Search

Background: It is known that refugees have an elevated risk of common mental disorders (CMDs, including depression, anxiety, and stress-related disorders). The effect of the coronavirus disease pandemic on healthcare use due to CMDs in refugees is yet unknown, especially in socioeconomically deprived groups. We conducted a population-wide study comparing specialized healthcare use for CMDs and antidepressant prescriptions before and during the pandemic in refugees and Swedish-born, and investigated differences by labor market marginalization and education., Methods: An interrupted time series analysis of quarterly cohorts (2018.01.01-2021.12.31) of all refugees and Swedish-born, aged 19 to 65 was applied. Information on outcome measures and covariates were linked individually from administrative registers. We applied interrupted time series and estimated incidence rate ratios (IRR) of the incidence rates (IR) and their corresponding confidence intervals (CI) before and during the pandemic., Results: A total of 4,932,916 individuals, of whom 488,299 (9.9%) were refugees, were included at baseline. We observed a 3% (95% CI: 1%, 5%) quarterly increase in trends of healthcare use due to CMDs in refugees, but no changes in Swedish-born individuals. The IRRs were larger in refugees whose labor market position was marginalized (IRR: 6%, (3%, 9%)), and refugees with low education level (IRR: 4% (1%, 7%)). There were no substantial changes in antidepressant prescription., Conclusion: Refugees, especially those already in a marginalized position, had increased CMD-related mental healthcare use during the pandemic. Strategies to meet the mental health care needs of marginalized refugees are of outmost public health importance., Competing Interests: Declarations. Ethics approval and consent to participate: The project was approved by the Regional Ethical Review Board, Karolinska Institutet, Stockholm, Sweden (Dnr: 2007/762–31 and 2021–06441-02). No participants were contacted since data was retrieved from nationwide administrative registers. Competing interests: The authors declare no competing interests., (© 2025. The Author(s).)

The co-occurrence of substance use (SUD) and mental disorders is increasing in the US. Integrating mental health services into SUD treatment facilities improves treatment retention and success, but access to integrated services is lagging behind growing demand. The purpose of this study was to map the locations of SUD treatment facilities that offer integrated mental health services and identify community characteristics associated with whether a treatment facility offers more comprehensive integrated services. We used the Mental health and Addiction Treatment Tracking Repository to identify the location and characteristics of licensed outpatient SUD treatment facilities in the US (2022; N = 8,858). Our focal predictors included the percentage of a census block group that was White, Black, and Hispanic. We used multilevel multiple logistic regression to model whether a facility offered integrated mental health (y/n), adjusted for relevant facility-, county-, and state-level covariates, and defined state as a random effect. The majority of integrated facilities were located in the eastern US, with notable concentrations around large metropolitan areas of Minneapolis, MN, Chicago, IL, Atlanta, GA, and New York, NY. For every 10-percentage point increase in a census block group's Black and Hispanic population, there was a 5% and 7% decrease in the odds of offering integrated services, respectively (aOR Black  = 0.95, 95% CI = 0.91-0.99, p = 0.04; aOR Hispanic  = 0.93, 95% CI = 0.90-0.96, p < 0.0001). We frame our findings around social conditions as fundamental drivers of disease and healthcare access and acknowledge the country's historical disinvestment in nonwhite and rural communities. Racially targeted programs are needed to effectively address growing racial and ethnic inequities in SUD and mental healthcare., (Copyright © 2025 Elsevier Ltd. All rights reserved.)

Background: Pediatric emergency department (ED) visits for mental health are costly and often preventable. Access to primary care and behavioral health providers can improve mental health and reduce unnecessary ED visits., Methods: Quantitative analysis of the Virginia All-Payers Claims Database to assess mental health ED and outpatient care for children and adolescents up to age 21 years between 2016 and 2021. We determined the proportion of children and adolescents seen by primary care or behavioral health one week and one year before an ED visit, and how many had follow-up care within one and two months after., Results: From 2016 to 2021, pediatric ED visits dropped 14%, but mental health visits rose 10.6%, and suicidality visits tripled (301 to 929, p < 0.001). Only 5% of youth with suicidality ED visits had a primary care visit within 7 days prior, and 18% saw a mental health provider. During the pandemic, prior-year primary care visits for mental health ED cases declined (68.1-61.8%, p < 0.0001). Follow-ups within 60 days dropped for primary care (mental health: 40.0-34.2%; suicidality: 37.5-33.5%), slightly improved for behavioral health (32.2-37.1%), and stayed stable for suicidality (64.1-63.0%)., Conclusions: The pediatric mental health crisis has worsened since the pandemic. There were substantial missed opportunities for prevention and intervention for children and adolescents prior to and following an ED visit for mental health or suicidality., Competing Interests: Declarations. Ethics approval and consent to participate: This study was approved by the Institutional Review Board at Virginia Commonwealth University and was conducted in accordance with the Declaration of Helsinki. Human Ethics and Consent to participate: Not applicable. Consent for publication: Not applicable. Competing interests: The authors declare no competing interests., (© 2025. The Author(s).)

Aims: Prompt initial contact with a treatment provider is a critical first step in seeking help for a mental or substance use disorders (SUDs). The aim of the current study was to provide estimates of patterns and predictors of delay in making initial treatment contact based on the recently completed Australian National Survey of Mental Health and Wellbeing., Methods: Data came a nationally representative epidemiological survey of n = 15,893 Australians. Measures included DSM-IV lifetime diagnoses of mood (MD), anxiety (AD) and SUDs; age of disorder onset; and age of first treatment contact. Correlates of treatment delay were examined., Results: SUDs exhibited the lowest lifetime treatment rate (27%), compared to MD (94%) and ADs (85%). Individuals with AD experienced the longest delay in seeking treatment (Mdn = 11 years), followed by those with SUDs (Mdn = 8 years) and MDs (Mdn = 3 years). Females had higher odds of seeking treatment for MD and AD but lower odds for SUDs. Recent birth cohorts showed increased treatment seeking across disorders, and higher education was associated with increased treatment seeking for MD and AD. Age of onset, country of birth and co-occurring disorders had mixed associations with treatment seeking., Conclusions: The study reveals stark disparities in treatment-seeking behaviour and delays across mental and substance use disorders, with a pronounced underutilization of services for SUDs. Additionally, attention should be directed towards early intervention for individuals with earlier symptom onset, those from earlier cohorts and those with co-occurring SUDs.

Background: There is an unprecedented societal focus on young people's mental health, including efforts to expand access to child and adolescent mental health services (CAMHS). There has, however, been a lack of research to date to investigate adult mental health outcomes of young people who attend CAMHS., Methods: We linked Finland's healthcare registries for all individuals born between 1987 and 1992. We investigated mental disorder diagnoses recorded in specialist adult mental health services (AMHS) and both inpatient and outpatient service use by age 29 (December 31, 2016) for former CAMHS patients., Results: Before the end of their 20s, more than half (52.4%, n  = 21,183) of all CAMHS patients had gone on to attend AMHS. The most prevalent recorded adult psychiatric diagnoses received by former CAMHS patients were depressive disorders (30%, n  = 11,768), non-phobic anxiety disorders (21%, n  = 7,910), alcohol use disorders (9.5%, n  = 3,427), personality disorders (9.3%, n  = 3,366), and schizophrenia-spectrum disorders (7.6%, n  = 2,945). In the total population, more than half of all AMHS appointments (53.1%, k  = 714,239/1,345,060) were for former CAMHS patients. More than half of all inpatient psychiatry bed days were for former CAMHS patients (53.1%, k  = 1,192,991/2,245,247)., Conclusion: While there is a strong focus on intervening in childhood and adolescence to reduce the burden of mental illness, these findings suggest that young people who receive childhood intervention very frequently continue to require specialist psychiatric interventions in adulthood, including taking up a majority of both outpatient and inpatient service use. These findings highlight the need for a greater focus on research to alter the long-term trajectories of CAMHS patients.

Background: While studies have observed mental health inequities across aggregated Asian and Latine populations, a critical gap exists in our understanding of inequities within and across Asian and Latine subpopulations., Objective: We examined the prevalence of mental health symptoms and variations in mental health service use across Black and White populations and Asian and Latine subpopulations at a more granular level., Methods: We conducted a cross-sectional study using data from the 2016-2021 Medical Expenditure Panel Survey. Outcomes included mental health symptoms (mild and serious) and mental health service use (outpatient mental health visits and psychotropic medication fills). The primary independent variable was the category of 13 racial/ethnic groups: Black and non-Latine White individuals and Asian (Asian Indian, Chinese, Filipino, and Other Asian) and Latine (Central/South American, Cuban, Dominican, Mexican, Other Latine, and Puerto Rican) subpopulation individuals., Results: We found modest differences in mental health symptoms by race/ethnicity. However, significant differences were observed in mental health service use among individuals with mental health symptoms. These differences were pronounced across Asian subpopulations with serious mental health symptoms. The likelihood of having any outpatient mental health visit was lower among Asian Indian (- 12.2 percentage points [95% CI - 18.2, - 6.2], Chinese (- 11.7 [- 21.6, - 1.7]), and Filipino individuals (- 16.1 [- 22.5, - 9.8]) than White individuals. The likelihood of having psychotropic medication fill was lower among Asian Indian (- 23.3 [- 34, - 12.7]), Chinese (- 19.8 [- 30.7, - 8.9]), Filipino (- 27.6 [- 40.2, - 14.9]), and other Asian individuals (- 22.5 [- 29.4, - 15.6]) than White individuals. On the other hand, some of these differences were observed in certain Latine subpopulations but not in others., Conclusions: There is a heterogeneity in inequities in mental health service use among Asian and Latine subpopulation groups. These findings underscore the importance of studying granular categories of race/ethnicity for targeting mental health inequities., Competing Interests: Declarations:. Conflict of Interest:: The authors declare no competing interests., (© 2024. The Author(s), under exclusive licence to Society of General Internal Medicine.)

