Access to therapy for child sexual abuse survivors: Preliminary dialogue of barriers and facilitators between caregivers.

BACKGROUND: Difficulties in access to therapy were highlighted by COVID-19 measures restricting in-person gatherings. Additional challenges arise when focusing on caregivers of child sexual abuse (CSA) survivors in particular, which are a population that has been historically difficult to engage with due to issues of stigma and confidentiality. OBJECTIVES: To present preliminary qualitative results from caregivers of CSA survivors. METHODS: This study was conducted with caregivers of CSA survivors. Two hybrid webinar/focus groups were conducted using a video conferencing platform in fall of 2021 with two groups of stakeholders (11 caregivers and 5 moderators/clinical staff at Little Warriors, an intensive episodic treatment facility). Sessions were recorded, transcribed, and thematically-analyzed using standard qualitative methodology. RESULTS: A total of 11 caregivers contributed to the data. Themes include: (1) Challenges of starting and maintaining treatment (i.e., emotional impact of intake day, challenges of enrolling), (2) Therapeutic benefits of specialized treatment (i.e., feeling safe and supported and the importance of trauma-informed care), and (3) Barriers and facilitators of treatment (i.e., avenues to scale-up and self-care). CONCLUSION: The importance of a strong therapeutic alliance was highlighted by both caregivers/clinical staff and further support is needed for families post-treatment. The present hybrid webinar/focus group also achieved engagement goals in a population that is typically difficult to reach. Overall, the response rate (12%) was equivalent to reported registrant attendance rates for general business to consumer webinars and the recommended focus group size. This preliminary approach warrants replication in other populations outside our clinical context.

Shifting to Trauma-Informed Care in Inpatient Psychiatry: A Case Study of an Individual with Dissociative PTSD Undergoing EMDR Therapy.

Caring for patients with personality disorders can be challenging due to risks associated with suicidal ideation, homicidal threats, splitting, and acting out with problematic behavior in psychiatric inpatient units. Limited resources on inpatient units further add to the stress and burden on staff. This case summarizes how trauma-informed care was implemented in an inpatient setting to produce marked improvement in a patient's treatment outcomes as well as better staff engagement and satisfaction. This culture change in the approach to care was not an easy process, as effortful planning and resources were required for key elements such as ongoing coaching, education, and regular staff debriefings. This case report signals the need for service providers to enable health systems to examine rules and exceptions from a cultural perspective of considering equity, diversity, and inclusion (EDI)-to allow openness to rational exceptions, even if they are unconventional.

What Is the Prevalence of Intimate Partner Violence and Traumatic Brain Injury in Fracture Clinic Patients?

BACKGROUND: Individuals in violent intimate relationships are at a high risk of sustaining both orthopaedic fractures and traumatic brain injury (TBI), and the fracture clinic may be the first place that concurrent intimate partner violence (IPV) and TBI are recognized. Both IPV and TBI can affect all aspects of fracture management, but prevalence of TBI and comorbid TBI and IPV is unknown. QUESTIONS/PURPOSES: (1) What are the previous-year and lifetime prevalence of IPV and TBI in women presenting to an outpatient orthopaedic fracture clinic? (2) What are the conditional probabilities of TBI in the presence of IPV and the reverse, to explore whether screening for one condition could effectively identify patients with the other? (3) Do patients with TBI, IPV, or both have worse neurobehavioral symptoms than patients without TBI and IPV? METHODS: The study was completed in the fracture clinic at a community Level 1 trauma center in Southern Ontario from July 2018 to March 2019 and included patients seen by three orthopaedic surgeons. Inclusion criteria were self-identification as a woman, age 18 years or older, and the ability to complete forms in English without assistance from the person who brought them to the clinic (for participant safety and privacy). We invited 263 women to participate: 22 were ineligible (for example, they were patients of a surgeon who was not on the study protocol), 87 declined before hearing the topic of the study, and data from eight were excluded because the data were incomplete or lost. Complete data were obtained from 146 participants. Participants' mean age was 52 ± 16 years, and the most common diagnosis was upper or lower limb fracture. Prevalence of IPV was calculated as the number of women who answered "sometimes" or "often" to direct questions from the Woman Abuse Screening Tool, which asks about physical, emotional, and sexual abuse in the past year or person's lifetime. The prevalence of TBI was calculated as the number of women who reported at least one head or neck injury that resulted in feeling dazed or confused or in loss of consciousness lasting 30 minutes or less on the Ohio State University Traumatic Brain Injury Identification Method, a standardized procedure for eliciting lifetime history of TBI through a 3- to 5-minute structured interview. Conditional probabilities were calculated using a Bayesian analysis. Neurobehavioral symptoms were characterized using the Neurobehavioral Symptom Inventory, a standard self-report measure of everyday emotional, somatic, and cognitive complaints after TBI, with total scores compared across groups using a one-way ANOVA. RESULTS: Previous-year prevalence of physical IPV was 7% (10 of 146), and lifetime prevalence was 28% (41 of 146). Previous-year prevalence of TBI was 8% (12 of 146), and lifetime prevalence was 49% (72 of 146). The probability of TBI in the presence of IPV was 0.77, and probability of IPV in the presence of TBI was 0.36. Thus, screening for IPV identified proportionately more patients with TBI than screening for TBI, but the reverse was not true. Neurobehavioral Symptom Inventory scores were higher (more symptoms) in patients with TBI only (23 ± 16) than those with fractures only (12 ± 11, mean difference 11 [95% CI 8 to 18]; p < 0.001), in those with IPV only (17 ± 11) versus fractures only (mean difference 5 [95% CI -1 to -11]; p < 0.05), and in those with both TBI and IPV (25 ± 14) than with fractures only (mean difference 13 [95% CI 8 to 18]; p < 0.001) or those with IPV alone (17 ± 11, mean difference 8 [95% CI -1 to 16]; p < 0.05). CONCLUSION: Using a brief screening interview, we identified a high self-reported prevalence of TBI and IPV alone, consistent with previous studies, and a novel finding of high comorbidity of IPV and TBI. Given that the fracture clinic may be the first healthcare contact for women with IPV and TBI, especially mild TBI associated with IPV, we recommend educating frontline staff on how to identify IPV and TBI as well as implementing brief screening and referral and universal design modifications that support effective, efficient, and accurate communication patients with TBI-related cognitive and communication challenges. LEVEL OF EVIDENCE: Level II, prognostic study.

