An Integrated Care Pathway for depression in adolescents: protocol for a Type 1 Hybrid Effectiveness-implementation, Non-randomized, Cluster Controlled Trial.

INTRODUCTION: Our group developed an Integrated Care Pathway to facilitate the delivery of evidence-based care for adolescents experiencing depression called CARIBOU-2 (Care for Adolescents who Receive Information 'Bout OUtcomes, 2nd iteration). The core pathway components are assessment, psychoeducation, psychotherapy options, medication options, caregiver support, measurement-based care team reviews and graduation. We aim to test the clinical and implementation effectiveness of the CARIBOU-2 pathway relative to treatment-as-usual (TAU) in community mental health settings. METHODS AND ANALYSIS: We will use a Type 1 Hybrid Effectiveness-Implementation, Non-randomized Cluster Controlled Trial Design. Primary participants will be adolescents (planned n = 300, aged 13-18 years) with depressive symptoms, presenting to one of six community mental health agencies. All sites will begin in the TAU condition and transition to the CARIBOU-2 intervention after enrolling 25 adolescents. The primary clinical outcome is the rate of change of depressive symptoms from baseline to the 24-week endpoint using the Childhood Depression Rating Scale-Revised (CDRS-R). Generalized mixed effects modelling will be conducted to compare this outcome between intervention types. Our primary hypothesis is that there will be a greater rate of reduction in depressive symptoms in the group receiving the CARIBOU-2 intervention relative to TAU over 24 weeks as per the CDRS-R. Implementation outcomes will also be examined, including clinician fidelity to the pathway and its components, and cost-effectiveness. ETHICS AND DISSEMINATION: Research ethics board approvals have been obtained. Should our results support our hypotheses, systematic implementation of the CARIBOU-2 intervention in other community mental health agencies would be indicated.

Racial/Ethnic Disparities in Psychiatric Traits and Diagnoses within a Community-based Sample of Children and Youth: Disparités raciales/ethniques dans les traits et diagnostics psychiatriques au sein d'un échantillon communautaire d'enfants et de jeunes.

OBJECTIVE: Racial/ethnic disparities in the prevalence of psychiatric disorders have been reported, but have not accounted for the prevalence of the traits that underlie these disorders. Examining rates of diagnoses in relation to traits may yield a clearer understanding of the degree to which racial/ethnic minority youth in Canada differ in their access to care. We sought to examine differences in self/parent-reported rates of diagnoses for obsessive-compulsive disorder (OCD), attention-deficit/hyperactivity disorder (ADHD) and anxiety disorders after adjusting for differences in trait levels between youth from three racial/ethnic groups: White, South Asian and East Asian. METHOD: We collected parent or self-reported ratings of OCD, ADHD and anxiety traits and diagnoses for 6- to 17-year-olds from a Canadian general population sample (Spit for Science). We examined racial/ethnic differences in trait levels and the odds of reporting a diagnosis using mixed-effects linear models and logistic regression models. RESULTS: East Asian (N = 1301) and South Asian (N = 730) youth reported significantly higher levels of OCD and anxiety traits than White youth (N = 6896). East Asian and South Asian youth had significantly lower odds of reporting a diagnosis for OCD (odds ratio [OR]East Asian = 0.08 [0.02, 0.41]; ORSouth Asian = 0.05 [0.00, 0.81]), ADHD (OREast Asian = 0.27 [0.16, 0.45]; ORSouth Asian = 0.09 [0.03, 0.30]) and anxiety (OREast Asian = 0.21 [0.11, 0.39]; ORSouth Asian = 0.12 [0.05, 0.32]) than White youth after accounting for psychiatric trait levels. CONCLUSIONS: These results suggest a discrepancy between trait levels of OCD, ADHD and anxiety and rates of diagnoses for East Asian and South Asian youth. This discrepancy may be due to increased barriers for ethnically diverse youth to access mental health care. Efforts to understand and mitigate these barriers in Canada are needed.

