Community Mental Health System Research Articles

Mandated Parent Education: Applications, Impacts, and Future Directions.

Mandated participation in parent education programs is a common practice across the United States for families who are undergoing divorce or who are involved in the child welfare or juvenile justice systems. Mandates to participate in parenting programs create substantial challenges for families, service providers, and service systems. Furthermore, the type and quality of the parenting services accessed vary widely, and their impacts need to be better understood. To address this need, an overview of the current state of the empirical literature on the impacts and outcomes of mandated parenting interventions for divorce and in child welfare and juvenile justice settings is provided, and suggestions to the field are offered to refine research related to mandated parenting programs. Given the challenges that mandated parenting programs pose, an alternative approach that views parenting through a public health lens is highlighted to build on the growing body of research on the impacts of population-wide applications of parenting support programs, and as a possible way to decrease the number of parents who are required to attend parenting programs. Opportunities to advance universal parenting support within a range of community settings, including primary care, early childhood education, and community mental health systems are offered. Gaps in knowledge regarding mechanisms of action of universal supports and impacts on the number of parents mandated to treatment are highlighted, and future directions for research in this area are suggested.

Roles and Dynamics within Community Mental Health Systems During the COVID-19 Pandemic: A Qualitative Systematic Review and Meta-Ethnography

ABSTRACT Globally, COVID-19 had an immense impact on mental health systems, but research on how community mental health (CMH) systems and services contributed to the pandemic mental health response is limited. We conducted a systematic review and meta-ethnography to understand the roles of CMH services, determinants of the quality of CMH care, and dynamics within CMH systems during COVID-19. We searched and screened across five databases and appraised study quality using the CASP tool, which yielded 27 qualitative studies. Our meta-ethnographic process used Noblit and Hare’s approach for synthesizing findings and applying interpretive analysis to original research. This identified several key themes. Firstly, CMH systems played the valuable pandemic role of safety nets and networks for the broader mental health ecosystem, while CMH service providers offered a continuous relationship of trust to service users amidst pandemic disruptions. Secondly, we found that the determinants of quality CMH care during COVID-19 included resourcing and capacity, connections across service providers, customized care options, ease of access, and human connection. Finally, we observed that power dynamics across the CMH landscape disproportionately excluded marginalized groups from mainstream CMH systems and services. Our findings suggest that while the pandemic role of CMH was clear, effectiveness was driven by the efforts of individual service providers to meet demand and service users’ needs. To reprise its pandemic role in the future, a concerted effort is needed to make CMH systems a valuable part of countries’ disaster mental health response and to invest in quality care, particularly for marginalized groups.

Inverting the deficit model in global mental health: An examination of strengths and assets of community mental health care in Ghana, India, Occupied Palestinian territories, and South Africa.

Global mental health [GMH] scholarship and practice has typically focused on the unmet needs and barriers to mental health in communities, developing biomedical and psychosocial interventions for integration into formal health care platforms in response. In this article, we analyse four diverse settings to disrupt the emphasises on health system weaknesses, treatment gaps and barriers which can perpetuate harmful hierarchies and colonial and medical assumptions, or a 'deficit model'. We draw on the experiential knowledge of community mental health practitioners and researchers working in Ghana, India, the Occupied Palestinian Territory and South Africa to describe key assets existing in 'informal' community mental health care systems and how these are shaped by socio-political contexts. These qualitative case studies emerged from an online mutual learning process convened between 39 academic and community-based collaborators working in 24 countries who interrogated key tenets to inform a social paradigm for global mental health. Bringing together diverse expertise gained from professional practice and research, our sub-group explored the role of Community Mental Health Systems in GMH through comparative country case studies describing the features of community care beyond the health and social care system. We found that the socio-political health determinants of global economic structures in all four countries exert significant influence on local community health systems. We identified that key assets across sites included: family and community care, and support from non-profit organisations and religious and faith-based organisations. Strengthening community assets may promote reciprocal relationships between the formal and informal sectors, providing resources for support and training for communities while communities collaborate in the design and delivery of interventions rooted in localised expertise. This paper highlights the value of informal care, the unique social structures of each local context, and resources within local communities as key existing assets for mental health.

