Mental Health Care System Research Articles

Improving the rights of people with mental disorders in the Republic of Croatia

Abstract The mental health care system in the Republic of Croatia, despite the ongoing reform, is still based on hospital treatment. Hospitalizations due to mental disorders are in first place according to the length of stay. According to the annual report of the Ombudsman in the Republic of Croatia, 2% of hospitalizations due to mental disorders are involuntary hospitalization. Coercive measures and deprivation of business capacity are also often used. In order to reduce the number of coercive measures, involuntary hospitalizations and deprivation of professional capacity, it is necessary to increase mental health literacy and knowledge about human rights and the rights of persons with mental disorders, both among mental health experts and among patients and their families, as well as the general public. In order to increase knowledge and skills related to the rights of people with mental disorders, the Croatian Institute of Public Health, has been conducting WHO Quality Rights workshops in Croatian counties since 2019. The two-day workshops include all stakeholders: local politicians and decision-makers, associations of people with mental disorders and their families, employees in the mental health care system with the involvement of the media. So far, the training has been conducted in five major Croatian counties. The Quality Rights e-training platform has been translated into Croatian and the link to access the training is available online. In order to ensure the sustainability of the program and expand knowledge and skills, obtaining a certificate of completed Quality Right training became a requirement for passing the specialist exam in public health and in psychiatry. In five years of implementation of the program, the number of coercive measures in psychiatric hospitals decreased by 58%. Respect for human rights is a prerequisite for improving the mental health care system and the mental health. of both patients and the entire population. Key messages • Respect for human rights is necessary for the mental health of the population. • Knowledge and skills about the rights of patients with mental disorders reduce the rate of coercive measures.

Building bridges: mobile mental health care units in four European countries

Abstract Background Individuals living in rural and remote areas may have limited access to mental healthcare due to lack of facilities, socioeconomic reasons, stigma and lack of mental health literacy. To meet the needs and provide needs-based care care mobile mental health care clinics were established in some countries in Europe, including in Belgium, Germany, Greece and in Moldowa. A mobile clinic is a customized motor vehicle that travels to communities to provide mental health care. The mobile clinics are an integral part of the health care system and help ensure access to mental care. Aims To describe mobile care clinics in two countries in Europe using a case study design. Results Mobile clinics deliver a wide variety of mental health services, are heterogeneous and consist of multidisciplinary teams, including physicians, social workers, and other health professionals. The organization and financing of the Mobile mental health clinics is different in the four countries (e.g. part of the mental health care system in Belgium, and Moldova, part of initiatives in Germany and Greece). Due to data protection no detailed data on patients can be provided at the moment. The structures on mental health care mobile clinics in the four countries will be described in detail in the talk. Discussion Mobile clinics often serve as a bridge between communities and the mental health care system. Another important issue in rural areas is the ongoing aging of the population. The number of Elderly patients is expected to rise in the future. The care of those patients is challenging for the mental health and the primary care system. There is a necessity for establishing bridges between mobile clinics and hospital care.

Community mental health care in Croatia: Mobile team for psychosocial support in the community

Abstract The Republic of Croatia has initiated numerous reforms in the mental health care system in the community. Within the framework of EU JA Implement, a mobile team was formed to provide interventions in the community, that is, in the homes of persons discharged from psychiatric hospitals. The mobile team was formed during 2023. The team includes: one psychiatrist, leader and coordinator of the mobile team, three graduate nurses, a case manager, a social worker, three experienced experts who are employed in the team as peer workers, and one social pedagogue and psychologist. The wider composition of the team includes a psychiatrist who provides outpatient psychiatric treatment, who is familiar with the individual recovery plan and, if necessary, participates in the development of the plan. The goal of establishing a mobile team is to implement an individual recovery plan in the community, that is, in the patient’s home, using biopsychosocial interventions, with the aim of better and faster recovery of the user and inclusion in the community, as well as prevention of rehospitalization and disability. Before the patients home visits, the experts in the team were trained. 15 patients were included in the pilot project, with whom 96 home visits or interventions were carried out in the time period from the establishment of the team to April 2024. As a result of the effectiveness of the pilot project, in 2024, in accordance with the Strategic Framework for the Development of Mental Health until 2030, the Republic of Croatia adopted a new network of health institutions, within which 30 mobile psychiatric teams and 24 psychological teams at the primary level of health care are planned. Empowerment of users, engagement of people with experience in the implementation of interventions, increase in mental health literacy of the population and destigmatization are additional results of the implementation of mental health protection in the community through JA impleMENTAL.

