Care integration goes Beyond Co-Location: Creating a Medical Home.

How to successfully integrate mental health and primary care remains a critically important question given the continued morbidity and early mortality of people with serious mental illness. This study investigated integration in a community mental health center (MHC) primarily treating people with SMI in a large, urban northeastern city where an on-site primary care center (PCC) was opened resulting in co-located mental health and primary care services being provided. Using focus groups and online surveys this study asked participants about their thoughts and interactions with the on-site PCC. Participants included staff from clinical, non-clinical, and leadership roles in the mental health center (MHC; PCC staff; and MHC clients who did not use the on-site PCC). MHC staff also offered their thoughts about and experiences with the on-site PCC one year and two years after the on-site PCC opened through an on-line survey. In both methods, staff reported limited awareness and expectations of the PCC in the first year. Staff indicated that successful care integration goes beyond co-location and peer health navigation can enhance integration. Finally, staff discussed desires for enhancing care integration and co-located services into a medical home that included communicating across medical records and providers at different agencies. Our results suggest that, in addition to the previously researched three C's of care integration (consultation, coordination, and collaboration), two more C's were essential to successful care integration: co-location and communication. Communication across medical records and providers at different agencies was an essential component of care integration, and co-location added increased ability to communicate across providers.

A Qualitative Study of Racial, Ethnic, and Cultural Experiences of Minority Clinicians During Agitation Care in the Emergency Department.

STUDY OBJECTIVE: Racial and ethnic bias in health care has been documented at structural, organizational, and clinical levels, impacting emergency care, including agitation management in the emergency department (ED). Little is known about the experiences of racial and ethnic minority ED clinicians caring for racial and ethnic minority groups, especially during their agitated state. The objective of this study was to explore the lived experiences of racial and ethnic minority ED clinicians who have treated patients with agitation in the ED. METHODS: We performed semistructured individual interviews of Black, Latino, and multiracial clinicians who worked at 1 of 3 EDs from an urban quaternary care medical center in the Northeast United States between August 2020 and June 2022. We performed thematic analysis through open coding of initial transcripts and identifying additional codes through sequential iterative rounds of group discussion. Once the codebook was finalized and applied to all transcripts, the team identified key themes and subthemes. RESULTS: Of the 27 participants interviewed, 14 (52%) identified as Black, 9 (33%) identified as Hispanic/Latino, and 4 (15%) identified as multiracial and/or other race and ethnicity. Three primary themes emerged from racial and ethnic minority clinician experiences of managing agitation: witness of perceived bias during clinical interactions with patients of color who bear racialized presumptions of agitation, moral injury and added workload to address perceived biased agitation management practices while facing discrimination in the workplace, and natural advocacy and allyship for agitated patients of color based on a shared identity and life experience. CONCLUSIONS: Our study found that through their shared minority status, racial and ethnic minority clinicians had a unique vantage point to observe perceived bias in the management of agitation in minority patients. Although they faced added challenges as racial and ethnic minority clinicians, their allyship offered potential mitigation strategies for addressing disparities in caring for an underserved and historically marginalized patient population.

What's race got to do with it? Factors contributing to self-change from cocaine use disorder among Black adults.

INTRODUCTION: A substantial number of people with substance use disorders recover without formal treatment, though we know little about the process of self-change among Black adults with cocaine use disorder (CUD) and whether racism contributes to the development of CUD and these adults' process of self-change. METHODS: The study team conducted qualitative interviews with 29 Black adults using a narrative and phenomenological approach. At the time of the interview, all participants met criteria for DSM-5 CUD prior to the past year but did not meet criteria for CUD in the past year and reported that they reduced their cocaine use without formal treatment. Participants completed a qualitative interview followed by the UConn Racial/Ethnic Stress & Trauma Survey. Thematic analyses informed key themes from the qualitative interviews. RESULTS: Qualitative analyses indicated several major factors that contributed to self-change from CUD: racial identity, responsibility to family, social regard, spirituality, turning point for change, and changing one's environment. These results highlight that self-change from CUD is a complex, ongoing, and multifaceted process. The identified themes align with several theories of recovery, including social control theory and the theory of stress and coping. Furthermore, the results suggest that experiences of racism are common among Black adults recovering from CUD, and that the multiple strategies employed for coping with racism may be consistent with the process of self-change. CONCLUSIONS: This study shows that multiple race-related factors contribute to the development of, maintenance of, and self-change from CUD among Black adults. Better understanding these factors can help to inform drug treatment.

