The Impact of a Culturally Meaningful Storytelling Intervention on Stigma and Attitudes About Mental Health Treatment.

ABSTRACT: The fear of being devalued or discriminated against is a salient deterrent to seeking mental health care, especially in communities of color where racial stigma also impacts mental health and perceptions of service utilization. To address this issue, our research team partnered with This Is My Brave Inc to develop and evaluate a virtual storytelling intervention to highlight and amplify the voices of Black and Brown Americans living with mental illness and/or addiction. We utilized a pretest-posttest survey design administered electronically to viewers of the series ( n = 100 Black, indigenous, people of color and n = 144 non-Hispanic White). Results indicated that postintervention, scores on public stigma and perceived discrimination measures were significantly reduced. We identified significant interaction effects, such that Black, indigenous, people of color viewers showed a greater rate of improvement on outcomes. This study provides strong preliminary evidence of the impact of a culturally meaningful virtual approach to addressing stigma and improving attitudes about mental health treatment.

A Pilot Study of Brief, Stepped Behavioral Activation for Primary Care Patients with Depressive Symptoms.

In a prior pilot study with primary care patients experiencing depressive symptoms, we observed positive outcomes for a behavioral activation protocol involving one visit and three calls. We aimed to pilot test a stepped version with flexible numbers of contacts. Fifteen primary care patients scoring 5-14 on the Patient Health Questionnaire-9 engaged in the three-tiered telephone-based intervention: (1) two calls (15-20 min each); (2) one 30-60 min encounter followed by two calls; and (3) one to six calls. Participants completed assessments at pre-treatment, post-treatment, and three months later. Participants improved from baseline to post-treatment and three months later for depressive symptoms, anxiety symptoms, and disability. Most participants (9 of 15) engaged in the first tier only, averaging less than one hour of contact, and reported benefits and high satisfaction. This intervention showed preliminary evidence of feasibility, acceptability, satisfaction, and benefits, warranting further pilot testing with primary care personnel.

Screening and Priority-Setting to Determine Home- and Community-Based Aging Services for Older Floridians.

The National Aging Network serves millions of older Americans seeking home- and community-based services, but places others on waitlists due to limited resources. Little is known about how states determine service delivery and waitlists. We therefore conducted a process evaluation and analyzed data from one five-county Area Agency on Aging in Florida, where an algorithm calculates clients' priority scores for service delivery. From 23,225 screenings over 5.5 years, clients with higher priority scores were older, married, living with caregivers, and had more health problems and needs for assistance. Approximately 51% received services (e.g., meals/nutrition, case management, caregiver support), 11% were eligible/being enrolled, and 38% remained on waitlists. Service status was complex due to multiple service enrollments and terminations, funding priorities, and transfers to third-party providers. More research is needed regarding how other states determine eligibility and deliver services, potentially informing national standards that promote optimal health in older Americans.

Health care Affordability and Associated Concerns Among Adults Aged 65 and above in Florida.

OBJECTIVE: This study assessed affordability of care in a diverse sample of Floridians aged ≥ 65 to ascertain concerns about health care costs. METHODS: We surveyed 170 adults (40.6% white, 27.6% black, and 31.8% Hispanic) and conducted three race/ethnic-stratified focus groups (n = 27). RESULTS: Most participants had Medicare (97.1%). Among whites, 11.6% reported problems paying medical bills in the past 12 months versus 14.9% of blacks and 24.1% of Hispanics. In addition, 13% of whites, 19.2% of blacks, and 20.4% of Hispanics reported not getting needed prescription drugs because of costs. The most frequently identified concerns from the focus groups were the cost of prescription drugs, out-of-pocket expenses, and medical billing. Concerns about medical billing included understanding bills, transparency, timely postings, and uncertainty about who to contact about problems. DISCUSSION: Our findings suggest that practices that help older adults effectively manage medical bills and costs may alleviate their concerns and guard against financial burdens.

The Influence of Health Literacy and Social Support on Loneliness Among Patients With Severe Mental Illness in Rural Southwest China.

