Three Lessons Learned About Power and Improving Recruitment of Underrepresented Populations in Clinical Trials

This Open Forum is relevant for investigators who conduct research with historically understudied and marginalized populations. The authors introduce a U.S. Department of Veterans Affairs clinical trial that experienced challenges with recruitment of African American or Black veterans and was terminated for not achieving its recruitment goals. The role of power dynamics in clinical research is discussed, specifically how unequal distributions of power may create recruitment challenges. The authors summarize three lessons learned and offer recommendations for sharing power equitably between investigators and potential participants. By recounting these experiences, the authors seek to promote culturally sensitive, veteran-centered approaches to recruitment in future clinical trials.

The Cascade of Care for Early Psychosis Detection in a College Counseling Center

OBJECTIVE

Programs for early detection of psychosis help identify individuals experiencing emerging psychosis and link them with appropriate services, thereby reducing the duration of untreated psychosis (DUP). The authors used the cascade-of-care framework to identify various care stages between screening and enrollment in coordinated specialty care (CSC) and to determine attrition at each stage, with the goal of identifying points in the referral process that may affect DUP.

METHODS

Project partners included a college counseling center and CSC program. All college students seeking mental health services at a counseling center between 2020 and 2022 (N=1,945) completed the Prodromal Questionnaire-Brief (PQ-B) at intake. Students who met the distress cutoff score were referred for a phone screening. Those who met criteria on the basis of this screening were referred for assessment and possible enrollment into CSC.

RESULTS

Six stages in the cascade of care for early detection were identified. Of the students who completed the PQ-B as part of intake (stage 1), 547 (28%) met the PQ-B cutoff score (stage 2). Counselors referred 428 (78%) students who met the PQ-B cutoff score (stage 3), and 212 (50%) of these students completed the phone screening (stage 4). Seventy-two (34%) students completed a CSC eligibility assessment (stage 5), 21 (29%) of whom were enrolled in CSC (stage 6).

CONCLUSIONS

The cascade-of-care framework helped conceptualize the flow within a program for early psychosis detection in order to identify stages that may contribute to lengthier DUP. Future research is warranted to better understand the factors that contribute to DUP at these stages.

Dual Relationships in Mental Health Peer Support

Mental health peer support is a growing care modality; yet, understanding is limited regarding the ethical complexities that distinguish it from clinical mental health services. In particular, clinicians in mental health care do not navigate boundaries in the same way as peer workers, whose relationships with clients are notably different and may include interactions with clients outside designated support programs ("dual relationships"). Drawing on data from ongoing qualitative research, two researchers with lived experience of serious mental illness highlight the implications of dual relationships for both peer practice and research.

Barriers to Meaningful Participatory Mental Health Services Research and Priority Next Steps: Findings From a National Survey

OBJECTIVE

A growing consensus has emerged regarding the importance of stakeholder involvement in mental health services research. To identify barriers to and the extent of stakeholder involvement in participatory research, the authors undertook a mixed-methods study of researchers and community members who reported participation in such research.

METHODS

Eight consultative focus groups were conducted with diverse groups of stakeholders in mental health services research (N=51 unique participants, mostly service users), followed by a survey of service users, family members, community providers, and researchers (N=98) with participatory research experience. Focus groups helped identify facilitators and barriers to meaningful research collaboration, which were operationalized in the national survey. Participants were also asked about high-priority next steps.

RESULTS

The barrier most strongly endorsed as a large or very large problem in the field was lack of funding for stakeholder-led mental health services research (76%), followed by lack of researcher training in participatory methods (74%) and insufficiently diverse backgrounds among stakeholders (69%). The two most frequently identified high-priority next steps were ensuring training and continuing education for researchers and stakeholders (33%) and authentically centering lived experience and reducing tokenism in research (26%).

CONCLUSIONS

These findings suggest a need for increased attention to and investment in the development, implementation, and sustainment of participatory methods that prioritize collaboration with direct stakeholders, particularly service users, in U.S. mental health services research. The findings also underscore the presence and potentially important role of researchers who dually identify as service users and actively contribute a broader orientation from the service user-survivor movement.

