Development and initial validation of the Mount Sinai Resilience Scale

OBJECTIVE

The construct of psychological resilience has received increasing attention in the mental health field. This article describes the development and initial validation of a novel self-report resilience scale, which addresses gaps in the resilience measurement literature by assessing thoughts and behaviors that help promote resilience rather than traits, and simultaneously evaluating multiple factors previously associated with resilience.

METHOD

Following consensus meetings focused on scale development, we conducted an online study (n = 1,864) of U.S. adults to develop and validate an initial version of the Mount Sinai Resilience Scale (MSRS).

RESULTS

An exploratory factor analysis in a random 50% of the sample suggested a seven-factor solution; this solution was then generally supported by a follow-up confirmatory factor analysis in the remaining 50% of the sample. After removing poor-fitting items, a revised 24-item scale correlated in the expected directions with established measures of perceived resilience and resilience-related constructs (e.g., social support and optimism).

CONCLUSIONS

Collectively, the results of this study provide initial support for the convergent and discriminant validity of the MSRS and describe its factor structure. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Provision of Cognitive Behavior Therapy for Depression and Anxiety Disorders by Medical Student Trainees

OBJECTIVE

The purpose of the article is to evaluate an innovative education program in which medical students were trained in cognitive behavior therapy (CBT) and provided CBT treatments under supervision to uninsured individuals with depressive, anxiety, adjustment, and trauma-based disorders.

METHODS

The authors assessed improvements in trainees' CBT knowledge using the Cognitive Therapy Awareness Scale before and after their didactic training. CBT supervisors rated trainees' clinical competencies utilizing standardized checklist evaluations based upon supervision reports. The authors employed mixed effects ANOVA and regression modeling to test the association between the addition of CBT to treatment as usual (TAU) and improvements in patients' depressive and anxious symptom severity. The authors collected feedback and self-assessment of functioning with a Psychotherapy Feedback Questionnaire.

RESULTS

Medical students showed increases in CBT knowledge that were maintained six months later and demonstrated satisfactory competency in CBT techniques. The addition of CBT to TAU was associated with greater improvements in depressive, but not anxious, symptom severity. However, among the TAU + CBT group, there was an association between the number of CBT sessions received and the magnitude of improvement in anxious symptoms from baseline. Patients gave positive feedback to medical student CBT providers and reported improvements in broad domains of psychosocial functioning.

CONCLUSIONS

Medical students can provide competent and clinically beneficial CBT treatments for depression and anxiety disorders. These findings have implications for medical training and support the use of medical students to deliver care for individuals with limited access to psychotherapy.

A Resilience Program for Hospital Security Officers During the COVID-19 Pandemic Using a Community Engagement Model

Security officers in health systems are subject to high levels of stress and current support interventions do not necessarily target their needs. To address this gap, a resilience center at a major urban tertiary care hospital utilized community engagement principles to adapt and implement resilience and mental health awareness workshops, which were informed by initial piloting. The program consisted of twelve short briefings in which officers were provided psychoeducation on psychological first aid and adaptive coping. The program reached 107 security officers (89.5% men, 95.2% people of color); both qualitative and quantitative feedback indicated a generally positive reception. Further efforts to support security officers are warranted given their high exposure to patient crises and under-acknowledgement as frontline workers in healthcare.

Supporting Faith-Based Communities Through and Beyond the Pandemic

The COVID-19 pandemic brought widespread and notable effects to the physical and mental health of communities across New York City with disproportionate suffering Black/African American and Hispanic/Latino communities alongside additional stressors such as racism and economic hardship. This report describes the adaptation of a previously successful evidence-based community engagement health education program for the deployment of resilience promoting workshop program in faith-based organizations in BIPOC communities in New York City. From June 2021 to June 2022, nine faith-based organizations implemented 58 workshops to 1,101 non-unique workshop participants. Most of the workshops were delivered online with more women (N = 803) than men (N = 298) participating. All organizations completed the full curriculum; the workshop focused on self-care and physical fitness was repeated most frequently (N = 13). Participants in the workshops ranged from 4 to 73 per meeting and were largely female. The Building Community Resilience Project is an easy and effective way to modify an existing, evidence-based community health education program to address new and relevant health needs such as resilience and stress amidst the COVID-19 pandemic among faith communities serving BIPOC populations. More research is needed regarding the impact of the workshops as well as adaptability for other faith traditions.

"I'd like to let people know what we did:" values of Fukushima medical students following the Great East Japan Earthquake

BACKGROUND

The Great East Japan Earthquake and the resulting tsunami and nuclear disaster on March 11, 2011 have had a profound and lasting effect on residents of Japan's Fukushima Prefecture, particularly among evacuees. While there continues to be extensive news coverage and academic study of Fukushima Prefecture's recovery, there has been little exploration of individual narratives. This study aims to illuminate some individual stories of medical students at Fukushima Medical University (FMU) who lived in the Prefecture at the time of the Earthquake.

METHODS

A qualitative approach was taken in order to investigate individuals' experiences with the goal of adding a personal dimension to quantitative studies on the subject. 10 open-ended ethnographic interviews were conducted with medical students at FMU in years 1-5 who lived in Fukushima Prefecture at the time of the Great East Japan Earthquake. All interviews were audio recorded and transcribed. Transcriptions were reviewed using inductive thematic analysis under the lens of ethnographic anthropology.

RESULTS

Three major themes emerged from these interviews: first, that the events following the Earthquake influenced not only these students' decisions to pursue careers in medicine, but the ways in which they hope to practice medicine in the future. Second, that these students were motivated to share their experiences by a want to change Fukushima Prefecture's public image. And lastly, that the students viewed the opportunity to discuss their experiences through these interviews as healing, both for themselves and for the future.

CONCLUSIONS

While multiple factors undoubtably contributed these students' medical education, they cite the Earthquake as essential to their approach to their medical careers. Additionally, opportunities for the participants to discuss their experiences following the Earthquake appear to be rare but valued, as the students view their stories as their "legacies." The enduring, burdening effects of the Earthquake appear to have galvanized the participating students to act on behalf of their communities and their Prefecture. Further qualitative studies in more generalizable populations are needed to improve and deepen our understanding of the societal, cultural, and personal impacts of the Great East Japan Earthquake.

