States, counties, and cities are making substantial investments to enhance crisis services. States have leveraged Centers for Medicare and Medicaid Services (CMS) Medicaid dollars to advance crisis services along at least five avenues: CMS planning grants for crisis services, Medicaid state plan amendments, Children's Health Insurance Program state plan amendments, Medicaid Section 1115 demonstrations, and 1915(c) Medicaid home- and community-based services authorities. The authors recommend that local crisis care providers optimize Medicaid billing and that state mental health agencies work with state Medicaid agencies to ensure that crisis services billing opportunities are optimized in the state plan for Medicaid-billing organizations.

States and provider agencies have leveraged Substance Abuse and Mental Health Services Administration (SAMHSA) dollars in several ways to improve crisis services: SAMHSA's Community Mental Health Services Block Grant and 5% set-aside for crisis services, Cooperative Agreements for Innovative Community Crisis Response Partnerships (in fiscal years 2022-2024), and planning and expansion grants for certified community behavioral health clinics (CCBHCs). The authors recommend that Congress increase SAMHSA's funding to further support states (e.g., increasing the 5% set-aside to a minimum of 10%), that SAMHSA provide additional funding opportunities that prioritize sustainability of crisis services, and that state mental health agencies ensure optimal distribution or coverage of CCBHCs.

In the past 5 years, significant federal, state, and local efforts have focused on building behavioral health crisis response services and on shifting this responsibility away from law enforcement. However, these efforts have been hampered by limitations of the behavioral health workforce. Strategies are needed to expand the workforce and to ensure that crisis responders have the competencies and skills necessary to meet the needs of the individuals they serve. Existing federal, state, and local mechanisms can be leveraged to support the development of this workforce. This effort includes investing in crisis response workforce development and training, supporting the development of a community behavioral health crisis responder credential, partnering with community colleges to expand the workforce pipeline, and establishing regional centers of excellence for training. It also includes developing strategies to ensure adequate and sustainable funding.

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.

Abstract Violence risk is elevated during the early phase of psychosis and can have significant consequences for engagement, recovery, and safety. BRAVE (Behavioral Response Against Violence Engagement) is a cognitive-behavioural intervention adapted from the PICASSO model for use in early intervention services (EIS) that targets dynamic, modifiable mechanisms associated with psychosis-related violence. This open pilot trial evaluated the feasibility, acceptability, fidelity, and preliminary target engagement of BRAVE when delivered by clinicians within routine EIS care. Seven clinician–client dyads were enrolled across OnTrackNY sites; five completed the intervention, with a mean of 11.4 sessions. Feasibility and acceptability were high: clinicians rated BRAVE as useful and deliverable within standard visit structures. Fidelity ratings were high across both clinician and client checklists. Although violent behaviour was infrequent at baseline, exploratory clinical outcomes suggested reductions in violent ideation over time. The primary hypothesized mechanistic target, impulsivity, remained stable but secondary mechanistic outcomes showed directionally positive movement across the affective, cognitive, behavioural, and physiological domains expected to shift with BRAVE, including reductions in hostility, negative self-appraisal, persecutory thinking, substance use, and sleep disturbance, alongside increased coping self-efficacy. Overall, findings indicate that BRAVE can be implemented with high fidelity and strong acceptability within participating clinician–client dyads in EIS settings, and offer preliminary descriptive patterns consistent with the hypothesized mechanistic model. Key learning aims (1) To describe how BRAVE was adapted for early intervention services (EIS) and delivered by clinicians within routine care, including considerations of feasibility, acceptability, and fidelity. (2) To summarize descriptive, pre–post observations from an open pilot trial of BRAVE, including changes in impulsivity and related affective, cognitive, behavioral, and physiological processes. (3) To identify implications for future implementation and evaluation, including lessons learned about fidelity measurement, patient-facing materials, and considerations for a larger pragmatic trial.