Early Mental Health Foundations: A Scoping Review of Reflective Functioning in Caregiver-Child Dyads.

International public health strategies indicate a need for equitable resources for wellness in younger children and their caregivers. Reflective functioning, a proxy for emotional regulation abilities, is a key area in this domain. As an emerging area, reflective functioning has not been mapped comprehensively and requires systematic investigation. This review examines "what qualitative and quantitative evidence is there for the value of reflective functioning assessment and intervention studies in caregiver-child dyads?" This scoping review focused on data published to September 2021, focusing on caregivers of children ≤36 months of age (including Medline, PsycINFO, CINAHL, ERIC, Scopus, Web of Science, and Embase). Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews guidelines were followed. From 5162 initial articles, 608 papers were screened for full text yielding a final 181 papers. Only 69 studies included multiple ethnicities. Seven of the 69 studies included at least 1 Indigenous person. No studies were conducted in low- to middle-income countries, and no studies reported data on gender identity. This review comprises a novel and comprehensive mapping of the reflective functioning literature in terms of both assessment and intervention studies. The present mapping of the reflective functioning literature indicates the importance of health disparities in caregiver-child dyads (these include gaps and needs for future research). In relation to gaps, studies of adverse childhood experience, consideration of equity, diversity, and inclusion, and global mental health are underrepresented. Future research is needed to provide information on the relevance of gender identity and low- to middle-income countries in relation to the impact on reflective functioning in this context.

Effects of Transcranial Direct Current Stimulation on Cognitive Deficits in Depression: A Systematic Review.

Background: Major depressive disorder is the leading cause of mental health-related burden globally and up to one-third of major depressive disorder patients never achieve remission. Transcranial Direct Current Stimulation is a non-invasive intervention used to treat individuals diagnosed with major depressive disorder and bipolar disorder. Since the last transcranial direct current stimulation review specifically focusing on cognitive symptoms in major depressive disorder, twice as many papers have been published. Methods: A systematic review was conducted with 5 electronic databases from database inception until March 21, 2022. Randomized controlled trials with at least 1 arm evaluating transcranial direct current stimulation in adults (diagnosed with major depressive disorder or bipolar disorder using the Diagnostic and Statistical Manual of Mental Disorders or International Classification of Diseases criteria) aged 18 or older were included. Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were adopted. Results: : A total of 972 participants were included across 14 studies (60.5% female; mean age of 47.0 years [SD = 16.8]). Nine studies focused on participants with major depressive disorder and all studies used the Diagnostic and Statistical Manual of Mental Disorders to diagnose the participants. Seven out of the 14 studies showed significant improvements in at least 1 cognitive outcome measure in the active transcranial direct current stimulation group compared to the sham group. Several cognitive measures were used across studies, and 12 of the 14 studies reported mild-to-moderate side effects from treatment. Conclusion: : Current transcranial direct current stimulation literature has shown limited evidence for the treatment of cognitive impairments in major depressive disorder and bipolar disorder. Future research that applies machine learning algorithms may enable us to distinguish responders from non-responders, increasing clinical benefits of transcranial direct current stimulation.

Moral Injury and Recovery in Uniformed Professionals: Lessons From Conversations Among International Students and Experts.

