Abstract

Objective: Suicide is a major public health concern in the United States, but few effective and scalable interventions exist to help those with suicidal thoughts. We hypothesized that reading first-person narratives about working through suicidal thoughts would reduce the desire to die among adults and that this effect would be mediated by increased perceived shared experience and optimism.

Method: Using a randomized waitlist-controlled trial, we tested the effect of digital narrative-based bibliotherapy among 528 adults visiting a social media platform dedicated to providing mental health support. Participants were randomized to either a treatment condition (n = 266), in which they read one suicide narrative per day for 14 days or to a waitlist control condition (n = 262). The primary outcome was a measure of desire to die assessed daily for the 14-day trial period and at 2-week follow-up.

Results: Participants in the treatment condition reported lower desire to die than participants in the control condition during the 14-day trial period (β = -0.26, p = .001) and at 2-week follow-up (t = -2.82, p = .005). Increased perceived shared experience (indirect effect b = -0.55, p < .001) and optimism (indirect effect b = -0.85, p < .001) mediated the effect of treatment on desire to die.

Conclusions: Digital narrative-based bibliotherapy may be an effective intervention for those at risk for suicide, and may work in part by increasing feelings of perceived shared experience and optimism. Future research is needed to test the generalizability of these results to other platforms, groups, and conditions. (PsycInfo Database Record (c) 2022 APA, all rights reserved).: Participants in the treatment condition reported lower desire to die than participants in the control condition during the 14-day trial period (β = -0.26, p = .001) and at 2-week follow-up (t = -2.82, p = .005). Increased perceived shared experience (indirect effect b = -0.55, p < .001) and optimism (indirect effect b = -0.85, p < .001) mediated the effect of treatment on desire to die.

To cite: Franz, P. J., Mou, D., Kessler, D. T., Stubbing, J., Jaroszewski, A. C., Ray, S., Cao-Silveira, V. B., Bachman, S., Schuster, S., Graupensperger, D., Alpert, J. E., Porath, M., & Nock, M. K. (2022). Digital bibliotherapy as a scalable intervention for suicidal thoughts: A randomized controlled trial. Journal of Consulting and Clinical Psychology, 90(8), 626–637. https://doi.org/10.1037/ccp0000752

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Abstract

Introduction and aims: Despite growing evidence demonstrating the negative mental health effects of racism-related experiences, racial/ethnic discrimination is seldom examined in youth suicide risk. The present study tested the association between racial/ethnic discrimination and well-supported correlates of suicide-related risk including emotion reactivity and dysregulation, and severity of psychiatric symptoms in a sample of ethnoracially minoritized adolescents receiving outpatient psychiatric services.

Methods: Participants were adolescents (N = 46; 80.4% female; 65.2% Latinx) who ranged in age from 13-20 years old (M=15.42; SD=1.83) recruited from a child outpatient psychiatry clinic in a low-resourced community in Northeast US. Youth completed a clinical interview and a battery of surveys.

Results: Findings from separate linear regression models show that increases in frequency of racial/ethnic discrimination were associated with increases in severity of suicidal ideation (SI), independent of emotion reactivity and dysregulation, and symptoms of PTSD and depression. Discriminatory experiences involving personal insults, witnessing family being discriminated, and school-based contexts were uniquely associated with SI.

Discussion and conclusion: Preliminary findings support the association between racial/ethnic discrimination and increased severity of suicide-related risk in ethnoracially minoritized adolescents. Accounting for racial/ethnic discrimination may improve the cultural responsiveness of youth suicide prevention strategies within outpatient psychiatric care.

To cite: Polanco-Roman, L., DeLapp, R. C., Dackis, M. N., Ebrahimi, C. T., Mafnas, K. S., Gabbay, V., & Pimentel, S. S. (2023). Racial/ethnic discrimination and suicide-related risk in a treatment-seeking group of ethnoracially minoritized adolescents. Clinical Child Psychology and Psychiatry, 28(4), 1305–1320. https://doi.org/10.1177/13591045221132682

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Abstract

Background: Impaired reflective functioning (RF) is common among patients with borderline personality disorder (BPD). Transference-focused psychotherapy (TFP) has been demonstrated to improve RF compared to other common BPD treatments. If RF reflects a treatment mechanism for TFP, differences in pretreatment RF may also serve as a prescriptive factor for TFP's effects.

