Site downsizing: a blessing or a curse?

AimsTo measure staff wellbeing and morale, which in 2015 was described by CQC as 'low', following a downsizing of premises.BackgroundIn 2019, due to loss of mental health funding, Camden & Islington NHS Foundation Trust controversially sold the much-loved Queen Anne-style mansion Lyndhurts Gardens. The Rehab & Recovery team caring for those with serious mental illness were relocated to one floor of the much smaller Daleham Gardens. It was hypothesed by the authors that this would impact negatively on the already unhappy workforce.MethodThe same staff wellbeing survey was used as in in 2015 (following CQC's description of 'poor' morale), nearly 5 years on and following the site relocation. All clinical, managerial and administrative staff members were encouraged to participate by posting their survey anonymously in a make-shift postbox. Sweet treats were used to encourage participation within the busy team.ResultQualitative and quantitative data were collected from the team (response rate 44%). Exact tables will be shown but in summary; in the new building there was an increase in the number of staff who felt they could use initiative at work, make improvements at work, looked forward to going into work and felt enthusiastic about their job. Improvement cited were 'increased socials after work' and consequent 'wellbeing', in addition to 'good team atmosphere', 'good team work' and 'good relationships' in the new space. Further ideas were generated for additional improvements going forward.ConclusionWhilst caseloads and workloads are often cited as the cause of burnout, and indeed other changes in the 5 years could act as confounders, the design of work buildings is not to be underestimated. Contrary to what the authors had suspected, 'bigger' was not necessarily 'better' and a more condensed working environment made for greater togetherness amongst the team. In this age where economically desperate NHS trusts are forced to sell off their prized assets, observations that this is not always at the detriment of staff morale will provide some cause for optimism.

Doing More With Less: A Survey of Economic Precarity, Financial Strain, Burnout, and Secondary Traumatic Stress in Philadelphia’s Public Mental Health System

Background: Efforts to increase the implementation of evidence-based interventions come at a time of rising inequality and cuts to public mental health funding. Clinicians in publicly funded mental health clinics face increased demands, work long hours, experience financial stress, and treat clinically severe, under-resourced patients. A detailed understanding of clinicians' economic precarity, financial strain, and job-related stressors, and an understanding of how these factors relate to treatment delivery, is needed. Methods: In July 2020, we surveyed 49 clinicians working in Philadelphia’s public mental health system who participated in a large-scale trauma-focused cognitive behavioral therapy (TF-CBT) training initiative. Respondents reported on professional burnout, economic precarity, financial strain, secondary traumatic stress, and self-reported use of TF-CBT. We examined associations between clinicians’ economic precarity, job-related stressors, and their TF-CBT use with mixed models. We used content coding to organize open-ended responses into themes.Results: Economic precarity, financial strain, burnout, and secondary traumatic stress among respondents was high. Thirty-seven percent of clinicians were independent contractors, and of those, 44% reported desiring a salaried position. Most clinicians (76%) had outstanding education loans, and of those, 38% reported over $100,000 in education debt. In the last year, 29% of clinicians went without personal mental healthcare due to cost. Most clinicians (73%) endorsed at least one symptom of secondary traumatic stress, with 22% scoring above the clinical cutoff. Education debt was negatively associated with TF-CBT use (p<0.001). Secondary traumatic stress, measured continuously and categorically, was associated with burnout (ps<0.05).Discussion: Clinicians in Philadelphia’s public mental health system experience burnout, economic precarity, financial strain, and secondary traumatic stress, which were associated with TF-CBT use. The economic strain and stress of providing care in under-resourced clinical settings may interfere with ongoing efforts to integrate scientific evidence into mental health services. Financial investment in the mental health workforce is essential.

Barriers and drivers to stakeholder engagement in global mental health projects

Background Engagement with diverse stakeholders, including policy makers, care providers and service users and communities, is essential for successful implementation of global mental health interventions. Despite being a fundamental factor in the implementation process, evidence about challenges and drivers to stakeholder engagement is limited in the global mental health literature. Methods We conducted semi-structured qualitative interviews with 29 recipients of Grand Challenges Canada Global Mental Health funding to assess barriers and drivers to global mental health implementation across a portfolio of projects. We used framework analysis to identify key themes related to implementation barriers and drivers. This paper reports on barriers and drivers to stakeholder engagement, with results related to capacity development and service delivery reported elsewhere in this journal. Results Barriers and drivers to stakeholder engagement were identified across four themes: (1) Contextual Considerations, (2) Resources, (3) Participation, Uptake and Empowerment, and (4) Stigma. While complex contextual challenges create barriers, mechanisms such as formative research can facilitate a deeper contextual understanding that supports effective implementation planning. Limited financial and human resources and competing priorities can lead to substantial challenges. Investing in and leveraging existing local resources and expertise can help to mitigate these barriers. The challenge of achieving active participation from stakeholders and diverging expectations about the nature of participation were identified as barriers, while providing opportunities for meaningful participation and empowerment acted as drivers. Stigma at the institutional, community and individual level was also identified as a substantial barrier to engagement. Conclusion The findings of this study are relevant to implementers in global mental health. They also have implications for global mental health funding agencies and policy organizations, who can support improved stakeholder engagement by investing in high-quality formative research, supporting capacity building for policy engagement, investing in longer-term funding schemes to support sustainable partnerships and scale-up, thus fostering successful engagement and supporting effective implementation of global mental health innovations.

