Mental Health Disparities, Treatment Engagement, and Attrition Among Racial/Ethnic Minorities with Severe Mental Illness: A Review

Comparing outcomes of psychiatric rehabilitation between ethnic-religious groups in Israel

Psychiatric rehabilitation for people with severe mental illness (SMI) has many documented benefits, but less is known about cultural related aspects. To date, no comparison of psychiatric rehabilitation outcomes between Israeli Jews and Israeli Arabs has been carried out. Thus, the purpose of the present study was to compare the outcome measures of Israeli Arabs and Israeli Jews consuming psychiatric rehabilitation services. As part of the Israeli Psychiatric Rehabilitation Reported Outcome Measurement project (PR-ROM), a cross-sectional study comparing different ethnic-religious groups was performed. Data is based on 6,751 pairs of psychiatric rehabilitation consumers and their service providers. The consumers filled questionnaires on quality of life (QoL) and functioning, and their providers completed mirroring instruments. The findings revealed that QoL and functioning ratings were lower among Muslim Arabs compared to Jews on both consumers' and providers' ratings. Among Muslim Arabs, differences in outcomes according to the service's location were indicated. The observed differences between Israeli Arabs and Israeli Jews with SMI in the PR-ROM point to the need for culturally adapted rehabilitation services that take into account how cultural differences may affect the benefits of such services.

Access to mental health services in urban areas: examine the availability, affordability, and accessibility of mental health services in urban settings, particularly for individuals with intersecting marginalized identities

PURPOSE OF REVIEW

To offer an integrative overview of mental health services in urban areas across different social groups and underscore the challenges and potential solutions to improve access to mental health services in urban areas.

RECENT FINDINGS

The process of urbanization places a lot of toll on the current mental health services system. Challenges to both mental health and mental health services include the elevated risk of some mental and behavioral health issues, the increased demand for mental health services, and the intensification of mental health inequalities. The phenomenon of mental health inequalities is exacerbated in urban areas, with certain disadvantaged population groups more likely to report higher mental health issues and difficulties in accessing mental health services. Targeted and dedicated strategies are warranted to develop and allocate resources to address the mental health services needs among those simultaneously with multiple disadvantaged social and economic characteristics.

SUMMARY

Urbanization places a substantive burden on both mental health and mental health services and creates challenges to mental health services access. Integrative and multisectoral initiatives could shed light on effectively addressing the issues of access to mental health services in urban cities.

Using latent class analysis to investigate enduring effects of intersectional social disadvantage on long-term vocational and financial outcomes in the 20-year prospective Chicago Longitudinal Study

BACKGROUND

Class and social disadvantage have long been identified as significant factors in the etiology and epidemiology of psychosis. Few studies have explicitly examined the impact of intersecting social disadvantage on long-term employment and financial independence.

METHODS

We applied latent class analysis (LCA) to 20-year longitudinal data from participants with affective and non-affective psychosis (n = 256) within the Chicago Longitudinal Research. LCA groups were modeled using multiple indicators of pre-morbid disadvantage (parental social class, educational attainment, race, gender, and work and social functioning prior to psychosis onset). The comparative longitudinal work and financial functioning of LCA groups were then examined.

RESULTS

We identified three distinct latent classes: one comprised entirely of White participants, with the highest parental class and highest levels of educational attainment; a second predominantly working-class group, with equal numbers of Black and White participants; and a third with the lowest parental social class, lowest levels of education and a mix of Black and White participants. The latter, our highest social disadvantage group experienced significantly poorer employment and financial outcomes at all time-points, controlling for diagnosis, symptoms, and hospitalizations prior to baseline. Contrary to our hypotheses, on most measures, the two less disadvantaged groups did not significantly differ from each other.

CONCLUSIONS

Our analyses add to a growing literature on the impact of multiple forms of social disadvantage on long-term functional trajectories, underscoring the importance of proactive attention to sociostructural disadvantage early in treatment, and the development and evaluation of interventions designed to mitigate ongoing social stratification.

The effect of the cultural formulation interview on therapeutic working alliance: a study protocol

Background

The Cultural Formulation Interview (CFI) is designed to improve understanding of patients' mental health care needs. The lack of empirical evidence on the impact and effectiveness of CFI use in clarifying people's perspectives, experiences, context, and identity, and in preventing cultural misunderstandings between migrant patients and clinicians, inspired this study. The objective is to examine the effect of the CFI on the strength of therapeutic working alliances, and the potential mediating or moderating role of perceived empathy.

Materials and methods

A multicenter randomized controlled trial will be conducted, involving migrant patients, their confidants, and clinicians. The CFI will be administered in the intervention group, but not in the control group. Validated questionnaires will be used to assess therapeutic working alliances and perceived empathy. T-tests and linear regression analyses will be conducted to investigate between-group differences and possible mediating or moderating effects.

Results

This study will indicate whether or not the CFI strengthens the therapeutic working alliance between patients and clinicians, as moderated and/or mediated by perceived empathy.

Discussion

Research on the effect and impact of using the CFI in mental health care for migrant patients is important to clarify whether its use strengthens the therapeutic working alliance with clinicians. This can lead to a reduction in cultural misunderstandings and improve mental health care for migrant patients. The results may also be important for the implementation of the CFI as a standard of care.

Ethics and dissemination

This research protocol was tailored to the needs of patients in collaboration with experts by experience. It was approved by the Ethical Review Board of the Tilburg Law School and registered in the Clinical Trials Register under number NCT05788315. Positive results may stimulate further implementation of the CFI in clinical practice, and contribute to improving the impact of the CFI on the therapeutic working alliances.

Serious mental illness is associated with elevated risk of hospital readmission in veterans with heart failure

OBJECTIVE

Adults with serious mental illness (SMI) have high rates of cardiovascular disease, particularly heart failure, which contribute to premature mortality. The aims were to examine 90- and 365-day all-cause medical or surgical hospital readmission in Veterans with SMI discharged from a heart failure hospitalization. The exploratory aim was to evaluate 180-day post-discharge engagement in cardiac rehabilitation, an effective intervention for heart failure.

METHODS

This study used administrative data from the Veterans Health Administration (VHA) and Centers for Medicare & Medicaid Services between 2011 and 2019. SMI status and medical comorbidity were assessed in the year prior to hospitalization. Cox proportional hazards models (competing risk of death) were used to evaluate the relationship between SMI status and outcomes. Models were adjusted for VHA hospital site, demographics, and medical characteristics.

RESULTS

The sample comprised 189,767 Veterans of which 23,671 (12.5%) had SMI. Compared to those without SMI, Veterans with SMI had significantly higher readmission rates at 90 (16.1% vs. 13.9%) and 365 (42.6% vs. 37.1%) days. After adjustment, risk of readmission remained significant (90 days: HR: 1.07, 95% CI: 1.03, 1.11; 365 days: HR: 1.10, 95% CI: 1.07, 1.12). SMI status was not significantly associated with 180-day cardiac rehabilitation engagement (HR: 0.98, 95% CI: 0.91, 1.07).

CONCLUSIONS

Veterans with SMI and heart failure have higher 90- and 365-day hospital readmission rates even after adjustment. There were no differences in cardiac rehabilitation engagement based on SMI status. Future work should consider a broader range of post-discharge interventions to understand contributors to readmission.

tDCS reduces depression and state anxiety symptoms in older adults from the augmenting cognitive training in older adults study (ACT)

BACKGROUND

Pharmacological interventions for depression and anxiety in older adults often have significant side effects, presenting the need for more tolerable alternatives. Transcranial direct current stimulation (tDCS) is a promising non-pharmacological intervention for depression in clinical populations. However, its effects on depression and anxiety symptoms, particularly in older adults from the general public, are understudied.

OBJECTIVE

We conducted a secondary analysis of the Augmenting Cognitive Training in Older Adults (ACT) trial to assess tDCS efficacy in reducing psychological symptoms in older adults. We hypothesized that active stimulation would yield greater reductions in depression and state anxiety compared to sham post-intervention and at the one-year follow-up. We also explored tDCS effects in subgroups characterized by baseline symptom severity.

METHODS

A sample of 378 older adults recruited from the community completed a 12-week tDCS intervention with cognitive or education training. Electrodes were placed at F3/F4, and participants received active or sham tDCS during training sessions. We assessed the association between tDCS group and changes in depression, state anxiety, and trait anxiety from baseline to post-intervention and one-year controlling for covariates.

