The Road to 988/911 Interoperability: Three Case Studies on Call Transfer, Colocation, and Community Response.

The 988 Suicide and Crisis Lifeline-known more simply as 988-holds promise for significantly improving the mental health of Americans and accelerating the decriminalization of mental illness. However, the rapid transition to 988 has left many gaps as communities scramble to prepare-not the least of which includes determining how 988 will interface with local 911 response systems and law enforcement. 911 is often the default option for individuals experiencing mental health emergencies, despite the fact that 911 call centers have limited resources to address behavioral health crises. Since 988 launched in 2022, one key area of focus has been ways that jurisdictions approach 988/911 interoperability: the existence of formal protocols, procedures, or agreements that allow for the transfer of calls from 988 to 911 and vice versa. This study presents case studies from three jurisdictions that have established models of 988/911 interoperability. It provides details related to interoperability in each model, including the role of each agency, points of interagency communication, and decision points that can affect the way a call flows through the local system. It also identifies facilitators, barriers, and equity-related considerations of each jurisdiction's approach, as well as lessons learned from implementation. This study should be of interest to jurisdictions that are looking to implement 988/911 interoperability, including those that are spearheading local initiatives and those that are responding to state-level legislation. Its findings are relevant to 988 call centers, public safety answering points, mobile crisis units, law enforcement, and local and state decisionmakers.

Do stigma and efficacy mediate the association between training and suicide prevention behavior among Army noncommissioned officers?

INTRODUCTION: Rates of suicide in the Active Component of the military have significantly increased since 2010, with particularly high rates among Army service members. One element of the Army's approach to suicide prevention relies on noncommissioned officers (NCOs) as gatekeepers who have regular contact with soldiers. NCOs receive suicide prevention training, but there is limited evidence that such training leads to behavior change. METHODS: We surveyed 2468 Army NCOs participating in leadership development courses to determine (a) if training on suicide prevention and soft skills (e.g., active listening) was associated with gatekeeper behavior and use of soft skills; and (b) whether that association was explained by two potential barriers, stigma and perceptions of efficacy. RESULTS: Both the number of suicide prevention training topics and soft skills trained were associated with increased gatekeeper behavior; these relationships were explained in part by lower stigma and higher efficacy for use of soft skills. The use of interactive training methods and receiving coaching after training were not associated with stigma or efficacy, though both methods were associated with more frequent use of soft skills. CONCLUSION: Results suggest that the content and format of training is important to preparing NCOs to fulfill a gatekeeper role.

The application of implementation science methods in correctional health intervention research: a systematic review.

BACKGROUND: Improving access to high-quality healthcare for individuals in correctional settings is critical to advancing health equity in the United States. Compared to the general population, criminal-legal involved individuals experience higher rates of chronic health conditions and poorer health outcomes. Implementation science frameworks and strategies offer useful tools to integrate health interventions into criminal-legal settings and to improve care. A review of implementation science in criminal-legal settings to date is necessary to advance future applications. This systematic review summarizes research that has harnessed implementation science to promote the uptake of effective health interventions in adult criminal-legal settings. METHODS: A systematic review of seven databases (Academic Search Premier, Cumulative Index to Nursing and Allied Health Literature, PsycINFO, Social Work Abstracts, ProQuest Criminal Justice Database, ProQuest Sociological Abstracts, MEDLINE/PubMed) was conducted. Eligible studies used an implementation science framework to assess implementation outcomes, determinants, and/or implementation strategies in adult criminal-legal settings. Qualitative synthesis was used to extract and summarize settings, study designs, sample characteristics, methods, and application of implementation science methods. Implementation strategies were further analyzed using the Pragmatic Implementation Reporting Tool. RESULTS: Twenty-four studies met inclusion criteria. Studies implemented interventions to address infectious diseases (n=9), substance use (n=6), mental health (n=5), co-occurring substance use and mental health (n=2), or other health conditions (n=2). Studies varied in their operationalization and description of guiding implementation frameworks/taxonomies. Sixteen studies reported implementation determinants and 12 studies measured implementation outcomes, with acceptability (n=5), feasibility (n=3), and reach (n=2) commonly assessed. Six studies tested implementation strategies. Systematic review results were used to generate recommendations for improving implementation success in criminal-legal contexts. CONCLUSIONS: The focus on implementation determinants in correctional health studies reflects the need to tailor implementation efforts to complex organizational and inter-agency contexts. Future studies should investigate policy factors that influence implementation success, design, and test implementation strategies tailored to determinants, and investigate a wider array of implementation outcomes relevant to criminal-legal settings, health interventions relevant to adult and juvenile populations, and health equity outcomes. TRIAL REGISTRATION: A study protocol (CRD42020114111) was registered with Prospero.