Loneliness is an important risk factor for poor health outcomes among adults, especially among those with severe mental illnesses (SMIs). Existing research has shown that adults with SMIs often lack health literacy, which contributes to more restricted social networks and low levels of social support. The objective of this cross-sectional study was to examine the influence of health literacy and social support on the loneliness of patients with SMI in rural Southwest China. We recruited 300 patients with SMI in rural Southwest China between December, 2017 to May, 2018 via a multi-stage stratified random sampling approach. We used structural equation modeling (SEM) test the hypothesized relationships among the variables of the 270 patients who completed the survey. Results of the SEM showed that health literacy was both directly and indirectly associated with loneliness, with social support playing a mediating role. These findings suggest psychoeducation for SMI patients, and their informal caregivers, may offer beneficial effects toward reducing loneliness in this vulnerable population. Further, social support is another potential target for intervention development for improving patient outcomes.

Enhancing care transitions intervention with peer support to improve outcomes among older adults with co-occurring clinical depression: a pilot study.

The Care Transitions Intervention (CTI) is an evidence-based intervention aimed at supporting the transition from hospital back to the community for patients to ultimately reduce preventable re-hospitalization. In a pilot randomized controlled trial, we examined the preliminary effectiveness of an Enhanced Care Transitions Intervention (ECTI), CTI with the addition of peer support, for a racially/ethnically diverse sample of older adults (age 60+) with co-morbid major depression. We observed a significant decline in health-related quality of life (HRQOL) after being discharged from the hospital among those who received CTI. Additionally, those who received ECTI either maintained HRQOL scores, or, saw improvement in HRQOL scores. Findings suggest the Enhanced Care Transitions Intervention can maintain or improve HRQOL and reduce disparities for older participants from diverse racial/ethnic backgrounds with clinical depression.

Social support and quality of life among rural family caregivers of persons with severe mental illness in Sichuan Province, China: mediating roles of care burden and loneliness.

OBJECTIVE: To explore the relationship between social support and quality of life (QoL) among family caregivers of persons with severe mental illness (SMI) and examine the mediating roles of care burden and loneliness. METHODS: A cross-sectional study was carried out between December 2017 and May 2018. A random sample of 256 family caregivers of persons with SMI in rural areas of Sichuan Province, China was recruited for participation. Survey data on socio-demographics, social support, care burden, loneliness, and QoL were collected via in-person interviews. Multiple linear regression analysis and structural equation modeling (SEM) were used to test the hypothesized relationships. RESULTS: The majority (72.7%) of family caregivers of persons with SMI in this study reported having low QoL. Social support was positively associated with QoL and negatively associated with care burden and loneliness. The findings suggested the mediating roles of care burden and loneliness on the association between social support and QoL. CONCLUSION: The hypothesized model was found to be a suitable model for predicting QoL among family caregivers of persons with SMI. The findings can help inform the design of future interventions aimed at enhancing social support, reducing care burden and loneliness, which may be helpful to improve caregivers' QoL. Future study is required to find a causal path to promote QoL among family caregivers of persons with SMI.

The Strong Black Woman versus Mental Health Utilization: A Qualitative Study.

Recent investigations have elucidated the influence of the strong Black woman (SBW) ideal on the mental health and treatment-seeking behaviors of Black women in the United States. However, factors related to how the SBW ideal affects Black women's positive and negative attitudes toward seeking professional psychological help have yet to be identified. The current study fills this void in the literature through a qualitative examination of how the SBW ideal affects Black women's mental health utilization. Analyses were based on 62 participants, including college students and community members, ranging in age from 18 to 72 years. The present study advances the idea that endorsement of the SBW ideal affects Black women's mental utilization. These results offer evidence and clarification of the impact of the SBW ideal on Black women's mental health and identity-specific points of intervention for mental health practitioners conducting therapeutic work with Black women. Authors provide practice recommendations for practitioners and suggestions for future research.

