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ObjectiveThis study examined the extent to which prehospital treatment engagement is related to posthospital follow-up treatment among psychiatric inpatients and whether the effects of inpatient discharge planning on posthospital follow-up treatment vary by level of pretreatment engagement in care.MethodsNew York State Medicaid and other administrative databases were used to examine service use by 18,793 adult patients discharged to the community after inpatient psychiatric care in 2012-2013. Outcomes included attending an outpatient mental health service within 7 days and within 30 days after discharge. The sample was stratified by whether patients had high, partial, low, or no engagement in outpatient psychiatric services in the 6 months before admission.ResultsScheduling an outpatient appointment as part of the patient's discharge plan was significantly associated with attending outpatient psychiatric appointments, regardless of the patient's level of engagement in care before admission. The differences were most pronounced for patients who had not received any outpatient care in the 6 months before admission. When an appointment was scheduled, these patients were three times more likely to follow up with care within 7 days and more than twice as likely to follow up within 30 days than were patients without a scheduled appointment.ConclusionsThe likelihood of psychiatric inpatients following up with outpatient psychiatric care was directly related to their level of outpatient care engagement before hospital admission. Even among those who had not been engaged in outpatient care, inpatient discharge planning was associated with a greater likelihood of receiving follow-up outpatient care.

Readmission after inpatient care for a psychiatric condition is associated with a range of adverse events including suicide and all-cause mortality. This study estimated 30-day readmission rates in a large cohort of inpatient psychiatric admissions in New York State and examined how these rates varied by patient, hospital, and service system characteristics. Data were obtained from Medicaid claims records, and clinician, hospital, and region data, for individuals with a diagnosis of any mental disorder admitted to psychiatric inpatient units in New York State from 2012 to 2013. Psychiatric readmission was defined as any unplanned inpatient stay with a mental health diagnosis with an admission date within 30 days of being discharged. Unadjusted and adjusted odds ratios of being readmitted within 30 days were estimated using logistic regression analyses. Over 15% of individuals discharged from inpatient units between 2012 and 2013 were readmitted within 30 days. Patients who were readmitted were more likely to be homeless, have a schizoaffective disorder or schizophrenia, and have medical comorbidity. Readmission rates varied in this cohort mainly because of individual-level characteristics. Homeless patients were at the highest risk of being readmitted after discharge.

Motivational interviewing (MI) is an empirically supported clinical method to help individuals make behavioral changes to achieve a personal goal. Through a set of specific techniques, MI helps individuals mobilize their own intrinsic values and goals to explore and resolve ambivalence about change. This article examines how MI-informed approaches can be applied to help staff adopt new evidence-based practices in organizational settings. Although the implementation science literature offers strategies for implementing new practices within organizations, leaders of quality improvement initiatives often encounter ambivalence about change among staff. Implementation approaches that require staff to make substantial changes may be facilitated by drawing from MI strategies. These include building a sense of collaboration from the beginning, eliciting "change talk," and addressing any ambivalence encountered. Motivational interviewing techniques may be particularly helpful in working with those in a stage of precontemplation (who have yet to see a reason for change) and those who are contemplating change (who see that a problem exists but are ambivalent about change). This article provides examples of how an MI-informed approach can be applied to help facilitate change in staff within organizations that are implementing quality improvement initiatives. These techniques are illustrated using a representative scenario.

OBJECTIVE: This study examined whether communications between inpatient and outpatient mental health providers during patients’ inpatient stays were associated with attendance at post-hospital discharge appointments. METHODS: One-hundred-eighty-nine psychiatric inpatient medical records of Medicaid recipients at two hospitals were reviewed to document whether inpatient staff communicated with current or prior outpatient providers. Medicaid claims provided demographic, clinical, and outpatient attendance data. Analyses evaluated the association between provider communications and follow-up care for patients who had/had not received outpatient mental health care within 30 days prior to admission. RESULTS: Inpatient staff communicated with outpatient providers for 118 (62%) patients. For patients who did not receive outpatient care within 30 days of admission, communication was associated with increased odds of attending timely outpatient appointments post discharge (OR:2.73, 95% CI:1.09–6.84). CONCLUSIONS: Communicating with outpatient providers may be especially important for patients who were not engaged in outpatient care prior to admission.

OBJECTIVES: People with severe mental illness (SMI) are ten times more likely to have HIV/AIDS than the general population, yet little is known about the characteristics and frequency of recognition of pre-existing HIV/AIDS diagnoses among inpatients with SMI. This study examines documentation rates of pre-existing HIV/AIDS among inpatients within psychiatric hospitals in New York State. DESIGN: Retrospective cohort study to examine recognition of pre-existing HIV/AIDS among psychiatric inpatients. METHODS: Patient-level Medicaid claims records were linked with hospital and regional data for people admitted to psychiatric inpatient units in New York State. Presence of HIV/AIDS diagnoses prior to psychiatric hospitalization was coded for each inpatient (n=14,602). Adjusted odds ratios (aORs) of undocumented HIV/AIDS diagnoses at the time of discharge were calculated using logistic regression analyses. RESULTS: 5.1% (741/14,602) of unique psychiatric inpatients had pre-existing HIV/AIDS diagnoses. Of these inpatients, 58.3% (432/741) were not coded as having HIV/AIDS upon discharge. Higher rates of missed detection were associated with younger age, non-Hispanic white race/ethnicity, shorter length of stay, more distal coding of an HIV/AIDS diagnosis, and fewer HIV/AIDS-related Medicaid claims in the past year. Hospitals with higher re-admission rates also had higher rates of undetected HIV/AIDS diagnoses. CONCLUSION: Over half of inpatients previously diagnosed with HIV/AIDS did not have their HIV-positive status noted upon discharge from psychiatric hospitalization. This finding underscores how frequently clinically significant medical comorbidities fail to be incorporated into psychiatric treatment and treatment planning. Inpatient clinicians are missing important opportunities to optimize HIV/AIDS treatment and reduce morbidity and mortality.

