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Beigel L, Forrester A, Torales J, Aboaja A, Rivera Aroyo G, Roche MO, Opitz-Welke A, Mundt AP. Mental health intervention research in Latin American correctional settings: A scoping review. Int J Soc Psychiatry 2023; 69:1560-1577. [PMID: 37332202 DOI: 10.1177/00207640231174372] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/20/2023]
Abstract
BACKGROUND The Latin American prison population has grown faster than anywhere else globally over the past two decades, reaching a total of 1.7 million people at any given time. However, research on mental health prevention and treatment interventions in Latin American prisons remains scarce. AIMS This study aimed to systematically review and synthesize research on prison mental health interventions conducted in the region. METHODS We used a two-stage scoping review design guided by the JBI Manual for Evidence Synthesis. Searches took place in December 2021 in nine databases using descriptors and synonyms. First, all prison mental health research in Latin America was retained. Secondly, using title and abstract screening, all research possibly related to interventions was retained for full text evaluation. Studies reporting interventions were assessed by country, language, institution, population, intervention type, intervention focus and outcomes. RESULTS N = 34 studies were included in this review. These were 13 case reports, seven expert consensus papers and 14 quantitative studies (four randomized controlled trials, nine cohort studies, one quasi-experimental study). Fourteen interventions were targeted at promoting prosocial behavior, seven studies each aimed to improve mental health and to treat substance use disorders. Six studies involved the treatment of sexual offending behavior, and 3 focused on reducing criminal recidivism. Psychoeducation (n = 12) and motivational interviewing (n = 5) were the most frequent intervention types studied. Promising data from trials showed that anger management, depression, substance use and reoffending could be successfully addressed through interventions. CONCLUSIONS Implementation and effectiveness research of mental health interventions in Latin American prisons is scarce. Addressing mental health, substance use and prosocial behavior outcomes should be considered in future research. There is a particular dearth of controlled trials describing quantifiable outcomes.
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Affiliation(s)
- Lukas Beigel
- Department of Psychiatry and Psychotherapy Charité Campus Mitte, Charité Universitätsmedizin Berlin, Germany
- Departamento de Psiquiatría y Salud Mental, Facultad de Medicina, Universidad de Chile, Santiago, Chile
| | - Andrew Forrester
- Division of Psychological Medicine and Clinical Neurosciences, Cardiff University, UK
| | - Julio Torales
- Department of Mental Health, Universidad Nacional de Asunción, Paraguay
| | - Anne Aboaja
- Mental Health and Addictions Research Group, University of York, UK
- Tees, Esk and Wear Valleys NHS Foundation Trust, Middlesbrough, UK
| | | | | | - Annette Opitz-Welke
- Department of Forensic Psychiatry, Charité Universitätsmedizin Berlin, Germany
| | - Adrian P Mundt
- Facultad de Medicina, Universidad Diego Portales, Santiago, Chile
- Departamento de Psiquiatría y Salud Mental, Facultad de Medicina, Universidad de Chile, Santiago, Chile
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2
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Sethuram C, Helmer-Smith M, Karunananthan S, Keely E, Singh J, Liddy C. Electronic consultation in correctional facilities worldwide: a scoping review. BMJ Open 2022; 12:e055049. [PMID: 35922103 PMCID: PMC9352998 DOI: 10.1136/bmjopen-2021-055049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE To provide an overview of the use of and evidence for eConsult in correctional facilities worldwide. DESIGN Scoping review. DATA SOURCES Three academic databases (MEDLINE, Embase and CINAHL) were searched to identify papers published between 1990 and 2020 that presented data on eConsult use in correctional facilities. The grey literature was also searched for any resources that discussed eConsult use in correctional facilities. Articles and resources were excluded if they discussed synchronous, patient-to-provider or unsecure communication. The reference lists of included articles were also hand searched. RESULTS Of the 226 records retrieved from the academic literature search and 595 from the grey literature search, 22 were included in the review. Most study populations included adult male offenders in a variety of correctional environments. These resources identified 13 unique eConsult services in six countries. Six of these services involved multiple medical specialties, while the remaining services were single specialty. The available evidence was organised into five identified themes: feasibility, cost-effectiveness, access to care, provider satisfaction and clinical impact. CONCLUSIONS This study identified evidence that the use of eConsult in correctional facilities is beneficial and avoids unnecessary transportation of offenders outside of the facilities. It is feasible, cost-effective, increases access to care, has an impact on clinical care and has high provider satisfaction. Some gaps in the literature remain, and we suggest further research on patient satisfaction, enablers and barriers to implementation, and women, youth and transgender populations in this setting to inform service providers and stakeholders. Despite some gaps, eConsult is evidently an important tool to provide timely, high-quality care to offenders.
