Curriculum development in Liberia's first postgraduate psychiatry training programme.

This paper describes the implementation of curricula for Liberia's first-ever psychiatry training programme in 2019 and the actions of the only two Liberian psychiatrists in the country at the time in developing and executing a first-year postgraduate psychiatry training programme (i.e. residency) with support from international collaborators. It explores cultural differences in training models among collaborators and strategies to synergise them best. It highlights the assessment of trainees' (residents') basic knowledge on entry into the programme and how it guided immediate and short-term priority teaching objectives, including integrated training in neuroscience and neurology. The paper describes the strengths and challenges of this approach as well as opportunities for continued growth.

Building a postgraduate psychiatry training program in Liberia through cross-country collaborations: initiation stages, challenges, and opportunities.

Background: About 80% of the nearly 2 billion people experiencing psychiatric conditions worldwide do not have access to quality, affordable mental health care. In Africa, there are 0.004 psychiatrists per 10,000 people, with the shortage exacerbated by a limited number of postgraduate psychiatry training opportunities. As of 2018, there were only two psychiatrists in Liberia. Methods: This paper aims to offer a framework for developing postgraduate (i.e., residency) psychiatry training in resource-constrained settings to disseminate best practices and lessons learned. This article describes the approach to developing the formal global academic partnership that supported the initiation of Liberia's first postgraduate psychiatry training program in July 2019. Results: Authors describe strengths, challenges, and opportunities for improvement in the planning and initiation stages of the postgraduate program. Key strengths of the program planning process include: (1) collaboration with a coalition of local and national stakeholders committed to improving mental health care in Liberia; (2) early procurement of quality video conferencing equipment and internet service to facilitate remote learning and broaden access to digital materials; and (3) leveraging of intra-continental partnerships for subspecialty training. Challenges experienced include: (1) navigating the intricacies of local political and administrative processes; (2) recruiting candidates to a medical specialty with historically lower salaries; and (3) the added burden placed on the limited number of local specialists. Identified opportunities include building a monitoring, evaluation, and learning (MEL) framework, further diversifying subspecialty areas of psychiatric and neurological training, and obtaining full accreditation of the postgraduate psychiatry program through the West African College of Physicians (WACP). Conclusion: The successful launch of the postgraduate psychiatry training program in Liberia is attributed to several factors, including a long-standing academic collaboration of over 10 years and support for mental health capacity-building efforts at national and local levels.

Changes Over Time in Outcomes of School-Age Children and Parents Receiving Integrated Mental Health Care in Federally Qualified Health Centers.

OBJECTIVE: The purpose of this study is to understand change in parent-reported outcomes of mental health symptoms, health-related quality of life (QoL), and school-related functioning among children receiving mental health care at 3 federally qualified health centers engaging in a comprehensive pediatric mental health integration model. METHODS: Trained personnel enrolled English- or Spanish-speaking families of 6- to 12-year-old children who had recently started receiving integrated mental health care and surveyed their parent/caregiver at 3 time points: entry into the cohort, 6-month follow-up, and 12-month follow-up (unique N = 51). Primary outcomes included validated measures of child symptoms, child health-related QoL, and child school-related functioning. Secondary outcomes focused on parental functioning and included validated measures of parental stress and depressive and internalizing symptoms. A multilevel mixed-effects generalized linear model was used to estimate the change in parent-reported outcomes over time, with inverse probability weights used to address attrition. Additional analyses were conducted to determine the degree to which changes in symptoms over time were associated with improvements in school-related functioning. RESULTS: Over 12 months, children's mental health symptoms, health-related QoL, and school-related functional outcomes significantly improved. No changes in parental functioning were observed. In addition, improvements in mental health symptoms and health-related QoL were associated with improvements in school-related functional outcomes over time. CONCLUSION: Findings demonstrate that outcomes of children who received integrated mental health care improved over time, both in regard to mental health and school functioning.

Association of Integrating Mental Health Into Pediatric Primary Care at Federally Qualified Health Centers With Utilization and Follow-up Care.

