Protocol for an economic evaluation of scalable strategies to improve mental health among perinatal women: non-specialist care delivered via telemedicine vs. specialist care delivered in-person.

BACKGROUND: Perinatal depression affects an estimated 1 in 5 women in North America during the perinatal period, with annualized lifetime costs estimated at $20.6 billion CAD in Canada and over $45.9 billion USD in the US. Access to psychological treatments remains limited for most perinatal women suffering from depression and anxiety. Some barriers to effective care can be addressed through task-sharing to non-specialist providers and through telemedicine platforms. The cost-effectiveness of these strategies compared to traditional specialist and in-person models remains unknown. This protocol describes an economic evaluation of non-specialist providers and telemedicine, in comparison to specialist providers and in-person sessions within the ongoing Scaling Up Maternal Mental healthcare by Increasing access to Treatment (SUMMIT) trial. METHODS: The economic evaluation will be undertaken alongside the SUMMIT trial. SUMMIT is a pragmatic, randomized, non-inferiority trial across five North American study sites (N = 1,226) of the comparable effectiveness of two types of providers (specialist vs. non-specialist) and delivery modes (telemedicine vs. in-person) of a behavioural activation treatment for perinatal depressive and anxiety symptoms. The primary economic evaluation will be a cost-utility analysis. The outcome will be the incremental cost-effectiveness ratio, which will be expressed as the additional cost required to achieve an additional quality-adjusted life-year, as assessed by the EuroQol 5-Dimension 5-Level instrument. A secondary cost-effectiveness analysis will use participants' depressive symptom scores. A micro-costing analysis will be conducted to estimate the resources/costs required to implement and sustain the interventions; healthcare resource utilization will be captured via self-report. Data will be pooled and analysed using uniform price and utility weights to determine cost-utility across all trial sites. Secondary country-specific cost-utility and cost-effectiveness analyses will also be completed. Sensitivity analyses will be conducted, and cost-effectiveness acceptability-curves will be generated, in all instances. DISCUSSION: Results of this study are expected to inform key decisions related to dissemination and scale up of evidence-based psychological interventions in Canada, the US, and possibly worldwide. There is potential impact on real-world practice by informing decision makers of the long-term savings to the larger healthcare setting in services to support perinatal women with common mental health conditions.

Exploring physician gender bias in the initiation of prescribing cascades for older men and women: a qualitative clinical vignette study protocol.

INTRODUCTION: A prescribing cascade occurs when a drug is prescribed to manage the often unrecognised side effect of another drug; these cascades are of particular concern for older adults who are at heightened risk for drug-related harm. It is unknown whether, and to what extent, gender bias influences physician decision-making in the context of prescribing cascades. The aim of this transnational study is to explore the potential impact of physician implicit gender biases on prescribing decisions that may lead to the initiation of prescribing cascades in older men and women in two countries, namely: Canada and Italy. METHODS AND ANALYSIS: Male and female primary care physicians at each site will be randomised 1:1 to a case vignette that features either a male or female older patient who presents with concerns consistent with the side effect of a medication they are taking. During individual interviews, while masked to the true purpose of the study, participants will read the vignette and use the think-aloud method to describe their ongoing thought processes as they consider the patient's concerns and determine a course of action. Interviews will be recorded, transcribed verbatim and thematic analysis will be conducted to highlight differences in decisions in the interviews/transcripts, using a common analytical framework across the sites. ETHICS AND DISSEMINATION: This study has received ethics approval at each study site. Verbal informed consent will be received from participants prior to data collection and all data will be deidentified and stored on password-protected servers. Results of this study will be disseminated through peer-reviewed journal articles and presented at relevant national and international conferences.

ThinkCascades: A Tool for Identifying Clinically Important Prescribing Cascades Affecting Older People.