Longitudinal Mental Health Outcomes of Third-year Medical Students Rotating Through the Wards During COVID-19

This study investigated third year medical students' psychological well-being during clinical rotations at Mount Sinai hospitals in New York City during the COVID-19 pandemic. All students (n = 147) starting rotations (psychiatry, surgery, obstetrics-gynecology, neurology, pediatrics, and medicine) could participate in quarterly, online, anonymous surveys comprised of validated screeners for: psychological symptoms, risk, coping, and protective factors, demographics, COVID-19 worries, and stressful clerkship-related events. Associations between variables were examined with Chi-squared, Fisher's exact, t-, Wilcoxon Rank Sum, one-way ANOVA, and McNemar tests. Significant univariate predictors of psychological distress were included in stepwise multivariable linear regression models. The baseline survey was completed by 110 (74.8%) students; ninety-two (62.6%) completed at least one other survey. During the year, 68 (73.9%) students screened positive for depression, anxiety, or PTSD. The prevalence of psychiatric symptoms peaked in June 2020 without significant changes in average scores over time. COVID-19 worries decreased over time but did not influence psychological symptoms at year-end. Eighty-three students (90.2%) experienced stressful clerkship-related events, which were traumatic and/or COVID-19-related for 26 (28.3%) and 22 students (24.0%), respectively. Baseline psychological distress, childhood emotional abuse, and resilience predicted depression, anxiety, and/or PTSD by year-end. This study highlights the importance of recognizing psychological distress and implementing interventions to support students' well-being.

Understanding mental distress in Arcahaie, Haiti: Heterogeneous uses of idioms of distress in communicating psychological suffering

Research on mental health in specific communities requires careful attention to cultural context and language. Studies on global mental health have increasingly analyzed idioms of distress, or culturally situated ways of conceptualizing, experiencing, and expressing distress. This study examines how idioms of distress are used and understood in Arcahaie, Haiti. The goal was to enrich current understanding of mental health conceptualization and communication by exploring the heterogeneity of common idioms of distress. Interviews with community members (N = 47) explored meanings and perceived causations of 13 idioms of distress. Major themes included pervasiveness of poverty, ruminative thinking, effects of Vodou and Christian belief systems, embodied distress, and the behavior of "crazy" people (moun fou). The findings suggest some specific pathways for potential community engagement projects, including training lay-leaders in cognitive behavioral therapy using existing socioreligious infrastructure and expanding access to social engagement activities. This research contributes to a small but growing body of literature on mental illness in Haiti and to methods for studying idioms of distress.

Design of and outcomes in a student-run free mental health clinic serving the uninsured in East Harlem

BACKGROUND

Safety-net clinics are an important source of low-cost or free mental healthcare to those with limited financial resources. Such clinics are often staffed by trainees in early stages of their career. Only limited data exist on best practices in treatment-implementation and on clinical outcomes attained in such clinics. The primary purpose of this article is to describe the design of an outpatient psychiatry student-run free clinic (SRFC) serving uninsured individuals in New York City's East Harlem neighborhood and to analyze the quality of services provided and the clinical outcomes attained.

METHODS

The authors conducted a retrospective chart review of n = 69 patients treated in the EHHOP Mental Health Clinic (E-MHC) to describe the demographic and clinical characteristics of the study population. Utilizing Health Effectiveness Data and Information Set metrics, they estimated the likelihoods of patients meeting metric quality criteria compared to those in other New York State (NYS) insurance groups. The authors derived linear mixed effect and logistic regression models to ascertain factors associated with clinical outcomes. Finally, the authors collected patient feedback on the clinical services received using a customized survey.

RESULTS

Almost all patients were of Hispanic ethnicity, and about half of patients had more than one psychiatric disorder. The clinical service performance of the E-MHC was non-inferior on most measures examined. Factors associated with symptom improvement were the number of treatment sessions and certain demographic and clinical variables. Patients provided highly positive feedback on the mental healthcare services they received.

CONCLUSIONS

SRFCs can provide quality care to vulnerable patients that leads to clinically meaningful reductions in psychiatric symptoms and is well-received by patients.

Immigration Judges' Perceptionsof Telephonic and In-Person Forensic Mental Health Evaluations

Clinicians affiliated with medical human rights programs throughout the United States perform forensic evaluations of asylum seekers. Much of the best practice literature reflects the perspectives of clinicians and attorneys, rather than the viewpoints of immigration judges who incorporate forensic reports into their decision-making. The purpose of this study was to assess former immigration judges' perspectives on forensic mental health evaluations of asylum seekers. We examined the factors that immigration judges use to assess the affidavits resulting from mental health evaluations and explored their attitudes toward telehealth evaluations. We conducted semistructured interviews in April and May 2020 with nine former judges and systematically analyzed them using consensual qualitative research methodology. Our findings were grouped in five domains: general preferences for affidavits; roles of affidavits in current legal climate; appraisal and comparison of sample affidavits; attitudes toward telephonic evaluations; and recommendations for telephonic evaluations. Forensic evaluators should consider the practice recommendations of judges, both for telephonic and in-person evaluations, which can bolster the usefulness of their evaluations in the adjudication process. To our knowledge, this is the first published study to incorporate immigration judges' perceptions of forensic mental health evaluations, and the first to assess judges' attitudes toward telephonic evaluations.

The Psychiatric Burden on Medical Students in New York City Entering Clinical Clerkships During the COVID-19 Pandemic

For medical students first entering the clinical space in July 2020, the unique challenges related to the coronavirus pandemic threatened to amplify the psychological distress associated with clerkship rotations. This study aimed to characterize the mental health of third-year medical students starting clinical clerkships in the midst of a pandemic by assessing symptoms of major depressive disorder (MDD), generalized anxiety disorder (GAD), and posttraumatic stress disorder (PTSD) as well as risk, coping, and protective factors associated with psychological outcomes. Of 147 third-year medical students at the Icahn School of Medicine at Mount Sinai in New York City, 110 (75%) participated in this prospective survey-based study with 108 included in the final analysis. 43 (39.8%) respondents screened positive for symptoms of either MDD, GAD, or PTSD. Multiple regression analyses revealed that greater overall symptom severity was associated with more avoidant coping, more traumatic events witnessed, poorer student and leisure functioning, lower trait emotional stability, and lower social support. Worries related to COVID-19 did not significantly influence outcome variables. To better understand the role of the pandemic on psychological outcomes in third-year medical students, additional research should focus on the trajectory of these outcomes over the year during the coronavirus pandemic.