Background: Childhood adversity is robustly associated with mental ill-health. Yet questions remain about how different ways of conceptualising adversity relate to psychiatric diagnoses and service activity. This research aims to examine associations between typological and cumulative conceptualisations of adversity, and psychiatric diagnosis and service activity., Methods: We analysed risk assessment data from 21,072 young people attending mental health services in South London. These assessments include items relating to maltreatment, parental mental health difficulties, substance misuse, self-harm, and violent behaviour. Using latent class analysis, we identified the following risk typologies: 'Maltreatment and externalising behaviours' (n = 971, 4·6 %), 'Maltreatment but low risk to self and others' (n = 2526, 12·0 %), 'Anti-social behaviour' (n = 2669, 12·7 %), 'Inadequate caregiver supervision and risk to self and others' (n = 907, 4·3 %), 'Risk to self but not to others' (n = 1725, 8·2 %), and 'Mental health needs but low risk to self and others' (n = 12,274, 58·2 %). Two cumulative risk models were created: 1) all risk items 2) Adverse Childhood Experiences-related cumulative risk (ACES-CR). Controlling for gender, ethnicity, age, and deprivation, we examined associations between risk typologies, cumulative risk, and the following outcomes: 1) psychiatric diagnosis 2) face-to-face appointments 3) missed appointments 4) referral to social services., Outcomes: Risk in its various conceptualisations was consistently and robustly associated with conduct disorder. Risk also tended to be associated with more face-to-face appointments, missed appointments, and referral to social services. Associations between individual risk typologies and psychiatric diagnosis and service activity are discussed., Interpretation: Our findings suggest that typological and cumulative approaches to risk and adversity can produce unique insights about diagnostic practices and service activity. This work provides further evidence for the contribution of contextual factors to mental ill-health and further work is required to explore the longer-term trajectories of these young people., Competing Interests: Declaration of competing interest No conflicts to declare., (Crown Copyright © 2025. Published by Elsevier Inc. All rights reserved.)

Objective: Characterize the association between Medicare Accountable Care Organizations' (ACOs) behavioral health integration capability and quality and utilization among adults with serious mental illness (SMI)., Background: Controlled research supports the efficacy of integrating physical and mental health care for adults with SMI, yet little is known about the organizations integrating care and associations between integration capability and quality., Methods: We surveyed Medicare ACOs (2017-2018 National Survey of ACOs, response rate 69%) and linked responses to 2016-2017 fee-for-service Medicare claims for beneficiaries with SMI. We examined the cross-sectional association between ACO-reported integration capability (tertiles of a 14-item index) and 7 patient-level quality and utilization outcomes. We fit generalized linear models for each outcome as a function of ACO integration capability, adjusting for ACO and beneficiary characteristics., Results: Study sample included 274,928 beneficiary years (199,910 unique beneficiaries) attributed to 265 Medicare ACOs. ACOs with high behavioral health integration capability (top-tertile) served more dual-eligible beneficiaries (67.8%) than bottom-tertile (63.7%) and middle-tertile ACOs (63.3%). Most beneficiaries received follow-up 30 days after mental health hospitalization and chronic disease monitoring-exceeding national quality benchmarks-but beneficiaries receiving care from top-tertile (vs bottom-tertile) ACOs were modestly less likely to receive follow-up [-2.17 percentage points (pp), P < 0.05], diabetes monitoring (-2.19 pp, P < 0.05), and cardiovascular disease monitoring (-6.07 pp, P < 0.05). Integration capability was not correlated with utilization., Conclusions: ACOs serving adults with substantial physical and mental health needs were more likely to report comprehensive integration capability but were not yet meeting the primary care needs of many adults with SMI., Competing Interests: The authors declare no conflict of interest., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Emergency Department (ED) presentations for Mental Health (MH) help-seeking have been rising rapidly, with EDs as the main entry point for most individuals in Australia. The objective of this retrospective cohort study was to analyse the sociodemographic and presentation features of people who sought mental healthcare in two EDs located in a regional coastal setting in New South Wales (NSW), Australia from 2016 to 2021. This article is a part of a broader research study on the utilisation of machine learning in MH. The objective of this study is to identify the factors that lead to the admission of individuals to an MH inpatient facility when they seek MH care in an ED. Data were collected using existing records and analysed using descriptive univariate analysis with statistical significance between the two sites was determined using Chi squared test, p < 0.05. Two main themes characterise dominant help-seeking dynamics for MH conditions in ED, suicidal ideation, and access and egress pathways. The main findings indicate that suicidal ideation was the most common presenting problem (38.19%). People presenting to ED who 'Did not wait' or 'Left at own risk' accounted for 10.20% of departures from ED. A large number of presentations arrived via the ambulance, accounting for 45.91%. A large proportion of presentations are related to a potentially life-threatening condition (suicidal ideation). The largest proportion of triage code 1 'Resuscitation' was for people with presenting problem of 'Behavioural Disturbance'. Departure and arrival dynamics need to be better understood in consultation with community and lived experience groups to improve future service alignment with the access and egress pathways for emergency MH care., (© 2024 The Author(s). International Journal of Mental Health Nursing published by John Wiley & Sons Australia, Ltd.)

To improve the quality of life for people living with HIV (PLWH), it is vital their treatment plans closely follow the HIV care continuum. However, many barriers, such as mental health disorders (MHD), can complicate treatment. Patients being treated for HIV with comorbid MHD are more likely to not be retained in care and maintain an unsuppressed viral load. As PLWH and people vulnerable to acquiring HIV are more commonly diagnosed with MHD in comparison to the general population, it is important that steps to mitigate the possible effects of MHD are addressed during treatment. This study examines how minimal mental health care in a safety-net hospital system in the U.S. South can show benefits in retaining patients throughout their treatment of HIV. The results showed that older individuals retained a higher level of viral suppression when they followed up regularly with a mental health care provider during treatment. In addition, regardless of age, the higher the number of mental health care visits a patient attended during treatment, the higher the likelihood of viral suppression. By incorporating mental health care into the HIV treatment plan, the patients who met at least one of these criteria had better treatment outcomes and progressed further along the HIV care continuum., Competing Interests: Declarations. Ethical Approval: This work was reviewed and approved by the University of Tennessee Health Science Center institutional review board and Regional One Health Office of Medical Research before any research activities were performed. The authors certify that the study was performed in accordance with the ethical standards as laid down in the 1964 Declaration of Helsinki and its later amendments or comparable ethical standards. Informed Consent: Informed consent was not possible due to the retrospective nature of the work. Waiver of informed consent was approved by the University of Tennessee Health Science Center institutional review board and Regional One Health Office of Medical Research before any research activities were performed. Conflict of Interest: The authors report no potential conflicts of interest., (© 2024. The Author(s).)

Objective: This report describes characteristics of patients who had high out-of-pocket (OOP) spending on mental health care relative to income., Methods: A sample of 8,923 U.S. adults with outpatient mental health visits was drawn from the 2018-2021 Medical Expenditure Panel Survey. Respondents who spent ≥10% of their disposable family incomes on OOP mental health visits were defined as having a high OOP cost burden., Results: Using weighted percentages, the authors found that 2.4% of psychiatric outpatients had a high OOP burden; among those below the federal poverty level, 12.8% had a high OOP burden. Patients with a high (vs. low) OOP burden were statistically significantly more likely to be uninsured (7.5% vs. 2.4%) or diagnosed as having a substance use disorder (8.7% vs. 2.8%) or bipolar disorder (14.5% vs. 8.0%)., Conclusions: Despite federal policies extending the availability of insurance for mental health care, many low-income psychiatric outpatients experience high OOP cost burden., Competing Interests: The authors report no financial relationships with commercial interests.

Objective: To examine factors associated with high intensity physician-based mental health care services in a population-based sample of children and youth in Ontario, Canada., Methods: Data from the 2014 Ontario Child Health Study (OCHS) were linked at the person-level to longitudinal health administrative databases containing physician contacts in outpatient settings, emergency departments and hospitals. Our analytical sample (15.8% of 9,301, n  = 1,423) included children and youth with at least one physician-based contact for a mental health concern in the 24-month period post-OCHS. Over the same follow-up period, we classified high intensity service use as those in the top 10th and fifth percentiles of physician-based mental health service cost contributors. Costs were assessed using physician billing data, as well as estimated emergency department visit and hospitalization costs., Results: Among those with at least one contact, being older (PR: 1.15, 95% CI: 1.04, 1.25), having more severe symptoms of mental ill-health (PR: 1.04, 95% CI: 1.01, 1.06) and having a history of mental health service use (PR: 3.99, 95% CI: 1.37, 11.61), were positively associated with high-intensity service use, while living in a rural setting (PR: 0.35, 95% CI: 0.15, 0.30) was negatively associated. Findings were largely consistent between the top 10th and fifth percentiles. Notably, among youth ages 14-17 years, self-reported prior suicide attempt was positively associated with high-intensity (top fifth percentile) service use (PR: 6.09, 95% CI: 1.41, 26.26)., Conclusions: Our findings suggest older age, non-rural residency, mental health symptom severity and suicidal behaviour are important factors associated with high-intensity physician-based mental health service use. Our findings will inform efforts to better identify children and youth who may benefit from early and personalized interventions., Plain Language Summary Title: Understanding Children and Youth with the Greatest Mental Health Related Service Needs., Competing Interests: Declaration of Conflicting InterestsThe authors declared no potential conflicts of interest with respect to the research, authorship and/or publication of this article.

