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.

Examining the Effectiveness, Acceptability, and Feasibility of Virtually Delivered Trauma-Focused Domestic Violence and Sexual Violence Interventions: A Rapid Evidence Assessment.

The COVID-19 pandemic has forced a rapid shift to virtual delivery of treatment and care to individuals affected by domestic violence and sexual violence. A rapid evidence assessment (REA) was undertaken to examine the effectiveness, feasibility and acceptability of trauma-focused virtual interventions for persons affected by domestic violence and sexual violence. The findings from this review will provide guidance for service providers and organizational leaders with the implementation of virtual domestic violence and sexual violence-focused interventions. The REA included comprehensive search strategies and systematic screening of and relevant articles. Papers were included into this review (1) if they included trauma-focused interventions; (2) if the intervention was delivered virtually; and (3) if the article was published in the English-language. Twenty-one papers met inclusion criteria and were included for analysis. Findings from the rapid review demonstrate that virtual interventions that incorporate trauma-focused treatment are scarce. Online interventions that incorporate trauma-focused treatment for this at-risk group are limited in scope, and effectiveness data are preliminary in nature. Additionally, there is limited evidence of acceptability, feasibility and effectiveness of virtual interventions for ethnically, culturally, and linguistically diverse populations experiencing domestic violence and sexual violence. Accessing virtual interventions was also highlighted as a barrier to among participants in studies included in the review. Despite the potential of virtual interventions to respond to the needs of individuals affected by domestic violence and/or sexual violence, the acceptability and effectiveness of virtual trauma-focused care for a diverse range of populations at risk of violence are significantly understudied.

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.

Child sexual abuse survivors: Differential complex multimodal treatment outcomes for pre-COVID and COVID era cohorts.

BACKGROUND: Child sexual abuse (CSA) is a form of early-life trauma that affects youth worldwide. In the midst of the current COVID-19 pandemic, it is imperative to investigate the potential impact of added stress on already vulnerable populations. OBJECTIVE: The aim of this study was to evaluate the effectiveness of a multimodal treatment program on mental health outcomes for youth CSA survivors aged 8-17. Secondary to this, we explored the potential impact of the COVID-19 on treatment outcomes. PARTICIPANTS AND SETTING: Participants of this study were children and youth aged 8-17 who were engaged in a complex multimodal treatment program specifically designed for youth CSA survivors. METHODS: Participants were asked to complete self-report surveys at baseline and at the end of two subsequent treatment rounds. Surveys consisted of measures pertaining to: (1) PTSD, (2) depression, (3) anxiety, (4) quality of life, and (5) self-esteem. RESULTS: Median scores improved for all groups at all timepoints for all five domains. For the pre-Covid participants, the largest improvements in the child program were reported in depression (36.6 %, p = 0.05); in the adolescent program anxiety showed the largest improvement (-35.7 %, p = 0.006). Improvements were generally maintained or increased at the end of round two. In almost every domain, the improvements of the pre-COVID group were greater than those of the COVID-I group. CONCLUSIONS: A complex multimodal treatment program specifically designed for youth CSA survivors has the capacity to improve a number of relevant determinants of mental health and well-being. The COVID-19 pandemic may have retraumatized participants, resulting in treatment resistance.

Perspectives on delivering safe and equitable trauma-focused intimate partner violence interventions via virtual means: A qualitative study during COVID-19 pandemic.

BACKGROUND: The COVID-19 pandemic has been linked with increased rates of intimate partner violence (IPV) and associated experiences of compounded trauma. The emergence of this global pandemic and the public health measures introduced to limit its transmission necessitated the need for virtually delivered interventions to support continuity of care and access to interventions for individuals affected by IPV throughout the crisis. With the rapid shift to virtual delivery, understanding the barriers to accessing virtually delivering trauma-focused IPV interventions to these individuals was missed. This study aimed to qualitatively describe the challenges experienced by service providers with delivering virtually delivered IPV services that are safe, equitable, and accessible for their diverse clients during the COVID-19 pandemic. METHODS: The study involved semi-structured interviews with 24 service providers within the anti-violence sector in Alberta, Canada working with and serving individuals affected by IPV. The interviews focused on the perspectives and experiences of the providers as an indirect source of information about virtual delivery of IPV interventions for a diverse range of individuals affected by IPV. Interview transcripts were analyzed using inductive thematic analysis. RESULTS: Findings in our study show the concepts of equity and safety are more complex for individuals affected by IPV, especially those who are socially disadvantaged. Service providers acknowledged pre-existing systemic and institutional barriers faced by underserved individuals impact their access to IPV interventions more generally. The COVID-19 pandemic further compounded these pre-existing challenges and hindered virtual access to IPV interventions. Service providers also highlighted the pandemic exacerbated structural vulnerabilities already experienced by underserved populations, which intensified the barriers they face in seeking help, and reduced their ability to receive safe and equitable interventions virtually. CONCLUSION: The findings from this qualitative research identified key determining factors for delivering safe, equitable, and accessible virtually delivered intervention for a diverse range of populations. To ensure virtual interventions are safe and equitable it is necessary for service providers to acknowledge and attend to underlying systemic and institutional barriers including discrimination and social exclusion. There is also a need for a collaborative commitment from multiple levels of the social, health, and political systems.