BACKGROUND: Diabetes prevalence is twice as high among people with severe mental illness (SMI) when compared to the general population. Despite high prevalence, care outcomes are not well understood. OBJECTIVE: To compare diabetes health outcomes received by people with and without comorbid SMI, and to understand demographic factors associated with poor diabetes control among those with SMI. DESIGN: Retrospective cohort study PARTICIPANTS: 269,243 adults with diabetes MAIN MEASURES: Primary outcomes included optimal glycemic control (A1c < 7) or poor diabetes control (A1c > 9) in 2014. Secondary outcomes included control of other cardiometabolic risk factors (hypertension, dyslipidemia, smoking) and recommended diabetes monitoring. KEY RESULTS: Among this cohort, people with SMI (N = 4,399), compared to those without SMI (N = 264,844), were more likely to have optimal glycemic control, adjusting for various covariates (adjusted relative risk (aRR) 1.25, 95% CI 1.21–1.28, p < .001) and less likely to have poor control (aRR 0.92, 95% CI 0.87–0.98, p = 0.012). Better blood pressure and lipid control was more prevalent among people with SMI when compared to those without SMI (aRR 1.03; 95% CI 1.02–1.05, p < .001; aRR 1.02; 95% CI 1.00–1.05, p = 0.044, respectively). No differences were observed in recommended A1c or LDL testing, but people with SMI were more likely to have blood pressure checked (aRR 1.02, 95% CI 1.02–1.03, p < .001) and less likely to receive retinopathy screening (aRR 0.80, 95% CI 0.71–0.91, p < .001) than those without SMI. Among people with diabetes and comorbid SMI, younger adults and Hispanics were more likely to have poor diabetes control. CONCLUSIONS: Adults with diabetes and comorbid SMI had better cardiometabolic control than people with diabetes who did not have SMI, despite lower rates of retinopathy screening. Among those with comorbid SMI, younger adults and Hispanics were more vulnerable to poor A1c control. ELECTRONIC SUPPLEMENTARY MATERIAL: The online version of this article (10.1007/s11606-019-05489-3) contains supplementary material, which is available to authorized users.

Objective This study examined a cohort of 15,520 inpatient psychiatric discharges to determine associations between scheduling an outpatient mental health appointment as part of discharge planning and attending outpatient care following discharge after control for patient, hospital, and system characteristics. Methods 2012-2013 New York State Medicaid and other administrative databases were used to examine patients who were aged under 65 years, admitted to an inpatient psychiatric unit, and discharged to the community. Outcomes included attending an outpatient mental health service within 7 and 30 days following inpatient discharge. Scheduling a mental health outpatient appointment as part of the discharge plan was the primary predictor variable, and potentially confounding covariates were addressed by adjusting for propensity scores estimating the likelihood of having an outpatient appointment scheduled. Results Among 15,520 discharged patients, 11,945 (77%) had an outpatient appointment scheduled with a mental health provider as part of their discharge planning. After adjustment for propensity scores, patients who had an outpatient appointment scheduled were significantly more likely to attend an outpatient mental health service within 7 (OR = 1.69; 95% CI, 1.48-1.94) and 30 days (OR = 1.65; 95% CI, 1.42-1.93) compared to patients who did not have an appointment scheduled. Even among those with a low propensity to have an appointment scheduled, scheduling an outpatient appointment was associated with attending outpatient services. Conclusions Scheduling an outpatient mental health appointment is an effective and low-resource discharge planning practice that should be an important target for inpatient psychiatric clinical quality measurement and improvement.

Hoarding disorder has significant health consequences, including the devastating threat of eviction. In this pilot study, critical time intervention (CTI), an evidence-based model of case management shown to be effective for vulnerable populations, was adapted for individuals with severe symptoms of hoarding disorder at risk for eviction (CTI-HD). Of the 14 adults who enrolled, 11 participants completed the 9-month intervention. Completers reported a modest decrease in hoarding severity, suggesting that, while helpful, CTI-HD alone is unlikely to eliminate the risk of eviction for individuals with severe symptoms of hoarding disorder. Clinicaltrials.gov Registry Numbers: NCT02367430

Objective Shortened life expectancy of people with mental disorders has been attributed to medical comorbidities, yet these conditions remain under-recognized and under-treated. This study characterizes the medical demands placed on inpatient psychiatric units to help guide medical assessment and management practices in these settings. Methods Medicaid claims records and clinician data were linked with hospital and regional data for individuals with a principal diagnosis of any mental disorder admitted to psychiatric inpatient units in New York State from 2012 to 2013. A modified Elixhauser Comorbidity Index (ECI) score was calculated for each unique individual (n = 14,458). Adjusted odds ratios (AORs) of having a medical comorbidity were calculated using logistic regression analyses. Results 74.9% of psychiatric inpatients had at least one medical comorbidity, including 57.5% of people ages 18–24. Higher rates of medical comorbidity were associated with older age, female gender, non-schizophrenia diagnoses, and engagement in care prior to hospitalization. Patients with medical comorbidities had lower odds (AOR 0.54; 99% CI 0.35–0.83) of being treated in hospitals with 100 or more total beds compared to smaller hospitals. Conclusions A high prevalence of common medical diagnoses among psychiatric inpatients underscores the importance of adequate detection and medical treatment of medical comorbidities in psychiatric inpatient settings.

BACKGROUND:Severe mental illness (SMI) is associated with increased risk for type 2 diabetes, partly due to adverse metabolic effects of antipsychotic medications. In public health care settings, annual screening rates are 30%. We measured adherence to national diabetes screening guidelines for patients taking antipsychotic medications. OBJECTIVE:To estimate diabetes screening prevalence among patients with SMI within an integrated health care system, and to assess characteristics associated with lack of screening. DESIGN:Retrospective cohort study. PARTICIPANTS:Antipsychotic-treated adults with SMI. We excluded participants with known diabetes. MAIN MEASURES:Primary outcome was screening via fasting glucose test or hemoglobin A1c during a 1-year period. KEY RESULTS:In 2014, 16,754 patients with SMI diagnoses were receiving antipsychotics. Seventy-four percent of these patients' providers ordered diabetes screening tests that year, but only 55% (9247/16,754) received screening. When the observation time frame was extended to 2years, 73% (12,250/16,754) were screened. Adjusting for sex and race/ethnicity, young adults (aged 18-29 years) were less likely to receive screening than older age groups [adjusted RR (aRR) 1.23-1.57, p&nbsp

