Mental health interventions for individuals with serious mental illness in the criminal legal system: a systematic review.

BACKGROUND: Globally, individuals with mental illness get in contact with the law at a greater rate than the general population. The goal of this review was to identify and describe: (1) effectiveness of mental health interventions for individuals with serious mental illness (SMI) who have criminal legal involvement; (2) additional outcomes targeted by these interventions; (3) settings/contexts where interventions were delivered; and (4) barriers and facilitating factors for implementing these interventions. METHODS: A systematic review was conducted to summarize the mental health treatment literature for individuals with serious mental illness with criminal legal involvement (i.e., bipolar disorder, schizophrenia, major depressive disorder). Searches were conducted using PsychINFO, Embase, ProQuest, PubMed, and Web of Science. Articles were eligible if they were intervention studies among criminal legal involved populations with a mental health primary outcome and provided description of the intervention. RESULTS: A total of 13 eligible studies were identified. Tested interventions were categorized as cognitive/behavioral, community-based, interpersonal (IPT), psychoeducational, or court-based. Studies that used IPT-based interventions reported clinically significant improvements in mental health symptoms and were also feasible and acceptable. Other interventions demonstrated positive trends favoring the mental health outcomes but did not show statistically and clinically significant changes. All studies reported treatment outcomes, with only 8 studies reporting both treatment and implementation outcomes. CONCLUSION: Our findings highlight a need for more mental health research in this population. Studies with randomized design, larger sample size and studies that utilize non-clinicians are needed.

Correlates of Informant Discrepancies in Self-Harm Among Youth Involved in Child Protective Services.

Youth involved with child protective services (CPS) are at elevated risk for engaging in self-harm. Participation in interventions or treatments that may reduce youths' self-harm behaviors often depends on the accurate reporting of their self-injurious behaviors. However, informants often disagree on the presence or severity of self-harm engagement, making the identification of youth in need of treatment more challenging. The current study aims to characterize discrepancies between youth and caregiver reports of children's self-harm among a sample of youth with a history of CPS involvement, and to identify factors (e.g., demographics, youth and caregiver psychological impairments, aspects of the caregiving environment) associated with these discrepancies. Participants (N = 258) were drawn from a large, nationally representative sample of youth under the age of 18 (mean age = 13.8) and their caregivers who were investigated by CPS. Multinomial logistic regressions were used to examine correlates of discrepancies in caregiver and youth reports of youth self-harm. Results indicated that 10% of caregiver-child dyads agreed on children's engagement in self-harm. In 33% of cases, only the child reported self-harm and in 57% of cases, only the caregiver reported youth self-harm. Being a biological caregiver, child female sex, higher levels of internalizing symptoms; higher post-traumatic stress disorder (PTSD) symptoms; and greater caregiver alcohol use was associated with a lower likelihood of caregivers reporting self-harm only. Older child age; lower externalizing symptoms; higher PTSD symptoms, and greater levels of caregiver emotional security and structure were linked to lower odds of children reporting self-harm only. These results underscore important factors to consider when assessing self-harm among youth involved with CPS and have potential implications for practice guidelines in this population.

Peer Activate: A Feasibility Trial of a Peer-Delivered Intervention to Decrease Disparities in Substance Use, Depression, and Linkage to Substance Use Treatment.

Although effective evidence-based interventions (EBIs) exist, racial/ethnic minority individuals with lower income are less likely to have access to these interventions and may experience greater stigma in the health care system, resulting in disproportionate rates of morbidity and mortality. Peer recovery specialists (PRSs) may be uniquely suited to address barriers faced by those from impoverished areas; however, peers have not traditionally been trained in implementing EBIs. The current open-label trial (N = 8) was performed to evaluate implementation and preliminary effectiveness of an adapted EBI supporting recovery, linkage to treatment, and reduced depression. Results suggest the intervention was feasible, acceptable, and appropriate for linking individuals from a community setting to substance use treatment and could be delivered with fidelity by a peer interventionist. Participants who completed the intervention demonstrated clinically reliable decreases in substance use and depressive symptoms. Findings provide initial support for PRS dissemination of EBIs to increase linkage to care and support recovery in traditionally underserved populations. [Journal of Psychosocial Nursing and Mental Health Services, 61(11), 23-31.].