Qualitative study of patient experiences and care observations during agitation events in the emergency department: implications for systems-based practice.

OBJECTIVES: Agitation, defined as excessive psychomotor activity leading to aggressive or violent behaviour, is prevalent in the emergency department (ED) due to rising behavioural-related visits. Experts recommend use of verbal de-escalation and avoidance of physical restraint to manage agitation. However, bedside applications of these recommendations may be limited by system challenges in emergency care. This qualitative study aims to use a systems-based approach, which considers the larger context and system of healthcare delivery, to identify sociotechnical, structural, and process-related factors leading to agitation events and physical restraint use in the ED. DESIGN: Qualitative study using a grounded theory approach to triangulate interviews of patients who have been physically restrained with direct observations of agitation events. SETTING: Two EDs in the Northeast USA, one at a tertiary care academic centre and the other at a community-based teaching hospital. PARTICIPANTS: We recruited 25 individuals who experienced physical restraint during an ED visit. In addition, we performed 95 observations of clinical encounters of agitation events on unique patients. Patients represented both behavioural (psychiatric, alcohol/drug use) and non-behavioural (medical, trauma) chief complaints. RESULTS: Three primary themes with implications for systems-based practice of agitation events in the ED emerged: (1) pathways within health and social systems; (2) interpersonal contexts as reflections of systemic stressors on behavioural emergency care and (3) systems-based and patient-oriented strategies and solutions. CONCLUSIONS: Agitation events represented manifestations of patients' structural barriers to care from socioeconomic inequities and high burden of emotional and physical trauma as well as staff members' simultaneous exposure to external stressors from social and healthcare systems. Potential long-term solutions may include care approaches that recognise agitated patients' exposure to psychological trauma, improved coordination within the mental health emergency care network, and optimisation of physical environment conditions and organisational culture.

A qualitative study on identity in individuals at clinical high risk for psychosis: " Why does it have to be one thing?".

OBJECTIVE: Qualitative research can shed light on the subjective experiences of individuals at clinical high risk (CHR) for psychosis, complement quantitative research, broaden our understanding of experiencing CHR, and inform intervention development. The aim of this study was to explore life experiences of individuals at CHR through qualitative research. METHOD: Participants were 37 individuals at CHR (20 male, 17 female) aged 16-34 (Mage = 23.32 ± 5.26), and 16 healthy controls (HCs; 7 male, 9 female) aged 18-34 (Mage = 25.37 ± 4.05). Qualitative data were obtained through open-ended interviews (30-45 min). No a priori hypotheses were made, and thematic analyses were used to develop themes. RESULTS: Four major themes and one subtheme related to identity were identified through the iterative thematic analysis: defining a self-concept (with a subtheme of creativity), identity development/formation, feeling different from others, and change from a former self. Over 80% of the CHR cohort spontaneously discussed topics related to their identity, compared to 38% of HCs. HCs only reported content within the defining a self-concept theme, while the CHR group reported content within all themes. CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: The present study demonstrates that identity formation is a major process for youth in general and that psychosis experiences can make this process more challenging. CHR participants spontaneously brought up multiple themes related to identity in open-ended interviews, suggesting the relevance of this topic in this population. Clinicians should continue to probe identity-related concerns on an individual basis and research should focus on integrating this framework into the conceptualization and treatment of CHR. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Conceptual Framework for Personal Recovery in Patients With Acute Myocardial Infarction.