RESULTS

The active tDCS group demonstrated greater reductions in depression and state anxiety compared to sham post-intervention, particularly in individuals with mild depression and moderate/severe state anxiety at baseline. Furthermore, the active tDCS group with moderate/severe state anxiety maintained greater symptom reductions at one-year.

CONCLUSIONS

tDCS effectively reduced depression and state anxiety symptoms in a large sample of older adults. These findings highlight the importance of considering symptom severity when identifying those who may benefit most from this intervention.

The association between rurality, dual Medicare/Medicaid eligibility and chronic conditions with telehealth utilization: An analysis of 2019-2020 national Medicare claims

INTRODUCTION

Telehealth services have the potential to increase healthcare access among underserved populations, such as rural residents and racial/ethnic minority groups. The COVID-19 public health emergency led to unprecedented growth in telehealth utilization, but evidence suggests the growth has not been equitable across all patient populations. This study aimed to explore whether telehealth utilization and expansion changed equitably from 2019 to 2020 among sub-groups of Medicare beneficiaries.

METHODS

We conducted an analysis of telehealth utilization among a 20% random sample of 2019-2020 Medicare beneficiaries on a national level. We fit multivariable logistic regression models and calculated average marginal effects (AME) to assess the association between demographic and clinical characteristics on telehealth utilization.

RESULTS

We found telehealth utilization was less likely among non-Hispanic Black/African-American (2019: adjusted odds ratio [aOR] = 0.77, AME = -0.15; 2020: aOR = 0.85, AME = -3.50) and Hispanic (2019: aOR = 0.79, AME = -0.13; 2020: aOR = 0.87, AME = -2.89) beneficiaries, relative to non-Hispanic White beneficiaries in both 2019 and 2020, with larger disparities in 2020. Rural beneficiaries were more likely to utilize telehealth than urban beneficiaries in 2019 (aOR = 2.62, AME = 0.84), but less likely in 2020 (aOR = 0.57, AME = -14.47). In both years, dually eligible Medicare/Medicaid beneficiaries were more likely than non-dually eligible beneficiaries to utilize telehealth (2019: aOR = 4.75, AME = 0.84; 2020: aOR = 1.34, AME = 2.25). However, the effects of dual eligibility and rurality changed in both models as the number of chronic conditions increased.

DISCUSSION

We found evidence of increasing disparities in telehealth utilization among several Medicare beneficiary sub-groups in 2020 relative to 2019, including individuals of minority race/ethnicity, rural residents, and dually eligible beneficiaries, with disparities increasing among individuals with more chronic conditions. Although telehealth has the potential to address health inequities, our findings suggest that many of the patients in greatest need of healthcare are least likely to utilize telehealth services.

Perspectives of adults with neurofibromatosis regarding the design of psychosocial trials: Results from an anonymous online survey

BACKGROUND/AIMS

Individuals with neurofibromatosis, including neurofibromatosis 1 (NF1), neurofibromatosis 2 (NF2)-related schwannomatosis (SWN), and other forms of SWN, often experience disease manifestations and mental health difficulties for which psychosocial interventions may help. An anonymous online survey of adults with neurofibromatosis assessed their physical, social, and emotional well-being and preferences about psychosocial interventions to inform clinical trial design.

METHODS

Neurofibromatosis clinical researchers and patient representatives from the Response Evaluation in Neurofibromatosis and Schwannomatosis International Collaboration developed the survey. Eligibility criteria included age ≥ 18 years, self-reported diagnosis of NF1, NF2, or SWN, and ability to read and understand English. The online survey was distributed internationally by the Neurofibromatosis Registry and other neurofibromatosis foundations from June to August 2020.

RESULTS

Surveys were completed by 630 adults (18-81 years of age; M = 45.5) with NF1 (78%), NF2 (14%), and SWN (8%) who were mostly White, not Hispanic/Latino, female, and from the United States. The majority (91%) reported that their neurofibromatosis symptoms had at least some impact on daily life. In the total sample, 51% endorsed a mental health diagnosis, and 27% without a diagnosis believed they had an undiagnosed mental health condition. Participants indicated that neurofibromatosis affected their emotional (44%), physical (38%), and social (35%) functioning to a high degree. Few reported ever having participated in a drug (6%) or psychosocial (7%) clinical trial, yet 68% reported they "probably" or "definitely" would want to participate in a psychosocial trial if it targeted a relevant concern. Top treatment targets were anxiety, healthier lifestyle, and daily stress. Top barriers to participating in psychosocial trials were distance to clinic, costs, and time commitment. Respondents preferred interventions delivered by clinicians via individual sessions or a combination of group and individual sessions, with limited in-person and mostly remote participation. There were no significant group differences by neurofibromatosis type in willingness to participate in psychosocial trials (p = 0.27). Regarding interest in intervention targets, adults with SWN were more likely to prefer psychosocial trials for pain support compared to those with NF1 (p < 0.001) and NF2 (p < 0.001).

CONCLUSION

This study conducted the largest survey assessing physical symptoms, mental health needs, and preferences for psychosocial trials in adults with neurofibromatosis. Results indicate a high prevalence of disease manifestations, psychosocial difficulties, and untreated mental health problems in adults with neurofibromatosis and a high degree of willingness to participate in psychosocial clinical trials. Patient preferences should be considered when designing and implementing psychosocial interventions to develop the most feasible and meaningful studies.

Addressing Inequities in Access to Mental Healthcare: A Policy Analysis of Community Mental Health Systems Serving Minoritized Populations in North Carolina

Racial and ethnic minoritized uninsured populations in the United States face the greatest barriers to accessing mental healthcare. Historically, systems of care in the U.S. were set up using inadequate evidence at the federal, state, and local levels, driving inequities in access to quality care for minoritized populations. These inequities are most evident in community-based mental health services, which are partially or fully funded by federal programs and predominantly serve historically minoritized groups. In this descriptive policy analysis, we outline the history of federal legislative policies that have dictated community mental health systems and how these policies were implemented in North Carolina, which has a high percentage of uninsured communities of color. Several gaps between laws passed in the last 60 years and research on improving inequities in access to mental health services are discussed. Recommendations to expand/fix these policies include funding accurate data collection and implementation methods such as electronic health record (EHR) systems to ensure policies are informed by extensive data, implementation of evidence-informed and culturally sensitive interventions, and prioritizing preventative services that move past traditional models of mental healthcare.

"It's Not That We Care Less": Insights into Health Care Utilization for Comorbid Diabetes and Depression among Latinos

Despite robust knowledge regarding the socio-economic and cultural factors affecting Latino* access to healthcare, limited research has explored service utilization in the context of comorbid conditions like diabetes and depression. This qualitative study, embedded in a larger mixed-methods project, aimed to investigate perceptions held by Latinos and their social support systems (i.e., family members) regarding comorbid diabetes and depression and to identify barriers and facilitators to their help-seeking behaviors and treatment engagement. Bilingual and bicultural researchers conducted eight focus groups with 94 participants in a large U.S. metropolitan area and were primarily conducted in Spanish. The participants either had a diagnosis of diabetes and depression or were closely associated with someone who did. This study identified key individual and structural barriers and facilitators affecting healthcare access and treatment for Latinos living with comorbid diagnoses. A thematic analysis revealed structural barriers to healthcare access, including financial burdens and navigating healthcare institutions. Personal barriers included fears, personal responsibility, and negative family dynamics. Facilitators included accessible information, family support, and spirituality. These findings underscore the need to address these multi-level factors and for healthcare institutions and providers to actively involve Hispanic community members in developing services and interventions.

Addressing Mental Health Disability in Unsheltered Homelessness: Outpatient Conservatorship in Los Angeles

OBJECTIVE

The authors sought to describe a pilot program for gravely disabled individuals experiencing unsheltered homelessness in Los Angeles County that illustrates a promising public health framework to address mental health-related disability in homeless populations.

METHODS

Homeless outreach teams implementing the outpatient conservatorship (OPC) pilot program adopted a population health approach, multisystem care coordination, and prioritization of the least restrictive environments. The program allowed initiation of a Lanterman-Petris-Short (LPS) conservatorship outside of a hospital, with the goal of serving highly vulnerable individuals in the least restrictive settings. Between August 2020 and July 2021, the OPC pilot program served 43 clients, corresponding to 2% of those served by the outreach teams during that period. Using observational program evaluation data, the authors examined the impact of the program on this sample of participants.

RESULTS

At 12 months, 81% of OPC clients were no longer experiencing unsheltered homelessness; 65% accessed an LPS conservatorship. Although most OPC clients utilized a psychiatric hospital, 54% left locked settings earlier than would have been possible without the program. One-third of clients referred for LPS conservatorship used unlocked licensed residential facilities in the first year. Negative events, such as remaining in unsheltered homelessness, were more common among clients not referred for LPS conservatorship.