Implementation and Outcome Evaluation of LA DOOR: A Proposition 47-Funded Program in Los Angeles: Cohort 2 Final Evaluation Report.

The Los Angeles Diversion, Outreach, and Opportunities for Recovery (LA DOOR) program is a Proposition 47-funded program designed by the Los Angeles City Attorney's Office (LACA) to provide a comprehensive, health-focused, preventative approach that proactively engages individuals at elevated risk of returning to LACA on a new misdemeanor offense related to substance use, mental illness, or homelessness. This study documents the findings of a process and outcome evaluation of Cohort 2 of the LA DOOR program, covering services provided from January 2020 through February 2023. The goal of this evaluation is to better understand how the LA DOOR program was implemented and examine the effect of the program on various outcomes. This study describes an overview of the program, evaluation methods, the logic model that guided the evaluation, findings from stakeholder interviews and client focus groups, and analyses of program data. Qualitative interviews and focus groups revealed key strengths and challenges of the program and focused on specific challenges of operating during the coronavirus disease 2019 (COVID-19) pandemic. Analyses of quantitative data describe the population of clients who are receiving LA DOOR services, the needs of that population, and the services provided. Together, these findings shed light on opportunities for future program implementation and evaluation. Interested stakeholders of this report include LACA, the California Board of State and Community Corrections, and the City of Los Angeles, as well as other entities that provide supportive services to criminal justice populations or that might be interested in implementing a similar program.

Pathways for VA and community stakeholder management of military veterans with sexual offenses: Sexual and nonsexual recidivism rates and risk factors in military veterans released from California sexually violent predator (SVP) commitment.

Military veterans with sexual offenses committed after discharge are often eligible for Veterans Affairs (VA) services including health care. There are few, if any, studies of sexual recidivism among military veterans with sexual offense histories to guide clinical management. This study examined diagnostic and postrelease sexual and nonsexual recidivism among military sexual offenders released from California sexually violent predator (SVP) commitment. The sample consisted of 363 males; 131 were identified as military veterans and 232 as civilians. The rates of recidivism were assessed for two follow-up periods: a fixed 5-year and a total 21-year follow-up. Recidivism was operationalized as any new sexual, violent, or general criminal arrest or conviction occurring after discharge to the community in California. We found a low risk for sexual reoffense for both groups. Specific to veterans, the rates for sexual and nonsexual violent recidivism were under 7% for both follow-up periods. Diagnostically, veterans had a significantly higher rate of pedophilic disorder and lower rate of antisocial personality disorder than civilians; neither were predictive of sexual recidivism or any other recidivism. On average, veterans were 61 years old at discharge; and older age at discharge was associated with a significantly lower likelihood of recidivism of any type. A relatively high proportion of veterans had a history of childhood sexual abuse and head trauma. Trauma-informed care may be a particularly valuable treatment approach for veterans with sexual offenses. These data may aid the VA and other providers in forming evidence-based decisions regarding the management of veterans with sexual offenses. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Upstream suicide prevention in the U.S. Army: Noncommissioned officers' perspectives.

The goal of this study was to examine the factors associated with Army noncommissioned officer (NCO) experiences, attitudes, and behaviors in their role of identifying potential suicide risk factors in their fellow soldiers. To better understand the perspectives of NCOs, an anonymous survey was administered to 2,468 Army NCOs. Descriptive statistics and linear regressions were conducted to compare subgroups of NCOs. Most (71%) Army NCOs have received many (11 or more) hours of suicide prevention training, but training in soft skills that may be important for the gatekeeper role was less consistently reported. Active Component soldiers reported greater confidence in their intervention skills (Cohen's d = 0.25) and fewer logistical barriers (e.g., time and space to talk) to intervening with at-risk soldiers (Cohen's d = 0.80) compared to Reserve and National Guard soldiers. Formal coursework in mental health areas like psychology or chaplaincy was associated with a greater level of confidence in intervention skills (Cohen's d = 0.23) and in more frequent intervention behavior (Cohen's d = 0.13). Army NCO trainings should be modified to better equip soldiers with the soft skills (e.g., active listening skills and verbally and nonverbally conveying nonjudgment/acceptance and empathy) needed to have effective conversations with soldiers about suicide risk factors and other sensitive topics. Strategies used within mental health education, which appears to be a strength for NCO gatekeepers, could be used to achieve this goal. Reserve and Guard NCOs may need additional supports and tailored trainings to better fit their operational context. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

National preparedness for 988-the new mental health emergency hotline in the United States.