Background Although there has been movement in cardiology to advance patient-centered approaches to postacute myocardial infarction (AMI) care, work remains to be done in aligning patient preferences with clinical care. Our objective was to characterize patients' experience of AMI and treatment to develop a new conceptual framework of patient-centered recovery in cardiology. Methods and Results We conducted in-depth interviews with people who previously experienced an AMI (2016-2019). The interview focused on participants' experiences of their recovery, which were audio-recorded, transcribed verbatim, and analyzed using a phenomenological framework. The overarching theme described by the 42 participants was feeling like a "different person" after the AMI. This shift manifested itself in both losses and gains, each of which posed new challenges to everyday life. The experience appeared to be an active process requiring people to take responsibility for their health. In terms of loss, participants describe how the AMI threatened their sense of safety and security and led to social isolation, fragility, uncertainty about the future, and difficulty expressing emotions accompanied this new fear. A conceptual framework describing the relationship between AMI, identity change, and functioning was developed. Conclusions Participants experienced the AMI as an unexpected disruption in their lives that had far-reaching effects on their daily functioning, and were resolved in numerous ways. The conceptual framework may assist in providing a theoretical basis for future interventions in cardiology that not only engage and retain patients in care but also improve long-term adherence to secondary prevention and other aspects of self-care.

An "oasis within a desert," but the desert remains: Clubhouse members' experiences of social belonging and societal oppression.

Persons living with mental health challenges are at increased risk of stigma, social isolation, and social exclusion. Due to its emphasis on member participation and community, the clubhouse model of mental health may help address these issues. In this study, we examined experiences of social belonging and of various social determinants of mental health among members attending a psychosocial clubhouse. Twelve members of a large psychosocial clubhouse were interviewed regarding their experiences of community life and belonging. Phenomenological qualitative methods were utilized to examine the meaning and structure of these experiences. Members overwhelmingly experienced the clubhouse as a central site of belonging ("an oasis"), but members also recounted devastating portraits of life in the outside world ("a desert"). This world presented fundamental restrictions on their movement and speech and held deeply sedimented norms pertaining to who is considered valuable, productive, and even human, which they were reminded of through an endless tyranny of questions ("what do you do," "where do you live," etc.). Life in the clubhouse presented an alternative world for members to experience nourishment, dignity, reaffirmed personhood, and a sense of beauty. And yet, the desert outside remained. Implications of these findings for clubhouses, mental health practice, and sociopolitical and community engagement are discussed, including the need to address profound deprivations and power imbalances within the wider world, beyond the walls of humane spaces such as these. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Tele-Mental Health Utilization Among People with Mental Illness to Access Care During the COVID-19 Pandemic.

Shortly after the COVID-19 pandemic arrived at the United States, mental health services moved towards using tele-mental health to provide care. A survey about resilience and tele-mental health was developed and conducted with ForLikeMinds' members and followers. Correlational analysis was used to examine relationships between quantitative variables. A phenomenological approach was used to analyze open questions responses. Sixteen percent of participants were coping well with the pandemic; 50% were coping okay; and 34% said that they were coping poorly. Three main themes emerged from the qualitative analysis: accessibility to care; self-care strategies; and community support and relationship. The responses from participants seems to reflect the combination of two main factors-the challenges they were facing in accessing care through tele-mental health plus the mental health consequences from COVID-19. This survey reflects the importance of building innovative strategies to create a working alliance with people who need care through tele-mental health.

"Is My Heart Healing?" A Meta-synthesis of Patients' Experiences After Acute Myocardial Infarction.

BACKGROUND: Recovery from acute myocardial infarction (AMI) has been primarily understood in a narrow medical sense. For patients who survive, secondary prevention focuses largely on enhancing clinical outcomes. As a result, there is a lack of descriptive accounts of patients' experiences after AMI and little is known about how people go about the challenge of recovering from such an event. OBJECTIVE: We conducted a meta-synthesis of the available literature on qualitative accounts of patients' experiences after AMI. METHODS: We searched for relevant papers that were descriptive, qualitative accounts of participants' experiences after AMI across 4 electronic databases (April 2016). Using an adapted meta-ethnography approach, we analyzed the findings by translating studies into one another and synthesizing the findings from the studies. RESULTS: After a review of titles/abstracts, reading each article twice in full, and cross-referencing articles, this process resulted in 17 studies with 224 participants (48% women) aged 23 to 90 years. All participants provided a first-person account of an AMI within the 3-day to 25-year time frame. Two major themes emerged that characterized patients' experiences: navigating lifestyle changes and navigating the emotional reaction to the event-consisting of various subthemes. CONCLUSION: Although AMI tends to be seen as a discrete event, participants are left with little professional guidance as to how to negotiate significant, and often discordant, psychosocial changes that have long-lasting effects on their lives, similar to persons with chronic illnesses but without research in place to figure out how to best support them.