Engagement in psychosocial mental health services has been found to support and facilitate the process of recovery in individuals with serious mental illness. However, many individuals eligible for these services are not receiving them. Presently, little is known about the factors that contribute to treatment engagement. This study aimed to identify attitudes related to treatment engagement among veterans with serious mental illness enrolled at a large VA medical center. Thirty-six veterans participated in individual qualitative interviews about their beliefs about the efficacy and purpose of mental health care; their perceptions of societal attitudes regarding mental health; and their experiences accessing mental health care. Based on their level of treatment engagement in the last year, veterans were classified as either engaged in psychosocial mental health services ( n = 15), engaged in psychiatric medication management only ( n = 14), or not engaged in VA mental health services ( n = 7). Attitudes associated with level of service usage were examined to identify factors that might improve engagement in treatment and quality of mental health services. Results suggest that provider expertise and rapport were critical to engagement. Our findings also suggest that barriers to accessing care included beliefs about when it was appropriate to request services, stigmatizing attitudes within one's social network, the complexity of the mental health system, and failures of providers and the treatment system to address the needs of a diverse patient population. Implications for clinical training and practice are discussed. (PsycInfo Database Record (c) 2025 APA, all rights reserved).

Young adults access mental health services at lower rates than both older and younger age groups despite high levels of need. Mental health service use is known to be influenced by prior experiences with treatment, with episodes of symptoms and treatment producing patterns of service use over time, or what we call a "symptom management career". This qualitative study examined the symptom management careers of 55 young adults (ages 18-25) who were admitted to an inpatient, short term, crisis stabilization unit. Participants completed research interviews at the hospital following a psychiatrist's assessment. During semi-structured qualitative interviews, participants retrospectively narrated their experiences of mental health symptoms and service use from symptom onset to the current episode. The research team used an inductive qualitative approach to identify distinct patterns of symptom management, while also examining factors that contributed to service use. Six distinct types of symptom management careers were identified based on the timing of symptom onset and service participation. Notably, none of the participants experienced an uninterrupted pattern of service use from adolescence into young adulthood. The team identified a set of themes that influenced these patterns including traumatic experiences, social supports, social service systems, and substance use. Findings highlight the developmental nature of service connection and disconnection and suggest potential points of intervention in non-specialty settings, such as schools, child welfare, and the juvenile legal system. Findings also demonstrate the need for flexible services that respond to the developmental need for autonomy and self-determination as youth transition into young adulthood., (Copyright © 2024 Elsevier Ltd. All rights reserved.)

Research shows that jailed women have disproportionately elevated rates of behavioral health conditions, including serious mental illness and substance use disorders; however, jails have not been able to effectively address these needs. There is a research gap in our understanding of mental health screening tools, linkages to care, and behavioral health service utilization for jailed women, specifically across multiple jails situated in urban and rural contexts. This two-part study compares the behavioral health needs and service utilization of women and men in eight Michigan jails. Results show significant differences in women's and men's behavioral health needs, including proportions of severe mental illness, alcohol and drug misuse, opioid preference, concerns for withdrawal, and length of jail stays. Mental health outcomes show significant gendered differences in advocacy for early release and jail- and post-jail treatment engagement. These findings highlight the need for jails to better assess behavioral health needs among women and may inform interventions aimed at improving women's (and men's) experiences while jailed. (PsycInfo Database Record (c) 2025 APA, all rights reserved).

Globally, youth mental health services are evolving, with Australia's headspace services presented as a leading exemplar. headspace services were designed as enhanced primary care-based entities and were expected to collaborate with local acute, and specialist clinical and psychosocial services. The lack of large-scale health services trials necessitates understanding their impact through systematic monitoring and evaluation. This paper compares data from differing sources that describe the demographic and clinical features, and functional outcomes, of young people presenting to various headspace services. headspace National reports that care is provided largely to youth with transient distress, minimal clinical disorders, suicidality or comorbidities and limited functional impairment. Almost 50% of clients are reported to have no significant psychological symptoms or risk factors, and less than 30% to have a clinical disorder. Consequently, 36% receive only a single session of care and the median number of clinical sessions provided is three. By contrast, empirically derived estimates, utilising data from an academic centre and its affiliated centres, other independent agencies and more refined analyses of headspace national data variously portray 50-60% of youth as presenting with at least moderate clinical complexity (including at least 20% with high complexity), and with another 27% requiring active clinical intervention. Together, these data suggest approximately 75% of attendees require substantive clinical care. Clinical outcomes data from all sources indicate limited impacts on functional outcomes, with less than a third achieving significant improvement. These data support the original intent of headspace services to focus on equitable access to multidimensional and clinical assessment, evidence-based early interventions for early stages of major anxiety, mood or psychotic disorders. As demand for youth services continues to rise, there is an urgent need to reconfigure our national youth service networks to address the unmet clinical and psychosocial needs of youth presenting in the early stages of major mental disorders., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: IBH is the Co-Director, Health and Policy at the Brain and Mind Centre (BMC) University of Sydney. The BMC operates an early-intervention youth services at Camperdown under contract to headspace. IBH is the Chief Scientific Advisor to, and a 3.2% equity shareholder in, Innowell Pty Ltd, which supports the transformation of mental health services internationally through the use of innovative technologies. EMS is Principal Research Fellow at the Brain and Mind Centre, The University of Sydney. EMS is Discipline Leader of Adult Mental Health, School of Medicine, University of Notre Dame, and a Consultant Psychiatrist. EMS was the Medical Director, Young Adult Mental Health Unit, St Vincent’s Hospital Darlinghurst until January 2021. EMS has received honoraria for educational seminars related to the clinical management of depressive disorders supported by Servier, Janssen and Eli-Lilly pharmaceuticals. EMS has participated in a national advisory board for the antidepressant compound Pristiq, manufactured by Pfizer. EMS was the National Coordinator of an antidepressant trial sponsored by Servier. All other authors declare no financial or non-financial competing interests.

Background: Patient satisfaction with services is both a direct and indirect indicator of healthcare quality. It influences healthcare outcomes, patient retention, and the likelihood of medical malpractice claims. However, there is limited evidence on patient satisfaction with mental health services in Africa. Therefore, we aimed to assess mental health service satisfaction and its determinants in adult patients with mental illness in an outpatient clinic in Northwest Ethiopia., Methods: A hospital-based cross-sectional study was conducted from October to March 2023. Participants were selected using systematic random sampling with a sample interval of three, resulting in a total sample size of 638 invited to participate. Service satisfaction was measured using the interviewer-administered Client Satisfaction Questionnaire-8 (CSQ-8). Data entry, coding, and analysis were performed using SPSS-28. To examine the association of sociodemographic, clinical, social support, and substance use factors, bivariate and multivariate logistic regression analyses were applied. Statistical significance was declared at a p -value of <0.05 and 95% CI., Results: The rate of low mental health service satisfaction among people with mental illness in this study was 24.7%. According to our multivariate logistic regression analysis, people with urban residence 1.77 (1.15, 2.72), poor self-reported health 3.62(1.97, 6.67), having episodic illness ≥2/yr. 0.48 (0.32, 0.74), having relapse 1.75 (1.12, 2.73), and poor drug adherence 2.28 (1.20, 4.35) were more likely to have low mental health service satisfaction than their counterparts., Conclusions and Recommendation: One-quarter of patients with mental illness in the outpatient clinic reported low satisfaction with mental health services. Factors associated with lower satisfaction included urban residency, episodic illness, relapse, poor self-reported health, and poor drug adherence. To enhance patient satisfaction, the clinic should prioritize targeted support for patients facing these challenges., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2025 Alemu, Mwanri, Due, Azale and Ziersch.)

