Michael B. Blank

Alternative Mental Health Services: The Role of the Black Church in the South

OBJECTIVES This study determined the extent to which churches in the South were providing mental health and social services to congregations and had established linkages with formal systems of care. METHODS A computer-assisted telephone interview (CATI) survey was conducted with pastors from 269 Southern churches. RESULTS Black churches reported providing many more services than did White churches, regardless of urban or rural location. Few links between churches and formal provider systems were found, irrespective of the location--urban or rural--or racial composition of the churches. CONCLUSIONS Results are discussed in terms of the potential for linking faith communities and formal systems of care, given the centrality of the Black church in historical context.

DE FACTO MENTAL HEALTH SERVICES IN THE RURAL SOUTH

Health care reform efforts highlighted the continuing scarcity of mental health services for the rural poor. Most mental health services are provided in the general medical sector, a concept first described by Regier and colleagues in 1978 as the de facto mental health service system, rather than through formal mental health specialist services. The de facto system combines specialty mental health services with general medical services such as primary care and nursing home care, ministers and counselors, self-help groups, families, and friends. The nature of the de facto system in rural areas with large minority populations remains largely unknown due to minimal available data. This article examines the availability, accessibility, and use of mental health services in the rural South and the applicability of the de facto model to rural areas. The critical need for data necessary to inform changes in health care relative to rural mental health service delivery is emphasized.

Barriers to Help Seeking for Mental Disorders in a Rural Impoverished Population

This study examined barriers to seeking mental health care reported by individuals in a rural impoverished population, by screening 646 randomly selected adults for depression, anxiety, and alcohol abuse. Respondents who screened positive were randomly assigned to one of three groups: (1) no intervention, (2) an educational intervention alone, or (3) the educational intervention in the presence of a significant other. Those who screened positive for disorders cited barriers to care at significantly higher rates than respondents who screened negative. Respondents who received the educational intervention endorsed several barriers at significantly lower rates in the follow-up telephone call (subsequent to the intervention) than in the original interview (prior to the intervention). Virtually all respondents in a subsample of 142 subjects (99.3%) said they would seek mental health care if they thought mental health services would help them.

The impact of mental health and substance abuse factors on HIV prevention and treatment.

The convergence of HIV, substance abuse (SA), and mental illness (MI) represents a distinctive challenge to health care providers, policy makers, and researchers. Previous research with the mentally ill and substance-abusing populations has demonstrated high rates of psychiatric and general medical comorbidity. Additionally, persons living with HIV/AIDS have dramatically elevated rates of MI and other physical comorbidities. This pattern of co-occurring conditions has been described as a syndemic. Syndemic health problems occur when linked health problems involving 2 or more afflictions interact synergistically and contribute to the excess burden of disease in a population. Evidence for syndemics arises when health-related problems cluster by person, place, or time. This article describes a research agenda for beginning to understand the complex relations among MI, SA, and HIV and outlines a research agenda for the Social and Behavioral Science Research Network in these areas.

Challenges in Addressing Depression in HIV Research: Assessment, Cultural Context, and Methods

Depression is one of the most common co-morbidities of HIV infection. It negatively impacts self-care, quality of life, and biomedical outcomes among people living with HIV (PLWH) and may interfere with their ability to benefit from health promotion interventions. State-of-the-science research among PLWH, therefore, must address depression. To guide researchers, we describe the main diagnostic, screening, and symptom-rating measures of depression, offering suggestions for selecting the most appropriate instrument. We also address cultural considerations in the assessment of depression among PLWH, emphasizing the need to consider measurement equivalence and offering strategies for developing measures that are valid cross-culturally. Finally, acknowledging the high prevalence of depression among PLWH, we provide guidance to researchers on incorporating depression into the theoretical framework of their studies and employing procedures that account for participants with depression.

Behind the Cascade: Analyzing Spatial Patterns along the HIV Care Continuum

Background:Successful HIV treatment as prevention requires individuals to be tested, aware of their status, linked to and retained in care, and virally suppressed. Spatial analysis may be useful for monitoring HIV care by identifying geographic areas with poor outcomes. Methods:Retrospective cohort of 1704 people newly diagnosed with HIV identified from Philadelphias Enhanced HIV/AIDS Reporting System in 2008–2009, with follow-up to 2011. Outcomes of interest were not linked to care, not linked to care within 90 days, not retained in care, and not virally suppressed. Spatial patterns were analyzed using K-functions to identify “hot spots” for targeted intervention. Geographic components were included in regression analyses along with demographic factors to determine their impact on each outcome. Results:Overall, 1404 persons (82%) linked to care; 75% (1059/1404) linked within 90 days; 37% (526/1059) were retained in care; and 72% (379/526) achieved viral suppression. Fifty-nine census tracts were in hot spots, with no overlap between outcomes. Persons residing in geographic areas identified by the local K-function analyses were more likely to not link to care [adjusted odds ratio 1.76 (95% confidence interval: 1.30 to 2.40)], not link to care within 90 days (1.49, 1.12–1.99), not be retained in care (1.84, 1.39–2.43), and not be virally suppressed (3.23, 1.87–5.59) than persons not residing in the identified areas. Conclusions:This study is the first to identify spatial patterns as a strong independent predictor of linkage to care, retention in care, and viral suppression. Spatial analyses are a valuable tool for characterizing the HIV epidemic and treatment cascade.