988, a national mental health emergency hotline number, went live throughout the United States in July 2022. 988 connects callers to the 988 Crisis & Suicide Lifeline, previously known as the National Suicide Prevention Lifeline. The transition to the three-digit number aimed to respond to a growing national mental health crisis and to expand access to crisis care. We examined preparedness throughout the U.S. for the transition to 988. In February and March 2022, we administered a national survey of state, regional, and county behavioral health program directors. Respondents (n = 180) represented jurisdictional coverage of 120 million Americans. We found that communities throughout the U.S. appeared ill-prepared for rollout of 988. Fewer than half of respondents reported their jurisdictions were 'somewhat' or 'very' prepared for 988 in terms of financing (29%), staffing (41%), infrastructure (41%), or service coordination (47%). Counties with higher representation of Hispanic/Latinx individuals were less likely to report being prepared for 988 in terms of staffing (OR: 0.62, 95 %CI: 0.45, 0.86) and infrastructure (OR: 0.68, 95 %CI: 0.48, 0.98). In terms of existing services, sixty percent of respondents reported a shortage of crisis beds and fewer than half reported availability of short-term crisis stabilization programs in their jurisdictions. Our study highlights components of local, regional, and state behavioral health systems in the U.S. that require greater investments to support 988 and mental health crisis care.

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.

US Military Healthcare Professionals' Practice, Knowledge, and Misconceptions About Concussion.

OBJECTIVE: To determine the US military healthcare professionals' knowledge and training preferences to improve diagnosis and management of concussion sustained in nondeployed settings. PARTICIPANTS: US military healthcare professionals (physicians, physician assistants, and nurse practitioners) completed online surveys to investigate practices, knowledge, and attitudes about concussion diagnosis and treatment, as well as preferences on future training. There were 744 responses from active duty US military healthcare providers, all of whom had cared for at least one patient with mild traumatic brain injury (mTBI) in the previous 24 months. RESULTS: The majority of physicians reported they were confident in their ability to evaluate a patient for a new mTBI (82.1%) and order appropriate imaging for mTBI (78.3%). Accuracy of identifying "red flag" symptoms ranged between 28.2% and 92.6%. A Likert scale from 1 ("not at all confident") to 4 ("very confident") was used to assess providers' confidence in their ability to perform services for patients with mTBI. With respect to barriers to optimal patient care, nurse practitioners consistently reported highest levels of barriers (90.8%). CONCLUSIONS: Although US military providers regularly care for patients with concussion, many report experiencing barriers to providing care, low confidence in basic skills, and inadequate training to diagnose and manage these patients. Customized provider education based on branch of service and occupation, and broader dissemination and utilization of decision support tools or practice guidelines, and patient information tool kits could help improve concussion care.

Reset for systematic action: Removing VA barriers to housing and treatment for military veterans with sexual offenses.

Though the U.S. Department of Veterans Affairs (VA) provides housing, residential treatment, and mental health care to justice involved veterans, those with sexual offenses face daunting obstacles to securing such services, including exclusion from housing programs, and lack of mental health services to treat sexual deviancy disorders. The VA's strategy to date may reflect a large system's caution in systematically addressing a problem that involves a population with an even higher degree of stigma than homelessness. Failure to develop strategies to address this problem reflects the need for a VA system-wide, consistent, and effective approach across relevant domains that incorporate the current state of knowledge and practice. Since 2006, the VA's program serving justice system veterans has been highly effective in serving the reentry veteran population. The challenge of serving veterans with sex offenses can and must be met with a similar level of effectiveness. In this commentary, we propose that the VA, beginning with the Secretary, adopt a "reset" policy and programmatic action agenda to enhance access to housing and treatment for sexual deviancy disorders. We offer specific pathways for implementation. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Longitudinal associations between sleep and BMI in a low-income, predominantly Black American sample.

