Community-based Mental Health Treatment Research Articles

School and community-based interventions for refugee and asylum seeking children: a systematic review.

BackgroundResearch for effective psychological interventions for refugee and asylum-seeking children has intensified. The need for interventions in environments more easily accessed by children and families is especially relevant for newly arrived populations. This paper reviews the literature on school and community-based interventions aimed at reducing psychological disorders in refugee and asylum-seeking children.Methods and FindingsComprehensive searches were conducted in seven databases and further information was obtained through searching reference lists, grey literature, and contacting experts in the field. Studies were included if they reported on the efficacy of a school or community-based mental health intervention for refugee or asylum-seeking children. Two independent reviewers made the final study selection, extracted data, and reached consensus on study quality. Results were summarized descriptively. The marked heterogeneity of studies excluded conducting a meta-analysis but study effect-sizes were calculated where possible. Twenty one studies met inclusion criteria for the review reporting on interventions for approximately 1800 refugee children. Fourteen studies were carried out in high-income countries in either a school (n = 11) or community (n = 3) setting and seven studies were carried out in refugee camps. Interventions were either primarily focused on the verbal processing of past experiences (n = 9), or on an array of creative art techniques (n = 7) and others used a combination of these interventions (n = 5). While both intervention types reported significant changes in symptomatology, effect sizes ranged from 0.31 to 0.93 and could mainly be calculated for interventions focusing on the verbal processing of past experiences.ConclusionsOnly a small number of studies fulfilled inclusion criteria and the majority of these were in the school setting. The findings suggest that interventions delivered within the school setting can be successful in helping children overcome difficulties associated with forced migration.

Measuring Gang Involvement in a Justice-Referred Sample of Youth in Treatment

Gangs are present in about 34% of all jurisdictions in the United States. Given elevations in violence and victimization associated with gang involvement, effective means are needed for measuring involvement among individual youth. This is especially the case among youth receiving services for problem behavior who might benefit from targeted treatments helping them reduce involvement in gangs. We assessed gang involvement among 421 youth referred by the justice system for intensive home- and community-based mental health treatment. Using self-report survey and therapist-recorded data, we identified 94 (22%) youth as gang involved. Risk factor measures provided support for our classification, driven primarily by self-reported indicators of gang involvement as opposed to therapist-recorded indicators.

EPA-1125 – The tech connect program: A psychosocial treatment adherence intervention for adolescents with depression

Despite annual investments of millions of dollars to develop and disseminate interventions for mood disorders in adolescence, approximately a third of youth dropout or terminate prematurely. Low adherence remains a fundamental impediment to treatment effectiveness and mental health outcomes. To address this issue, the Tech Connect Program was developed as a proactive and simple to implement package of manualized between-session contacts (e.g., texting, phone calls) and structural supports (e.g., transportation, childcare) that are individualized to increase adherence of adolescents with mood disorders who are at high risk of treatment dropout from community-based treatments. A 2-arm randomized controlled trial (RCT) with depressed youths (age 13-17 years) and parents randomized to either standard community-based mental health care (control condition) or the Tech Connect Program plus standard clinical care (treatment condition) was implemented to examine the feasibility and acceptability of the Tech Connect Program protocols, to estimate intervention parameters including recruitment and attrition rates, and assess the preliminary impact of the intervention on treatment adherence and mental health outcomes. Findings show that Tech Connect Program is both feasible and acceptable to clinicians, youth and their families. Although further research is needed to evaluate the Tech Connect Program, this feasibility pilot study has demonstrated an innovative, novel intervention to improve adolescent engagement and adherence to community-based mental health treatment.

