Towards practice change: a qualitative study examining the impact of a Child Psychiatric Access Program (Project TEACH) on Primary Care Provider practices in New York State during pandemic times.

BACKGROUND: This study aims to explore the perceived impact of Project TEACH (Training and Education for the Advancement of Children's Health), a New York State Office of Mental Health funded Child Psychiatric Access Program (CPAP), on pediatric Primary Care Providers (PCPs) and their practice. Practice change over time was assessed in the context of rising mental health needs and in the context of COVID19 pandemic. METHODS: Focus groups utilizing a semi-structured format were conducted with pediatric PCPs who have been high utilizers of Project TEACH over the past 5-10 years and PCPs in similar regions who have been low or non-utilizers of the program. The semi-structured interview focused on practice change, asking about pediatric mental health, practice setting and flow, professional development, and changes over time in the context of COVID-19 pandemic and Project TEACH. RESULTS: Themes identified include increasing confidence of PCPs, particularly those who are high utilizers of the phone consultation line, increased routine use of screening and comfort bridging pediatric patients with mental health needs. Challenges include rising mental health needs, inadequate mental health services, difficulties with family follow through and high emotional burden on PCPs caring for these patients. In this context, participants noted that collaboration with Project TEACH provided needed emotional support. CONCLUSIONS: Integrated care and CPAPs such as Project TEACH are vital to helping PCPs handle rising mental health needs particularly in current crisis times. Ongoing systemic challenges accessing care remain and contribute to emotional burden placed on pediatric PCPs.

A Study of a Cultural Competence and Humility Intervention for Third-Year Medical Students.

OBJECTIVE: This study evaluates the effectiveness of a cultural competence and humility intervention for third-year medical students by assessing changes in clinical evaluation assessments in patient encounters. METHODS: This study examines the effect of a 1-h educational intervention on cultural competence and cultural humility for third-year medical students. Clinical assessments during observed patient encounters are compared in the clerkship before and after the intervention. The intervention adapts a previously studied cultural competence didactic and emphasizes cultural humility practices. Change in scores from the intervention cohort (clinical year 2019-2020) is compared to a pre-intervention cohort (2018-2019). RESULTS: Students who completed the intervention demonstrate greater clinical competency in "relating to patients in a respectful, caring, empathetic manner" as assessed by supervising physicians compared with pre-intervention cohort students (2.7% difference in earning top two scores in subsequent clerkship, P value 0.05, Cramer's V 0.04). Greater clinical competencies were also found in the intervention students compared with pre-intervention students in the domains "demonstrates accountability, contribution and commitment to patient care" and "develops insightful, focused, pertinent questions based on clinical scenarios" (3.8% difference in earning top two scores in subsequent clerkship, P value 0.01 and 5.1% difference, P-value 0.003 with Cramer's V of 0.05 and 0.06, respectively). CONCLUSIONS: Educational interventions to improve cultural competence and cultural humility are important during clinical years to shape future physicians. Our study suggests that brief interventions may improve medical students' clinical competencies. A future study with a more robust intervention is expected to yield more substantial results.

Reflechi twòp--thinking too much: description of a cultural syndrome in Haiti's Central Plateau.

A rich Haitian ethnopsychology has been described, detailing concepts of personhood, explanatory models of illness, and links between mind and body. However, little research has engaged explicitly with mental illness, and that which does focuses on the Kreyòl term fou (madness), a term that psychiatrists associate with schizophrenia and other psychoses. More work is needed to characterize potential forms of mild-to-moderate mental illness. Idioms of distress provide a promising avenue for exploring common mental disorders. Working in Haiti's Central Plateau, we aimed to identify idioms of distress that represent cultural syndromes. We used ethnographic and epidemiologic methods to explore the idiom of distress reflechi twòp (thinking too much). This syndrome is characterized by troubled rumination at the intersection of sadness, severe mental disorder, suicide, and social and structural hardship. Persons with "thinking too much" have greater scores on the Beck Depression Inventory and Beck Anxiety Inventory. "Thinking too much" is associated with 8 times greater odds of suicidal ideation. Untreated "thinking too much" is sometimes perceived to lead to psychosis. Recognizing and understanding "thinking too much" may allow early clinical recognition and interventions to reduce long-term psychosocial suffering in Haiti's Central Plateau.