We know that there is there are differences in the prevalence of childhood mental illnesses by race/ethnic group, which may be related to disproportionate access to mental health care. What is unknown is whether there this difference in prevalence is related to differences in the presence of symptoms for mental illness or whether children and youth from marginalized racial/ethnic groups have symptoms but are not getting diagnosed. This information is needed to understand the degree to which children and youth from marginalized race/ethnicity groups are accessing mental health care in Canada. We tested the differences in reported symptoms and diagnosis of three common and impairing childhood-onset disorders (obsessive-compulsive disorder­OCD), attention-deficit/hyperactivity disorder­ADHD and anxiety disorders) in children and youth (6­17 years of age) living in Canada that were from three racial/ethnic groups: White, South Asian and East Asian. East Asian and South Asian youth reported significantly higher levels of OCD and anxiety traits than White youth. However, East Asian and South Asian youth were significantly less likely than White youth to have a reported diagnosis of OCD, ADHD or anxiety even after accounting for symptom levels for each disorder. Our findings suggest that East and South Asian children are less likely than White children to get a diagnosis for common mental illness even if they have symptoms of that mental illness. This gap in receiving a diagnosis might be because of more barriers to mental health care for children and youth from marginalized racial/ethnic groups but we need more research to pinpoint the cause.

Talking 'Bout Better outcomes for Adolescent Depression: Youth and Caregiver Perspectives on an Integrated Care Pathway for Depression.

BACKGROUND: Depression is a common condition among adolescents, with rates continuing to rise. A gap exists between evidence-based recommendations for the treatment of depression and clinical practice. Integrated Care Pathways (ICPs) can help address this gap, but to date no study has examined how young people and their caregivers experience ICPs and whether these pathways are an acceptable form of care. This study used focus groups with adolescents, caregivers, and service providers to examine experiences of an ICP. METHODS: Six individual interviews with service providers, four focus groups with youth, and two focus groups with caregivers were completed. Data was analyzed consistent with Braun & Clarke's Thematic Analysis Framework within an interpretivist paradigm. RESULTS AND CONCLUSION: The study demonstrated that ICPs are acceptable to youth and their caregivers and that ICPs facilitate shared decision making between youth/caregivers and care providers. Findings also indicated that youth are willing to engage with ICPs particularly when there is a trusted clinician involved who helps interpret and tailor the ICP to the young person's experience. Further questions include how to best integrate these into the overall system and how to further tailor these pathways to support youth with diagnostic complexity and treatment resistance.

Social and Structural Drivers of Health and Transition to Adult Care.

CONTEXT: Youth with chronic health conditions experience challenges during their transition to adult care. Those with marginalized identities likely experience further disparities in care as they navigate structural barriers throughout transition. OBJECTIVES: This scoping review aims to identify the social and structural drivers of health (SSDOH) associated with outcomes for youth transitioning to adult care, particularly those who experience structural marginalization, including Black, Indigenous, and 2-spirit, lesbian, gay, bisexual, transgender, queer or questioning, and others youth. DATA SOURCES: Medline, Embase, CINAHL, and PsycINFO were searched from earliest available date to May 2022. STUDY SELECTION: Two reviewers screened titles and abstracts, followed by full-text. Disagreements were resolved by a third reviewer. Primary research studying the association between SSDOH and transition outcomes were included. DATA EXTRACTION: SSDOH were subcategorized as social drivers, structural drivers, and demographic characteristics. Transition outcomes were classified into themes. Associations between SSDOH and outcomes were assessed according to their statistical significance and were categorized into significant (P < .05), nonsignificant (P > .05), and unclear significance. RESULTS: 101 studies were included, identifying 12 social drivers (childhood environment, income, education, employment, health literacy, insurance, geographic location, language, immigration, food security, psychosocial stressors, and stigma) and 5 demographic characteristics (race and ethnicity, gender, illness type, illness severity, and comorbidity). No structural drivers were studied. Gender was significantly associated with communication, quality of life, transfer satisfaction, transfer completion, and transfer timing, and race and ethnicity with appointment keeping and transfer completion. LIMITATIONS: Studies were heterogeneous and a meta-analysis was not possible. CONCLUSIONS: Gender and race and ethnicity are associated with inequities in transition outcomes. Understanding these associations is crucial in informing transition interventions and mitigating health inequities.