OBJECTIVE: Black individuals and those experiencing socioeconomic disadvantage are at increased risk for sleep problems and obesity. This study adds to the limited extant literature examining longitudinal associations between objectively measured sleep and changes in body mass index (BMI) in Black Americans. DESIGN: We focused on individuals with at least 1 observation of sleep and BMI at 1 of 3 study time points (2013, 2016, and 2018). We modeled longitudinal trends in BMI as a function of time, average of each sleep variable across assessments, and within-person deviations in each sleep variable over time. SETTING: Data were collected via interviewer-administered at-home surveys and actigraphy in Pittsburgh, PA. PARTICIPANTS: Our sample comprised 1115 low-income, primarily Black adults, including 862 women and 253 men. MEASUREMENTS: Sleep measures included actigraphy-measured total sleep time, sleep efficiency, and wakefulness after sleep onset, as well as self-reported sleep quality. We also included objectively measured BMI. RESULTS: In models adjusted for age, gender, and other sociodemographic covariates (eg, income, marital status), there were no significant longitudinal associations between total sleep time, sleep efficiency, wakefulness after sleep onset, or subjective sleep quality and changes in BMI. CONCLUSIONS: This study provides further evidence that, among a sample of low-income Black adults, sleep problems are not longitudinally predictive of BMI. Although ample cross-sectional evidence demonstrates that sleep problems and obesity commonly co-occur, longitudinal evidence is mixed. Better understanding the overlap of sleep and obesity over time may contribute to prevention and intervention efforts.

Mental Health Emergency Hotlines in the United States: A Scoping Review (2012-2021).

OBJECTIVE: Mental health emergency hotlines provide clinical supports and connection to services. This scoping review describes the current literature on hotlines in the United States, including which populations they do and do not reach, typical call volumes and engagement levels, barriers to and facilitators of implementation, and common call outcomes. The review also identifies gaps in the literature and presents recommendations. METHODS: A systematic search of peer-reviewed articles on U.S.-based telephone, text, and chat hotlines published between January 2012 and December 2021 retrieved 1,049 articles. In total, 96 articles met criteria for full-text review, of which 53 met full inclusion criteria. RESULTS: Approximately half of the included studies (N=25) focused on descriptive information of callers, most of whom were females, younger adults, and White; veteran hotlines typically reached older men. Common reasons for calling were suicidality, depression, and interpersonal problems. Of studies examining intervention effects (N=20), few assessed hotlines as interventions (N=6), and few evaluated caller behavioral outcomes (N=4), reporting reduced distress and suicidality among callers after hotline engagement. However, these studies also suggested areas for improvement, including reaching underrepresented high-risk populations. Six studies reported implementation needs, such as investments in data collection and evaluation, staff training, and sustainable funding. CONCLUSIONS: Hotlines appear to be more effective at reaching some populations than others, indicating that more intensive outreach efforts may be necessary to engage underrepresented high-risk populations. The findings also indicated limited evidence on the relationship between use of hotlines-particularly local text and chat hotlines-and caller outcomes, highlighting an area for further investigation.

Optimizing the Role of Military Behavioral Health Technicians: A Survey of Behavioral Health Technicians and Mental Health Providers.

Behavioral health technicians (BHTs), who are enlisted service members with the technical training to work alongside licensed mental health providers (MHPs), are an important part of the Military Health System (MHS) workforce. However, each service branch has different training requirements for BHTs, making it difficult to identify common qualifications across the BHT workforce and ensure that the MHS is making the best use of their skills. Building on prior RAND research that found inconsistencies in how BHTs were integrated across the force, researchers conducted what might be the largest survey to date of BHTs and MHPs. The results provide insights on BHTs' practice patterns, training and supervisory needs, and job satisfaction, as well as barriers to better integrating BHTs into clinical practice and steps that the MHS could take to optimize BHTs' contributions to the health and readiness of the force. Posing parallel sets of questions to BHTs and MHPs allowed comparisons of these groups' perspectives on these topics. The results revealed differences in views by service branch, time in practice, deployment history, and other characteristics. The researchers drew on these findings and recommendations to identify opportunities to optimize the BHT role.

Final Evaluation of LA DOOR: Proposition 47 Grant Program.

The Los Angeles Diversion, Outreach, and Opportunities for Recovery program (LA DOOR) was designed by the Los Angeles City Attorney's Office (LACA) to provide a comprehensive, health-focused, preventative approach that proactively engages individuals at elevated risk of returning to LACA on a new misdemeanor offense related to substance use, mental illness, or homelessness. LA DOOR was funded through the grant program of Proposition 47. Programs funded through Proposition 47 are intended to serve individuals with a history of criminal justice involvement and mental health issues or substance use disorders and to offer mental health services, substance use disorder treatment, and diversion programs for justice-involved individuals. Grant-funded projects such as LA DOOR are required to be evaluated to understand how they are being implemented and whether they are achieving their intended outcomes. The formal evaluation of the program is being conducted by the RAND Corporation and its subcontractor, KH Consulting Group. This final evaluation summarizes the authors' findings from a process and outcome evaluation of Cohort 1 of LA DOOR, which provided services from July 2018 to March 2021. Interested stakeholders of this research include LACA, the California Board of State and Community Corrections, the City of Los Angeles, and other jurisdictions that provide supportive services to criminal justice populations or might be interested in implementing a similar program.

