Evaluation of a patient activation and empowerment intervention in mental health care

Supported decision-making interventions in mental healthcare: A systematic review of current evidence and implementation barriers

BACKGROUND

There is a growing momentum around the world to foster greater opportunities for the involvement of mental health service users in their care and treatment planning. In-principle support for this aim is widespread across mental healthcare professionals. Yet, progress in mental health services towards this objective has lagged in practice.

OBJECTIVES

We conducted a systematic review of quantitative, qualitative and mixed-method research on interventions to improve opportunities for the involvement of mental healthcare service users in treatment planning, to understand the current research evidence and the barriers to implementation.

METHODS

Seven databases were searched and 5137 articles were screened. Articles were included if they reported on an intervention for adult service users, were published between 2008 and October 2023 and were in English. Evidence in the 140 included articles was synthesised according to the JBI guidance on Mixed Methods Systematic Reviews.

RESULTS

Research in this field remains exploratory in nature, with a wide range of interventions investigated to date but little experimental replication. Overarching barriers to shared and supported decision-making in mental health treatment planning were (1) Organisational (resource limitations, culture barriers, risk management priorities and structure); (2) Process (lack of knowledge, time constraints, health-related concerns, problems completing and using plans); and (3) Relationship barriers (fear and distrust for both service users and clinicians).

CONCLUSIONS

On the basis of the barriers identified, recommendations are made to enable the implementation of new policies and programs, the designing of new tools and for clinicians seeking to practice shared and supported decision-making in the healthcare they offer.

PATIENT OR PUBLIC CONTRIBUTION

This systematic review has been guided at all stages by a researcher with experience of mental health service use, who does not wish to be identified at this point in time. The findings may inform organisations, researchers and practitioners on implementing supported decision-making, for the greater involvement of people with mental ill health in their healthcare.

Associations Between Patient Comfort with a Primary Care Provider and Three Measures of Behavioral Health Services Utilization

BACKGROUND

Behavioral health services (BHS) can help improve and treat mental and emotional health problems. Yet, attitudinal and/or structural barriers often prevent individuals from accessing and benefiting from these services. Positive provider-patient interactions in healthcare, encompassing patient comfort with a primary care provider (PCP), which is often enhanced by shared decision-making, may mitigate the stigma associated with seeing a mental health professional; this may improve BHS utilization among patients who need these services. However, few studies have examined how patient comfort with a PCP, often through shared decision-making, may influence patients' BHS utilization in the real world. This study sought to address this gap in practice.

METHOD

Multivariable regression analyses, using weighted data from an internet panel survey of Los Angeles County adults (n = 749), were carried out to examine the associations between patient comfort with a PCP and three measures of BHS utilization. Subsequent analyses were conducted to explore the extent to which shared decision-making moderated these associations.

RESULTS

Participants who reported an intermediate or high comfort level with a provider had higher odds of reporting that they were likely to see (aOR = 2.10 and 3.84, respectively) and get advice (aOR = 2.75 and 4.76, respectively) from a mental health professional compared to participants who reported a low comfort level. Although shared decision-making influenced participants' likelihood of seeing and getting advice from a mental health professional, it was not a statistically significant moderator in these associations.

CONCLUSION

Building stronger relationships with patients may improve BHS utilization, a provider practice that is likely underutilized.

Communication and activation in pain to enhance relationships and treat pain with equity (COOPERATE): a randomized clinical trial

ABSTRACT

Racialized disparities in chronic pain care are well-documented and persist despite national priorities focused on health equity. Similar disparities have been observed in patient activation (ie, having the knowledge, confidence, and skills to manage one's health). As such, interventions targeting patient activation represent a novel approach to addressing and reducing disparities in pain care. Communication and Activation in Pain to Enhance Relationships and Treat Pain with Equity is a randomized controlled trial of a 6-session telephone-delivered intervention to increase patient activation for Black patients with chronic pain. Two hundred fifty Black patients from a Midwestern Veterans Affairs medical center were randomized to the intervention or attention control. The primary outcome was patient activation; secondary outcomes included communication self-efficacy, pain, and psychological functioning. Outcomes were assessed at baseline and at 3 (primary endpoint), 6, and 9 months (sustained effects). Analyses used an intent-to-treat approach. Compared with baseline, patient activation increased 4.6 points at 3 months (versus +0.13 in control group, 95% CI: 0.48, 7.34; P = 0.03). These improvements in the intervention group were sustained, with +7 from baseline at 6 months and +5.77 at 9 months, and remained statistically significant from the control group. Communication self-efficacy increased significantly relative to the control group from baseline to 3 months. Pain intensity and interference improved at 3 months, but differences were not significant after adjusting for multiple comparisons. Most other secondary outcomes improved, but group differences were not statistically significant after controlling for multiple comparisons. Results suggest that increasing patient activation is a potentially fruitful path toward improving pain management and achieving health equity.

Factors associated with patient activation among individuals with depression within racial/ethnic groups in the United States

Increasing patient activation may be vital for improving quality of care for individuals with depression. Among adults with depression who reside in the United States, we sought to examine the association of depression severity, race/ethnicity, and household income with patient activation and within identify factors associated with patient activation within race/ethnicity groups. Data from the 2020 US National Health and Wellness Survey, a cross-sectional, general population survey, were used to identify White, Black/African American, Asian, and Hispanic respondents with self-reported physician-diagnosed depression. Generalized linear models were used to identify factors associated with patient activation. Analyses included 8,216 respondents (mean age = 44 years, 68.0% female). Depression severity was negatively associated with patient activation (β = -0.29, p < 0.001). Patient activation was significantly higher in Black vs. White respondents (β = 1.50, p = 0.001) and in respondents with a household income of $25,000-$49,999 (β = 0.96, p = 0.015), $50,000-$99,000 (β = 0.88, p = 0.031), and ≥$100,000 (β = 1.78, p < 0.001) vs. <$25,000. Adjusted mean patient activation scores were highest among Black respondents (61.1), followed by Hispanic (60.2), White (59.6), and Asian (59.0) respondents. Neither race/ethnicity nor household income moderated the relationship between depression severity and patient activation; however, the factors most strongly associated with patient activation differed by race/ethnicity. These results indicate that the pathway to improving patient activation in individuals with depression may vary by race/ethnicity. Understanding factors associated with patient activation can help inform the design of interventions to increase patient activation in individuals with depression.

Shared decision making between community therapists and Latinx caregivers during evidence-based practice delivery in publicly-funded children's mental health services

OBJECTIVES

This observational study examined shared decision-making (SDM) with caregivers of Latinx youth within the delivery of multiple evidence-based practices (EBPs) in community mental health services. Study aims were to (1) Characterize therapist use of SDM strategies and (2) Describe the types of treatment decisions that were the focus of therapist use of SDM.

METHODS

The OPTION instrument was used to measure SDM in 210 audio-recorded therapy sessions with 62 community therapists and 109 Latinx caregivers; frequency and mean ratings of OPTION items were examined. Qualitative analysis on the descriptions of treatment decisions being deliberated was also conducted.

RESULTS

Results revealed that therapists used at least one SDM step in most sessions (N = 192; 91.43%) with a mean composite score of 32.78 (SD=17.79; range: 6.25-81.25). Four superordinate categories of decisions were: (1) Treatment planning, (2) Evidence-based Parenting Strategies, (3) Addressing Youth Functioning, and (4) Addressing Family Psychosocial Needs.

CONCLUSIONS

Findings suggest that community therapists serving Latinx families are naturalistically engaging in SDM steps about a variety of decisions during most EBP sessions, but only at modest levels.