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.

Model of Post-traumatic Growth in Newly Traumatized vs. Retraumatized Adolescents.

Background: In our analysis of adolescents affected by the 2016 Fort McMurray wildfire, we observed many negative mental health effects in individuals with a prior history of psychological trauma. Elevated rates of depression and markers of post-traumatic stress disorder (PTSD) were observed, consistent with the hypothesis that prior trauma may reduce sensitivity thresholds for later psychopathology (stress sensitization). Surprisingly, levels of anxiety did not differ based on prior trauma history, nor were retraumatized individuals at increased risk for recent (past month) suicidal ideation. These results are more suggestive of inoculation by prior trauma than stress sensitization. This led us to consider whether individuals with a prior trauma history showed evidence of Post-Traumatic Growth (PTG), a condition in which the experience of a previous trauma leads to areas of sparing or even improvement. Method: To investigate this issue, we generated a structural equation model (SEM) exploring the role of anxiety in previously traumatized (n = 295) and wildfire trauma alone (n = 740) groups. Specifically, models were estimated to explore the relationship between hopelessness, anxiety, PTSD symptoms, self-efficacy and potential protective factors such as friend and family support in both groups. The model was tested using a cross-sectional sample of affected youth, comparing effects between the two groups. Results: While both models produced relatively good fit, differences in the effects and chi-squared values led us to conclude that the groups are subject to different causal specifications in a number of areas, although details warrant caution pending additional investigation. Discussion: We found that adolescents with a prior trauma history appear to have a more realistic appraisal of potential difficulties associated with traumatic events, and seem less reactive to potentially unsettling PTSD symptoms. They also seemed less prone to overconfidence as they got older, an effect seen in the adolescents without a history of trauma. Our findings provide preliminary evidence that the construct of anxiety may work differently in newly traumatized and retraumatized individuals, particularly in the context of mass trauma events.

Nurturing Spiritual Resilience to Promote Post-disaster Community Recovery: The 2016 Alberta Wildfire in Canada.

The 2016 Alberta wildfire, the largest insured natural disaster in Canada, led to a mass evacuation of residents of Fort McMurray, a small city in northern Alberta. The wildfire resulted in significant damages to housing and community infrastructure. The entire community was displaced for several weeks. Post-disaster, community members experienced individual and collective trauma, and other negative mental health impacts in response to the significant losses and grief they endured. Spirituality has been found to be a major protective factor in facilitating resiliency and recovery following the experience of disaster. Nonetheless, little focus has been directed toward how spirituality can strengthen and empower community capacity and growth during post-disaster recovery. Our study explored various meanings and concerns, along with tools and strategies that helped to nurture spiritual resilience and well-being among residents of Fort McMurray following the Alberta wildfire. Data were collected through interviews and focus group discussions with community influencers working to support long-term recovery efforts in the city. Participants identified a number of spiritual resources such as a strong sense of belonging, a shared positive outlook, faith and hope, compassion, and sense of gratitude, which contributed to increased resilience and positive health and well-being and helped them to support families and communities in the post disaster recovery period. Our findings indicate that spiritual values and beliefs can play a significant role in building resilience and promoting individual and communal healing and recovery post-disaster. These findings have important implications for post-disaster recovery strategies, as they highlight the need to ensure supports for interventions and initiatives that strengthen a collective sense of identity and social cohesion, informed by communal norms and beliefs, including programs and resources which support opportunities for reflexivity to foster shared healing and ongoing recovery processes.

