This column describes a state-funded initiative that provides intensive inpatient care for individuals whose chronic homelessness appears to be driven by three factors: serious mental illness, the inability to be engaged in care even with repeated assertive outreach, and fulfillment of the criteria for involuntary admission (usually by virtue of grave disability). Stable housing and ongoing engagement in care are the key outcomes. For the initial cohort of patients with 6 months of follow-up data (N=51), 61% remained stably housed, and 71% remained engaged in care. Length of stay-expected to be approximately 6 months-has gradually increased. Lessons learned are discussed.
OBJECTIVE:Brief screening and triage tools are essential for reducing mental health disparities and for expanding access to care globally. This article describes the validation of the 13-item Mental Wellness Tool (mwTool-13) against routine psychiatric assessment in an acute care setting. METHODS:The mwTool-13 is a brief two-step questionnaire used to screen for the presence of psychiatric conditions and to stratify positive results into four categories: common mental disorders, severe mental disorders, substance use disorders, and suicide risk. The tool was administered to 269 patients receiving care in a psychiatric emergency department (ED); the tool's results were compared with the diagnoses made through routine psychiatric ED assessment. RESULTS:The tool's first step (three items) was highly sensitive in identifying the presence of any mental disorder (sensitivity=0.95). The sensitivity and specificity of the entire tool were, respectively, 0.97 and 0.67 for common mental disorders, 0.65 and 0.71 for severe mental disorders, 0.80 and 0.58 for substance use disorders (alcohol, drugs, or both), and 0.93 and 0.50 for suicide risk. CONCLUSIONS:With three items, the tool performed well in identifying the presence of any mental disorder. The complete 13-item tool performed well in identifying conditions and classifying them into common or severe mental disorders, substance use disorders, and suicide risk. The mwTool-13 can enhance early identification and triage of mental health needs in diverse settings.
The October 7, 2023, attack on Israel and the ensuing war created widespread distress and an urgent need for trauma-informed mental health care. This article describes "Homiyah," a nationwide Israeli initiative led by local and international psychiatry, psychology, and trauma care experts to promote evidence-based treatment during ongoing mass trauma. The framework, developed in response to unprecedented events, began with nationwide training of public-sector mental health professionals (N=153) in evidence-based, trauma-informed care. Subsequently, experts refined training, expanded initial workshops into semiweekly clinical meetings, used a train-the-trainer model, and identified clinical leaders to guide teams with biweekly online peer consultation. Next, the initiative focused on developing evidence-based guidelines for trauma care centers and screening protocols to support a personalized approach to trauma care, integrating routine outcome monitoring to inform treatment decisions and improve effectiveness through patient-reported outcome measures and measurement-based care. Finally, national stakeholder engagement was achieved through a 2-day consensus conference and the dissemination and implementation of guidelines across the mental health system. This scalable, evidence-informed model demonstrates how interdisciplinary collaboration, rapid mobilization, and implementation science can translate research into practical clinical responses to strengthen recovery, resilience, and mental health system readiness under mass trauma conditions.
Columbia University's Justice-Involved Behavioral Health Workgroup held a symposium about emergency psychiatric evaluations of people under arrest, using a participatory policymaking approach. Four principles emerged to guide emergency departments when developing patient-centered policies: psychiatric evaluation of patients under arrest should be based on clinical presentation, not custody status; peer specialists should be employed in psychiatric emergency settings; use of restraints by law enforcement should be limited during emergency psychiatric care; and private space should be allocated for psychiatric evaluations.
OBJECTIVE:Professional structures to assist peer support workers (PSWs) are lacking, which could negatively affect PSW retention and job progression. The aim of this study was to assess PSWs' professional development needs. METHODS:Using reflexive thematic analysis, the authors conducted a qualitative interview study in Canada and completed semistructured interviews with 17 PSWs via videoconferencing software. RESULTS:Participants identified the need for career progression opportunities that did not require changing job titles. In particular, they highlighted the need for continuing education support to reinforce the evidence-based nature of their work. Participants wanted sustainable pay as well as increased recognition and advocacy from their professional unions. Finally, participants highlighted the need for peer leadership structures, wherein senior colleagues could provide mentorship and support to junior PSWs. CONCLUSIONS:Addiction health care leaders should create professional structures for PSWs mirroring those of other professional groups. Increasing PSWs' professional development supports will promote employee retention and satisfaction.
