Mental Health Agencies Research Articles

Implementation of strengths model case management in seven mental health agencies in Canada: Direct-service practitioners' implementation experience.

Implementation of strengths model case management is increasing internationally. However, few studies have focused on its implementation process, and none have specifically addressed the implementation experience of direct-service practitioners. This paper presents factors that facilitate and impede the successful implementation of the strengths model, with a specific focus on practitioners who deliver the intervention directly to service recipients. To address this objective, a qualitative study of seven mental health agencies that implemented the model was conducted, involving a combination of participant observations and qualitative semistructured interviews with case managers, team supervisors, and senior managers. Qualitative data were analyzed using open coding followed by axial coding. Finally, the findings were aligned with an adapted Consolidated Framework for Implementation Research. Implementation of the strengths model involved a significant change in practice for case management practitioners. The results confirm that at the beginning of implementation, the strengths model was perceived as complex and not always adaptable to on-the-ground realities. With time, and with support from management, ongoing training and supervision sessions, and reflection and discussion, practitioners regained feelings of competence and resistance to the model diminished. The use of the model's structured team-based supervision tools was fundamental to supporting the implementation process by enabling an interactive and concrete training approach. The more an approach leads to changes in daily practice and is perceived as complex, the more concrete support is needed during implementation. This article highlights the importance of attending to a practitioner's sense of personal effectiveness and competence in the adoption of new practices.

The Working Alliance as a Mediator Between Fidelity to Strengths Model Case Management and Client Outcomes.

The purpose of this study was to examine how the client–case manager working alliance in strengths model case management (SMCM) mediates the relationship between fidelity to the SMCM intervention and clients’ quality of life, hope, and community functioning. In total, 311 people with severe mental illness, served at seven community mental health agencies in Canada, participated in the study. They were new to SMCM and participated in five structured interviews every 4.5 months for 18 months to measure the quality of the client–case manager working alliance and clients’ quality of life, hope, and community functioning. The team-level SMCM fidelity scale was administered six times over 3 years. Ordinary least-squares path analysis was used to test simple mediation models. Higher fidelity to SMCM was associated with better client outcomes indirectly through the working alliance. Higher SMCM fidelity predicted a stronger working alliance, which in turn predicted greater improvements in client quality of life (at 9 months and 18 months), hope (at 18 months), and community functioning (at 9 months). The results support the view that SMCM is an effective intervention. When the intervention was implemented as planned, it fostered stronger working alliances between clients and case managers and contributed to greater improvements in the quality of life, hope, and functioning of people with severe mental illness. The findings of this study highlight the value of ongoing monitoring of implementation fidelity to achieve high-fidelity interventions that may lead to positive client outcomes.

Coming Up…

The New Jersey Association of Mental Health and Addiction Agencies is holding its spring conference, “Nurturing Diverse Communities,” April 5, to be held virtually. For more information, visit https://njamha.org/FB/2022‐spring‐conference‐registration/index.html.

Inter-agency collaboration is associated with increased frequency of research use in children's mental health policy making.

To determine whether the self-report frequency of inter-agency collaboration about children's mental health issues is associated with the self-report frequency of using research evidence in children's mental health policy and program decision making in mental health agencies (MHAs). Primary data were collected through web-based surveys of state (N=221) and county (N=117) MHA officials. The primary independent variable was a composite score quantifying the frequency of collaboration about children's mental health issues between officials in MHAs and six other state agencies. The dependent variables were composite scores quantifying the frequency of research use in children's mental health policy and program decision making in general and for specific purposes (i.e., conceptual, instrumental, tactical, imposed). Covariates were composite scores quantifying well-established determinants of research use (e.g., agency leadership, research use skills) in agency policy and program decision making. Separate multiple linear regression models estimated associations between frequency of inter-agency collaboration and research use scores, adjusting for other determinants of research use, respondent state, and other covariates. Data from state and county officials were analyzed separately. The frequency of inter-agency collaboration was positively and independently associated with the frequency of research use in children's mental health policy making among state (β=0.22, p = 0.004) and county (β=0.39, p < 0.0001) MHA officials. Inter-agency collaboration was also the only variable significantly associated with the frequency of research use for all four specific purposes among state MHA officials, and similar findings we observed among county MHA officials. The magnitudes of associations between inter-agency collaboration and frequency of research use were generally stronger than for more well-established determinants of research use in policy making. Strategies that promote collaboration between MHA officials and external agencies could increase the use of research evidence in children's mental health policy and program decision making in MHAs.