Social-Ecological Factors Associated With Higher Levels of Resilience in Children and Youth After Disaster: The Importance of Caregiver and Peer Support.

Children and youth are among the most vulnerable to the devastating effects of disaster due to the physical, cognitive, and social factors related to their developmental life stage. Yet children and youth also have the capacity to be resilient and act as powerful catalysts for change in their own lives and wider communities following disaster. Specific factors that contribute to resilience in children and youth, however, remain relatively unexplored. This article examines factors associated with high levels of resilience in 100 children and youth aged 5- to 18-years old who experienced the 2016 Fort McMurray, Alberta wildfire. A mixed-methods design was employed combining quantitative and qualitative data. Quantitative data was obtained from the Children and Youth Resilience Measure (CYRM-28) which measured individual, caregiver, and context factors influencing resilience processes among the participants. Qualitative data was collected through semi-structured interviews to gain further insight into the disaster experiences of children and youth. Quantitative findings reveal higher than average levels of resilience among the participants compared to normative scores. Qualitative findings suggest high levels of resilience were associated with both caregiver factors (specifically physical caregiving), and individual factors (primarily peer support). We discuss how physical caregiving and peer support during and after the wildfire helped mitigate the negative effects of disaster, thus bolstering children and youth's resilience. Implications for understanding the specific social-ecological factors that facilitate and support resiliency processes and overall recovery of children and youth following disaster are also discussed.

Collective Trauma and Mental Health in Adolescents: A Retrospective Cohort Study of the Effects of Retraumatization.

In the wake of the massive Canadian wildfire of May 2016 in the area of Fort McMurray Alberta, we observed increased rates of mental health problems, particularly post-traumatic stress disorder (PTSD), in school-aged adolescents (ages 11-19). Surprisingly, we did not see these rates decline over the 3.5-year follow-up period. Additionally, our research suggested that the impact of this mass incident resulted in other unanticipated effects, including the finding that children who were not present for and relatively unaffected by the wildfire showed a similar PTSD symptom profile to children more directly involved, suggesting some degree of spillover or stress contagion. A potential explanation for these high rates in individuals who were not present could be undiagnosed retraumatization in some of the students. To investigate this possibility, we compared two groups of students: those who reported the wildfire as their most significant trauma (n = 740) and those who had their most significant trauma prior to the wildfire (n = 295). Those with significant pre-existing trauma had significantly higher rates of both depression and PTSD symptoms, although, unexpectedly the groups exhibited no differences in anxiety level. Taken together, this evidence suggests retraumatization is both longer-lasting and more widespread than might be predicted on a case-by-case basis, suggesting the need to reconceptualize the role of past trauma history in present symptomatology. These findings point to the need to recognize that crises instigated by natural disasters are mass phenomena which expose those involved to numerous unanticipated risks. New trauma-informed treatment approaches are required that incorporate sensitivity to the collective impact of mass crises, and recognize the risk of poorer long-term mental health outcomes for those who experienced trauma in the past.

Mental Health Symptoms Unexpectedly Increased in Students Aged 11-19 Years During the 3.5 Years After the 2016 Fort McMurray Wildfire: Findings From 9,376 Survey Responses.

In Fort McMurray, Alberta, Canada, the wildfire of May 2016 forced the population of 88,000 to rapidly evacuate in a traumatic and chaotic manner. Ten percentage of the homes in the city were destroyed, and many more structures were damaged. Since youth are particularly vulnerable to negative effects of natural disasters, we examined possible long-term psychological impacts. To assess this, we partnered with Fort McMurray Public and Catholic Schools, who surveyed Grade 7-12 students (aged 11-19) in November 2017, 2018, and 2019-i.e., at 1.5, 2.5, and 3.5 years after the wildfire. The survey included validated measurement scales for post-traumatic stress disorder (PTSD), depression, anxiety, drug use, alcohol use, tobacco use, quality of life, self-esteem, and resilience. Data analysis was done on large-scale anonymous surveys including 3,070 samples in 2017; 3,265 samples in 2018; and 3,041 samples in 2019. The results were unexpected and showed that all mental health symptoms increased from 2017 to 2019, with the exception of tobacco use. Consistent with this pattern, self-esteem and quality of life scores decreased. Resilience scores did not change significantly. Thus, mental health measures worsened, in contrast to our initial hypothesis that they would improve over time. Of note, we observed higher levels of mental health distress among older students, in females compared to male students, and in individuals with a minority gender identity, including transgender and gender-non-conforming individuals. These findings demonstrate that deleterious mental health effects can persist in youth for years following a wildfire disaster. This highlights the need for multi-year mental health support programs for youth in post-disaster situations. The indication that multi-year, post-disaster support is warranted is relatively novel, although not unknown. There is a need to systematically investigate factors associated with youth recovery following a wildfire disaster, as well as efficacy of psychosocial strategies during later phases of disaster recovery relative to early post-disaster interventions.