Factors predicting help seeking for mental illness among college students.

BACKGROUND: Evidence supports the contribution of various stigma-related constructs to help-seeking. These constructs have yet to be tested in a single model among college students, a group highly affected by mental illness. AIMS: Using data from 153 college students, this study examines factors contributing to help seeking for mental illness. METHOD: Using path analysis, the current study evaluated a model of the relationship between level of familiarity, personal stigma, desired social distance, label avoidance, attitudes towards treatment seeking and intentions to seek treatment. RESULTS: Findings support a model of help-seeking describing the relationship between familiarity with mental illness, personal stigma, social distance, label avoidance, attitudes and intentions to seek treatment. CONCLUSIONS: Findings suggest label avoidance, attitudes towards treatment seeking and intentions to seek treatment might be augmented through interventions aimed at increasing college students' levels of familiarity, or intimate contact, with individuals with mental illness. Additional implications for practice and further research are addressed.

Effects of in-person and telephone-based cognitive behavioral therapies on health services use and expenditures among African-American dementia caregivers with depressive symptoms.

Objectives: To compare the effects of telephone-based and in-person cognitive behavioral therapy (CBT) on health services use and expenditures among African-American dementia caregivers (CGs) with depressive symptoms.Methods: We analyzed data collected from 109 caregivers in a randomized controlled trial comparing the effects of telephone-based and in-person CBT on health services use and costs. Study participants were assigned randomly to either telephone or in-person CBT. Data were collected one week before and one week after the 12-week intervention. The Health Service Composite (HSC) was used to collect information on health services (physical and mental health, emergency room, hospital) utilization and associated expenditures. Intervention cost data were collected using micro-costing analysis. We used generalized linear models to examine whether the two groups differed in total health care expenditures over the six-month study period.Results: CG characteristics and health services use were similar at pre-intervention. CGs' monthly health expenditures averaged $924 and $844 in the in-person and telephone-based groups, respectively. However, intervention costs were lower for telephone-based than in-person CBT. Adjusting for CG characteristics and pre-intervention health status, there were no statistically significant differences in average monthly expenditures between the two intervention groups across time.Discussion: Findings suggest that while telephone-based CBT offers more participation flexibility, it has a similar cost profile as compared to the in-person CBT. Despite the lack of cost saving, telephone-based CBT may be an important option for providing skills building and support to older African-American family CGs with barriers to access resources for respite care and transportation.

Individual and Organizational Factors Associated With Hospital Readmission Rates: Evidence From a U.S. National Sample.

Objective: Hospital readmission rate is an important indicator for assessing quality of care in the acute and postacute settings. Identifying factors that increase risk for hospital readmissions can aid in the recognition of potential targets for quality improvement efforts. The main objective of this brief report was to examine the factors that predict increased risk of 30-day readmissions. Method: We analyzed data from the 2013 National Readmission Database (NRD). Results: The main factors that predicted increased risk of 30-day readmission were number of chronic conditions, severity of illness, mortality risk, and hospital ownership. Unexpectedly, discharge from a for-profit hospital was associated with greater risk for hospital readmission in the United States. Discussion and Conclusion: These findings suggest that patients with severe physical illness and multiple chronic conditions should be the primary targets for hospital transitional care interventions to help reduce the rate of unnecessary hospital readmissions.

Factors associated with the choice of primary care facilities for initial treatment among rural and urban residents in Southwestern China.