OBJECTIVE In this study, we examined the pursuit of education and employment among participants in the Recovery After an Initial Schizophrenia Episode (RAISE) Connection Program (Dixon et al., 2015; Essock et al., 2015), a first-episode psychosis (FEP) treatment program emphasizing participation in school and work. METHOD Data were collected between 2011 and 2013 from all 65 individuals in the RAISE Connection Program. Descriptive statistics, analysis of variance, and multinomial logit random-effects models were used to examine rates and predictors of work/school participation. RESULTS Most participants who eventually engaged in vocational activities did so within the first year of participation. Many engaged in both school and work. Those working (alone or with school) had better premorbid functioning and cognition and less severe concurrent symptoms. CONCLUSION AND IMPLICATIONS FOR PRACTICE Participants in FEP programs emphasizing school and work can have high rates of vocational participation and early engagement, often simultaneously in work and school. (PsycINFO Database Record

This study examined discharge planning practices by hospital providers for 17,053 psychiatric discharges in New York's statewide Medicaid program.Claims data were linked to information reported to New York State by managed behavioral health care organizations (MBHOs) conducting inpatient utilization reviews. MBHOs documented hospital providers' reports of the presence of three discharge planning practices for each discharge: communicating with an outpatient provider prior to discharge, scheduling an aftercare appointment, and forwarding a discharge summary.Hospital providers reported completing at least one of the three discharge planning practices for 85% of discharges. Individuals who received all three discharge planning practices had a higher likelihood of follow-up and kept their first outpatient follow-up visit at almost twice the speed compared with individuals who received none of the practices (hazard ratio=1.96, p.001).This study provided baseline information concerning routine discharge planning practices and their relationship to timeliness of care transitions.

Involving family in the care of inpatients with serious mental illness is known to be beneficial. This study examined frequencies of involvement by family in the care and discharge planning for 179 psychiatric inpatients.Involvement by family in care and discharge planning was assessed from randomly selected medical records of inpatients with Medicaid and severe mental illness at two New York hospitals from 2012 to 2013. "Family" also included anyone close to the patient who provided support. Medicaid claims were reviewed for patient demographic and clinical characteristics and for postdischarge outpatient attendance data. Multiple regression models were used to test whether involvement by family was associated with comprehensive discharge planning (contacting outpatient providers, scheduling follow-up appointments, and forwarding a discharge summary to a provider) and initiation of outpatient treatment.Inpatient staff contacted a family member for 134 (75%) patients. Sixty-seven (37%) patients received comprehensive discharge planning, and 96 (53%) and 139 (78%) attended an outpatient appointment within 7 and 30 days of discharge, respectively. Inpatient staff contacting family, communicating about the patient's health and/or mental health, and communicating about the discharge plan were significantly associated with entry into follow-up care by 7 and 30 days postdischarge. Family phone calls and/or visits with patients, attendance at family therapy sessions, and communication with inpatient staff about services available to families were significantly associated with patients receiving comprehensive discharge planning. When analyses controlled for demographic and clinical factors, having any involvement between family members and inpatient staff was significantly associated with patients' attending an outpatient appointment by 7 days (odds ratio [OR]=2.79, 95% confidence interval [CI]=1.28-6.08) or 30 days (OR=3.07, 95% CI=1.29-7.32) after discharge.The association of family involvement with comprehensive discharge planning and prompt entry into outpatient care underscores the importance of family contact and communication with staff during inpatient hospitalizations.

The New York City (NYC) Board of Health amended the city's health code to require hospitals to report to the Department of Health and Mental Hygiene when individuals ages 18-30 are hospitalized for first-episode psychosis (FEP). This study examined the implementation of NYC START, a program that meets patients hospitalized with FEP to offer a voluntary, 3-month critical time intervention provided by social workers and peer specialists to connect individuals to appropriate community mental health services after discharge.Service logs completed by program staff were summarized to determine the mean number of contacts received per client per week, types of services provided by social workers and peer specialists, survival analyses of time to discharge from NYC START, and connection rates with community mental health services.Of the 285 clients who accepted NYC START services in 2016, 87% attended an initial mental health appointment after hospital discharge and 78% completed at least 3 months of the program. Consistent with the program model, contacts were most frequent in clients' first week in NYC START, with a mean of 2.5±1.4 contacts, 1.9 of which were with social workers and 0.5 of which were with peer specialists. Social workers provided a mean of 17.3±4.4 client-specific activities per week, and peer specialists provided a mean of 8.5±3.5.NYC START serves as a critical time intervention to connect people hospitalized with FEP to community mental health treatment.

IntroductionSmoking is a significant modifiable risk factor for mortality for persons with serious mental illness (SMI), who have a life expectancy 15-20years shorter than the general population. Individuals with SMI and comorbid diabetes who are smokers face an even higher risk of cardiovascular complications and early death. Yet despite high rates of smoking among people with SMI, tobacco cessation interventions have not been broadly offered to this population.MethodsWe conducted a retrospective cohort study using electronic health records from 2014 in a large integrated care delivery system to examine whether use of smoking cessation pharmacotherapy among smokers with type 2 diabetes varies by serious mental illness (SMI) diagnosis. We analyzed smoking cessation medication prescription fills among adult smokers with diabetes, comparing those with SMI (N=634) and without SMI (N=18,021). Risk ratios were adjusted for age, gender, race, urban area type, and medical facility.ResultsOf the SMI group, 19.09% filled at least one smoking cessation prescription compared to 9.73% of the non-SMI group (adjusted risk ratio 1.80 [95% CI 1.52-2.13]; p&nbsp

This study examined the adherence of psychiatrists to the Schedule of Recommended First and Second Line Antipsychotic Medications ("Antipsychotic Schedule"), which was implemented in two Recovery After an Initial Schizophrenia Episode (RAISE) Connection Program Implementation and Evaluation Study clinics.Sixty-five individuals with a first episode of psychosis were enrolled in the RAISE Connection Program clinics. Two psychiatrists received training and ongoing consultation on use of a shared decision-making approach to prescribing antipsychotic medications according to the Antipsychotic Schedule. Information about participants, prescribed antipsychotic medications, and completion of side-effect assessments were obtained from standardized research assessments and chart extractions. Descriptive statistics were used to characterize the extent to which patterns of antipsychotic prescribing and side-effect monitoring were consistent with the Antipsychotic Schedule.Ninety-two percent of participants were prescribed an antipsychotic medication and received the medication on 76%±35% of the days they were in treatment. Seventy-seven percent of participants were prescribed at least one Antipsychotic Schedule first-line antipsychotic, 20% were prescribed olanzapine, and 10% received a trial of clozapine. Regarding monitoring for metabolic side effects, 92% of participants had at least one weight recorded, 72% had at least one blood glucose measure recorded, and 62% had at least one lipid profile recorded.In the context of a study in which training and ongoing clinical supervision by experts was provided to psychiatrists and shared decision making was encouraged, antipsychotic prescribing patterns closely adhered to recommendations established by the RAISE Connection Program.

