Barriers to treatment among African Americans with obsessive-compulsive disorder

The Effectiveness of a Cell Phone eHealth App in Changing Knowledge, Stigmatizing Attitudes, and Intention to Seek Help Associated With Obsessive-Compulsive Disorder: Pilot Questionnaire Study

BACKGROUND

Obsessive-compulsive disorder (OCD) is a disabling disorder associated with high interference in people's lives. However, patients with OCD either do not seek help or delay seeking help. Research suggests that this could be explained by poor mental health literacy about the disorder and the associated stigma.

OBJECTIVE

This study aims to evaluate the feasibility, acceptability, and preliminary effectiveness of a mental health mobile app, esTOCma, developed to improve knowledge about OCD and its treatment, increase help-seeking intention, and reduce stigmatizing attitudes and social distance associated with OCD.

METHODS

We used preintervention, postintervention, and 3-month follow-up assessments in this single-arm pilot intervention. Overall, 90 participants were recruited from the community using the snowball sampling method. We used esTOCma to defeat the "stigma monster" over the course of 10 missions. The participants completed the sociodemographic information and Obsessive-Compulsive Inventory-Revised at preassessment and an acceptability questionnaire at postassessment. All other measures were completed at the preassessment, postassessment, and 3-month follow-up (ie, the Spanish Mental Illness Stigma Attribution Questionnaire-27, the General Help-Seeking Questionnaire, the Social Distance Scale, and the Mental Health Literacy Questionnaire).

RESULTS

Of the 90 participants from the community that were assessed for eligibility, 86% (n=78) were allocated to intervention. Of these 78 participants, 79% (n=62) completed the game and answered the postintervention assessment (completer group). Overall, 69% (43/62) of the participants also completed the 3-month follow-up assessment. The participants completing the study were older (P=.003) and had a higher baseline knowledge of OCD (P=.05). The participants took an average of 13.64 (SD 10.50) days to complete the intervention, including the pre- and postassessments. The participants spent an average of 4.56 (SD 3.33) days completing the 10 missions included in the app. Each mission took a mean of between 2 (SD 3.01) and 9.35 (SD 3.06) minutes. The app was rated as useful or very useful by the vast majority of participants 90% (56/62). Moreover, 90% (56/62) of the participants reported that they had learned or learned a lot, and 98% (61/62) of the participants reported that they would recommend the app to a friend. Repeated measures ANOVA (43/62, 69%) showed that after the intervention participants showed an increased knowledge of mental health and intention to seek help as well as fewer stigmatizing attitudes and less social distance.

CONCLUSIONS

Preliminary data show that esTOCma is a feasible and acceptable app, and after completing its 10 missions, there is an increase in the understanding of OCD and help-seeking intention along with a decrease in the social stigma and social distance associated with OCD that lasts for at least 3 months. The results support the potential of technology-based interventions to increase the intention to seek help and reduce the stigma associated with OCD. A larger, community-controlled study is also recommended.

Retrospective State Medicaid Claims Analysis of Children and Adults With Obsessive-Compulsive Disorder

OBJECTIVE

With a lifetime U.S. prevalence of 2.3%, obsessive-compulsive disorder (OCD) is a chronic condition often producing reduced quality of life and disability when left untreated. Little is known about the prevalence or treatment of diagnosed OCD in public behavioral health systems.

METHODS

Using a claims analysis of 2019 New York State Medicaid data (N=2,245,084 children; N=4,274,100 adults), the authors investigated the prevalence and characteristics of children and adults with OCD. The authors also examined whether these individuals received treatment with medication or psychotherapy.

RESULTS

The prevalence of OCD was 0.2% among children and 0.3% among adults. Fewer than half of children (40.0%) and adults (37.5%) received U.S. Food and Drug Administration-approved medications (with or without psychotherapy); another 19.4% of children and 11.0% of adults received 45- or 60-minute psychotherapy alone.

CONCLUSIONS

These data demonstrate the need for public behavioral health systems to increase their capacity to identify and treat OCD.

Geospatial Distribution of Obsessive-Compulsive Disorder Specialists: Understanding Access as a Function of Distance, Insurance Status, and Neighborhood Socioeconomic Status

Obsessive-compulsive disorder is an impairing psychiatric condition affecting 1-2% of adults and youth. Cognitive-behavioral therapy with exposure and response prevention (CBT) is an efficacious intervention but requires specialty training and access is often limited. While certain factors are associated with treatment access, one key barrier that has not been explored is the geographic availability of OCD treatment providers. Using integrated geographically-referenced data, we examined the geographic distribution of OCD CBT specialty providers across the state of Texas, with particular attention to the relationship to neighborhood socioeconomic disadvantage, insurance status, and rural versus urban status. We found that specialist providers are almost exclusively located inside the highly urbanized parts of the state, primarily in more affluent areas, and often only accept self-pay. The characteristics of the areas located the furthest away from specialty OCD care include a high proportion of persons identifying as Hispanic; a high proportion of non-English speakers, households with income below poverty; households with no vehicles; and persons with no health insurance. Average household income decreased as distances from specialist providers increased. Broadly, findings confirm that OCD CBT specialty providers are clustered in large socially advantaged areas and that economic disadvantage remains a significant barrier to care. As inadequate or inappropriate treatment of OCD is likely to result in sustained and impairing symptoms, this is of great concern.

Does Using a Mindfulness App Reduce Anxiety and Worry? A Randomized-Controlled Trial

Objectives: the availability of smartphone-based mindfulness training applications (apps) may circumvent many barriers to receiving in-person help, but little controlled research has been conducted on them. This study sought to evaluate the effectiveness of a widely used -mindfulness training app, Headspace, at reducing anxiety and worry. Methods: this study used a randomized-controlled design to examine the app using a 3 (Time; baseline, 4 weeks, 8 weeks) × 2 (Access; immediate, delayed for 4 weeks) design. Participants who reported moderate to high anxiety or worry were randomly assigned to receive -either -immediate access or delayed access to the app. For null hypothesis significance testing (NHST), analyses of variance were used to test the hypotheses that app access for 4 and 8 weeks would reduce anxiety and worry as compared to waitlist or baseline and that app access for 8 weeks would reduce anxiety and worry as compared to 4 weeks. Bayes estimates were used to -determine the level of evidence for the hypothesis that app access reduces anxiety and worry. Results: four weeks of app access significantly reduced anxiety symptoms, as did 8 weeks, but NHST indicated there were no significant difference between 4 and 8 weeks of access. We failed to reject the null for the analysis of variance on worry, but Bayesian estimates indicated substantial evidence for the hypothesis that the mindfulness training app reduces worry. Conclusions: this research shows that using Headspace can reduce anxiety and worry, but that there does not appear to be a consistent dose relation.

False safety behavior use among Black adults

Anxiety is among the most prevalent psychiatric conditions, yet little attention has been paid to whether putative cognitive vulnerability factors related to anxiety in predominantly White samples are related to anxiety among Black individuals. Yet, given less mental health service utilization and greater experience of some life stressors, Black persons may be especially at risk for using false safety behaviors (FSB; designed to decrease anxiety in the short term, but are associated with more longer-term mental health problems). We tested whether non-Hispanic/Latin Black persons (n = 133) reported greater FSB use than non-Hispanic/Latin White participants (n = 844) as well as whether FSB use was related to more mental health problems among Black participants. Data were collected online among undergraduates. Black participants did endorse more frequent FSB use, especially FSB-Avoidance and FSB-Body Sensations. Results indicate that among Black participants, FSB use was related to more anxiety, depression, and suicidal thoughts and behaviors. FSB may be an important behavioral vulnerability factor related to anxiety and associated mental health problems among Black young adults.

