An Integrative Review of Barriers and Facilitators Associated With Mental Health Help Seeking Among Indigenous Populations

Racial/Ethnic Trends in Virtual Mental Health Care Utilization Among Undergraduate Students: A Descriptive Study

BACKGROUND

Undergraduate students are particularly in need of mental health support, but demand has far surpassed resources. This gap between mental health diagnoses and support is particularly large among Asian, Hispanic/Latinx, and Black students. Supplementing on-campus care with a virtual-only behavioral health partner may shift these trends.

OBJECTIVE

This study is aimed at comparing the number of undergraduate students from different racial/ethnic groups (White, Asian, Islander, Hispanic/Latinx, Black, Native, and Multiracial) engaging in virtual mental health visits as part of a partnership with a company providing virtual-only care, with the total enrolled undergraduate students at the same 113 institutions.

METHODS

We used de-identified visit data and self-reported race/ethnicity to define the "patient" population of undergraduates accessing care. We compared that to the full "student" population of undergraduates among the same schools, available as part of the Integrated Postsecondary Education Data System (IPEDS).

RESULTS

Patient population race/ethnicity (N = 14,870) differed significantly from student population race/ethnicity (N = 619,459). A significant effect ( χ 26 = 2258, P < .001) indicated that patient demographics differed from student demographics. We found proportionally more Asian, Black, and Multiracial patients than students. At the same time, we found proportionally fewer White and Hispanic/Latinx patients than students.

CONCLUSIONS

We conclude that, in contrast to prior literature in traditional mental health care, some racial/ethnic minority undergraduates (Asian, Black, and Multiracial) may actually access care at a higher rate under a fully virtual model. On the other hand, White and Hispanic/Latinx students may access care less frequently.

Dementia prevalence and dementia risk in Indigenous Peoples: recent findings, current developments, and future directions

PURPOSE OF REVIEW

To highlight recent findings on the prevalence and risk and protective factors for dementia in Indigenous Peoples, who are disproportionately affected by health inequities driven by social determinants of health and historical injustices. With increasing numbers of Indigenous individuals entering older age, there is a growing need for research to better understand dementia and opportunities for prevention in Indigenous Peoples.

RECENT FINDINGS

Recent studies highlight a wide range of dementia prevalence across Indigenous Peoples, with estimates varying significantly by methodology, socio-cultural context, and region with stark gaps in regional representation. Studies suggested that Indigenous Peoples show distinct profiles of dementia risk factors, including higher rates of cardiovascular disease, lower educational attainment, and socioeconomic disadvantage. However, traditional lifestyles, strong social ties, and culturally grounded practices are suggested to offer protective effects against cognitive decline.

SUMMARY

Despite growing research attention, significant limitations remain in understanding dementia in Indigenous Peoples. The available evidence points to the need for culturally sensitive approaches in research and dementia prevention, as well as greater consideration of the social and environmental factors shaping brain health. Future research should aim to incorporate Indigenous knowledge systems and address the social determinants of dementia risk in Indigenous Peoples.

Cultural Factors, Social Structures, and Social Determinants of Health: The Need for Clarity in Assessing Psychopathology

ABSTRACT

Over the past decade, researchers translating anthropological theories for clinical use have debated how practitioners should assess cultural factors, social structures, and social determinants of health with patients. Advocates of structural competency have suggested that clinical cultural competency programs demonstrate limited effects on health outcomes because of the static understanding of culture employed. They recommend that cultural factors be reformulated with an emphasis on social structures. In response, researchers in cultural psychiatry specializing in cultural assessments have developed three models-sociocultural formulation, the cultural-ecosocial view, and the contextual developmental assessment-to integrate cultural and structural factors. Their methods for integration, however, differ, resulting in various understandings of psychopathology mechanisms. This paper analyzes arguments from all four positions in this debate. It reveals a lack of consensus about interrelationships among these constructs, their definitions, and methods for assessment. The article concludes with recommendations, such as developing consensus definitions with broad stakeholder involvement; adopting a data-driven approach to clarify how specific cultural, social, or structural factors interact; and identifying how extant assessments capture clinically relevant factors across constructs to develop additional assessment tools.

