Mental Health Treatment Initiation Research Articles

Development of a peer-delivered primary care intervention to improve veteran mental health treatment engagement.

Veteran engagement in mental health treatment (MHT) remains low. Peer specialists (PS) are well positioned to implement interventions addressing barriers to MHT engagement, given their familiarity with the process. This study aimed to develop and assess the acceptability of a primary care-based, PS-delivered intervention to improve MHT initiation. Aim 1 utilized modified Delphi methods with a committee of 12 stakeholders (e.g., PS, psychologists, and veteran patients) who provided input on the proposed PS-delivered MHT engagement intervention. The proposed intervention components included questionnaires to identify barriers to engagement and targeted strategies for the barriers (e.g., motivational interviewing, cognitive restructuring). Aim 2 consisted of qualitative interviews with veterans entering MHT, focused on acceptability and feasibility, and gathered additional feedback for the intervention drafted in Aim 1. PS in primary care also reviewed the intervention and provided feedback. Results from Aim 1 demonstrated the acceptability of PS utilizing questionnaires in their work with Veterans, emphasized the importance of rapport building, and provided consensus on the identification of tailored treatment strategies. Veterans entering MHT (n = 9) reported that they were excited about the option of PS being involved in treatment engagement. PS (n = 18) also reported the overall acceptability of the intervention and provided feedback impacting the implementation of the intervention. Incorporating primary care PS into MHT engagement is acceptable. This study serves as the first step in developing a PS-delivered intervention to improve engagement in veteran MHT with input from a diverse group of stakeholders. Implications and future directions will be explored. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Beliefs about mental health treatment, treatment initiation, and suicidal behaviors among veterans and service members at-risk for suicide and not in treatment.

Previous research has identified a variety of barriers to mental health care among military personnel and veterans, despite high rates of mental health symptoms. The current study is the first to examine beliefs about mental health treatment barriers among post-9/11 military personnel and veterans at elevated suicide risk not involved in treatment and whether these beliefs are associated with treatment initiation, engagement, or suicidal behaviors. Four hundred and twenty-two participants reported on beliefs about treatment during a cognitive behavioral treatment session and responded to follow-up questionnaires on mental health treatment initiation, engagement, and suicidal behaviors over 12 months. Beliefs identified in the therapy session were coded thematically, and rates of treatment initiation, engagement, and suicidal behavior were examined by belief category. Nine belief themes emerged. Participants reporting logistical barriers and preferences about treatment type were least likely to initiate mental health treatment and participated in the fewest number of sessions, respectively. Participants endorsing beliefs about stigma or using other ways to cope were most likely to engage in suicidal behavior. The current findings point to specific beliefs that may identify individuals who would benefit from systemic and individual interventions for mental health treatment engagement.

A Family-Based Mental Health Navigator Intervention for Youth in the Child Welfare System: Protocol for a Randomized Controlled Trial.

Youth in the child welfare system (child welfare-involved [CWI] youth) have high documented rates of mental health symptoms and experience significant disparities in mental health care services access and engagement. Adolescence is a developmental stage that confers increased likelihood of experiencing mental health symptoms and the emergence of disorders that can persist into adulthood. Despite a high documented need for evidence-based mental health services for CWI youth, coordination between child welfare and mental health service systems to increase access to care remains inadequate, and engagement in mental health services is low. Navigator models developed in the health care field to address challenges of service access, fragmentation, and continuity that affect the quality of care provide a promising approach to increase linkage to, and engagement in, mental health services for CWI youth. However, at present, there is no empirically supported mental health navigator model to address the unique and complex mental health needs of CWI youth and their families. Using a randomized controlled trial, this study aims to develop and test a foster care family navigator (FCFN) model to improve mental health service outcomes for CWI adolescents (aged 12-17 years). The navigator model leverages an in-person navigator and use of adjunctive digital health technology to engage with, and improve, care coordination, tracking, and monitoring of mental health service needs for CWI youth and families. In total, 80 caregiver-youth dyads will be randomized to receive either the FCFN intervention or standard of care (clinical case management services): 40 (50%) to FCFN and 40 (50%) to control. Qualitative exit interviews will inform the feasibility and acceptability of the services received during the 6-month period. The primary trial outcomes are mental health treatment initiation and engagement. Other pre- and postservice outcomes, such as proportion screened and time to screening, will also be evaluated. We hypothesize that youth receiving the FCFN intervention will have higher rates of mental health treatment initiation and engagement than youth receiving standard of care. We propose enrollment of 80 dyads by March 2024, final data collection by September 2024, and the publication of main findings in March 2025. After final data analysis and writing of the results, the resulting manuscripts will be submitted to journals for dissemination. This study will be the first to produce empirically driven conclusions and recommendations for implementing a family mental health navigation model for CWI youth with long-standing and unaddressed disparities in behavioral health services access. The study findings have potential to have large-scale trial applicability and be feasible and acceptable for eventual system implementation and adoption. ClinicalTrials.gov NCT04506437; https://www.clinicaltrials.gov/study/NCT04506437. DERR1-10.2196/49999.