Simulating the role of knowledge brokers in policy making in state agencies: An agent-based model.

To model children's mental health policy making dynamics and simulate the impacts of knowledge broker interventions. Primary data from surveys (n=221) and interviews (n=64) conducted in 2019-2021 with mental health agency (MHA) officials in state agencies. A prototype agent-based model (ABM) was developed using the PARTE (Properties, Actions, Rules, Time, Environment) framework and informed through primary data collection. In each simulation, a policy is randomly generated (salience weights: cost, contextual alignment, and strength of evidence) and discussed among agents. Agents are MHA officials and heterogenous in their properties (policy making power and network influence) and policy preferences (based on salience weights). Knowledge broker interventions add agents to the MHA social network who primarily focus on the policy's research evidence. A sequential explanatory mixed method approach was used. Descriptive and regression analyses were used for the survey data and directed content analysis was used to code interview data. Triangulated results informed ABM development. In the ABM, policy makers with various degrees of decision influence interact in a scale-free network before and after knowledge broker interventions. Over time, each decides to support or oppose a policy proposal based on policy salience weights and their own properties and interactions. The main outcome is an agency-level decision based on policy maker support. Each intervention and baseline simulation runs 250 times across 50 timesteps. Surveys and interviews revealed that barriers to research use could be addressed by knowledge brokers. Simulations indicated that policy decision outcomes varied by policy making context within agencies. This is the first application of ABM to evidence-informed mental health policy making. Results suggest that the presence of knowledge brokers can: (1) influence consensus formation in MHAs, (2) accelerate policy decisions, and (3) increase the likelihood of evidence-informed policy adoption.

Mediators between Positive and Negative Parenting and Child Depressive and Anxious Symptoms: Findings from a Diverse, At-Risk Sample

Background: Although children’s depressive and anxious symptoms have been broadly construed as internalizing problems, the current study sought to identify factors that may differentially contribute to these two mental health problems in a high-risk sample. Prior research has not adequately tested both depressive versus anxious symptoms simultaneously, nor has it adequately considered the role of negative versus positive parenting simultaneously, thereby neglecting the potential overlap in both sets of constructs. Overlooking such potential statistical overlap obfuscates how factors may differentially contribute to either depressive versus anxious symptoms. Existing research has also focused on lower-risk community samples. Method: The present study investigated whether children’s negative self-concept or maladaptive attributional style mediated the link between both negative and positive parenting in a racially diverse, at-risk sample of 65 primary school-age children recruited from mental health agencies. Results: When tested together, more negative parenting, but not less positive parenting, retained direct effects on both depressive and anxious symptoms. Both negative self-concept and maladaptive attributional style fully mediated the association between less positive parenting and children’s depressive symptoms, whereas positive self-concept, but not attributional style, mediated between less positive parenting and anxious symptoms. Conclusions: The current findings underscore potential differential intervention targets for these two internalizing problems and highlight the need for future research to consider both depressive and anxious symptoms, and related predictors, simultaneously to control for their shared variance.

