Symptoms, circumstances, and service systems: Pathways to psychiatric crisis service use among uninsured young adults

Young adults have low rates of outpatient service utilization and higher rates of emergency service use compared to older adults. This study explored pathways to crisis service use for uninsured young adults who accessed emergency psychiatric treatment. Participants were 55 young adults (ages 18-25) who were on an inpatient short-term stabilization unit and had qualifying diagnoses for outpatient services (bipolar, major depression, or schizophrenia). Semistructured qualitative interviews were conducted to understand decision-making and the events that led to service use. A team of coders used an open coding approach to develop a codebook and participated in iterative discussions of coded text to generate results presented. Themes across 3 dimensions were identified. Participants formed the intention to seek treatment through the interaction of escalating symptoms, triggering events, and motivating factors. Intention was translated to actualized service use through individual and systemic facilitators. Natural supports and service systems influenced the entire process. Findings highlight the importance of understanding motivating factors to better engage young people in treatment and including their support systems in efforts to increase awareness of problems and treatments. Systemic barriers identified suggest the need for enhanced coordination of care across systems such as drug and alcohol treatment, homeless services, and criminal justice and for ready access to outpatient services to reduce crisis psychiatric service use. (PsycINFO Database Record

Development and piloting of a treatment foster care program for older youth with psychiatric problems

BACKGROUND

Older youth in out-of-home care often live in restrictive settings and face psychiatric issues without sufficient family support. This paper reports on the development and piloting of a manualized treatment foster care program designed to step down older youth with high psychiatric needs from residential programs to treatment foster care homes.

METHODS

A team of researchers and agency partners set out to develop a treatment foster care model for older youth based on Multi-dimensional Treatment Foster Care (MTFC). After matching youth by mental health condition and determining for whom randomization would be allowed, 14 youth were randomized to treatment as usual or a treatment foster home intervention. Stakeholders were interviewed qualitatively at multiple time points. Quantitative measures assessed mental health symptoms, days in locked facilities, employment and educational outcomes.

RESULTS

Development efforts led to substantial variations from the MTFC model and a new model, Treatment Foster Care for Older Youth was piloted. Feasibility monitoring suggested that it was difficult, but possible to recruit and randomize youth from and out of residential homes and that foster parents could be recruited to serve them. Qualitative data pointed to some qualified clinical successes. Stakeholders viewed two team roles - that of psychiatric nurse and skills coaches - very highly. However, results also suggested that foster parents and some staff did not tolerate the intervention well and struggled to address the emotion dysregulation issues of the young people they served. Quantitative data demonstrated that the intervention was not keeping youth out of locked facilities.

CONCLUSIONS

The intervention needed further refinement prior to a broader trial. Intervention development work continued until components were developed to help address emotion regulation problems among fostered youth. Psychiatric nurses and skills coaches who work with youth in community settings hold promise as important supports for older youth with psychiatric needs.

Conceptualizing the Step-Down for Foster Youth Approaching Adulthood: Perceptions of Service Providers, Caseworkers, and Foster Parents

Studies find considerable movement between residential treatment and less restrictive foster home settings, with approximately half of foster youth who are stepped down eventually returning to a higher level of care. Very little is known about the step down for foster youth who are approaching adulthood in locked residential facilities. A qualitative study of stepping down a small sample of foster youth, as perceived by team members delivering a model of treatment foster care, is presented. These findings reveal the dimensions of stepping down foster youth at the onset of adulthood, and highlight the importance of providing foster youth with developmental opportunities to engage in the social roles and tasks of late adolescence and/or early adulthood. Implications for further refining the concept of stepping down from a developmental perspective are discussed.

Stepping Down and Stepping In: Youth's Perspectives on Making the Transition from Residential Treatment to Treatment Foster Care

Older youth preparing to emancipate from the foster care system are often served in residential treatment settings where they have limited opportunities to practice skills for independent living in a community setting. Stepping these youth down to less restrictive environments such as treatment foster care is a growing trend, especially for youth with mental health issues. Yet, few studies have explored the youth's perspective on making this transition. This study utilized qualitative interviews with youths who were participating in a treatment foster care intervention study (n=8) to gain their perspectives on the process of transitioning from residential care. Youths were interviewed right before they exited residential care and two months after placement in the new foster home. Youths reported hopes for gaining family in the new home as well as fears of placement disruption. Findings point to the need to enlist youths in discussion and problem solving about difficulties they anticipate in the new home and expectations for their relationship with the new foster parents. In addition, the struggles described after two months in the home point to the need for youths to build specific skills to better manage ongoing relationships with foster parents and for foster parent training on how to help build these skills.

