Mental Health Concerns During COVID-19: An Observational Study Among a Predominantly Black Community in New York City.

PURPOSE: This study examined the prevalence of mental health concerns and its association with COVID-19, selected social determinants of health, and psychosocial risk factors in a predominantly racial/ethnic minoritized neighborhood in New York City. METHODS: Adult Harlem residents (N = 393) completed an online cross-sectional survey from April to September 2021. The Patient Health Questionnaire (PHQ-4) and the Post-Traumatic Stress Disorder (PC-PTSD) were used to evaluate mental health concerns. Poisson regression with robust variance quantified the associations of interests via prevalence ratios (PR) and 95% confidence intervals (CI). RESULTS: Two-thirds (66.4%) of the residents reported experiencing mental health concerns, including PTSD (25.7%), depression (41.2%), and anxiety (48.1%). Residents with low-income housing status (PR = 1.16; 95% CI 1.01, 1.34), alcohol misuse (PR = 1.68; 95% CI 1.40, 2.01), food insecurity (PR = 1.23; 95% CI 1.07, 1.42), exposure to interpersonal violence (PR = 1.33; 95% CI 1.08, 2.65), and experience of discrimination (PR = 1.53, 95% CI 1.23-1.92) were more likely to report mental health concerns. Better community perception of the police (PR = 0.97, 95% CI 0.95, 0.99) was associated with fewer mental health concerns. No associations were observed for employment insecurity, housing insecurity, or household COVID-19 positivity with mental health concerns. CONCLUSIONS: This study showed a high prevalence of mental health concerns in a low-income racial/ethnic minoritized community, where COVID-19 and social risk factors compounded these concerns. Harlem residents face mental health risks including increased financial precarity, interpersonal violence, and discrimination exposure. Interventions are needed to address these concurrent mental health and psychosocial risk factors, particularly in racial/ethnic minoritized residents.

Mental Health Service Use, Barriers, and Service Preferences During COVID-19 among Low-Income Housing and Market-Rate Housing Residents of Harlem in New York City.

This study examined the differences in mental health service use, barriers, and service preferences among 393 low-income housing (LIH) and market-rate housing (MRH) Harlem residents in New York City. One-third (34.6%) endorsed the need for professional support for psychological issues, 27.2% and 15.8% reported using counseling services and psychotropic medication, with no differences between housing types. LIH residents (21.6-38.8%) reported significantly higher use of all types of mental health resources (e.g., websites, anonymous hotlines, self-help tools) compared with MRH residents (16.1-26.4%). Eighty-six percent reported barriers to mental health access, with LIH residents reporting more than double the barriers. Particularly, LIH residents reported greater difficulty getting time off work (34.1% vs. 14%), lack of health insurance (18.7% vs. 9.8%), lack of trust in mental health providers (14.6% vs. 4.7%), and stigma (12.2% vs. 5.1%) compared with MRH residents. Residents most preferred places of services were health clinics and houses of worship; provided by healthcare and mental health providers; and services delivered in-person and phone-based counseling. In contrast, residents least preferred getting support at mental health clinics; from family/friends; and by the Internet. No differences were found between service preferences by housing type. LIH residents reported higher use of mental health services and resources, but they face significantly more barriers to mental health care, suggesting a need to address specific barriers. Preferences for mental health services suggest a need for expanding mental health services to different settings given the low preference for services to be delivered at mental health clinics.

Substance Use Patterns and Their Association with Depression and Social Factors During COVID-19 Among Harlem Residents in New York City.

