Should We Trust You? Strategies to Improve Access to Mental Healthcare to BIPOC Communities During the COVID-19 Pandemic.

Black, Indigenous, and People of Color (BIPOC) communities have weathered centuries of racism, causing transgenerational mental health consequences and hindering access to quality treatment. In this commentary, we describe the systemic challenges of engaging BIPOC to promote mental health equity during the COVID-19 pandemic. We then describe an initiative that illustrates these strategies, provide recommendations and further readings for academic institutions seeking to partner with community organizations to provide equitable mental health services to populations that have been traditionally overlooked.

Engagement of individuals with serious mental illness in outpatient mental health services and telehealth use during the COVID-19 pandemic.

Questions remain regarding whether the transition and continued use of telehealth was associated with changes in treatment engagement among patients with serious mental illness (SMI). Using NYS Medicaid claims, we identified 116,497 individuals with SMI receiving outpatient mental health services from September 1, 2019-February 28, 2021 and a comparison cohort of 101,995 from September 1, 2017-February 28, 2019 to account for unmeasured and seasonal variation. We characterized engagement in three 6-month increments (T0-T1-T2) using clinically meaningful measures of high, partial, low, and none. Subgroup differences were compared, and telehealth users were compared to those with only in-person visits. Engagement, as characterized, was largely maintained during COVID. The 19.0 % with only in-person visits during COVID had different characteristics than telehealth users. Telehealth use was greater among younger people by T2 (33.1 %), women (57.7 %), non-Hispanic White people (38.9 %), and those with MDD (18.0 %), but lower among non-Hispanic Black people, in NYC, and those with schizophrenia or SUD. Most telehealth users were highly engaged (77.1 %); most using only in-person services had low engagement (47.5 %). The shift to telehealth preserved access to many outpatient services for this SMI population. Exploring reasons for not using telehealth may identify opportunities to increase care access.

Participants' Engagement With and Results From a Web-Based Integrative Population Mental Wellness Program (CHAMindWell) During the COVID-19 Pandemic: Program Evaluation Study.

BACKGROUND: The COVID-19 pandemic involved a prolonged period of collective trauma and stress during which substantial increases in mental health concerns, like depression and anxiety, were observed across the population. In this context, CHAMindWell was developed as a web-based intervention to improve resilience and reduce symptom severity among a public health care system's patient population. OBJECTIVE: This program evaluation was conducted to explore participants' engagement with and outcomes from CHAMindWell by retrospectively examining demographic information and mental health symptom severity scores throughout program participation. METHODS: We examined participants' symptom severity scores from repeated, web-based symptom screenings through Computerized Adaptive Testing for Mental Health (CAT-MH) surveys, and categorized participants into symptom severity-based tiers (tier 1=asymptomatic to mild; tier 2=moderate; and tier 3=severe). Participants were provided tier-based mindfulness resources, treatment recommendations, and referrals. Logistic regressions were conducted to evaluate associations between demographic variables and survey completion. The McNemar exact test and paired sample t tests were performed to evaluate changes in the numbers of participants in tier 1 versus tier 2 or 3 and changes in depression, anxiety, and posttraumatic stress disorder severity scores between baseline and follow-up. RESULTS: The program enrolled 903 participants (664/903, 73.5% female; 556/903, 61.6% White; 113/903, 12.5% Black; 84/903, 9.3% Asian; 7/903, 0.8% Native; 36/903, 4% other; and 227/903, 25.1% Hispanic) between December 16, 2020, and March 17, 2022. Of those, 623 (69%) completed a baseline CAT-MH survey, and 196 completed at least one follow-up survey 3 to 6 months after baseline. White racial identity was associated with completing baseline CAT-MH (odds ratio [OR] 1.80, 95% CI 1.14-2.84; P=.01). Participants' odds of having symptom severity below the clinical threshold (ie, tier 1) were significantly greater at follow-up (OR 2.60, 95% CI 1.40-5.08; P=.001), and significant reductions were observed across symptom domains over time. CONCLUSIONS: CHAMindWell is associated with reduced severity of mental health symptoms. Future work should aim to address program engagement inequities and attrition and compare the impacts of CHAMindWell to a control condition to better characterize its effects.

