The development of accessible and sustainable transgender health education for rural-serving medical providers in Appalachia.

Context and issues: Rural regions in Southeastern USA are predominantly under-resourced and have poorer health outcomes compared to national averages. People living in rural Appalachia with intersectional identities often have limited choices in providers along with other systemic barriers to obtaining good health care. Barriers to competent and safe health care disproportionately impact people who are marginalized because of their identity. For transgender patients in South Central Appalachia, intersectional identities constitute barriers to receiving competent health care and increase the risk of poorer health outcomes. Literature indicates providers nationally receive on average between 45 minutes and 5 hours of training on transgender healthcare provision, which may exacerbate poor care experiences in South Central Appalachia. The present study aimed to develop and implement a training program for rural-serving medical residents in primary care in South Central Appalachia. A six-stage pilot development study is described. Lessons learned: This project developed a cultural competency training for rural-serving medical providers specific to transgender health needs. The Kern Model was utilized to structure the development of this training. Data from clinic stakeholders, resident liaisons, and transgender community members were utilized throughout phases of development. Two major themes arose from planning with these key stakeholders: accessibility/reusability of the material and usefulness of the material to the residents. Stakeholders were asked to identify areas of competency that would be beneficial for their practices and what baseline information would be necessary for all participants to know. Trainings were a hybrid of virtual and live delivery to pivot in response to space allocations at each clinic and to allow residents who were on hospital rotations to attend. An educational consultant was utilized to inform the best style of training design to meet the stated pedagogical goals. Previous studies have indicated that medical providers receive limited training on transgender health needs. However, there is also literature suggesting differences in general medical education due to resource competition. Therefore, developing sustainable, accessible, and useful medical education is imperative. The inclusion of resident and community member feedback in the content creation of this project allowed customization to community and resident needs. Stakeholder input on the pedagogy of this project was also imperative due to physical space constraints with social distancing guidelines. This training highlights the value in engaging virtual curricula, as it allows optimal accessibility for rural clinics. This project aimed to develop a training specific for South Central Appalachian providers that was informed by transgender people in the region and tailored specifically for regional providers based on stakeholder input. The resulting training may be an invaluable tool for future medical providers in a rural-serving region that is medically, educationally under-resourced and experiences inflated intersectional discrimination at systemic and interpersonal levels.

A predictive model for conversion to psychosis in clinical high-risk patients.

BACKGROUND: The authors developed a practical and clinically useful model to predict the risk of psychosis that utilizes clinical characteristics empirically demonstrated to be strong predictors of conversion to psychosis in clinical high-risk (CHR) individuals. The model is based upon the Structured Interview for Psychosis Risk Syndromes (SIPS) and accompanying clinical interview, and yields scores indicating one's risk of conversion. METHODS: Baseline data, including demographic and clinical characteristics measured by the SIPS, were obtained on 199 CHR individuals seeking evaluation in the early detection and intervention for mental disorders program at the New York State Psychiatric Institute at Columbia University Medical Center. Each patient was followed for up to 2 years or until they developed a syndromal DSM-4 disorder. A LASSO logistic fitting procedure was used to construct a model for conversion specifically to a psychotic disorder. RESULTS: At 2 years, 64 patients (32.2%) converted to a psychotic disorder. The top five variables with relatively large standardized effect sizes included SIPS subscales of visual perceptual abnormalities, dysphoric mood, unusual thought content, disorganized communication, and violent ideation. The concordance index (c-index) was 0.73, indicating a moderately strong ability to discriminate between converters and non-converters. CONCLUSIONS: The prediction model performed well in classifying converters and non-converters and revealed SIPS measures that are relatively strong predictors of conversion, comparable with the risk calculator published by NAPLS (c-index = 0.71), but requiring only a structured clinical interview. Future work will seek to externally validate the model and enhance its performance with the incorporation of relevant biomarkers.

Prevalence and phenomenology of violent ideation and behavior among 200 young people at clinical high-risk for psychosis: an emerging model of violence and psychotic illness.

