A New Agenda for Optimizing Investments in Community Mental Health and Reducing Disparities
Abstract
Why a Public Health Approach Is Needed to Change the Tide
Intervention | Description | Study Design and Study N | Mental Health and Mental Health-Related Outcomes |
---|---|---|---|
1. Universal school meal programs | State and federal government-funded programs that provide free meals to all students in public schools K-12. Implemented in Maine, California, and Massachusetts | Longitudinal interview assessments with students (N=97) in 4th–6th grade and their parents, before and 6 months after the start of a universal free breakfast program in three Boston Public Schools (23) | Increased daily nutrient intake was associated with improvements in psychosocial functioning, as measured by the Pediatric Symptom Checklist |
Longitudinal (N=133) and cross-sectional (N=1,627) study of children in public schools (22) | Reductions in hyperactivity, anxiety, and depression symptoms | ||
2. Child Development Accounts (CDAs), also called Child Savings Accounts (CSAs) | Savings accounts with public and/or private funding, often started at birth. The individual can begin to withdraw funds at age 18 for qualified expenses (e.g., education or business) Example: Maine has a universal, automatic program with participation of 100% of newborns in the state | Experimental study with adolescents (N=267) randomly assigned to the intervention or control group (32) | Improved mental health functioning compared with the control condition |
Randomized controlled trial where children and their caregiver(s) were assigned to CDAs built on the existing Oklahoma 529 College Savings Plan (N=1,358) or a control group (N=1,346) and followed up after 4 years (31, 34) | Enhanced socioemotional development outcomes; decrease in mothers’ depression symptoms compared with the control group; greater impact among families with lower income or lower education | ||
3. Comprehensive Behavioral Health Model, Boston Public Schools | Tiered model of mental health prevention and intervention currently in 68 Boston public schools (39). Tier I (prevention, for all students) includes teacher and parent consultation, professional development, universal socioemotional learning curriculum, and universal screening. Tier II (targeted, for some students) includes small group intervention and classroom managements. Tier III (intensive, for a few students) includes testing, counseling, and crisis work | Longitudinal study of 1,200 students at 14 participating elementary schools (K-5) over a 3-year period (40); universal screening data were collected in Fall 2013, 2014, and 2015 and included the teacher-reported Behavior Intervention Monitoring Assessment System (BIMAS-2) | Students with “some risk” or “high risk” on the BIMAS-2 screener experienced clinically meaningful improvements on the following BIMAS-2 scales: conduct, negative affect, cognitive attention, and social functioning; gains in year 1 were sustained into year 2, and no negative effects were observed for students with normative social, emotional, and behavioral health |
4. Community-based interventions delivered by paraprofessionals in after-school recreational programs | Workforce support: a model of mental health consultation, training, and support to enhance benefits of publicly funded recreational after-school programs in communities of concentrated poverty | Randomized controlled trial of three after-school sites (staff, N=15; children, N=89) and three demographically matched comparison sites (staff, N=12; children, N=38) aiming to assess the feasibility and impact of the workforce support intervention on program quality and children’s psychosocial outcomes (42) | Modest improvements in children’s social and behavioral functioning compared with the demographically matched sites |
The Fit2Lead intervention is a park-based youth mental health promotion program involving activities for physical activity, meditation, resilience, and life skills | Open trial design (N=9 parks) with 198 youths participating in the Fit2Lead program, who completed questionnaires before the intervention and after (end of the year); youths were ages 9–15, in middle school, predominantly Black and/or Latinx and living in low-income neighborhoods with high rates of community violence (45) | Youths’ and parents’ mental health remained stable over the course of a school year, indicated by no significant change in self-reported mental health before and after the intervention |
Intervention | Description | Study Design and Study N | Mental Health and Mental Health-Related Outcomes |
---|---|---|---|
1. Housing First program | Programs that provide housing and health, mental health, and other supportive services for people with disabilities experiencing homelessness, without requiring them to abstain from substance use or be receiving psychiatric treatment | Systematic review (46) of the literature comparing Housing First to usual care or Treatment First (which requires that clients be “housing ready,” i.e., in psychiatric treatment and substance free prior to permanent housing); 26 studies assessing Housing First programs implemented in high-income nations serving persons with disabilities experiencing homelessness | For clients with HIV, Housing First reduced depression by 13%, emergency department use by 41%, hospitalization by 36%, and mortality by 37% compared with Treatment First |