Building organizational readiness: initial field testing of an expert-informed typology of implementation strategies

BackgroundOrganizational readiness is a known barrier to implementing evidence-based practices (EBPs) in community mental health services. A robust methodology for enhancing organizational readiness for implementation (ORI) has the potential to improve implementation outcomes of EBPs and ensure better services for people with a psychiatric disability. Prior work established a framework of implementation strategies targeting ORI enhancement by asking a group of implementation experts from various fields to categorize strategies from the “Expert Recommendations for Implementing Change” (ERIC) Project into three readiness stages, consistent with the pre-action stages of the Transtheoretical Model of behavioral change: Pre-contemplation, Contemplation, and Preparation. The current study provides initial confirmation and refinement to this expert-driven typology based on community mental health field experiences.MethodsWe conducted in-depth interviews with stakeholders involved in a recent EBP implementation project. Participants included staff (n=9) from four community mental health agencies and the implementation team who facilitated the project (n=3). Their pre-implementation experiences were compared with the experts’ typology to identify consistencies and discrepancies.ResultsThe participants’ experiences were congruent with two thirds of the strategies identified by the experts for specific ORI stages. The refinements included 12 strategies used in additional stages beyond the experts’ classification, four strategies from the ERIC list that were not included in the ORI typology, and five new strategies.ConclusionsThis study provides initial confirmation and refinements to the previously published ORI typology. The results offer guidance as to how ORI could be enhanced in the community mental health field.

Psychometric properties of post-traumatic stress disorder (PTSD) checklist for DSM-5 in persons with serious mental illness

ABSTRACT Background PCL-5 is a self-report measure consisting of 20 items that are used to assess the symptoms of Post-Traumatic Stress Disorder (PTSD) according to the DSM-5. Objective This study evaluated the factor structure of the Post-Traumatic Stress Disorder (PTSD) Checklist for DSM-5 (PCL-5) in people with serious mental illness. Method The sample in Study 1 included 536 participants with serious mental illness who were receiving supported employment services through community mental health agencies or supported housing programmes. Confirmatory factor analysis assessed the fit of six different models of PTSD. Results Results indicated that Armour’s Hybrid 7-factor model composed of re-experiencing, avoidance, dysphoria, dysphoric arousal, anxious arousal, negative affect, anhedonia, and externalizing behaviours demonstrated the best fit. Study 2 found support for convergent validity for PCL-5 among 132 participants who met criteria for PTSD. Conclusion Findings provide support for the psychometric properties of the PCL-5 and the conceptualization of the 7-factor hybrid model and the 4-factor DSM-5 model of PTSD among persons living with serious mental illness.

NJAMHAA campaign empowers diverse community, emphasizes funding needs

Observing an urgent need for mental health and substance use disorder treatment and supports to address growing service demand, along with a need for investments to support the state's community behavioral health care system and grow its workforce, is the impetus behind a new campaign developed by the New Jersey Association of Mental Health and Addiction Agencies Inc. (NJAMHAA) with a call for increased contract funding and reimbursement rates to ensure service access.

Bullying Involvement among Children Receiving Clinical Care: Links to Mental Health Indicators, Individual Strengths, and Parenting Challenges

Bullying has harmful effects on mental health, and it is particularly toxic to children already struggling with mental health challenges. We explored mental health indicators in children, their individual strengths, and challenges in parenting in relation to children’s bullying involvement, assessed through parent and clinician reports. Results of our study involving 91 children (ages 4–11 years) receiving services at a children’s mental health agency indicated significant differences on dependent variables across four different bullying involvement groups: bully, victim, bully-victim, and non-involved. Results indicated children in our clinical sample were involved in school bullying at much higher rates and many more were involved as bully-victims than what is observed in community samples. Children in the bully-victim group were assessed as having the highest level of externalizing behavior and their parents as having the most challenges. Victims presented the highest level of internalizing problems, and non-involved children were assessed as having higher individual strengths than all children that were involved in bullying. Findings suggest that children’s mental health service providers should routinely screen for bullying problems, and interventions targeting bullying involvement and its consequences should be part of mental health care for these children.

Exploring Provider Perspectives on Implementing Coordinated Specialty Care: A Qualitative Study.