Mapping mental health care services for children and youth population in Colombia’s Pacific: potential for boundary spanning between community and formal services

BackgroundConflict and violence can impact on the mental health of children and young people, who are in a crucial stage of their personal growth. Not much is known about the provision of mental health care to young people in conflict-affected areas. Community-based care can be essential, as state-led services are often scarce in conflict contexts, like Colombia’s Pacific region where this research was conducted. According to the WHO, such care is ideally provided in the form of a network of interconnected services, offered by different actors beyond the formal health sector. This article describes the relationship between the formal and community mental health systems in Colombia’s Pacific region, and identifies ways of improving their interaction.MethodsQualitative data were collected through 98 semi-structured interviews with community organisations, schools, international organisations and state institutions. These interviews aimed to identify the strategies used to promote young people’s mental health and the interactions between the different providers. Boundary spanning theory was used to analyse how different actors and forms of mental health care provision could coordinate better.ResultsCommunity organisations and schools use a wide array of strategies to attend to the mental health of children and young people, often of a collective and psychosocial nature. State institutions offer more clinically focused strategies, which are however limited in terms of accessibility and continuity. International organisations aim to strengthen state capacity, but often struggle due to high staff turnover. Although mental health care pathways exist, their effectiveness is limited due to ineffective coordination between actors.ConclusionsTo make sure that the variety of strategies to improve young people’s mental health effectively reach their beneficiaries, better coordination is needed between the different actors. Mental health care pathways should therefore integrate community organisations, while community connectors can help to manage the coordination between different actors and forms of clinical and psychosocial support.

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.

How to achieve delivery of a cardiovascular health intervention in community mental health settings: a process evaluation of Flinders Program using RE-AIM framework

Background, research problem & context: Globally, it is well recorded that adults with severe mental illness (SMI) die 10-20 years earlier than the general population, with cardiovascular disease being recorded as the key contributor to this health inequity. To address this health gap, the Flinders Chronic Condition Self-Management Program (will be referred to as Flinders Programme from here onward) was delivered within an NHMRC-funded randomised controlled trial (RCT) during 2018-2020 among 130 South Australian community-living adults diagnosed with SMI and CVD risk factors. Intervention design: The Flinders Programme is a person-centred care planning approach designed by Flinders University Behavioural Health Unit’s researchers. For this study, the programme aimed to improve the heart health and quality of life of the study participants. Intervention evaluation methods: This study sat alongside the RCT research and employed a longitudinal qualitative methodology underpinned by Roy Bhaskar’s Critical Realism philosophy and ontology. The aim was to understand why, how, and under which contexts the Flinders Program worked (or not). Alongside an outcome evaluation, this study also investigated how the Flinders Programme was delivered. Reach (R), Effectiveness/Efficacy (E), Adoption (A), Implementation/Delivery (I), Maintenance (M) or RE-AIM framework was used to conduct this qualitative process evaluation. Data were collected from 19 trial team members at multiple time points using multiple methods. In total, ten in-depth interviews, two focus group discussions, ten meeting minutes, and five reflective journals were analysed. Data analysis involved a Critical Realist Analysis (CRA) approach. Results & impact: The key findings were organised within the RE-AIM framework: Reach (low recruitment, strategies taken to increase recruitment), Effectiveness (non-specific effects, ‘invisible’ changes such as enhanced awareness, motivation, hope), Adoption (model of care, work atmosphere, the physical structure of the setting), Implementation (preparation, pilot survey, revising study design, actual trial and adaptations, fidelity), Maintenance (self-management capacity, resources, care continuity). Learning for the international audience: This study described the steps taken in delivering the Flinders Programme within a few South Australian metropolitan community mental health settings between the period November 2017 – September 2020. The trial team faced difficulties in fulfilling the recruitment target for the trial. There were a few critical reasons identified- the South Australian community mental health system went through a significant restructuring during the same time, resulting in enormous workload increases in an already resource-scarce sector. Health system-level politics had a direct negative effect on the trial. Besides, improving the cardiovascular health of SMI was not deemed a priority in a system that was struggling to deal with acute mentally ill patients within a crisis-driven system. There was a clear indication that most sites did not have enough clear communication from the trial team before recruitment and throughout the trial period. The next steps: In the future, more preparation, including education sessions among clinicians, are required before delivering such physical health interventions within mental health settings. 