OBJECTIVE:The COVID-19 pandemic exacerbated health disparities and increased alcohol use and its health consequences. Although prepandemic research identified racial and ethnic disparities in receipt of alcohol use disorder treatment, few studies have described postpandemic disparities or have assessed the role social determinants of health (SDOHs) may play in these inequities. The authors examined how rates of treatment for alcohol use disorder differ by race and ethnicity, SDOHs, and at the intersection of both. METHODS:In this cross-sectional analysis, the authors used a nationally representative sample of 5,785 U.S. adults with past-year alcohol use disorder from the 2023 National Survey on Drug Use and Health (NSDUH). Multivariable logistic regression models were used to estimate the probability of any past-year alcohol use disorder treatment overall, by the intersection of race and ethnicity with 20 SDOH subcategories, and across treatment settings. RESULTS:Only 9.6% of adults with alcohol use disorder in the NSDUH received any treatment in 2023. Compared with other racial and ethnic groups, non-Hispanic Black or African American adults had the lowest probability of receiving treatment for alcohol use disorder overall and in the stratified analyses of nine of 20 SDOH subcategories. CONCLUSIONS:These findings highlight significant disparities in the receipt of treatment for alcohol use disorder among non-Hispanic Black or African American adults, generally concentrated within the more vulnerable SDOH categories. These results underscore a critical need for clinically and culturally nuanced policies and practices tailored to specific populations with health disparities.
OBJECTIVE:The authors aimed to examine the relationship between characteristics of patients and health systems and receipt of mental health treatment among patients assigned to collaborative care (CC) for opioid use disorder co-occurring with depression, posttraumatic stress disorder (PTSD), or both. METHODS:This secondary analysis used data from the intervention arm (N=400 participants) of a randomized clinical trial of CC, implemented in 18 low-resourced clinics, for patients with opioid use disorder co-occurring with depression, PTSD, or both. Outcomes were receipt of psychiatric medication or counseling during the 6-month intervention, as obtained from the electronic health records data or a caseload tracking tool. Baseline characteristics were assessed by using t tests for continuous variables and chi-square tests for categorical and binary measures. Adjusted logistic regression was used to identify associations between treatment receipt and characteristics; predicted probabilities for covariates were used to demonstrate effect size. RESULTS:Of the patients, 51% received psychiatric medication and 44% received counseling. In the adjusted models, co-use of stimulants was associated with less likelihood of receiving psychiatric medication (adjusted odds ratio [AOR]=0.95) or counseling (AOR=0.92), as was lower education. Male sex and health system characteristics were associated with a lower likelihood of receiving counseling; non-Hispanic ethnicity and more severe depression and PTSD symptoms were associated with a greater likelihood of receiving counseling. CONCLUSIONS:Even within CC settings, substantial unmet need for mental health treatment remained, particularly among individuals co-using stimulants. Future research should examine additional support to increase mental health treatment among individuals with co-occurring disorders.
OBJECTIVE:Inpatient psychiatric health care workers are at high risk for exposure to workplace violence, with nurses and psychiatric technicians particularly vulnerable because of frequent direct patient contact. Despite growing awareness of this issue, limited research has examined how violence exposure differs across professional disciplines and how such exposure affects staff members' well-being. This study aimed to compare rates of violence exposure across staff disciplines in an inpatient psychiatric hospital and examine associations between trauma exposure and staff psychological well-being. METHODS:A cross-sectional survey was conducted at a 274-bed inpatient psychiatric hospital in Texas. Using a modified version of the Staff Workplace Experiences Questionnaire, 142 staff members reported their experiences of workplace violence and related emotional impacts. Participants were grouped by level of patient contact (high, moderate, or low direct care), and multiple regression analyses were used to assess relationships between discipline and trauma exposure and well-being indicators (e.g., helplessness or perceived support). RESULTS:Staff in high direct care roles (nurses and psychiatric technicians) reported significantly higher rates of trauma exposure (total, witnessed, and experienced) than those in moderate or low direct care roles. High direct care staff also reported increased feelings of fear, helplessness, and being very upset and decreased perceptions of safety and support. Across disciplines, higher trauma exposure was associated with increased psychological distress and lower perceived support. CONCLUSIONS:These findings highlight the disproportionate burden of trauma on direct care psychiatric staff and underscore the need for trauma-responsive organizational strategies and specific interventions to reduce violence exposure and support staff well-being.