Spanish-Language Community-Based Mental Health Treatment Programs, Policy-Required Language-Assistance Programming, and Mental Health Treatment Access Among Spanish-Speaking Clients

We investigated the extent to which implementing language assistance programming through contracting with community-based organizations improved the accessibility of mental health care under Medi-Cal (California's Medicaid program) for Spanish-speaking persons with limited English proficiency, and whether it reduced language-based treatment access disparities. Using a time series nonequivalent control group design, we studied county-level penetration of language assistance programming over 10 years (1997-2006) for Spanish-speaking persons with limited English proficiency covered under Medi-Cal. We used linear regression with county fixed effects to control for ongoing trends and other influences. When county mental health plans contracted with community-based organizations, those implementing language assistance programming increased penetration rates of Spanish-language mental health services under Medi-Cal more than other plans (0.28 percentage points, a 25% increase on average; P < .05). However, the increase was insufficient to significantly reduce language-related disparities. Mental health treatment programs operated by community-based organizations may have moderately improved access after implementing required language assistance programming, but the programming did not reduce entrenched disparities in the accessibility of mental health services.

Professional Roles in Community Mental Health Practice: Generalist Versus Specialist

Major trends in the mental health field, including the transition toward deinstitutionalization and community-based care, the increased focus on cost-effectiveness and accountability, and the rise of consumer-based health care have had significant impacts on mental health practice. With the shift to community-based mental health, multidisciplinary teams and generic interventions have become the dominant means of providing client services. This shift to generic interventions has had detrimental effects on professional identity and self-efficacy, client care, and interdisciplinary team collaboration.

Community mental health services for the mentally ill: Practices and ethics

Background. Approximately 54 million people around the world suffer from severe mental disorders such as schizophrenia and bipolar affective disorder (manic-depressive illness). In addition, 154 million people suffer from depression. Globally, progressive reforms have determined the changes in the provision of mental health services, with the current emphasis on community orientated care.Objective. This paper focuses on the strategies in use in developing countries and enlisting interventions in high resource settings. The ethics of community interventions are highlighted.Methods. English language literature on the subject was obtained thorough searches in PubMed, other indexed journals and published books.Results. Literature indicates the heterogeneity of the community programmes. While abundant literature exists on ethics in research, the ethical issues of community-based mental health intervention has not been widely dealt with.Conclusion. Community care is emerging globally as an important method of service provision. While obstacles in varying forms remain, the benefits are gradually becoming visible. Mental health services can develop effectively if there is adherence to a principle ethical base, which respects the human rights of individuals living with mental illness.

Preliminary outcome study on assertive community treatment in Japan

The beneficial effects of assertive community treatment (ACT), which has been widely acclaimed as being successful in several foreign countries, must also be objectively evaluated with respect to the transition from inpatient to community-based mental health treatment in Japan. This was the first study that examined effects of the ACT program in Japan using pre/post design data of the pilot trial of the ACT program in Japan project. The study included 41 subjects hospitalized at Kohnodai Hospital, National Center of Neurology and Psychiatry between May 2003 and April 2004 for severe mental illness and who met inclusion criteria for entry regarding age, diagnosis, residence, utilization of mental health services, social adjustment, and ability to function in daily activities. All subjects provided informed consent for study participation and were followed for 1 year after hospital discharge. Comparison of the number of days and frequency of inpatient psychiatric hospitalization and frequency of emergency psychiatric visits between the 1-year period before hospitalization and 1-year period after hospital discharge showed a significant decrease in number of days and frequency of hospitalization. Comparison at 1 year after discharge with baseline showed no change in satisfaction with overall quality of life or Brief Psychiatric Rating Scale scores, but the Global Assessment of Functioning score significantly increased, and the antipsychotic dose (chlorpromazine equivalent) significantly decreased. Despite some limitations in methodology and conclusions, this study suggests that ACT enables persons with severe mental illness to live for longer periods in the community, without worsening of symptoms, decreased social function, or deterioration in quality of life.

Therapist Focus on Parent Involvement in Community-Based Youth Psychotherapy.

