Review: Impact of urgent youth outpatient mental health care on patient and health system outcomes - a scoping review.

BACKGROUND: Young people often face barriers to psychiatric care and are increasingly seeking crisis services for mental health issues through the emergency department (ED). Urgent psychiatric care models provide youth in crisis with rapid access to time-limited mental health care on an outpatient basis. This scoping review aims to evaluate the impact of such urgent psychiatric services for youth aged 13-25 on patient and health system outcomes. METHODS: We conducted a literature search on PubMed, EMBASE, MEDLINE, PsycINFO, and the Cochrane Database of Systematic Reviews for studies published from inception to November 20, 2020. We included studies that described outpatient psychiatric services designed for youth aged 13 to 25, took place in a clinical setting, and offered any combination of assessment, treatment, and referral. We excluded studies describing suicide intervention programmes. RESULTS: Our search yielded six studies, four of which were descriptive studies and two of which were randomized controlled trials. Most studies found that access to urgent psychiatric care for youth was associated with reduced ED volumes, fewer health system costs, and fewer hospitalizations. None of the studies presented evidence that urgent psychiatric services are associated with improved patient symptomatology or functioning. CONCLUSIONS: The results of this scoping review highlight the scarcity of robust evidence evaluating the effectiveness of urgent care for youth mental health. Further experimental studies and a set of standardized quality measures for evaluating these services are needed to bridge this critical gap in mental health care for youth in crisis.

Early Adolescence is a Critical Period for the Maturation of Inhibitory Behavior.

Psychiatric conditions marked by impairments in cognitive control often emerge during adolescence, when the prefrontal cortex (PFC) and its inputs undergo structural and functional maturation and are vulnerable to disruption by external events. It is not known, however, whether there exists a specific temporal window within the broad range of adolescence when the development of PFC circuitry and its related behaviors are sensitive to disruption. Here we show, in male mice, that repeated exposure to amphetamine during early adolescence leads to impaired behavioral inhibition, aberrant PFC dopamine connectivity, and reduced PFC dopamine function in adulthood. Remarkably, these deficits are not observed following exposure to the exact same amphetamine regimen at later times. These findings demonstrate that there is a critical period for the disruption of the adolescent maturation of cognitive control and PFC dopamine function and suggest that early adolescence is particularly relevant to the emergence of psychopathology in humans.

Amphetamine disrupts dopamine axon growth in adolescence by a sex-specific mechanism in mice.

Initiating drug use during adolescence increases the risk of developing addiction or other psychopathologies later in life, with long-term outcomes varying according to sex and exact timing of use. The cellular and molecular underpinnings explaining this differential sensitivity to detrimental drug effects remain unexplained. The Netrin-1/DCC guidance cue system segregates cortical and limbic dopamine pathways in adolescence. Here we show that amphetamine, by dysregulating Netrin-1/DCC signaling, triggers ectopic growth of mesolimbic dopamine axons to the prefrontal cortex, only in early-adolescent male mice, underlying a male-specific vulnerability to enduring cognitive deficits. In adolescent females, compensatory changes in Netrin-1 protect against the deleterious consequences of amphetamine on dopamine connectivity and cognitive outcomes. Netrin-1/DCC signaling functions as a molecular switch which can be differentially regulated by the same drug experience as function of an individual's sex and adolescent age, and lead to divergent long-term outcomes associated with vulnerable or resilient phenotypes.

The Implicit Association Test in health professions education: A meta-narrative review.

INTRODUCTION: Implicit bias is a growing area of interest among educators. Educational strategies used to elicit awareness of implicit biases commonly include the Implicit Association Test (IAT). Although the topic of implicit bias is gaining increased attention, emerging critique of the IAT suggests the need to subject its use to greater theoretical and empirical scrutiny. METHODS: The authors employed a meta-narrative synthesis to review existing research on the use of the IAT in health professions education. Four databases were searched using key terms yielding 1151 titles. After title, abstract and full-text screening, 38 articles were chosen for inclusion. Coding and analysis of articles sought a meaningful synthesis of educational approaches relating to the IAT, and the assumptions and theoretical positions that informed these approaches. RESULTS: Distinct, yet complementary, meta-narratives were found in the literature. The dominant perspective utilizes the IAT as a metric of implicit bias to evaluate the success of an educational activity. A contrasting narrative describes the IAT as a tool to promote awareness while triggering discussion and reflection. DISCUSSION: Whether used as a tool to measure bias, raise awareness or trigger reflection, the use of the IAT provokes tension between distinct meta-narratives, posing a challenge to educators. Curriculum designers should consider the premise behind the IAT before using it, and be prepared to address potential reactions from learners such as defensiveness or criticism. Overall, findings suggest that educational approaches regarding implicit bias require critical reflexivity regarding assumptions, values and theoretical positioning related to the IAT.