COVID-19 Pandemic Support Programs for Healthcare Workers and Implications for Occupational Mental Health: A Narrative Review

This narrative review aims to summarize initiatives developed during the COVID-19 pandemic to support healthcare workers' emotional well-being within the context of a pre-existing framework of occupational mental health guidelines. This occupational mental health framework integrates principles from multiple disciplines to optimize prevention and management of mental health issues among employees. We conducted an online search on Medline/PubMed, Cochrane Library, and Embase for studies that reported on design or execution of medical institution-based interventions, aiming to support healthcare worker mental health during the COVID-19 pandemic. Inclusion criteria was intentionally broad in order to incorporate as many types of interventions at varying stages of development or evaluation. We included 31 studies in our review that reported on newly designed psychological support interventions for healthcare workers (HCW) during the COVID-19 pandemic. We found that most programs commonly supported HCW mental health through offering one or more of the following initiatives: expanded basic need resources/services, additional workplace training programs that bolstered professional preparedness while also indirectly boosting HCW emotional health, and/or expanded psychological support programs, such as peer support programs, psychoeducational or counseling services. Most programs, however, did not consider methods to ensure program longevity or sustainability. The COVID-19 pandemic has underscored the acuity of HCW mental health issues and is likely to leave long lasting mental health strains among HCW. This pandemic is a critical point in time to catalyze much needed progress in reducing stigma and expanding HCW mental health care access.

Association of Social Gaming with Well-Being (Escape COVID-19): A Sentiment Analysis

BACKGROUND

During the 2020-2021 coronavirus disease 2019 (COVID-19) lockdown, social activities were limited by the government-recommended social distancing guidelines, leading to an abundance of mental health issues.

METHODS

We hypothesized that Twitter sentiment analysis may shed some light on Animal Crossing: New Horizons and its impact on mental health during the COVID-19 pandemic.

RESULTS

We found that social gaming and social media may be used as tools to cope with stress during the COVID-19 pandemic.

CONCLUSIONS

Further research, including randomized study designs and prospective measurements of mental health outcomes related to social gaming behavior are required.

Developments in the first year of a resilience-focused program for health care workers

The present article comprises a one-year retrospective review of the efforts of the Mount Sinai Center for Stress, Resilience and Personal Growth, an initiative to support the resilience and well-being of health care workers that was founded amid the first peak of the pandemic in New York in 2020. Specific offerings to date have included evidence-backed resilience workshops, a digital health platform, and a specialty screening and treatment service. All services have been modified or expanded in response to changing needs and are subject to ongoing research. Robust evidence-based programming that addressing health care worker well-being, regardless of role, may prove beneficial to institutions well beyond the pandemic.

On-Site Prescription Dispensing Improves Antidepressant Adherence among Uninsured Depressed Patients

The successful treatment of depressive disorders critically depends on adherence to prescribed treatment regimens. Despite increasing rates of antidepressant medication prescription, adherence to the full treatment course remains poor. Rates of antidepressant non-adherence are higher for uninsured patients and members of some marginalized racial and ethnic communities due to factors such as inequities in healthcare and access to insurance. Among patients treated in a free, student-run and faculty-supervised clinic serving uninsured patients in a majority Hispanic community in East Harlem, adherence rates are lower than those observed in patients with private or public New York State health insurance coverage. A prior study of adherence in these patients revealed that difficulty in obtaining medications from an off-site hospital pharmacy was a leading factor that patients cited for non-adherence. To alleviate this barrier to obtaining prescriptions, we tested the effectiveness of on-site, in-clinic medication dispensing for improving antidepressant medication adherence rates among uninsured patients. We found that dispensing medications directly to patients in clinic was associated with increased visits at which patients self-reported proper adherence and increased overall adherence rates. Furthermore, we found evidence that higher rates of antidepressant medication adherence were associated with more favorable treatment outcomes. All patients interviewed reported increased satisfaction with on-site dispensing. Overall, this study provides promising evidence that on-site antidepressant dispensing in a resource-limited setting improves medication adherence rates and leads to more favorable treatment outcomes with enhanced patient satisfaction.

Perspectives on Working with Immigrants Held in Detention Using Photovoice

Those who work with immigrants in detention centers may be at increased risk of secondary trauma. This study used Photovoice to capture reflections on how the lives of volunteers are affected by their work on behalf of immigrant family detainees. Participants were recruited over a two-month period in 2018 from amongst the volunteers of a non-governmental organization that provides legal services to the detainees at one immigration detention center. Participants submitted photos and captions that explored their experiences with their work. Thirteen volunteers consented to participate and submitted 44 photos with captions to the project. Major themes included emotional challenges of the work, frustrations with the U.S. government, comparison of their experiences to those of their clients', and finding uplifting moments. Our findings regarding the significant emotional challenges of this work are of particular importance given the increasing coverage of immigration detention in the media and the increased interest in volunteer opportunities to support this population.

A Resilience-Building App to Support the Mental Health of Health Care Workers in the COVID-19 Era: Design Process, Distribution, and Evaluation

Background

The COVID-19 pandemic has resulted in increased strain on health care systems and negative psychological effects on health care workers (HCWs). This is anticipated to result in long-term negative mental health effects on the population, with HCWs representing a particularly vulnerable group. The scope of the COVID-19 pandemic necessitates the development of a scalable mental health platform to provide services to large numbers of at-risk or affected individuals. The Mount Sinai Health System in New York City was at the epicenter of the pandemic in the United States.

Objective

The Center for Stress, Resilience, and Personal Growth (CSRPG) was created to address the current and anticipated psychological impact of the pandemic on the HCWs in the health system. The mission of the Center is to support the resilience and mental health of employees through educational offerings, outreach, and clinical care. Our aim was to build a mobile app to support the newly founded Center in its mission.

Methods

We built the app as a standalone digital platform that hosts a suite of tools that users can interact with on a daily basis. With consideration for the Center’s aims, we determined the overall vision, initiatives, and goals for the Wellness Hub app, followed by specific milestone tasks and deliverables for development. We defined the app’s primary features based on the mental health assessment and needs of HCWs. Feature definition was informed by the results of a resilience survey widely distributed to Mount Sinai HCWs and by the resources offered at CSRPG, including workshop content.

