An Intersectional Approach to Ethnoracial Disparities in Pathways to Care Among Individuals With Psychosis in Coordinated Specialty Care.

Importance: Intersecting factors of social position including ethnoracial background may provide meaningful ways to understand disparities in pathways to care for people with a first episode of psychosis. Objective: To examine differences in pathways to care by ethnoracial groups and by empirically derived clusters combining multiple factors of social and clinical context in an ethnoracially diverse multisite early-intervention service program for first-episode psychosis. Design, Setting, and Participants: This cohort study used data collected on individuals with recent-onset psychosis (<2 years) by clinicians with standardized forms from October 2013 to January 2020 from a network of 21 coordinated specialty care (CSC) programs in New York State providing recovery-oriented, evidence-based psychosocial interventions and medications to young people experiencing early psychosis. Exposures: Ethnoracial group and other factors of social position (eg, insurance status, living situation, English fluency, geographic region) intersecting with first-contact experiences (ie, type of first service, referral source, and symptoms at referral). Main Outcomes and Measures: Outcome measures were time from onset to first contact, first contact to CSC, and onset to CSC. Results: The total study sample consists of 1726 individuals aged 16 to 30 years and included 452 women (26%), 1263 men (73%), and 11 (<1%) with another gender enrolled in the network of CSC programs. The total sample consisted of 153 Asian (9%), 599 Black (35%), 454 Latinx (26%), and 417 White individuals (24%). White individuals had a significantly shorter time from onset to first contact (median [IQR], 17 [0-80] days) than Asian (median [IQR], 34 [7-94] days) and Black (median [IQR], 30 [1-108] days) individuals but had the longest period from first contact to CSC (median [IQR], 102.5 [45-258] days). Five distinct clusters of individuals emerged that cut across ethnoracial groups. The more disadvantaged clusters in terms of both social position and first-contact experiences had the longest time from onset to first contact, which were longer than for any single ethnoracial group. Conclusions and Relevance: In this cohort study of individuals with recent-onset psychosis, time-to-treatment outcomes differed by ethnoracial group and by empirically derived clusters combining multiple factors of social and clinical context. The examination of disparities in durations to treatment through an intersectional, ethnoracial lens may improve understanding of the inequities resulting from the various intersecting factors that may compound delays in treatment initiation.

Financing Early Psychosis Intervention Programs: Provider Organization Perspectives.

OBJECTIVE: The authors aimed to identify prominent financing approaches for coordinated specialty care (CSC) of patients with first-episode psychosis, alignment or misalignment of such approaches with sustained CSC implementation, and CSC provider perspectives on ideal payment models. METHODS: Semistructured interviews were conducted with informants from CSC provider organizations. Purposeful sampling of CSC program directors, team leaders, and other administrators from a national e-mail Listserv was supplemented by snowball sampling via participant recommendations. Interview data from 19 CSC programs in 14 states were analyzed by using an integrated (inductive and deductive) approach to derive themes. RESULTS: The results indicated that financing approaches to CSC were patchwork and highly varied. Three major sources of funding were cited: insurance billing (largely fee for service [FFS] to Medicaid and private insurance), set-aside funding from the federal Mental Health Block Grant (MHBG) program, and state funding. The findings revealed limited coverage and restrictive rules associated with FFS insurance billing that were misaligned with CSC implementation. The grant nature of MHBG and other public funding was seen as a threat to long-term CSC sustainability and deployment. CSC stakeholders endorsed a bundled-payment approach by public and private payers and supported tying payment to client outcomes to reflect CSC's recovery orientation. CONCLUSIONS: Reliance on FFS insurance billing and public funding is likely to be unsustainable. Additionally, FFS billing is misaligned with CSC goals. Because of the diversity in CSC programs, populations, and existing funding mechanisms and rules, payer-provider collaboration will be essential in designing a bundled-payment model that meets local needs.

