Examining racial disparity in psychotic disorders related ambulatory care visits: an observational study using national ambulatory medical care survey 2010-2015.

BACKGROUND: One of the most consistent research findings related to race and mental health diseases is the disproportionately high rate of psychotic disorder diagnoses among people of color, specifically people of African descent. It is important to examine if a similar pattern exists among specific psychotic disorders. We aimed to examine the racial/ethnic differences in ambulatory care visits diagnosed with schizophrenia-spectrum disorders (SSDs). METHODS: We analyzed data from the National Ambulatory Medical Care Survey (NAMCS) 2010-2015. The study sample included physician office-based visits by individuals diagnosed with SSDs, including schizophrenia, schizoaffective, and unspecified psychotic disorder (n = 1155). We used descriptive and bivariate analysis by race/ethnicity and three multinomial logistic regression models to test the association between the SSDs and race/ethnicity, adjusting for age, gender, insurance, disposition, medication Rx, and co-morbidity, considering the design and weight. RESULT: Of the 1155 visits for SSDs, 44.8% had schizophrenia, 37.4% had schizoaffective disorder diagnosis, and 19.0% had unspecified psychosis disorder. We found significant racial disparities in the diagnosis of SSDs. Black patients were overrepresented in all three categories: schizophrenia (24%), schizoaffective disorder (17%), and unspecified psychosis disorder (26%). Also, a notable percentage of Black patients (20%) were referred to another physician in cases of schizophrenia compared to other ethnoracial groups (p < 0.0001). Moreover, we found a significant disparity in insurance coverage for schizoaffective disorder, with a higher percentage of Black patients (48%) having Medicaid insurance compared to patients from other ethnoracial groups (p < 0.0001). Black patients had nearly twice the odds of receiving a diagnosis of schizophrenia compared to White patients [AOR = 1.94; 95% CI: 1.28-2.95; P = 0.001]. However, they had significantly lower odds of being diagnosed with schizoaffective disorder [AOR = 0.42, 95% CI: 0.26-0.68; P = 0.003]. Race/ethnicity was not associated with receiving an unspecified psychosis disorder. CONCLUSIONS: Our results show that SSDs, more specifically schizophrenia, continue to burden the mental health of Black individuals. Validation of our findings requires rigorous research at the population level that reveals the epidemiological difference of SSDs diagnoses in different race/ethnicity groups. Also, advancing our understanding of the nature of disparity in SSDs diagnoses among the Black population requires disentangling etiologic and systemic factors in play. This could include psychological stress, the pathway to care, services use, provider diagnostic practice, and experiencing discrimination and institutional and structural racism.

Contribution of a positive psychology-based conceptual framework in reducing physician burnout and improving well-being: a systematic review.

BACKGROUND: The PERMA Model, as a positive psychology conceptual framework, has increased our understanding of the role of Positive emotion, Engagement, Relationships, Meaning, and Achievements in enhancing human potentials, performance and wellbeing. We aimed to assess the utility of PERMA as a multidimensional model of positive psychology in reducing physician burnout and improving their well-being. METHODS: Eligible studies include peer-reviewed English language studies of randomized control trials and non-randomized design. Attending physicians, residents, and fellows of any specialty in the primary, secondary, or intensive care setting comprised the study population. Eligible studies also involved positive psychology interventions designed to enhance physician well-being or reduce physician burnout. Using free text and the medical subject headings we searched CINAHL, Ovid PsychINFO, MEDLINE, and Google Scholar (GS) electronic bibliographic databases from 2000 until March 2020. We use keywords for a combination of three general or block of terms (Health Personnel OR Health Professionals OR Physician OR Internship and Residency OR Medical Staff Or Fellow) AND (Burnout) AND (Positive Psychology OR PERMA OR Wellbeing Intervention OR Well-being Model OR Wellbeing Theory). RESULTS: Our search retrieved 1886 results (1804 through CINAHL, Ovid PsychINFO, MEDLINE, and 82 through GS) before duplicates were removed and 1723 after duplicates were removed. The final review included 21 studies. Studies represented eight countries, with the majority conducted in Spain (n = 3), followed by the US (n = 8), and Australia (n = 3). Except for one study that used a bio-psychosocial approach to guide the intervention, none of the other interventions in this review were based on a conceptual model, including PERMA. However, retrospectively, ten studies used strategies that resonate with the PERMA components. CONCLUSION: Consideration of the utility of PERMA as a multidimensional model of positive psychology to guide interventions to reduce burnout and enhance well-being among physicians is missing in the literature. Nevertheless, the majority of the studies reported some level of positive outcome regarding reducing burnout or improving well-being by using a physician or a system-directed intervention. Albeit, we found more favorable outcomes in the system-directed intervention. Future studies are needed to evaluate if PERMA as a framework can be used to guide system-directed interventions in reducing physician burnout and improving their well-being.