Background: Stigma is recognised as one of the most significant barriers to treatment for people with mental health conditions. However, limited studies are available in low-resource settings., Objectives: To assess the magnitude of internalised stigma and associated factors among people with mental health conditions attending tertiary outpatient psychiatric services in Ethiopia., Methods: A hospital-based cross-sectional study was conducted among 306 consecutively selected outpatient attendees of mental health services. Stigma was assessed using an interviewer administered instrument, the Internalised Stigma of Mental Illness Scale (ISMI) previously adapted for use in the Ethiopian setting. Data were collected using standard tools for medication adherence, social support, quality of life and self-esteem. Clinical information was extracted from medical record. Binary logistic regression analysis was carried out to assess factors associated with internalised stigma. Odds ratios along with 95% confidence intervals were estimated to measure the strength of the association., Results: The magnitude of internalised stigma among participants was 36.6% [95% CI: (31.2%,42.3%)]. Having anxiety disorder [adjusted odds ratio (AOR) = 0.22; 95% confidence interval (CI): (0.07,0.66)], having other milder forms of psychiatric disorders [AOR = 0.19; 95% CI: (0.05,0.78)], a history of suicide attempt [AOR = 1.99; 95% CI: (1.02,3.87)], low self-esteem [AOR = 7.52; 95% CI: (3.58,15.78)] and poor quality of life [AOR = 2.06; 95% CI: (1.06,4.02)] were associated with internalised stigma among participants., Conclusion: Internalised stigma remains a significant challenge among mental health service users in Ethiopia. Interventions that target individuals with psychotic, bipolar and depressive disorders with a history of suicide, low self-esteem and poor quality of life should be implemented to reduce internalised stigma among people with mental health conditions. Efforts should also target external factors, such as improving mental health literacy and challenging negative stereotypes., Competing Interests: Declarations. Ethics approval and consent to participate: Ethical approval was obtained from the Institutional Review Board of Jimma University before conducting the study. Written informed consent was obtained from each participant. Participants were provided adequate information about the study, potential benefits, and risks. Participation was voluntary, and confidentiality was maintained. Consent for publication: Not applicable. Competing interests: The authors declare no competing interests., (© 2024. The Author(s).)

Background: Little is known regarding those who die by suicide without having received help. The aim of this study was to compare those who died by suicide without having attended psychiatric care with controls (a) with a psychiatric diagnosis and (b) from the general population., Methods: Cases were all individuals 15+ who lived in Denmark during 2010-2021 and had died by suicide without having attended hospital-based psychiatric care. Cases were matched to controls from the two comparison-groups using a 1:10 ratio and compared using age-and sex-adjusted logistic regression analyses. Geographical variations in psychiatric care utilization were examined., Results: Among 7119 individuals who died by suicide, 3474 (48.8 %) had not attended psychiatric care. Compared to controls with a psychiatric diagnosis, cases were more likely to be male (OR, 3.9, 95% CI, 3.6-4.2), older (80+ years: OR, 10.7, 95 % CI, 9.2-12.5), have lost a close relative (OR, 1.8, 95 % CI, 1.3-2.6) or recently retired (OR, 1.4, 95 % CI, 1.0-1.1.8). Compared to controls from the general population, cases were associated with male sex (OR, 4.6, 95 % CI, 4.2-5.0), living alone (OR, 2.3, 95 % CI, 2.2-2.5), unemployment (OR, 2.1, 95 % CI, 1.8-2.5), as well as having lost a close relative (OR, 5.0, 95 % CI, 3.5-7.2) or divorced within the last 1 year (OR, 3.6, 95 % CI, 2.7-4.9)., Limitations: Characteristics and preceding events were limited to available register data., Conclusions: About half of all who died by suicide had not attended psychiatric care. Being older, male, or exposed to recent stressors were some of the major markers when compared to controls., Competing Interests: Declaration of competing interest The authors have no competing interests to declare., (Copyright © 2024 Elsevier B.V. All rights reserved.)

South Asians (SAs) underutilize mental health services compared to many racial and ethnic groups in the United States (US), yet there is limited research on the experiences of SAs living with severe mental illness (SMI). This study examined psychiatric healthcare experiences of SA patients with SMI diagnoses (e.g., severe depression, bipolar disorder, schizophrenia) in New York City. Data collection included semi-structured interviews with 36 participants (21 patients, 11 family members, 4 clinicians). Data was managed in NVivo. Two pairs of SA researchers conducted thematic analysis. Limited mental health knowledge led to delayed care for SAs due to a low perceived need for help. Ease of access, linguistic resources, patient-provider relationships, and family involvement influenced psychiatric healthcare experiences. Prescribed medications, self-motivation, communication, and religious practices were factors aiding symptom management and recovery. Findings highlight the need for improving psychiatric healthcare access and culturally-salient mental health education for SA communities., Competing Interests: Declarations. Conflict of interest: The authors have no conflicts of interest to disclose., (© 2024. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background: More than 50% of people receiving long-term sickness benefits in Denmark have a common mental illness. At the same time, a significant treatment gap exists where less than 30% receive sufficient care for their mental illness., Methods: The trial was designed as an investigator-initiated, randomized, two-group parallel superiority trial. Nine hundred participants with a common mental illness were randomly assigned into two groups: (1) IBBIS II, consisting of integrated mental health care and vocational rehabilitation, or (2) service as usual (SAU), at two sites in Denmark. The primary outcome was the difference between the two groups in time to return to work (RTW) at 12 months., Results: There was no difference between the integrated IBBIS II intervention and SAU in time from baseline to RTW at the 12-month follow-up (Hazard ratio (HR) = 1.16 (95% CI 0.99-1.37), p  = 0.07), but there was a tendency that the IBBIS II group had worse outcomes on several exploratory employment measures, including time to return to work at 6-month follow-up (HR = 1.36 (95% CI 1.03-1.55), p  = 0.02), and number of weeks in work at 12-month follow-up (incidence rate ratio = 1.14 (95% CI 1.04-1.27), p  = 0.008)., Discussion: The integrated employment and health intervention (IBBIS II) was not more effective than SAU in any of the included vocational outcomes and may even have been inferior to SAU on certain outcome measures. Based on these results, it is not recommended that the IBBIS II intervention is widely implemented in countries with service as usual comparable with Denmark., Trial Registration: ClinicalTrials.gov. Registered June 16, 2020, NCT04432129. https://clinicaltrials.gov/ct2/show/NCT04432129?term = IBBIS+II.

Background: Adults with intellectual disabilities (IDs) are at greater risk for psychiatric disorders than the general population. Yet, they have limited access to mental health services., Objectives: To examine the prevalence of psychiatric disorders in adults with ID. To describe evidence-based interventions for this population, their access to mental health care, and outline opportunities for improved access., Design: This manuscript summarizes literature regarding psychiatric disorders in adults with ID and their access to behavioral health care. We considered articles referencing mental health care for adults with ID. PubMed and a variety of search terms were used. Studies published in English from 2010 to the date of the searches were included. Quantitative and qualitative study designs, review articles, program descriptions, and opinion papers were considered for inclusion. Additional references from the selected articles were also considered., Results: We identified 2864 records. One hundred two records were included, consisting of work commenting on mental health and ID and access to care in the United States. The articles describe increased psychiatric comorbidities in adults with ID. They highlight the few evidence-based interventions for psychiatric comorbidities and the limited access to care., Conclusions: Our mental health care providers generally have minimal training and experience with people with ID, limiting access to appropriate care for these individuals. Improved access could be created by increasing education and experiences with these populations for mental health providers. Aligning policies, financing, and adequate insurance reimbursement to develop a continuum of care will be critical for these individuals., Competing Interests: J.A.F. has received research funding from the NIH, Autism Speaks, Tetra Pharmaceuticals, Quadrant, and Helix. A.K.W. served as an advisor and editor of the Pediatric Behavioral Health Urgent Care report published by the Children’s Mental Health Campaign in 2020, which is cited in this article. L.H. declares no conflict of interest., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Introduction: Early intervention represents an opportunity to contain psychological distress and intervene promptly on conditions that, otherwise, could assume a chronic course. Based on these observations, an early intervention programme for people 18-25 years old, the 'Progetto Giovani' (Youth Project), was implemented in two adult mental health services (AMHSs) in the northwest of Italy., Methods: This study aims to describe the socio-demographic and clinical characteristics of the patients included in the Youth Project from 1 January 2013 to 31 December 2022. A retrospective observational design was used., Results: In 10 years, 323 patients were taken into care. More than half (56.3%) were females; the mean age was 20.7 years (SD 2.3). The most frequent diagnosis was anxiety disorder (38%). Seventy per cent of subjects benefitted from psychological treatment, and 60.8% had a pharmacological prescription. In 87.8% of cases, the care pathway was ≤ 24 months, and more than two-thirds of the subjects did not go to another AMHS after discharge. More than 90% of subjects did not require hospitalisation in the psychiatric diagnostic and treatment service., Conclusions: These findings suggest that early intervention programmes may be a valuable tool for AMHSs to improve patient outcomes and reduce the burden on the healthcare system., (© 2024 John Wiley & Sons Australia, Ltd.)

Background: Psychiatric disorders often emerge during adolescence or young adulthood, leading to significant disability among youth. The transition from Child and Adolescent Mental Health Services (CAMHS) to Adult Mental Health Services (AMHS) is critical for individuals experiencing emerging psychopathology, with delayed access to care negatively impacting long-term outcomes. Accessing mental health services for adolescents and young adults is often complex and delayed due to challenges in service visibility, accessibility and appropriateness., Methods: This study examines the care trajectories of individuals consecutively accessing the early detection and intervention (EDI) centre C'JAAD (Evaluation Centre for Young Adults and Adolescents) in Paris (France) over the year 2021. The main goal was to clarify the role of this EDI centre in the continuity of care and transition to AMHS. Data about their history of care, hospitalisations and referral sources were collected retrospectively., Results: The sample comprised 194 individuals, with 57.2% males and a median age of 20 years. Most patients (67.5%) were ≥18 years old upon arrival, with 31% in a situation of not being in education, employment, or training (NEET). Over one-third (35.2%) had prior psychiatric hospitalisations. Patients were mainly referred to our EDI centre from other hospital departments (42.3%). Regarding care in CAMHS, 50.3% of the total sample had medical follow-up during childhood, of whom 41.9% had discontinued care upon arrival at the EDI centre. The median onset age of care in CAMHS was 14, with a median duration of 12 months. Adult patients experienced an approximately 3-year gap between the end of CAMHS care and assessment at the EDI centre., Discussion: The sample's characteristics resemble those of other EDI centres, but concerns persist regarding referral timing and the NEET status of many youths. Lack of prior medical follow-up and challenges in transitioning to AMHS underscore the need to enhance care continuity and address difficulties in accessing care during the transition to adulthood., (© 2024 The Author(s). Early Intervention in Psychiatry published by John Wiley & Sons Australia, Ltd.)

