Pilot of a screening, brief intervention and referral to treatment process for symptoms of trauma among primary care patients.

BACKGROUND: For populations with high rates of trauma exposure yet low behavioural health service use, identifying and addressing trauma in the primary care setting could improve health outcomes, reduce disability and increase the efficiency of health system resources. OBJECTIVE: To assess the acceptability and feasibility of a screening, brief intervention and referral to treatment (SBIRT) process for trauma and symptoms of posttraumatic stress disorder (PTSD) among American Indian and Alaska Native people. We also examine the short-term effects on service utilization and the screening accuracy of the Primary Care Posttraumatic Stress Disorder Screen. METHODS: Cross-sectional pilot in two tribal primary care settings. Surveys and interviews measured acceptability among patients and providers. Health service utilization was used to examine impact. Structured clinical interview and a functional disability measure were used to assess screening accuracy. RESULTS: Over 90% of patient participants (N = 99) reported the screening time was acceptable, the questions were easily understood, the right staff were involved and the process satisfactory. Ninety-nine percent would recommend the process. Participants screening positive had higher behavioural health utilization in the 3 months after the process than those screening negative. The Primary Care Posttraumatic Stress Disorder Screen was 100% sensitive to detect current PTSD with 51% specificity. Providers and administrators reported satisfaction with the process. CONCLUSIONS: The SBIRT process shows promise for identifying and addressing trauma in primary care settings. Future research should explore site specific factors, cost analyses and utility compared to other behavioural health screenings.

Telepsychiatry in an Alaska Native Residential Substance Abuse Treatment Program.

Introduction: Alaska Native communities experience high rates of alcohol and substance abuse and face challenges accessing quality, culturally appropriate treatment. Telepsychiatry could help bridge this gap, but no publications have examined its impacts for alcohol and substance abuse treatment directed at Alaska Native communities. This study explores one telepsychiatry clinic's impact on a residential substance abuse treatment serving the Alaska Native community in Anchorage, Alaska. Methods: Using a matched case - control design, 103 cases receiving telepsychiatry services between 2007 and 2012 were matched with 103 controls who did not. Outcome measures included length of stay, discharge plans, emergency room visits, and hospital admissions; clinical history, including previous suicide attempts, history of violence, and trauma history; social stressors such as current legal issues, unemployment, and homelessness; mental health, medical, and substance abuse diagnoses; and number of telepsychiatry appointments and nature of telepsychiatry services rendered. Results: Both groups exhibited high rates of mental and medical illness, socioeconomic challenges, and substance abuse. However, the telepsychiatry group demonstrated a significantly higher rate of post-traumatic stress disorder, history of violence, ongoing legal issues, and children in outside custody. It also remained engaged in treatment longer, had fewer discharges against medical advice, and was more likely to complete treatment. Discussion/Conclusions: Our study highlights this telepsychiatry clinic's real-world difference serving the complex substance abuse treatment needs of Alaska Native individuals. It also reinforces telepsychiatry's promise in serving other communities facing a high burden of addiction and mental illness yet facing barriers to high-quality, culturally competent services.

Law Enforcement Agencies' Perceptions of the Benefits of and Barriers to Temporary Firearm Storage to Prevent Suicide.

OBJECTIVES: To examine the perceived benefits of and barriers to law enforcement agencies providing increased access to voluntary and temporary firearm storage. METHODS: We surveyed 448 police chiefs and sheriffs in 8 US Mountain West states about firearm storage practices, benefits of and barriers to storage, and related attitudes and beliefs. Data collection occurred during the spring and summer of 2016. RESULTS: Nearly three quarters of agencies reported that they are already providing storage and perceive relatively few barriers in doing so. Agency characteristics were not associated with current provision of firearm storage. Among the barriers identified included state laws, limited space, training needs, and community perceptions. Benefits of storage included being perceived positively by the community and supporting health care workers. CONCLUSIONS: Engaging with law enforcement agencies in suicide prevention efforts and addressing their perceived barriers to providing temporary firearm storage have promise as part of a comprehensive suicide prevention approach.

Transforming through leadership: a qualitative study of successful American Indian Alaska Native behavioral health leaders.