Helmet use and bicycle-related trauma injury outcomes.

Background: It is essential to identify factors that predict helmet use, so as to mitigate the injury and mortality from bicycle accidents.Objective: To examine the relationship between helmet use and the bicycle-related trauma injury outcomes among bicyclists with head/neck injury in the US.Methods: Data from the 2002-2012 National Trauma Data Bank were used, including all trauma bicycle riders involved in bicycle-related accidents whose primary reason for the hospital or Intensive Care Unit stay was head or neck injury. Using multiple logistic regression, the association between helmet use, Injury severity score (ISS), length of stay in hospital (HLOS) and Intensive Care Unit (ICULOS), and mortality was examined.Results: Of the 76,032 bicyclists with head/neck injury, 22% worn helmets. The lowest was among Blacks, Hispanics, and <17 years old. Wearing a helmet significantly reduces injury severity, HLOS, ICULOS, and mortality (i.e total and in-hospital). Males had a severe injury, longer HLOS, ICULOS, and higher mortality than female. Blacks and Hispanics had longer HLOS and ICULOS and higher total mortality than Whites, but had a similar chance for in-hospital mortality.Conclusions: More effort is needed to enhance helmet use among at-risk bicycle riders, which may reduce injury severity, HLOS, ICULOS, and mortality.

Cannabis effects on brain structure, function, and cognition: considerations for medical uses of cannabis and its derivatives.

Background: Cannabis is the most widely used illicit substance worldwide, and legalization for recreational and medical purposes has substantially increased its availability and use in the United States.Objectives: Decades of research have suggested that recreational cannabis use confers risk for cognitive impairment across various domains, and structural and functional differences in the brain have been linked to early and heavy cannabis use.Methods: With substantial evidence for the role of the endocannabinoid system in neural development and understanding that brain development continues into early adulthood, the rising use of cannabis in adolescents and young adults raises major concerns. Yet some formulations of cannabinoid compounds are FDA-approved for medical uses, including applications in children.Results: Potential effects on the trajectory of brain morphology and cognition, therefore, should be considered. The goal of this review is to update and consolidate relevant findings in order to inform attitudes and public policy regarding the recreational and medical use of cannabis and cannabinoid compounds.Conclusions: The findings point to considerations for age limits and guidelines for use.

Adolescent Tobacco/Nicotine Use and the Potential Role of Contingency Management-based Interventions.

ABSTRACT: The high prevalence of tobacco/nicotine use among youth, including e-cigarettes, is a public health problem in the United States. Early exposure leads to an increased risk of dependence and health consequences in adulthood. We reviewed the literature on current treatment approaches for nicotine/tobacco use in adolescents/young adults and highlighted underexplored areas of treatment research. There are no current Food and Drug Administration-approved medications for treatment of nicotine/tobacco use disorders in adolescents. However, in research settings and on a case-to-case basis, clinical practice medications (including nicotine replacement therapy, bupropion, and varenicline) have been prescribed to this population with consideration of risk-benefit analysis when behavioral treatments are not sufficient to address dependence. Among the nonpharmacological interventions, there is evidence to support the potential for expanded use of contingency management in youth. Neural differences predisposing adolescents to substance use, along with higher attentiveness to value of options in decision making (flexible reward system) may enhance the effectiveness of reward-based approaches for treatment of substance use disorders in this population. The overall high rates of nonresponders across psychosocial and pharmacological treatments highlight the importance of considering novel strategies to improve existing interventions. We suggest that future research be done that considers unique characteristics of today's adolescents, such as high social activism and engagement with digital rewards to tailor contingency management for this age group and assess its effectiveness. Adolescents could potentially benefit from rewards administered through digital media (eg, video games, computer-based apps, and social media influencers).

Implementing a Holistic Review Process for Psychiatry Residency Screening and Interviewing.

Within psychiatry, the proportions of individuals underrepresented in medicine (URM) are lower than are the proportions among the general U.S. population. Holistic review of residency applications may alleviate deficiencies in representation and disparities in care. A holistic review process was implemented (2021-2022) in the University of California, San Diego, psychiatry residency program. The data (2016-2022) were extracted from the Electronic Residency Application Service to compare differences in the applicant pool before and after implementation of the holistic review. A total of 6,602 individuals applied to the program between 2016 and 2022, increasing from 762 in 2016 to 1,148 in 2021. The proportion of women applying significantly increased (χ2=12.6, p<0.002), from 42.3% in 2016 to 50.6% in 2022. Across all years, a significantly greater proportion (χ2=22.0, p<0.001) of those selected to interview were women (55.1%), with the greatest proportion in 2022 (64.5%), after implementation of the holistic review. The proportion of applicants from URM groups significantly increased (χ2=28.0, p<0.001), from 13.4% in 2016 to 21.3% in 2022. There were no significant differences in the proportion of these applicants selected to interview across all years and no increase following the holistic review. The proportion of women interviewed was greater than the proportion of women who applied, particularly after implementing the holistic review. The proportion of applicants from URM groups increased over time and, although the proportion interviewed remained greater than the number applying, that number did not change across the years studied.