OBJECTIVE: To explore influential factors contributing to the choice of primary care facilities (PCFs) for the initial treatment among rural and urban residents in Southwestern China. METHODS: A face-to-face survey was conducted on a multistage stratified random sample of 456 rural and 459 urban residents in Sichuan Province from January to August in 2014. A structured questionnaire was used to collect data on residents' characteristics, provider of initial treatment and principal reason for the choice. Multivariate logistic regression was performed to identify factors associated with choosing PCFs for the initial treatment. RESULTS: The result showed that 65.4% of the rural residents and 50.5% of the urban residents chose PCFs as their initial contact for medical care. Among both rural and urban residents, the principal reason for choosing medical institutions for the initial treatment was convenience (42.3% versus 40.5%, respectively), followed by high quality of medical care (26.5% versus 29.4%, respectively). Compared to rural residents, urban residents were more likely to value trust in doctors and high quality of medical care but were less likely to value the insurance designation status of the facilities. Logistic regression analysis showed that both rural and urban residents were less likely to choose PCFs for the initial treatment if they lived more than 15 minutes (by walk) from the nearest facilities (rural: OR = 0.15, 95%CI = 0.09-0.26; urban: OR = 0.19, 95%CI = 0.10-0.36), had fair (rural: OR = 0.49, 95%CI = 0.26-0.92; urban: OR = 0.31, 95%CI = 0.15-0.64) or poor (rural: OR = 0.14, 95%CI = 0.07-0.30; urban: OR = 0.22, 95%CI = 0.11-0.44) self-reported health status. Among rural residents, attending college or higher education (OR = 0.21, 95%CI = 0.08-0.59), being retired (OR = 0.90, 95%CI = 0.44-1.84) and earning a per capita annual income of household of 10,000-29,999 (OR = 0.24, 95%CI = 0.11-0.52) and 30,000-49,999 (OR = 0.26, 95%CI = 0.07-0.92) were associated with lower rates of seeking care at PCFs. CONCLUSION: Efforts should be made to improve the accessibility of PCFs and to upgrade the services capability of PCFs both in rural and urban areas in China. At the same time, resources should be prioritized to residents with poorer self-reported health status, and rural residents who retire or have better education and higher income levels should be taken into account.

The Reduction of Public and Internalized Stigma in Late-Life Depression: A Pilot Study.

Innovative strategies are needed to reduce the impact of stigma as a barrier to mental health services for older adults living with a mental illness. The purpose of this brief report was to examine the impact of a 3-month peer educator (PE) intervention on stigma reduction in a sample of depressed older adults. PEs are individuals of similar age, and racial and socioeconomic backgrounds who have been previously treated for depression, and are trained to provide support and education to depressed individuals within their community. Participants (N = 21) aged 60 and older completed a demographic questionnaire, public stigma, and internalized stigma measures pre- and post-PE intervention. The results of paired samples t tests indicated that the use of PEs significantly reduced both public and internalized stigma among depressed older adults. PEs may be an effective strategy toward alleviating stigma and increasing mental health service utilization among older adults with depression.

Factors associated with willingness to enter long-term care facilities among older adults in Chengdu, China.

OBJECTIVE: To describe Chinese older adults' willingness to enter long-term care facilities and to examine individual factors associated with the willingness of using this growing model of long-term care in China. METHODS: A cross-sectional study involving a random sample of 670 adults aged 60+ in the Hezuo community in Chengdu, China in 2016. Respondents were interviewed by trained staff on socio-demographics, health status, quality of life, social support, and willingness to enter long-term care facilities. RESULTS: Only 11.9% of the respondents were willing to enter long-term care facilities for meeting their medical and social service needs. Multivariable logistic regression analysis showed that willingness to enter long-term care facilities was associated with higher household income (OR = 4.55, 95% CI:1.72-12.00), insurance of Urban Resident Basic Medical Insurance (OR = 4.80, 95% CI:1.17-19.67) and unemployment (OR = 0.48, 95% CI:0.24-0.99). Among those who were willing to enter long-term care facilities, an overwhelming majority (81.2%) would prefer going to a facility within 30-minute walking distance from their current residence, 82.5% indicated the need of nursing care, and 90.0% expected a partnership between the long-term care facility and a large hospital. CONCLUSIONS: A minority of older Chinese were willing to receive long-term care delivered at a facility within walking distance from their current residence. Recent policy aimed at increasing the supply of long-term care facilities may not be consistent with consumer preference for home and community-based care. Balancing investment between home and community-based care, and establishing long-term care insurance remain the top priorities for long-term care research and policy development in China.