A trauma-informed approach to suicide prevention for the COVID-19 pandemic.

During the COVID-19 pandemic, researchers have questioned how the devastation of the pandemic might impact suicide rates. While initial evidence on suicide rates during the early stages of the pandemic is mixed, there are signs we should still remain vigilant. One way of conceptualizing the long-term effects of the pandemic is as a source of multiple traumatic events: the collective trauma of widespread illness and death and social upheaval, individual traumas from the virus itself (e.g., serious illness and disability, traumatic grief, vicarious trauma), traumas from the social and economic consequences (e.g., domestic violence, unemployment), and its intersections with pre-pandemic traumas and oppression. Given trauma is a well-established risk factor for suicide, this carries significant implications for suicide prevention in the wake of the pandemic. Yet access to trauma-informed care, education, and research remains limited. The pandemic presents a unique opportunity to address these gaps and implement a trauma-informed approach to suicide prevention. Building on existing frameworks, we describe how effective suicide prevention for the pandemic must incorporate trauma-informed and trauma-specific services, strategies, and policies; capacity building; collaborative research; and knowledge exchange. Attending to the traumatic effects of the pandemic may reduce the long-term impact on suicide rates.

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.

Exploring the perspectives of healthcare providers that care for non-insured individuals utilizing emergency departments in Toronto.

BACKGROUND: Non-insured individuals have different healthcare needs from the general Canadian population and face unique barriers when accessing emergency department (ED) care. This qualitative study aims to better understand the system of emergency care for non-insured individuals from the perspective of healthcare providers. METHODS: The study uses a critical realist framework to explore structural factors that facilitate or impede access to care for non-insured individuals. Semi-structured interviews were conducted with 13 interdisciplinary healthcare professionals with experience working with non-insured populations in the ED and in community health centres. Data were analyzed with the use of Braun and Clark's thematic analysis framework and organized into themes through an iterative process until thematic saturation was reached. RESULTS: Healthcare providers face distinct challenges when providing care for non-insured patients including patients presenting with increased illness complexity and providers having to navigate systemic barriers. Interview participants noted stigma and bias, lack of privacy, unclear care pathways, and access to post-ED care as challenges facing non-insured patients. Suggestions to improve the ED experience for non-insured patients include improved staff training, clearer policies, and consistency between hospitals. Most of all, healthcare providers believed that the most effective way to improve the care of non-insured patients would be to make permanent the temporary extension of health coverage to non-insured patients enacted during the COVID-19 pandemic. CONCLUSION: Interviews with healthcare professionals have highlighted that marginalized populations, including non-insured individuals, face multiple barriers when accessing the ED, especially during the COVID-19 pandemic. At the same time, the temporary extension of health coverage to non-insured patients enacted during the COVID-19 pandemic has likely improved patients' healthcare experience, which we will explore directly with non-insured patients in a future study. In this post-COVID world, we now have an opportunity to learn from our experiences and build a more equitable ED system together.

