Administrative, clinical, and ethical issues surrounding the use of waiting lists in the delivery of mental health services

Student preferences for treatment in college counseling centers: examining evidence-based models of care

Objective: This study surveyed undergraduates to understand current experiences of on-campus mental healthcare. The study assessed student ratings of specific interventions for addressing mental health issues in college counseling centers. Participants: 160 undergraduate students. Methods: A mixed-methods approach was used. Quantitative data included acceptability ratings of therapeutic approaches and treatment strategies, and preferences for therapeutic options for two hypothetical scenarios. Qualitative data included narrative responses about treatment models. Results: Individual therapy was the preferred approach for treating typical concerns based on acceptability ratings and qualitative data. Male participants were more likely to rate self-help and non-therapist-assisted treatments as acceptable than females. Students of color were less likely to find therapist-assisted interventions acceptable. Conclusions: Undergraduate students prefer individualized therapy methods, although preferences are associated with gender and racial identity. Further research should focus on clarifying the preferences of males and students of color and incorporating preferences into decisions about treatment delivery.

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.

Reducing waiting times from 65 to under 40 days for children and adolescents receiving mental health services using a new scheduling policy

The aim of this study is to conduct an intervention that tests whether a new scheduling policy designed to reduce waiting times actually will lead to a reduction in waiting times. The new scheduling policy was developed using mixed methods. Qualitative data was gathered to fully understand current planning processes, while quantitative methods were used to model and predict future waiting times. If current planning practices are continued, waiting times will only increase. Additionally, the findings show that simulation modeling can be used to predict the capacity needed for intakes (first appointment) to reduce and maintain target waiting times over time. In our study, this meant a slight increase in capacity for intakes. This new scheduling policy led to a reduction in waiting times from 65 days in 2016, to under 40 days post-intervention in 2017. Waiting times have been held under 40 days since implementation of the new policy, 2017-2020. Our study shows that setting appropriate (weekly) intake goals, will lead to maintaining acceptable levels of variation in waiting times. This theory was tested and proven to be effective.

Female youth and mental health service providers' perspectives on the JoyPop™ app: a qualitative study

Introduction

Mobile health (mHealth) apps are a promising adjunct to traditional mental health services, especially in underserviced areas. Developed to foster resilience in youth, the JoyPop™ app has a growing evidence base showing improvement in emotion regulation and mental health symptoms among youth. However, whether this novel technology will be accepted among those using or providing mental health services remains unknown. This study aimed to evaluate the JoyPop™ app's acceptance among (a) a clinical sample of youth and (b) mental health service providers.

Method

A qualitative descriptive approach involving one-on-one semi-structured interviews was conducted. Interviews were guided by the Technology Acceptance Model and were analyzed using a deductive-inductive content analysis approach.

Results

All youth (n = 6 females; Mage = 14.60, range 12-17) found the app easy to learn and use and expressed positive feelings towards using the app. Youth found the app useful because it facilitated accessibility to helpful coping skills (e.g., journaling to express their emotions; breathing exercises to increase calmness) and positive mental health outcomes (e.g., increased relaxation and reduced stress). All service providers (n = 7 females; Mage = 43.75, range 32-60) perceived the app to be useful and easy to use by youth within their services and expressed positive feelings about integrating the app into usual care. Service providers also highlighted various organizational factors affecting the app's acceptance. Youth and service providers raised some concerns about apps in general and provided recommendations to improve the JoyPop™ app.

Discussion

Results support youth and service providers' acceptance of the JoyPop™ app and lend support for it as an adjunctive resource to traditional mental health services for youth with emotion regulation difficulties.