CONCLUSIONS

Timely receipt of street-based services and coordination of care before, during, and after referral for LPS conservatorship reduced use of restrictive settings. The OPC program's components constitute a promising triadic framework for addressing mental health disability among unsheltered individuals that warrants further investigation.

Are Family Factors Differentially Associated with Externalizing Symptoms Among Youth with Perinatally Acquired HIV?

Youth with perinatally-acquired HIV (PHIV) face unique psychosocial stressors. They are at risk for externalizing problems, including symptoms of oppositional defiant disorder, conduct disorder (CD), and attention-deficit/hyperactivity disorder (ADHD), as well as risk-taking behaviors, such as substance use (SU). Although family factors have been differentially associated with externalizing and SU behaviors based on youth sex in prior research, there is a dearth of literature considering these processes among youth with PHIV. Participants included 314 youth with PHIV (M = 12.88 years, SD = 3.08 years; 50.80% male; 85.30% Black or Latinx). Boys exhibited higher levels of ADHD symptoms than girls. Among boys, lower levels of consistency in discipline were associated with higher CD symptoms. Lower levels of family cohesion were associated with higher levels of SU among girls, and higher levels of CD symptoms across youth sex. Findings support the need for family-focused behavioral interventions among youth with PHIV.

Bring It Up: An Adapted Collaborative Care Model for Depression in a Safety-Net Primary Care Clinic

Objective

Over 90 clinical trials demonstrate the efficacy of the collaborative care model (CoCM) to treat depression in primary care but there is significant variability in real-world CoCM implementation and scalability. This study aimed to determine the feasibility and effectiveness of an adapted CoCM in a safety-net primary care setting.

Methods

Bring It Up! (BIU) is a pilot trial comparing an adapted CoCM (intervention group) to usual care (historical controls) for primary care safety-net clinic patients with depression. Inclusion criteria: (1) age ≥18; (2) Patient Health Questionnaire-9 (PHQ-9) score ≥10; and (3) major depressive disorder diagnosis. Patients who completed ≥6 months of treatment upon rolling enrollment (April 1, 2018-October 31, 2019) were included. Historical controls completed ≥6 months of usual care in 2017. BIU included all aspects of CoCM except accountable care and leveraged existing staff rather than a dedicated care manager. The primary outcome was depression remission (PHQ-9 <5) within 6 months. Secondary outcomes included depression response, adherence to treatment guidelines and care coordination process. Data were extracted from the electronic health record.

Results

Thirty-six patients received the intervention; 41 controls received usual care. Depression remission was achieved in 33.3% of intervention patients and 0% of controls (p = 0.001). Of intervention patients, 44.4% achieved ≥50% reduction in PHQ-9 compared to 4.9% of controls (p = 0.003). Further, 66.7% of intervention patients had guideline-recommended antidepressant medication titration compared to 26.9% of controls (p = 0.003); 94.4% of intervention patients had PHQ-9 repeated compared to 53.7% of controls (p < 0.001).

Conclusions

An adapted CoCM was feasible and improved depression care in a safety-net clinic.

Patient-Reported Outcomes and Medical Provider Satisfaction Among Adult and Pediatric Ataxia-Telangiectasia Patients

PURPOSE

Ataxia-telangiectasia (A-T) is a rare genetic condition with malfunctioning DNA repair processes resulting in significant clinical findings, including progressive neurologic decline, elevated malignancy risk, immunodeficiency, oculocutaneous telangiectasias, and severe pulmonary disease. Research has been limited into the quality of life of such patients and yet to be completed are studies quantitatively analyzing psychosocial, physical, and cognitive patient-reported outcomes (PROs) within the A-T population.

METHODS

PRO evaluations of 90 international adult and pediatric A-T patients and their caregivers were completed via secure online administration of Patient-Reported Outcomes Measurement Information System (PROMIS) short forms evaluating anger, cognition, mood, social health, fatigue, pain, anxiety, and upper extremity function. The impact of age, gender, race/ethnicity, prior malignancy diagnosis, and current supportive treatment interventions on such PROs was additionally assessed. Finally, given the importance of medical providers in the care of A-T patients and the impact of patient satisfaction on healthcare outcomes, we further analyzed, via a novel survey, how patients and caregivers perceived their primary A-T healthcare provider's A-T expertise, trustworthiness, accessibility, and level of compassion.

RESULTS/CONCLUSION

It was found that a diagnosis of A-T complexly impacts patient PROs, but such data offers the potential for preventative and therapeutic interventions to improve the care of such patients. While most A-T patients and their caregivers feel their primary A-T medical provider has expertise and compassion in addition to being accessible and trustworthy, a significant percentage of study subjects did not agree that their provider was an expert in A-T or overall trustworthy.

Depressive Symptoms and Their Longitudinal Impact on Physical Activity and Sedentary Behaviors Among Mexican-Heritage Youth

The purpose of this study is to examine the longitudinal impact of depressive symptoms on physical activity (PA) levels, sedentary behavior, and screen time among first-generation, Mexican-heritage youth. Mexican-heritage families were recruited by promotoras de salud from colonias in Hidalgo County, Texas. Participants (n = 200 youth, 116 families in final sample) completed at-home, interviewer-administered surveys once during the summer (June-July) and once during the fall (August-December). Youth PA and sedentary behaviors were assessed using a validated 7-day recall instrument. The validated Center for Epidemiology Studies-Depression Child scale was used to assess depression symptoms. Linear mixed-effects models were used to analyze the relationships of PA and sedentary behavior with depressive symptoms. Results showed that those depression symptoms were significantly associated with decreased number of self-reported minutes of sitting and screen time over time in the full sample and among male youth. Depression symptoms also significantly decreased the number of self-reported active and moderate to vigorous PA minutes over time among male youth. Researchers can build on our findings by identifying the mechanisms driving the relationships between depression and PA/sedentary behavior. Public health-programing efforts should intentionally consider the impact that depressive symptoms have on PA.

Black therapists' experiences with their Black clients: A systematic review

This systematic review explores Black therapists' experiences with their Black clients. The search initially identified 459 possible articles. Through the study selection process, following the Cochrane Collaboration's guidelines, the 459 studies were narrowed down to 11 studies. A total of eight qualitative studies and three quantitative studies were identified. The analytic process of this review mirrored that of a thematic analysis due to the proportion of qualitative articles. Five themes emerged: Understanding the Black Experience, Connection to Clients, Working with Black Clients, Working While Black, and Training Black Therapists. Implications for training and supervision are discussed.

Ethnoracial disparities in care on a consultation-liaison service at an academic hospital

BACKGROUND

There is currently an increasing recognition of and focus on structural and institutional racism and its impacts on health disparities. In psychiatry and mental health, research has focused on racial and ethnic disparities in the availability and utilization of mental health services, care in emergency departments, and inpatient psychiatric services. Little is known about disparities in care on general hospital psychiatry consultation-liaison (CL) services.

METHODS

In this exploratory study, we conducted a retrospective chart review using electronic health record (EHR) data of all adults (≥ 18 years of age) admitted to inpatient medical or surgical floors at an urban academic medical center for whom a psychiatric consultation was requested during the study period. We examined differences by race and ethnicity in: rates of consultation requests; use of legal holds, constant observation, restraints; follow-up by the CL service; and ultimate disposition.

RESULTS

The service received 310 unique consults during the study period. Compared to hospital-wide numbers, Black-identifying patients were over-represented in our sample (11.9% vs 6.6%), while Latinx patients were underrepresented (6.1% vs 9.8%). Of the clinical and outcome variables collected, there were higher odds of being placed on a legal hold both prior to (OR 2.6) and after the consult question (OR 2.98) and in the odds of having a one-to-one observer prior to (OR 2.47) and after (OR 2.9) the initial consult visit for Black-identifying patients, when adjusting for confounders. There were no other measurable differences in care or outcomes by racial or ethnic categories.

CONCLUSION

Black-identifying patients may be more likely to receive psychiatric consultation and be placed on legal holds because of a combination of chronic adverse social determinants of health and race-based bias. Conversely, Latinx patients may be less likely to receive psychiatric consultation because of language barriers among other factors. The lack of disparities identified in other domains may be encouraging, but larger studies are needed. Further research is also needed to identify causality and interventions that could help close the gap in care and outcomes for racial and ethnic minorities.