Parent involvement in the treatment of childhood disruptive behavior problems is a critical component of effective care. Yet little is known about the amount of time therapists are involving parents in treatment and factors that predict therapists' efforts to involve parents in routine care. The purpose of this study is to examine therapists' within-session involvement of parents in community-based outpatient mental health treatment. The data are from a larger longitudinal observational study of psychotherapy for children ages 4-13 with disruptive behavior problems and include videotaped psychotherapy sessions coded for the therapeutic strategies delivered as well as measures of child, parent/family, and therapist characteristics at baseline. Parent involvement is defined as the proportion of time in the session that therapists direct treatment strategies towards parents. Results indicated that therapists directed treatment strategies towards parents an average of 44% of the time within a session. Multilevel modeling was used to examine client-level (child, parent, and family functioning) and provider-level (therapist experience and background) predictors of parent involvement. Therapists involved parents more when the child had higher levels of behavior problems, when the parent reported higher levels of internalized caregiver strain, and when the therapist was more experienced. The results highlight potential areas to target in efforts to increase parent involvement, including training less experienced therapists to increase their focus on directing strategies towards parents.

Community-Based Mental Health Intervention for Underprivileged Women in Rural India: An Experiential Report

Objective. To share experiences from a project that integrates a mental health intervention within a developmental framework of microcredit activity for economically underprivileged women in rural India. Method. The mental health intervention had two components: group counseling and stress management. The former comprised of ventilation and reassurance and the latter strengthening of coping skills and a relaxation technique. Focus group discussions were used to understand women's perception of how microcredit economic activity and the mental health intervention had affected their lives. Results. Women in the mental health intervention group reported reduction in psychological distress and bodily aches and pains. Majority (86%) reported that the quality of their sleep had improved with regular practice of relaxation and that sharing their problems in the group had helped them to unburden. The social support extended by the members to each other, made them feel that they were not alone and could face any life situation. Conclusion. The study provided qualitative evidence that adding the mental health intervention to the ongoing economic activity had made a positive difference in the lives of the women. Addressing mental health concerns along with livelihood initiatives can help to enhance both economic and social capital in rural poor women.

A clinical study of those who utter threats to kill

The current study sought to examine the psychiatric characteristics and rate of subsequent violence among those who uttered explicit threats to kill. Data were drawn from 144 referrals of adults to a community-based forensic mental health consultation and treatment service. Each had explicitly threatened to kill a person other than themselves. Assaults were made by over 20%, including one homicide, within 12 months of assessment. Two participants committed suicide in the follow-up period. Factors found to contribute to violence risk were substance abuse, prior violence, limited education and untreated mental disorders. Threateners were often habitual in their threatening behaviour and typically targeted those they interacted with on a daily basis. Clinical characteristics showed a psychiatrically complex group who shared many features of other offender groups. The type of threat that led to referral for a mental health assessment was not uncommonly followed by violence. Factors enhancing risk resemble findings from other groups of offenders. Those referred for clinical evaluation typically have complex clinical presentations and marked deficits in effectively managing interpersonal conflict.

Engaging Adolescent Mothers in a Longitudinal Mental Health Intervention Study: Challenges and Lessons Learned

Little is known about recruiting and retaining adolescent mothers in research studies. Investigators who study adolescent mothers have been guided by trial and error, clinical experience, qualitative inquiry, literature of special populations, or the advice of stakeholders. This paper describes the challenges and lessons learned in engaging adolescent mothers in a longitudinal community-based mental health intervention study. Audio-recorded data that describes the circumstances of five adolescent mothers lost to attrition were extracted from a longitudinal mental health intervention study. Adolescent mothers described a chaotic home environment with multiple demands, family conflict, health issues, limited access to a telephone, transportation, financial, and social support. Utilizing a multidisciplinary community advisory group, dedicated telephone, and free electronic media may assist in overcoming modifiable barriers to recruitment and retention of adolescent mothers. Exploring a waiver of informed consent and the engagement of mothers of adolescents in research are indicated.

