Cannabis legalization and hospitalizations in Alberta: Interrupted time series analysis by age and sex.

OBJECTIVES: Recent research has focused on the effects of legalization on cannabis-related emergency department visits, but the considerable healthcare costs of cannabis-related hospitalizations merit attention. We will examine the association between recreational cannabis legalization and cannabis-related hospitalizations. METHODS: A cohort of 3,493,864 adults from Alberta was examined (October 2015-May 2021) over three periods: pre-legalization, post-legalization of flowers and herbs (phase one), and post-legalization of edibles, extracts, and topicals (phase two). Interrupted time series analyses were used to detect changes. RESULTS: The study found an increase in hospitalization rates among younger adults (18-24) before legalization, yet no increased risk was associated with cannabis legalization, for either younger (18-24) or older adults (25+). CONCLUSIONS: Clinicians should be aware of the increased risk in younger groups and may benefit from early identification and intervention strategies, including screening and brief interventions in primary care settings.

Current and ideal living arrangements and supports for Canadian adults with fetal alcohol spectrum disorder (FASD)-Part I: Perspectives from adults with FASD.

BACKGROUND: Adults with fetal alcohol spectrum disorder (FASD) can thrive with lifelong support in daily living activities. Previous research examining living support for adults with FASD has heavily relied on caregiver reports rather than lived experiences, which can undermine opportunities for self-determination. In this study, we examined the perspectives of adults with FASD to better understand: (1) the ways in which they are supported with daily life activities; and (2) their ideal future living arrangements and supports. METHODS: This article presents findings from the perspective of adults with FASD as part of a broader project involving both adults with FASD and the caregivers who support them. Interviews were conducted with four Canadian adults with FASD who live in housing with supportive services and seven adults with FASD who live at home with the support of caregivers. Framework analyses, a structured approach to analyzing qualitative data, were used to examine participants' perspectives. RESULTS: In addition to providing support for previous findings, participants provided novel information regarding: (1) their daily living supports; (2) positive and negative aspects of their arrangements; and (3) ideal living environments and supports. CONCLUSIONS: This study offers insight into participants' perspectives regarding their living support, which is critical to inform housing and aid in self-determination. Areas of support outlined by participants can be used to begin conversations regarding the support required in housing arrangements for adults with FASD.

Current and ideal living arrangements and supports for Canadian adults with fetal alcohol spectrum disorder: Part II-Perspectives from caregivers.

BACKGROUND: Caregivers supporting adults with fetal alcohol spectrum disorder (FASD) report concerns regarding living arrangements and services for their adult children with FASD. Best practices for living support for adults with FASD are under-researched, and few studies have explored the experiences of caregivers whose children are adults. This study examined the perspectives of caregivers who support adults (18+) with FASD regarding: (1) current ways adults with FASD are supported with daily life activities; and (2) ideal future living arrangements and supports. METHODS: This article presents findings from the perspective of caregivers who support adults with FASD, as part of a broader project involving both adults with FASD and caregivers. Semi-structured interviews were conducted with 11 Canadian caregivers who live at home with an adult with FASD (aged 18+). Responses were examined using framework analysis, a structured approach to analyzing qualitative data. RESULTS: Caregivers described their experiences and perspectives regarding: (1) current ways adults with FASD are supported in their daily activities; (2) strategies for successful support; (3) ideal future living arrangements and supports; and (4) concerns for the future. Notably, almost every participant raised pressing concerns regarding the future living arrangements for the person they support once they are no longer able to provide care. CONCLUSIONS: This study explores caregivers' perspectives regarding living support needed by adults with FASD, which can inform support programs and housing services. Findings demonstrate an urgent need for policy change directed toward developing available, affordable, and appropriate housing for adults with FASD.

Parent-child relationship outcomes in a randomized controlled trial of housing first for indigenous and non-Indigenous parents experiencing homelessness, mental illness, and separation from their children.