Leveraging multistakeholder engagement to develop an implementation blueprint for a brief trauma-focused cognitive behavioral therapy in primary care

Objective: The implementation of evidence-based treatments (EBTs) to address posttraumatic stress disorder (PTSD) is a public health priority. Successful EBT implementation requires effective collaboration between multiple stakeholder groups, including hospital leaders, providers, and patients, to build buy-in for this effort. Method: We describe our implementation science approach to meaningful stakeholder engagement, as part of a hybrid type I effectiveness-implementation trial of Skills Training in Affective and Interpersonal Regulation for PTSD treatment in primary care (STAIR-PC) at a large safety net hospital. We used primary care and patient community advisory boards (CABs) to interpret key informant interviews and identify strategies to adapt the intervention to ensure fit with the primary care setting. We documented our stakeholder engagement methodology through comprehensive field notes and minutes from CAB meetings, detailing the focus of meetings, suggestions for intervention and delivery adaptations, decision-making processes, and how disagreements about adaptations between stakeholders were resolved. To support replicability, we specify and operationalize implementation strategies to be used across each implementation phase of the trial. Results: Key strategies involved a) ensuring that research questions are relevant to both patients and clinical providers; b) tailoring interventions that are flexible and adaptable to the needs of the local setting; c) continuous engagement of patients and providers throughout the implementation process; and d) building mutual respect, trust, and credibility between the research team, various provider groups, and patients. Conclusions: Our approach to engaging stakeholders informed an implementation blueprint to guide implementation of EBTs for PTSD in safety net hospital primary care clinics. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Co-occurring OCD and Panic Disorder: A Review of Their Etiology and Treatment

Estimated rates of co-occurrence between obsessive and compulsive disorder (OCD) and panic disorder (PD) are notable, but vary considerably, with rates from epidemiological and clinical studies ranging from 1.8% to 22% (Rector et al., 2017). We reviewed the current empirical literature on the etiology, treatment, diagnostic assessment, and differential diagnosis of co-occurring OCD/PD. Best practices for cognitive-behavioral treatment, including identifying and addressing treatment barriers are also addressed. Although it is acknowledged in current literature that co-occurring OCD and PD levels may be clinically significant, there remains a need to thoroughly examine the possible consequences and future research directions of this overlap. Future research must continue to elucidate the biological and environmental causes of OCD/PD co-occurrence.

Lifetime Trauma Exposure and Posttraumatic Stress Disorder Among African Americans and Black Caribbeans by Sex and Ethnicity

OBJECTIVE

Posttraumatic stress disorder (PTSD) is a debilitating disorder requiring timely diagnosis and treatment, with special attention needed for Black populations in the U.S. Yet, stakeholders often fail to recognize Black communities' heterogeneous ethnic composition, thus not allowing diverse sociocultural realities to inform PTSD interventions. This study aims to characterize sex and ethnic differences in lifetime trauma exposure, lifetime PTSD diagnosis and symptoms, and help-seeking among the African Americans and Black Caribbeans in the U.S.

METHOD

This study relied on data from the National Survey of American Life 2001-2003 (NSAL) to investigate the lifetime exposure to traumatic events and prevalence of a clinical PTSD diagnosis based on the DSM-IV among African American (n = 3,570) and Black Caribbean (n = 1,623) adults. 44.5% of respondents were men and 55.5% were women. Logistic regression was utilized to investigate the impact of traumatic events on PTSD.

RESULTS

Several ethnic and sex differences in exposure to potentially traumatic events were identified. African American respondents were more likely to experience spousal abuse and toxin exposure than their Black Caribbean counterparts. Black Caribbeans reported higher lifetime exposure to muggings, natural disasters, harsh parental discipline, being a civilian living in terror and/or being a refugee than African American respondents. Specific to sex, Black men reported more events of combat, a peacekeeper/relief worker, being mugged, toxin exposure, seeing atrocities, and/or injuring someone. Black women were more likely to have been rape/sexual assault and/or intimate partner violence victims. The assaultive violence trauma type was most predictive of lifetime PTSD diagnosis among Black Americans. African American women were more likely to report PTSD symptoms than men, with almost no significant differences in Black Caribbean men and women. Approximately half of Black Americans sought help for their worst traumatic event, commonly engaging family/friends, psychiatrists, and mental health professionals. Further, there were almost no ethnic and sex differences related to professional and non-professional help sought.

CONCLUSION

Future PTSD-related research should aim to characterize the heterogenous experiences of potentially traumatic events within different Black communities. Clinicians working with Black clients should strive to understand the limitations within their tools/interventions in meeting the needs of diverse groups.

Duration of untreated illness of patients with obsessive-compulsive disorder in Japan

AIM

Obsessive-compulsive disorder (OCD) is a common and severe disease; however, the duration of untreated illness (DUI) of OCD is approximately 7 years, which is longer than that of other psychiatric disorders. Differences in medical environments have been reported to affect the DUI. Therefore, we surveyed the DUI of OCD in Japan and the reason for delayed treatment.

METHODS

The study participants were outpatients who visited the OCD specialty outpatient clinic for the first time between June 1, 2017 and May 31, 2019. Obsessive-compulsive disorder was diagnosed using the criteria in the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition, and semistructured clinical interviews, which included asking the reason for the delay in seeking treatment and treatment drop-out history.

RESULTS

Seventy-one patients met the inclusion criteria for the study. The mean period between OCD and the first visit to the hospital was 2.8 years and the mean DUI of OCD was 4.7 years. There was a significant difference in the history of tic disorders and treatment drop out between patients with a DUI of >2 years and those with a DUI of ≤2 years. The most common reason for delaying treatment was that the patient did not consider the symptoms of OCD to be those of an illness, and the most common reason for dropping out of treatment was lack of improvement.

CONCLUSIONS

This was the first study on the DUI of OCD in Japan. The DUI was relatively shorter than that found by studies in other countries. Stopping treatment lengthened the duration of the illness. Preventing the patient from dropping out of treatment could further shorten the duration of the illness.

Association between obsessive-compulsive disorder and obstetrical and neonatal outcomes in the USA: a population-based cohort study

Obsessive-compulsive disorder (OCD) is a mental disorder linked to functional impairments and adverse health outcomes. We sought to examine the association between pregnant women with OCD and obstetrical and neonatal outcomes in the USA. A retrospective population-based cohort study was conducted using data provided by pregnant women from the Nationwide Inpatient Sample, a nationally representative database of hospitalizations in the USA, from 1999 to 2015. Using diagnostic and procedure codes from the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM), we identified births and classified women by OCD status. Demographic and clinical characteristics were compared for women with and without OCD and multivariate logistic regressions were used to obtain odds ratios (OR) to compare obstetrical and neonatal outcomes between the two groups, adjusting for relevant demographic and clinical variables. Between 1999 and 2015, there were 3365 births to women with OCD, corresponding to an overall prevalence of 24.40 per 100,000 births. Women with OCD were more likely to be older than 25, Caucasian, of higher socioeconomic status, smokers or used drugs and alcohol, and have other comorbid psychiatric conditions. In adjusted models, OCD was associated with a higher risk of gestational hypertension, preeclampsia, premature rupture of membranes, caesarean and instrumental deliveries, venous thromboembolisms and preterm birth. Pregnancies in women with OCD are at high risk of adverse obstetrical and neonatal outcomes. A multidisciplinary approach should be used to identify high risk behaviours and ensure adequate prenatal follow-up and care be available for those with high risk pregnancies.

Psychometric Evaluation of a Barriers to Mental Health Treatment Questionnaire for Latina/o/x Caregivers of Children and Adolescents

Background

Knowledge regarding barriers faced by Latina/o/x caregivers in accessing youth mental health services (MHS) have largely depended on resource intensive interview-based assessments.

Objective

We evaluated a questionnaire for Latina/o/x caregivers of youths that presents a briefer and more feasible alternative.

Method

We conducted a psychometric evaluation of the Barriers to Treatment Questionnaire - Latina/o/x Caregivers (BTQ-LC) with a sample of 598 Latina/o/x caregivers from across the United States. Descriptive statistics and confirmatory factor analyses were used to identify common barriers to services, confirm the factor structure of the scale, and establish construct validity.