Conceptualizing Community Mental Health Service Utilization for BIPOC Youth

Historically, children and adolescents who identify as Black, Indigenous, and other people of Color (BIPOC) have had inequitable access to mental healthcare, and research shows that they are significantly less likely than their white American counterparts to utilize available services. Research identifies barriers that disproportionately impact racially minoritized youth; however, a need remains to examine and change systems and processes that create and maintain racial inequities in mental health service utilization. The current manuscript critically reviews the literature and provides an ecologically based conceptual model synthesizing previous literature relating to BIPOC youth barriers for service utilization. The review emphasizes client (e.g. stigma, system mistrust, childcare needs, help seeking attitudes), provider (e.g. implicit bias, cultural humility, clinician efficacy), structural/organizational (clinic location/proximity to public transportation, hours of operation, wraparound services, accepting Medicaid and other insurance-related issues), and community (e.g. improving experiences in education, the juvenile criminal-legal system, medical, and social service systems) factors that serve as barriers and facilitators contributing to disparities in community mental health service utilization for BIPOC youth. Importantly, we conclude with suggestions for dismantling inequitable systems, increasing accessibility, availability, appropriateness, and acceptability of services, and ultimately reducing disparities in efficacious mental health service utilization for BIPOC youth.

Strategic and principled approach to the ethical challenges of epilepsy monitoring unit triage

Electroencephalographic monitoring provides critical diagnostic and management information about patients with epilepsy and seizure mimics. Admission to an epilepsy monitoring unit (EMU) is the gold standard for such monitoring in major medical facilities worldwide. In many countries, access can be challenged by limited resources compared to need. Today, triaging admission to such units is generally approached by unwritten protocols that vary by institution. In the absence of explicit guidance, decisions can be ethically taxing and are easy to challenge. In an effort to address this gap, we propose a two-component approach to EMU triage that takes into account the unique landscape of epilepsy monitoring informed by triage literature from other areas of medicine. Through the strategic component, we focus on the EMU wait list management infrastructure at the institutional level. Through the principled component, we apply a combination of the ethical principles of prioritarianism, utilitarianism and justice to triage; and we use individual case examples to illustrate how they apply. The effective implementation of this approach to specific epilepsy centres will need to be customised to the nuances of different settings, including diverse practice patterns, patient populations and constraints on resource distribution, but the conceptual consolidation of its components can alleviate some of the pressures imposed by the complex decisions involved in EMU triage.

Waiting Lists for Psychotherapy and Provider Attitudes Toward Low-Intensity Treatments as Potential Interventions: Survey Study

BACKGROUND

Common mental disorders, including depression and anxiety, are leading causes of disability worldwide. Digital mental health interventions, such as web-based self-help and other low-intensity treatments (LITs) that are not digital (eg, bibliotherapy), have the potential to reach many individuals by circumventing common barriers present in traditional mental health care. It is unclear how often LITs are used in clinical practice, or whether providers would be interested in their use for treatment waiting lists.

OBJECTIVE

The aims of this study were to (1) describe current practices for treatment waiting lists, (2) describe providers' attitudes toward digital and nondigital LITs for patients on a waiting list, and (3) explore providers' willingness to use digital and nondigital LITs and their decisions to learn about them.

METHODS

We surveyed 141 practicing mental health care providers (eg, therapists and psychologists) and provided an opportunity for them to learn about LITs.

RESULTS

Most participants reported keeping a waiting list. Few participants reported currently recommending digital or nondigital LITs, though most were willing to use at least one for patients on their waiting list. Attitudes toward digital and nondigital LITs were neutral to positive. Guided digital and nondigital LITs were generally perceived to be more effective but less accessible, and unguided interventions were perceived to be less effective but more accessible. Most participants selected to access additional information on LITs, with the most popular being web-based self-help.

CONCLUSIONS

Results suggest providers are currently not recommending LITs for patients on treatment waiting lists but would be willing to recommend them. Future work should explore barriers and facilitators to implementing digital and nondigital LITs for patients on treatment waiting lists.