BACKGROUND AND OBJECTIVE: Prescribing cascades occur when a drug is prescribed to manage side effects of another drug, typically when a side effect is misinterpreted as a new condition. A consensus list of clinically important prescribing cascades that adversely affect older persons' health (i.e., where risks of the prescribing cascade usually exceed benefits) was developed to help identify, prevent, and manage prescribing cascades. METHODS: Three rounds of a modified Delphi process were conducted with a multidisciplinary panel of 38 clinicians from six countries with expertise in geriatric pharmacotherapy. The clinical importance of 139 prescribing cascades was assessed in Round 1. Cascades highly rated by ≥ 70% of panelists were included in subsequent rounds. Factors influencing ratings in Rounds 1 and 3 were categorized. After three Delphi rounds, highly rated prescribing cascades were reviewed by the study team to determine the final list of clinically important cascades consistent with potentially inappropriate prescribing. RESULTS: After three rounds, 13 prescribing cascades were highly rated by panelists. Following a study team review, the final tool includes nine clinically important prescribing cascades consistent with potentially inappropriate prescribing. Panelists reported that their ratings were influenced by many factors (e.g., how commonly they encountered the medications involved and the cascade itself, the severity of side effects, availability of alternatives). The relative importance of these factors in determining clinical importance varied by panelist. CONCLUSIONS: A nine-item consensus-based list of clinically important prescribing cascades, representing potentially inappropriate prescribing, was developed. Panelists' decisions about what constituted a clinically important prescribing cascade were multi-factorial. This tool not only raises awareness about these cascades but will also help clinicians recognize these and other important prescribing cascades. This list contributes to the prevention and management of polypharmacy and medication-related harm in older people.

The Factors Associated With Nonuse of Social Media or Video Communications to Connect With Friends and Family During the COVID-19 Pandemic in Older Adults: Web-Based Survey Study.

BACKGROUND: Digital technologies have enabled social connection during prolonged periods of physical distancing and travel restrictions throughout the COVID-19 pandemic. These solutions may exclude older adults, who are at higher risk for social isolation, loneliness, and severe outcomes if infected with SARS-CoV-2. OBJECTIVE: This study investigated factors associated with nonuse of social media or video communications to connect with friends and family among older adults during the pandemic's first wave. METHODS: A web-based, cross-sectional survey was administered to members of a national retired educators' organization based in Ontario, Canada, between May 6 and 19, 2020. Respondents (N=4879) were asked about their use of social networking websites or apps to communicate with friends and family, their internet connection and smartphone access, loneliness, and sociodemographic characteristics. Factors associated with nonuse were evaluated using multivariable logistic regression. A thematic analysis was performed on open-ended survey responses that described experiences with technology and virtual connection. RESULTS: Overall, 15.4% (751/4868) of respondents did not use social networking websites or apps. After adjustment, male gender (odds ratio [OR] 1.60, 95% CI 1.33-1.92), advanced age (OR 1.88, 95% CI 1.38-2.55), living alone (OR 1.68, 95% CI 1.39-2.02), poorer health (OR 1.33, 95% CI 1.04-1.71), and lower social support (OR 1.44, 95% CI 1.20-1.71) increased the odds of nonuse. The reliability of internet connection and access to a smartphone also predicted nonuse. Many respondents viewed these technologies as beneficial, especially for maintaining pre-COVID-19 social contacts and routines, despite preferences for in-person connection. CONCLUSIONS: Several factors including advanced age, living alone, and low social support increased the odds of nonuse of social media in older adults to communicate with friends and family during COVID-19's first wave. Our findings identified socially vulnerable subgroups who may benefit from intervention (eg, improved access, digital literacy, and telephone outreach) to improve social connection.

Identifying key prescribing cascades in older people (iKASCADE): a transnational initiative on drug safety through a sex and gender lens-rationale and design.