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Affiliation(s)
- Claire Sethuram
- C.T. Lamont Primary Health Care Research Centre, Bruyere Research Institute, Ottawa, Ontario, Canada
- Department of Family Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Mary Helmer-Smith
- C.T. Lamont Primary Health Care Research Centre, Bruyere Research Institute, Ottawa, Ontario, Canada
- Department of Family Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Sathya Karunananthan
- C.T. Lamont Primary Health Care Research Centre, Bruyere Research Institute, Ottawa, Ontario, Canada
- Department of Family Medicine, University of Ottawa, Ottawa, Ontario, Canada
- Interdisciplinary School of Health Sciences, University of Ottawa, Ottawa, Ontario, Canada
| | - Erin Keely
- Ontario eConsult Centre of Excellence, The Ottawa Hospital, Ottawa, Ontario, Canada
- Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
- Division of Endocrinology/Metabolism, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Jatinderpreet Singh
- Department of Family Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Clare Liddy
- C.T. Lamont Primary Health Care Research Centre, Bruyere Research Institute, Ottawa, Ontario, Canada
- Department of Family Medicine, University of Ottawa, Ottawa, Ontario, Canada
- Ontario eConsult Centre of Excellence, The Ottawa Hospital, Ottawa, Ontario, Canada
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3
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Orsolini L, Bellagamba S, Marchetti V, Menculini G, Tempia Valenta S, Salvi V, Volpe U. A Preliminary Italian Cross-Sectional Study on the Level of Digital Psychiatry Training, Knowledge, Beliefs and Experiences among Medical Students, Psychiatry Trainees and Professionals. Healthcare (Basel) 2022; 10:healthcare10020390. [PMID: 35207004 PMCID: PMC8871870 DOI: 10.3390/healthcare10020390] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Revised: 02/14/2022] [Accepted: 02/15/2022] [Indexed: 11/16/2022] Open
Abstract
The COVID-19 pandemic led to the implementation of digital psychiatry (DP), resulting in the need for a new skilled healthcare workforce. The purpose of this study was to investigate the level of training, knowledge, beliefs, and experiences of young mental health professionals and medical students in DP. An ad hoc cross-sectional survey was administered and descriptive analyses, Student’s t and ANOVA tests were conducted, together with an exploratory factor analysis, bivariate correlations and linear regression. Most of the sample (N = 239) declared that DP was never discussed within their academic training (89.1%), mainly revealing an overall lack of knowledge on the issue. Nevertheless, subjects mostly declared that DP represents a valuable therapeutic tool in mental health (80%) and that their training should include this topic (54.4%). Moreover, most subjects declared that digital interventions are less effective than face-to-face ones (73.2%), despite the emerging evidence that being trained in DP is significantly associated with the belief that digital and in-person interventions are comparable in their effectiveness (p ≤ 0.05). Strong positive correlations were found between the knowledge score (KS) and perceived significance index (PSI) (r = 0.148, p < 0.001), and KS and Digital Psychiatry Opinion (DPO) index (r = 0.193, p < 0.001). PSI scores statistically significantly predicted KS total scores (F(1, 237) = 5.283, R2 = 0.022, p = 0.022). KS scores statistically significantly predicted DPO total scores (F(1, 237) = 9.136, R2 = 0.037, p = 0.003). During the current pandemic, DP represented an ideal response to the forced physical distancing by ensuring the advantage of greater access to care. However, this kind of intervention is still uncommon, and mental health professionals still prove to be skeptical. The lack of formal training on DP during the academic years could be a limiting factor.
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Affiliation(s)
- Laura Orsolini
- Unit of Clinical Psychiatry, Department of Neurosciences/DIMSC, Polytechnic University of Marche, 60126 Ancona, Italy; (L.O.); (S.B.); (S.T.V.); (V.S.)
| | - Silvia Bellagamba
- Unit of Clinical Psychiatry, Department of Neurosciences/DIMSC, Polytechnic University of Marche, 60126 Ancona, Italy; (L.O.); (S.B.); (S.T.V.); (V.S.)
| | - Virginia Marchetti
- School of Medicine and Surgery, Polytechnic University of Marche, 60126 Ancona, Italy;
| | - Giulia Menculini
- Department of Psychiatry, University of Perugia, 06100 Perugia, Italy;
| | - Silvia Tempia Valenta
- Unit of Clinical Psychiatry, Department of Neurosciences/DIMSC, Polytechnic University of Marche, 60126 Ancona, Italy; (L.O.); (S.B.); (S.T.V.); (V.S.)
| | - Virginio Salvi
- Unit of Clinical Psychiatry, Department of Neurosciences/DIMSC, Polytechnic University of Marche, 60126 Ancona, Italy; (L.O.); (S.B.); (S.T.V.); (V.S.)
| | - Umberto Volpe
- Unit of Clinical Psychiatry, Department of Neurosciences/DIMSC, Polytechnic University of Marche, 60126 Ancona, Italy; (L.O.); (S.B.); (S.T.V.); (V.S.)
- Correspondence:
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Lieng MK, Aurora MS, Kang Y, Kim JM, Marcin JP, Chan SR, Mouzoon JL, Tancredi DJ, Parish M, Gonzalez AD, Scher L, Xiong G, McCarron RM, Yellowlees P. Primary Care Physician Adherence to Telepsychiatry Recommendations: Intermediate Outcomes from a Randomized Clinical Trial. Telemed J E Health 2021; 28:838-846. [PMID: 34726542 DOI: 10.1089/tmj.2021.0389] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Objective: To compare clinical recommendations given by psychiatrists and the adherence to these recommendations by primary care physicians (PCP) following consultations conducted by asynchronous telepsychiatry (ATP) and synchronous telepsychiatry (STP). Materials and Methods: ATP and STP consultations were compared using intermediate data from a randomized clinical trial with adult participant enrollment between April 2014 and December 2017. In both study arms, PCPs received written recommendations from the psychiatrist after each encounter. Independent clinicians reviewed PCP documentation to measure adherence to those recommendations in the 6 months following the baseline consultation. Results: Medical records were reviewed for 645 psychiatrists' consult recommendations; 344 from 61 ATP consultations and 301 from 62 STP consultations. Of those recommendations, 191 (56%) and 173 (58%) were rated fully adherent by two independent raters for ATP and STP, respectively. In a multilevel ordinal logistic regression model adjusted for recommendation type and recommended implementation timing, there was no statistically significant difference in adherence to recommendations for ATP compared with STP (adjusted odds ratio = 0.91, 95% confidence interval = 0.51-1.62). The profiles of recommendation type were comparable between ATP and STP. Conclusions: This is the first PCP adherence study comparing two forms of telemedicine. Although we did not find evidence of a difference between ATP and STP; this study supports the feasibility and acceptability of ATP and STP for the provision of collaborative psychiatric care. Clinical Trial Identifier NCT02084979.