A pilot trial of behavioural activation with a contingency management component: Preliminary examination of changes in smoking and alternative rewards among low-income individuals.

The heaviest smoking and burden of tobacco-related illness occurs among low-income individuals. Using a behavioural economics framework, this non-randomised pilot study examined the preliminary efficacy of behavioural activation (BA) with a contingency management (CM) component designed to encourage continued use of BA skills and reductions in cigarettes smoked. Eighty-four participants were recruited from a community centre. Data were collected at the start of every other group and at four different follow-up time points. Domains assessed included number of cigarettes smoked, activity level, and environmental rewards (i.e. alternative environmental reinforcers). Over time, cigarette smoking decreased (p < .001), environmental reward increased (p = .03), and reward probability and activity level were associated over time with cigarette smoking (p ≤ .03) above and beyond the effect of nicotine dependence. The continued use of BA skills was associated with greater environmental rewards (p = .04). While further research is needed to replicate this work, results suggest initial evidence for the utility of this intervention in a traditionally underserved community.

Behavioral Activation Disseminated by Non-Mental Health Professionals, Paraprofessionals, and Peers: A Systematic Review.

There is a striking disparity between the number of individuals with significant mental health concerns and those who are able to access care globally. One promising solution to expanding the mental health taskforce is task-sharing, or employing nonspecialists in the delivery of evidence-based interventions. Behavioral activation (BA), a brief intervention that focuses on scheduling rewarding activities into one's daily life, may have promise for delivery using task-sharing approaches due to its straightforward, flexible nature. The aim of this systematic review was to examine the current state of the literature on non-specialist-delivered BA and evaluate the evidence base of this approach. Three databases (Pubmed, PsycInfo, and Cochrane) were searched, and all articles were screened for inclusion criteria by two research assistants, included the review of titles, abstracts, and full-text. The final dataset consisted of 13 research studies, represented through 15 articles. A meta-analysis was conducted to examine the overall pooled effects of peer-delivered BA on depressive symptoms (the most widely examined clinical outcome). Studies reported on effectiveness and implementation outcomes of non-specialist-delivered BA for depression, substance use, loneliness, trauma survivors, and individuals with comorbid physical health conditions. Results provide initial support for the effectiveness of BA utilizing a task-sharing approach, and highlight the feasibility and acceptability of using nonspecialists to deliver BA in a variety of contexts, including low-resource settings.

Psychosocial challenges affecting patient-defined medication for opioid use disorder treatment outcomes in a low-income, underserved population: Application of the social-ecological framework.

INTRODUCTION: Successful engagement with medication treatment for opioid use disorder is an important focus in reducing mortality associated with the opioid crisis. Mortality remains at unacceptably high levels, pointing to a need for improved understanding of factors that affect medication for opioid use disorder outcomes. This study aims to understand how barriers co-occur and interact to interfere with outcomes in methadone treatment for a low-income, underserved patient population with opioid use disorder. METHODS: This study was conducted at a community-based drug treatment center that serves a predominately low-income, racially diverse population. Guided by the social-ecological framework, we analyzed semi-structured interviews and focus groups with patients and providers working in opioid use disorder care and recovery across Baltimore City (N = 32) to assess factors that influence methadone treatment outcomes, and how barriers co-occur and interact to worsen treatment outcomes. The study used patient-centered definitions to describe successful treatment outcomes. RESULTS: Barriers described by both patients and providers fit into several broad levels: individual, interpersonal, institutional, community, and stigma. Participants described co-occurrence of many barriers. Further, the study identified potential interactive effects, such that interrelated barriers were seen as fueling one another and having a deleterious effect on treatment outcomes. Specifically, interrelationships between barriers were described for 1) unstable housing with social influences and mental health factors; 2) transportation with poor physical health and other competing responsibilities; 3) treatment program policies and schedule with competing responsibilities; and 4) stigma with poor physical and mental health. CONCLUSIONS: Understanding barriers to successful medication for opioid use disorder outcomes and considering their co-occurrence may help to identify and promote interventions to mitigate their impact. This work is intended to guide future research to adapt conceptual frameworks for understanding psychosocial and structural barriers affecting opioid use disorder treatment and ultimately intervention efforts to improve treatment outcomes.