Reducing psychiatric illness in the perinatal period: A review and commentary

This brief overview highlights the global crisis of perinatal psychiatric illness (PPI). PPI is a major contributor to many adverse pregnancy, childbirth, and childhood development outcomes. It contributes to billions of dollars in spending worldwide each year and has a significant impact on the individual, their family, and their community. It is also highly preventable. Current recommendations for intervention and management of PPI are limited and vary considerably from country to country. Furthermore, there are several significant challenges asso-ciated with implementation of these recommendations. These challenges are magnified in number and consequence among women of color and/or minority populations, who experience persistent and negative health disparities during pregnancy and the postpartum period. This paper aims to provide a broad overview of the current state of recommendations and implementation challenges for PPI and layout a framework for overcoming these challenges. An equity-informed model of care that provides universal intervention for pregnant women may be one solution to address the preventable consequences of PPI on child and maternal health. Uniquely, this model emphasizes the importance of managing and eliminating known barriers to traditional health care models. Culturally and contextually specific challenges must be overcome to fully realize the impact of improved management of PPI.

Relationship between patient activation and self-efficacy among patients undergoing hemodialysis: a cross-sectional study

Background

Patient activation in chronic kidney disease (CKD) is increasingly being prioritized and considered a quality metric in CKD. Given the importance of patients’ activation in improving the quality of chronic disease care, this study aimed to assess patients’ activation levels and its relationship with self-efficacy among patients undergoing hemodialysis.

Methods

In this cross-sectional study, a total of 180 patients undergoing maintenance hemodialysis were selected by random sampling from the largest hemodialysis center (dialysis center of Emam Reza hospital, Tabriz) in Iran. Data were collected by demographics, patient activation measure, and chronic kidney disease self-efficacy (CKD-SE) scale from March to May 2021. Collected data were analyzed using SPSS software (ver. 26) using ANOVA, t-test, Pearson correlation coefficient, and multiple regression tests.

Results

The majority of the participants (35%) were at level 1 of activation and only 28.9% of the individuals were at level 4. According to the results, the mean score of self-efficacy in patients undergoing hemodialysis (in a possible range of 0–10) was 5.50 ± 1.45. Multiple regression analysis showed that factors including self-efficacy, educational level, and marital status were significant predictors of change in patient activation (R2 = 0.85, adjusted R2 = 0.66, p < 0.001). The results showed that self-efficacy was the main predictor of patient activation (β = 0.49, p < 0.001).

Conclusion

According to the result, improving the patients' self-efficacy could improve the patient's activation. Moreover, patients with lower educational level reported the lower activation score; therefore, health care providers should improve the knowledge of patients with lower educational level, encourage them to be more active in their health care, and help them in providing more tailored strategies to improve the quality of care more efficiently. Furthermore, Measuring patients' activation level at admission to the dialysis unit is recommended for all patients undergoing hemodialysis.

Health Literacy and Patient Activation in the Pediatric to Adult Transition in Systemic Lupus Erythematosus: Patient and Health Care Team Perspectives

Objective

Methods

Results

Conclusion

Communication and Activation in Pain to Enhance Relationships and Treat Pain with Equity (COOPERATE): Rationale, study design, methods, and sample characteristics

BACKGROUND

Chronic pain is associated with profound negative effects, and racial disparities are well-documented in chronic pain treatment. In addition, Black patients report poorer communication with providers and exhibit lower levels of patient activation (self-management self-efficacy) than White patients. Although the causes of healthcare disparities are complex and require intervention at multiple levels, empowering patients is one critical path to achieving health equity. The current study is a coaching intervention focused on increasing patient activation and building communication skills for Black patients with chronic pain.

METHODS

In this randomized controlled trial, 250 Black patients with chronic pain were randomized to either the coaching intervention or an attention control arm. Intervention patients attended 6 telephone-delivered individual coaching sessions over 12 weeks. Coaching focused on clarifying and prioritizing goals and on communication skills, such as agenda setting. The primary outcome is patient activation. Secondary outcomes include communication self-efficacy, pain intensity and interference, and psychological functioning.

DISCUSSION

Having the knowledge and confidence to participate in one's pain care, coupled with the skills needed to effectively communicate with providers, is essential to optimize chronic pain care. This is particularly important for Black patients who often experience lower quality pain care. Interventions such as COOPERATE hold promise for helping patients to acquire the requisite tools to take greater control of their chronic pain care.

TRIAL REGISTRATION

clinicaltrials.gov, # NCT03562793.

Testing the Impact of a Peer-Delivered Family Support Program: A Randomized Clinical Effectiveness Trial

OBJECTIVE

The effectiveness of NAMI Basics, a peer-led family support program for caregivers of children with mental health concerns, was tested in a sample of caregivers referred to five National Alliance on Mental Illness (NAMI) affiliates in a large southwestern state.

METHOD

Caregivers of children with mental health concerns (N=111; 69% biological mothers, 45% Hispanic/Latinx, 33% Caucasian, and 12% African American) were randomly assigned to a six-class NAMI Basics course led by peer parents or an 8-week waitlist condition. At baseline and 8 weeks after the course began, all caregivers completed measures assessing services engagement and activation, attitudes toward mental health services, parenting stress, and youth symptoms. Data were analyzed by using linear regression.

RESULTS

Compared with caregivers in the waitlist condition, NAMI Basics participants reported significant increases in parent engagement and activation, as well as intentions to engage with mental health services. NAMI Basics participants also reported significant decreases in their child's intrapersonal and interpersonal distress, compared with those in the waitlist group. No significant differences were noted on measures of parenting stress, attitudes toward mental health services, or stigma.

CONCLUSIONS

NAMI Basics affected caregiver outcomes and youth symptoms, as measured by caregiver report, compared with a waitlist control group. Peer-led services, such as NAMI Basics, may increase engagement with effective mental health services for youths and families.

Smartphone App to Promote Patient Activation and Support Shared Decision Making in People With a Diagnosis of Schizophrenia in Outpatient Treatment Settings (Momentum Trial): Randomized Controlled Assessor-blinded Trial (Preprint)

Background

Shared decision-making (SDM) is a process aimed at facilitating patient-centered care by ensuring that the patient and provider are actively involved in treatment decisions. In mental health care, SDM has been advocated as a means for the patient to gain or regain control and responsibility over their life and recovery process. To support the process of patient-centered care and SDM, digital tools may have advantages in terms of accessibility, structure, and reminders.

Objective

In this randomized controlled trial, we aimed to investigate the effect of a digital tool to support patient activation and SDM.

Methods

The trial was designed as a randomized, assessor-blinded, 2-armed, parallel-group multicenter trial investigating the use of a digital SDM intervention for 6 months compared with treatment as usual. Participants with a diagnosis of schizophrenia, schizotypal or delusional disorder were recruited from 9 outpatient treatment sites in the Capital Region of Denmark. The primary outcome was the self-reported level of activation at the postintervention time point. The secondary outcomes included self-efficacy, hope, working alliance, satisfaction, preparedness for treatment consultation, symptom severity, and level of functioning. Explorative outcomes on the effect of the intervention at the midintervention time point along with objective data on the use of the digital tool were collected.

Results

In total, 194 participants were included. The intention-to-treat analysis revealed a statistically significant effect favoring the intervention group on patient activation (mean difference 4.39, 95% CI 0.99-7.79; Cohen d=0.33; P=.01), confidence in communicating with one’s provider (mean difference 1.85, 95% CI 0.01-3.69; Cohen d=0.24; P=.05), and feeling prepared for decision-making (mean difference 5.12, 95% CI 0.16-10.08; Cohen d=0.27; P=.04). We found no effect of the digital SDM tool on treatment satisfaction, hope, self-efficacy, working alliance, severity of symptoms, level of functioning, use of antipsychotic medicine, and number or length of psychiatric hospital admissions.