Taking outside in, turning inside out: Exploring social dimensions and psychotherapeutic process in the play therapy of a young girl in foster care

ABSTRACT This paper, a collaborative effort, describes the work of A Home Within (AHW), a volunteer community-based organization providing pro-bono long term psychotherapy to current and former foster youth. We provide a brief description of the treatment model, present a report of treatment conducted by an AHW volunteer, and discuss further reflections on the societal context of our psychoanalytically-informed work. In-depth psychotherapeutic process from the treatment of a young girl in a pre-adoptive foster placement elucidates the psychotherapeutic possibilities when a psychoanalytic treatment model is accessible to current and former foster youth, usually deprived of this form of treatment due to overburdened, underfunded community mental health systems in the U.S. Open-ended psychotherapy afforded this traumatized child an unusual opportunity to work through past relational traumas in order to form new and more secure attachment relationships. We reflect further on the case from the vantage points of both the psychotherapeutic process and the greater societal context of this community-based program.

Using participatory action research to reimagine community mental health services in Colombia: a mixed-method study protocol

IntroductionMental healthcare systems are challenged by how they hear and respond to what marginalised communities experience as drivers of mental distress. In Colombia, this challenge intersects with wider challenges facing...

Exploring the Use of Hospital and Community Mental Health Services Among Newly Resettled Refugees

Resettled refugees in high-income countries represent a vulnerable population. It is known that refugees have high rates of trauma-related mental health issues; however, ad hoc research has generally revealed low rates of health services use among refugees. Such research usually samples a population at a single point in time and is based on targeted surveys. Because refugee populations change over time, such research becomes expensive and time-consuming for agencies interested in routinely publishing statistics of mental health services use among refugees. The linking of large administrative data sets to establish rates of use of mental health services among resettled refugees is a flexible and relatively inexpensive approach. To use data linkage to establish rates of mental health services use among resettled refugees relative to the general population. This cross-sectional study implemented data linkage from the Refugee Health Nurse Program for 10 050 refugees who resettled in Sydney, Australia, from October 23, 2012, to June 8, 2017, with data concerning use of community mental health services and mental health hospitalization from New South Wales Health databases. Data were analyzed between June 1, 2019, and December 31, 2021. Rates of service contacts with community mental health services among the resettled refugees were compared with those of the general population by age, sex, and the most common International Statistical Classification of Diseases and Related Health Problems, Tenth Revision, diagnosis codes. Length of community mental health service sessions and rates of mental health hospitalizations were also compared. Among the 255 resettled refugees who had contacts with community mental health care services and were not missing data (median age, 35 [range, 4-80] years; 117 [64%] male and 138 [54%] female), 153 (60%) were born in Iraq and 156 (61%) were Arabic speaking. This population was less likely to use mental health services than the general population and had shorter community mental health consultations. The rate of contacts with community mental health services for depressive disorders among the resettled refugee population was 40% (95% CI, 33%-46%) lower than that among the general population. Rates of same-day hospitalization per 10 000 person-years were not significantly different between the refugee population (4 [95% CI, 2-8]) and the general Australian population (7 [95% CI, 7-7]). However, the refugee population was 17% (95% CI, 6%-29%) more likely than the general Australian population to interact with the community mental health system for severe stress- and adjustment disorder-related diagnoses. These findings suggest that refugees who have resettled in Australia tend to use fewer mental health services than the general population except for services devoted to stress- and adjustment disorder-related diagnoses. These findings also suggest that it is possible to successfully leverage data linkage to study patterns of mental health services use among resettled refugees.

Reimagining Community Mental Health Care Services: Case Study of a Need Based Biopsychosocial Response Initiated During Pandemic.

