In an effort to increase access to care, the US Department of Veterans Affairs (VA) has created 2 additional pathways for veterans to receive mental health (MH) services: regional VA Clinical Resource Hubs (CRHs) and VA-purchased community care (CC). Previous studies have found that veterans rate their satisfaction with VA MH care, including via CRHs, higher than CC. It is unclear whether increased CRH use decreases referrals to CC.

To determine whether clinics with higher CRH utilization have fewer CC referrals or, alternatively, whether clinics with local care shortages rely on both CRH and CC at similar levels to ensure adequate access to MH care.

This longitudinal cohort study included all veterans with at least 1 outpatient MH encounter between 2018 and 2019 in 1149 MH clinics within the VA. The study evaluated changes in CC referral rates at clinics with and without CRH visits between baseline and post-CRH implementation (October 1, 2017, through September 30, 2023). In addition, CC referral rates at clinics with higher use of CRH were compared with clinics with lower CRH utilization. Data were analyzed from August 20, 2024, to July 25, 2025.

Clinics were classified based on whether they had any CRH utilization, as well as whether their per-patient rate of CRH visits fell in the top 25% (high penetration) or bottom 25% (low penetration).

The main outcome was the number of CC referrals per 1000 patients. Difference-in-differences (DID) analyses were used.

The sample included 1 120 250 patients (mean [SD] age, 60.04 [15.38] years; 15.99% female). Clinics with any CRH utilization showed a slight but statistically significant increase in CC referrals in the post-CRH implementation period compared with clinics with no CRH utilization (DID, 0.525; 95% CI, 0.181-0.868; P = .003). However, clinics with high penetration of CRH had fewer CC referrals per month compared with low-penetration clinics at the end of the CRH implementation period (DID, -20.00 referrals; 95% CI, -21.90 to -18.20; P < .001).

In this cohort study of VA MH clinics, successful CRH implementation was associated with fewer CC referrals, suggesting that clinics with higher CRH utilization were less reliant on VA-purchased CC. Results underscore the importance of developing strong CRH infrastructures to ensure veteran access to high-quality MH care.

Suicide rates are high among individuals with schizophrenia spectrum disorders (SSDs) and community mental health (CMH) settings have potential to play a critical role in suicide prevention efforts. Crisis lines, such as the 988 Lifeline, are found to positively impact mental health and suicide outcomes, yet data show utilization rates are low among high-risk individuals, such as those with SSDs. This qualitative study employs community-engaged methods to modify a brief single-session Crisis Line Facilitation (CLF) intervention for individuals with SSDs in CMH to increase the likelihood of engagement with the 988 Lifeline and reduce suicide outcomes. Participants (n = 10) included consumers with SSD diagnosis, mental health providers, peer support specialists, and leadership in CMH. Data were collected in qualitative interviews to learn about perceptions of CLF, barriers and facilitators of CLF implementation, and suggested modifications to CLF for SSD tailoring. Interview questions were informed by the Consolidated Framework for Implementation Research and a hybrid analytic approach with inductive and deductive coding was used to identify themes and subsequent modifications. Themes pertained to the need for CLF in CMH, help-seeking and psychosis symptoms as implementation barriers, and provider preparation and CMH awareness as implementation facilitators. Modifications and study implications signal the importance of provider training, proactively addressing consumer help-seeking barriers, and embedding CLF within routine CMH workflows for sustainability. Study efforts emphasize CLF's potential to prepare SSD consumers for suicide crises, motivate future 988 engagement, and prevent premature suicide death.

This narrative review synthesizes current knowledge on emotional support (ES) in the context of illness. Based on 78 empirical and theoretical studies across psychology, health, and caregiving, it examines diverse populations facing various illnesses (chronic/acute conditions, mental disorders). First, the definitions, characteristics, and theoretical underpinnings of ES are examined, highlighting its heterogeneity and conceptual fragmentation in the literature. The impacts of ES are then explored, including its beneficial effects on patients' well-being and the emotional cost for caregivers. A novel conceptual model is subsequently proposed that accounts for the bidirectional nature of ES and integrates key components such as emotional availability, recognition, relational balance, and expectations. This model is the first to conceptualize ES specifically within illness contexts, emphasizing its reciprocal dynamics between the patient and the relative. It aims to guide future empirical studies and inform clinical practice by clarifying how ES is perceived, provided, and experienced.

Men with presentations consistent with borderline personality disorder (BPD) and antisocial personality disorder (ASPD) are highly visible in community and forensic services. However, mis/underdiagnosis may be a consequence of their lower than expected engagement with mental health services, and when they do engage, systematised diagnostic biases may inaccurately differentiate these two subtypes. Given the substantial harms experienced by men who have personality disorder (PD), it is important to understand how personality disorder can be better identified and supported in clinical and forensic settings.

