2019 Editor’s Choice Collections

This first collection focuses on integrated care. Research has shown the shortened life spans of individuals with behavioral health disorders and the many challenges of reducing that mortality and improving overall quality of life. These papers examine the application of integrated care models to target health disparities in community mental health settings, particularly among people with serious mental illness. Druss et al.’s “Psychiatry’s Role in Improving the Physical Health of Patients With Serious Mental Illness: A Report From the American Psychiatric Association” serves as a primer on psychiatry’s role in addressing these health disparities. The collection describes various models of integrated care, including within collaborative care, assertive community treatment, and behavioral health homes. The articles explore ways that integrated care has been implemented within systems of care, including the New York State Office of Mental Health and Los Angeles County, and through teleconsultation with Project Echo. Critical considerations explored within these articles include addressing racial and ethnic health disparities, utilization of peer support specialists, and the financial impact of implementing integrated care models. With effective integration of behavioral health and general health care, we can provide the high-quality care that our patients deserve.

Recovery-oriented thinking has been an increasing driver in mental health services delivery. Notably, in 2003, the President's New Freedom Commission on Mental Health—the first presidential mental health commission in 25 years—concluded, “The goal of a transformed system [is] recovery.”

These articles cover the theoretical framework of recovery, what recovery looks like in practice, how to measure personal recovery, how to integrate recovery into mental health quality metrics, and how to systematically transform systems of care to become recovery oriented. Because recovery has been defined in many ways, the collection starts with Nora Jacobson and Dianne Greenley’s 2001 article, “What Is Recovery? A Conceptual Model and Explication,” to provide a foundational view of the topic. The articles in the collection then delve into the debates that often emerge in discussions about recovery, such as how to integrate the biomedical perspective with the recovery perspective and how to bridge scientific research with the recovery model. Finally, the collection finishes up with recent research articles looking at rates of functional recovery for individuals with serious mental illness and the impact of recovery-focused interventions on personal recovery, hope, and empowerment.

Peer support services, a primary component of a recovery-based model of care, are services in which individuals with lived experience of mental illness aid others in their recovery (Chinman et al., 2017). Peer support services are provided across a variety of settings and include a wide range of work activities, such as education, mentoring, case management, research support, and vocational support (Hendrix-Brown & Bourdeau, 2019; Lapidos et al., 2018; Becker, 2015; Salzer et al., 2010). In 2001, states began developing certification programs for peer support specialists, and starting in 2007, Medicaid began to reimburse for peer support services (Wolf, 2018). As of 2016, all but three states had or were creating peer support certification programs, and across the country there were 25,317 certified peer support specialists (Wolf, 2018). This collection provides an overview of current research pertaining to peer support services, including descriptions of various forms of peer work and its impact on peer support workers, intervention evaluations, systematic reviews of the evidence base, and an Open Forum that provides the groundwork for creating a further research agenda on peer support work.

Providing high-quality psychiatric care during the perinatal period has been a growing area of focus. The perinatal period, defined as the period during pregnancy until one year after delivery, is an especially vulnerable time, when women are navigating complex hormonal, neurochemical, and identity shifts. Specifically, perinatal depression affects up to 20% of mothers, elevating this issue to a public health emergency. Just a few months ago, the U.S. Preventive Services Task Force issued a recommendation that clinicians provide or refer pregnant and postpartum women who are at increased risk of perinatal depression to counseling interventions before symptoms become severe. This collection of articles from the past 20 years reflects the evolution of the field, first introducing the complex presentation of perinatal mental illness, then taking a closer look at practice habits, including prescribing trends, and exploring the challenges associated with access to care, including stigma. It concludes by exploring the movement toward collaborative care models. This collection mirrors the development of the field of perinatal psychiatry, which calls for early identification and accessible, practical treatment interventions for at-risk mothers.

Homelessness is a term that varies from country to country. The U.S. Department of Housing and Urban Development describes a homeless person as someone who “lacks a fixed, regular, and adequate nighttime residence.” Roughly 553,000 Americans experienced homelessness on a single night in 2018 (2018 Annual Homelessness Assessment Report). Of those, 37,800 (6.8%) were homeless veterans. In the collection presented below, the first two articles focus on U.S. Department of Veterans Affairs services for homeless veterans and the effect of homelessness on mortality. Homelessness has multiple etiologies, among them economic difficulties, cognitive impairment, mental illness, and substance use disorders. The next two articles, about Supplemental Security Income/Social Security Disability Insurance Outreach, Access, and Recovery (SOAR) and emergency department use, examine the characteristics of people accessing these services. Several articles in this collection focus on the effects of housing, including Housing First models, which help reduce homelessness and decrease use of nonroutine health services. Interventions to prevent homelessness are explored, including critical time intervention. Two studies examined the relationship between housing and forensic encounters and how community integration affects homeless individuals who have severe mental illness. This collection offers the opportunity to better understand the social contexts and challenges this unique population faces, as well as some exciting ideas as to how these challenges can be addressed.