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Affiliation(s)
- Monica K Lieng
- Department of Pediatrics, Center for Health and Technology, University of California Davis Health, Sacramento, California, USA.,School of Medicine, University of California Davis Health, Sacramento, California, USA
| | - Magi S Aurora
- Department of Psychiatry, Center for Health and Technology, University of California Davis Health, Sacramento, California, USA.,Department of Family Medicine, Center for Health and Technology, University of California Davis Health, Sacramento, California, USA
| | - Young Kang
- School of Medicine, University of California Davis Health, Sacramento, California, USA.,Department of Internal Medicine, Center for Health and Technology, University of California Davis Health, Sacramento, California, USA
| | - Joseph M Kim
- Department of Psychiatry, Center for Health and Technology, University of California Davis Health, Sacramento, California, USA.,Department of Internal Medicine, Center for Health and Technology, University of California Davis Health, Sacramento, California, USA
| | - James P Marcin
- Department of Pediatrics, Center for Health and Technology, University of California Davis Health, Sacramento, California, USA
| | - Steven R Chan
- Department of Psychiatry, Center for Health and Technology, University of California Davis Health, Sacramento, California, USA.,Veterans Health Administration, Palo Alto Health Care System, Palo Alto, California, USA
| | - Jamie L Mouzoon
- Department of Pediatrics, Center for Health and Technology, University of California Davis Health, Sacramento, California, USA
| | - Daniel J Tancredi
- Department of Pediatrics, Center for Health and Technology, University of California Davis Health, Sacramento, California, USA
| | - Michelle Parish
- Department of Psychiatry, Center for Health and Technology, University of California Davis Health, Sacramento, California, USA
| | - Alvaro D Gonzalez
- Department of Psychiatry, Center for Health and Technology, University of California Davis Health, Sacramento, California, USA
| | - Lorin Scher
- Department of Psychiatry, Center for Health and Technology, University of California Davis Health, Sacramento, California, USA
| | - Glen Xiong
- Department of Psychiatry, Center for Health and Technology, University of California Davis Health, Sacramento, California, USA
| | - Robert M McCarron
- School of Medicine, University of California Irvine, Irvine, California, USA
| | - Peter Yellowlees
- Department of Psychiatry, Center for Health and Technology, University of California Davis Health, Sacramento, California, USA
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5
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Echelard JF. Use of Telemedicine in Depression Care by Physicians: Scoping Review. JMIR Form Res 2021; 5:e29159. [PMID: 34309571 PMCID: PMC8367159 DOI: 10.2196/29159] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Revised: 05/15/2021] [Accepted: 05/31/2021] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND Depression is a common disorder, and it creates burdens on people's mental and physical health as well as societal costs. Although traditional in-person consultations are the usual mode of caring for patients with depression, telemedicine may be well suited to psychiatric assessment and management. Telepsychiatry can be defined as the use of information and communication technologies such as videoconferencing and telephone calls for the care of psychopathologies. OBJECTIVE This review aims to evaluate the extent and nature of the existing literature on the use of telemedicine for the care of depression by physicians. This review also aims to examine the effects and perceptions regarding this virtual care and determine how it compares to traditional in-person care. METHODS The Arksey and O'Malley framework and the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews) guidelines were followed. Relevant articles were identified through a search of three databases (MEDLINE, Cochrane Database of Systematic Reviews, and PsycArticles) on October 11, 2020. The search terms were "(virtual OR telemedicine OR teleconsultation* OR telehealth OR phone* OR webcam* OR telepsychiatry) AND (depress*)". Eligibility criteria were applied to select studies about the use of telemedicine for the care of patients with depression specifically by physicians. An Excel file (Microsoft Corporation) was used to chart data from all included articles. RESULTS The search resulted in the identification of 28 articles, and all 13 nonreview studies were analyzed in detail. Most nonreview studies were conducted in the United States during the last decade. Most telemedicine programs were led by psychiatrists, and the average study population size was 135. In all applicable studies, telepsychiatry tended to perform at least as well as in-person care regarding improvement in depression severity, patient satisfaction, quality of life, functioning, cost-effectiveness, and most other perceptions and variables. Cultural sensitivity and collaborative care were part of the design of some telemedicine programs. CONCLUSIONS Additional randomized, high-quality studies are recommended to evaluate various outcomes of the use of telemedicine for depression care, including depression variables, perceptions, health care outcomes and other outcomes. Studies should be conducted in various clinical contexts, including primary care. Telepsychiatry is a promising modality of care for patients suffering from depression.
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Barnett P, Goulding L, Casetta C, Jordan H, Sheridan-Rains L, Steare T, Williams J, Wood L, Gaughran F, Johnson S. Implementation of Telemental Health Services Before COVID-19: Rapid Umbrella Review of Systematic Reviews. J Med Internet Res 2021; 23:e26492. [PMID: 34061758 PMCID: PMC8335619 DOI: 10.2196/26492] [Citation(s) in RCA: 61] [Impact Index Per Article: 20.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Revised: 03/30/2021] [Accepted: 04/30/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Telemental health care has been rapidly adopted for maintaining services during the COVID-19 pandemic, and a substantial interest is now being devoted in its future role. Service planning and policy making for recovery from the pandemic and beyond should draw on both COVID-19 experiences and the substantial research evidence accumulated before this pandemic. OBJECTIVE We aim to conduct an umbrella review of systematic reviews available on the literature and evidence-based guidance on telemental health, including both qualitative and quantitative literature. METHODS Three databases were searched between January 2010 and August 2020 for systematic reviews meeting the predefined criteria. The retrieved reviews were independently screened, and those meeting the inclusion criteria were synthesized and assessed for risk of bias. Narrative synthesis was used to report these findings. RESULTS In total, 19 systematic reviews met the inclusion criteria. A total of 15 reviews examined clinical effectiveness, 8 reported on the aspects of telemental health implementation, 10 reported on acceptability to service users and clinicians, 2 reported on cost-effectiveness, and 1 reported on guidance. Most reviews were assessed to be of low quality. The findings suggested that video-based communication could be as effective and acceptable as face-to-face formats, at least in the short term. Evidence on the extent of digital exclusion and how it can be overcome and that on some significant contexts, such as children and young people's services and inpatient settings, was found to be lacking. CONCLUSIONS This umbrella review suggests that telemental health has the potential to be an effective and acceptable form of service delivery. However, we found limited evidence on the impact of its large-scale implementation across catchment areas. Combining previous evidence and COVID-19 experiences may allow realistic planning for the future implementation of telemental health.