The purpose of this study is to examine the relationship between the type of mental health care received and metropolitan status. We combined data from the National Survey for Drug Use and Health (NSDUH) to examine mental health treatment. We grouped participants by metropolitan status and receipt of mental health treatment. We conducted a logistic regression using interaction terms to compare the likelihood of receiving inpatient and/or outpatient treatment for mental health, relative to prescription medication alone. There was an association between the type of mental health treatment received and metropolitan status. For women, living outside a large metropolitan area was associated with a higher likelihood of receiving only prescription medication (p < 0.001). Policy makers may use these results to consider ways to increase access to care, including increasing funding for behavioral health or recruitment incentives for specialists., (© 2024. The Author(s).)

The negative consequences of the COVID-19 pandemic and the subsequent restrictive measures on the mental health and well-being of the population and psychiatric patients have been widely recognized. Patients' treatment attendance and engagement with mental health services had been negatively affected by the pandemic, whereas patients were less likely to receive timely outpatient care. The pandemic also impacted the use of inpatient services. The aim of the present study was to explore the variability of attendance and admissions to a general hospital psychiatric ward over a 12-month interval after the onset of the pandemic (March 2020), compared to the respective 12-month pre-pandemic interval. A retrospective, observational pre/post study was performed, involving a general hospital psychiatric ward in Corfu, Northwest Greece, which serves an insular catchment area of approximately 100,000 inhabitants. For data analysis, c- and u-charts of statistical process control charts were employed, using monthly data (March 2019 to February 2021). Overall, a significant decline in attendance rates was observed, mostly accounted for by a 26.5% reduction in voluntary attendance rates (1516 patients prior vs. 1114 patients after the onset of the pandemic). The involuntary commitment of patients did not differ between the two periods (106 prior vs. 100 after the onset of the pandemic). Admission rates did not change significantly between the two periods. Diagnoses that exhibited significant variance in examinations between the two study periods were mood disorders and personality disorders, whereas there was no significant variation in the number of admissions across different diagnoses. Length of hospital stay increased significantly by 13.2% over the first year of the pandemic, from 25.57 days (Md= 13, IQR= 22) during the pre-COVID-19 period to 28.95 days (Md= 22, IQR= 28) during the COVID-19 period. Patients with schizophrenia and related disorders (Mean= 34.25 days, SD= 43.19) and mood disorders (Mean= 26.26, SD= 33.48) had prolonged hospital stays compared to other diagnoses. These findings highlight significant shifts in psychiatric care delivery during the pandemic and underscore the need for targeted interventions to address the evolving demands on mental health services during public health crises.

Background: This study investigated socio-demographic, psychiatric, and psychological characteristics of patients with high versus low utilization of psychiatric inpatient services. Our objective was to better understand the utilization pattern and to contribute to improving psychiatric care., Methods: One-hundred and twenty inpatients of the University Psychiatric Clinics (UPK) Basel, Switzerland, participated in this cross-sectional study. All patients were interviewed using different clinical scales. As target variables we investigated the number of days of psychiatric inpatient treatment within a 30-month period., Results: Despite including multiple relevant patient variables and using elaborate statistical models (classic univariate und multiple regression, LASSO regression, and non-linear random forest models), the selected variables explained only a small percentage of variance in the number of days of psychiatric inpatient treatment with cross-validated R 2 values ranging from 0.16 to 0.22. The number of unmet needs of patients turned out to be a meaningful and hence potentially clinically relevant correlate of the number of days of psychiatric inpatient treatment in each of the applied statistical models., Conclusions: High utilization behavior remains a complex phenomenon, which can only partly be explained by psychiatric, psychological, or social/demographic characteristics. Self-reported unmet patient needs seems to be a promising variable which may be targeted by further research in order to potentially reduce unnecessary hospitalizations or develop better tailored psychiatric treatments., Competing Interests: Declarations. Ethics approval and consent to participate: Ethics approval was obtained from the Approval Committee “Ethics Committee Northwest and Central Switzerland (EKNZ)” under protocol number EKNZ BASEC 2016–00407 (Clinical trial number: not applicable). All participants provided informed consent and the study was carried out in compliance with the Declaration of Helsinki. Consent for publication: Not applicable. Competing interests: The authors declare no competing interests., (© 2024. The Author(s).)

Australia is an ethnically diverse nation with large numbers of migrants and refugees entering the country yearly. Despite research demonstrating that individuals from culturally and linguistically diverse (CaLD) communities experience an elevated risk of developing a mental illness, mental health services uptake is consistently low. To improve the mental health outcomes of these CaLD individuals in Australia, there is an urgent need to understand barriers to treatment, such as stigma. Research has noted that gender may play a role in mental health stigma and help-seeking. Using a qualitative approach as part of the Embrace Multicultural Mental Health Project, the aim of this study was to explore gender perspectives in mental health stigma and help-seeking among Arabic-speaking and Swahili-speaking individuals in Sydney. A total of five focus group discussions and 18 interviews were undertaken online using Zoom, digitally recorded, transcribed, and thematically analysed. Three major themes were identified. The first theme related to stigma and the fears regarding mental illness being discovered by others. The second theme related to the different approaches to confronting stigma. The last theme related to the various issues considered when identifying sources of help. Our findings suggest that a nuanced approach using the 'what matters most' framework can explain how men and women within each community may experience stigma and emphasise different aspects of help-seeking. These findings can help to guide clinical practitioners in delivering gender-specific and culturally sensitive and effective treatment sessions with these CaLD individuals, in addition to offering directions for stigma-reduction initiatives.

Aim: Mental disorders affect approximately 15%-20% of childhood. However, due to various factors, these individuals do not benefit sufficiently from mental health services. Therefore, psychiatry emergency services become a key system in the need of psychiatric care for these children. This study aims to reveal the factors that predict recurrent admissions in children and adolescents admitted to the emergency department of a psychiatric hospital and the tendencies of clinicians during management., Methods: In our study, the data of patients aged 0-18 years who applied to the emergency department between 1 March 2022 and 01 March 2023 were scanned retrospectively. Participants who applied once were included in the 'single applicant' group, whereas patients who applied two or more times were included in the 'repeated applicants' group., Results: A total of 1563 emergency applications were recorded by 785 different patients. A total of 62.2% of the patients visited the emergency department once, while 37.8% applied two or more times. Non-suicidal self-injury, delusion/hallucination, irritability and depression were significantly higher in recurrent applicants (P < 0.05). Psychotic disorder, bipolar disorder, major depression and borderline personality traits were significantly frequent in these patients (P < 0.05). Additionally, it was determined that the number of psychiatric diagnoses, referral time, need for chemical restraint, having a diagnosis of psychotic disorder or borderline personality traits increased the likelihood of recurrence., Conclusions: Our results indicate some special risk factors that increase the likelihood of recurrent emergency admissions in children and adolescents. Further research with larger sample sizes may elucidate the unique needs of these children in order to use of community resources beneficially., (© 2024 Paediatrics and Child Health Division (The Royal Australasian College of Physicians).)

The unmet need for mental health care is a global concern. There is a lack of cross-cultural studies examining adolescent help-seeking behavior from both formal and informal sources, including both high-and lower-income countries. This study investigates mental health help-seeking behavior in eight Asian and European countries. Data from 13,184 adolescents aged 13-15 (51% girls) was analysed using mixed-effects logistic regression with school-wise random intercepts to compare countries and genders. Although a significant proportion of adolescents considered getting or sought informal help, formal help-seeking remained exceptionally low, especially in middle-income countries (< 1%), while it ranged from 2 to 7% in high-income countries. Among adolescents with high emotional and behavioral problems (scoring above the 90th percentile on the Strengths and Difficulties Questionnaire), 1-2% of those in middle-income countries and 6-25% of those in high-income countries sought formal help. Girls generally seek more help than boys. The study shows the most adolescents do not receive formal help for mental health problems. The unmet need gap is enormous, especially in lower-income countries. Informal sources of support, including relatives, peers, and teachers, play a crucial role, especially in lower-income countries., Competing Interests: Declarations. Ethical approval: Informed consent was obtained from the parents or school authorities, according to each country’s policies. Conflict of interest: The authors declare that they have no conflict of interest., (© 2024. The Author(s).)