COVID-19 Concerns Among Persons With Mental Illness.

OBJECTIVE: The coronavirus disease (COVID-19) pandemic has been recognized as causing a wide variety of behavioral health problems. Society must mitigate this impact by recognizing that COVID-19 can trigger people's fears of exacerbating an existing mental illness. A survey about COVID-19 for people with mental illness was developed. METHODS: Two hundred fourteen people responded to the survey, of whom 193 self-identified as living with a mental illness. RESULTS: Almost all participants living with a mental illness (98%) said they had at least one major concern regarding the COVID-19 pandemic, and 62% said they had at least three major concerns. CONCLUSIONS: People living with a mental illness are very concerned about disruption of services, running out of medication, and social isolation during this pandemic. Providers and mental health services could address these fears by connecting with people living with mental illness through text messaging and social media.

Themes in experiences of PTSD symptoms and relationships among male veterans with risky sexual behavior.

OBJECTIVE: United States veterans with posttraumatic stress disorder (PTSD) symptoms are at elevated risk for high-risk sexual behavior (HRSB). Although quantitative research has examined relationships between PTSD symptoms and HRSB, qualitative research to understand the lived experiences of veterans with PTSD symptoms and HRSB has not been conducted. METHOD: Qualitative interviews were conducted with N = 29 male veterans of Operation Enduring Freedom or Operation Iraqi Freedom who had PTSD symptoms and reported recent HRSB. The interviews were analyzed using a phenomenological framework. RESULTS: Six themes emerged: (a) avoiding social contact due to feeling different since return from service; (b) effortful self-management; (c) supportive relationships; (d) sex as a means to an end; (e) sex, risk, and intimacy; and (f) responsibility and growth. CONCLUSION: Male veterans with PTSD symptoms and HRSB reported engagement in significant self-management to reengage in life, and still reported high levels of difficulty in relationships. They described both wanting to avoid perceived risk associated with intimate relationships and wanting to take risks that caused them to feel alive. Implications for treatment include increased efforts to facilitate coping, to recognize and moderate risk-taking urges, and to build intimacy and trust. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Experiences of Individuals Who Were Physically Restrained in the Emergency Department.

Importance: Individuals with behavioral disorders are increasingly presenting to the emergency department (ED), and associated episodes of agitation can cause significant safety threats to patients and the staff caring for them. Treatment includes the use of physical restraints, which may be associated with injuries and psychological trauma; to date, little is known regarding the perceptions of the use of physical restraint among individuals who experienced it in the ED. Objective: To characterize how individuals experience episodes of physical restraint during their ED visits. Design, Setting, and Participants: In this qualitative study, semistructured, 1-on-1, in-depth interviews were conducted with 25 adults (ie, aged 18 years or older) with a diverse range of chief concerns and socioeconomic backgrounds who had a physical restraint order associated with an ED visit. Eligible visits included those presenting to 2 EDs in an urban Northeast city between March 2016 and February 2018. Data analysis occurred between July 2017 and June 2018. Main Outcomes and Measures: Basic participant demographic information, self-reported responses to the MacArthur Perceived Coercion Scale, and experiences of physical restraint in the ED. Results: Data saturation was reached with 25 interviews (17 [68%] men; 18 [72%] white; 19 [76%] non-Hispanic). The time between the patient's last restraint and the interview ranged from less than 2 weeks to more than 6 months. Of those interviewed, 22 (88%) reported a combination of mental illness and/or substance use as contributing to their restraint experience. Most patients (20 [80%]) said that they felt coerced to present to the ED. Three primary themes were identified from interviews, as follows: (1) harmful experiences of restraint use and care provision, (2) diverse and complex personal contexts affecting visits to the ED, and (3) challenges in resolving their restraint experiences, leading to negative consequences on well-being. Conclusions and Relevance: In this qualitative study, participants described a desire for compassion and therapeutic engagement, even after they experienced coercion and physical restraint during their visits that created lasting negative consequences. Future work may need to consider more patient-centered approaches that minimize harm.