Clinical profiles and factors associated with treatment initiation in survivors of sex trafficking: A comparison with survivors of domestic violence and sexual assault.

Little is known about formal help-seeking for mental health issues in survivors of human sex trafficking (ST) and if their experiences are different from those initiating treatment for sexual assault (SA) or domestic violence (DV). This study sought to characterize the clinical and trauma profiles of treatment-seeking survivors of ST as compared with DV and SA and the predictors of mental health treatment initiation in these three groups. The research was based on a secondary data analysis of data gathered from 1,264 treatment-seeking adults from a community mental health treatment facility in the United States. Compared with DV and SA survivors, ST survivors were significantly younger, female, Black, single, unemployed, completed less than high school, and were from the United States. Despite the presence of clinical symptoms among all three groups, findings suggest significant differences in clinical and trauma profiles, with ST survivors reporting lower levels of mental health symptomology compared to DV and SA survivors. Older age (OR = 1.03, 95% CI [1.01, 1.05]), female sex (OR = 3.03, 95% CI [1.89, 4.88]), employment (OR = 0.40, 95% CI [0.24, 0.66]), and better social relationships (OR = 1.09, 95% CI [1.01, 1.16]) were significantly associated with treatment initiation. This research highlights some important predictors of formal help-seeking, including perceived social relationships. Assessing for support systems in these three groups of survivors of interpersonal violence early when engaging survivors is recommended. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Referral Patterns and Sociodemographic Predictors of Adult and Pediatric Behavioral Health Referrals in a Federally Qualified Health Center.

Federally Qualified Health Centers (FQHCs) provide comprehensive care to medically underserved populations whose access to behavioral health services may be limited. The goal of the current study was to examine referral patterns to specialty mental health and subsequent treatment initiation in an FQHC. In a 13-month period from March 2017 to March 2018, 1201 patients received a specialty mental healthcare referral. Of these patients, 37% reported scheduling an appointment with this referral, 44% refused the referral, 4% reported improvement in symptoms and not needing a referral, and 5% were not able to be reached due to a contact number being out of service. Common referral reasons among adults were depression, anxiety, and stress, and the most prevalent pediatric referral reasons were behavioral problems, depression, attention deficit hyperactivity disorder (ADHD), and anxiety. These data suggest that of the patients who received a specialty mental health referral, only one-third scheduled an appointment. The study also suggested that anxiety problems may be underrecognized in both adult and pediatric patients. Although significant attention has been put on increasing access to behavioral health services, there is still an unmet need. Universal mental health screening and increased coordination with specialty mental health providers in the community may better address this need.

Internet-based family training with telephone coaching to promote mental health treatment initiation among veterans with posttraumatic stress disorder: A pilot study.