BACKGROUND: Effective leadership is vital in the struggle to decrease the behavioral health disparities between the US population and American Indian Alaska Native (AIAN) communities. AIAN communities have a pre-colonization history of highly effective leadership, yet some AIAN leadership traditions have been eradicated through decades of trauma and genocidal efforts. There is a paucity of research on AIAN public health leadership, and most existing research relies on samples of individuals holding leadership positions rather than individuals purposely selected because of their effectiveness. The aim of the study was to investigate the experiences of successful AIAN behavioral health leaders and present an emerging AIAN public health leadership model. METHODS: Thirty-eight public health leaders in the Substance Abuse and Mental Health Service Administration (SAMHSA) funded Circles of Care project were observed over the course of their three-year leadership role. Stringent criteria for successful community participatory leadership resulted in the selection of 11 of the 38 leaders for inclusion in the study. Ultimately eight leaders (21% of the population of observed leaders) participated in the study. Semi-structured, one-on-one qualitative interviews were conducted. The methods were informed by phenomenology and the data were analyzed using a thematic content analysis approach. RESULTS: The analysis resulted in ten themes: Hopeful Vision for the People, Cultural Humility, Awareness of Historical Context, Purpose Driven Work Behavior, Cultural and Bi-Cultural Knowledge, Trusting a Broader Process, Caring Orientation, Holistic Supervision, Community Centered, and Influence Through Education. Respondents were strongly motivated by a desire to help future generations. They described their success in terms of the application of traditional AIAN values such as cultural humility and community orientation, but also relied heavily on task orientation. An emerging AIAN leadership model is presented. CONCLUSIONS: It is important to encourage AIAN public health leaders to employ leadership research and models conducted or developed in the context of AIAN communities. The emerging model presented in this study could serve as an initial basis for AIAN leadership training. Given the challenging context of AIAN leadership, the lessons taught by these successful leaders could be adapted for use by leaders in non AIAN settings.

CONTEXTUAL ISSUES FOR IMPLEMENTATION AND EVALUATION OF HOME-VISITATION PROGRAMS FOR AMERICAN INDIAN AND ALASKA NATIVE COMMUNITIES: AN INTRODUCTION TO THE TRIBAL MATERNAL, INFANT, AND EARLY CHILDHOOD HOME VISITING PROGRAM.

Home-visiting programs have become a key component of evidence-based services for pregnant women, new mothers, their infants, and their families. When Congress authorized the Maternal Infant and Early Childhood Home Visiting Program (MIECHV) in 2010, it set aside 3% of the $1.5 billion in funding to support home-visiting programs operated by tribes, Tribal MIECHV programs have been funded in 14 states and have served over 3,100 families, providing nearly 55,000 home visits to families at risk for poor child, maternal, and family outcomes. In this Introduction to the Special Issue of the Infant Mental Health Journal on the Tribal MIECHV initiative, we provide some key contexts of the work of the Tribal MIECHV grantees as well as an overview of the issues covered in the other articles.

ADDRESSING SUBSTANCE-USE PROBLEMS IN TRIBAL HOME VISITING.

Given the high rates for substance use among women and men of childbearing age, perinatal and early childhood home-visiting programs serving tribal communities must consider how they will address substance-use problems among the families they support. In this study, we explored the approaches to identifying and addressing family-based substance-use problems that were implemented by nine home-visiting programs serving American Indian/Alaska Native (AI/AN) communities that are funded through the federal Tribal Maternal, Infant, and Early Childhood Home Visiting Program (Tribal MIECHV). These programs demonstrated a high awareness of substance-use problems and took concrete action to address them above and beyond that included in the home-visiting model they used. All nine programs reported that they provided substance-use preventive services and screened for substance-use problems. While all programs referred to substance-use treatment programs when needed, in six programs the home visitor provided substance-use services. Through Tribal MIECHV, the intense need for substance-use education, assessment, service delivery, and referral in many AI/AN communities is pushing the home-visiting field forward to address this increasingly critical issue for low-income families across the United States and the world.

USING SINGLE-CASE DESIGNS TO EVALUATE COMPONENTS OF TRIBAL HOME-VISITATION PROGRAMS.

