Psychiatric Services From Pages to Practice

Dr. Debra A. Pinals, M.D., joins Dr. Dixon and Dr. Berezin to discuss two forthcoming articles from Psychiatric Services looking at persons with intellectual and developmental disabilities in mental health systems.  The first paper addresses clinical considerations, and the second looks at policy and systems considerations.

Dr. Pinals is a Clinical Professor of Psychiatry and the Director of the Program in Psychiatry, Law, and Ethics at the University of Michigan Medical School in Ann Arbor, Michigan.

Topics discussed in this episode:

• Mental health systems and law enforcement
• Medicaid-funded and state-funded systems
• Defining the patient population
• “Beyond Beds” and the psychiatric continuum of care
• Seeing the population beyond just crisis
• Dealing with aggressive behavior and overmedicating the population
• Restricting individual autonomy as a last resort
• Applied Behavioral Analysis
• Overlooked stressors and potential drivers of crisis
• Role of evidence-based practices in this population
• Distinguishing between mental illness and intellectual disabilities, and how they interact
• Encouraging communication across systems
• Expansion of crisis services
• Rehabilitation services versus habilitation services
• Where does neurology fit in?
• What system does care take place in?
• How do we improve things from here?

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Deborah K. Padgett, Ph.D., M.P.H., and Daniel Herman, M.S.W., Ph.D., join Dr. Dixon and Dr. Berezin to discuss a potentially effective and affordable approach to ending homelessness for many Americans by extending the authorization that U.S. health authorities gave to shelter providers to move residents into hotels.

Dr. Padgett is a Professor at New York University’s Silver School of Social Work. Dr. Herman is a Professor at Hunter College’s Silberman School of Social Work and Director of the Center for the Advancement of Critical Time Intervention.

Topics discussed in this episode:

• Career trajectories: planned and unplanned transitions
• Homelessness issue pre-pandemic: 40 years in 4 minutes
• Structural racism as a contributor
• SMI: a subset of homelessness issue
• COVID contagion leading to general agreement on the need to “de-densify” shelters
• Permanent hotel housing: measurable outcome improvements and qualitative game changer
• Discussion of Critical Time Intervention

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Check out Editor's Choice, a set of curated collections from the rich resource of articles published in the journal. Sign up to receive notification of new Editor's Choice collections.

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Sidney H. Hankerson, M.D., M.B.A., joins Dr. Dixon and Dr. Berezin to discuss efforts to train African American clergy interested in interpersonal counseling in managing major depression among community members, as they are positioned to curb the cultural mistrust and depression stigma that impedes the use of traditional psychiatric services among African Americans.

Dr. Hankerson is Assistant Professor of Clinical Psychiatry at Columbia University, College of Physicians and Surgeons, and the New York State Psychiatric Institute.

• Journey to this area of research 
• Grady Hospital patients requesting pastor involvement 
• Importance of NAMI-sponsored suicide prevention program at a large church in Queens 
• Summary of current paper 
• Description of and relationship with church involved in the study 
• Talking with pastors and community members about the intervention 
• Distrust of institutions 
• Depression stigma 
• Future work involving community health workers 
• How to get involved 
• Personal connection with mental health 

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Benjamin G. Druss, M.D., M.P.H., joins Dr. Dixon and Dr. Berezin to discuss two articles:

1) A qualitative study of barriers and facilitators to transitions from the emergency department to outpatient mental health care

2) Supporting the mental health workforce during and after COVID-19.

Dr. Druss is a psychiatrist and a professor in the Department of Health Policy and Management at the School of Public Health at Emory University.

• How research interests and career path have provided expertise on these two seemingly very disparate articles (1:36)
• Background on interests in emergency department transitions (3:01)
• Methodology of ED transition study (4:23)
• Questions asked of subjects (7:52)
• Client, provider, and system perspectives (8:50)
• Social determinants of treatment seeking and post-discharge care (12:09)
• Surprising findings (14:38)
• How ED visits are often a confluence of factors that are outside of the control of patients (16:35)
• Structural factors compounding transition difficulties (18:38)
• How technical assistance supports the adoption and sustainment of evidence-based practices (23:00)
• Factors affecting successful implementation of evidence-based interventions (26:44)
• COVID disruption (29:00)
• COVID’s long-term effects on mental health service delivery (33:00)
• Panoramic view of COVID’s effects on the field from adjudicating papers (34:51)

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Check out Editor's Choice, a set of curated collections from the rich resource of articles published in the journal

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Marie Brown, Ph.D., and Nev Jones, Ph.D., join Dr. Dixon and Dr. Berezin to discuss steps to build a pipeline of researchers with significant psychiatric disabilities and intersecting lived experiences and to increase service user participation in the U.S. mental health care system.