Ten nationally and internationally recognised clinician participants who have expertise in the diagnosis and treatment of men with PD (80% male; 60% psychologists, 40% psychiatrists) participated in individual, semi-structured qualitative interviews. Participants shared their observations regarding PD presentations in men and recommendations for maximising treatment engagement in community and forensic settings. Transcripts from the 60-90-min interviews were analysed using inductive and deductive thematic analysis.

The analysis identified four themes: Getting men through the door, Unmasking Complexity, Holding Steady in the Face of Risk, and Addressing Shame through Connection. Men with BPD tend to under-report their symptoms and distrust mental health services. Clinicians may struggle to differentiate BPD from ASPD, as men's emotional dysregulation often manifests as anger. Participants emphasised appealing to the person's self-interest, building a trusting therapeutic alliance, and carefully addressing shame to facilitate treatment engagement.

Half of the expert clinicians were employed in forensic settings where men with BPD are disproportionately prevalent, rendering their perspectives especially valuable. Assessment of empathetic functioning can help counterbalance clinicians' overemphasis on aggressive behaviours when differentiating BPD from ASPD in men. Incorporation of gendered attributes and targeting associated defensive barriers may improve treatment engagement and effectiveness for men with personality disorder.

Tailored implementation strategies are frequently recommended to improve healthcare professional practice. Tailoring involves the selection and design of strategies to address context-specific barriers (referred to as determinants of practice) to best practice recommended in clinical guidelines. Improvements in practice are thought to be more likely if implementation strategies are selected to address identified practice determinants. This is an update of a review published in 2015.

To assess the effect of tailored implementation strategies, compared with a non-tailored strategy or no strategy, in improving healthcare professional practice. Secondary objectives were to assess whether the effects of tailored implementation strategies differ according to whether theory, evidence of the effectiveness of strategies, and input from stakeholders were involved in the tailoring process, and to assess whether the effects of tailored implementation strategies differ according to setting (high- or low-income country).

We searched CENTRAL, MEDLINE, Embase, two other databases and two trials registers from 2014 to 5 March 2024. We performed a forward citation search for papers citing the previous update. We did not apply any restrictions on date of publication, publication status or language.

We included randomised controlled trials (RCTs), including cluster-RCTs, that compared tailored implementation strategies with strategies not tailored to address determinants of health professional practice, or no strategy. We excluded studies of tailored strategies targeting behaviour change among patients only.

The primary outcome was healthcare professional practice assessed using measures of adherence to recommended practices or guidelines in a healthcare setting.

We used the Cochrane risk of bias tool version 2 (RoB 2) to assess risk of bias in the studies.

Review authors (working in pairs) screened all citations, extracted data, and assessed risk of bias independently and in duplicate. A third review author resolved disagreements. We performed meta-analyses using random-effects models for the primary outcome using the most conservative estimate of effect where multiple outcomes were reported. We also performed meta-analyses using the least conservative estimate in sensitivity analysis. Where data were unsuitable for pooling in meta-analyses, we conducted a narrative synthesis using a vote-counting approach. We assessed heterogeneity using the I² statistic and the certainty of the evidence for the main comparison using GRADE.

The previous version of this review included 32 studies. In this update, we excluded five of those studies as they no longer met the review's eligibility criteria; they did not meet the definition of tailoring or focused on patient outcomes only. We added 52 new studies (including two from trials registers), bringing the total number of included studies to 79. Participant numbers were available for 41 of these studies (n = 25,630); participant counts were not reported or were unclear in the other 38 studies.

Overall, 35 studies with a total of 5015 healthcare professionals examined the effect of a tailored implementation strategy on professional practice compared to a non-tailored strategy. In total, 44 studies with a total of 20,615 healthcare professionals examined the effect of a tailored strategy on professional practice compared to no strategy. We judged 41 of the 45 studies included in the meta-analysis as free from high risks of bias across all domains. Bias in the measurement of the outcome was the most common domain judged at high risk of bias among the remaining studies. Overall, the certainty of the evidence in the main comparison (tailored vs non-tailored) was moderate, reflecting visual inconsistency and high heterogeneity between study results. We found that tailored implementation strategies probably lead to a slight improvement in professional practice compared with non-tailored strategies (odds ratio (OR) 1.49, 95% confidence interval (CI) 1.26 to 1.75; 23 studies, 2600 participants, moderate-certainty evidence). An OR greater than 1 indicates a small improvement in professional practice compared with no strategy. Some studies included effect measures for more than one outcome. Sensitivity analysis pooling the least conservative effect measures that were reported showed an OR of 1.74 (95% CI 1.3 to 2.24. For tailored implementation strategies compared with no strategy, we report a pooled OR of 1.34 (95% CI 1.17 to 1.53; 24 studies, 8250 participants). Some studies included effect measures for more than one outcome. Sensitivity analysis pooling the least conservative effect measures that were reported showed an OR of 1.51 (95% CI 1.28 to 1.79; P < 0.0001).