JA ImpleMENTAL Implementing the Belgian Best Practice on Community Mental Health system Reform

Abstract Mental health challenges affect more than one in six people across the EU. In order to support Member States to proceed with mental health care system transformation and suicide prevention JA ImpleMENTAL, was initiated on the request of Member States, on October 2021 under the European Union 3rd Health Program. The JA consists of 39 organizations from 21 countries, more than 180 persons are working. Two advisory bodies support the consortium and provide their insights and expertise, a stakeholder forum with 10 key European Organizations in Mental Health including EUPHA Mental Health Section and WHO Europe and OECD, and the Member State Policy Committee which ensures the involvement of ministries and enables the practices to be embedded in health systems. Within the 11 countries implementing pilots under the Belgium model using a common Implementation Strategy, a total 163 activities are implemented under the 5 following key areas: 62 on structural measures needed for the establishment of local networks promoting a user’s centered, human’s right based recovery approach, 43 for the development and/or transformation of mental health services, 22 on training & capacity building in support of the reform and cultural change, 22 on continuous communication, information and awareness raising, and 13 on data collection, monitoring and evaluation. An analysis of MS pilot action plans shows that most service transformation efforts have concentrated on: defining care pathways for people at risk and for those with mild to severe mental health conditions including smooth transition from child and adolescent to Adult Mental Health services, as well as from inpatient to community services, the nomination of case managers for assisting individuals to their recovery process the development of individual service plans, the Involvement of users in various layers of service delivery including peer support and the provision of assertive treatment through mobile units.

Attachment-informed mental healthcare systems as 'organisational caregivers': ideas for the future.

Over the past 50 years, mental health services have evolved significantly, influenced by shifts in theoretical and practical approaches to mental disorders. Key among these changes are the biopsychosocial and recovery models, which highlight resilience and quality of life in treatment. However, traditional psychiatry has often struggled to embrace these changes because of reductionist perspectives that overlook psychosocial factors, resulting in fragmented care and reduced accessibility. Proposed solutions have faced implementation barriers in absence of a coherent theoretical framework. Here, we outline how attachment theory may offer a promising framework to drive systemic change in mental health by emphasising secure emotional bonds at both the organisational and individual level. Within an attachment-informed culture, services may act as 'organisational caregivers' that promote continuity of care, independence and stronger clinical relationships. In turn, this may foster more inclusive, responsive and resilient mental healthcare systems that prioritise patients' needs and empowerment.

Evaluating Pakistan’s mental healthcare system using World Health Organization’s assessment instrument for mental health system (WHO-AIMS)

BackgroundPakistan faces profound mental health challenges, which necessitate the urgent need for a comprehensive assessment of its mental healthcare system. A holistic understanding of the mental health landscape is essential to identify strengths, weaknesses, and existing gaps within the system, which can inform targeted interventions and policy enhancements to improve mental healthcare accessibility.ObjectiveThe primary objective of this desk research is to conduct an in-depth analysis of Pakistan’s mental healthcare system across various dimensions, guided by the World Health Organization’s Assessment Tool for Mental Health Systems (WHO-AIMS).MethodsData for this desk research and scoping was obtained through desk research, including an examination of existing policies and legislation and consultations with various health facilities across Pakistan. This comprehensive analysis focused on six critical domains within the WHO-AIMS framework: policy and legislation, mental health services, integration of mental health into primary care, public awareness and collaboration with other sectors, human resources, and monitoring and research initiatives.ResultsThe findings provides a snapshot of strength and opportunities for improvement in Pakistan’s mental healthcare system that can serve as the foundation for revising and updating national priorities. Key areas of focus include enhancing policy and legislation, expanding access to mental health services, improving existing initiatives for better integration of mental health into primary care, improving public awareness and sector collaboration, addressing human resource challenges, and strengthening monitoring and research initiatives.ConclusionThis desk research provides a roadmap for refining and enhancing Pakistan’s mental health ecosystem and informs the prioritization of mental health campaigning efforts.

