From Diversity, Equity, and Inclusion to an Antiracism Strategic Plan: An Academic Department of Psychiatry's Journey.

The efforts of an academic psychiatry department to embark on an antiracism strategic planning process are outlined, including the establishment of an antiracism task force charged with the development of an antiracism strategic plan. The initial process of the task force is described, recommendations are summarized, and future directions are outlined.

Building a Diverse Psychiatric Workforce for the Future and Helping Them Thrive: Recommendations for Psychiatry Training Directors.

The COVID-19 pandemic and murder of Mr George Floyd served as catalysts for examining antiracism efforts in psychiatry training programs and health care systems. Our recruitment and retention of Black, Indigenous, and other racial/ethnic minority psychiatry trainees has not met the demand for care and does not represent the communities served. Training directors at a critical juncture in creating systemic changes to recruitment, retention, policies, and curricular competencies to address ongoing inequities and disparities in health care. We describe several strategies and considerations for training directors in supporting a diverse psychiatric workforce.

Treatment Seeking for Anxiety and Depression Among Black Adults: A Multilevel and Empirically Informed Psycho-Sociocultural Model.

Black adults with anxiety and/or depressive disorders underutilize outpatient psychotherapy and pharmacological treatment compared to White adults. Notably, anxiety and depressive disorders tend to be chronic and Black individuals with these disorders experience greater functional impairment than White individuals. Documented racial disparities in mental health treatment initiation indicate a need for research that addresses culture-specific barriers to treatment. This review paper critically evaluates existing theoretical models of treatment seeking among Black adults to inform a novel integrated, culturally contextualized model. This model extends previous ones by incorporating factors relevant to treatment seeking among Black adults (e.g., racial identity, perceived discrimination, medical mistrust) and critically examines how these factors intersect with key factors at three levels of influence of the treatment seeking process: the individual level, the community level, and the societal level. We posit interactions among factors at the three levels of influence and how these may impact treatment seeking decisions among Black adults. This model informs suggestions for enhancing interventions designed to support outpatient service use among Black adults.

Treatment of Overthinking: A Multidisciplinary Approach to Rumination and Obsession Spectrum.

Classic psychiatry patients are rare; real-world patients tend to have overlapping features of multiple disorders. Striving for diagnostic certainty, and treatments aimed at tentative diagnoses, often fail these patients. In such cases, tolerating diagnostic ambiguity and "treating the symptoms" can sometimes be transformative. An important symptom, often undertreated in a diagnosis-based approach, is rumination. We present a case study of a woman who, after 20 years of treatment failure, achieved significant symptom relief when her primary complaint-"labored thinking"-was targeted specifically. However, because no seriously ill person has only 1 symptom, 6 clinicians from different subdisciplines will discuss the patient's other issues, ones that an overfocus on rumination might leave out.

Building a Diverse Psychiatric Workforce for the Future and Helping Them Thrive: Recommendations for Psychiatry Training Directors.

The COVID-19 pandemic and murder of Mr George Floyd served as catalysts for examining antiracism efforts in psychiatry training programs and health care systems. Our recruitment and retention of Black, Indigenous, and other racial/ethnic minority psychiatry trainees has not met the demand for care and does not represent the communities served. Training directors at a critical juncture in creating systemic changes to recruitment, retention, policies, and curricular competencies to address ongoing inequities and disparities in health care. We describe several strategies and considerations for training directors in supporting a diverse psychiatric workforce.

Trauma-Informed Care for Hospitalized Adolescents.

Purpose of Review: Exposure to trauma accelerates during the adolescence, and due to increased behavioral and psychiatric vulnerability during this developmental period, traumatic events during this time are more likely to cause a lasting impact. In this article, we use three case studies of hospitalized adolescents to illustrate the application of trauma-informed principles of care with this unique population. Recent Findings: Adolescents today are caught in the crosshairs of two syndemics-racism and other structural inequities and the COVID-19 pandemic. Increased hospitalizations and mental health diagnoses during the past two years signal toxic levels of stress affecting this group. Trauma-informed care promotes health, healing, and equity. Summary: This concept of the "trauma-informed approach" is still novel; through examples and practice, providers can learn to universally apply the trauma-informed care framework to every patient encounter to address the harmful effects of trauma and promote recovery and resilience.

Identification and Management of the Consequences of Racism and Discrimination: The Crucial Role of Primary Care Providers.

The Psychiatric Consultation Service at Massachusetts General Hospital sees medical and surgical inpatients with comorbid psychiatric symptoms and conditions. During their twice-weekly rounds, Dr Stern and other members of the Consultation Service discuss diagnosis and management of hospitalized patients with complex medical or surgical problems who also demonstrate psychiatric symptoms or conditions. These discussions have given rise to rounds reports that will prove useful for clinicians practicing at the interface of medicine and psychiatry.

Burn model system national longitudinal database representativeness by race, ethnicity, gender, and age.