PURPOSE: To describe the objectives, methods and expected impact of an international consortium (iKASCADE) whose purpose is to improve drug safety for older adults by addressing prescribing cascades through a sex and gender lens. METHODS: To create a comprehensive, internationally relevant inventory of prescribing cascades affecting older adults, the consortium has created a modified Delphi procedure where international experts in prescribing and managing pharmacotherapy for older adults will rank a list of prescribing cascades as to their clinical importance. We will use administrative and clinical data on older adults to evaluate the frequency of prescribing cascades by sex internationally, in the hospital, long-term care and community settings. Finally, we will use semi-structured interviews and realistic, country-specific vignettes, each incorporating a prescribing cascade with identified sex differences, to explore how socially constructed gender roles contribute to the experience, presentation and management of prescribing cascades. RESULTS: The consortium will synthesize the quantitative and qualitative results to produce a position paper and products-aimed at knowledge users within and outside of academia-designed to elevate the importance of integrating a gender dimension in the identification and prevention of prescribing cascades. CONCLUSION: Findings will improve our understanding of how adverse drug events are different between older women and men and inform the development and dissemination of tailored knowledge translation products to reduce the frequency and impact of prescribing cascades.

Loneliness among older adults in the community during COVID-19: a cross-sectional survey in Canada.

OBJECTIVE: Physical distancing and stay-at-home measures implemented to slow transmission of novel coronavirus disease (COVID-19) may intensify feelings of loneliness in older adults, especially those living alone. Our aim was to characterise the extent of loneliness during the first wave in a sample of older adults living in the community and assess characteristics associated with loneliness. DESIGN: Online cross-sectional survey between 6 May and 19 May 2020. SETTING: Ontario, Canada. PARTICIPANTS: Convenience sample of members of a national retired educators' organisation. PRIMARY OUTCOME MEASURES: Self-reported loneliness, including differences between women and men. RESULTS: 4879 respondents (71.0% women; 67.4% 65-79 years) reported that in the preceding week, 43.1% felt lonely at least some of the time, including 8.3% who felt lonely always or often. Women had increased odds of loneliness compared with men, whether living alone (adjusted OR (aOR) 1.52, 95% CI 1.13 to 2.04) or with others (2.44, 95% CI 2.04 to 2.92). Increasing age group decreased the odds of loneliness (aOR 0.69 (95% CI 0.59 to 0.81) 65-79 years and 0.50 (95% CI 0.39 to 0.65) 80+ years compared with <65 years). Living alone was associated with loneliness, with a greater association in men (aOR 4.26, 95% CI 3.15 to 5.76) than women (aOR 2.65, 95% CI 2.26 to 3.11). Other factors associated with loneliness included: fair or poor health (aOR 1.93, 95% CI 1.54 to 2.41), being a caregiver (aOR 1.18, 95% CI 1.02 to 1.37), receiving care (aOR 1.47, 95% CI 1.19 to 1.81), high concern for the pandemic (aOR 1.55, 95% CI 1.31 to 1.84), not experiencing positive effects of pandemic distancing measures (aOR 1.94, 95% CI 1.62 to 2.32) and changes to daily routine (aOR 2.81, 95% CI 1.96 to 4.03). CONCLUSIONS: While many older adults reported feeling lonely during COVID-19, several characteristics-such as being female and living alone-increased the odds of loneliness. These characteristics may help identify priorities for targeting interventions to reduce loneliness.

Implementation and Effectiveness of Nonspecialist-Delivered Interventions for Perinatal Mental Health in High-Income Countries: A Systematic Review and Meta-analysis.