This study aimed to identify the prevalence of substance use before and during COVID-19; and examined its association with depression and social factors among 437 residents from the neighborhood of Harlem in Northern Manhattan, New York City. Over a third of respondents reported using any substance before COVID-19, and initiating/increasing substance use during COVID-19. The most common substances used before COVID-19 and initiated/increased during COVID-19 were smoking (20.8% vs. 18.3%), marijuana (18.8% vs. 15.3%), and vaping (14.2% and 11.4%). The percentages of any hard drug use were 7.3% and 3.4%, respectively. After adjustment, residents with mild (Prevalence Ratio [PR] = 2.86, 95% CI 1.65, 4.92) and moderate (PR = 3.21, 95% CI 1.86, 5.56) symptoms of depression, and housing insecurity (PR = 1.47, 95% CI 1.12, 1.91) had at least a 47% greater probability of initiating and/or increasing substance use. Conversely, respondents with employment insecurity (PR = 0.71, 95% CI 0.57, 0.88) were 29% less likely to report such patterns. No association was found between substance use initiation and/or increase and food insecurity. High prevalence of substance use during COVID-19 may lead residents to turn to substance use as a coping mechanism for psychosocial stressors. Thus, it is essential to provide accessible and culturally sensitive mental health and substance use services.

Alcohol Misuse, Binge Drinking, and their Associations with Psychosocial Factors during COVID-19 among Harlem Residents in New York City.

This study examined alcohol misuse and binge drinking prevalence among Harlem residents, in New York City, and their associations with psycho-social factors such as substance use, depression symptom severity, and perception of community policing during COVID-19. An online cross-sectional study was conducted among 398 adult residents between April and September 2021. Participants with a score of at least 3 for females or at least 4 for males out of 12 on the Alcohol Use Disorders Identification Test were considered to have alcohol misuse. Binge drinking was defined as self-reporting having six or more drinks on one occasion. Modified Poisson regression models were used to examine associations. Results showed that 42.7% used alcohol before COVID-19, 69.1% used it during COVID-19, with 39% initiating or increasing alcohol use during COVID-19. Alcohol misuse and binge drinking prevalence during COVID-19 were 52.3% and 57.0%, respectively. Higher severity of depression symptomatology, history of drug use and smoking cigarettes, and experiencing housing insecurity were positively associated with both alcohol misuse and binge drinking. Lower satisfaction with community policing was only associated with alcohol misuse, while no significant associations were found between employment insecurity and food insecurity with alcohol misuse or binge drinking. The findings suggest that Harlem residents may have resorted to alcohol use as a coping mechanism to deal with the impacts of depression and social stressors during COVID-19. To mitigate alcohol misuse, improving access to mental health and substance use disorder services, and addressing public safety through improving relations with police could be beneficial.

Implementation of a Community-Partnered Research Suicide-Risk Management Protocol: Case Study From Community Partners in Care.

OBJECTIVE: Suicidality is common among participants in clinical trials and health services research, but approaches to suicide risk assessment and mitigation vary widely. Studies involving vulnerable populations with limited access to care raise additional ethical concerns. The authors applied a community-partnered approach to develop and implement a suicide-risk management protocol (SRMP) in a depression study in an underresourced setting in Los Angeles. METHODS: Using a community-partnered participatory research framework, the authors designed and adapted the SRMP. Qualitative data regarding SRMP implementation included notes from SRMP development meetings and from study clinicians conducting outreach calls to study participants. Analyses included baseline and 6- and 12-month telephone survey data from 1,018 enrolled adults with moderate to severe depressive symptoms (8-item Patient Health Questionnaire score ≥10), of whom 48% were Black and 40% Latino. RESULTS: Community stakeholders prioritized a robust SRMP to ensure participant safety. Features included rapid telephone outreach by study clinicians in all cases of reported recent suicidality and expedited treatment access. Using a suicidality timeframe prompt of "in the past 2 weeks," endorsement of suicidality was common (15% at baseline, 32% cumulative). Midway through the study, the SRMP was modified to assess for present suicidality, which reduced the frequency of clinician involvement. Overall, 318 outreach calls were placed, with none requiring an emergency response. Treatment referrals were provided in 157 calls, and outreach was well received. CONCLUSIONS: SRMP implementation in research involving underresourced and vulnerable communities merits additional considerations. Partnering with community stakeholders can facilitate the development of acceptable and feasible SRMP procedures.

Adolescents' family obligation and activities in rural and urban Vietnam: Implications for social change.

