing family planning, maternal and child health, and HIV-related services for all HIV-affected individuals and families. Ensuring that HIV-positive women have access to high-quality health services to enable them to choose whether and when to have children is an essential component of this approach.

Racial-ethnic differences in referral source, diagnosis, and length of stay in inpatient substance abuse treatment.

OBJECTIVE: Racial-ethnic differences in referral source, diagnosis, and length of stay in substance abuse treatment were examined. METHODS: Data from 495 African Americans, 492 Hispanics, and 497 non-Hispanic whites were analyzed. RESULTS: Hispanics were less likely than whites to be referred by crisis services; African Americans were more likely than other groups to be referred from criminal justice settings. At admission Hispanics and African Americans were more likely to have a drug use disorder, and whites were more likely to have an alcohol use disorder. Both African Americans and Hispanics were more likely than whites to have a cluster B personality disorder diagnosis at discharge. African Americans had longer stays than other groups. CONCLUSIONS: The findings could be used to design interventions to reduce disparities in inpatient substance abuse treatment.

The Need for Patient-Subjective Data in the DSM and the ICD.

One improvement from the second to the third edition of the Diagnostic and Statistical Manual of Mental Disorders was to replace clinicians' subjective interpretations of mental disorders with objective descriptions of signs and symptoms that could be rated reliably across investigators. Along with clinicians' subjective impressions, however, the subjective experiences of the person with the mental disorder were minimized. This information could be valuable, as people's subjective experiences of disorders may indicate major underlying processes and be different from how characteristics of disorders appear objectively to outside observers. The authors suggest that empirically derived, patient-subjective characteristics of mental disorders be incorporated into future editions of the DSM and the ICD. Not only will these data offer important information that will help to enhance the accuracy of the diagnostic categories of the DSM and ICD, but such data also may serve to enhance clinicians' abilities to conceptualize accurately and empathically treat these disorders in their patients. Examples of patient-subjective criteria and their relationship to current DSM criteria are examined for borderline personality disorder and schizophrenia and suggestions for DSM-V and ICD-11 are offered. Diagnostic criteria that accurately reflect patients' subjective experience could also increase clinicians' ability to empathize with patients, one of the most important variables in treatment alliances.

Passing for "normal": features that affect the community inclusion of people with mental illness.

OBJECTIVE: The purpose of this study was to investigate specific features that indicate to community members that a person has a mental illness and the emotional reactions elicited by these features, in hopes of understanding barriers to the community integration of people living with mental illnesses. METHOD: Participants were 15 community members who had considerable experience with people with mental illnesses but no extensive clinical training (e.g., store clerks, landlords, clergy). A mixed qualitative-quantitative design elicited 1) participants' subjective experience of interacting with people with mental illness and 2) participants' ratings of specified features of people with mental illness. RESULTS: Interpretive phenomenological analysis of qualitative interviews suggested that a person's mental illness was only apparent from afar if s/he was responding to internal stimuli or wearing bizarre or inappropriate clothing. The person's illness usually became apparent through interacting with the community member. Participants reported feeling kind benevolence towards people with mental illness and rated the likelihood of people with mental illness to be threatening or violent as very low. Overall, participants' ratings of features of people with mental illness corroborated qualitative themes. CONCLUSIONS: These data suggest that stigma is not elicited simply by the presence of a person with a mental illness, and that the presence of a mental illness in most cases only becomes apparent through social interaction. Also, these data support conclusions that personal experience with people with mental illness reduces fear and increases benevolence and that personal contact should be integral to community integration and anti-stigma campaigns.