The 2001 landmark Surgeon General’s report, Mental Health: Culture, Race, and Ethnicity, underscored significant disparities in initiation of and engagement in mental health care among persons from racial-ethnic minority groups. Now, almost 20 years later, these disparities persist, with higher rates of morbidity from decreased engagement in high-quality care, including use of evidence-based medications and psychotherapies. Reasons for lower treatment engagement are multifactorial and range from a lack of culturally informed treatment options to absence of a diverse mental health workforce, racism, mistrust of health care systems, variance in the quality of mental health treatment offered, and lack of attention to the social determinants of health. This collection highlights the severity of the problem among adults from racial and ethnic minority groups, with consideration of cultural issues related to higher attrition rates and structural challenges associated with access to care. It also highlights the importance of addressing key issues, such as stigma, and the value of including the patient in the decision-making process to improve mental health outcomes. We include possible solutions to these ongoing disparities, including integrated health care services, culturally informed evidence-based treatment interventions, partnership with faith-based organizations, and the need for a more diverse addiction workforce.

Substance use disorders are chronic, multifaceted conditions. Comorbidity is common; close to 99% of individuals with a substance use disorder have one or more comorbid mental disorders or chronic general medical conditions. Individuals with co-occurring substance use and mental disorders often do not seek needed treatment, or if they do, they demonstrate a marginal response and have higher rates of dropping out of treatment. Mental health professionals have the potential to address treatment gaps and advocate for strategies that focus on treatment effectiveness, address stigma, and reduce the negative consequences associated with substance use. Early treatment is best, and for many people, the most effective mental health treatment involves a combination of therapy and medication. Appropriate treatment can save lives and associated costs related to health care, comorbid medical conditions, and societal consequences such as legal issues and jail.

This month’s collection explores interventions for people with early psychosis and those at clinical high risk for psychosis. The interventions seek to improve outcomes through a range of evidence-based pharmacologic, psychotherapeutic, and psychosocial methods. Early intervention has received increasing attention and support over the past decade, particularly with the NIMH-funded RAISE (Recovery After an Initial Schizophrenia Episode) project and targeted funding through community mental health block grants. The following articles describe innovations in screening, engagement, and treatment. These include a description of the Early Detection, Intervention and Prevention of Psychosis Program, reports from coordinated specialty care across the United States with examples from California to OnTrackNY, use of Internet-based advertising for patient engagement, and NYC START’s efforts to enhance hospital-to-community transitions. These efforts to improve mental health outcomes and quality of life for people with early psychosis or at clinical high risk of developing psychosis target previously missed opportunities by offering timely, evidence-based approaches.

An estimated two million individuals with serious mental illness cycle through U.S. jails every year. People with mental illness may experience a delay or interruption in receiving mental health care while in jail or prison and may be better served by community mental health programs. Justice diversion programs provide a critical strategy to limit this population’s involvement in the criminal justice system and shift the focus to improving mental health. This Editor’s Choice collection starts with an article outlining the sequential intercept model, which has served as a nationwide framework for justice diversion. Subsequent articles are organized by intercept points as described in the model. The collection concludes with an article that specifically addresses young adults with first-episode psychosis, because that population may be at high risk of criminal justice involvement.

When people experience a mental health crisis (e.g., has suicidal thoughts, symptoms of psychosis, or relapse of substance use), they often seek assistance from mental health crisis services. Psychiatric Services has published several seminal studies regarding crisis services, as highlighted in this month’s Editor’s Choice.

The first three articles in this collection detail how crisis services have been prioritized by state and federal policy makers as a response to system pressures such as emergency department boarding of psychiatric patients and limited psychiatric inpatient bed capacity. Subsequent articles are organized by service models described in the 2016 National Action Alliance for Suicide Prevention’s Crisis Services Task Force report, “Crisis Now: Transforming Services is Within Our Reach.” In a comprehensive crisis system, community-based services can be utilized as a continuum of care; whereas some crises will resolve with a phone call to a crisis call center, others will require mobile crisis team dispatch, and a minority will require further escalation to a crisis facility with services such as 23-hour observation, short-term respite, or longer-term crisis residential services. Access to these services relies on collaboration with law enforcement through models such as the crisis intervention team, which are described in the last section of the collection.

Engaging family members and caregivers in the care of people with serious mental illness is widely regarded as a core component of successful treatment and recovery. We begin this month’s collection by highlighting the experiences of family members and caregivers of individuals with serious mental illness, including the psychological and financial impact they often face. The collection then focuses on several articles describing the importance of family member and caregiver involvement in the care process, including shared decision making during and after hospitalization. Next, the collection provides examples of key articles that have helped establish the evidence base for family education and other family support services. Finally, we present articles on family-to-family programs, an effective and generalizable model for family education. We include an article that describes a family support program targeting family members of veterans and active duty soldiers. As a whole, this collection offers the opportunity to better understand the unique issues facing family members and caregivers of people with serious mental illness, as well as services that have the potential to improve their own experiences and the recovery of their loved ones.

The relationship between violence and mental illness, as understood by the general public, is fraught with misinformation. The complexity and emotional valence surrounding violence coupled with the stigma associated with mental illness demands sound research and thoughtful dialogue. In this month’s collection, we present several articles exploring the relationship between violence and mental illness. The first section describes two risk assessment models: the COVR (Classification of Violence Risk), which is an actuarial tool, and violence risk self-assessment. The next section focuses on gun violence, presenting a Viewpoint on mental illness and gun violence and underscoring the relatively low rates of gun violence among individuals with mental illness. The following sections are organized by site of violent behavior (on inpatient units or in the community) and reveal the unique challenges of characterizing and preventing violence in each setting. The final article in this collection highlights an intervention to reduce and perhaps prevent future violence by individuals with both mental illness and criminal justice involvement.