Effects of childhood adversity on the volumes of the amygdala subnuclei and hippocampal subfields in individuals with major depressive disorder.

Background: Reductions in total hippocampus volume have frequently been reported in MRI studies in major depressive disorder (MDD), but reports of differences in total amygdala volume have been inconsistent. Childhood maltreatment is an important risk factor for MDD in adulthood and may affect the volume of the hippocampus and amygdala. In the present study, we examined associations between the volumes of the amygdala subnuclei and hippocampal subfields and history of childhood maltreatment in participants with MDD. Methods: We recruited 35 patients who met the DSM-IV criteria for MDD and 35 healthy controls. We acquired MRI data sets on a 4.7 T Varian Inova scanner. We manually delineated the amygdala subnuclei (lateral, basal and accessory basal nuclei, and the cortical and centromedial groups) and hippocampal subfields (cornu ammonis, subiculum and dentate gyrus) using reliable volumetric methods. We assessed childhood maltreatment using the Childhood Trauma Questionnaire in participants with MDD. Results: In participants with MDD, a history of childhood maltreatment had significant negative associations with volume in the right amygdala, anterior hippocampus and total cornu ammonis subfield bilaterally. For volumes of the amygdala subnuclei, such effects were limited to the basal, accessory basal and cortical subnuclei in the right hemisphere, but they did not survive correction for multiple comparisons. We did not find significant effects of MDD or antidepressant treatment on volumes of the amygdala subnuclei. Limitations: Our study was a cross-sectional study. Conclusion: Our results provide evidence of negative associations between history of childhood maltreatment and volumes of medial temporal lobe structures in participants with MDD. This may help to identify potential mechanisms by which maltreatment leads to clinical impacts.

A Novel 2-week Intensive Multimodal Treatment Program for Child Sexual Abuse (CSA) Survivors is Associated with Mental Health Benefits for Females aged 13-16.

OBJECTIVE: The aim of this study was to evaluate the psychiatric outcomes for the first cohorts of adolescent female Child Sexual Abuse (CSA) survivors after two-weeks in an intensive multimodal treatment program designed for this population. METHODS: Baseline data was collected at intake and again immediately prior to discharge. Data collected included demographic information, as well as measurement of standardized scales for PTSD, depression, anxiety, quality of life, self-esteem, and resilience. Mean scores at baseline and discharge were statistically analyzed to assess for changes following the treatment program on these measures. RESULTS: From the first twenty-seven (27) adolescent female CSA survivors, who completed two-weeks of the multimodal treatment program, all three symptomatic scales showed statistically significant improvements from baseline. There were decreases in mean questionnaire scores for Depression (-23.8%, p = 0.001), Anxiety (-20.6%, p = 0.006), and PTSD (-20.3%, p = 0.002), as well as decrease of nearly 50% in the number of participants who were having active suicidal thoughts. In keeping with this, there were also statistically significant improvements in ratings for Quality of Life (17.6%, p = 0.022), Self-Esteem (22.9%, p = 0.010), and Resilience (6.9%, p = 0.019). CONCLUSION: This study presents preliminary findings from an intensive two-week multimodal treatment program specifically designed to help survivors of child sexual abuse (CSA). The highly positive short-term findings suggest that further longer-term follow-up in larger groups is appropriate. These preliminary results also support ongoing research for such intensive multimodal programs.

