Employment of Certified Peer Specialists in Mental Health Professional Shortage Areas.

The current demand for mental health services is exacerbated by an ongoing shortage of behavioral health care providers in the United States. The Health Resources and Services Administration has identified 5,833 Mental Health Professional Shortage Areas (MHPSAs), many of which are rural, and could be served by Certified Peer Specialists (CPSs). This paper examines the relationship between CPS employment and MHPSA residency. Data are from a 2020 survey of 572 CPS certified in one of four states. Random effects logistic regression models were used to test the relationship between MHPSA residence and employment outcomes. Of 166 unique counties identified by participant zip codes, 47 were characterized as being MHPSAs with 14% of participants residing in one of these counties. A higher proportion of those living in MHPSAs were employed in peer support jobs (rather than other job types or unemployed) compared to those living in non-MHPSAs (68% vs. 54%, p = .020). MHPSA residential status was not a significant predictor of employment status (OR = 1.14, p = .728) but was significantly associated with greater likelihood of employment in peer support compared to other jobs, both for the entire sample (OR = 2.13, p = .026), and among those currently employed (OR = 2.90, p = .032). The greater likelihood of working in peer support among those residing in MHPSAs suggests that CPSs may leverage their credential to address shortages. As a result, peer support may become a more necessary part of the traditional service array. Policies that enable CPS to practice in MHPSAs should be encouraged.

Enhancing pre-employment transition services: A type 1 hybrid randomized controlled trial protocol for evaluating WorkChat: A Virtual Workday among autistic transition-age youth.

Autistic transition-age youth experience high rates of unemployment and underemployment, in part due to the social challenges they may face when having conversations in the workplace. In an effort to help enhance conversational abilities in the workplace, our collaborative team partnered to develop WorkChat: A Virtual Workday. Specifically, our team of scientists, community partners, and diversity and inclusion experts participated in a community-engaged process to develop WorkChat using iterative feedback from autistic transition-age youth and their teachers. With initial development complete, this study reports on the protocol that our collaborative team developed, reviewed, and approved to conduct a randomized controlled trial (RCT) to evaluate the real-world effectiveness and initial implementation process outcomes of WorkChat when integrated into post-secondary pre-employment transition services (Pre-ETS). Our aims are to: 1) evaluate whether services-as-usual in combination with WorkChat, compared to services-as-usual with an attention control, enhances social cognition and work-based social ability (between pre- and post-test); reduces anxiety about work-based social encounters (between pre- and post-test), and increases sustained employment by 9-month follow-up; 2) evaluate whether social cognitive ability and work-based social ability mediate the effect of WorkChat on sustained employment; and 3) conduct a multilevel, mixed-method process evaluation of WorkChat implementation.

Psychometric properties of the mock interview rating scale for schizophrenia and other serious mental illnesses.

Background: Over the past 10 years, job interview training has emerged as an area of study among adults with schizophrenia and other serious mental illnesses who face significant challenges when navigating job interviews. The field of mental health services research has limited access to assessments of job interview skills with rigorously evaluated psychometric properties. Objective: We sought to evaluate the initial psychometric properties of a measure assessing job interview skills via role-play performance. Methods: As part of a randomized controlled trial, 90 adults with schizophrenia or other serious mental illnesses completed a job interview role-play assessment with eight items (and scored using anchors) called the mock interview rating scale (MIRS). A classical test theory analysis was conducted including confirmatory factor analyses, Rasch model analysis and calibration, and differential item functioning; along with inter-rater, internal consistency, and test-retest reliabilities. Pearson correlations were used to evaluate construct, convergent, divergent, criterion, and predictive validity by correlating the MIRS with demographic, clinical, cognitive, work history measures, and employment outcomes. Results: Our analyses resulted in the removal of a single item (sounding honest) and yielded a unidimensional total score measurement with support for its inter-rater reliability, internal consistency, and test-retest reliability. There was initial support for the construct, convergent, criterion, and predictive validities of the MIRS, as it correlated with measures of social competence, neurocognition, valuing job interview training, and employment outcomes. Meanwhile, the lack of correlations with race, physical health, and substance abuse lent support for divergent validity. Conclusion: This study presents initial evidence that the seven-item version of the MIRS has acceptable psychometric properties supporting its use to assess job interview skills reliably and validly among adults with schizophrenia and other serious mental illnesses. Clinical Trial Registration: NCT03049813.