Lessons from a theory of change-driven evaluation of a global mental health funding portfolio

Background Given the underinvestment in global mental health to-date, it is important to consider how best to maximize the impact of existing investments. Theory of Change (ToC) is increasingly attracting the interest of funders seeking to evaluate their own impact. This is one of four papers investigating Grand Challenges Canada’s (GCC’s) first global mental health research funding portfolio (2012–2016) using a ToC-driven approach. Methods A portfolio-level ToC map was developed through a collaborative process involving GCC grantees and other key stakeholders. Proposed ToC indicators were harmonised with GCC’s pre-existing Results-based Management and Accountability Framework to produce a “Core Metrics Framework” of 23 indicators linked to 17 outcomes of the ToC map. For each indicator relevant to their project, the grantee was asked to set a target prior to the start of implementation, then report results at six-month intervals. We used the latest available dataset from all 56 projects in GCC’s global mental health funding portfolio to produce a descriptive analysis of projects’ characteristics and outcomes related to delivery. Results 12,999 people were trained to provide services, the majority of whom were lay or other non-specialist health workers. Most projects exceeded their training targets for capacity-building, except for those training lay health workers. Of the 321,933 people screened by GCC-funded projects, 162,915 received treatment. Most projects focused on more than one disorder and exceeded all their targets for screening, diagnosis and treatment. Fewer people than intended were screened for common mental disorders and epilepsy (60% and 54%, respectively), but many more were diagnosed and treated than originally proposed (148% and 174%, respectively). In contrast, the three projects that focused on perinatal depression exceeded screening and diagnosis targets, but only treated 43% of their intended target. Conclusions Under- or over-achievement of targets may reflect operational challenges such as high staff turnover, or challenges in setting appropriate targets, for example due to insufficient epidemiological evidence. Differences in delivery outcomes when disaggregated by disorder suggest that these challenges are not universal. We caution implementers, funders and evaluators from taking a one-size-fits all approach and make several recommendations for how to facilitate more in-depth, multi-method evaluation of impact using portfolio-level ToC.

Social Processes in Late-Life Suicide

Suicide is the tenth leading cause of death in the United States, and social isolation – either real or perceived – is one of the primary risk factors for a suicidal attempt (Calati et al.,2019). Late adulthood is characterized by both rapid increases in both social isolation (Cornwell,2011) and loneliness (i.e., perceived social isolation; Hawkley, Wroblewski, Kaiser, Luhmann, & Schumm,2019), which enhance risk of mental disorders (Santini et al.,2020), as well as by suicide rates that are higher than in any other age group (SAMSHA,2017). What are the mechanisms by which social isolation confers risk (and social connection confers resilience) to suicidal thoughts and behaviors in aging, and what promising interventions exist for addressing social impediments in older adulthood? What barriers exist to providing services to socially isolated older adults contemplating suicide, and what are the public health implications of social isolation and suicide in late life? This symposium will feature talks on the role of social motivation and empathy in the development of (or resilience to) suicidal ideation in older adults, on interventions that draw upon the Interpersonal Theory of Suicide and utilize social engagement and digital ‘mHealth’ services to reduce late-life social isolation, depression, and suicidal ideation, and on National Institute of Mental Health funding priorities and efforts to address suicide. After attending this session, participants will be able to articulate mechanisms by which social isolation confers risk for suicide in older adulthood and to identify opportunities and obstacles for effective intervention implementation.

Fairness, Justice, and Economical Thinking in Psychotherapy

Despite a robust and growing evidence base to support the effectiveness of psychotherapy in treating mental illness and promoting mental health, funding and access is often limited. Psychotherapy’s claim on a share of individual and social resources must compete, on the one hand, with other mental health services devoted to treating mental illness, and on the other hand, with a variety of social services that promote mental health and human flourishing. This chapter focuses on different theories of justice to consider (a) whether a case might be made for the unique value of psychotherapy amongst other competing services, and (b) if not, what criteria might be relevant in assessing its relative cost and value. The chapter begins by reviewing some relevant concepts of justice and how they might be applicable to allocation of psychotherapy resources, specifically, Rawlsian, capabilities, utilitarian, and communitarian theories. It then discusses how these concepts of justice can be used to navigate research about psychotherapy outcomes as well as its cost-effectiveness. Decisions about which outcomes to consider are not value-neutral and can be guided by relevant theories of justice. The chapter concludes with a brief discussion of lower-income countries.