Importance: Task sharing-or training of nonspecialist providers with no formal training in counseling-is an effective strategy to improve access to evidence-based counseling interventions and has the potential to address the burden of perinatal depression and anxiety. Objectives: To identify the relevant implementation processes (who, what, where, and how) and to assess the effectiveness of counseling interventions delivered by nonspecialist providers for perinatal depression and anxiety in high-income countries. Data Sources: CINAHL, Ovid MEDLINE, Ovid MEDLINE In-Process, PsycINFO, Web of Science, Cochrane Central Register of Controlled Trials, and Embase through December 31, 2019. Relevant systematic reviews were also considered. Study Selection: Randomized clinical trials of counseling interventions that assessed depression or anxiety after intervention, delivered by a nonspecialist provider for adults, and that targeted perinatal populations in a high-income country were included. Self-help interventions that did not include a provider component were excluded. Data Extraction and Synthesis: Four researchers independently reviewed abstracts and full-text articles, and 2 independently rated the quality of included studies. Random-effects meta-analysis was used to estimate the benefits of the interventions. The Preferred Reporting Items for Systematic Reviews and Meta-analyses reporting guideline was followed. Main Outcomes and Measures: For implementation processes, the frequencies represented by a total or percentage were estimated, where the denominator is the total number of eligible trials, unless otherwise indicated. For effectiveness, primary and secondary outcome data of depression, anxiety, or both symptoms were used, with separate analyses for prevention and treatment, stratified by depression or anxiety. Subgroup analyses compared outcome types (anxiety vs depression) and study objectives (treatment vs prevention). Results: In total, 46 trials (18 321 participants) were included in the systematic review; 44 trials (18 101 participants) were included in the meta-analysis. Interventions were implemented across 11 countries, with the majority in Australia, UK, and US. Two-thirds (65%) of counseling interventions were provided by nurses and midwives, lasted a mean of 11.2 weeks (95% CI, 6.4-16.0 weeks), and most were delivered face to face (31 [67.4%]). Only 2 interventions were delivered online. A dearth of information related to important implementation processes, such as supervision, fidelity, and participant sociodemographic characteristics, was observed in many articles. Compared with controls, counseling interventions were associated with lower depressive symptoms (standardized mean difference [SMD], 0.24 [95% CI, 0.14-0.34]; 43 trials; I2 = 81%) and anxiety scores (SMD, 0.30 [95% CI, 0.11-0.50]; 11 trials; I2 = 80%). Treatment interventions were reported to be effective for both depressive symptoms (SMD, 0.38 [95% CI, 0.17-0.59]; 15 trials; I2 = 69%) and anxiety symptoms (SMD, 0.34 [95% CI, 0.09-0.58]; 6 trials; I2 = 71%). However, heterogeneity was high among the trials included in this analysis. Conclusions and Relevance: This study found evidence in high-income countries indicating that nonspecialist providers may be effective in delivering counseling interventions. Additional studies are needed to assess digital interventions and ensure the reporting of implementation processes to inform the optimal delivery and scale-up of these services.

The Relationship Between Childhood Adversity and Other Aspects of Clinical Complexity in Psychiatric Outpatients.

Childhood abuse, neglect, and loss are common in psychiatric patients, and the relationship between childhood adversity and adult mental illness is well known. However, beyond diagnoses that are specifically trauma-related, such as posttraumatic stress disorder, there has been little research on how childhood adversity contributes to complex presentations that require more intensive treatment. We examined the relationship between childhood adversity and other contributors to clinical complexity in adult outpatients seeking mental health assessment. In a cross-sectional study, patients completed standard measures of psychological distress and functional impairment. Psychiatrists completed an inventory of clinical complexity, which included childhood abuse, neglect, and loss. Of 4,903 patients seen over 15 months, 1,315 (27%) both consented to research and had the measure of complexity completed. Childhood abuse or neglect was identified in 474 (36.0%) and significant childhood loss in 236 (17.9%). Correcting for multiple comparisons and controlling for psychiatric diagnosis, age, and sex, patients with childhood abuse or neglect were significantly more likely to also have 11 of 31 other indices of clinical complexity, with odds ratios ranging from 1.7 to 5.0. Both childhood abuse or neglect and childhood loss were associated with greater overall complexity (i.e., more indices of complexity, χ2 = 136 and 38 respectively, each p < .001). Childhood abuse and neglect (but not childhood loss) were significantly associated with psychological distress (Kessler Psychological Distress Scale [K10] score, F = 6.2, p = .01) and disability (World Health Organization Disability Assessment Scale 2.0 [WHODAS 2.0] score, F = 5.0, p = .03). Childhood abuse and neglect were associated with many characteristics that contribute to clinical complexity, and thus to suboptimal outcomes to standard, guideline-based care. Screening may alert psychiatrists to the need for intensive, patient-centered, and trauma-informed treatments. Identifying childhood adversity as a common antecedent of complexity may facilitate developing transdiagnostic programs that specifically target sources of complexity.

Lithium Prescribing and Therapeutic Drug Monitoring in Bipolar Disorder: A Survey of Current Practices and Perspectives.