'You're on the waiting list': An interpretive phenomenological analysis of young adults' experiences of waiting lists within mental health services in the UK

Waiting lists in mental health services are currently considered too long. Lengthy waits of up to 18 weeks are commonly reported in the UK. Waiting lists have long been associated with a variety of negative psychological responses, however there is little understanding behind young adults’ personal experiences of such delays within mental health services. The current study aimed to explore young adults’ experiences of waiting lists in mental healthcare in the UK. Seven young adults were interviewed in the current study (aged 19–22). Interpretive phenomenological analysis was utilised to explore participant accounts. Three super-ordinate themes were generated: Reliance on Alternative Methods of Support; Inability to Function Sufficiently; and Emergence of Negative Beliefs, Emotions and Thoughts. Participants primarily reported a variety of negative psychological and behavioural consequences associated with waiting lists in mental health services, as well as exacerbated existing physical and psychological health issues. In accordance with the limited number of previous studies, waiting lists are considered by patients to be barriers to mental health support and intervention. Future direction is advised.

Barriers and facilitators for implementation of a patient prioritization tool in two specialized rehabilitation programs

INTRODUCTION AND AIMS

Prioritization tools aim to manage access to care by ranking patients equitably in waiting lists based on determined criteria. Patient prioritization has been studied in a wide variety of clinical health services, including rehabilitation contexts. We created a web-based patient prioritization tool (PPT) with the participation of stakeholders in two rehabilitation programs, which we aim to implement into clinical practice. Successful implementation of such innovation can be influenced by a variety of determinants. The goal of this study was to explore facilitators and barriers to the implementation of a PPT in rehabilitation programs.

METHODS

We used two questionnaires and conducted two focus groups among service providers from two rehabilitation programs. We used descriptive statistics to report results of the questionnaires and qualitative content analysis based on the Consolidated Framework for Implementation Research.

RESULTS

Key facilitators are the flexibility and relative advantage of the tool to improve clinical practices and produce beneficial outcomes for patients. Main barriers are the lack of training, financial support and human resources to sustain the implementation process.

CONCLUSION

This is the first study that highlights organizational, individual and innovation levels facilitators and barriers for the implementation of a prioritization tool from service providers' perspective.

Increasing Access to Psychiatric Services in Schools: The Bridge Program

One in 5 youth experience a psychiatric disorder in any given year, but fewer than half of these youth receive mental health services. This lack of service utilization is often attributed to structural and perceptual barriers, and school-based mental health programs have been proposed as a means of addressing these barriers and increasing youths' access to services. While universal prevention programs and targeted treatments may benefit most youth receiving services in schools, collaborations between schools and child psychiatry may benefit youth with the most severe symptoms and the greatest impairment. This article describes the Bridge Program, a school-based psychiatric program funded by a county-wide mental health tax initiative designed to provide psychiatric services in local schools without any out-of-pocket expenses for youth and families within 10 days of referral. Two case reports provide a description of the delivery of psychiatric services through the Bridge Program. Future research is needed to compare the feasibility and effectiveness of different approaches to increasing access to youth psychiatric care.

Enhancing metabolic monitoring for children and adolescents using second-generation antipsychotics

The prevalence of children and adolescents using second-generation antipsychotics (SGAs) has increased significantly in recent years. In this population, SGAs are used to treat mood and behavioural disorders although considered 'off-label' or not approved for these indications. Metabolic monitoring is the systematic physical health assessment of antipsychotic users utilized to detect cardiovascular and endocrine side effects and prevent adverse events such as weight gain, hyperglycaemia, hyperlipidemia, and arrhythmias. This practice ensures safe and efficacious SGA use among children and adolescents. Despite widely available, evidence-based metabolic monitoring guidelines, rates of monitoring continue to be suboptimal; this exposes children to the unnecessary risk of developing poor cardiovascular health and long-term disease. In this discursive paper, existing approaches to metabolic monitoring as well as challenges to implementing monitoring guidelines in practice are explored. The strengths and weaknesses of providing metabolic monitoring across outpatient psychiatry, primary care, and collaborative community settings are discussed. We suggest that there is no one-size-fits-all solution to improving metabolic monitoring care for children and adolescents using SGA in all settings. However, we advocate for a pragmatic global approach to enhance safety of children and adolescents taking SGAs through collaboration among healthcare disciplines with a focus on integrating nurses as champions of metabolic monitoring.