A Pilot Study of Training Peer Recovery Specialists in Behavioral Activation in the United States: Preliminary Outcomes and Predictors of Competence.

BACKGROUND: The peer recovery specialist (PRS) workforce has rapidly expanded to increase access to substance-use disorder services for underserved communities. PRSs are not typically trained in evidence-based interventions (EBIs) outside of motivational interviewing, although evidence demonstrates the feasibility of PRS delivery of certain EBIs, such as a brief behavioral intervention, behavioral activation. However, characteristics that predict PRS competency in delivering EBIs such as behavioral activation remain unknown, and are critical for PRS selection, training, and supervision if the PRS role is expanded. This study aimed to explore the outcomes of a brief PRS training period in behavioral activation and identify predictors of competence. METHOD: Twenty PRSs in the United States completed a two-hour training on PRS-delivered behavioral activation. Participants completed baseline and post-training assessments, including roleplay and assessments of PRS characteristics, attitudes towards EBIs, and theoretically relevant personality constructs. Roleplays were coded for competence (behavioral activation specific and PRS skills more broadly, i.e., PRS competence) and changes were assessed from baseline to post-training. Linear regression models tested factors predicting post-training competence, controlling for baseline competence. RESULTS: There was a significant pre-post increase in behavioral activation competence (t = -7.02, p < 0.001). Years working as a PRS significantly predicted post-training behavioral activation skills (B = 0.16, p = 0.005). No variables predicted post-training PRS competence. CONCLUSIONS: This study provides preliminary evidence that behavioral activation may be appropriate for dissemination to PRSs through brief trainings, particularly for PRSs with more work experience. However, additional research is needed to examine predictors of competence among PRSs.

"Sometimes you have to take the person and show them how": adapting behavioral activation for peer recovery specialist-delivery to improve methadone treatment retention.

BACKGROUND: Despite efficacy of medication for opioid use disorder, low-income, ethno-racial minoritized populations often experience poor opioid use disorder treatment outcomes. Peer recovery specialists, individuals with lived experience of substance use and recovery, are well-positioned to engage hard-to-reach patients in treatment for opioid use disorder. Traditionally, peer recovery specialists have focused on bridging to care rather than delivering interventions. This study builds on research in other low-resource contexts that has explored peer delivery of evidence-based interventions, such as behavioral activation, to expand access to care. METHODS: We sought feedback on the feasibility and acceptability of a peer recovery specialist-delivered behavioral activation intervention supporting retention in methadone treatment by increasing positive reinforcement. We recruited patients and staff at a community-based methadone treatment center and peer recovery specialist working across Baltimore City, Maryland, USA. Semi-structured interviews and focus groups inquired about the feasibility and acceptability of behavioral activation, recommendations for adaptation, and acceptability of working with a peer alongside methadone treatment. RESULTS: Participants (N = 32) shared that peer recovery specialist-delivered behavioral activation could be feasible and acceptable with adaptations. They described common challenges associated with unstructured time, for which behavioral activation could be particularly relevant. Participants provided examples of how a peer-delivered intervention could fit well in the context of methadone treatment, emphasizing the importance of flexibility and specific peer qualities. CONCLUSIONS: Improving medication for opioid use disorder outcomes is a national priority that must be met with cost-effective, sustainable strategies to support individuals in treatment. Findings will guide adaptation of a peer recovery specialist-delivered behavioral activation intervention to improve methadone treatment retention for underserved, ethno-racial minoritized individuals living with opioid use disorder.

A Preliminary Experimental Study of Self-Objectification and Risky Sex Behavior Among a University Sample of Cisgender Women in the U.S.