An Approach to Providing Timely Mental Health Services to Diverse Youth Populations

Importance

Accessing mental health care is challenging for youths, especially those facing intersectional disadvantages, but whether enhancing youth services increases reach and timeliness has rarely been investigated. ACCESS Open Minds (ACCESS-OM) transformed services at urban, rural, and Indigenous sites in Canada using 5 principles (early identification, rapid access, appropriate care, no age-based transitions from 11-25 years, and youth and family engagement).

Objective

To evaluate whether the number of youths referred (hypothesis 1), offered evaluation appointments within 72 hours of referral (hypothesis 2), and receiving services within 30 days of the first appointment (hypothesis 3) increased over the course of ACCESS-OM's implementation.

Design, Setting, and Participants

This cohort study included youths (aged 11-25 years) at 11 sites referred between March 2016 and December 2020. Data were analyzed from April 2022 to April 2024.

Exposure

Existing primary and/or community services implemented ACCESS-OM's core components: broad-spectrum mental health services, outreach, youth-friendly walk-in spaces, open systems accepting referrals from multiple sources, and response-time benchmarks (72 hours to evaluation and 30 days to start treatment).

Main Outcomes and Measures

Outcomes were the referral rate and the probability of being offered a first evaluation within 72 hours and receiving services within 30 days. Dates of referral and/or help-seeking, first offered appointment, first evaluation, and first services received were recorded. Multilevel negative binomial regression was used for hypothesis 1, and time-to-event analyses followed by multilevel accelerated failure time (AFT) models were used for hypotheses 2 and 3.

Results

A total of 7889 youths were referred; 4519 (mean [SD] age, 19.3 [3.4] years; 2440 [54%] cisgender women; 1049 [23.21%] Indigenous; 991 [21.93%] Visible Minority [Arab, Black, Chinese, Filipino, Japanese, Korean, Latin American, South Asian, Southeast Asian, West Asian, other ethnicity, and multiple ethnicities]; and 1525 [49.10%] White) were evaluated before March 2020. Each 6-month progression after implementation was associated with a 10% increase in referral rates (IRR, 1.10; 95% CI, 1.07-1.13). The probability of being offered an initial appointment (χ22 = 20.30; P < .001) and receiving services (χ22 = 4.48; P = .01) after any given delay differed significantly over the 3 years. In adjusted AFT models, each 6-month progression was associated with a 3% decrease in time to offered evaluation (time ratio [TR], 0.97; 95% CI, 0.95-0.99) and first services (TR, 0.97; 95% CI, 0.94-1.00). Moderate to severe mental health problems were associated with longer delays to offered first appointments (TR, 1.14; 95% CI, 1.06-1.24) and services (TR, 1.11; 95% CI, 1.01-1.22).

Conclusions and Relevance

As hypothesized, after ACCESS-OM implementation, more youths sought help, and the timeliness of initial response and services improved over time. These findings suggest that core principles, benchmarks, and implementation supports are valuable in organizing youth mental health care. Future efforts should make benefits equitable for those with severe problems.

Growing the peer workforce in rural mental health and social and emotional well-being services: A scoping review of the literature

INTRODUCTION

Growing the mental health peer workforce holds promise for rural communities, but we currently lack an understanding of the guidance available to support the development, implementation and sustainability of this workforce in rural settings.

OBJECTIVE

Study aims are to: (1) determine the extent and nature of the literature that provides guidance for growing the peer workforce in rural mental health services; and (2) identify and explore any guidance relevant to rural peer work services dedicated to First Nations communities, including those promoting social and emotional well-being within this body of literature.

DESIGN

A scoping review method was employed to identify relevant peer-reviewed and grey literature published between 2013 and 2022 across PsychInfo, Medline, Embase and CINAHL, Scopus and Informit HealthInfoNet databases, as well as targeted organisation websites and Google Advanced Search.