‘The doctor doesn’t understand Xhosa and the service user doesn’t understand English’ - exploring the role of security guards acting as informal interpreters in psychiatric care in South Africa

IntroductionAssigning qualified interpreters is considered one of the most effective approaches to facilitate communication in language-discordant encounters in mental healthcare. However, particularly in settings with fewer resources, they are not always available and informal practices are often used.ObjectiveThis study aimed to investigate informal interpreting practices in mental healthcare in South Africa, focusing on security guards (SGs) serving as interpreters.MethodsGuided interviews were conducted with SGs (n = 12) and mental healthcare providers (MHCPs) (n = 18) at a psychiatric hospital in South Africa. The interviews were audio recorded, transcribed verbatim and analyzed using a thematic analysis approach.ResultsDespite recognizing that SGs serving as interpreters is not an ideal solution to overcome language barriers and could potentially jeopardize the quality of treatment and its outcomes, MHCPs reported relying heavily on them due to the underrepresentation of South Africa’s linguistic diversity among them. Given the lack of formal interpreting services, the perceived racial, linguistic and socioeconomic similarities between SGs and some service users, as well as their immediate accessibility, were described as beneficial to providing a minimal level of care (e.g. obtaining information about service users’ backgrounds, getting an understanding of their symptoms, psychoeducation, explaining treatment options). Drawbacks reported are SGs being pulled away from their actual duties, experiencing emotional distress, juggling multiple sometimes conflicting roles, and the risk of incorrect interpretation, which could compromise ethical standards of care. Additionally, the complexity of power became apparent: While SGs hold little institutional power within the mental healthcare system, they become powerful figures when serving as interpreters.ConclusionIt can be assumed that MHCPs will resort to informal interpreting practices as long as effective alternatives are lacking. In doing so, risks such as reduced quality of care are accepted, and the consequences and effects on those serving as interpreters are neglected, which raises concerns from an ethical point of view.

Integration Telemental Health to Reach Out Patients at Community Mental Health Services: A Systematic Review

Low- and middle-income countries (LMICs) need to digitize mental health services to address disparities and improve access to healthcare. This study systematically reviewed the digitalization of integration mental health services that can reach interactions between service providers and recipients with media such as telemental health and mobile health. A literature search was conducted in March 2023. Randomized controlled trial (RCT) data were used from available studies. RCT data sources were obtained from internationally reputable journal articles with the theme of telehealth. The literature used was obtained from the databases Scopus, Web of Science, and PubMed. Integration digitalized mental healthcare system under the auspices of the Ministry of Health that reach-nationally, official psychiatrists and other professional mental healthcare that provides mental healthcare support to areas lacking specialists consisting crisis and emergency, stable conditions, as well as the process of counseling and follow-up therapy with telemental health and mobile health media. Telemental health plays a major role in mental health services and modality therapy that can be accessed effectively and efficiently, especially for mental patients in remote areas who experience barriers to attending in person.

Current status of paternal mental health care in obstetric institutes in Japan.

SynopsisThere should be an urgent need to establish a mental health care system for partners in Japan.

Self-diagnosis of psychiatric conditions as a threat to personal autonomy

ABSTRACT I argue that the recurring practice of self-diagnosis of psychiatric conditions such as autism spectrum disorder and attention-deficit/hyperactivity disorder on social media platforms poses a threat to personal autonomy understood as self-governance. My main argument is that self-diagnosis conducted without professional expertise is prone to lead to misdiagnosis, which can take the form of a distortion of self-image. This may result in pathologizing normal experiences and behaviors and the adoption of behavioral adjustments that harm those who engage in self-diagnosis. Acknowledging that the surge of self-diagnosis content is a response to inadequacies of mental health care systems in many parts of the world, I argue against prohibiting such content and end with a more modest suggestion of implementing warnings alongside it on social media platforms, as is already common practice for misinformation content on diseases like Covid-19.