Randomized Controlled Trial of Self-Directed Care for Medically Uninsured Adults With Serious Mental Illness.

OBJECTIVE: Self-directed care (SDC) is a treatment model in which recipients self-manage funds designated for provision of services. The model is designed to cost no more than traditional services while achieving superior participant outcomes. The authors examined the model's impact on outcomes, service costs, and user satisfaction among medically uninsured, low-income individuals with serious mental illness. METHODS: Adults in the public mental health system (N=42) were randomly assigned (1:1) to receive SDC or services as usual and were assessed at baseline and 6- and 12-month follow-ups. Outcomes included perceived competence for mental health self-management, met and unmet needs, degree of autonomy support, self-perceived recovery, and employment. Mixed-effects random regression analysis tested for differences in longitudinal changes in outcomes between the two study conditions. Differences in service costs were analyzed with negative binomial regression models. RESULTS: Compared with individuals in the control condition, SDC participants reported greater improvement in perceived competence, met and unmet needs, autonomy support, recovery from symptom domination, and employment. No differences were found between the two groups in total per-person service costs or costs for individual services. The most frequent nontraditional purchases were for medical, dental, and vision services (33%) and health and wellness supports (33%). Satisfaction with SDC services was high. CONCLUSIONS: Mental health SDC services achieved participant outcomes superior to treatment as usual, with equivalent service use and costs and high user satisfaction. This model may be well suited to the needs of uninsured adults with low income who receive public behavioral health care.

Trauma Across the Life Span and Multisystem Morbidity in Women With HIV.

OBJECTIVE: Sexual and physical abuse are highly prevalent among women living with HIV (WLWH) and are risk factors for the development of mental health and substance use disorders (MHDs, SUDs), and cognitive and medical comorbidities. We examined empirically derived patterns of trauma, MHD, and SUD, and associations with later cognitive and health outcomes. METHODS: A total of 1027 WLWH (average age = 48.6 years) in the Women's Interagency HIV Study completed the World Mental Health Composite International Diagnostic Interview from 2010 to 2013 to identify MHDs, SUDs, and age at onset of sexual and physical abuse. Then, cognitive impairment, cardiovascular/metabolic conditions, and HIV disease outcomes were assessed for up to 8.8 years. Latent class analysis identified patterns of co-occurring trauma, MHDs, and/or SUDs. Generalized estimating equations determined associations between these patterns and midlife cognitive and medical outcomes. RESULTS: Six distinct profiles emerged: no/negligible sexual/physical trauma, MHD, or SUD (39%); preadolescent/adolescent sexual trauma with anxiety and SUD (22%); SUD only (16%); MHD + SUD only (12%); early childhood sexual/physical trauma only (6%); and early childhood sexual/physical trauma with later MHD + SUD (4%). Profiles including early childhood trauma had the largest number of midlife conditions (i.e., cognitive, cardiovascular, HIV-related). Preadolescent/adolescent sexual trauma with anxiety and SUD predicted both global and domain-specific cognitive declines. Only SUD without trauma predicted lower CD4, whereas childhood trauma with MHD + SUD predicted increased CD8. CONCLUSIONS: WLWH have complex multisystem profiles of abuse, MHD, and/or SUD that predict midlife cognitive, metabolic/cardiovascular, and HIV outcomes. Understanding the interplay between these factors over time can identify risks and personalize preventative and treatment interventions.

Outcomes of Peer-Provided Individual Placement and Support Services in a Mental Health Peer-Run Vocational Program.