Posttraumatic stress disorder (PTSD) is common among military veterans, yet many affected veterans do not seek treatment. Family members of these veterans often experience compromised well-being and a desire for the veteran to receive mental health care. The Veterans Affairs (VA)-Community Reinforcement and Family Training (VA-CRAFT) for PTSD is an internet-based intervention intended to teach veterans' family members skills to encourage veterans to initiate mental health care. This study assessed the feasibility, acceptability, and potential efficacy of VA-CRAFT with telephone coaching in a sample of 12 spouses and intimate partners of veterans with PTSD. Participants completed the intervention over 12 weeks and were assessed pre- and posttreatment. For feasibility, 75.0% (n = 9) of participants completed the intervention and reported few difficulties and ease of use. Supporting acceptability, all nine completers had mostly favorable impressions of the intervention and perceived it as helpful. Finally, six (50.0%) participants got the PTSD-affected veteran to engage in mental health care; however, aside from potentially increasing treatment talk frequency, outcome expectancy, and self-efficacy, ds = 0.60-1.08, no apparent improvements were observed for any well-being outcomes, ds = 0.01-0.40. Although the findings are promising, given the study limitations, future research is required to evaluate this approach in a full-scale randomized controlled trial.

35.4 Community Mental Health Centers Can Help Address Disparities in Access Across Race and Income

Delays in the initiation of mental health (MH) treatment are associated with poorer youth outcomes, including more severe illness, academic problems, and lower quality of life. Youth from low-income and/or racial/ethnic minority (especially BIPOC) families may be less likely to receive MH treatment due to barriers such as cost, accessibility, and stigma. Community MH centers (CMHCs) aim to address these obstacles to care. We measured disparities in the timeliness of MH service access at a CMHC and a nearby academic medical center (AMC).

Leveraging behavioral economics and implementation science to engage patients at risk for suicide in mental health treatment: a pilot study protocol

BackgroundPrimary care is an ideal setting to connect individuals at risk for suicide to follow-up care; however, only half of the patients referred from the primary care attend an initial mental health visit. We aim to develop acceptable, feasible, low-cost, and effective new strategies to increase treatment initiation among at-risk individuals identified in primary care.MethodsWe will conduct a multi-phase, mixed-methods study. First, we will conduct a chart review study by using administrative data, including medical records, to identify characteristics of primary care patients at risk for suicide who do or do not attend an initial mental health visit following a referral. Second, we will conduct a mixed methods study by using direct observations and qualitative interviews with key stakeholders (N = 65) to understand barriers and facilitators to mental health service initiation among at-risk individuals. Stakeholders will include patients with suicidal ideation referred from primary care who do and do not attend a first mental health visit, primary care and behavioral health providers, and individuals involved in the referral process. We also will collect preliminary self-report and behavioral data regarding potential mechanisms of behavior change (i.e., self-regulation and social support) from patients. Third, we will leverage these findings, relevant frameworks, and the extant literature to conduct a multi-arm, non-randomized feasibility trial. During this trial, we will rapidly prototype and test strategies to support attendance at initial mental health visits. Strategies will be developed with subject matter experts (N = 10) and iteratively pilot tested (~5 patients per strategy) and refined. Research will be completed in the Penn Integrated Care Program (PIC), which includes fourteen primary care clinics in Philadelphia that provide infrastructure for electronic referrals, patient communication, and data access.DiscussionWe will leverage frameworks and methods from behavioral economics and implementation science to develop strategies to increase mental health treatment initiation among individuals at risk for suicide identified in primary care. This project will lead to an evaluation of these strategies in a fully powered randomized trial and contribute to improvements in access to and engagement in mental health services for individuals at risk for suicide.Trial registrationClinicalTrials.gov Identifier: NCT05021224

Suicide Risk Before Mental Health Treatment Initiation: Implications for Screening and Access to Care.

With rising suicide rates in the United States over the past two decades, a critical need has emerged to improve interventions to prevent suicide. Previous research has indicated that the period before initiation of mental health treatment may be a particularly vulnerable time for individuals with suicidal behavior. Presence of suicide risk before treatment initiation highlights the need to improve suicide screening and access to care. The authors propose various care and policy considerations to increase, support, and maintain suicide prevention efforts.