Toward Population Health: Using a Learning Behavioral Health System and Measurement-Based Care to Improve Access, Care, Outcomes, and Disparities.

Achieving population behavioral health is urgently needed. The mental health system struggles with enormous challenges of providing access to mental health services, improving quality and equitability of care, and ensuring good health outcomes across subpopulations. Little data exists about increasing access within highly constrained resources, staging/sequencing treatment along care pathways, or personalizing treatments. The conceptual model of the learning healthcare system offers a potential paradigm shift for addressing these challenges. In this article we present an overview of how the three constructs of population health, learning health systems, and measurement-based care are inter-related, and we provide an example of how one academic, community-based, safety net health system is approaching integrating these paradigms into its service delivery system. Implementation outcomes will be described in a subsequent publication. We close by discussing how ultimately, to meaningfully improve population behavioral health, a learning healthcare system could expand into a learning health community in order to target critical points of prevention and intervention.

Assessing the Long-Term Effectiveness of a Behavioral Health Home for Adults With Bipolar and Psychotic Disorders.

OBJECTIVE: This study aimed to examine the impact of a behavioral health home (BHH) to better understand its potential to improve health for individuals with serious mental illness. METHODS: Propensity score-weighted interrupted time series analysis was used to estimate service utilization and chronic disease management through 3.5 years after BHH implementation and to compre BHH enrollees (N=413) with other patients with serious mental illness in the same health system (N=1,929). RESULTS: Relative to control group members, BHH patients had an immediate increase in primary care visits (+0.18 visits/month), which remained higher throughout follow-up, and an immediate decrease in emergency department visits (-0.031 visits/month). Behavioral health outpatient visits, which were increasing for BHH participants before implementation, began decreasing postimplementation; this decrease (-0.016 visits/month) was significantly larger than for the control group. Inpatient and outpatient visits for general medical health were decreasing over time for both groups before implementation but decreased more slowly for BHH patients postimplementation. Although behavioral health inpatient visits decreased for both groups around the start of the BHH program and remained lower, this initial drop was larger for the non-BHH group. BHH participation was associated with decreases in hemoglobin A1c values but no shift in low-density lipoprotein cholesterol values. CONCLUSIONS: The results reflect the challenges of improving health for patients with serious mental illness, even as access to primary care is increased. Further study is needed about which complex interventions inside and outside of the health care system can help offset the 20- to 30-year mortality gap faced by this population.

The interrelationships of motivation, positive symptoms, stigma, and role functioning in early psychosis.

AIM: Avolition, or the lack of motivation, has consistently been shown to be a significant predictor of poor psychosocial outcome, with decreased overall motivation as the single strongest predictor of poor work or school outcome in first episode psychosis. This study aimed to better understand the ways in which motivation impacts work and school functioning. This study first examined the factors related to motivation in people recovering from a recent onset of psychosis, then explored the unique interrelationships between positive symptoms, stigma, and motivation and how they influence role functioning. METHODS: A total of 40 participants with early psychosis were recruited for this cross-sectional design study; with a mean of 14.5 months of treatment prior to study assessment. RESULTS: Neither experienced nor internalized stigma were related to motivation in this sample, but internalized stigma was related to work and school functioning. Positive symptoms were significantly inversely related to both work and school functioning and motivation, with mediation analyses showing that motivation significantly mediates the relationship between positive symptoms and role functioning. CONCLUSION: This relationship may shed light on the link between motivational deficits and work and school outcomes early in the course of psychosis, an area of critical importance for early intervention.

Care Management for Serious Mental Illness: A Systematic Review and Meta-Analysis.