Results

Descriptive statistics suggest that not knowing where and how to access services, and normalization of youth psychopathology were the most frequently reported barriers among caregivers of youth with clinically elevated problems on the CBCL. Confirmatory factor analysis suggests that the BTQ-LC was best represented by a three-factor structure: (1) structural, (2) perceptions regarding mental health problems, and (3) services. Our finding suggest that the BTQ-LC could also be used as a single factor as fit indices ranged from acceptable to poor. BTQ-LC scales were all negatively correlated with the utilization of common youth MHS (i.e., psychological counseling, medical doctors, school professionals).

Conclusions

The BTQ-LC represents an important step towards improving our understanding and assessment of barriers to services contributing to mental health disparities among Latina/o/x youths.

Help-Seeking Intention in Obsessive-Compulsive Disorder: Predictors and Barriers in South Africa

Introduction: Many individuals with obsessive-compulsive disorder (OCD) delay seeking help, leading to greater illness severity, additional comorbidity, and increased functional impairment. Patterns of help-seeking for OCD have however not yet been described in South Africa, a low-and middle-income country with many health service challenges. Using the health belief model as a conceptual framework, study aims were to identify predictors of and barriers to help-seeking among South Africans with OCD. Methods: Fifty adults with OCD completed an online survey to assess (1) socio-demographic characteristics, (2) OCD symptom severity, (3) treatment barriers, (4) perceived treatment benefits, (5) self-efficacy, and (6) help-seeking intention. Multiple linear regression analysis was used to establish predictors of help-seeking intention. Descriptive statistics were used to determine the most endorsed help-seeking barriers. Results: 42.6% of the variance in help-seeking intention was explained by the investigated constructs (R 2 = 0.426, F = 4.45 and p < 0.01). Perceived treatment benefits were the only significant predictor of help-seeking intention (B = 1.37, t = 5.16, and p < 0.01). More than a third (36%) of the sample endorsed wanting to handle the problem independently as a significant barrier, followed by treatment concerns (26%), affordability (22%), and shame (20%). Conclusion: An innovative analysis of help-seeking patterns suggested that perceived treatment benefits were the only significant predictor of help-seeking intention among South African adults with OCD. Psychoeducation and mental health literacy programmes may be useful in increasing public appreciation of the benefits of OCD treatment, and in mitigating key help-seeking barriers.

Knowledge and competency standards for specialized cognitive behavior therapy for adult obsessive-compulsive disorder

Obsessive-Compulsive Disorder (OCD) is a leading cause of disability world-wide (World Health Organization, 2008). Treatment of OCD is a specialized field whose aim is recovery from illness for as many patients as possible. The evidence-based psychotherapeutic treatment for OCD is specialized cognitive behavior therapy (CBT, NICE, 2005, Koran and Simpson, 2013). However, these treatments are not accessible to many sufferers around the world. Currently available guidelines for care are deemed to be essential but insufficient because of highly variable clinician knowledge and competencies specific to OCD. The phase two mandate of the 14 nation International OCD Accreditation Task Force (ATF) created by the Canadian Institute for Obsessive Compulsive Disorders is development of knowledge and competency standards for specialized treatments for OCD through the lifespan deemed by experts to be foundational to transformative change in this field. This paper presents knowledge and competency standards for specialized CBT for adult OCD developed to inform, advance, and offer a model for clinical practice and training for OCD. During upcoming ATF phases three and four criteria and processes for training in specialized treatments for OCD through the lifespan for certification (individuals) and accreditation (sites) will be developed based on the ATF standards.

Defining and Addressing Gaps in Care for Obsessive-Compulsive Disorder in the United States

OBJECTIVE

Obsessive-compulsive disorder (OCD) can be a chronic and disabling illness with a lifetime prevalence of 2%, twice that of schizophrenia. Although effective treatments exist, OCD often remains underdetected and undertreated.

METHODS

The authors performed a scoping review of the literature (of articles in PubMed and PsycINFO published from January 1, 2000, to February 1, 2020) to define gaps in OCD diagnosis and treatment among U.S. adults. Interventions at the patient, clinician, and health care system levels used to address these gaps are described, and promising approaches from around the world are highlighted.

RESULTS

Of 102 potential studies identified in the search, 27 (including five non-U.S. studies) were included. The studies revealed that lack of clinician and patient knowledge about OCD and misdiagnosis contributes to its underdetection. Suboptimal prescribing of selective serotonin reuptake inhibitor medications and limited use of exposure and response prevention, as a first-line psychotherapy, contribute to OCD undertreatment. Digital health technologies show promise in increasing OCD detection and delivery of evidence-based care and in ensuring continuity of care (including during the COVID-19 pandemic).

CONCLUSIONS

Given the significant rates of disability, morbidity, and mortality associated with OCD, addressing gaps in OCD care will reduce the U.S. burden of mental illness. Further research is needed to determine how the use of digital health technologies can increase the detection and management of OCD.

Teachers' Knowledge and Stigmatizing Attitudes Associated With Obsessive-Compulsive Disorder: Effectiveness of a Brief Educational Intervention

Because children and adolescents are vulnerable to developing obsessive-compulsive disorder (OCD), classroom teachers play an important role in the early identification and intervention in students with OCD. The present study aims to explore the recognition of OCD, general knowledge about this disorder, implications in the classroom, and stigmatizing attitudes among teachers, as well as the effectiveness of a brief educational intervention about OCD. Participants (n = 95; mean age = 43. 29 years old; 64.3% female) were primary and secondary school teachers who were randomly assigned to an experimental group or a control group. All of them completed a set of self-report questionnaires, read an educational fact sheet (either about OCD in the experimental group or about a healthy diet in the control group), and again completed the questionnaires. Results show that prior to the intervention, most of the teachers identified the contamination and order OCD symptoms described in a vignette as specific to OCD (82.1%) and would recommend talking about the problem (98.9%) and seeking help (94.7%). However, only a few (36.8%) knew about the most effective OCD treatments or identified compulsions as a main OCD symptom (33%). Moreover, only about half of the teachers correctly identified OCD's possible interference in classroom routines, such as delays to achieve perfection or concentration problems, and strategies for dealing with OCD, such as continuing with the class rhythm. Stigma levels were from low to moderate. After the brief educational intervention, participants in the experimental group increased their knowledge about OCD, improved their strategies for managing a student with OCD symptoms, and had fewer stigmatizing attitudes associated with pity (p < 0.05). These changes were not observed in the control group. We can conclude that this brief and easy-to-administer intervention is an effective educational intervention to significantly improve teachers' knowledge and attitudes, at least in the short-term. These results are especially relevant because OCD is associated with high interference and long delays in seeking treatment, and teachers have a unique opportunity to help with prevention, early identification, and recommending an adequate intervention for OCD.

Cultural competency in the treatment of obsessive-compulsive disorder: practitioner guidelines

This article provides clinical guidelines for basic knowledge and skills essential for successful work with clients who have obsessive-compulsive disorder (OCD) across ethnic, racial and religious differences. We emphasise multiculturalist and anti-racist approaches and the role of culture in shaping the presentation of OCD in clients. Several competencies are discussed to help clinicians differentiate between behaviour that is consistent with group norms versus behaviour that is excessive and psychopathological in nature. Symptom presentation, mental health literacy and explanatory models may differ across cultural groups. The article also highlights the possibility of violating client beliefs and values during cognitive behavioural therapy (CBT), and subsequently offers strategies to mitigate such problems, such as consulting community members, clergy, religious scholars and other authoritative sources. Finally, there is a discussion of how clinicians can help clients from diverse populations overcome a variety of obstacles and challenges faced in the therapeutic context, including stigma and cultural mistrust.