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Affiliation(s)
- Phoebe Barnett
- Centre for Outcomes Research and Effectiveness, Division of Psychology and Language Sciences, University College London, London, United Kingdom.,NIHR Mental Health Policy Research Unit, Division of Psychiatry, University College London, London, United Kingdom
| | - Lucy Goulding
- King's Improvement Science, Centre for Implementation Science, King's College London, London, United Kingdom
| | - Cecilia Casetta
- NIHR Applied Research Collaboration, King's College London, London, United Kingdom
| | - Harriet Jordan
- NIHR Applied Research Collaboration, King's College London, London, United Kingdom.,Institute of Psychiatry, Psychology and Neuroscience, King's College London and South London and Maudsley NHS Trust, London, United Kingdom
| | - Luke Sheridan-Rains
- NIHR Mental Health Policy Research Unit, Division of Psychiatry, University College London, London, United Kingdom
| | - Thomas Steare
- NIHR Mental Health Policy Research Unit, Division of Psychiatry, University College London, London, United Kingdom
| | - Julie Williams
- Centre for Implementation Science, Health Service and Population Research Department, King's College London, London, United Kingdom
| | - Lisa Wood
- Division of Psychiatry, University College London, London, United Kingdom
| | - Fiona Gaughran
- NIHR Applied Research Collaboration, King's College London, London, United Kingdom.,Institute of Psychiatry, Psychology and Neuroscience, King's College London and South London and Maudsley NHS Trust, London, United Kingdom
| | - Sonia Johnson
- NIHR Mental Health Policy Research Unit, Division of Psychiatry, University College London, London, United Kingdom.,Camden and Islington NHS Foundation Trust, London, United Kingdom
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7
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Cano JF, González-Díaz JM, Vallejo-Silva A, Alzate-García M, Córdoba-Rojas RN. The role of Colombian psychiatrists in the midst of the COVID-19 pandemic. REVISTA COLOMBIANA DE PSIQUIATRIA (ENGLISH ED.) 2021; 50:184-188. [PMID: 34479844 PMCID: PMC8349683 DOI: 10.1016/j.rcpeng.2021.08.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Accepted: 04/28/2021] [Indexed: 12/02/2022]
Abstract
INTRODUCTION The COVID-19 pandemic is having an impact on multiple levels, one being the way of providing mental health care services. A study was proposed in order to identify the standpoints regarding the role we must assume as psychiatrists in the setting of this pandemic in Colombia. METHODS A study was developed employing a Delphi-type methodology. Three types of psychiatrist were included for the application of the instrument: directors of academic psychiatry programmes, directors of mental health institutions and private practitioners. RESULTS Responses were collected over the course of a month (between April and May) by 24 participants corresponding to 14 private practitioners (58.3%), 6 heads of academic programmes (25.1%) and 4 directors of mental health services (16.6%). The results, grouped around the psychiatric work, describe the impact generated by the pandemic and the possible role of the specialist. CONCLUSIONS Consistency was identified around the need to provide a differential approach according to the vulnerabilities of each group of people exposed to the pandemic; as well as the remote provision of health care through technology, often using videoconferencing.
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Affiliation(s)
- Juan Fernando Cano
- Centro Rosarista de Salud Mental - CeRSaMe, Escuela de Medicina y Ciencias de la Salud - EMCS, Universidad del Rosario, Bogotá, Colombia.
| | - Jairo Mario González-Díaz
- Centro Rosarista de Salud Mental - CeRSaMe, Escuela de Medicina y Ciencias de la Salud - EMCS, Universidad del Rosario, Bogotá, Colombia
| | - Alexie Vallejo-Silva
- Centro Rosarista de Salud Mental - CeRSaMe, Escuela de Medicina y Ciencias de la Salud - EMCS, Universidad del Rosario, Bogotá, Colombia
| | | | - Rodrigo Nel Córdoba-Rojas
- Centro Rosarista de Salud Mental - CeRSaMe, Escuela de Medicina y Ciencias de la Salud - EMCS, Universidad del Rosario, Bogotá, Colombia; Centro de Investigaciones del Sistema Nervioso - Grupo CISNE, Bogotá, Colombia
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8
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Cano JF, González-Díaz JM, Vallejo-Silva A, Alzate-García M, Córdoba-Rojas RN. [The Role of Colombian Psychiatrists in the Midst of the COVID 19 Pandemic]. REVISTA COLOMBIANA DE PSIQUIATRIA 2021; 50:184-188. [PMID: 34629560 PMCID: PMC8214169 DOI: 10.1016/j.rcp.2021.04.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Accepted: 04/28/2021] [Indexed: 11/30/2022]
Abstract
INTRODUCTION The COVID-19 pandemic is having an impact on multiple levels, one being the way of providing mental health care services. A study was proposed in order to identify the standpoints regarding the role we must assume as psychiatrists in the setting of this pandemic in Colombia. METHODS A study was developed employing a Delphi-type methodology. Three types of psychiatrist were included for the application of the instrument: directors of academic psychiatry programmes, directors of mental health institutions and private practitioners. RESULTS Responses were collected over the course of a month (between April and May) by 24 participants corresponding to 14 private practitioners (58.3%), 6 heads of academic programmes (25.1%) and 4 directors of mental health services (16.6%). The results, grouped around the psychiatric work, describe the impact generated by the pandemic and the possible role of the specialist. CONCLUSIONS Consistency was identified around the need to provide a differential approach according to the vulnerabilities of each group of people exposed to the pandemic; as well as the remote provision of health care through technology, often using videoconferencing.