A Text Message Intervention for Adolescents With Depression and Their Parents or Caregivers to Overcome Cognitive Barriers to Mental Health Treatment Initiation: Focus Groups and Pilot Trial.

BackgroundMany adolescents with depression do not pursue mental health treatment following a health care provider referral. We developed a theory-based automated SMS text message intervention (Text to Connect [T2C]) that attempts to reduce cognitive barriers to the initiation of mental health care.ObjectiveIn this two-phase study, we seek to first understand the potential of T2C and then test its engagement, usability, and potential efficacy among adolescents with depression and their parents or caregivers.MethodsIn phase 1, we conducted focus groups with adolescents with depression (n=9) and their parents or caregivers (n=9) separately, and transcripts were examined to determine themes. In phase 2, we conducted an open trial of T2C comprising adolescents with depression referred to mental health care (n=43) and their parents or caregivers (n=28). We assessed usability by examining program engagement, usability ratings, and qualitative feedback at the 4-week follow-up. We also assessed potential effectiveness by examining changes in perceived barriers to treatment and mental health care initiation from baseline to 4 weeks.ResultsIn phase 1, we found that the themes supported the T2C approach. In phase 2, we observed high engagement with daily negative affect check-ins, high usability ratings, and decreased self-reported barriers to mental health treatment over time among adolescents. Overall, 52% (22/42) of the adolescents who completed follow-up reported that they had attended an appointment with a mental health care specialist. Of the 20 adolescents who had not attended a mental health care appointment, 5% (1/20) reported that it was scheduled for a future date, 10% (2/20) reported that the primary care site did not have the ability to help them schedule a mental health care appointment, and 15% (3/20) reported that they were no longer interested in receiving mental health care.ConclusionsThe findings from this study suggest that T2C is acceptable to adolescents with depression and most parents or caregivers; it is used at high rates; and it may be helpful to reduce cognitive barriers to mental health care initiation.

Physical functioning and mental health treatment initiation and retention for veterans with posttraumatic stress disorder: a prospective cohort study

BackgroundMost US adults with posttraumatic stress disorder (PTSD) do not initiate mental health treatment within a year of diagnosis. Increasing treatment uptake can improve health and quality of life for those with PTSD. Individuals with PTSD are more likely to report poor physical functioning, which may contribute to difficulty with treatment initiation and retention. We sought to determine the effects of poor physical functioning on mental health treatment initiation and retention for individuals with PTSD.MethodsWe used data for a national cohort of veterans in VA care; diagnosed with PTSD in June 2008-July 2009; with no mental health treatment in the prior year; and who responded to baseline surveys on physical functioning and PTSD symptoms (n = 6,765). Physical functioning was assessed using Veterans RAND 12-item Short Form Health Survey, and encoded as limitations in physical functioning and role limitations due to physical health. Treatment initiation (within 6 months of diagnosis) was determined using VA data and categorized as none (reference), only medications, only psychotherapy, or both. Treatment retention was defined as having ≥ 4 months of appropriate antidepressant or ≥ 8 psychotherapy encounters.ResultsIn multinomial models, greater limitations in physical functioning were associated with lower odds of initiating only psychotherapy (OR 0.82 [95 % CI 0.68, 0.97] for limited a little and OR 0.74 [0.61, 0.90] for limited a lot, compared to reference “Not limited at all”). However, it was not associated with initiation of medications alone (OR 1.04 [0.85, 1.28] for limited a little and OR 1.07 [0.86, 1.34] for limited a lot) or combined with psychotherapy (OR 1.03 [0.85, 1.25] for limited a little and OR 0.95 [0.78, 1.17] for limited a lot). Greater limitations in physical functioning were also associated with lower odds of psychotherapy retention (OR 0.69 [0.53, 0.89] for limited a lot) but not for medications (e.g., OR 0.96 [0.79, 1.17] for limited a lot). Role limitations was only associated with initiation of both medications and psychotherapy, but there was no effect gradient (OR 1.38 [1.03, 1.86] for limitations a little or some of the time, and OR 1.18 [0.63, 1.06] for most or all of the time, compared to reference “None of the time”). Accounting for chronic physical health conditions did not attenuate associations between limitations in physical functioning (or role limitations) and PTSD treatment; having more chronic conditions was associated with lower odds of both initiation and retention for all treatments (e.g., for 2 + conditions OR 0.53 [0.41, 0.67] for initiation of psychotherapy).ConclusionsGreater limitations in physical functioning may be a barrier to psychotherapy initiation and retention. Future interventions addressing physical functioning may enhance uptake of psychotherapy.