Key learning aims

(1)

Correlates of Obsessive-Compulsive Symptoms Among Black Caribbean Americans

Despite the rapid growth of the Black Caribbean population in the United States, we know little about the presentation and prevalence of obsessive-compulsive disorder (OCD) among these groups. This study examines the demographic correlates and the effect of racial discrimination on OCD symptoms among a nationally-representative sample of Black Caribbean and African American adults (n = 5,191). Drawing on the Composite International Diagnostic Interview Short Form (CIDI-SF) for OCD, we examine two types of obsessions (harm and contamination) and four types of compulsions (repeating, washing, ordering, and counting). There we no significant differences between Black Caribbeans and African Americans in obsessions and compulsions. Analysis among Black Caribbeans found that compared with Jamaican and Trinidadian Americans, Haitian American individuals reported the fewest number of obsessions and compulsions. We show that Black Caribbean Americans with lower income, lower self-rated physical and mental health, and more experiences with racial discrimination report higher levels of OCD. More specifically, racial discrimination was associated with contamination and harm obsessions, as well as washing and repeating compulsions. Our findings highlight the need to consider specific domains of OCD relative to Black Caribbeans, and the relationship between social and demographic variables on symptomology.

EPA guidance on cultural competence training

The stress of migration as well as social factors and changes related to the receiving society may lead to the manifestation of psychiatric disorders in vulnerable individuals after migration. The diversity of cultures, ethnicities, races and reasons for migration poses a challenge for those seeking to understand how illness is experienced by immigrants whose backgrounds differ significantly from their clinicians. Cultural competence represents good clinical practice and can be defined as such that a clinician regards each patient in the context of the patient's own culture as well as from the perspective of the clinician's cultural values and prejudices. The EPA Guidance on cultural competence training outlines some of the key issues related to cultural competence and how to deal with these. It points out that cultural competence represents a comprehensive response to the mental health care needs of immigrant patients and requires knowledge, skills and attitudes which can improve the effectiveness of psychiatric treatment. To reach these aims, both individual and organizational competence are needed, as well as teaching competence in terms of educational leadership. The WPA Guidance on Mental Health and Mental Health Care for Migrants and the EPA Guidance on Mental Health Care for Migrants list a series of recommendations for policy makers, service providers and clinicians; these are aimed at improving mental health care for immigrants. The authors of this paper would like to underline these recommendations and, focusing on cultural competency and training, believe that they will be of positive value.

Association Splitting for Obsessive-Compulsive Disorder: A Systematic Review

Background:

Association splitting is a cognitive technique that targets obsessions in obsessive-compulsive disorder (OCD) by weakening biased semantic associations among OCDrelevant concepts.

Objective:

In this systematic review, we examine studies on the efficacy of association splitting for reducing OCD symptoms.

Methods:

Following PRISMA guidelines, six studies were included, with diversity in sample characteristics, mode of administration (i.e., self-help vs therapist-assisted), language of administration, comparator groups, etc.

Results:

Results indicated that association splitting, as a self-help intervention, was efficacious in reducing overall OCD symptom severity, specific OCD symptoms (i.e., sexual obsessions), subclinical unwanted intrusions, and thought suppression, with small-to-large effect sizes (e.g., across relevant studies, ds = .28-1.07). Findings were less clear when association splitting was administered on a therapist-assisted basis as an add-on to standard cognitive-behavior therapy (CBT). Nonetheless, across studies, the majority of participants reported high acceptability, ease of comprehension, and adherence to daily association splitting practice.

Conclusion:

Although association splitting is an efficacious and acceptable self-help intervention for OCD symptoms, future studies should include appropriate comparison groups, conduct longitudinal assessments, examine efficacy for different symptom dimensions, and assess changes in semantic networks as proof of mechanistic change. There should also be greater representation of marginalized groups in future studies to assess association splitting’s utility in circumventing barriers to face-to-face CBT. Ethical considerations are also discussed.

Exploring Racial Disparities in Mental Health Diagnoses and Neighborhood Disorganization Among an Urban Cohort of Children and Adolescents with Chronic Medical Conditions

Objective: This article describes the demographic distribution of, and association between, neighborhood disorganization and mental health diagnosis by race in a large cohort of urban children with chronic medical conditions. Methods: Data for this study were from Coordinated Healthcare for Complex Kids (CHECK), a health care demonstration project funded by the Center for Medicare and Medicaid Innovation. We conducted regression analyses to examine the relationship between neighborhood disorganization and mental health diagnosis among 6,458 children enrolled in CHECK. Results: The most common mental health diagnoses were mood disorders (8.6%), Attention-Deficit/Hyperactivity Disorder (7.4%), conduct disorders (6.1%), and anxiety disorders (4.8%). Black children had the highest neighborhood disorganization scores compared with other racial/ethnic categories. However, Black children had the lowest proportion of mental health diagnoses. Lower neighborhood disorganization was associated with having a mental health diagnosis; however, when adding race/ethnicity to the model, neighborhood disorganization no longer was significant. Conclusions: Level of neighborhood disorganization was highly correlated with racial/ethnic composition of the neighborhoods, and Black children disproportionately resided in highly disorganized neighborhoods compared with other groups. Neighborhood disorganization may not have sufficient variability within the racial/ethnic categories, which may explain the absence of an interaction between race/ethnicity and mental health diagnosis.

Attitudes of Community-Leading Occupational Groups Towards Mental Illnesses: The Sample of a City in Western Turkey

This descriptive study aims to determine attitudes of community-leading occupational groups towards mental illnesses. The sample of this descriptive study consisted of a total of 1100 participants from clergymen, headmen, teachers, policemen and primary healthcare professionals working in Düzce, Turkey. Data were collected using the Personal Information Form and the Beliefs Toward Mental Illness Scale-BTMIS. Occupational groups were determined to have moderate beliefs about mental diseases according to their BTMIS scale total scores. The occupational groups that had most negative beliefs toward mental illnesses were headmen, police officers, teachers, healthcare professionals and clergymen, respectively. Data were evaluated using descriptive statistics of mean, standard deviation, minimum, maximum, and percentage. Community-leading occupational groups should be actively involved in anti-stigma activities to change quickly and effectively community attitudes towards mental illnesses.

Culturally informed research design issues in a study for MDMA-assisted psychotherapy for posttraumatic stress disorder

Recent research suggests that psychedelic drugs can be powerful agents of change when utilized in conjunction with psychotherapy. Methylenedioxymethamphetamine (MDMA)-assisted psychotherapy has been studied as a means of helping people overcome posttraumatic stress disorder, believed to work by reducing fear of traumatic memories and increasing feelings of trust and compassion toward others, without inhibiting access to difficult emotions. However, research studies for psychedelic psychotherapies have largely excluded people of color, leaving important questions unaddressed for these populations. At the University of Connecticut, we participated as a study site in a MAPS-sponsored, FDA-reviewed Phase 2 open-label multisite study, with a focus on providing culturally informed care to people of color. We discuss the development of a study site focused on the ethnic minority trauma experience, including assessment of racial trauma, design of informed consent documents to improve understanding and acceptability to people of color, diversification of the treatment team, ongoing training for team members, validation of participant experiences of racial oppression at a cultural and individual level, examination of the setting and music used during sessions for cultural congruence, training for the independent rater pool, community outreach, and institutional resistance. We also discuss next steps in ensuring that access to culturally informed care is prioritized as MDMA and other psychedelics move into late phase trials, including the importance of diverse sites and training focused on therapy providers of color.

Public Recognition and Perceptions of Obsessive Compulsive Disorder

Previous research has indicated that the public's knowledge on obsessive compulsive disorder (OCD) is poor. Public understanding and perception of OCD may be one contributor to this issue. Given that mental health literacy is an important first step for those to receive the appropriate care, we sought to understand more about the public's awareness and perceptions of OCD. Data regarding knowledge of OCD were collected through a New York statewide telephone survey (N = 806). Results indicated that those who had never heard of OCD were more likely to be ethnic minorities, have a lower income, and less education. Most participants described OCD either in terms of compulsions or in terms of perfectionism. Almost half (46.5%) of participants did not think there is a difference between someone with OCD and someone who is obsessive-compulsive. These findings are consistent with previous literature regarding race and treatment seeking behaviors.