Conclusions

This trial showed a significant effect of a digital SDM tool on the subjective level of patient activation, confidence in communicating with one’s provider, and feeling prepared for decision-making at the postintervention time point. The effect size was smaller than the 0.42 effect size that we had anticipated and sampled for. The trial contributes to the evidence on how digital tools may support patient-centered care and SDM in mental health care.

Trial Registration

ClinicalTrials.gov NCT03554655; https://clinicaltrials.gov/ct2/show/NCT03554655

International Registered Report Identifier (IRRID)

RR2-doi: 10.1186/s12888-019-2143-2

Social Media and Social Support: A Framework for Patient Satisfaction in Healthcare

Social media has been a powerful source of social support for health consumers. In the healthcare sector, social media has thrived, building on various dynamic platforms supporting the connection between social relationships, health, and wellbeing. While prior research has shown that social support exerts a positive impact on health outcomes, there is scant literature examining the implications of social support for patient satisfaction, which suggests that there is a profound gap in the extant literature. The objective of this study is to develop and test a theoretical model for understanding the relationship between different dimensions of social support and patient empowerment. The study further investigates the debated relationship between patient empowerment and patient satisfaction. The measurement model indicated an acceptable fit (χ2 = 260.226; df, 107, χ2/df = 2.432, RMSEA = 0.07, GFI = 0.90, IFI = 0.95, TLI = 0.94, and CFI = 0.95). Findings indicate that emotional support (p < 0.001), information support (p < 0.05), and network support (p < 0.001) positively influence the notion of patient empowerment. In turn, patient empowerment positively influences patient satisfaction (p < 0.001). The proposed framework contributes to the health communication literature by introducing a novel framework for patient satisfaction in the social media context, which provides important inputs for healthcare service providers in developing patient empowerment strategies.

Views on health activation and support services among formerly homeless adults living in Permanent Supportive Housing in the United States

Individuals who have experienced chronic homelessness often have unmet physical and mental health needs and experiences of trauma and stigma. This study aimed to measure, for the first time, health activation (self-advocacy and empowerment) levels among formerly homeless adults living in Permanent Supportive Housing or PSH (referred to hereafter as residents). In addition, residents' experiences accessing health services, and their sense of health activation and efforts to manage their health within PSH settings, were explored. A mixed-methods study was conducted in Southern California (October 2018-June 2019) using a validated survey and interviews with a randomly selected group of residents (n = 61) from three PSH agencies. Activation levels were measured using the Patient Activation Measure. Descriptive and univariate survey analyses were conducted. Interview data was analysed using NVivo. Two coders coded all transcripts, and team meetings were held to reach consensus. Results showed most residents were female (64%), racial and ethnic minorities (66%), on average 54-year-olds, with 37 months of PSH residency, and 43% were taking some action to manage their health (intermediate activation level). Challenges accessing care were due to breakdowns in care, unpleasant experiences with providers, low health literacy and feeling overwhelmed by co-occurring chronic conditions. Health activation related to knowing when to take care of their health on their own and when to seek care. Unique challenges emerged related to PSH, such as lack of resident control within the housing setting and limited personnel responding to health emergencies. These challenges were magnified because residents live alone, per PSH requirements.

Activation in persons with mental health disorders: An integrative review

WHAT IS KNOWN ON THE SUBJECT?: Evidence indicates a strong relationship between patient activation (i.e. confidence, knowledge and skills to self-manage health) and positive health behaviours and outcomes in a variety of clinical populations. Because persons with mental health disorders experience significant disease burden but often underutilize mental health treatment or experience poor treatment outcomes, they would likely benefit from increases in activation. No systematic reviews have been conducted to summarize and synthesize research on patient activation in persons with mental health disorders. WHAT THIS PAPER ADDS TO EXISTING KNOWLEDGE?: To our knowledge, this is the first comprehensive review to identify factors associated with activation and interventions that have shown to be effective in persons with mental health disorders. This integrative review indicates that better health status, less depression, positive health attitudes and behaviours, and higher quality therapeutic relationships may be associated with higher levels of activation in persons with mental health disorders. This review also indicates that a variety of interventions, most notably educational programs, are effective in increasing levels of patient activation in persons with mental health disorders. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Psychiatric mental health nurses and other clinicians should consider routine assessment of patient activation to inform individualized treatment plans for their clients. Clinicians should aim to form high-quality therapeutic relationships with clients as a way to promote higher levels of activation. Interventions that have been found to be effective in improving activation could be offered in a variety of mental health settings. ABSTRACT: Introduction Patient activation is understanding one's role in the healthcare process and having confidence, knowledge, and skills to self-manage one's health and health care. Researchers have begun to investigate patient activation in persons with mental health disorders, but no systematic reviews have been conducted to summarize and synthesize this research. For psychiatric mental health nurses and other clinicians to develop strategies to increase patient activation in this population, more information is needed about factors associated with activation and interventions that increase activation. Review Questions (1) What factors are associated with levels of activation in persons diagnosed with mental health disorders? (2) What interventions have shown to be effective at increasing levels of activation in persons diagnosed with mental health disorders? Method A 5-stage integrative review as described by Whittemore & Knafl. Results Twenty-nine articles were included in the review. Ten provided correlations between activation and other factors, and 20 examined the effects of interventions on activation. Some studies revealed significant correlations between a variety of health and treatment-related factors, and others revealed that some interventions, most notably educational programs, were shown to increase activation. Discussion The findings of this comprehensive review can inform psychiatric mental health nurses and other clinicians in developing strategies to increase activation in the patients with whom they work. More research is needed to provide a deeper understanding of the role of activation in the recovery and treatment of persons with mental health disorders. Implications for Practice Psychiatric nurses and other clinicians should assess for patient activation and incorporate strategies to increase levels of activation in patients in their practice. Positive therapeutic relationships likely enhance activation in persons with mental health disorders.

Piloting I-SLEEP: a patient-centered education and empowerment intervention to improve patients' in-hospital sleep

Background

Sleep disturbances in hospitalized patients are linked to poor recovery. In preparation for a future randomized controlled trial, this pilot study evaluated the feasibility and acceptability of a multi-component intervention (I-SLEEP) that educates and empowers inpatients to advocate for fewer nighttime disruptions in order to improve sleep during periods of hospitalization.

Methods

Eligible inpatients received I-SLEEP, which included an educational video, brochure, sleep kit, and three questions patients can ask their team to reduce nighttime disruptions. Following I-SLEEP, inpatients were surveyed on the primary feasibility outcomes of satisfaction with and use of I-SLEEP components. Inpatients were also surveyed regarding empowerment and understanding of intervention materials. Patient charts were reviewed to collect data on nighttime (11 PM–7 AM) vital sign and blood draws disruptions.

Results

Ninety percent (n = 26/29) of patients were satisfied with the brochure and 87% (n = 27/31) with the video. Nearly all (95%, n = 36/37) patients felt empowered to ask their providers to minimize nighttime disruptions and 68% (n = 26/37) intended to alter sleep habits post-discharge. Forty-nine percent (n = 18/37) of patients asked an I-SLEEP question. Patients who asked an I-SLEEP question were significantly more likely to experience nights with fewer disruptions due to nighttime vitals (19% vs. 2.1%, p = 0.008).

Conclusion

This pilot study found that I-SLEEP was well-accepted and enabled hospitalized patients to advocate for less disrupted sleep. Educating patients to advocate for reducing nighttime disruptions may be a patient-centered, low-cost strategy to improve patients’ care and in-hospital experience. These results suggest that I-SLEEP is ready to be evaluated against routine care in a future randomized controlled trial.

Trial registration

ClinicalTrials.Gov NCT04151251.