This study aimed to explore clinician roles and experiences related to the implementation and sustainability of coordinated specialty care (CSC) programs for first episode psychosis. Qualitative interviews were conducted with 20 CSC providers and team members, recruited from five CSC programs. Using a semi-structured guide, interviews explored experiences with the delivery of CSC in the context of community-based outpatient mental health agencies and the challenges with implementation. Interviews were audio recorded, transcribed, and analyzed using thematic analysis. Themes were parsed into two overarching categories, provider, and organizational-level factors, and further distilled into subthemes which interacted with one another to form an interacting web of barriers to successful programmatic implementation for CSC programs. Study findings have important implications for development of future policy for financing mental health agencies, the creation of additional materials, supports for the model, and hiring and retention of staff for future implemented CSC programs.

The Social Determinants of Mental Health: A Descriptive Study of State Mental Health Agencies' Priorities.

Social determinants are receiving renewed attention as research demonstrates the effects of social factors on individuals’ physical and mental health and elucidates the biological and psychological mechanisms underlying those effects. Through spheres of influence from policy and regulation development to direct service provision, state mental health agencies are in a unique position to lead primary and secondary prevention efforts aimed at addressing social determinants with both client-level and structural-level interventions. A survey of social determinants-related activity was sent to the Medical Directors of the state offices of mental health in all 50 states. The survey results suggest consensus among respondents as to the importance of addressing specific social determinants. However, few state mental health agencies have taken on a comprehensive and intentional approach to addressing social determinants as a unique area of activity. Specific activities are reviewed, and implications for future work is discussed.

Delivering collaborative mental health care within supportive housing: implementation evaluation of a community-hospital partnership

BackgroundApproaches to address unmet mental health care needs in supportive housing settings are needed. Collaborative approaches to delivering psychiatric care have robust evidence in multiple settings, however such approaches have not been adequately studied in housing settings. This study evaluates the implementation of a shifted outpatient collaborative care initiative in which a psychiatrist was added to existing housing, community mental health, and primary care supports in a women-centered supportive housing complex in Toronto, Canada.MethodsThe initiative was designed and implemented by stakeholders from an academic hospital and from community housing and mental health agencies. Program activities comprised multidisciplinary support for tenants (e.g. multidisciplinary care teams, case conferences), tenant engagement (psychoeducation sessions), and staff capacity-building (e.g. formal trainings, informal ad hoc questions). This mixed methods implementation evaluation sought to understand (1) program activity delivery including satisfaction with these activities, (2) consistency with team-based tenant-centered care and with pre-specified shared lenses (trauma-informed, culturally safe, harm reduction), and (3) facilitators and barriers to implementation over a one-year period. Quantitative data included reporting of program activity delivery (weekly and monthly), staff surveys, and tenant surveys (post-group surveys following tenant psychoeducation groups and an all-tenant survey). Qualitative data included focus groups with staff and stakeholders, program documents, and free-text survey responses.ResultsAll three program activity domains (multidisciplinary supports, tenant engagement, staff capacity-building) were successfully implemented. Main program activities were multidisciplinary case conferences, direct psychiatric consultation, tenant psychoeducation sessions, formal staff training, and informal staff support. Psychoeducation for tenants and informal/formal staff support were particularly valued. Most activities were team-based. Of the shared lenses, trauma-informed care was the most consistently implemented. Facilitators to implementation were shared lenses, psychiatrist characteristics, shared time/space, balance between structure and flexibility, building trust, logistical support, and the embedded evaluation. Barriers were that the initial model was driven by leadership, confusion in initial processes, different workflows across organizations, and staff turnover; where possible, iterative changes were implemented to address barriers.ConclusionsThis evaluation highlights the process of successfully implementing a shifted outpatient collaborative mental health care initiative in supportive housing. Further work is warranted to evaluate whether collaborative care adaptations in supportive housing settings lead to improvements in tenant- and program-level outcomes.

Risk of Injury to Others: The Development of an Algorithm to Identify Children and Youth at High-Risk of Aggressive Behaviours.