Inclusion of people of color in psychedelic-assisted psychotherapy: a review of the literature

BACKGROUND

Despite renewed interest in studying the safety and efficacy of psychedelic-assisted psychotherapy for the treatment of psychological disorders, the enrollment of racially diverse participants and the unique presentation of psychopathology in this population has not been a focus of this potentially ground-breaking area of research. In 1993, the United States National Institutes of Health issued a mandate that funded research must include participants of color and proposals must include methods for achieving diverse samples.

METHODS

A methodological search of psychedelic studies from 1993 to 2017 was conducted to evaluate ethnoracial differences in inclusion and effective methods of recruiting peopple of color.

RESULTS

Of the 18 studies that met full criteria (n = 282 participants), 82.3% of the participants were non-Hispanic White, 2.5% were African-American, 2.1% were of Latino origin, 1.8% were of Asian origin, 4.6% were of indigenous origin, 4.6% were of mixed race, 1.8% identified their race as "other," and the ethnicity of 8.2% of participants was unknown. There were no significant differences in recruitment methodologies between those studies that had higher (> 20%) rates of inclusion.

CONCLUSIONS

As minorities are greatly underrepresented in psychedelic medicine studies, reported treatment outcomes may not generalize to all ethnic and cultural groups. Inclusion of minorities in futures studies and improved recruitment strategies are necessary to better understand the efficacy of psychedelic-assisted psychotherapy in people of color and provide all with equal opportunities for involvement in this potentially promising treatment paradigm.

Perceived treatment barriers and experiences in the use of services for obsessive-compulsive disorder across different ethnic groups: a thematic analysis

BACKGROUND

Patients from ethnic minority backgrounds are underrepresented in clinical settings. Factors like cost of treatment, poor knowledge of the health system, geographic availability of services, lack of mental health literacy, differences in health beliefs, and social barriers have been identified as reasons for these inequalities. The aim of this study was to identify and compare barriers that parents from different ethnic groups face when accessing specialist services for obsessive-compulsive disorder (OCD) for their children.

METHOD

Ten parents from White backgrounds and 10 from ethnic minority backgrounds were recruited from the National and Specialist OCD, BDD, and Related Disorders Clinic for Young People, London, United Kingdom. They were interviewed about their opinions and experiences when accessing treatment.

RESULTS

Using thematic analysis, several common barriers for both groups were identified. These included a lack of knowledge of OCD, lack of resources within the health system, previous negative experiences, lack of trust in the mental health system, lack of time and financial issues, no support out of hours, bullying, and inconvenient location of services. In addition, there were several barriers that were endorsed by ethnic minority groups but not by the parents from White backgrounds, namely stigma and discrimination from within their communities, shame and denial, a general lack of trust in the health system by their cultural group, different beliefs about mental health issues, and discrimination from within the system.

CONCLUSIONS

Policy-makers and clinicians should be aware of the additional barriers minority patients may face in accessing treatment and should support interventions designed to overcome them.

Discrimination and symptoms of obsessive-compulsive disorder among African Americans

This study examined symptoms of obsessive-compulsive disorder (OCD) in a nationally representative sample of African American adults (n = 3,570) and correlations between OCD symptom dimensions and experiences of discrimination. Two categories of discrimination were examined, everyday racial discrimination and everyday nonracial discrimination (e.g., because of gender, age, and weight), to determine if racial discrimination had a unique impact on OCD symptoms. Results indicated that everyday racial discrimination was related to both categories of obsessions and all 4 categories of compulsions. Everyday nonracial discrimination, however, was not related to any of the categories of obsessions or compulsions. This indicates that racial discrimination is uniquely related to obsessions and compulsions for African Americans. The implications of these findings are discussed. (PsycINFO Database Record

Missed diagnoses in African Americans with obsessive-compulsive disorder: the structured clinical interview for DSM-IV Axis I disorders (SCID-I)

BACKGROUND

Research on the utility of structured interviews in assessing OCD is scarce, and even more so, in its use for OCD in African Americans. The purpose of this study was to examine the utility of the Structured Clinical Interview for DSM-IV Axis I Disorders (SCID-I) in detecting OCD in African Americans when used by well-trained, culturally competent clinicians.

METHODS

Seventy-four African American adults with OCD were assessed with the SCID-I and additional measures of OCD.

RESULTS

Results revealed the poor diagnostic utility of the SCID OCD section (SCID-OCD), with 66.2% (N = 49) correctly identified and 33.8% (N = 25) incorrectly diagnosed. Participants receiving the correct diagnosis were more likely to endorse compulsive behaviors, specifically ordering compulsions, and experience greater symptom severity.

CONCLUSION

The lack of sensitivity for identification of OCD is discussed as the SCID-OCD seems to often miss a true diagnosis of OCD in African Americans.

Demographic and health-related correlates of obsessive-compulsive symptoms among African Americans

This study examined the correlates of the symptoms of obsessive-compulsive disorder (OCD) among a nationally-representative sample of African American adults (n = 3,570). Demographic and several self-rated health variables were examined. Although only 1.6% of the sample met DSM-IV diagnostic criteria for OCD, a sizeable proportion of the sample reported compulsions (12.5%) and obsessions (15.3%). Material hardship was positively associated with nearly all measured symptoms of OCD and fewer years of educational attainment was related to greater compulsive symptoms. Self-rated mental health was related to both compulsions and obsessions, and self-rated physical health was associated with counting and repeating compulsions. Implications and areas for further research with African Americans are discussed, including improving access to care for those most in need of services.

Seeking help for obsessive compulsive disorder (OCD): a qualitative study of the enablers and barriers conducted by a researcher with personal experience of OCD

OBJECTIVES

Obsessive compulsive disorder (OCD) can be hugely disabling. Although very effective psychological treatments exist, many people delay years before seeking help or never seek treatment. There have been clinical observation and short questionnaire studies on why people delay, but little qualitative research exists on this complex subject. The present qualitative study aimed to identify the barriers to seeking treatment and the factors that encourage or push people to seek help for their OCD (positive and negative enablers).

DESIGN

A qualitative, exploratory study using in-depth, individual, semi-structured interviews was conducted by a researcher with personal experience of OCD.

METHODS

Seventeen people with OCD, contacted through the charity OCD-UK, were interviewed about the factors that impacted on their decision to seek help or not. The interviews were analysed using thematic analysis.

RESULTS

Barriers identified were stigma, 'internal / cognitive' factors, not knowing what their problem was, factors relating to their GP or treatment, and fear of criminalisation. Positive enablers identified were being supported to seek help, information and personal accounts of OCD in the media, and confidence in their GP. Negative enablers were reaching a crisis point and for some participants (whose intrusive thoughts were about harming children) feeling driven to seek treatment because of the nature of the thoughts, that is, seeking help to prevent the 'harm' they feared they were capable of doing.

CONCLUSIONS

Participants identified a range of barriers and enablers that impacted on their decision to seek help or not. These give important indicators about the likely causes for delayed help seeking in OCD and ways in which people might be encouraged to seek help earlier.

PRACTITIONER POINTS

People with OCD may face a wide range of barriers to seeking help, including concern about the reaction of health professionals. The level of awareness, kindness, and understanding shown by first-line practitioners can be very important to those seeking help. Acknowledging a person's journey prior to seeking help is likely to foster trust between therapist and patient. Some barriers to seeking help, for example, fear of criminalisation, may continue to have an important effect afterwards unless sensitively explored and understood.

