BackgroundIndividuals with severe mental illness (e.g., schizophrenia, bipolar disorder) die 10–25 years earlier than the general population, primarily from premature cardiovascular disease (CVD). Contributing factors are complex, but include systemic-related factors of poorly integrated primary care and mental health services. Although evidence-based models exist for integrating mental health care into primary care settings, the evidence base for integrating medical care into specialty mental health settings is limited. Such models are referred to as “reverse” integration. In this paper, we describe the application of an implementation science framework in designing a model to improve CVD outcomes for individuals with severe mental illness (SMI) who receive services in a community mental health setting.MethodsUsing principles from the theory of planned behavior, focus groups were conducted to understand stakeholder perspectives of barriers to CVD risk factor screening and treatment identify potential target behaviors. We then applied results to the overarching Behavior Change Wheel framework, a systematic and theory-driven approach that incorporates the COM-B model (capability, opportunity, motivation, and behavior), to build an intervention to improve CVD risk factor screening and treatment for people with SMI.ResultsFollowing a stepped approach from the Behavior Change Wheel framework, a model to deliver primary preventive care for people that use community mental health settings as their de facto health home was developed. The CRANIUM (cardiometabolic risk assessment and treatment through a novel integration model for underserved populations with mental illness) model focuses on engaging community psychiatrists to expand their scope of practice to become responsible for CVD risk, with significant clinical decision support.ConclusionThe CRANIUM model was designed by integrating behavioral change theory and implementation theory. CRANIUM is feasible to implement, is highly acceptable to, and targets provider behavior change, and is replicable and efficient for helping to integrate primary preventive care services in community mental health settings. CRANIUM can be scaled up to increase CVD preventive care delivery and ultimately improve health outcomes among people with SMI served within a public mental health care system.

Objective To test the hypothesis that Problem Solving Therapy (PST) is more effective than Supportive Therapy (ST) in reducing suicidal ideation in older adults with major depression and executive dysfunction. We further explored whether patient characteristics, such as age, gender and additional cognitive impairment load (eg: memory impairments) were related to changes in suicidal ideation over time. Design Secondary data analysis using data from a randomized clinical trial allocating participants to PST or ST at 1:1 ratio. Raters were blind to patients' assignments. Setting University medical centers. Participants 221 people aged 65 years old and older with major depression determined by SCID diagnosis and executive dysfunction as defined by a score of 33 or less on the Initiation-Perseveration Score of the Mattis Dementia Rating Scale or Stroop Interference Task score of 25 or less. Interventions 12 weekly sessions of Problem Solving Therapy or Supportive Therapy. Main Outcome Measures The suicide item of the Hamilton Depression Rating Scale (HDRS). Results Of the 221 participants, 61% reported suicidal ideation (SI). The ST group had a lower rate of improvement in SI after 12 weeks (44.6%) than did the PST group (60.4%, Fisher's exact test p = 0.031). Logistic regression showed significantly greater reductions in SI in elders who received PST at both 12 weeks (OR = .50, Z=-2.16, p = 0.031) and 36 weeks (OR=0.5, Z=-1.96, p=0.05) after treatment. Conclusion PST is a promising intervention for older adults who are at risk for suicide.

Despite the tremendous growth of the peer specialist workforce in recent decades, significant ethical, political, and procedural challenges remain regarding recruitment and retention of peer staff. This column explores such challenges and potential pitfalls by examining the limits of current accommodation practices, the complexity of "shared identities," and the fraught interplay of disability,