OBJECTIVE: The authors sought to determine whether staff at a peer-run agency could deliver supported employment services with high fidelity to the individual placement and support (IPS) model and whether employment outcomes of peer-delivered IPS plus work-specific health promotion were superior to usual supported employment services. METHODS: Two teams from a vocational program of a large peer-run agency were studied from July 2015 to July 2017. One team received training and supervision in delivering IPS plus employment-focused physical wellness support and mentoring. The other team continued providing usual supported employment services. Study data included vocational outcomes from 348 clients served by the two teams (IPS, N=184; comparison condition, N=164) and the results of IPS fidelity reviews of the IPS team at study baseline, midpoint, and end. The authors modeled the primary outcome of competitive employment with random-effects logistic regression and adjusted propensity scores for age, gender, race, ethnicity, education, and months of service receipt. RESULTS: Following training, the IPS team demonstrated acceptable and increasing fidelity to the IPS model, achieving "good fidelity" by the end of the 25-month observation period. Among IPS recipients, 43% achieved competitive employment versus 21% of comparison recipients (p<0.001). Multivariable analysis indicated that IPS recipients were significantly more likely to achieve competitive employment than individuals in the comparison group (OR=4.06, p<0.001). CONCLUSIONS: Providing training in IPS along with health promotion to the behavioral health peer workforce may help address the severe shortage of IPS services and enhance the competitive employment outcomes of people served by peer-run programs.

Nutrition and Exercise for Wellness and Recovery: A Randomized Controlled Trial of a Community-Based Health Intervention.

OBJECTIVE: The purpose of this study was to examine the efficacy of the Nutrition and Exercise for Wellness and Recovery (NEW-R) intervention for improving competency and behaviors related to diet, physical activity, and weight management. METHODS: Participants with psychiatric disabilities were recruited from four community mental health agencies and a hospital-based psychiatric outpatient clinic and randomly assigned to the NEW-R intervention (N=55) or control condition (N=58). Outcome measures included the Perceived Competence Scale, Health-Promoting Lifestyle Profile (HPLP), and weight change; random-effects regression models were used. A follow-up analysis examined the interactions of group, time, and site. RESULTS: Fifty of the 55 intervention participants and 57 of the 58 control participants completed the study. The two groups did not differ significantly on any measured baseline characteristic. The intervention group had statistically significant improvements, compared with the control group, in perceived competence for exercise and healthy eating, total HPLP score, and scores on two HPLP subscales (nutrition and spiritual growth). No significant difference between groups was found for weight loss. A study condition × time × site effect was observed: at the three sites where mean weight loss occurred, NEW-R participants lost significantly more weight than did control participants. CONCLUSIONS: NEW-R offers promise as an intervention that can initiate the change to healthy lifestyle behaviors and boost perceived competence in a healthy lifestyle. It may also be effective for weight loss when administered in supportive settings.

Predictors of worklife burnout among mental health certified peer specialists.

Certified peer specialists (CPSs) are a growing workforce that uses their lived experience of a behavioral health disorders plus skills learned in formal training to deliver support services. Despite their important role in the mental health care system and research on their working conditions, experiences of burnout have not been widely studied among CPSs. This study uses survey data from CPSs who were currently employed in any type of job, providing peer support services or not. Using the Maslach Burnout Inventory (MBI) and Areas of Worklife Survey (AWS), along with other measures of personal and job characteristics, relationships of predictors variables to burnout measures were described in unadjusted and adjusted linear regression models. Scores on each of the averaged burnout measures differed significantly between those employed in peer services jobs and those in other job types, with those in peer services jobs reporting lower exhaustion, cynicism, and higher professional efficacy. Better workload and fairness were associated with significantly lower exhaustion, and better reward and community were both associated with significantly lower cynicism. Those employed in peer services jobs had fewer signs of burnout than those in other occupations, in keeping with prior research. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Employment Outcomes After Certification as a Behavioral Health Peer Specialist in Four U.S. States.