Results

We launched our app over the course of two phases, the first phase being a “soft” launch and the second being a broader launch to all of Mount Sinai. Of the 231 HCWs who downloaded the app, 173 (74.9%) completed our baseline assessment of all mental health screeners in the app. Results from the baseline assessment show that more than half of the users demonstrate a need for support in at least one psychological area. As of 3 months after the Phase 2 launch, approximately 55% of users re-entered the app after their first opening to explore additional features, with an average of 4 app openings per person.

Conclusions

To address the mental health needs of HCWs during the COVID-19 pandemic, the Wellness Hub app was built and deployed throughout the Mount Sinai Health System. To our knowledge, this is the first resilience app of its kind. The Wellness Hub app is a promising proof of concept, with room to grow, for those who wish to build a secure mobile health app to support their employees, communities, or others in managing and improving mental and physical well-being. It is a novel tool offering mental health support broadly.

Psychological distress in the face of a pandemic: An observational study characterizing the impact of COVID-19 on immigrant outpatient mental health

Undocumented immigrants have disproportionately suffered during the novel coronavirus disease 2019 (COVID-19) pandemic due to factors including limited medical access and financial insecurity, which can exacerbate pandemic-associated distress. Psychological outcomes for immigrant outpatients were assessed after transition to telepsychiatry in March 2020. Mental health was assessed with Patient Health Questionnaire (PHQ-2) and Generalized Anxiety Disorder (GAD-2) inventories, a novel coronavirus-specific survey, and the Kessler Psychological Distress Scale (K10+). Feedback on telepsychiatry sessions and access to non-clinical resources were also gathered, after which multivariable linear regression modeling identified psychosocial factors underlying changes in distress levels. 48.57% and 45.71% of participants reported worsened anxiety and depression levels due to the pandemic, respectively. From March to April, PHQ-2 and GAD-2 scores significantly increased by 0.81 and 0.63 points, respectively. The average total psychological distress score was 23.8, with 60% of scores reflecting serious mental illness. Factors that most influenced K10+ scores included a pre-existing depressive disorder, food insecurity, and comfort during telepsychiatry visits. 93.75% of participants believed access to remote psychiatry helped their mental health during COVID-19. The negative impact of COVID-19 on mental health in vulnerable populations stems from medical and psychosocial factors such as pre-existing psychiatric conditions and unmet essential needs.

Piloting forensic tele-mental health evaluations of asylum seekers

While the number of medical human rights programs has increased, there is substantial unmet need for forensic evaluations among asylum seekers throughout the United States. From September 2019 through May 2020, the Mount Sinai Human Rights Program has coordinated pro bono forensic mental health evaluations by telephone or video for individuals seeking protected immigration status who are unable to access in-person services. The national network clinicians conducted 32 forensic evaluations of individuals in eight U.S. states and Mexico seeking immigration relief. Remote forensic services have been a relevant solution for individuals in immigration detention, particularly during the COVID-19 pandemic.

Parents' Knowledge, Attitudes, and Experiences in Child Sexual Abuse Prevention in El Salvador

Childhood sexual abuse (CSA), a global public health problem, is often underreported especially in low-income countries such as El Salvador, and prevention efforts are needed. The purpose of this study was to examine knowledge, attitudes and experiences of CSA prevention and characteristics related to greater knowledge and openness to engaging in child abuse prevention among Salvadoran parents. Salvadoran parents (N = 478) completed questionnaires regarding demographics, definition and signs and symptoms of child abuse, personal experiences of CSA, CSA prevention training, and knowledge, attitudes and practices about preventing CSA. Most parents were knowledgeable about CSA, viewed CSA prevention as their responsibility, and had talked with their children about CSA, although 65.7% incorrectly believed that children are more likely to be abused by strangers. Parents with lower income were less knowledgeable and willing to participate in CSA prevention. CSA programing needs to involve parents and specifically target low-income parents.

Characterization of the mental health of immigrant children separated from their mothers at the U.S.-Mexico border

Immigrant children who faced forced separation from their parents may be at heightened risk of developing mental health disorders, including depression, post-traumatic stress disorder (PTSD), and anxiety disorders. This cross-sectional study assessed the mental health of children being held in U.S. immigration detention who had been previously separated from their mothers. We interviewed 73 mothers about their eldest child age 5-17 using the Parent-Report version of the Strengths and Difficulties Questionnaire (SDQ). Among these children, many had elevated scores for emotional problems (49%), peer problems (21%), and total difficulties (15%). Male children demonstrated significantly higher rates of abnormal peer problems compared to females. Younger children (age 5-11 years) also demonstrated significantly higher rates of abnormal conduct problems, hyperactivity, and total difficulties. Scores did not differ significantly based on length of separation. Results reveal that children who had been separated from their parents experience high levels of mental health distress, which are especially high in younger children. Regardless of length of separation, these children would benefit from comprehensive mental health treatment with a culturally-responsive and trauma-informed lens.

Knowledge of and Attitudes Towards Mental Illness Among ASHA and Anganwadi Workers in Vadodara District, Gujarat State, India

Unmet needs in mental health care are high in low and middle-income countries like India. We propose recruiting community health workers (CHWs) to provide mental health services and address the treatment gap, but there is limited data available on the training needs for this potential role. The aim of this study is to help determine what type of formal mental health training and programming could most benefit CHWs in India. This was a cross sectional study design. Self-administered surveys were conducted amongst CHWs in the villages of Vadodara District, Gujarat, India. Statistical analyses included two tailed t-tests using Microsoft Excel 2011. The most common causes for mental illness were attributed to anxiety (61%) and brain disease (61%) followed by stress (45%) and alcohol use disorder (38%). CHWs were dismissive of faith healers ability to treat mental illness (72.9%) showing a strong approval for recommending psychiatric care for the mentally ill (84.4%). Over 50% of participants believed that mentally ill have a lower IQ and that they were unpredictable, but at the same time asserted that people with mental illness can live in the community (80.8%), and recover if given treatment and support (91.8%). Results are promising with CHWs displaying basic knowledge of the etiology and treatment of disease harboring positive attitudes towards psychiatrist's ability to treat mental illness. Future direction should focus on training CHWs towards minimizing stigmatizing views and increasing their knowledge of mental illness in order to scale up mental health services in these low resource communities.