Nonstimulant Medications for Attention-Deficit/Hyperactivity Disorder (ADHD) in Adults: Systematic Review and Meta-analysis.

BACKGROUND: For some adults with Attention-Deficit/Hyperactivity Disorder (ADHD), nonstimulants need to be considered either as a monotherapy or as an adjunct to stimulants. OBJECTIVES: The objectives of this systematic review and meta-analysis were to assess the efficacy, acceptability, and tolerability of nonstimulants in adults with ADHD. METHODS: Data sources, searches, and study selection were based on a previously published network meta-analysis of randomized clinical trials (RCTs) by Cortese at al. (Lancet Psychiatry 5(9):727-738, 2018), which we updated in March 2022. Specifically, we searched PubMed, BIOSIS Previews, CINAHL, the Cochrane Central Register of Controlled Trials, EMBASE, ERIC, MEDLINE, PsycINFO, OpenGrey, Web of Science Core Collection, ProQuest Dissertations and Theses (UK and Ireland), ProQuest Dissertations and Theses (abstracts and international), and the WHO International Trials Registry Platform, including ClinicalTrials.gov for double-blind RCTs with a placebo arm, lasting at least one week, including adults with a diagnosis of ADHD based on DSM-III, DSM-III-R, DSM-IV(TR), DSM-5 or ICD-9- or 10, and reporting data on efficacy, tolerability (drop-out due to side effects) and acceptability (drop-out due to any cause) of guanfacine, clonidine, or atomoxetine. Additionally, we searched for RCTs of viloxazine extended release (ER), approved for ADHD in 2021. Random-effects meta-analyses were conducted, and the risk of bias for individual RCTs was assessed using the Cochrane Risk of Bias tool. RESULTS: We included 18 studies in the meta-analyses (4308 participants) plus one additional study in the narrative synthesis (374 participants). The meta-analysis showed that atomoxetine (15 RCTs) (Hedge's g = - 0.48, 95% CI [- 0.64; - 0.33]), guanfacine (two RCTs) (Hedge's g = - 0.66, 95% CI [- 0.94; - 0.38]) and viloxazine ER (one RCT) were significantly more efficacious than placebo. Atomoxetine was less well tolerated than placebo, while tolerability of guanfacine and viloxazine ER could not be meta-analysed, since only one study, for each medication, reported on it. CONCLUSIONS: All investigated nonstimulants were more efficacious in the treatment of ADHD in adults, than placebo, while the placebo had better acceptability and tolerability. PROTOCOL: https://osf.io/5vnmt/?view_only=2bf87ed12ba94645babedceeee4c0120 .

Explanatory models and mental health treatment: is vodou an obstacle to psychiatric treatment in rural Haiti?

Vodou as an explanatory framework for illness has been considered an impediment to biomedical psychiatric treatment in rural Haiti by some scholars and Haitian professionals. According to this perspective, attribution of mental illness to supernatural possession drives individuals to seek care from houngan-s (Vodou priests) and other folk practitioners, rather than physicians, psychologists, or psychiatrists. This study investigates whether explanatory models of mental illness invoking supernatural causation result in care-seeking from folk practitioners and resistance to biomedical treatment. The study comprised 31 semi-structured interviews with community leaders, traditional healers, religious leaders, and biomedical providers, 10 focus group discussions with community members, community health workers, health promoters, community leaders, and church members; and four in-depth case studies of individuals exhibiting mental illness symptoms conducted in Haiti's Central Plateau. Respondents invoked multiple explanatory models for mental illness and expressed willingness to receive treatment from both traditional and biomedical practitioners. Folk practitioners expressed a desire to collaborate with biomedical providers and often referred patients to hospitals. At the same time, respondents perceived the biomedical system as largely ineffective for treating mental health problems. Explanatory models rooted in Vodou ethnopsychology were not primary barriers to pursuing psychiatric treatment. Rather, structural factors including scarcity of treatment resources and lack of psychiatric training among health practitioners created the greatest impediments to biomedical care for mental health concerns in rural Haiti.

