Poverty and birth cohort effects of experiencing the 2007-2009 Great Recession during adolescence on major depressive episodes and mental health treatment of young adults in the United States.

PURPOSE: Household economic adversity during adolescence is hypothesized to be a risk factor for poor mental health later in life. To test this hypothesis, we conducted a quasi-experimental analysis of an economic shock, the Great Recession of 2007-2009. We tested if going through adolescence during the Great Recession was associated with increased risk of major depressive episodes (MDE) and mental health treatment in young adulthood with potential moderation by household poverty to explore differences by economic adversity. METHODS: We analyzed data on young adults age 18-29 years from the 2005-2019 National Survey on Drug Use and Health (N = 145,394). We compared participants who were adolescents during the recession to those followed-up prior to the recession. Regression analysis tested effect modification by household poverty status. RESULTS: Adolescent exposure to the Great Recession was associated with higher likelihood of MDE during young adulthood (aOR = 1.30, 95% CI = 1.23, 1.37); there was no relationship with mental health treatment. Effects on MDE were stronger among those in households with higher incomes compared to those living in poverty. CONCLUSION: Findings support the hypothesis that exposure to the Great Recession during adolescence may have increased risk for MDE, but raise questions about whether the mechanism of this association is economic distress.

A longitudinal study of predictors of serious psychological distress during COVID-19 pandemic.

BACKGROUND: The prevalence of serious psychological distress (SPD) was elevated during the COVID-19 pandemic in the USA, but the relationships of SPD during the pandemic with pre-pandemic SPD, pre-pandemic socioeconomic status, and pandemic-related social stressors remain unexamined. METHODS: A probability-based sample (N = 1751) of the US population age 20 and over was followed prospectively from February 2019 (T1), with subsequent interviews in May 2020 (T2) and August 2020 (T3). Multinomial logistic regression was used to assess prospective relationships between T1 SPD with experiences of disruption of employment, health care, and childcare at T2. Binary logistic regression was then used to assess relationships of T1 SPD, and socioeconomic status and T2 pandemic-related stressors with T3 SPD. RESULTS: At T1, SPD was associated with age, race/ethnicity, and household income. SPD at T1 predicted disruption of employment (OR 4.5, 95% CI 1.4-3.8) and health care (OR 3.2, 95% CI 1.4-7.1) at T2. SPD at T1 (OR 10.2, 95% CI 4.5-23.3), low household income at T1 (OR 2.6, 95% CI 1.1-6.4), disruption of employment at T2 (OR 3.2, 95% CI 1.4-7.6), and disruption of healthcare at T2 (OR 3.3, 95% CI 1.5-7.2) were all significantly associated with elevated risk for SPD at T3. CONCLUSIONS: Elevated risk for SPD during the COVID-19 pandemic is related to multiple psychological and social pathways that are likely to interact over the life course. Policies and interventions that target individuals with pre-existing mental health conditions as well as those experiencing persistent unemployment should be high priorities in the mental health response to the pandemic.

An integrative literature review of birth cohort and time period trends in adolescent depression in the United States.

PURPOSE: The aim of this literature review is to examine evidence of time trends and birth cohort effects in depressive disorders and symptoms among US adolescents in peer-reviewed articles from January 2004 to April 2022. METHODS: We conducted an integrative systematic literature review. Three reviewers participated at different stages of article review. Of the 2234 articles identified in three databases (Pubmed, ProQuest Central, Ebscohost), 10 met inclusion criteria (i.e., adolescent aged United States populations, included information about birth cohort and survey year, focused on depressive symptoms/disorders). RESULTS: All 10 articles observed increases in depressive symptoms and disorders in adolescents across recent survey years with increases observed between 1991 and 2020. Of the 3 articles that assessed birth cohort trends, birth cohort trends were less prominent than time period trends. Proposed explanations for increases included social media, economic-related reasons, changes in mental health screening and diagnosis, declining mental health stigma, increased treatment, and, in more recent years, the COVID-19 pandemic. CONCLUSIONS: Multiple cross-sectional surveys and cohort studies documented rising prevalence of depressive symptoms and disorder among adolescents from 1991 to 2020. Mechanisms driving this increase are still unknown. Research to identify these mechanisms is needed to inform depression screening and intervention efforts for adolescents.

Heterogeneity in Unmet Treatment Need and Barriers to Accessing Mental Health Services Among U.S. Military Service Members with Serious Psychological Distress.