Method: A total of 194 patients with BPD were randomized across two clinical trials to receive TFP (n = 83), dialectical behavior therapy (DBT; n = 31), supportive psychodynamic therapy (SPT; n = 28), or an enhanced treatment as usual (eTAU; n = 52). A mixed-effects model was used to examine whether baseline RF interacted with treatment condition to predict slopes of change in the Brief Symptom Inventory, the shared symptom outcome between trials. Moderation of changes in RF was also examined.

Results: Treatment interacted with baseline RF to predict BSI slopes (p = .011). In TFP/SPT, RF did not predict outcomes, β = -0.00, p = .973, while higher RF was associated with relatively better outcomes in DBT/eTAU, β = -0.54, p < .001. Patients with poor RF (scores of 0/1) benefitted more from TFP/SPT, while patients with relatively ordinary RF (score of 4) had better outcomes in DBT/eTAU. Treatment effects on RF change were also moderated by baseline RF (p = .014), such that TFP improved RF most strongly among poor RF patients, SPT only among very poor RF patients, and DBT/eTAU not at all.

Discussion: Low RF may reflect a deficit that may be targeted by TFP and other manualized psychodynamic treatments for BPD, which may be especially helpful among patients presenting with low RF. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

To cite: Keefe, J. R., Levy, K. N., Sowislo, J. F., Diamond, D., Doering, S., Hörz-Sagstetter, S., Buchheim, A., Fischer-Kern, M., & Clarkin, J. F. (2023). Reflective functioning and its potential to moderate the efficacy of manualized psychodynamic therapies versus other treatments for borderline personality disorder. Journal of Consulting and Clinical Psychology, 91(1), 50–56. https://doi.org/10.1037/ccp0000760

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Abstract

Objective: To examine trends in mental health care use for Black and Latinx children and adolescents.

Method: Data from the Medical Expenditure Panel Survey for 2010-2017 were analyzed to assess trends among youth ages 5-17 in use and expenditures for any mental health care, outpatient mental health care, and psychotropic medication prescription fills. Unadjusted trends for all youth and the subpopulation of youth reporting need for mental health care and disparities adjusting for need were examined.

Results: Between 2010 and 2017, Black youth rates of any past year mental health care use decreased (from 9% to 8%), while White (from 13% to 15%) and Latinx (from 6% to 8%) youth rates increased. Among the subpopulation with need and in regression analysis adjusting for need, we identified significant Black–White and Latinx–White disparities in any mental health care use and any outpatient mental health care use in 2010-2011 and 2016-2017, with significant worsening of Black–White disparities over time. White youth were more than twice as likely as Latinx youth to use psychotropic medications, and Latinx–White and Black–White disparities in psychotropic medication prescription fills persisted over time. Black–White disparities existed in overall mental health expenditures (2016-2017) and outpatient mental health expenditures (2010-2011 and 2016-2017).

Conclusion: Affordable, ubiquitous access to mental health care for Black and Latinx youth remains an elusive target. Significant disparities exist in receiving mental health care despite reforms and policies designed to increase mental health care access in the general population. Additional outreach and treatment strategies tailored to the cultural, linguistic, and structural needs of youth of color are required.