A Resident-Based Telepsychiatry Supervision Pilot Program in Liberia

Worldwide, attention to mental disorders lags far behind the staggering morbidity attributed to them. In low-resource settings, the majority of people with serious mental illness go untreated, and a major reason for this treatment gap is the worldwide shortage of mental health professionals. In Liberia, this shortfall has been addressed by training and licensing nurses, midwives, and physician assistants as mental health clinicians (MHCs) via an intensive 6-month training program. This column describes a pilot program utilizing senior American psychiatry residents to provide remote posttraining supervision to the MHCs via live teleconferencing.

Bartenders' and Rum Shopkeepers' Knowledge of and Attitudes Toward "Problem Drinking" in Saint Vincent and the Grenadines

Harmful alcohol use encompasses a spectrum of habits, including heavy episodic drinking (HED) which increases the risk of acute alcohol-related harms. The prevalence of HED in Saint Vincent and the Grenadines (SVG) is 5.7% among the overall population aged 15 years and older and 10.2% among drinkers. Responsible Beverage Service interventions train alcohol servers to limit levels of intoxication attained by customers and decrease acute alcohol-related harms. The objectives of this study were to determine bar tenders' and rum shopkeepers' knowledge of and attitudes toward problem drinking and willingness to participate in server training. Researchers used convenience and purposive sampling to recruit 30 participants from Barraouile, Kingstown, and Calliaqua to participate in semi-structured interviews designed to explore study objectives. Results and conclusions were derived from grounded theory analysis. Heavy episodic drinking is common but not stigmatized. Heavy drinking is considered a "problem" if the customer attains a level of disinhibition causing drunken and disruptive or injurious behavior. Bartenders and rum shopkeepers reported intervening with visibly intoxicated patrons and encouraging cessation of continued alcohol consumption. Participants cited economic incentives, prevention of alcohol-related harms, and personal morals as motivators to prevent drunkenness. Respondents acknowledged that encouraging responsible drinking was a legitimate part of their role and were favorable to server training. However, there were mixed opinions about the intervention's perceived efficacy given absent community-wide standards on preventing intoxication and limitations of existing alcohol policy. Given respondents' motivation and lack of standardized alcohol server training in SVG, mandated server training can be an effective strategy when promoted as one piece of a multi-component alcohol policy.

Medical Student Reactions to Disaster after the 2011 Great East Japan Earthquake: Motivation and Posttraumatic Growth

Medical students often become involved as post-disaster emergency responders despite incomplete training, and in doing so may suppress their immediate experiences as victims and survivors. This experience, however, may lead them to increase their motivation to help others. We examined how cognitive and emotional reactions to disaster correlated with posttraumatic growth (PTG) in medical students in Fukushima, Japan after the Great East Japan Earthquake of March 11, 2011. To date, Fukushima continues to suffer from radiation concerns following the nuclear power plant meltdown. In a survey three years after the onset of a long-term disaster, with a cross-sectional research design, medical students (N = 494) reported their negative post-disaster reactions, desire to help, and demonstrations of capability, and completed the Posttraumatic Growth Inventory (PTGI). We conducted hierarchical regression analyses and found that the addition of variables pertaining to negative post-disaster reactions (e.g. confusion, anger, and sadness) led to the largest increase in predictive value for PTGI scores; students reporting a past traumatic experience were also more likely to experience PTG. Our results indicate that weathering stressful disaster circumstances created opportunities for positive personal growth and reinforcement at a crucial time in medical students' professional development.

Fukushima Triple Disaster and the Road to Recovery: a Qualitative Exploration of Resilience in Internally Displaced Residents

Six years after the March 2011 Triple Disaster, over 35,000 Japanese individuals remain in temporary housing. Evacuated residents, many of who are elderly, face mental health challenges. This study evaluates the well being of individuals living in temporary housing within Fukushima. Reactions to relocation were explored using Photovoice, a community-based participatory research method, in which a set of research questions are examined qualitatively through photographs and interviews. Seven participants (average age = 69.7) were provided cameras to answer a set of self-generated questions, a process that was repeated three times. An initial analysis found resilience among participants, which was explored using a theoretical framework of resiliency. Residents discussed how relocation has disrupted their lives and coping strategies they employ to ameliorate stressors. They were often optimistic and future-oriented, stating that they wanted to "live strong" after the disaster. These resilient mindsets were personified in action: all engaged in hobbies, critical for their emotional well being. Participants also emphasized the importance of community and familial support. The evidence of resilience in participants is encouraging, suggesting that these vulnerable elderly internally displaced residents are recovering from the disruption of relocation. These themes should be explored in larger temporary housing communities. Considering the number of relocated individuals today, understanding how to foster resilience could be used to inform the development of future temporary housing shelters.

Psychiatric Outpatients After the 3.11 Complex Disaster in Fukushima, Japan

BACKGROUND

After the 3.11 complex disaster, fear of radioactive contamination and forced evacuation influenced a number of residents to seek psychiatric care.

OBJECTIVES

This study assessed the sequential changes in the number of new outpatients and patients with acute stress disorder (ASD), post-traumatic stress disorder (PTSD), adjustment disorder, and depression after the Fukushima disaster.

METHODS

We distributed questionnaires to 77 psychiatric institutions to determine the number of new outpatients between March and June in 2010, 2011, and 2012.

FINDINGS

There were 771, 1000, and 733 new patients in 2010, 2011, and 2012, respectively. We observed a statistically significant increase in new patients with ASD or PTSD and a significant decrease in patients with depression in 2011, which returned to predisaster levels in 2012.

CONCLUSIONS

There were time- and disease-dependent changes in the numbers of psychiatric care-seeking individuals after the 3.11 complex disaster in Fukushima.

Psychiatric symptoms in Ground Zero ironworkers in the aftermath of 9/11: prevalence and predictors

Aims and Method

To establish the prevalence of, and risk factors for, psychiatric symptoms in Ground Zero ironworkers. Questionnaires commonly used to screen for psychiatric symptoms were completed by 124 workers.