FINDINGS

A total of 26 unique studies/projects were included from the US, UK, Canada and Australia with public mental health, non-government/for purpose and private sector service settings represented in the literature. Grey literature, such as reports of evaluations and frameworks, formed the majority of included texts. While there is a lesser volume of rurally focused literature relative to the general peer work literature, this is a rich body of knowledge, which includes guidance concerning services dedicated to First Nations communities. Via synthesis critical considerations were identified for the development, implementation and sustainability of peer work in rural mental health services across six domains: 'Working with community members and stakeholders', 'Organisational culture and governance', Working with others and in teams, Professional expertise and experience, Being part of and working in the community and 'Local mental health services capacity'.

DISCUSSION

While there are considerations relevant across a range of settings, the domains of: 'working with community members and stakeholders', 'being part of and working in the community' and 'local mental health services capacity', capture additional, distinct and nuanced challenges and opportunities for growing the peer work in rural services.

CONCLUSION

The literature offers insights valuable for service planning, policy development and the allocation of resources to support rural peer workforce growth.

Community Mental Health Workers: Their Workplaces, Roles, and Impact

Mental health care in the U.S. is at a critical crisis, compounded with a severe shortage of providers. The cost burden is immense, with severe disparity seen in traditionally marginalized communities and rural populations. Community health workers have been used to increase access to physical health care in the U.S. for over seventy years-and have been used abroad for centuries. Their use in mental health care is more recent and can increase access, but raises policy, reimbursement, triage, and scopes-of-practice considerations. They are especially beneficial for many at-risk populations including communities of color, those with serious mental illness, rural communities, the elderly, and youth. This literature review searched PubMed, EMBASE, and Google Scholar and provides a broad review of the different types of community mental health workers (community health workers/promotores de salud, peer support, peer navigators, and lay counselors), how they increase access to care, skill sets, practice locations, and uses for specific at-risk populations. Increasing and expanding the use of community mental health workers expands much needed mental health care to those at risk by task-shifting the burden on the traditional professional workforce, offering a solution to both the workforce shortage and the lack of equity in mental health care.

Intravenous Drug Use in the Hospital Setting: Advancing Reconciliation for Indigenous Canadians Using In-Hospital Harm Reduction and Culturally Safe Care

ABSTRACT

People who inject drugs are likely to end up admitted to a hospital due to complications associated with substance use. While in hospital, many of these patients will continue the self-administration of nonprescribed drugs. When implemented without a harm reduction approach, self-administration can lead to an increase in the acquisition of infectious diseases, injection-related infections, and fatal and nonfatal overdoses. Often, administrators and providers use punitive approaches to manage this behavior among patients and providers. This abstinence-based approach has, and continues to, disproportionally impact structurally vulnerable communities. To mobilize the Truth and Reconciliation Commission's Calls to Action, Canadian hospitals must respond transparently and urgently to Indigenous peoples, patients, and communities. For example, First Nations, Inuit, and Metis people and communities living in Canada are significantly affected by the opioid epidemic, which can be traced back to the legacy of and continued colonialism and systemic discrimination in health care. Colonial policies and systems manifest as Indigenous populations experiencing a high prevalence of socioeconomic disadvantage and poor access to quality health and social services, on- and off-reserve. Clinicians must understand and receive cultural safety training to adequately care for Indigenous patient populations, as well as other structurally vulnerable populations. Additionally, Canadian hospitals should acknowledge and measure intravenous drug use in their organizations and take a harm reduction approach to mitigate associated adverse outcomes. Finally, hospitals should work with academic institutions to train, recruit, and retain Indigenous clinicians from diverse sociocultural backgrounds.

Patient perspectives for improving treatment initiation for new episodes of depression in historically minoritized racial and ethnic groups

OBJECTIVE

Depression is one of the costliest and most prevalent health conditions in the U.S. with 21 million adults having experienced at least one major depressive episode. Despite the availability of evidence-based treatments for depression, a large proportion of people with new diagnoses fail to initiate formal mental health treatment. Although individuals across all racial and ethnic groups fail to initiate treatment for depression, historically minoritized racial/ethnic groups are at even greater risk.