Racial inequalities in mental healthcare use and mortality: a cross-sectional analysis of 1.2 million low-income individuals in Rio de Janeiro, Brazil 2010-2016

INTRODUCTION

Mental health inequalities across racial and ethnic groups are large and unjust in many countries, yet these inequalities remain under-researched, particularly in low-income and middle-income countries such as Brazil. This study investigates racial and socioeconomic inequalities in primary healthcare usage, hospitalisation and mortality for mental health disorders in Rio de Janeiro, Brazil.

METHODS

A cohort of 1.2 million low-income adults from Rio de Janeiro, Brazil with linked socioeconomic, demographic, healthcare use and mortality records was cross-sectionally analysed. Poisson regression models were used to investigate associations between self-defined race/colour and primary healthcare (PHC) usage, hospitalisation and mortality due to mental disorders, adjusting for socioeconomic factors. Interactions between race/colour and socioeconomic characteristics (sex, education level, income) explored if black and pardo (mixed race) individuals faced compounded risk of adverse mental health outcomes.

RESULTS

There were 272 532 PHC consultations, 10 970 hospitalisations and 259 deaths due to mental disorders between 2010 and 2016. After adjusting for a wide range of socioeconomic factors, the lowest PHC usage rates were observed in black (adjusted rate ratio (ARR): 0.64; 95% CI 0.60 to 0.68; compared with white) and pardo individuals (ARR: 0.87; 95% CI 0.83 to 0.92). Black individuals were more likely to die from mental disorders (ARR: 1.68; 95% CI 1.19 to 2.37; compared with white), as were those with lower educational attainment and household income. In interaction models, being black or pardo conferred additional disadvantage across mental health outcomes. The highest educated black (ARR: 0.56; 95% CI 0.47 to 0.66) and pardo (ARR: 0.75; 95% CI 0.66 to 0.87) individuals had lower rates of PHC usage for mental disorders compared with the least educated white individuals. Black individuals were 3.7 times (ARR: 3.67; 95% CI 1.29 to 10.42) more likely to die from mental disorders compared with white individuals with the same education level.

CONCLUSION

In low-income individuals in Rio de Janeiro, racial/colour inequalities in mental health outcomes were large and not fully explainable by socioeconomic status. Black and pardo Brazilians were consistently negatively affected, with lower PHC usage and worse mental health outcomes.

Black Moms Matter: A Qualitative Approach to Understanding Barriers to Service Utilization at a Children's Advocacy Center Following Childhood Abuse

Black families are significantly less likely to receive evidence-based trauma treatment services; however, little is known about factors impacting engagement, particularly at Children's Advocacy Centers (CACs). The goal of this study is to better understand barriers and facilitators of service utilization for Black caregivers of CAC referred youth. Participants (n = 15) were randomly selected Black maternal caregivers (ages 26-42) recruited from a pool of individuals who were referred to receive CAC services. Black maternal caregivers reported barriers to accessing services at CACs including a lack of assistance and information in the referral and onboarding process, transportation issues, childcare, employment hours, system mistrust, stigma associated with the service system, and outside stressors such as stressors related to parenting. Maternal caregivers also shared suggestions for improving services at CACs including increasing the length, breadth, and clarity of investigations conducted by child protection services and law enforcement (LE) agencies, providing case management services, and having more diverse staff and discussing racial stressors. We conclude by identifying specific barriers to the initiation and engagement in services for Black families, and we provide suggestions for CACs seeking to improve engagement of Black families referred for trauma-related mental health services.

Treating Trauma in Criminal Justice-Involved with SMI: "Trauma Is a Huge Part of It"

Individuals with serious mental illness are both disproportionately represented in the criminal justice system and more likely to experience correlates with offending (e.g., trauma, substance abuse, and homelessness). Moreover, research using the Adverse Childhood Experiences has found strong correlation between childhood trauma and later negative outcomes, including criminal justice involvement. Despite this, research has yet to examine how trauma can influence treatment decisions for criminal justice-involved individuals with SMI. Using a qualitative approach and in-depth semi-structured interviews with 61 community mental health service providers, the current study addresses this gap in the literature. Findings confirm the high prevalence of trauma in this population as well as suggests a number of key findings for this population including (1) how trauma affects treatment decisions, (2) the existing barriers related to the treatment of trauma, and (3) what service providers need to effectively treat trauma. Implications for policy and practice are extensive.

Flourishing mental health despite disabling chronic pain: Findings from a nationally representative sample of Canadians with arthritis

This study aims to determine the prevalence of, and factors associated with, the "absence of psychiatric disorders" (APD) and "complete mental health" (CMH) among individuals with arthritis who report disabling chronic pain. There are three aspects of CMH: a) APD; b) happiness and/or life satisfaction in the past month on a daily or almost daily basis, and c) high levels of psychological and social well-being. A secondary analysis of a nationally representative sample (n = 620) of individuals with arthritis who report chronic and debilitating pain was conducted. Data were drawn from the Canadian Community Health Survey-Mental Health. The results of this study indicate that many people with arthritis who are living with disabling chronic pain are free of psychiatric disorders (76%) and are in CMH (56%). Factors associated with higher odds of APD and CMH among the sample include having a confidant, being free from insomnia, and having no lifetime history of major depressive disorder and/or generalized anxiety disorder. White respondents were almost 3-fold more likely to be in a state of CMH compared to racialized individuals. Respondents in the top 50% of household incomes were almost 4-fold more likely to be APD compared to the lowest 10%. In conclusion, many individuals with arthritis have excellent mental health despite disabling pain. Clinicians should be attuned to the mental health of their patients, with particular focus on those who may be more vulnerable to adverse mental health outcomes, such as racialized individuals, those in impoverished households, and those who lack social support.

The Future of the Psychiatric Mental Health Nursing Workforce: Using Our Skill Set to Address Incongruities in Mental Health Care Delivery

The USA is dealing with well-documented issues around mental health and its treatment. The Psychiatric Mental Health (PMH) workforce is growing and practicing in a variety of roles within the mental health system. How will PMH nurses address instances when the structure of services does not meet the mental health needs of the population? In this piece, I argue that to some degree the future of the PMH workforce will be determined by how well we use our capacity and capabilities to address incongruities in service structure and population needs. Five areas of concern with mental health services are outlined; they all involve factors that can be addressed with innovative approaches and optimum utilization of the PMH workforce. Included are suggestions on how PMH nurses might direct efforts toward these service issues, particularly by using their skill set and presence in the mental health system. Strategies include forging a tighter connection between the work of advanced practice and registered nurses in delivering care. Broadly, these efforts should be directed at building models of patient-centered care that address the needs of populations, reducing disparities, and demonstrating how engagement is a critical lever of effective inpatient and community-based care.

A Reasoned Action Approach to Social Connection and Mental Health: Racial Group Differences and Similarities in Attitudes, Norms, and Intentions

This study employed a Reasoned Action Approach to investigate two communication behaviors that were being built into a statewide behavioral health campaign: initiating a conversation about one's own mental health struggles, and starting a conversation to discuss someone else's mental health difficulties. We examined whether the extent of attitudes, perceived norms, and perceived behavioral control regarding intent to perform these behaviors varied by racial identity. Using original survey data from Texans (N = 2,033), we conducted regression analyses for the two communication behaviors and found that intention to seek help was primarily explained by instrumental attitude, injunctive norm, descriptive norm, and perceived capacity; and intention to start a conversation to help someone else was primarily explained by instrumental attitude, injunctive norm, and perceived capacity. Additionally, we identified important common and distinct determinants of the two behaviors across different racial groups. Implications for health communication campaign message development and audience segmentation are discussed.

The Effects of Dose, Practice Habits, and Objects of Focus on Digital Meditation Effectiveness and Adherence: Longitudinal Study of 280,000 Digital Meditation Sessions Across 103 Countries

BACKGROUND

The efficacy of digital meditation is well established. However, the extent to which the benefits remain after 12 weeks in real-world settings remains unknown. Additionally, findings related to dosage and practice habits have been mixed, and the studies were conducted on small and homogeneous samples and used a limited range of analytical procedures and meditation techniques. Findings related to the predictors of adherence are also lacking and may help inform future meditators and meditation programs on how to best structure healthy sustainable practices.

OBJECTIVE

This study aimed to measure outcome change across a large and globally diverse population of meditators and meditations in their naturalistic practice environments, assess the dose-response relationships between practice habits and outcome change, and identify predictors of adherence.