Single-case designs are typically used in classroom and clinical settings to assess the behavioral impacts of an intervention with an individual child. Using two illustrative case studies, this article describes the extension of this model to home-visitation programs serving tribal communities and examines the lessons learned throughout the process of adapting this approach. Our experience suggests that the benefits of using this design outweigh the associated challenges and allows researchers to expand the use of single-case designs to previously unexplored settings. Specifically, some of the benefits discussed include allowing for evaluative rigor in contexts with small samples, allowing everyone who qualifies to immediately participate, providing visual representations of the outcome-making the results more tangible and accessible to a broader audience, and allowing for a deep level of cultural sensitivity. The article also provides some general guidelines to address the practical challenges one may face when attempting to use single-case designs in novel ways within nonschool settings.

Counseling Suicidal Patients About Access to Lethal Means: Attitudes of Emergency Nurse Leaders.

INTRODUCTION: For ED patients at risk of suicide, counseling to reduce access to lethal means (including firearms) is recommended yet not routine. To enhance practice uptake, we sought to examine the attitudes and beliefs of emergency nurse leaders concerning the acceptability and effectiveness of lethal-means counseling. METHODS: We invited a nurse leader (ED nurse manager or Chief Nursing Officer [CNO]) at each hospital-based emergency department in the 8-state Mountain West region of the United States to complete a closed-ended telephone survey. Questions assessed current practices and leaders' views on suicide prevention and lethal-means counseling. Reponses were weighted to all eligible hospitals to adjust for nonresponse. RESULTS: From 363 eligible hospitals, 190 emergency nurse leaders responded (overall response rate: 52%). Emergency nurse leaders thought providers at their emergency departments did an excellent job of safety counseling (74%) for suicidal patients. Most respondents believed that talking about firearms with suicidal patients is acceptable to patients (77%), supported by hospital administration (64%), effective in preventing suicide (69%), and something that providers should do (91%). However, the majority also had doubts about whether suicide is preventable (60%). DISCUSSION: Despite expressing high levels of support for the acceptability and effectiveness of lethal-means counseling, high proportions of emergency nurse leaders expressed skepticism regarding the preventability of suicide, a finding consistent with previous work. Our results support the need to address and modify misperceptions about prevention of suicide in any efforts for widespread implementation and dissemination of lethal-means counseling.

Law Enforcement and Gun Retailers as Partners for Safely Storing Guns to Prevent Suicide: A Study in 8 Mountain West States.

OBJECTIVES: To examine the extent to which law enforcement agencies (LEAs) and gun retailers are willing to offer voluntary, temporary storage as a part of an overall suicide prevention effort. METHODS: We invited all LEAs and gun retailers in 8 US states to respond to questionnaires asking about their willingness to offer temporary gun storage and their recommendations to gun owners about safe storage. RESULTS: We collected data in 2016 from 448 LEAs and 95 retailers (response rates of 53% and 25%, respectively). Three quarters of LEAs (74.8%; 95% confidence interval [CI] = 72.1, 77.5) indicated they already provided temporary storage compared with 47.6% (95% CI = 39.2, 56.0) of retailers. LEAs were most willing to provide storage when a gun owner was concerned about the mental health of a family member. Retailers were more receptive than were LEAs to providing storage when visitors were coming or for people wanting storage while traveling. Both groups recommended locking devices within the home, but LEAs were slightly more favorable to storing guns away from the home. CONCLUSIONS: Law enforcement agencies and gun retailers are important resources for families concerned about suicide.

A Preliminary Multimethod Comparison of Sleep Among Adolescents With and Without Generalized Anxiety Disorder.