OnTrackNY is a coordinated specialty care program that delivers early intervention services to youths experiencing a first episode of nonaffective psychosis. Treatment aims to help individuals improve their mental health and achieve personal goals related to work, school, and social relationships. This column describes OnTrackNY's progression from a research project to real-world implementation. The authors describe the treatment model, approach to training and dissemination, and procedures for collecting and sharing data with OnTrackNY teams and provide data on client characteristics and selected outcomes.

Background In a large statewide initiative, New York State implemented collaborative care (CC) from 2012 to 2014 in 32 primary care settings where residents were trained and supported its sustainability through payment reforms implemented in 2015. Twenty-six clinics entered the sustainability phase and six opted out, providing an opportunity to examine factors predicting continued CC participation and fidelity. Methods We used descriptive statistics to assess implementation metrics in sustaining vs. opt-out clinics and trends in implementation fidelity 1 and 2 years into the sustainability phase among sustaining clinics. To characterize barriers and facilitators, we conducted 31 semi-structured interviews with psychiatrists, clinic administrators, primary care physicians, and depression care managers (24 at sustaining, 7 at opt-out clinics). Results At the end of the implementation phase, clinics opting to continue the program had significantly higher care manager full-time equivalents (FTEs) and achieved greater clinical improvement rates (46% vs. 7.5%, p = 0.004) than opt-out clinics. At 1 and 2 years into sustainability, the 26 sustaining clinics had steady rates of depression screening, staffing FTEs and treatment titration rates, significantly higher contacts/patient and improvement rates and fewer enrolled patients/FTE. During the sustainability phase, opt-out sites reported lower patient caseloads/FTE, psychiatry and care manager FTEs, and physician/psychiatrist CC involvement compared to sustaining clinics. Key barriers to sustainability noted by respondents included time/resources/personnel (71% of respondents from sustaining clinics vs. 86% from opt-out), patient engagement (67% vs. 43%), and staff/provider engagement (50% vs. 43%). Fewer respondents mentioned early implementation barriers such as leadership support, training, finance, and screening/referral logistics. Facilitators included engaging patients (e.g., warm handoffs) (79% vs. 86%) and staff/providers (71% vs. 100%), and hiring personnel (75% vs. 57%), particularly paraprofessionals for administrative tasks (67% vs. 0%). Conclusions Clinics that saw early clinical improvement and who invested in staffing FTEs were more likely to elect to enter the sustainability phase. Structural rules (e.g., payment reform) both encouraged participation in the sustainability phase and boosted long-term outcomes. While limited to settings with academic affiliations, these results demonstrate that patient and provider engagement and care manager resources are critical factors to ensuring sustainability. Electronic supplementary material The online version of this article (10.1186/s13012-018-0818-6) contains supplementary material, which is available to authorized users.

OBJECTIVE: We sought to understand stakeholder perspectives on barriers to metabolic screening for people with severe mental illness. We additionally assessed the feasibility of expanding psychiatrists’ scope of practice to include treatment of cardiometabolic abnormalities. METHODS: We conducted four focus groups among patients with severe mental illness, community psychiatrists, primary care providers, and public health administrators. Focus group transcripts were thematically analyzed. RESULTS: Three domains emerged: challenges with patient navigation of the complex health care system, problem list prioritization difficulties, and concern that treatment of cardiometabolic abnormalities were beyond the scope of practice of psychiatrists. CONCLUSIONS: Stakeholders agreed that navigating the health care system was challenging for this population and led to undertreatment of cardiometabolic risk factors. Expansion of psychiatrists’ scope of practice within community mental health appears acceptable to patients and may be a mechanism to improve cardiometabolic care among people with severe mental illness.

OBJECTIVE: This study aimed to understand the pathways to care from the onset of first episode psychosis to entry into a specialized early intervention service (EIS) for individuals with non-affective psychosis. METHODS: A sample of 20 individuals who participated in EIS and 10 of their family members were enrolled. Semi-structured qualitative interviews were used to characterize participants’ lives during the onset of psychosis and explore their help-seeking events from the onset of psychosis to entry into EIS. Data were analyzed using grounded theory and a case study methodology. RESULTS: The median duration between the onset and entry into EIS was 4.5 months. A grounded model emerged from our analysis capturing how help-seeking decisions were influenced by the misattribution of symptoms, stigma, and self-reliance which created a cloud of uncertainty in which individuals experiencing early psychosis and their family members struggled to make sense of what was happening, how and when to seek help, and what to expect from treatment. Contacts with the health care system were a critical juncture in the pathway to care that could reduce or increase uncertainty and expedite or delay entry into EIS. CONCLUSIONS: Study findings indicate that efforts to expedite entering EIS should focus on reducing the uncertainty affected individuals and their family members face when seeking care by improving their experiences with mental health services.

Objective:This study assessed factors that facilitated or impeded clients’ engagement in services offered by the Recovery After an Initial Schizophrenia Episode (RAISE) Connection Program for youths and young adults experiencing early psychosis. It was part of the larger RAISE Implementation and Engagement Study.Methods:Thematic qualitative analyses of data from in-person, semistructured interviews with 32 clients were used to examine experiences of program services, staff practices, clients’ engagement behaviors, and related factors, such as expectations, family involvement, illness, and setting. Eighteen clients were well engaged with services, and 14 were not. Thirteen were interviewed early in their program involvement (two to nine months after enrollment) and 18 others later (12 to 24 months after enrollment).Results:Four domains of factors influenced engagement: individualized care, program attributes, family member engagement, and personal attributes. A central factor was the program’s focus on cli...

The RAISE (Recovery After an Initial Schizophrenia Episode) Connection Program Implementation and Evaluation Study developed tools necessary to implement and disseminate an innovative team-based intervention designed to promote engagement and treatment participation, foster recovery, and minimize disability among individuals experiencing early psychosis. This article describes the treatment model and reports on service utilization and outcomes. It was hypothesized that individuals' symptoms and functioning would improve over time.A total of 65 individuals in RAISE Connection Program treatment across two sites (Baltimore and New York City) were enrolled and received services for up to two years. Primary outcomes, including social and occupational functioning and symptoms, were evaluated. Trajectories for individuals' outcomes over time were examined with linear and quadratic mixed-effects models with repeated measures.Measures of occupational and social functioning improved significantly over time, symptoms declined, and rates of remission improved. Visits were most frequent during the first three months, with a mean±SD of 23.2±11.5 unduplicated staff encounters per quarter. Such encounters decreased to 8.8±5.2 in the final quarter of year 2.The overall project was successful in that the treatment program was delivered and tools useful to other clinical settings were produced. The strengths of this study lie in the demonstrated feasibility of delivering the coordinated specialty care model and the associated high rates of engagement among individuals who are typically difficult to engage in treatment. Notwithstanding the lack of a built-in comparison group, participant outcomes were promising, with improvements comparable to those seen with other successful interventions.

