Primary Care Providers' Perspectives on Prescribing Antidepressant Medication to Latino Immigrant Patients: A Preliminary Study.

Latinos in the United States are less likely to take antidepressants than non-Latino whites, and more likely to prefer depression treatment in primary care. This preliminary study comprised focus groups (2) with primary care providers (12) serving uninsured immigrant Latinos regarding their experiences prescribing and counseling patients about antidepressants. Barriers and challenges included health literacy, language barriers, and illiteracy; perceived stigma; patients' concerns about addiction, polypharmacy, and adverse effects; time constraints of office visits; and difficulty discussing comorbid posttraumatic stress disorder. Messages providers try to share with patients included allowing time for medications to work, taking medications daily as prescribed, mechanisms of action, weighing risks versus benefits, and flexible options for treatment. Providers' recommendations for improving this process included better low-literacy, culturally appropriate written materials with pictures or videos discussing depression. More research is needed to understand patients' and providers' needs in optimizing counseling about antidepressants, particularly regarding underserved and at-risk US populations.

Treatment of depression and PTSD in primary care clinics serving uninsured low-income mostly Latina/o immigrants: A naturalistic prospective evaluation.

OBJECTIVES: Uninsured immigrants to the United States are psychologically vulnerable due to limited access to mental health services. Latina/o immigrants from Central and South America are further at risk due to high levels of trauma exposure, both in their country of origin and their adopted country. Effective behavioral interventions in primary care are needed to address this services gap for common trauma-related mental disorders, including depression and posttraumatic stress disorder (PTSD). A naturalistic prospective study compared depression and PTSD outcomes for uninsured primary care patients, mostly Latina/o immigrants, in clinics with distinct models for integrating behavioral health services. One clinic had a collaborative care program, that is, a multicomponent, system-level intervention with the goals of facilitating increased screening, improving diagnostic accuracy, increasing uptake of evidence-based treatment, and utilizing measurement-based treatment to target. The other had colocated services, with an on-site therapist. METHOD: One hundred thirty-eight patients with presumptive depression were interviewed at baseline. Follow-up data were collected 8 months later. Care received between the two assessments was ascertained by chart review. RESULTS: There was a significant decrease in depression symptoms regardless of clinic. Factors associated with improved depression outcomes included absence of comorbid PTSD and lack of additional trauma exposures. Although there was overall improvement in PTSD, there was significantly more improvement in the collaborative care clinic. CONCLUSIONS: Results suggest that both models were effective for depression and PTSD; however, the collaborative care model had added benefits for those patients with PTSD. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Knowledge and Preferences Regarding Antidepressant Medication Among Depressed Latino Patients in Primary Care.

US Latinos are less likely to utilize mental health services than non-Latino whites and to take antidepressant medications. This mixed-method study followed a subset (N = 28) of a research sample of depressed Latino immigrant primary care patients, who took depression medication, with a telephone interview to study their knowledge about and experiences with antidepressant medications. Most (82%) reported taking medication for 2 months or more, and 75% reported feeling better, whereas more than half reported side effects. Most (61%) agreed that antidepressants are generally safe and helpful in treating depression (68%); however, many believed they could be addictive (39%). Fifty percent of patients who discontinued their medication did not inform their providers. Twelve of the 28 patients also participated in focus groups about interactions with providers and made suggestions for conveying information about antidepressants. Patients suggested videos as a format to disseminate medication information because they do not require written comprehension. Other patient recommendations are presented.

Enhancing motivational interviewing training in a family medicine clerkship.

PROBLEM: Despite the prevalence of unhealthy behaviors among patients in the healthcare system, traditional medical training involves little or no exposure to effective behavior change techniques such as Motivational Interviewing. INTERVENTION: An online learning community for enhanced training in Motivational Interviewing was developed for 3rd-year medical students. The website included educational materials about Motivational Interviewing as well as problematic health behaviors, a repository of exemplar videos and student videos with feedback, and a discussion board. Student participants were given the opportunity to record an encounter with a patient and to receive feedback on their use of Motivational Interviewing from a faculty member. CONTEXT: Student volunteers in the Family Medicine Clerkship at Georgetown University School of Medicine were randomized to enhanced training, which included the online learning community, or training as usual. All student volunteers completed a questionnaire assessing self-efficacy initially and at the end of the clerkship. Students also participated in an Observed Structured Clinical Exam, which was subsequently coded by a blinded rater for behavioral counts of Motivational Interviewing techniques, key steps in Motivational Interviewing, and overall Motivational Interviewing style. OUTCOME: Students in the enhanced training arm were rated as having significantly higher scores in Motivational Interviewing style in the Observed Structured Clinical Exam than training as usual students. A significant increase in self-efficacy from pre- to posttest in the overall sample was observed but between-group differences were not significant. Student feedback was particularly positive regarding video recorded practice sessions with patients and individualized feedback. LESSONS LEARNED: The results of this study as well as student feedback suggest that future work should include patient practice sessions and individualized feedback in developing Motivational Interviewing curricula.

