APA Journal Pilots Race, Ethnicity, and Culture Checklist for Submissions, Review of MH Research

“Structural racism … has a long history in medical journals, and Psychiatric Services is no exception,” wrote Psychiatric Services Editor Lisa Dixon, M.D., M.P.H., and colleagues in an editorial published today in the journal. It “affects who runs the journal, who submits and reviews, what topics are emphasized, how the role of racism and ethnoracial categories are conceptualized and included or ignored in analyses and discussions, and what policy and services recommendations are made.”

Since 2020, Psychiatric Services has taken steps to examine the effects of structural racism on the journal and institute changes to address it, including enhancing the diversity of the editorial board and column editors; appointing a 12-member antiracism task force to advise the journal; publishing peer-reviewed articles and commentaries that address racism; and more. Psychiatric Services will now “embark on the next phase of this process, which directly involves the submission and peer-review procedures,” Dixon and colleagues wrote.

As part of a six-month pilot, authors submitting research articles to the journal will be prompted to use a 16-item checklist during the submission process to assess the comprehensiveness and applicability of factors related to race/racialization, ethnicity, and culture (REC) in their mental health research articles. (The checklist that Psychiatric Services will use is a modified version of an REC checklist developed by the Cultural Committee of the Group for the Advancement of Psychiatry, under the leadership of Roberto Lewis-Fernández, M.D., a professor of clinical psychiatry at Columbia University.)

The journal editors will seek feedback from authors and reviewers about the use of the checklist. “Our accumulated experience will be used to guide ongoing use of the checklist and possible expansion to other types of articles. Our experience may also serve as a guide for other journals interested in the use of the checklist,” Dixon and colleagues wrote.

They concluded, “Our aim as a journal is to engage in a continuous process of reevaluation and improvement to produce a corpus of high-quality published work that contributes to the ongoing process of promoting health equity and eliminating the impact of structural racism in mental health services. Implementing the REC Checklist is one more step in this process. We welcome your input and suggestions for additional ways to achieve our goal; comments may be directed to PSCentral@psych.org (subject line: REC Checklist).”

(Image: iStock/Ridofranz)

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Early Psychosis Treatment Succeeding but Challenges Remain for Sustainability

Early treatment of psychosis has moved out of the research arena into on-the-ground community practice, said Lisa Dixon, M.D., a professor of psychiatry at Columbia University and editor of the APA journal Psychiatric Services. She spoke yesterday at the “Early Psychosis Preconference” held in conjunction with APA’s IPS: The Mental Health Services Conference in New York.

There has been success reaching patients in need and improvements in the course of their illness and treatment outcomes, but achieving long-term sustainability is a challenge for early psychosis programs, requiring advocates to pay attention to public health policy, funding, and reimbursement. “In order to be successful, we must of course focus on patient care. But we need to do more,” Dixon said.

The preconference brought together some 350 mental health professionals involved in the identification and treatment of individuals with psychosis and included a rich variety of presenters.

Dixon presented an overview and evaluation of OnTrackNY, a program of the Center for Practice Innovations at Columbia University/New York State Psychiatric Institute and the New York State Office of Mental Health. Established in 2013, it now includes 23 sites in New York state and serves individuals aged 16 to 30 who have experienced nonaffective psychosis for less than two years.

OnTrackNY is one of the most well-established early psychosis programs in the United States, according to Dixon. Using a framework developed by health services researchers to evaluate program implementation known as RE-AIM (Reach, Effectiveness, Adoption, Implementation, and Maintenance), Dixon noted some of the lessons learned from the program to date:

Reach: OnTrackNY has served over 1,600 patients since 2013; the program has the capacity to care for 900 patients at a time. “While the growth of OnTrackNY has been remarkable, the actual need may be closer to 2,000 slots based on assumptions about the incidence of schizophrenia and nonaffective psychosis,” Dixon said.

Effectiveness: Rates of participation in treatment, data on rehospitalization, work and school status, and overall functioning are positive, but there is substantial variability across clinics. Also, more needs to be done to identify and help patients with poorer outcomes.

Adoption: The program has thrived in a diversity of sites and locations across the state, but the ability to serve individuals in rural areas remains a challenge.

Implementation: OnTrackNY developed training models to ensure “fidelity,” or the ability of clinics to abide by a model of treatment standardized across sites. Most teams within OnTrackNY have met that standard; the most common unmet domains are metabolic screening of patients and use of peer supports.

Maintenance: OnTrackNY has been fortunate in having the financial support of the state, but long-term funding remains a challenge. There is a need for a more systematic approach to discharge patients, step-down to less intensive services, and long-term follow-up.

“Progress in the implementation of early intervention programs for individuals experiencing early psychosis is palpable,” Dixon said. “The lessons learned inspire strategies for ongoing improvement.”

More coverage of the early psychosis conference and IPS will appear in future issues of Psychiatric News.

For related information, see the Psychiatric Services article “Results of a Coordinated Specialty Care Program for Early Psychosis and Predictors of Outcomes.”

(Image: Mark Moran)

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NY State Initiative Helps Patients Move Toward Recovery With Less Intensive Services

A New York state initiative to identify and transition some patients in assertive community treatment (ACT) programs to less intensive services so that others in need of such care can access it appears to be working: even as median time spent in ACT fell and turnover rates accelerated over a six-year period, the outcomes of those transitioned remained stable.

Those are among the findings of a report appearing in Psychiatric Services. Journal Editor Lisa Dixon, M.D. (pictured left), a co-author of the report, told Psychiatric News that the findings show the ways that statewide data can be used to influence care.

“ACT should be seen as one treatment in the care continuum, a step on the road to recovery,” she said. A vast literature since the 1980s has shown ACT to be effective in the care of individuals with serious mental illness. Originally, Dixon explained, it was believed that ACT needed to be sustained indefinitely; otherwise, patients would relapse. But, more recent evidence indicates that a subgroup of patients can successfully transition to less intensive care.

The New York State Office of Mental Health (NYSOMH) first implemented ACT statewide in the early 1990s. By 2008, 79 ACT teams were operating, with the capacity to serve about 5,000 people. By 2014, the ACT system had grown to 82 teams to meet the needs of approximately 5,200 people. During this period, as the waiting list grew, the state began to focus on transitioning participants through ACT so that additional patients could receive this service.

Strategies were developed to shift the ACT model from one in which patients would receive ACT care indefinitely to a model that routinely promotes participant transition to less intensive services. These included the development of an ACT Transition Readiness Scale (TRS) to monitor participants’ readiness for the transition from ACT, a learning collaborative focused on transition practices, and a biannual report for monitoring the flow of participants through ACT.

Between 2008 and 2014 the median time spent by individuals in the ACT program dropped by one year, from 44.4 months to 32.4 months. The percentage of participants who met ACT treatment objectives and transitioned from ACT rose from 13% in 2008 to 25% in 2014.

In addition, the percentage of Medicaid-eligible individuals with an ambulatory follow-up within 90 days of leaving ACT increased from 50% in 2008 to 61% in 2014, whereas the percentage with a psychiatric hospitalization within 90 days of disengagement from ACT decreased from 14% to 13%.

Dixon said that the effort is designed to allow ACT teams to use aggregated state-level data to inform decisions about individual patients. “Data are used as ‘touch points’ for looking at individual ACT participants,” she said. “This prompts a review of clinical opportunities to refocus the ACT team to recovery-oriented practices and to problem solve around barriers to transition to less intensive services.”

For related information, see the Psychiatric News article “What Role Can Technology Play in Assertive Community Treatment?”