METHODS

We used ecological momentary assessment to assess participants' well-being over a 14-month period. We engineered outcomes related to the variability of change over time (equanimity) and recovery following a drop in mood (resilience) and established the convergent and divergent validity of these outcomes using a validated scale. Using linear mixed-effects and generalized additive mixed-effects models, we modeled outcome changes and patterns of dose-response across outcomes. We then used logistic regression to study the practice habits of participants in their first 30 sessions to derive odds ratios of long-term adherence.

RESULTS

Significant improvements were observed in all outcomes (P<.001). Generalized additive mixed models revealed rapid improvements over the first 50-100 sessions, with further improvements observed until the end of the study period. Outcome change corresponded to 1 extra day of improved mood for every 5 days meditated and half-a-day-faster mood recovery compared with baseline. Overall, consistency of practice was associated with the largest outcome change (4-7 d/wk). No significant differences were observed across session lengths in linear models (mood: P=.19; equanimity: P=.10; resilience: P=.29); however, generalized additive models revealed significant differences over time (P<.001). Longer sessions (21-30 min) were associated with the largest magnitude of change in mood from the 20th session onward and fewer sessions to recovery (increased resilience); midlength sessions (11-20 min) were associated with the largest decreases in recovery; and mood stability was similar across session lengths (equanimity). Completing a greater variety of practice types was associated with significantly greater improvements across all outcomes. Adhering to a long-term practice was best predicted by practice consistency (4-7 d/wk), a morning routine, and maintaining an equal balance between interoceptive and exteroceptive meditations.

CONCLUSIONS

Long-term real-world digital meditation practice is effective and associated with improvements in mood, equanimity, and resilience. Practice consistency and variety rather than length best predict improvement. Long-term sustainable practices are best predicted by consistency, a morning routine, and a practice balanced across objects of focus that are internal and external to the body.

Patterns of psychiatric hospitalizations of Arab and Jewish adults with chronic psychotic disorders, before and after national mental health reforms, Israel, 1991-2016

BACKGROUND

Members of the Arab minority in Israel are at increased risk of developing mental illness, although less likely to seek care and have accessible treatment. This study compares trends in psychiatric hospitalizations between Arabs and Jews with chronic psychotic disorders, before and after introduction of the Community Rehabilitation of Persons with Mental Disability Law in 2000, and governmental recognition of the need to allocate resources for patients with co-occurring substance use disorder and mental illness in 2010.

METHODS

The National Psychiatric Case Registry provided data on 18,684 adults with schizophrenia/schizoaffective disorder, hospitalized in 1991-2016 (at least once in 2010-2015). Repeated-measures ANOVA was used to measure the effect (and interactions) of population-group (Arabs and Jews), time-period (Period1: 1991-2000, Period2: 2001-2009, Period3: 2010-2016) and sex, on average length of stay (LOS), annual number of hospitalizations and hospitalization days.

RESULTS

The proportion of Arab patients hospitalized with a diagnosis of chronic psychotic disorder (14.4%) was significantly lower than their proportion in the general population (21%), and their average age at first hospitalization (28.4 years) was older than that of Jewish inpatients (27.0 years). The average number of hospitalization days and LOS of Jewish patients were double that of Arab patients in Period1. Following implementation of the Rehabilitation Law, hospitalization days increased among Arab patients and decreased slightly among Jewish patients, such that by Period3 the average number of hospitalization days was similar among Jewish (41) and Arab (37) patients. The increase in hospitalization days among Arab patients was limited to men with no change noted among women. The number of hospitalization days among Arab women was about half that of Jewish women (p < 0.0001).

CONCLUSIONS

The findings reveal a narrowing of disparities in psychiatric hospitalizations between Arab and Jewish patients in Israel over time. However, among Arab women the number of hospitalization days remains considerably lower than that of Jewish women, raising concerns that Arab women may be receiving insufficient care. Further study is needed to fully understand the underpinnings of these disparities, although increasing the number of Arabic-language mental health services and providing psycho-education, will help further close the gap.

A Call to Action on Assessing and Mitigating Bias in Artificial Intelligence Applications for Mental Health

Advances in computer science and data-analytic methods are driving a new era in mental health research and application. Artificial intelligence (AI) technologies hold the potential to enhance the assessment, diagnosis, and treatment of people experiencing mental health problems and to increase the reach and impact of mental health care. However, AI applications will not mitigate mental health disparities if they are built from historical data that reflect underlying social biases and inequities. AI models biased against sensitive classes could reinforce and even perpetuate existing inequities if these models create legacies that differentially impact who is diagnosed and treated, and how effectively. The current article reviews the health-equity implications of applying AI to mental health problems, outlines state-of-the-art methods for assessing and mitigating algorithmic bias, and presents a call to action to guide the development of fair-aware AI in psychological science.

Racial and ethnic differences in suicidal behavior and mental health service use among US adults, 2009-2020

BACKGROUND

While suicide rates have recently declined for White individuals, rates among Black and Hispanic individuals have increased. Yet, little is known about racial/ethnic differences in precursors to suicide, including suicidal ideation (SI) and suicide attempts (SA).

METHODS

Data from 2009-2020 National Survey of Drug Use and Health (NSDUH) consisted of non-institutionalized US civilians aged ⩾18 (n = 426 008). We compared proportions of White, Black, and Hispanics among adults reporting no past-year suicidal thoughts/behavior, SI, and SA. Multivariable-adjusted analyses were used to evaluate the independence of observed racial/ethnic differences in past-year SI, SA, and mental health service use.

RESULTS

In the entire sample, 20 791 (4.9%) reported past-year SI only and 3661 (0.9%) reported a SA. Compared to White individuals, Black and Hispanic individuals were significantly less likely to report past-year SI [OR 0.73 (95% CI 0.69-0.77); OR 0.75 (95% CI 0.71-0.79), respectively], but more likely to report a past-year SA [OR 1.45 (95% CI 1.28-1.64); OR 1.19 (95% CI 1.04-1.37), respectively] even after multivariable adjustment. Black and Hispanic individuals were significantly less likely to use mental health services, but the lack of significant interactions between race/ethnicity and SI/SA in association with service use suggests differences in service use do not account for differences in SI or SA.

CONCLUSIONS

Black and Hispanic individuals are significantly less likely than White individuals to report SI but more likely to report SAs, suggesting differences in suicidal behavior across race/ethnicity that may be impacted by socio-culturally acceptable expressions of distress and structural racism in the healthcare system.

Effects of Mental Illness Amongst Adults in the United States Living With Diabetes Mellitus on Hospital Admissions

OBJECTIVE

To examine the influence of comorbid mental illness on hospitalization among adults reporting diabetes mellitus.

METHODS

This cross-sectional observational study used National Health Interview Survey (NHIS) data from 2000-2018 to examine hospitalization. Mental illness was defined as no to low psychological distress (NLPD), moderate psychological distress (MPD), and serious psychological distress (SPD) as per the Kessler-6 scale. Socio-demographic factors and health status were added as covariates in binary logistic regression.

RESULTS

This study involved 48,807 survey participants and reflected an estimated population of 17,524,418 adults with diabetes in the United States, of whom 19.9% were hospitalized in the year prior to the survey. Among those who were hospitalized, 71.5% exhibited None to Low Psychological Distress (NLPD), 17.7% reported Moderate Psychological Distress (MPD), and 10.8% reported Serious Psychological Distress (SPD). Conversely, among non-hospitalized individuals, the percentages were as follows: 83.2% had NLPD, 11.4% had MPD, and 5.3% had SPD. The odds ratio (OR) for hospitalization was found to be OR=1.31 (95% CI: 1.20, 1.43, p<0.0001) for MPD and OR=1.42 (95% CI: 1.28, 1.58, p<0.0001) for SPD, in comparison to those with no or low psychological distress.

CONCLUSION

Among adults with diabetes mellitus, those with mental illness were more likely to be hospitalized than those without mental illness. Programs and policies to improve care among adults with both mental illness and diabetes may help to reduce hospitalizations.

Exploring the Impact of Education Strategies on Individuals' Attitude Towards Telemental Health Service: Findings from a Survey Experiment Study

While COVID-19 has caused significant mental health consequences, telemental health services have the potential to mitigate this problem. But due to the sensitive nature of mental health issues, such services are seriously underutilized. Based on an integrated variance-process theoretical framework, this study examines the impact of applying different education strategies on individuals' attitude toward telemental health and subsequently their intention to adopt telemental health. Two different education videos on telemental health (peer- or professional-narrated) were developed based on social identity theory. A survey experiment study was conducted at a major historically black university, with 282 student participants randomly assigned to the two education videos. Individual perceptions of the telemental health service (usefulness, ease of use, subjective norms, relative advantage, trust, and stigma) and their attitude and usage intention data were collected. The results show that ease of use, subjective norms, trust, relative advantage, and stigma significantly influence individuals' attitude toward telemental health in the peer-narrated video group. Only trust and relative advantage were found to be significant factors toward attitude in the professional-narrated video group. This study highlights the importance of designing education strategies and builds a theoretical foundation for understanding the nuanced differences in individuals' responsiveness to different educational materials.