Understanding Barriers to Initial Treatment Engagement among Underserved Families Seeking Mental Health Services

This mixed method study examined factors associated with parents not attending their child's mental health treatment after initially seeking help for their 2-5 year old child. It was part of a larger study comparing two evidence-based treatments among low-income racial/ethnic minority families seeking child mental health services. Of 123 parents who initiated mental health treatment (71% African American or multi-racial; 97.6% low-income), 36 (29.3%) never attended their child's first treatment session. Socio-demographic characteristics, parenting stress, depression, severity of child behavior problems, and length of treatment delay from intake to first scheduled treatment session were compared for families who did and did not attend their first treatment session. Parents who never attended their child's first treatment session were more likely to live with more than 4 adults and children (p=.007) and have more depressive symptoms (p=.003). Median length of treatment delay was 80 days (IQR =55) for those who attended and 85 days (IQR =67.5) for those who did not attend their child's first treatment session (p=.142). Three themes emerged from caregiver interviews: (a) expectations about the treatment, (b) delays in getting help, and (c) ambivalence about research participation. Findings suggest the need to develop better strategies for addressing risk factors early in the treatment process and reducing the length of time families with adverse psychosocial circumstances must wait for child mental health treatment.

Predicting Therapeutic Effects of Psychodiagnostic Assessment Among Children and Adolescents Participating in Randomized Controlled Trials

This study explored predictors of improvement after completing a psychodiagnostic screening assessment but before randomization among youth who participated in two pilot randomized controlled trials of omega-3 supplementation and Individual-Family Psychoeducational Psychotherapy (PEP). Ninety-five youth (56.8% male, 61.1% White) ages 7-14 with mood disorders completed screening and baseline assessments (including Clinical Global Impressions-Improvement [CGI-I], Children's Depression Rating Scale-Revised, Young Mania Rating Scale), then were randomized into a 12-week trial of omega-3, PEP, their combination, or placebo. Between screening and randomization, 35.8% minimally improved (CGI-I = 3), 12.6% much improved (CGI-I < 3), totaling 48.4% improved. Caregiver postsecondary education (p = .018), absence of attention-deficit/hyperactivity disorder (p = .027), and lower screen depression severity (p = .034) were associated with CGI-I. Caregiver postsecondary education (p = .020) and absence of a disruptive behavior diagnosis (p = .038) were associated with depression severity improvement. Prerandomization improvement moderated treatment outcomes: Among youth who improved prerandomization, those who received PEP (alone or with omega-3) had more favorable placebo-controlled depression trajectories due to a lack of placebo response. This open-label trial of psychodiagnostic assessment provides suggestive evidence that psychodiagnostic assessment is beneficial, especially for those with depression and without externalizing disorders. Prerandomization improvement is associated with better placebo-controlled treatment response. Future research should test alternative hypotheses for change and determine if less intensive (shorter and/or automated) assessments would provide comparable results.

Same-Day Counseling: Study Protocol for the Evaluation of a New Mental Health Service

Background

Single-session counseling is being implemented across Canada to increase the accessibility and availability of mental health services. Despite increasing use, existing research on single-session counseling is sparse and has methodological limitations. In addition, some stakeholders are skeptical that this model of care can support meaningful change for clients.

Objective

The aim of this study is to evaluate a new single-session counseling program (called Same-Day Counseling) offered in an outpatient community mental health clinic in Northwestern Ontario, Canada.

Methods

Clients who attend Same-Day Counseling services will be given the opportunity to participate in the program evaluation. Those who consent will complete measures before their session, after their session, and at 1-month follow-up. Data will provide information on who accesses Same-Day Counseling (eg, typical presenting problems, symptom severity), client satisfaction with services, and whether clients benefit from the services (eg, improved functioning and reduced symptom severity).