Strengthening Review and Publication of Participatory Mental Health Research to Promote Empowerment and Prevent Co-optation

As reviewers, editors, and researchers with lived experience of mental health challenges, addiction, and/or psychosocial distress/disability, the authors have struggled to find an adequate way to address inappropriate or misleading use of the term "participatory methods" to describe research that involves people with lived experience in only a superficial or tokenistic manner. The authors of this article have found that, in their experience, editors or other reviewers often appear to give authors extensive leeway on claims of participatory methods that more accurately reflect tokenism or superficial involvement. The problem of co-optation is described, examples from the authors' experiences are given, the potential harms arising from co-optation are articulated, and a series of concrete actions that journal editors, reviewers, and authors can take to preserve the core intent of participatory approaches are offered. The authors conclude with a call to action: the mental health field must ensure that power imbalances that sustain epistemic injustice against people with lived experience are not worsened by poorly conducted or reported studies or by tokenistic participatory methods.

Addressing Mental Health Through Community Partnerships in a Muslim Community

The mental health of American Muslims remains significantly understudied and unaddressed, despite known obstacles to Muslims' utilization of mental health services, such as stigma and institutional mistrust. Since the inception of the Stanford Muslim Mental Health and Islamic Psychology Lab in 2014, partnerships across the Bay Area were formed among key Muslim community establishments to address obstacles to good mental health. Through a community-centered approach, diverse stakeholders engaged to identify and address the community's most pressing mental health challenges. Successful outcomes of this approach include facilitated research and mental health initiatives to support the Bay Area Muslim community.

Research on the Tufts Be Well at Work Program for Employees With Depression: 2005-2020

OBJECTIVE

Although depression is a prevalent and costly health problem exacting a large toll on work productivity, interventions targeting occupational functioning are rare. This article describes the development of the Tufts Be Well at Work intervention, a brief telephonic program designed to improve occupational functioning among employees with depression and reduce depression symptom severity. Results from 15 years of research are summarized evaluating the occupational, clinical, and economic impact of Be Well at Work.

METHODS

The design, methods, and results of all six Tufts Be Well at Work studies are reported. Studies included an initial workplace pilot study, two workplace randomized clinical trials (RCTs), one RCT in a health care system, and two pilot implementation studies conducted in a workplace and in an academic medical center. RCTs compared Tufts Be Well at Work to usual care.

RESULTS

Tufts Be Well at Work consistently and significantly improved occupational functioning, work productivity, and depression symptom severity. Employees randomly assigned to usual care experienced smaller gains. The program also delivered a positive return on investment.

CONCLUSIONS

Evidence suggests that Tufts Be Well at Work is an effective intervention for improving occupational and clinical functioning. Its relatively low cost and its impact on work productivity contribute to its positive economic impact.

Dementia ascertainment using existing data in UK longitudinal and cohort studies: a systematic review of methodology

BACKGROUND

Studies investigating the risk factors for or causation of dementia must consider subjects prior to disease onset. To overcome the limitations of prospective studies and self-reported recall of information, the use of existing data is key. This review provides a narrative account of dementia ascertainment methods using sources of existing data.

METHODS

The literature search was performed using: MEDLINE, EMBASE, PsychInfo and Web of Science. Included articles reported a UK-based study of dementia in which cases were ascertained using existing data. Existing data included that which was routinely collected and that which was collected for previous research. After removing duplicates, abstracts were screened and the remaining articles were included for full-text review. A quality tool was used to evaluate the description of the ascertainment methodology.

RESULTS

Of the 3545 abstracts screened, 360 articles were selected for full-text review. 47 articles were included for final consideration. Data sources for ascertainment included: death records, national datasets, research databases and hospital records among others. 36 articles used existing data alone for ascertainment, of which 27 used only a single data source. The most frequently used source was a research database. Quality scores ranged from 7/16 to 16/16. Quality scores were better for articles with dementia ascertainment as an outcome. Some papers performed validation studies of dementia ascertainment and most indicated that observed rates of dementia were lower than expected.

CONCLUSIONS

We identified a lack of consistency in dementia ascertainment methodology using existing data. With no data source identified as a "gold-standard", we suggest the use of multiple sources. Where possible, studies should access records with evidence to confirm the diagnosis. Studies should also calculate the dementia ascertainment rate for the population being studied to enable a comparison with an expected rate.