Youth violence is considered one of the most preventable causes of morbidity and premature mortality. Various risk factors have previously been identified, however, there is presently a crucial need to develop effective decision-support tools in order to identify children and youth at increased risk for violence. The current study utilised data collected from the interRAI Child and Youth Mental Health Screener (ChYMH-S), within the province of Ontario, to develop and validate a methodology for the purpose of identifying young persons who were at greater risk of harm to others. Additional data from 59 mental health agencies validated the algorithm, and it was found to be a strong predictor of harmful behaviour toward others. The RIO algorithm provides a valuable decision-support tool with strong psychometric properties that may be used to identify young persons who exhibit signs or symptoms associated with increased likelihood of harm toward others, in order to provide early intervention efforts for these vulnerable youth, thereby reducing the likelihood of future aggressive behaviours.

New Jersey provider association dedicates new website to increasing equity

The New Jersey Association of Mental Health and Addiction Agencies Inc., representing 160 behavioral health care providers, wrapped up its 70th year with a new website featuring easier navigation and a “compelling illustration” of NJAMHAA's commitment to increasing access to services for everyone in the state's richly diverse population, its leaders stated in a news release. The new homepage (www.njamhaa.org) features clear navigation, with all menus across the top of the page. The membership menu includes links to details on applying for NJAMHAA membership as provider organizations and councils (business partners), and testimonials from current members. “We are proud to have served as a champion for transforming lives and behavioral health care for more than 70 years, and we are excited to unveil a new website that further demonstrates our mission to ensure that every New Jersey resident — regardless of their race, ethnicity, etc. — can access life‐saving services,” said Debra L. Wentz, president and CEO of NJAMHAA.

Examining the Mental Health Presentations of Treatment-Seeking Transgender and Gender Nonconforming (TGNC) Youth

Recent research suggests that transgender and/or gender nonconforming (TGNC) youth present with heightened levels of mental health problems compared to peers. This study seeks to examine the mental health needs of a large sample of treatment-seeking TGNC youth by comparing them to cisgender males and females. Participants were 94,804 children and youth ages 4–18 years (M = 12.1, SD = 3.72) who completed the interRAI Child and Youth Mental Health Instrument (ChYMH) or Screener (ChYMH-S) at participating mental health agencies in the Ontario, Canada. Overall, the mental health presentations of TGNC youth were similar to cisgender females but at higher acuity levels. TGNC youth showed significantly higher levels of anxiety, depression, social disengagement, positive symptoms, risk of suicide/self-harm, and were more likely to report experiencing emotional abuse, past suicide attempts, and a less strong, supportive family relationship than cisgender females and males. Clinical implications of these findings are discussed.

The implementation potential of a method to monitor empirically-supported children\u2019s mental health treatment through claims data

BackgroundThe delivery of evidence-supported treatments (EST) in children’s mental health could be a valuable measure for monitoring mental healthcare quality; however, efforts to monitor the use of EST in real world systems are hindered by the lack of pragmatic methods. This mixed methods study examined the implementation and agency response rate of a pragmatic, claims-based measure of EST designed to be applied as a universal quality measure for child psychotherapy encounters in a state Medicaid system.MethodsImplementation potential of the EST measure was assessed with healthcare leader rankings of the reporting method’s acceptability, appropriateness and feasibility (n = 53), and post-implementation ratings of EST rate accuracy. Ability of the healthcare system to monitor EST through claims was measured by examining the agency responsivity in using the claims-based measure across 98 Medicaid-contracted community mental health (CMH) agencies in Washington State.ResultsThe analysis found the reporting method had high implementation potential. The method was able to measure the use of an EST for 83% of children covered by Medicaid with 58% CMH agencies reporting > 0 ESTs in one quarter. Qualitative analyses revealed that the most significant barrier to reporting ESTs was the operability of electronic health record systems and agencies’ mixed views regarding the accuracy and benefits of reporting.ConclusionsMeasurement of child mental health ESTs through Medicaid claims reporting has acceptable implementation potential and promising real world responsiveness from CMH agencies in one state. Variation in reporting by agency site and low to moderate perceived value by agency leaders suggests the need for additional implementation supports for wider uptake.

