Community-based Mental Health Clinic Research Articles

Serious Mental Illness, Glycemic Control, and Neighborhood Factors within an Urban Diabetes Cohort.

Serious mental illness (SMI) may compromise diabetes self-management. This study assessed the association between SMI and glycemic control, and explored sociodemographic predictors and geographic clustering of this outcome among patients with and without SMI. We used electronic health record data for adult primary care patients with diabetes from 2 San Francisco health care delivery systems. The primary outcome was poor glycemic control (hemoglobin A1c >9.0%), which was modeled on SMI diagnosis status and sociodemographics. Geospatial analyses examined hotspots of poor glycemic control and neighborhood characteristics. The study included 11 694 participants with diabetes, 21% with comorbid SMI, of whom 22% had a schizophrenia spectrum or bipolar disorder. Median age was 62 years; 52% were female and 79% were Asian, Black, or Hispanic. In adjusted models, having schizophrenia spectrum disorder or bipolar disorder was associated with greater risk for poor glycemic control (vs participants without SMI, adjusted relative risk [aRR] = 1.24; 95% confidence interval, 1.02, 1.49), but having broadly defined SMI was not. People with and without SMI had similar sociodemographic correlates of poor glycemic control including younger versus older age, Hispanic versus non-Hispanic White race/ethnicity, and English versus Chinese language preference. Hotspots for poor glycemic control were found in neighborhoods with more lower-income, Hispanic, and Black residents. Poor diabetes control was significantly related to having a schizophrenia spectrum or bipolar disorder, and to sociodemographic factors and neighborhood. Community-based mental health clinics in hotspots could be targets for implementation of diabetes management services.

Prevalence of Childhood Trauma in a Community-Based Mental Health Clinic.

A large number of individuals in the US have experienced childhood trauma. However, little is known about the prevalence of trauma in a diverse patient population entering treatment in a community mental health center. To assess early trauma in this population, the Adverse Childhood Experience (ACEs) questionnaire was administered to 856 participants over a nine-month period. 40% reported four or more ACEs. Among high scorers, emotional abuse, physical abuse and emotional neglect were the most prevalent ACE experiences. High mean ACE sum scores were observed among patients with PTSD, depression, impulse disorder and substance use disorder. Having a higher ACE sum score was associated with a greater number of co-occurring psychiatric disorders. Characterizing ACEs by patient sociodemographic attributes and psychiatric diagnoses extracted from the electronic medical records (EMR) can benefit therapeutic interventions. These findings indicate a need for creating more trauma-informed settings with knowledgeable, trained staff.

STAYING CONNECTED: SERVICE-USER EXPERIENCE OF THE RECOVERY JOURNEY AND LONG-TERM ENGAGEMENT WITH A MENTAL HEALTH CLINIC

While there has been much interest in recent years about the potential impact that short-term therapy can have on those needing mental health support, relatively little attention has been paid to the needs of those who require long-term support. In this phenomenological study exploring long-term service-users’ experiences of the recovery journey and the role of mental health support in facilitating that journey, a sample (n = 6) of service-users who had a minimum of five years of continuous involvement with a community-based mental health clinic participated in a pair of focus groups designed to help them share their experience of the recovery journey. Our analysis revealed themes of contending not just with extreme violence and other adversities, but also with an often unhelpful helping system, as service-users expended effort in locating the consistent, accessible support they needed in order to find a reason to go on in the wake of devastating personal experiences. The study also emphasized how prioritizing the top-down need for efficiency over the bottom-up need for consistent, flexible support can have the inadvertent effect of extending rather than shortening treatment. Implications of these findings for the delivery of mental health services are discussed.