2. Individual placement and support (IPS) for employment | An evidence-based model of supported employment for people with serious mental illness, substance use disorders, and other disabilities (50). IPS principles include a rapid job search with an IPS specialist, competitive paid employment, and integration with mental health treatment | A meta-analysis of 30 studies (51), including 25 original randomized controlled trials (RCTs), two follow-ups of RCTs, and three secondary analyses of previous RCTs | Compared to treatment as usual, the meta-analysis found a small and heterogeneous effect of IPS on improvement in clinical mental health symptoms. IPS is associated with improvements in quality of life and global functioning, sustained mental health status, and lower likelihood of experiencing mental health hospitalizations |
3. Earned Income Tax Credit | Tax credits for individuals of low to moderate income who are eligible | In a randomized controlled trial (58), American adults without dependent children were randomly assigned to either the Paycheck Plus program (N=2,997) or a control group (N=2,971) | Paycheck Plus participants had reductions in psychological distress compared to the control group. Women and noncustodial parents experienced the greatest reductions in distress |
Secondary data analyses from the longitudinal study of National Survey of Families and Households; the sample comprised 13,007 adults at baseline (55) | Decreased depressive symptoms among those receiving earned income tax credits relative to the comparison group | ||
4. Community-led interventions for mental health offered by paraprofessionals in underresourced communities | Mental health programs offered by community health workers | Systematic review of 38 studies (62); 27 were RCTs offered in mostly low- and middle-income countries that included evidence-based or evidence-informed mental health interventions; 31 studies evaluated a model where a community health worker is the sole provider of the intervention | In 69% of the 27 RCTs of community health worker–involved mental health interventions, mental health outcomes were significantly better than in the comparison condition |
Community coalitions, including the Community Partners in Care model for depression collaborative care (63) | 95 health care and community programs randomized to a coalition intervention (Community Engagement and Planning) or individual program technical assistance; adults with depression, 3-year sample 2010–2014 (N=1,018) and 4-year sample 2016 (N=283) (63) | People attending the sites randomized to Community Engagement and Planning on average experienced increased depression remission at 4 years compared with people attending the sites with the comparison condition of receiving technical assistance | |
5. Mental health literacy campaigns | La CLAve film workshop facilitated by community health educators | Focus groups and pre- and postworkshop evaluations (65) among Latinx adults with serious mental illness (N=57) and family caregivers of people with schizophrenia (N=38) | Increased psychosis literacy |
Pre- and postworkshop questionnaires (68) among community residents ages 15–84 (N=81) | Increased psychosis literacy | ||
Randomized controlled trial (67) where adults from Mexico (N=125) were randomly assigned to either the La CLAve film or a psychoeducational program regarding caregiving | Psychosis literacy gains were only observed in the La CLAve intervention condition and not in the control group | ||
“Secret Feelings”: Spanish-language fotonovela | Randomized controlled trial with 142 immigrant Latina adults at risk for depression (70) | Increased knowledge of depression and help-seeking self-efficacy and reduced stigma compared with the control group | |
Randomized controlled trial with 157 Hispanic adults at a community adult school, randomly assigned to read the fotonovela or a text pamphlet about depression, who completed a survey immediately before reading, immediately after, and 1 month later (69) | Both interventions improved depression knowledge and self-efficacy in identifying depression, but the fotonovela group had larger reductions in stigma toward antidepressants and mental health care |
Intervention | Description | Study Design and Study N | Mental Health and Mental Health-Related Outcomes |
---|---|---|---|
1. Green and blue spaces | Expansions of green (e.g., parks, fields, gardens) and blue (e.g., oceans, lakes) spaces in neighborhoods. Exposure to green and blue natural environments also promotes increased social interactions and exercise | Cluster randomized trial of greening vacant urban land (74); 442 community-dwelling adults living within 110 vacant lot clusters assigned to one of three study groups: greening, trash cleanup, or no intervention | Decrease in feelings of depression and worthlessness among greening site residents compared with control site residents |