The goal of the current study is to examine heterogeneity in mental health treatment utilization, perceived unmet treatment need, and barriers to accessing care among U.S. military members with probable need for treatment. Using data from the 2018 Department of Defense Health Related Behavior Survey, we examined a subsample of 2,336 respondents with serious psychological distress (SPD; past-year K6 score ≥ 13) and defined four mutually exclusive groups based on past-year mental health treatment (treated, untreated) and self-perceived unmet treatment need (recognized, unrecognized). We used chi-square tests and adjusted regression models to compare groups on sociodemographic factors, impairment (K6 score; lost work days), and endorsement of treatment barriers. Approximately 43% of respondents with SPD reported past-year treatment and no unmet need (Needs Met). The remainder (57%) met criteria for unmet need: 18% endorsed treatment and recognized unmet need (Treated/Additional Need); 7% reported no treatment and recognized unmet need (Untreated/Recognized Need); and 32% reported no treatment and no unmet need (Untreated/Unrecognized Need). Compared to other groups, those with Untreated/Unrecognized Need tended to be younger (ages 18-24; p = 0.0002) and never married (p = 0.003). The Treated/Additional Need and Untreated/Recognized Need groups showed similar patterns of treatment barrier endorsement, whereas the Untreated/Unrecognized Need group endorsed nearly all barriers at lower rates. Different strategies may be needed to increase appropriate mental health service use among different subgroups of service members with unmet treatment need, particularly those who may not self-perceive need for treatment.

A Qualitative Investigation of Preparedness for the Launch of 988: Implications for the Continuum of Emergency Mental Health Care.

On July 16, 2022, the 988 mental health crisis hotline launched nationwide. In addition to preparing for an increase in call volume, many jurisdictions used the launch of 988 as an opportunity to examine their full continuum of emergency mental health care. Our goal was to understand the characteristics of jurisdictions' existing continuums of care, identify factors that distinguished jurisdictions that were more- versus less-prepared for 988, and explore perceived strengths and limitations of the planning process. We conducted 15 qualitative interviews with state and local mental health program directors representing 10 states based on their preparedness for the 988 rollout. Interviews focused on 988 call centers, mobile crisis response, and crisis stabilization, as well as strengths and limitations of the 988 planning process. Data were analyzed using rapid qualitative analysis, an approach designed to draw insights on evolving processes and extract actionable findings. Interviewees from jurisdictions that reported that they were more-prepared for the launch of 988 tended to have local 988 call centers and already had local access to mobile crisis teams and crisis stabilization units. Interviewees across jurisdictions described challenges to offering a robust continuum of crisis services, including workforce shortages and geographic constraints. Though jurisdictions acknowledged the importance of integrating peer support staff and serving diverse populations, many perceived room for growth in these areas. Though 988 has launched, efforts to bolster the existing continuum will continue and hinge on efforts to expand the behavioral health workforce, engage diverse partners, and collect relevant data.

A longitudinal study of psychological distress in the United States before and during the COVID-19 pandemic.

The COVID-19 pandemic has caused financial stress and disrupted daily life more quickly than any prior economic downturn and on a scale beyond any prior natural disaster. This study aimed to assess the impact of the pandemic on psychological distress and identify vulnerable groups using longitudinal data to account for pre-pandemic mental health status. Clinically significant psychological distress was assessed with the Kessler-6 in a national probability sample of adults in the United States at two time points, February 2019 (T1) and May 2020 (T2). To identify increases in distress, psychological distress during the worst month of the past year at T1 was compared with psychological distress over the past 30-days at T2. Survey adjusted logistic regression was used to estimate associations of demographic characteristics at T1 (gender, age, race, and income) and census region at T2 with within-person increases in psychological distress. The past-month prevalence of serious psychological distress at T2 was as high as the past-year prevalence at T1 (10.9% vs. 10.2%). Psychological distress was strongly associated across assessments (X2(4) = 174.6, p < .0001). Increase in psychological distress above T1 was associated with gender, age, household income, and census region. Equal numbers of people experienced serious psychological distress in 30-days during the pandemic as did over an entire year prior to the pandemic. Mental health services and research efforts should be targeted to those with a history of mental health conditions and groups identified as at high risk for increases in distress above pre-pandemic levels.

Empirically identified networks of healthcare providers for adults with mental illness.