Barriers and Drivers to Stakeholder Engagement in Global Mental Health Projects

Background: Engagement with diverse stakeholders, including policy makers, care providers and end users, is essential for successful implementation of global mental health interventions. Despite being a fundamental factor in the implementation process, evidence about challenges and drivers to stakeholder engagement is limited in the global mental health literature. Methods: We conducted semi-structured qualitative interviews with n=29 recipients of global Grand Challenges Canada Global Mental Health funding to assess barriers and drivers to global mental health implementation across a portfolio of Grand Challenges Canada-funded projects. We used framework analysis to identify key themes related to implementation barriers and facilitators. This paper reports on barriers and facilitators to stakeholder engagement, with results related to capacity development and service delivery reported elsewhere in this volume. Results: Barriers and drivers to stakeholder engagement were identified across four themes: 1) Contextual Considerations, 2) Resources, 3) Participation, Uptake and Empowerment, and 3) Stigma. While complex contextual challenges create barriers, mechanisms such as formative research can facilitate a deeper contextual understanding that supports effective implementation planning. Limited financial and human resources and competing priorities can lead to substantial challenges. Investing in and leveraging existing local resources and expertise can help to mitigate these barriers. The challenge of achieving active participation from stakeholders and diverging expectations about the nature of participation were identified as barriers, while providing opportunities for meaningful participation and empowerment acted as facilitators. Stigma at the institutional and individual level was also identified as a substantial barrier to engagement. Conclusion: Stakeholder engagement is critical to successful implementation of global mental health interventions, particularly for promoting scale-up and sustainability. The findings of this study are relevant to implementors in global mental health. They also have implications for global mental health funding agencies and policy organizations, who can support improved stakeholder engagement in several ways. Investing in high-quality formative research, supporting capacity building in methods such as integrated knowledge translation and participatory priority-setting, investing in longer-term funding schemes to support sustainable partnerships and scale-up and supporting researchers to build skills in policy engagement would help to foster successful engagement and thus support effective implementation of global mental health innovations.

Lessons From a Theory of Change-driven Evaluation of a Global Mental Health Funding Portfolio

BackgroundGiven the underinvestment in global mental health to-date, it is important to consider how best to maximize the impact of existing investments. Theory of Change (ToC) is increasingly attracting the interest of funders seeking to evaluate their own impact. This is the first of four papers investigating Grand Challenges Canada’s (GCC’s) first global mental health research funding portfolio (2012-2016) using a ToC-driven approach.MethodsA portfolio-level ToC map was developed through a collaborative process involving GCC grantees and other key stakeholders. Proposed ToC indicators were harmonised with GCC’s pre-existing Results-based Management and Accountability Framework to produce a “Core Metrics Framework” of 23 indicators linked to 17 outcomes of the ToC map. For each indicator relevant to their project, the grantee was asked to set a target prior to the start of implementation, then report results at six-month intervals. We used the latest available dataset from all 56 projects in GCC’s global mental health funding portfolio to produce a descriptive analysis of projects’ characteristics and outcomes related to delivery. Results12,999 people were trained to provide services, the majority of whom were lay or other non-specialist health workers. Most projects exceeded their training targets for capacity-building, except for those training lay health workers. Of the 321,933 people screened by GCC-funded projects, 162,915 received treatment. Most projects focused on more than one disorder and exceeded all their targets for screening, diagnosis and treatment. Fewer people than intended were screened for common mental disorders and epilepsy (60% and 54%, respectively), but many more were diagnosed and treated than originally proposed (148% and 174%, respectively). In contrast, the three projects that focused on perinatal depression exceeded screening and diagnosis targets, but only treated 43% of their intended target. ConclusionsUnder- or over-achievement of targets may reflect operational challenges such as high staff turnover, or challenges in setting appropriate targets, for example due to insufficient epidemiological evidence. Differences in delivery outcomes when disaggregated by disorder suggest that these challenges are not universal. We caution implementers, funders and evaluators from taking a one-size-fits all approach and make several recommendations for how to facilitate more in-depth, multi-method evaluation of impact using portfolio-level ToC.

Association among income loss, financial strain and depressive symptoms during COVID-19: evidence from two longitudinal studies

Background. The COVID-19 pandemic has major ramifications for global health and the economy, with growing concerns about economic recession and implications for mental health. Here we investigated the associations between COVID-19 pandemic-related income loss with financial strain and mental health trajectories over a 1-month course. Methods. Two independent studies were conducted in the U.S and in Israel at the beginning of the outbreak (March-April 2020, T1; N = 4 171) and at a 1-month follow-up (T2; N = 1 559). Mixed-effects models were applied to assess associations among COVID-19-related income loss, financial strain, and pandemic-related worries about health, with anxiety and depression, controlling for multiple covariates including pre-COVID-19 income. Findings. In both studies, income loss and financial strain were associated with greater depressive symptoms at T1, above and beyond T1 anxiety, worries about health, and pre-COVID-19 income. Worsening of income loss was associated with exacerbation of depression at T2 in both studies. Worsening of subjective financial strain was associated with exacerbation of depression at T2 in one study (US). Interpretation. Income loss and financial strain were uniquely associated with depressive symptoms and the exacerbation of symptoms over time, above and beyond pandemic-related anxiety. Considering the painful dilemma of lockdown versus reopening, with the tradeoff between public health and economic wellbeing, our findings provide evidence that the economic impact of COVID-19 has negative implications for mental health. Funding. This study was supported by grants from the National Institute of Mental Health, the US-Israel Binational Science Foundation, Foundation Dora and Kirsh Foundation.