Mediators of measurement-based care implementation in community mental health settings: results from a mixed-methods evaluation

BackgroundTailored implementation approaches are touted as superior to standardized ones with the reasoning that tailored approaches afford opportunities to select strategies to resolve determinants of the local context. However, results from implementation trials on this topic are equivocal. Therefore, it is important to explore relevant contextual factors that function as determinants to evaluate if they are improved by tailoring and subsequently associated with changes in implementation outcomes (i.e., via statistical mediation) to better understand how tailoring achieves (or does not achieve) its effects. The present study examined the association between a tailored and standardized implementation approach, contextual factors that might mediate change, and a target implementation outcome in an initiative to implement measurement-based care (specifically the clinical integration of the Patient Health Questionnaire [PHQ-9] for depression) in a community mental health organization.MethodsUsing a cluster randomized control design, twelve community-based mental health clinics were assigned to a tailored or standardized implementation group. Clinicians completed a self-report battery assessing contextual factors that served as candidate mediators informed by the Framework for Dissemination at three time points: baseline, 5 months after active implementation support, and 10 months after sustainment monitoring. A subset of clinicians also participated in focus groups at 5 months. The routine use of the PHQ-9 (implementation outcome) was monitored during the 10-month sustainment period. Multi-level mediation analyses assessed the association between the implementation group and contextual factors and the association between contextual factors and PHQ-9 completion. Quantitative results were then elaborated by analyzing qualitative data from exemplar sites.ResultsAlthough tailored clinics outperformed standard clinics in terms of PHQ-9 completion at the end of active implementation, these group differences disappeared post sustainment monitoring. Perhaps related to this, no significant mediators emerged from our quantitative analyses. Exploratory qualitative analyses of focus group content emphasized the importance of support from colleagues, supervisors, and leadership when implementing clinical innovations in practice.ConclusionsAlthough rates of PHQ-9 completion improved across the study, their sustained levels were roughly equivalent across groups and low overall. No mediators were established using quantitative methods; however, several partial quantitative pathways, as well as themes from the qualitative data, reveal fruitful areas for future research.Trial registrationStandardizedversus tailored implementation of measurement-based care for depression. ClinicalTrials.govNCT02266134, first posted on October16, 2014

Trauma-focused cognitive behavioral therapy with Puerto Rican youth in a post-disaster context: Tailoring, implementation, and program evaluation outcomes

PurposeTrauma-Focused Cognitive Behavioral Therapy (TF-CBT) has not yet been systematically evaluated in the Caribbean context, particularly with Hispanic youth exposed to multiple disasters. The objective of this project was twofold: 1) to train mental health providers in Puerto Rico in TF-CBT as part of a clinical implementation project within the largest managed behavioral health organization (MBHO) on the island, and 2) to conduct a program evaluation to determine the feasibility of implementation and the effectiveness of the treatment. MethodFifteen psychologists were trained in TF-CBT. These psychologists then provided TF-CBT to 56 children and adolescents, ages 5–18, in community-based mental health clinics and one primary care clinic with a co-located psychologist in Puerto Rico. The mean number of traumatic events reported by youth referred for TF-CBT was 4.11. ResultsThirty-six out of 56 children enrolled in the project (64.3%) successfully completed all components of TF-CBT. Results demonstrated large effect sizes for reduction in youth-reported posttraumatic stress symptoms (PTSS) (Cohen's d = 1.32), depressive symptoms (Cohen's d = 1.32), and anxiety symptoms (Cohen's d = 1.18). ConclusionsThese results suggest that it was feasible to train providers in TF-CBT, that providers were able to deliver TF-CBT in community-based settings both in person and via telehealth (due to the COVID-19 pandemic), and that TF-CBT was an effective treatment option to address trauma-related concerns for youth in Puerto Rico in a post-disaster context. This project is an important first step in the dissemination and implementation of evidence-based trauma-focused treatment for Hispanic youth and disaster-affected youth in the Caribbean.

Improving Youth Mental Health Services Access Using a Single-Session Therapy Approach

This article describes the implementation and evaluation of a single-session therapy (SST) pilot project in a youth community-based mental health clinic. The intent was to improve access to therapy services in order to reduce wait times, support youth's and their caregivers’ functioning, relieve immediate distress and connect youth to resources while waiting for ongoing therapy. Wait times were reduced by 90 days when SST was implemented following intake. Caregivers reported clinically significant improvement in adolescent well-being at one-month follow-up using the Outcome Rating Scale. Clinicians embraced the implementation of SST as a complementary service to multisession therapy in the clinic setting.

