Public Mental Health Service System Research Articles

Public mental health service use among U.S. adults age 50+ compared to younger age groups

ABSTRACT Despite increasing numbers of older-adult mental health service users, few studies have examined their use of public mental health services. Using the 2018 and 2019 Mental Health-Client Level data for clients age 18+ (N = 4,291,737 in 2018 and N = 4,513,946 in 2019), we examined whether those age 50+ who received outpatient-only, both outpatient and inpatient, or inpatient-only services had greater odds of certain types of mental disorders, especially schizophrenia, than younger adults. Of all users, 25.3% were age 50–64 and 6.7% were age 65 + . Multivariable logistic regression results, controlling for gender, race/ethnicity, census region, and alcohol/substance use disorder, showed that compared to the 30–49 age group, the 50–64 and 65+ age groups had higher odds of having depressive disorder in outpatient-only settings; however, they had consistently higher odds of a diagnosis of schizophrenia or other psychotic disorder in all three service settings. Along with advocating for increased funding for publicly-financed mental health services, social workers in public mental health service systems should ensure that they utilize effective intervention skills for older adults with serious mental illness.

Disseminating clinical and fiscal practices across the New York State behavioral healthcare system

ABSTRACT In order to facilitate the adoption of innovative practices in the mental health service system, providers require access to both new information and methodologies, and ongoing training, supervision and consultation. Technical Assistance centers have been proposed as a way to disseminate effective interventions through the provision of resources including information, ongoing training and consultation. The purpose of this study is to describe the New York State Technical Assistance Center’s reach across the child public mental health service system and variations in characteristics of training activities, including dosage, content and method of format. Between 2011 and 2015, 460 (92.6%) of all New York State mental health clinics attended a training. The most highly attended events focused on business practices, followed by evidence-based treatments and clinic practices, and trauma-informed care. All were delivered via a webinar format, and were less than one day in duration. The behavioral health service system must be equipped to adapt to changing clinical and business practices in order to provide quality care and remain fiscally viable. New York State’s TA center reached the majority of child mental health service providers across the state. Next steps are to closely examine the impact of TA supports upon adoption and sustained use of practices. Implications of these findings and additional future directions are presented.

An Examination of Peer-Delivered Parenting Skills Programs Across New York State.

Peers are an important adjunct to the public mental health service system, and are being increasingly utilized across the country as a cost-effective solution to workforce shortages. Despite the tremendous growth of peer-delivered support over the past two decades, it has only been within the past few years that peer programs have been the subject of empirical inquiry. The purpose of this study was to examine the prevalence and characteristics of peer-delivered parenting programs across the New York State public mental health service system. We surveyed 46 family peer organizations across New York State regarding their delivery of structured peer-delivered parenting programs. Thirty-four (76%) completed the questionnaire, and of them, 18 (53%) delivered a parenting program. Subsequent interviews with seven of the 18 organizations revealed peer organizations had been delivering eight unique parenting programs for upwards of two decades. Additionally, organizations offered multiple supports to families to participate. Training, supervision, and issues around fidelity are discussed, as well as the implications of this study for states utilizing a peer workforce.

Who is accessing family mental health programs? Demographic differences before and after system reform

Childhood mental health disorders are on the rise in the United States. To ensure equitable access to care, it is important to examine the characteristics of children and families who access services. This study compares the demographic characteristics of two samples of families who participated in National Institute of Mental Health-funded studies of a Multiple Family Group model, entitled the 4Rs and 2Ss Multiple Family Group (4Rs and 2Ss) in New York City. One sample is currently receiving services, and the other received services a decade ago. Significant differences in demographic characteristics were found between the two samples pertaining to child race, child nativity, caregiver age, primary caregiver, caregiver marital status, caregiver race, caregiver education, caregiver employment, and family income. Families currently engaging in the public mental health service system are primarily White, and are less disadvantaged than families a decade ago. These differences are examined in light of changing policy and epidemiological trends, and potential unintended consequences are discussed.