Importance: More than 1 in 5 children in low-income families report a mental health (MH) problem, yet most face barriers accessing MH services. Integrating MH services into primary care at pediatric practices such as federally qualified health centers (FQHCs) may address these barriers. Objective: To examine the association of a comprehensive MH integration model with health care utilization, psychotropic medication use, and MH follow-up care among Medicaid-enrolled children at FQHCs. Design, Setting, and Participants: This retrospective cohort study used Massachusetts claims data from 2014 to 2017 to conduct difference-in-differences (DID) analyses before vs after implementation of a complete FQHC-based MH integration model. The sample included Medicaid-enrolled children aged 3 to 17 years who received primary care at 3 intervention FQHCs or 6 geographically proximal nonintervention FQHCs in Massachusetts. Data were analyzed in July 2022. Exposures: Receipt of care at an FQHC implementing the Transforming and Expanding Access to Mental Health Care in Urban Pediatrics (TEAM UP) model, which began fully integrating MH care into pediatrics in mid-2016. Main Outcomes and Measures: Utilization outcomes included primary care visits, MH service visits, emergency department (ED) visits, inpatient admissions, and psychotropic medication use. Follow-up visits within 7 days of a MH-related ED visit or hospitalization were also examined. Results: Among the 20 170 unique children in the study sample, at baseline (2014), their mean (SD) age was 9.0 (4.1) years, and 4876 (51.2%) were female. In contrast to nonintervention FQHCs, TEAM UP was positively associated with primary care visits with MH diagnoses (DID, 4.35 visits per 1000 patients per quarter; 95% CI, 0.02 to 8.67 visits per 1000 patients per quarter) and MH service use (DID, 54.86 visits per 1000 patients per quarter; 95% CI, 1.29 to 108.43 visits per 1000 patients per quarter) and was negatively associated with rates of psychotropic medication use (DID, -0.4%; 95% CI -0.7% to -0.01%) and polypharmacy (DID, -0.3%; 95% CI, -0.4% to -0.1%). TEAM UP was positively associated with ED visits without MH diagnoses (DID, 9.45 visits per 1000 patients per quarter; 95% CI, 1.06 to 17.84 visits per 1000 patients per quarter), but was not significantly associated with ED visits with MH diagnoses. No statistically significant changes were observed in inpatient admissions, follow-up visits after MH ED visits, or follow-up visits after MH hospitalizations. Conclusions and Relevance: The first 1.5 years of MH integration enhanced access to pediatric MH services while limiting the use of psychotropic medications. Additional implementation time is necessary to determine whether these changes will translate into reductions in avoidable utilization.

Implementation of a Novel Pediatric Behavioral Health Integration Initiative.

This study explores healthcare professionals' perspectives about the impact of behavioral health integration (BHI) on pediatric primary care delivery in community health centers (CHCs). A concurrent, qualitative-dominant mixed methods empirical study design was utilized, applying semi-structured interviews with healthcare professionals at the end of the implementation phase of a 3-year co-development, implementation, and evaluation process. Surveys were also administered at three time points. Via thematic analysis, emergent qualitative themes were mapped onto the Relational Coordination (RC) conceptual framework to triangulate and complement final qualitative results with quantitative results. Interview findings reveal five emergent themes aligning with RC domains. Survey results show that healthcare professionals reported increased behavioral healthcare integration into clinic practice (p = 0.0002) and increased clinic readiness to address behavioral health needs (p = 0.0010). Effective pediatric BHI and care delivery at CHCs may rely on strong professional relationships and communication. Additional research from the patient/caregiver perspective is needed.

Integrating Pediatric Universal Behavioral Health Care at Federally Qualified Health Centers.

BACKGROUND: Research supports integrated pediatric behavioral health (BH), but evidence gaps remain in ensuring equitable care for children of all ages. In response, an interdisciplinary team codeveloped a stepped care model that expands BH services at 3 federally qualified health centers (FQHCs). METHODS: FQHCs reported monthly electronic medical record data regarding detection of BH issues, receipt of services, and psychotropic medications. Study staff reviewed charts of children with attention-deficit/hyperactivity disorder (ADHD) before and after implementation. RESULTS: Across 47 437 well-child visits, >80% included a complete BH screen, significantly higher than the state's long-term average (67.5%; P < .001). Primary care providers identified >30% of children as having BH issues. Of these, 11.2% of children <5 years, 53.8% of 5-12 years, and 74.6% >12 years were referred for care. Children seen by BH staff on the day of referral (ie, "warm hand-off") were more likely to complete an additional BH visit than children seen later (hazard ratio = 1.37; P < .0001). There was no change in the proportion of children prescribed psychotropic medications, but polypharmacy declined (from 9.5% to 5.7%; P < .001). After implementation, diagnostic rates for ADHD more than doubled compared with baseline, follow-up with a clinician within 30 days of diagnosis increased (62.9% before vs 78.3% after; P = .03) and prescriptions for psychotropic medication decreased (61.4% before vs 43.9% after; P = .03). CONCLUSIONS: Adding to a growing literature, results demonstrate that integrated BH care can improve services for children of all ages in FQHCs that predominantly serve marginalized populations.