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Affiliation(s)
- Juan Fernando Cano
- Centro Rosarista de Salud Mental - CeRSaMe, Escuela de Medicina y Ciencias de la Salud - EMCS, Universidad del Rosario, Bogotá, Colombia
| | - Jairo Mario González-Díaz
- Centro Rosarista de Salud Mental - CeRSaMe, Escuela de Medicina y Ciencias de la Salud - EMCS, Universidad del Rosario, Bogotá, Colombia
| | - Alexie Vallejo-Silva
- Centro Rosarista de Salud Mental - CeRSaMe, Escuela de Medicina y Ciencias de la Salud - EMCS, Universidad del Rosario, Bogotá, Colombia
| | | | - Rodrigo Nel Córdoba-Rojas
- Centro Rosarista de Salud Mental - CeRSaMe, Escuela de Medicina y Ciencias de la Salud - EMCS, Universidad del Rosario, Bogotá, Colombia
- Centro de Investigaciones del Sistema Nervioso - Grupo CISNE, Bogotá, Colombia
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Telepsiquiatría: una experiencia exitosa en Antioquia, Colombia. ACTA ACUST UNITED AC 2020; 49:239-245. [DOI: 10.1016/j.rcp.2019.06.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2018] [Revised: 03/29/2019] [Accepted: 06/04/2019] [Indexed: 11/18/2022]
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Naslund JA, Mitchell LM, Joshi U, Nagda D, Lu C. Economic evaluation and costs of telepsychiatry programmes: A systematic review. J Telemed Telecare 2020; 28:311-330. [PMID: 32746762 DOI: 10.1177/1357633x20938919] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
OBJECTIVE Telepsychiatry involves use of telecommunications technology to deliver psychiatric care and offers promise to reduce costs and increase access to mental health services. This systematic review examined cost reporting of telepsychiatry programmes for mental healthcare. METHODS We systematically searched electronic databases for studies reporting costs, including economic evaluations such as cost-effectiveness analyses, or costs of developing telepsychiatry programmes for clinical care of mental disorders. Included studies enrolled participants with mental disorders and involved telepsychiatry for depression, anxiety disorders, serious mental illnesses including schizophrenia spectrum disorders and bipolar disorder, post-traumatic stress disorder, dementia or epilepsy. RESULTS Twenty-six unique studies met inclusion criteria (17,967 participants), with most targeting depression (n = 7; 27%), general mental disorders and screening (n = 7; 27%), child mental health (n = 4; 15%) and geriatric mental health (n = 4; 15%). Nearly all studies (n = 25; 96%) compared telepsychiatry programme costs with either standard in-person consultation or usual care, with 15 (60%) reporting that telepsychiatry programmes were less expensive, and 8 (32%) showing telepsychiatry programmes were more expensive. Three studies reported cost-effectiveness analyses, favouring telepsychiatry programmes, but at highly elevated cost-effectiveness thresholds. Few studies reported costs of developing or delivering telepsychiatry programmes. CONCLUSION Costs of telepsychiatry programmes varied widely, with substantial heterogeneity in how costs were defined and reported. Some programmes cost less than in-person services while others cost more. Therefore, rigorous cost-effectiveness studies following established standards in economic evaluation are needed to inform implementation and sustainability of these programmes in health systems.
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Affiliation(s)
- John A Naslund
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA
| | | | | | | | - Chunling Lu
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA.,Brigham and Women's Hospital, Harvard Medical School, Boston, MA
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Edge C, Black G, King E, George J, Patel S, Hayward A. Improving care quality with prison telemedicine: The effects of context and multiplicity on successful implementation and use. J Telemed Telecare 2019; 27:325-342. [PMID: 31640460 DOI: 10.1177/1357633x19869131] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Prison telemedicine can improve the access, cost and quality of healthcare for prisoners, however adoption in prison systems worldwide has been variable despite these demonstrable benefits. This study examines anticipated and realised benefits, barriers and enablers for prison telemedicine, thereby providing evidence to improve the chances of successful implementation. METHODS A systematic search was conducted using a combination of medical subject headings and text word searches for prisons and telemedicine. Databases searched included: PubMed, Embase, CINAHL Plus, PsycINFO, Web of Science, Scopus and International Bibliography of the Social Sciences. Articles were included if they reported information regarding the use of/advocacy for telemedicine, for people residing within a secure correctional facility. A scoping summary and subsequent thematic qualitative analysis was undertaken on articles selected for inclusion in the review, to identify issues associated with successful implementation and use. RESULTS One thousand, eight hundred and eighty-two non-duplicate articles were returned, 225 were identified for full text review. A total of 163 articles were included in the final literature set. Important considerations for prison telemedicine implementation include: differences between anticipated and realised benefits and barriers, differing wants and needs of prison and community healthcare providers, the importance of top-down and bottom-up support and consideration of logistical and clinical compatibility. CONCLUSIONS When implemented well, patients, prison and hospital staff are generally satisfied with telemedicine. Successful implementation requires careful consideration at outset of the partners to be engaged, the local context for implementation and the potential benefits that should be communicated to encourage participation.