Previous studies suggest that youth with anxiety disorders experience their sleep as more disrupted and unsatisfying than their healthy peers. However, it is unclear whether these subjective complaints align with objective measures of sleep quantity and quality. The purpose of this preliminary study was to assess subjective and objective sleep parameters, and their relationships with anxiety symptomatology, among adolescents (62.8% female, 81.4% Caucasian), ages 12 to 18 (M = 15.29 years), with generalized anxiety disorder (n = 26) and controls without any psychopathology (n = 17). We measured sleep over 7 nights using sleep diaries and actigraphy and collected self- and parent-report questionnaires pertaining to sleep, anxiety, and depression. Repeated-measures mixed models were used to examine relationships between nightly sleep duration and morning anxiety. We found a number of differences in sleep between our anxious and healthy participants. Via sleep diary, our anxious participants had longer sleep onset latencies and lower satisfaction with sleep relative to controls, whereas via actigraphy we found longer sleep onset latencies but greater overall sleep duration among anxious versus control participants. Actigraphic measures of sleep disturbance were associated with parent-report of anxiety and depression. Our mixed-model analyses revealed that decreases in nightly sleep duration were associated with increased morning anxiety, but only among our participants with generalized anxiety disorder. Findings suggest that sleep disturbance among anxious adolescents can be detected using both subjective and objective measures and that, for these individuals, fluctuations in sleep duration may have real consequences for daytime anxiety.

Gender differences among Alaska Native people seeking alcohol withdrawal treatment.

BACKGROUND: Few studies focus on gender differences among patients who utilize detoxification services; even fewer focus on detoxification for Alaska Native people. This analysis focused on gender differences at admission among a sample of Alaska Native patients seeking alcohol withdrawal treatment. METHODS: The sample included 383 adult Alaska Native patients admitted to an inpatient alcohol detoxification unit during 2006 and 2007. Logistic regression was used to estimate unadjusted and adjusted associations with gender. RESULTS: Women were 88% more likely to have stable housing than men (odds ratio [OR] = 1.88, 95% confidence interval [CI] = 1.15, 3.05, P = .01). Women were 87% less likely to be seasonal workers (OR = 0.13, 95% CI = 0.03, 0.48, P = .003) and 50% less likely than men to be seeking employment (OR = 0.50, 95% CI = 0.29, 0.84, P = .01) at admission. Women had more than 5 times the odds of having children in the home at admission (OR = 5.64, 95% CI = 3.03, 10.56, P < .001) and almost 3 times the odds of experiencing physical abuse than men (OR = 2.96, 95% CI = 1.31, 6.66, P = .01). Additionally, women were 50% less likely to accept a referral to substance abuse treatment following detoxification (OR = 0.50, 95% CI = 0.30, 0.83, P = .01). CONCLUSIONS: The study found significant differences based upon gender. For instance, women are in need of services that accommodate women with children and services that address histories of physical abuse. Conversely, men are in need of housing and employment opportunities. Post detoxification follow-up, case management, and transition to care should include gender as a factor in treatment planning.

Telemental health for children and adolescents.

Most children and adolescents across the USA fail to receive adequate mental health services, especially in rural or underserved communities. The supply of child and adolescent psychiatrists is insufficient for the number of children in need of services and is not anticipated to grow. This calls for novel approaches to mental health care. Telemental health (TMH) offers one approach to increase access. TMH programmes serving young people are developing rapidly and available studies demonstrate that these services are feasible, acceptable, sustainable and likely as effective as in-person services. TMH services are utilized in clinical settings to provide direct care and consultation to primary care providers (PCPs), as well as in non-traditional settings, such as schools, correctional facilities and the home. Delivery of services to young people through TMH requires several adjustments to practice with adults regarding the model of care, cultural values, participating adults, rapport-building, pharmacotherapy and psychotherapy. Additional infrastructure accommodations at the patient site include space and staffing to conduct developmentally appropriate evaluations and treatment planning with parents, other providers, and community services. For TMH to optimally impact young people's access to mental health care, collaborative models of care are needed to support PCPs as frontline mental health-care providers, thereby effectively expanding the child and adolescent mental health workforce.

Challenges to providing quality substance abuse treatment services for American Indian and Alaska Native communities: perspectives of staff from 18 treatment centers.