A comparison of policy and direct practice stakeholder perceptions of factors affecting evidence-based practice implementation using concept mapping

BackgroundThe goal of this study was to assess potential differences between administrators/policymakers and those involved in direct practice regarding factors believed to be barriers or facilitating factors to evidence-based practice (EBP) implementation in a large public mental health service system in the United States.MethodsParticipants included mental health system county officials, agency directors, program managers, clinical staff, administrative staff, and consumers. As part of concept mapping procedures, brainstorming groups were conducted with each target group to identify specific factors believed to be barriers or facilitating factors to EBP implementation in a large public mental health system. Statements were sorted by similarity and rated by each participant in regard to their perceived importance and changeability. Multidimensional scaling, cluster analysis, descriptive statistics and t-tests were used to analyze the data.ResultsA total of 105 statements were distilled into 14 clusters using concept-mapping procedures. Perceptions of importance of factors affecting EBP implementation varied between the two groups, with those involved in direct practice assigning significantly higher ratings to the importance of Clinical Perceptions and the impact of EBP implementation on clinical practice. Consistent with previous studies, financial concerns (costs, funding) were rated among the most important and least likely to change by both groups.ConclusionsEBP implementation is a complex process, and different stakeholders may hold different opinions regarding the relative importance of the impact of EBP implementation. Implementation efforts must include input from stakeholders at multiple levels to bring divergent and convergent perspectives to light.

Implementing evidence-based practice in community mental health agencies: a multiple stakeholder analysis.

We sought to identify factors believed to facilitate or hinder evidence-based practice (EBP) implementation in public mental health service systems as a step in developing theory to be tested in future studies. Focusing across levels of an entire large public sector mental health service system for youths, we engaged participants from 6 stakeholder groups: county officials, agency directors, program managers, clinical staff, administrative staff, and consumers. Participants generated 105 unique statements identifying implementation barriers and facilitators. Participants rated each statement on importance and changeability (i.e., the degree to which each barrier or facilitator is considered changeable). Data analyses distilled statements into 14 factors or dimensions. Descriptive analyses suggest that perceptions of importance and changeability varied across stakeholder groups. Implementation of EBP is a complex process. Cross-system-level approaches are needed to bring divergent and convergent perspectives to light. Examples include agency and program directors facilitating EBP implementation by supporting staff, actively sharing information with policymakers and administrators about EBP effectiveness and fit with clients' needs and preferences, and helping clinicians to present and deliver EBPs and address consumer concerns.

Establishing an implementation network: lessons learned from community-based participatory research

BackgroundImplementation of evidence-based mental health assessment and intervention in community public health practice is a high priority for multiple stakeholders. Academic-community partnerships can assist in the implementation of efficacious treatments in community settings; yet, little is known about the processes by which these collaborations are developed. In this paper, we discuss our application of community-based participatory research (CBPR) approach to implementation, and we present six lessons we have learned from the establishment of an academic-community partnership.MethodsWith older adults with psychosis as a focus, we have developed a partnership between a university research center and a public mental health service system based on CBPR. The long-term goal of the partnership is to collaboratively establish an evidence-based implementation network that is sustainable within the public mental healthcare system.ResultsIn building a sustainable partnership, we found that the following lessons were instrumental: changing attitudes; sharing staff; expecting obstacles and formalizing solutions; monitoring and evaluating; adapting and adjusting; and taking advantage of emerging opportunities. Some of these lessons were previously known principles that were modified as the result of the CBPR process, while some lessons derived directly from the interactive process of forming the partnership.ConclusionThe process of forming of academic-public partnerships is challenging and time consuming, yet crucial for the development and implementation of state-of-the-art approaches to assessment and interventions to improve the functioning and quality of life for persons with serious mental illnesses. These partnerships provide necessary organizational support to facilitate the implementation of clinical research findings in community practice benefiting consumers, researchers, and providers.

Educational Collaboration in Psychiatric Disability, Rehabilitation, and Recovery: Developing Transformative Solutions

This article describes an innovative statewide collaboration between schools of social work and public mental health departments to transform social work curriculum and address the workforce crisis in public mental health service systems. The collaborative partnership has fostered the development of a Mental Health Initiative that has developed a set of mental health competencies offered in each of the participating master's in social work (MSW) programs in California. These competencies identify critical skills and knowledge necessary to support recovery, resiliency, evidence-based practice, and psychosocial rehabilitation principles. A statewide stipend program to support final-year MSW students in their graduate study and a requirement for a year of employment payback in the public mental health system is also presented, as well as a brief discussion of the organizational and structural principles supporting the collaborative organization. Current successes, future challenges, and strategies for the partnership collaborative in their task of developing a workforce are addressed.

