Outpatient Mental Health Services Research Articles

Patterns and correlates of health service contact prior to serious offences by people with severe mental illness.

Contact with health services prior to offences committed by people with mental illness is an opportunity for intervention and prevention. This study examines the pattern and correlates of health service contact by people with severe mental illness before a serious offence. Linkage of a cohort of 477 Forensic Patients found not guilty due to mental illness between 1990 and 2016, and statewide databases of contact with emergency departments, hospital admission and outpatient mental health services in the state of New South Wales, Australia. A total of 84% of the sample had contact with any health service and 76% had contact with an outpatient mental health service prior to the index offence. About two-thirds of the sample had contact with a mental health service in the year before the offence. Factors independently associated with the absence of contact at any point prior to the index offence were non-English-speaking background, being engaged in employment or study, and an absence of childhood abuse or neglect. Although nearly every Forensic Patient had a psychotic illness at the time of the index offence, psychosis was not diagnosed at the time of 61/106 (57.5%) emergency department presentations, in 54/174 (31.0%) hospital admissions and 149/222 (67.1%) attendances at outpatient mental health services prior to the offence. Most Forensic Patients had contact with health services prior to their offences but many were not identified as having a psychotic illness. Although the symptoms of psychosis may have emerged in the period between contact and the offence, the findings suggest that emerging or underlying psychosis were missed or attributed to other conditions.

The need and acceptability of a youth mental health mentoring model to supplement adolescent outpatient mental health services

Youth mental health challenges in the United States continue to escalate at an alarming rate. To address this crisis, there is an urgent need to develop innovative strategies for delivering effective mental health care to youth. The aim of this study was to assess the need and acceptability of a youth mental health mentoring model for adolescents engaged in outpatient mental health services. Participants included adolescents currently engaged in outpatient mental health services (n = 3, 14–17 years old; 66 % Black; 100 % cisgender boys), parents/guardians of adolescents currently engaged in mental health services (n = 4; 50 % Black; 100 % cisgender women), clinicians who provide adolescent mental health services in an outpatient setting (n = 5; 100 % White cisgender women), and potential paraprofessional mental health mentors recruited from a large land-grant University (n = 5; 40 % White; 60 % cisgender women). All participants were recruited from an urban setting in the midwestern United States. Data collection occurred remotely. Following protocols that were approved by an Institutional Review Board, participant groups were provided an overview of the proposed model and asked a series of open-ended questions in four separate focus groups to gauge the perceived need and acceptability of this type of program model. Thematic data analysis was used to analyze data. Across participant groups, results indicated a clear need for supplemental mental health services and high acceptability of the proposed youth mental health mentoring model. Participants offered specific recommendations for model development, especially related to mentor selection, training and supervision.

Racial and ethnic disparities in healthcare utilization among children in U.S. foster care: Recommendations to challenge the status quo based on a scoping review

Prior work has examined racial and ethnic disparities in the access to and utilization of healthcare services. However, evidence across studies is mixed, making it challenging to precisely identify where the racial and ethnic disparities in healthcare utilization are amongst children in foster care, and which race and ethnicity groups are most impacted by such disparities. As such, the purpose of the current study was to conduct a scoping review to synthesize evidence on the topic of racial and ethnic disparities in the physical and mental or behavioral healthcare utilization for children in the U.S. foster care system (PROSPERO ID: CRD42021272072). Comprehensive literature searches were conducted in PubMed, EMBASE, PsycINFO, CINAHL, Cochrane Library, and Psychology and Behavioral Sciences Collection. Of the 414 studies identified, 23 met inclusion criteria: peer-reviewed journal article, published between 1991 and 2023, written in English, examined healthcare access or utilization of children in the U.S. foster care system as outcomes, included and disaggregated results by children’s race and ethnicity, conducted quantitative analysis, and was observational in study design. In the physical healthcare utilization domain, Black children were less likely to utilize routine and preventative check-ups and more likely to utilize medical services for treating chronic illnesses such as asthma, compared to White children. In the mental or behavioral healthcare utilization domain, Black and Hispanic/Latinx children were less likely to utilize both inpatient and outpatient mental health services, compared to White children. Furthermore, notable variations were observed by specific service types and continuity of services over time. Implications include additional research and education about racial and ethnic disparities in healthcare utilization amongst children in foster care, as well as implementing regulations and oversights that mandate racial equity in the child welfare and healthcare service pathways.

