Adaptation of a Mobile Interactive Obesity Treatment Approach for Early Severe Mental Illness: Protocol for a Mixed Methods Implementation and Pilot Randomized Controlled Trial.

BACKGROUND: Obesity is common in individuals with severe mental illness (SMI), contributing to a significantly shortened lifespan when compared to the general population. Available weight loss treatments have attenuated efficacy in this population, underscoring the importance of prevention and early intervention. OBJECTIVE: Here, we describe a type 1 hybrid study design for adapting and pilot-testing an existing mobile health intervention for obesity prevention in individuals with early SMI and Class I or early-stage obesity, defined as a BMI of 30-35. METHODS: An existing, evidence-based interactive obesity treatment approach using low-cost, semiautomated SMS text messaging was selected for adaptation. Community mental health clinics and Clubhouse settings in Eastern Missouri and South Florida were identified to participate. This study has the following 3 aims. First, using the Enhanced Framework for Reporting Adaptations and Modifications to Evidence-based interventions, contextual aspects of the clinical and digital treatment environments are identified for adaptation, considering 5 main stakeholder groups (clinical administrators, prescribing clinicians, case managers, nurses, and patients). Following a 2-week trial of unadapted SMS text messaging, Innovation Corps methods are used to discover needed intervention adaptations by stakeholder group and clinical setting. Second, adaptations to digital functionality and intervention content will be made based on themes identified in aim 1, followed by rapid usability testing with key stakeholders. A process for iterative treatment adaptation will be developed for making unplanned modifications during the aim 3 implementation pilot study. Individuals working in partner community mental health clinics and Clubhouse settings will be trained in intervention delivery. Third, in a randomized pilot and feasibility trial, adults with 5 years or less of treatment for an SMI diagnosis will be randomized 2:1 to 6 months of an adapted interactive obesity treatment approach or to an attentional control condition, followed by a 3-month extension phase of SMS text messages only. Changes in weight, BMI, and behavioral outcomes, as well as implementation challenges, will be evaluated at 6 and 9 months. RESULTS: Institutional review board approval for aims 1 and 2 was granted on August 12, 2018, with 72 focus group participants enrolled; institutional review board approval for aim 3 was granted on May 6, 2020. To date, 52 participants have been enrolled in the study protocol. CONCLUSIONS: In this type 1 hybrid study design, we apply an evidence-based treatment adaptation framework to plan, adapt, and feasibility test a mobile health intervention in real-world treatment settings. Resting at the intersection of community mental health treatment and physical health promotion, this study aims to advance the use of simple technology for obesity prevention in individuals with early-stage mental illness. TRIAL REGISTRATION: ClinicalTrials.gov NCT03980743; https://clinicaltrials.gov/ct2/show/NCT03980743. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/42114.

ADHD Diagnostic Trends: Increased Recognition or Overdiagnosis?

The prevalence of Attention Deficit Hyperactivity Disorder (ADHD) has seen a consistent rise in recent years. These numbers spark a debate over the reason for the observed trends, with some concerned about over diagnosis and over prescription of stimulant medications, and others raising the issue of diagnostic disparities, particularly in underrepresented populations. In this paper we look at both sides, starting with the history of ADHD and its diagnostic criteria changes, from early concepts of alterations in attention and hyperactivity in the 19th and 20th century, to its introduction in the Diagnostical and Statistical Manual of Mental Disorders (DSM), and its evolution into how it is defined today. The general broadening of ADHD diagnostically over time plays a role in the increased prevalence over the years, but it is not the only reason. Increased awareness of physicians and the public is also believed to play a big role, particularly in underrepresented minorities and women. However, there continues to be disparities in detection of ADHD in these groups. There are significant consequences to a patient's social, interpersonal, and professional life when ADHD is left unrecognized and untreated. Thoughtful evaluation, accurate diagnosis, and adequate treatment can make a big difference.

Using Digital Technology to Overcome Racial Disparities in Child and Adolescent Psychiatry.

Racial inequity in mental health care quality is influenced by many systems-level factors, as elucidated by critical race theory, structural competency, and other keystone frameworks.1 A growing body of literature also suggests provider-level bias to be a key driver.1-3 There is specific evidence that racism is an important driver of health inequities among youth4 and that it is mediated, in part, by provider-level processes related to diagnosis and treatment.2 For example, in child and adolescent psychiatry, youth who are Black, Indigenous, and People of Color (BIPOC) experience disproportionate rates of delayed diagnosis and treatment of autism spectrum disorder, overdiagnosis of conduct disorder, and underdiagnosis of attention-deficit/hyperactivity disorder.4 Black and multiracial adolescents are at highest risk of suicide,5 yet are least likely to receive preventive psychotherapy.4.