Community mental health systems worldwide have undergone transformation in order to accommodate enormous demands of the pandemic and its mitigation efforts. The pandemic created unprecedented challenges that required Mehac Foundation (further referred as Mehac), a not for profit organization based in Kerala, to reassess our care delivery model. The aim of this report is to present a flexible, need-based biopsychosocial response; a case study effectuated by the Non-Governmental Organization (NGO) with a focus on minimizing the impact of COVID 19 on vulnerable communities, while adhering to timely regulations issued by the government. The key aspect of our biopsychosocial response was implementation of a phased approach that was rooted in real time need identification. The strategies will be described under broad headings of (i) adaptations for maintaining continuity of care, (ii) identifying vulnerable subgroups and need based psychological response, (iii) exploring social dimensions of the pandemic and implementing strategies to address them, (iv) ensuring team well-being and enhancing skills to effectively respond to the challenges.

A Public Partnership to Support Well-Being: Population Health Implementation of Trauma and Resilience Informed Care Across Child and Family Ecosystems.

Early life adversity and trauma can jeopardize child and family well-being. Mitigating the effects of early adversity and trauma requires a tiered, public health approach that includes trauma-informed mental health promotion, prevention, screening, early intervention, and effective and equitable treatment across community ecosystems and service systems. This article describes the development of a partnership between a public academic (University of California at Los Angeles) and community mental health system (Los Angeles County Department of Mental Health) and provides a roadmap for core principles and actionable steps to implement coherent, comprehensive, and adaptive trauma-informed community systems of support for children.

ADA turns 31; Bazelon Center urges legislative support from Congress

The Americans with Disabilities Act (ADA) turned 31 July 26. It has made a tremendous impact on the lives of people with disabilities and has made it possible for thousands to live in their own homes and communities, the Bazelon Center for Mental Health Law recently noted. But segregation remains far too common in our disability service systems, the Bazelon Center said in a statement. “Congress has the opportunity to pass new legislation that would make an unprecedented new investment in home and community‐based services for people with disabilities,” legal advocates stated. “The Better Care Better Jobs Act, introduced in both the U.S. Senate and the House of Representatives, would create a permanent 10% increase in the federal government's reimbursement to states for Medicaid home and community‐based services. The bill reflects President Biden's commitment in his American Jobs Plan to direct $400 billion to new home and community‐based services. Community mental health systems suffered devastating effects from the COVID‐19 pandemic. Now is the time to invest in community mental health services and other community‐based services for people with disabilities.”

Health interventions implemented in post-disaster South Asia: A scoping review

Increasing in frequency and impact worldwide, disasters (both man-made and natural) continue to affect millions of people each year. According to the United Nations Economic and Social Commission for Asia and the Pacific, floods are the most frequent disaster with the largest economic impact in South Asia. This paper identifies theoretical models, types of health issues, and the qualitative and quantitative approaches used for health interventions implemented in South Asia post-disaster. It also locates gaps in the implemented public health interventions, research studies and evaluation of interventions.We conducted a scoping review by searching PubMed, ProQuest Research Library, ProQuest Health Management, Social Sciences Full Text (H.W. Wilson), Sociological Abstracts, PsycINFO, Communication & Mass Media Complete, Academic Search Premier, Communication Abstracts, PAIS International, and Google from January 2006 to April 2021. We found and included experimental, quasi-experimental, qualitative and observational studies (empirical research) that described the implementation of a health intervention, and had a South Asia focus as well as a well-defined outcome with scope for replication. Two reviewers screened and abstracted articles independently. The data were charted, and a narrative review of the results was made.After screening 2532 titles and abstracts, 84 studies reported in 64 publications were retrieved. From the 84 studies 66 articles were rejected leaving 18 studies that were chosen for the scoping review. A majority of the interventions implemented psychosocial rehabilitation programs (n = 6) using community-based participatory approaches (n = 10). Programs relayed information through both interpersonal (n = 1) and mass communication (n = 2). The interventions that were conceived keeping the local cultural context (n = 9) in view were more successful. Issues that need to be resolved in future interventions include the need to engage disempowered groups such as women and to address sexual and reproductive issues (n = 2). Despite evidence of infectious disease (n = 2), none of the studies focused on its treatment or prevention. Findings strongly suggested the prevalence of mental health issues (n = 10) among victims of disaster and the urgent need to address psychiatric disorders. Only one study (n = 1) developed protocols for the rehabilitation of physically impaired earthquake victims.We found that a few studies used theories from psychosocial care and communication and applied quantitative and qualitative methods in designing health interventions in post-disaster South Asia. Most of the studies focused on psychosocial rehabilitation because there was recurrent evidence of mental health issues among victims of disasters. Future research could focus on the gaps identified in this study: developing, implementing, and evaluating, psychosocial capacity-building measures, and developing community mental health systems and skills training.