Self-objectification is associated with a number of negative mental and behavioral outcomes. Though previous research has established associations between self-objectification and risky sex, no study to date has examined whether self-objectification affects propensity to engage in risky sex. The current research employed an experimental design to examine the effect of heightened self-objectification on a laboratory analog of risky sex (n = 181). We observed that when college-attending women experienced a heightened state of self-objectification, they were more likely to engage in sex without a condom and less likely to wait to use a condom with a highly desirable partner. Given the frequency of intended and unintended objectifying messages that young women face, this increase in willingness to engage in risky sex behavior represents a consequential health concern.

Peer Recovery Coaches Perceptions of Their Work and Their Implications for Training, Support and Personal Recovery.

The peer recovery workforce, including individuals in sustained recovery from substance use, has grown rapidly in the previous decades. Peer recovery coaches represent a scalable, resource-efficient, and acceptable approach to increasing service delivery, specifically among individuals receiving substance use services in low-resource communities. Despite the potential to improve access to care in traditionally underserved settings, there are a number of barriers to successfully integrating peer recovery coaches in existing recovery services. The current study presents results from two focus groups composed of peer recovery coaches. Findings suggest that peer recovery coaches report discordance between their perceived role and their daily responsibilities and experience both inter- and intrapersonal challenges that impact their own recovery processes. These results point to several promising policy and structural changes that may support and enhance this growing workforce.

Patient perceptions regarding alcohol use after bariatric surgery.

INTRODUCTION: Patients who have undergone bariatric surgery are at increased risk of an alcohol use disorder. Though patients understand this risk, the majority engage in post-surgical alcohol use. This suggests that education alone is not sufficient to reduce post-surgical drinking. To prevent development of post-surgical alcohol use disorders, we need better understanding of the reasons patients use alcohol following surgery. The purpose of this study was to identify factors associated with post-surgical alcohol use. METHOD: Patients (N = 20) who were 1-3 years post-bariatric surgery and were consuming alcohol at least twice monthly participated in a 60-min interview. Participants responded about their knowledge regarding risk of post-surgical alcohol use and reasons why patients may start drinking. Deductive and inductive coding were completed by two independent raters. RESULTS: Although nearly all participants were aware of the risks associated with post-surgical alcohol use, most believed that lifelong abstinence from alcohol was unrealistic. Common reasons identified for using alcohol after bariatric surgery included social gatherings, resuming pre-surgical use, and addiction transfer. Inductive coding identified three themes: participants consumed alcohol in different ways compared to prior to surgery; the effect of alcohol was substantially stronger than pre-surgery; and beliefs about why patients develop problematic alcohol use following surgery. CONCLUSION: Patients consume alcohol after bariatric surgery for a variety of reasons and they do not believe recommending abstinence is useful. Understanding patient perceptions can inform interventions to minimize alcohol use after bariatric surgery. Modifications to traditional alcohol relapse prevention strategies may provide a more robust solution to decreasing negative outcomes experienced by individuals undergoing bariatric surgery.

Cancer and psychiatric diagnoses in the year preceding suicide.

BACKGROUND: Patients with cancer are known to be at increased risk for suicide but little is known about the interaction between cancer and psychiatric diagnoses, another well-documented risk factor. METHODS: Electronic medical records from nine healthcare systems participating in the Mental Health Research Network were aggregated to form a retrospective case-control study, with ICD-9 codes used to identify diagnoses in the 1 year prior to death by suicide for cases (N = 3330) or matching index date for controls (N = 297,034). Conditional logistic regression was used to assess differences in cancer and psychiatric diagnoses between cases and controls, controlling for sex and age. RESULTS: Among patients without concurrent psychiatric diagnoses, cancer at disease sites with lower average 5-year survival rates were associated with significantly greater relative risk, while cancer disease sites with survival rates of >70% conferred no increased risk. Patients with most psychiatric diagnoses were at higher risk, however, there was no additional risk conferred to these patients by a concurrent cancer diagnosis. CONCLUSION: We found no evidence of a synergistic effect between cancer and psychiatric diagnoses. However, cancer patients with a concurrent psychiatric illness remain at the highest relative risk for suicide, regardless of cancer disease site, due to strong independent associations between psychiatric diagnoses and suicide. For patients without a concurrent psychiatric illness, cancer disease sites associated with worse prognoses appeared to confer greater suicide risk.