OBJECTIVE: The goal of this survey study was to assess specific aspects of lithium therapy for bipolar disorder, including psychiatrists' prescribing practices, understanding of therapeutic drug monitoring, and concerns and perspectives regarding lithium therapy. METHODS: A 14-item survey was electronically distributed to 225 staff psychiatrists at 8 academic hospitals. RESULTS: The survey was completed by 85 psychiatrists (38% of the 225 psychiatrists to whom the survey was distributed), with between 81 and 85 respondents completing the different items. When asked about the agents with which they initiated therapy, 49 (61%) reported initiating therapy with an atypical antipsychotic and 34 (42%) reported starting with lithium therapy in 50% or more of patients newly diagnosed with bipolar disorder. When prescribing lithium, most of the respondents (n=68, 82%) reported that they used once daily dosing, and 67 respondents (79%) indicated that they ordered lithium blood levels 12 hours postdose. When interpreting lithium levels, 46 respondents (55%) reported "always" changing a clinically stable patient's lithium dose when the level was above the therapeutic range, compared with 4 (5%) who reported always changing the dose when the level was below the therapeutic range. When asked about their concerns regarding lithium therapy, more than half of the respondents reported that they were especially concerned about toxicity, organ dysfunction, and other adverse effects, as well as therapeutic drug monitoring. CONCLUSION: Shifts in prescribing practices, inconsistent interpretation of lithium levels, and concerns about safety and therapeutic drug monitoring highlight the need for evidence-informed guidelines reflective of current practice.

Implementing Psychological Interventions Through Nonspecialist Providers and Telemedicine in High-Income Countries: Qualitative Study from a Multistakeholder Perspective.

BACKGROUND: Task sharing has been used worldwide to improve access to mental health care, where nonspecialist providers-individuals with no formal training in mental health-have been trained to effectively treat perinatal depressive and anxiety symptoms. Little formative research has been conducted to examine relevant barriers and facilitators of nonspecialist providers and the use of telemedicine in treatment service delivery. OBJECTIVE: The primary objective of this study was to examine the main barriers and facilitators of nonspecialist provider-delivered psychological treatments for perinatal populations with common mental health disorders, such as depression and anxiety, from a multistakeholder perspective. METHODS: This study took place in Toronto, Canada. In total, 33 in-depth interviews were conducted with multiple stakeholder groups (women with lived experience and their significant others, as well as health and mental health professionals). Qualitative data were quantified to estimate commonly endorsed themes within and across stakeholder groups. RESULTS: Psychological treatments delivered by nonspecialist providers were considered acceptable by the vast majority of participants (30/33, 90%). Across all stakeholder groups, nurses (20/33, 61%) and midwives (14/33, 42%) were the most commonly endorsed cadre of nonspecialist providers. The majority of stakeholders (32/33, 97%) were amenable to nonspecialist providers delivering psychological treatment via telemedicine (27/33, 82%), although concerns were raised about the ability to establish a therapeutic alliance via telemedicine (16/33, 48%). Empathy was the most desired characteristic of a nonspecialist provider (61%). Patient and patient advocate stakeholders were more likely to emphasize stigma as an important barrier to accessing psychological treatments (7/12, 58%), compared to clinicians (2/9, 22%) and spouses (1/5, 20%). Clinician stakeholders were more likely to emphasize the importance of ensuring nonspecialist providers were trained to deliver psychological treatments (3/9, 33%), compared to other stakeholder groups. CONCLUSIONS: These results can inform the design, implementation, and integration of nonspecialist-delivered interventions via telemedicine for women with perinatal depressive and anxiety symptoms in high-income country contexts.

Psychotherapy Patients of Psychiatry Residents: A Descriptive Study.