Computerized Intervention in Primary Care for Women Veterans with Sexual Assault Histories and Psychosocial Health Risks: a Randomized Clinical Trial

ImportanceSexual assault is a public health concern for women and is associated with subsequent psychosocial health risks of posttraumatic stress disorder (PTSD), hazardous drinking, and intimate partner violence (IPV). Sexual assault is associated with social stigma and other barriers shown to inhibit one from seeking mental health care. Digital health technologies may overcome these barriers.ObjectiveTo test the impact of a brief computerized intervention delivered in primary care to reduce health risks and increase mental health treatment utilization among women with histories of sexual assault and current health risks.Design, Setting, and ParticipantsThe Safe and Healthy Experiences (SHE) program was tested in a randomized controlled trial with N = 153 women veterans at a Veterans Health Administration (VHA) medical center, and they completed assessments at baseline, 2 months, and 4 months.InterventionSHE is a brief motivational interviewing and psychoeducation-based computerized intervention. SHE was compared to a screen and referral-only control condition.Main MeasuresHealth risks were measured via validated self-report instruments. Treatment initiation and utilization were measured via self-report and chart review.ResultsSHE did not impact women’s number of health risks (all p’s > .05). However, women randomized to SHE showed significantly greater increases in treatment use compared to women in the control group, as measured by chart review (χ2 (1, n = 153) = 4.38, p = .036, rs = .16), and self-report (χ2 (1, n = 130) = 5.89, p = .015, rs = .21). SHE was found to be an acceptable intervention.ConclusionsSHE was effective in improving mental health treatment initiation and utilization compared to a control group. Computer-based interventions to address sexual trauma and its consequences are acceptable, are highly scalable, and can add value to primary care with little cost or increase in provider time.Trial RegistrationClinicaltrials.gov identifier NCT02957747.

Provider Perspectives on Implementing Shared Decision Making for PTSD Treatment in VA Primary Care.

Shared decision making is an important implementation "pull" strategy for increasing uptake of evidence-based mental health practices. In this qualitative study, we explored provider perspectives on implementing shared decision making at the point of mental health treatment initiation using a publicly available, patient-facing decision support tool for post-traumatic stress disorder (PTSD). We conducted semi-structured interviews with 22 mental health providers (psychiatrists, nurses, psychologists, and social workers) working in one of five VA primary care clinics. Interviewed were analyzed using thematic analysis. Provider were enthusiastic about using decision aids as a source of high quality information that could improve patient experience and confidence in treatment. However, providers had concerns about decision aid accessibility, time constraints to conduct shared decision making in-session, and patient motivation to engage in shared decision making. Providers stated they would prefer to use shared decision making with patients that they felt were most likely to follow through with treatment. While providers believed that shared decision making could improve PTSD treatment planning, they thought it most appropriate for patients with the highest levels of motivation and fewest barriers to care. These beliefs may limit widespread adoption and reflect missed opportunities to reach difficult-to-engage patients.