BACKGROUND: Substance abuse continues to exact a significant toll, despite promising advancements in treatment, and American Indian and Alaska Native (AI/AN) communities remain disproportionately impacted. Understanding the challenges to providing quality substance abuse treatment to AI/AN communities could ultimately result in more effective treatment interventions, but no multi-site studies have examined this important issue. METHODS: This qualitative study examined the challenges of providing substance abuse treatment services for American Indian and Alaska Native (AI/AN) communities. We conducted key informant interviews and focus groups at 18 substance abuse treatment programs serving AI/AN communities. Seventy-six service participants (21 individuals in clinical administrative positions and 55 front-line clinicians) participated in the project. Interview transcripts were coded to identify key themes. RESULTS: We found that the challenges of bringing effective substance abuse treatment to AI/AN communities fell into three broad categories: challenges associated with providing clinical services, those associated with the infrastructure of treatment settings, and those associated with the greater service/treatment system. These sets of challenges interact to form a highly complex set of conditions for the delivery of these services. CONCLUSIONS: Our findings suggest that substance abuse treatment services for AI/AN communities require more integrated, individualized, comprehensive, and longer-term approaches to care. Our three categories of challenges provide a useful framework for eliciting challenges to providing quality substance abuse treatment in other substance abuse treatment settings.

Editors' Best of 2023.

There is, in the content of the Journal, an embarrassment of riches, and picking a "best" seems to demand a certain qualification: is the "best" the most interesting, most surprising, most educational, most important, most provocative, most enjoyable? How to choose? We are hardly unbiased and can admit to a special affection for the ones that we and the authors worked hardest on, modifying version after version into shape. Acknowledging these biases, here are the 2023 articles that we think deserve your attention or at least a second read.

Racial Implicit Associations in Child Psychiatry.

OBJECTIVE: Racial disparities in diagnosis and treatment are prevalent in child psychiatry, including disparate diagnosis rates of internalizing and externalizing disorders in Black and White children. However, limited research has investigated mechanisms that contribute to these disparities. This study examined child racial implicit associations in psychiatric clinicians and medical students to address this gap. METHOD: Psychiatrists and trainees completed an online survey including 2 race Implicit Association Tests (IATs) pairing child faces to words with either positive or negative valence, and words related to internalizing or externalizing behavioral problems. We further investigated psychiatrists' and trainees' demographic predictors of implicit associations. RESULTS: Data were analyzed from 235 psychiatrists and trainees (112 child and adolescent psychiatrists and fellows) who met inclusion criteria. Psychiatrists and trainees demonstrated greater moderate-to-strong association between Black child faces and "bad" words (44.3%) vs "good" words (6.4%), and between externalizing words (41.7%) and internalizing words (7.2%). Psychiatrists' and trainees' demographic characteristics including being female (ß = -0.12; 95% CI = -0.23 to -0.01; p < .05), Black (ß = -0.36; 95% CI = -0.54 to -0.18; p < .001), or an attending physician (ß = -0.26; 95% CI = -0.45 to -0.06; p = .01) were significant predictors of decreased association between Black child faces and negative valence words. Being female was a significant predictor of decreased association between Black child faces and externalizing words (ß = -0.26; 95% CI = -0.45 to -0.06; p = .01). CONCLUSION: Participating psychiatrists and trainees demonstrated bias toward associating Black rather than White child faces with negative words and externalizing behavioral problems. Future research should examine the following: (1) racial implicit associations in a more generalizable sample, (2) the relationship between race IATs and provider behavior, and (3) interventions to reduce racial inequities in psychiatry, including individual and systemic solutions. DIVERSITY & INCLUSION STATEMENT: We worked to ensure sex and gender balance in the recruitment of human participants. We worked to ensure race, ethnic, and/or other types of diversity in the recruitment of human participants. We worked to ensure that the study questionnaires were prepared in an inclusive way. One or more of the authors of this paper self-identifies as a member of one or more historically underrepresented sexual and/or gender groups in science. We actively worked to promote sex and gender balance in our author group. We actively worked to promote inclusion of historically underrepresented racial and/or ethnic groups in science in our author group. One or more of the authors of this paper self-identifies as a member of one or more historically underrepresented racial and/or ethnic groups in science. One or more of the authors of this paper received support from a program designed to increase minority representation in science.

Reaching rural communities with culturally appropriate care: a model for adapting remote monitoring to American Indian veterans with posttraumatic stress disorder.