Ethnic Identity and Regional Differences in Mental Health in a National Sample of African American Young Adults

Prior research has found that a strong positive ethnic identity is a protective factor against anxiety and depression in African Americans. In this study, ethnic identity is examined in a geographically representative sample of African American young adults (n = 242), using the Multigroup Ethnic Identity Measure (MEIM) (Phinney in J Adolescent Res 7:156-76, 15). The two-factor structure of the measure (Roberts et al. in J Early Adolescence 19:301-22, 1) was analyzed using a structural equation model and displayed an acceptable fit only when multiple error terms were correlated. A multigroup confirmatory factor analysis revealed measurement equivalence of the two-factor structure between African Americans from Southern and non-Southern regions of the USA. We found that significantly higher levels of ethnic identity were present among African American in the South compared to other regions, and region significantly predicted total ethnic identity scores in a linear regression, even when controlling for gender, age, urbanicity, and years of education. Furthermore, among African Americans, living in the South was significantly correlated with less help-seeking for diagnosed depression, anxiety, and/or obsessive-compulsive disorder, where help-seeking was defined as obtaining a diagnosis by a professional. The role of ethnic identity and social support are discussed in the context of African American mental health.

What do Spanish adolescents think about obsessive-compulsive disorder? Mental health literacy and stigma associated with symmetry/order and aggression-related symptoms

Obsessive-compulsive disorder (OCD) is a frequent and disabling disorder with a long delay in seeking help that could partly be due to poor mental health literacy and stigmatizing attitudes. This study analyzes the mental health literacy and stigma associated with symmetry/order and aggression-related OCD in a Spanish adolescent sample. This age group was chosen because adolescence is a vulnerable period for the development of OCD, and adolescents are often reluctant to seek professional help. One hundred and two non-clinical adolescents read two vignettes describing symmetry/order and aggression-related OCD. Then, referring to these two vignettes, they answered questions related to problem recognition, causality perception, need for treatment, treatment recommendations, and stigma. Results show that a high percentage of adolescents recognize the interference of order- and aggression-related OCD, consider that a peer with order- or aggression-related OCD needs treatment, and would recommend a formal source of help. Although order symptoms are highly recognized as OCD by adolescents, aggression-related OCD is frequently misidentified as schizophrenia or depression. Results also show higher levels of stigmatizing attitudes in adolescents, associated with aggression-OCD (versus order-OCD), especially in male adolescents and adolescents with no previous experience with mental health services/providers. Results suggest the need to develop school-based programs emphasizing OCD content heterogeneity, especially the aggression, sexual, and religious contents, and work toward eliminating stigma.

OCD Taboo Thoughts and Stigmatizing Attitudes in Clinicians

Individuals who suffer from obsessive-compulsive disorder have persistent intrusive thoughts that cause severe distress that impairs daily functioning. These individuals often conceal their intrusive thoughts and delay help-seeking for fear of being stigmatized. Stigma can be problematic when it is present among mental health professionals because they may distance themselves from their clients and have a negative outlook on treatment outcome. To date there has not been any research that focuses on stigma that clinician's may hold towards obsessive-compulsive disorder or specific obsessions; however, there is evidence that mental health professionals may have prejudices towards individuals who suffer from other mental illnesses. The current study aimed to explore clinician and student clinician attitudes about obsessional content from varying symptom dimensions. Results indicated participants were more likely to socially reject or be concerned by individuals with obsessions related to contamination, harming, and sexual obsessions than those with scrupulous obsessions, and that they would be less likely to reveal sexual obsessions to others if they were experiencing them than the other three types of obsessions.

Register-based study of the incidence, comorbidities and demographics of obsessive-compulsive disorder in specialist healthcare

BACKGROUND

Incidence of obsessive-compulsive disorder (OCD) has been suspected to increase but nationwide epidemiological studies are limited. This study aims to examine sex-specific incidence time trends and characterize psychiatric and neurodevelopmental comorbidities and sociodemographic risk factors of OCD in specialist healthcare in Finland.

METHODS

A nationwide register-based study using data from four Finnish registers identified 3372 OCD cases and 13,372 matched controls (1:4). Cumulative incidence in subjects born between 1987 and 2001 was estimated at ages of 10, 15, 20 and 23 years. Conditional logistic regression was used to examine the sociodemographic factors.

RESULTS

The cumulative incidence of OCD was 0.4% by age 23. Incidence by age 15 among three cohorts increased from 12.4 to 23.7 /10000 live born males and 8.5 to 28.0 /10000 live born females. 73% of the sample had a comorbid condition. Males were significantly more comorbid with psychotic and developmental disorders; females were more comorbid with depressive and anxiety disorders (p <0.001). Higher maternal SES was associated with an increased risk of OCD (OR 1.4; 95% CI 1.1-1.6).

CONCLUSIONS

These findings suggest that incidence of treated OCD in specialist healthcare has increased. The reason may be increased awareness and rate of referrals but a true increase cannot be ruled out. Further research on risk factors of OCD is warranted.

Psychiatric Comorbidity and Hoarding Symptoms in African Americans With Obsessive-Compulsive Disorder

This study investigated comorbidity and hoarding symptoms in a sample of African American adults with obsessive-compulsive disorder ( N = 75). For lifetime disorders, 87.9% of participants had at least one other comorbid condition. The most prevalent comorbidities were mood disorders (67.1%), anxiety disorders (51.4%), and substance abuse disorders (38.0%). There was low comorbidity with eating disorders, as only 4.1% had binge-eating disorder and none met criteria for anorexia or bulimia nervosa. In terms of gender differences, females were more likely to have posttraumatic stress disorder and males were more likely to have a comorbid alcohol use disorder. Over half of the participants had hoarding compulsions (56.0%) as indicated by the Yale-Brown Obsessive-Compulsive Scale. Individuals with hoarding compulsions were more likely to have comorbid anxiety-related disorders than those without, and experienced greater indecisiveness, pathological slowness, and doubting; they also had less education and earning power than those without these behaviors. African Americans with obsessive-compulsive disorder tend to have high rates of comorbid disorders, with patterns that resemble findings in non-Hispanic White populations.

Implementation and evaluation of treatments for children and adolescents with conduct problems: Findings, challenges, and future directions

OBJECTIVE

The intervention work of our clinical-research team has focused on the treatment of children and young adolescents referred for Conduct Disorder or Oppositional Defiant Disorder.

METHOD

We have evaluated two interventions: parent management training (PMT) and cognitive problem-solving skills training in several randomized controlled clinical trials.

RESULTS

Our findings have indicated the treatments, alone or in combination, produce reliable and significant reductions in oppositional, aggressive, and antisocial behaviour and increases in prosocial behaviour among children. Parent dysfunction (depression, multiple symptom domains) and stress decline and family relations improve as well. Apart from outcome studies, we have studied the therapeutic alliance, factors that influence dropping out and retaining cases, and variations of treatment delivery (e.g., computer based, reduced therapist contact).

CONCLUSIONS

The article considers challenges in conducting controlled trials in clinic settings (e.g., recruiting cases, maintaining treatment integrity, securing funding) and activities related to implementation that are not easily covered within the confines of research articles. The article ends with a discussion of one of the treatments (PMT) and the broad role it can play in treatment, prevention, and help with many parenting challenges of everyday life.

Theoretical domains framework to assess barriers to change for planning health care quality interventions: a systematic literature review

BACKGROUND

Theoretical domains framework (TDF) provides an integrative model for assessing barriers to behavioral changes in order to suggest interventions for improvement in behavior and ultimately outcomes. However, there are other tools that are used to assess barriers.

OBJECTIVE

The objective of this study is to determine the degree of concordance between domains and constructs identified in two versions of the TDF including original (2005) and refined version (2012) and independent studies of other tools.

METHODS

We searched six databases for articles that studied barriers to health-related behavior changes of health care professionals or the general public. We reviewed quantitative papers published in English which included their questionnaires in the article. A table including the TDF domains of both original and refined versions and related constructs was developed to serve as a reference to describe the barriers assessed in the independent studies; descriptive statistics were used to express the results.

RESULTS

Out of 552 papers retrieved, 50 were eligible to review. The barrier domains explored in these articles belonged to two to eleven domains of the refined TDF. Eighteen articles (36%) used constructs outside of the refined version. The spectrum of barrier constructs of the original TDF was broader and could meet the domains studied in 48 studies (96%). Barriers in domains of "environmental context and resources", "beliefs about consequences", and "social influences" were the most frequently explored in 42 (84%), 37 (74%), and 33 (66%) of the 50 articles, respectively.