Effectiveness of written exposure therapy for Korean patients with post-traumatic stress disorder: non-randomized treatment-as-usual waitlist-controlled study

ABSTRACT Written exposure therapy (WET) is a five-session exposure-based protocol for treating post-traumatic stress disorder (PTSD). The brevity and tolerability of WET present the potential to overcome barriers in implementing evidence-based therapy for PTSD within the Korean mental healthcare system. This study investigated the effectiveness of WET in Korean patients with PTSD through a waitlist-controlled trial (KCT0008112). A total of 57 patients with PTSD were allocated non-randomly to either WET (n = 27) or treatment-as-usual waitlist groups (n = 30). Both groups were followed up until the twenty-fourth week after the initial session. Primary outcomes assessed included PTSD symptoms, depressive symptoms, and general function. In the WET group, significant improvements were observed in PTSD symptoms, depressive symptoms, and general function compared to the control group. After the waiting period, the waitlist group also participated in WET, and exhibited significant improvement in all scores. The between- and within-group effect sizes were large. The dropout rate in both groups was 10.9%, and the mean satisfaction ratings were 28.24 ± 3.33 (range 22–32; scale range 8–32). The present study provides evidence of WET successfully reducing PTSD and depressive symptoms and improving general function among Korean patients with PTSD. Moreover, WET was well tolerated and received by Korean patients with PTSD.

Reductions in inpatient and outpatient mental health care in germany during the first year of the COVID-19 pandemic - What can we learn for a better crisis preparedness?

During the COVID-19 pandemic, reports from several European mental health care systems hinted at important changes in utilization. So far, no study examined changes in utilization in the German mental health care inpatient and outpatient mental health care system comprehensively. This longitudinal observational study used claims data from two major German statutory health insurances, AOK PLUS and BKK, covering 162,905 inpatients and 2,131,186 outpatients with mental disorders nationwide. We analyzed changes in inpatient and outpatient mental health service utilization over the course of the first two lockdown phases (LDPs) of the pandemic in 2020 compared to a pre-COVID-19 reference period dating from March 2019 to February 2020 using a time series forecast model. We observed significant decreases in the number of inpatient hospital admissions by 24-28% compared to the reference period. Day clinic admissions were even further reduced by 44-61%. Length of stay was significantly decreased for day clinic care but not for inpatient care. In the outpatient sector, the data showed a significant reduction in the number of incident outpatient diagnoses. Indirect evidence regarding the consequences of the reductions in both the inpatient and outpatient sector of care described in this study is ambiguous and direct evidence on treatment outcomes and quality of trans-sectoral mental healthcare is sparse. In line with WHO and OECD we propose a comprehensive mental health system surveillance to prepare for a better oversight and thereby a better resilience during future global major disruptions.

Reducing mental health emergency visits: population-level strategies from participatory modelling

BackgroundEmergency departments (EDs) are often the front door for urgent mental health care, especially when demand exceeds capacity. Long waits in EDs exert strain on hospital resources and worsen distress for individuals experiencing a mental health crisis. We used as a test case the Australian Capital Territory (ACT), with a population surge of over 27% across 2011–2021 and a lagging increase in mental health care capacity, to evaluate population-based approaches to reduce mental health-related ED presentations.MethodsWe developed a system dynamics model for the ACT region using a participatory approach involving local stakeholders, including health planners, health providers and young people with lived experience of mental health disorders. Outcomes were projected over 2023–2032 for youth (aged 15–24) and for the general population.ResultsImproving the overall mental health care system through strategies such as doubling the annual capacity growth rate of mental health services or leveraging digital technologies for triage and care coordination is projected to decrease youth mental health-related ED visits by 4.3% and 4.8% respectively. Implementation of mobile crisis response teams (consisting of a mental health nurse accompanying police or ambulance officers) is projected to reduce youth mental health-related ED visits by 10.2% by de-escalating some emergency situations and directly transferring selected individuals to community mental health centres. Other effective interventions include limiting re-presentations to ED by screening for suicide risk and following up with calls post-discharge (6.4% reduction), and limiting presentations of frequent users of ED by providing psychosocial education to families of people with schizophrenia (5.1% reduction). Finally, combining these five approaches is projected to reduce youth mental health-related ED presentations by 26.6% by the end of 2032.ConclusionsPolicies to decrease youth mental health-related ED presentations should not be limited to increasing mental health care capacity, but also include structural reforms.