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Affiliation(s)
- Chantal Edge
- UCL Collaborative Centre for Inclusion Health, London, UK
| | - Georgia Black
- UCL Department of Applied Health Research, London, UK
| | - Emma King
- UCL Collaborative Centre for Inclusion Health, London, UK
| | | | - Shamir Patel
- Central North West London NHS Foundation Trust, London, UK
| | - Andrew Hayward
- UCL Institute of Epidemiology and Health Care, London, UK
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Jiménez-Molina Á, Franco P, Martínez V, Martínez P, Rojas G, Araya R. Internet-Based Interventions for the Prevention and Treatment of Mental Disorders in Latin America: A Scoping Review. Front Psychiatry 2019; 10:664. [PMID: 31572242 PMCID: PMC6753742 DOI: 10.3389/fpsyt.2019.00664] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2019] [Accepted: 08/19/2019] [Indexed: 01/14/2023] Open
Abstract
Background: There is a huge gap in the treatment of mental disorders in Latin America, especially among socioeconomically disadvantaged groups. Given the sharp increase in Internet access and the rapid penetration of smartphones in the region, the use of Internet-based technologies might potentially contribute to overcoming this gap and to provide more widely distributed and low-cost mental health care in a variety of contexts. Methods: We conducted a scoping review of the literature in order to systematically map the existing evidence on use of Internet-based interventions for prevention, treatment, and management of mental disorders across Latin American countries, as well as to identify existing gaps in knowledge. Six electronic databases were searched for published papers (PubMed, Embase, CINAHL, Web of Science, SciELO, and CENTRAL). Results: After the eligibility assessment, we identified 22 Internet-based studies carried out in Latin America for prevention, treatment, education, or facilitating self-management of mental disorders. Included studies mainly targeted depression (n = 11), substance misuse (n = 6), anxiety (n = 3), and mental health literacy for education and health professionals (n = 2). Most studies were undertaken in Brazil (n = 6), Mexico (n = 5), and Chile (n = 4). Only 3 studies were randomized controlled trials (RCTs), 4 were pilot RCTs, and 15 were naturalistic, acceptability, or feasibility studies. The three RCTs identified showed disparate results, but overall, there are challenges to face. Better results are seen in the short-term (postintervention or after 3 months), but most studies do not explore outcomes for long enough (follow-up after 6 or 12 months). Most of the feasibility and pilot studies showed reasonably good acceptability for a wide range of strategies but difficulties to engage and retain participants for long enough or adhering to established protocols. Conclusion: This study shows that Internet-based interventions for the prevention and treatment of mental disorders are growing rapidly in Latin America, but there are few studies on effectiveness and cost effectiveness, making it difficult to provide the evidence needed to justify scaling up these interventions.
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Affiliation(s)
- Álvaro Jiménez-Molina
- Millennium Nucleus to Improve the Mental Health of Adolescents and Youths (Imhay), Santiago, Chile
- Millennium Institute for Research in Depression and Personality (MIDAP), Santiago, Chile
- Millennium Nucleus in Social Development (DESOC), Santiago, Chile
| | - Pamela Franco
- Programa de Doctorado en Psicoterapia, Facultad de Ciencias Sociales and Facultad de Medicina, Pontificia Universidad Católica de Chile and Universidad de Chile, Santiago, Chile
| | - Vania Martínez
- Millennium Nucleus to Improve the Mental Health of Adolescents and Youths (Imhay), Santiago, Chile
- Millennium Institute for Research in Depression and Personality (MIDAP), Santiago, Chile
- CEMERA, Facultad de Medicina, Universidad de Chile, Santiago, Chile
| | - Pablo Martínez
- Millennium Nucleus to Improve the Mental Health of Adolescents and Youths (Imhay), Santiago, Chile
- Millennium Institute for Research in Depression and Personality (MIDAP), Santiago, Chile
- Escuela de Psicología, Facultad de Humanidades, Universidad de Santiago de Chile, Santiago, Chile
- Hospital Clínico, Universidad de Chile, Santiago, Chile
| | - Graciela Rojas
- Millennium Nucleus to Improve the Mental Health of Adolescents and Youths (Imhay), Santiago, Chile
- Millennium Institute for Research in Depression and Personality (MIDAP), Santiago, Chile
- Millennium Nucleus in Social Development (DESOC), Santiago, Chile
- Hospital Clínico, Universidad de Chile, Santiago, Chile
| | - Ricardo Araya
- Millennium Nucleus to Improve the Mental Health of Adolescents and Youths (Imhay), Santiago, Chile
- Centre for Global Mental Health, Institute of Psychiatry, Psychology & Neuroscience, King’s College London, London, United Kingdom
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Ospina-Pinillos L, Davenport T, Mendoza Diaz A, Navarro-Mancilla A, Scott EM, Hickie IB. Using Participatory Design Methodologies to Co-Design and Culturally Adapt the Spanish Version of the Mental Health eClinic: Qualitative Study. J Med Internet Res 2019; 21:e14127. [PMID: 31376271 PMCID: PMC6696860 DOI: 10.2196/14127] [Citation(s) in RCA: 43] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2019] [Revised: 06/11/2019] [Accepted: 06/12/2019] [Indexed: 12/11/2022] Open
Abstract
Background The Mental Health eClinic (MHeC) aims to deliver best-practice clinical services to young people experiencing mental health problems by making clinical care accessible, affordable, and available to young people whenever and wherever they need it most. The original MHeC consists of home page with a visible triage system for those requiring urgent help; a online physical and mental health self-report assessment; a results dashboard; a booking and videoconferencing system; and the generation of a personalized well-being plan. Populations who do not speak English and reside in English-speaking countries are less likely to receive mental health care. In Australia, international students have been identified as disadvantaged compared with their peers; have weaker social support networks; and have higher rates of psychological distress. This scenario is acquiring significant relevance as Spanish-speaking migration is rapidly growing in Australia, and the mental health services for culturally and linguistically diverse populations are limited. Having a Spanish version (MHeC-S) of the Mental Health eClinic would greatly benefit these students. Objective We used participatory design methodologies with users (young people aged 16-30 years, supportive others, and health professionals) to (1) conduct workshops with users to co-design and culturally adapt the MHeC; (2) inform the development of the MHeC-S alpha prototype; (3) test the usability of the MHeC-S alpha prototype; (4) translate, culturally adapt, and face-validate the MHeC-S self-report assessment; and (5) collect information to inform its beta prototype. Methods A research and development cycle included several participatory design phases: co-design workshops; knowledge translation; language translation and cultural