This study examined how urbanisation may modify adolescents' values and activities concerning family obligation by surveying 572 adolescents (Mage  = 15.75, SD = .73) in rural and urban Vietnam. Compared with their rural peers, urban adolescents reported a stronger sense of family obligation but spent less time actually engaging in family assistance, findings that were partly explained by urban households' less financial hardship and higher parental education levels. As expected, stronger family obligation values were associated with greater family assistance activities across rural and urban Vietnam. However, stronger family obligation values were associated with more study hours only in urban Vietnam, indicating that urbanisation may broaden the meaning of family obligation to encompass the academic domain. Additionally, weaker family obligation values were associated with more employment hours only in rural Vietnam, suggesting that rural adolescents with little attachment to the traditional value of family obligation may pursue autonomy through employment outside the home. In traditionally familistic societies undergoing urbanisation, family obligation may take on different meaning depending on adolescents' ecological settings that construct cultural values and behavioural norms.

Effects of Family Obligation Values and Autonomy Support on Internalizing Symptoms of Vietnamese-American and European-American Adolescents.

Objectives: Although negotiation of family relatedness and personal autonomy is a key developmental task of adolescence, what is most adaptive for adolescents may vary across cultures. The purpose of the present study was to examine whether relations between family obligation values and adolescent internalizing symptoms may vary as a function of the level of parental autonomy support perceived by the adolescent, and to assess the extent to which such associations vary by ethnic group. Methods: The study included 614 adolescents (Mean age = 15.57 years, 50% male) from Vietnamese-American (55%) and European-American (45%) backgrounds. Adolescents reported their: (a) family obligation values to (a1) respect, (a2) provide current assistance, and (a3) provide future support to the family, (b) perceived maternal and paternal autonomy support, and (c) internalizing symptoms. Results: Effects of family obligation values differed across the three subdomains as a function of maternal autonomy support and ethnic group. Family obligation values to respect the family (a1, above) were related to lower levels of internalizing symptoms for both Vietnamese- and European-American adolescents who received high levels of maternal autonomy support. Ethnic differences emerged such that only among Vietnamese-American adolescents, there was a negative relation between current assistance values (a2, above) and internalizing symptoms among adolescents with high maternal autonomy support. Conclusions: Overall, findings highlight the importance for parents to nurture adolescents' family obligation values while also promoting their autonomy development.

Comparative Effectiveness of Coalitions Versus Technical Assistance for Depression Quality Improvement in Persons with Multiple Chronic Conditions.

Significance: Prior research suggests that Community Engagement and Planning (CEP) for coalition support compared with Resources for Services (RS) for program technical assistance to implement depression quality improvement programs improves 6- and 12-month client mental-health related quality of life (MHRQL); however, effects for clients with multiple chronic medical conditions (MCC) are unknown. Objective: To explore effectiveness of CEP vs RS in MCC and non-MCC subgroups. Design: Secondary analyses of a cluster-randomized trial. Setting: 93 health care and community-based programs in two neighborhoods. Participants: Of 4,440 clients screened, 1,322 depressed (Patient Health Questionnaire, PHQ8) provided contact information, 1,246 enrolled and 1,018 (548 with ≥3 MCC) completed baseline, 6- or 12-month surveys. Intervention: CEP or RS for implementing depression quality improvement programs. Outcomes and Analyses: Primary: depression (PHQ9 <10), poor MHRQL (Short Form Health Survey, SF-12<40); Secondary: mental wellness, good physical health, behavioral health hospitalization, chronic homelessness risk, work/workloss days, services use at 6 and 12 months. End-point regressions were used to estimate intervention effects on outcomes for subgroups with ≥3 MCC, non-MCC, and intervention-by-MCC interactions (exploratory). Results: Among MCC clients at 6 months, CEP vs RS lowered likelihoods of depression and poor MHRQL; increased likelihood of mental wellness; reduced work-loss days among employed and likelihoods of ≥4 behavioral-health hospitalization nights and chronic homelessness risk, while increasing faith-based and park community center depression services; and at 12 months, likelihood of good physical health and park community center depression services use (each P<.05). There were no significant interactions or primary outcome effects for non-MCC. Conclusions: CEP was more effective than RS in improving 6-month primary outcomes among depressed MCC clients, without significant interactions.