Systematic review of 35 quantitative studies, most conducted between 2012 and 2017 (77); the authors identified 22 studies as being of “good quality” | The 35 studies had a range of exposures and outcomes, but overall, the evidence suggests a positive association between exposure to outdoor green space and mental health and well-being | ||
Cross-sectional study of 249,405 Medicare beneficiaries living in Miami-Dade County, Fla. (72); analyzed the association of changes in block-level greenness (vegetative presence) with individuals’ mental health outcomes | An increase in block-level greenness from 1 standard deviation below the mean to 1 above the mean was associated with lowering the odds of depression by 37% in low-income neighborhoods, 27% in medium-income neighborhoods, and 21% in high-income neighborhoods | ||
2. Senior centers offering health promotion activities | Also referred to in the literature as “adult day service centers,” these centers are community organizations for older adults and their caregivers that provide a range of resources such as adult education, health promotion activities, and opportunities for socializing | Systematic review of 61 studies (83) evaluating the effectiveness of adult day service centers in improving caregiver outcomes (19 studies), participant health outcomes (39 studies), and adult day services and health care utilization (10 studies); eight studies were randomized controlled trials, and the rest were longitudinal, quasi-experimental, or cross-sectional | The majority of quasi-experimental studies assessing participant depression and quality of life found greater improvements for intervention participants compared with control subjects; most quasi-experimental studies assessing caregiver burden and stress found greater improvements for intervention caregivers compared with control subjects |
3. Community-based disability prevention programs | A dual exercise and psychosocial program for older adults, delivered by paraprofessionals either virtually, in-person, or hybrid; available in English, Spanish, Mandarin, and Cantonese | Randomized controlled trial (84) involving 307 participants (intervention, N=153; control, N=154) in Massachusetts, New York, Florida, and Puerto Rico; most participants were Asian or Latinx | Compared with people receiving enhanced usual care, those in the intervention group experienced reductions in mood symptoms at 6 and 12 months |
“EnhanceFitness” is a low-cost group exercise program implemented across a range of community settings (e.g., religious institutions, recreational and senior centers) | Randomized controlled trial (89) involving 100 older adults (intervention, N=53; control, N=47) | After 6 months, people in the intervention group had fewer depressive symptoms compared with those in the control group | |
Pre-post study (90) of older adults (N=382) | Decreased social isolation and loneliness | ||
“EnhanceWellness” pairs older adults with health and wellness coaches trained in motivational interviewing | Five-state dissemination of a community-based program. Within-group pre-post study (85) of older adults with chronic illness (N=224) | Among the participants completing the 1-year follow-up, there was a significant decrease in their depression symptom severity from enrollment to 1-year follow-up | |
4. Chronic Disease Self-Management Program (CDSMP) | 6-week peer-led education program designed to help older adults gain skills and improve confidence to better manage chronic conditions | Meta-analysis of 18 studies of CDSMP outcomes among small English-speaking groups (93) | Small to moderate improvements in all measures of psychological health at 4–6 months and 9–12 months; significant improvements in energy, fatigue, and self-rated health (4–6 months only), cognitive symptom management (4–6 months and 9–12 months) |
Randomized community-based outcome trial (94) of the Spanish-language version of the CDSMP, with Spanish speakers (mean age, 57) with heart disease, lung disease, or type 2 diabetes; participants were randomized to the treatment group (N=327) or a wait-list usual-care control group (N=224) | At 4 months, intervention participants showed improved health status, health behavior, and self-efficacy and fewer emergency department visits compared with people in usual care; at 1 year, intervention participants (N=271) maintained these improvements, which were significantly different from baseline |
Identifying Community Factors, Interventions, Programs, or Policies as Ideal Targets for Improving Community Mental Health Across the Lifespan
Children and Adolescents
Social determinants.
School-based services.
Community-based initiatives.
Adults
Social determinants.
Community-based initiatives.
Older Adults
Social determinants.
Community-based initiatives.
Logistics to Support Change
Establishing Collaborations Between Academic Institutions, Government, and Community Organizations
Limitations
A Vision of Building Community Mental Health
Footnote
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