adaptation; and rapid prototyping and user testing of the MHeC-S alpha prototype. Results We held 2 co-design workshops with 17 users (10 young people, 7 health professionals). A total of 15 participated in the one-on-one user testing sessions (7 young people, 5 health professionals, 3 supportive others). We collected 225 source documents, and thematic analysis resulted in 5 main themes (help-seeking barriers, technology platform, functionality, content, and user interface). A random sample of 106 source documents analyzed by 2 independent raters revealed almost perfect agreement for functionality (kappa=.86; P<.001) and content (kappa=.92; P<.001) and substantial agreement for the user interface (kappa=.785; P<.001). In this random sample, no annotations were coded for help-seeking barriers or the technology platform. Language was identified as the main barrier to getting medical or psychological services, and smartphones were the most-used device to access the internet. Acceptability was adequate for the prototype’s 5 main elements: home page and triage system, self-report assessment, dashboard of results, booking and video visit system, and personalized well-being plan. The data also revealed gaps in the alpha prototype, such as the need for tailored assessment tools and a greater integration with Spanish-speaking services and communities. Spanish-language apps and e-tools, as well as online mental health information, were lacking. Conclusions Through a research and development process, we co-designed and culturally adapted, developed and user tested, and evaluated the MHeC-S. By translating and culturally adapting the MHeC to Spanish, we aimed to increase accessibility and availability of e-mental health care in the developing world, and assist vulnerable populations that have migrated to English-speaking countries.
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Affiliation(s)
- Laura Ospina-Pinillos
- Brain and Mind Centre, The University of Sydney, Sydney, NSW, Australia.,Department of Psychiatry and Mental Health, Pontifical Javeriana University, Bogota, Colombia
| | - Tracey Davenport
- Brain and Mind Centre, The University of Sydney, Sydney, NSW, Australia
| | - Antonio Mendoza Diaz
- School of Psychiatry, Department of Medicine, University of New South Wales, Sydney, NSW, Australia
| | | | - Elizabeth M Scott
- School of Medicine, University of Notre Dame Australia, Sydney, NSW, Australia
| | - Ian B Hickie
- Brain and Mind Centre, The University of Sydney, Sydney, NSW, Australia
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Senanayake B, Wickramasinghe SI, Eriksson L, Smith AC, Edirippulige S. Telemedicine in the correctional setting: A scoping review. J Telemed Telecare 2018; 24:669-675. [DOI: 10.1177/1357633x18800858] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
Introduction The access healthcare services to inmates within correctional settings has generally been low and problematic due to specific nature of the prison setting. Telemedicine has been used as an alternative delivery mode. This study aimed to collate the current evidence related to the use of telemedicine to deliver health services within correctional settings. Methods A comprehensive search of seven databases – PubMed, Embase, CINAHL, Informit, Cochrane Central Register of Controlled Trials, PsycINFO and Scopus, for peer-reviewed publications was conducted in April, 2018. Results Initial search identified 1147 articles. After review of the title and abstract, 36 articles were included in the final review. Of the included articles, 19 (53%) were published during the period of 2010-2018. Articles were predominantly from the USA ( n = 23; 64 %), France and Australia. There were 23 descriptive studies (64%), five costing studies (14%) five experimental studies (14%), two mixed methods (6%) and one qualitative study (3%). The experimental studies were predominantly focused on mental health services ( n = 4, 80%). The commonest telemedicine intervention used was synchronous videoconferencing ( n = 21, 58%), while eight articles (22%) described asynchronous interventions. Telemedicine interventions were mainly used for mental health ( n = 13), and ophthalmology ( n = 4) disciplines. Discussion In the right circumstances, telemedicine interventions within correctional settings seem to be a useful method in connecting inmates with essential health services.
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Affiliation(s)
- Buddhika Senanayake
- Centre for Online Health, Faculty of Medicine, The University of Queensland, Brisbane, Australia
| | - Sumudu I Wickramasinghe
- Centre for Online Health, Faculty of Medicine, The University of Queensland, Brisbane, Australia
| | - Lars Eriksson
- Health Sciences Library, Faculty of Medicine, The University of Queensland, Brisbane, Australia
| | - Anthony C Smith
- Centre for Online Health, Faculty of Medicine, The University of Queensland, Brisbane, Australia
| | - Sisira Edirippulige
- Centre for Online Health, Faculty of Medicine, The University of Queensland, Brisbane, Australia
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Kohrt BA, Asher L, Bhardwaj A, Fazel M, Jordans MJD, Mutamba BB, Nadkarni A, Pedersen GA, Singla DR, Patel V. The Role of Communities in Mental Health Care in Low- and Middle-Income Countries: A Meta-Review of Components and Competencies. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2018; 15:E1279. [PMID: 29914185 PMCID: PMC6025474 DOI: 10.3390/ijerph15061279] [Citation(s) in RCA: 147] [Impact Index Per Article: 24.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/09/2018] [Revised: 06/13/2018] [Accepted: 06/14/2018] [Indexed: 12/14/2022]
Abstract
Community-based mental health services are emphasized in the World Health Organization’s Mental Health Action Plan, the World Bank’s Disease Control Priorities, and the Action Plan of the World Psychiatric Association. There is increasing evidence for effectiveness of mental health interventions delivered by non-specialists in community platforms in low- and middle-income countries (LMIC). However, the role of community components has yet to be summarized. Our objective was to map community interventions in LMIC, identify competencies for community-based providers, and highlight research gaps. Using a review-of-reviews strategy, we identified 23 reviews for the narrative synthesis. Motivations to employ community components included greater accessibility and acceptability compared to healthcare facilities, greater clinical effectiveness through ongoing contact and use of trusted local providers, family involvement, and economic benefits. Locations included homes, schools, and refugee camps, as well as technology-aided delivery. Activities included awareness raising, psychoeducation, skills training, rehabilitation, and psychological treatments. There was substantial variation in the degree to which community components were integrated with primary care services. Addressing gaps in current practice will require assuring collaboration with service users, utilizing implementation science methods, creating tools to facilitate community services and evaluate competencies of providers, and developing standardized reporting for community-based programs.