‘How can you worry about employment and survival at the same time?’: employment and mental health among precariously employed cisgender and transgender sexual minority adult men in Toronto, Canada

This study addresses a gap in the labour market and occupational health literatures among sexual and gender minority workers by exploring the relationship between precarious employment and mental health through a political economy framework. Narratives from 20 cisgender and transgender sexual minority men were analysed to uncover the production of employment and mental health inequities. Results are presented temporally, including employment readiness, looking for work, and on the job, illuminating the social and structural processes that underly participants’ stories of precarious employment and mental health. A cyclical pattern was identified whereby participants’ mental ill-health resulted in separation from the labour market and increased employment precarity that subsequently further impacted their mental health. Interventions and programmes must consider multipronged approaches that address all aspects of this syndemic, including social stigma and discrimination towards sexual and gender minority people and improved access to stable employment, mental healthcare, and adequate social welfare systems.

Impact of a collaborative model on community clinician confidence in child and adolescent mental health care, wellbeing, and access to child psychiatry expertise.

The COVID-19 pandemic was associated with an increase in child and adolescent mental health disorders, with subsequent worsening of patient access to specialist mental health care. Clinicians working in the community were faced with increased demands to diagnose and manage pediatric mental health disorders, without always having the confidence and knowledge to do so. We therefore developed COnnecting Mental-health PAediatric Specialists and community Services (COMPASS)-a collaborative model designed to upskill community clinicians in child and adolescent mental health care and provide them with better access to child and adolescent psychiatry expertise. COMPASS comprises (1) an online Community of Practice (CoP) with fortnightly one-hour sessions covering: anxiety; aggression and challenging behaviours; depression; self-harm and suicidality; eating disorders; and autism spectrum disorder/complex cases and (2) primary and secondary consultations for general practitioners and paediatricians with an experienced child psychiatrist. We aimed to assess the impact of COMPASS on community clinician self-reported confidence in: managing common child and adolescent mental health disorders (Objective 1, primary outcome); navigating the mental health care system (i.e. knowing how services are organised, accessed, and how to refer patients, Objective 2); diagnosing conditions (Objective 3); prescribing psychotropic medications (Objective 4) as well as the impact on, clinician practice and wellbeing (Objective 5) and outcomes of patients referred by COMPASS clinicians to the child psychiatrist (Objective 6). We evaluated COMPASS in its first year, with COMPASS running from March to July 2021. Participating clinicians completed pre-post surveys evaluating change in Objectives 1 to 4 above, using study-designed measures. A purposive sample of clinicians was then invited to a semi-structured interview to understand their experience of COMPASS and its impacts on practice and wellbeing (Objective 5). We adopted an inductive approach to the qualitative analysis using the Framework Method. This involved selecting five random transcripts which were double coded and categorized, to generate an initial framework against which all subsequent transcripts were analysed. Themes and subthemes were generated from the data set, by reviewing the matrix and making connections within and between clinicians, codes and categories One child psychiatrist completed a 2-week logbook of the nature and outcomes of primary and secondary consultations (Objective 6). 51 (86%) clinicians attended CoP sessions and completed pre-post surveys, with 92% recommending COMPASS to peers. Clinicians reported increased confidence in the pharmacological and non-pharmacological management of all conditions, most notably for management of self-harm. They also reported increased knowledge of how to navigate the mental health system and prescribe medications. Qualitative analysis (n = 27 interviews) found that COMPASS increased clinician wellbeing and reduced feelings of professional isolation and burnout. Over the 2-week snapshot, the child psychiatrist consulted on 22 patients and referred all back to the community clinician. COMPASS is associated with improved clinician confidence to manage child and adolescent mental health concerns, navigate the mental health system, improved clinician wellbeing, and reduced need for ongoing mental health care by specialists.