BACKGROUND: Policies target networks of providers who treat people with mental illnesses, but little is known about the empirical structures of these networks and related variation in patient care. The goal of this paper is to describe networks of providers who treat adults with mental illness in a multi-payer database based medical claims data in a U.S. state. METHODS: Provider networks were identified and characterized using paid inpatient, outpatient and pharmacy claims related to care for people with a mental health diagnosis from an all-payer claims dataset that covers both public and private payers. RESULTS: Three nested levels of network structures were identified: an overall network, which included 21% of providers (N = 8256) and 97% of patients (N = 476,802), five communities and 24 sub-communities. Sub-communities were characterized by size, provider composition, continuity-of-care (CoC), and network structure measures including mean number of connections per provider (degree) and average number of connections who were connected to each other (transitivity). Sub-community size was positively associated with number of connections (r = .37) and the proportion of psychiatrists (r = .41) and uncorrelated with network transitivity (r = -.02) and continuity of care (r = .00). Network transitivity was not associated with CoC after adjustment for provider type, number of patients, and average connection CoC (p = .85). CONCLUSIONS: These exploratory analyses suggest that network analysis can provide information about the networks of providers that treat people with mental illness that is not captured in traditional measures and may be useful in designing, implementing, and studying interventions to improve systems of care. Though initial results are promising, additional empirical work is needed to develop network-based measures and tools for policymakers.

Providing Health Physicals and/or Health Monitoring Services in Mental Health Clinics: Impact on Laboratory Screening and Monitoring for High Risk Populations.

Providing physical health care in specialty mental health clinics is a promising approach to improving the health status of adults with serious mental illness, but most programs examined in prior studies are not financially sustainable. This study assessed the impact on quality of care of a low-cost program implemented in New York State that allowed mental health clinics to be reimbursed by Medicaid for provision of health monitoring and health physicals (HM/HP). Medicaid claims data were analyzed with generalized linear multilevel models to examine change over time in quality of physical health care associated with HM/HP services. Recipients of HM/HP services were compared to control clinic patients [Per protocol (PP)] and with non-recipients of HM/HP services from both intervention and control clinics [As-Treated (AT)]. HM/HP clinic patients, regardless of receipt of HM/HP services, were compared with control clinic patients [Intent-to-Treat (ITT)]. Analyses were conducted with adjustment for patient demographic and clinical characteristics and prior year service use. The PP and AT analyses found significant improvement in measure of blood glucose screening for patients on antipsychotic medication and HbA1C testing for patients with diabetes (AOR range 1.26-1.33) and the AT analysis found significant improvement in cholesterol screening for patients on antipsychotic medication (AOR 1.24). However, ITT analysis found no significant changes in quality of care in HM/HP clinic caseloads relative to control clinics. The low-cost HM/HP program has the potential to benefit patients who receive supported services, but its impact is limited by remaining barriers to service implementation.

Impact of the Affordable Care Act Medicaid Expansion on Utilization of Mental Health Care.

BACKGROUND: The Affordable Care Act's Medicaid expansions (ME) increased insurance coverage for low-income Americans, among whom unmet need for mental health care is high. Empirical evidence regarding the impact of expanding insurance coverage on use of mental health services among low income and minority populations is lacking. METHODS: Data on mental health service use collected between 2007 and 2015 by the Medical Expenditures Panel Survey from nationally representative cross-sectional samples of low income (income<138% of the federal poverty line) adults were analyzed. Use trends among people in states that expanded Medicaid (ME states; n=29,827) were compared with concurrent trends among people in states that did not (non-ME states; n=22,873), with statistical adjustment for demographic characteristics and psychological distress. RESULTS: Annual outpatient visits for mental health conditions increased by 0.513 (0.053-0.974) visits per person, from a baseline rate in ME states of 0.894 visits per person. However, no significant changes were observed in number of mental health related hospital stays, emergency department visits or prescription fills. The increase outpatient visits was limited to Hispanics and non-Hispanic Whites, with no increase in service use observed among non-Hispanic Blacks. There was no apparent increase in the number of users of outpatient mental health care (AOR=0.992, P=0.942) and a marginally significant (P=0.096) increase of 3.144 visits per user. DISCUSSION: ME had a limited but positive impact on use of mental health services by low income Americans, although it may also have increased racial/ethnic disparities.

Social Marketing of Mental Health Treatment: California's Mental Illness Stigma Reduction Campaign.