Assertive community treatment as an alternative to incarceration for American pretrial detainees

In the United States and elsewhere around the world, people with serious mental illness (SMI) are overrepresented in the criminal justice system. Clinical interventions to divert such individuals out of correctional settings, including Assertive Community Treatment (ACT), have been shown to reduce rates of criminal justice recidivism when modified to allow for the use of court sanctions to encourage treatment adherence. However, these interventions are noted to be underutilized as alternative to incarceration (ATI) programs.This paper summarizes the results of a retrospective cohort study conducted in a New York State forensic psychiatric hospital of 87 pretrial detainees admitted after being found incompetent to stand trial between January 2019 and January 2022. Of these, 49 patients were referred to an ACT team that served as an ATI program. The study outcomes noted that patients referred to this ACT team were 20% less likely to remain in pretrial detention than those that were not. Moreover, patients referred to the ACT program were also 34% more likely to be granted an ATI plea bargain in the community that did not involve serving a prison term. These results suggest that pretrial detainees with SMI are more likely to be granted an ATI program that offers more intensive treatment services such as ACT, due to the capability of such programs to also provide more intensive outreach and community supervision than traditional outpatient mental health service providers.

Exploring the association of Indigeneity, social adversity status and externalizing symptoms in children and adolescents.

The relationship between Indigeneity, social adversity status and externalizing symptoms is complex and unclear. This study investigates how Indigeneity, social adversity status and externalizing symptoms are related in young people. A total of 132 Indigenous and 247 non-Indigenous young people aged 6-16 years were recruited from a hospital mental health outpatient service. Normality plots with statistics for social adversity status and parent-reported externalizing symptoms were completed for the two groups, matched for age, gender, mental disorder symptom severity, symptom-linked distress and impairment. Standard multiple regression was used to examine how Indigeneity moderates the relationship between social adversity status and parent-reported externalizing symptoms. A scatterplot investigated the association between Indigeneity and social adversity status in young people with parent-reported externalizing symptoms. The distributions of the two groups and (1) social adversity status and (2) parent -reported externalizing symptoms were non-normal but acceptable for a moderator analysis. Indigeneity and social adversity status made independent significant positive contributions to externalizing symptoms. In contrast the interaction between Indigeneity and social adversity status made a nonsignificant negative trend to externalizing symptoms. A scatterplot revealed Indigeneity moderated the link between social adversity status and externalizing symptoms. High social adversity status is linked to externalizing symptoms in non-Indigenous young people but despite higher social adversity, Indigenous young people don't necessarily externalize. Potential protective resilience factors for externalizing symptoms in the Indigenous young people need to be ascertained and nurtured. Future systematic investigations of the contribution of these protective factors to Indigenous referral pathways and management are needed. It is also crucial that increased social adversity status is addressed and managed in all young people, regardless of Indigeneity.

Validation of a Multivariable Model to Predict Suicide Attempt in a Mental Health Intake Sample

Given that suicide rates have been increasing over the past decade and the demand for mental health care is at an all-time high, targeted prevention efforts are needed to identify individuals seeking to initiate mental health outpatient services who are at high risk for suicide. Suicide prediction models have been developed using outpatient mental health encounters, but their performance among intake appointments has not been directly examined. To assess the performance of a predictive model of suicide attempts among individuals seeking to initiate an episode of outpatient mental health care. This prognostic study tested the performance of a previously developed machine learning model designed to predict suicide attempts within 90 days of any mental health outpatient visit. All mental health intake appointments scheduled between January 1, 2012, and April 1, 2022, at Kaiser Permanente Northern California, a large integrated health care delivery system serving over 4.5 million patients, were included. Data were extracted and analyzed from August 9, 2022, to July 31, 2023. Suicide attempts (including completed suicides) within 90 days of the appointment, determined by diagnostic codes and government databases. All predictors were extracted from electronic health records. The study included 1 623 232 scheduled appointments from 835 616 unique patients. There were 2800 scheduled appointments (0.17%) followed by a suicide attempt within 90 days. The mean (SD) age across appointments was 39.7 (15.8) years, and most appointments were for women (1 103 184 [68.0%]). The model had an area under the receiver operating characteristic curve of 0.77 (95% CI, 0.76-0.78), an area under the precision-recall curve of 0.02 (95% CI, 0.02-0.02), an expected calibration error of 0.0012 (95% CI, 0.0011-0.0013), and sensitivities of 37.2% (95% CI, 35.5%-38.9%) and 18.8% (95% CI, 17.3%-20.2%) at specificities of 95% and 99%, respectively. The 10% of appointments at the highest risk level accounted for 48.8% (95% CI, 47.0%-50.6%) of the appointments followed by a suicide attempt. In this prognostic study involving mental health intakes, a previously developed machine learning model of suicide attempts showed good overall classification performance. Implementation research is needed to determine appropriate thresholds and interventions for applying the model in an intake setting to target high-risk cases in a manner that is acceptable to patients and clinicians.

