The State School Mental Health Profile: Findings from 25 States

BACKGROUND

State-level leadership and conditions are instrumental to local and regional comprehensive school mental health system (CSMHS) quality, sustainability, and growth. However, systematic documentation of state-level school mental health (SMH) policy, infrastructure, funding, and practice is limited.

METHODS

Using a multi-phase, multi-method process, we developed the State School Mental Health Profile (State Profile) to offer a comprehensive landscape of state SMH efforts. State leaders in 25 states completed the State Profile once over a 3-year data collection period. Mixed methods results are reported in 8 domains.

RESULTS

State education agencies were reportedly most involved in SMH technical assistance, advocacy, leadership, funding, and service provision, with mental health agencies reported as second most involved. Nearly half of state respondents reported having a state-level SMH director or coordinator. Policies with the greatest perceived impact require implementation of and funding for SMH services and supports. Despite leveraging multiple sources of funding, most states emphasized lack of funding as a primary barrier to establishing CSMHSs. All states reported staffing shortages.

CONCLUSION

The State Profile can assist multi-agency state leadership teams to self-assess policy, infrastructure, and resources to support CSMHSs statewide. Findings point to areas of opportunity to advance equity across resource allocation, service provision, and policy development.

Using the Whole School, Whole Community, Whole Child Model to Support Mental Health in Schools

The COVID-19 pandemic increased already high rates of student mental health concerns and further underscored inequities and disparities in access to services and care. As schools continue to address the effects of the pandemic, they must prioritize student mental health and well-being. In this commentary, using feedback from the Maryland School Health Council, we present the connection between mental health in school and the Whole School, Whole Community, Whole Child (WSCC) model, a school health model commonly employed by schools and school districts. In doing so, we aim to highlight how school districts can use this model to address child mental health needs across a multi-tiered system of support.

Effectiveness of an online suicide prevention program for college faculty and students

Objective: Suicide prevention programs help college staff and students identify students at-risk for suicide. Kognito is an online, simulation-based suicide prevention program. The purpose of the current study was to evaluate Kognito's effectiveness in changing suicide prevention attitudes and behavior. Participants: 170 college students and 140 college staff completed the training module and three surveys. Methods: College staff and students from 24 public, private, and community colleges and universities in Maryland completed Kognito modules and pre-, post-, and 3-month follow-up assessments. Results: Both college staff and students exhibited significant improvements in reported Preparedness, Likelihood, and Self-Efficacy in gatekeeper attitudes. Students reported significant gains in gatekeeper intervention behaviors. Conclusions: The current results suggest that Kognito is associated with attitudinal change for college staff and students, but only college students demonstrated statistically significant behavioral impact for both being more likely to ask about suicide and refer peers to counseling.

Trauma-Focused Cognitive Behavioral Therapy in 13 Urban Public Schools: Mixed Methods Results of Barriers, Facilitators, and Implementation Outcomes

Trauma-focused cognitive behavioral therapy (TF-CBT) is an evidence-based intervention to treat Post-traumatic Stress Disorder among youth ages 3-18 years. In this pilot study, 31 clinicians in 13 urban public schools received TF-CBT training to improve access to a high-quality trauma treatment for youth in need. A mixed methods design was used to assess implementation barriers, facilitators and outcomes to examine initial feasibility, acceptability, and appropriateness of TF-CBT delivered in school settings. Although 70% of clinicians reported confidence in the evidence-base of TF-CBT and its potential to support their students who have a very high prevalence of lifetime trauma exposure, implementation practice outcomes suggest a wide range of TF-CBT use (Range = 0 to 11 students enrolled per clinician, Mean = 1.4 students) with 23 clinicians implementing the TF-CBT model with at least one case. Results point to the potential value of training school mental health clinicians in TF-CBT based on its compatibility with student needs. Yet, by connecting focus group results to top-rated barriers and facilitators, we identify several adjustments that should be made to improve intervention-setting fit in future studies. Specifically, school setting-specific intervention adaptations, school-tailored implementation support and thoughtful consideration of school-based clinicians' roles and responsibilities are needed to enhance future implementation success.

Novel cryoballoon to isolate pulmonary veins in patients with paroxysmal atrial fibrillation: one-year outcomes in a multicenter study

Background

Recently, a novel cryoballoon (CB; POLARx) has been developed with increased steerability which maintains size and pressure throughout the ablation. Initial clinical data has demonstrated acute procedural safety and efficacy in de novo pulmonary vein isolation (PVI) procedures in patients with paroxysmal atrial fibrillation (AF). However, there are limited studies demonstrating the long-term efficacy of the CB.

Purpose

To evaluate the long-term safety and efficacy of the novel CB in treating paroxysmal AF.