12-Month Cost Outcomes of Community Engagement Versus Technical Assistance for Depression Quality Improvement: A Partnered, Cluster Randomized, Comparative-Effectiveness Trial.

Objective: To compare community engagement and planning (CEP) for coalition support to implement depression quality improvement (QI) to resources for services (RS) effects on service-use costs over a 12-month period. Design: Matched health and community programs (N=93) were cluster-randomized within communities to CEP or RS. Setting: Two Los Angeles communities. Participants: Adults (N=1,013) with depressive symptoms (Patient Health Questionnaire (PHQ-8) ≥10); 85% African American and Latino. Interventions: CEP and RS to support programs in depression QI. Main Outcome Measures: Intervention training and service-use costs over 12 months. Results: CEP planning and training costs were almost 3 times higher than RS, largely due to greater CEP provider training participation vs RS, with no significant differences in 12-month service-use costs. Conclusions: Compared with RS, CEP had higher planning and training costs with similar service-use costs.

Comparative Effectiveness of Two Models of Depression Services Quality Improvement in Health and Community Sectors.

OBJECTIVE: The effectiveness of community coalition building and program technical assistance was compared in implementation of collaborative care for depression among health care and community sector clients. METHODS: In under-resourced communities, within 93 programs randomly assigned to coalition building (Community Engagement and Planning) or program technical assistance (Resources for Services) models, 1,018 clients completed surveys at baseline and at six, 12, or 36 months. Regression analysis was used to estimate intervention effects and intervention-by-sector interaction effects on depression, mental health-related quality of life, and community-prioritized outcomes and on services use. RESULTS: For outcomes, there were few significant intervention-by-sector interactions, and stratified findings suggested benefits of coalition building in both sectors. For services use, at 36 months, increases were found for coalition building in primary care visits, self-help visits, and appropriate treatment for community clients and in community-based services use for health care clients. CONCLUSIONS: Relative to program technical assistance, community coalition building benefited clients across sectors and shifted long-term utilization across sectors.

A Psychometric Study of the Modified Bridges for Newborns Screening Tool.

Welcome Baby, a program that First 5 Los Angeles (First 5 LA) sponsors, provides new mothers with supportive services intended to create enriching environments for their children. To identify mothers in need of these services, First 5 LA employs hospital liaisons who administer a maternal risk assessment tool, the Modified Bridges for Newborns screening tool, during postpartum interviews of mothers. First 5 LA uses risk assessment scores from the Modified Bridges to classify mothers as low, moderate, or high risk; high-risk mothers are eligible for additional supportive services that are not available to low- and moderate-risk mothers. This article describes RAND Corporation work evaluating the psychometric characteristics of the Modified Bridges.

A Community-Partnered, Participatory, Cluster-Randomized Study of Depression Care Quality Improvement: Three-Year Outcomes.

OBJECTIVE: Community Partners in Care, a community-partnered, cluster-randomized trial with depressed clients from 93 Los Angeles health and community programs, examined the added value of a community coalition approach (Community Engagement and Planning [CEP]) versus individual program technical assistance (Resources for Services [RS]) for implementing depression quality improvement in underserved communities. CEP was more effective than RS in improving mental health-related quality of life, reducing behavioral health hospitalizations, and shifting services toward community-based programs at six months. At 12 months, continued evidence of improvement was found. This study examined three-year outcomes. METHODS: Among 1,004 participants with depression who were eligible for three-year follow-up, 600 participants from 89 programs completed surveys. Multiple regression analyses estimated intervention effects on poor mental health-related quality of life and depression, physical health-related quality of life, behavioral health hospital nights, and use of services. RESULTS: At three years, no differences were found in the effects of CEP versus RS on depression or mental health-related quality of life, but CEP had modest effects in improving physical health-related quality of life and reducing behavioral health hospital nights, and CEP participants had more social- and community-sector depression visits and greater use of mood stabilizers. Sensitivity analyses with longitudinal modeling reproduced these findings but found no significant differences between groups in change from baseline to three years. CONCLUSIONS: At three years, CEP and RS did not have differential effects on primary mental health outcomes, but CEP participants had modest improvements in physical health and fewer behavioral health hospital nights.