RéSUMé: CONTEXTE: Les personnes non assurées ont des besoins en matière de soins de santé différents de ceux de la population canadienne en général et sont confrontées à des obstacles uniques lorsqu'elles veulent accéder aux soins d'urgence. Cette étude qualitative vise à mieux comprendre le système de soins d'urgence pour les personnes non assurées du point de vue des prestataires de soins de santé. MéTHODES: L'étude utilise un cadre réaliste critique pour explorer les facteurs structurels qui facilitent ou entravent l'accès aux soins pour les personnes non assurées. Des entretiens semi-structurés ont été menés auprès de 13 professionnels de la santé interdisciplinaires ayant l'expérience du travail avec les populations non assurées aux urgences et dans les centres de santé communautaires. Les données ont été analysées à l'aide du cadre d'analyse thématique de Braun & Clark et organisées en thèmes par un processus itératif jusqu'à ce que la saturation thématique soit atteinte. RéSULTATS: Les prestataires de soins de santé sont confrontés à des défis distincts lorsqu'ils fournissent des soins à des patients non assurés, notamment des patients présentant une complexité de maladie accrue et des prestataires devant surmonter les obstacles systémiques. Les participants aux entretiens ont noté que la stigmatisation et les préjugés, le manque d'intimité, le manque de clarté des parcours de soins et l'accès aux soins post-urgence sont des défis auxquels sont confrontés les patients non assurés. Les suggestions visant à améliorer l'expérience des patients non assurés aux urgences comprennent une meilleure formation du personnel, des politiques plus claires et une cohérence entre les hôpitaux. Par-dessus tout, les prestataires de soins de santé ont estimé que le moyen le plus efficace d'améliorer les soins aux patients non assurés serait de pérenniser l'extension temporaire de la couverture médicale aux patients non assurés promulguée pendant la pandémie de COVID-19. CONCLUSION: Les entretiens avec les professionnels de la santé ont mis en évidence que les populations marginalisées, notamment les personnes non assurées, sont confrontées à de multiples obstacles lorsqu'elles accèdent aux urgences, en particulier pendant la pandémie de COVID-19. En même temps, l'extension temporaire de la couverture médicale aux patients non assurés, promulguée pendant la pandémie de COVID-19, a probablement amélioré l'expérience des patients en matière de soins de santé, ce que nous explorerons directement auprès des patients non assurés dans une étude future. Dans ce monde post-COVID, nous avons maintenant l'occasion de tirer les leçons de nos expériences et de construire ensemble un système d'urgence plus équitable.

What's race got to do with it? A proposed framework to address racism's impacts on child and adolescent mental health in Canada.

This commentary responds to current events that have highlighted the ways that systemic racism affects a wide variety of health outcomes. We specifically discuss how systemic racism adversely affects the mental health of children and adolescents in a Canadian context and use a structural framework to demonstrate how race is embedded in various Canadian systems and thus affects child and adolescent mental health in both conscious and unconscious ways throughout the lifespan. Experiences of systemic racism affect the mental health of Canadian young people in multiple complex and intersecting ways including access to care, experience of mental health services, and outcomes of care. We currently lack a national best practice framework for mental health professionals that unifies approaches to research, education, and clinical care for young racialized Canadians; in addition, concerted efforts to collect race-based data are lacking. We suggest that a blueprint for improved services for racialized young people in Canada would include: Development of a funded and sustainable research agenda responsive to community expertise, development and implementation of a Canadian Child and Adolescent task force focused on educational strategies on racism and service provision at both the postgraduate and continuing professional development (CPD) levels, and consideration of clinical parameters that improve access to, and experience of, care for Canadian racialized youth.

Ce commentaire est en réponse aux événements actuels qui ont fait ressortir les façons dont le racisme systémique touche une grande variété de résultats de santé. Nous discutons particulièrement de la façon dont le racisme systémique affecte la santé mentale des enfants et des adolescents dans un contexte canadien et nous utilisons un cadre structurel pour démontrer comment la race est intégrée dans divers systèmes canadiens et qu'elle affecte ainsi la santé mentale des enfants et des adolescents tant au niveau conscient qu'inconscient toute la vie. Les expériences de racisme systémique affectent la santé mentale des jeunes canadiens de multiples façons complexes et croisées, notamment l'accès aux soins, l'expérience des services de santé mentale, et les résultats des soins. Nous n'avons pas présentement de cadre national des pratiques exemplaires pour les professionnels de la santé mentale qui unifie les approches de la recherche de l'éducation, et des soins cliniques pour les jeunes canadiens racialisés; en outre, les efforts concertés pour recueillir les données basées sur la race sont manquants. Nous suggérons qu'un plan de services améliorés pour les jeunes racialisés au Canada comprenne : le développement d'un programme de recherche financé et viable sensible à l'expertise communautaire, la formation et la mise en œuvre d'un groupe de travail pour enfants et adolescents canadiens axé sur les stratégies éducatives à l'égard du racisme, la prestation de services aux niveaux des études supérieures et du développement professionnel continu (DPC), et la prise en compte des paramètres cliniques qui améliorent l'accès aux soins et l'expérience qu'en font les jeunes canadiens racialisés.