Dr. Brown is a licensed clinical psychologist, postdoctoral fellow at Columbia University Irving Medical Center, and a cofounder of Hearing Voices Network NYC. Dr. Jones is an assistant professor in the Department of Psychiatry at the University of South Florida.

• How the authors began their collaboration [1:35]
• Genesis of the collaboration on the two Open Forum pieces in Psychiatric Services [2:38]
• Background of advocacy to have people with lived experience in mental health research positions [5:00]
• A paradigm of what meaningful participation would look like [7:59]
• Should the same standards of participation and inclusion apply to other research areas? [11:47]
• Is research disconnected from practice? [16:01]
• Steps the research community and academia can take to address these issues [22:11]
• Self-disclosure of psychiatric disability/lived experience [27:30]
• Deepening engagement of service user participation within the mental health system [31:50]
• The “radical roots” of the concept of peer support [34:33]
• What relational psychotherapy has to do with deepening engagement and service user participation [39:18]
• How Dr. Brown’s experience with the Hearing Voices movement has informed her work [46:31]
• Activities designed to deepen engagement and help build a diverse lived experience pipeline [48:19]

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Check out Editor's Choice, a set of curated collections from the rich resource of articles published in the journal

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Milton L. Wainberg, M.D., joins Dr. Dixon and Dr. Berezin to discuss protocols for studies implementing comprehensive mental health services in low- and middle-income countries.

Dr. Wainberg is a professor of clinical psychiatry at Columbia University and the New York State Psychiatric Institute and director of the Global Mental Health Implementation Science program at Columbia University.

• Development of the author's partnership with Psychiatric Services to publish protocols to address the gap between global mental health research and treatment [1:59]
• Applying lessons learned in low- and middle-income countries to the United States [11:17]
• Overriding themes of the published protocols [15:41]
• Key advantages, challenges, and design solutions of these programs [20:15]
• Overview of what related studies are doing at other sites [21:35]
• A call to be bold in engaging with complex problems in mental health care [28:11]

List of published Global Mental Health Implementation Science Protocols:

• Adaptation and Implementation of the Multiple-Family Group Intervention in Ghana
• The Sub-Saharan Africa Regional Partnership (SHARP) for Mental Health Capacity-Building Scale-Up Trial: Study Design and Protocol
• Technology-Assisted Teachers’ Training to Promote Socioemotional Well-Being of Children in Public Schools in Rural Pakistan
• Youth Functioning and Organizational Success for West African Regional Development (Youth FORWARD): Study Protocol
• Partnerships in Research to Implement and Disseminate Sustainable and Scalable Evidence-Based Practices (PRIDE) in Mozambique

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Leopoldo J. Cabassa, Ph.D., M.S.W., and Ana Stefancic, Ph.D., join Dr. Dixon to discuss the effectiveness of the Peer-led Group Lifestyle Balance intervention, a 12-month manualized healthy lifestyle intervention delivered by peer specialists, in a sample of persons with serious mental illness who were overweight or obese and living in supportive housing.

Dr. Cabassa is an associate professor at the Brown School at Washington University in St. Louis. He also is director of the NIMH T-32 Training Program and co-director of the Center for Mental Health Services Research at the university. His work aims to improve care for underserved communities, with a focus on disparities among racial-ethnic minorities with serious mental illness.

Dr. Stefancic is an associate research scientist in the Department of Psychiatry at Columbia University. Her research interests focus on evaluating housing and support services for individuals who have experienced homelessness, psychiatric disabilities, and other medical conditions.

• How the authors became interested in this field [2:08]
• Summary of study findings [6:20]
• Details of the supportive housing sites [10:05]
• Description of the peer-led program intervention [14:04]
• Work of the peer specialists within the program [16:35]
• Discussion of usual care [19:16]
• Details of the main outcomes [21:27]
• Differences between peer-led and usual care [22:31]
• Discussion of fidelity [27:02]
• Discussion of patient-level randomization [28:22]
• Remembering peer specialist Kelli Adams [33:41]
• One key takeaway from the work [36:44]

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Wanda G. Wright, D.D.S., M.S.D., joins Dr. Dixon and Dr. Berezin to explore barriers and facilitators in addressing the oral health needs of individuals with mental illness from the perspectives of patients, psychiatrists, and dentists.