OBJECTIVE: Psychiatry residents learn psychodynamic psychotherapy for generalizable skills and as a transdiagnostic, long-term treatment indicated for patients with chronic mood, anxiety, or personality disorders. It is unknown how these indications align with actual patients of trainees. The aim of this descriptive study was to define characteristics of outpatients receiving psychodynamic psychotherapy from psychiatry residents. METHODS: Case reports (N=204) from 184 psychiatry residents were analyzed for patients' diagnoses and past treatments. RESULTS: Eighty-six percent of patients had prior psychiatric medication or treatment, 31% had three or more past courses of psychotherapy, and 48% had two or more diagnoses, including depression (62%), anxiety (46%), and personality disorders or traits (27%). CONCLUSIONS: Patients receiving psychodynamic psychotherapy from psychiatry residents had multiple psychiatric illnesses and a history of prior treatments that had not achieved or sustained recovery, suggesting complex and chronic illness. Consistent with community-based findings, these patient characteristics correspond with psychodynamic psychotherapy treatment indications.

Integrating Evidence-Supported Psychotherapy Principles in Mental Health Case Management: A Capacity-Building Pilot.

OBJECTIVES: Mental health case managers comprise a large workforce who help patients who struggle with complex mental illnesses and unmet needs with respect to the social determinants of health. This mixed-methods capacity-building pilot examined the feasibility, experiences, and outcomes of training community-based mental health case managers to integrate evidence-based psychotherapy principles into their case conceptualization and management practices. METHODS: Case-based, once-weekly, group consultations and training in applied therapeutic principles from mentalizing, interpersonal psychotherapy, motivational interviewing, and other evidence-based psychotherapies were provided to case managers over 8 months. A trauma-informed and culturally sensitive approach was emphasized to improve therapeutic alliances and to foster adaptive expertise and an appreciation of individual patient differences. RESULTS: Qualitative analyses of focus groups and individualized interviews identified a shift toward being more reflective rather than reactive, with improved empathy, patient engagement, morale, and confidence resulting from the training (N = 16). Self-reported pre-post counseling self-efficacy changes revealed significant improvements overall, driven by improved microskills and an ability to deal with challenging client behaviors (N = 10; P < 0.05). CONCLUSIONS: This pilot demonstrated that case-based consultations and training of mental health case managers within a community-of-practice in trauma-informed, culturally sensitive application of evidence-supported psychotherapy principles were feasible and acceptable with scalable potential to improve case managers' counseling self-efficacy, reflective capacity, empathy, and morale. Further research in this area is needed with a larger sample, and patient and health systems outcomes.

Proactive Psychiatry Intervention Using a Nurse-Led Behavioral Response Model for Hospitalized Patients With Behavioral Disturbances.

BACKGROUND: The health care sector has one of the highest rates of workplace violence, putting staff at risk and impeding care. To deliver quality health care, staff need targeted resources. This article describes a program to improve staff safety and reduce barriers to care for patients with behavioral disturbances. PROGRAM DESCRIPTION: A nurse-led behavioral response team was created to identify high-risk patients and offer prompt targeted interventions. The Behavioral Optimization and Outcomes Support Team (BOOST) was implemented in November 2012, in conjunction with a proactive model of care, enabling psychiatric intervention. Advanced practice nurses in psychiatry respond to requests from staff on medical/surgical units to assist with management of behavioral disturbances. METHODS: Consultation and intervention data were reviewed, and staff satisfaction surveys were completed to evaluate the program. RESULTS: The program has contributed to staff feeling more supported and safer at work. There has also been a reduction in staff's experience of perceived burden in the care of patients with behavioral disturbances although they are caring for more of these patients. CONCLUSIONS: Although violence risk in health care continues to be a significant issue, programs to intervene early can be effective in supporting staff to minimize these risks.

Interpersonal Psychotherapy: A Scoping Review and Historical Perspective (1974-2017).

