Mental Health Service Engagement Among Underserved Minority Adolescents and Young Adults: a Systematic Review

Sociocultural Responsive Frameworks to Increase Engagement in Service Systems Through a Peer-to-Peer Model

Service engagement is critical when working with children and families experiencing chronic adversities because of their socially marginalized status. Further, sociodemographic disparities exist in service engagement within service systems including Community-Based Behavioral Health; likely in part, a result of structural issues driving unresponsive service systems. Despite this knowledge, a large proportion of the family engagement literature continues to be approached through a deficit-based and family-centric lens leaving out important systemic considerations and furthering health inequities. Drawing from a Socio-Ecological Framework (Stokols, 1996), this study focuses on exploring the value of peer support providers (PSPs) to understand how sociocultural responsiveness functions under this service model. Individual interviews and focus group data were collected from both families and PSPs. Thematic analysis (Braun & Clarke in Qualitative Research in Psychology, 3(2), 77-101, 2006) was utilized to code and synthetize the data collected. Findings highlight the importance of capitalizing on meaningful and trusting relationships to foster family engagement in services. These findings solidify the understanding that family engagement is a function of crucial relationships between family, provider, and systems. This work also illustrates how PSPs organic embodiment of sociocultural responsiveness through cultural humility is an avenue through which family engagement can be sustained.

Adolescent engagement in a stepped care, transdiagnostic mental health intervention delivered in Indian schools

Given the relationship between poor engagement and worse treatment outcomes, improving engagement has been the focus of attention in recent years. Engagement is a particular challenge among minoritized and otherwise challenged youth, such as those from socioeconomically disadvantaged groups, including youth in low- and middle-income countries (LMICs), where they face lower levels of access to resources, including mental health treatment. The present study describes engagement challenges that arose in an uncontrolled pre-post evaluation of a school-based, modular, multi-problem, stepped-care intervention delivered in urban Indian communities. Specifically, the study aimed to (1) characterize barriers and facilitators of youth treatment engagement; and (2) evaluate treatment acceptability and fit of treatment from the youth perspective. Youth participants completed semi-structured interviews, which were transcribed and coded using thematic analysis. Participants described numerous facilitators to engagement (e.g., positive therapeutic relationship) and reported high overall satisfaction with the intervention, while also identifying barriers to engagement (e.g., concerns about confidentiality) and offering suggestions to increase fit and acceptability (e.g., more visually appealing treatment materials). Findings highlight ways in which engagement can be enhanced and implementation supports improved to maximize treatment effectiveness among minoritized and disadvantaged youth in LMICs.

Supplementary Information

The online version contains supplementary material available at 10.1007/s44202-024-00154-1.

The role of culture on the phenomenology of hallucinations and delusions, explanatory models, and help-seeking attitudes: A narrative review

AIM

Culture has been posited to be involved in the formation and maintenance of delusions and hallucinations. The extent of these differences and how they affect explanatory models of psychosis and help-seeking attitudes remains to be understood. This review aims to present a cultural formulation to account for psychosis onset, symptom maintenance, and help-seeking attitudes.

METHODS

A narrative review was conducted to summarize the existing evidence base regarding cross-cultural differences in hallucinatory and delusional prevalence, explanatory models, and help-seeking attitudes in First Episode Psychosis (FEP) and Non-FEP Schizophrenia samples.

RESULTS

Sixteen studies were eligible for inclusion. In terms of positive symptom specificity, cross-cultural differences were found. Specifically, auditory and visual hallucinations occurred most frequently in African patients, persecutory and grandiose delusions occurred at higher rates in African, Pakistani, and Latino patients, while delusions of reference were most prevalent in White-British groups. Three explanatory models were identified. Westerners tended to endorse a bio-psychosocial explanation, which was associated with increased help-seeking, engagement, and positive medication attitudes. Asian, Latino, Polish, and Māori patients endorsed religious-spiritual explanatory models, while African patients opted for a bewitchment model. The religious-spiritual and bewitchment models were associated with a longer duration of untreated psychosis (DUP) and poorer engagement with mental health services.

CONCLUSIONS

These findings highlight the important influence of culture in the formation and maintenance of positive symptoms of psychosis, engagement, and help-seeking attitudes across different ethnic groups. The incorporation of cultural beliefs in formulation development could facilitate enriched CBTp practices and improved engagement amongst different cultural groups with Early Intervention Services.