Racial and Ethnic Differences in Depressive Profiles of Child Welfare-Involved Families Receiving Home Visitation Services.

Profiles of depressive symptoms were identified among Hispanic, Black, and White parents involved in the child welfare service system, including changes in symptoms over time. Participants (N=2,109) were parents receiving SafeCare, a home visitation intervention provided in a large, diverse child welfare system. Depressive symptoms were assessed with the Centers for Epidemiological Studies Depression Scale at baseline and at approximately every sixth home visit, up to a total of four times. Univariate tests examined the relationship between baseline symptoms, race-ethnicity, and service participation. Latent class growth analyses identified trajectories of depressive symptoms during participation in child welfare services. Participation in services was affected by depressive symptoms. Forty percent of parents did not remain long enough in the program to complete a second CES-D assessment, and those who reported more symptoms at baseline were significantly less likely to do so. Among parents who engaged in services, distinct profiles of depressive symptoms emerged that differed by race-ethnicity. For non-Hispanic Black parents, no changes in depressive symptoms over time were noted, regardless of level of severity at baseline. Parents with the highest levels of symptoms did not improve over time. Despite receipt of supportive and recovery-oriented services specifically focused on empowering child welfare-involved parents, many experienced elevated depressive symptoms. Integration of child welfare and community mental health systems may improve both service engagement and mental health among child welfare-involved families.

Interdependence among mental health care providers: evidence from a spatial dynamic panel data model with interactive fixed effects

Understanding the pricing and operation mechanism of community mental health (CMH) providers is important for designing effective health care policies as the CMH system has been playing an essential role in providing mental health services. This paper studies the delivery of community-based mental health care and interdependence among CMH providers by investigating the pricing patterns of CMH providers in the Detroit-Wayne County of Michigan. We employ a spatial dynamic panel data model with interactive fixed effects to identify the strategic interactions among the providers, along both dimensions of time-series and cross-section spatial variations. We find evidence for significant spatial interdependence among the CMH providers, even after controlling for the interactive fixed effects. In contrast, the coefficient on the spatial-dynamic term is insignificant, suggesting that no time-space simultaneous effects exist. We also find the pure dynamic effect to be positive and significant. These findings provide important implications for mental health care policy and practice decisions.

Exploring Community Mental Health Systems - A Participatory Health Needs and Assets Assessment in the Yamuna Valley, North India.

Background: In India and global mental health, a key component of the care gap for people with mental health problems is poor system engagement with the contexts and priorities of community members. This study aimed to explore the nature of community mental health systems by conducting a participatory community assessment of the assets and needs for mental health in Uttarkashi, a remote district in North India. Methods: The data collection and analysis process were emergent, iterative, dialogic and participatory. Transcripts of 28 in-depth interviews (IDIs) with key informants such as traditional healers, people with lived experience and doctors at the government health centres (CHCs), as well as 10 participatory rural appraisal (PRA) meetings with 120 people in community and public health systems, were thematically analysed. The 753 codes were grouped into 93 categories and ultimately nine themes and three meta-themes (place, people, practices), paying attention to equity. Results: Yamuna valley was described as both ‘blessed’ and limited by geography, with bountiful natural resources enhancing mental health, yet remoteness limiting access to care. The people described strong norms of social support, yet hierarchical with entrenched exclusions related to caste and gender, and social conformity that limited social accountability of services. Care practices were porous, pluralist and fragmented, with operational primary care services that acknowledged traditional care providers, and trusted resources for mental health such as traditional healers (malis) and government health workers (accredited social health activists. ASHAs). Yet care was often absent or limited by being experienced as disrespectful or of low quality. Conclusion: Findings support the value of participatory methods, and policy actions that address power relations as well as social determinants within community and public health systems. To improve mental health in this remote setting and other South Asian rural locations, community and public health systems must dialogue with the local context, assets and priorities and be socially accountable.