Five-Year Trends in Pediatric Mental Health Emergency Department Visits in Massachusetts: A Population-Based Cohort Study.

OBJECTIVES: To evaluate temporal changes in pediatric emergency department (ED) visits for mental health problems in Massachusetts based on diagnoses and patient characteristics and to assess trends in all-cause pediatric ED visits. STUDY DESIGN: This statewide population-based retrospective cohort study used the Massachusetts All-Payer Claims Database, which includes almost all Massachusetts residents. The study sample consisted of residents aged <21 years who were enrolled in a health plan between 2013 and 2017. Using multivariate regression, we examined temporal trends in mental health-related and all-cause ED visits in 2013-2017, with person-quarter as the unit of analysis; we also estimated differential trends by sociodemographic and diagnostic subgroups. The outcomes were number of mental health-related (any diagnosis, plus 14 individual diagnoses) and all-cause ED visits/1000 patients/quarter. RESULTS: Of the 967 590 Massachusetts residents in our study (representing 14.8 million person-quarters), the mean age was 8.1 years, 48% were female, and 57% had Medicaid coverage. For this population, mental health-related (any) and all-cause ED visits decreased from 2013 to 2017 (P < .001). Persons aged 18-21 years experienced the largest declines in mental health-related (63.0% decrease) and all-cause (60.9% decrease) ED visits. Although mental health-related ED visits declined across most diagnostic subgroups, ED visits related to autism spectrum disorder-related and suicide-related diagnoses increased by 108% and 44%, respectively. CONCLUSIONS: Overall rates of pediatric ED visits with mental health diagnoses in Massachusetts declined from 2013 to 2017, although ED visits with autism- and suicide-related diagnoses increased. Massachusetts' policies and care delivery models aimed at pediatric mental health may hold promise, although there are important opportunities for improvement.

Using local terminology to measure substance use behaviours among youth in post-conflict Liberia: a mixed methods study.

This mixed methods study aimed to use local terminology to accurately characterize the prevalence and risk factors associated with substance use and risky health behaviors among school-based youth in Monrovia, Liberia. An 86-question survey was validated using qualitative data obtained from focus groups at two secondary schools in central and greater Monrovia. The revised survey was then administered to 400 students from eight different secondary schools in this region. The observed prevalence estimates for lifetime and current substance use were considerably higher than previously reported among adolescents in the West African region. Among students who were former child soldiers, the rates of current substance use were 5.8-33.8% higher compared to the overall study sample. Male gender, academic seniority, and peer approval of substance use were all found to be strong predictors of current substance use among secondary students. Results suggest the need for targeted, trauma-informed interventions to reduce rates of substance use and risky health behaviors among youth in Liberia and similar post-conflict settings.

A Qualitative Analysis of Substance Use among Liberian Youth: Understanding Behaviors, Consequences, and Protective Factors Involving School Youth and the School Milieu.

OBJECTIVE: Substance use is a significant and common problem among school-aged youths throughout Africa. Like other countries on this continent, the West-African nation of Liberia is recovering from civil war. A well-educated population of young people is critical to the recovery efforts and long-term success of Liberia. Substance use by school-aged youths has important public health consequences that could undermine Liberia's post-conflict recovery efforts. We wanted to better understand the culturally significant themes and subthemes related to substance use among youths attending public schools in Monrovia, Liberia. METHODS: A qualitative research design was used to collect data from 72 students attending public school in Monrovia, Liberia. Nine focus groups of 6-8 students from three public schools were facilitated using a semi-structured format to guide discussions on substance use. Student narratives were translated and re-occurring themes and subthemes were coded and analyzed. RESULTS: Four emergent themes described in this study were: Behaviors associated with substance useConsequences associated with individual useConsequences of substance use that affected the school milieuSchool-related factors that were protective from substance use.Subthemes associated with substance use included concealment of substances, intoxication and disruption of the classroom environment, expulsion from school, school drop-out, and school as protective against substance use. CONCLUSION: Liberian school-aged youths described important themes and subthemes associated with substance use occurring within the school milieu. These data have germane public health ramifications, and could help inform larger epidemiologic study methods and public health interventions for Liberia and countries with similar profiles.