Patterns of distress, precipitating events, and reflections on suicide attempts by young Latinas

By most epidemiological accounts, young US Latinas attempt suicide more often than other youth. Little is known, however, about the circumstance and internal experiences of the attempts. To understand this phenomenon, we conducted thematic analyses of twenty-seven qualitative interviews with teenage Latinas (aged 11-19) living in New York City who had attempted suicide. Collected between July 2005 and July 2009, the interviews explored the emotional, cognitive and physical experiences of the attempts and the social situations in which they took place. Results show that the girls were divisible nearly equally into a group with a stated intent of death and a group that did not intend death. The pathways to the suicidal event consisted of a pattern of continuous, escalating stress (primarily at home) that created the emotionally combustible conditions for the attempt. A trigger event that either reminded them of past stress or revived feelings of that stress catalyzed the attempt. Guilt and remorse were common responses to the suicide attempts, and on reflection the girls demonstrated some broader perspectives. Results of the analysis clarify the sociocultural context of the suicide attempts, underscoring the cultural discontinuity experienced by adolescent Latinas, who struggle to reconcile traditional Hispanic gender socialization with their own insertion in a modern Western society.

Funneling Child Welfare Consumers into and through the Mental Health System: Assessment, Referral, and Quality Issues

This qualitative study explores how consumers of child welfare services reach nonpsychiatric mental health providers and the perceived quality of these services. It relies on iterative interviews with individuals and groups, as well as on court observations from one metropolitan area. Results suggest that, consistent with theories of street-level bureaucracy, efficiency issues drive mental health service use, as clients are routinely subjected to psychological evaluations and funneled into mental health services as a matter of course. Referral practices are shaped by child welfare professionals' routines, discretion, and desire to meet such system objectives as providing short turnaround times for reports. The results suggest that, despite stakeholders' best intentions, maltreated children are not benefiting from thoughtful processes geared to screen for, assess, and provide targeted treatment for unmet mental health needs.

Case managers speak out: responding to depression in community long-term care

OBJECTIVE

This study sought to understand how case managers in one publicly funded health and social service system, community long-term care, understand and address depression among their clients.

METHODS

Four focus groups with a total of 18 case managers were conducted. Case managers were asked a series of questions about their perspectives on the recognition and treatment of depression, including subthreshold depression, in community long-term care.

RESULTS

Case managers perceived addressing depression as complex because of competing demands. Furthermore, case managers perceived conflict between their current role and what it would take to expand their role to include addressing depression.

CONCLUSIONS

Case managers suggested that in order to successfully improve the detection and treatment of depression in community long-term care, systemic changes, such as increased support and training, may be necessary, along with a shift in the professional role of case managers.

Implementation of evidence-based practice in community behavioral health: agency director perspectives

Despite a growing supply of evidence-based mental health treatments, we have little evidence about how to implement them in real-world care. This qualitative pilot study captured the perspectives of agency directors on the challenge of implementing evidence-based practices in community mental health agencies. Directors identified challenges as limited access to research, provider resistance, and training costs. Director leadership, support to providers, and partnerships with universities were leverage points to implement evidenced-based treatments. Directors' mental models of EBP invoked such concepts as agency reputation, financial solvency, and market niche. Findings have potential to shape implementation interventions.

A crisis of credibility: professionals' concerns about the psychiatric care provided to clients of the child welfare system

OBJECTIVES

This study examined child welfare and mental health professionals' views of the quality of psychiatric services received by consumers of the child welfare system and explored root causes of perceived quality problems.

METHODS

One hundred and thirty child welfare, mental health and court professionals participated in qualitative interviews individually or in groups. Data analyses identified perceived problems in quality and perceived causes of quality problems. Participants in member checking groups were then asked to comment on and further clarify the results.

RESULTS

The participants reported concerns related to overuse of psychotropic medication, overmedicated children, short inpatient stays, and continuity of psychiatric care. Overuse of psychotropic medications and overmedication were perceived to be driven by short evaluations, liability concerns, short inpatient stays and a lack of clinical feedback to psychiatrists from child welfare partners. Medicaid reimbursement policies were at the heart of several quality concerns. These problems contributed to a distrust of psychiatric practices among child welfare professionals.

CONCLUSIONS

These findings underscore the adverse effects of modern marketplace medicine coupled with low Medicaid reimbursement rates on quality of care for vulnerable groups. Child welfare and mental health professionals and their associated stakeholders may together possess substantial clout to advocate for a reimbursement system and structure that promotes quality service. The findings also point to a crisis of credibility toward psychiatric practice among social service and other non-psychiatrist mental health professionals. Efforts are needed to increase the capacity for psychiatrists and child welfare professionals to communicate effectively with each other and for psychiatrists to receive the information that they need from their child welfare partners to ensure accurate diagnosis and effective treatment.