METHOD

Thirty-four participants representing historically underserved racial and ethnic populations from two large health care systems in the U.S. participated in qualitative interviews or focus group to identify factors that impede and facilitate depression treatment initiation in primary care settings.

RESULTS

Participants identified individual and systemic barriers and facilitators of treatment initiation for depression and suggested several ideas for increasing treatment engagement (i.e., increased communication and education from providers, community events, information on social media).

CONCLUSION

Novel interventions are needed to improve treatment initiation following initial diagnosis of depression in primary care settings. Findings from this study offer suggestions for improving treatment initiation in traditionally underserved communities.

Assessing violence and injury prevention plans, strategies and indicators in eighteen Pacific Islands countries: an environmental scan

Background

Similar to many other resource poor settings, due to competing priorities, injury is often neglected in the Pacific Islands despite being a prevalent cause of death and disability. This study identifies, and synthesises existing plans and strategies, and assesses progress against indicators for the prevention of violence and injury in 18 Pacific Islands nations to identify gaps and highlight opportunities.

Methods

An environmental scan of known government repositories and Google Advanced was conducted to identify publicly available documents describing/evaluating national-level injury prevention strategies and plans in the Pacific Islands. Data were extracted on the strategy/plan, country, government department responsible, indicators and related progress.

Findings

We identified 44 relevant documents. Most were published in more resourced countries (e.g., Fiji, Cook Islands) and described strategies/plans relating to traffic injury, injury from natural disaster and/or intimate partner violence. No strategies/plans to prevent injury mechanisms of drowning, falls, suffocation, burns, or electrocution were identified. Progress against only one indicator was reported for road traffic injury in the Commonwealth of the Northern Mariana Islands.

Interpretation

This study suggests that there would be benefit in Pacific Islands nations to develop more robust data systems to assess progress against indicators of existing strategies and plans for traffic-injury, natural disaster and intimate partner violence. Development of strategies and implementation plans to address neglected injury areas such as drowning and falls which account for a significant burden of injury in the Pacific Islands is also recommended.

Funding

This work was funded by the World Health Organization Regional Office for the Western Pacific (RG 221962).

A formative assessment of client characteristics associated with missed appointments in integrated primary care services in rural Arizona

INTRODUCTION

Integrating primary care services in mental healthcare facilities is an uncommon model of care in the United States that could bring several benefits (e.g., improved access to physical healthcare) for vulnerable populations experiencing mental health conditions, especially those living in underserved regions like rural Arizona.

AIM

This formative assessment aimed to understand the sociodemographic and clinical characteristics of clients accessing integrated primary care (IPC) services implemented in 2021 at a community mental healthcare facility in rural Arizona and to explore the proportion of missed appointments. Additionally, we analysed the association between client characteristics and IPC missed appointments.

METHODS

The authors collaborated with a community mental health facility in rural Arizona, which provided deidentified data from 280 clients who accessed IPC services from June 2021 to February 2022.

RESULTS

Most clients were White and of vulnerable socioeconomic status, with a substantial proportion of Native Americans (23.58%). The majority of clients (55.75%) had a mental health disorder (MHD), 23.74% had a substance use disorder (SUD), and 15.10% had comorbid MHD and SUD. Linear regression revealed that experiencing comorbid MHD and SUD was significantly associated with missed appointments. Compared with White clients, Native Americans missed fewer appointments.

CONCLUSION

Future studies conducted from a culturally-centred perspective are crucial to guide strategies to reduce missed appointments in rural IPC services.

Exploring the relevance of a psychology-based resilience app (JoyPop™) for Indigenous youth

BACKGROUND

Despite facing challenges to mental wellness from ongoing multifold trauma, Indigenous youth continue to galvanize their resilience. One pathway undertaken is embracing technology. The JoyPop™ youth resilience mobile application (app) was invited by Six Nations of the Grand River (SN) leadership to consider its use with their reserve youth.