OBJECTIVE: To examine the impacts of Housing First (HF) on parent-child relationships for Indigenous and non-Indigenous parents experiencing homelessness and mental illness. METHOD: Data on parent-child relationships were obtained through baseline and 18-month narrative interviews with parents (N = 43). Participants were randomly assigned to HF (N = 27) or treatment as usual (TAU; N = 16). Parent-child relationship changes were coded as positive or no change. Comparisons between HF and TAU groups were examined for Indigenous parents (N = 21) and non-Indigenous parents (N = 22). RESULTS: Parents in HF reported more positive changes, proportionally, in their relationships with their children, when compared with parents in the TAU group. Among Indigenous parents, proportionally more in HF (eight of 13 parents) reported positive changes in their relationships with their children, compared with those in TAU (one of eight parents). For non-Indigenous parents, however, those in HF (five of 14 parents) reported proportionally similar positive changes in relationships with their children to those in TAU (two of eight parents). Narratives of Indigenous parents in HF showed that they made considerable progress over 18 months in reconciling with their children. CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: Findings underscore the potential of HF to promote positive parent-child relationships. For Indigenous parents, HF programs that are designed, implemented, and staffed by Indigenous service-providers; guided by Indigenous worldviews; and employ culturally relevant and culturally safe practices are exemplars for understanding how HF programs can be adapted to positively impact parent-child relationships. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Case managers' reflections of a brief case management intervention in Canada.

Introduction: As demand for intensive case management services continues to outpace supply, community mental health agencies in Toronto, Ontario, introduced Short-Term Case Management (STCM). Objective: This study sought to explore case managers' perspectives and experiences with this new service delivery model. Methods: Focus groups were conducted with twenty-one case managers, and transcripts analyzed using thematic analysis. Results: Emerging themes suggest that despite embracing a recovery approach, case managers expressed mixed views on the acceptability and appropriateness of this service delivery model as an intervention. Conclusion: The ideal population for this intervention are adults with mental health issues in need of system navigation, and those motivated to address their goals. Further research is needed to establish fidelity criteria.

Disparities in cannabis-related emergency department visits across depressed and non-depressed individuals and the impact of recreational cannabis policy in Ontario, Canada.

BACKGROUND: Recreational cannabis policies are being considered in many jurisdictions internationally. Given that cannabis use is more prevalent among people with depression, legalisation may lead to more adverse events in this population. Cannabis legalisation in Canada included the legalisation of flower and herbs (phase 1) in October 2018, and the deregulation of cannabis edibles one year later (phase 2). This study investigated disparities in cannabis-related emergency department (ED) visits in depressed and non-depressed individuals in each phase. METHODS: Using administrative data, we identified all adults diagnosed with depression 60 months prior to legalisation (n = 929 844). A non-depressed comparison group was identified using propensity score matching. We compared the pre-post policy differences in cannabis-related ED-visits in depressed individuals v. matched (and unmatched) non-depressed individuals. RESULTS: In the matched sample (i.e. comparison with non-depressed people similar to the depressed group), people with depression had approximately four times higher risk of cannabis-related ED-visits relative to the non-depressed over the entire period. Phases 1 and 2 were not associated with any changes in the matched depressed and non-depressed groups. In the unmatched sample (i.e. comparison with the non-depressed general population), the disparity between individuals with and without depression is greater. While phase 1 was associated with an immediate increase in ED-visits among the general population, phase 2 was not associated with any changes in the unmatched depressed and non-depressed groups. CONCLUSIONS: Depression is a risk factor for cannabis-related ED-visits. Cannabis legalisation did not further elevate the risk among individuals diagnosed with depression.

Community mental health funding, stakeholder engagement and outcomes: a realist synthesis.

Mental health services continues to be a high priority for healthcare and social service systems. Funding structures within community mental health settings have shown to impact service providers' behaviour and practices. Additionally, stakeholder engagement is suggested as an important mechanism to achieving the intended goals. However, the literature on community mental health funding reform and associated outcomes is inconsistent and there are no consistent best practices for stakeholder engagement in such efforts. OBJECTIVES: This study sought to understand how stakeholder engagement impacts outcomes when there is a change in public funding within community mental health settings. DESIGN: A realist synthesis approach was used to address the research question to fully understand the role of stakeholder engagement as a mechanism in achieving outcomes (system and service user) in the context of community mental health service reform. An iterative process was used to identify programme theories and context-mechanism-outcome configurations within the literature. RESULTS: Findings highlight that in the absence of stakeholder engagement, funding changes may lead to negative outcomes. When stakeholders were engaged in some form, funding changes were more often associated with positive outcomes. Stakeholder engagement is multifaceted and requires considerable time and investment to support achieving intended outcomes when funding changes are implemented. CONCLUSIONS: To support successful transformation of community mental health programmes, it is important that stakeholders are meaningfully engaged during funding allocation changes. Stakeholder engagement may entail connecting around a shared purpose, individual participation and meaningful interactions and dialogue.