Missing Ingredients in Shared Decision-Making?

Shared decision-making (SDM) is a collaborative approach to making decisions in health care, and is a cornerstone of person-centered care. While providers are increasingly expected to utilize SDM in routine practice, widespread and sustainable implementation has proven difficult, especially in the care of individuals diagnosed with serious mental illnesses, and physicians and patients continue to identify barriers to effective collaboration. To date, SDM research has largely focused on the provision of high-quality clinical information from doctors to patients to the neglect of what may be the most important, and transformative, aspect of SDM-the relationship itself. In this forum, the lack of attention to the relationship in SDM research and practice will be explored, along with the relational qualities that need to be in place to implement SDM in the care of persons with serious mental illness based on the findings from a mixed-methods, participatory research project.

Home Groups: Integrating Peer Support and Clinical Care in a Community Mental Health Center.

With peer supporters now comprising one of the most rapidly growing components of the mental health workforce, group interventions that combine their expertise with those of more traditional mental health providers are needed. An example of one such intervention, developed and implemented at a large community mental health center for individuals with serious mental illnesses, is presented. Called a "Home Group" and co-led by peers and clinical psychology interns, this intervention provides unique learning opportunities for peers and trainees and many potential benefits to group members. Vignettes to illustrate the model are presented and the potential therapeutic and empowering aspects of this innovative and promising approach are identified and discussed.

A Pilot Study of Motive Control to Reduce Vengeance Cravings.

Violence is a serious public health problem in the United States, and a common risk factor for many forms of violence is the perpetrator's motivation to achieve personal justice for past wrongs and injustices. Using a fictional transgression scenario to stimulate revenge feelings, we studied the preliminary efficacy of an intervention designed to mitigate revenge desires among victims of perceived injustice. The intervention consisted of a guided role-play of key figures in the justice system (e.g., victim, prosecutor, defendant, judge, etc.) in an imaginary mock trial of the offender. Study participants' revenge desires toward the perpetrator decreased significantly immediately after the intervention and at a 2-week follow-up interview. Benevolence toward the offender increased immediately postintervention and at a 2-week follow-up interview. These results suggest that the intervention has promise to decrease revenge desires in people who have been victimized, and it potentially opens the door to behavioral health motive control approaches to violence prevention. Findings on the roles of vengeance and the desire for retaliation in relation to violent acts, as well as neuroscience research that suggests a connection between retaliatory aggression and the neural circuitry of anticipated reward and cravings, are discussed. Limitations of this pilot study are also discussed, and recommendations for future research are provided.

Patient-Centered Decision Support: Formative Usability Evaluation of Integrated Clinical Decision Support With a Patient Decision Aid for Minor Head Injury in the Emergency Department.