Developing and implementing a culturally informed FAmily Motivational Engagement Strategy (FAMES) to increase family engagement in first episode psychosis programs: mixed methods pilot study protocol

IntroductionDespite the proven effectiveness of coordinated specialty care (CSC) programmes for first episode psychosis in the USA, CSC programmes often have low levels of engagement in family psychoeducation, and engagement...

Use of a Mobile App to Augment Psychotherapy in a Community Psychiatric Clinic: Feasibility and Fidelity Trial.

BackgroundEven though 1 in 5 Americans experience some form of mental illness each year, 80% have been shown to discontinue psychotherapy prematurely. The traditional psychotherapy service delivery model, consisting of isolated clinical sessions, lacks the ability to keep patients engaged outside clinical sessions. Newer digital mental health platforms can address the clinical need for a robust tool that tracks mental well-being and improves engagement in patients with depressive symptoms.ObjectiveThe primary goals of this feasibility study were to (1) assess compliance among providers and their patients with a digital mental health platform protocol, and (2) examine the usability and fidelity of a mobile app through structured participant feedback.MethodsA sample of 30 participants was recruited for a 5-week study from a community-based mental health clinic in Baltimore, Maryland, USA. Inclusion criteria were: aged 18 years or older, having access to a smartphone, and having at least mild-to-moderate depression and/or anxiety as measured by the Patient Health Questionnaire-9 (PHQ-9) and Generalized Anxiety Disorder-7 (GAD-7) scales, respectively. Eligible participants were randomized into one of two study arms: (1) the intervention arm or (2) the waitlist control arm. Participants in the intervention arm were asked to download the Rose app and were prompted to complete clinical assessments (PHQ-9 and GAD-7) every other week, daily mood and anxiety Likert scales, and daily journal entries. The participants in the waitlist arm served as controls for the study and completed the clinical assessments only. Both arms engaged in weekly psychotherapy sessions, with participant in-app input informing the psychotherapy process of the intervention arm, while those in the waitlist control arm continued their standard care. Outcomes of interest included adherence to completion of in-app assessments and usability of the Rose mobile app assessed through the modified Mobile Application Rating Scale.ResultsOver the study period, a sample of 30 participants used the Rose app 2834 times to complete clinical assessments. On average, 70% (21; 95% CI 61.14%-77.41%) of participants completed mood and anxiety daily check-ins and journal entries 5 days per week. Nearly all participants (29/30, 97%) completed all PHQ-9 and GAD-7 in-app scales during the study. Subjective impressions showed that 73% (22/30) of participants found the mobile app to be engaging and in line with their needs, and approximately 70% (21/30) of participants reported the app functionality and quality of information to be excellent. Additionally, more than two-thirds of the participants felt that their knowledge and awareness of depression and anxiety management improved through using the app.ConclusionsSteady compliance and high app ratings showcase the utility of the Rose mobile mental health app in augmenting the psychotherapy process for patients with mood disorders and improving mental health knowledge. Future studies are needed to further examine the impact of Rose on treatment outcomes.Trial RegistrationClinicalTrials.gov NCT04200170; https://clinicaltrials.gov/ct2/show/NCT04200170

Clinical state tracking in serious mental illness through computational analysis of speech.

Individuals with serious mental illness experience changes in their clinical states over time that are difficult to assess and that result in increased disease burden and care utilization. It is not known if features derived from speech can serve as a transdiagnostic marker of these clinical states. This study evaluates the feasibility of collecting speech samples from people with serious mental illness and explores the potential utility for tracking changes in clinical state over time. Patients (n = 47) were recruited from a community-based mental health clinic with diagnoses of bipolar disorder, major depressive disorder, schizophrenia or schizoaffective disorder. Patients used an interactive voice response system for at least 4 months to provide speech samples. Clinic providers (n = 13) reviewed responses and provided global assessment ratings. We computed features of speech and used machine learning to create models of outcome measures trained using either population data or an individual’s own data over time. The system was feasible to use, recording 1101 phone calls and 117 hours of speech. Most (92%) of the patients agreed that it was easy to use. The individually-trained models demonstrated the highest correlation with provider ratings (rho = 0.78, p<0.001). Population-level models demonstrated statistically significant correlations with provider global assessment ratings (rho = 0.44, p<0.001), future provider ratings (rho = 0.33, p<0.05), BASIS-24 summary score, depression sub score, and self-harm sub score (rho = 0.25,0.25, and 0.28 respectively; p<0.05), and the SF-12 mental health sub score (rho = 0.25, p<0.05), but not with other BASIS-24 or SF-12 sub scores. This study brings together longitudinal collection of objective behavioral markers along with a transdiagnostic, personalized approach for tracking of mental health clinical state in a community-based clinical setting.