The prevalence and impact of mental health conditions calls for measuring the adequacy of care, but progress in measuring mental health outcomes in the USA has been uneven, with some important domains (such as employment and other measures of everyday functioning) rarely captured. Bright spots include progress in adopting uniform measures of the quality of inpatient mental healthcare and early progress in measuring adequacy of medication and psychotherapy treatment. To some extent, progress in measurement has been limited by separate governing structures and payment rules in mental health and overall health settings. This is becoming a critical problem as awareness of the scope and impact of mental health co-morbidities emerges at the same time as pressures for healthcare cost controls intensify. A search for better measures may be accelerated as problems linked to co-morbid mental health problems (e.g. readmission to hospitals) come into sharper focus due to changes in healthcare financing related to the US Patient Protection and Affordable Care Act, 2010.

Project Connect, a clinical demonstration program developed in consultation with the New York State Office of Mental Health, adapted critical time intervention for frequent users of a large urban psychiatric emergency room (ER). Peer staff provided frequent users with time-limited care coordination. Participants increased their use of outpatient services over 12 months, compared with a similar group not enrolled in the program. For persons with significant general medical, psychiatric, and social needs, provision of this intervention alone is unlikely to reduce reliance on ERs, especially among homeless individuals.

Introduction by the column editors: This column demonstrates the use of an electronic mailing list (e-list) to generate a collaborative problem-solving process. The process is modeled on key features of the academic curriculum of the Columbia University Public Psychiatry Fellowship (PPF) (ppf.hs.columbia.edu). PPF alumni who encounter management problems at their worksite may present these concerns to current PPF fellows and faculty and lead a discussion aimed at identifying potential solutions. This column describes one such solution that involves information sharing among psychiatrists working in busy psychiatric emergency rooms in New York City. It describes variations in management approaches and the sharing of promising practices as informed by the e-list discussion. Ravi N. Shah,M.D.,M.B.A., a Columbia psychiatry resident, and Kendra Campbell, M.D., a PPF fellow and emergency psychiatry fellow, established the e-list and communicatedwith psychiatric emergency roomdirectors and attending physicians in New York City to facilitate discussion of management approaches. Readers are invited to submit suggestions for e-list discussions of management problems to column editor Jules Ranz, M.D. (e-mail: jmr1@columbia.edu).

Objective To explore the acceptability of currently available treatments and services for individuals who self-report hoarding behaviors. Method Between 10/2013 and 8/2014, participants were invited to complete an online survey that provided them descriptions of eleven treatments and services for hoarding behaviors and asked them to evaluate their acceptability using quantitative (0 [not at all acceptable]−10 [completely acceptable]) Likert scale ratings. The a priori definition of acceptability for a given resource was an average Likert scale score of six or greater. Two well-validated self-report measures assessed hoarding symptom severity: the Saving Inventory-Revised and the Clutter Image Rating Scale. Results Two hundred and seventy two participants who self-reported having hoarding behaviors completed the questionnaire. Analyses focused on the 73% of responders ( n =203) who reported clinically significant hoarding behaviors (i.e., Saving Inventory-Revised scores of ≥40). The three most acceptable treatments were individual cognitive behavioral therapy (6.2±3.1 on the Likert scale), professional organizing service (6.1±3.2), and use of a self-help book (6.0±3.0). Conclusion In this sample of individuals with self-reported clinically significant hoarding behaviors ( n =203), only 3 out of 11 treatments and services for hoarding were deemed acceptable using an a priori score. While needing replication, these findings indicate the need to design more acceptable treatments and services to engage clients and maximize treatment outcomes for hoarding disorder.

Le priorita dei finanziamenti per la ricerca sulla salute mentale nei Paesi ad alto reddito deve mantenere un equilibrio tra gli investimenti a lungo termine per la ricerca sulle basi neurobiologiche dei disturbi mentali e gli investimenti a breve termine per la ricerca su nuove strategie preventive e terapeutiche che possano alleggerire il peso della malattia mentale che oggi grava sui pazienti, le famiglie e la comunita. Dare maggiore priorita a un’area di ricerca scientifica piuttosto che a un’altra rischia di ridurre i guadagni dell’intero portfolio degli investimenti nella salute mentale. (Questo testo e un editoriale uscito nel n. 6/2016 del British Journal of Psychiatry, e in questa traduzione italiana e seguito da due interventi di discussione, rispettivamente di Andrea Fagiolini e Giacomo Rizzolatti).

As health information technology advances, efforts to use administrative data to inform real-time treatment planning for individuals are increasing, despite few empirical studies demonstrating that such administrative data predict subsequent clinical events. Medicaid claims for individuals with frequent psychiatric hospitalizations were examined to test how well patterns of service use predict subsequent high short-term risk of continued psychiatric hospitalizations.Medicaid claims files from New York and Pennsylvania were used to identify Medicaid recipients ages 18-64 with two or more inpatient psychiatric admissions during a target year ending March 31, 2009. Definitions from a quality-improvement initiative were used to identify patterns of inpatient and outpatient service use and prescription fills suggestive of clinical concerns. Generalized estimating equations and Markov models were applied to examine claims through March 2011, to see what patterns of service use were sufficiently predictive of additional hospitalizations to be clinically useful.A total of 11,801 individuals in New York and 1,859 in Pennsylvania identified met the cohort definition. In both Pennsylvania and New York, multiple recent hospitalizations, but not failure to use outpatient services or failure to fill medication prescriptions, were significant predictors of high risk of continued frequent hospitalizations, with odds ratios greater than 4.0.Administrative data can be used to identify individuals at high risk of continued frequent hospitalizations. Payers and system administrators could use such information to authorize special services (such as mobile outreach) for such individuals to promote service engagement and prevent rapid rehospitalizations.