Comorbidities, healthcare use, and contact with healthcare transition services in older veterans after incarceration.

The Health Care for Reentry Veterans (HCRV) program was established to support community reintegration for veterans after incarceration. Yet, it is unclear how those with and without HCRV contact differ. We sought to evaluate differences in medical and psychiatric conditions and healthcare utilization among mid-to late-life reentry veterans who did and did not receive HCRV outreach. Study participants were veterans aged ≥50 years who qualified for Medicare fee-for-service, had experienced incarceration for ≥1 year, and were released from incarceration between October 1, 2006, and September 30, 2018 (N = 9733). Using VA and Medicare claims data, we compared prevalence of medical and psychiatric diagnoses, and use of emergency, inpatient, and outpatient medical and mental health services up to 12 months after release between those with and without HCRV contact. Veterans with HCRV contact (35.5%) had significantly higher rates of psychiatric conditions and medical conditions related to substance use (e.g., liver disease) compared to veterans without HCRV contact. Average time between release and first healthcare service use was significantly lower for HCRV veterans (36.5 ± SD 59.5 days) versus non-HCRV veterans (58.9 ± SD 77.5 days) and HCRV veterans were more likely to utilize the emergency department, inpatient and outpatient mental health services, and inpatient medical services. HCRV reaches older reentry veterans with a large burden of mental health and substance use disorders. However, levels of multimorbidity were high among all older reentry veterans, pointing to a need to develop specialized geriatric models of care for this reentry population.

Going Beyond Waitlists in Mental Healthcare.

Managing waitlists for outpatient mental health services particularly in community health settings is difficult to standardize, poses an administrative burden, and are barriers rather than gateways to access to care particularly for low-income communities. While telehealth has initially expanded access to mental healthcare at the onset of the COVID-19 pandemic, it has not resolved the challenges associated with the increasing demand for services and the shortage of available providers. This commentary explores the intricate interconnections between wait times, readiness for and appropriateness of therapy, and engagement in treatment. Drawing on insights from waiting line theory to question the attachment to and utility of waitlists for non-emergency, outpatient mental healthcare, this commentary questions the utility and efficacy of waitlists. Alternative solutions that capitalize on community resources and collaboration and harness patients' agency for change are discussed.

Trends in Psychological Distress and Outpatient Mental Health Care of Adults During the COVID-19 Era.

In addition to the physical disease burden of the COVID-19 pandemic, concern exists over its adverse mental health effects. To characterize trends in psychological distress and outpatient mental health care among U.S. adults from 2018 to 2021 and to describe patterns of in-person, telephone, and video outpatient mental health care. Cross-sectional nationally representative survey of noninstitutionalized adults. United States. Adults included in the Medical Expenditure Panel Survey Household Component, 2018 to 2021 (n = 86658). Psychological distress was measured with the Kessler-6 scale (range of 0 to 24, with higher scores indicating more severe distress), with a score of 13 or higher defined as serious psychological distress, 1 to 12 as less serious distress, and 0 as no distress. Outpatient mental health care use was measured via computer-assisted personal interviews. Between 2018 and 2021, the rate of serious psychological distress among adults increased from 3.5% to 4.2%. Although the rate of outpatient mental health care increased from 11.2% to 12.4% overall, the rate decreased from 46.5% to 40.4% among adults with serious psychological distress. When age, sex, and distress were controlled for, a significant increase in outpatient mental health care was observed for young adults (aged 18 to 44 years) but not middle-aged (aged 45 to 64 years) and older (aged >65 years) adults and for employed adults but not unemployed adults. In 2021, 33.4% of mental health outpatients received at least 1 video visit, including a disproportionate percentage of young, college-educated, higher-income, employed, and urban adults. Information about outpatient mental health service modality (in-person, video, telephone) was first fully available in the 2021 survey. These trends and patterns underscore the persistent challenges of connecting older adults, unemployed persons, and seriously distressed adults to outpatient mental health care and the difficulties faced by older, less educated, lower-income, unemployed, and rural patients in accessing outpatient mental health care via video. None.