Public-Academic Partnerships: Improving Care for Older Persons With Schizophrenia Through an Academic-Community Partnership

Translating evidence-based mental health interventions designed in research settings into community practice is a priority for multiple stakeholders. Partnerships between academic and public institutions can facilitate this translation. To improve care for middle-aged and older adults with schizophrenia, the authors developed a collaboration between a university research center and a public mental health service system using principles from community-based participatory research and cultural exchange theory. They describe the process that has led to a number of mutually beneficial products. Despite the challenges involved, building and maintaining academic-public collaborations will be essential for improving mental health care for persons with schizophrenia.

The Use of Public Mental Health Services by Older Californians and Complementary Service System Effects

Older adults with mental disorders are less likely to use specialty care than any other population group. In this study, we created a multisource secondary data file and examined the use of public mental health services by older adults across California's county-based community mental health systems. We specifically considered complementary service system effects relative to compositional effects representing individual service users and more general contextual effects. Service use was defined in terms of treated prevalence rates, repeat service use, and intensity of service use. Differences across 49 county-based systems were evaluated by regressing the 3 service use measures onto compositional characteristics including client age, diagnosis, and insurance status; variables reflecting complementary service systems including mental health, health, long-term care, and aging services; and other contextual effects such as the size of the county population and average education level. The analyses were adjusted statistically for regional, yearly, and seasonal differences, and for longitudinal clustering within the 49 counties over 12 quarters of observation. Results suggested that older adults' service use varied significantly from one county to the next, and differences were associated with both compositional and contextual effects. As the aging population continues to grow and place an increasing demand on public mental health service systems, this research may help policy makers and program administrators understand some of the critical elements that affect service use patterns among older adults.

A Typology of Advance Statements in Mental Health Care

A Typology of Advance Statements in Mental Health Care

Reforming Mental Health Care in Victoria: A Decade Later

From 1994, the Australian State of Victoria began a major transformation of its public mental health service system. In June 2006, St Vincent's Mental Health hosted a conference to reflect on the changes and identify steps to be taken over the next decade. Participants came from Victoria's 21 adult mental health services, consumer and carer groups, and psychiatric disability rehabilitation and support organizations. They met in small groups, and discussed pre-set topics. Their observations were pooled in plenary sessions. Participants agreed the changes had had many positive outcomes. People most affected by mental illness had priority for treatment. Services were better structured to meet their needs, and staff were more familiar with community-based care. Negatives included restricted service access for some groups, insufficient resourcing to meet increased service demand and clinical staff not maintaining specialist skills. The conference enabled experiences to be shared and ideas exchanged about improvements.

Violence and Leveraged Community Treatment for Persons With Mental Disorders

Objective: This article explores the link between violence and the practice of legally mandating treatment in the community or leveraging benefits from the social welfare system, such as subsidized housing and disability income support, to ensure adherence to treatment. Method: Data are presented from a survey of 1,011 persons with psychiatric disorders receiving treatment in public mental health service systems in five U.S. cities. Multinomial logit analysis was used to examine the association between physically assaultive behavior and experience of social welfare leverage, legal leverage, or both types of leverage, with the analyses controlling for demographic and clinical characteristics. Results: Across study sites, 18% to 21% of participants reported having committed violent acts in the past 6 months; 3% to 9% reported having used or made threats with a lethal weapon, committed sexual assault, or caused injury. About three-quarters of subjects who reported such serious violence also reported having experienced some form of leveraged treatment, compared with about one-half of subjects who did not report serious violence. Demographic and clinical factors that were independently associated with the likelihood of experiencing both types of leverage included younger age, male gender, poorer clinical functioning, more years in treatment, more frequent hospitalizations, higher frequency of outpatient visits, and negative attitudes toward medication adherence. Among participants who did not voluntarily take psychotropic medication, even minor assaultiveness was associated with having experienced legal leverage. Conclusions: A combination of concerns about safety and treatment nonadherence may influence decisions by clinicians and judges to apply legal leverage.

Violence and Leveraged Community Treatment for Persons With Mental Disorders

This article explores the link between violence and the practice of legally mandating treatment in the community or leveraging benefits from the social welfare system, such as subsidized housing and disability income support, to ensure adherence to treatment. Data are presented from a survey of 1,011 persons with psychiatric disorders receiving treatment in public mental health service systems in five U.S. cities. Multinomial logit analysis was used to examine the association between physically assaultive behavior and experience of social welfare leverage, legal leverage, or both types of leverage, with the analyses controlling for demographic and clinical characteristics. Across study sites, 18% to 21% of participants reported having committed violent acts in the past 6 months; 3% to 9% reported having used or made threats with a lethal weapon, committed sexual assault, or caused injury. About three-quarters of subjects who reported such serious violence also reported having experienced some form of leveraged treatment, compared with about one-half of subjects who did not report serious violence. Demographic and clinical factors that were independently associated with the likelihood of experiencing both types of leverage included younger age, male gender, poorer clinical functioning, more years in treatment, more frequent hospitalizations, higher frequency of outpatient visits, and negative attitudes toward medication adherence. Among participants who did not voluntarily take psychotropic medication, even minor assaultiveness was associated with having experienced legal leverage. A combination of concerns about safety and treatment nonadherence may influence decisions by clinicians and judges to apply legal leverage.