OBJECTIVE: Providing specialized healthcare to rural communities can be extremely difficult, and consequently many health organizations are turning to the use of telehealth technologies for care delivery. One such technology, remote monitoring, has been successfully implemented with patients suffering from chronic and other medical conditions. A drawback, however, is that remote monitoring devices are programmed to reach a broad audience, and consequently the content may not be suitable for all patients-especially those who are not a part of the dominant culture. SUBJECTS AND METHODS: This report provides a model for adapting remote monitoring to specific populations who are undergoing care for posttraumatic stress disorder. Adaptation changes focus on (1) information gathering, (2) process and dialogue changes, (3) testing, and (4) patient and administrative feedback. Data for such modifications were gathered through a series of community meetings, patient interviews, and provider feedback. A case example highlights the successful implementation of the adaptation model for a rural American Indian Veteran population. RESULTS: Patients showed high acceptability of both the programmatic and cultural adaptations. Feasibility of the program also appeared positive, with most patients reporting that the readability of the program was appropriate, the dialogue duration was not burdensome, and technical problems were rare. CONCLUSIONS: Remote monitoring provides the ability to be modified for use with certain subpopulations. Procedural recommendations in this report highlight special considerations for working with American Indians living on or near reservation areas, although the model can be broadly adapted to several groups.

Study Registration: Encouraging the Practice of Hypothetical-Deductive Research in the Journal Revisited.

Five years ago, we wrote to you regarding our launching a new initiative for JAACAP: study registration.1 As we noted then, "study registration divides the peer review process into two stages. The first stage, preregistration, occurs at the time that the study is being planned, whereas the second occurs after the study is completed." To preregister their study, authors submit a manuscript consisting of the introduction and method sections for their study, along with a study synopsis, for peer review. If the study preregistration is approved after this initial peer review, the Journal will issue an in-principle acceptance to the authors, and the study synopsis will be published in JAACAP as a registered study protocol. When the study is completed, the authors will submit a complete manuscript, using the introduction and method sections that have already been reviewed and accepted (with an updated literature review) as well as their new results and discussion sections. This complete manuscript will undergo a second peer review focused on how consistent the manuscript is with the study's preregistration. If the paper is then accepted, it will be published as a Registered Report.1 We are pleased to report that with this issue of the Journal we have now published 2 such research articles, each demonstrating the strengths of this process.

Dermatology Access and Needs of American Indian and Alaska Native People.

OBJECTIVES: To describe skin disease prevalence, access to dermatologic care, and teledermatology interest among American Indians and Alaska Natives. METHODS: Data were collected via self-report surveys administered in person at two community powwows in Denver, Colorado in 2021 and 2022. RESULTS: Most American Indian and/or Alaska Native respondents (94.5%, n=225) reported at least one skin disease. The top three active skin diseases among adolescents were acne, scarring, and eczema. The top three among adults were dry skin, hair loss, and acne. Only 20.9% (n=47) of respondents with skin disease had seen a dermatologist. Approximately one-third of respondents (34.0%, n=81) were open to engaging with teledermatology in their home; 43.3% (n=103) were open to engaging with teledermatology in their local clinic; 42.0% (n=100) were not interested in engaging teledermatology from their home or in their local clinic. CONCLUSIONS: Skin disease is prevalent and access to dermatologic care is poor among American Indian and Alaska Native people.

Editors' Best of 2022.

There is, in the content of the Journal, an embarrassment of riches, and picking a "best" seems to demand a certain qualification: is the "best" the most interesting, most surprising, most educational, most important, most provocative, most enjoyable? How to choose? We are hardly unbiased and can admit to a special affection for the ones that we and the authors worked hardest on, hammering version after version into shape. Acknowledging these biases, here are the 2022 articles that we think deserve your attention or at least a second read.

Editors' Note: Third Annual Report Regarding JAACAP's Antiracist Journey.

In 2020, we wrote to you of our dedication and vision for JAACAP "to be antiracist at every level."1 Over the last 3 years, we have pursued initiatives "to reshape the Journal to pursue this vision."2,3 In this article, we provide an update on these goals and initiatives (Figure 1). With the launching of our new open access journal, JAACAP Open,4 in late 2022, we now extend these initiatives to both scientific journals in the JAACAP family and aspire to be a leader among mental health journals in our intentional pursuit of antiracist policies and practices.