Factors associated with repeat sexual offending among U.S. military veterans compared to civilians.

Although veterans have lower incarceration rates than civilians, large national surveys find higher rates of incarceration for sexual offenses among veterans compared to non-veterans. However, little is known about the factors associated with repeat sexual offending among veterans. This study examines characteristics of veterans who committed sexual offenses and how they differ from civilians with those offenses. It also examined if the factors that differ between veterans and civilians who have a history of repeat sexual offenses and those who do not. Based on previous research related to risk in veterans, we expected there may be veteran-specific risk factors. This study used the Survey of Inmates in State and Federal Correctional Facilities. Predictors were identified through a review of the literature regarding sexual offense risk assessment and justice-involved veterans. Risk factors were examined using logistic regression analysis. In a multivariate logistic regression, there were significant interactions between veteran status and age, race, and education in the prediction of repeat offense status. Prior incarceration for a non-sexual offense was also associated with repeat offense status. Findings suggests that civilian risk factors are relevant to veteran risk assessment, an important finding that can help inform intervention and risk management with veterans.

Estimating the Size of the Los Angeles County Jail Mental Health Population Appropriate for Release into Community Services.

In 2015, the Office of Diversion and Reentry Division (ODR), an internal department of the Los Angeles County Department of Health Services, was created to redirect individuals with serious mental illness from the criminal justice system. Part of ODR's mission is to identify individuals currently incarcerated in a Los Angeles County jail who are experiencing a serious mental health disorder and, to the extent practical, provide them with appropriate community-based care with the goals of reducing recidivism and improving health outcomes. Such redirection from the traditional criminal justice process is often characterized as diversion. To better build and scale efforts to support this work, in 2018, the Los Angeles County's Board of Supervisors asked for a study of the existing county jail mental health population to identify those who would likely be eligible for diversion based on legal and clinical factors. Researchers found that an estimated 61 percent of the jail mental health population were likely appropriate candidates for diversion; 7 percent were potentially appropriate; and 32 percent were likely not appropriate candidates for diversion. These findings will help the county determine how it would need to scale community-based treatment programs to accommodate these individuals. The authors also provide recommendations for future programming and research. This study will be of interest to state and county governments as well as other organizations serving criminal justice-involved populations with serious mental illness.

Mixed Effects of Neighborhood Revitalization on Residents' Cardiometabolic Health.

INTRODUCTION: Despite the growing recognition of the importance of neighborhood conditions for cardiometabolic health, causal relationships have been difficult to establish owing to a reliance on cross-sectional designs and selection bias. This is the first natural experiment to examine the impact of neighborhood revitalization on cardiometabolic outcomes in residents from 2 predominantly African American neighborhoods, one of which has experienced significant revitalization (intervention), whereas the other has not (comparison). METHODS: The sample included 532 adults (95% African American, 80% female, mean age=58.9 years) from 2 sociodemographically similar, low-income neighborhoods in Pittsburgh, PA, with preintervention and postintervention measures (2016 and 2018) of BMI, diastolic and systolic blood pressure, HbA1c, and high-density lipoprotein cholesterol and covariates. Data were collected in 2016 and 2018 and analyzed in 2020. RESULTS: Difference-in-difference analyses showed significant improvement in high-density lipoprotein cholesterol in intervention residents relative to that in the comparison neighborhood (ß=3.88, 95% CI=0.47, 7.29). There was also a significant difference-in-difference estimate in diastolic blood pressure (ß=3.00, 95% CI=0.57, 5.43), with residents of the intervention neighborhood showing a greater increase in diastolic blood pressure than those in the comparison neighborhood. No statistically significant differences were found for other outcomes. CONCLUSIONS: Investing in disadvantaged neighborhoods has been suggested as a strategy to reduce health disparities. Using a natural experiment, findings suggest that improving neighborhood conditions may have a mixed impact on certain aspects of cardiometabolic health. Findings underscore the importance of examining the upstream causes of health disparities using rigorous designs and longer follow-up periods that provide more powerful tests of causality.

Examining the diagnostic validity of the Berlin Questionnaire in a low-income Black American sample.