Specific Pathways from Parental Distress Reactions to Adolescent Depressive Symptoms: The Mediating Role of Youths' Reactions to Negative Life Events.

The current multimethod longitudinal study examines how parents' distress reactions to adolescents' negative emotions may shape youths' own perceptions of negative life events and subsequent increases in depressive symptomology. Ninety adolescents (41 girls, 49 boys, average age = 16.5 years old) and their parents were assessed over three timepoints. We found that greater parent-reported distress reactions to adolescents' emotions predicted subsequent increase in youths' own self-reported negative reactions to stressful experiences over a two-week period, which in turn predicted steeper increases in youth-reported depressive symptoms across this same two-week period. Moreover, youths' negative reactions mediated the relation between parent emotion socialization and increases in adolescent depressive symptoms. These findings support the use of interventions that simultaneously target parent and child distress to prevent the onset of adolescent depression.

Peer recovery specialist-delivered, behavioral activation intervention to improve retention in methadone treatment: Results from an open-label, Type 1 hybrid effectiveness-implementation pilot trial.

BACKGROUND: Despite the efficacy of methadone to treat opioid use disorder (OUD), retention is an urgent priority, particularly among low-income, minoritized populations. Peer recovery specialists are well-positioned to engage vulnerable patients, particularly when trained in an evidence-based intervention to promote retention. This hybrid effectiveness-implementation pilot trial aimed to demonstrate the proof of concept of a peer recovery specialist-delivered behavioral activation and problem solving-based approach (Peer Activate) to improve methadone retention. METHODS: Implementation outcomes included feasibility, acceptability, and fidelity. Feasibility and acceptability were defined by the percentage of participants who initiated the intervention (≥75%) and completed ≥75% of core sessions, respectively. Fidelity was assessed via independent rating of a randomly selected 20% of sessions. The primary effectiveness outcome was methadone retention at three-months post-intervention vs. a comparison cohort initiating methadone during the same time period. Secondary outcomes included methadone adherence, substance use frequency, and substance use-related problems. RESULTS: Benchmarks for feasibility and acceptability were surpassed: 86.5% (32/37) initiated the intervention, and 81.3% of participants who initiated attended ≥75% of core sessions. The mean independent rater fidelity score was 87.9%, indicating high peer fidelity. For effectiveness outcomes, 88.6% of participants in Peer Activate were retained in methadone treatment at three-months post-intervention-28.9% higher than individuals initiating methadone treatment alone in the same time period [χ2(1) = 10.10, p = 0.001]. Among Peer Activate participants, urine-verified methadone adherence reached 97% at post-intervention, and there was a significant reduction in substance use frequency from 48% of past two-week days used at baseline to 31.9% at post-intervention [t(25) = 1.82, p = .041]. Among participants who completed the core Peer Activate sessions (n = 26), there was a significant reduction in substance use-related problems [t(21) = 1.84, p = 0.040]. CONCLUSION: Given the rapid scale-up of peer recovery specialist programs nationwide and the urgent need to promote methadone retention, these results, although preliminary, have important potential clinical significance. The next steps are to conduct a Type 1 hybrid effectiveness-implementation randomized trial with a larger sample size and longer-term follow-up to further establish the implementation and effectiveness of the Peer Activate approach.

Belonging to Something Greater Than Self: Flint Women Giving Back to the Community.

BACKGROUND: Having meaning in life promotes happiness and well-being across the lifespan. METHODS: A community-based participatory qualitative study was conducted to understand meaning in life, having a voice and the different ways women give back to their community by serving others. Interviews were held with participants (n = 100) who were community residents, people serving women, or both. RESULTS: Participants defined meaning in life as having a sense of significance, a deep connection to their community, and a sense of acknowledgement for their overall contributions. They emphasized the importance of opportunities for women to contribute to something greater than themselves. Participants suggested organizations would be responsive to the needs of women when women have a stronger voice. CONCLUSIONS: Women served their community in many roles. However, despite some societal progress, women continue to be underpaid and their contributions undervalued. Rectifying these inequities might contribute to better addressing the needs of women.

