FRONTLINE REPORTS
Frontline Reports The Frontline Reports column features short descriptions of novel approaches to mental health problems or creative applications of established concepts in different settings. Material submitted for the column should be 350 to 750 words long, with a maximum of three authors (one is preferred) and no references, tables, or figures. Send material to Francine Cournos, M.D., at the New York State Psychiatric Institute ([email protected]) or to Stephen M. Goldfinger, M.D., at SUNY Downstate Medical Center (smgoldfi[email protected]).
Healthy Minds: Promoting Mental Health for At-Risk Youths Urban youths in underserved communities are disproportionately faced with increased stressors, including violent neighborhoods, substance abuse, poverty, lack of support, and limited resources. They also have increased risk of entry into the juvenile justice system. This study aimed to create a cost-effective and reproducible program that promotes the mental health of at-risk youths from racial-ethnic minority groups in underserved communities. The study received institutional review board approval by the University of Pittsburgh and was conducted at University Preparatory Middle School in Pittsburgh’s Hill District and funded by an American Psychiatric Foundation Helping Hands Grant. We recruited 13 medical student volunteers (six women and seven men, with ten identifying as African American and three as Caucasian) by making the Healthy Minds program an approved community service site for curriculum credit offered by the University of Pittsburgh School of Medicine via the school’s Student National Medical Association chapter. Each volunteer attended a one-hour training session led by a community expert on one of four topics: stress management and ways to cope with trauma, family planning and sex education, body image and dealing with depression, and professional development. These experts were doctors, nurses, or social workers who volunteered their time. The Healthy Minds program was offered as an elective during The Zone! after-school program at University Prep in 2012. Two to three medical student volunteers led each interactive workshop delivered in a two-part series, given a month apart. The Healthy Minds curriculum was written by the student coinvestigators with input from community professionals. Recruited middle school students participated in eight weekly one-hour sessions. Healthy snacks were provided. Program participation was voluntary. Students were offered a $30 gift card and school supplies upon completion of the program. Twelve students initially enrolled in the Healthy Minds program. Seven students received parental consent to participate, and one female dropped out at week 2 because of behavioral problems at school. 104
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Data were collected on the sex, age, grade, and race-ethnicity of each child. Four of the six participants were male. Average student age was 13 years. All student participants were African American. A sign-in sheet was used to track weekly attendance. Pretest and posttest assessments based on the lesson plans from each workshop were used to evaluate knowledge retention. Program satisfaction surveys developed by coinvestigators revealed an average student satisfaction rating of 9.2 out of 10 points, indicating strong satisfaction. Students’ self-esteem was measured with the Rosenberg Self-Esteem Scale (range 0–30, with scores ,15 indicating low self-esteem) administered at the beginning of week 5 and the end of week 8 of programming. Results showed an average 7-point increase and progression from low to normal self-esteem scores for two out of six students in a one-month time frame. When participants were asked to indicate the best part of the program, the most common responses were “the activities” and “[It] teaches us new things that we did not know.” These responses suggest that an interactive teaching style is more effective than a traditional lecture style. Prior research has found that the racial-ethnic match of health care providers and clients is one of three culture-compatibility components that best predict retention in mental health services. A majority of medical student volunteers and all student participants in this study were African American. Future studies should evaluate the effect of volunteers’ race-ethnicity on satisfaction rates. In a health care system with shrinking resources, affordable community primary prevention programs are needed to promote overall mental health. Underserved youths from racial-ethnic minorities are at increased risk of mental health dysfunction and of entering the juvenile justice system. The average cost for a child in the Pennsylvania juvenile justice system is approximately $360 per day, plus an additional $50 per day for youths with mental illnesses. In comparison, the average cost per child for this school-based mental health program was approximately $60 per day. The primary goal of the Healthy Minds program is to empower adolescents to make positive life changes. Our objectives were to address factors contributing to the prevalence of mental health issues, teach coping mechanisms for stressful life situations, and expose youths to positive student Psychiatric Services 66:1, January 2015
FRONTLINE REPORTS
role models. Although conclusions are limited by a small sample size, this Healthy Minds pilot project may serve as a blueprint for a sustainable, affordable community health program led by students. A larger study is required to more accurately assess program effectiveness. Judy-April N. Oparaji, R.D. Enyinna L. Nwachuku, B.S. Jason M. Rosenstock, M.D. Ms. Oparaji and Mr. Nwachuku are medical students at the University of Pittsburgh School of Medicine (e-mail: [email protected]). Dr. Rosenstock is with the Department of Psychiatry, University of Pittsburgh Medical Center. Psychiatric Services 2015; 66:104–105; doi: 10.1176/appi.ps.651008
