To address high-cost inpatient utilization for those with severe and persistent mental illness, stakeholders from a County Department of Human Services, a Behavioral Health Managed Care Organization, and mental health providers created a value-based payment (VBP) model to shift funding from inpatient mental health treatment (IPMH) to intensive, evidence-based, community-based mental health treatment, Assertive Community Treatment (ACT). Using a retrospective observational study, individuals who received ACT from providers participating in the VBP (N = 2) were compared to individuals who received ACT from providers (N = 17) not supported through a VBP. Results show decreasing average ACT and IPMH expenditures as well as shorter lengths of stay over time for providers under a VBP compared to those not in a VBP. Access to care was not impacted. These results, including implications for behavioral health, are discussed in the context of quality of care.

Suicide prevention is a critical public health priority. The opportunity to intervene with this population is often in the primary care setting, but many at-risk individuals do not seek treatment. This study examines demographic differences in healthcare utilization patterns among suicide decedents, categorized into three groups: decedents who accessed care for mental health conditions, decedents who accessed care for non-mental health conditions, and decedents who did not access care. Data from the Arkansas All-Payers Claims Database (2013-2021) were linked to vital records to identify adult decedents who died by suicide. Healthcare utilization was categorized based on insurance claims filed in the year before death. Multinomial logistic regression was used to identify predictors of healthcare utilization, including age, gender, race, education, marital status, and rurality. Among 1678 decedents, 38.9% accessed care for mental health conditions, 23.5% accessed care for non-mental health conditions, and 37.5% did not access care in the year before death. Younger decedents (18-44 years) were 49% less likely to access mental health services and 81% less likely to access non-mental health services compared to seniors (65+ years; p < 0.0001). Men were 50% less likely to access mental health services than women (p < 0.0001). African-Americans were more likely to access care for non-mental health conditions (p = 0.01). Identifying decedent characteristics of suicide based on healthcare utilization can help develop targeted interventions for this population. Additional efforts should be made to encourage young people to seek healthcare more regularly, particularly during periods of severe stress.

Peer support workers (PSWs) play a key role in the substance use disorder (SUD) recovery field. According to organizational support theory, organizational actions and policies are key factors that promote perceived support and positive job-related outcomes. However, limited qualitative research has examined the construct of perceived organizational support from the perspective of PSWs working in the SUD recovery field. This study sought to determine what organizational actions and policies are perceived as supportive for PSWs. Semi-structured qualitative interviews were conducted with 25 PSWs actively working in the recovery field in South Carolina. Participants were asked "How does your employer or organization support you in the work that you do?" and "How could your organization support you better?" Interviews were recorded and transcribed verbatim. A team-based, rapid qualitative analysis approach was used to analyze data. Themes were identified and mapped onto existing guidelines for incorporation of PSWs into addiction medicine settings. PSWs reported that organizations can foster organizational support for PSWs through valuing PSWs as people with lived experiences. PSWs noted important supports such as living wages, insurance, job-related resources, and high-quality training and supervision. In addition, PSWs described how autonomy and reduced workload enable PSWs to optimize their time. Implications for organizations employing PSWs and recommended best practices are discussed.

Peer support workers (PSWs) are trained behavioral health professionals with lived experience of substance use disorders. PSWs are employed by behavioral health agencies to increase uptake of and retention in treatment and recovery services. As their presence in these settings grows, it remains unclear how well PSW job functions align with their unique skills and personal experiences. To fill this gap, a content analysis of online job postings for PSW roles in Missouri across geographic regions and types of behavioral healthcare settings (i.e., treatment facilities, recovery housing, recovery community centers, hospitals, criminal justice settings) posted between April 2023 and September 2024 was conducted and analyzed to assess how they reflect role expectations and the distinct value PSWs contribute to the system. Job tasks were organized into categories and classified as authentic (utilizing PSWs' experience and training, e.g., mentoring, recovery goal setting, and peer advocacy) or generic (not specific to peer roles, e.g., administrative duties, transportation, maintaining relationships with external stakeholders). Results showed that PSWs are expected to perform a near even split of authentic (49.8%) and generic (50.2%) tasks. These findings suggest a lack of consistency in how agencies define and implement the PSW role, potentially contributing to job dissatisfaction and turnover. As organizations continue to employ PSWs in greater numbers, it will be important for agencies to prioritize job clarity and satisfaction, as well as determine the optimal balance of tasks for a more consistent system-level understanding of how to best utilize PSWs in the workplace.