Mental health of HIV-seropositive women during pregnancy and postpartum period: a comprehensive literature review.

With growing numbers of HIV-seropositive (HIV+) women of child-bearing age and increased access to effective clinical protocols for preventing mother-to-child transmission (MTCT) of HIV, mental health-related factors have become increasingly relevant due to their potential to affect the women's quality of life, obstetric outcomes and risk of MTCT. This review synthesizes evidence from 53 peer-reviewed publications examining mental health-related variables in pregnant and postpartum HIV+ women. The presentation of results is organized by the level of socioeconomic resources in the countries where studies were conducted (i.e., high-, middle-, and low-income countries). It is concluded that psychiatric symptoms, particularly depression, and mental health vulnerabilities (e.g., inadequate coping skills) are widespread among pregnant HIV+ women globally and have a potential to affect psychological well-being, quality of life and salient clinical outcomes. The current body of evidence provides rationale for developing and evaluating clinical and structural interventions aimed at improving mental health outcomes and their clinical correlates in pregnant HIV+ women.

Validation of a Standardized Patient Checklist for Patient-Centered Communication: The G-PACER.

This study sought to validate the Georgetown PAtient-CEnteredness Rating Scale (G-PACER) standardized patient (SP) checklist as a measure of patient-centered communication in patient-provider interactions. Patient centeredness is associated with improved doctor-patient communication and better health outcomes. Simulated medical encounters using SPs are an important way to teach and evaluate provider communication skills, yet validated SP scales that focus on patient-centered communication are limited. Two versions of an SP checklist of provider interaction behaviors, the G-PACER, were developed as part of a training designed to improve relationships between providers and patients who have experienced trauma. Concurrent validity of the G-PACER was assessed with Roter Interaction Analysis System (RIAS) summary scores, particularly the patient-centeredness summary score. Item-total correlations were conducted to determine which items should be retained for future versions of the scale. Scores on the G-PACER were significantly correlated with the RIAS Patient-Centeredness score. Correlation analysis also revealed significant associations between G-PACER Total Score and RIAS Global Affect Ratings. The twelve-item version of the G-PACER performed at a commensurate level with the longer version; thus, it's use is recommended in future research. This study represents an important step in the development of reliable, valid, and efficient tools to add to those available for evaluating patient-provider interactions from the SP perspective.

Using Technology to Enhance Teaching of Patient-Centered Interviewing for Early Medical Students.

INTRODUCTION: Effective strategies for teaching communication skills to health professions students are needed. This article describes the design and evaluation of immersive and interactive video simulations for medical students to practice basic communication skills. METHODS: Three simulations were developed, focusing on patient-centered interviewing techniques such as using open-ended questions, reflections, and empathic responses while assessing a patient's history of present illness. First-year medical students were randomized to simulation or education-as-usual arms. Students in the simulation arm were given access to three interactive video simulations developed using Articulate Storyline, an e-learning authoring tool, to practice and receive feedback on patient-centered interviewing techniques to prepare for their Observed Structured Clinical Examination (OSCE). Trained raters evaluated videos of two OSCE cases for each participant to assess specific communication skills used during the history of present illness component of the interview. RESULTS: Eighty-seven percent of the students in the simulation arm interacted with at least one simulation during the history of present illness. For both OSCE cases, students in the simulation arm asked significantly more open-ended questions. Students in the simulation arm asked significantly fewer closed-ended questions and offered significantly more empathic responses in one OSCE case. No differences were found for reflections. Students reported that the simulations helped improve their communication skills. CONCLUSION: The use of interactive video simulations was found to be feasible to incorporate into the curriculum and was appealing to students. In addition, students in the simulation arm displayed more behaviors consistent with the patient-centered interviewing model practiced in the simulations. Continued development and research are warranted.

Communicative Coping Behavior Checklist: Observation of Persons With Dementia in the Home Environment.

PURPOSE OF THE STUDY: Communication contributes to increased stress, mortality, and decreased quality of life (QOL) for persons with dementia (PWD) and caregivers. PWD use communicative coping behaviors (CCBs) to manage the demands of the disease. However, most assessments neither look for nor give credit to communication behaviors. This is the first study to examine CCBs in the home environment as measured by the Communicative Coping Behavior Checklist (CCBC). DESIGN AND METHODS: This cross-sectional quantitative study included 26 dementia and 18 cognitively normal control dyads. Raters observed their partners' CCBs at home, over several weeks and completed the CCBC. We analyzed the endorsement rates (how often behaviors were observed by a rater) of emotion and activity-focused CCBs in dementia and control dyads. RESULTS: The primary outcome was rate of CCB endorsement. Secondary outcomes included dementia diagnosis, cognitive status, depressive mood, life satisfaction (SWL) and QOL. Dementia dyads endorsed 11 of 23 CCBs significantly more than control dyads. Action-focused CCBs (p < .001) were more frequent than emotion-focused CCBs (p = .004) in dementia dyads. Specific CCBs such as humor correlated with higher caregiver QOL (p = .019) and PWD's SWL (p = .003). Another CCB, general humor, correlated with lower PWD's SWL (p = .024). IMPLICATIONS: This was the first study to examine CCBs in the home environment comparing dementia and control dyads. Higher endorsement rates of action-focused than emotion-focused CCBs were seen in dementia dyads. We conclude that attention to CCBs during treatment and care will improve QOL and SWL of PWD and caregivers.