Masculinity and mental health treatment initiation for former political prisoners in Yangon, Myanmar \u2013 a qualitative investigation

BackgroundMen living in low- and middle-income countries are unlikely to seek mental health care, where poor healthcare infrastructure, differences in illness conceptualization, and stigma can impact treatment seeking. Vulnerable groups, such as former political prisoners, are more likely than others to experience potentially traumatic events that may lead to negative mental health outcomes. To improve the likelihood of successful engagement of vulnerable men in psychotherapy, it is necessary to identify factors that influence treatment adherence, and to better understand men’s attitudes surrounding decisions to seek and initiate care. The purpose of this investigation was to explore themes of masculinity, treatment seeking, and differences between male former political prisoners who accepted and declined therapy in an urban low-income context.MethodsWe conducted a qualitative, interview-based investigation with 30 former political prisoners in Yangon, Myanmar who were eligible to receive mental health counseling provided by the non-governmental organization (NGO), Assistance Association for Political Prisoners. Men were initially screened using a composite questionnaire with items related to depression, anxiety, and posttraumatic stress symptom severity. After screening, if potential clients were identified as having probable mental health problems, they were asked if they would like to participate in a multi-session cognitive behavioral therapy program. Semi-structured, open-ended interviews were conducted with 15 participants who accepted and 15 participants who declined therapy. Interviews were transcribed and translated by local partners and thematically coded by the authors. We used thematic analysis to identify and explore differences in treatment-seeking attitudes between men who accepted and men who declined the intervention.ResultsMen described that being a community leader, self-reliance, morality, and honesty were defining characteristics of masculinity. A focus on self-correction often led to declining psychotherapy. A general lack of familiarity with psychological therapy and how it differed from locally available treatments (e.g. astrologists) was connected to stigma regarding mental health treatment.ConclusionsMasculinity was described in similar terms by both groups of participants. The interpretation of masculine qualities within the context of help-seeking (e.g. self-reliance as refusing help from others versus listening to others and applying that guidance) was a driving factor behind men’s decision to enter psychotherapy.

Use of mental health supports by civilians exposed to the November 2015 terrorist attacks in Paris

BackgroundThe use of mental health supports by populations exposed to terrorist attacks is rarely studied despite their need for psychotrauma care. This article focuses on civilians exposed to the November 2015 terrorist attacks in Paris and describes the different combinations of mental health supports (MHSu) used in the following year according to type of exposure and type of mental health disorder (MHD).MethodsSanté publique France conducted a web-based survey of civilians 8–11 months after their exposure to the November 2015 terrorist attacks in Paris. All 454 respondents met criterion A of the DSM-5 definition of post-traumatic stress disorder (PTSD). MHD (anxiety, depression, PTSD) were assessed using the PCL-5 checklist and the Hospital Anxiety and Depression Scale. MHSu provided were grouped under outreach psychological support, visits for psychological difficulties to a victims’ or victim support association, consultation with a general practitioner (GP), consultation with a psychiatrist or psychologist (specialist), and initiation of regular mental health treatment (RMHT). Chi-squared tests highlighted differences in MHSu use according to type of exposure (directly threatened, witnessed, indirectly exposed) and MHD. Phi coefficients and joint tabulations were employed to analyse combinations of MHSu use.ResultsTwo-thirds of respondents used MHSu in the months following the attacks. Visits to a specialist and RMHT were more frequent than visits to a GP (respectively, 39, 33, 17%). These were the three MHSu most frequently used among people with PTSD (46,46,23%), with depression (52,39,20%), or with both (56,58, 33%). Witnesses with PTSD were more likely not to have RMHT than those directly threatened (respectively, 65,35%). Outreach support (35%) and visiting an association (16%) were both associated with RMHT (Phi = 0.20 and 0.38, respectively). Very few (1%) respondents initiated RMHT directly. Those who indirectly initiated it (32%) had taken one or more intermediate steps. Visiting a specialist, not a GP, was the most frequent of these steps.ConclusionOur results highlight possibilities for greater coordination of mental health care after exposure to terrorist attacks including involving GP for screening and referral, and associations to promote targeted RMHT. They also indicate that greater efforts should be made to follow witnesses.

Stigma and discrimination as correlates of mental health treatment engagement among adults with serious mental illness.