Results

We have established the prevalence of screening positive for symptoms of post-traumatic stress disorder, panic attacks, generalised anxiety, depression and alcohol misuse. Among the risk factors were alcohol misuse, injury to or death of a family member, friend or co-worker at Ground Zero and one or more adverse life events since 9/11.

Clinical Implications

Ironworkers at Ground Zero tend to have significant psychiatric symptoms likely to be associated with the traumatic experience of working there during the clean-up operation. Risk factors for psychiatric symptoms were established.

Latent typologies of posttraumatic stress disorder in World Trade Center responders

Posttraumatic stress disorder (PTSD) is a debilitating and often chronic psychiatric disorder. Following the 9/11/2001 World Trade Center (WTC) attacks, thousands of individuals were involved in rescue, recovery and clean-up efforts. While a growing body of literature has documented the prevalence and correlates of PTSD in WTC responders, no study has evaluated predominant typologies of PTSD in this population. Participants were 4352 WTC responders with probable WTC-related DSM-IV PTSD. Latent class analyses were conducted to identify predominant typologies of PTSD symptoms and associated correlates. A 3-class solution provided the optimal representation of latent PTSD symptom typologies. The first class, labeled "High-Symptom (n = 1,973, 45.3%)," was characterized by high probabilities of all PTSD symptoms. The second class, "Dysphoric (n = 1,371, 31.5%)," exhibited relatively high probabilities of emotional numbing and dysphoric arousal (e.g., sleep disturbance). The third class, "Threat (n = 1,008, 23.2%)," was characterized by high probabilities of re-experiencing, avoidance and anxious arousal (e.g., hypervigilance). Compared to the Threat class, the Dysphoric class reported a greater number of life stressors after 9/11/2001 (OR = 1.06). The High-Symptom class was more likely than the Threat class to have a positive psychiatric history before 9/11/2001 (OR = 1.7) and reported a greater number of life stressors after 9/11/2001 (OR = 1.1). The High-Symptom class was more likely than the Dysphoric class, which was more likely than the Threat class, to screen positive for depression (83% > 74% > 53%, respectively), and to report greater functional impairment (High-Symptom > Dysphoric [Cohen d = 0.19], Dysphoric > Threat [Cohen d = 0.24]). These results may help inform assessment, risk stratification, and treatment approaches for PTSD in WTC and disaster responders.

Post-traumatic stress disorder dimensions and asthma morbidity in World Trade Center rescue and recovery workers

OBJECTIVE

Using data from a cohort of World Trade Center (WTC) rescue and recovery workers with asthma, we assessed whether meeting criteria for post-traumatic stress disorder (PTSD), sub-threshold PTSD, and for specific PTSD symptom dimensions are associated with increased asthma morbidity.

METHODS

Participants underwent a Structured Clinical Interview for Diagnostic and Statistical Manual to assess the presence of PTSD following DSM-IV criteria during in-person interviews between December 2013 and April 2015. We defined sub-threshold PTSD as meeting criteria for two of three symptom dimensions: re-experiencing, avoidance, or hyper-arousal. Asthma control, acute asthma-related healthcare utilization, and asthma-related quality of life data were collected using validated scales. Unadjusted and multiple regression analyses were performed to assess the relationship between sub-threshold PTSD and PTSD symptom domains with asthma morbidity measures.

RESULTS

Of the 181 WTC workers with asthma recruited into the study, 28% had PTSD and 25% had sub-threshold PTSD. Patients with PTSD showed worse asthma control, higher rates of inpatient healthcare utilization, and poorer asthma quality of life than those with sub-threshold or no PTSD. After adjusting for potential confounders, among patients not meeting the criteria for full PTSD, those presenting symptoms of re-experiencing exhibited poorer quality of life (p = 0.003). Avoidance was associated with increased acute healthcare use (p = 0.05). Sub-threshold PTSD was not associated with asthma morbidity (p > 0.05 for all comparisons).

CONCLUSIONS

There may be benefit in assessing asthma control in patients with sub-threshold PTSD symptoms as well as those with full PTSD to more effectively identify ongoing asthma symptoms and target management strategies.

Risk, coping and PTSD symptom trajectories in World Trade Center responders

Trajectories of disaster-related posttraumatic stress disorder (PTSD) symptoms are often heterogeneous, and associated with common and unique risk factors, yet little is known about potentially modifiable psychosocial characteristics associated with low-symptom and recovering trajectories in disaster responders. A total of 4487 rescue and recovery workers (1874 police and 2613 non-traditional responders) involved during and in the aftermath of the unprecedented World Trade Center (WTC) attacks, were assessed an average of 3, 6, 8, and 12 years post-9/11/2001. Among police responders, WTC-related PTSD symptoms were characterized by four trajectories, including no/low-symptom (76.1%), worsening (12.1%), improving (7.5%), and chronic (4.4%) trajectories. In non-traditional responders, a five-trajectory solution was optimal, with fewer responders in a no/low-symptom trajectory (55.5%), and the remainder in subtly worsening (19.3%), chronic (10.8%), improving (8.5%), and steeply worsening (5.9%) trajectories. Consistent factors associated with symptomatic PTSD trajectories across responder groups included Hispanic ethnicity, pre-9/11 psychiatric history, greater WTC exposure, greater medical illness burden, life stressors and post-9/11 traumas, and maladaptive coping (e.g., substance use, avoidance coping). Higher perceived preparedness, greater sense of purpose in life, and positive emotion-focused coping (e.g., positive reframing, acceptance) were negatively associated with symptomatic trajectories. Findings in this unique cohort indicate considerable heterogeneity in WTC-related PTSD symptom trajectories over 12 years post-9/11/2001, with lower rates of elevated PTSD symptoms in police than in non-traditional responders. They further provide a comprehensive risk prediction model of PTSD symptom trajectories, which can inform prevention, monitoring, and treatment efforts in WTC and other disaster responders.

Perceptions of traditional healing for mental illness in rural Gujarat

BACKGROUND

Despite the significant toll of mental illness on the Indian population, resources for patients often are scarce, especially in rural areas. Traditional healing has a long history in India and is still widely used, including for mental illnesses. However, its use has rarely been studied systematically.

OBJECTIVE

The aim of this study was to determine the perspective of patients, their families, and healthy community members toward faith healing for mental illness, including the type of interventions received, perceptions of its efficacy, and overall satisfaction with the process. We also sought to explore the range of care received in the community and investigate possibilities for enhancing mental health treatment in rural Gujarat.