Editorial Perspective: Reducing mental health disparities among underserved youth: using technology to equip parents as agents of change

Prevalence rates for youth psychopathology have steadily increased over the last two decades. Youth from underserved families (e.g. racial/ethnic minority, rural, poor, gender, and sexual minority) are disparately impacted as they face myriad risk factors that adversely affect their mental health. Parents play an integral role in their mental health of underserved youth as they are responsible for making sure that their children get the help that they need. Yet, parents in underserved families often cannot access mental health treatment due to persistent barriers they face such as stigma, discrimination, and high treatment costs, to name a few. Consequently, parents from these families are less likely to receive the psychological training necessary to intervene in their youths' mental health. Although traditional parent management training programs have made progress toward equipping parents with important mental health services, these programs often require considerable investment of time and resources (e.g. money, childcare, in-person attendance) that make them inaccessible to disadvantaged families. Digital mental health interventions (DMHIs) offer to provide parents in underserved families with the psychological training they need to effectively intervene in their youth's mental health while overcoming barriers to care. However, few to no culturally sensitive and evidence-based DMHIs exist to address the mental health needs of underserved families. This editorial perspective highlights the need to develop and implement parent-focused DMHIs for underserved families so that parents will have the mental health resources they need to act as agents of change.

Real-Time Mental Health Crisis Response in the United States to COVID-19

Background: Data are scarce on assessing the impact of the COVID-19 pandemic on young people. Aim: To examine changes in crisis text patterns in the United States during the pandemic compared to the prepandemic period. Method: Nonintrusive data from a national digital crisis texting platform were analyzed using an interrupted time series design. Poisson regression with repeated-measures examined help-seeking patterns for stress, anxiety, depression, suicidal thoughts, and other mental health concerns in the pandemic (March 13 to July 20, 2020) compared to the prepandemic period (March 13 to July 20, 2019). Results: An abrupt increase in national crisis response texts occurred during the pandemic for stress and anxiety, substance abuse, bereavement, isolation, and abuse compared to the prepandemic period. Similar trends of excess texts for isolation and abuse were reported among children (relative risk [RR]_abuse: 1.16, CI: 1.03, 1.31; RR_isolation: 1.15, CI: 1.09, 1.21) and adolescents (RR_abuse: 1.17, CI: 1.11, 1.24; RR_isolation: 1.08, CI: 1.05, 1.11), bereavement among Black (RR: 1.31, CI: 1.12, 1.54) and Hispanic (RR: 1.28, CI: 1.10, 1.49) texters, and isolation and bereavement in female (RR_isolation: 1.09, CI: 1.06, 1.11; RR_bereavement: 1.21, CI: 1.13, 1.28) or nonconforming youth (RR_isolation: 1.19, CI: 1.08, 1.32; RR_bereavement: 1.50, CI: 1.08, 2.09) texters. Conversely, the risks of reporting bullying, depression, relationship issues, and suicidal thoughts as reasons for texting were significantly lower during COVID-19. Limitations: Results may underestimate crisis support-seeking in some groups because demographic data were not captured on all texters. Conclusion: Findings illuminated the real-time crisis response of young people across the United States and can inform more responsive interventions to alleviate the mental health consequences brought on by the COVID-19 pandemic.

Self-reported anxiety and depression problems and suicide ideation among black and latinx adults and the moderating role of social support

Suicide is a critical public health problem. Over the past decade, suicide rates have increased among Black and Latinx adults in the U.S. Though depression is the most prevalent psychiatric contributor to suicide risk, Black and Latinx Americans uniquely experience distress and stress (e.g., structural adversity) that can independently operate to worsen suicide risk. This makes it important to investigate non-clinical, subjective assessment of mental health as a predictor of suicide ideation. We also investigate whether social support can buffer the deleterious impact of poor mental health on suicide ideation.We analyzed data from 1,503 Black and Latinx participants of the Washington Heights Community Survey, a 2015 survey of residents of a NYC neighborhood. Multivariable logistic regression was conducted to examine the effect of subjectively experienced problems with anxiety and depression on suicide ideation independent of depression diagnosis, and the role of social support as a moderator.Estimated prevalence of past two-week suicide ideation was 5.8%. Regression estimates showed significantly increased odds of suicide ideation among participants reporting moderate (OR = 8.54,95% CI = 2.44-29.93) and severe (OR = 16.84,95% CI = 2.88-98.46) versus no problems with anxiety and depression, after adjustment for depression diagnosis. Informational support, i.e., having someone to provide good advice in a crisis, reduced the negative impact of moderate levels of anxiety and depression problems on suicide ideation.Findings suggest that among Black and Latinx Americans, subjective feelings of anxiety and depression account for a significant portion of the suicide ideation risk related to poor mental health. Further, social support, particularly informational support, may provide protection against suicide ideation.