OBJECTIF: La présente étude visait à évaluer les résultats psychiatriques des premières cohortes d'adolescentes survivantes d'abus sexuels sur des enfants (ASE) après deux semaines d'un programme de traitement multimodal intensif conçu pour cette population. MÉTHODES: Les données de base ont été recueillies à l'admission et de nouveau, immédiatement avant le congé. Les données recueillies comprenaient l'information démographique ainsi que les mesures aux échelles normalisées du trouble de stress post-traumatique (TSPT), de la dépression, de l'anxiété, de la qualité de vie, de l'estime de soi et de la résilience. Les scores moyens à la base et au congé ont été statistiquement analysés pour évaluer les changements suite au programme de traitement sur ces mesures. RÉSULTATS: Pour les vingt-sept (27) premières adolescentes survivantes d'ASE qui ont suivi les deux semaines du programme de traitement multimodal, les trois échelles symptomatiques indiquaient des améliorations statistiquement significatives par rapport à la base. Il y a eu diminution des scores moyens aux questionnaires pour la dépression (−23,8 %, p = 0,001), l'anxiété (−20,6 %, p = 0,006), et le TSPT (−20,3 %, p = 0,002), ainsi qu'une réduction de près de 50 % du nombre de participantes qui avaient une idéation suicidaire active. Dans le même ordre d'idées, il y a aussi eu des améliorations statistiquement significatives des scores de la qualité de vie (17,6 %, p = 0,022), de l'estime de soi (22,9 %, p = 0,010), et de la résilience (6,9 %, p = 0,019). CONCLUSION: Cette étude présente les résultats préliminaires d'un programme de traitement multimodal intensif de deux semaines spécifiquement conçu pour aider les survivants d'abus sexuel sur les enfants (ASE). Les résultats à court terme très positifs suggèrent qu'un suivi à plus long terme pour de grands groupes est approprié. Ces résultats préliminaires suggèrent aussi la poursuite des recherches de tels programmes multimodaux intensifs.

High Rates of Mental Health Disorders in Civilian Employees Working in Police Organizations.

Working in a police organization often involves being exposed to potentially traumatic events and stressful circumstances regardless of occupation or rank. Police mental health is a public health concern, but the mental health of civilian employees working in police organizations has been much less studied. The current study aims to compare the frequency of mental health conditions in both police officers and civilians. This was evaluated by measuring mean scores on several mental health screening tools including scales to determine symptom severity for posttraumatic stress disorder (PTSD) with the PTSD Checklist - PCL-5, depression with the Patient Health Questionnaire-9 (PHQ), general anxiety with the Generalized Anxiety Disorder 7-item scale (GAD-7), and alcohol use with the Alcohol Use Disorders Identification Test (AUDIT). The total potential population was 1,225 civilian employees and 3,714 police officers, of which 513 (10%) participated. Of these, 201 (16%) were civilians, and 312 (8%) were police officers (p<0.001). In the study population, 26% screened positive for any mental health disorder. Somewhat surprisingly, we found significantly more civilians (32.8%) than police officers (22.7%) met diagnostic criteria. We also found that civilian participants had higher mean scores in measures of PTSD, anxiety, and depression, although only for depression did this reach statistical significance. Civilians were 1.7 times more likely to screen positive for depression compared to police officers, a statistically significant difference. In contrast, police officers demonstrated statistically higher scores for alcohol use than civilians. One limitation of this study is that the data reflects responses from only a minority of the overall population and, therefore, may not accurately reflect the frequency of mental health issues in the total police organization including civilian employees. Nonetheless, the results strongly suggest that the mental health of all employees can be negatively impacted by working in a police environment, and this is important given the growing number of civilians employed within police organizations. These findings support initiatives aimed at destigmatizing mental health disorders, improving stress management, and increasing access to mental health care on an organization-wide basis, and not just limited to front-line police officers.

Long-Term Mental Health Effects of a Devastating Wildfire Are Amplified by Socio-Demographic and Clinical Antecedents in Elementary and High School Staff.

OBJECTIVES: To assess the likely prevalence rates of Major Depressive Disorder (MDD), Generalized Anxiety Disorder (GAD) and Post-Traumatic Stress Disorder (PTSD) in staff of Fort McMurray School Districts eighteen months after a May 2016 wildfire, and to determine possible predictors. METHODS: A quantitative cross-sectional survey was used to collect data through self-administered online questionnaires to determine likely MDD, GAD and PTSD using well validated self-report questionnaires. RESULTS: Of 1,446 staff who were sent the online survey link in an e-mail, 197 completed the survey, of which there were 168 females (85%) and 29 males (15%). The one-month prevalence rates for likely MDD, GAD and PTSD among the school staff were 18.3, 15.7 and 10.2% respectively. There were statistically significant associations between multiple socio-demographic and clinical variables likely MDD, GAD and PTSD among respondents. CONCLUSION: Knowledge of key factors for MDD, GAD and PTSD may be helpful for policy makers when formulating population level social and clinical programs, to mitigate the mental health effects of future natural disasters.