Addressing Patient-Centered Care Through Mindful Listening and Mentalizing in Psychiatry.

This 21st-Century Psychiatrist column reflects the authors' perceptions of the importance of addressing patient-centered care through mindful listening and mentalizing in psychiatry. The authors maintain that adopting a mentalizing stance is a promising approach for clinicians with diverse backgrounds to humanize clinical practice, especially in today's dynamic high-speed, high-paced, and high-technology environment. Mindful listening and mentalizing are particularly consequential for the field of psychiatry since the COVID-19 pandemic prompted an abrupt transition from in-person to virtual platforms for education and clinical care.

Schizophrenia hospitalization in the US 2005-2014: Examination of trends in demographics, length of stay, and cost.

ABSTRACT: Primarily we aimed to examine the crude and standardized schizophrenia hospitalization trend from 2005 to 2014. We hypothesized that there will be a statistically significant linear trend in hospitalization rates for schizophrenia from 2005 to 2014. Secondarily we also examined trends in hospitalization by race/ethnicity, age, gender, as well as trends in hospitalization Length of Stay (LOS) and inflation adjusted cost.In this observational study, we used Nationwide Inpatient Sample data and International Classification of Diseases, Eleventh Revisions codes for Schizophrenia, which revealed 6,122,284 cases for this study. Outcomes included crude and standardized hospitalization rates, race/ethnicity, age, cost, and LOS. The analysis included descriptive statistics, indirect standardization, Rao-Scott Chi-Square test, t-test, and adjusted linear regression trend.Hospitalizations were most prevalent for individuals ages 45-64 (38.8%), African Americans were overrepresented (25.8% of hospitalizations), and the gender distribution was nearly equivalent. Mean LOS was 9.08 days (95% confidence interval 8.71-9.45). Medicare was the primary payer for most hospitalizations (55.4%), with most of the costs ranging from $10,000-$49,999 (57.1%). The crude hospitalization rates ranged from 790-1142/100,000 admissions, while the US 2010 census standardized rates were 380-552/100,000 from 2005-2014. Linear regression trend analysis showed no significant difference in trend for race/ethnicity, age, nor gender (P > .001). The hospitalizations' overall rates increased while LOS significantly decreased, while hospitalization costs and Charlson's co-morbidity index increased (P < .001).From 2005-2014, the overall US hospitalization rates significantly increased. Over this period, observed disparities in hospitalizations for middle-aged and African Americans were unchanged, and LOS has gone down while costs have gone up. Further studies addressing the important disparities in race/ethnicity and age and reducing costs of acute hospitalization are needed.

Socio-Demographic and Mental Health Profile of Admitted Cases of Self-Inflicted Harm in the US Population.

Self-inflicted harm (SIH) has a substantial lifetime prevalence, it is associated with tremendous costs, and its rate is increasing on a national scale. To examine the characteristics of those admitted for SIH in the US and to investigate the factors that potentially modify the methods used for SIH. This was a retrospective analysis of admitted cases of SIH including suicide attempts between 2007 and 2012 using the National Trauma Data Bank. We included a total of 204,633 cases admitted for SIH. Our participants were 75.1% males. Those aged 15-24 (21%), 25-34 (22%), 35-44 (19%), 45-54 (19%), and 55-64 (10%) years comprised the largest age groups among our cases-70.8%, 11.5%, 11.1%, and 6.6% were, respectively, Caucasians, Hispanics, Blacks, and Asian/Others. Analyses of the SIH methods revealed that Blacks were less likely to self-poison [Odds Ratio (OR): 0.78] compared to Whites, whereas individuals with psychiatric disorders or substance abuse carried 2.5 and 2.0-fold higher risk, respectively. Blacks were also less likely to use anoxic methods (OR: 0.69), whereas patients with psychiatric disorders or substance abuse carried 1.5-fold higher risk. Being Black, Hispanic, and Asian (OR: 0.58, 0.55, and 0.55, respectively) as well as having psychiatric disorders (OR: 0.80) were associated with lower risks of using firearms, whereas its risk was increased with increasing age. Blacks (OR: 0.77) were less likely to cut or pierce in contrast to Hispanics (OR: 1.4), Asians/Others (OR: 1.29), and those with psychiatric disorders (2.5-fold higher risk) or drug abuse (2-fold higher risk). Blacks (OR: 1.11), Hispanics (OR: 1.13), and Asians/Others (OR: 1.57) were more likely to jump from high places, whereas those with substance abuse were less likely (OR: 0.77). Among patients admitted for SIH, males, those aged 15-64 years, and Whites comprised the largest sex, age, and racial/ethnic groups, respectively. We also found that several factors including race/ethnicity, gender, age, and having concurrent psychiatric or drug abuse disorders can potentially influence the methods used for SIH.