Experiences of Violence Among Individuals With Schizophrenia in Indonesia: A Phenomenological Study

Individuals with schizophrenia have a greater risk of violence compared to the general population. However, the contribution of schizophrenia to violence is heavily debated and remains unclear. The purpose of the current phenomenological study was to explore experiences of violence among individuals with schizophrenia (N = 40, mean age = 35.6 years) in West Java, Indonesia. A purposive sampling method was used to select participants from main referral hospitals. Focus group discussions were held, revealing two main themes-victimization by nurses and victimization by family-and eight sub-themes. Sub-themes for victimization by nurses included physical violence, verbal violence, restraint, neglected basic human needs, and no informed consent. Sub-themes for victimization by family were physical violence, verbal violence, and deception. Patients with schizophrenia have the same rights as all other patients, including the right to dignified treatment, the right to informed consent, and the right to patient safety. [Journal of Psychosocial Nursing and Mental Health Services, xx(x), xx-xx.].

Psychotropic Medication Adherence in Children and Adolescents

Researchers believe that almost 20% of children and adolescents struggle with chronic and persistent mental health concerns. Mental health is the leading cause of disability in the United States. Youth can struggle with several impairing mental health disorders, such as attention-deficit/hyperactivity disorder, mood disorders, psychotic disorders, and autism spectrum disorder. Inadequately treated chronic mental illnesses can adversely affect the growing brain profoundly, including academic decline, early school dropout, cognitive deficits, interpersonal relationship concerns, aggression, suicide attempts or completion, substance use disorders, frequent hospital admissions, and inability to maintain employment. Even if diagnosed early in their course of illness, many of these individuals struggle to continue medications as prescribed. The factors predicting adherence to medications are underresearched in children and adolescents. Psychotropic medication compliance is a complicated issue that is tied to various aspects of caring for a minor individual. Hence, it is relevant to discuss factors that are predicted to contribute to noncompliance in this age group. The purpose of this review is to carefully consider the gaps in knowledge, suggesting interventions by using established instruments and clinical strategies to resolve the identified barriers for improving medication adherence. Compliance should be targeted at various levels, including the entire family tree and the treatment team.

Associations of depression and sociodemographic characteristics with patient activation among those presenting for spine surgery

Purpose

To investigate the associations of sociodemographic characteristics and PROMIS domain scores with patient activation among patients presenting for spine surgery at a university-affiliated spine center.

Methods

Patients completed a survey collecting demographic and social information. Patients also completed the Patient-Reported Outcomes Measurement Information System (PROMIS) and Patient Activation Measure questionnaires. The associations of PROMIS scores and sociodemographic characteristics with patient activation were assessed using linear and ordinal logistic regression (patient activation stage as ordinal).

Results

A total of 1018 patients were included. Most respondents were white (84%), married (73%), and female (52%). Patients were distributed among the 4 activation stages as follows: stage I, 7.7%; stage II, 12%; stage III, 26%; and stage IV, 55%. Mean (±standard deviation) patient activation score was 70 ± 17 points. Female sex (adjusted coefficient [AC] = 4.3; 95% confidence interval [CI] 2.1, 6.4) and annual household income >$80,000 (OR = 3.7; 95% CI 0.54, 6.9) were associated with higher patient activation scores. Lower patient activation scores were associated with worse PROMIS Depression (AC = -0.31; 95% CI -0.48, -0.14), Fatigue (OR = -0.19; 95% CI -0.33, -0.05), Pain (OR = 0.22; 95% CI 0.01, 0.43), and Social Satisfaction (OR = 0.33; 95% CI 0.14, 0.51) scores.

Conclusion

Depression and socioeconomic status, along with PROMIS Pain, Fatigue, and Social Satisfaction domains, were associated with patient activation. Patients with a greater burden of depressive symptoms had lower patient activation; conversely, women and those with higher income had greater patient activation.

Level of evidence

Level 1.

Increasing patient activation scores of vulnerable youth by partnering medical residency programs with public high schools

OBJECTIVE

To assess whether participation in Stanford Youth Coaches Programs (SYCP) increases patient activation scores and patient activation levels for vulnerable youth from low income communities.

METHODS

From 2016 to 18, seven high schools and four residency programs in California, Alabama, Kansas and Missouri participated in SYCPs. Enrolled youth participants completed online pre and post-participation surveys including the Patient Activation Measure (PAM®10). We used paired T-tests, chi square tests, and linear multivariate models to compare pre-and post-scores and levels.

RESULTS

143 participants completed pre- and post-participation surveys. The PAM®10 mean pre-test score was 64.5 and post-test was 69.37, with mean difference 4.89 (p=.002). Participants showed significant improvement in patient activation levels after participation. 60 % participants in lowest activation Level 1; 63 % in Level 2; and 32 % in Level 3 moved to a higher level of activation after participation; 46 % who started in Level 4 moved down to Level 3 after participation.

CONCLUSION AND PRACTICE IMPLICATIONS

Participation in SYCPs has potential to significantly increase patient activation for vulnerable youth which could lead to lifelong improvements in health outcomes and decrease in healthcare costs.

The Wellness Quest: A health literacy and self-advocacy tool developed by youth for youth mental health

Background

Less than 20% of youth who experience mental health difficulties access and receive appropriate treatment. This is exacerbated by barriers such as stigma, confidentiality concerns and lack of mental health literacy. A youth team developed the Wellness Quest: a health literacy tool to enable help‐seeking youth to advocate for themselves.

Objective

To evaluate the content, presentation and utility of the Wellness Quest tool among youth.

Participants

Participants aged 14 to 26.

Methods

A youth research team conducted five focus groups and one online survey to evaluate the Wellness Quest tool. Thematic analysis was used to analyse the qualitative data, and descriptive statistics were used to explore the survey results.

Main results

Overall evaluations of the Wellness Quest were positive: participants felt it would be useful during their mental health help‐seeking journey. Participants expressed the need for information about services for specific populations, such as Indigenous, immigrants, refugees and 2SLGBTQ + youth. They expressed that the tool should be available in complementary online and print versions.

Discussion

Improving mental health literacy may improve mental health by enabling youth and those who support them to recognize and respond to signs of distress and understanding where and how to get help. The Wellness Quest tool may equip youth with the knowledge to make informed decisions and advocate for their own mental health, thereby facilitating help‐seeking among youth.

Patient or public contribution

Youth as service users led all stages of the project, from designing and conducting the study and analysing the data to writing the manuscript.

Can one or two simple questions predict poor medication adherence?

RATIONALE, AIMS, AND OBJECTIVES

Poor adherence to evidence-based medications is a major problem in conventional clinical practise. Better prognostic tools are needed to identify those with the highest likelihood of being non-adherent. The objective of this study is to determine if a 2-item patient activation status (PAS) measure identifies Medicare beneficiaries at risk of poor adherence to drugs typically recommended in treating type 2 diabetes.

METHODS

PAS and medication adherence were assessed for respondents to the 2009 Medicare Current Beneficiary Survey and then compared using bivariate and multivariate tests. Participants' PAS was classified as "active," "high effort," "complacent," or "passive" based on how confident they were in identifying needed medical care and whether they brought medication lists to their doctors' visits. Adherence with oral antidiabetic drugs, angiotensin-converting enzyme-inhibitors/angiotensin receptor blockers, and statins was assessed using proportion of days covered (PDC).

RESULTS

A total of 940 Medicare beneficiaries with diabetes enrolled in Part D plans in 2009. The overall effect of PAS on medication adherence was small (3% lower PDC for complacent/passive vs active/high effort beneficiaries, P < 0.10). However, interactions of complacent/passive PAS with other characteristics associated with poor adherence identified certain subgroups as especially prone to problematic adherence: age < 65 (PDC -11%, P < 0.05), non-Hispanic black (PDC -13%, P < 0.05), and morbidly obese (-9%, P < 0.10).

CONCLUSION

A single question relating to taking medication lists to doctor visits may help identify patient subgroups prone to poor adherence in conventional practise, but larger samples are necessary to validate and extend these findings.