Methods

This was a non-randomized, prospective, multi-center study. Fifty-eight consecutive patients with paroxysmal AF were enrolled at 4 centers for de novo PVI procedures. Cryoablation was delivered for 180s if time to isolation was ≤60s. Otherwise a 240s cryoablation was performed. PVI was confirmed with entrance and exit block testing. Patients were followed for 1 year with 24-hour Holter monitoring at 3, 6, and 12 months. After a 3-month blanking period, recurrence was defined as having any documented, symptomatic episode(s) of AF or atrial tachycardia.

Results

Acute isolation with the CB was achieved in 230 of 231 pulmonary veins (99.6%) with 5.2±1.5 cryoapplications per patient (1.3±0.6 cryoapplications per vein). There were 4 patients (6.9%) with phrenic nerve injury (3 resolved during the index procedure; 1 resolved at 6 months follow-up). One serious adverse device event was reported: femoral arterial embolism event occurring 2 weeks post index procedure (1.7%). Of the 56 patients that had complete 12-month follow-up, 43 (76.8%) were free from recurrent atrial arrhythmias.

Conclusion

Initial multicenter clinical experience with the novel CB has demonstrated long-term safety and efficacy of PVI in patients with paroxysmal AF. Further studies are underway to confirm these findings.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): Boston Scientific

Baseline brain function in the preadolescents of the ABCD Study

The Adolescent Brain Cognitive Development (ABCD) Study® is a 10-year longitudinal study of children recruited at ages 9 and 10. A battery of neuroimaging tasks are administered biennially to track neurodevelopment and identify individual differences in brain function. This study reports activation patterns from functional MRI (fMRI) tasks completed at baseline, which were designed to measure cognitive impulse control with a stop signal task (SST; N = 5,547), reward anticipation and receipt with a monetary incentive delay (MID) task (N = 6,657) and working memory and emotion reactivity with an emotional N-back (EN-back) task (N = 6,009). Further, we report the spatial reproducibility of activation patterns by assessing between-group vertex/voxelwise correlations of blood oxygen level-dependent (BOLD) activation. Analyses reveal robust brain activations that are consistent with the published literature, vary across fMRI tasks/contrasts and slightly correlate with individual behavioral performance on the tasks. These results establish the preadolescent brain function baseline, guide interpretation of cross-sectional analyses and will enable the investigation of longitudinal changes during adolescent development.

P1415Wide antral circumferential pulmonary vein isolation ablation using a novel balloon cryoablation catheter

Background

Pulmonary vein isolation using cryotherapy is an established treatment for the management of patients with paroxysmal atrial fibrillation. Ablation using the commercially available balloon cryocatheter has been shown to create wide antral pulmonary vein isolation. A novel balloon cryocatheter (BCC) has been designed to maintain uniform pressure and size during ablation, potentially improving contact with the antral anatomy. The extent of ablation created using the novel BCC has not previously been established.

Purpose

To determine the anatomical extent of pulmonary vein isolation using electroanatomical mapping when performing catheter ablation for paroxysmal atrial fibrillation using the novel BCC.

Methods

Nine consecutive patients underwent pre-procedure computed tomography angiography of the left atrium to quantify the chamber dimensions. An electroanatomical map was created using the cryoablation system mapping catheter and a high definition mapping system. A bipolar voltage map was obtained following ablation to determine the extent of pulmonary vein isolation ablation. A volumetric technique was used to quantify the extent of vein and posterior wall electrical isolation in addition to traditional techniques for proving entrance and exit block.

Results

All patients had paroxysmal atrial fibrillation, mean age 56 years, 7 (78%) male. Electrical isolation was achieved for 100% of the pulmonary veins; mean total procedure time was 109 min (+/- 26 SD), and fluoroscopy time 14.9 min (+/- 2.4 SD). The median treatment applications per vein was one (range one - four), and median treatment duration 180 sec (range 180 -240). Left atrial volume 32 mL/m2 (+/- 7 SD), and mean left atrial posterior wall area 22 cm2 (+/- 4 SD). Data was available for quantitative assessment of the extent of ablation for eight patients. No lesions (0 of 32) were ostial in nature. The antral surface area of ablation was not statistically different between the left and right sided pulmonary veins (p 0.63), which were 5.9 (1.6 SD) and 5.4 (2.1 SD) cm2 respectively. In total 50% of the posterior left atrial wall was ablated. 

Conclusion

Pulmonary vein isolation using a novel BCC provides a wide and antral lesion set. There is significant debulking of the posterior wall of the left atrium.

Abstract Figure.

Can We Move the Needle on School Mental Health Quality Through Systematic Quality Improvement Collaboratives?