Acculturation, coping, and PTSD in Hispanic 9/11 rescue and recovery workers.

Objective: Research examining the responders of the World Trade Center terrorist attacks of 9/11 has found that Hispanic responders are at greater risk for posttraumatic stress disorder (PTSD) than non-Hispanic White responders. However, no studies have examined how acculturation may influence the relationship between coping and PTSD in Hispanic 9/11 responders. This novel study is the first to examine differences in coping and PTSD among Hispanic responders by level of acculturation. Methods: The sample is composed of 845 Hispanic 9/11 responders who were seen at the World Trade Center Health Program and participated in a web-based survey. Using logistic and multiple linear regression, we examined how acculturation is related to their coping strategies and risk for PTSD. We also tested for interaction to examine whether level of acculturation moderated the relationship between coping and PTSD symptom severity. Results: Key findings revealed that higher acculturation is associated with the use of substances, venting, and humor to cope, while lower acculturation is associated with the use of active coping and self-distraction in this sample. We also found that less acculturated responders were more likely to experience more severe PTSD. Lastly, our findings revealed that Hispanics who are more acculturated and used substances to cope had more severe PTSD than less acculturated responders. Conclusion: These findings highlight the need to consider the role of acculturation in Hispanic responders' coping and PTSD. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Sociodemographic, clinical and help-seeking characteristics of homeless young people with recent onset of psychosis enrolled in specialized early intervention services.

AIM: To examine differences in demographic, clinical, social, functional and help-seeking characteristics of homeless vs housed individuals enrolled in specialized early intervention teams in the United States. METHODS: Participants comprised 1349 individuals enrolled across 21 teams. Teams report individual-level data including homelessness status at admission. Bivariate differences between homeless and housed participants were analysed using Wilcoxon-rank, chi-square, Fisher-exact and t tests, as appropriate. RESULTS: Approximately 5% of participants were homeless at admission. Homeless participants were less likely to be enrolled in school and/or employed (12.2% vs 43.4%); to have more involvement in the legal system (23.0% vs 6.2%); and to have had a more restrictive pathway to care, than housed participants. CONCLUSIONS: Homeless young people with recent-onset psychosis have a substantially greater need for a diversity of services for psychosocial needs. Homeless individuals may also have a more adverse pathway to care and directed outreach to engage this population may be needed.

Design of a Payment Decision-Support Tool for Coordinated Specialty Care for Early Psychosis.

A strengthened evidence base and earmarked federal funding have spurred the implementation of coordinated specialty care (CSC) for people experiencing early psychosis. However, existing funding mechanisms are insufficient and unsustainable to support population-wide deployment of CSC. This article describes the design framework of an innovative payment model for CSC that includes a bundled case rate payment and an optional outcome-based payment. To assist CSC payer and provider organizations in designing payment systems tailored to local preferences and circumstances, the research team is developing a decision-support tool that allows users to define design choices and provide input. The authors document the analytical algorithms underlying the tool and discuss how it could be further developed or expanded for CSC and other behavioral health interventions that feature an interdisciplinary team of clinicians and nonclinical professionals, public education and outreach, patient centeredness, and a recovery orientation.

Predictors of Early Discharge From Early Intervention Services for Psychosis in New York State.

OBJECTIVE: Although specialized early intervention services (EISs) for psychosis promote engagement in care, a substantial number of individuals who receive these services are discharged from care earlier than expected. The main goal of this study was to examine predictors of early discharge in a large sample of individuals enrolled in an EIS program in the United States. METHODS: This cohort study (N=1,349) used programmatic data from OnTrackNY, an EIS program that delivers evidence-based interventions to youths across New York State experiencing a first episode of nonaffective psychosis. The main outcome was "early discharge," which was operationalized as discharge prior to completing 12 months of treatment. Cox proportional hazard regression models were used to assess the association between sociodemographic, clinical, and support system predictors and early discharge. RESULTS: The estimated probability of discharge before 1 year was 32%. Participants who at baseline had poor medication adherence, had no health insurance, were living alone or with nonparental family, or were using cannabis were at higher risk of leaving services within the first 12 months after enrollment. Individuals with higher social functioning were at lower risk of being discharged early from OnTrackNY, but those with higher occupational functioning were at a higher risk. CONCLUSIONS: Predictors of early discharge from EISs largely overlapped with previously identified predictors of poor prognosis in early psychosis. However, the association between early discharge and high occupational functioning indicates that trajectories leading up to discharge are heterogeneous.