CONCLUSION

Both refined and original TDFs cataloged barriers measured by the other studies that did not use TDF as their framework. However, the original version of TDF explored a broader spectrum of barriers than the refined version. From this perspective, the original version of the TDF seems to be a more comprehensive tool for assessing barriers in practice.

[Help-seeking behavior and pathways to care for patients with obsessive-compulsive disorders]

BACKGROUND

Obsessive-compulsive disorder (OCD) is a chronic and debilitating disorder that is relatively common and is associated with a wide range of functional impairments. This is partly associated with delayed help-seeking behavior of OCD patients, which shows a lag of up to 10 years after onset of the obsessive-compulsive symptoms to the first attempt at seeking professional treatment. The reasons for the delay in initial help-seeking behavior by OCD patients are manifold but still not clear. Early detection and early treatment might, however, have beneficial effects on the treatment-seeking behavior.

AIM

The aim of the study was to examine the help-seeking behavior and the pathways to care of patients with OCD using a modified version of the structured pathways to care questionnaire initially designed for research into schizophrenia.

RESULTS

For the 40 outpatients with OCD who completed the interview retrospectively, the latent period between symptom onset and first seeking professional contact was on average 6.5 years, while the median delay to a third attempt at seeking treatment was nearly 15 years. Although the majority of participants consulted a professional neurological and psychotherapeutic practice even at the first attempt and 90% complained of specific OCD symptoms, only 20% received the standard treatment consisting of cognitive behavioral therapy and medication with a selective serotonin reuptake inhibitor (SSRI). The most common reason for delaying seeking treatment was that the patient was not convinced of having a mental illness such as OCD and of the necessity for treatment. Even so, approximately 40% of the participants reported fear of stigmatization and discrimination as a major reason for the delay in the first attempt at seeking help.

CONCLUSION

Psychoeducation and broad utilization of evidence-based treatment still appears necessary and can contribute to improvement in the help-seeking behavior of OCD patients.

Illness perception, help-seeking attitudes, and knowledge related to obsessive-compulsive disorder across different ethnic groups: a community survey

PURPOSE

Despite similar prevalence rates across ethnicities, ethnic minorities with obsessive-compulsive disorder (OCD) are under-represented in research and clinical settings. The reasons for this disproportion have been sparsely studied. We explored potential differences in illness perception, help-seeking attitudes, illness knowledge, and causal attributions that could help explain the lower uptake of treatment for OCD amongst ethnic minorities.

METHODS

Two-hundred and ninety-three parents (139 White British, 61 Black African, 46 Black Caribbean, and 47 Indian) were recruited from the general population in South-East London, UK. Using a text vignette methodology, participants completed a survey including questions on illness perception, help-seeking attitudes, OCD knowledge, and causal attributions.

RESULTS

The groups did not differ in socio-demographic characteristics and family history of OCD. White British parents perceived that the OCD difficulties would have more negative impact on their children and that treatment would be more helpful, compared to the ethnic minorities; the largest differences were observed between White British and Indian parents. Ethnic minorities were more prone to say that would seek help from their religious communities. Black African parents were more in favor of not seeking help for the described difficulties and, in general, perceived more treatment barriers. White British parents seemed to be better informed about OCD than ethnic minority parents.

CONCLUSIONS

The results offer some plausible explanations for the large inequalities in access to services amongst ethnic minorities with OCD. Clinicians and policy-makers need to be aware of these socio-cultural factors when designing strategies to encourage help-seeking behaviors in these populations.

Ethnic inequalities in the use of secondary and tertiary mental health services among patients with obsessive-compulsive disorder

BACKGROUND

Obsessive-compulsive disorder (OCD) has similar prevalence rates across ethnic groups. However, ethnic minorities are underrepresented in clinical trials of OCD. It is unclear whether this is also the case in clinical services.

AIMS

To explore whether ethnic minorities with OCD are underrepresented in secondary and tertiary mental health services in the South London and Maudsley (SLaM) NHS Foundation Trust.

METHOD

The ethnic distribution of patients with OCD seen between 1999 and 2013 in SLaM (n = 1528) was compared with that of the general population in the catchment area using census data. A cohort of patients with depression (n = 22 716) was used for comparative purposes.

RESULTS

Ethnic minorities with OCD were severely underrepresented across services (-57%, 95% CI -62% to -52%). The magnitude of the observed inequalities was significantly more pronounced than in depression (-29%, 95% CI -31% to -27%).

CONCLUSIONS

There is a clear need to understand the reasons behind such ethnic inequalities and implement measures to reduce them.

Overcoming barriers to recruiting ethnic minorities to mental health research: a typology of recruitment strategies

BACKGROUND

The ethnic minority population in developed countries is increasing over time. These groups are at higher risk of mental illness and demonstrate lower participation in research. Published evidence suggests that multiple factors like stigma, lack of trust, differences in explanatory models, logistical issues and lack of culturally aware researchers act as barriers to ethnic minority recruitment into mental health research. To reduce inequalities in participation, there is a need to devise innovative and culturally sensitive recruitment strategies. It is important that researchers share their experience of employing these strategies so that ethnic minority participation can be facilitated.

METHODS

We previously published a systematic review of barriers to recruiting ethnic minority participants into mental health research. The nine papers included in our prior review formed the basis for developing a typology of barriers to recruiting ethnic minorities into mental health research. This typology identified 33 barriers, described under five themes. We further extracted data on the strategies used to overcome these recruitment barriers, as described in the included studies.

RESULTS

The strategies employed by the authors could be matched to all but two barriers (psychopathology/substance misuse and limited resource availability). There was evidence that multiple strategies were employed, and that these depended upon the population, clinical set-up and resources available.

CONCLUSIONS

This typology of strategies to overcome barriers to recruiting ethnic minorities provides guidance on achieving higher rates of recruitment. It is important that researchers plan to deploy these strategies well in advance of initiating recruitment. Whilst adopting these strategies, the authors have not been able to quantify the positive impact of these strategies on recruitment. The typology should encourage researchers to employ these strategies in future research, refine them further and quantitatively evaluate their impact.

Race/Ethnicity and Treatment Outcome in a Randomized Controlled Trial for Trichotillomania (Hair-Pulling Disorder)

OBJECTIVE

Treatment outcome was compared among non-Hispanic White and racial/ethnic minority participants with trichotillomania (TTM), or hair-pulling disorder.

METHOD

Symptom severity, quality of life, and TTM-related disability were compared in a behavior therapy trial with a stepped care approach: web-based self-help and then individual behavior therapy. The sample comprised 72% (n = 38) non-Hispanic White participants and 28% (n = 15) minority participants.

RESULTS

The ethnic groups responded differently to treatment, with fewer minority participants showing improvement during web-based self-help. Response rates were equivalent between ethnic groups during the in-person behavior therapy. These results should be interpreted with caution because of the small sample size of minorities in the study and consequent inability to analyze results for each racial/ethnic group individually.

CONCLUSIONS

Future studies should focus on the investigation of factors that may enable or hinder racial and ethnic minority participants to benefit from online and/or self-help behavior therapy for TTM.

Factors associated with the duration of untreated illness among patients with obsessive compulsive disorder

BACKGROUND

Patients suffering from obsessive compulsive disorder (OCD), despite heightened levels of functional impairment and disability, often wait several years before starting pharmacological treatment. The interval between the onset of a specific psychiatric disorder and administration of the first pharmacological treatment has been conceptualized as the duration of untreated illness (DUI). The DUI has been increasingly investigated as a predictor of long-term outcomes for OCD and other anxiety disorders. The present study investigated DUI, and demographic-clinical factors associated with DUI, among a sample of patients with OCD. The relationships between DUI, insight, and treatment outcomes were also assessed.