Type 2 Diabetes and Depression: A Pilot Trial of an Integrated Self-management Intervention for Latino Immigrants.

PURPOSE: The purpose of the current study was to determine the feasibility, acceptability, and preliminary effectiveness of an integrated self-management intervention that simultaneously targets diabetes and depression self-management in a primary care clinic that serves the Latino immigrant community. METHODS: The integrated intervention included behavioral activation and motivational interviewing techniques. It was developed with patient, family member, and provider stakeholders, and it comprised 6 individual sessions, followed by 2 monthly booster sessions. Eighteen Latino immigrants participated in an open trial of the intervention. A1C levels were examined at baseline and postintervention. Participants also completed measures of depression, diabetes self-management behaviors, patient activation, and diabetes-related self-efficacy and gave open-ended feedback about the intervention. RESULTS: Feasibility of delivering the intervention in the primary care setting and acceptability to the target population were demonstrated. Among participants completing the intervention, A1C levels decreased significantly from baseline. A significant reduction in depressive symptoms and an improvement in diabetes self-management behaviors, patient activation, and diabetes-related self-efficacy were observed. Qualitative responses from participants indicated unilateral positive responses to the intervention and endorsed its continuation in the clinic. CONCLUSIONS: This pilot trial demonstrated the feasibility and acceptability of an integrated self-management intervention for diabetes and depression. In addition, preliminary data suggest that the intervention may have a positive impact on diabetes and depression-related outcomes. Further evaluation is warranted.

The impact of mind-body medicine facilitation on affirming and enhancing professional identity in health care professions faculty.

PROBLEM: Georgetown University School of Medicine (GUSOM) offers medical students a course in mind-body medicine (MBM) that introduces them to tools that reduce stress and foster self-awareness. Previous studies reported decreases in students' perceived stress and increases in mindfulness-changes that were associated with increased empathic concern and other elements of professional identity formation. However, no reports have described the impact of an MBM course on the facilitators themselves. APPROACH: To explore whether MBM facilitation is associated with changes in professional identity, self-awareness, and/or perceived stress, 62 facilitators, trained by the GUSOM MBM program, were invited to complete two validated surveys: the Freiburg Mindfulness Inventory (FMI) and the Perceived Stress Scale (PSS). Forty-two participants also completed a six-item open-ended questionnaire addressing their experience in the context of their professional identity. OUTCOMES: Facilitators' scores were significantly lower on PSS and higher on FMI compared with normative controls (P < .05), and the two parameters were inversely correlated (-0.46, P < .01). Qualitative analysis revealed three main themes: (1) aspects of professional identity (with subthemes of communication; connections and community; empathy and active listening; and self-confidence); (2) self-care; and (3) mindful awareness. NEXT STEPS: Preliminary findings will be extended with larger studies that examine longitudinal quantitative assessment of communication, connection, and self-confidence outcomes in MBM facilitators, and the impact of MBM facilitation on burnout and resilience.

Type 2 Diabetes and Depression: Patient, Family Member, and Primary Care Provider Perspectives on the Development of an Integrated Self-Management Intervention.

PURPOSE: The purpose of the current study was to engage a local primary care clinic community that serves the Latino immigrant population to obtain their input regarding the design and implementation of a proposed integrated behavioral intervention that will simultaneously target T2DM and depression self-management in this high risk patient population. METHODS: Nine key informant interviews and 3 focus groups were conducted. Key informant interviews were conducted with the medical director, a primary care provider, a diabetes educator, and a medical assistant from each site, as well as the counselor who serves both sites. Fourteen patients with T2DM who screened positive for depression and 7 of their family members participated in the focus groups. Key informants and focus group participants were asked about patient challenges with diabetes management, the role of depression in T2DM, their impressions of the proposed intervention, and motivators and barriers to participation in the intervention. RESULTS: Commonly reported challenges with diabetes management included the struggle with healthy eating and information exchange upon diagnosis. T2DM and depression were seen as interrelated and described by many as having a cyclical relationship. Key informants and focus group participants uniformly supported the proposed intervention and recommended the involvement of family members. CONCLUSIONS: Results of this study support the need and acceptability of individualized behavioral interventions that target T2DM and depression simultaneously.