Psychological Correlates of Change in Emotion Regulation Over 8 Months of Psychotherapy

Emotion regulation corresponds to the individual’s ability to identify and modulate emotional experiences and improvements thereof over the course of psychotherapy are associated with the reduction in psychiatric symptoms across multiple diagnoses. However, the extent to which changes in the capacity for emotion regulation over the course of therapy relate to individual differences in emotion-related self-perceptions, degree of psychiatric distress, and the reasons for seeking psychotherapy remain understudied. This study explored the relations between changes in the capacity for emotion regulation over 8 months of psychotherapy, as defined by all subscales of the Difficulties for Emotion Regulation Scale, trait emotional intelligence and psychological distress. In addition, this study examined whether changes in the capacity for emotion regulation differed between patients reporting at least one regulation treatment goal and those reporting other goals. Data were collected as part of an ongoing program evaluation at an urban community-based mental health clinic. Self-report questionnaires were completed by 74 patients prior to beginning psychotherapy and after completing 8 months of psychotherapy. We found that higher trait emotional intelligence and lower psychological distress were related to improvements in emotion regulation. Moreover, the capacity for emotion regulation, particularly emotional awareness and limited access to emotion regulation strategies, worsened among individuals who reported at least one regulation treatment goal relative to those who reported other goals. As such, an initial phase of psychotherapy that focuses on integrating skills and self-awareness of emotional sensations prior to or in conjunction with embarking on an open-ended exploratory treatment is recommended.

Prevalence of Adverse Childhood Experiences Among Veterans

The adverse childhood experiences (ACE) study showed that childhood trauma is common in the general population and has enduring effects on adult emotional and physical health. Levels of childhood adversity among individuals with a history of military service have been found to match or exceed those among individuals with no history of military service. Most studies to date have found that ACEs are associated with poorer mental health outcomes among service members and veterans, although the ways in which childhood adversity may contribute to vulnerability or resilience are not fully understood. Further, the prevalence of ACEs specifically among veterans has not been clearly established. We evaluated the prevalence of childhood adversity at a community-based outpatient mental health clinic within the Department of Veterans Affairs (VA) and found that 85.0% of participating veterans reported experiencing at least one category of ACE before the age of 18, while nearly half of veteran participants (46.0%) reported experiencing four or more categories. We discuss the implications of a high burden of childhood adversity for neurobiological development and psychological functioning among veterans, and for mental health treatment within the VA. Further, we describe the development of a trauma-informed program which utilizes a phase-based, modular approach to better address the psychological sequelae of childhood adversity, and foster resilience and posttraumatic growth. Several case examples are discussed, along with recommendations for future research.

Examining the role of trait emotional intelligence on psychiatric symptom clusters in the context of lifetime trauma

ObjectiveThis article examines the role of socio-demographic variables, lifetime trauma and trait emotional intelligence (EI) as predictors of trauma-related symptom clusters (depression, anxiety, and somatization). Method202 adults receiving seeking psychological services at a community-based mental health clinic completed self-report questionnaires. ResultsSocio-demographic variables, lifetime trauma and trait EI significantly related to all outcomes, but trait EI had the largest impact. Trait EI was negatively related to the measures of psychological distress, with standardized coefficients ranging between −0.39 to −0.67. Combined, the three groups of variables explained between 28 and up to 50% of the variance in the outcomes. ConclusionsThese results suggest that trait EI is valuable in the prevention and treatment of depression, anxiety, and somatization symptom clusters among individuals exposed to trauma, in particular among individuals with low income and education.