METHODS

We evaluated 96 subjects with a DSM-IV diagnosis of OCD using the Structured Clinical Interview for DSM-IV Axis I disorders, a semistructured interview for sociodemographic and clinical features, the Yale-Brown Obsessive-Compulsive Scale (Y-BOCS), and a questionnaire designed by our group to identify reasons for delaying psychiatric admission. Patients with OCD showed a mean DUI of 84 months. However, DUI was not predictive of remission defined by a Y-BOCS total score of 10. Using the median value, a categorical cut-off for DUI of 4 years was calculated.

RESULTS

For patients with a shorter DUI (≤4 years), the age of OCD onset was significantly older than patients with a longer DUI (>4 years) (p<.001). The following four items related to reasons for delaying treatment were significantly endorsed by patients: the fact that symptoms were spontaneously fluctuating over time (61.5%), believing that OCD symptoms were not associated with an illness (60.4%), believing that one can overcome symptoms by him/herself (55.2%), and not being significantly disturbed by OCD symptoms (33.3%). Delaying treatment because of perceived social stigma was only endorsed by 12.5% of patients. Believing that OCD symptoms were not associated with an illness was significantly associated with a longer DUI (p=.039).

CONCLUSIONS

Results from the present study suggest that patients with OCD show a significant inclination toward delaying treatment admission. However, DUI was not predictive of remission in terms of symptomatology. Believing that OCD symptoms are not associated with an illness might indicate impairment in insight, a denial of the problem or could be associated with awareness of OCD as a mental illness. Factors related to the nature and course of OCD appear to be important determinants in delaying treatment among patients with OCD.

Factors associated with non-treatment or delayed treatment seeking in OCD sufferers: a review of the literature

Obsessive-compulsive disorder (OCD) is a disabling disorder that can be successfully treated. However, a high percentage of sufferers neither ask for nor receive treatment for their symptoms, or they delay seeking treatment. The factors underlying the treatment-seeking behaviour of OCD patients are still not clear. This review includes 12 studies published before April 2014 that analyse the possible variables related to the delayed help-seeking behaviour of OCD patients. Studies showed that individuals who asked for help were more impaired and reported poorer quality of life. Help-seeking behaviour was associated with greater insight, severity, specific obsessive-compulsive symptoms, such as aggressive and other unpleasant obsessions, and comorbidity. Common barriers to seeking treatment were shame about the symptoms or about asking for treatment, not knowing where to find help, or inconveniences associated with treatment. Inconsistencies among the reviewed studies highlight the need to further evaluate the variables that keep OCD patients from seeking help. The review highlights the need for educational campaigns designed to detect underdiagnosed OCD individuals and improve access to mental health services, which could shorten delays in seeking treatment and, therefore, reduce the personal and financial costs of OCD. Guidelines for educational programs and future lines of research are discussed.

The Barriers to Seeking Treatment for Obsessive-Compulsive Disorder in an Australian Population

Individuals with obsessive-compulsive disorder (OCD) experience a significant deterioration in quality of life (Fontenelle et al., 2010; Kugler et al., 2013) and marked functional impairment (Markarian et al., 2010). Despite this, a large proportion of these individuals do not seek any type of help (Goodwin, Koenen, Hellman, Guardino, & Struening, 2002; Mayerovitch et al., 2003). The current study investigated the barriers to seeking OCD treatment using an online survey that was completed by 86 participants living in Australia who identified as having OCD. Results showed that the three main barriers to seeking OCD treatment were: (a) preference for handling problems alone; (b) cost of treatment; and (c) lack of knowledge about available mental health treatment. Individuals who reported receiving an OCD diagnosis (n = 57) demonstrated more severe symptoms, poorer quality of life and higher symptom intrusiveness than those who had not received a diagnosis (n = 29). Furthermore, significant associations were found between religious affiliation and barriers to treatment where greater religious attendance was correlated with a higher likelihood of identifying cultural factors as a barrier to OCD treatment. Additionally, higher levels of religious attendance were associated with a greater understanding of where to go for OCD treatment, not wanting to handle problems alone, and recognising that symptoms are a problem. This article considers approaches to overcoming barriers to accessing effective evidence-based treatment for people with OCD symptoms, and highlights future directions for research.

Quality of care and quality of life: convergence or divergence?

The aim of this study was to explore the impact of quality of care (QoC) on patients' quality of life (QoL). In a cross-sectional study, two domains of QoC and the World Health Organization Quality of Life-Bref questionnaire were combined to collect data from 1,059 pre-discharge patients in four accredited hospitals (ACCHs) and four non-accredited hospitals (NACCHs) in Saudi Arabia. Health and well-being are often restricted to the characterization of sensory qualities in certain settings such as unrestricted access to healthcare, effective treatment, and social welfare. The patients admitted to tertiary health care facilities are generally able to present themselves with a holistic approach as to how they experience the impact of health policy. The statistical results indicated that patients reported a very limited correlation between QoC and QoL in both settings. The model established a positive, but ultimately weak and insignificant, association between QoC (access and effective treatment) and QoL (r = 0.349, P = 0.000; r = 0.161, P = 0.000, respectively). Even though the two settings are theoretically different in terms of being able to conceptualize, adopt, and implement QoC, the outcomes from both settings demonstrated insignificant relationships with QoL as the results were quite similar. Though modern medicine has substantially improved QoL around the world, this paper proposes that health accreditation has a very limited impact on improving QoL. This paper raises awareness of this topic with multiple healthcare professionals who are interested in correlating QoC and QoL. Hopefully, it will stimulate further research from other professional groups that have new and different perspectives. Addressing a transitional health care system that is in the process of endorsing accreditation, investigating the experience of tertiary cases, and analyzing deviated data may limit the generalization of this study. Global interest in applying public health policy underlines the impact of such process on patients' outcomes. As QoC accreditation does not automatically produce improved QoL outcomes, the proposed study encourages further investigation of the value of health accreditation on personal and social well-being.

Cultural adaptations of prolonged exposure therapy for treatment and prevention of posttraumatic stress disorder in african americans

Posttraumatic stress disorder (PTSD) is a highly disabling disorder, afflicting African Americans at disproportionately higher rates than the general population. When receiving treatment, African Americans may feel differently towards a European American clinician due to cultural mistrust. Furthermore, racism and discrimination experienced before or during the traumatic event may compound posttrauma reactions, impacting the severity of symptoms. Failure to adapt treatment approaches to encompass cultural differences and racism-related traumas may decrease treatment success for African American clients. Cognitive behavioral treatment approaches are highly effective, and Prolonged Exposure (PE) in particular has the most empirical support for the treatment of PTSD. This article discusses culturally-informed adaptations of PE that incorporates race-related trauma themes specific to the Black experience. These include adding more sessions at the front end to better establish rapport, asking directly about race-related themes during the assessment process, and deliberately bringing to the forefront race-related experiences and discrimination during treatment when indicated. Guidelines for assessment and the development of appropriate exposures are provided. Case examples are presented demonstrating adaptation of PE for a survivor of race-related trauma and for a woman who developed internalized racism following a sexual assault. Both individuals experienced improvement in their posttrauma reactions using culturally-informed adaptations to PE.

Direct-to-consumer marketing of psychological treatments for anxiety disorders

Progress disseminating and implementing evidence-based psychological treatments (EBPTs) for the anxiety disorders has been gradual. To date, the dominant approach for promoting the uptake of EBPTs in clinical settings has been to target the education and training of mental health providers, with many consumers remaining unaware of the potential benefits of EBPTs for anxiety disorders. Direct-to-consumer (DTC) marketing may be a promising vehicle for increasing EBPT utilization rates in the treatment of anxiety disorders. This paper provides an overview of the rationale and important considerations for applying DTC efforts to promote evidence-based care in the treatment of anxiety disorders, and reviews current DTC efforts in this area, including resources on the Internet and other media and in-person events. We conclude with recommendations for future efforts in the DTC marketing of EBPTs for the anxiety disorders, including the need for increased funding and grassroots efforts to inform consumers about anxiety disorders and their most effective treatments.