INTRODUCTION: Representativeness of research populations impacts the ability to extrapolate findings. The Burn Model System (BMS) National Database is one of the largest prospective, longitudinal, multi-center research repositories collecting patient-reported outcomes after burn injury. OBJECTIVE: To assess if the BMS Database is representative of the population that is eligible to participate. DESIGN: Data on adult burn survivors who were eligible for the BMS Database from 2015 to 2019 were analyzed. SETTING: Not applicable. PARTICIPANTS: Burn survivors treated at BMS centers meeting eligibility criteria for the BMS Database. Eligibility for the database is based on burn size and receipt of autografting surgery. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURE(S): Race, ethnicity, gender, and age were compared between individuals who did and did not enroll. Regression analysis examined the correlation between demographic characteristics and study enrollment. Additional regression analysis examined the association between enrollment and the intersection of race, ethnicity, and gender. RESULTS: A total of 982 adult burn survivors were eligible for the BMS database during the study period. Of those who were eligible, 72.1% Enrolled and 27.9% were Not Enrolled. The Enrolled group included more female and more younger survivors compared to the Not Enrolled group. In regression analyses, Black/African American burn survivors were less likely and individuals identifying as female were more likely to enroll in the BMS Database. Furthermore, White men and women were more likely to enroll compared to Black/African American men and women, and non-Hispanic/Latino men were more likely to enroll compared to Hispanic/Latino men. CONCLUSIONS: This study found differences in BMS Database enrollment by race, ethnicity, and gender. Further research is warranted to investigate causes for the disparities found in this study. In addition, strategies are needed to improve enrollment to ensure future representativeness.

Former Inpatient Psychiatric Patients' Past Experiences With Traditional Frontline Staff and Their Thoughts on the Benefits of Peers as Part of Frontline Staff.

Little is known about how integrating peers into frontline staff might improve the quality of inpatient psychiatric care. In the current study, we interviewed 18 former adult patients of inpatient psychiatric facilities using semi-structured interviews. We first asked about positive and negative past experiences with traditional staff. We then asked participants to share their opinions on the potential benefits of peers as part of frontline staff. We identified themes through a joint inductive and deductive approach. Participants reported past positive experiences with traditional staff as being (a) personable and caring, (b) validating feelings and experiences, (c) de-escalating, and (d) providing agency. Past negative experiences included (a) not sharing information, (b) being inattentive, (c) not providing agency, (d) being dehumanizing/disrespectful, (e) incompetency, (f) escalating situations, and (g) being apathetic. Participants believed that peers as part of frontline staff could champion emotional needs in humanizing and nonjudgmental ways, help navigate the system, and disrupt power imbalances between staff and patients. Further research is needed to understand financial, organizational, and cultural barriers to integrating peers into frontline staff. [Journal of Psychosocial Nursing and Mental Health Services, 60(3), 15-22.].

Predicting Depression and Posttraumatic Stress Symptoms Following Burn Injury: A Risk Scoring System.

Depression and posttraumatic stress (DPTS) are common psychiatric comorbidities following burn injury. The purpose of this study was to develop an admission scoring system that assesses the risk of development of depression or posttraumatic symptoms in the burn population. This study is a retrospective review of the prospectively collected Burn Model System National Database. Adult burn survivors enrolled from 2014 to 2018 (n = 486) were included. The primary outcome was the presence of DPTS symptoms at 6, 12, or 24 months postinjury. Logistic regression analysis was used to identify demographic and clinical predictors of DPTS symptoms. A risk scoring system was then created based on assigning point values to relevant predictor factors. The study population had a mean age of 46.5 ± 15.8 years, mean burn size of 18.3 ± 19.7%, and was 68.3% male. Prior to injury, 71.3% of the population was working, 47.9% were married, and 50.8% had completed more than a high school education. An 8-point risk scoring system was developed using the following predictors of DPTS symptom development: gender, psychiatric treatment in the past year, graft size, head/neck graft, etiology of injury, and education level. This study is the first to develop a DPTS symptom risk scoring system for burn injury. This scoring system will aid in identifying burn survivors at high risk of long-term psychiatric symptoms that may be used to improve screening, monitoring, timely diagnosis, and interventions.

Lessons Learned: Developing an Online Training Program for Cultural Sensitivity in an Academic Psychiatry Department.

This column describes the development and impact of an innovative three-part online cultural sensitivity training program for faculty and staff of an academic medical center's psychiatry department. The goal of the training was to equip faculty and staff with skills to address issues of diversity in their clinical practice. Three online modules were offered. Evaluations after the second module suggested that participants felt most comfortable interacting with people of diverse backgrounds and least comfortable intervening after witnessing a microaggression. Participants found the modules to meet the learning objectives and the technology to be user friendly. Future directions include embedding cultural humility and antiracism frameworks within department practices and policies.

Moving from Cultural Competence to Cultural Humility in Psychiatric Education.