From Structural Disparities to Neuropharmacology: A Review of Adult Attention-Deficit/Hyperactivity Disorder Medication Treatment.

Adult attention-deficit/hyperactivity disorder (ADHD) is an early-onset disorder with many functional impairments and psychiatric comorbidities. Although no treatment fully mitigates impairments associated with ADHD, effective management is possible with pharmacologic and nonpharmacologic treatments. The etiology and pathophysiology of ADHD are remarkably complex and the disorder is continuously distributed in the population. While these findings have been well documented in studies with predominantly white samples, ADHD may affect racial and ethnic minorities differentially, given diagnostic and treatment disparities. This review provides an updated overview of the epidemiology, etiology, neurobiology, and neuropharmacology of ADHD, addressing racial and ethnic disparities whereby data are available.

Dialog Across Cultures: Therapy for Diverse Families.

Child and adolescent psychiatrists (CAPs) work at the intersections of families, cultures, and systems, which affect engagement in care, assessment, and treatment planning. There are several practical strategies that CAPs can apply to practice cultural humility, to join with families, to facilitate difficult conversations and to work through misalignment. Culturally inclusive family-based care can promote greater understanding and lead to stronger outcomes with families as well as help mitigate mental health impact of structural racism and social inequities.

Experiences of Intimate Partner Violence: Findings From Interviews With South Asian Women in the United States.

Eleven South Asian women were recruited from three domestic violence agencies in the United States and interviewed to examine their experiences with intimate partner violence (IPV). The interviews were analyzed using a grounded theory approach. Themes included detailed barriers and facilitators to disclosure of the abuse and leaving the abusive relationship. Findings suggest that families of origin and in-laws play a significant role in the process of leaving the relationship. Children are often cited as a source of strength for the women. The process of healing and recovery after leaving a relationship with IPV was also discussed by women enrolled in this study. Pragmatic approaches to addressing IPV among South Asian women in health care settings are also considered.

Interoception in Psychiatric Disorders: A Review of Randomized, Controlled Trials with Interoception-Based Interventions.

Interoception, or the process of sensing, interpreting, and integrating internal bodily signals, has increasingly been the subject of scientific research over the past decade but is still not well known in clinical practice. The aim of this article is to review clinical treatment interventions that use interoception, to synthesize the current research knowledge, and to identify the gaps where future research is needed. We conducted a comprehensive literature search on randomized, controlled trials that both include interoception in treatment interventions for individuals with psychiatric disorders and measure aspects of interoception using self-report measures. Out of 14 randomized, controlled trials identified, 7 found that interventions with interoception were effective in ameliorating symptoms. These studies included individuals with anxiety disorders, eating disorders, psychosomatic disorders, and addictive disorders. All of the intervention studies with positive clinical outcomes also demonstrated changes on interoceptive measures; however, these measures were often related to specific illness symptoms. Interoception may be a mechanism of action in improving clinical symptomatology, though studies incorporating general, symptom-independent interoceptive measures remain scarce. To further our understanding of the role interoception has in psychiatric disorders and their treatment, more studies integrating interoceptive measures are needed, along with a clearer definition of interoceptive terms used.

Strategies for assessing mental health in Haiti: local instrument development and transcultural translation.

The lack of culturally appropriate mental health assessment instruments is a major barrier to screening and evaluating efficacy of interventions. Simple translation of questionnaires produces misleading and inaccurate conclusions. Multiple alternate approaches have been proposed, and this study compared two approaches tested in rural Haiti. First, an established transcultural translation process was used to develop Haitian Kreyòl versions of the Beck Depression Inventory (BDI) and Beck Anxiety Inventory (BAI). This entailed focus group discussions evaluating comprehensibility, acceptability, relevance, and completeness. Second, qualitative data collection was employed to develop new instruments: the Kreyòl Distress Idioms (KDI) and Kreyòl Function Assessment (KFA) scales. For the BDI and BAI, some items were found to be nonequivalent due to lack of specificity, interpersonal interpretation, or conceptual nonequivalence. For all screening tools, items were adjusted if they were difficult to endorse or severely stigmatizing, represented somatic experiences of physical illness, or were difficult to understand. After the qualitative development phases, the BDI and BAI were piloted with 31 and 27 adults, respectively, and achieved good reliability. Without these efforts to develop appropriate tools, attempts at screening would have captured a combination of atypical suffering, everyday phenomena, and potential psychotic symptoms. Ultimately, a combination of transculturally adapted and locally developed instruments appropriately identified those in need of care through accounting for locally salient symptoms of distress and their negative sequelae.