Mental Health Effects in Primary Care Patients 18 Months After a Major Wildfire in Fort McMurray: Risk Increased by Social Demographic Issues, Clinical Antecedents, and Degree of Fire Exposure.

Objectives: To assess prevalence of likely posttraumatic stress disorder (PTSD), major depressive disorder (MDD), and generalized anxiety disorder (GAD) in patients attending the only out-of-hours primary care clinic in Fort McMurray some 18 months following a major fire. Methods: A quantitative cross-sectional survey was used to collect data through self-administered paper-based questionnaires to determine likely PTSD, MDD, and GAD using the PTSD Checklists for Diagnostic and Statistical Manual (DSM) 5, Patient Health Questionnaire (PHQ) 9, and GAD-7, respectively, from residents of Fort McMurray who were impacted by the wildfires. This was carried out eighteen (18) months after a major wildfire, which required the rapid evacuation of the entire city population (approximately 90,000 individuals). Results: We achieved a response rate of 48% and results from the 290 respondents showed the 1 month prevalence rate for likely PTSD was 13.6%, likely MDD was 24.8%, and likely GAD was 18.0%. Compared to self-reported prevalence rates before the wildfire (0%, 15.2%, and 14.5% respectively), these were increased for all diagnoses. After controlling for other factors in a logistic regression model, there were statistically significant associations between individuals who had likely PTSD, MDD, and GAD diagnoses and multiple socio-demographic, clinical, and exposure-related variables as follows: PTSD: History of anxiety disorder and received counselling had odds ratios (ORs) of 5.80 and 7.14, respectively. MDD: Age, witnessed the burning of homes, history of depressive disorder, and receiving low level support from friends and family had ORs of 2.08, 2.29, 4.63, and 2.5, respectively. GAD: Fearful for their lives or the lives of friends/family, history of depressive disorder, and history of anxiety disorder had ORs of 3.52, 3.04, and 2.68, respectively. There were also associations between individuals with a likely psychiatric diagnosis and those who also had likely alcohol or drug abuse/dependence. Conclusion: Our study suggests there are high prevalence rates for mental health and addiction conditions in patients attending the out-of-hours clinic 18 months after the wildfires, with significant associations between multiple variables and likely PTSD, MDD, and GAD. Further studies are needed to explore the impact of population-based mental health interventions on the long-term mental health effects of the wildfires.

Significant PTSD and Other Mental Health Effects Present 18 Months After the Fort Mcmurray Wildfire: Findings From 3,070 Grades 7-12 Students.

Background: The May 2016 wildfire in Fort McMurray, Alberta, Canada forced evacuation of the population of 88,000 individuals and destroyed 10% of the homes. Youth are particularly impacted by disaster. Methods: Eighteen months after the wildfire, Fort McMurray Public and Catholic Schools surveyed 3,252 of the 4,407 students in Grades 7-12 to determine possible long-term psychological impacts. The survey included validated measurement scales for post-traumatic stress disorder (PTSD), depression, anxiety, use of drugs, alcohol, and tobacco, quality of life, self-esteem, and resilience. Data analysis was possible for only 3,070 students, i.e., 70% of the total student population. Anonymized data were analyzed to compare students who directly experienced lesser or greater impact from the wildfire, with greater impact defined as personally seeing the fire or having one's home destroyed. Also, students with greater or lesser scores on the Child and Youth Resilience Measure (CYRM-12) were compared. Results: Of the 3,070 students, 37% met criteria for probable PTSD; 31% met criteria for probable depression, and 17% for probable depression of at least moderate severity; 27% of students met criteria for probable anxiety, and 15% for probable alcohol or substance use disorder; 46% of all students met criteria for one or more probable diagnosis of PTSD, depression, anxiety, or alcohol/substance abuse, and this included students who were both present and not present in Fort McMurray at the time of the wildfire. Students with greater impact from the wildfire exhibited significantly higher scores on measures of PTSD, depression, anxiety, and alcohol/substance use. They also had lower self-esteem and quality of life scores. Students with lower resilience scores exhibited a similar pattern. Conclusions: These findings highlight first the negative impact of disasters on youth mental health, particularly for those who directly experience wildfire, and second the role of resilience on youth mental health, with lower resilience associated with substantially lower mental health outcomes. These results emphasize the need for long-term mental health supports for youth post-disaster, with specific focus on increasing youth resilience, which may serve as a protective factor against effects of disaster on mental health.