Objectives. To understand the processes involved in effective social marketing of mental health treatment. Methods. California adults experiencing symptoms of probable mental illness were surveyed in 2014 and 2016 during a major stigma reduction campaign (n = 1954). Cross-sectional associations of campaign exposure with stigma, treatment overall, and 2 stages of treatment seeking (perceiving a need for treatment and use conditional on perceiving a need) were examined in covariate-adjusted multivariable regression models. Results. Campaign exposure predicted treatment use overall (odds ratio [OR] = 1.82; 95% confidence interval [CI] = 1.17, 2.83). Exposure was associated with perceived need for services (OR = 1.64; 95% CI = 1.09, 2.47) but was not significantly associated with treatment use in models conditioned on perceiving a need (OR = 1.52; 95% CI = 0.78, 2.96). Exposure was associated with less stigma, but adjustment for stigma did not affect associations between exposure and either perceived need or treatment use. Conclusions. The California campaign appears to have increased service use by leading more individuals to interpret symptoms of distress as indicating a need for treatment. Social marketing has potential for addressing underuse of mental health services and may benefit from an increased focus on perceived need.

Associations between provider communication and personal recovery outcomes.

BACKGROUND: This study examined whether two types of provider communication considered important to quality of care (i.e., shows respect and explains understandably) are associated with mental health outcomes related to personal recovery (i.e., connectedness, hope, internalized stigma, life satisfaction, and empowerment). This study also tested whether these associations varied by the type of provider seen (i.e., mental health professional versus general medical doctor). METHODS: This sample included participants from the 2014 California Well-Being Survey, a representative survey of California residents with probable mental illness, who had recently obtained mental health services (N = 429). Multiple regression was used to test associations between provider communication and personal recovery outcomes and whether these associations were modified by provider type. RESULTS: Providers showing respect was associated with better outcomes across all five of the personal recovery domains, connectedness (ß = 1.12; p < .001), hope (ß = 0.72; p < .0001), empowerment (ß = 0.38; p < .05), life satisfaction (ß = 1.10; p < .001) and internalized stigma (ß = - 0.49; p < .05). Associations between provider showing respect and recovery outcomes were stronger among those who had seen a mental health professional only versus a general medical doctor only. CONCLUSIONS: Respectful communication may result in greater personal recovery from mental health problems. Respecting consumer perspectives is a hallmark feature of both recovery-oriented services and quality care, yet these fields have operated independently of one another. Greater integration between these two areas could significantly improve recovery-oriented mental health outcomes and quality of care.

Predictors of Receipt of Physical Health Services in Mental Health Clinics.

To inform efforts to improve physical health care for adults with serious mental illness, this study examines predictors of provision and receipt of physical health services in freestanding mental health clinics in New York state. The number of services provided over the initial 12-months of implementation varied across clinics from 0 to 1407. Receipt of services was associated with a diagnosis of schizophrenia, frequent mental and physical health visits in the prior year, and prescription of antipsychotic medications. Additional support may also be needed to enable clinics to target patients without established patterns of frequent mental health or medical visits.

Impacts of the Dependent Care Expansion on the Allocation of Mental Health Care.

We examine the impact of insurance expansion under the Affordable Care Act's Dependent Care Expansion (DCE) on allocation of mental health care across illness severity, types of care and racial/ethnic groups. Evidence suggests that the increase in mental health care utilization resulting from the DCE was restricted to individuals with clinically significant mental health conditions. There is no evidence suggesting that the increase occurred disproportionately in medication-only treatment or that it increased racial/ethnic disparities. The DCE appears to have been successful in increasing utilization of mental health care among a high need group without lowering quality or increasing disparities.

Differential Association of Stigma with Perceived Need and Mental Health Service Use.

This study examined the role of stigma at two stages of the treatment-seeking process by assessing associations between various types of stigma and perceived need for mental health treatment as well as actual treatment use. We analyzed cross-sectional data from the 2014 and 2016 California Well-Being Survey, a telephone survey with a representative sample of 1954 California residents with probable mental illness. Multivariable logistic regression indicated that perceived need was associated with less negative beliefs about mental illness (odds ratio [OR] = 0.72; 95% confidence interval [CI] = 0.54, 0.95) and greater intentions to conceal a mental illness (OR = 1.47; 95% CI = 1.12-1.92). Among respondents with perceived need, treatment use was associated with greater mental health knowledge/advocacy (OR = 1.63; 95% CI = 1.03-2.56) and less negative treatment attitudes (OR = 0.66; 95% CI = 0.43-1.00). Understanding which aspects of stigma are related to different stages of the help-seeking process is essential to guiding policy and program initiatives aimed at ensuring individuals with mental illness obtain needed mental health services.