Keywords: children, Medical Expenditure Panel Survey, mental health care access, mental health policy, racial/ethnic disparities

To Cite: Rodgers, C. R., Flores, M. W., Bassey, O., Augenblick, J. M., & Lê Cook, B. (2021). Racial/ethnic disparity trends in children’s mental health care access and expenditures from 2010 to 2017: Disparities remain despite sweeping policy reform. Journal of the American Academy of Child & Adolescent Psychiatry, 61(7), 915-925. https://doi.org/10.1016/j.jaac.2021.09.420

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Abstract

Depression is the leading cause of disability and disease burden in the US.1,2 Research using the National Comorbidity Survey (fielded 1990-1992) showed that while lifetime and past-year rates of major depressive disorder were lower among individuals from minoritized racial and ethnic groups compared with White adults,3 major depressive disorder persistence was greater for Black and Latino adults.3 Analysis of the National Survey of American Life (fielded 2001-2003) found similar or lower major depressive disorder prevalence among Black adults compared with White adults but greater major depressive disorder chronicity, severity, and disability.4 We provide an update of these findings, analyzing nationally representative data to estimate differences in major depressive episode (MDE) prevalence, persistence, and severity among racial and ethnic groups.

To Cite: Flores, M. W., Moyer, M., Rodgers, C. R., & Lê Cook, B. (2021). Major depressive episode severity among adults from marginalized racial and ethnic backgrounds in the US. JAMA Psychiatry, 78(11), 1279-1280. https://doi.org/10.1001/jamapsychiatry.2021.2485

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Abstract

This article contextualizes and challenges race, class, and gender inequity in psychiatric use of force. In particular, this article examines (1) how uses of force—seclusion, restraint, compulsion—have been codified in policy and law, (2) inequity in force utilization, and (3) connections between systemic oppression and individuals’ responses—including fear and retraumatization—to feeling threatened by force in clinical settings. This article proposes multilevel strategies to abolish inequity in uses of force in clinical settings and questions whether it is ever possible to use force compassionately where inequity persists.

To Cite: Bhattacharyya, S., Breslow, A., Carrasco, J., & Cook, B. (2021). When structural inequity is ubiquitous, can force ever be compassionate? American Medical Association Journal of Ethics, 23(4), E340-348. https://doi.org/10.1001/amajethics.2021.340

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Abstract

As a part of a larger, mixed-methods research study, we conducted semi-structured interviews with 21 adults with depressive symptoms to understand the role that past health care discrimination plays in shaping help-seeking for depression treatment and receiving preferred treatment modalities. We recruited to achieve heterogeneity of racial/ethnic backgrounds and history of health care discrimination in our participant sample. Participants were Hispanic/Latino (n = 4), non-Hispanic/Latino Black (n = 8), or non-Hispanic/Latino White (n = 9). Twelve reported health care discrimination due to race/ethnicity, language, perceived social class, and/or mental health diagnosis. Health care discrimination exacerbated barriers to initiating and continuing depression treatment among patients from diverse backgrounds or with stigmatized mental health conditions. Treatment preferences emerged as fluid and shaped by shared decisions made within a trustworthy patient–provider relationship. However, patients who had experienced health care discrimination faced greater challenges to forming trusting relationships with providers and thus engaging in shared decision-making processes.

Keywords: depression, mental health and illness, race, racism, social issues, qualitative, semi-structured interviews, psychiatry, United States of America

To Cite: Progovac, A. M., Cortés, D. E., Chambers, V., Delman, J., Delman, D., McCormick, D., ... & Cook, B. L. (2020). Understanding the role of past health care discrimination in help-seeking and shared decision-making for depression treatment preferences. Qualitative Health Research, 30(12), 1833-1850.

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Abstract

Background: Emerging adulthood is a vulnerable period for poor blood glucose control and self-management behaviors (SMBs) among individuals with type 1 diabetes. Racial/ethnic minority young adults have poorer glycemic outcomes than non-Hispanic whites; however, little is known about possible racial/ethnic differences in frequency of SMBs among emerging adults (EAs).

Objective: To examine racial/ethnic differences in SMBs and to determine associations between SMBs and blood glucose control.

Methods: A sample of EAs (ages 18-25 years; N = 3456) from the type 1 diabetes exchange registry was used to conduct multivariate analyses to examine (a) racial/ethnic differences in SMBs and (b) associations between SMBs and blood glucose control for each racial/ethnic group.