Effects of Depression Alleviation on Work Productivity and Income Among HIV Patients in Uganda.

PURPOSE: Depression is common among people living with HIV, and it is associated with impaired work functioning. However, little research has examined whether depression alleviation improves work-related outcomes in this population, which is the focus of this analysis. METHOD: A sample of 1028 depressed HIV clients in Uganda enrolled in a comparative trial of depression care models and were surveyed over 12 months. Serial regression analyses examined whether depression alleviation (measured by the nine-item Patient Health Questionnaire) was associated with change in self-reported weekly amount of hours worked and income earned, and whether these relationships were mediated by change in work-related self-efficacy. RESULTS: Among those with major depression, depression alleviation was associated with nearly a doubling of weekly hours worked in bivariate analysis. The relationship between depression alleviation and hours worked was partially mediated by change in work self-efficacy among those with major depression, as well as those with minor depression, in multivariate regression analysis that controlled for demographic and health covariates. Depression alleviation was not significantly associated with change in weekly income. CONCLUSION: These findings suggest that depression alleviation benefits work functioning at least in part through improved confidence to engage in work-related activities. Integration of depression care services into HIV care may be important for improving the economic well-being of people living with HIV.

Effects of Depression Alleviation on ART Adherence and HIV Clinic Attendance in Uganda, and the Mediating Roles of Self-Efficacy and Motivation.

With depression known to impede HIV care adherence and retention, we examined whether depression alleviation improves these disease management behaviors. A sample of 1028 depressed HIV clients in Uganda enrolled in a cluster randomized controlled trial of two depression care models, and were surveyed over 12 months. Serial regression analyses examined whether depression alleviation was associated with self-reported antiretroviral therapy (ART) adherence and clinic attendance at month 12, and whether these relationships were mediated by self-efficacy and motivation. Among those with major depression, depression alleviation was associated with better ART adherence and clinic attendance at month 12; these relationships were fully mediated by self-efficacy at month 12, while adherence motivation partially mediated the relationship between depression alleviation and ART adherence. When both mediators were entered simultaneously, only self-efficacy was a significant predictor and still fully mediated the relationship between depression alleviation and adherence. These findings suggest that depression alleviation benefits both ART adherence and clinic attendance, in large part through improved confidence and motivation to engage in these disease management behaviors.

Community Engagement Compared With Technical Assistance to Disseminate Depression Care Among Low-Income, Minority Women: A Randomized Controlled Effectiveness Study.

OBJECTIVES: To compare the effectiveness of a (CEP) versus a technical assistance approach (Resources for Services, or RS) to disseminate depression care for low-income ethnic minority women. METHODS: We conducted secondary analyses of intervention effects for largely low-income, minority women subsample (n = 595; 45.1% Latino and 45.4% African American) in a matched, clustered, randomized control trial conducted in 2 low-resource communities in Los Angeles, California, between 2010 and 2012. Outcomes assessed included mental health, socioeconomic factors, and service use at 6- and 12-month follow-up. RESULTS: Although we found no intervention difference for depressive symptoms, there were statistically significant effects for mental health quality of life, resiliency, homelessness risk, and financial difficulties at 6 months, as well as missed work days, self-efficacy, and care barriers at 12 months favoring CEP relative to RS. CEP increased use of outpatient substance abuse services and faith-based depression visits at 6 months. CONCLUSIONS: Engaging health care and social community programs may offer modest improvements on key functional and socioeconomic outcomes, reduce care barriers, and increase engagement in alternative depression services for low-income, predominantly ethnic minority women.

Linkages between mental health need and help-seeking behavior among adolescents: Moderating role of ethnicity and cultural values.