Despite the increase in the number of new studies identified, our overall finding is like that of the previous review. Tailored implementation strategies probably result in a slight improvement in professional practice.

Dr Sheena McHugh received funding from the Irish Health Research Board (HRB-RL-2020-004) that helped to support the conduct of this review.

Registration: Zenodo, 7104299, via DOI: 10.5281/zenodo.7104299 Protocol available via DOI: https://doi.org/10.5281/zenodo.7104299 Previous versions available via: DOI: 10.1002/14651858.CD005470.pub3, DOI: 10.1002/14651858.CD005470.pub2, and DOI: 10.1002/14651858.CD005470.

Chronic obstructive pulmonary disease (COPD) is a growing global public health concern, not only due to its physical effects but also because of the significant psychological distress it causes, including anxiety and depression. This perspective stresses the importance of addressing mental health issues in the management of COPD, discussing current treatment options, which include non-pharmacological interventions.

This perspective synthesizes current literature on psychological distress in COPD and reviews evidence for non-pharmacological approaches, including pulmonary rehabilitation, cognitive behavioral therapy, self-management programs, telerehabilitation, education, and peer support. It draws on recent literature and guidelines to identify gaps and opportunities for integrated care.

Individuals with COPD experience substantially higher rates of anxiety and depression compared to the general population, and this can negatively impact quality of life, disease progression, and healthcare outcomes. Despite this, mental health symptoms often remain undiagnosed and untreated due to limited awareness, training, and resources. Psychological and non-pharmacological interventions reveal encouraging results in reducing distress and improving overall well-being. Pulmonary rehabilitation, combined with psychological support, demonstrates particular benefits but is underutilized due to patient and systemic barriers. Alternative approaches such as telerehabilitation and remote therapies offer potential for increased access. Moreover, education and peer support play a crucial role in empowering patients, improving coping skills, and fostering social connectedness, which contribute positively to psychological well-being. This perspective advocates for integrated COPD management, which prioritizes mental health literacy, collaborative care models, and patient engagement.

Addressing both the physical and psychological aspects of COPD is essential for holistic care and enhancing the quality of life of individuals with COPD. Further research and healthcare policy efforts are needed to close existing gaps and deliver comprehensive support for people living with COPD.

Background Displaced populations have increased rates of mental health problems, which have been shown to have a bidirectional relationship with economic insecurity. Despite growing calls globally to integrate mental health and psychosocial support (MHPSS) with economic inclusion (EI) programming, few models exist for practical implementation. We co-developed and piloted the Building the Future Toolkit (i.e., the Toolkit), an integrated MHPSS-EI intervention for displaced families in Ecuador, a country that hosts a large number of displaced persons. Here, we present participant and implementer perspectives on the barriers and facilitators to implementation of the Toolkit . Methods Fifty displaced families in Quito participated in a pilot trial of the Toolkit between October 2023 and May 2024. Following completion of the trial, we conducted six focus group discussions (n=31; 22 intervention participants, 9 staff) to explore determinants of implementation outcomes, guided by Proctor's Implementation Outcomes Framework and the Consolidated Framework for Implementation Research 2.0. Data were analyzed thematically using a hybrid inductive-deductive approach. Results Both intervention participants and staff viewed the Toolkit as highly acceptable, appropriate, feasible, and usable, with strong potential for sustainability. Key facilitators included the holistic integration of mental health and livelihood skills, enhanced social network building among displaced families, the Toolkit's standardized yet adaptable structure, and alignment with organizational values and existing activities. Barriers included competing economic demands, childcare responsibilities, transportation costs, limited participation of men and youth, and challenges related to donor reporting indicators. Contextual disruptions-such as Ecuador's 2024 insecurity and energy crisis-posed additional challenges but also demonstrated the Toolkit's adaptability in unstable environments. Conclusions The Building the Future Toolkit illustrates how integrated MHPSS-EI programming can be designed and implemented in humanitarian contexts through participatory methods. Our findings highlight the multilevel determinants supporting successful implementation and promoting sustainability. Future integrated program efforts should address structural participation barriers, develop strategies to target engagement of men and youth, and work with funding institutions to create indicators that recognize the interdependence of mental health and livelihoods.