Results: Compared to non-Hispanic whites, African Americans and Hispanics less frequently took an insulin bolus for snacks, less frequently checked blood glucose with a meter, and were more likely to not use insulin to carbohydrate ratios. African Americans also less frequently checked blood glucose prior to mealtime boluses and more frequently missed insulin doses. SMBs that were associated with blood glucose control across groups were frequency of checking blood glucose at mealtime, missing an insulin dose, and checking blood glucose with a meter.

Conclusions: Promoting two SMBs: checking blood glucose and taking insulin doses as needed among African American EAs may be important to address racial disparities in glycemic outcomes. Future research should evaluate possible social and contextual mechanisms contributing to low engagement in these behaviors among African Americans to inform strategies to address racial differences in glycemic outcomes.

To Cite: Butler, A. M., Weller, B. E., Rodgers, C. R., & Teasdale, A. E. (2020). Type 1 Diabetes self‐management behaviors among emerging adults: Racial/ethnic differences. Pediatric Diabetes, 21(6), 979-986. https://doi.org/10.1111/pedi.13061

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Abstract

To our knowledge, few alternative payment models (APMs) to date have focused on children’s health. The Center for Medicare and Medicaid Innovation just launched its first major model aimed at improving care for children, the Integrated Care for Kids (InCK) model, to catalyze greater state investment in this area.1 While promising, the InCK process raises questions as to what kept states from initiating child-focused APMs and why might they merit priority in the future.

To Cite: Counts, N. Z., Billioux, A., Perrin, J. M. (2020). Short-term and long-term returns for states implementing pediatric alternative payment models. JAMA Pediatrics, 174(5), 403-404. https://doi.org/10.1001/jamapediatrics.2019.6248

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Abstract

Objective: The objective was to examine mental health treatment access disparities between Asians and whites in the United States as well as the role of perceived and objective need and barriers to treatment in these disparities.

Methods: Data are five annual cross-sections (2012–2016) of responses from Asian Americans and whites to the nationally representative National Survey on Drug Use and Health. Multivariate logistic regression analyses adjusting for sociodemographic factors were conducted to compare past-year treatment access rates between Asians and whites across three need subgroups: those with perceived need for treatment, those with past-year serious psychological distress, and those with a past-year major depressive episode. Barriers to treatment were compared between Asians and whites with perceived need.

Results: Asians were less likely than whites to have accessed mental health treatment in the past year in all analyses. Compared with Asians with need determined by structured diagnostic instruments, Asians with perceived need had higher rates of mental health care access, but even among respondents with perceived need, the disparity between whites and Asians remained. Regarding barriers to treatment, only one barrier (not knowing where to go for treatment) was more likely to be reported for Asians than whites.

Conclusions: Differences between Asians and whites in perceived need for mental health treatment do not explain the wide disparities in mental health care access between these two groups. Clinical interventions improving the relevance and fit of mental health care and community-based outreach interventions increasing awareness of available services are needed to improve access to mental health treatment among Asians.

To Cite: Yang, K. G., Rodgers, C. R., Lee, E., & Lê Cook, B. (2020). Disparities in Mental Health Care Utilization and Perceived Need Among Asian Americans: 2012–2016. Psychiatric Services, 71(1), 21-27. https://doi.org/10.1176/appi.ps.201900126

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Abstract

Purpose of Review: We review 2016–2019 peer-reviewed literature which summarizes the factors contributing to high expense of treating depression among adults in the USA, and interventions that have been conducted to decrease depression treatment expenditures.

Recent Findings: Treatment expenditures associated with depression are high and growing, driven in part by increased health care utilization and a shift toward increased insurance coverage of medications and therapies. The majority of identified articles describe the elevated financial burden associated with treating individuals with chronic medical conditions who also have a depression diagnosis. The few available studies documenting health care system-level interventions identify that multi-target treatment for comorbid illness, collaborative care management, and integration of psychiatric treatment into primary care show promise for reducing depression treatment expenditures.

Summary: Additional research is needed to identify innovative, cost-effective state, and federal payer-initiated depression treatment models, and evaluation of collaborative care and integrated care models implemented to scale across multiple health care systems.