Food insecurity is a prominent, modifiable driver of poor diet quality and medical comorbidities like overweight/obesity, hypertension, metabolic syndrome, type 2 diabetes, and cardiovascular disease. High rates of these conditions among individuals with psychotic disorders are due to complex factors, including poor access to healthy food. Those with psychotic disorders and other forms of serious mental illnesses have a very high prevalence of food insecurity (i.e., being without reliable access to enough food) and nutrition insecurity (i.e., poor access to nutritious food in particular). Access to healthy food and diet quality are not equally distributed; some groups face much greater disadvantages than others. Individuals with psychotic disorders should be screened for food and nutrition insecurity, evaluated further in the context of a positive screening, and referred to local resources where food-related needs can be addressed.

Objective Although diverse strategies to reduce police involvement in mental health crisis response are emerging, people with serious mental illnesses and/or those experiencing a mental health crisis routinely encounter police. Officers need training to safely and effectively interact in these situations. The Crisis Intervention Team (CIT) model is a collaborative approach that includes a 40‐h training of officers who self‐select to become CIT officers. Despite widespread adoption across thousands of U.S. communities, no randomized, controlled trial (RCT) has assessed CIT training's effectiveness. Our objective is to determine the effectiveness of CIT training on officers' demonstrated skills and behaviors in three outcome areas: (1) verbal and non‐verbal crisis de‐escalation skills (the primary outcome), (2) officers' use of four domains of procedural justice, and (3) disposition‐related decision‐making. Hypothesized mediators and moderators will also be assessed. Methods A total of approximately 240 officers from seven or eight U.S. sites will engage in video‐recorded standardized scenarios at baseline, with half being randomized to receive CIT training within the following 3 weeks. Officers will then be reassessed at 3 and 6 months after the CIT training week. Trained raters, blinded to site, treatment arm, and timepoint, will evaluate the primary outcome. Survey‐based data will capture officer characteristics and hypothesized mediators and moderators. Results This study employs innovative methods, including standardized scenarios with professional actors portraying psychosis with agitation, depression with suicidality, and mania with refusal to leave, to measure officers' skills and behaviors. Conclusions The multi‐site RCT will yield generalizable, high‐impact findings to inform policy and practice, addressing critical gaps in research on CIT training.

OBJECTIVE:To qualitatively evaluate the acceptability and end-user perspectives of a 3-component Fresh Produce and Healthy Eating intervention seeking to increase fruit and vegetable consumption among individuals with serious mental illnesses (SMI) in residential settings. METHODS:Twenty-seven interviews were conducted with housing residents with SMI, curriculum instructors, agency leadership, and mobile market staff. Interviews were analyzed using thematic analysis. RESULTS:Each intervention component had high levels of acceptability. Residents perceived improved knowledge and self-efficacy for preparing and eating produce, and instructors noted impacts on their eating habits. Barriers to program implementation included logistical hurdles. Recommendations for improvement related to kitchen space, safety protocols, transportation, and skill building. CONCLUSIONS AND IMPLICATIONS:Findings reveal the acceptability of this novel intervention. Future research is needed to understand how this intervention may require modifications for different subpopulations of people with SMI or residential settings. Additional research is warranted to track sustainability and effectiveness in changing dietary habits.

IntroductionCommunities across the United States and elsewhere are working to implement alternatives to law enforcement as primary responders to behavioral health crises. These efforts can only be successful if there is a skilled workforce prepared to take on this role. We argue that this workforce must be developed, and propose a new, credentialed Community Behavioral Health Crisis Responder (CBHCR) role.MethodsGuided by a 13-member advisory board with expertise across behavioral health, crisis services, and law enforcement, we conducted a literature review, key informant interviews, and focus groups to identify the foundational values, competencies, and skills for this proposed role.ResultsInterview and focus group participants discussed desired characteristics of CBHCRs and emphasized values such as cultural humility, a nonjudgmental approach, and the importance of lived experience broadly defined. Competencies and skills included engagement and communication strategies that enhance safety and trust, suicide prevention, conflict resolution, and situational awareness. Participants highlighted the need to train CBHCRs to provide compassionate, trauma-informed crisis intervention, de-escalation, support, and connection to needed resources. In conjunction with our advisory board and external experts, we used the findings to iteratively refine the values, competencies, and skills of CBHCRs.DiscussionWe discuss the next steps in creating this new, skilled and credentialed crisis response workforce.