METHODS

We interviewed 49 individuals in July 2013 at Dhiraj General Hospital and in 8 villages surrounding Vadodara. A structured qualitative interview elicited attitudes toward faith healing for mental illnesses and other diseases. Qualitative analysis was performed on the completed data set using grounded theory methodology.

FINDINGS

Subjects treated by both a doctor and a healer reported they overwhelmingly would recommend a doctor over a healer. Almost all who were treated with medication recognized an improvement in their condition. Many subjects felt that traditional healing can be beneficial and believed that patients should initially go to a healer for their problems. Many also felt that healers are not effective for mental illness or are dishonest and should not be used.

CONCLUSIONS

Subjects were largely dissatisfied with their experiences with traditional healers, but healing is still an incredibly common first-line practice in Gujarat. Because healers are such integral parts of their communities and so commonly sought out, collaboration between faith healers and medical practitioners would hold significant promise as a means to benefit patients. This partnership could improve access to care and decrease the burden of mental illness experienced by patients and their communities.

Knowledge of and attitudes toward clinical depression among health providers in Gujarat, India

BACKGROUND

Clinical depression is a major leading cause of morbidity and mortality but it is oftentimes overlooked and undertreated. The negative perception and lack of understanding of this condition prevents millions of people from seeking appropriate and on-time medical help, leading to distress and increased burden for affected people and their families. The implementation of public education campaigns and training of non-psychiatric health professionals on mental health and clinical depression has been neglected in several countries, including India, which is the second most populous country in the world with a population of more than 1.2 billion people, almost one-fifth of the world's population.

OBJECTIVE

This study sought to explore the knowledge and attitudes toward the diagnosis and treatment of clinical depression in nonpsychiatric health care providers in Vadodara, Gujarat, India.

METHODS

A cross-sectional survey was conducted over a 4-week period In Gujarat, India among resident physicians and community health workers about their knowledge and views on clinical depression.

FINDINGS

We found considerable stigma and misinformation about depression especially among health care workers in India. Most of the community health workers had a great deal of difficulty when defining clinical depression, and a large majority said that they never heard about depression or its definition and although the overwhelming majority of respondents did not believe that clinical depression results from a punishment from God (82% disagreed or strongly disagreed with this belief) or evil spirits (77.5%), a much smaller proportion disagreed with the assertions that depression was either solely due to difficult circumstances (38.2%) or that sufferers only had themselves to blame (47.2%). Meanwhile, only 32.6% disagreed with the position that clinical depression is a sign of weakness and 39.4% disagreed with the statement that suicide was a sign of weakness.

CONCLUSIONS

Our findings underscore the considerable public health priority facing India's policymakers and planners to better educate more non-psychiatric physicians and community health workers to identify, understand, and respond to early signs of mental illnesses, especially clinical depression.

Impact of Community Interventions on the Social Representation of Depression in Rural Gujarat

There is a pressing need to develop community interventions that will address stigma against mental illness in rural India. This cross-sectional study will compare social representations of depression in villages where educational programs have targeted mental illness and stigma versus control villages. Participants from the villages exposed to the educational interventions (n = 146) will be compared with a sample from six control villages (n = 187) in the same geographic region, using a structured questionnaire. The impact of the intervention as a predictor for questionnaire score will be assessed along with socio-demographic variables. The intervention villages showed higher levels of literacy regarding depression and lower levels of stigma, after adjusting for all other socio-demographic variables. While some demographic factors associated with the knowledge and attitudes towards depression are not modifiable, our research provides evidence in favor of the positive influence a community grassroots intervention can have on mental health literacy in rural settings.

Treatment of Mentally Ill Offenders in Nine Developing Latin American Countries

The prevalence of psychiatric conditions among prisoners in Latin America is greatly underestimated, and because of the lack of awareness about mental illness among service providers in Latin American prisons, oftentimes these conditions go unrecognized or are not treated properly. In the worst-case scenarios, human rights violations occur. Despite the high levels of need, many prisoners have not received adequate or timely treatment. The sparse existing literature documents prison conditions throughout Latin American countries, ranging from poor to extremely harsh, overcrowded, and life threatening. Most prison systems do not meet international prison standards. The information on forensic mental health services and the treatment of offenders with mental illness have been less extensively studied and compared with forensic practices in developed American nations. This study analyzes the existing literature on forensic psychiatry, focusing on nine socioeconomically developing nations in Latin America, to improve understanding of treatment approaches for offenders with mental illness and identify emerging themes. A review was conducted and data were included in regression analyses to investigate information relative to the treatment of offenders with mental illness and its interaction with the mental health system.

Psychodynamic psychotherapy and global health

This study surveys and examines the literature about psychodynamic psychotherapy in low and middle income countries. Although much has been written on this topic, the literature remains disjointed, unsystematic, and lacks randomized controlled trials. This trend is in stark contrast with a growing body of systematic literature and randomized controlled trials that exist in other types of psychotherapy used in low and middle income countries. While there is evidence that other types of psychotherapy are useful in these countries, questions remain regarding the implementation of psychodynamic psychotherapy. Is psychodynamic psychotherapy relevant to non-Western cultures? Are changes necessary to make it relevant? Is psychodynamic psychotherapy economically feasible in low and middle income countries? Although definitive answers to these questions do not yet exist, as psychodynamic psychotherapy is open-ended and client-centered, it is likely to be flexible across a wide range of cultures.

Dimensional structure and course of post-traumatic stress symptomatology in World Trade Center responders

BACKGROUND

Post-traumatic stress disorder (PTSD) in response to the World Trade Center (WTC) disaster of 11 September 2001 (9/11) is one of the most prevalent and persistent health conditions among both professional (e.g. police) and non-traditional (e.g. construction worker) WTC responders, even several years after 9/11. However, little is known about the dimensionality and natural course of WTC-related PTSD symptomatology in these populations.

METHOD

Data were analysed from 10 835 WTC responders, including 4035 police and 6800 non-traditional responders who were evaluated as part of the WTC Health Program, a clinic network in the New York area established by the National Institute for Occupational Safety and Health. Confirmatory factor analyses (CFAs) were used to evaluate structural models of PTSD symptom dimensionality; and autoregressive cross-lagged (ARCL) panel regressions were used to examine the prospective interrelationships among PTSD symptom clusters at 3, 6 and 8 years after 9/11.