BACKGROUND: Interpersonal Psychotherapy (IPT) is an affect- and relationally focused, time-limited treatment supported by research spanning >4 decades. IPT focuses on stressful interpersonal experiences of loss, life changes, disputes, and social isolation. It emphasizes the role of relationships in recovery. This scoping review describes, within a historical perspective, IPT's evolution as an evidence-supported treatment of psychiatric disorders. METHODS: English-language publications (n = 1119) identified via EMBASE, MEDLINE, PsycINFO, and Web of Science databases (1974-2017), augmented with manual reference searches, were coded for clinical focus, population demographics, format, setting, publication type, and research type. Quantitative and qualitative analyses identified IPT publications' characteristics and trends over four epochs of psychotherapy research. RESULTS: IPT literature primarily focused on depression (n = 772 articles; 69%), eating disorders (n = 135; 12%), anxiety disorders (n = 68; 6%), and bipolar disorder (n = 44; 4%), with rising publication rates and numbers of well-conducted randomized, controlled trials over time, justifying inclusion in consensus treatment guidelines. Research trends shifted from efficacy trials to effectiveness studies and population-based dissemination initiatives. Process research examined correlates of improvement and efficacy moderators. Innovations included global initiatives, prevention trials, and digital, web-based training and treatment. CONCLUSION: Sparked by clinical innovations and scientific advances, IPT has evolved as an effective treatment of psychiatric disorders across the lifespan for diverse patients, including underserved clinical populations. Future research to elucidate mechanisms of change, improve access, and adapt to changing frameworks of psychopathology and treatment planning is needed. IPT addresses the universal centrality of relationships to mental health, which is as relevant today as it was over 40 years ago.

Use of Text Messaging for Postpartum Depression Screening and Information Provision.

OBJECTIVE: The objective of this study was to evaluate the feasibility of using text messages to enhance mental health screening and education of women in the immediate postpartum period. METHODS: A total of 937 postpartum women were recruited from an obstetrics and gynecology clinic of a large urban hospital. Participants received a text message containing a two-question screen for postpartum depression every two weeks and three text messages per week about postpartum mental health for the first 12 weeks postpartum. Those who screened positive were administered the Edinburgh Postnatal Depression Scale. They were matched with a subset of women who were also assessed with the Edinburgh Postnatal Depression Scale after screening negative for depression with the text messaging screen. At 12 to 13 weeks postpartum, all participants received an online survey assessing satisfaction with the text messages. RESULTS: Of 937 participants, 126 (13%) screened positive. Agreement between the texted screen and the Edinburgh Postnatal Depression Scale was moderate (κ=0.45), with good sensitivity (0.90, 95% confidence interval [95% CI]=0.81-0.96) and specificity (0.82, 95% CI=0.79-0.85). Nine hundred thirty (99%) participants responded to at least one of the six texted screens, whereas 632 (67%) responded to all six. Of the 589 (63%) who responded to the satisfaction survey, 459 (78%) recommended that all women be screened for postpartum depression via text messaging and that all women in the postpartum period be sent information texts about postpartum depression (N=504, 91%). CONCLUSIONS: Using text messaging technology to screen women for postpartum depression and provide information on postpartum mental health appears to be sensitive, feasible, and well accepted.

Psychotherapy Competency Milestones: an Exploratory Pilot of CBT and Psychodynamic Psychotherapy Skills Acquisition in Junior Psychiatry Residents.

OBJECTIVE: Psychiatry residents train in Psychodynamic Psychotherapy and Cognitive Behavioral Therapy (CBT), evidence-supported treatments used in mental health care that can facilitate clinical reasoning, foster therapeutic alliances, and improve clinical outcomes. However, empirically derived milestones are needed to evaluate competency. This exploratory pilot examined changes over 1 year of training in junior psychiatry residents' competency milestone elements in Psychodynamic Psychotherapy and CBT. METHODS: Seventy-nine randomly selected audio-recorded sessions from differing phases of Psychodynamic Psychotherapy and CBT with five junior residents and ten patients were rated using the Psychotherapy Process Q-sort (PQS). RESULTS: In both treatments, patient engagement with attention to in-session emotions improved. In CBT, residents were directive, supported patients' self-efficacy, emphasized patients' accepting responsibility for their problems, discussed homework such as thought records, and focused on termination in the concluding sessions. In Psychodynamic Psychotherapy, residents attended to emotional arousal and linked patients' feelings or perceptions to past situations or behavior. Growth and hierarchical linear modeling differentiated these treatments, with CBT v. Psychodynamic adherence to PQS modality-specific ideal elements being 52% v.19%. CONCLUSION: Teaching and observation using empirically derived observable psychotherapy practice behaviors is feasible and can be used to assess milestone elements for competency-based education of psychiatry trainees.