Lack of Identity and Suicidality: The Mediating Role of Emotion Regulation Difficulties.

Identity disturbance has been connected to both psychological distress and suicidality, and associated with emotion dysregulation. However, despite empirical evidence of a relationship between lack of identity and poor psychiatric outcomes, the link between impaired identity and emotion dysregulation in suicide risk remains underexplored, particularly among individuals seeking outpatient mental health services. Using data from a large clinical sample (n = 246), the present study examined the association between lack of identity and suicidality and the role of emotion dysregulation within this process. Findings indicated that the mediation model was significant, with emotion regulation difficulties significantly mediating the association between lack of identity and future suicidal behavior. Furthermore, the indirect effect of lack of identity on anticipated suicidality remained significant beyond general distress and past suicide attempt. Our findings add to the literature examining the complex relationship among lack of identity, emotion regulation, and suicidality.

Usefulness of working with a person-centred intervention in a group: Perspectives from facilitators and persons with mental illness.

When implementing new interventions into clinical practice, it is of great importance to investigate the implementation process to better understand factors promoting and impeding the implementation to stimulate engagement and sustainability of the intervention. It is essential to consider perspectives both from the health professionals delivering the intervention and those receiving the intervention to be open to their suggestions for enhancing the dissemination and implementation of the intervention. The aim of the study was to evaluate adoption, acceptabilityand appropriateness of a person-centred group intervention (PCGI) from the perspectives of facilitators and participants with mental illness in mental health outpatient services right after delivery. A qualitative interview study design was used. Interview data from three individual interviews, one group interview with facilitatorsand 16 individual interviews with participants were analyzed through content analysis. As described in the following three categories, the facilitators and participants found the PCGI overall useful and meaningful to deliver and receive: (1) application of a PCGI in clinical practice, (2) balancing the facilitator roleand (3) establishing and maintaining a safe relationship. Facilitators and participants found the form and structure of the PCGI useful and meaningful. Some participants dropped out as they did not feel comfortable in a group setting. The components in the sessions, questions on cards and reflectionsheets together with peer-to-peer interactions provided a safe environment. However, facilitation from facilitators requires appropriate skills and qualifications, which must be provided by the hospital together with supervision and the possibility for peer feedback and exchange of experiences.

Perceived Stressful Life Events and Suicide Risk in Adolescence: The Mediating Role of Perceived Family Functioning.

Suicidal behavior is a serious public health problem and a major cause of death among adolescents. Three categories of major risk factors have been identified: psychological factors, stressful life events, and personality traits. Severe and objective stressful life events (SLEs), such as childhood mistreatment or abuse, have been clearly associated with higher rates of suicide risk. However, the relationship between suicide risk and adolescents' perceptions of the SLE impact is not as clear. This paper studies the relationship between SLE impact perception and suicide risk and the possible mediating role of perceived family functioning in this relationship. The need for longer-term or more intense psychological or psychiatric treatment in relation to SLE impact perception is also addressed. One hundred forty-seven adolescents aged 11-17 were consecutively recruited from the Child and Adolescent Mental Health Outpatient Services Department of a general hospital in Madrid, Spain. Self-informed questionnaires were used to assess suicide risk, SLEs, and family functioning. In addition, the clinical records of the participants were consulted to collect information about their treatment histories, including the number of appointments and the duration of follow-up. SLE impact perception correlates significantly with suicide risk, the number of clinical appointments, the duration of treatment, and the perceived level of family functioning. The mediation model of the family functioning perception variable in the relationship between SLE impact perception and suicide risk is significant. The linear regression model of SLE impact perception and family functioning perception on suicide risk is also significant, accounting for 25.7% of the variance. Beyond the clear and proven effect of serious and objective SLEs, the perceived impact of SLEs reported by adolescents is related to an increased risk of suicide and more intense psychological and/or psychiatric follow-up. This relationship is mediated by the perceived level of family functioning. Adolescents' perceptions of their life experiences and perceived family support may be key determinants of suicide risk prevention.