Service Needs of Clients Before and After Short Term Community Mental Health Case Management.

This study evaluated level of service need before and after a short-term community mental health case management intervention from the perspective of both clients and case managers. Ontario Common Assessment of Need data were used to describe client needs. McNemar's test was applied to assess differences in pre- and post- need scores. Psychological distress, company, daytime activities, and physical health were most commonly rated by clients as unmet needs at enrolment. At discharge, there was a significant change in psychological distress from the perspective of clients, and in psychological distress and daytime activities from the perspective of case managers. Statistically significant changes were observed for Total Need, Total Unmet Need and Met Need scores from the perspective of case managers. While both clients and case managers reported changes in total service needs between admission and discharge from short-term case management, clients were less likely to report a difference in needs.

Client Experiences With a Short-Term Case Management Mental Health Service.

Short Term Case Management (STCM) was introduced in 2016 in Toronto, Ontario, as a brief intervention to address long wait-lists for case management services. STCM provides individuals with mental illness, living in the community, case management services on a weekly basis over 3 months to identify personal goals and work toward an improved state of health and well-being. Despite the small but growing body of evidence on short-term case management, there is limited research on clients' reported experiences of these services. This study used a phenomenological approach to answer the question "What are the experiences with services of individuals who received short-term case management services?" Eight qualitative semistructured interviews were conducted between November 2019 and January 2020 to collect the perspectives and experiences of clients who had received STCM. Most participants valued engaging in a brief therapeutic relationship. Additionally, participants described that the intervention helped them connect with other agencies for ongoing support and begin achieving their own long-term goals. Some participants voiced concerns about the brief duration of the intervention. Future research should explore the role of briefcase management in the continuum of services and the typology of clients who may benefit from longer therapeutic relationship to achieve their goals.

Effectiveness of Narrative Messaging Styles about the Social Determinants of Health and Health Inequities in Ontario, Canada.

Health inequities are systemic, avoidable, and unjust differences in health between populations. These differences are often determined by social and structural factors, such as income and social status, employment and working conditions, or race/racism, which are referred to as the social determinants of health (SDOH). According to public opinion, health is considered to be largely determined by the choices and behaviours of individuals. However, evidence suggests that social and structural factors are the key determinants of health. There is likely a lack of public understanding of the role that social and structural factors play in determining health and producing health inequities. Public opinion and priorities can drive governmental action, so the aim of this work was to determine the most impactful way to increase knowledge and awareness about the social determinants of health (SDOH) and health inequities in the province of Ontario, Canada. A study to test the effectiveness of four different messaging styles about health inequities and the SDOH was conducted with a sample of 805 adult residents of Ontario. Findings show that messages highlighting the challenges faced by those experiencing the negative effects of the SDOH, while still acknowledging individual responsibility for health, were the most effective for eliciting an empathetic response from Ontarians. These findings can be used to inform public awareness campaigns focused on changing the current public narrative about the SDOH toward a more empathetic response, with the goal of increasing political will to enact policies to address health inequities in Ontario.

A principles-focused evaluation of community mental health short-term case management.

Principles-focused evaluations allow evaluators to appraise each principle that guides an organization or program. This study completed a principles-focused evaluation of a new community mental health intervention called Short Term Case Management (STCM) in Toronto, Canada. STCM is a time limited intervention for clients to address unmet needs and personalized goals over 3 months. Findings showcase that a principles-focused evaluation, assessing whether program principles are guiding, useful, inspiring, developmental and/or evaluable (GUIDE), is a practical formative evaluation approach. Specifically, offering an understanding of a novel intervention, including its key components of assessment and planning, support plan implementation and evaluation and care transitions. Findings also highlight that STCM may work best for those clients ready to participate in achieving their own goals. Future research should explore how best to apply the GUIDE framework to complex interventions, including multiple principles, to increase evaluation feasibility and focus.