Impact of a brief intervention to improve engagement in a recovery program for young adults with serious mental illness

OBJECTIVE

Serious mental illnesses (SMI) commonly emerge during young adulthood. Effective treatments for this population exist; however, engagement in treatment is a persistent challenge. This study examines the impact of Just Do You (JDY), an innovative intake-focused intervention designed to improve engagement in treatment and enhance personal recovery.

METHODS

The study used a parallel group randomized trial to examine if and how JDY improved recovery among 121 young adults with SMI from low-resourced communities referred to personalized recovery-oriented services (PROS). Measures of engagement (buy-in and attendance) and personal recovery in this pilot study were assessed at baseline and 3-month follow-up.

RESULTS

Participants in JDY reported more positive engagement outcomes; that is, relative to the control group they reported higher past two week attendance (b = 0.72, p < 0.05, Cohen's d = 0.56) and higher levels of buy-in to treatment (b = 2.42, p < 0.05, Cohen's d = 0.50). JDY also impacted young adults' personal recovery (b = 0.99, p < 0.05, Cohen's d = 1.15) and did so largely by increasing their level of buy-in to the treatment program.

CONCLUSION

This study suggests that an engagement intervention for young adults that orients, prepares, and empowers them to be active and involved in the larger treatment program makes a difference by improving engagement and enhancing recovery. Data also support conceptualizing and examining engagement beyond treatment attendance; in this study what mattered most for recovery was the level of buy-in to treatment among young adults.

A Systematic Review of Music-Based Interventions to Improve Treatment Engagement and Mental Health Outcomes for Adolescents and Young Adults

Mental health disorders and suicidality are rising among adolescents and young adults (A-YA) while rates of treatment engagement remain notoriously low. Emerging research supports the potential of music-based interventions to improve mental health, but their efficacy remains unclear for A-YA. This systematic review evaluates the evidence on music-based psychosocial interventions to improve engagement in treatment and/or mental health outcomes among A-YA. This review was prospectively registered with PROSPERO and followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Twenty-six studies were extracted. There was heterogeneity of designs, populations, measures, and outcomes. A typology of music-based interventions emerged, which is characterized by combinations of three broad categories: 1) Somatosensory, 2) Social-Emotional, and 3) Cognitive-Reflective. Most interventions are Socio-Cognitive and Holistically Integrated (combines all three) followed by Socio-Somatic. All interventions involved Social-Emotional processes. Results indicate that most studies report significant effects for mental health outcomes related to social and emotional improvements and reductions of internalizing symptoms for adolescents. Few studies targeted young adults and effects on engagement were rarely measured. There is a need for more studies that use rigorous methods. This review illuminated a need for interventions that are developmentally and culturally tailored to subgroups. Finally, the field is ripe from more studies that apply experimental therapeutics to conceptualize, operationalize, and test mechanisms of change to improve the understanding of how and for whom music-based interventions work. Recommendations for embedding these innovative strategies into research and practice for A-YA are discussed.

Supplementary Information

The online version contains supplementary material available at 10.1007/s10560-022-00893-x.

Addressing Structural Racism Is Critical for Ameliorating the Childhood Obesity Epidemic in Black Youth

Racism and childhood obesity are both pervasive factors adversely affecting the health and wellbeing of children and adolescents in the United States. The association between racism and obesity has been touched upon in the literature; yet most work has focused on a few dimensions of intersectionality of these two domains at one time. The renewed focus on structural racism as the primary contributor to distress of Black individuals in the United States has highlighted the urgency of identifying the contributions of racism to the childhood obesity epidemic. The current article is not a complete review of the literature, rather, it is meant to take a broad narrative review of the myriad ways in which racism contributes to the obesity epidemic in Black youth to serve as a call to action for more research, prevention, and intervention. The current article illustrates how a number of mechanisms for the etiology and maintenance of obesity are heavily influenced by racism and how addressing racism is critical for ameliorating the childhood obesity epidemic.

Crisis Response and Suicidal Patterns in U.S. Youth Before and During COVID-19: A Latent Class Analysis

PURPOSE

This study characterized the unobserved patterns in crisis response among youth in the U.S. from March to December 2020 and determined the characteristics of vulnerable subgroups who were at increased risk for suicide due to the pandemic.