Wellness Program for People With Early Psychosis: Promoting Skills and Attitudes for Recovery Antipsychotic medication can improve symptoms for people with psychotic disorders, but this treatment does not consistently translate into improved psychosocial outcomes for people with early psychosis. In 2005, the Nova Scotia Early Psychosis Program held focus groups to ask patients what would help them recover. The patients said they wanted opportunities to do fun, recreational activities together and learn how to lead healthier lives. To address the outcomes of the focus groups, the Nova Scotia Early Psychosis Program created a wellness program, a 12-week, group-based program to promote healthy lifestyles through experiential education. The twice-weekly program included four healthy eating sessions, 22 recreation sessions, four stress management sessions, and six group therapy sessions. The Healthy Eating sessions integrated nutritional information and menu planning on a budget with sampling new foods, preparing meals, and shopping at a grocery store. The recreation sessions included education about physical fitness and navigating community resources with activities aligned with youth culture, progressing from hospital based to community based. The stress management sessions combined discussion about the stress response with participation in stress reduction practices such as meditation and yoga. Group therapy incorporated aspects of cognitive-behavioral therapy, motivational interviewing (MI), and peer support. A psychiatrist, a recreation therapist, and a peer motivator facilitated the program. The peer motivator was a recovered, young adult with psychosis who played a key role by representing participants’ perspective in the planning stages of the program, providing positive role modeling, and facilitating peer support. The facilitators were trained in MI, a conversation style that strengthens a person’s own motivation for change within a collaborative, accepting relationship. The program was piloted in a study with three cohorts from 2006 to 2007. Thirteen of 25 participants completed the study (52%), with the majority of dropouts happening prior to the program start or right after the first session. Participants who completed the study had an average attendance rate of 83% and demonstrated improvements in leisure functioning.
Psychiatric Services 66:1, January 2015
The leisure skills of community participation and integration improved from levels where they required assistance through verbal cueing to being functionally independent. Exit interviews with participants revealed other benefits of the program. A majority (80%290%) thought the program improved hope, self-confidence, and motivation—attitudes that are essential to the recovery process. Kevin reported, “I guess I had very little hope at one point and . . . just talking to the group and sharing ideas and sharing experiences, just kinda built some of that hope back up.” Chelsea explained, “It was really helpful just to get up and go and do these things. It made it seem much easier to do, like it was, ‘Oh, it’s not that hard, I can actually do this again.’ ” From 30% to 40% of the participants stated that the program facilitated healthy lifestyle changes; reduced self-stigma, with greater acceptance of their mental illness; and improved self-awareness. Participants described program elements they valued and how these contributed to their gains. Most participants valued the relationships they had with each other and with the staff, engaging in program activities, the positive atmosphere (fun, relaxing, voluntary, and safe), and the structure provided by the program. Hopefulness was ascribed to having peer role models to identify with, having meaningful relationships with others in the program, and having fun again. Natasha explained, “It really helped to have someone who had already gone through [psychotic illness] to tell you that it’s going to be okay. . . [and] give you ideas or heads up on what’s good.” The growth in self-confidence was attributed to doing activities that developed participants’ sense of mastery. Increased motivation was credited to the voluntary nature of the program and to witnessing the accomplishments of peers. Despite the perceived success of the program, resources needed to employ a permanent recreation therapist and provide transportation assistance (a factor in our high attendance rate) are barriers to incorporating the program into the regular services of our Early Psychosis Program. The participants reported that the program was too short, ending just as they had developed a sense of community with their peers and felt motivated to make lifestyle changes. Offering a less resource-dependent peer support group and lifestyle counseling with their primary clinicians postgroup may address this concern. The results of the pilot study of the wellness program suggest that recreation therapy, peer support, and training mental health professionals in motivational interviewing would be worthwhile interventions to augment mental health services for people with psychosis. Zenovia Ursuliak, M.D., Ph.D. Heather Milliken, M.D., C.M. Neal Morgan, M.B., B.Ch. Dr. Ursuliak and Dr. Milliken are with the Nova Scotia Early Psychosis Program, Capital District Health Authority, Halifax, Nova Scotia, Canada, and the Department of Psychiatry, Dalhousie University, Halifax (e-mail: zenovia. [email protected]). Dr. Morgan is with the South Shore District Health Authority, Bridgewater, Nova Scotia. Psychiatric Services 2015; 66:105; doi: 10.1176/appi.ps.660103
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Frontline Reports The Frontline Reports column features short descriptions of novel approaches to mental health problems or creative applications of established concepts in different settings. Material submitted for the column should be 350 to 750 words long, with a maximum of three authors (one is preferred) and no references, tables, or figures. Send material to Francine Cournos, M.D., at the New York State Psychiatric Institute ([email protected]) or to Stephen M. Goldfinger, M.D., at SUNY Downstate Medical Center (smgoldfi[email protected]).