OBJECTIVE: Persons with serious mental illness face adverse psychiatric and medical outcomes, and their care is associated with a large burden of health care costs. Care management, in which assessment, care planning, and care coordination are provided, is a common model of support, yet the evidence supporting its use among psychiatric populations is mixed. A systematic review and a meta-analysis were undertaken to determine the impact of care management on clinical outcomes, acute care utilization, cost, and satisfaction among adults with serious mental illness. METHODS: A multidatabase literature search was performed. Articles were included if they compared standard outpatient care plus care management with standard outpatient care alone for adults with serious mental illness and reported on one or more predefined outcomes. Randomized controlled trials (RCTs) and other study designs were permitted for inclusion in the systematic review. The meta-analysis included only RCTs. RESULTS: For the systematic review, 34 articles representing 28 unique studies were included. Fifteen of these articles, representing 12 unique studies, were included in the meta-analysis, which indicated that care management was associated with small, statistically significant improvements in psychiatric symptoms, overall quality of life (QOL), and mental QOL (Hedges' g range 0.13-0.26). In addition, care management was associated with a small, statistically significant reduction in inpatient psychiatric hospital days (Hedges' g=0.16, p=0.02). CONCLUSIONS: Care management is associated with fewer psychiatric symptoms and greater QOL for persons with serious mental illness. Further work is needed to determine which components of the intervention are associated with effectiveness.

Promoting Population Behavioral Health in a Safety-Net Health System During the COVID-19 Pandemic.

The COVID-19 pandemic has been expected to lead to substantial increases in need for behavioral health care. A population health framework can facilitate the development of interventions and policies to promote the equitable distribution of care across the population. This column describes the application of population behavioral health principles in a safety-net health system during the pandemic. The approach includes stepped models of care, interventions to target individuals at high behavioral health risk, and measurement-based care. Early data suggest that these strategies have resulted in expanded behavioral health care capacity.

Recognizing and Seizing the Opportunities That Value-Based Payment Models Offer Behavioral Health Care.

The rapid rise of value-based payment (VBP) models presents both new opportunities and challenges for behavioral health providers, especially in health systems that serve low-income and marginalized communities. This column discusses the experience of a community health care system as an early adopter of VBP in order to demonstrate both the constraints and possibilities health systems face when implementing VBP models. This example and the lessons drawn from it can assist other health systems seeking to implement these models.

Patient and provider perception of appropriateness, acceptability, and feasibility of behavioral health home (BHH) core components based on program implementation in an urban, safety-net health system.