People with severe mental illnesses (SMI) such as schizophrenia and bipolar disorder have an increased risk for diabetes (1), in part due to treatment with both first- and second-generation antipsychotics (2). A large systematic review estimated that 15% of people with SMI have type 2 diabetes, a prevalence double that of age-matched samples from the general population during the same time period (1). Preliminary evidence suggests that racial/ethnic minorities with SMI may be at especially high risk for diabetes compared with whites; unfortunately, similar data regarding prevalence of prediabetes is more limited (2). Understanding of the prevalence of prediabetes and diabetes in a large, racially and ethnically diverse and representative sample is an important first step in reducing diabetes prevalence and related adverse outcomes in this particularly vulnerable population. In this study, we estimate diabetes and prediabetes prevalence among antipsychotic-treated patients within an integrated health care system and determine whether racial/ethnic differences exist. In this retrospective cohort study of adults with SMI in Kaiser Permanente Northern California (KPNC), our primary outcome was evidence of diabetes. The cohort used for this study has been previously described (3). To estimate diabetes prevalence, the primary outcome measure was inclusion in the KPNC diabetes registry at any time before 31 December 2014 (4). To estimate our secondary outcome, prediabetes prevalence, we first excluded people who were in the …

Mental health programs can address many components of fidelity with routinely available data. Information from client interviews can be used to corroborate these administrative data. This column describes a practical approach to measuring fidelity that used both data sources. The approach was used in the Recovery After an Initial Schizophrenia Episode (RAISE) Connection Program, a team-based intervention designed to implement evidence-based practices for people experiencing early psychosis suggestive of schizophrenia. Data indicated that the intervention was implemented as intended, including program elements related to shared decision making and a range of evidence-based clinical interventions.

SummaryMental health research funding priorities in high-income countries must balance longer-term investment in identifying neurobiological mechanisms of disease with shorter-term funding of novel prevention and treatment strategies to alleviate the current burden of mental illness. Prioritising one area of science over others risks reduced returns on the entire scientific portfolio.

Objective This multisite randomized trial addressed risks and benefits of staying on long-acting injectable haloperidol or fluphenazine versus switching to long-acting injectable risperidone microspheres.

This article describes the creation, validation, and use of an assertive community treatment (ACT) Transition Readiness Scale (TRS) to identify clients who may be ready to transition from ACT services. Scale development was prompted by concerns over long stays on ACT teams and the resulting impact on access.Data were extracted from a centralized clinical reporting system for all 1,365 persons enrolled for at least 12 months as of August 2008 in the 42 ACT teams in New York City, including 382 clients of eight of those ACT teams. Data in seven domains deemed relevant to transition readiness were used to calculate readiness scores for each client. An algorithm assigned clients to one of three categories: consider for transition, readiness unclear, and not ready.Via the TRS algorithm, of the 1,365 clients, 192 (14%) were assigned to the consider-for-transition group, 382 (28%) to the unclear group, and 791 (58%) to the not ready group. Clinicians on the eight ACT teams categorized 15% of their current clients in the consider-for-transition group, whereas the TRS algorithm classified 18% in this category. Overall, the TRS agreed with the category assigned by ACT team clinicians in 69% of cases.The TRS may provide ACT teams and program administrators with a tool to identify clients who may be ready to transition to less intensive services, thereby opening scarce slots. Because ACT cases are complex, data summaries can offer useful syntheses of information, particularly when data from several assessments are used to summarize a client's trajectory.

Published guidelines recommend metabolic monitoring for patients prescribed second-generation antipsychotic (SGA) medications. This study determined monitoring rates, and examined predictors of monitoring, for total cholesterol and weight among patients prescribed SGAs during a period when awareness of metabolic side effects was emerging, but prior to the wide promulgation of guidelines.This retrospective study used administrative data from four Veterans Health Administration facilities to examine monitoring rates for total cholesterol and weight during baseline and follow-up periods from October 1, 2000-September 30, 2003 among patients with schizophrenia initiating SGA treatment. The study used logistic regression to identify characteristics that predicted monitoring. Background monitoring rates during routine care were estimated using a resampling procedure.Initiating SGA treatment did not appear to trigger annual monitoring above estimated background rates of 54% for total cholesterol and 47% for weight. Patients with metabolic risk factors were monitored at higher rates independent of the start of treatment with an SGA.This paper provides a window into side effect monitoring practices prior to the widespread promulgation of guidelines and associated quality improvement efforts and serves as a benchmark for future interventions. Prior to publication of monitoring guidelines, patients initiating treatment with SGAs did not receive adequate metabolic monitoring routinely, nor did SGA treatment appear to trigger additional monitoring. Some studies that have assessed the impact of monitoring guidelines on clinical practice show only limited impact. Quality improvement strategies to increase metabolic monitoring over the rates seen here and in other studies should be developed and implemented.

Although the provision of publicly funded health and mental health services to homeless persons has expanded greatly in the past decade, primary prevention of homelessness has received relatively little attention (O’Connell et al., 2005). Evictions are a major proximate cause of homelessness, and numerous studies show that evictions primarily result from tenants’ nonpayment of rent (Stenberg and van Laere, 2009; Van Laere et al., 2009). However, evidence also suggests that, for some housed persons, untreated mental health problems may also increase eviction risk by contributing to behaviors that jeopardize continued tenancy (Crane et al., 2005; Van Laere et al., 2009). Hoarding disorder (HD; Mataix-Cols et al., 2010) is one mental health condition that may precipitate homelessness by placing housed individuals at risk of eviction (Mataix-Cols D, Grayton L, Bonner A, Luscombe C, Taylor PJ, van den Bree M. A putative link between compulsive hoarding and homelessness: A pilot study [submitted for publication]; Tolin, et al., 2008). Also known as “compulsive hoarding syndrome” (Saxena, 2008), HD is defined as persistent difficulty in discarding personal possessions of limited value, which results in clutter that precludes normal use of living spaces and causes clinically significant distress or impairment (Frost and Gross, 1993; Frost and Hartl, 1996; Mataix-Cols et al., 2010). Once considered a subtype of obsessive-compulsive disorder (OCD), HD is now considered a separable syndrome and has been proposed as a new diagnostic category in DSM-V (Mataix-Cols et al., 2010; Phillips et al., 2010). Epidemiological surveys estimate a 2% to 5% prevalence of HD in the general population (Iervolino et al., 2009; Mataix-Cols et al., 2010; Samuels et al., 2008). Recommended treatment strategies for HD include medication (e.g., paroxetine and venlafaxine) and cognitive behavioral therapy (Saxena, 2008, 2011; Steketee and Frost, 2003). HD is associated with high levels of disability and impairment (Frost et al., 2000; Tolin et al., 2008). It causes public health problems when clutter attracts pest infestations or obstructs fire exits in apartment buildings, endangering both personal and neighbors’safety (Frost et al., 2000; Frost et al., 1999; Patronek, 1999). These conditions may lead neighbors and landlords to complain, resulting in legal proceedings and eviction (Frost et al., 1999). Two studies have examined the putative link between HD, eviction, and homelessness. An Internet study of the economic and social burden of HD surveyed 864 individuals with HD and found that 2% reported being evicted and 6% endorsed being threatened with eviction (Tolin et al., 2008). A study in the United Kingdom evaluated the prevalence of HD in 78 randomly selected homeless individuals newly admitted to Salvation Army shelters (Mataix-Cols D, Grayton L, Bonner A, Luscombe C, Taylor PJ, van den Bree M. A putative link between compulsive hoarding and homelessness: A pilot study [submitted for publication]): up to 21% of these individuals endorsed hoarding symptoms and 8% reported that hoarding problems directly contributed to their homeless state. Although these studies suggest that HD may contribute to eviction and homelessness, to our knowledge, no studies have examined the prevalence and correlates of HD in a population seeking housing assistance and at potential risk for eviction. To begin to address this gap, we evaluated the prevalence of HD in a sample of people seeking services from a not-for-profit community organization focused on helping individuals with housing problems including eviction. In further characterizing this sample, we also assessed sociodemographic correlates, threat of imminent eviction, history of eviction, and mental health treatment utilization.