METHODS

A latent class analysis of crisis support-seeking from a national text-based crisis platform, (n = 179,497, aged 24 years or younger) for 11 crisis concerns (e.g., depression, anxiety/stress, suicidal thoughts, isolation, abuse, bereavement, relationships) was performed on three study periods: (1) January 2017 to December 2020, (2) prepandemic: 1 January 2017 to 12 March 2020, and (3) pandemic: 13 March to 20 December 2020. Demographic characteristics (age, race/ethnicity, sexual orientation, and gender identity) were used as predictors for class membership using the three-step method.

RESULTS

Four latent classes were identified: (1) depression/isolation/self-harm (D/I/S) (18,694 texters, 10.4%), (2) interpersonal stress/mood-anxiety (I/M) (32,640 texters, 18.2%), (3) suicidal thoughts/depressed (S/D) (34,067, 19.0%), and (4) adjustment/stress (A/S) (94,096 texters, 52.4%). During the pandemic, an increase in suicidal thoughts and active rescues occurred in the D/I/S and S/D higher-risk subclasses. Characteristics of vulnerable groups in higher-risk classes since the pandemic included children, LGBTQ, American Indian, White, Black, Asian, female, and gender-nonconforming youth.

CONCLUSIONS

Results identified a strong association with class membership in more severe risk classes during the pandemic and an increase in suicidal help-seeking, particularly among children and LGBTQ youth. Low-cost and targeted crisis text-based platforms for support-seeking in youth may be one potential safety net strategy to address the effects of the COVID-19 pandemic on mental health in youth.

Outcomes of a Metaintervention to Improve Treatment Engagement Among Young Adults With Serious Mental Illnesses: Application of a Pilot Randomized Explanatory Design

PURPOSE

The objective of this study was to conduct a preliminary evaluation of a new young adult-centered metaintervention to improve treatment engagement among those with serious mental illness.

METHODS

Young adults, clinic staff, and policy makers provided feedback on the intervention, which is a two-module engagement program provided by a clinician and person with lived experience (peer) during intake. A two-group pilot randomized explanatory trial design was conducted, comparing treatment as usual with treatment as usual plus the engagement program, Just Do You. The primary outcomes were treatment engagement and presumed mediators of program effects measured at 3 months after baseline.

RESULTS

The randomized explanatory trial indicated that young adults in Just Do You were more engaged in treatment than treatment as usual and that changes in several mediators of engagement occurred. Mechanisms that demonstrated between-group differences were stigma, perceived expertise of providers, trust in providers, and beliefs about the benefits of treatment. Results also provide diagnostic information on mediators that the program failed to change, such as hope, self-efficacy, and emotional reactions to treatment. These results inform next steps in the development of this promising intervention.

CONCLUSIONS

Just Do You illustrated feasibility, acceptability and preliminary impact. It represents an innovative metaintervention that has promise for improving treatment engagement in mental health services among young adults who have a history of poor engagement.

A Multidimensional Examination of the Measurement of Treatment Engagement: Implications for Children's Mental Health Services and Research

Objective: The gap between rates of children's mental health problems and their participation in services highlights the need to address concerns related to engagement in mental health services more effectively. To identify, understand, and resolve engagement concerns appropriately requires effective measurement. In this study, we employed a multidimensional conceptual framework of engagement to examine the measurement of engagement in intervention studies focused on improving children's and/or families' engagement in services.Method: We coded 52 randomized controlled trials (RCTs) of interventions designed to enhance treatment engagement published between 1974 and 2019 to examine what engagement constructs have been measured, how these constructs have been measured, who has provided information about engagement, and when and why engagement measures have been administered.Results: Attendance was measured in 94.2% of studies, and 59.6% of studies measured only attendance. Furthermore, most studies (61.5%) measured only one engagement dimension. One hundred twelve unique indicators of treatment engagement were used (61.6% measuring attendance). Infrequent measurement of youth (19.2% of studies) or caregiver (26.9%) perspectives was apparent. About half (54.7%) of measures were completed on one occasion, with 53.7% of measures completed after treatment was concluded.Conclusions: Results highlight how the field's measurement of engagement has focused narrowly on attendance and on interventions that improve attendance. We consider promising new directions for capturing the multidimensional, dynamic, and subjective aspects of engagement, and for leveraging measurement in research and practice settings to feasibly and effectively identify, monitor, and address engagement challenges.

Engagement intervention versus treatment as usual for young adults with serious mental illness: a randomized pilot trial

BACKGROUND

Young adults have elevated rates of mental health disorders, yet they often do not receive consistent care. The challenge of continuing to engage young adults has been pervasive worldwide. Few engagement interventions have been designed for young adults with serious mental illness. Just Do You is a theoretically guided engagement intervention. It uses innovative modalities (i.e., technology, expressive arts activities, narrative expression, mentoring) to engage participants in conversations about services and how they work, while simultaneously orienting them to treatment.