The Impact of Increasing Community-Directed State Mental Health Agency Expenditures on Violent Crime.

Violent crime remains a prevalent threat to population health within the United States. States offer varying policy approaches to prevent violent crime and support behavioral health, such as community-based programs that include substance use disorder prevention and treatment. Using state mental health agency data, we construct a panel of U.S. states over nine years and apply an instrumental variables empirical model with state and time fixed effects to adjust for policy endogeneity, omitted variable bias, and time trends. We find that a 10% increase in community-directed state mental health agency expenditures yielded nearly a 4% reduction in violent crime rates. Larger magnitude reductions in violent crime rates were associated with the presence of gun control regulations and increases in the proportion of the population completing secondary education. Policymakers should consider the added benefit of violent crime reduction when considering budgetary allocations of community-directed state mental health agency expenditures.

ICCareD: The Development of an Algorithm to Identify Factors Associated With Distress Among Caregivers of Children and Youth Referred for Mental Health Services.

Caregiver well-being plays an important role in children's development and a number of factors have been found to impact distress levels among caregivers of children and youth referred for mental health services. Further, caregiver distress impacts youth psychopathology, its acuity as well as related mental health interventions. The purpose of this study was to develop and validate an algorithm for identifying caregivers who are at greatest risk of experiencing caregiver distress. This algorithm was derived from, and will be embedded in, existing comprehensive interRAI child and youth instruments. Ontario data based on the interRAI Child and Youth Mental Health assessment instruments (ChYMH and ChYMH-DD) were analyzed to identify predictors of distress among caregivers of children and youth ages 4–18 years. Starting with proactive aggression, the algorithm uses 40 assessment items to assign one of 30 nodes that are grouped into five levels of risk. The interRAI ChYMH Caregiver Distress (iCCareD) algorithm was validated using longitudinal data from mental health agencies across Ontario and was found to be a good predictor among this sample with a c-statistic of 0.71 for predicting new or ongoing caregiver distress and 65% for both sensitivity and specificity using algorithm values of 3 or greater. This algorithm provides an evidence-based decision-support tool embedded within a comprehensive assessment tool that may be used by clinicians to inform their selection of supports and services for families.

Following the Epidemic Waves: Child and Youth Mental Health Assessments in Ontario Through Multiple Pandemic Waves.

Emerging studies across the globe are reporting the impact of COVID-19 and its related virus containment measures, such as school closures and social distancing, on the mental health presentations and service utilization of children and youth during the early stages of lockdowns in their respective countries. However, there remains a need for studies which examine the impact of COVID-19 on children and youth's mental health needs and service utilization across multiple waves of the pandemic. The present study used data from 35,162 interRAI Child and Youth Mental Health (ChYMH) assessments across 53 participating mental health agencies in Ontario, Canada, to assess the mental health presentations and referral trends of children and youth across the first two waves of the COVID-19 pandemic in the province. Wave 1 consisted of data from March to June 2020, with Wave 2 consisting of data from September 2020 to January 2021. Data from each wave were compared to each other and to the equivalent period one year prior. While assessment volumes declined during both pandemic waves, during the second wave, child and youth assessments in low-income neighborhoods declined more than those within high-income neighborhoods. There were changes in family stressors noted in both waves. Notably, the proportion of children exposed to domestic violence and recent parental stressors increased in both waves of the pandemic, whereas there were decreases noted in the proportion of parents expressing feelings of distress, anger, or depression and reporting recent family involvement with child protection services. When comparing the two waves, while depressive symptoms and recent self-injurious attempts were more prevalent in the second wave of the pandemic when compared to the first, a decrease was noted in the prevalence of disruptive/aggressive behaviors and risk of injury to others from Wave 1 to Wave 2. These findings highlight the multifaceted impact of multiple pandemic waves on children and youth's mental health needs and underscore the need for future research into factors impacting children and youth's access to mental health agencies during this time.