Association of Psychiatric Diagnostic Conditions with Hospital Care Outcomes of Patients with Orthopedic Injuries.

CONTEXT: Psychiatric comorbidity is common in orthopedic injury, but the effects on hospital care outcomes have been identified only generally. OBJECTIVE: To quantify psychiatric comorbidity and its outcome effects in a large, multicenter population of inpatients with orthopedic injuries. DESIGN: Retrospective analysis of patient discharge data from 507 California hospitals from 2001 to 2010. Study sample included orthopedic diagnoses using International Classification of Diseases codes for major pelvic and lower extremity injuries in patients older than age 17 years. From the injury data, we extracted psychiatric diagnoses, alcoholism, substance abuse, and sociodemographic characteristics. MAIN OUTCOME MEASURES: Length of stay, surgical complications, and inpatient deaths. RESULTS: The entire injury admissions represented about 1.9% of all hospital admissions and were predominantly older than age 64 years, white, and women with conventional health care insurance. The most common comorbidity in the patients with injury was psychiatric illness (24.7%). The most common psychiatric diagnoses in orthopedic injury admissions were dementia (14.3%) and depression (6.9%) without association. Compared with the injury admissions with no psychiatric diagnosis, admissions with psychiatric diagnosis had higher odds of a hospital stay of 7 or more days, surgical treatment complications, and inhospital death. CONCLUSION: Psychiatric comorbidity adversely affects several hospital outcomes in patients with orthopedic injuries: Length of stay, surgical complications, and inpatient mortality. In low-income populations, the adverse psychiatric effects are incrementally worse. The adverse effects of psychiatric comorbidity, particularly dementia and depression, on hospital outcomes should stimulate improved psychiatric care of many patients at risk of poor clinical outcomes.

The Burden of Road Traffic Injuries in Iran and 15 Surrounding Countries: 1990-2016.

BACKGROUND: The Global Burden of Disease (GBD) Study provides estimates of deaths, years of life lost (YLL), years of life lived with disability (YLD), and disability-adjusted life years (DALYs) due to 249 causes of death, 315 diseases and injuries, and 79 behavioral, environmental, occupational, and metabolic risk factors in 195 countries, territories, and regions by sex and 20 age categories in 195 countries and regions since 1990. In this study, we aimed to present the burden of road traffic injuries (RTIs) in Iran and 15 surrounding countries in 1990-2016. METHODS: The standard Cause of Death Ensemble modeling (CODEm) is used to estimate deaths due to all causes of injury by age, sex, country and year. A range of 27 causes is used for estimating non-fatal health outcomes based on inpatient and outpatient datasets using DisMod-MR 2.0. Disability-adjusted life years (DALYs) estimate quantify the total burden of years lost due to premature death or disability and was computed by summing the fatal burden and non-fatal burden associated with a cause (i.e., YLL+YLD). RESULTS: In 2016, age-standardized transport injuries in Iran accounted for 35.6 (UI: 29.64-43.44) deaths per 100000 compared to 60.8 (UI: 51.04-72.49) in 1990. Transport injury became the fourth leading cause of death in Iran in 2016, up from the 5th leading cause of death in 1990. The burden of RTIs was mainly caused by motor vehicles and motorcycles and mostly affected the economically productive age groups (15-49), males and children, especially those at school age. Afghanistan with 59.14 deaths (52.09-66.8) and UAE with 53.71 deaths (36.59-72.77) had the largest transport injury death rates per 100000. From 1990 to 2016, Iran had -2.06 annual percent change in transport death rates. The lowest annual percent change is reported for Turkmenistan at -3.43. While Pakistan, UAE and Qatar had the highest annual percent change in transport injury. Across all countries, the observed-to-expected ratios for transport injury death rates varied considerably in 2016.The UAE had the largest age-standardized ratios of observed-to-expected rate (2.93), followed by Oman (2.39), Saudi Arabia (2.23), Afghanistan (2.04) and Iran (1.95). CONCLUSIONS: RTIs continue to be a public health burden in Iran and its neighboring countries, even though, there is evidence for decline in RTIs across all countries except Pakistan. The most frequent sub-causes of death and injury are the motor vehicle, motorcycle, and pedestrian injuries. The most vulnerable road users are children and young adults.