Peer Education: Productive Engagement for Older African Americans in Recovery From Depression.

Background and Objectives: Older adults who have personal experience with the mental health service delivery system gain unique and potentially valuable insight from their treatment experiences. Research suggests that incorporating trained individuals in recovery from a mental illness (i.e., peer educators) into mental health service delivery roles results in substantial benefits for current mental health consumers, particularly for older adults and racial and ethnic minorities who may feel disenfranchised from the traditional mental health service delivery system. However, little research has examined the impact of participating in these activities on the peer educators themselves. Research Design and Methods: This mixed methods study examines the experiences of 10 African American older adults in recovery from depression currently working as trained peer educators. Peer educators reported feeling more positive, feeling their lives had significantly improved, and feeling better in general due to their peer educator roles. Results: This qualitative investigation highlights four unique themes that can explain the benefit of serving in this capacity (i.e., Community Engagement, Life Long Learning and Education, Mental Health Recovery and Productive Aging). Discussion and Implications: This study suggests that serving has a peer educator has a number of beneficial outcomes for African American older adults in recovery from depression.

Cross-sectional study of factors associated with community health centre use in a recently urbanised community in Chengdu, China.

OBJECTIVES: Public investment in community health centres (CHCs) has been increasing as a response to rapid urbanisation in China. The objectives of this study were: (1) to examine factors associated with CHC use among residents from a recently urbanised community in western China and (2) to describe satisfaction with CHC among users. DESIGN: Cross-sectional design. SETTING: A community recently converted to urban status with a newly constructed CHC in Southwest China. PARTICIPANTS: A random sample of 2259 adults in the Hezuo community in Chengdu, China, completed the survey in 2013. OUTCOME MEASURES: Trained staff interviewed study participants in their homes using structured questionnaires. The survey included questions regarding sociodemographics, health status, access to and usage of healthcare, health behaviours and CHC use. The Andersen's behavioural model of health service use was used to guide multivariable logistic regression modelling in identifying predisposing, enabling and need factors associated with the likelihood of using CHC. Descriptive statistics were used to describe residents' satisfaction with the CHC. RESULTS: A total of 71.8% of the respondents reported using the CHC during the past year. Factors influencing adults' CHC use included: gender, marital status, education level and knowledge of one's blood pressure (predisposing factors); annual household per capita income and walking time to the CHC (enabling factors) and self-rated health as well as physical activities (need factors). CHC users reported modest satisfaction across various aspects of the CHC. CONCLUSIONS: Neighbourhood CHC in urban areas provides important services to these residents living in a recently urbanised community. All three categories of factors in the Andersen model help explain the likelihood of CHC use. There is much room for improvement in CHC to enhance customer satisfaction. Future research is needed to improve access to CHCs and promote their use in urbanised populations with low to modest education.

Peer education as a strategy for reducing internalized stigma among depressed older adults.

OBJECTIVE: This article examines the mechanisms through which peer educator (PE) intervention targets and reduces internalized stigma. There is substantial evidence that internalized stigma negatively impacts the lives of those suffering with mental health concerns, and has been identified as 1 of the most significant barriers to seeking professional mental health services. There has been a push toward identifying interventions and programs that effectively reduce and mitigate the impact of internalized stigma. Research suggests that contact with other individuals who share a stigmatized condition may be a promising approach to targeting and reducing internalized stigma. However, there is a dearth of research that has identified the mechanism through which this contact impacts internalized stigma. METHODS: Study participants (n = 19) completed a 3-month PE intervention. Each participant was matched with an older adult with a history of depression currently in recovery who provided psychoeducation, social support, and motivational interviewing. Participants completed a demographic questionnaire, public stigma (PDD), and internalized stigma (Internalized Stigma of Mental Illness, ISMI) scales pre- and post-PE intervention. They further participated in a brief semistructured qualitative interview to attain in-depth information about their perceptions of stigma and of working with a PE. RESULTS: Overall, internalized stigma scores were significantly reduced after participating in the PE intervention. In addition, participants identified 4 mechanisms through which contact with their PE impacted their stigmatized beliefs: age related concerns, shared understanding, improved mental health literacy, and mutual support. CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: This study suggests that PE is a potentially valuable approach toward reducing internalized stigma among older adults with depression.