Patterns and effects of social integration on housing stability, mental health and substance use outcomes among participants in a randomized controlled Housing First trial.

INTRODUCTION: Recent research has shown that social integration, involving community integration and social support, can be protective resources for the health of homeless individuals. However, it is not clear how social integration affects health in the transition from homelessness into housing, and subsequent housing retention. This paper examines, through mixed quantitative and qualitative methods, how social integration changes over time, and how these changes relate to housing stability, substance use and mental health outcomes among a sample of homeless individuals experiencing mental illness participating in the At Home/Chez Soi Housing First randomized controlled trial in Canada. METHODS: Longitudinal quantitative data (baseline, 6, 12, 24 month) and qualitative data ( 18 month) from the five trial sites (Moncton, Montreal, Toronto, Winnipeg and Vancouver) were examined using mixed models, mediation analyses, and thematic analysis. RESULTS: Social integration (i.e., social network size, social interest, psychological integration) increased over time among study participants, with social network size increasing significantly more among Housing First participants than Treatment as Usual participants. Social network size mediated the effect of the intervention on the percentage of days in stable housing, indicating that the Housing First intervention may have increased participants' social network size, which in turn increased the percentage of days stably housed. No significant mediation of social integration on the effects of the intervention on mental health and substance use outcomes was found. Findings from the qualitative interviews support and expand upon these quantitative findings.

Indigenous and non-Indigenous parents separated from their children and experiencing homelessness and mental illness in Canada.

The purpose of this study is to examine the parent-child experiences of Indigenous and non-Indigenous mothers and fathers experiencing homelessness, mental illness, and separation from their children. A qualitative thematic analysis of baseline and 18-month follow-up narrative interviews was used to compare 12 mothers (n = 8 Indigenous and n = 4 nonindigenous) with 24 fathers (n = 13 Indigenous and n = 11 non-Indigenous). First, it was found that children are more central in the lives of mothers than fathers. Second, Indigenous parents' narratives were characterized by interpersonal and systemic violence, racism and trauma, and cultural disconnection, but also more cultural healing resources. Third, an intersectional analysis showed that children were peripheral in the lives of non-Indigenous fathers, and most central to the identities of Indigenous mothers. Gender identity, Indigenous, and intersectional theories are used to interpret the findings. Implications for future theory, research, and culturally relevant intervention are discussed.

Tobacco outlet density, neighbourhood stressors and smoking prevalence in Toronto, Canada.

A growing body of research has shown that neighbourhood-level factors, such as the density of retail outlets selling tobacco and neighbourhood socioeconomic disadvantage affect smoking prevalence, with high levels of outlet density and neighbourhood disadvantage related to higher smoking prevalence. However, few studies have considered the role of other neighbourhood processes like stressors including perceived neighbourhood disorder in these effects. The present study examined the effects of tobacco outlet density, neighbourhood income and perceived neighbourhood disorder on smoking prevalence among a representative sample of 2,412 adult neighbourhood residents in a large urban centre in Canada. Tobacco outlet density and perceived neighbourhood disorder were significantly associated with smoking in an unadjusted multilevel model, but only perceived neighbourhood disorder remained significant in a model adjusting for other confounders. Findings suggest the need for community-based interventions to address the relationship between neighbourhood disorder and smoking, as well as more research on the combined role of tobacco availability and neighbourhood stressors, beyond neighbourhood socioeconomic disadvantage, on smoking behaviour.

Evaluating same-source bias in the association between neighbourhood characteristics and depression in a community sample from Toronto, Canada.