Dr. Wright is affiliated with the School of Dental Medicine at East Carolina University, where she is Assistant Dean for Diversity, Equity, and Inclusion; Assistant Professor; and Division Director of Dental Public Health.

• Introduction to the field of dental public health [1:39]
• Issues of diversity, equity, and inclusion in dentistry and dental health [2:50]
• How Dr. Wright became interested in this area, and the type of collaboration that is involved [4:44]
• Details of the research [6:40]
• Did any results from the research stand out to Dr. Wright? [10:26]
• Key findings of the research [11:58]
• Description of public sector funding for dental services [12:44]
• Examples of integrated dental and mental health clinics, training, and hospital care [14:57]
• Discussion of stigma [19:18]
• Challenges around referring patients for dental care and around access [21:10]
• The one policy Dr. Wright would change, and what mental health providers should know about oral health in general [23:19]
• The next phase of this research [26:12]

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Michael F. Hogan, Ph.D., joins Dr. Dixon and Dr. Berezin to discuss the challenges and opportunities for nationwide reform in systems of care for individuals in psychiatric crisis in the United States.

Dr. Hogan has served as commissioner of the New York State Office of Mental Health, director of the Ohio Department of Mental Health, and commissioner of the Connecticut Department of Mental Health and Addiction Services. He was chair of the President’s New Freedom Commission on Mental Health under President George W. Bush. He has been appointed to the board of The Joint Commission and as a member of the National Action Alliance for Suicide Prevention.

• How Dr. Hogan became interested in this area of research [2:10]
• How an ideal crisis system would operate, and what aspects of such a system are currently missing [7:10]
• How widespread is this model throughout the United States? [16:02]
• Other recommendations the article makes to improve crisis services [23:22]
• Efforts to improve the National Suicide Prevention Lifeline [29:12]
• How has nonsuicidal crisis been incorporated into the new three-digit (988) hotline? [32:11]
• Examples of larger structural changes in crises services [36:30]
• How issues of race and social injustice tie in to this conversation [38:56]
• Dr. Hogan’s thoughts on what the future holds [44:38]

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Check out Editor's Choice, a set of curated collections from the rich resource of articles published in the journal. Sign up to receive notification of new Editor's Choice collections.

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This article is part of the Think Bigger, Do Good series commissioned by the Thomas Scattergood Behavioral Health Foundation, Peg’s Foundation, the Patrick P. Lee Foundation, and the Peter & Elizabeth Tower Foundation. The full series can be viewed at www.ThinkBiggerDoGood.org.

John Torous, M.D., M.B.I., joins Dr. Dixon and Dr. Berezin to discuss the expanded access to smartphone apps for mental health on college campuses as well as issues regarding the privacy, efficacy, and quality of mental health apps.

Dr. Torous is the director of the digital psychiatry division at Beth Israel Deaconess Medical Center and an instructor in psychiatry at Harvard Medical School.

• How Dr. Torous became interested in this area of research [1:27]
• What does it mean to be a director of digital psychiatry? [2:27]
• Why colleges are a good place to study digital psychiatry [3:47]
• A sense of the landscape of digital mental health or digital psychiatry on college campuses [5:20]
• Pros and cons of digital mental health tools [7:25]
• Major findings of the study [12:39]
• Key conclusions of the study [16:42]
• Evidence base for mental health apps [18:34]
• Recommendations for college mental health organizations [20:35]
• Questions surrounding legal liability [22:57]
• Emerging issues in the field [25:08]
• Final thoughts from Dr. Torous [27:05]

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Check out Editor's Choice, a set of curated collections from the rich resource of articles published in the journal. Sign up to receive notification of new Editor's Choice collections.

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Ayana Jordan, M.D., Ph.D., joins Dr. Dixon and Dr. Berezin to discuss disparities in initiation of and engagement in mental health care among persons from racial-ethnic minority groups. This topic formed the basis of an Editor's Choice collection assembled by Dr. Jordan.

Dr. Jordan is the associate program director of the adult psychiatry training program and an assistant professor of psychiatry at the Yale University School of Medicine. She also is a member of the Psychiatric Services Early-Career Psychiatrist Advisory Committee.