An Experimental Case Study Series Showing Induced Altruism’s Efficacy in Severely Disturbed Inner-City Children

ABSTRACTUsing descriptions of inner-city adolescents being seen at a community-based mental health clinic, the authors demonstrate how the use of altruism enabled the adolescents to alter their inner lives and their behavior. The trajectory of development toward relatedness, creativity, and fulfillment was reestablished.

Interrupting the Mental Illness–Incarceration-Recidivism Cycle

Individuals with serious mental illness such as schizophrenia, bipolar, and major depressive disorders are being disproportionately relegated to US prisons and jails instead of community-based mental health clinics. They enter a system designed for criminal offenders. It is estimated that 10% to 20% of jail inmates and 25% of prison inmates have a serious mental illness; the proportion of affected jail inmates is estimated to be 3 to 6 times the rate in the general population.1 A significant percentage of these individuals are not receiving the psychiatric care they need and deserve. The lack of psychiatric beds in the United States likely contributes to this problem

Caregiver Treatment Preferences for Children with a New Versus Existing Attention-Deficit/Hyperactivity Disorder Diagnosis.

Parental experiences with managing their child's attention-deficit/hyperactivity disorder (ADHD) can influence priorities for treatment. This study aimed to identify the ADHD management options caregivers most prefer and to determine if preferences differ by time since initial ADHD diagnosis. Primary caregivers (n = 184) of a child aged 4-14 years old in care for ADHD were recruited from January 2013 through March 2015 from community-based pediatric and mental health clinics and family support organizations across the state of Maryland. Participants completed a survey that included child/family demographics, child clinical treatment, and a Best-Worst Scaling (BWS) experiment to elicit ADHD management preferences. The BWS comprised 18 ADHD management profiles showing seven treatment attributes, where the best and worst attribute levels were selected from each profile. A conditional logit model using effect-coded variables was used to estimate preference weights stratified by time since ADHD diagnosis. Participants were primarily the mother (84%) and had a college or postgraduate education (76%) with 75% of the children on stimulant medications. One-on-one caregiver behavior training, medication use seven days a week, therapy in a clinic, and an individualized education program were most preferred for managing ADHD. Aside from caregiver training and monthly out-of-pocket costs, caregivers of children diagnosed with ADHD for less than two years prioritized medication use lower than other care management attributes and caregivers of children diagnosed with ADHD for two or more years preferred school accommodations, medication, and provider specialty. Preferences for ADHD treatment differ based on the duration of the child's ADHD. Acknowledging that preferences change over the course of care could facilitate patient/family-centered care planning across a range of resources and a multidisciplinary team of professionals.

Mothering from the Inside Out: results of a pilot study testing a mentalization-based therapy for mothers enrolled in mental health services

ABSTRACTMothers who are involved with mental health services (for themselves or their children) rarely receive adequate support for their role as parents. Mental illness in a parent or child often exacerbates the challenges of managing psychological distress that is germane to the parenting roll. Mentalization-based approaches to psychotherapy for parents have the potential to address challenges of emotional regulation in parents by supporting their capacity to recognize and modulate negative affect during stressful parenting situations. In this study, we piloted Mothering from the Inside Out (MIO) with 17 mothers receiving services at a community-based mental health clinic. MIO is a 12-week, mentalization-based parenting intervention that demonstrated efficacy in two previous randomized controlled trials with substance using mothers. In this study, we were interested in determining whether community-based clinicians could deliver MIO with sustained fidelity. We were also interested in examining the preliminary feasibility, acceptability and efficacy of MIO when delivered by clinicians in a community mental health center. Finally, we were interested in replicating prior tests of the proposed treatment mechanisms. Treatment outcomes included maternal reflective functioning, psychiatric and parenting stress, and mother–child interaction quality. Our findings indicated that MIO was feasible and acceptable when delivered in the community-based setting and that all maternal indices improved. However, no improvement in mother–child interaction quality was found, possibly because of insufficient time for these changes to consolidate.

