Inequality on the frontline: A multi-country study on gender differences in mental health among healthcare workers during the COVID-19 pandemic.

Healthcare workers (HCWs) were at increased risk for mental health problems during the COVID-19 pandemic, with prior data suggesting women may be particularly vulnerable. Our global mental health study aimed to examine factors associated with gender differences in psychological distress and depressive symptoms among HCWs during COVID-19. Across 22 countries in South America, Europe, Asia and Africa, 32,410 HCWs participated in the COVID-19 HEalth caRe wOrkErS (HEROES) study between March 2020 and February 2021. They completed the General Health Questionnaire-12, the Patient Health Questionnaire-9 and questions about pandemic-relevant exposures. Consistently across countries, women reported elevated mental health problems compared to men. Women also reported increased COVID-19-relevant stressors, including insufficient personal protective equipment and less support from colleagues, while men reported increased contact with COVID-19 patients. At the country level, HCWs in countries with higher gender inequality reported less mental health problems. Higher COVID-19 mortality rates were associated with increased psychological distress merely among women. Our findings suggest that among HCWs, women may have been disproportionately exposed to COVID-19-relevant stressors at the individual and country level. This highlights the importance of considering gender in emergency response efforts to safeguard women's well-being and ensure healthcare system preparedness during future public health crises.

Disability benefits protect against lost income for South Africans living with Schizophrenia.

Little is known about the economic impact of disability grants for people living with schizophrenia in low- and middle- income countries. In this brief report, we show that receipt of disability benefits is significantly associated (ß = 0.105, p < 0.0001) with increased household and personal wealth in large sample of people living with schizophrenia in South Africa (n = 1154). This study provides further support for the use of disability grants as a mechanism to protect people living with schizophrenia and their families against the economic costs associated with schizophrenia.

Psychometric Properties and Diagnostic Associations of the Short-Form Community Assessment of Psychic Experiences in a Population-Based Sample of 29 021 Adult Men.

BACKGROUND AND HYPOTHESIS: Around 5%-7% of the adult population are estimated to have lifetime psychotic experiences (PEs), which are associated with psychosis risk. PEs assessed with Community Assessment of Psychic Experiences (CAPE) are associated with psychosis but also non-psychotic disorders, which could be partly explained by CAPE indirectly capturing emotional symptoms. We investigated the psychometric properties of a shorter version, CAPE-9, and whether CAPE-9 scores are associated with lifetime psychotic or non-psychotic mental disorders after controlling for current anxiety and depressive symptoms. DESIGN: CAPE-9 questionnaire data were obtained from 29 021 men (42.4 ± 5.6 yrs.) from the Norwegian Mother, Father, and Child Cohort Study. We investigated CAPE-9 reliability and factor structure. Logistic regression was used to test effects of current anxiety and depressive symptoms (SCL-12) on associations between CAPE-9 scores and psychiatric diagnoses. RESULTS: CAPE-9 fit a previously reported 3-factor structure and showed good reliability. Twenty-six percent reported at least one lifetime PE. CAPE-9 scores were significantly associated with most psychiatric disorders (schizophrenia, depression, bipolar disorder, substance abuse, anxiety, trauma-related disorders, and ADHD). After controlling for concurrent emotional symptoms, only associations with schizophrenia (OR = 1.29; 95% CI = 1.18-1.38) and trauma-related disorders (OR = 1.09; CI = 1.02-1.15) remained significant. CONCLUSIONS: CAPE-9 showed good psychometric properties in this large population-based adult male sample, and PEs were more clearly associated with psychotic disorders after controlling for current emotional symptoms. These results support the use of the short CAPE-9 as a cost-effective tool for informing public health initiatives and advancing our understanding of the dimensionality of psychosis.

Psychotic experiences among Black college students in the United States: The role of socioeconomic factors and discrimination.

BACKGROUND: Psychosis is more prevalent among Black individuals compared with White individuals. However, it is unknown whether this disparity exists among college populations in the United States, and if so, what factors contribute to the disparity. METHODS: We analyzed data from Black and White young adult students using the Health Minds Study (2020-2021), which is a survey administered at 140 colleges in the U.S. Using mediation analysis, we examined the extent to which the relation between race and psychotic experiences was mediated by socioeconomic factors (past and current financial distress, food insecurity, parental education) and discrimination. RESULTS: Approximately 38 % of Black students and 30 % of White students reported lifetime psychotic experiences. Including all socioeconomic factors together in the same model accounted for just over half (50.2 %) the association between race and psychotic experiences. We then conducted additional analyses examining discrimination, all the socioeconomic factors plus discrimination accounted for 81.5 % of the association between race and psychotic experiences. When disentangling the mediators, food insecurity and discrimination accounted for the largest percentages of the association. The effects of past financial distress and parental education were modified by race. CONCLUSION: Black college students were more likely to report lifetime psychotic experiences than their White counterparts. Moreover, socioeconomic factors and discrimination made significant contributions to this racial difference.