Healthy Minds: Promoting Mental Health for At-Risk Youths Urban youths in underserved communities are disproportionately faced with increased stressors, including violent neighborhoods, substance abuse, poverty, lack of support, and limited resources. They also have increased risk of entry into the juvenile justice system. This study aimed to create a cost-effective and reproducible program that promotes the mental health of at-risk youths from racial-ethnic minority groups in underserved communities. The study received institutional review board approval by the University of Pittsburgh and was conducted at University Preparatory Middle School in Pittsburgh’s Hill District and funded by an American Psychiatric Foundation Helping Hands Grant. We recruited 13 medical student volunteers (six women and seven men, with ten identifying as African American and three as Caucasian) by making the Healthy Minds program an approved community service site for curriculum credit offered by the University of Pittsburgh School of Medicine via the school’s Student National Medical Association chapter. Each volunteer attended a one-hour training session led by a community expert on one of four topics: stress management and ways to cope with trauma, family planning and sex education, body image and dealing with depression, and professional development. These experts were doctors, nurses, or social workers who volunteered their time. The Healthy Minds program was offered as an elective during The Zone! after-school program at University Prep in 2012. Two to three medical student volunteers led each interactive workshop delivered in a two-part series, given a month apart. The Healthy Minds curriculum was written by the student coinvestigators with input from community professionals. Recruited middle school students participated in eight weekly one-hour sessions. Healthy snacks were provided. Program participation was voluntary. Students were offered a $30 gift card and school supplies upon completion of the program. Twelve students initially enrolled in the Healthy Minds program. Seven students received parental consent to participate, and one female dropped out at week 2 because of behavioral problems at school. 104
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Data were collected on the sex, age, grade, and race-ethnicity of each child. Four of the six participants were male. Average student age was 13 years. All student participants were African American. A sign-in sheet was used to track weekly attendance. Pretest and posttest assessments based on the lesson plans from each workshop were used to evaluate knowledge retention. Program satisfaction surveys developed by coinvestigators revealed an average student satisfaction rating of 9.2 out of 10 points, indicating strong satisfaction. Students’ self-esteem was measured with the Rosenberg Self-Esteem Scale (range 0–30, with scores ,15 indicating low self-esteem) administered at the beginning of week 5 and the end of week 8 of programming. Results showed an average 7-point increase and progression from low to normal self-esteem scores for two out of six students in a one-month time frame. When participants were asked to indicate the best part of the program, the most common responses were “the activities” and “[It] teaches us new things that we did not know.” These responses suggest that an interactive teaching style is more effective than a traditional lecture style. Prior research has found that the racial-ethnic match of health care providers and clients is one of three culture-compatibility components that best predict retention in mental health services. A majority of medical student volunteers and all student participants in this study were African American. Future studies should evaluate the effect of volunteers’ race-ethnicity on satisfaction rates. In a health care system with shrinking resources, affordable community primary prevention programs are needed to promote overall mental health. Underserved youths from racial-ethnic minorities are at increased risk of mental health dysfunction and of entering the juvenile justice system. The average cost for a child in the Pennsylvania juvenile justice system is approximately $360 per day, plus an additional $50 per day for youths with mental illnesses. In comparison, the average cost per child for this school-based mental health program was approximately $60 per day. The primary goal of the Healthy Minds program is to empower adolescents to make positive life changes. Our objectives were to address factors contributing to the prevalence of mental health issues, teach coping mechanisms for stressful life situations, and expose youths to positive student Psychiatric Services 66:1, January 2015
FRONTLINE REPORTS
role models. Although conclusions are limited by a small sample size, this Healthy Minds pilot project may serve as a blueprint for a sustainable, affordable community health program led by students. A larger study is required to more accurately assess program effectiveness. Judy-April N. Oparaji, R.D. Enyinna L. Nwachuku, B.S. Jason M. Rosenstock, M.D. Ms. Oparaji and Mr. Nwachuku are medical students at the University of Pittsburgh School of Medicine (e-mail: [email protected]). Dr. Rosenstock is with the Department of Psychiatry, University of Pittsburgh Medical Center. Psychiatric Services 2015; 66:104–105; doi: 10.1176/appi.ps.651008