Despite evidence supporting the involvement of family members in early-intervention services for psychosis, rates of family engagement have been relatively low, and disparities exist. This study investigated the acceptability, feasibility, and preliminary impact of Family Motivational Engagement Strategy (FAMES) with family members of clients enrolled in coordinated specialty care (CSC). A feasibility and acceptability pilot study of FAMES was conducted in five CSC programs for FEP using a modified stepped-wedge design. FAMES consists of brief weekly contacts based on communication preferences (i.e., phone, text messages, email) and the use of culturally responsive strategies over 12 weeks. Assessments were completed at baseline and weeks 4, 8, and 12. Primary outcomes were feasibility and acceptability, and secondary outcomes were engagement in FAMES and CSC. Forty-three participants were recruited (approximately 85% of the target recruitment sample of 50) and 72% (n = 31) completed all 12 weeks. Participants reported high rates of satisfaction with FAMES. Regarding engagement, 86% of scheduled FAMES appointments were attended, and no significant ethnoracial differences in engagement were observed. Exploratory analyses revealed engagement in FAMES was associated with engagement in CSC. Findings demonstrated the feasibility and acceptability of delivering FAMES within CSC settings for family members/support persons. A subsequent study is needed to examine the efficacy and real-world implementation of FAMES.

BACKGROUND:Early exposure to neighborhood social fragmentation has been shown to be associated with schizophrenia. The impact of social fragmentation and friendships on distressing psychotic-like experiences (PLE) remains unknown. We investigate the relationships between neighborhood social fragmentation, number of friends, and distressing PLE among early adolescents. METHODS:Data were collected from the Adolescent Brain Cognitive Development Study. Generalized linear mixed models tested associations between social fragmentation and distressing PLE, as well as the moderating role of the number of total and close friends. RESULTS:Participants included 11 133 adolescents aged 9 to 10, with 52.3% being males. Greater neighborhood social fragmentation was associated with higher levels of distressing PLE (adjusted β = 0.05; 95% CI: 0.01-0.09). The number of close but not total friends significantly interacted with social fragmentation to predict distressing PLE (adjusted β = -0.02; 95% CI: -0.04 to <-0.01). Among those with fewer close friends, the association between neighborhood social fragmentation and distressing PLE was significant (adjusted β = 0.07; 95% CI: 0.03-0.11). However, among those with more close friends, the association was non-significant (adjusted β = 0.03; 95% CI: -0.01 to 0.07). CONCLUSIONS:Greater neighborhood social fragmentation is associated with higher levels of distressing PLE, particularly among those with fewer close friends. Further research is needed to disentangle aspects of the interaction between neighborhood characteristics and the quality of social interactions that may contribute to psychosis, which would have implications for developing effective interventions at the individual and community levels.

Young adults with early psychosis are at higher risk of violent behavior, but no studies have explored using CBT-based interventions to reduce violence in specialized early intervention services (EIS) settings. This study describes formative research about the acceptability and feasibility of the Psychological Intervention for Complex PTSD and Schizophrenia-Spectrum disorder (PICASSO) to reduce violence, using interviews with EIS participants and staff. Generated themes regarding acceptability included negative experiences of violence and the desire to control and minimize violence. Themes regarding feasibility raised concerns about time constraints, consistency of participation in the intervention, and implementation issues in the context of stigma related to both psychosis and perpetration of violence. Findings from this study suggest there is a need for an intervention addressing violence risk. If adequate resources are devoted to addressing implementation issues, a CBT intervention for violence like PICASSO appears both acceptable and feasible for EIS participants and staff.