Recent violence and legal involvement among young adults with early psychosis enrolled in Coordinated Specialty Care.

AIM: Individuals with serious mental illnesses have a small increased risk of engaging in violence or legal involvement compared to the general population. This seems to be particularly true for young adults experiencing early stages of psychosis. This study analysed the prevalence of and risk factors for reports of violence and legal involvement in a sample of young adults receiving Coordinated Specialty Care for early non-affective psychosis. METHODS: A total of 373 young adults (ages 16-30) within 2 years of the onset of non-affective psychosis were enrolled in 10 Coordinated Specialty Care sites in New York State from October 2013 to August 2016. Baseline violent ideation or behaviour and legal involvement was described and predictors identified. RESULTS: Approximately one-quarter of individuals had either recent violent ideation or behaviour at baseline (n = 90, 24.6%); nearly one-tenth of the sample reported recent legal involvement (n = 33, 9.0%). Individuals with violent ideation or behaviour had lower levels of education and were less likely to be working. Those with recent legal involvement were more likely to be male and more likely to have substance use (alcohol, cannabis and other drugs). CONCLUSIONS: The overall rate of recent violent ideation or behaviour is similar to other studies; up to one-third of individuals experiencing a first-episode of psychosis (FEP) report violence. Recent legal involvement was strongly associated with substance use. This study presents insight into violence and legal involvement among individuals with FEP and indicates the need for further research.

Results of a Coordinated Specialty Care Program for Early Psychosis and Predictors of Outcomes.

OBJECTIVE: This study prospectively evaluated outcomes of OnTrackNY, a statewide coordinated specialty care (CSC) program for treatment of early psychosis in community settings, as well as predictors of outcomes. METHODS: The sample included 325 individuals ages 16-30 with recent-onset nonaffective psychosis who were enrolled in OnTrackNY and who had at least one three-month follow-up. Clinicians provided data at baseline and quarterly up to one year. Domains assessed included demographic and clinical characteristics, social and occupational functioning, medications, suicidality and violence, hospitalization, and time to intervention. Primary outcomes included the symptoms, occupational functioning, and social functioning scales of the Global Assessment of Functioning (GAF), as adapted by the U.S. Department of Veterans Affairs Mental Illness Research, Education and Clinical Center; education and employment status; and psychiatric hospitalization rate. RESULTS: Education and employment rates increased from 40% to 80% by six months, hospitalization rates decreased from 70% to 10% by three months, and improvement in GAF scores continued for 12 months. Female gender, non-Hispanic white race-ethnicity, and more education at baseline predicted better education and employment status at follow-up. CONCLUSIONS: Individuals with early psychosis receiving CSC achieved significant improvements in education and employment and experienced a decrease in hospitalization rate. Demographic variables and baseline education predicted education and employment outcomes. CSC teams should make particular effort to support the occupational goals of individuals at increased risk of not engaging in work or school, including male participants and participants from racial and ethnic minority groups.

Understanding Pathways to Care of Individuals Entering a Specialized Early Intervention Service for First-Episode Psychosis.