Emergency department (ED) presentations for mental health (MH) help-seeking have been rising rapidly in recent years. This research aims to identify the service usage demographic for people seeking MH care in the ED, specifically in this case, to understand the usage by First Nation people. This retrospective cohort study examined the sociodemographic and presentation characteristics of individuals seeking MH care in two EDs between 2016 and 2021. Data were collected using existing records and analysed using descriptive univariate analysis with statistical significance between the two sites determined using chi-squared test, p < 0.05. The overall data presented in this analysis show an overall ED mental health presentation rate of 12.02% for those who identified as 'Aboriginal but not Torres Strait Islander origin', 0.36% as 'Both Aboriginal and Torres Strait Islander' and 0.27% as 'Torres Strait Islander' totalling 12.63%. This is an overrepresentation compared to the regional population of 4.9%. One site recorded 14.1% of ED presentations that identified as Aboriginal and/or Torres Strait Islander, over double the site's demographic of 6.3%. Given the disproportionately high representation of First Nation people in MH-related ED presentations, further research is required to prioritise a First Nation research perspective that draws on First Nation research methods, such as yarning and storytelling to understand the unique cultural needs and challenges experienced by First Nation people accessing MH care via ED. Understanding the demographic is but one step in supporting the Cultural Safety needs of First Nation people. Additionally, research should be designed, governed and led by First Nation researchers., (© 2024 The Author(s). International Journal of Mental Health Nursing published by John Wiley & Sons Australia, Ltd.)

Background: During the COVID-19 pandemic, reports from several European mental health care systems hinted at important changes in utilization. So far, no study examined changes in utilization in the German mental health care inpatient and outpatient mental health care system comprehensively., Methods: This longitudinal observational study used claims data from two major German statutory health insurances, AOK PLUS and BKK, covering 162,905 inpatients and 2,131,186 outpatients with mental disorders nationwide. We analyzed changes in inpatient and outpatient mental health service utilization over the course of the first two lockdown phases (LDPs) of the pandemic in 2020 compared to a pre-COVID-19 reference period dating from March 2019 to February 2020 using a time series forecast model., Results: We observed significant decreases in the number of inpatient hospital admissions by 24-28% compared to the reference period. Day clinic admissions were even further reduced by 44-61%. Length of stay was significantly decreased for day clinic care but not for inpatient care. In the outpatient sector, the data showed a significant reduction in the number of incident outpatient diagnoses., Conclusion: Indirect evidence regarding the consequences of the reductions in both the inpatient and outpatient sector of care described in this study is ambiguous and direct evidence on treatment outcomes and quality of trans-sectoral mental healthcare is sparse. In line with WHO and OECD we propose a comprehensive mental health system surveillance to prepare for a better oversight and thereby a better resilience during future global major disruptions., Competing Interests: Declarations. Conflict of interest: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (© 2024. The Author(s).)

Objectives: To understand the key descriptors of the Top End Mental Health Service, Northern Territory's, perinatal mental health consultation service (PMHCS)., Method: A retrospective cross-sectional review of all referrals to the PMHCS in the 12 months period 1 January to 31 December 2021 inclusive was undertaken. The study was descriptive in nature., Results: From January 2021 to December 2021, there were 266 women referred to the service. There was a large proportion of Aboriginal and Torres Strait Islanders. Mean age was 28.8 (SD = 6.04) years. A statistically significant difference was identified between the average age of the Aboriginal and Torres Strait Islander women ( n = 53, M = 24.6 years, SD = 6.31) which was significantly less than Caucasian women ( n = 161, M = 29.4037, SD = 4.982) and women of other cultural backgrounds ( n = 52, M = 31.154, SD = 6.792), p < .00,001. Sixty two percent of patients managed had a history of trauma with significantly more service contact., Conclusion: This data gives insight into a unique population group. It also highlights the impact that trauma has on patient care and management., Competing Interests: DisclosureThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Purpose: Young adults from minoritized racial and ethnic groups have lower rates of engagement in treatment for serious mental illnesses (SMI). Previous research suggests a relationship between ethnic identity development and engagement in mental health services, but it remains unclear how a sense of belonging and attachment to one's racial and ethnic group influences participation in treatment among young adults with SMI., Methods: Bivariate analyses and structural equation modeling (SEM) were used to examine whether ethnic identity was associated with treatment engagement (attendance and investment in treatment) and how ethnic identity might influence engagement through theoretical proximal mediators. Eighty-three young adults with SMI (95% from minoritized racial and ethnic groups) were recruited from four outpatient psychiatric rehabilitation programs and assessed at least 3 months after initiating services., Results: Stronger ethnic identity was associated with greater investment in treatment but not with treatment attendance. The SEM analysis indicated that stronger ethnic identity may improve investment in treatment by enhancing hope (0.53, p < .05) and beliefs that mental health providers are credible (0.32, p < .05), and by increasing self-efficacy (-0.09, p < .05). Proximal mediators of engagement were associated with investment in treatment (hope and credibility, p < .05, and self-efficacy p = 0.055)., Conclusions: Findings provide preliminary evidence of an empirical and theoretical relationship between ethnic identity development and engagement in treatment among young adults with SMI. Assessment and strengthening of a young person's ethnic identity may be a promising approach for improving their engagement in services and reducing inequities in their care., Competing Interests: Declarations Ethics Approval The study was approved by New York University’s Committee on Activities Involving Human Subjects (reference number IRB-FY2017-1002). Consent to Participate Informed consent was obtained from all individual participants included in the study. Consent for Publication The manuscript does not contain any individual person’s data in any form. Competing Interests The authors declare no competing interests., (© 2023. W. Montague Cobb-NMA Health Institute.)

Purpose: Loneliness disproportionately affects people with mental disorders, but associations with mental health outcomes in groups affected remain less well understood., Method: A cohort of patients receiving mental healthcare on 30th June 2012 was assembled from a large mental health records database covering a south London catchment area. Recorded loneliness within the preceding 2 years was extracted using natural language processing and outcomes were measured between 30th June 2012 until 30th December 2019, except for survival which applied a censoring point of 6th December 2020 according to data available at the time of extraction. The following mental healthcare outcomes: (i) time to first crisis episode; (ii) time to first emergency presentation; (iii) all-cause mortality; (iv) days active to service per year; and (v) face-to-face contacts per year., Results: Loneliness was recorded in 4,483 (16.7%) patients in the study population and fully adjusted models showed associations with subsequent crisis episode (HR 1.17, 95% CI 1.07-1.29), emergency presentation (HR 1.30, 1.21-1.40), days active per year (IRR 1.04, 1.03-1.05), and face-to-face contacts per year (IRR 1.28, 1.27-1.30). Recorded loneliness in patients with substance misuse problems was particularly strongly associated with adverse outcomes, including risk of emergency presentation (HR 1.68, 1.29-2.18) and mortality (HR 1.29, 1.01-1.65)., Conclusion: Patients receiving mental healthcare who are recorded as lonely have a higher risk of several adverse outcomes which may require a need for higher service input., (© 2024. The Author(s).)

Aims: Achieving equitable healthcare access is a global challenge. Improving whole-population mental health and reducing the global burden of mental disorders is a key recommendation of the 2018 Lancet Global Mental Health Commission, which proposed monitoring national indicators, including the proportion of people with severe mental disorders who are service-users. This study aims to derive an equity indicator from national datasets integrating need, service utilisation and socioeconomic status, and demonstrate its utility in identifying gaps in mental health service use amongst those with the greatest need, thereby guiding equitable healthcare delivery., Methods: We present a case study of a universal health insurance scheme (Medicare) in Australia. We developed the equity indicator using three national datasets. Geographic areas were linked to an area-based socioeconomic deprivation quintile (Census 2016). Per geographic area, we estimated the number with a mental healthcare need using scores ≥30 on the Kessler-10 (Australian National Health Surveys 2015 and 2018), and obtained the number of services used, defined as mental health-related contacts with general practitioners and mental health professionals (Medicare administrative data 2015-2019). We divided the number of services by the population with an estimated mental healthcare need and averaged these use-rates across each socioeconomic deprivation quintile. The equity indicator is the ratio of the use-rates in the least versus most deprived quintiles., Results: Those estimated to have the greatest need for mental healthcare in 2019 ranged between 8.2% in the most disadvantaged area quintile (Q1) and 2.4% in the least (Q5), corresponding to a proportional increase of 27.7% in Q1 and 19.5% in Q5 since 2015. Equity-indicator-adjusted service rates of 4.2 (3.8-4.6) and 23.9 (22.4-25.4) showed that individuals with the highest need for care residing in Q1 areas received a stark 6 times fewer services compared to their Q5 counterparts, producing an equity indicator of 6., Conclusions: As the global prevalence of common mental disorders may be increasing, it is crucial to calculate robust indicators evaluating the equity of mental health service use. In this Australian case study, we developed an equity indicator enabling the direct comparison of geographic areas with different need profiles. The results revealed striking inequities that persisted despite publicly-funded universal healthcare, recent service reforms and being a high-income country. This study demonstrates the importance and feasibility of generating such an indicator to inform and empower communities, healthcare providers and policymakers to pursue equitable service provision.

Objective: Black women in the United States experience increased risk for mental disorders and are less likely to have access to appropriate mental health treatment compared with White women. To develop culturally responsive strategies to improve Black women's access to mental health treatment, the authors evaluated social determinants associated with mental health treatment utilization and unmet mental health needs among Black reproductive-age women with serious psychological distress., Methods: The authors performed a secondary analysis of data from the National Survey on Drug Use and Health. Data from 2009 to 2019 were pooled and restricted to Black women ages 18-44 years with serious psychological distress (N=4,171). Logistic regressions were conducted to identify personal and social determinants (e.g., education, employment status, poverty, and insurance status) of mental health treatment utilization, alternative mental health treatment utilization (e.g., spiritual support and self-help), and perceived unmet mental health needs., Results: Education and employment status were significantly associated with all three outcomes. Among the women who reported unmet mental health needs, opposition to treatment and cost were the highest endorsed barriers. Differences were found by pregnancy status, with pregnant women being significantly less likely to endorse cost (p<0.001) and more likely to endorse time and transportation as barriers (p<0.01) to receiving mental health treatment., Conclusions: Strategies to improve mental health outcomes for Black women should focus on reducing cost and transportation barriers and on the development of culturally responsive intervention approaches that address Black women's concerns about mental health treatment., Competing Interests: The authors report no financial relationships with commercial interests.