Differences in treatment attitudes between depressed African-American and Caucasian veterans in primary care.

OBJECTIVES: Depressive disorders are common, and it is important to understand the factors that contribute to racial disparities in depression treatment. This primary care study of veterans with subsyndromal depression examined two hypotheses: that African Americans would be less likely than Caucasians to believe that medication is beneficial in depression treatment and would be more likely to believe that counseling or psychotherapy is beneficial. METHODS: Primary care patients with subsyndromal depression were referred to the Philadelphia Department of Veterans Affairs Behavioral Health Laboratory and asked about past experiences and attitudes toward depression treatment. RESULTS: Among 111 African-American and 95 Caucasian participants, logistic regression analyses determined that African Americans were less likely to view medication as beneficial (odds ratio=.44). No racial differences were found in participants' attitude toward counseling or psychotherapy. CONCLUSIONS: The findings support the premise that clinicians treating patients with subsyndromal depressive syndromes should take into account racial differences in attitudes toward treatment.

Barriers to treatment and culturally endorsed coping strategies among depressed African-American older adults.

OBJECTIVE: Older adults are particularly vulnerable to the effects of depression, however, they are less likely to seek and engage in mental health treatment. African-American older adults are even less likely than their White counterparts to seek and engage in mental health treatment. This qualitative study examined the experience of being depressed among African-American elders and their perceptions of barriers confronted when contemplating seeking mental health services. In addition, we examined how coping strategies are utilized by African-American elders who choose not to seek professional mental health services. METHOD: A total of 37 interviews were conducted with African-American elders endorsing at least mild symptoms of depression. Interviews were audiotaped and subsequently transcribed. Content analysis was utilized to analyze the qualitative data. RESULTS: Thematic analysis of the interviews with African-American older adults is presented within three areas: (1) Beliefs about Depression Among Older African-Americans; (2) Barriers to Seeking Treatment for Older African-Americans; and (3) Cultural Coping Strategies for Depressed African-American Older Adults. CONCLUSION: Older African-Americans in this study identified a number of experiences living in the Black community that impacted their treatment seeking attitudes and behaviors, which led to identification and utilization of more culturally endorsed coping strategies to deal with their depression. Findings from this study provide a greater understanding of the stigma associated with having a mental illness and its influence on attitudes toward mental health services.

Mental health treatment seeking among older adults with depression: the impact of stigma and race.

OBJECTIVE: Stigma associated with mental illness continues to be a significant barrier to help seeking, leading to negative attitudes about mental health treatment and deterring individuals who need services from seeking care. This study examined the impact of public stigma (negative attitudes held by the public) and internalized stigma (negative attitudes held by stigmatized individuals about themselves) on racial differences in treatment-seeking attitudes and behaviors among older adults with depression. METHOD: Random digit dialing was utilized to identify a representative sample of 248 African American and white older adults (older than 60 years) with depression (symptoms assessed by the Patient Health Questionnaire-9). Telephone-based surveys were conducted to assess their treatment-seeking attitudes and behaviors and the factors that impacted these behaviors. RESULTS: Depressed older adult participants endorsed a high level of public stigma and were not likely to be currently engaged in or did they intend to seek mental health treatment. Results also suggested that African American older adults were more likely to internalize stigma and endorsed less positive attitudes toward seeking mental health treatment than their white counterparts. Multiple regression analysis indicated that internalized stigma partially mediated the relationship between race and attitudes toward treatment. CONCLUSION: Stigma associated with having a mental illness has a negative influence on attitudes and intentions toward seeking mental health services among older adults with depression, particularly African American elders. Interventions to target internalized stigma are needed to help engage this population in psychosocial mental health treatments.