Treating immigrant patients in psychiatric emergency rooms

We examine whether patient variables (geographic origin, gender, Spanish language proficiency) and subjective clinician aspects in emergency department psychiatric encounters (diagnostic certainty, clinician's comfort level with patient) are associated with diagnosis and the use of coercive measures. Using a descriptive cross-sectional design, we recorded 467 visits (400 foreign-born and 67 native-born patients) in hospital psychiatry emergency rooms (ERs) in Barcelona between 2007 and 2015. We first assessed the association of patient variables and subjective clinician aspects of psychiatric encounters with service use outcomes and with mental illness diagnosis. Fitted logistic models predicted the likelihood of service use outcomes and estimated the propensity of receiving each diagnosis. The null model evaluated the role of patient's geographical origin, while the full model evaluated the additional roles of patient's gender and language, the clinician's assessment of the influence of culture in diagnosis, and clinician comfort with two outcomes: patient's diagnosis and use of coercive measures in the ER. Women were less likely to receive coercive measures or intramuscular medications compared to men. Significant ethnic/racial and gender differences were found in receiving certain diagnoses. Additionally, a patient's lower Spanish proficiency was correlated with a higher probability of receiving a psychosis diagnosis. The clinician's level of diagnostic certainty was also positively correlated with increasing clinician-reported comfort with patient. Overall, ethnic factors and the subjective aspects of psychiatric encounters were found to influence diagnosis and the use of coercive measures. Cultural competency programs and interpreter services within psychiatric ER settings should thus be required.

Mental Health Equity in the Twenty-First Century: Setting the Stage

Significant mental health disparities persist in screening, diagnosis, and treatment for racial and ethnic minorities compared with non-Latinx white people. Reducing mental health disparities, and ultimately achieving mental health equity, requires understanding the wide range of factors that influence health outcomes at multiple levels. Components of an effective strategy to achieve mental health equity include increasing population-based care; increasing community-based health care services; addressing the social determinants of health; engaging the community; enhancing the pipeline; and supporting a diverse, structurally competent workforce.

Improving Research Quality to Achieve Mental Health Equity

Inequities and the resulting disparities that exist in mental health for a variety of socially disadvantaged groups have roots in the history and ongoing processes of medical and mental health research, as well as in persisting implicit bias in our society and health care system. The inclusion of historically excluded communities in the research to practice pipeline is vital to ensuring that treatments and interventions are developed to increase equity in mental health. A research framework is proposed based on the integration of community-based participatory research and human-centered design as an avenue for removing inequities and barriers in mental health.

Promoting chronic disease management in persons with complex social needs: A qualitative descriptive study

While there are both ethical and practical imperatives to address health inequity issues related to chronic disease management for persons with social complexity, existing programs often do not appropriately address the needs of these individuals. This leads to low levels of participation in programs, suboptimal chronic disease management, and higher health-care utilization. The aims of this project were to describe the challenges related to availability, accessibility, and acceptability faced by socially complex patients with Chronic Obstructive Pulmonary Disease (COPD) who were eligible, but declined enrollment in a traditional Chronic Disease Management Program (CDMP). Using a qualitative descriptive study approach informed by a health equity lens, interviews with participants, managers, and a focus group with providers were used to gather data addressing the above aims. Qualitative data were analyzed using Braun and Clarke’s theoretical thematic analysis approach. The ability of participants to manage chronic disease was profoundly influenced by contextual and personal factors, such as poverty, disability, personal attitudes and beliefs (including shame, mistrust, and hopelessness), and barriers inherent in the organization of the health-care system. The existing chronic disease management program did not adequately address the most critical needs of socially complex patients. Challenges with accessibility and acceptability of chronic disease management and health services played important roles in the ways these socially complex participants managed their chronic illness. The individualistic approach to self-management of chronic illness inherent in conventional CDMP can be poorly aligned with the needs, capacity, and circumstances of many socially complex patients. Innovative models of care that promote incremental and guided approaches to enhancing health and improving self-efficacy need further development and evaluation.

Parenting Self-Efficacy in Immigrant Families-A Systematic Review

Introduction: Parenting self-efficacy (PSE) refers to parents' belief in their ability to perform the parenting role successfully, and derives from Bandura's concept of personal self-efficacy formulated within the social cognitive theory. PSE has been demonstrated to be a strong predictor of parenting functioning. At the same time, relatively less is known about its possible role in the situation of migration, when a family experiences acculturation stress in the process of adaptation to the new culture. Therefore, the aim of this systematic review was to summarize available data on the conceptualization, measurement, and the role of parenting self-efficacy in the context of acculturation processes, and in various groups of immigrant parents.

Methods: An extensive search of eight electronic databases was conducted in August 2018 and updated in February 2020 to identify peer-reviewed articles on parenting self -efficacy among immigrants. Eleven studies met pre-specified criteria for inclusion. Nine of the studies employed a quantitative design, whereas the remaining two studies used qualitative methods. In three of the quantitative studies, interventions/programs for immigrants were assessed.

Results: Three different approaches to conceptualizing and measuring PSE were identified in the analyzed papers: domain-general, domain-specific, and narrow domain. Incongruent results were found with regards to the links between the strength of PSE and immigrants' cultural orientation. Additionally, PSE was identified as a mediator between a stronger orientation toward the mainstream culture and more supportive parenting. The qualitative studies indicated that a reduction in PSE was typical for the initial period of immigration and might be a consequence of a forced orientation toward the standards of the receiving country, which was a consequence of the parents wanting to maintain close relations with their teenage children.

Discussion: Overall, the theoretical and methodological quality of the reported studies varied and hence their findings have to be interpreted with caution. Our analysis clearly points to the usefulness of a multifaceted approach to PSE. Further research is needed to understand the mechanisms by which parental self-efficacy may exert a positive effect on the functioning of immigrant families.

Measuring Activation in Parents of Youth with Emotional and Behavioral Disorders

For parents of youth with emotional and behavioral disorders, activation, or having the knowledge, skills, and confidence to access and engage in appropriate services for their children, is important for managing their child's mental health care. The Parent Activation Measure (PAM) was modified to create the Parent Patient Activation Measure-Mental Health (P-PAM-MH) to measure activation as part of a randomized controlled trial of a peer parent support intervention for parents of youth with emotional and behavioral problems. Results from this study provide initial support for use of the P-PAM-MH as a measure of activation in this population and for the reliability and validity of the measure. Implications of the findings from this study for research and practice in behavioral health are discussed.

A Systematic Review of Parent and Caregiver Mental Health Literacy

This study aimed to systematically review the current body of research on parent and caregiver mental health literacy. Electronic databases were searched in January 2018 with 21 studies meeting inclusion criteria. A narrative synthesis of quantitative and qualitative studies was conducted. Findings across studies suggest that parents and caregivers had limited mental health knowledge. Factors associated with help-seeking included cultural and religious beliefs, financial and knowledge barriers, fear and mistrust of treatment services, and stigma. Notable limitations include non-representative samples, cross-sectional research designs, and use of inconsistent and non-validated study measures. Research would benefit from more diverse samples, an increased focus on prevention, and controlled trials of educational programmes targeting mental health literacy.

Conversations between Latina mothers and their child's mental health provider: An observational study of shared decision-making regarding pediatric patient mental health needs

OBJECTIVE

To evaluate shared decision-making (SDM) and delineate SDM processes in audio-recorded conversations between language congruent Spanish-/English-speaking clinicians and parents of pediatric mental health patients.

METHODS

Transcripts from audio-recorded consultations were rated using the 5-Item Observing Patient Involvement in Decision Making (Observer OPTION⁵) instrument. One hundred encounters between seventeen clinicians and 100 parents were rated. Interrater reliability for total score was 0.98 between two trained coders (ICC range: 0.799-0.879).