Comparing different operationalizations of allostatic load measured in mid-life and their patterning by race and cumulative life course socioeconomic status.

Since its conceptualization, there has been a lack of consensus on the best way to operationalize allostatic load (AL). As a marker of the cumulative, physiological wear and tear on the body resulting from chronic exposure to stressors, it follows that AL should be higher among people who have faced more stressful life experiences. Thus, the purpose of this study was to construct AL scores using different operationalizations and, as a measure of construct validity, compare whether each construction produced expected disparities in AL by race and a composite socioeconomic status (SES) variable which accounts for measures over the life course; we also explored differences by sex. We conducted the study in a sample of 45-52-year-old offspring from the Child Health and Development Studies, a longitudinal birth cohort established in the early 1960s. AL scores were constructed in 6 different ways and included 10 biomarkers from inflammatory, neuroendocrine, cardiovascular, and metabolic systems. Our main approach to constructing AL was to sum across high-risk biomarker quartiles, correct for medication use, and use sex-specific high-risk quartiles for specific biomarkers. Alternative constructions did not use sex-specific quartiles and/or weighted biomarkers within subsystems and/or did not correct for medication use. We estimated differences in AL scores by race, SES, sex and their pairwise interactions. All constructions of AL, including the main approach, produced expected disparities by race (higher scores for Black vs. non-Black participants) and life course SES (higher scores for low vs. high SES participants). However, disparities by sex only emerged when the AL score was constructed via approaches that did not use sex-specific high-risk quartiles; for these alternative constructions, overall, female participants had higher AL scores than male participants and Black female participants had the highest AL scores in the sample. For most constructions, the pairwise interaction between sex and SES, showed a stronger disparity in AL scores between low and high-SES female compared with low- and high-SES male participants; this suggests that, in terms of lowering AL, high life course SES may be more important for female than male participants. In conclusion, our results suggest that the basic AL concept is consistently expressed in different operationalizations, making it an especially useful and robust tool for understanding disparities by race and SES.

Efficacy and cost-effectiveness of task-shared care for people with severe mental disorders in Ethiopia (TaSCS): a single-blind, randomised, controlled, phase 3 non-inferiority trial.

BACKGROUND: There have been no trials of task-shared care (TSC) using WHO's mental health Gap Action Programme for people with severe mental disorders (psychosis or affective disorder) in low-income or middle-income countries. We aimed to evaluate the efficacy and cost-effectiveness of TSC compared with enhanced specialist mental health care in rural Ethiopia. METHODS: In this single-blind, phase 3, randomised, controlled, non-inferiority trial, participants had a confirmed diagnosis of a severe mental disorder, recruited from either the community or a local outpatient psychiatric clinic. The intervention was TSC, delivered by supervised, non-physician primary health care workers trained in the mental health Gap Action Programme and working with community health workers. The active comparison group was outpatient psychiatric nurse care augmented with community lay workers (PSY). Our primary endpoint was whether TSC would be non-inferior to PSY at 12 months for the primary outcome of clinical symptom severity using the Brief Psychiatric Rating Scale, Expanded version (BPRS-E; non-inferiority margin of 6 points). Randomisation was stratified by health facility using random permuted blocks. Independent clinicians allocated groups using sealed envelopes with concealment and outcome assessors and investigators were masked. We analysed the primary outcome in the modified intention-to-treat group and safety in the per-protocol group. This trial is registered with ClinicalTrials.gov, number NCT02308956. FINDINGS: We recruited participants between March 13, 2015 and May 21, 2016. We randomly assigned 329 participants (111 female and 218 male) who were aged 25-72 years and were predominantly of Gurage (198 [60%]), Silte (58 [18%]), and Mareko (53 [16%]) ethnicity. Five participants were found to be ineligible after randomisation, giving a modified intention-to-treat sample of 324. Of these, 12-month assessments were completed in 155 (98%) of 158 in the TSC group and in 158 (95%) of 166 in the PSY group. For the primary outcome, there was no evidence of inferiority of TSC compared with PSY. The mean BPRS-E score was 27·7 (SD 4·7) for TSC and 27·8 (SD 4·6) for PSY, with an adjusted mean difference of 0·06 (90% CI -0·80 to 0·89). Per-protocol analyses (n=291) were similar. There were 47 serious adverse events (18 in the TSC group, 29 in the PSY group), affecting 28 participants. These included 17 episodes of perpetrated violence and seven episodes of violent victimisation leading to injury, ten suicide attempts, six hospital admissions for physical health conditions, four psychiatric admissions, and three deaths (one in the TSC group, two in the PSY group). The incremental cost-effectiveness ratio for TSC indicated lower cost of -US$299·82 (95% CI -454·95 to -144·69) per unit increase in BPRS-E scores from a health care sector perspective at 12 months. INTERPRETATION: WHO's mental health Gap Action Programme for people with severe mental disorders is as cost-effective as existing specialist models of care and can be implemented effectively and safely by supervised non-specialists in resource-poor settings. FUNDING: US National Institute of Mental Health.