Objective: Discriminatory practices in mental health care undermine the right to health of marginalized service users. Intersectional approaches enable consideration of multiple forms of discrimination that occur simultaneously and remain invisible in single-axis analyses. The authors reviewed intersectionality-informed qualitative literature on discriminatory practices in mental health care to better understand the experiences of marginalized service users and their evaluation and navigation of mental health care., Methods: The authors searched EBSCO, PubMed, MEDLINE, and JSTOR for studies published January 1, 1989-December 14, 2022. Qualitative and mixed-methods studies were eligible if they used an intersectional approach to examine discrimination (experiences, mechanisms, and coping strategies) in mental health care settings from the perspective of service users and providers. A qualitative evidence synthesis with thematic analysis was performed., Results: Fifteen studies were included in the qualitative evidence synthesis. These studies represented the experiences of 383 service users and 114 providers. Most studies considered the intersections of mental illness with race, sexual and gender diversity, or both and were performed in the United States or Canada. Four themes were identified: the relevance of social identity in mental health care settings, knowledge-related concerns in mental health care, microaggressions in clinical practice, and service users' responses to discriminatory practices., Conclusions: Discriminatory practices in mental health care lead to specific barriers to care for multiply marginalized service users. Universities and hospitals may improve care by building competencies in recognizing and preventing discrimination through institutionalized training., Competing Interests: The authors report no financial relationships with commercial interests.

A cross-sectoral partnership was formed in 2021 in support of the recommendations in an audit on access to state-funded mental health services. In this first paper, we aimed to describe the demographic and service utilisation of adults with a mental health diagnosis in the Western Australian state-funded health system from 2005 to 2021. Inpatient, emergency department, specialised (ambulatory) community mental health service, and death records were linked in individuals aged ≥ 18 years with a mental health diagnosis in Western Australia. Altogether, 392,238 individuals with at least one mental health service contact between 1st January 2005 and 31st December 2021 were included for analysis. Females, Aboriginal and/or Torres Strait Islander people, and those who lived outside major cities or in the most disadvantaged areas were more likely to access state-funded mental health services. While the number of individuals who accessed community mental health services increased over time (from 28,769 in 2005 to 50,690 in 2021), the percentage increase relative to 2005 was notably greater for emergency department attendances (127% for emergency department; 76% for community; and 63% for inpatient). Conditions that contributed to the increase for emergency department were mainly alcohol disorder, reaction to severe stress and adjustment disorders, and anxiety disorders. Sex differences were observed between conditions. The pattern of access increased for emergency department and the community plus emergency department combination. This study confirmed that the patterns of access of state-funded mental health services have changed markedly over time and the potential drivers underlying these changes warrant further investigation., Competing Interests: Declarations. Ethics approval and consent to participate: This study was approved by the Department of Health Western Australia Human Research Ethics Committee (approval number: RGS0000004782) and the Curtin University Human Research Ethics Committee (approval number: HRE2022-0001). A waiver of consent was sought for the project. Consent for Publication: This manuscript followed the Reporting of studies Conducted using Observational Routinely-collected Data (RECORDS) statement ( https://www.record-statement.org/checklist.php ). Competing Interests: The authors have no competing interests to declare that are relevant to this article., (© 2024. The Author(s).)

Homeless seniors confront distinct challenges regarding their mental health needs and service access. This study aims to illuminate the mental health landscape of homeless seniors by examining the prevalence of mental illness, utilization of mental health services, and perceived need for mental health care. The study comprises 177 homeless seniors in New York, NY. Findings indicate 10.2% experiencing depression, 10.2% schizophrenia, and 5.7% bipolar disorder. Despite high prevalence, there is a significant gap between diagnosed mental health conditions and service utilization, with only 50% of those with depression seeking care. Perceived need for mental health services emerges as a critical aspect of the study, with over half of those suffering from depression (61.1%; n = 11), PTSD (75%; n = 3), schizophrenia (77.8%; n = 14), and other mental illnesses (100%; n = 1) expressing a need for mental health care. Also, mental health conditions, loneliness, and levels of social support play significant roles in a need for mental health services., Competing Interests: Declarations. Research Involving Human Participants: - In February 2019, this study was approved by the IRB. All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. Informed Consent: Informed consent was collected from all individual participants. Conflict of interest: The authors of this study declare that we have no conflict of interest., (© 2024. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Objectives: Young Australians living in rural and remote locations have poorer mental health outcomes and higher rates of self-harm and suicide than their major city counterparts. Significant service gaps and barriers exist in accessing general and youth-specific mental health services. With a lack of access, comes delays in treatment and associated poorer outcomes. This paper describes the characteristics of young people requiring an aeromedical retrieval (AR) for acute inpatient psychiatric care., Study Design and Methods: A retrospective secondary analysis was conducted of Royal Flying Doctor Service ARs for a six-year period from 2016 to 2021. Data were summarised by demographic, geographic, and diagnostic factors., Results: The total sample size was 1534 (60% male, 40% female; and 31% aged 12-17 years, 69% aged 18-24 years), with 668 (43.5%) affected by schizophrenia and related disorders. Port Augusta, 300 km north of Adelaide, had the highest proportion of aeromedical retrievals (4.4%). The Women's and Children's Hospital in Adelaide received the highest proportion of retrievals (25.6%). Statistically significant gender and age differences were identified as were specific high-usage geographical locations across several Australian states., Conclusions: AR is essential for young people in accessing specialist acute health services. Developmentally appropriate, responsive, youth mental health services are mostly located in large, already well-resourced major cities. Our study provides valuable information to assist governments, communities, and services to enhance the resources available for young people who live rurally., (Copyright © 2024 The Royal Society for Public Health. Published by Elsevier Ltd. All rights reserved.)

Background: Transition readiness, or skills and preparation for navigating adult health care, is an important factor in the successful transition from child and adolescent mental health services (CAMHS) to adult care; however, predictors of transition readiness are not fully understood. One factor which may impact transition readiness among youth accessing CAMHS is the presence of a co-occurring physical health condition; however, this has not been previously examined. Within a cohort of youth receiving CAMHS, the objective of this study was to understand if there is an association between co-occurring physical health conditions and transition readiness and if this relationship is impacted by severity of mental health symptoms., Methods: This study was a secondary analysis of baseline data from the Longitudinal Youth in Transition Study, including 237 16- to 18-year-old youth accessing outpatient CAMHS from four different clinical sites. Participants completed self-report measures on mental health symptoms, functioning, service use, transition readiness, and physical health conditions. Multiple linear regression models were used to measure the association between the presence of health conditions and transition readiness scores as well as determine if there was an interaction between mental health symptoms and physical health conditions to predict transition readiness., Results: Co-occurring physical conditions were reported by 41% of youth and were associated with greater overall transition readiness. There was no interaction between mental health symptom severity and co-occurring physical conditions, though attention problems were independently associated with lower transition readiness scores., Conclusions: Youth accessing CAMHS who have a co-occurring physical condition have overall greater transition readiness than youth without a co-occurring condition. Further research should explore the role of frequency and types of healthcare encounters in transition readiness for transition age youth needing ongoing mental health care to better understand how to support self-management and care navigation skill development., (© 2024 The Author(s). Child: Care, Health and Development published by John Wiley & Sons Ltd.)

Introduction: Many mental disorders begin in early childhood. Without timely treatment, mental disorders experienced by young children can impair their learning ability and relationships with others, causing lifelong complications. However, not all children with a mental disorder in early childhood receive treatment., Methods: Using data collected from 46,424 children aged 2 to 8 years in the 2 most recent cycles of the National Survey of Children's Health (2021 and 2022), we estimated the prevalence of having a mental disorder and investigated factors associated with young children not receiving mental health care when needed. All analyses were adjusted for survey weights to account for the complex sampling design and nonresponse biases in generating nationally representative estimates., Results: In 2021 and 2022, 19.0% of US children aged 2 to 8 years had 1 or more mental disorders. Of these children, 9.1% reported not receiving any needed health care in the previous 12 months, and of these, 45.8% reported not receiving mental health services when needed. The primary reasons for not receiving needed health care were problems getting an appointment (72.1%), issues related to cost (39.3%), and services needed not being available in the area (38.5%). Poor experiences with health care providers were consistently associated with not receiving needed mental health services among children with mental disorders., Conclusion: Our findings suggest a strong link between health care factors and not receiving needed mental health services among US children with a mental disorder in early childhood. In addition to increasing the availability of mental health services and expanding health insurance coverage, future public health efforts should prioritize enhancing patients' experiences with health care providers.