Introduction: In the course of service, military members, leaders, and uniformed professionals are at risk of exposure to potentially morally injurious events (PMIEs). Serious mental health consequences including Moral Injury (MI) and Post-traumatic stress disorder (PTSD) can result. Guilt, shame, spiritual/existential conflict, and loss of trust are described as core symptoms of MI. These can overlap with anxiety, anger, re-experiencing, self-harm, and social problems commonly seen in PTSD. The experiences of General (retired) Romeo Dallaire and other international experts who have led in times of crisis can help us better understand MI and recovery. Objectives: In honor of Dallaire, online opportunities were created for international students and leaders/experts to discuss topics of MI, stigma, and moral codes in times of adversity as well as the moral impact of war. We aimed to (1) better understand MI and moral dilemmas, and (2) identify key insights that could inform prevention of and recovery from MI. Materials and Methods: Webinars and conversations of 75-90 min duration on MI and recovery were facilitated by Leiden University, the University of Alberta and the Dallaire Institute for Children, Peace and Security between General Dallaire, world experts, and graduate students. Sessions were recorded, transcribed and thematically analyzed with NVivo using standard qualitative methodology. Results: Ninety four participants engaged in conversations. Student engagements were attended by participants [N = 51; female (29), male (22)] from the Netherlands and Canada. Conversations were held with international experts [N = 43; female (19) and male (24)] from North America, Europe, Australia and the global south. Themes included: (1) recognizing the impact of exposure to PMIEs, (2) reducing stigma around MI, and (3) embracing the spiritual depth of humanity. Conclusion: Exposure to PMIEs can have devastating impacts on military members, leaders and other uniformed professionals. This may lead to development of MI and PTSD. Recognizing MI as honorable may reduce stigma and psychological harm, and facilitate help-seeking among uniformed personnel and other trauma-affected populations. Salient efforts to address MI must include use of accurate measurements of MI and integrated holistic therapeutic approaches, inclusive of spiritual and social components. Urgency remains regarding the prediction, identification and treatment of MI.

Five year cost savings of a multimodal treatment program for child sexual abuse (CSA): a social return on investment study.

BACKGROUND: Specialized mental health services for the treatment of Child Sexual Abuse (CSA) are generally expensive and labour intensive. They require a trauma-informed approach that may involve multiple services and therapeutic modalities, provided over the course of several months. That said, given the broad-ranging, long term negative sequelae of CSA, an evaluation of the cost-benefit analysis of treatment is clearly justified. METHODS: We performed a Social Return on Investment (SROI) analysis of data gathered as part of the treatment program at the Be Brave Ranch in Edmonton, Canada to determine the value-for-money of the services provided. We endeavoured to take a conservative, medium-term (5 year) perspective; this is in contrast to short term (1-2 year) effects, which may rapidly dissipate, or long term (15-20 year) effects, which are likely diffuse and difficult to measure. As such, our analysis was based on an average annual intake of 100 children/adolescents (60:40 split) and their families, followed over a five-year timeframe. Financial proxies were assigned to benefits not easily monetized, and six potential domains of cost savings were identified. RESULTS: Our analyses suggest that each dollar spent in treatment results in an average cost savings of $11.60 (sensitivity analysis suggests range of 9.20-12.80). The largest value-for-money was identified as the domain of crisis prevention, via the avoidance of rare but costly events associated with the long term impacts of CSA. Somewhat surprisingly, savings related to the area of criminal justice were minimal, compared to other social domains analysed. Implications are discussed. CONCLUSIONS: Our results support the cost effectiveness of the investment associated with specialized, evidence-based early interventions for CSA. These approaches alleviate severe, negative outcomes associated with CSA, resulting in both economic savings and social benefits. These findings rest upon a number of assumptions, and generalizability of these results is therefore limited to similar programs located in comparable areas. However, the SROI ratio achieved in this analysis, in excess of $11:1, supports the idea that, while costly, these services more than pay for themselves over time.

The early impact of COVID-19 on the incidence, prevalence, and severity of alcohol use and other drugs: A systematic review.

BACKGROUND: The aim of this paper was to examine the early impact of COVID-19 on substance use to assess implications for planning substance use treatment and support systems. METHOD: A systematic review of literature published up to March 2021 was conducted to summarize changes in prevalence, incidence, and severity of substance use associated with COVID-19 and the accompanying public health measures, including lockdown, stay-at-home orders, and social distancing. RESULTS: We identified 53 papers describing changes to substance use at the population level. The majority of papers described changes related to alcohol use and most relied on self-reported measures of consumption during the COVID-19 pandemic, compared with pre-pandemic use. There was less evidence to support changes in non-alcohol substance use. In general, risky pre-pandemic alcohol use, caregiving responsibilities, stress, depression, anxiety, and current treatment for a mental disorder were found to be associated with increased substance use. CONCLUSION: This review provides preliminary data on changes in substance use, indicating that certain segments of the population increased their alcohol use early on in the COVID-19 pandemic and may be at greater risk of harm and in need of additional services. There is a need for additional population-level information on substance use to inform evidence-based rapid responses from a treatment system perspective.