Learning collaboratives (LCs) have often been used to improve somatic health care quality in hospitals and other medical settings, and to some extent to improve social services and behavioral health care. This initiative is the first demonstration of a national, systematic LC to advance comprehensive school mental health system quality among school district teams. Twenty-four districts representing urban, rural, and suburban communities in 14 states participated in one of two 15-month LCs. Call attendance (M = 73%) and monthly data submission (M = 98% for PDSA cycles and M = 65% for progress measures) indicated active engagement in and feasibility of this approach. Participants reported that LC methods, particularly data submission, helped them identify, monitor and improve school mental health quality in their district. Qualitative feedback expands quantitative findings by detailing specific benefits and challenges reported by participants and informs recommendations for future research on school mental health LCs. Rapid-cycle tests of improvement allowed teams to pursue challenging and meaningful school mental health quality efforts, including mental health screening in schools, tracking the number of students receiving early intervention (Tier 2) and treatment (Tier 3) services, and monitoring psychosocial and academic improvement for students served.

Enhancing the Relevance and Effectiveness of a Youth Gambling Prevention Program for Urban, Minority Youth: A Pilot Study of Maryland Smart Choices

Youth with problem gambling behaviors are susceptible to serious academic, behavioral, and mental health consequences including school failure, criminal involvement, and depression. Coupled with increased exposure to gambling formats, issues related to youth gambling have been deemed a serious public health issue requiring increased prevention efforts. However, the literature is limited in terms of evidence-based gambling prevention programs warranting the development of The Maryland Smart Choices Program (MD-Smart Choices), a gambling prevention program for middle and high school youth. This 3-session, 45-min program was developed for implementation in Baltimore City Public Schools, an urban and predominately African American district with specific aims to engage students, encourage positive behavior, and facilitate learning related to gambling disorder. Pre-post program participation assessments were collected from 72 students across 5 different schools. Results yielded significant increases in student awareness and knowledge following participation in MD-Smart Choices. Focus group data collected from program facilitators suggested high student engagement and participation, program feasibility, and ease of implementation. Study implications and future directions are discussed.

School-Based Telepsychiatry in an Urban Setting: Efficiency and Satisfaction with Care

Background and Introduction: Given the shortage of child psychiatrists in most areas, telepsychiatry may increase accessibility of psychiatric care in schools, in part by improving psychiatrists' efficiency and reach. The current study assessed consumer and provider satisfaction with school-based telepsychiatry versus in-person sessions in 25 urban public schools and compared the efficiency of these service delivery models. Materials and Methods: In total, 714 satisfaction surveys were completed by parents, students, school clinicians, and child psychiatrists following initial (26.3%) and follow-up (67.2%) visits (6.4% did not indicate type of visit). Most of these surveyed visits were for medication management (69.9%) or initiation of medication (22%). Efficiency analyses compared time saved via telepsychiatry versus in-person care. Researchers also conducted focus groups with providers to clarify preferences and concerns about telepsychiatry versus in-person visits. Results: Consumers were highly satisfied with both in-person and telepsychiatry-provided school psychiatry services and showed no significant differences in preference. Providers reported both in-person and telepsychiatry were equally effective and showed a slight preference for in-person sessions, citing concerns about ease of video equipment use. Telepsychiatry services were more efficient than in-person services, as commute/setup occupied about 28 psychiatrist hours total per month. Discussion and Conclusions: Findings suggest that students, parents, and school clinicians perceive school-based telepsychiatry positively and equal to on-site care. Child psychiatrists have apprehension about using equipment, so equipment training/preparation and provision of technical support are needed. Implications of study findings for telepsychiatry training and implementation in schools are discussed.

Telemental Health in Schools

OBJECTIVE

The purpose of this study was to describe the potential and limits of school telemental health (TMH) to support a full continuum from mental health promotion to intervention, particularly for students less likely to access community care.

METHODS

A review of school TMH literature and model programs, and of data from focus groups with child psychiatry fellows, was undertaken to inform best practices and future directions for TMH in schools.

RESULTS

Existing data suggest that TMH with children and adolescents is promising and well received. Child and adolescent psychiatrists use various models for conducting school-based TMH, which differ in the level of direct care and types of services provided. Literature review and focus group data suggest that advantages of school TMH include greater efficiency, the capacity for higher volume, and increased access to care for many students who would be unlikely to reach traditional community mental healthcare because of barriers such as transportation and healthcare coverage. Disadvantages of school TMH service provision include patient concerns about their own privacy as well as concerns related to the psychiatrist's ability to effectively engage families in care without being present in person. Fellows also noted that the training experience of physically being in the school building and experiencing the school expectations and culture helps them move toward greater appreciation and understanding of the structures, policies, and opportunities and challenges for schools and school-based professionals. Most agreed that a "hybrid" model of care, with some in-person and some TMH care may be most beneficial to all parties, promoting both engagement and efficiency simultaneously.