Cost-effectiveness analysis of a randomized study of depression treatment options in primary care suggests stepped-care treatment may have economic benefits.

BACKGROUND: The stepped-care pathway (SCP) model has previously been found to be clinically effective for depressive disorder in some studies, but not all. Several groups have suggested that a stepped-care approach is the most appropriate in primary care. There is relatively little information, however, regarding which specific stepped-care pathway may be best. This analysis aimed to determine cost-effectiveness of a stepped-care pathway for depression in adults in primary care versus standard care (SC), treatment-as-usual (TAU), and online cognitive behavioural therapy (CBT). METHODS: We conducted a randomized trial with 1400 participants and 12-week follow-up to assess the impact of the four treatment options on health-related quality of life and depression severity. Costs for the groups were calculated on the basis of physician, outpatient, and inpatient services using administrative data. We then calculated the incremental cost-effectiveness ratios using this information. Cost-effectiveness acceptability curves and incremental cost-effectiveness scatterplots were created using Monte Carlo simulation with 10,000 replications. A subgroup analysis was conducted for participants who screened as depressed at baseline. RESULTS: For all participants, TAU was the most expensive followed by CBT, SC, and SCP. QALYs were highest in SCP, followed by SC, CBT, and TAU. In the depressed subgroup, TAU was still the most expensive, followed by SC, SCP, and CBT, while QALYs were still highest in SCP, followed by SC, CBT, and TAU. The cost-effectiveness acceptability curves suggested that SCP had a higher probability for cost-effectiveness than the other three alternatives in all participants. In the depressed subgroup, CBT was associated with the highest probability of cost-effectiveness for a willingness-to-pay cut-off of less than approximately $50,000, while SCP was the highest at a cut-off higher than $50,000. There is considerable uncertainty around the cost-effectiveness estimates. CONCLUSIONS: Our analysis showed that even where there are no clinically significant differences in health outcomes between treatment approaches, there may be economic benefit from implementing the stepped-care model. While more work is required to identify the most clinically effective versions of a stepped-care pathway, our findings suggest that the care pathway may have potential to improve health care system value. TRIAL REGISTRATION: NCT01975207 . The trial was prospectively registered on 4 November 2013.

Correction to: After the Fort McMurray wildfire there are significant increases in mental health symptoms in grade 7-12 students compared to controls.

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After the Fort McMurray wildfire there are significant increases in mental health symptoms in grade 7-12 students compared to controls.

BACKGROUND: In order to examine the impact of disasters on adolescent mental health, this study compared population mental health survey data from two communities in Alberta, Canada: Fort McMurray, which experienced a major natural disaster, and Red Deer, which did not. METHODS: Data from 3070 grade 7-12 students from Fort McMurray, Alberta, Canada (collected in 2017, 18 months after the 2016 wildfire) was compared with data from 2796 grade 7-12 students from Red Deer, Alberta, Canada (collected in 2014). The same measurement scales were used for both surveys. Both of these cities have populations of approximately 100,000, and both cities are located in Alberta, Canada. For this reason, Red Deer is an appropriate non-disaster impacted community to compare to the disaster impacted community of Fort McMurray. RESULTS: The results of this comparison demonstrate that mental health symptoms were statistically significantly elevated in the Fort McMurray population when compared to the control population in Red Deer. This occurred for scores consistent with a diagnosis of depression (31% vs. 17%), moderately severe depression (17% vs. 9%), suicidal thinking (16% vs. 4%), and tobacco use (13% vs. 10%). Consistent with there being major mental health impacts from the 2016 Fort McMurray wildfire, self-esteem scores and quality of life scores were also statistically significantly lower in Fort McMurray. While the rates of anxiety disorder were similar (15% vs. 16%), the mean scores on the anxiety scale were slightly higher, with this difference reaching statistical significance. There were no statistical differences in the rates or scores for alcohol or substance use. CONCLUSIONS: Our results are consistent with previous findings showing a significant negative impact of disasters on many aspects of adolescent mental, with a particular increase in symptoms related to depression and suicidal thinking. These findings highlight first, the need to identify adolescents most at risk of developing psychiatric symptoms after experiencing the trauma of disaster and second, the importance and necessity of implementing short and long term mental health intervention programs specifically aimed at adolescents, in order to help mitigate the negative effects of disasters on their mental health.