Health Care Reform and Care at the Behavioral Health--Primary Care Interface

Health Care Reform and Care at the Behavioral Health--Primary Care Interface

Assessing and Treating Co-occurring Disorders in Adolescents: Examining Typical Practice of Community-Based Mental Health and Substance Use Treatment Providers

Co-occurring mental health and substance use disorders in adolescents are common. However, limited efforts have been directed at understanding how treatment providers in community settings deal with this frequent challenge. In this study, treatment providers from both substance use and mental health settings were interviewed to examine their common practices regarding the assessment and treatment of co-occurring depression and substance use disorders in adolescence. About 93% of treatment providers reported treating adolescents with these co-occurring conditions. However, few providers reported using formal assessment practices (23-30%) or treatment protocols for co-occurrence (10%). Providers in mental health settings (particularly psychologists) were more likely than those in substance use settings to formally assess for depression [Chi2(1, N = 30) = 3.62, P = .065] but less likely to do so for substance use [Chi2(1, N = 30) = 9.46, P = .004]. Findings are considered with regard to implications for assessment and treatment outcomes in this high-risk population.

Success indicators for integrating mental health interventions with community-based rehabilitation projects

Community interventions for people with physical disabilities and for people with mental illness have evolved following similar trajectories, although at different periods of time. This study develops and tests indicators for successful integration of community-based rehabilitation (CBR)-mental health and development (MHD) services. An in-depth study was conducted of two organizations in Sri Lanka and India that successfully integrated CBR and MHD services as well as two organizations in Nepal and Bangladesh, which were planning integration. Interviews and focus groups were used to gather nonconfidential information. The study suggests many benefits of integration and several indicators of readiness: willingness to work with mentally ill people, a basic understanding of the mental health concept and mental illness problems, a match of context and strategy between current CBR activities and proposed MHD activities, stability of basic resources and infrastructure in the organization. A second set of indicators determined the long-term viability of an integrated CBR-MHD approach: ability to strategize and plan a mental health programme, ability to network with stakeholders effectively, ability to make use of resources efficiently. A major finding of the study was the need for training in the practical aspects of integration of mental health interventions with CBR. Tool sets are available that can be used by donors and by local organizations for assessing needs and readiness as well as developing viable strategies for the integration of community-based mental health interventions into existing CBR work.

Trends in child welfare's focus on children's mental health and services from 1980–2004

This study examined how one of the oldest and most widely distributed child welfare practice journals addressed children's mental health issues over a 25-year period. The content of 478 articles was coded. Logistic regression findings indicate that mental health issues were discussed less frequently over the first half of the period examined, and then more frequently over the last decade. Residential treatment was discussed less frequently over time, but other community-based alternatives to residential treatment were rarely discussed at any point, so that overall the content related to treatment of mental health issues decreased as discussion of residential treatment decreased. These findings suggest that although the child welfare literature has recently focused more on children's mental health, dissemination of specific concepts from the mental health to the child welfare literature does not naturally occur over time. Efforts targeted at dissemination of effective community-based mental health interventions for foster children may be needed to support this process.