Mental health of transitional aged youth in Nicaragua: Perceptions and experiences of educators.

Mental illnesses contribute to a large proportion of the disease burden in children and adolescents in low and middle-income countries (LMICs). There is limited research completed in LMICs about paediatric mental health, particularly related to youth. School is a place where many adolescents first seek mental health support. This study examined how educators in Nicaragua view youth mental health and how mental health can be supported in LMIC schools. Focus groups were completed with teachers serving youth from a variety of socioeconomic settings within León, Nicaragua. The study was completed from an Interpretivist theoretical paradigm and coding of qualitative data was completed consistent with Constructivist Grounded Theory. Educators described their roles in as detecting mental health problems and liasing with other supports; they noted barriers as cross-sector integration and social challenges. Educators felt that youth would be better served by improving integration of care, addressing structural factors, and providing more teacher supports. A model for addressing youth mental health in LMICs could include a stepped-care approach with schools providing preventative programming as well as developing within school referral strategies for youth with higher needs. There may be a role for the use of community health promoters.

Interventions for perinatal depression in low and middle-income countries: A systematic review.

BACKGROUND: Perinatal depression has been associated with infant low birth weight and with multiple health indicators affecting childhood morbidity and mortality. The condition is twice as prevalent in low and middle-income countries (LMICs) compared to high-income countries but poorly studied. AIM: To conduct a review of published literature on interventions for perinatal depression in LMICs. METHODS: A search of the literature was performed for articles published up to October 2017. The key inclusion criteria were peer-reviewed studies focusing on interventions for perinatal depression during pregnancy and/or up to one-year postpartum. RESULTS: 1088 citations were retrieved, of which 18 studies with representation from countries in Africa, Asia, North America (Mexico) and South America were included. The majority of interventions were conducted in lower-income settings. Most were psychosocial in nature and often provided by lay health workers and in the community. Interventions integrated as part of general health programs and employing psychotherapeutic approaches were more effective and were also preferred. Only one study incorporated the use of psychiatric medications. CONCLUSION: Despite the limited publications, there is reasonable evidence for the benefit of psychological interventions in perinatal depression in LMICs. More research is needed to verify and extend these results and, in particular, to evaluate the benefit of adjunctive medications when treating moderate to severe depression and whether interventions can increase social supports.

The ethics and safety of medical student global health electives.

OBJECTIVE: To explore and characterize the ethical and safety challenges of global health experiences as they affect medical students in order to better prepare trainees to face them. METHODS: Semi-structured interviews were conducted with 23 Canadian medical trainees who had participated in global health experiences during medical school. Convenience and snowball sampling were utilized. Using Moustakas's transcendental phenomenological approach, participant descriptions of ethical dilemmas and patient/trainee safety problems were analyzed. This generated an aggregate that illustrates the essential meanings of global health experience ethical and safety issues faced. RESULTS: We interviewed 23 participants who had completed 38 electives (71%, n=27, during pre-clinical years) spending a mean 6.9 weeks abroad, and having visited 23 countries. Sixty percent (n=23) had pre-departure training while 36% (n=14) had post-experience debriefing. Three macro-level themes were identified: resource disparities and provision of care; navigating clinical ethical dilemmas; and threats to trainee safety. CONCLUSIONS: Medical schools have a responsibility to ensure ethical and safe global health experiences. However, our findings suggest that medical students are often poorly prepared for the ethical and safety dilemmas they encounter during these electives. Medical students require intensive pre-departure training that will prepare them emotionally to deal with these dilemmas. Such training should include discussions of how to comply with clinical limitations.