Psychotropic medications prescribing patterns for children and adolescents in New York's public mental health system.

Breakthroughs in the development of effective medications for a number of psychiatric disorders have led to increased use of these compounds in the treatment of children. To understand the use of psychotropic medications in the treatment of children, a state-wide study was undertaken based on the data collected in a large planning study. DATA AND SETTING: A stratified random sample of 10 different program types in New York State produced data on children served in different specialty mental health services. Randomly selected cases were reviewed at a randomly selected sites to generate a sample of 1592 cases on which data were collected on clinical presentation and service use, including psychotropic medication prescriptions. The Child and Adolescent Needs and Strengths (CANS-MH) tool was used to provide a reliable review of clinical indicators. Psychotropic medication use is common in the children's public mental health service system in New York. Most children served in high intensity settings receive medication as a part of their treatment. It appears that most prescriptions for stimulants and antidepressants are consistent with either diagnostic or symptom indications. Many children with these indications are not on medications. On the other hand, a large number of children without evidence of psychosis receive antipsychotic medications. The evidence suggests that stimulant and antidepressant are not over-prescribed. However, the use of antipsychotic medications for other indications is a priority for further research.

Clinicians and outcome measurement: what's the use?

The goal of this study was to learn more about clinicians' experiences with, and perceptions of the utility, validity, and feasibility of standardized outcome measures in practice. Fifty randomly selected clinicians from multiple disciplines and multiple service agencies in a large children's public mental health service system were interviewed individually (n = 30) or in focus groups (n = 20) using semistructured interviews. There was great variability across clinicians in attitudes about empirical methods of treatment evaluation. There was consensus regarding feasibility challenges of administering standardized measures, including time burden and literacy barriers. Although all participants had received scored assessment profiles for their clients, the vast majority reported that they did not use the scores in treatment planning or monitoring. Their suggestions for improved clinical utility of outcome measurement are included. With increased attention and resources devoted to performance outcome assessment, it is concerning that most clinicians perceive little clinical utility of outcome measurement.

Why Do States Privatize Mental Health Services? Six State Experiences

State governments fund more than one-half of public mental health service system costs through mental health departments, other state agencies, and the Medicaid program. They use some of these resources to finance community-based mental health services through purchase-of-service contracts. I explored the reasons why states privatize mental health services and focused on political, economic, and organizational theories as possible frameworks for contracting. I gathered data during site visits to Massachusetts, Michigan, New York, Oregon, Tennessee, and Texas, where I interviewed more than one hundred individual stakeholders about mental health purchase-of-service contracting. I also examined relevant documents about contracting practices for mental health services in each state. My results suggest that state policy makers can use mental health contracting to effect multiple goals. Contracting helps states achieve political, economic, and organizational objectives, such as avoiding the influence of interest groups and leveraging state resources, while avoiding conflict. With contracting, state policy makers can also continue the ongoing mental health policy paradigm shift begun during deinstitutionalization, in which persons with serious and persistent mental illnesses receive services from community-based providers rather than in state hospitals. Finally, my results suggest that contracting will continue to be an important state policy tool in further development of state-supported mental health systems.

Who Is Served by Programs for the Homeless? Admission to a Domiciliary Care Program for Homeless Veterans

Demographic and clinical data are presented on 4,138 veterans assessed in the 20-site Department of Veterans Affairs (VA) Domiciliary Care for Homeless Veterans program during its first year of operation. More than two-thirds of the veterans who were screened had been hospitalized in VA medical centers during the year before assessment, and 34 percent were hospitalized at the time of assessment. Compared with veterans who were not admitted for residential treatment, veterans who were admitted were more likely to be previously involved in mental health treatment, literally homeless rather than at risk for homelessness, and without public financial support. Specialized service programs for the homeless such as the VA domiciliary care program may also be called on to play a broader role in the discharge and rehabilitative efforts of public mental health service systems.