SAMHSA Assesses Alternatives to Seclusion, Restraint

Back to table of contents Previous article Next article Professional NewsFull AccessSAMHSA Assesses Alternatives to Seclusion, RestraintRich DalyRich DalySearch for more papers by this authorPublished Online:19 Oct 2007https://doi.org/10.1176/pn.42.20.0008aThe Substance Abuse and Mental Health Services Administration (SAMHSA) awarded grants to programs in eight states in September, worth a total of more than $5 million over three years, to reduce and ultimately eliminate the use of seclusion and restraint among institutional and community-based mental health treatment centers.“Too often, seclusion and restraint are the cause of additional trauma, injury, and even death,” said SAMHSA Administrator Terry Cline, Ph.D. The grants aim to ensure that states invest in “sustainable solutions and strategies for the treatment of those with serious mental illness.”The funds were awarded under SAMHSA's Alternatives to Restraint and Seclusion State Incentive Grant program, which supports activities that build a foundation for delivering and sustaining “effective recovery-based substance abuse prevention, treatment, and/or mental health services,” including services for people with co-occurring substance abuse and other mental health disorders.Continuation of the grants is subject to the availability of funds as well as the progress achieved by the grantees. Total funding for the first year is $1.7 million.The grantees are in Connecticut, Indiana, New Jersey, New York, Oklahoma, Texas, Vermont, and Virginia. They include a Connecticut Department of Mental Health and Addiction Services program that aims to develop and implement a strategic plan that will reduce and eliminate the use of seclusion and restraint among young adults aged 18 to 25 who have serious mental illness.Another program is an Indiana Family and Social Services Administration program to reduce the incidence of seclusion and restraint at two state-operated facilities that treat youth aged 5 to 18.The New Jersey Division of Mental Health Services is using a $214,000 grant in four state psychiatric hospitals to monitor “relevant outcomes” and to partner with a consumer-run mental health organization that will provide on-site peer advocates.The New York State Office of Mental Health says it will use its $214,000 grant to help build capacity at inpatient and residential treatment programs that use “positive alternatives” to seclusion and restraint as part of their treatment of children with severe emotional disturbances.More information on the SAMHSA grants is posted at<www.samhsa.gov/newsroom/advisories/070921rs_award3327.aspx>.▪ ISSUES NewArchived

Re: Community Treatment Orders for Psychiatric Patients: The Emperor with No Clothes

Dear Editor: We appreciated reading the spirited debate between Dr O'Reilly, on the one hand, and Dr Kisely and Ms Campbell, on the other, about community treatment orders (CTOs)14 and were pleased to see that the results of our North Carolina study5 continue to animate discussion of this important and controversial topic. Clearly, the use of legal leverage in community-based mental health treatment poses challenging questions for research and policy; it is hardly surprising that experts disagree, in good faith, about both the intervention and the evidence for its effectiveness. Several points underlying Kisely and Campbell's critique of our study in North Carolina warrant further comment. First, Kisely and Campbell write, The 1-year follow-up is therefore of a highly selected and potentially unrepresentative population that was not dangerous and was sufficiently compliant to participate in baseline and follow-up assessments.1,p 684 The attrition problem that these authors highlight (18% in our study) was substantial but irrelevant to the hospital outcome data. We included admissions data for all study participants-even dropouts-in the intent-to-treat analysis of hospital recidivism. Kisely and Campbell's suggestion that our study excluded all patients who were dangerous requires a qualifier. The exclusion criterion applied to patients with a documented recent history of serious violent behaviour involving weapon use or causing physical injury. However, one-third of randomized participants had engaged in acts of simple battery, or had been involved in physical fights, during the 4 months preceding enrolment. An additional 20% had made verbal threats of harm to others. Suicidality was also not an exclusion criterion. We think our study generalizes to a broader clinical population than one might imagine from reading Kisely and Campbell's critique. Second, these authors write that the study failed to show significant differences between intervention and control groups in terms of hospital or other outcomes ... over the following 12 months.1 In fact, using repeated-measures analysis, we found that assignment to the outpatient commitment group was associated with a significantly lower odds of any readmission (odds ratio 0.64; 95% confidence interval, 0.46 to 0.88; P As Kisely and Campbell correctly observe, our analysis also revealed that the apparent effect of the intervention was concentrated heavily among participants who received extended court-ordered treatment. Still, the result was sufficiently strong to achieve statistical significance for the experimental group as a whole. Finally, Kisely and Campbell state, Analysis of subjects who have not been randomly assigned to CTO groups of less or more than 180 days may reflect a bias where a CTO was selectively extended when it seemed to be helping the patient.1, p 684 Our evidence suggests the opposite was true. Participating mental health centres agreed in advance to systematically review each expiring court order and file a petition to renew if the patient continued to meet legal criteria for outpatient commitment. Consequently, patients with a history of treatment noncompliance and poor insight were significantly more likely to have their orders renewed. This possibly amounted to a selection bias, but one favouring a negative finding, making it harder-not easier-to show an effect for CTOs. In the end, some will be persuaded by these results and others will not. As researchers, we take no advocacy position with respect to the policy of CTOs. Our goal has been to help build a base of evidence to inform the policy debate. Clearly, however, this is an area that warrants careful reflection as well as further research in different populations and jurisdictions. …