OBJECTIVE: A 3-year study explores employment outcomes of certified peer specialists (CPSs). Analyses reported here identified relationships between demographic, clinical, work history, and geographic characteristics and employment status and current employment in peer services jobs versus other jobs. METHODS: The study recruited adults who recently became a CPS, regardless of current employment status, in four states. Online survey data were collected from March to October 2020 and included demographic information, health status and diagnoses, mental health service use, motivations for becoming certified, employment history, and job characteristics, including job satisfaction. Descriptive statistics and logistic regression models were used to compare groups. RESULTS: Of 681 respondents, 591 provided data on current employment and were included. Participants who received Social Security Disability Insurance or Supplemental Security Income, veterans, those who used outpatient counseling or therapy, and those who did not disclose their mental health status in the workplace were less likely to report current employment. Lack of disclosure and higher local unemployment rates contributed to a lower likelihood of working in peer services jobs, whereas individuals reporting depressive disorders were more likely to hold such jobs. Compared with those in other jobs, those in peer services jobs reported longer job tenure, and a larger proportion received employee benefits. Job satisfaction was significantly higher among those with peer services jobs. CONCLUSIONS: Workers with a CPS credential had higher employment rates, compared with adults with psychiatric disabilities, and the quality of peer specialist jobs was equal to or higher than the quality of other jobs held by study participants.

An RCT of Virtual Reality Job Interview Training for Individuals With Serious Mental Illness in IPS Supported Employment.

OBJECTIVE: Virtual Reality Job Interview Training (VR-JIT) is a computerized interview simulator with efficacy at enhancing interview skills and employment outcomes. A randomized controlled trial assessed VR-JIT effectiveness for participants in individual placement and support (IPS), in which approximately 55% of individuals with serious mental illness obtain employment. METHODS: Ninety participants with serious mental illness were randomly assigned to IPS+VR-JIT (N=54) or IPS as usual (N=36), completing pretest-posttest assessments and an employment evaluation at 9 months. Intent-to-treat chi-square analysis, multivariable logistic regression, Cox proportional hazards models, and mixed-effects linear regressions were conducted. Fifty-one percent were IPS nonresponders (i.e., no employment within the first 90 days of IPS). RESULTS: IPS+VR-JIT participants did not have significantly higher employment rates, compared with IPS-as-usual participants (43% versus 28%). IPS nonresponders (N=46) in the IPS+VR-JIT group had greater odds of obtaining employment (odds ratio [OR]=5.82, p=0.014) and shorter time to employment (hazard ratio=2.70, p=0.044) compared with IPS nonresponders in the IPS-as-usual group. Intent-to-treat mixed-effects linear analyses indicated that IPS+VR-JIT, compared with IPS as usual, significantly improved interview skills (p=0.006), interview confidence (p=0.013), and interview anxiety (p=0.019). CONCLUSIONS: VR-JIT's potential benefits (increased employment in a shorter time) appeared to be specific to IPS nonresponders, whereas employment outcomes for recent IPS enrollees were not affected. VR-JIT could be a valuable resource for employment specialists to support IPS nonresponders, because 47% of participants engaged in mock interview training with their specialist. Future research should focus on evaluating the effectiveness and implementation of VR-JIT among IPS nonresponders.

Registry-Managed Care Coordination and Education for Patients With Co-occurring Diabetes and Serious Mental Illness.

OBJECTIVE: Longitudinal changes in health outcomes of patients with serious mental illness and co-occurring diabetes were examined after introduction of an intervention involving electronic disease management, care coordination, and personalized patient education. METHODS: This observational cohort study included 179 patients with serious mental illness and diabetes mellitus type 2 at a behavioral health home in Chicago. The intervention employed a care coordinator who used a diabetes registry to integrate services; patients also received personalized diabetes self-management education. Outcomes included glucose, lipid, and blood pressure levels as assessed by glycosylated hemoglobin, low-density lipoprotein, triglycerides, and systolic/diastolic values from electronic medical records and completion of specialty visits confirmed with optometrists and podiatrists. Interrupted time-series segmented random-effects regression models tested for level changes in the eight study quarters following intervention implementation compared with eight preimplementation study quarters, controlling for clinic site and preimplementation secular trends. RESULTS: Significant declines were found in levels of glucose, lipids, and blood pressure postimplementation. In addition, completed optometry referrals increased by 44% and completed podiatry referrals increased by 60%. CONCLUSIONS: Significant improvement in medical outcomes was found among patients of a behavioral health home who had comorbid diabetes and mental illness after introduction of a multicomponent care coordination intervention, regardless of which clinic they attended.

Supporting business owners with psychiatric disabilities: An exploratory analysis of challenges and supports.