Critical issues in reforming rural mental health service delivery

Critical issues in reforming rural mental health service delivery systems under health care reform are outlined. It is argued that the exclusive focus on health care financing reform fails to include obstacles to effective mental health service delivery in rural areas, which should focus on issues of availability, accessibility, and acceptability, as well as financing and accountability. Characteristics of rural areas are delineated and three assumptions about the structure of rural communities which are shaping the dialogue on rural health and mental health service delivery are examined. These assumptions include the notion that rural communities are more closely knit than urban ones, that rural services can be effectively delivered through urban hubs, and that rural dwellers represent a low risk population which can be effectively served through existing facilities and by extending existing services.

Mental disorders and help seeking in a rural impoverished population.

Objective: This study examined the impact of an in-home screening and educational intervention on help seeking among rural impoverished individuals with untreated mental disorders. The effect of including a significant other in the intervention and reasons for not seeking help were explored. Method: The sample was randomly selected from households in nine rural counties in Virginia. The short form of the CIDI was used to screen 646 adult residents. Respondents who screened positive were randomly assigned to one of three groups: 1) no intervention, 2) an educational intervention, or 3) the educational intervention with a significant other. A list of local sources of health and mental health care was distributed. At one-month post interview, respondents were telephoned to inquire about help seeking. Results: Almost one-third (32.4%) of these respondents screened positive for at least one disorder. Five hundred and sixty-six (87.6%) were successfully followed up, and thirty-three of the 566 (5.8%) reported that they had sought professional help since the interview. Eighty-four subjects who screened positive and received the educational intervention reported in follow up that they had discussed the interview with a friend or family member, but only eleven (13.1%) received encouragement to seek treatment. The predominant reason endorsed for not seeking help was “felt there was no need,” even among respondents who were informed that they had a disorder. Conclusions: A significant proportion of this rural impoverished sample screened positive for a mental disorder. Few individuals sought professional help and significant others did not encourage them to seek treatment. The implication of these results for investigators and service providers is that motivating individuals to seek mental health services is a complex process; more attention must be devoted to the development of culturally relevant methods for facilitating help seeking.

NPACT: enhancing programs of assertive community treatment for the seriously mentally ill.

Morbidity and mortality due to physical illness is extremely high in the population of persons with serious mental illness. The purpose of this study was to examine the impact on psychiatric and physical outcomes through enhancing a standard Program of Assertive Community Treatment (PACT) with Advanced Practice Psychiatric Mental Health Nurses (APNs) and stabilized consumer peer providers (NPACT). In a two-group community comparison design, 38 participants receiving NPACT were compared to 21 participants receiving traditional PACT. Evaluations were conducted at baseline and 6 months. Significant improvements over time were demonstrated for both groups on all summary variables. Treatment effects for NPACT over PACT were demonstrated for psychiatric symptoms, community functioning, and consumer satisfaction. Conclusions: Enhancements for PACT using advanced practice nurses and consumer peer providers have the potential to address both health and mental health problems for the seriously mentally ill.

A Multisite Study of the Prevalence of HIV With Rapid Testing in Mental Health Settings

OBJECTIVES We estimated HIV prevalence and risk factors among persons receiving mental health treatment in Philadelphia, Pennsylvania, and Baltimore, Maryland, January 2009 to August 2011. METHODS We used a multisite, cross-sectional design stratified by clinical setting. We tested 1061 individuals for HIV in university-based inpatient psychiatric units (n = 287), intensive case-management programs (n = 273), and community mental health centers (n = 501). RESULTS Fifty-one individuals (4.8%) were HIV-infected. Confirmed positive HIV tests were 5.9% (95% confidence interval [CI] = 3.7%, 9.4%) for inpatient units, 5.1% (95% CI = 3.1%, 8.5%) for intensive case-management programs, and 4.0% (95% CI = 2.6%, 6.1%) for community mental health centers. Characteristics associated with HIV included Black race, homosexual or bisexual identity, and HCV infection. CONCLUSIONS HIV prevalence for individuals receiving mental health services was about 4 times as high as in the general population. We found a positive association between psychiatric symptom severity and HIV infection, indicating that engaging persons with mental illness in appropriate mental health treatment may be important to HIV prevention. These findings reinforce recommendations for routine HIV testing in all clinical settings to ensure that HIV-infected persons receiving mental health services are identified and referred to timely infectious disease care.