The negative impacts of stigma on mental health treatment initiation are well established, but the relationship of stigma to proactive engagement in mental health treatment (e.g., actively working toward therapy goals) is largely unexamined. This study examined the relationship between mental health treatment engagement and stigma experiences, discrimination experiences, and internalized stigma among adults with serious mental illness. Age, race, gender, and education were tested as moderators of the relationships between stigma-related variables and treatment engagement. Data were collected from 167 adults with serious mental illnesses who were receiving services at 5 psychosocial rehabilitation programs. Treatment engagement was assessed by participants' primary mental health care providers, using the Service Engagement Scale. The relationship between treatment engagement, stigma, and discrimination as well as potential demographic moderators were tested with Pearson's correlations and multiple linear regressions. Treatment engagement was not correlated with experiences of stigma, experiences of discrimination, or application of stigmatizing beliefs to self. Gender, race, and age were not significant moderators but education was. Experiences of stigma were associated with greater treatment engagement in those with a higher level of education (p = .007), whereas application of stigma to one's self was associated with poorer treatment engagement in those with a higher level of education (p = .005). Among individuals with higher levels of education, efforts to prevent internalization of public stigma may be crucial to promote proactive mental health treatment. Replication studies are needed to confirm these findings. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Addressing maternal mental health to increase participation in home visiting

Maternal depression poses a significant threat to the healthy development of young children and is associated with increased child behavior problems and poorer cognitive development. Home visiting programs provide critical support for children and families during early childhood, but further research is needed to examine how programs address maternal depression and whether referral to outside mental health services impacts parental participation in home visiting. This study aimed to examine rates of depression among mothers in the national Parent as Teachers (PAT) home-visiting program, whether various high needs characteristics were associated with elevated depressive symptoms, and whether depressive symptomology and initiation of outside mental health treatment were associated with attendance and retention in services, particularly after considering important family risk factors. Data from all participating affiliates was collected nationally. Measures included family demographics, high needs characteristics, rates of depression screening, initiation of maternal mental health services, and PAT program attendance and retention. Several high needs characteristics were strongly associated with maternal depressive symptoms, including intimate partner violence exposure, parental substance abuse, and parental disability. Results also showed that mothers who screened in either the probable Major Depressive Disorder or subclinical depression range on the Edinburgh Postnatal Depression Scale were enrolled for fewer months in PAT. However, depressed mothers who accessed outside mental health services stayed enrolled for more months than mothers who did not access services. Results demonstrate that mothers with higher depressive symptoms, including those in the subclinical range, have a harder time participating in home-visiting services, even though they may need the support the most. However, when PAT home-visitors address maternal mental health and mothers initiate treatment, mothers appear to be better equipped to participate in home visiting.

Military Service and Military Health Care Coverage are Associated with Reduced Racial Disparities in Time to Mental Health Treatment Initiation.

We aimed to evaluate whether military service and access to veteran heath care coverage attenuates racial/ethnic disparities in time to mental health treatment initiation for posttraumatic stress disorder (PTSD), major depressive disorder, and/or alcohol-use disorder. Results are based on 13,528 civilians and 1392 veterans from NESARC-III. Among civilians, racial/ethnic minorities reported longer time to PTSD and depression treatment initiation than non-Hispanic whites. Among veterans, racial/ethnic minorities did not differ from whites in time to PTSD and depression treatment initiation, and showed shorter time to treatment initiation for alcohol-use disorder treatment. Racial/ethnic minorities with past year veteran health care coverage showed the strongest evidence for attenuated disparities.