Wellness Program for People With Early Psychosis: Promoting Skills and Attitudes for Recovery Antipsychotic medication can improve symptoms for people with psychotic disorders, but this treatment does not consistently translate into improved psychosocial outcomes for people with early psychosis. In 2005, the Nova Scotia Early Psychosis Program held focus groups to ask patients what would help them recover. The patients said they wanted opportunities to do fun, recreational activities together and learn how to lead healthier lives. To address the outcomes of the focus groups, the Nova Scotia Early Psychosis Program created a wellness program, a 12-week, group-based program to promote healthy lifestyles through experiential education. The twice-weekly program included four healthy eating sessions, 22 recreation sessions, four stress management sessions, and six group therapy sessions. The Healthy Eating sessions integrated nutritional information and menu planning on a budget with sampling new foods, preparing meals, and shopping at a grocery store. The recreation sessions included education about physical fitness and navigating community resources with activities aligned with youth culture, progressing from hospital based to community based. The stress management sessions combined discussion about the stress response with participation in stress reduction practices such as meditation and yoga. Group therapy incorporated aspects of cognitive-behavioral therapy, motivational interviewing (MI), and peer support. A psychiatrist, a recreation therapist, and a peer motivator facilitated the program. The peer motivator was a recovered, young adult with psychosis who played a key role by representing participants’ perspective in the planning stages of the program, providing positive role modeling, and facilitating peer support. The facilitators were trained in MI, a conversation style that strengthens a person’s own motivation for change within a collaborative, accepting relationship. The program was piloted in a study with three cohorts from 2006 to 2007. Thirteen of 25 participants completed the study (52%), with the majority of dropouts happening prior to the program start or right after the first session. Participants who completed the study had an average attendance rate of 83% and demonstrated improvements in leisure functioning.
Psychiatric Services 66:1, January 2015
The leisure skills of community participation and integration improved from levels where they required assistance through verbal cueing to being functionally independent. Exit interviews with participants revealed other benefits of the program. A majority (80%290%) thought the program improved hope, self-confidence, and motivation—attitudes that are essential to the recovery process. Kevin reported, “I guess I had very little hope at one point and . . . just talking to the group and sharing ideas and sharing experiences, just kinda built some of that hope back up.” Chelsea explained, “It was really helpful just to get up and go and do these things. It made it seem much easier to do, like it was, ‘Oh, it’s not that hard, I can actually do this again.’ ” From 30% to 40% of the participants stated that the program facilitated healthy lifestyle changes; reduced self-stigma, with greater acceptance of their mental illness; and improved self-awareness. Participants described program elements they valued and how these contributed to their gains. Most participants valued the relationships they had with each other and with the staff, engaging in program activities, the positive atmosphere (fun, relaxing, voluntary, and safe), and the structure provided by the program. Hopefulness was ascribed to having peer role models to identify with, having meaningful relationships with others in the program, and having fun again. Natasha explained, “It really helped to have someone who had already gone through [psychotic illness] to tell you that it’s going to be okay. . . [and] give you ideas or heads up on what’s good.” The growth in self-confidence was attributed to doing activities that developed participants’ sense of mastery. Increased motivation was credited to the voluntary nature of the program and to witnessing the accomplishments of peers. Despite the perceived success of the program, resources needed to employ a permanent recreation therapist and provide transportation assistance (a factor in our high attendance rate) are barriers to incorporating the program into the regular services of our Early Psychosis Program. The participants reported that the program was too short, ending just as they had developed a sense of community with their peers and felt motivated to make lifestyle changes. Offering a less resource-dependent peer support group and lifestyle counseling with their primary clinicians postgroup may address this concern. The results of the pilot study of the wellness program suggest that recreation therapy, peer support, and training mental health professionals in motivational interviewing would be worthwhile interventions to augment mental health services for people with psychosis. Zenovia Ursuliak, M.D., Ph.D. Heather Milliken, M.D., C.M. Neal Morgan, M.B., B.Ch. Dr. Ursuliak and Dr. Milliken are with the Nova Scotia Early Psychosis Program, Capital District Health Authority, Halifax, Nova Scotia, Canada, and the Department of Psychiatry, Dalhousie University, Halifax (e-mail: zenovia. [email protected]). Dr. Morgan is with the South Shore District Health Authority, Bridgewater, Nova Scotia. Psychiatric Services 2015; 66:105; doi: 10.1176/appi.ps.660103
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105