Inpatient Psychiatric Treatment: Should We Revive a Shrinking System?

INPATIENT PSYCHIATRIC TREATMENT appears to be shrinking. The most recent national data indicate that in the 2-year span between 1998 and 2000, 20% of private psychiatric hospitals closed and the number of inpatient beds declined by some 20%, across all types of hospitals (Manderscheid et al., 2004). There are 16 states reporting inpatient bed shortages (Mulligan, 2002). The shortages are particularly pronounced in the country’s Western and Midwestern sections where bed rates per 100,000 citizens are half of those in several Mid-Atlantic States. Shrinking services means decreased access for persons who need hospital-level care, leaving little option save for emergency room treatment (National Association of Psychiatric Hospital Systems [NAPHS] 2003). In one sense, inpatient care is vulnerable to rapid downsizing. It is an expensive form of treatment that has been slow to produce a body of outcome research demonstrating its worth. In some instances, reimbursement streams (both Medicare/Medicaid and private insurance) do not cover the true cost of hospitalization, often making the inpatient service a drain on the hospital balance sheet. Finally, there exists the popular wisdom that one way to expand funding for community-based mental health treatment is to use resources gained by decreasing inpatient services. A belief that has persisted for 20 years despite data demonstrating

Perceived Fairness and Effectiveness of Leveraged Community Treatment Among Public Mental Health Consumers in Five U.S. Cities

Policies to leverage adherence with community-based mental health treatment have become widespread; however, little research exists on the attitudes of persons with psychiatric disorders regarding such leverage. This study examines the appraisals of 1,011 persons with psychiatric disorders regarding the fairness and effectiveness of leverage. A majority of consumers perceives leverage to be both fair and effective; these perceptions are highly correlated. Multivariate models suggest that perceived coercion and insight into illness are associated with both outcomes while number of hospitalizations, years in treatment, and appointment reminders are associated with either outcome. However, consumers with a psychotic diagnosis and high barriers to care view leverage as unfair when controlling for effectiveness. Consumers who experience less coercion and have better insight believe that they benefit from formal and informal sanctions to adhere to treatment. However, perceived barriers to care impact the evaluation of the fairness of leverage.

Unmet Need For Community-Based Mental Health and Substance Use Treatment Among Rural Adolescents

This research assessed the extent of unmet service need for rural youth with mental health (MH) and/or substance use (SU) problems. All adolescents (12-18 years old) living in a three-county region of Iowa and discharged from outpatient MH or SU treatment were included (n = 177). Chart review was used to retrospectively assess service utilization and clinical characteristics at time of admission and discharge. Two-thirds (64%) of adolescents with co-occurring disorders did not receive treatment consistent with widely supported guidelines recommending that individuals with co-occurring disorders receive treatment for both their MH and SU problems. Higher severity of depression, more supports, prior MH service utilization and lower prevalence of prior abuse predicted the receipt of dual services. Finally, adolescents with co-occurring problems who received only MH treatment showed improvement on MH needs at discharge but no improvement on SU needs. Similarly, adolescents with co-occurring problems who received only SU treatment showed improvement on SU needs but not on MH needs. There is considerable unmet treatment need among rural adolescents with co-occurring disorders. Efforts to improve care must focus on adolescent, familial, program, funding and policy factors that act as barriers to unifying philosophies and practices needed to advance appropriate care.