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NIMH Mental Health Services 2016: Removing Barriers to Care

15 Sep 2016

by Carolyn Graybeal

On August 2, 2016, the second day of the Mental Health Services Research conference at the National Institute of Mental Health in Bethesda, Maryland, First Lady of New York City Chirlane McCray (left) and New York City Department of Health and Mental Hygiene Executive Deputy Commissioner Gary Belkin gave a joint keynote address on ThriveNYC, New York’s citywide mental health program. Mental health became a personal issue for McCray when her daughter was diagnosed with anxiety, depression, and addiction. It became her signature issue as she learned more about the community, and the monetary and health costs of mental illness. Launched in 2015, ThriveNYC aims to educate, destigmatize, and support mental health well-being. In October 2016, the city will launch NYC Support, a mobile app available in various languages that will help users locate mental health support. In the coming years, ThriveNYC aims to train 250,000 mental health first-aid workers.

In discussing the program’s approach, Belkin outlined a six-pronged strategy echoing what the previous day’s speakers (see SRF conference report) had said: changing culture, acting early, closing gaps in access, community partnerships, data-driven changes, and government involvement. He mentioned some approaches ThriveNYC has already taken such as increasing socioemotional learning in schools and partnering every public school with a mental health consultant. The overarching goal, Belkin said, “is to create new ‘normal habits’ to establish a public health strategy.”

Philip Yanos of John Jay College of Criminal Justice, City University of New York, shared early research examining the efficacy of cognitive behavioral interventions to alleviate self-stigma in people with severe mental illness (SMI). Internalization of negative stereotypes or "self-stigma" is reported in a third of people with SMI, with higher percentages in schizophrenia populations. Yanos and colleagues previously suggested a model in which self-stigma indirectly influences the severity of psychotic symptoms and could predict levels of vocational functioning, social isolation, and help seeking (Yanos et al., 2010).

His new research project, scheduled to be completed in 2017, compares the efficacy of narrative enhancement and cognitive therapy (NECT) to supportive group therapy in lessening self-stigma in people with schizophrenia or schizoaffective disorder. NECT is a user-driven intervention that includes educating people about research related to their illness, promoting skills to challenge negative stereotypes, and empowering the person through hope-fostering story-telling—“narrative enhancement.” Yanos reported preliminary but encouraging results that NECT can help reduce self-stigma and positively influence functional outcomes such as motivation and social engagement. He painted this intervention as one piece in a larger toolkit of treatment, which might include providing employment, social and housing opportunities, education and training for independent living, and galvanizing hope and positive outlooks.

Beth McGinty of Johns Hopkins University in Baltimore, Maryland, reported on the first of a three-part study examining Maryland’s Medicaid Health Home Programs. Under the ACA Demonstration Program, states are allowed to bill for home services provided to high-cost, high-need populations. Along with a few other states, Maryland chose to target people with SMI, but Maryland is unique in that its health homes are run through a community-based psychiatric rehabilitation program providing integrated delivery of somatic, behavioral, and social services. Results from the nearly completed survey suggest some key areas of consideration when providing coordinated care. For example, geographic proximity is helpful but insufficient without regular means of communication among services, high-quality somatic care or primary care physicians familiar with addressing the somatic needs of people with SMI, and information exchange between hands-off and hands-on care services.

Social barriers can also contribute to the accessibility of healthcare. For example, psychological illiteracy can prolong the duration of untreated psychosis. Certain communities, either because of language barriers, cultural norms, or simply a lack of awareness, might miss warning signs of psychosis. In his presentation, Steven Lopez of the University of Southern California in Los Angeles shared survey techniques he is using to assess psychosis literacy in Latino communities in California. Latino groups, particularly immigrants or Spanish-only speakers, access mental healthcare at a lower rate than non-Hispanic whites. He noted that this is particularly troublesome, as research conducted in Europe shows higher incidence rates of psychosis in immigrant populations.

A key component of his survey was a video vignette in which a woman describes the behavior of her hypothetical neighbor "Olga." The goal of the vignette was to mimic a real-world experience. Following the video, participants were asked a series of open-ended questions, and only at the end were they directly asked about mental illness. “We wanted to measure their understanding,” explained Lopez. “Some psychosis literacy studies ask ‘does this person have schizophrenia?’ Yes or no. It is pretty leading.” In his survey, 37 percent identified psychosis, but most participants attributed Olga’s behavior to a social cause such as divorce. These same participants were less likely to recommend professional help. Previous work by Lopez showed that prior psychosis education did not affect survey participants’ recognition of psychosis in Olga. “These data tell us there is room for improvement in Latino communities,” said Lopez. “But we are also rethinking contextualization. Is it really about education, or is it about opening up a dialogue, getting people to talk?”

Susan Azrin, conference co-chair and NIMH Primary Care Research Program chief, reflected on some of the themes and messages of the conference. “One of the breakthroughs in the early psychosis field is the findings from the RAISE study showing the efficacy of coordinated specialty care to produce better outcomes. So the next step is scaling up,” she told SRF. “Technology has great promise for scaling up training of coordinated specialty care teams and to reach people with unmet mental health needs.”

Azrin was also very pleased with the interest and feedback she has gotten from attendees. “We had record-breaking registration. More than 400 people registered. And for the first time, we offered webcasting of all the plenaries and two of the concurrent sessions. I have had so many people come up to me and tell me they couldn’t make it to one session so they watched it online. It is something we hope to do in the future.”

The webcast recording of the conference is available here.