RESULTS

Scores ranged between 0 and 70 on a 100-point scale, with an average total Observer OPTION⁵ score of 33.2 (SD = 17.36). This corresponded to modest success at mutual shared decision-making. Clinicians and parents both showed effort at identifying a problem with treatment options and engaging in team talk. However, preference elicitation and integration were largely lacking.

CONCLUSION

The present sample performed on par with other populations studied to date. It expands the evaluation of observed SDM to include Latino patients and new clinician populations.

PRACTICE IMPLICATIONS

Use of the Observer OPTION^{5 Item} instrument highlights that eliciting and integrating parent/patient preferences is a skill that requires attention when delivering culturally competent interventions.

Parent activation and pediatric primary care outcomes for vulnerable children: A mixed methods study

OBJECTIVE

Among children in low-income families 1) examine associations between parent activation and pediatric primary care outcomes and 2) explore parent perspectives on Parent-Patient Activation Measure (P-PAM) questions in relation to pediatric primary care experiences.

METHODS

We examined associations between P-PAM score via Spanish- or English-language survey and healthcare outcomes abstracted from electronic medical records for parent/child dyads at an urban general pediatrics clinic. Parent perspectives were elicited via qualitative interviews with a subsample of parents who "thought aloud" during P-PAM completion.

RESULTS

Among 316 Spanish (68%) and English-language parent/child dyads, we found associations between parent activation and primary care outcomes only among Spanish-language dyads and only for weight and health status. Findings from 21 interviews provided possible explanations for quantitative findings including question limitations in assessing knowledge, skills, and confidence in pediatric primary care and P-PAM cultural and linguistic appropriateness for low-income Latino populations.

CONCLUSIONS

Pairing quantitative and qualitative methods provided insight on P-PAM measurement limitations and raised questions about its use in patient engagement interventions to reduce health disparities.

PRACTICE IMPLICATIONS

Practices serving vulnerable children and families should consider the limitations of the P-PAM for measuring parent healthcare engagement before utilizing the P-PAM in patient engagement interventions.

Predictors of Adherence to Treatment in Behavioral Health Therapy for Latino Immigrants: The Importance of Trust

A complex array of barriers to care influence patients' adherence to behavioral healthcare services. Understanding barriers to care is critical to ensure sufficient dosage of treatment. This study assessed the influence of perceived barriers on Latino migrants' prospective adherence to treatment for co-occurring mental health and substance use disorders as part of a clinical trial. Eligible participants (18-70 years-old) were recruited from community-based settings and classified according to their intervention session attendance. Baseline assessments included socio-demographic factors, clinical characteristics (i.e., depression, anxiety, post-traumatic stress disorder, substance use), psychosocial and cultural factors (i.e., ethnic identity, health literacy, discrimination), and perceived attitudinal and structural barriers to care. Treatment involved 10-sessions of cognitive-behavioral therapy, psychoeducation, and mindfulness (Integrated Intervention for Dual problems and Early Action) and emphasized participant's engagement in treatment. We used multinomial logistic regression models to examine the association between barriers to care reported at baseline, sociodemographic characteristics, psychosocial and cultural factors, clinical factors, and treatment adherence. Mistrust in previous behavioral health treatment(s) was the reported barrier significantly associated with completion of the program after adjusting for clinical, psychosocial, and cultural factors, with those expressing mistrust in previous treatment(s) showing higher rates of completion compared to those who did not report this barrier. Evidence-based and culturally-tailored interventions provided by ethnically matched providers may overcome cultural mistrust and increase adherence to behavioral health care among Latino immigrants.

Consumers' Suggestions for Improving the Mental Healthcare System: Options, Autonomy, and Respect

While the mental healthcare-consumer voice has gained in legitimacy and perceived value, policy initiatives and system improvements still lack input from consumers. This study explores consumers' suggestions for improving the mental healthcare system. Participants (N = 46) were conveniently recruited and responded to an online survey asking: "What are your suggestions for improving the mental healthcare system?" Eight themes were identified using iterative, inductive and deductive coding. Themes included treatment options, autonomy and empowerment, respect and relationships, medication management, peer support, insurance and access, funding and government support, and treatment environment. Theoretically, there is interdependence among themes where five of the themes are foundational for the three main themes (i.e. treatment options, autonomy and empowerment, respect and relationships). Findings suggest that consumers see the need for improvement in patient-centered care. While access is the focus of much mental healthcare policy discussions, the ultimate goal should be provisioning person-centered mental healthcare.

Change in Patient Activation and Mental Illness Symptoms After Communication Training: A Multisite Study With a Diverse Patient Sample

OBJECTIVE

Patient activation involves patients' ability and motivation to communicate about their health and health care. Research has demonstrated that clinician or patient interventions may improve patient activation. This study explored the degree to which clinician and patient interventions affected both patient activation and symptoms of depression and anxiety in a racially and ethnically diverse clinical sample.

METHODS

Data were from a randomized clinical trial that included 312 patients and 74 clinicians from 13 Massachusetts community- and hospital-based outpatient behavioral health clinics. Patients completed measures of patient activation and depression and anxiety symptoms. Secondary data analyses were conducted to examine the effect of patient and clinician interventions (DECIDE-PA and DECIDE-PC, respectively) on depression and anxiety symptoms and patient activation. A multilevel, mixed-effects simultaneous-equation model was estimated to assess the relationship between the interventions, changes in patients' symptoms, and patient activation.

RESULTS

Clinicians' greater intervention dosage (i.e., more completed DECIDE-PC training sessions) was associated with patients' decreased anxiety symptoms, but associations with patient activation or depression symptoms were not significant. The effect of clinician training dosage on anxiety symptoms was stronger when patients and clinicians were not of the same race-ethnicity. The reduction in patients' anxiety symptoms appeared to increase patient activation.

CONCLUSIONS

Clinician interventions designed to boost patient-clinician communication and the therapeutic alliance may serve to lessen patients' anxiety and may ultimately improve patient activation.

Culturally competent healthcare - A scoping review of strategies implemented in healthcare organizations and a model of culturally competent healthcare provision

Background

Culturally and linguistically diverse patients access healthcare services less than the host populations and are confronted with different barriers such as language barriers, legal restrictions or differences in health beliefs. In order to reduce these disparities, the promotion of cultural competence in healthcare organizations has been a political goal. This scoping review aims to collect components and strategies from evaluated interventions that provide culturally competent healthcare for culturally and linguistically diverse patients within healthcare organizations and to examine their effects on selected outcome measures. Thereafter, we aim to organize identified components into a model of culturally competent healthcare provisions.

Methods and findings

A systematic literature search was carried out using three databases (Pubmed, PsycINFO and Web of Science) to identify studies which have implemented and evaluated cultural competence interventions in healthcare facilities. PICO criteria were adapted to formulate the research question and to systematically choose relevant search terms. Sixty-seven studies implementing culturally competent healthcare interventions were included in the final synthesis. Identified strategies and components of culturally competent healthcare extracted from these studies were clustered into twenty categories, which were organized in four groups: Components of culturally competent healthcare–Individual level; Components of culturally competent healthcare–Organizational level; Strategies to implement culturally competent healthcare and Strategies to provide access to culturally competent healthcare. A model integrating the results is proposed. The overall effects on patient outcomes and utilization rates of identified components or strategies were positive but often small or not significant. Qualitative data suggest that components and strategies of culturally competent healthcare were appreciated by patients and providers.

Conclusion

This scoping review used a bottom-up approach to identify components and strategies of culturally competent healthcare interventions and synthesized the results in a model of culturally competent healthcare provision. Reported effects of single components or strategies are limited because most studies implemented a combination of different components and strategies simultaneously.