Interventions promoting recovery from depression for patients transitioning from outpatient mental health services to primary care: A scoping review.

Major Depressive Disorder (MDD) is one of the most prevalent mental disorders worldwide with significant personal and public health consequences. After an episode of MDD, the likelihood of relapse is high. Therefore, there is a need for interventions that prevent relapse of depression when outpatient mental health care treatment has ended. This scoping review aimed to systematically map the evidence and identify knowledge gaps in interventions that aimed to promote recovery from MDD for patients transitioning from outpatient mental health services to primary care. We followed the guidance by Joanna Briggs Institute in tandem with the PRISMA extension for Scoping Reviews checklist. Four electronic databases were systematically searched using controlled index-or thesaurus terms and free text terms, as well as backward and forward citation tracking of included studies. The search strategy was based on the identification of any type of intervention, whether simple, multicomponent, or complex. Three authors independently screened for eligibility and extracted data. 18 studies were included for review. The studies had high heterogeneity in design, methods, sample size, recovery rating scales, and type of interventions. All studies used several elements in their interventions; however, the majority used cognitive behavioural therapy conducted in outpatient mental health services. No studies addressed the transitioning phase from outpatient mental health services to primary care. Most studies included patients during their outpatient mental health care treatment of MDD. We identified several knowledge gaps. Recovery interventions for patients with MDD transitioning from outpatient mental health services to primary care are understudied. No studies addressed interventions in this transitioning phase or the patient's experience of the transitioning process. Research is needed to bridge this gap, both regarding interventions for patients transitioning from secondary to primary care, and patients' and health care professionals' experiences of the interventions and of what promotes recovery. A protocol was prepared in advance and registered in Open Science Framework (https://osf.io/ah3sv), published in the medRxiv server (https://doi.org/10.1101/2022.10.06.22280499) and in PLOS ONE (https://doi.org/10.1371/journal.pone.0291559).

Demographic and mental health profile of youth in a gender service: An African case series.

Despite a massive global increase in research on gender-diverse youth, there have been no studies in Africa on gender-diverse children and adolescents presenting to health services. This study aimed to present the first African findings of the demographic and mental health profile of youth who have presented at a gender service in South Africa. A specialist mental health outpatient service, consisting of psychiatry, psychology and nursing input, for gender-diverse child and adolescent patients in the Western Cape. All consenting youth seen at a gender service, consisting of psychiatry, psychology and nursing input, in state and by the same clinician in private practice between January 2012 and May 2019 were participants of a retrospective, sequential case series study. Data of interest, including gender identity and sexuality, mental health history and social information, were extracted from the psychiatry files of participants. Thirty-nine participants were part of the registry and qualified for the study: 72% self-identified as white, 15% as coloured and 13% as black African. The rate of co-occurring psychopathology was high (64%) and included high rates of autism, particularly in trans males (26%), suicidal ideation in 31% and a history of suicide attempt(s) in 10%. This first study describing gender-diverse youth seeking support relating to their gender identity in Africa showed they had remarkable similarities to those studied internationally. Establishing that transgender youth of all major racial groups in the province with similar demographic profiles to other parts of the world are presenting to services in South Africa and in need of mental health support and interventions.

Psychiatric admissions in young people after expiration of criminal justice supervision in Australia: a retrospective data linkage study

BackgroundMental health services are available for young people involved with the criminal justice system. However, they have unmet mental health needs after the expiration of criminal justice supervision.ObjectiveTo determine the...

Children and Adolescents With Suicidal Ideation and the Emergency Department

This Viewpoint discusses the need for formal training in suicide prevention for frontline emergency clinicians and staff, including standardized screening practices, assessment and targeted interventions, and increased connection to outpatient mental health services after discharge from the emergency department.