• Dr. Jordan's career interests [2:11]
• Development of the Editor's Choice collection on mental health disparities by race and ethnicity of adults [6:44]
• Dr. Jordan's perspectives in the area of mental health disparities [10:50]
• Dr. Dixon's statement on racism and creation of an advisory group to address racism as it relates to the journal [17:37]
• Dr. Jordan's plans to update the Editor's Choice collection [20:21]
• Dr. Berezin's take on the Editor's Choice collection [23:08]
• How health care systems can engage with policy, historical, and structural issues involving racism [24:37]
• Interventions required to address racism in health care and in scientific research [28:33]
• How funding priorities in scientific research affect racism [36:16]
• Final thoughts on the subject [38:38]

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Check out Editor's Choice, a set of curated collections from the rich resource of articles published in the journal. Sign up to receive notification of new Editor's Choice collections.

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Erik Messamore, M.D., Ph.D., joins Dr. Dixon and Dr. Berezin to discuss suggestions for informing the public more effectively about the potential benefits and risks of marijuana in state medical marijuana programs.

Dr. Messamore is Associate Professor of Psychiatry at Northeast Ohio Medical University and Medical Director of the university's Best Practices in Schizophrenia Treatment Center.

• How Dr. Messamore became interested in medical marijuana policy [2:33]
• Points raised by patients regarding the benefits and risks of medical marijuana [5:57]
• A history of the legalization of medical marijuana in the United States [7:54]
• The difference between the authorization of marijuana for medical use relative to recreational use [10:24]
• Discrepancies between the approval processes of regular medicines and medical marijuana [12:32]
• The role of industry and lobbying [18:09]
• Recommendations for what state governments should be doing [19:22]
• Side effects of cannabis [20:43]
• Arguments for the continued loosening of cannabis policies [24:40]
• Response to cannabis advocates [27:28]

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Check out Editor's Choice, a set of curated collections from the rich resource of articles published in the journal. Sign up to receive notification of new Editor's Choice collections.

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Be sure to let your colleagues know about the podcast, and please rate and review it wherever you listen to it.

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This article is part of the Think Bigger, Do Good series commissioned by the Thomas Scattergood Behavioral Health Foundation, Peg's Foundation, the Patrick P. Lee Foundation, and the Peter & Elizabeth Tower Foundation. The full series can be viewed at www.ThinkBiggerDoGood.org.

Matthew Goldman, M.D., M.S., joins Dr. Dixon and Dr. Berezin to discuss the significant changes in mental health policy prompted by the COVID-19 crisis across five major areas: legislation, regulation, financing, accountability, and workforce development. Special considerations for mental health policy are discussed, including social determinants of health, innovative technologies, and research and evaluation.

The article was authored by the members of the Psychiatric Services Policy Advisory Group, which aims to guide the journal on how to maximize its relevance and impact on mental health policy.

• Dr. Goldman's research interests, and how his responsibilities have changed during the COVID-19 pandemic [3:29]
• What is mental health policy, and how is policy evolving during the pandemic? [6:35]
• Differences between legislative and regulatory frameworks [9:13]
• Discussion of changes involving financing, accountability, and workforce development [14:14]
• Discussion of changes involving state licensing [17:41]
• Umbrella issues that affect policy [19:57]

Dr. Goldman is a Public Psychiatry Fellow at the University of California, San Francisco, and is a clinical instructor in the Department of Psychiatry at UCSF.

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Check out Editor's Choice, a set of curated collections from the rich resource of articles published in the journal. Sign up to receive notification of new Editor's Choice collections.

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Mark Munetz, M.D., and Elizabeth Ford, M.D., join Dr. Dixon and Dr. Berezin to discuss their work in the field of providing services to individuals who have criminal justice contact and serious mental illness.

Articles discussed:

Black Robe/White Coat: Mental Health Providers Must Reclaim the Role of Caring Clinician

Clinical Outcomes of Specialized Treatment Units for Patients With Serious Mental Illness in the New York City Jail System

• How each author became interested in the field in general and the topic of their article [2:14]
• Take-home messages from Dr. Ford's work [9:07]
• Dr. Munetz's experience with mental health courts [9:38]
• Areas of overlap between the articles [12:41]
• How to approach these areas of research [18:29]
• How unusual are the examples featured in the articles? [21:28]
• With improved funding, would individuals be more empathic toward people involved with criminal justice? [24:39]
• How the personal reflections discussed in these articles may interact with the field generally [26:40]
• What advice do the authors have for younger professionals? [30:42]

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Check out Editor's Choice, a set of curated collections from the rich resource of articles published in the journal. Sign up to receive notification of new Editor's Choice collections.