Mental health difficulties have been on the rise in recent years. Self-disclosure of mental health symptoms is related to a range of positive outcomes, and seeking help for mental health can be life-saving. Help-seeking for one's mental health can be impacted by a variety of factors, such as the help-seeking target (e.g., friend, family member, or professional source) and the presenting problem (e.g., a personal emotional problem vs suicidal ideation). Internalized stigma of mental illness can impede help-seeking; however, it is not known if internalized stigma impedes (1) only certain types of problems or (2) help-seeking only from certain targets. It was hypothesized that the relationship between internalized stigma and willingness to seek help would vary based on (1) help-seeking target and (2) whether someone is seeking help for a personal emotional problem or suicidal thinking. Utilizing a sample of undergraduate students and a sample recruited through Prolific of adults with a history of help-seeking for mental health, bifactor models were run with stigma included as a manifest variable predicting willingness to seek help for suicidal ideation and personal emotional problems (each included as general factors) from three types of targets (friends/intimate partners, family members, and professional sources, each included as specific factors). Results indicate that internalized stigma negatively predicts willingness to seek help for suicidal thinking across targets and negatively predicts willingness to seek help for personal/emotional problems from friends/intimate partners and family members, but not from professional targets. These findings demonstrate that the relationship between internalized stigma and willingness to seek help is not uniform across help-seeking targets and presenting problems.

Delta-8 THC is a psychoactive cannabinoid typically synthesized from hemp, with similar intoxicating effects as delta-9 THC. Surging public interest alongside the lack of federal regulation of delta-8 THC has led to an unclear legal landscape and increasing safety concerns. Educating young adults about the dangers of delta-8 THC is imperative. The current study investigated the effects of a brief educational video about delta-8 THC for college students. First, to help develop the intervention, an exploratory online survey was administered (N = 291) to gather information about perceptions of delta-8 THC and motivations for use. Mixed-methods analysis indicated that many students perceive delta-8 THC to have weaker (less intense, shorter-lasting) effects while being beneficial for mental and physical health. A strong motive for consumption was to enhance positive feelings, while conformity was a significantly weaker motive. These results informed the development of an educational video for students to highlight the risks of delta-8 THC and improve decision-making. Participants (N = 120) were randomly assigned to watch either a brief educational video about delta-8 THC or an unrelated control video about attending college. Results found that the educational video increased knowledge about delta-8 THC across all students, and lowered intentions to use delta-8 THC specifically for students who reported prior but not recent use of the substance. Perceived benefits, perceived costs, and attitudes towards legislation were not affected. Overall, results demonstrate support for the format of a brief stand-alone video intervention to increase knowledge and reduce behavioral intentions regarding delta-8 THC.

Major Depressive Disorder is one of the most common mental illnesses worldwide, with oral antidepressant medication being the first-line psychopharmacological treatment option. The term Treatment Resistant Depression (TRD) is used to describe patients who remain symptomatic despite multiple trials of antidepressant medication. There had been limited FDA-approved treatment options for patients with TRD, but in 2019, intranasal esketamine was approved by the FDA for patients with TRD after safety and efficacy were established in the drug development clinical trial program. Since approval, multiple researchers have explored esketamine's effectiveness in real-world treatment settings. Despite established efficacy and effectiveness, most psychiatric treatment settings do not offer intranasal esketamine. This limited implementation is reviewed using the Consolidated Framework for Implementation Research (CFIR), and steps forward are proposed to improve accessibility for patients with TRD.