OBJECTIVE: This study aimed to understand the pathways to care from the onset of a first episode of psychosis to entry into a specialized early intervention service (EIS) for individuals with nonaffective psychosis. METHODS: A sample of 20 individuals who participated in an EIS and ten of their family members were enrolled. Semistructured qualitative interviews were used to characterize participants' lives during the onset of psychosis and explore their help-seeking events from the onset of psychosis to entry into the EIS. Data were analyzed by using grounded theory and a case study methodology. RESULTS: The median duration between the onset of psychosis and EIS entry was 4.5 months. A grounded model emerged from the analysis that captured how help-seeking decisions were influenced by the misattribution of symptoms, stigma, and self-reliance. These factors created a cloud of uncertainty in which individuals experiencing early psychosis and their family members struggled to make sense of what was happening, how and when to seek help, and what to expect from treatment. Contacts with the health care system were critical junctures in the pathway to care that could reduce or increase uncertainty and expedite or delay EIS entry. CONCLUSIONS: Findings indicate that efforts to expedite EIS entry should focus on reducing the uncertainty that affected individuals and their family members face when seeking care by improving their experiences with mental health services.

Family Involvement in the Clinical Care of Clients With First-Episode Psychosis in the RAISE Connection Program.

OBJECTIVE: This study described how families were involved in the RAISE Connection Program for clients with first-episode psychosis (FEP) and examined factors that predicted family involvement. METHODS: Presence of family members at clinical visits for 65 clients with FEP was described. Multiple regressions were conducted to determine whether demographic characteristics, clinical factors, or client-provider discussions regarding family predicted family involvement during the first six months of the program. RESULTS: Most participants (95%) had at least one family member attend a clinical visit during program involvement. Age of the client with FEP, psychiatric symptoms, and substance use predicted the number of days family members attended visits during the first six months of program participation; client-provider discussions about family did not. CONCLUSIONS: Family involvement in the ongoing care of clients with FEP is common when efforts are made to engage clients with FEP and their families.

OnTrackNY: The Development of a Coordinated Specialty Care Program for Individuals Experiencing Early Psychosis.

OnTrackNY is a coordinated specialty care program that delivers early intervention services to youths experiencing a first episode of nonaffective psychosis. Treatment aims to help individuals improve their mental health and achieve personal goals related to work, school, and social relationships. This column describes OnTrackNY's progression from a research project to real-world implementation. The authors describe the treatment model, approach to training and dissemination, and procedures for collecting and sharing data with OnTrackNY teams and provide data on client characteristics and selected outcomes.

An exploratory pilot study of mechanisms of action within normative feedback for adult drinkers.

Background. Normative feedback (NF), or receiving information about one's drinking compared to peer drinking norms, is one of the most widely used brief interventions for prevention and intervention for hazardous alcohol use. NF has demonstrated predominantly small but significant effect sizes for intention to change and other drinking related outcomes. Identifying mechanisms of action may improve the effectiveness of NF; however, few studies have examined NF's mechanisms of action, particularly among adults. Objective. This study is an exploratory analysis of two theorized mechanisms of NF: discrepancy (specifically personal dissonance-the affective response to feedback) and belief in the accuracy of feedback. Method. Using Amazon's Mechanical Turk, 87 men (n = 56) and women (n = 31) completed an online survey during which they were asked about their perceptions about their drinking and actual drinking behaviors. Then participants were provided tailored NF and evaluated for their reactions. Severity of discrepancy was measured by the difference between one's estimated percentile ranking of drinking compared to peers and actual percentile ranking. Surprise and worry reported due to the discrepancy were proxies for personal dissonance. Participants were also asked if they believed the feedback and if they had any plans to change their drinking. Mediation analyses were implemented, exploring whether surprise, worry, or belief in the accuracy of feedback mediated severity of discrepancy's impact on plan for change. Results. Among this sample of adult drinkers, severity of discrepancy did not predict plan for change, and personal dissonance did not mediate severity of discrepancy. Severity of discrepancy was mediated by belief in the accuracy of feedback. In addition, viewing one's drinking as a problem prior to feedback and post-NF worry both predicted plan for change independently. Conclusions. Results revealed that NF may not work to create personal dissonance through discrepancy, but belief in the accuracy of feedback may be important. It appears the more one believes the feedback, the more one makes a plan for change, suggesting practitioners should be mindful of how information within feedback is presented. Findings also indicate NF may work by validating a preexisting perception that drinking is a problem instead of creating concern related to discrepancy where none existed. Limitations regarding generalizability are discussed.