Background: This manuscript evaluates patient and provider perspectives on the core components of a Behavioral Health Home (BHH) implemented in an urban, safety-net health system. The BHH integrated primary care and wellness services (e.g., on-site Nurse Practitioner and Care Manager, wellness groups and tools, population health management) into an existing outpatient clinic for people with serious mental illness (SMI). Methods: As the qualitative component of a Hybrid Type I effectiveness-implementation study, semi-structured interviews were conducted with providers and patients 6 months after program implementation, and responses were analyzed using thematic analysis. Valence coding (i.e., positive vs. negative acceptability) was also used to rate interviewees' transcriptions with respect to their feedback of the appropriateness, acceptability, and feasibility/sustainability of 9 well-described and desirable Integrated Behavioral Health Core components (seven from prior literature and two additional components developed for this intervention). Themes from the thematic analysis were then mapped and organized by each of the 9 components and the degree to which these themes explain valence ratings by component. Results: Responses about the team-based approach and universal screening for health conditions had the most positive valence across appropriateness, acceptability, and feasibility/sustainability by both providers and patients. Areas of especially high mismatch between perceived provider appropriateness and measures of acceptability and feasibility/sustainability included population health management and use of evidence-based clinical models to improve physical wellness where patient engagement in specific activities and tools varied. Social and peer support was highly valued by patients while incorporating patient voice was also found to be challenging. Conclusions: Findings reveal component-specific challenges regarding the acceptability, feasibility, and sustainability of specific components. These findings may partly explain mixed results from BHH models studied thus far in the peer-reviewed literature and may help provide concrete data for providers to improve BHH program implementation in clinical settings. Plain language abstract: Many people with serious mental illness also have medical problems, which are made worse by lack of access to primary care. The Behavioral Health Home (BHH) model seeks to address this by adding primary care access into existing interdisciplinary mental health clinics. As these models are implemented with increasing frequency nationwide and a growing body of research continues to assess their health impacts, it is crucial to examine patient and provider experiences of BHH implementation to understand how implementation factors may contribute to clinical effectiveness. This study examines provider and patient perspectives of acceptability, appropriateness, and feasibility/sustainability of BHH model components at 6-7 months after program implementation at an urban, safety-net health system. The team-based approach of the BHH was perceived to be highly acceptable and appropriate. Although providers found certain BHH components to be highly appropriate in theory (e.g., population-level health management), their acceptability of these approaches as implemented in practice was not as high, and their feedback provides suggestions for model improvements at this and other health systems. Similarly, social and peer support was found to be highly appropriate by both providers and patients, but in practice, at months 6-7, the BHH studied had not yet developed a process of engaging patients in ongoing program operations that was highly acceptable by providers and patients alike. We provide these data on each specific BHH model component, which will be useful to improving implementation in clinical settings of BHH programs that share some or all of these program components.

Mind the Gap: Developing an Integrated Behavioral Health Home to Address Health Disparities in Serious Mental Illness.

OBJECTIVE: This study evaluated the impact of an integrated behavioral health home (BHH) pilot on adults with psychotic and bipolar disorders. METHODS: Quasi-experimental methods were used to compare outcomes before (September 2014-August 2015) and after the intervention (September 2015-August 2016) among ambulatory BHH patients and a control group. Electronic health records were compared between 424 BHH patients (N=369, psychotic disorder; N=55, bipolar disorder) and 1,521 individuals from the same urban, safety-net health system who were not enrolled in the BHH. Groups were weighted by propensity score on the basis of sex, age, race-ethnicity, language, 2010 U.S. Census block group characteristics, Medicare and Medicaid enrollment, and diabetes diagnosis. RESULTS: BHH patients had fewer total psychiatric hospitalizations and fewer total emergency visits compared with the control group, a difference that was predominantly driven by patients with at least one psychiatric hospitalization or ED visit. There were no differences in medical hospitalizations. Although BHH patients were more likely to receive HbA1c screening, there were no differences between the groups in lipid monitoring. Regarding secondary outcomes, there were no significant differences in changes in metabolic monitoring parameters among patients with diabetes. CONCLUSIONS: Participation in a pilot ambulatory BHH program among patients with psychotic and bipolar disorders was associated with significant reductions in ED visits and psychiatric hospitalizations and increased HbA1c monitoring. This evaluation builds on prior research by specifying intervention details and the clinical target population, strengthening the evidence base for care integration to support further program dissemination.

Randomized controlled trial of an internet cognitive behavioral skills-based program for auditory hallucinations in persons with psychosis.

OBJECTIVE: Despite strong evidence supporting the effectiveness of cognitive-behavioral therapy for psychosis (CBTp), most clinicians in the United States have received little or no training in the approach and access remains very low, indicating a potential role for technology in increasing access to this intervention. Coping With Voices (CWV) is a 10-session, interactive, Web-based CBTp skills program that was developed to meet this need, and was shown to be feasible and associated with reduced severity of auditory hallucinations in a previous pilot study. To more rigorously evaluate this program, a randomized controlled trial was conducted comparing the efficacy of CWV to usual care (UC). METHOD: The trial was conducted with a sample of 37 community mental health center clients with schizophrenia and moderate-to-severe auditory hallucinations, with assessments conducted at baseline, posttreatment, and 3-month follow-up. RESULTS: Engagement in and satisfaction with the CWV program were high. Both the CWV and UC groups improved comparably in severity of auditory hallucinations and other symptoms over the treatment and at follow-up. However, participants in the CWV program showed significantly greater increases in social functioning and in knowledge about CBTp. CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: The results suggest that the CWV program has promise for increasing access to CBTp, and associated benefits in the management of distressing psychotic symptoms and improving social functioning. (PsycINFO Database Record

Older adults' perceptions of recovery from mental illness: Impact of psychiatric hospitalization prior to 1990.