OBJECTIVE: Self-employed individuals with psychiatric disabilities may face unique challenges to running small businesses. This study aims to identify business-related challenges and examine whether supports designed to alleviate those challenges are associated with positive business milestones and self-employment satisfaction. METHODS: Data were collected via a survey of 60 participants with a history of psychiatric disability who were operating a U.S.-based small business. This exploratory study used descriptive statistics to look at the relationship between business challenges, business development supports, business milestones, and satisfaction with self-employment. RESULTS: Although most participants reported experiencing business challenges and using supports, relatively few supports were helpful in the context of specific challenges. The number of challenges was positively correlated with the amount of supports used. Respondents used interpersonal or informal supports more often than help from organizations or institutions and tended to find these more helpful. The satisfaction of owning a business was generally high and positively correlated with the age of the business. Satisfaction was not necessarily tied to normative reasons such as business gross or percent of income. CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: In this study, self-employed individuals with a psychiatric disability appear to prefer-or have greater access to-informal or interpersonal support, compared to institutional support. This may indicate that these owners have different needs for support, or that they do not use mainstream institutional resources that facilitate sustainability and growth, and therefore targeted efforts to provide formal support may be needed. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Serious mental illness, other mental health disorders, and outpatient health care as predictors of 30-day readmissions following medical hospitalization.

OBJECTIVE: Prior research has not addressed whether both serious mental illness (SMI) and other mental health (OMH) disorders affect the likelihood of 30-day readmissions after medical hospitalizations, or whether post-discharge use of outpatient medical, mental health, and pharmacy services is associated with readmission likelihood. METHODS: Using the Truven Health Analytics MarketScan® Medicaid Multi-State Database, we studied 43,817 Medicaid beneficiaries, age 18-64, following discharge from medical hospitalizations in 2011. Logistic regression models compared all-cause, 30-day readmissions among those with SMI, OMH, and no psychiatric diagnosis, and examined associations of 30-day outpatient service use with 30-day readmissions. RESULTS: Thirty-day readmission rates were 15.9% (SMI), 13.8% (OMH), and 11.7% (no mental illness). In multivariable analysis, compared to patients without mental illness, odds of readmission were greater for those with SMI (aOR = 1.43, 95%CI:1.32-1.51) and OMH (aOR = 1.21, 95%CI:1.12-1.30), and lower among those using outpatient mental health services (aOR = 0.50, 95%CI: 0.44-0.56). CONCLUSION: The adult Medicaid population disproportionately includes patients with SMI and OMH disorders, both of which were found to be associated with 30-day hospital readmissions. Receiving outpatient mental health services after hospital discharge may be protective against readmission following medical hospitalizations, suggesting the need for further research on these topics.

Development and properties of a measure designed to assess core competencies in intentional peer support.

OBJECTIVE: Intentional Peer Support (IPS) is a peer-developed, theoretically based, manualized approach that is used in multiple countries. This research aimed to develop and test a measure that can be administered to service users to provide quantitative data for assessing IPS core competencies (IPSCC) in outcomes research. METHODS: Ten items based on IPSCC dimensions were developed and revised in an iterative process and administered in face-to-face interviews with 84 respondents. Internal consistency, test-retest reliability, and convergent validity were examined. RESULTS: The IPSCC measure demonstrated good internal consistency (Cronbach's alpha of .85) and 2-week test-retest reliability (r = .98, p < .001), as well as satisfactory convergent validity. CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: This study provides a foundation for future process-oriented research on IPS, and potentially other forms of peer support, to systematically document and appraise participant experiences. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

The Costs of Silencing the Self and Divided Self in the Context of Physical Abuse, Racial/Ethnic Identity, and Medication Adherence in Women Living with HIV.