As the emphasis on home-based care grows, it is important to understand factors that affect caregivers' quality of life (QOL). Despite the rise of caregiving responsibilities among all demographics, limited literature examines young adult caregivers. The purpose of this study was to 1) examine the difference in mental health (MH) and QOL among young adult caregivers (YAC) and non-caregivers (YANC) and 2) explore how coping and psychological inflexibility moderate the association of caregiver status with MH and QOL. 60 YAC and YANC (age 18-29) were matched via a one-to-one nearest-neighbor propensity score matching with a caliper of 0.1. Participants completed a questionnaire measuring depression and anxiety, QOL, psychological inflexibility, and coping. ANCOVA revealed YAC reported lower physical health-related QOL than YANC (η = .09, p = .024) but there were no significant differences in depression, anxiety, or mental health-related QOL. Moderation analyses revealed avoidant coping was associated with worse depression, anxiety, and MH-related QOL among YANC (p's < .0001), but not YAC. Exploratory moderated mediation analyses revealed that for YANC, psychological inflexibility was associated with greater avoidant coping, which in turn was associated with worse depression, anxiety, and MH-related QOL; this indirect effect was not observed for YAC. In this study, YAC did not report significantly worse mental health than YANC, but did report poorer physical health-related QOL. Additionally, results suggest being a YAC may buffer the impact of avoidant coping on MH. Further studies are needed for a better understanding of the young adult caregiver experience. Trial Registration: This study was pre-registered on Open Science Framework ( https://osf.io/hcwqg/?view_only=d777b5061b724801914df6893a426aa4 ).

Substance use disorders (SUDs) are a major public health concern in the USA. In 2023, over 167 million Americans reported substance use, and more than 48 million met the DSM-5 criteria for a diagnosable SUD. Due to this high prevalence, behavioral health providers (i.e., psychologists, social workers, mental health counselors, and marriage and family therapists) regularly encounter clients affected by these disorders. However, many of these providers report receiving limited training in the assessment and treatment of SUDs. This gap in training is especially concerning given how widespread SUDs are and how frequently they co-occur with mental health conditions. To address this issue, this commentary will (1) examine research on SUD training gaps in graduate programs, (2) highlight the risks associated with inadequate SUD training, and (3) propose actionable strategies to enhance SUD-focused training across the behavioral health workforce.

The COVID-19 pandemic led to ongoing unmet demand for mental health services, with integrated behavioral health (BH) in primary care facing challenges due to reduced in-person consultations. Although telehealth helped maintain access, opportunities for collaboration in resident precepting clinics were limited. The authors developed a program in two academic primary care practices in 2021-2022, adapting the BH clinician schedules to support regular, timely consultation during resident precepting clinics, while balancing financial sustainability in the clinical sites' fee-for-service payment models. BH collaboration time was consolidated into a single clinic session to align with resident precepting clinics. BH clinicians tracked data related to consult volume, source, clinical domain, time spent, disposition, and direct patient contact. Preliminary data suggests that regular availability and accessibility of BH clinicians contributed to consultation by multiple medical team members across two practices. This flexible scheduling improved collaboration between medical and BH team member and maintained care access.

Telehealth is increasingly a standard and routine clinical option, indicating a changing outlook for SUD treatment from in-person to the more convenient option of telehealth. As populations across geographies increasingly prefer telehealth, more research is warranted that focuses on how where a person lives is associated with telehealth availability. The authors used the Mental Health and Addiction Treatment Tracking Repository (MATTR 2024) to identify telehealth availability among all known licensed SUD treatment facilities in the USA (N = 10,492 facilities). The authors merged external geocoded data to MATTR to characterize the communities and spaces immediately surrounding each facility, including social vulnerability indices (census tract), population demographics (county), and state-level telehealth policies. Multilevel multivariable logistic regression was used to model telehealth availability. Roughly 4 out of 5 treatment facilities (81%) offered telehealth. At the census tract level, for every additional point on the racial/ethnic minority status vulnerability scale, the odds of a facility offering telehealth decreased by 4% (aOR = 0.96, 95% CI = 0.93-0.99, p = 0.02). Compared to states with substantial legal barriers about starting telehealth by any mode, facilities in states with stronger, innovation-ready laws had higher odds of offering telehealth (aOR = 1.47, 95% CI = 1.13-1.92, p < 0.01). Similarly, facilities in states that minimize barriers to allowing nurses to practice and use telehealth independently had higher odds of offering telehealth (aOR = 1.42, 95% CI = 1.09-1.84, p < 0.01). State-level health policies impact access to SUD care in a multitude of ways, and new policies that promote telehealth by minimizing barriers to service delivery will benefit people in need of SUD treatment.