Implementation of a pilot community-based psychosocial intervention for patients with psychoses in Chile and Brazil: a comparative analysis of users' perspectives.

BACKGROUND: Few studies provide clear rationale for and the reception of adaptations of evidence-based interventions. To address this gap, we describe the context-dependent adaptations in critical time intervention-task shifting (CTI-TS), a manualized recovery program for individuals with psychosis in Rio de Janeiro, Brazil and Santiago, Chile. Implications of the adaptations - incorporating a task-shifting approach and modifying the mode of community-based service delivery - are examined from users' perspectives. METHODS: A secondary analysis of in-depth interviews with CTI-TS users (n = 9 in Brazil; n = 15 in Chile) was conducted. Using the framework method, we thematically compared how participants from each site perceived the main adapted components of CTI-TS. RESULTS: Users of both sites appreciated the task-shifting worker pair to provide personalized, flexible, and relatable support. They wanted CTI-TS to be longer and experienced difficulty maintaining intervention benefits in the long-term. In Chile, stigma and a perceived professional hierarchy toward the task-shifting providers were more profound than in Brazil. Engagement with community-based services delivery in homes and neighborhoods (Chile), and at community mental health centers (Brazil) were influenced by various personal, familial, financial, and social factors. Uniquely, community violence was a significant barrier to engagement in Brazil. CONCLUSION: CTI-TS' major adaptations were informed by the distinct mental health systems and social context of Santiago and Rio. Evaluation of user experiences with these adaptations provides insights into implementing and scaling-up task-shifting and community-oriented interventions in the region through the creation of specialized roles for the worker pair, targeting sustained intervention effects, and addressing socio-cultural barriers.

Racial differences in alcohol and tobacco use in adolescence and mid-adulthood in a community-based sample.

PURPOSE: Smoking and alcohol use have been posited as possible contributors to racial health disparities, despite higher smoking and alcohol use among non-Hispanic White youth and young adults compared to Blacks. To further investigate this claim, we aim to assess variation in alcohol and cigarette use across two distinct points of the life course. METHOD: Data are from a subset of 559 (279 male, 280 female) self-identified Black and White participants of the Child Health and Development study. Self-report alcohol and cigarette use were collected between age 15-17 and at mean age 50. Logistic regressions were estimated; supplementary analyses adjusted for maternal age, prenatal smoking, household income, childhood SES, and education. RESULTS: White participants were more likely to drink regularly (Odds ratio (OR) 2.2; 95%CI 1.2, 4.0) and be intoxicated (OR 2.0; 95%CI 1.2, 3.2) in adolescence compared with Blacks. In mid-adulthood, Whites remained more likely to currently drink (OR 2.3; 95%CI 1.6, 3.4) but among drinkers, less likely to binge drink (OR 0.4; 95%CI 0.2, 0.8). White participants were less likely to smoke in mid-adulthood (OR 0.4; 95%CI 0.3, 0.6), but among smokers, were more likely to smoke ≥ ½ a pack per day (OR 3.4; 95%CI 1.5, 7.8). CONCLUSIONS: Blacks were less likely to engage in drinking across the life course, but, among drinkers, more likely to binge drink in mid-adulthood. Blacks were more likely to smoke in mid-adulthood, but smoked infrequently compared with Whites. These patterns suggest that a reframing of disparities mechanisms to focus on broader structural and social factors may benefit progress in understanding and ameliorating inequities.

Service Use Following First-Episode Schizophrenia Among Commercially Insured Youth.