Schools As a Vital Component of the Child and Adolescent Mental Health System.

This review examines the history and contemporary landscape of school mental health, describing evidence that schools are an essential component of the system of child and adolescent care and providing recommendations to advance this vital care delivery system. This literature review of scientific data and shifts to policy and practice in school mental health documents the evolution of collaboration between the education and mental health systems to support student mental health. This review describes best practices and provides examples for achieving the standards of the comprehensive school mental health systems model in states and local communities. Data demonstrate that multitiered systems of mental health support and services in schools, including mental health promotion, prevention, early intervention, and treatment, improve academic and psychosocial functioning and reduce risk of poor outcomes, including mental illness and school failure. Policy and practice shifts in the field reflect a movement toward integrating mental health systems into the education sector, including preparing the education workforce to promote mental health and to support early identification of and intervention to address mental illness. To create a full continuum of mental health supports for students, states and districts can draw on national best practices and state exemplars as they install multitiered systems of mental health supports in all schools, conduct universal student mental health monitoring, and coordinate school and community mental health systems.

Attorney will evaluate Mississippi mental health services

A special assistant attorney general in Mississippi has been appointed to a new role in state government as the coordinator of mental health accessibility, Tri‐City Herald reported Oct. 25. William Rosamond will evaluate the quality of mental health care to possibly change services offered in some counties. Mississippi Department of Finance and Administration executive director Liz Welch recently appointed him to the role, the Northeast Mississippi Daily Journal reported. Rosamond has previously provided legal counsel for the Mississippi Department of Mental Health. In the new role, he will have authority to evaluate what mental health services counties offer, review financial statements and move counties to a different community mental health region if a certain region's services are inadequate. Senate Public Health Committee Chairman Hob Bryan, a Democrat from Amory, wrote the legislation that created the coordinator position and said he believes Rosamond is qualified. “He essentially has the authority to close a community mental health system,” Bryan said. “I don't think that's going to occur, but having that authority gives him the gravitas to find out what's needed.”

Formulating another’s report of troubles in peer support

This study stems from an interest in peer support talk, an underexplored area of research, and in how supportive actions such as formulated summaries function in comparison to more professional healthcare settings. Using conversation analysis, this study explores 35 instances of formulations within 65 calls to four different ‘warm lines’, a term for peer-to-peer telephone support within the community mental health system in the United States. Formulations can be characterized across two related axes: client versus professional perspective, and directive versus nondirective. The findings show that formulations within peer support were overwhelmingly nondirective, in terms of meeting institutional agendas to let callers talk. However, formulations ranged from client-oriented ones that highlight or repeat caller reports to those which transform caller reports through integrating past caller experiences or implicit caller emotions. These tactics are found to have similarities to how formulations function in professional healthcare settings.

Parent Training for Youth with Autism Served in Community Settings: A Mixed-Methods Investigation Within a Community Mental Health System.

Parent training programs focus on parent knowledge and/or skill development regarding strategies to improve child outcomes. Parent training programs are considered evidenced-based treatments for autism spectrum disorder (ASD). Yet little is known about parent training use for youth with ASD served in community settings. This mixed methods project examined parent training for Medicaid-enrolled youth with ASD under age 21. Data were obtained from Medicaid claims for 879 youth and surveys from 97 applied behavior analysis (ABA) providers. Open-ended survey items were analyzed with content analysis. Results demonstrated that the frequency of parent training was low and providers' conceptualization of parent training was inconsistent with evidence-based models. Providers are largely unaware of evidence-based components (i.e., modeling, caregiver practice with feedback) and use them infrequently. Implications for increasing parent training in community settings are discussed.