This paper outlines the development of standardized scenarios used to assess the efficacy of Crisis Intervention Team (CIT) training in a randomized, controlled trial. The objective was to create scenarios that accurately simulate mental health crisis situations for law enforcement officers, ensuring that each scenario tests specific CIT skills relevant to real-world encounters. Our process involved building an interdisciplinary team and drawing from the knowledge and experience of professionals in law enforcement, mental health, and performance arts to design a set of scenarios that are both realistic and challenging. The scenarios were developed to represent mental health crises that officers frequently encounter, such as mania, psychosis with agitation, and depression with suicidality. Each scenario requires officers to demonstrate CIT-specific skills such as verbal de-escalation, empathy, and critical decision-making. Our structured approach to developing these scenarios provides a replicable model for future studies that aim to assess the real-world effectiveness of mental health training for law enforcement as well as other professional groups.

AIMS:Despite the public health impact of violence among young adults with psychosis, behavioural interventions to reduce the risk of engaging in violence remain rare. For young adults with early psychosis, cognitive behavioural therapy (CBT)-based psychotherapy has efficacy in reducing impairment and improving functioning. However, no CBT-based intervention to reduce violence has been formally adapted for young adults with early psychosis. This protocol outlines the first clinical trial of a behavioural intervention to reduce violence for young adults with early psychosis. This study is set in an early intervention services (EIS) setting and seeks to adapt and pilot Psychological Intervention for Complex PTSD and Schizophrenia-Spectrum Disorder (PICASSO), a CBT-based intervention, through an iterative process utilizing mixed-methods assessments. METHODS:All research will occur at OnTrackNY, the largest EIS program in the United States. This study will consist of an open pilot trial, with four EIS clinicians delivering the intervention to one to two EIS participants per round. In this mixed-methods study, both quantitative measures (acceptability, feasibility and hypothesized mediators of target outcome collected on a weekly basis) and qualitative interviews (with EIS clinicians at weeks 4, 8 and 12) will be conducted. Transcripts will be analyzed using thematic content analysis. Two to three rounds of iterative modifications are anticipated (n = 10-16 EIS participants total). RESULTS:Recruitment began in February 2024 and is expected to continue over a 9-12-month period. CONCLUSIONS:Because violent behaviour causes interpersonal disruptions such as incarceration and increased caregiver burden, an innovative intervention to reduce violence risk could have broader health impact for this vulnerable population. Adapting the PICASSO intervention to the EIS setting will optimize its acceptability and feasibility by the intended target population.

Communities across the United States are working to improve community-based mental health crisis response, with 1 goal being to reduce criminal legal system involvement among individuals with mental illnesses, behavioral disorders, or mental health crises. Existing and recently developed models can generally be divided into non-law enforcement-based response models and law enforcement-based response models. Wide variation exists in terms of staffing, how response teams are called out or dispatched, hours of operation and immediacy of response, and approaches to crisis resolution.

The Criminal Sentiments Scale -Modified (CSS-M) has been widely used as a measure of criminal attitudes. This analysis examined CSS-M scores in a large sample of outpatients with serious mental illnesses and a criminal legal system history. We compared total and subscale scores in our sample to scores from two other previously published U.S. studies in which the CSS-M was used, and evaluated associations between total CSS-M score and nine variables (age, educational attainment, gender, race, marital status, employment status, diagnostic category, substance use disorder comorbidity, and adverse childhood experiences (ACE) score). Scores were higher than in two prior U.S. studies involving other types of samples. Independently significant predictors of higher CSS-M scores included being younger ( P < .001), having a higher ACE score ( P < .001), being male ( P = .03), not identifying as White ( P < .001), not having a psychotic disorder ( P < .001), and having a comorbid substance use disorder ( P = .002). Future research should test the hypothesis that these factors increase risk for arrest and that arrest events, and subsequent criminal legal system involvement, are characterized by negative experiences and perceptions of poor procedural justice, which in turn underpin the negative opinions referred to as " criminal sentiments " or criminal attitudes.