Effect of a Motivational Interviewing–Based Intervention on Initiation of Mental Health Treatment and Mental Health After an Emergency Department Visit Among Suicidal Adolescents

Emergency department (ED) visits present opportunities to identify and refer suicidal youth for outpatient mental health care, although this practice is not routine. To examine whether a motivational interviewing-based intervention increases linkage of adolescents to outpatient mental health services and reduces depression symptoms and suicidal ideation in adolescents seeking emergency care for non-mental health-related concerns who screen positive for suicide risk. In this randomized clinical trial, adolescents aged 12 to 17 years who screened positive on the Ask Suicide Screening Questions (ASQ) during a nonpsychiatric ED visit at 2 academic pediatric EDs in Ohio were recruited from April 2013 to July 2015. Intention-to-treat analyses were performed from September 2018 to October 2019. The Suicidal Teens Accessing Treatment After an Emergency Department Visit (STAT-ED) intervention included motivational interviewing to target family engagement, problem solving, referral assistance, and limited case management. The enhanced usual care (EUC) intervention consisted of brief mental health care consultation and referral. Primary outcomes were mental health treatment initiation and attendance within 2 months of ED discharge and suicidal ideation (assessed by the Suicidal Ideation Questionnaire JR) and depression symptoms (assessed by the Center for Epidemiologic Studies-Depression scale) at 2 and 6 months. Exploratory outcomes included treatment initiation and attendance and suicide attempts at 6 months. A total of 168 participants were randomized and 159 included in the intention-to-treat analyses (mean [SD] age, 15.0 [1.5] years; 126 [79.2%] female; and 80 [50.3%] white). Seventy-nine participants were randomized to receive the STAT-ED intervention and 80 to receive EUC. At 2 months, youth in the STAT-ED group had similar rates of mental health treatment initiation compared with youth in the EUC group as assessed by parent report (29 [50.9%] vs 22 [34.9%]; adjusted odds ratio [OR], 2.08; 95% CI, 0.97-4.45) and administrative data from mental health care agencies (19 [29.7%] vs 11 [19.3%]; adjusted OR, 1.77; 95% CI, 0.76-4.15). At 2 months, youth in the STAT-ED group and the EUC group had similar rates of treatment attendance (1 appointment: 6 [9.7%] vs 2 [3.6%]; adjusted OR, 2.97; 95% CI, 0.56-15.73; ≥2 appointments: 10 [16.1%] vs 7 [12.7%]; adjusted OR, 1.43; 95% CI, 0.50-4.11). There were no significant group × time differences in suicidal ideation (F = 0.28; P = .72) and depression symptoms (F = 0.49; P = .60) during the 6-month follow-up period. In exploratory analyses, at 6 months, STAT-ED participants had significantly higher rates of agency-reported mental health treatment initiation (adjusted OR, 2.48; 95% CI, 1.16-5.28) and more completed appointments (t99.7 = 2.58; P = .01). This study's findings indicate that no differences were found on any primary outcome by study condition. However, STAT-ED was more efficacious than EUC at increasing mental health treatment initiation and attendance at 6 months. ClinicalTrials.gov identifier: NCT01779414.

Message Framing and Engagement in Specialty Mental Health Care.

Engagement rates in specialty mental health care for depression are suboptimal. This study examined the extent to which framing-by gain, by loss, or neutral- of health messages promotes appointment attendance among patients referred to specialty mental health care. The study employed a randomized, prospective, experimental design. Patients meeting criteria for major depression and referred to specialty mental health care at the Corporal Michael J. Crescenz Department of Veterans Affairs Medical Center were randomly assigned (N=360) to receive a patient reminder letter routinely mailed prior to scheduled specialty care appointments (neutral) or one of two messages (gain framed versus loss framed) that were added to the routine letter. Appointment and attendance data were extracted from the computerized system. Logistic regression was used to determine the association between message frame condition and initial appointment attendance. The sample (mean±SD age=51.5±13.5) was primarily male (85%) and nonwhite (62%), and the mean depressive symptom score indicated moderately severe depression. Participants who received the gain-framed message after being referred to specialty mental health care were significantly more likely to attend their appointment than those who received a neutral letter (p=.04). No statistically significant differences were noted among those receiving a loss-framed message compared with the other two arms. Findings suggest that highlighting the benefits of attending an initial specialty mental health care appointment, even if in writing, can affect engagement rates. If replicated, results have the potential to improve mental health treatment initiation rates in a timely, efficient, and cost-effective manner.