In the aftermath of the September 11, 2001, attacks on the World Trade Center, the public mental health system in New York City mounted the largest mental health disaster response in history, called Project Liberty. The successes and challenges of Project Liberty are evaluated.The development of Project Liberty is summarized and analyzed from the perspective of the New York State and New York City officials and scientists who led the disaster response. Lessons learned that have implications for mental health support in future disaster responses are offered.A high level of interagency collaboration, engagement of nongovernmental organizations to provide services, media education efforts, and ongoing program evaluation all contributed to the program's successes. Mental health professionals' limited experiences with trauma, options for funding treatment, duration of clinical program, and existing needs assessments methodologies all proved challenging.Project Liberty was a massive and invaluable resource during the years of rebuilding in New York City in the wake of the attacks. Challenges faced have led to lessons of generalizable import for other mental health responses to large-scale events.

Objective: Integrated, evidence-based treatment for co-occurring severe mental illness and substance use disorder (co-occurring disorders) reduces substance use, hospitalization, homelessness, incarceration, and treatment costs and promotes individuals’ recovery, independent living, and employment. This report describes and characterizes early uptake of New York State's Web-based training and distance implementation supports to promote statewide dissemination of integrated, evidence-based co-occurring disorders services. Methods: Thirty-five half-hour online modules provide training on integrated evidence-based co-occurring disorders treatment. Distance supports for implementation include monthly webinars, phone calls, and virtual learning communities. The authors calculated the proportion of programs with one or more practitioners who accessed the Web-based resources and the cumulative number of modules completed as an indicator of the reach of the Web-based approach to scaling up an innovation. They als...

This randomized trial addressed the risks and benefits of staying on antipsychotic polypharmacy or switching to monotherapy.Adult outpatients with schizophrenia taking two antipsychotics (127 participants across 19 sites) were randomly assigned to stay on polypharmacy or switch to monotherapy by discontinuing one antipsychotic. The trial lasted 6 months, with a 6-month naturalistic follow-up. Kaplan-Meier and Cox regression analyses examined time to discontinuation of assigned antipsychotic treatment, and random regression models examined additional outcomes over time.Patients assigned to switch to monotherapy had shorter times to all-cause treatment discontinuation than those assigned to stay on polypharmacy. By month 6, 86% (N=48) of those assigned to stay on polypharmacy were still taking both medications, whereas 69% (N=40) of those assigned to switch to monotherapy were still taking the same medication. Most monotherapy discontinuations entailed returning to the original polypharmacy. The two groups did not differ with respect to psychiatric symptoms or hospitalizations. On average, the monotherapy group lost weight, whereas the polypharmacy group gained weight.Discontinuing one of two antipsychotics was followed by treatment discontinuation more often and more quickly than when both antipsychotics were continued. However, two-thirds of participants successfully switched, the groups did not differ with respect to symptom control, and switching to monotherapy resulted in weight loss. These results support the reasonableness of prescribing guidelines encouraging trials of antipsychotic monotherapy for individuals receiving antipsychotic polypharmacy, with the caveat that patients should be free to return to polypharmacy if an adequate trial on antipsychotic monotherapy proves unsatisfactory.

The study determined rates of reengagement in services for individuals with serious mental illness who had discontinued services.As part of a quality assurance program in New York City involving continuous review of Medicaid claims and other administrative data, clinician care monitors identified 2,834 individuals with serious mental illness who were apparently in need of care but disengaged from services. The care monitors reviewed monthly updates of Medicaid claims, encouraged outreach from providers who had previously worked with identified individuals, and determined whether individuals had reengaged in services.Reengagement rates over a 12-month follow-up period were low, particularly for individuals who had been incarcerated or for whom no service provider was available to provide outreach.Subgroups of disengaged individuals with serious mental illness have different rates of reengagement. Active outreach by providers might benefit some, but such targeting is inefficient when the individual cannot be located.

Objective: This qualitative study examined consumer preferences regarding the content and use of provider performance data and other provider information to aid in consumers’ decision making. Methods: Focus groups were conducted with 41 adults who were consumers of mental health care, and discussions were transcribed and analyzed with standard qualitative research methods. Results: Consumers supported trends toward enhancing information about providers and its availability. Several key themes emerged, including the need for easily accessible information and the most and least useful types of information. Conclusions: Current efforts to share provider performance information do not meet consumer preferences. Modest changes in the types of information being shared and the manner in which it is shared may substantially enhance use of such information. Such changes may help consumers to be more informed and empowered in making decisions about care, improve the quality of the care delivered, and support the movement toward a more recovery-focused system of care. (Psychiatric Services 60:689–692, 2009)

Purpose:Previous analysis of data from CATIE showed that patients randomly assigned to switch to a new medication were more likely to discontinue study drug than those who stayed on the medication they had been taking prior to randomization. This study addresses additional outcomes measures evaluating symptoms, neurocognition, quality of life, neurological side effects, weight, and health costs. First, considering patients randomized to olanzapine or risperidone, outcomes among patients who had been on the drug to which they were randomized prior to CATIE (N = 129 “stayers”) were compared to outcomes of those who switched to either of these two drugs (N = 269 “switchers”). A second set of analyses considered patients on baseline monotherapy with olanzapine (N = 297); risperidone (N = 252) or quetiapine (n = 87) and compared those randomly assigned to stay on each of these medications with those assigned to switch to any of the other five phase 1 medications in CATIE. In mixed models of each outcome the in...