BACKGROUND AND PURPOSE: It is common in prior studies of the influence of neighbourhood characteristics on mental health to use participant-assessed neighbourhood exposures, which can lead to same-source bias since an individual's mental health status may influence their judgement of their neighbourhood. To avoid this potential bias, we evaluated the use of individually assessed neighbourhood exposures to understand how they compare to collectively assessed measures (by aggregating multiple responses within the same neighbourhood). This would increase the validity of the measure by decoupling the neighbourhood measure from an individual's mental health status. METHODS: We conducted a stratified-randomised survey of 2411 adults across 87 census tracts in Toronto, Canada (mean of 28 per census tract) to investigate how self-reported (individually assessed) social environmental neighbourhood measures compared to aggregated, collectively assessed, measures for neighbourhood problems/disorder, safety, service quality, and linking, bonding and bridging social capital. The outcome, experience of major depression in the past 12 months, was measured using the Composite International Diagnostic Studies Depression Scale Short Form. RESULTS: (1) Individually assessed neighbourhood problems, (2) low (individually assessed) neighbourhood safety, (3) low (individually assessed) neighbourhood service quality, and (4) low (individually assessed) linking social capital were independently associated with depression (all at least p < 0.05). However, when the individually assessed exposures were aggregated over residents in the same neighbourhood, none of them were significantly associated with depression. CONCLUSIONS: Our study provides evidence for same-source bias in studies of social environmental determinants of depression that relies on individually assessed neighbourhood measures. We caution future studies from solely relying on individually assessed neighbourhood exposures especially in the study of social environmental influences on mental health outcomes.

The Generation of Integration: The Early Experience of Implementing Bundled Care in Ontario, Canada.

Policy Points Policymakers interested in advancing integrated models of care may benefit from understanding how integration itself is generated. Integration is analyzed as the generation of connectivity and consensus-the coming together of people, practices, and things. Integration was mediated by chosen program structures and generated by establishing partnerships, building trust, developing thoughtful models, engaging clinicians in strategies, and sharing data across systems. This study provides examples of on-the-ground integration strategies in 6 programs, suggests contexts that better lend themselves to integration initiatives, and demonstrates how programs may be examined for the very thing they seek to implement-integration itself. CONTEXT: By bundling services and encouraging interprofessional and interorganizational collaboration, integrated health care models counter fragmented health care delivery and rising system costs. Building on a policy impetus toward integration, the Ministry of Health and Long-Term Care in the Canadian province of Ontario chose 6 programs, each comprising multiple hospital and community partners, to implement bundled care, also referred to as integrated-funding models. While research has been conducted on the facilitators and challenges of integration, there is less known about how integration is generated. This article explores the generation of integration through the dynamic interplay of contexts and mechanisms and of structures and subjects. METHODS: For this qualitative study, we conducted 48 interviews with program stakeholders, from organization leaders and managers to physicians and integrated care coordinators, across the hospital-community spectrum. We then used content analysis to explore the extent to which themes were shared across programs and to identify idiosyncrasies, followed by a realist evaluation approach to understand how integration was produced in structural and everyday ways in local program contexts. FINDINGS: Integration was generated through the successful production of connectivity and consensus-the coming together of people, practice, and things, as perceived and experienced by stakeholders. When able, the programs harnessed existing cultures of clinician engagement, and leveraged established partnerships. However, integration could be achieved even without these histories, by building trust, developing thoughtful models, using clinicians' existing engagement strategies, and implementing shared systems and technologies. The programs' structures (from their scale to their chosen patient population) also contextualized and mediated integration. CONCLUSIONS: This article has both practical and theoretical implications. It provides transferable insights into the strategies by which integration is generated. It also contributes conceptually to realist approaches to evaluation by advancing an understanding of mechanisms as contextually and temporally contingent, with the capacity to produce new contexts, which in turn generate new sets of mechanisms.

Co-responding police-mental health programmes: Service user experiences and outcomes in a large urban centre.