OBJECTIVE: To investigate patterns of mental health service and antipsychotic use following a first-episode schizophrenia (FES) and to examine the role of the treatment setting in which individuals are first diagnosed. METHOD: Analysis of de-identified administrative claims data from the OptumLabs Data Warehouse was used to identify 1450 privately insured youth and young adults aged 14 through 30 with FES from January 1, 2011 through December 31, 2015. Regression analysis was used to estimate the use of mental health services during the year following FES, by type of service and by site of index diagnosis. RESULTS: In the year following FES, 79.7% of youth received outpatient mental health services and 35.8% filled a prescription for antipsychotic medication. Among service users, mean outpatient visits were 15.9 and mean antipsychotic fills were 8.3. Youth who received an index diagnosis of FES in an inpatient setting were more likely to fill an antipsychotic medication than youth with FES in other settings. Youth who received an index diagnosis of FES during a specialty mental health outpatient visit had greater use of outpatient mental health than youth who received their diagnosis during a primary care visit. CONCLUSIONS: Despite evidence-based guidelines supporting outpatient psychosocial care and antipsychotic treatment for FES, one-fifth of this cohort did not use outpatient services and the majority did not fill any prescriptions for antipsychotic medications during the year following FES. Our findings provide renewed urgency to ongoing efforts to accelerate early identification and care coordination for youth with FES.

Body mass index across the life course: emergence of race-by-sex disparities in early childhood.

PURPOSE: The purpose of this study was to assess when in the life-course race-by-sex disparities in body mass index (BMI) emerge. METHODS: Child Health and Development Studies participants, from whom height and weight data were collected at ages 5, 9-11, and 15-17 years, were followed up at the age of 50 years for anthropometric outcomes. Follow-up was completed for 605 subjects, 460 of whom were assessed for height and weight at the age of 50 years, had at least one available childhood BMI measure, and self-identified as either non-Hispanic black or non-Hispanic white. Linear regression analyses were conducted to determine whether interactions existed between race (black vs. white) and sex for predicting BMI at ages 5, 9-11, 15-17, and 50 years. RESULTS: At age 5 years, BMI was independent of sex for both blacks and whites, but by the age of 9-11 years, BMI was sex-dependent in blacks, with higher BMI observed among black females. This sex dependence for BMI among blacks persisted at ages 15-17 years and age 50 years. The race-by-sex interaction was significant at ages 9-11, 15-17, and 50 years (P for interaction = 0.001, 0.002, and 0.01, respectively). CONCLUSIONS: Race-by-sex disparities in body size were observed by the age of 9-11 years and persisted until the age of 50 years.

Understanding the implementation of coordinated specialty Care for Early Psychosis in New York state: A guide using the RE-AIM framework.

AIM: Consistent evidence shows that early interventions for individuals with psychosis lead to improvements in symptoms, social functioning and treatment satisfaction. These results, combined with the allocation of specific funds for early psychosis services, have contributed to the emergence and dissemination of coordinated specialty care for early psychosis in the United States. Despite the rapid growth of such services across the country over the last 5 years, implementation processes are not yet well understood. We employ the RE-AIM (Reach, Effectiveness, Adoption, Implementation and Maintenance) framework to describe processes, achievements and challenges of an early psychosis program called OnTrackNY that has been implemented in New York State. METHODS: OnTrackNY is a coordinated specialty care program that delivers early intervention services that include both medications and psychosocial interventions to youths experiencing a first episode of non-affective psychosis. By drawing on outcome and care process data that are collected quarterly from all OnTrackNY sites, we describe the status of each RE-AIM dimension regarding OnTrackNY implementation followed by an evaluation of both achievements and shortcomings. RESULTS: In general terms, OnTrackNY has shown to be a scalable and sustainable model for addressing early psychosis, reaching and providing recovery-oriented services to a large population in need. CONCLUSION: Despite its advancements, a series of limitations pose challenges to the implementation and maintenance of the model including, but not to, the lack of incentives for coordination of services, the fragmentation of child and adult services, and concerns about financial sustainability.

Disparities in self-rated health across generations and through the life course.

Extensive evidence leads us to expect that health disparities by race and socioeconomic status found in one generation might be reproduced in the next. To the extent that this occurs it is important to assess life course processes responsible for the reproduction. Prospective evidence concerning such life course processes is hard to come by as it requires long-term follow-up of individuals from childhood through adult life. We present data from the Child Health and Development Disparities study that provides evidence relevant to this issue with respect to self-rated health. Mothers and offspring recruited in California's Bay Area between 1959 and 1967 were assessed during pregnancy with follow-up exams of offspring along with in-person interviews with mothers (at offspring ages 5, 9-11, 15-17) and offspring (at ages 15-17, ∼50). Available data allow us to assess the importance of three potential life course pathways in the reproduction of inequalities in self-rated health - socioeconomic pathways, cognitive pathways and pathways involving emerging health itself. As expected we found that race and SES disparities in SRH are reproduced across generations. They are evident in mothers, not strong or significant in offspring at 15-17, but present once again in offspring at age ∼50. Concerning potential pathways, we found that indicators of child health were related to adult SRH and played some role in accounting for race but not SES disparities in adult SRH. Cognitive abilities were unrelated to adult SRH with childhood SES controlled. Childhood SES was associated with adult SRH independent of other childhood factors and is reduced to non-significance only when offspring college attainment is controlled. Race and SES disparities in self-reported health in one generation are re-expressed in the next with strongest support for SES pathways in this transmission.