Results

Data collection is underway with 80 participants having completed baseline measures and 55 participants having completed follow-up measures. Data collection is expected to conclude in December 2015.

Conclusions

This study is designed to contribute to the literature regarding the integration of single-session counseling into ongoing mental health services, with additional attention to methodological rigour. Our approach will help to address ongoing concerns regarding the implementation of single-session counseling, and inform health care providers and policy makers regarding the utility of this model for addressing the mental health care need of the community.

Profiles and service utilization for children accessing a mental health walk-in clinic versus usual care

Many children and adolescents with mental health problems do not receive the treatment they need. Unmet need raises questions about specific barriers that may prevent service use, and/or the characteristics of children and families who are less likely to receive care. Brief interventions or single-session psychotherapy delivered in a highly accessible manner are methods of addressing the problems associated with waitlists and limited access to care. In the current study the authors offer an exploratory evaluation of the West End Walk-In Counseling Centre for children and youth with psychosocial problems. Children 4 to 18 years of age who accessed the Walk-In Counseling Centre and a comparison group of clients who accessed usual care were assessed at intake, post-treatment, and 3-month follow-up on demographic characteristics, behavioral/emotional adjustment and functioning, client satisfaction, and service use. Children in the walk-in group had more severe behavioral/emotional adjustment and functioning than usual care clients at baseline. At post-treatment, walk-in clients had lower scores on Total Mental Health Problems and Internalizing Behaviors, and exhibited fewer problems across all scales at follow-up. Walk-in clients found the wait time for service more reasonable and at follow-up, felt the service addressed concerns and had higher regard for counselor availability and cultural sensitivity of the service than usual care clients. Service utilization, assessed at post-treatment and 3-month follow-up, showed that both groups were more likely to access mental health and education services rather than health or child welfare services, and were more likely to have used services in the 12 months prior to service than the 3 months following service completion. Walk-in clients had steeper rates of improvement compared to usual care clients despite equivalence in psychosocial functioning at baseline. The walk-in model may be an effective alternative to usual care, particularly for those clients only willing to wait up to 2 weeks for service.

Reducing Waiting Times: Using an Opt-In System and Changing Prioritisation Criteria

BACKGROUND

  The Highland Clinical Psychology Service for Children and Young People, faced with excessive waiting lists, a large geographical remit, and only three psychologists, sought to change waiting list management to improve services.

METHOD

  An opt-in appointment system and outcome research were used to inform waiting list management. Referrals with the characteristics of cases where psychological interventions are helpful were prioritised over cases that had characteristics of poor outcomes.

RESULTS

  Attendance at first appointments was significantly increased and waiting times were significantly reduced.

CONCLUSIONS

  The success of the opt-in system replicated research in other CAMHS. It is also hypothesised that the new waiting list prioritisation criteria had an effect, although this needs further research. Issues associated with the change in waiting list prioritisation are discussed and it is suggested that prioritising treatable cases over complex cases is an appropriate, effective and ethical use of scarce resources.

Parents' and Clinicians' Perception of Severity of Referral Problems

BACKGROUND

  Referral meetings are commonly used in CAMH Services to allocate a priority rating that reflects urgency, and thus severity, of the referral. Whilst it is recognised that a system is needed to manage the current level of demand, the literature suggests that decisions about severity are often inaccurate.

METHOD

  The current study aimed to evaluate a CAMHS referral system by looking at whether the priority ratings allocated by the Multi-Disciplinary Team (MDT) accorded with the parents' and the individual clinician's perception of the severity of the child's difficulties. Data were taken from the Service's outcome database.

RESULTS

  The results showed that priority ratings did not reflect the parents' and the individual clinician's perception of the problem. It is therefore suggested that the current system for prioritising referrals requires some reform.

CONCLUSION

  There is discussion of procedures that might improve the accuracy of the priority rating process, such as using scores on standardised measures as part of the decision-making process.