Implicit Bias and the Feedback Paradox: Exploring How Health Professionals Engage With Feedback While Questioning Its Credibility.

PURPOSE: Learners and practicing health professionals may dismiss emotionally charged feedback related to self, yet little research has examined how to address feedback that threatens an individual's identity. The implicit association test (IAT) provides feedback to individuals regarding their implicit biases. Anticipating feedback about implicit bias might be emotionally charged for mental health professionals, this study explored their experience of taking the IAT and receiving their results, to better understand the challenges of identity-threatening feedback. METHOD: The researchers sampled 32 psychiatry nurses, psychiatrists, and psychiatric residents at Western University in Ontario, Canada, after they completed the mental illness IAT and received their results. Using constructivist grounded theory, semistructured interviews were conducted from April to October 2017 regarding participants' experience of taking the IAT. Using constant comparative analysis, transcripts were iteratively coded and analyzed for results. RESULTS: While most participants critiqued the IAT and questioned its credibility, many also described the experience of receiving feedback about their implicit biases as positive or neutral. Most justified their implicit biases while acknowledging the need to better manage them. CONCLUSIONS: These findings highlight a feedback paradox, calling into question assumptions regarding self-related feedback. Participants' reactions to the IAT suggest that potentially threatening self-related feedback may still be useful to participants who question its credibility. Further exploration of how the feedback conversation influences engagement with self-related feedback is needed.

Striving While Accepting: Exploring the Relationship Between Identity and Implicit Bias Recognition and Management.

PURPOSE: Implicit biases worsen outcomes for underserved and marginalized populations. Once health professionals are made aware of their implicit biases, a process ensues where they must reconcile this information with their personal and professional identities. The authors sought to explore how identity influences the process of implicit bias recognition and management. METHOD: Using constructivist grounded theory, the authors recruited 11 faculty and 10 resident participants working at an academic health science center in Canada. Interviews took place from June to October 2017. Participants took an online version of the mental illness implicit association test (IAT) which provides users with their degree of implicit dangerousness bias toward individuals with either physical or mental illness. Once they completed the IAT, participants were invited to draw a rich picture and interviewed about their picture and experience of taking their IAT. Data were analyzed using constant comparative procedures to develop focused codes and work toward the development of a deeper understanding of relationships among themes. RESULTS: Once implicit biases were brought into conscious awareness, participants acknowledged vulnerabilities which provoked tension between their personal and professional identities. Participants suggested that they reconcile these tensions through a process described as striving for the ideal while accepting the actual. Relationships were central to the process; however, residents and faculty viewed the role of relationships differently. CONCLUSIONS: Striving for self-improvement while accepting individual shortcomings may provide a model for addressing implicit bias among health professionals, and relational dynamics appear to influence the process of recognizing and managing biases.

DCC Receptors Drive Prefrontal Cortex Maturation by Determining Dopamine Axon Targeting in Adolescence.

BACKGROUND: Dopaminergic input to the prefrontal cortex (PFC) increases throughout adolescence and, by establishing precisely localized synapses, calibrates cognitive function. However, why and how mesocortical dopamine axon density increases across adolescence remains unknown. METHODS: We used a developmental application of axon-initiated recombination to label and track the growth of dopamine axons across adolescence in mice. We then paired this recombination with cell-specific knockdown of the netrin-1 receptor DCC to determine its role in adolescent dopamine axon growth. We then assessed how altering adolescent PFC dopamine axon growth changes the structural and functional development of the PFC by quantifying pyramidal neuron morphology and cognitive performance. RESULTS: We show, for the first time, that dopamine axons continue to grow from the striatum to the PFC during adolescence. Importantly, we discover that DCC, a guidance cue receptor, controls the extent of this protracted growth by determining where and when dopamine axons recognize their final target. When DCC-dependent adolescent targeting events are disrupted, dopamine axons continue to grow ectopically from the nucleus accumbens to the PFC and profoundly change PFC structural and functional development. This leads to alterations in cognitive processes known to be impaired across psychiatric conditions. CONCLUSIONS: The prolonged growth of dopamine axons represents an extraordinary period for experience to influence their adolescent trajectory and predispose to or protect against psychopathology. DCC receptor signaling in dopamine neurons is a molecular link where genetic and environmental factors may interact in adolescence to influence the development and function of the prefrontal cortex.