In a previously reported longitudinal study of violent ideation (VI) and violent behavior (VB) among 200 youths at clinical high-risk (CHR) for psychosis, we found that VI, hitherto underinvestigated, strongly predicted transition to first-episode psychosis (FEP) and VB, in close temporal proximity. Here, we present participants' baseline characteristics, examining clinical and demographic correlates of VI and VB. These participants, aged 13-30, were examined at Columbia University Medical Center's Center of Prevention and Evaluation, using clinical interviews and the structured interview for psychosis-risk syndromes (SIPS). At the onset of our longitudinal study, we gathered demographics, signs and symptoms, and descriptions of VI and VB. One-third of participants reported VI (n = 65, 32.5%) at baseline, experienced as intrusive and ego-dystonic, and associated with higher suspiciousness and overall positive symptoms. Less than one-tenth reported VB within 6 months of baseline (n = 17, 8.5%), which was unrelated to SIPS-positive symptoms, any DSM diagnosis or other clinical characteristic. The period from conversion through post-FEP stabilization may be characterized by heightened risk of behavioral disinhibition and violence. We provide a preliminary model of how violence risk may peak at various points in the course of psychotic illness.

Impact of lifetime traumatic experiences on suicidality and likelihood of conversion in a cohort of individuals at clinical high-risk for psychosis.

Recent research suggests that trauma history (TH) is a strong socio-environmental risk factor for the development of psychosis. While reported rates of childhood trauma are higher among individuals at clinical high-risk (CHR) for psychosis than in the general population, little research has explored the effects of trauma upon the severity of attenuated positive symptoms. We aimed to explore the specific relationships between TH and baseline symptom severity; likelihood of conversion to full-blown psychosis; suicidal ideation (SI); and suicidal behavior (SB) in a cohort of 200 help-seeking CHR individuals. Participants were evaluated every three months for up to two years using the Structured Interview for Psychosis-Risk Syndromes (SIPS). More trauma history was reported by females and Hispanic/Latino participants, while age and race did not significantly distinguish those with and without TH. Individuals with TH reported higher rates of SI and SB than those without. While TH was positively associated with several SIPS subscales, including Unusual Thought Content, Perceptual Abnormalities/Hallucinations, Bizarre Thinking, Sleep Disturbances, and Dysphoric Mood, and negatively associated with Expressed Emotion, results indicated that TH was not significantly related to conversion to psychosis. Moreover, baseline SI was unrelated to conversion and baseline DSM diagnosis, with the exception of Post-Traumatic Stress Disorder (PTSD). These results suggest that traumatic experiences may significantly impact the severity of attenuated positive symptoms and suicidality in the CHR state, providing new windows for further research and potential intervention.

A Longitudinal Study of Violent Behavior in a Psychosis-Risk Cohort.

There is a lack of insight into the relationships between violent ideation, violent behavior, and early, particularly attenuated, psychosis. Our aims were to examine the relationships between baseline violent behavior and violent ideation and outcome violent behavior and conversion to psychosis in at-risk individuals. We longitudinally assessed 200 individuals at clinical high risk for psychosis for violent ideation and violent behavior using the Structured Interview for Psychosis-Risk Syndromes (SIPS), and rated these according to MacArthur Community Violence categories. Fifty-six individuals (28%) reported violent ideation at baseline, 12 (6%) reported violent behavior within 6 months pre-baseline, and 8 (4%) committed acts of violence during the follow-up time period. Information about violent ideation was obtained only by indirect, but not direct, inquiry about violent ideation. Both violent ideation and violent behavior at baseline significantly predicted violent behavior (RR=13.9, p=0.001; RR=8.3, p=0.003, respectively) during follow-up, as well as a diagnosis of psychosis (RR=2.3 and 2.4, respectively; both p<0.001), independent of more than 40 clinical and demographic variables. The targets of the subjects' violent ideation at baseline were completely different than their subsequent targets of violent behavior. Violent behavior occurred within 7 days (SD 35 days) of a diagnosis of syndromal psychosis. These data suggest that checking carefully for violent ideation and behavior in clinical high-risk patients is essential, as these have predictive value for conversion to psychosis and likelihood of violence in the future.