Risk of developing emotional and behavioral mental health problems increases markedly during adolescence. Despite this increasing need, most adolescents, particularly ethnic minority youth, do not seek professional help. Informed by conceptual models of health behavior, the current study examined how cultural values are related to help seeking among adolescents from 2 distinct racial/ethnic groups. Using a prospective survey design, 169 Vietnamese American and European American youth in 10th and 11th grade reported on their mental health need, as measured by emotional/behavioral mental health symptoms and stressful life events, with participants reporting on their help-seeking behavior at 6-month follow-up assessments. Multinomial logistic regression analyses indicated that mental health need interacted with cultural values and ethnicity to predict help-seeking behavior. Specifically, associations between symptoms and stressful life events, and help-seeking behavior were smaller among Vietnamese American adolescents, and among adolescents with strong family obligation values. These results underscore the complex sociocultural factors influencing adolescents' help-seeking behavior, which have important implications for engaging youth in needed mental health care.

Participation in Training for Depression Care Quality Improvement: A Randomized Trial of Community Engagement or Technical Support.

OBJECTIVE: Community engagement and planning (CEP) could improve dissemination of depression care quality improvement in underresourced communities, but whether its effects on provider training participation differ from those of standard technical assistance, or resources for services (RS), is unknown. This study compared program- and staff-level participation in depression care quality improvement training among programs enrolled in CEP, which trained networks of health care and social-community agencies jointly, and RS, which provided technical support to individual programs. METHODS: Matched programs from health care and social-community service sectors in two communities were randomly assigned to RS or CEP. Data were from 1,622 eligible staff members from 95 enrolled programs. Primary outcomes were any staff trained (for programs) and total hours of training (for staff). Secondary staff-level outcomes were hours of training in specific depression collaborative care components. RESULTS: CEP programs were more likely than RS programs to participate in any training (p=.006). Within health care sectors, CEP programs were more likely than RS programs to participate in training (p=.016), but within social-community sectors, there was no difference in training by intervention. Among staff who participated in training, mean training hours were greater among CEP programs versus RS programs for any type of training (p<.001) and for training related to each component of depression care (p<.001) except medication management. CONCLUSIONS: CEP may be an effective strategy to promote staff participation in depression care improvement efforts in underresourced communities.

Test of "Facilitation" vs. "Proximal Process" Moderator Models for the Effects of Multisystemic Therapy on Adolescents with Severe Conduct Problem.

The present study identified moderators of Multisystemic Therapy's (MST) effects on adolescent conduct problems, considering facilitation and proximal process moderation models. The sample included 164 adolescents (mean age = 14.6 years; 83% male) randomly assigned to receive MST or services as usual; parent, youth, and teacher reports of adolescent functioning were obtained. A number of significant moderators were identified. Proximal process moderation patterns were identified (e.g., families with parents with lower levels of adaptive child discipline skills gained more from MST), but the majority of significant interactions showed a facilitation moderation pattern with, for instance, higher levels of adaptive functioning in families and parents appearing to facilitate MST (i.e., greater benefits from MST were found for these families). This facilitation pattern may reflect such families being more capable of and/or more motivated to use the resources provided by MST. It is suggested that factors consistently identified as facilitation moderators may serve as useful foci for MST's strength-based levers of change approach. Other implications of these findings for individualized treatment also are discussed.

Effectiveness of antidepressants and predictors of treatment response for depressed HIV patients in Uganda.

Antidepressant medication is well established for the treatment of depression but little is known about its effectiveness for HIV populations in sub-Saharan Africa. This study examined the effectiveness of antidepressant treatment and predictors of treatment response among depressed HIV patients in Uganda. Data were obtained from two open-label trials in which 184 HIV patients were diagnosed with depression and started on antidepressants. Data at treatment baseline and month 6 were compared to assess treatment response, and baseline predictors of response were assessed. A total of 154 completed month 6, of whom 122 (79%) had responded to treatment and were no longer depressed (Patient Health Questionnaire-9, score < 5). Bivariate analysis found that education, CD4 count, general health functioning, physical health, pain, quality of life and social support variables were associated with antidepressant treatment response; however, only secondary education and social support independently predicted treatment response in logistic multiple regression analysis. Baseline depression severity was not associated with treatment response. In conclusion, antidepressants are effective in treating both moderate and more severe depression among persons living with HIV in Uganda, and education [OR (95% CI) = 4.33 (1.33-14.11)] and social support [OR (95% CI) = 1.54 (1.03-2.30)] were most predictive of treatment response.