Racial/ethnic minority status and physical abuse history are risk factors for higher mortality rates and lower adherence to antiretroviral therapy (ART) in women living with HIV (WLWH) in the United States. The current study tested the hypotheses that minority status and physical abuse history might lead women to silence the self (minimize and hide thoughts and feelings in order to avoid relational conflict, loss, and/or abuse) as measured by the Silencing the Self Scale (STSS), and that STSS might mediate and moderate relationships of physical abuse and racial/ethnic minority status with ART adherence. Divided Self (DS; acting in ways inconsistent with inner thoughts and feelings), an STSS subscale, was targeted for study along with the total STSS score. Participants were 513 women from the U.S. Women's Interagency HIV Study (M age = 46; 387, 75%, Black; 66, 13%, Hispanic; 60, 12%, White). Multiple logistic regressions indicated that across all racial/ethnic groups, physical abuse history related to higher DS and lower adherence. DS significantly mediated relationships between abuse and adherence. Compared to White women, Black women demonstrated worse ART adherence, but had lower total STSS. Racial/ethnic minority women and women with a physical abuse history who had higher DS had lower adherence than other groups. Results indicate that being a racial/ethnic minority or having a history of physical abuse may increase vulnerability to the deleterious effects of DS on ART adherence, findings that can help inform interventions to decrease health disparities in WLWH.

Whole Health Action Management: A Randomized Controlled Trial of a Peer-Led Health Promotion Intervention.

OBJECTIVE: Adults with serious mental illness have high rates of general medical comorbidity and encounter challenges in dealing with multiple health conditions. Chronic illness self-management programs may help them more effectively cope with comorbid illnesses, especially when instructors are certified peer specialists. This study assessed the longitudinal effectiveness of a peer-delivered health promotion program. METHODS: Community mental health program clients in Georgia and Illinois with serious mental illness and health impairments were randomly assigned to receive either Whole Health Action Management (WHAM), a medical illness self-management program led by peer specialists, or care as usual, resulting in a sample of N=139 (WHAM N=68, control N=71). Assessments were conducted at study baseline and at 3 and 6 months. Generalized estimating equations were used to examine change over time in the primary outcome of patient activation and secondary outcomes of general health, hope, and employment. RESULTS: Longitudinal analysis indicated that compared with control participants, WHAM participants demonstrated significantly greater improvement over time in patient activation for health care. Intervention participants also demonstrated greater improvement in their self-assessed general health, overall hopefulness, and paid employment. Reactions to the WHAM program were positive, with 97% reporting being very or somewhat satisfied, and almost two-thirds (63%) reporting that their health was better than before they joined the program. CONCLUSIONS: The WHAM program improved patient activation, perceived general medical health, hopefulness, and likelihood of paid employment among people with serious mental illness and co-occurring medical conditions. Results suggest that peer-delivered health self-management education is effective and well received by participants.

Factors associated with 30-day readmissions following medical hospitalizations among Medicaid beneficiaries with schizophrenia, bipolar disorder, and major depressive disorder.

While evidence suggests that adults with serious mental illness have an elevated rate of 30-day readmissions after medical hospitalizations, most studies are of patients who are privately insured or Medicare beneficiaries, and little is known about the differential experiences of people with schizophrenia, bipolar disorder, and major depression. We used the Truven Health Analytics MarketScan® Medicaid Multi-State Database to study 43,817 Medicaid enrollees from 11 states, age 18-64, who were discharged from medical hospitalizations in 2011. Our outcome was unplanned all-cause readmissions within 30 days of discharge. In a multivariable analysis, compared to those with no SMI, people with schizophrenia had the highest odds of 30-day readmission (aOR: 1.46, 95% CI: 1.33-1.59), followed by those with bipolar disorder (aOR: 1.25, 95% CI: 1.14-1.38), and those with major depressive disorder (aOR: 1.18, 95% CI: 1.06-1.30). Readmissions also were more likely among those with substance use disorders, males, those with Medicaid eligibility due to disability, patients with longer index hospitalizations, and those with 2 or more medical co-morbidities. This is the first large-scale study to demonstrate the elevated risk of hospital readmission among low-income, working-age adults with schizophrenia. Given their greater psychological, social, and economic vulnerability, our findings can be used to design transition interventions and service delivery systems that address their complex needs.

Cross-validation of transtheoretical model smoking cessation measures in Chicago WIHS women smokers with and at risk for HIV.