People with mental health and substance use disorders (SUDs) experience worse outcomes, including increased mortality risk, compared to those with SUDs alone. Access to safe, stable housing, in conjunction with treatment, such as intensive outpatient programs (IOP), is vital in early recovery. Nevertheless, those with historically marginalized identities may experience increased disparities in accessing and utilizing services. The aim of this study was to examine disparities in the utilization of recovery residences among adults receiving treatment for mental health disorders and SUDs in an IOP. Participants (n = 2803) were recruited as part of an ongoing program evaluation at a large Midwestern treatment agency offering to cover some of the monthly cost of living in independently operated recovery residences while admitted to the IOP. Collected data included demographic information and outcome variables. Logistic regression models examined factors associated with recovery residence enrollment. Most participants (80.5%, n = 2258) lived in a recovery residence during IOP. People who were female, Black-only, multiracial, had less education, or a legal history were less likely to live in recovery residences. Those with a prior treatment history, recently unhoused, or with more days abstinent from substances were more likely to live in recovery residences. In short, even with reduced cost barriers, disparities persist in the utilization of recovery residences in conjunction with IOPs, particularly those from historically marginalized groups. Future research should prioritize understanding this utilization gap and developing effective strategies to support individuals in utilizing recovery residences alongside IOP for improved outcomes.

This qualitative study explores what factors influence teaming in behavioral health settings, from the perspective of behavioral health providers. Twenty-four participants from a range of behavioral health professions engaged in semi-structured interviews. Using a grounded theory approach, data were analyzed, and a "prism" model was developed to capture the complexities of behavioral health providers' perceptions of factors influencing teaming in various mental health and/or substance use disorder treatment programs. Specific model components included: behavioral health context, individual factors, navigating disciplinary-specific approaches, workplace structures, communication as a "throughline," and varied perceptions of teaming. The prism model is dynamic, acknowledging the role of the individual in the system while also recognizing that participant perceptions of teaming are shaped by environmental and contextual forces. Each pathway is singular, with a variety of interacting factors. A key finding is that while teaming was viewed positively, there was no shared understanding of what teaming meant or whether it was occurring. The article concludes with implications for behavioral health education and practice, including support for new models of behavioral health care that incentivize teaming, expand community supports and peer workforce, prioritize the goals of recovery and wellness, and provide opportunities for more flexible financing.

Evidence-based practices (EBPs) are most effective when they are delivered with a high degree of fidelity, or as they are intended to be delivered. Because clinicians often deviate from fidelity, it is important to monitor EBP fidelity over time to guide corrective actions. However, little is known about current fidelity monitoring practices in community behavioral health care. The current study used a mixed methods approach to characterize current fidelity monitoring practices, as well as barriers and facilitators to fidelity monitoring, in community behavioral health care agencies. Therapists, supervisors, recovery coaches, executive leaders, and agency leaders (N = 191) from multiple agencies in a Midwestern state completed a survey measuring current fidelity monitoring methods at their agency and perceived acceptability and feasibility of potential fidelity monitoring methods and strategies. Additionally, agency leaders, supervisors, and therapists (N = 10) within the state and leaders of intermediary organizations (N = 11) across the United States participated in individual qualitative interviews asking about facilitators, barriers, and priorities related to ongoing fidelity monitoring. Most respondents indicated their agency currently monitors what practices are being delivered, with self-report and chart review the most frequently reported methods used and session recordings and role-play assessment the least-frequently endorsed. Mixed methods results revealed common barriers to and potential strategies for facilitating fidelity monitoring efforts at the clinician-, agency-, and system-level. Findings highlight the need for scalable and sustainable methods for monitoring fidelity and the need for multi-level approaches to support EBP fidelity monitoring in community behavioral health settings.