Why do some Mexicans with psychosis risk symptoms seek mental health care and others do not?

Help-seeking barriers differ according to the sociocultural context and country-specific mental healthcare system. More research is needed in low-middle-income countries, where early psychosis programs are still scarce, and the mental health care gap is wide. This study aims to explore predisposing, enabling, and need factors associated with mental health service utilization in 481 Mexicans self-reporting psychosis risk symptoms, as well as differences between those who were currently mental health service users (MHSU) and those who were not (non-MHSU). Participants responded to self-reported measures through an online survey. The factors associated with an increased probability of using mental health services were having an occupation, having a medium/high socioeconomic status, an intention to seek help from a mental health professional, fewer help-seeking barriers, moderate/severe anxious symptoms, higher distress associated with psychosis risk symptoms and social functioning impairment. Findings provide relevant information for designing more effective strategies to improve help-seeking, early identification, and timely treatment delivery in Mexico. The need to generate strategies focused on reducing stigma, enhancing psychosis literacy in the community, and increasing the identification of emerging signs of psychosis in primary healthcare professionals is highlighted, mainly when co-occurring with other psychiatric symptoms.

Efficacy of internet-based cognitive behavioral and interpersonal treatment for depression in Arabic speaking countries: A randomized controlled trial

BackgroundPolitically and economically unstable contexts have been associated with increased prevalence rates of depression. Despite high demand, the availability of mental health experts and care systems is limited in Arabic-speaking countries. Internet-based interventions might provide an opportunity to treat patients independently of location. Therefore, we investigated the efficacy of internet-based cognitive behavioral treatment (iCBT) and interpersonal treatment (iIPT) for depression in Arabic-speaking countries. MethodsIn total, 743 Arabic-speaking adults with depression were randomly allocated to iCBT (n = 243), iIPT (n = 247), or waitlist (n = 253). Depressive, anxiety, and somatoform symptoms, perceived social support and quality of life (QoL) were assessed at pre-, and post-treatment and at three months follow-up. Multiple imputation was performed for missing data. Changes associated with treatment were analyzed using regression in the completer and intention-to-treat sample. ResultsParticipants in both treatment groups showed lower depressive and anxiety symptom severity, higher QoL, and perceived social support compared to the waitlist group (p < .001). Somatoform symptom severity was significantly lower in participants receiving iIPT compared to waitlist (p < .001). Differences between the two treatments in all outcomes were non-significant (p > .05). Three-month follow-up treatment effects regarding depressive symptoms were indicated. LimitationsThe sample mainly consists of educated, single, female adults. Three-month follow-up results rely on a small subsample and must be interpreted with caution. ConclusionsThis is the first randomized controlled trial to demonstrate the efficacy of iCBT and iIPT for depression in Arabic-speaking countries. It provides first indications that internet-based interventions might help specific individuals in this region.

An examination of the ohio scales, short form, hopefulness domain, youth- and caregiver-report versions in a community care setting

The current study examined the utility of the Ohio Scales, Hopefulness Scale (OS Hopefulness Scale; Ogles et al., 2004), a free multi-informant four-item measure of hopefulness used within a large statewide public mental health care system. Collectively, the six aims of this study (done for both youth- and caregiver-report versions) examined (a) the measure’s factor structure and (b) internal consistency, (c) the relationship between youth- and caregiver-reported hopefulness, (d) the measure’s relationships with numerous domains of psychopathology (e.g., depression, anxiety, delinquency) and (e) functioning, and (f) sensitivity to change. Using a sample of 986 participants, who were ethnically diverse (30.5 % multiethnic, n = 301), 61.0 % male (n = 601), with an average age of 12.74 (SD=3.46), the study found good factor structure, acceptable internal consistency, and a significant positive association between youth-reported and caregiver-hopefulness. Additionally, significant inverse relationships were found between caregiver-reported hopefulness with youth mental health problems and youth functioning; while youth-reported hopefulness was found to be significantly inversely related to youth mental health problems but not youth functioning. Finally, significant positive changes in hopefulness and significant inverse relationships with youth functioning were also evident at three-month follow up for both youth- and caregiver-reported hopefulness. The constellation of our findings demonstrates potential for this four-item measure of hopefulness to be a useful, efficient, and cost-effective tool with ethnically diverse samples, which are substantially different from samples included in previous studies of hopefulness. Implications and suggestions for future research are discussed.