526 Mental health services research provides a critical bridge between efficacy demonstrated in randomized controlled trials and treatment effectiveness in real-world settings. It does so by taking into account multiple influences—for example, characteristics of service systems, consumers, and providers—that influence the effectiveness of treatments in service delivery settings (1). One way to understand the impact of these multiple influences is by developing a program theory (2,3) or heuristic model (1) to guide an effectiveness evaluation from inception to interpretation. The heuristic model proposed by Shern and Evans (1) provides a framework for guiding mental health services research by identifying five domains that affect both consumer and service outcomes: consumer characteristics, such as demographic characteristics, clinical status, and functional status; organizational characteristics, such as rules that govern behavior in an organization; practitioner behavior, such as prescribing, and practitioner characteristics, including training, values, beliefs, and therapeutic orientation; services environment, such as attitudes, values, and beliefs of staff; and service system characteristics, such as external laws and regulations influencing service delivery and reimbursement. From the perspective of this heuristic model, we discuss the implications that the findings of the Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE) have for monitoring and influencing the behavior of prescribers through changes in the service system that should have an impact on both consumer outcomes (for example, change in clinical status or side effect burden) and system outcomes (for example, changes in resources devoted to different prescribing patterns).

Objective: The lack of an accepted standard for measuring cognitive change in schizophrenia has been a major obstacle to regulatory approval of cognition-enhancing treatments. A primary mandate of the National Institute of Mental Health’s Measurement and Treatment Research to Improve Cognition in Schizophrenia (MATRICS) initiative was to develop a consensus cognitive battery for clinical trials of cognition-enhancing treatments for schizophrenia through a broadly based scientific evaluation of measures. Method: The MATRICS Neurocognition Committee evaluated more than 90 tests in seven cognitive domains to identify the 36 most promising measures. A separate expert panel evaluated the degree to which each test met specific selection criteria. Twenty tests were selected as a beta battery. The beta battery was administered to 176 individuals with schizophrenia and readministered to 167 of them 4 weeks later so that the 20 tests could be compared directly. Results: The expert panel ratings are presented for th...

BACKGROUND: A panel of academic psychiatrists and pharmacists, clinicians from the Texas public mental health system, advocates, and consumers met in June 2006 in Dallas, Tex., to review recent evidence in the pharmacologic treatment of schizophrenia. The goal of the consensus conference was to update and revise the Texas Medication Algorithm Project (TMAP) algorithm for schizophrenia used in the Texas Implementation of Medication Algorithms, a statewide quality assurance program for treatment of major psychiatric illness. METHOD: Four questions were identified via premeeting teleconferences. (1) Should antipsychotic treatment of first-episode schizophrenia be different from that of multiepisode schizophrenia? (2) In which algorithm stages should first-generation antipsychotics (FGAs) be an option? (3) How many antipsychotic trials should precede a clozapine trial? (4) What is the status of augmentation strategies for clozapine? Subgroups reviewed the evidence in each area and presented their findings at the conference. RESULTS: The algorithm was updated to incorporate the following recommendations. (1) Persons with first-episode schizophrenia typically require lower antipsychotic doses and are more sensitive to side effects such as weight gain and extrapyramidal symptoms (group consensus). Second-generation antipsychotics (SGAs) are preferred for treatment of first-episode schizophrenia (majority opinion). (2) FGAs should be included in algorithm stages after first episode that include SGAs other than clozapine as options (group consensus). (3) The recommended number of trials of other antipsychotics that should precede a clozapine trial is 2, but earlier use of clozapine should be considered in the presence of persistent problems such as suicidality, comorbid violence, and substance abuse (group consensus). (4) Augmentation is reasonable for persons with inadequate response to clozapine, but published results on augmenting agents have not identified replicable positive results (group consensus). CONCLUSIONS: These recommendations are meant to provide a framework for clinical decision making, not to replace clinical judgment. As with any algorithm, treatment practices will evolve beyond the recommendations of this consensus conference as new evidence and additional medications become available. Language: en

We examined prevalence and perceived distress resulting from self-reported side effects (SEs) attributed to psychotropic medications among individuals with severe mental illness participating in a study of consumer-operated services. We examined gender and racial differences using logistic regression, conducted factor analyses of SEs, and examined correlations between distress and self-reported symptoms. Over 90% reported at least one SE, and nearly two-thirds reported a high level of distress with at least one SE. The most distressing SEs reported were embarrassment from weight gain, weight gain, dry mouth, and sedation. The likelihood of distress by particular SEs varied by gender and race.

In a large (n = 1,827) multi-site study examining effectiveness of consumer operated service programs as an adjunct to traditional mental health services, we examined individuals' preferred term describing their status as service recipients, and we applied logistic regression to examine whether preference varied by gender, race or diagnosis. Preferred terms were client (39%), patient (22%), consumer (16%), survivor (11%), other (11%) and ex-patient (1%), varying by site. Controlling for site, preferences did not vary by gender, race, or diagnosis. The lack of consensus suggests clinicians, researchers, program administrators, and policymakers should be sensitive to individuals' preferences.

The aims of this study were to explore secondary outcomes of a coordinated specialty care program for persons with early psychosis, including quality of life and recovery, as well as to explore mediators and moderators of improvement in occupational and social functioning and symptoms. Sixty-five individuals across two sites were enrolled and received services for up to 2 years. Trajectories for individuals' outcomes over time were examined using linear and quadratic mixed-effects models with repeated measures. In addition, baseline prognostic factors of participant improvement in social and occupational functioning were explored based on previous literature and expert opinion of the analytic team. Results demonstrate that the program was effective in improving quality of life and recovery over time. Furthermore, processing speed was identified as a significant moderator of improvement in occupational Global Assessment of Function, and treatment fidelity, engagement, and family involvement were identified as mediators of improvement in social and occupational functioning.