Ethnic inequalities in community rehabilitation use and psychiatric hospitalizations among people with chronic psychotic disorder

PURPOSE

Community rehabilitation is crucial for the long-term treatment of people with chronic psychotic disorder. Ethnic minorities are less likely to seek care and have accessible treatment. This study examines whether the use of rehabilitation services and the relationship between rehabilitation and number of hospitalization days differ between Arabs and Jews.

METHODS

Data from the Israel National Psychiatric Case Register on 18,684 adults with schizophrenia/schizoaffective disorders hospitalized in 1963-2016 were merged with data from the national Mental Rehabilitation Register. Associations between the use of rehabilitation services and demographic and clinical characteristics were assessed through logistic regression modeling. Associations between ethnicity and duration of rehabilitation (housing or vocational) and annual hospitalization days during Period1: 2001-2009 and Period2: 2010-2016 were analyzed using ANOVA.

RESULTS

Among Jewish patients (N = 2556), 37% and 57% used rehabilitation services during Period1 and Period2, respectively, compared with 18% and 40% among Arab patients (N = 15,145) (p < 0.0001). The use of rehabilitation services was significantly higher among Jews (adjusted OR = 2.26, 95% CI 2.07-2.47). Average duration of housing and vocational rehabilitation services did not differ between Arab and Jewish patients. In both groups, duration of rehabilitation was inversely associated with annual hospitalization days.

CONCLUSIONS

The ethnic disparity in the use of rehabilitation services has narrowed over time, yet remains. Although fewer Arab patients use rehabilitation, Jewish and Arab benefit similarly from the services with regard to reduced hospitalization days. To further close the ethnic gap, greater efforts must be made to expand the availability of culturally appropriate rehabilitation services for the Arab minority.

Implementing psychological support for health and social care staff affected by the COVID-19 pandemic: a qualitative exploration of staff well-being hubs ('Resilience Hubs') using normalisation process theory

OBJECTIVES

Evaluate the implementation of Hubs providing access to psychological support for health and social care keyworkers affected by the COVID-19 pandemic.

DESIGN

Qualitative interviews informed by normalisation process theory to understand how the Hub model became embedded into normal practice, and factors that disrupted normalisation of this approach.

SETTING

Three Resilience Hubs in the North of England.

PARTICIPANTS

Hub staff, keyworkers who accessed Hub support (Hub clients), keyworkers who had not accessed a Hub, and wider stakeholders involved in the provision of staff support within the health and care system (N=63).

RESULTS

Hubs were generally seen as an effective way of supporting keyworkers, and Hub clients typically described very positive experiences. Flexibility and adaptability to local needs were strongly valued. Keyworkers accessed support when they understood the offer, valuing a confidential service that was separate from their organisation. Confusion about how Hubs differed from other support prevented some from enrolling. Beliefs about job roles, unsupportive managers, negative workplace cultures and systemic issues prevented keyworkers from valuing mental health support. Lack of support from managers discouraged keyworker engagement with Hubs. Black, Asian and minority ethnic keyworkers impacted by racism felt that the Hubs did not always meet their needs.

CONCLUSIONS

Hubs were seen as a valuable, responsive and distinct part of the health and care system. Findings highlight the importance of improving promotion and accessibility of Hubs, and continuation of confidential Hub support. Policy implications for the wider health and care sector include the central importance of genuine promotion of and value placed on mental health support by health and social care management, and the creation of psychologically safe work environments. Diversity and cultural competency training is needed to better reach under-represented communities. Findings are consistent with the international literature, therefore, likely to have applicability outside of the current context.

A Digital Music-Based Mindfulness Intervention for Black Americans With Elevated Race-Based Anxiety: A Multiple-Baseline Pilot Study

BACKGROUND

Race-based anxiety is a substantial health issue for the Black community. Although mindfulness interventions have demonstrated efficacy for alleviating anxiety, three central barriers prevent Black Americans from accessing existing mindfulness treatments: high costs, excessive time commitments, and limited cultural relevance. There is a need for novel mindfulness interventions for the Black community that can overcome these barriers.

OBJECTIVE

The goal of this web-based study was to examine the preliminary efficacy, feasibility, and acceptability of a novel digital music-based mindfulness intervention for middle-to-low-income Black Americans with elevated race-based anxiety.

METHODS

This study used a nonconcurrent multiple-baseline design (n=5). The intervention featured contributions from Lama Rod Owens (a world-renowned meditation teacher and LA Times best-selling author) and Terry Edmonds (the former chief speechwriter for President Bill Clinton). We examined the effect of the intervention on state anxiety and assessed its feasibility and acceptability using quantitative and qualitative measures.

RESULTS

Results revealed that administration of the intervention led to significant decreases in state anxiety (Tau-U range -0.75 to -0.38; P values<.001). Virtually all feasibility and acceptability metrics were high (ie, the average likelihood of recommending the intervention was 98 out of 100).

CONCLUSIONS

This study offers preliminary evidence that a digital music-based mindfulness intervention can decrease race-based anxiety in Black Americans. Future research is needed to replicate these results, test whether the intervention can elicit lasting changes in anxiety, assess mechanisms of change, and explore the efficacy of the intervention in real-world contexts.

From East to West: A Narrative Review of Healthcare Models in India and the United States

The global healthcare landscape is fraught with quality, cost, equity, and innovation challenges. Despite this, successful healthcare interventions have emerged from unexpected locations. In India, the eradication of certain communicable diseases, the expansion of access to primary care, and the implementation of innovative methods such as telemedicine have demonstrated the potential for community-centered care. In the United States (US), improvements in healthcare quality, accessibility, and the utilization of medical technology, such as the incorporation of telehealth and artificial intelligence, have highlighted opportunities for technological innovation in healthcare delivery. This manuscript reviews the history and development of healthcare systems in India and the US, highlighting each system's strengths, weaknesses, lessons learned, and opportunities for improvement. By examining both systems, we strive to promote a healthcare model that incorporates lessons from each country to improve community-centered care and ultimately provide equitable access to all.

Paranoid Thinking as a Function of Minority Group Status and Intersectionality: An International Examination of the Role of Negative Beliefs

BACKGROUND

Paranoia is higher in minority group individuals, especially those reporting intersecting aspects of difference. High negative and low positive self and other beliefs, and low social rank, are predictive of paranoia overtime; however, data are typically from majority group participants. This study examined whether social defeat or healthy cultural mistrust best characterizes paranoia in minority groups.

STUDY DESIGN

Using cross-sectional, survey design, with a large (n = 2510) international sample, moderation analyses (PROCESS) examined whether self and other beliefs, and perceived social rank, operate similarly or differently in minority vs majority group participants. Specifically, we tested whether beliefs moderated the influence of minority group, and intersecting aspects of difference, on paranoia.

STUDY RESULTS

Paranoia was consistently higher in participants from minority vs majority groups and level of paranoid thinking was significantly higher at each level of the intersectionality index. Negative self/other beliefs were associated with elevated paranoia in all participants. However, in support of the notion of healthy cultural mistrust, low social rank, and low positive self/other beliefs were significantly associated with paranoia in majority group participants but unrelated to paranoia in respective minority group members.

CONCLUSIONS

Although mixed, our findings signal the need to consider healthy cultural mistrust when examining paranoia in minority groups and bring into question whether "paranoia" accurately describes the experiences of marginalized individuals, at least at low levels of severity. Further research on paranoia in minority groups is crucial to developing culturally appropriate ways of understanding people's experiences in the context of victimization, discrimination, and difference.

Retention of older veterans with serious mental illness in a clinical exercise program

Older adults with serious mental illness (SMI) have compromised physical function that could be improved with exercise; however, retention in exercise programs is a challenge. This study was a retrospective analysis of retention for the 150 older veterans with SMI that enrolled in Gerofit, a clinical exercise program offered in the Veterans Health Administration. Chi-square and t-tests were conducted to evaluate baseline differences between those that were and were not retained at six and 12 months. Retention was 33% and better health-related quality of life and endurance were related to retention. Future work is needed to improve exercise program retention in this population.