The digital cumulative complexity model: a framework for improving engagement in digital mental health interventions.

Mental health disorders affect a substantial portion of the global population. Despite preferences for psychotherapy, access remains limited due to various barriers. Digital mental health interventions (DMHIs) have emerged to increase accessibility, yet engagement and treatment completion rates are concerning. Evidence across healthcare where some degree of self-management is required show that treatment engagement is negatively influenced by contextual complexity. This article examines the non-random factors influencing patient engagement in digital and face-to-face psychological therapies. It reviews established models and introduces an adapted version of the Cumulative Complexity Model (CuCoM) as a framework for understanding engagement in the context of digital mental health. Theoretical models like the Fogg Behavior Model, Persuasive System Design, Self-Determination Theory, and Supportive Accountability aim to explain disengagement. However, none adequately consider these broader contextual factors and their complex interactions with personal characteristics, intervention requirements and technology features. We expand on these models by proposing an application of CuCoM's application in mental health and digital contexts (known as DiCuCoM), focusing on the interplay between patient burden, personal capacity, and treatment demands. Standardized DMHIs often fail to consider individual variations in burden and capacity, leading to engagement variation. DiCuCoM highlights the need for balancing patient workload with capacity to improve engagement. Factors such as life demands, burden of treatment, and personal capacity are examined for their influence on treatment adherence. The article proposes a person-centered approach to treatment, informed by models like CuCoM and Minimally Disruptive Medicine, emphasizing the need for mental healthcare systems to acknowledge and address the unique burdens and capacities of individuals. Strategies for enhancing engagement include assessing personal capacity, reducing treatment burden, and utilizing technology to predict and respond to disengagement. New interventions informed by such models could lead to better engagement and ultimately better outcomes.

Social-ecological barriers and facilitators to seeking inpatient psychiatric care among transgender and nonbinary people: A qualitative descriptive study.

To assess barriers and facilitators to seeking inpatient psychiatric treatment among transgender and nonbinary people. Qualitative interview study. Semi-structured interviews were conducted from March 2019 to June 2022 with transgender and nonbinary people admitted to an inpatient psychiatric hospital in the United States during the past 5 years. Data were analysed using thematic analysis and constructed within a modified social-ecological model of stigma. Standards for Reporting Qualitative Research were used for this study. Participants (N = 15) described barriers and facilitators across all three social-ecological levels. i) Individual themes included distrust of the mental healthcare system, feeling unsafe, loss of autonomy, minimizing one's own mental health needs, and feelings of accountability to others. ii) Interpersonal themes included: lack of support for transgender/nonbinary identity, limited transgender/nonbinary knowledge among mental healthcare professionals, and allyship. iii) Structural themes included: carceral setting, financial costs, and availability of non-profit treatment options. Multi-level themes were identified as barriers and facilitators to seeking inpatient psychiatric care for transgender and nonbinary people, providing opportunities among inpatient settings to improve care delivery and engagement. Greater health equity can be achieved by addressing barriers to care. Incorporating inclusive and affirming practices in inpatient psychiatric services presents an opportunity to reduce barriers to seeking care. The present study describes the experiences of transgender and nonbinary people as they determine whether to voluntarily seek inpatient psychiatric treatment. This perspective allows nurses, health systems, and policymakers to integrate transgender and nonbinary people's needs to improve healthcare delivery. Transgender and nonbinary participants were recruited in collaboration with community organizations. Members of the transgender and nonbinary community participated in study design development and analysis and were part of the study team.