People with and at risk for HIV have high rates of smoking, increasing their morbidity and mortality. Effective cessation interventions are needed for this group. Transtheoretical model (TTM)-tailored interventions have demonstrated efficacy, but measures need cross-validation in this population. TTM cessation measures were evaluated in women smokers with and at risk for HIV (N = 111) from Chicago Women's Interagency HIV Study (WIHS). Confirmatory factor analyses evaluated measurement models. MANOVAs examined relationships between constructs and stage subgroups. For decisional balance, the two-factor uncorrelated model was best (χ2(20) = 13.96; comparative fit index [CFI], 1.0; root mean square error of approximation [RMSEA] = .00), with good (pros α = .78) and fair (cons α = .55) four-item alphas. The one-factor temptations model (α = .90) showed reasonable fit (χ2(18) = 80.22; CFI = .89; RMSEA = .177). Processes of change subscales had fair to good two-item alphas (α = .49-.77) and fit a 10-factor fully correlated model (χ2(125) = 222.72; CFI = .88; RMSEA = .084). MANOVAs by stage of change replicated expected patterns for the pros, overall temptations, and two process subscales with medium-sized effects (η2 = .06-.18). Contrary to expectations, no differences by stage were found for cons or temptation negative affect subscales. The structures of these TTM measures replicated with good internal and external validity, except for the cons, which needs refinement. Negative affect temptations was structurally sound, but did not vary by stage group potentially reflecting this sample's moderate depression levels and/or their reliance on smoking to deal with negative affect. Results support the use of most TTM measures in research and tailored interventions to increase smoking cessation among women smokers with and at risk for HIV and highlight the importance of managing negative affect in cessation materials targeting this group.

Mental Health Self-Directed Care Financing: Efficacy in Improving Outcomes and Controlling Costs for Adults With Serious Mental Illness.

OBJECTIVE: Self-directed care allows individuals with disabilities and elderly persons to control public funds to purchase goods and services that help them remain outside institutional settings. This study examined effects on outcomes, service costs, and user satisfaction among adults with serious mental illness. METHODS: Public mental health system clients were randomly assigned to self-directed care (N=114) versus services as usual (N=102) and assessed at baseline and 12 and 24 months. The primary outcome was self-perceived recovery. Secondary outcomes included psychosocial status, psychiatric symptom severity, and behavioral rehabilitation indicators. Mixed-effects random-regression analysis tested for longitudinal changes in outcomes between the two conditions. Differences in service costs were analyzed with negative binomial and zero-inflated negative binomial regression models. RESULTS: Compared with the control group, self-directed care participants had significantly greater improvement over time in recovery, self-esteem, coping mastery, autonomy support, somatic symptoms, employment, and education. No between-group differences were found in total per-person service costs in years 1 and 2 or both years combined. However, self-directed care participants were more likely than control group participants to have zero costs for six of 12 individual services and to have lower costs for four. The most frequent nontraditional purchases were for transportation (21%), communication (17%), medical care (15%), residential (14%), and health and wellness needs (11%). Client satisfaction with mental health services was significantly higher among intervention participants, compared with control participants, at both follow-ups. CONCLUSIONS: The budget-neutral self-directed care model achieved superior client outcomes and greater satisfaction with mental health care, compared with services as usual.

Prevalence, Comorbidity, and Correlates of Psychiatric and Substance Use Disorders and Associations with HIV Risk Behaviors in a Multisite Cohort of Women Living with HIV.

We used the World Health Organization's Composite International Diagnostic Interview to determine the prevalence, comorbidity, and correlates of lifetime and 12-month behavioral health disorders in a multisite cohort of 1027 women living with HIV in the United States. Most (82.6%) had one or more lifetime disorders including 34.2% with mood disorders, 61.6% with anxiety disorders, and 58.3% with substance use disorders. Over half (53.9%) had at least one 12-month disorder, including 22.1% with mood disorders, 45.4% with anxiety disorders, and 11.1% with substance use disorders. Behavioral health disorder onset preceded HIV diagnosis by an average of 19 years. In multivariable models, likelihood of disorders was associated with women's race/ethnicity, employment status, and income. Women with 12-month behavioral health disorders were significantly more likely than their counterparts to engage in subsequent sexual and substance use HIV risk behaviors. We discuss the complex physical and behavioral health needs of women living with HIV.