A brief psychological intervention for chronic pain in primary care: Examining long-term effects from a pilot randomized clinical trial.

BACKGROUND: Despite the existence of evidence-based psychological interventions for pain management, there are barriers that interfere with treatment engagement. A brief intervention integrated into primary care reduced barriers and showed promising benefits from pre- to post-intervention. However, it is unknown whether a brief intervention can provide long-term effects. The purpose of this study was to examine whether a brief psychological intervention offered benefits in pain severity, pain interference, pain catastrophizing, and depressive symptoms at 1- and 6-month follow-ups. METHODS: The majority of participants who enrolled in a pilot randomized clinical trial of a 5-session psychological intervention for chronic pain in primary care completed the 1-month (n = 54; 90%) and 6-month follow-ups (n = 50; 83.3%). Participants completed measures of pain severity, pain interference, pain catastrophizing, and depressive symptoms. RESULTS: From baseline to the 6-month follow-up, those in the intervention group had significantly better outcomes for pain severity (p = 0.01) and pain catastrophizing (p = 0.003) compared with the control group. There were no significant differences between the intervention and control groups for pain interference and depression. The percentage of patients in the intervention experiencing clinically significant improvement across all outcomes was higher than the control group. CONCLUSIONS: Findings suggest that a brief psychological intervention for chronic pain in primary care may offer longer-term benefits similar to that of lengthier interventions. Future studies should examine this through a randomized clinical trial with a larger sample size.

The Role of Delay Discounting in the Generation of Stressful Life Events Across Adolescence.

Hammen's (1991) model of stress generation suggests that depressed individuals are more likely to behave in ways that bring about greater exposure to negative life events. More recent research suggests that adolescents with other types of psychological vulnerabilities, including those more likely to make impulsive choices, may also be predisposed to experience greater increases in stress over time. The current study examined whether delay discounting (DD), defined as the tendency to prefer smaller but immediately available rewards relative to larger, delayed rewards, predicts the generation of negative life events across adolescence and whether this is due to the association between DD and depressive symptoms. Participants (n = 213, Mage = 15, range 12-17) completed self-report measures of depressive symptoms and negative life events, as well as a behavioral measure assessing DD annually over four years. Results of latent growth models suggest that both independent and dependent negative life events increased across adolescence. Consistent with a stress generation framework, DD predicted the growth in dependent, but not independent, negative life events over this time period, controlling for baseline levels of depressive symptoms. Further exploratory analyses suggest that DD was associated with increases in depressive symptomology across adolescence, but that the relation between DD and changes in independent negative life events was not better accounted for by increases in depressive symptoms over time. Taken together, these findings suggest the importance of DD in predicting youths' exposure to dependent negative life events and point to potential avenues for clinical intervention.

Social vulnerability, COVID-19 impact, and decision making among adults in a low-resource community.

Socially vulnerable individuals, including those with greater exposure to adversity and social instability, are at greater risk for a variety of negative outcomes following exposure to public health crises. One hypothesized mechanism linking social vulnerability to poor health outcomes is delay discounting, the behavioral tendency to select smaller immediately available rewards relative to larger delayed rewards. However, little research has examined the impact of real-world disease outbreaks, such as the COVID-19 pandemic, on the relation between social vulnerability and delay discounting. This study examined whether the severity of COVID-19 impact moderated the association between social vulnerability and delay discounting in a diverse sample of 72 human adults (Mage = 42.4; 69% Black; 87% female) drawn from two low-resource urban areas. Contrary to hypotheses, results indicated that exposure to more severe COVID-19 impacts did not affect decision making among individuals with higher levels of social vulnerability. Conversely, findings suggest that individuals with lower levels of social vulnerability who reported more significant impacts of COVID-19 evidenced a greater tendency to select larger, delayed rewards relative to individuals with greater social vulnerability. Findings suggest the recent pandemic may influence the relation between social vulnerability and behavioral processes underlying health decision-making.