BACKGROUND: The Canadian Computed Tomography (CT) Head Rule, a clinical decision rule designed to safely reduce imaging in minor head injury, has been rigorously validated and implemented, and yet expected decreases in CT were unsuccessful. Recent work has identified empathic care as a key component in decreasing CT overuse. Health information technology can hinder the clinician-patient relationship. Patient-centered decision tools to support the clinician-patient relationship are needed to promote evidence-based decisions. OBJECTIVE: Our objective is to formatively evaluate an electronic tool that not only helps clinicians at the bedside to determine the need for CT use based on the Canadian CT Head Rule but also promotes evidence-based conversations between patients and clinicians regarding patient-specific risk and patients' specific concerns. METHODS: User-centered design with practice-based and participatory decision aid development was used to design, develop, and evaluate patient-centered decision support regarding CT use in minor head injury in the emergency department. User experience and user interface (UX/UI) development involved successive iterations with incremental refinement in 4 phases: (1) initial prototype development, (2) usability assessment, (3) field testing, and (4) beta testing. This qualitative approach involved input from patients, emergency care clinicians, health services researchers, designers, and clinical informaticists at every stage. RESULTS: The Concussion or Brain Bleed app is the product of 16 successive iterative revisions in accordance with UX/UI industry design standards. This useful and usable final product integrates clinical decision support with a patient decision aid. It promotes shared use by emergency clinicians and patients at the point of care within the emergency department context. This tablet computer app facilitates evidence-based conversations regarding CT in minor head injury. It is adaptable to individual clinician practice styles. The resultant tool includes a patient injury evaluator based on the Canadian CT Head Rule and provides patient specific risks using pictographs with natural frequencies and cues for discussion about patient concerns. CONCLUSIONS: This tool was designed to align evidence-based practices about CT in minor head injury patients. It establishes trust, empowers active participation, and addresses patient concerns and uncertainty about their condition. We hypothesize that, when implemented, the Concussion or Brain Bleed app will support-not hinder-the clinician-patient relationship, safely reduce CT use, and improve the patient experience of care.

Recovery in Mind: Perspectives from Postgraduate Psychiatric Trainees.

OBJECTIVE: The authors assessed psychiatric trainees' understanding of recovery-oriented care, a therapeutic philosophy with varied meanings but wide purchase in contemporary mental health policy. METHODS: Four cohorts of residents were presented with a clinical vignette as part of a written curricular evaluation and asked what it would mean to engage the patient from a recovery-oriented perspective. Responses were subjected to qualitative analysis, with the analysts examining each cohort independently, then meeting to discuss their findings and build consensus on the most pertinent themes. RESULTS: Nine themes emerged in trainees' understanding of recovery-oriented care: (1) a person is more than his or her illness; (2) hope; (3) an emphasis on patient goals; (4) taking a collaborative approach; (5) an emphasis on level of social function; (6) valuing subjective experience; (7) psychosocial interventions; (8) empowerment of the patient; and (9) persistence of traditional attitudes. CONCLUSIONS: Residents revealed an understanding of recovery that reflected many, but not all, of the guiding principles in the Substance Abuse and Mental Health Services Administration's 2010 working definition. For many of these trainees, recovery-oriented care signified a shift in the traditional power dynamic between physician and patient that allowed patients to take an active role in their own care. Residents also recognized the importance of hope and the complexity of their patients' social identities, though some trainees had difficulty reconciling a collaborative approach with their perceived responsibilities as physicians. If educators wish to incorporate elements of the American Psychiatric Association's Recovery to Practice initiative into their curricula, they would do well to recognize residents' variable receptivity to elements of the model.

"I Want to Come Home": Vietnam-Era Veterans' Presenting for Mental Health Care, Roughly 40 Years After Vietnam.

There continues to be an increase in the number of Vietnam-era veterans receiving a diagnosis of PTSD in the Veterans Health Administration, nearly four decades after Vietnam. In the present study, our aim was to better understand what prompts Vietnam-era veterans to present to a VHA mental health clinic, and to determine the meaning of this experience for them. Participants were interviewed regarding the experiences that prompted their visit to the mental health clinic at a VA medical center. Ensuing narratives were analyzed via phenomenological qualitative methods. Findings revealed that veterans did not hold a clear and determinate understanding of "PTSD" prior to attending the mental health clinic. Their engagement was instead the culmination of a long process wherein trusted others (e.g., family, other veterans, primary care doctors) suggested that their difficulties may be indicative of a problematic pattern that required attention beyond the everyday ways of dealing with them. In general, veterans suffered from a longstanding experience of social rejection, abandonment, and even betrayal following the war, including pervasive stigmatizations and perceived "weaknesses," and their own preferences for self-reliance over inattentive social and governmental institutions. Many veterans were newly focused on renewing meaning and purpose in their lives. The findings suggest the need to build stronger bridges between the VA and veterans' community supports, who greatly influenced veterans' care seeking. Further efforts to welcome Vietnam-era veterans home, validate their experiences of rejection and abandonment, and respectfully process their ensuing pain and anger are warranted.