Given the significant, persistent health care inequities encountered by minority populations, health care organizations and training programs have sought to incorporate cultural competency training initiatives. However, the variety of pedagogical models demonstrate the current lack of a uniform standardized curriculum. Limitations of knowledge-based cultural competence initiatives have resulted in a shift toward attitude- and behavior-based "cultural humility." Cultural humility, the ability to maintain an interpersonal stance that is open in relation to aspects of cultural identity that are most important to the patient, expands on cultural competence, which is essential to improving patient care in mental health care settings.

Sexual activity and romantic relationships after burn injury: A Life Impact Burn Recovery Evaluation (LIBRE) study.

BACKGROUND: Engaging in healthy sexual activity and romantic relationships are important but often neglected areas of post-burn rehabilitation. The degree to which persons with burn injuries engage in sexual activity and romantic relationships is not well understood. This study examined demographic and clinical characteristics predicting engagement in sexual activity and romantic relationships in a sample of adult burn survivors compared to a general United States sample. METHODS: Data for the adult burn survivor sample were from 601 adult burn survivors who participated in field-testing for the calibration of the Life Impact Burn Recovery Evaluation (LIBRE) Profile, a burn-specific instrument assessing social participation on six scales including sexual activity and romantic relationships. Comparison data were obtained from a general population sample of 2000 adults through sample matching. Demographic predictors of sexual activity and romantic relationship status were examined in each sample using modified Poisson regression analyses. Clinical predictors of engaging in sexual activity and romantic relationships were also examined in the LIBRE sample. RESULTS: Participants were slightly more likely to report being sexually active in the adult burn survivor sample than in the general sample (65% vs. 57%, p < 0.01). There was not a significant difference in romantic relationship status between the two samples (64% vs. 62%, p = 0.31). In multivariable regression analyses, men in both samples were more likely to report being in a sexual relationship (RR in LIBRE sample = 1.23, 95% CI 1.08-1.39; RR in general sample = 1.10, 95% CI 1.02-1.18). Participants in both samples who were not working were less likely to report being sexually active or in a romantic relationship (RRs ranging from 0.73 to 0.83, p < 0.05 for all estimates). In the adult burn survivor sample, respondents with hand burns were more likely to report being sexually active and in a romantic relationship (RR = 1.16, 95% CI 1.01-1.33). Time since burn injury, burn size, and burns to other critical areas were not significantly associated with either outcome in adjusted analyses. CONCLUSIONS: The likelihood of engaging in sexual activity and romantic relationships is similar among adult burn survivors and the comparison group representing a general United States sample of adults. Further research addressing sexual activity and romantic relationships after burn injuries will help to foster better patient-clinician dialogue, pinpoint barriers, design interventions, and allocate appropriate resources.

Mental Health Equity in the Twenty-First Century: Setting the Stage.

Significant mental health disparities persist in screening, diagnosis, and treatment for racial and ethnic minorities compared with non-Latinx white people. Reducing mental health disparities, and ultimately achieving mental health equity, requires understanding the wide range of factors that influence health outcomes at multiple levels. Components of an effective strategy to achieve mental health equity include increasing population-based care; increasing community-based health care services; addressing the social determinants of health; engaging the community; enhancing the pipeline; and supporting a diverse, structurally competent workforce.

Low-Dose Testosterone Augmentation for Antidepressant-Resistant Major Depressive Disorder in Women: An 8-Week Randomized Placebo-Controlled Study.

OBJECTIVE: Low-dose testosterone has been shown to improve depression symptom severity, fatigue, and sexual function in small studies in women not formally diagnosed with major depressive disorder. The authors sought to determine whether adjunctive low-dose transdermal testosterone improves depression symptom severity, fatigue, and sexual function in women with antidepressant-resistant major depression. A functional MRI (fMRI) substudy examined effects on activity in the anterior cingulate cortex (ACC), a brain region important in mood regulation. METHODS: The authors conducted an 8-week randomized double-blind placebo-controlled trial of adjunctive testosterone cream in 101 women, ages 21-70, with antidepressant-resistant major depression. The primary outcome measure was depression symptom severity as assessed by the Montgomery-Åsberg Depression Rating Scale (MADRS). Secondary endpoints included fatigue, sexual function, and safety measures. The primary outcome of the fMRI substudy (N=20) was change in ACC activity. RESULTS: The participants' mean age was 47 years (SD=14) and their mean baseline MADRS score was 26.6 (SD=5.9). Eighty-seven (86%) participants completed 8 weeks of treatment. MADRS scores decreased in both study arms from baseline to week 8 (testosterone arm: from 26.8 [SD=6.3] to 15.3 [SD=9.6]; placebo arm: from 26.3 [SD=5.4] to 14.4 [SD=9.3]), with no significant difference between groups. Improvement in fatigue and sexual function did not differ between groups, nor did side effects. fMRI results showed a relationship between ACC activation and androgen levels before treatment but no difference in ACC activation with testosterone compared with placebo. CONCLUSIONS: Adjunctive transdermal testosterone, although well tolerated, was not more effective than placebo in improving symptoms of depression, fatigue, or sexual dysfunction. Imaging in a subset of participants demonstrated that testosterone did not result in greater activation of the ACC.