Depression, a prevalent health condition, substantially impacts both socioeconomic outcomes and individual wellbeing. Despite the availability of diagnostic tools, existing approaches for identifying depression severity often rely on single-indicator approaches, limiting accuracy. This retrospective study evaluates a multi-parameter analytics-enabled Identification and Stratification (IDS) framework designed to improve depression identification and severity stratification by leveraging health insurance claims and electronic health record data. For the evaluation, Highmark Health dataset was used, consisting of records for members aged 18 + with at least one healthcare encounter. The IDS framework identified 720,882 members with depression (16.6% of the population). The framework identified 258,206 more members (5.9% of the population) compared to using diagnoses alone. The stratification rules revealed variability in prevalence, with 5.0% mild, 8.5% moderate, 2.2% severe, with the remaining 0.9% in unknown, remission, or minimal. The IDS rules escalated 46% of mild and 19% of moderate cases to higher severity compared to single indicator assessments. Expenses for severe depression were, on average, 2.5 times higher than for minimal. The IDS framework demonstrated utility in identifying members with depression by linking fragmented data sources. Aligning multiple indicators provided a more comprehensive identification and a more nuanced severity evaluation compared to individual data elements. This enables targeting of cost-effective digital self-care tools to milder cases while reserving higher cost interventions for the most severely ill, potentially reducing costs while maintaining health outcomes. Implementation of this integrative platform can help focus efforts on those with the highest need and bridge the gap in treating depression.

Despite recommendations, screening for unhealthy alcohol use occurs infrequently in US ambulatory care. One barrier to screening often cited by physicians is misalignment of incentives, but it is unclear which financial arrangements contribute to or alleviate this misalignment. This analysis investigates how determinants of income-both patient care revenue and physician remuneration-encourage or discourage guideline-concordant alcohol screening. Cross-sectional data from the US National Ambulatory Medical Care Survey 2015, 2016, 2018, and 2019 are pooled. Covariate-adjusted logistic regression is used to estimate associations between alcohol screening during visits and variables capturing methods of patient care revenue generation and of physician remuneration. Methods of revenue generation include receipt of revenue from capitation and Medicaid. Methods of physician remuneration include payment by share of practice billings, consideration of productivity and patient satisfaction in determining compensation, and practice ownership. Of 10,607 visits under study, fewer than 3% included screening. In the adjusted model, visits to physicians who received > 25% of patient revenue from capitated payments had higher odds of including screening (adjusted odds ratio (aOR) = 5.94; 95% confidence interval (CI) = 2.33, 15.13) compared with visits to physicians who received less from capitation, as did visits to physicians for whom patient satisfaction surveys impacted compensation (aOR = 3.56; 95% CI = 1.51, 8.37). Payment methods that reward value (e.g., capitation) and patient-centered outcomes (e.g., patient satisfaction), rather than productivity, may promote alcohol screening in US ambulatory care. However, the low rates of screening observed suggest transitioning towards such methods will not be sufficient to achieve optimal screening rates.

This study examines older adults' perspectives on patient-centered care and engagement in a short-term behavioral health intervention, addressing persistent barriers to mental health access in aging populations. Guided by the NIH Stage Model (Stage 1), the goal was to refine the intervention by integrating participant feedback to enhance recruitment, retention, and overall program acceptability. Data were drawn from focus groups with residents of The Villages® community, alongside program participation and survey records. The 12-week intervention enrolled 183 participants; 115 (62.8%) completed all 10 sessions and both intake and exit surveys. Most completers were female (75.7%) and white (92.2%), with anxiety (60.9%) and depression (54.8%) as the most common treatment reasons. While completion rates were moderate, 37.2% dropped out, and only 33.8% of non-completers responded to follow-up inquiries, underscoring ongoing retention challenges. Findings highlight the potential of embedding behavioral health services within primary care to reduce stigma, improve accessibility, and leverage trust in existing provider relationships. Older adults valued clear communication, early demonstration of benefits, and interventions tailored to their preferences and cultural context. However, early discontinuation-often after perceived improvement-suggests a need for strategies that encourage sustained engagement, such as rapport-building, booster sessions, or follow-up reminders. From a systems perspective, integrating behavioral health into primary care can promote equity, reduce logistical barriers, and support more holistic care delivery. These insights can guide providers, policymakers, and researchers in designing responsive, patient-centered interventions that improve both engagement and outcomes for older adults.