CONCLUSIONS

School TMH should be considered as part of a comprehensive service delivery system for students, in order to address shortages and gaps in specialty child and adolescent mental healthcare, and to maximize efficiency and productivity.

Strategies for integrating mental health into schools via a multitiered system of support

To fully realize the potential of mental health supports in academic settings, it is essential to consider how to effectively integrate the mental health and education systems and their respective resources, staffing, and structures. Historically, school mental health services have not effectively spanned a full continuum of care from mental health promotion to treatment, and several implementation and service challenges have evolved. After an overview of these challenges, best practices and strategies for school and community partners are reviewed to systematically integrate mental health interventions within a school's multitiered system of student support.

Challenges and ideas from a research program on high-quality, evidence-based practice in school mental health

This article reviews the progression of a research program designed to develop, implement, and study the implementation of "achievable" evidence-based practices (EBPs) in schools. We review challenges encountered and ideas to overcome them to enhance this avenue of research. The article presents two federally funded randomized controlled trials involving comparison of a four-component targeted intervention (Quality Assessment and Improvement, Family Engagement and Empowerment, Modular Evidence-Based Practice, Implementation Support) versus a comparison intervention focused on personal wellness. In both studies, primary aims focused on changes in clinician attitudes and behavior, including the delivery of high-quality EBPs and secondary aims focused on student-level impacts. A number of challenges, many not reported in the literature, are reviewed, and ideas for overcoming them are presented. Given the reality that the majority of youth mental health services are delivered in schools and the potential of school mental health services to provide a continuum of mental health care from promotion to intervention, it is critical that the field consider and address the logistical and methodological challenges associated with implementing and studying EBP implementation by clinicians.

Telepsychiatry and school mental health

The provision of mental health services in schools has been one effective strategy for reaching out to a greater number of youth to identify and provide treatment for mental health issues. With the increasing challenges related to shortages in child and adolescent psychiatrists, it is critical to develop models of care that can maximize a full range of mental health services for all children and adolescents who need them. Telehealth offers an innovative distance technology strategy to effectively and efficiently provide access to psychiatric services in schools. Telepsychiatry has the potential to better link and enhance the provision of health services, and can be particularly beneficial in addressing geographic distance and/or capacity issues. This article describes the clinical, educational, and administrative uses of telemental health in the school environment with mental health professionals and staff.

Abnormal glucose metabolism and features of the metabolic syndrome are common in patients presenting for elective cardiac catheterization

BACKGROUND

Abnormalities of glucose metabolism and the metabolic syndrome, including excess bodyweight, are potentially modifiable risk factors for cardiac morbidity and mortality. This study aimed to determine the prevalence of these in a group of patients presenting for elective cardiac catheterization or percutaneous intervention.

METHODS

Data were prospectively collected on 297 consecutive patients presenting for elective cardiac catheterization or percutaneous intervention at a single tertiary referral centre. Demographic data, risk factors, medications and coronary angiogram results were recorded. Fasting lipids, fasting glucose, HbA1c levels were measured and if necessary an oral glucose tolerance test was carried out. Logistic regression and contingency table analysis examined associations of these with ethnicity.

RESULTS

Impaired glucose metabolism (diabetes, impaired glucose tolerance or impaired fasting glucose) was present in 46.1% with our screening programme detecting previously unknown impaired glucose metabolism in 22.9%. Impaired glucose metabolism was strongly associated with non-European ethnicity (P < 0.0001). The metabolic syndrome was present in 49.2%. When defined by ethnic specific cut-offs, overweight or obesity was present in >80% of patients in all ethnic groups.

CONCLUSION

There is a very high prevalence of impaired glucose metabolism and the metabolic syndrome in patients presenting for cardiac catheterization. Impaired glucose metabolism is particularly prevalent in the Polynesian and the Indian and the Sri Lankan ethnic groups. Screening of patients undergoing elective cardiac catheterization identifies a significant number of patients with undiagnosed impaired glucose metabolism and should be carried out routinely.

A drop-out prevention program for high-risk inner-city youth

Inner-city youth are at high risk for dropping out of high school. Within this article, risk factors associated with dropout and strategies for effective prevention and intervention are reviewed. An example of a school-based drop-out prevention program is highlighted. The FUTURES Program is a school-based drop-out prevention program designed to address the needs of high-risk youth through smaller classes, character development, career preparation, case management/mentoring, positive incentives, and access to mental health services. Components of the program are described in detail and data evaluating the effectiveness of the program are presented. Directions for the future development of programs and conducting research to prevent dropout by inner-city youth are discussed.