"Something very taboo": a qualitative exploration of beliefs, barriers, and recommendations for improving mental health care and access for Hispanic adults in the Paso del Norte U.S.-Mexico border region

Background

Hispanic adults with mental health conditions in the United States experience disproportionate access to and utilization of professional mental health treatment. This is believed to be in part due to systemic barriers and challenges, difficulty accessing care, cultural factors, and stigma. Studies to date have failed to examine these specific factors within the unique context of the Paso del Norte U.S.-Mexico border region.

Methods

For this study, 25 Hispanic adults identifying primarily of Mexican descent participated in four focus groups exploring these topics. Three groups were facilitated in Spanish and one group in both English and Spanish. Focus groups followed a semi-structured format eliciting perspectives on mental health and mental illness, help-seeking, barriers and facilitators of help-seeking and treatment access, and recommendations for mental health agencies and providers.

Results

Qualitative data analysis yielded the following themes: understanding of mental health and help-seeking; barriers to accessing care; mental health treatment facilitators; and recommendations for agencies, providers, and researchers.

Conclusion

Findings from this study support the need for innovative mental health engagement strategies to reduce stigma, increase understanding of mental health, foster support systems, reduce individual and systemic barriers to seeking and accessing care, and to continue to engage communities in mental health outreach and research.

Trends in Racial-Ethnic Disparities in Adult Mental Health Treatment Use From 2005 to 2019

OBJECTIVE

Although U.S. mental health treatment rates increased in the 2000s, gaps in treatment among racial-ethnic groups grew. Little is known, however, about national trends after 2012, when treatment access increased overall. This study assessed trends in racial-ethnic disparities in past-year treatment rates among people with a major depressive episode, serious psychological distress, or serious mental illness.

METHODS

National Survey on Drug Use and Health (2005-2019) data of adults with a past-year major depressive episode (N=49,791) or serious psychological distress (N=89,233) and of adults with past-year serious mental illness (N=24,944; 2008-2019) were analyzed. Linear risk regressions were used to model trends in past-year use of mental health treatment and included an interaction term between survey year and race-ethnicity.

RESULTS

Treatment use prevalence (2005-2019) among marginalized individuals with a major depressive episode remained lower than that among White people. The magnitude of the disparity in treatment use between White and Hispanic people with major depressive episode decreased slightly (percentage-point difference=-25.1% to -14.9%), whereas the disparity in treatment use between White people and American Indian/Alaska Native people with serious mental illness increased significantly (percentage-point difference=23.4% to -12.2%), from 2005 to 2019. The magnitude of the disparities for other marginalized racial-ethnic groups did not meaningfully change.

CONCLUSIONS

Racial-ethnic disparities in past-year mental health treatment use have persisted. Efforts to reduce disparities should consider structural barriers that hinder treatment use among marginalized groups.

Outpatient substance abuse treatment completion rates for racial-ethnic minorities during the Great Recession

There has been minimal research linking the effects on racial-ethnic minorities' health outcomes, particularly research focused on racial-ethnic minorities seeking outpatient substance abuse treatment in the United States. The Great Recession from December 2007 to June 2009 in the United States provides the backdrop against the completion of substance abuse treatments among racial-ethnic minorities that may be associated with the impacts on users' social realities. We utilized data from the 2006-2011 Treatment Episode Datasets-Discharge (TEDS-D) dataset which collects data on outpatient substance abuse treatment institutions throughout the United States. The substance abuse treatment completion rates were higher prior to the Great Recession and lower following the Great Recession. Hispanics were more likely than non-Hispanic whites to complete substance abuse treatment, while other minority groups such as Non-Hispanic Blacks, were less likely to do so. Clients in the Northeast and West regions were more likely to successfully complete substance abuse treatment than those in the South. These findings have implications for impacting outpatient substance abuse treatment completion rates following the Great Recession to reduce racial-ethnic disparities which were impacted by region. Even amid an economic recession, treatment for substance abuse should continue to be a top concern.

A pragmatic feasibility trial of the Primary Care Intervention for PTSD: A health service delivery model to reduce health disparities for low-income and BIPOC youth

OBJECTIVE

This study is a non-randomized pragmatic trial to assess the feasibility and acceptability of the Primary Care Intervention for Posttraumatic stress disorder (PCIP) (Srivastava et al., 2021), an Integrated Behavioral Health Care treatment for PTSD in adolescents.

METHOD

Following routine clinic procedures, youth who were suspected of having trauma-related mental health symptoms were referred by their primary care providers to integrated care social workers for evaluation. The integrated care social workers referred the first 23 youth whom they suspected of having PTSD to the research study. Twenty youth consented to the study and 19 completed the pre-assessment (17 female; mean age = 19.32, SD = 2.11; range 14-22 years). More than 40% identified as Black and a third as Hispanic/Latinx. PCIP mechanisms and clinical outcomes were assessed pre- and post-treatment, and at one-month follow-up. Participants and therapists completed post-treatment qualitative interviews to assess feasibility and acceptability, and treatment sessions were audio recorded to assess fidelity.

RESULTS

Findings suggest high acceptability, satisfaction, and feasibility of the PCIP delivered in "real-life" safety net pediatric primary care. Integrated care social workers had high treatment fidelity. Despite the small sample size, there was significant improvement in symptom scores of anxiety (g = 0.68, p = 0.02) and substance use (g = 0.36, p = 0.04) from pre to post, and depression symptoms (g = 0.38, p = 0.04) from pre to follow-up. Qualitative data from patients who completed exit interviews and integrated social workers indicated high satisfaction with the treatment, with some participants reporting that the integrated intervention was more acceptable and less stigmatizing than seeking mental health care outside of primary care.

CONCLUSIONS

The PCIP may improve treatment engagement and access for vulnerable youth. Promising findings of high acceptability, feasibility, and initial clinical effectiveness suggest that PCIP warrants larger-scale study as part of routine care in pediatric integrated care.

Disparities in disposition from trauma centers to inpatient psychiatric treatment in a national sample of patients with self-inflicted injury

BACKGROUND

Surgery providers are integral to the treatment of patients with self-inflicted injuries. Patient disposition (eg, home, inpatient psychiatric treatment, rehabilitation) is important to long-term outcomes, but little is known about factors influencing disposition after discharge following traumatic self-inflicted injury. We tested whether patient or injury characteristics were associated with disposition after treatment for self-inflicted injury.

METHODS

National Trauma Data Bank query for self-inflicted injuries from 2010 to 2018.

RESULTS

There were 77,731 patients treated for self-inflicted injuries during the study period. Discharge home was the most common disposition (45%), and those without insurance were less likely to discharge to inpatient psychiatric treatment than those with insurance. Racial minority patients were less likely to discharge to inpatient psychiatric treatment (18.9%) than nonminority patients (23.8%, P < .001). Additionally, patients discharged to inpatient psychiatric treatment had significantly lower injury severity score (7.24 ± 7.5) than those who did not (8.69 ± 9.1, P < .001).

CONCLUSION

Racial/ethnic minority patients and those without insurance were significantly less likely to discharge to an inpatient psychiatric facility after treatment at a trauma center for self-inflicted injury. Future research is needed to evaluate the internal factors (eg, trauma center practices) and external factors (eg, inpatient psychiatric facilities not accepting patients with wound care needs) driving disposition variability.

A Rapid Review of "Low-Threshold" Psychiatric Medication Prescribing: Considerations for Street Medicine and Beyond

OBJECTIVE

No widely accepted clinical guidelines, and scant directly applicable pragmatic research, are available to guide the prescription of psychiatric medications in "low-threshold" outpatient settings, such as street outreach, urgent care, and crisis care, as well as walk-in, shelter, and bridge and transition clinics. Providers frequently prescribe medications in these settings without patients' having firm psychiatric diagnoses and without medical records to guide clinical decision making. Persons who receive medications in these settings often seek help voluntarily and intermittently for mental illness symptoms. However, because of structural and individual factors, such patients may not engage in longitudinal outpatient psychiatric care. The authors reviewed the literature on psychiatric medication prescribing in low-threshold settings and offer clinical considerations for such prescribing.

METHODS

The authors conducted a rapid literature review (N=2,215 abstracts), which was augmented with up-to-date clinical prescribing literature, the authors' collective clinical experience, and DSM-5 section II diagnostic criteria to provide considerations for prescribing medications in low-threshold settings.