METHODS/DESIGN

This pilot and feasibility study utilizes a hybrid research design, examining feasibility, acceptability, and preliminary impact, alongside implementation. The study combines qualitative methods, a small pilot randomized trial, and a small cost-benefit analysis. Respondents are clinic staff and young adults who have made initial contact with the Personalized Recovery Oriented Services (PROS) program. Quantitative survey data are collected at baseline, 2 weeks (post-intervention), 1 month, and 3 months. The assessments focus on measuring feasibility, acceptability, engagement, and mental health outcomes. Medical record extraction will be used to triangulate self-report data. We will conduct single degree of freedom contrasts to examine whether Just Do You leads to improved outcomes relative to Treatment-As-Usual using robust regression for each outcome measure. We will examine whether changes in the proposed mediating variables occur across groups using a similar contrast strategy. In addition, we will use structural equation modeling to examine the contribution of mediators to ultimate outcomes. Finally, we will use constant comparison coding techniques for qualitative analyses.

DISCUSSION

The aim of this study is to examine the feasibility of a young adult engagement meta-intervention through an intensive preliminary pilot trial, learning through collaboration with stakeholders. Just Do You has the potential to fill a gap in the service system for young adults with serious mental illnesses, improving the seemingly intractable problem of disengagement. The program uses culturally responsive strategies, is recovery-oriented, and builds upon the best evidence to date. Our efforts align with local and national health care reform efforts embedding people with lived experience.

TRIAL REGISTRATION

This trial was registered with ClinicalTrials.gov (Identifier: NCT03423212) on April 18, 2018, as Protocol Record R34 MH111861-01, New York University, as the Just Do You Program for Young Adults with Serious Mental Illness.

Nonsuicidal Self-Injury Among African American and Hispanic Adolescents and Young Adults: a Systematic Review

While African American and Hispanic adolescents and young adults living in the USA are exposed to myriad stressors that may increase their risk for mental health difficulties, few studies have examined nonsuicidal self-injury (NSSI) among these youth. The purpose of this systematic review was to critically examine and synthesize current literature on NSSI among these understudied youth. Using multiple search terms related to NSSI, race/ethnicity, and developmental stage, electronic literature searches of PubMed, PsychINFO, and Google Scholar databases retrieved 3036 relevant articles published in the English language between 2000 and 2018; manual reference checks yielded an additional 17 articles. Ultimately, a total of 52 full-text studies were assessed for eligibility, and 15 articles were included in the present review. Although the majority of studies reported higher prevalence of NSSI among non-Hispanic White youth, evidence suggests that African American males are also at high risk of engaging in self-harm. Emotional dysregulation emerged as a common risk factor, while social support and feelings of connection were protective for some African American and Hispanic youth. Although racism and discrimination were not linked to NSSI in the reviewed studies, this remains an important area of future research for prevention and intervention efforts.

A Qualitative Investigation of Engagement in Mental Health Services Among Black and Hispanic LGB Young Adults

OBJECTIVE

Little attention has been paid to engagement in mental health services among racially and ethnically diverse youths who identify as a sexual minority, despite research indicating that they face significant mental health disparities. In this study, the authors assessed the service use experiences of black and Hispanic lesbian, gay, and bisexual (LGB) young adults to identify factors that promoted or hindered their engagement.

METHODS

Semistructured interviews with 38 young adults regarding past and present experiences with mental health services were analyzed thematically for perceived challenges to and support for engagement. Participants' service use histories were reviewed for significant interruptions in services reported over the past year.

RESULTS

Seventeen participants (45%) reported disengagement despite continuing to need services. Factors that influenced engagement were identified across four domains: personal, social environment, accessibility, and provider characteristics. Stigma related to sexual orientation and cultural attitudes presented engagement barriers, whereas providers who were knowledgeable about sexual-minority issues were important engagement promoters. Additional barriers to engagement were ambivalence about treatment efficacy, lack of family support, and difficulty finding suitable and affordable care. Peers who identified as a sexual minority helped participants locate LGB-affirming services. Rapport with providers and health care autonomy assisted participants to manage barriers to engagement.

CONCLUSIONS

These findings offer insights about factors that can influence engagement with treatment among black and Hispanic LGB young adults. The findings reveal important provider competencies and can inform interventions to improve engagement and reduce mental health inequities among these youths.