Racial And Ethnic Differences In The Attainment Of Behavioral Health Quality Measures In Medicare Advantage Plans

As the Medicare population becomes more diverse and its demand for behavioral health care grows, a better understanding of racial/ethnic disparities in the quality of behavioral health care is crucial. Medicare Advantage (MA) plans are accountable through the public reporting of quality performance on measures, including the Healthcare Effectiveness Data and Information Set (HEDIS). We examined HEDIS data on eight MA behavioral health care quality measures, using mixed-effects logistic regressions to distinguish racial/ethnic differences within and between MA health plans. We found that performance differed across racial/ethnic groups by more than 10 percentage points on most quality measures. Significant within-plan disparities were found in twenty of twenty-four comparisons of racial/ethnic minority groups with whites. Within-plan disparities varied widely across plans, with performance being equivalent across racial/ethnic groups in some plans and widely divergent in others. Unlike other types of medical care, in behavioral health within-plan quality disparities are prominent in MA plans, which suggests a role for stratified reporting by racial/ethnic group.

A Feasibility Trial of Power Up: Smartphone App to Support Patient Activation and Shared Decision Making for Mental Health in Young People

Background

Digital tools have the potential to support patient activation and shared decision making in the face of increasing levels of mental health problems in young people. There is a need for feasibility trials of digital interventions to determine the usage and acceptability of interventions. In addition, there is a need to determine the ability to recruit and retain research participants to plan rigorous effectiveness trials and, therefore, develop evidence-based recommendations for practice.

Objective

This study aimed to determine the feasibility of undertaking a cluster randomized controlled trial to test the effectiveness of a smartphone app, Power Up, co-designed with young people to support patient activation and shared decision making for mental health.

Methods

Overall, 270 young people were screened for participation and 52.5% (142/270) were recruited and completed baseline measures across 8 specialist child mental health services (n=62, mean age 14.66 (SD 1.99) year; 52% [32/62] female) and 2 mainstream secondary schools (n=80; mean age 16.88 [SD 0.68] years; 46% [37/80] female). Young people received Power Up in addition to management as usual or received management as usual only. Posttrial interviews were conducted with 11 young people from the intervention arms (specialist services n=6; schools n=5).

Results

Usage data showed that there were an estimated 50 (out of 64) users of Power Up in the intervention arms. Findings from the interviews indicated that young people found Power Up to be acceptable. Young people reported (1) their motivation for use of Power Up, (2) the impact of use, and (3) barriers to use. Out of the 142 recruited participants, 45.0% (64/142) completed follow-up measures, and the approaches to increase retention agreed by the steering group are discussed.

Conclusions

The findings of this study indicate that the app is acceptable, and it is feasible to examine the effectiveness of Power Up in a prospective cluster randomized controlled trial.

Trial Registration

ClinicalTrials.gov NCT02552797; https://clinicaltrials.gov/ct2/show/NCT02552797 (Archived by WebCite at http://www.webcitation.org/6td6MINP0)

Self-management support in primary care is associated with improvement in patient activation

OBJECTIVES

To examine: 1) whether patient characteristics predict perceived self-management support (usefulness of information and collaborative care planning) by primary care providers after six months, and 2) the association between perceived self-management support and patient activation at 6 months METHODS: We conducted a secondary analysis among 120 primary care patients aged 40 and over with a chronic physical condition and comorbid depressive symptoms who participated in a randomized controlled trial of a coaching intervention for depression self-management. Activation was measured at baseline (T0) and 6 months (T1). Self-management support was captured at T1 for physical and mood problems.

RESULTS

The sample of analysis was 120 patients who completed all relevant measures. At T1, the perceived usefulness of information for mood self-management was independently associated with activation. More severe depressive symptoms at T0 predicted lower perceived usefulness of chronic condition self-management information at T1. Lower T0 mental health-related quality of life predicted lower perceived usefulness of mood self-management information at T1.

CONCLUSIONS

Perceived informational support for mood self-management may contribute to increased activation. Patients with more severe mental health symptoms or impairment perceive that they receive less useful self-management information from their care team.

PRACTICE IMPLICATIONS

Care teams should determine whether patients with mood problems need greater self-management support.

In-Session Caregiver Behaviors during Evidence-Based Intervention Delivery for Children with ASD in Community Mental Health Services

An Individualized Mental Health Intervention for ASD, ("AIM HI"), is a collaborative, caregiver-mediated and child-directed intervention for reducing challenging behaviors in children with autism spectrum disorder developed for delivery in community mental health programs. Using observational data from AIM HI sessions, the present study characterized the occurrence of two types of in-session caregiver behaviors: expressed concerns (i.e., expressing concerns about treatment strategies; expressing difficulty using skills; expressing difficulty completing homework) and participation engagement (i.e., asking questions; participating in session activities; showing commitment to therapy). Further analyses examined cultural differences in caregiver behaviors and associations between caregiver behaviors and clinician adherence. Participants included 39 caregiver-clinician dyads enrolled in a community effectiveness trial of AIM HI. Video recordings from 107 sessions during the first two months of treatment were coded for in-session caregiver behaviors and clinician adherence. Results indicated that expressed concerns were observed in 47% of sessions. When controlling for household income, Latinx caregivers were rated lower for expressing concerns about treatment strategies and demonstrated lower participation engagement behaviors in session compared with non-Latinx White caregivers, suggesting that cultural factors may impact verbal engagement in sessions. Finally, expressing concerns about treatment strategies, expressing difficulty using skills, and participation engagement were positively associated with clinician adherence. Findings suggest that some expressed concerns and participation engagement behaviors may be indicators of positive caregiver engagement in the context of a collaborative intervention, and lower levels of such caregiver engagement may actually impede clinicians' delivery of intensive evidence-based intervention in routine care.

Determinants of quality of life among people diagnosed with schizophrenia at outpatient clinics

PURPOSE

The study examines the determinants of the quality of life (QoL) among outpatients with schizophrenia in Jordan.

DESIGN AND METHODS

A cross-sectional study design was used with 157 people with schizophrenia treated in outpatient clinics. Demographic, clinical and psychosocial variables were examined for their influence on QoL. Data were analysed with descriptive statistics, Pearson product moment correlation and stepwise forward multiple linear regression.

FINDINGS

The majority of the study participants were female, single, unemployed, had secondary level of education or less and were being supported financially by family members. QoL correlated negatively with advanced age, male gender, longer duration of illness, high body mass index and prescribed typical anti-psychotic medication. However, it was correlated positively with employment and being married. Illness duration, recurrent hospitalisation, knowledge level about schizophrenia, psychiatric symptoms and coping mechanisms were found to be key significant predictors of QoL among participants.

PRACTICAL IMPLICATIONS

The study findings enhance our understanding of socio-demographic, clinical and psychosocial characteristics influencing the QoL in people with schizophrenia. Involvement of families in the management process may improve patients' ability to be integrated in the community and be more socially active.

The correlation between the quality of life and clinical variables among outpatients with schizophrenia

The study identifies the correlation between the quality of life (QoL) among outpatients with schizophrenia and clinical outcomes. A cross-sectional study design was used with 157 people with schizophrenia treated in outpatient clinics. Demographic, clinical and psychosocial variables were examined for their influence on QoL. Data were analysed with descriptive statistics, Pearson product moment correlation and stepwise forward multiple linear regression. The majority of the study participants were female, single, unemployed, had secondary level of education or less and were being supported financially by family members. QoL correlated negatively with advanced age, male gender, longer duration of illness, high body mass index and prescribed typical anti-psychotic medication. However, it was related positively with employment and being married. Illness duration, recurrent hospitalisation, knowledge level about schizophrenia, psychiatric symptoms and coping mechanisms were found to be key significant predictors of QoL among participants. The study findings enhance our understanding of socio-demographic, clinical and psychosocial characteristics influencing the QoL in people with schizophrenia. Involvement of families in the management process may improve patients' ability to be integrated in the community and be more socially active.