OBJECTIVE

This study explored the feasibility of JoyPop™ research from the SN community adult perspective for appropriateness and relevance to SN youth, as a precursor to a user-experience study with community youth.

METHODS

Semi-structured, online interviews with 19 adult community members (26 % male) about JoyPop™ were conducted with nominated stakeholders from SN. Based on a standard presentation of the app, comments were solicited about app features, design, and relevance to Haudenosaunee culture. Interviews were transcribed, coded in a double-blind fashion, and analyzed for themes.

RESULTS

Most offered positive feedback, with some level of support for each feature of JoyPop™. Themes were identified (Need for Indigenous Design, Incorporation of Indigenous Culture, Appreciation of Ease, Flexibility and Personalization), stemming from comments of appraisal and suggestions for adaptations (e.g., incorporating more cultural elements, localized resources, simplification of app).

CONCLUSIONS

The JoyPop™ app was viewed as positive and relevant, based on feedback from adults within SN. Adaptations were identified by adults to better fit SN youth needs, and research with SN youth is pending before implementation of adaptations. Research with other communities is encouraged to expand the reach of technology interventions, to holistically support Indigenous youth mental health in a culturally relevant way.

Patient-Oriented Research to Improve Internet-Delivered Cognitive Behavioural Therapy for People of Diverse Ethnocultural Groups in Routine Practice

There has been limited research on improving Internet-delivered Cognitive Behavioural Therapy (ICBT) in routine online therapy clinics that serve people from diverse ethnocultural groups (PDEGs). This article describes a patient-oriented adaptation approach used to address this gap in research. A working group consisting of people with lived experience, community representatives, ICBT clinicians, managers, and researchers was formed. The working group examined archival feedback on ICBT from past patients who self-identified as being from diverse ethnocultural backgrounds (N = 278) and the results of interviews with current patients (N = 16), community representatives (N = 6), and clinicians (N = 3). The archival data and interviews revealed the majority of the patients reported being satisfied with and benefitting from ICBT. Suggestions for improvement were not related to the cognitive-behavioural model and techniques, but rather to making treatment materials more inclusive. Consequently, the ICBT adaptation focused on adding content related to cultural influences on mental health, addressing stigma, diversifying case stories, examples, and imagery, adding audiovisual introductions, and replacing English idioms with more descriptive language. Moreover, further training was offered to clinicians, and efforts were made to improve community outreach. This study demonstrates a process for using patient-oriented research to improve ICBT within routine care serving patients of diverse backgrounds.

A national-level examination of First Nations peoples' mental health data: Predicting mental well-being from social determinants of health using the 2017 Aboriginal Peoples Survey

Introduction

A history of colonization and assimilation have resulted in social, economic, and political disparities for Indigenous people in Canada. Decades of discriminatory policies (e.g., the Indian Act, the Residential School System) have led to numerous health and mental health inequities, which have been intergenerationally maintained. Four main social determinants of health (i.e., income, education, employment, and housing) disproportionately influence the health of Indigenous peoples. These four social determinants have also been used within the Community Well-Being (CWB) index, which assesses the socio-economic wellbeing of a community. This study sought to extend previous research by assessing how specific indicators of CWB predict self-reported mental wellbeing within First Nations populations across Canada in a national dataset with more recent data.

Methods

This study utilized the 2017 Aboriginal Peoples Survey, which includes data on the social and economic conditions of First Nations people living off reserve aged 15 years and over.

Results

Results from a factorial ANOVA indicated that perceptions of income security, housing satisfaction, higher education, and employment are associated with increased self-reported mental health among First Nations individuals living off-reserve.

Discussion

These results support the idea that individual mental health interventions on their own are not enough; instead, broader social interventions aimed at addressing inequities in various social determinants of health (e.g., housing first initiatives) are needed to better support individual wellbeing.