Misdemeanor Arrestees With Mental Health Needs: Diversion and Outpatient Services as a Recidivism Reduction Strategy.

Individuals with mental illnesses who are arrested for criminal activity cycle between criminal justice and mental health systems at disproportionately high rates. Studying recidivism of this population has been difficult due to separate system data bases. This study compared recidivism outcomes of 102 adults with mental illness who were arrested for a misdemeanor offense. One group had a diagnosed mental illness ( n = 58) and the other group was diagnosed with co-occurring mental health and substance abuse disorders ( n = 44). As a condition of their personal recognizance bond, both groups voluntarily agreed to stabilize on medication and report to community-based outpatient mental health clinic. Participants in both groups had fewer rearrests and fewer days in jail in the 12 months following discharge from diversion relative to the 12 months prior to diversion participation. Outpatient mental health service utilization following 24 hr in jail seems to be a viable means of reducing recidivism among accused misdemeanant defendants.

A pilot study examining the use of the autism diagnostic observation schedule in community-based mental health clinics

Community-based mental health (CMH) services play an important, but relatively understudied role in the identification and treatment of youth with autism spectrum disorder (ASD) who may be receiving care for other psychiatric conditions. Little is known about the role of standardized ASD assessment measures administered by providers working in generalist community-based mental health (CMH) settings. This pilot study extracted data from three CMH clinics to examine the use of the Autism Diagnostic Observation Schedule (ADOS) by 17CMH providers who received ASD assessment training with 62 youth (Mean=10.69 years) referred for an ASD diagnostic evaluation. Results indicated that 57% of youths assessed ultimately received an ASD diagnosis. All cases given a final ASD diagnosis were classified as “Autism” or “ASD” on the ADOS. Seventy percent of youth who did not receive a final ASD diagnosis were classified as “Non-Spectrum” on the ADOS. In these false positive cases, report narratives indicated that social communication difficulties identified on the ADOS were explained by symptoms of other mental health conditions (e.g., ADHD, anxiety). Future research is needed to examine the utility of the ADOS when used by CMH providers to facilitate CMH capacity to identify ASD.

Patient-Provider Therapeutic Alliance Contributes to Patient Activation in Community Mental Health Clinics.

Patient activation, often conceptualized as an individual trait, contributes to mental health outcomes. This study assessed the relational contributors to activation by estimating the longitudinal association of patient-provider communication and two factors of therapeutic alliance (agreement on tasks/goals and bond), with patient activation. Participants were patients (n=264) from 13 community-based mental health clinics across the United States. In multivariate models, controlling for patients' individual and clinical characteristics, the task/goal factor of therapeutic alliance emerged as a significant and independent predictor of greater change in patient activation scores. Improving patient activation may require addressing patient-provider interactions such as coming to collaborative agreement on the tasks/goals of care.

Tablet-based education to reduce depression-related stigma

Objectives: This study investigated the efficacy of a tablet-based multimedia education application, the Project Not Alone Depression Module, in improving depression literacy and reducing depression stigma among a community-based mental health clinic population. Methods: A total of 93 participants completed either a tablet-based multimedia education or a print education module containing the same content on depression. Primary outcomes were changes in depression literacy as measured by a knowledge quiz and stigma as measured by the Depression Stigma Scale administered before and after the education intervention. Secondary outcomes included participant preference, ease of use, and likeliness to discuss topic with a physician. Results: In comparison to print education, tablet-based multimedia education significantly increased depression-related knowledge and reduced depression stigma ( p &lt; .05). Among all participants, a reduction in the personal stigma score was correlated with an increase in knowledge score ( p &lt; .05). Participants preferred the tablet-based module to a human health educator ( p &lt; .05). Conclusion: With advantages of scalability, user preference, and efficacy in improving depression literacy and stigma, tablet-based multimedia education has the potential to improve the health outcomes of mental health clinic populations. Although the study findings are limited by small sample size and lack of randomisation, the results are encouraging for future research and development in tablet-based multimedia patient education.