Factors associated with dropout from outpatient tertiary mental health services

Background and Objective:
 There is a paucity of mental health hospital-based studies from Pakistan that have observed the contributing factors of dropout. This study aims to understand contributing factors to dropouts from mental health services.
 Method:
 This telephonic survey was conducted as a cross-sectional study from dropout outpatients of Karwan-e-Hayat Institute for Mental Health Care, a tertiary mental care hospital in Karachi, Pakistan. Using a simple questionnaire to assess socio-demographic variables, psychosocial assessment, and patient perspectives on treatment termination. A total of 158 participants out of 200 patients provided insight into their dropout experiences.
 Result: 
 Results revealed that younger adults, particularly those aged 18-40, demonstrated a greater tendency to discontinue treatment. Level of education was also associated with dropout rates, with uneducated and less educated individuals showing greater tendencies to drop out of treatment than their educated counterparts. Schizophrenia emerged as a leading psychiatric diagnosis associated with high dropout rates. Lack of insight into psychotherapy, patient dissatisfaction, and geographic distance from treatment centers were identified as key contributors to dropout.
 Conclusion:
 Factors such as age, educational status, diagnosis, insight into the disease, dissatisfaction with the treatment and distance from the treatment center were related to the dropout rate. Insights gained from this investigation advocate for tailored interventions focusing on education, patient satisfaction, and proximity to treatment facilities.

Mobile phone intervention to reduce dropout from treatment at an outpatient mental health service for older people in Nigeria

Background: Half of older Africans drop out of treatment after a single contact with biomedical mental health services.Objective: This study examined the effect of introducing a mobile phone reminder intervention delivered by volunteering health staff to reduce dropout from an outpatient mental health service for older people in Nigeria.Methods: 405 patients were studied using a quasi-experimental design: 169 who attended clinic pre-intervention (2016-2017) and 236 who attended during intervention (2018-2019). We estimated annual dropout rates, reasons for dropout and predictors of drop-out.Results: We found a trend for decreasing dropout rates during intervention (p<0.001). The most common reasons for dropout were distance to the clinic (19.5%) and unavailability of a caregiver (47.6%). Current single status (O.R =2.02, 95% C. I=1.02-3.99) and treatment without adjunctive pharmacotherapy (O. R=2.14, 95% CI; 1.07-4.26) predicted dropout.Conclusion: Mobile phone call reminders improved treatment engagement in this population. Findings are important for policy to improve access to mental healthcare in Africa.

Understanding the uptake of virtual care for first and return outpatient appointments in child and adolescent mental health services: a mixed-methods study

ObjectiveTo describe patterns of virtual and in-person outpatient mental health service use and factors that may influence the choice of modality in a child and adolescent service.DesignA pragmatic mixed-methods approach...

Mental Health and Stigmatization Linked to the COVID-19 Pandemic

Abstract: The COVID-19 pandemic has reached an entirely new level of severity. It has jolted the entire world and caused pervasive chaos. A significant portion of the psychological responses thus far have been reactions to events in other countries, worries about the future, and responses to confinement. Initial and prominent responses to the pandemic in India have been appalling, with a sense of impending and palpable danger. Concerns based on facts coexist with those based on the abundance of information and misinformation disseminated by the media, particularly social media. Even with the stringent requirements for testing, many individuals still seek reassurance through testing. Despite the lack of general indications for their use, they stockpile pharmaceuticals out of dread of contracting the disease. In addition to recommendations regarding hand cleansing, there are uncertainties regarding whether to wear a mask, the type of mask to use, the distance to be maintained, and how to disinfect surfaces. There are legitimate concerns regarding employment losses and economic decline during and after the pandemic. Social isolation and social prejudice are not synonymous. Maintaining a distance of 1-2 meters is permissible for security purposes. In terms of status and opportunities, everyone should be treated equally. The situation calls for a cheerful tone of speech. Using expressions such as "the end of the world" and "the plague" is discouraged. Contamination caused by rumors must be avoided. It is essential to promote early detection and prevention. Those who have been afflicted with COVID-19 must share their accounts of compassion and struggle. Before COVID-19, only a minority of individuals with mental health issues were treated. According to studies, the pandemic has widened the mental health treatment divide, and outpatient mental health services have been particularly disrupted.