As police officers are often the first responders to mental health crises, a number of approaches have emerged to support skilled police crisis responses. One such approach is the police-mental health co-responding team model, whereby mental health nurses and police officers jointly respond to mental health crises in the community. In the present mixed-method study, we evaluated outcomes of co-responding team interactions at a large Canadian urban centre by analysing administrative data for 2743 such interactions, and where comparison data were available, compared them to 16 226 police-only team responses. To understand service user experiences, we recruited 15 service users for in-depth qualitative interviews, and completed inductive thematic analysis. Co-responding team interactions had low rates of injury and arrest, and compared to police-only teams, co-responding teams had higher overall rates of escorts to hospital, but lower rates of involuntary escorts. Co-responding teams also spent less time on hospital handovers than police-only teams. Service users valued responders with mental health knowledge and verbal de-escalation skills, as well as a compassionate, empowering, and non-criminalizing approach. Current findings suggest that co-responding teams could be a useful component of existing crisis-response systems.

Effects of comorbid substance use disorders on outcomes in a Housing First intervention for homeless people with mental illness.

BACKGROUND AND AIMS: Evidence supports the effectiveness of Housing First (HF) programmes for people who are experiencing homelessness and mental illness; however, questions remain about its use in people with comorbid substance use disorders (SUD). The aim of this project was to test whether SUD modifies the effectiveness of an HF intervention. DESIGN: Secondary analysis of data from a randomized controlled trial of HF versus treatment-as-usual (TAU) with 24-month follow-up, comparing those with and without SUD at trial entry. SETTING: Vancouver, Toronto, Winnipeg, Moncton and Montreal, Canada. PARTICIPANTS: A total of 2154 participants recruited from 2009 to 2013 and randomized to HF versus TAU (67% male, mean age 40.8 ± 11.2, 25% ethno-cultural minority). All were homeless and had a mental disorder at baseline; 35% reported symptoms consistent with SUD. INTERVENTION: Housing paired with Intensive Case Management or Assertive Community Treatment. MEASUREMENTS: Primary outcomes were days housed and community functioning. Secondary outcomes were general and health-related quality of life and mental health symptoms. Predictors were SUD status crossed with intervention group (HF versus TAU). FINDINGS: People with SUD in both the HF and TAU groups spent less time in stable housing, but the effect of HF did not vary by SUD status [odds ratio (OR) = 1.17, 95% confidence interval (CI) = -0.77, 1.76]. Similarly, there was no difference between those with and without SUD in the effect of HF (over TAU) on community functioning (b = 0.75, 95% CI = -0.36, 1.87), quality of life (b = -1.27, 95% CI = -4.17, 1.63), health-related quality of life (b = -0.01, 95% CI = -0.03, 0.02) or mental health symptoms (b = 0.43, 95% CI = -0.99, 1.86). CONCLUSIONS: Housing First programs in Canada are equally effective in people with and without comorbid substance use disorder (SUD). Overall, the intervention appears to be able to engage people with SUD and is reasonably successful at housing them, without housing being contingent upon abstinence or treatment.

What works in implementation of integrated care programs for older adults with complex needs? A realist review.

PURPOSE: A realist review of the evaluative evidence was conducted on integrated care (IC) programs for older adults to identify key processes that lead to the success or failure of these programs in achieving outcomes such as reduced healthcare utilization, improved patient health, and improved patient and caregiver experience. DATA SOURCES: International academic literature was searched in 12 indexed, electronic databases and gray literature through internet searches, to identify evaluative studies. STUDY SELECTION: Inclusion criteria included evaluative literature on integrated, long-stay health and social care programs, published between January 1980 and July 2015, in English. DATA EXTRACTION: Data were extracted on the study purpose, period, setting, design, population, sample size, outcomes, and study results, as well as explanations of mechanisms and contextual factors influencing outcomes. RESULTS OF DATA SYNTHESIS: A total of 65 articles, representing 28 IC programs, were included in the review. Two context-mechanism-outcome configurations (CMOcs) were identified: (i) trusting multidisciplinary team relationships and (ii) provider commitment to and understanding of the model. Contextual factors such as strong leadership that sets clear goals and establishes an organizational culture in support of the program, along with joint governance structures, supported team collaboration and subsequent successful implementation. Furthermore, time to build an infrastructure to implement and flexibility in implementation, emerged as key processes instrumental to success of these programs. CONCLUSIONS: This review included a wide range of international evidence, and identified key processes for successful implementation of IC programs that should be considered by program planners, leaders and evaluators.