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Affiliation(s)
- Brandon A Kohrt
- Division of Global Mental Health, Department of Psychiatry and Behavioral Sciences, The George Washington University, Washington, DC 20037, USA.
| | - Laura Asher
- Division of Epidemiology and Public Health, University of Nottingham, NG7 2RD, UK.
| | - Anvita Bhardwaj
- Division of Global Mental Health, Department of Psychiatry and Behavioral Sciences, The George Washington University, Washington, DC 20037, USA.
| | - Mina Fazel
- Department of Psychiatry, University of Oxford, Warneford Lane, OX1 2JD, UK.
| | - Mark J D Jordans
- Center for Global Mental Health, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London SE5 8AF, UK.
- War Child, Research and Development, 1098 LE, Amsterdam, The Netherlands.
| | - Byamah B Mutamba
- Butabika National Mental Hospital, 2 Kirombe-Butabika Road, P.O. Box 7017 Kampala, Uganda.
- YouBelong, P.O. Box 36510 Kampala, Uganda.
| | - Abhijit Nadkarni
- Center for Global Mental Health, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London SE5 8AF, UK.
- Sangath, Socorro, Porvorim, Goa 403501, India.
| | - Gloria A Pedersen
- Division of Global Mental Health, Department of Psychiatry and Behavioral Sciences, The George Washington University, Washington, DC 20037, USA.
| | - Daisy R Singla
- Department of Psychiatry, Sinai Health System & University of Toronto, Toronto, ON M5G 1X5, Canada.
| | - Vikram Patel
- Sangath, Socorro, Porvorim, Goa 403501, India.
- Department of Global Health and Social Medicine, Harvard Medical School, Harvard University, Boston, MA 02115, USA.
- Harvard T. H. Chan School of Public Health, Harvard University, Boston, MA 02115, USA.
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Naslund JA, Aschbrenner KA, Araya R, Marsch LA, Unützer J, Patel V, Bartels SJ. Digital technology for treating and preventing mental disorders in low-income and middle-income countries: a narrative review of the literature. Lancet Psychiatry 2017; 4:486-500. [PMID: 28433615 PMCID: PMC5523650 DOI: 10.1016/s2215-0366(17)30096-2] [Citation(s) in RCA: 266] [Impact Index Per Article: 38.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2016] [Revised: 10/26/2016] [Accepted: 11/09/2016] [Indexed: 01/18/2023]
Abstract
Few individuals living with mental disorders around the globe have access to mental health care, yet most have access to a mobile phone. Digital technology holds promise for improving access to, and quality of, mental health care. We reviewed evidence on the use of mobile, online, and other remote technologies for treatment and prevention of mental disorders in low-income and middle-income countries. Of the 49 studies identified, most were preliminary evaluations of feasibility and acceptability. The findings were promising, showing the potential effectiveness of online, text-messaging, and telephone support interventions. We summarised the evaluations as: technology for supporting clinical care and educating health workers, mobile tools for facilitating diagnosis and detection of mental disorders, technologies for promoting treatment adherence and supporting recovery, online self-help programmes for individuals with mental disorders, and programmes for substance misuse prevention and treatment. Continued research is needed to rigorously evaluate effectiveness, assess costs, and carefully consider potential risks of digital technology interventions for mental disorders, while determining how emerging technologies might support the scale-up of mental health treatment and prevention efforts across low-resource settings.
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Affiliation(s)
- John A Naslund
- The Dartmouth Institute for Health Policy and Clinical Practice, Dartmouth College, Lebanon, NH, USA; Health Promotion Research Center at Dartmouth, Dartmouth College, Lebanon, NH, USA; Center for Technology and Behavioral Health, Dartmouth College, Lebanon, NH, USA.
| | - Kelly A Aschbrenner
- Health Promotion Research Center at Dartmouth, Dartmouth College, Lebanon, NH, USA; Department of Psychiatry, Geisel School of Medicine, Dartmouth College, Lebanon, NH, USA
| | - Ricardo Araya
- Centre for Global Mental Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Lisa A Marsch
- Center for Technology and Behavioral Health, Dartmouth College, Lebanon, NH, USA; Department of Psychiatry, Geisel School of Medicine, Dartmouth College, Lebanon, NH, USA
| | - Jürgen Unützer
- Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, WA, USA
| | - Vikram Patel
- Centre for Global Mental Health, London School of Hygiene and Tropical Medicine, London, UK; Sangath, Goa, India; Center for Chronic Conditions and Injuries, Public Health Foundation of India, New Delhi, India
| | - Stephen J Bartels
- The Dartmouth Institute for Health Policy and Clinical Practice, Dartmouth College, Lebanon, NH, USA; Health Promotion Research Center at Dartmouth, Dartmouth College, Lebanon, NH, USA; Department of Psychiatry, Geisel School of Medicine, Dartmouth College, Lebanon, NH, USA
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