RESULTS

For individuals for whom diagnostic uncertainty is prominent, a symptom-based diagnostic and treatment approach may be best suited to weigh the risks and benefits of medication use in low-threshold settings. Practical considerations for treating patients with clinical presentations of psychosis and trauma, as well as mood, anxiety, and substance use disorders, in low-threshold settings are discussed.

CONCLUSIONS

An urgent need exists to invest in pragmatic research and guideline development to delineate best-practice prescribing in low-threshold settings.

Evaluation of disparities in impact of mental health intensive case management on 6-month symptoms, functioning, and quality of life between black and white veterans diagnosed with schizophrenia

BACKGROUND

Substantial health disparities have been reported between Black and White Americans diagnosed with schizophrenia. The nature and extent of these disparities among individuals receiving services in an equal-access health care system remains understudied.

PURPOSE AND AIMS

The purpose of this study was to examine disparities in enrollment characteristics, service delivery and clinical outcomes between Black and White veterans diagnosed with schizophrenia who received care in the Veterans Health Administration (VHA), an equal-access health care system.

METHODS

National program evaluation data from the VHA Intensive Community Mental Health Recovery (ICMHR) program were used to evaluate disparities between 2436 Black and 3565 White veterans who enrolled between 1999 and 2013. Veterans and case managers completed measures of sociodemographic factors, clinical history, clinical characteristics, and justice system involvement at enrollment and six months. Chi square and ANOVAs were used to evaluate enrollment and service delivery differences. Six-month changes were evaluated using multiple regression controlling for potentially confounding baseline characteristics. Effect sizes were evaluated with Cohen's d.

RESULTS

Results indicated differences between Black and White veterans in clinical history, justice system involvement, and clinical characteristics at enrollment. Minimal differences in service delivery were noted and longitudinal analyses revealed no significant differences between Black and White veterans on the majority of outcomes.

CONCLUSION

Fewer racial disparities in service use and outcomes were observed in ICMHR than in standard non-VA clinic settings. This study demonstrates that disparities may emerge more strongly from systemic rather than individual-level differences.

The representation of authors of color in schizophrenia research articles published in high-impact psychiatric journals

OBJECTIVE

We evaluate how often scholars of color publish papers on schizophrenia in high-impact psychiatric journals, and whether they are more likely than white authors to prioritize race/ethnicity as a primary variable of interest in analyses.

METHODS

Prior work categorized the types of ethnoracial analyses reported in 474 papers about schizophrenia published in high-impact psychiatric journals between 2014 and 2016. In this study, the photographs of the first and last author for each paper were coded as "person of color" (POC) or "white". Additionally, each author was asked to self-report their race and ethnicity. The percentage of papers published by white versus POC authors was calculated. Chi-square analyses tested the hypotheses that (a) white scholars are more likely than POC scholars to conduct any sort of racial analysis; (b) POC scholars are more likely to conduct primary analyses by race/ethnicity; and (c) white scholars are more likely to analyze race/ethnicity as extraneous variables.

RESULTS

Eighteen percent of papers were published by POC first authors, and 17% were published by POC last authors. There were minimal differences in the types of analyses conducted by POC and white authors. Self-reported race/ethnicity showed that Asian scholars were the most highly represented within POC authors (9% of respondents), but only 3% of authors identified as Hispanic/Latinx and none identified as Black or Indigenous American.

CONCLUSIONS

People of color are underrepresented as authors in US-based schizophrenia research published in high-impact journals. Culturally-informed mentorship as well as prioritization of race/ethnicity in funding structures are important to increase representation of POC authors.

The associations between attenuated psychosis symptoms and functioning in Black and White youth at clinical high-risk for psychosis

Extensive research has demonstrated racial disparities, particularly among Black individuals, in both presentation and course of psychosis spectrum disorders. Few studies, however, have examined racial differences in the clinical high-risk (CHR) phase of illness. It is unclear if functional deficits seen in association with CHR symptoms generalize to marginalized racial groups, or whether race may play a role in the link between symptoms and functioning. In a sample of youth at CHR (N = 46), the present study examined the effect of race (Black and White represented in this sample) on the relation between CHR symptoms and social/role functioning. Race had a moderating effect on the relation between CHR symptoms and social functioning for total positive symptom score (p < .04, f² = 0.10). Although positive symptoms were associated with worse social functioning for White participants, no association was found for Black participants. Follow up analyses indicated suspiciousness was a statistically significant predictor of social functioning for White participants but was unrelated to functioning for Black participants. Results may be indicative of phenomenon experienced by individuals within racial minority groups (e.g., "healthy suspiciousness") or potential measurement validity concerns. Findings further the understanding of racial differences in the CHR phase of illness among White and Black youth and highlight limitations of the existing CHR literature and assessment tools for diverse youth.

A systematic review of client’s perspectives on the cultural and racial awareness and responsiveness of mental health practitioners

Culturally and racially responsive practice continues to be a common challenge among Mental Health Practitioners (MHPs). To the authors’ knowledge, this systematic review was the first to collate and synthesize clients’ perspectives of MHPs’ cultural and racial awareness and responsiveness from around the world. Original studies that were published between 2010 and 2021 reporting on qualitative data about clients’ perspectives regarding MHPs’ cultural-racial awareness and responsiveness were included in the review. The studies’ key findings that addressed this review’s question were synthesized and analyzed using reflexive thematic analysis. This review found 48 papers that met inclusion criteria, which represented the views of 652 clients across 10 countries. Three major themes and eight subthemes were established that concerned characteristics of the MHP, the client, and the therapeutic alliance. The results of this review indicate individual and systemic factors that influence mental health access for people from culturally and racially marginalized groups. Ongoing training of MHPs, increased racial and cultural representation among MHPs, inclusive physical settings, and reduced discrimination by MHPs are among the key findings and directions based on the results of this review.

Mental Health Underutilization by Palestinian-Arabs in Israel: Stigma-Related, Attitudinal, and Instrumental Barriers

BACKGROUND

Many studies show that members of minority groups underutilize mental health services and report more barriers to such utilization than majority groups. However, very little is known about these barriers and their relation to mental health service use among the Palestinian-Arab minority in Israel.

AIMS

This study examined barriers to mental health service use in this population based on the stigma-related, attitudinal, and instrumental barriers dimensions of the Barriers to Care Evaluation scale (BACE v3) and its correlates to mental health service use.

METHODS

The participants were a convenience sample of 231 Palestinian Arabs. They completed measures of BACE v3, mental health service use, and sociodemographic characteristics.

RESULTS

The findings showed that participants who reported using mental health services had lower levels of barriers in all dimensions compared to those who did not use such services. Attitudinal barriers were found to be the main determinants of mental health service use.

CONCLUSIONS

This study underscored the role of attitudinal barriers to the utilization of mental health services. The findings indicated that interventions addressing such barriers might be helpful in increasing mental health service use among the Palestinian-Arab minority in Israel as well as other minorities in Israel and elsewhere, who might share similar backgrounds and perceptions.

Access, retention, and effectiveness of individual placement and support in the US: Are there racial or ethnic differences?

BACKGROUND: Increased federal attention to advancing racial equity and support for underserved communities suggests the need for data on racial and ethnic differences in evidence-based employment services for people with serious mental illness. Individual Placement and Support (IPS) is an evidence-based model of supported employment for this population. OBJECTIVE: The objective was to identify differences based on race and ethnicity in IPS services. METHODS: This narrative review examined the empirical literature on IPS services in the U.S., assessing evidence of differences in access, retention, and outcomes for Black and Hispanic IPS clients, relative to non-Hispanic Whites. RESULTS: We identified 12 studies examining racial and ethnic differences in access (4 studies), retention (3 studies), and effectiveness (6 studies). The findings for access to IPS were mixed, with two studies showing no differences, one finding less access for Blacks, and another finding greater access for Blacks but less access for Hispanics. Three studies found better retention rates for clients enrolled in IPS regardless of race or ethnicity. Compared to clients receiving usual vocational services, all studies found better employment outcomes for IPS clients regardless of race or ethnicity. CONCLUSION: Unlike for most of health care, few racial and ethnic differences have been found for IPS employment services in the U.S. Access to IPS is inadequate for all groups, with conflicting evidence whether Blacks and Hispanics have even less access. Based on the available evidence, Black and Hispanic clients have comparable retention and employment outcomes in IPS as non-Hispanic White clients. State and local mental health leaders responsible for monitoring IPS outcomes should routinely report statistics on race and ethnicity. They should also give active attention to client needs and equity. Research designs should answer multifaceted questions regarding disparities for historically underserved populations.