OBJECTIVE: We tested the hypothesis that older adults are more likely than younger adults to consider their current mental health status when estimating their own recovery from psychiatric illness because many older people were first hospitalized for psychiatric illness prior to the emergence of the recovery movement in the 1990s, before recovery was redefined to include life improvements other than symptom alleviation. METHOD: Seventy-one members of a rehabilitation program (age 23 to 69; M = 49) were asked to rate satisfaction with their own recovery and with their current mental and physical health. The study hypothesis was tested in two hierarchical regression analyses that examined variation in the correlation between mental health and recovery self-ratings first by age and then by year of first hospitalization. RESULTS: The correspondence between mental health and recovery self-ratings was twice as strong for adults age 50 and older compared with those younger than age 50 and this same age difference in self-ratings was also evident for participants first hospitalized for a psychiatric illness earlier versus later than 1990. The correlation between physical health and recovery self-ratings did not vary by age or year of first hospitalization. CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: Recovery-oriented interventions will be most effective for older individuals when service providers take into account their personal histories and the propensity of many older adults to associate recovery with symptom improvement even while embracing other life improvements.

Social value of supported employment for psychosocial program participants.

Members of a psychiatric psychosocial program designed to provide both supported employment and peer support were surveyed about their current social activities, sources of social support, and social life improvement since joining the program. Survey respondents who worked a mainstream job (n=17) reported greater peer contact in community locations, and correspondingly greater social life improvement, than those who remained unemployed or worked volunteer jobs (n=45). Results of a hierarchical regression analysis (N=62) that explored this positive correlation between mainstream work, community-based peer contact, and social life satisfaction suggest that working a job in an integrated setting that paid at least minimum wage encouraged program participants to meet and interact in community locations, thereby strengthening peer mutual support while furthering social integration. This unique pattern of findings requires replication, and we recommend that other psychosocial programs conduct similar quality improvement studies to provide further insights into the relationship between peer support and community integration.

Adapting evidence-based interventions to fit usual practice: staff roles and consumer choice in psychiatric rehabilitation.

This proof-of-concept study tested the viability of adapting a specialized practice to fit multi-service programs by switching from specialist to generalist staff roles. The intervention under study was supported employment, an evidence-based practice for adults with severe mental illness. Program data on participant characteristics, attendance, staff contact, and employment were retrieved for the 2007 calendar year (N = 99). Two hierarchical regression analyses compared (1) participants with any versus no mainstream employment, and (2) participants who started a new job in 2007 versus all other participants. In both analyses, individual participant counts of days on which employment services were provided and count of different employment service providers independently predicted mainstream employment over and above program attendance and background factors. The study program's employment rate approximated rates published for specialized supported employment programs, suggesting that it is feasible to adapt specialized evidence-based practices to fit multi-service settings without compromising service quality.

Viability of using employment rates from randomized trials as benchmarks for supported employment program performance.

Cumulative employment rates published by randomized trials are based on each enrollee's pre-planned 18-24-months of study participation. By contrast, community programs typically report employment rates for clients active in services during a calendar quarter. Using data from three supported employment programs in randomized trials, we show that trial cumulative employment rates are about twice as large as quarterly employment rates for the same program. Therefore, we recommend that administrators, service networks, and mental health authorities begin to publish quarterly employment rates, and quarterly median earnings, to allow policymakers to set realistic performance expectations for supported employment programs.