Idioms of distress, ethnopsychology, and the clinical encounter in Haiti's Central Plateau.

Haiti's 2010 earthquake mobilized mental health and psychosocial interventions from across the globe. However, failure to understand how psychological distress is communicated between lay persons and health workers in rural clinics, where most Haitians access care, has been a major limitation in providing mental health services. The goal of this study was to map idioms of distress onto Haitian ethnopsychologies in a way that promotes improved communication between lay persons and clinicians in rural Haiti. In Haiti's Central Plateau, an ethnographic study was conducted in May and June 2010, utilizing participant observation in rural clinics, 31 key informant interviews, 11 focus groups, and four case studies. Key informants included biomedical practitioners, traditional healers, community leaders, and municipal and religious figures. Deductive and inductive themes were coded using content analysis (inter-rater reliability > 0.70). Forty-four terms for psychological distress were identified. Head (tèt) or heart (kè) terms comprise 55% of all qualitative text segments coded for idioms of distress. Twenty-eight of 142 observed patient-clinician contacts involved persons presenting with tèt terms, while 29 of the 142 contacts were presentations with kè terms. Thus, 40% of chief complaints were conveyed in either head or heart terms. Interpretations of these terms differed between lay and clinical groups. Lay respondents had broad and heterogeneous interpretations, whereas clinicians focused on biomedical concepts and excluded discussion of mental health concerns. This paper outlines preliminary evidence regarding the psychosocial dimensions of tèt and kè-based idioms of distress and calls for further exploration. Holistic approaches to mental healthcare in Haiti's Central Plateau should incorporate local ethnopsychological frameworks alongside biomedical models of healthcare.

The renin-angiotensin pathway in posttraumatic stress disorder: angiotensin-converting enzyme inhibitors and angiotensin receptor blockers are associated with fewer traumatic stress symptoms.

OBJECTIVE: Posttraumatic stress disorder (PTSD) is a debilitating stress-related illness associated with trauma exposure. The peripheral and central mechanisms mediating stress response in PTSD are incompletely understood. Recent data suggest that the renin-angiotensin pathway, essential to cardiovascular regulation, is also involved in mediating stress and anxiety. In this study, the authors examined the relationship between active treatment with blood pressure medication, including angiotensin-converting enzyme (ACE) inhibitors and angiotensin receptor blockers (ARBs), and PTSD symptom severity within a highly traumatized civilian medical population. METHOD: Cross-sectional, observational data were analyzed from a larger study; patients were recruited from Grady Memorial Hospital's outpatient population from 2006 to November 2010. Multivariable linear regression models were fit to statistically evaluate the independent association of being prescribed an ACE inhibitor or ARB with PTSD symptoms, using a subset of patients for whom medical information was available (n = 505). Categorical PTSD diagnosis was assessed using the modified PTSD Symptom Scale (PSS) based on DSM-IV criteria, and PTSD symptom severity (the primary outcome of interest) was measured using the PSS and Clinician Administered PTSD Scale. RESULTS: A significant association was determined between presence of an ACE inhibitor/ARB medication and decreased PTSD symptoms (mean PSS score 11.4 vs 14.9 for individuals prescribed vs not prescribed ACE inhibitors/ARBs, respectively [P = .014]). After adjustment for covariates, ACE inhibitor/ARB treatment remained significantly associated with decreased PTSD symptoms (P = .044). Notably, other blood pressure medications, including ß-blockers, calcium channel blockers, and diuretics, were not significantly associated with reduced PTSD symptoms. CONCLUSIONS: These data provide the first clinical evidence supporting a role for the renin-angiotensin system in the regulation of stress response in patients diagnosed with PTSD. Further studies should examine whether available medications targeting this pathway should be considered for future treatment and potential protection against PTSD symptoms.