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Delbert G. Robinson, M.D., joins Dr. Dixon and Dr. Berezin to discuss barriers to the use of long-acting injectable (LAI) antipsychotic medication.

• Dr. Robinson's path to this particular area of research [1:43]
• How have people traditionally viewed LAIs? [3:32]
• A different approach to LAIs [4:13]
• The trend to use qualitative methods to understand perspectives of different stakeholders [7:28]
• Scope of the study [8:13]
• What the barriers are to more uptake of the use of LAIs [14:18]
• Barriers stemming from the individual level (interactions between a clinician and a patient) and the systems level (clinics not having appropriate infrastructure) [19:48]
• What is the next step in this line of research? [22:20]

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Check out Editor's Choice, a set of curated collections from the rich resource of articles published in the journal. Sign up to receive notification of new Editor's Choice collections.

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Patricia E. Deegan, Ph.D., joins Dr. Dixon and Dr. Berezin to discuss the dynamic journey that is learning to use psychiatric medicine optimally to support recovery. It requires more than learning to take pills on schedule. As people recover, as they learn and grow, as they age, and as their concerns and interests evolve, the use of medication as a tool in recovery also evolves.

• What is Pat Deegan, Ph.D., & Associates? [1:15]
• Dr. Deegan's personal experience with mental illness [2:48]
• Recovery as a journey [5:06]
• Challenges people face when using medication [9:53]
• The clinician-patient relationship [14:04]
• Using analogy to understand the use of medication [17:25]
• Personal motivation for using medication [18:32]
• The context from which this Personal Accounts column emerged [22:44]

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Check out Editor's Choice, a new set of curated collections from the rich resource of articles published in the journal. Sign up to receive notification of new Editor's Choice collections.

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Natalie Bonfine, Ph.D., joins Dr. Dixon and Dr. Berezin to discuss the reasons why people with serious mental illness are overrepresented in the criminal justice system. Dr. Bonfine also outlines ways to address the multiple factors that contribute to justice involvement for this population.

• Dr. Bonfine's professional background and research interests [2:05]
• Development of Dr. Bonfine's article [3:20]
• What is the criminalization hypothesis? [5:06]
• What is the criminogenic risk perspective? [10:13]
• How can the community mental health system address this issue? [12:48]
• Discussion of the sequential intercept model [17:50]
• What changes are necessary for the community mental health system to become “intercept 0” [20:41]
• A counterargument [26:50]
• Final thoughts [28:55]

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Dr. Dixon and Dr. Berezin discuss substance use among LGBTQ young adults with probable substance use disorders and characteristics and job stressors associated with turnover and turnover intention among community mental health providers.

• Introduction to article on substance use among LGBTQ populations [1:00]
• Study design [2:12]
• Study results [6:32]
• Introduction to article on turnover at community mental health centers [15:16]
• Study design [16:06]
• Study results [18:16]

Check out Editor's Choice, a new set of curated collections from the rich resource of articles published in the journal. Sign up to receive notification of new Editor's Choice collections.

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Nev Jones, Ph.D., and Christina Mangurian, M.D., M.A.S., join Dr. Dixon and Dr. Berezin to discuss the significant ethical, political, and procedural challenges that affect recruitment and retention of the peer specialist workforce.

• Introduction to the topic [1:05]
• Outline of the case study described in the column [6:20]
• Challenges involved in hiring peer staff [11:28]
• Tips for helping clients [14:42]
• Challenges dealing with microaggressions [17:54]
• What progress has been made? [23:19]

Check out Editor's Choice, a new set of curated collections from the rich resource of articles published in the journal. Sign up to receive notification of new Editor's Choice collections.

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Dr. Dixon and Dr. Berezin discuss an innovative model to integrate medication-assisted treatment (MAT) in rural primary care settings for patients with opioid use disorders, and how mental health professionals can prepare and respond to the mental health consequences of increasingly dangerous storms.

• The barriers and facilitators that affect engagement with Project ECHO (Extension for Community Healthcare Outcomes) to implement MAT in primary care settings [0:58]
• How mental health professionals can help individuals affected by hurricanes [12:24]

We encourage listeners to donate to any trusted charity serving communities affected by Hurricane Dorian.

Check out Editor's Choice, a new set of curated collections from the rich resource of articles published in the journal. Sign up to receive notification of new Editor's Choice collections.

Other articles may be viewed at our web site.

Be sure to let your colleagues know about the podcast, and please rate and review it wherever you listen to it.

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E-mail us at psjournal@psych.org