Integrating Behavioral Health and Primary Care Services for People with Serious Mental Illness: A Qualitative Systems Analysis of Integration in New York.

People with co-occurring behavioral and physical conditions receive poorer care through traditional health care services. One solution has been to integrate behavioral and physical care services. This study assesses efforts to integrate behavioral health and primary care services in New York. Semi-structured interviews were conducted with 52 professionals in either group or individual settings. We aimed to identify factors which facilitate or hinder integration for people with serious mental illness and how these factors inter-relate. Content analysis identified structural, process, organizational ("internal") and contextual ("external") themes that were relevant to integration of care. Network analysis delineated the interactions between these. We show that effective integration does not advance along a single continuum from minimally to fully integrated care but along several, parallel pathways reliant upon consequential factors that aid or hinder one another.

Impact of a Mental Health Based Primary Care Program on Quality of Physical Health Care.

We examine the impact of mental health based primary care on physical health treatment among community mental health center patients in New York State using propensity score adjusted difference in difference models. Outcomes are quality indicators related to outpatient medical visits, diabetes HbA1c monitoring, and metabolic monitoring of antipsychotic treatment. Results suggest the program improved metabolic monitoring for patients on antipsychotics in one of two waves, but did not impact other quality indicators. Ceiling effects may have limited program impacts. More structured clinical programs to may be required to achieve improvements in quality of physical health care for this population.

Racial/ethnic differences in perception of need for mental health treatment in a US national sample.

PURPOSE: To resolve contradictory evidence regarding racial/ethnic differences in perceived need for mental health treatment in the USA using a large and diverse epidemiologic sample. METHODS: Samples from 6 years of a repeated cross-sectional survey of the US civilian non-institutionalized population were combined (N = 232,723). Perceived need was compared across three non-Hispanic groups (whites, blacks and Asian-Americans) and two Hispanic groups (English interviewees and Spanish interviewees). Logistic regression models were used to test for variation across groups in the relationship between severity of mental illness and perceived need for treatment. RESULTS: Adjusting statistically for demographic and socioeconomic characteristics and for severity of mental illness, perceived need was less common in all racial/ethnic minority groups compared to whites. The prevalence difference (relative to whites) was smallest among Hispanics interviewed in English, -5.8% (95% CI -6.5, -5.2%), and largest among Hispanics interviewed in Spanish, -11.2% (95% CI -12.4, -10.0%). Perceived need was significantly less common among all minority racial/ethnic groups at each level of severity. In particular, among those with serious mental illness, the largest prevalence differences (relative to whites) were among Asian-Americans, -23.3% (95% CI -34.9, -11.7%) and Hispanics interviewed in Spanish, 32.6% (95% CI -48.0, -17.2%). CONCLUSIONS: This study resolves the contradiction in empirical evidence regarding the existence of racial/ethnic differences in perception of need for mental health treatment; differences exist across the range of severity of mental illness and among those with no mental illness. These differences should be taken into account in an effort to reduce mental health-care disparities.

Substance Use and Cumulative Exposure to American Society: Findings From Both Sides of the US-Mexico Border Region.

OBJECTIVES: We investigated whether Mexican immigration to the United States exerts transnational effects on substance use in Mexico and the United States. METHODS: We performed a cross-sectional survey of 2336 Mexican Americans and 2460 Mexicans in 3 Texas border metropolitan areas and their sister cities in Mexico (the US-Mexico Study on Alcohol and Related Conditions, 2011-2013). We collected prevalence and risk factors for alcohol and drug use; Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, alcohol-use disorders; and 2 symptoms (hazardous use and quit or control) of drug use disorder across a continuum of migration experiences in the Mexican and Mexican American populations. RESULTS: Compared with Mexicans with no migrant experience, the adjusted odds ratios for this continuum of migration experiences ranged from 1.10 to 8.85 for 12-month drug use, 1.09 to 5.07 for 12-month alcohol use disorder, and 1.13 to 9.95 for 12-month drug-use disorder. Odds ratios increased with longer exposure to US society. These findings are consistent with those of 3 previous studies. CONCLUSIONS: People of Mexican origin have increased prevalence of substance use and disorders with cumulative exposure to US society.