STUDY OBJECTIVES: Black individuals and individuals of low socioeconomic status are at increased risk for obstructive sleep apnea (OSA). The Berlin Questionnaire is one of the most widely used screening tools for OSA; however, there is limited research on its diagnostic accuracy in low-income Black populations. METHODS: This study analyzed data from an ongoing study taking place among a cohort from 2 predominantly Black neighborhoods in Pittsburgh, Pennsylvania (96.3% Black, 79.6% female). The sample included 269 individuals without a prior diagnosis of OSA who completed the Berlin Questionnaire and also participated in a home sleep apnea test. An apnea-hypopnea index ≥ 15 events/h was used to identify individuals with moderate or severe OSA. RESULTS: 19.3% of individuals met criteria for moderate to severe OSA based on home sleep apnea test, while 31.2% of participants screened as high risk for OSA based on the overall Berlin index. Using apnea-hypopnea index ≥ 15 events/h as the reference standard, the Berlin Questionnaire had a sensitivity of 46.2%, specificity of 72.4%, positive predictive value of 28.6%, and negative predictive value of 84.9% among this sample. Analyses stratified by sex suggested that the Berlin Questionnaire had better diagnostic validity in women than men. CONCLUSIONS: The Berlin Questionnaire has lower sensitivity and positive predictive value in our sample than those observed in general population samples. The measure performed better among women, though a higher proportion of men fell into the moderate or severe OSA range based on the home sleep apnea test. Given the significant downstream consequences of OSA, utilizing screening tools that better detect OSA in Black communities is key. CITATION: Holliday SB, Haas A, Dong L, et al. Examining the diagnostic validity of the Berlin Questionnaire in a low-income Black American sample. J Clin Sleep Med. 2021;17(10):1987-1994.

Does investing in low-income urban neighborhoods improve sleep?

STUDY OBJECTIVES: Neighborhood disadvantage is associated with poor sleep, which may contribute to and exacerbate racial and socioeconomic health disparities. Most prior work has been cross-sectional and thus it has not been possible to estimate causal effects. METHODS: We leveraged a natural experiment opportunity in two low-income, predominantly African American Pittsburgh, PA neighborhoods, following a randomly selected cohort of households (n = 676) between 2013 and 2016. One of the neighborhoods received substantial public and private investments (housing, commercial) over the study period, while the other socio-demographically similar neighborhood received far fewer investments. Primary analyses used a difference-in-difference analysis based on neighborhood, to examine changes in actigraphy-assessed sleep duration, efficiency, and wakefulness after sleep onset (WASO), and self-reported sleep quality. Secondary analyses examined whether residents' proximity to investments, regardless of neighborhood, was associated with changes in sleep outcomes. RESULTS: Resident sleep worsened over time in both neighborhoods with no significant differences among residents between the two neighborhoods. Secondary analyses, including covariate adjustment and propensity score weighting to improve comparability, indicated that regardless of neighborhood, those who lived in closer proximity to investments (<0.1 mile) were significantly less likely to experience decreases in sleep duration, efficiency, and quality, or increases in WASO, compared to those who lived farther away. CONCLUSIONS: While we did not observe sleep differences among residents between neighborhoods, living closer to a neighborhood investment was associated with better sleep outcomes. Findings have relevance for public health and policy efforts focused on investing in historically disinvested neighborhoods.

Discussing measurement-based care with patients: An analysis of clinician-patient dyads.

Abstract Measurement-based care (MBC) refers to the use of three integrated strategies to improve effectiveness of behavioral health care: routine outcomes monitoring using symptom measures; regularly sharing these data with patients; and using these data to inform treatment decisions. This study examined how clinicians discuss MBC data with patients, including identifying what aspects of these discussions contribute to clinician-patient agreement on the value of MBC, and how clinicians use MBC data to inform treatment decisions. Twenty-six clinician-patient dyads participated in semi-structured interviews and provided a treatment session recording in which MBC data were discussed. Qualitative data analyses revealed four subtypes of dyads: clinician and patient both valued MBC; clinician valued MBC, patient passively participated in MBC; clinician valued MBC, patient had mixed perceptions of MBC; clinician and patient reported moderate or low value for MBC. In dyads for whom both the clinician and patient valued MBC, the clinician provided clear and repeated rationale for MBC, discussed data with patients at every administration, and connected observed scores to patient skills or strategies. Emerging best practices for discussing MBC include providing a strong rationale, discussing results frequently, actively engaging patients in discussions, and using graphs to visualize progress.