Beliefs about attention-deficit/hyperactivity disorder and response to stereotypes: youth postings in Facebook groups.

PURPOSE: Attention-deficit/hyperactivity disorder (ADHD) is a common childhood psychiatric disorder characterized by abnormal levels of hyperactivity and distractibility. However, very few studies have been conducted to examine how youth with ADHD view themselves in the context of their disorder. The aim of this project was to examine what youth think about having ADHD by collecting data in a naturalistic setting - a popular social networking site. METHODS: Using ethnographic content analysis, we examined text from 25 public, English-language Facebook groups with "ADHD" in the title. The groups chosen were those that were either created or administered by someone with a current high school or university affiliation and had at least 100 members. To capture narratives from youth, postings between September 1, 2006, and April 30, 2007 were examined; postings from individuals who self-identified as high school or university students were included. RESULTS: The dominant theme that was identified (202 of 479 coded items) concerned the collective construction of a positive group identity. The Facebook groups functioned like electronic support groups, with members providing support to one another and sharing experiences and information, including advice about medication. Many jokes referencing ADHD stereotypes were posted. CONCLUSION: Youth used the supportive environment of an electronic group to develop a positive group identity and to reject negative aspects of common stereotypes related to young people with ADHD.

Improving psychostimulant adherence in children with ADHD.

Attention-deficit/hyperactivity disorder (ADHD) is a common psychiatric disorder of childhood, characterized by excessive inattention, hyperactivity and impulsivity. Effective medication exists for the condition, yet suboptimal long-term effects persist for children with ADHD. Poor adherence is a common issue for individuals with chronic conditions, including children and those with psychiatric conditions, and ADHD is no exception. This review examines the available evidence regarding patterns of long-term use of stimulant medication and the predictors of medication discontinuation among children with ADHD, and suggests future clinical and research directions for improving adherence in children with ADHD.

Documenting adherence to psychostimulants in children with ADHD.

OBJECTIVE: This study evaluates the validity, inter-rater reliability, and stability over 3 months of a semi-structured telephone interview measuring adherence to stimulant treatment, the Stimulant Adherence Measure, against the Medication Event Monitoring System (MEMS). METHODS: Clinic-referred children (N=22, age 11.85 +/- 2.1 yrs) using psychostimulants for DSM-IV attention-deficit/hyperactivity disorder (ADHD) were eligible. Families used a MEMS device for the primary stimulant medication. Children and parents participated in a semi-structured telephone interview, the Stimulant Adherence Measure, for 3 consecutive months. Parent reports for previous 7 days and 28 days and child report for previous 7 days of medication use were compared to MEMS report. Inter-rater reliability and interview order were also examined. RESULTS: Nineteen children and parents completed (86%). Agreement between MEMS and parent report for previous 7 days at months 1, 2 and 3 (ICC=0.829, p<0.001; ICC=0.663, p<0.05; ICC=0.878, p<0.001 respectively) and for 28 days at months 1, 2 and 3 (ICC=0.793, p<0.001; ICC=0.907, p< 0.001; ICC=0.806, p<0.001 respectively) was good to excellent. Agreement between MEMS and child report for 7 days at months 1, 2 and 3 (ICC=0.773, p<0.001, ICC=0.542, p<0.05, ICC=0.606, p<0.05 respectively) was good. Inter-rater reliability was excellent (ICC=0.956, p<0.001). There was no interview order effect for parents (F=1.771, p>0.05) or children (F=1.621, p>0.05). CONCLUSION: The Stimulant Adherence Measure provides a valid and reliable method for determining stimulant medication use by children with ADHD.