Use of Peer Staff in a Critical Time Intervention for Frequent Users of a Psychiatric Emergency Room.

Project Connect, a clinical demonstration program developed in consultation with the New York State Office of Mental Health, adapted critical time intervention for frequent users of a large urban psychiatric emergency room (ER). Peer staff provided frequent users with time-limited care coordination. Participants increased their use of outpatient services over 12 months, compared with a similar group not enrolled in the program. For persons with significant general medical, psychiatric, and social needs, provision of this intervention alone is unlikely to reduce reliance on ERs, especially among homeless individuals.

Implementing Coordinated Specialty Care for Early Psychosis: The RAISE Connection Program.

OBJECTIVE: The RAISE (Recovery After an Initial Schizophrenia Episode) Connection Program Implementation and Evaluation Study developed tools necessary to implement and disseminate an innovative team-based intervention designed to promote engagement and treatment participation, foster recovery, and minimize disability among individuals experiencing early psychosis. This article describes the treatment model and reports on service utilization and outcomes. It was hypothesized that individuals' symptoms and functioning would improve over time. METHODS: A total of 65 individuals in RAISE Connection Program treatment across two sites (Baltimore and New York City) were enrolled and received services for up to two years. Primary outcomes, including social and occupational functioning and symptoms, were evaluated. Trajectories for individuals' outcomes over time were examined with linear and quadratic mixed-effects models with repeated measures. RESULTS: Measures of occupational and social functioning improved significantly over time, symptoms declined, and rates of remission improved. Visits were most frequent during the first three months, with a mean±SD of 23.2±11.5 unduplicated staff encounters per quarter. Such encounters decreased to 8.8±5.2 in the final quarter of year 2. CONCLUSIONS: The overall project was successful in that the treatment program was delivered and tools useful to other clinical settings were produced. The strengths of this study lie in the demonstrated feasibility of delivering the coordinated specialty care model and the associated high rates of engagement among individuals who are typically difficult to engage in treatment. Notwithstanding the lack of a built-in comparison group, participant outcomes were promising, with improvements comparable to those seen with other successful interventions.

Nativity and level of need: toward an integrative perspective of Asian American mental health.

This study uses data from the NLAAS to investigate the relationship between culture and the level of psychiatric needs. Contrary to trends, those U.S. born with non-serious disorders were less likely to use mental health services. Results indicate that in order to effectively treat Asian Americans with mental health disorders, interventions need to take into account service use patterns that are impacted by both acculturation and the level of need.

I think therefore I am: perceived ideal weight as a determinant of health.

OBJECTIVES: We examined whether stress related to negative body image perception and the desire to lose weight explained some of the body mass index-health gradient. METHODS: We used 2003 Behavioral Risk Factor Surveillance System data to examine the impact of desired body weight, independent of actual body mass index, on the amount of physically and mentally unhealthy days by race, ethnicity, and gender. RESULTS: The difference between actual and desired body weight was a stronger predictor than was body mass index (BMI) of mental and physical health. When we controlled for BMI and age, men who wished to lose 1%, 10%, and 20% of their body weight respectively suffered a net increase of 0.1, 0.9, and 2.7 unhealthy days per month relative to those who were happy with their weight. For women, the corresponding numbers were 0.1, 1.6, and 4.3 unhealthy days per month. The desire to lose weight was more predictive of unhealthy days among women than among men and among Whites than among Blacks or Hispanics. CONCLUSIONS: Our results raise the possibility that some of the health effects of the obesity epidemic are related to the way we see our bodies.