The COVID-19 pandemic has placed an unprecedented psychological and emotional burden on paediatric nurses, who have faced increased workload, increased stress, and burnout. Developing strategies to strengthen the mental resilience and well-being of healthcare professionals has become imperative. Dance, specifically Greek traditional dance (GTD), is a culturally embedded activity with proven benefits on physical, psychological, and social health.

This study aimed to assess the impact of a GTD training program on the psycho-emotional well-being of paediatric nurses during the COVID-19 pandemic.

A quasi-experimental study was conducted with a sample of 199 volunteer paediatric nurses, employed in the largest paediatric hospital in Athens, Greece. The participants were divided into an intervention group (Group A) (n=89; 44.7%), who attended 16 training sessions (two sessions per week for two months, lasting 45 minutes each), and a control group (Group B) (n=110; 55.3%), without intervention. Psycho-emotional status was assessed before and after the intervention using the following tools: Positive and Negative Affect Scale (PANAS), Psychological Well-Being Scales-Short Scales (PWBS), Life Satisfaction Scale (SWLS), and Life Orientation Test-Revised (LOT-R). Data analysis was performed with IBM SPSS Statistics for Windows, Version 26.0 (IBM Corp., Armonk, New York, United States), using Cronbach's alpha for reliability, t-test, ANOVA, and non-parametric correlations.

Most participants were women (96% in Group A and 92% in Group B). After completing the program, nurses in the traditional dance group showed significantly greater improvements in positive affect compared to the control group (M±SD=3.89±0.45) and a decrease in negative emotions (M±SD=1.65±0.47) compared to Group B (M±SD=1.94±0.63). At the same time, improvements were recorded in life satisfaction (M±SD=5.30±0.89), optimism (M±SD=3.02±0.72), and relaxation (M±SD=2.48±0.91). The greatest benefits were found in nurses working in wards with paediatric patients positive for COVID-19, who showed an improvement in both positive emotions and a reduction in negative ones, as well as in indicators of friendship and life satisfaction.

Participation in a standardized eight-week GTD program improved the psycho-emotional well-being of paediatric nurses during the COVID-19 pandemic. The results highlight the value of culturally relevant, group-based interventions in promoting the resilience and quality of life of healthcare professionals.

Despite high dialysis prevalence, access to kidney transplant waitlisting remains limited, with persistent socioeconomic and racial disparities. Prior studies have not captured patients evaluated but not listed for transplantation. During the COVID-19 pandemic, telemedicine-based evaluations may have further widened these gaps. We examined transplant evaluation and waitlisting before and during the pandemic at a large urban transplant center.

We hypothesized that the COVID-19 pandemic would adversely affect access to listing for kidney transplant (KT) for transplant candidates from minority ethnic groups. We evaluated differences in listing for kidney transplant between pre- and peri-pandemic eras, in-person (IPE) and telemedicine (TME) evaluations, and associations with race/ethnicity and other socioeconomic factors.

A retrospective chart review of 1061 KT evaluations included pre-pandemic (March 13, 2019, to March 13, 2020) and peri-pandemic (March 14, 2020, to March 14, 2021) eras. Categorical data are presented as proportions and frequencies, and continuous data as means ± standard deviation or medians ± interquartile range. Independent group t-tests and Fisher's exact tests were used for bivariate comparisons.

A total of 629 (59%) candidate evaluations were pre-pandemic, and 430 (41%) were peri-pandemic. Of these, 734 (72%) were IPE and 288 (28%) were TME. Overall, 553 (54%) candidates were denied listing for medical (310) and social (184) reasons. Peri-pandemic evaluations (p = 0.002), employment (p < 0.001), TME (p < 0.001), and mental health (p = 0.009) were associated with listing. Positive assessments of social support and overall social work assessment were associated with listing (p = 0.002; p < 0.001). Better social support was associated with listing pre-pandemic (p = 0.001) but not peri-pandemic (p = 0.769). Race/ethnicity (p = 0.951), employment (p = 0.202), and mental health (p = 0.742) were similar pre- and peri-pandemic. Race/ethnicity was not associated with listing (p = 0.809).

Overall, more candidates were listed for KT during the pandemic than before, despite fewer evaluations. This increase was associated with TME but not with race/ethnicity. Employment and mental health were similar in both eras despite pandemic stressors. Denial for social reasons mostly affected minority candidates, which warrants further study.