To Cite: Breslow, A. S., Tran, N. M., Lu, F. Q., Alpert, J. E., & Lê Cook, B. (2019). Depression Treatment Expenditures for Adults in the USA: a Systematic Review. Current psychiatry reports, 21(10), 105. https://doi.org/10.1007/s11920-019-1083-3

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Abstract

People with serious mental illnesses, particularly members of racial and ethnic minority groups, are rarely included in prioritizing research topics or developing the tools and measures important for improving their care. Community-based participatory research holds promise toward reducing mental health disparities. However, initiating research partnerships with community stakeholders is challenging and does not always lead to sustainable community health improvements. Using lessons learned from a project to improve understanding of patients’ preferences and discrimination in depression and diabetes treatment, we describe barriers and facilitators to initiating a meaningful partnership with disenfranchised groups. Barriers fell within four domains: trepidation of community stakeholders, complex research methods, uncertainty among academic partners, and unclear partnership decision-making protocols. Primary facilitators included the meaningfulness of the research topic to the community, the presence of a well-established community-based organization, academic financial investment, co-learning activities, and flexibility. Successful initiation of these partnerships holds significant potential for addressing health care disparities.

Topics: Supplementary Medical Insurance, Researchers, Mental Health, Decision Making, Communications, Health Disparities, Case, Studies, Grants, Serious Mental Illness

To Cite: Delman, J., Progovac, A. M., Flomenhoft, T., Delman, D., Chambers, V., & Cook, B. L. (2019). Barriers And Facilitators To Community-Based Participatory Mental Health Care Research For Racial And Ethnic Minorities. Health Affairs, 38(3), 391-398. https://doi.org/10.1377/hlthaff.2018.05040

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Abstract

Objectives: To investigate the inequality in medical care utilization and household catastrophic health spending (HCHS) between the poverty and non-poverty residents in rural Rwanda and their links with community-based health insurance (Mutuelles).

Methods: We used the 2005 and 2010 nationally representative Integrated Living Conditions Surveys. We estimated multilevel logistic regression models to obtain the adjusted levels and trends of both absolute and relative inequalities and examined associations between Mutuelles status and these inequalities.

Results: Significant inequality between the two income groups, in both absolute and relative measures of medical care utilization and HCHS remained unchanged in 2005 and 2010. Significant reduction in adjusted absolute inequality in percentage of HCHS between the two years was not associated with Mutuelles status.

Conclusions: While Mutuelles promoted medical care utilization and reduced HCHS, it did not play a significant role in reducing their inequalities by poverty status between 2005 and 2010. Future studies should assess the impact of additional strategies (e.g., the exemption of Mutuelles premiums and copayments for households living in poverty), on reducing inequality by poverty status.

To Cite: Liu, K., Cook, B., & Lu, C. (2019). Health inequality and community-based health insurance: a case study of rural Rwanda with repeated cross-sectional data. International journal of public health, 64(1), 7-14. https://doi.org/10.1007/s00038-018-1115-5

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Abstract

The Affordable Care Act established Medicaid health homes to provide care management and coordination for high-need individuals, including many with serious mental illness. The authors used data from the Medicaid Data Warehouse to examine health care utilization over 3 years among 10,193 individuals who enrolled in a New York State health home and had at least one outpatient mental health visit during the year prior to enrollment. Results for postenrollment year 2 indicated a 43% decrease in inpatient mental health discharges, a 38% decrease in substance use discharges, and a 7% reduction in general medical discharges, whereas mental health outpatient treatment and behavioral and nonbehavioral medication utilization increased. Further research is needed to determine the effectiveness of health home care management for individuals with serious mental illness.

To cite: Wetzler, S., Counts, N., Schwartz, B., Patel, U., & Holcombe, S. (2023). Impact of New York State's Health Home Model on Health Care Utilization. Psychiatric Services, 74(9), 1002–1005. https://doi.org/10.1176/appi.ps.20220264

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