There is a dose-response relationship between the incidence of psychiatric issues and poverty. To better understand disparities related to extreme poverty and inequality, this study aims to investigate whether there is a difference in mental health services between counties identified as persistent poverty counties and those not identified. Data from the National Survey on Substance Abuse and Mental Health Services and the U.S. Census American Community Survey were analyzed. A random-effects logit regression analysis was performed to determine the likelihood of access to various types of mental health facilities, behavioral health services, medical services, screening services, emergency services, and ancillary services. Adjusted regression results revealed that persistent poverty county status was associated with a lower likelihood of residential facility services (OR = 0.65, 95% CI 0.45, 0.96), a higher likelihood of medication use (OR = 1.58, 95% CI 1.20, 2.09), and a higher likelihood of ancillary services (OR = 1.10, 95% CI 1.05, 1.16), especially chronic disease management, housing, intensive case management, and peer support. Meanwhile, fewer trauma-related treatments were available in these counties. A subsample of rural counties showed similar results. Mental health providers in persistent poverty counties were less likely to offer residential and behavioral health services and more likely to provide medication and ancillary services. Implications for mental health policy and practitioners are discussed.

The objective of this study was to describe the clinical experiences associated with billing for short-term residential care for substance use disorder (SUD) under a Medicaid managed care organization (MCO) payment structure requiring prior authorization. The authors conducted a qualitative analysis of focus group data collected from residential adult services (RAS) facilities staff in West Virginia between 2020 and 2022. These primary data were derived from 17 semi-structured focus groups across 11 distinct RAS facilities, which included 28 administrators, 23 clinicians, and 10 peer recovery support specialists, and were recorded and transcribed before being coded. A phenomenological thematic analysis was employed using data describing reported experiences of RAS staff members billing MCOs under the 1115 Medicaid SUD Waiver. Two main themes arose related to billing MCOs for residential treatment. First, providers felt powerless in their roles as their focus moved from clinical to administrative due to the administrative burden of prior authorizations. Second, providers felt that the shorter lengths of stay for patients that resulted from the prior authorization requirements reduced the quality of care they could provide and that the low quality of care increased the risk of relapse among patients. Thus, MCOs' utilization of prior authorization as a cost management tool may create barriers for providers to fulfill their clinical roles and provide high-quality care. More research is needed to investigate the prior authorization process from the perspective of MCOs and to quantify the effects of prior authorization on patient outcomes.

Adolescence is often identified as the period of time when individuals first begin to experience mental health needs, though a gap remains between need and mental health service use. With limited knowledge of continued impact of mental health service use on future services and mental health need, this study aims to examine the longitudinal, bidirectional relations between mental health service utilization and mental health symptoms across four time points. Data came from four waves of the National Longitudinal Study of Adolescent Health (Add Health; N = 7,902). We examined mental health service (MHS) utilization in the past 12 months and depressive symptoms. Cross-lagged panel analyses were conducted, adjusting for sociodemographic characteristics. Findings indicated that school MHS utilization at Tn increased the odds of using MHS at Tn+1 across all waves (OR = 1.34, 1.53, and 1.61, respectively). Second, depressive symptoms at Tn also predicted depressive symptoms at Tn+1 (β = .21, .30, .30, respectively). Third, as MHS use at Tn predicted depressive symptoms at Tn+1 (β = .14 (school), .27, .11, .18, respectively), depressive symptoms at Tn were significantly related to future mental health service use at Tn+1 (OR = 1.09, 1.15, 1.05 respectively). The current study extends the understanding of the reciprocal relationship between MHS use and depressive symptoms. The study suggests the critical importance of using school-based services in adolescence to promote mental health service use in adulthood, highlighting implications for adolescent mental health service providers across service settings.