RESULTS

CFAs suggested that five stable symptom clusters best represent PTSD symptom dimensionality in both police and non-traditional WTC responders. This five-factor model was also invariant over time with respect to factor loadings and structural parameters, thereby demonstrating its longitudinal stability. ARCL panel regression analyses revealed that hyperarousal symptoms had a prominent role in predicting other symptom clusters of PTSD, with anxious arousal symptoms primarily driving re-experiencing symptoms, and dysphoric arousal symptoms primarily driving emotional numbing symptoms over time.

CONCLUSIONS

Results of this study suggest that disaster-related PTSD symptomatology in WTC responders is best represented by five symptom dimensions. Anxious arousal symptoms, which are characterized by hypervigilance and exaggerated startle, may primarily drive re-experiencing symptoms, while dysphoric arousal symptoms, which are characterized by sleep disturbance, irritability/anger and concentration difficulties, may primarily drive emotional numbing symptoms over time. These results underscore the importance of assessment, monitoring and early intervention of hyperarousal symptoms in WTC and other disaster responders.

Piloting self-help groups for alcohol use disorders in Saint Vincent/Grenadines

BACKGROUND

Although alcohol consumption is recognized as a global problem, little research to date explores treatment options for alcohol use disorders in developing nations. Given the scarce mental health resources available in Saint Vincent and the Grenadines, community self-help programming for alcohol use disorders could potentially provide an important complement to the existing mental health services.

OBJECTIVE

The aim of this study was to gather baseline data on knowledge and attitudes toward alcohol consumption among community members, and subsequently, to pilot self-help rehabilitation programs for alcohol use disorders, while determining factors that affect the feasibility and sustainability of such programs.

METHODS

Focus groups were conducted in 3 communities to discuss community perceptions of alcohol use and the feasibility of self-help programs. Focus group findings guided the development and implementation of the self-help groups. A postintervention focus group was held to determine the effectiveness and community-wide effect of the self-help programs.

FINDINGS

Focus group participants agreed that alcohol consumption was a problem in Saint Vincent, leading to underage drinking and violence. Suggestions to encourage self-help meeting attendance included organizing group activities and providing visuals to illustrate alcohol's effects on health. Self-help group members were surveyed about their group experience. Of the 35 members surveyed, 77% said the group was very helpful, and 91% indicated that they would attend again. Postintervention focus group participants stated that individuals had reduced alcohol consumption after attending at least 1 self-help meeting.

CONCLUSIONS

Elements that contributed to the sustainability of self-help groups included strong local leadership from district health nurses as well as willingness of participants to seek support. However, efforts need to be made to increase community awareness of alcohol use disorders and its associated dangers. Our results suggested self-help programs to address alcohol use disorders are a feasible intervention in Saint Vincent that warrants further development, dissemination, and exploration.

Trajectories of PTSD risk and resilience in World Trade Center responders: an 8-year prospective cohort study

BACKGROUND

Longitudinal symptoms of post-traumatic stress disorder (PTSD) are often characterized by heterogeneous trajectories, which may have unique pre-, peri- and post-trauma risk and protective factors. To date, however, no study has evaluated the nature and determinants of predominant trajectories of PTSD symptoms in World Trade Center (WTC) responders.

METHOD

A total of 10835 WTC responders, including 4035 professional police responders and 6800 non-traditional responders (e.g. construction workers) who participated in the WTC Health Program (WTC-HP), were evaluated an average of 3, 6 and 8 years after the WTC attacks.

RESULTS

Among police responders, longitudinal PTSD symptoms were best characterized by four classes, with the majority (77.8%) in a resistant/resilient trajectory and the remainder exhibiting chronic (5.3%), recovering (8.4%) or delayed-onset (8.5%) symptom trajectories. Among non-traditional responders, a six-class solution was optimal, with fewer responders in a resistant/resilient trajectory (58.0%) and the remainder exhibiting recovering (12.3%), severe chronic (9.5%), subsyndromal increasing (7.3%), delayed-onset (6.7%) and moderate chronic (6.2%) trajectories. Prior psychiatric history, Hispanic ethnicity, severity of WTC exposure and WTC-related medical conditions were most strongly associated with symptomatic trajectories of PTSD symptoms in both groups of responders, whereas greater education and family and work support while working at the WTC site were protective against several of these trajectories.

CONCLUSIONS

Trajectories of PTSD symptoms in WTC responders are heterogeneous and associated uniquely with pre-, peri- and post-trauma risk and protective factors. Police responders were more likely than non-traditional responders to exhibit a resistant/resilient trajectory. These results underscore the importance of prevention, screening and treatment efforts that target high-risk disaster responders, particularly those with prior psychiatric history, high levels of trauma exposure and work-related medical morbidities.

Patient-clinician agreement on treatment type and helpfulness: results from a WTC rescue and recovery worker cohort

OBJECTIVE

This study assessed patient and clinician agreement about treatment type and its association with treatment helpfulness among World Trade Center rescue and recovery workers.

METHODS

A total of 187 outpatients and 280 clinicians completed a survey, which gathered information on patient characteristics, treatment types, and treatment helpfulness. Kappa statistics and sensitivity and specificity analyses were used, and the association between patient-clinician agreement and reported treatment benefit was determined.

RESULTS

Patient-clinician agreement was highest for group therapy, medication management, eye movement desensitization and reprocessing, and couples therapy. Agreement about medication management, individual psychotherapy, and workers' compensation evaluation was associated with higher reported treatment benefits.

CONCLUSIONS

Findings support the hypothesis that agreement regarding treatment type is associated with higher reported benefit and extend findings of previous studies to a linguistically diverse, naturalistic sample exposed to a disaster trauma. Results also highlight the need for better understanding of eclectic therapies offered in real-world clinical practice.

First person: a mental health mission to post-earthquake El Salvador

In this article the author excerpts and discusses salient quotes or moments from the journal he compiled while visiting El Salvador in February 2001 as head of Disaster Psychiatry Outreach (DPO) to assist survivors of a major earthquake. This case discussion of a single disaster mental health response exemplifies key issues related to both short and long term mental health service delivery to disaster affected communities.