Physician referral to a psychologist: Testing alternative behavioral healthcare seeking models

OBJECTIVE

Primary care physicians (PCPs) often refer patients to psychological services, but help-seeking factors in the context of behavioral healthcare referral are understudied. This study examined perceptions of seeking psychological help for depression by comparing alternative structural equation models derived from the Theory of Reasoned Action (TRA).

METHOD

Internet survey participants (N = 685 US adults, 77% female, M _age  = 45) imagined themselves in a vignette scenario in which they are experiencing depression symptoms and encouraged by a PCP to see a psychologist.

RESULTS

Results supported the indirect model, in which the links between distal help-seeking factors (i.e., self-stigma, symptom recognition, perceived effectiveness of treatment) and intention to follow through on the referral to the psychologist were fully mediated by the more proximal TRA factors (i.e., attitudes, subjective norms, etc).

CONCLUSIONS

Our findings supported the use of TRA in understanding peoples' intention to seek psychological help for depression when referred by their PCP.

Examining contradictory evidence on racial/ethnic differences in perceived need for behavioral health treatment

OBJECTIVES

The study aims to investigate apparently contradictory evidence regarding racial/ethnic differences in perceived need for behavioral health treatment in two prominent surveys of the U.S. population, the National Comorbidity Survey Replication (NCS-R) and the National Survey of Drug Use and Health (NSDUH).

METHODS

The two surveys were compared with respect to two components of perceived need: service use and perceived need among the untreated. Logistic regression models were estimated to adjust comparisons for demographic characteristics. Comparisons were conducted in samples representing the entire population, without selection on a mental health assessment, and for samples meeting criteria for lifetime major depression.

RESULTS

The surveys are concordant with respect to racial/ethnic differences in service use and discordant with respect to perceived need among the untreated. For instance, among untreated individuals, the odds of perceiving a need for treatment are significantly higher in Blacks than Whites in the NCS-R (OR = 1.8, 95% CI [1.1, 2.9]) but do not differ between these groups in the NSDUH (OR = 0.9, 95% CI [0.7, 1.2]). Temporal trends do not appear to explain this discordance.

CONCLUSION

Assessments of racial/ethnic differences in perceived need among untreated individuals are affected by methodological differences across surveys. Resolving contradictory evidence is critical to efforts to reduce racial/ethnic disparities.

Interventions to Increase Depression Treatment Initiation in Primary Care Patients: a Systematic Review

INTRODUCTION

Nearly 50% of depressed primary care patients referred to mental health services do not initiate mental health treatment. The most promising interventions for increasing depression treatment initiation in primary care settings remain unclear.

METHODS

We performed a systematic search of publicly available databases from inception through August 2017 to identify interventions designed to increase depression treatment initiation. Two authors independently selected, extracted data, and rated risk of bias from included studies. Eligible studies used a randomized or pre-post design and assessed depression treatment initiation (i.e., ≥ 1 mental health visit or antidepressant fill) among adults, the majority of whom met criteria for depression. Interventions were classified as simple or complex and sub-classified into intervention strategies that were graded for strength of evidence.

RESULTS

Of 9516 articles identified, we included 14 unique studies representing 16 (4 simple and 12 complex) interventions and 8 treatment initiation strategies. We found low to moderate strength of evidence for collaborative/integrated care (3 studies), treatment preference matching (2 studies), and case management (2 studies) strategies. However, there was insufficient evidence to determine the benefit of cultural tailoring (2 studies), motivation (alone, with reminders or with cultural tailoring (5 studies)), education (1 study), and shared decision-making strategies (1 study). Overall, we found moderate strength of evidence for complex interventions (8 of 12 complex interventions demonstrated statistically significant effects on treatment initiation).

DISCUSSION

Collaborative/integrated care, preference treatment matching, and case management strategies had the best evidence for improving depression treatment initiation, but none of the strategies had high strength of evidence. While primary care settings can consider using some of these strategies when referring depressed patients to treatment, our review highlights the need for further rigorous research in this area.

Shared decision-making and parental experiences with health services to meet their child's special health care needs: Racial and ethnic disparities

OBJECTIVES

Test the relationship between shared decision-making (SDM) and parental report of frustration with efforts to get services for their child and to address unmet health needs; assess SDM's influence on minority parents' service experiences.

METHODS

Performed secondary analysis using the 2009-2010 National Survey of Children with Special Health Care Needs (n = 40,242). Used multivariate logistic regressions to test the association between SDM and parent-reported service experiences, and whether SDM influenced the association between minorities and negative service experiences. Propensity scores accounted for observed selection bias.

RESULTS

Families engaged in SDM had lower odds of reporting service dissatisfaction. Fewer minority parents reported SDM engagement compared with Whites (between 62% and 66% versus 74%). Blacks engaged in SDM had higher odds of reporting negative service experiences compared with SDM-engaged Whites. This disparity was no longer significant after adjusting for covariates.

CONCLUSION

SDM is associated with lower reports of parental service dissatisfaction. Stratified analyses showed that SDM seems to be experienced differently across minority groups.

PRACTICE IMPLICATIONS

SDM may be a promising engagement strategy to improve parental service experiences. The role of SDM on increasing Black parents' reports of service dissatisfaction, perhaps due to increased awareness of service challenges, should be investigated.

Evaluation of a Brief Intervention for Promoting Mental Health among Employees in Social Enterprises: A Cluster Randomized Controlled Trial

Evidence on the effectiveness of workplace mental health promotion for people with disabilities is limited. This study aimed to evaluate the effectiveness of a brief mental health promotion intervention in social enterprises. It had a non-blinded cluster randomized controlled trial design with follow-up one and four months after the intervention. In total 196 employees agreed to participate (86 intervention and 110 control). Empowerment was the main outcome; secondary outcomes were resilience, palliative behavior, determinants of four coping strategies of mental health, quality of life, and life satisfaction. A brief participant satisfaction survey was conducted after the intervention. No significant intervention effect on empowerment was found. However, at one month follow-up, significant favorable effects were found on perceived social support for coping strategies for mental health and on palliative behavior. At four months follow-up, favorable intervention effects were found on quality of life, but unfavorable effects were found on unjustified worrying. In addition, the intervention was well received by the employees. This brief intervention might be a promising first step to improve mental health in people with disabilities working in social enterprises. Nevertheless, additional monitoring by professionals and managers working in the organizations might be needed to maintain these effects.

Implementing CommonGround in a community mental health center: Lessons in a computerized decision support system

OBJECTIVE

Although shared decision making (SDM) is a key element of client-centered care, it has not been widely adopted. Accordingly, interventions have been developed to promote SDM. The aim of this study was to explore the implementation process of one SDM intervention, CommonGround, which utilizes peer specialists and a computerized decision support center to promote SDM.

METHOD

As part of a larger study, CommonGround was implemented in 4 treatment teams in a community mental health center. The implementation process was examined by conducting semistructured interviews with 12 staff members that were integral to the CommonGround implementation. Responses were analyzed using content analysis. Program fidelity and client program use were also examined.

RESULTS

Although key informants identified several client and staff benefits to using CommonGround, including improved treatment engagement and availability of peer specialists, most clients did not use CommonGround consistently throughout the implementation. Key informants and fidelity reports indicated a number of program (e.g., technological difficulties, increased staff burden) and contextual barriers (e.g., poor fit with service structure, decision support center location, low staff investment and high turnover) to the successful implementation of CommonGround. Strategies to maximize the implementation by increasing awareness, buy-in, and utilization are also reported.

CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

This implementation of CommonGround was limited in its success partly as a result of program and contextual barriers. Future implementations may benefit from incorporating the strategies identified to maximize implementation in order to obtain the full program benefits. (PsycINFO Database Record