US Asian adults and people with limited English proficiency (LEP) confront mental health treatment receipt disparities. At the intersection of racial and language injustice, Asian adults with LEP may face even greater disparity, but studies have not assessed this through explicitly intersectional approaches. Using 2019 and 2020 National Survey of Drug Use and Health data, we computed disparities in mental health treatment among those with mental illness comparing: non-Hispanic (NH) Asian adults with LEP to NH White adults without LEP (joint disparity), NH Asian adults without LEP to NH White adults without LEP (referent race disparity), NH Asian adults with LEP to those without LEP (referent LEP disparity), and the joint disparity versus the sum of referent disparities (excess intersectional disparity). In age- and gender-adjusted analyses, excess intersectional disparity was 26.8% (95% CI, -29.8 to 83.4) of the joint disparity in 2019 and 63.0% (95% CI, 29.1-96.8) in 2020. The 2019 joint disparity was 1.37 (95% CI, 0.31-2.42) times that if the race-related disparity did not vary by LEP, and if LEP-related disparity did not vary by race; this figure was 2.70 (95% CI, 0.23-5.17) in 2020. These findings highlight the necessity of considering the intersection of race and LEP in addressing mental health treatment disparities. This article is part of a Special Collection on Mental Health., (© The Author(s) 2024. Published by Oxford University Press on behalf of the Johns Hopkins Bloomberg School of Public Health. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Problem/background: Mental health problems are prevalent during the perinatal period and mental health service use is lower among perinatal women compared to the general population., Aim: This study examined the prevalence and variables associated with mental health service use (MHSU) among pregnant and postpartum women with a past-year mental disorder., Methods: We analyzed nationally representative data from the 2012-2013 National Epidemiologic Survey on Alcohol and Related Conditions (N = 36,309). Our study sample included all women aged 18 - 55 with a past year mental disorder (n = 6,295). Semi-structured interviews assessed past-year DSM-5 mental disorders, which were categorized into four groups: depressive/bipolar, anxiety, posttraumatic stress disorder, and substance use. Logistic regressions examined rates and variables associated with MHSU across perinatal status, adjusting for key sociodemographic characteristics., Findings: Compared to non-perinatal women 18-55 with a past-year mental disorder (38.5 %), postpartum women had reduced odds of MHSU (23.6 %; AOR = 0.56, p < 0.05), and pregnant women also sought services less than non-perinatal women (32.6 %; AOR = 0.89 p > 0.05). All groups had increased odds of MHSU when individuals had a greater number of mental disorders (AORs = 1.78 - 2.75, p = 0.01 and p < 0.001). Physical health conditions were also associated with increased odds of MHSU among all groups, except postpartum women (AORs = 1.26 - 1.62, p = 0.05, p < 0.001)., Discussion/conclusion: Results highlight that over 60 % of perinatal women with mental disorders do not receive mental health services. This emphasizes the importance of mental health screening for perinatal women, particularly in the postpartum period., Competing Interests: Declaration of competing interest The authors have no conflicts of interest to declare., (Copyright © 2024 Elsevier Ltd. All rights reserved.)

Purpose: We sought to identify trends and characteristics associated with the availability of tailored mental health services for individuals involved in the criminal justice system and ordered to treatment by a court, nationally in the US and by state., Methods: We used National Mental Health Services Survey to identify outpatient mental health treatment facilities in the US (2016 n = 4744; 2018 n = 4626; 2020 n = 4869). We used clustered multiple logistic regression to identify changes over time as well as facility- and state-level factors associated with the availability of specialty court-ordered services., Results: Slightly more than half of the outpatient mental health treatment facilities offered specialized services for individuals ordered to treatment by a court, with wide variation between states. Nationally, there was a significant increase in the odds of offering court-ordered treatment in 2020 compared to 2016 (aOR = 1.16, 95% CI = 1.06-1.27, p < 0.01). Notable associations included offering integrated substance use treatment (versus none, aOR = 2.95, 95% CI = 2.70-3.22, p < 0.0001) and offering trauma therapy (versus none, aOR = 2.05, 95% CI = 1.85-2.27, p < 0.0001)., Conclusion: The availability of mental health services for individuals ordered to treatment by a court is growing nationally but several states are lagging behind. Court ordered treatment is a promising strategy to improve health and reduce reliance on the carceral system as a healthcare provider. At the same time, we express caution around disparities within behavioral health courts and advocate for equity in access to incarceration alternatives., (© 2024. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany.)

Objective: Despite rapid advances in psychedelic sciences and the increasing number of countries legalizing psychedelics for the treatment of mental illnesses, the attitudes, knowledge and readiness of both mental health consumers and the general population remain largely unknown., Methods: A cross-sectional survey was conducted among Australians, targeting individuals with mental illness as potential mental health service users. A sub-sample of individuals free of mental illness was also surveyed to assess attitudes in the general population. Participants completed the Attitudes on Psychedelics Questionnaire, the Basic Knowledge of Psychedelics Test and a questionnaire by Corrigan et al. to capture attitudes toward psychedelic therapy by mental health service users., Results: Of the 502 respondents, 64.5% self-identified as having a mental illness. A significant proportion favored legalizing psychedelics for medical use (43%) and were open to their use (52.4%), yet fewer viewed their effects positively (24%) or considered them safe (33%). Most participants reported to be psychedelic naive (61%). Participants with mental illness had significantly more experience with psychedelics than participant free of mental illness (44.1% vs 29.7%). Experience, perceived knowledge and actual knowledge significantly predicted attitudes toward legalization, effects, risks and openness to psychedelics., Conclusions: While a large proportion of Australians are in favor of legalizing psychedelics for medical purposes, concerns about safety remain. People with self-identified mental illness, those with previous recreational psychedelic experience and those with greater knowledge of psychedelics were more likely to have positive attitudes toward psychedelics and psychedelic-assisted therapy., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared the following potential conflicts of interest with respect to the research, authorship and/or publication of this article: S.P. is an investigator on a clinical trial that has received funding from Woke Pharmaceuticals and has received in the past 5 years: research funding from The Common Good Foundation, Johnson & Johnson, Metro North Foundation, PA Foundation, RANZCP and Suicide Prevention Australia; and honoraria from Johnson & Johnson, RANZCP, Queensland Psychotherapy Training, CSL Seqirus and Tasmania Health. The other authors have no conflicts of interest to declare.

Objectives: The rate of mental health services provided to children and young people is increasing worldwide, including in Australia. The aim of this study was to describe patterns of hospital and ambulatory mental health service use among a large population cohort of adolescents followed from birth, with consideration of variation by age, sex and diagnosis., Methods: Characteristics of services provided for children with mental disorder diagnoses between birth and age 17.5 years were ascertained for a population cohort of 85,642 children (52.0% male) born between 2002 and 2005, from 'Admitted Patients', 'Emergency Department' and 'Mental Health Ambulatory' records provided by the New South Wales and Australian Capital Territory Health Departments., Results: A total of 11,205 (~13.1%) children received at least one hospital or ambulatory health occasion of service for a mental health condition in the observation period. More than two-fifths of children with mental disorders had diagnoses spanning multiple categories of disorder over time. Ambulatory services were the most heavily used and the most common point of first contact. The rate of mental health service contact increased with age across all services, and for most categories of mental disorder. Girls were more likely to receive services for mental disorders than boys, but boys generally had an earlier age of first service contact. Finally, 3.1% of children presenting to mental health services experienced involuntary psychiatric inpatient admission., Conclusions: The extent of hospital and ambulatory-based mental healthcare service among children emphasises the need for primary prevention and early intervention., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship and/or publication of this article.

Aim: To examine the impact of integrated employment support and mental health treatment (Individual Placement and Support, or "IPS") on Aotearoa New Zealand participants' employment, income, health, education and justice outcomes., Method: De-identified linked data from the Stats NZ Integrated Data Infrastructure and propensity score matching were used to estimate effects., Results: In total, 1,659 IPS participants were matched to 1,503 non-participants. Compared with matched non-participants, matched participants were 1.6 times more likely to be in employment at 12 months. Over 3 years, matched IPS participants had more earnings, more time in employment, greater total income and were more likely to gain qualifications. They also had more face-to-face contacts with mental health teams, mental health-related inpatient stays and mental health service crisis contacts than matched non-participants. Effects for Māori were similar in direction and scale to the overall results., Conclusion: Our results show that people with mental health conditions or problematic substance use who receive employment support made available together with mental health and addiction treatment have more employment, gains in qualifications and more independent income when compared to similar people who do not receive this support. More research is needed to understand differences in engagement with mental health services and effects on participants' health and wellbeing., Competing Interests: Wilson and Gray are employed by agencies that fund IPS. Lockett is employed by a non-government organisation that is associated with organisations that deliver IPS and IPS implementation support. The study was funded by the Ministry of Social Development. FC received funding from MSD to Katoa Ltd to cover time on this project. KM was paid as an analytical consultant under contract to MSD. SB and DP received funding from MSD to University of Otago to cover time on this project. Disclaimer: These results are not official statistics. They have been created for research purposes from the Integrated Data Infrastructure (IDI), which is carefully managed by Stats NZ. For more information about the IDI please visit https://www.stats.govt.nz/integrated-data/. The results are based in part on tax data supplied by Inland Revenue to Stats NZ under the Tax Administration Act 1994 for statistical purposes. Any discussion of data limitations or weaknesses is in the context of using the IDI for statistical purposes and is not related to the data’s ability to support Inland Revenue’s core operational requirements. The views, opinions, findings and recommendations expressed in this report are those of the authors. They do not necessarily reflect the views of the Ministry of Social Development, or people involved in the peer review process. Any errors or omissions are our own., (© PMA.)