Mervyn Susser and community psychiatry.

Mervyn Susser's contributions to community psychiatry from 1957-1968 comprised a creative and significant phase of his career, though less well known than his other work. This included work in Salford, a town next to Manchester, where he developed a programme to improve community health (including mental health care), as well as a programme of research on mental disorders. The publication of his book, Community Psychiatry: Epidemiologic and Social Themes (1968) attempted to set the stage for the practice of psychiatry in the community and to establish a future direction for development of the field.

Task sharing of a psychological intervention for maternal depression in Khayelitsha, South Africa: study protocol for a randomized controlled trial.

BACKGROUND: Maternal depression carries a major public health burden for mothers and their infants, yet there is a substantial treatment gap for this condition in low-resourced regions such as sub-Saharan Africa. To address this treatment gap, the strategy of "task sharing" has been proposed, involving the delivery of interventions by non-specialist health workers trained and supervised by specialists in routine healthcare delivery systems. Several psychological interventions have shown benefit in treating maternal depression, but few have been rigorously evaluated using a task sharing approach. The proposed trial will be the first randomised controlled trial (RCT) evaluating a task sharing model of delivering care for women with maternal depression in sub-Saharan Africa. The objective of this RCT is to determine the effectiveness and cost-effectiveness of a task sharing counseling intervention for maternal depression in South Africa. METHODS/DESIGN: The study is an individual-level two-arm RCT. A total of 420 depressed pregnant women will be recruited from two ante-natal clinics in a low-income township area of Cape Town, using the Edinburgh Postnatal Depression Scale to screen for depression; 210 women will be randomly allocated to each of the intervention and control arms. The intervention group will be given six sessions of basic counseling over a period of 3 to 4 months, provided by trained community health workers (CHW)s. The control group will receive three monthly phone calls from a CHW trained to conduct phone calls but not basic counseling. The primary outcome measure is the 17-Item Hamilton Depression Rating Scale (HDRS-17). The outcome measures will be applied at the baseline assessment, and at three follow-up points: 1 month before delivery, and 3 and 12 months after delivery. The primary analysis will be by intention-to-treat and secondary analyses will be on a per protocol population. The primary outcome measure will be analyzed using linear regression adjusting for baseline symptom severity measured using the HDRS-17. DISCUSSION: The findings of this trial can provide policy makers with evidence regarding the effectiveness and cost-effectiveness of structured psychological interventions for maternal depression delivered by appropriately trained and supervised non-specialist CHWs in sub-Saharan Africa. TRIAL REGISTRATION: Clinical Trials (ClinicalTrials.gov): NCT01977326, registered on 24/10/2013; Pan African Clinical Trials Registry (http://www.pactr.org): PACTR201403000676264, registered on 11/10/2013.

Maternal B vitamin status in pregnancy week 18 according to reported use of folic acid supplements.

SCOPE: Epidemiological studies on the association between pregnancy outcomes and use of periconceptional folic acid are often based on maternal reported intake. Use of folic acid during pregnancy is associated with a higher socioeconomic status known to have an impact on diet quality. We have studied plasma B vitamin status according to reported use of folic acid supplements during the periconceptional period in Norwegian women. METHODS AND RESULTS: Plasma levels of folate, cobalamin, pyridoxal 5'-phosphate (vitamin B6), riboflavin, and the metabolic markers total homocysteine, methylmalonic acid and 3-hydro-xykynurenine were measured in pregnancy week 18 and related to reported intake of folic acid from 4 weeks prior to conception throughout week 18 in 2911 women from the Norwegian Mother and Child Cohort Study (MoBa) conducted by the Norwegian Institute of Public Health. Being a folic acid user during the periconceptional period was associated with a better socioeconomic status, and a higher intake of several micronutrients, including vitamins, trace-metals, and omega 3 fatty acids. Folic acid users had a significantly better plasma B vitamin status. CONCLUSION: Epidemiological data based on maternal reported intake of folic acid supplements during pregnancy, should take into account the numerous nutritional implications, in addition to higher blood folate levels, of being a folic acid user.