Andres Barkil-Oteo

Mental health and psychosocial wellbeing of Syrians affected by armed conflict

AIMS This paper is based on a report commissioned by the United Nations High Commissioner for Refugees, which aims to provide information on cultural aspects of mental health and psychosocial wellbeing relevant to care and support for Syrians affected by the crisis. This paper aims to inform mental health and psychosocial support (MHPSS) staff of the mental health and psychosocial wellbeing issues facing Syrians who are internally displaced and Syrian refugees. METHODS We conducted a systematic literature search designed to capture clinical, social science and general literature examining the mental health of the Syrian population. The main medical, psychological and social sciences databases (e.g. Medline, PubMed, PsycInfo) were searched (until July 2015) in Arabic, English and French language sources. This search was supplemented with web-based searches in Arabic, English and French media, and in assessment reports and evaluations, by nongovernmental organisations, intergovernmental organisations and agencies of the United Nations. This search strategy should not be taken as a comprehensive review of all issues related to MHPSS of Syrians as some unpublished reports and evaluations were not reviewed. RESULTS Conflict affected Syrians may experience a wide range of mental health problems including (1) exacerbations of pre-existing mental disorders; (2) new problems caused by conflict related violence, displacement and multiple losses; as well as (3) issues related to adaptation to the post-emergency context, for example living conditions in the countries of refuge. Some populations are particularly vulnerable such as men and women survivors of sexual or gender based violence, children who have experienced violence and exploitation and Syrians who are lesbian, gay, bisexual, transgender or intersex. Several factors influence access to MHPSS services including language barriers, stigma associated with seeking mental health care and the power dynamics of the helping relationship. Trust and collaboration can be maximised by ensuring a culturally safe environment, respectful of diversity and based on mutual respect, in which the perspectives of clients and their families can be carefully explored. CONCLUSIONS Sociocultural knowledge and cultural competency can improve the design and delivery of interventions to promote mental health and psychosocial wellbeing of Syrians affected by armed conflict and displacement, both within Syria and in countries hosting refugees from Syria.

Psychiatry's identity crisis

Psychiatry has attempted to cope with its identity problem (April 7, p 1274) mainly by assuming an evidencebased approach, favoured throughout medicine. Evidence-based, however, became largely synonymous with psychopharmacological ap proaches, with relative disregard for other evidence-based modalities. 250 researchers linked to the university partners, plus very signifi cant research teams supported by a planned Wellcome Trust strategic award. From the outset there will be a great deal of new science in the Institute. Horton correctly notes that the Crick’s founding science strategy focuses on values, aspirations, and modes of delivery, rather than details of scientifi c programmes. This was deliberate, and refl ects the fact that the Crick will be operational for 50–70 years. Programmatic strategy can go stale quickly, whereas culture is much longer lasting and crucial for an institute’s success. If the Crick is to be more than the sum of its parts, we need a long-term vision that sets out broad and ambitious scientifi c objectives, underpinned by a focus on culture and mechanisms of research delivery that will enable us to refresh our research programmes constantly. That is what the Crick’s 2010 science vision and research strategy concentrates on. It is understandable that Horton’s two lunch companions are nervous about competition for research talent. However, the Crick will not aim to compete but to provide support for the whole UK biomedical research endeavour. We will use our international reputation, and our location in central London, to attract the best emerging scientifi c talent from around the world. We will focus our recruitment at an earlier career stage than is usual, providing comprehensive support and mentoring to help promising scientists realise their full potential. When our scientists are approaching the peaks of their careers, the Crick will work with them to place them in other research institutions within the UK. Our aim is to expand the pool of talent from which all UK institutions can recruit. It is never possible to do enough communication when launching a new project, so it is easy to criticise. However, we have sent 10 000 hard copies of a shortened version of the Crick strategy to universities, medical schools, pharmaceutical and biotechnology companies, hospitals, MRC unit directors, parliamentarians, and many others. In the past 18 months we have written two letters to vicechancellors and medical school deans to ask for advice on strategy; held three expert workshops on science, translation, and clinical research; met with scientists and administrators from around the world; and launched a regular email newsletter. The response from universities and our other stakeholders has been consistently positive. Our plans have also been scrutinised by the Commons Science and Technology Committee, which asked similar questions to Horton and concluded that “There is clear public interest in this impressive project”. We are now in the process of updating the 2010 science strategy, and refi ning our plans for the research programme and its mechanisms of delivery. We expect to complete this task around the end of 2012. We will continue to engage widely to explore how the Francis Crick Institute can best meet its aspiration to support a fl ourishing biomedical research community across the UK.

Teaching Collaborative Care in Primary Care Settings for Psychiatry Residents

BACKGROUND Job descriptions for psychiatrists will change significantly over the next decade, as psychiatrists will be called on to work as caseload consultants to the primary care team. OBJECTIVE The purpose of this pilot study was to examine the effects of an American Association of Directors of Psychiatric Residency Training-approved collaborative care curriculum on caseload consulting skills among psychiatry residents. METHODS In 2014, 46 psychiatry residents (5 postgraduate year 1s, 10 postgraduate year 2s, 22 postgraduate year 3s, and 9 postgraduate year 4s) from 5 academic psychiatry residency programs in the New England area were given the 2-hour pilot collaborative care curriculum. Participants were asked to complete an anonymous survey at both the beginning and the end of the workshop to rate their comfort level in aspects of collaborative care psychiatry (7 items from SBP4 psychiatry milestones) based on a Likert scale (1-not at all, 2-slightly, 3-moderately, and 4-extremely). Paired t-test was used to examine the difference between pretest and posttest results of residents participating in the workshop. RESULTS The pretest mean score for the group was 2.9 (standard deviation = 0.44), whereas the posttest mean was 3.51 (standard deviation = 0.42), p < 0.0001. Only 15% (n = 7) of residents reported having some form of primary care or ambulatory specialty care consultation experience while in training. CONCLUSION This brief collaborative care curriculum significantly improved resident confidence in milestone criteria related to population health and case-based consultations.

Using a Store-and-Forward System to Provide Global Telemental Health Supervision and Training: A Case from Syria

Not only in humanitarian conflict settings but throughout the globe, the provision of mental health services has always faced practical difficulties, such as the availability of flexible manpower of supervisors on the ground. Telemental health offers an alternative way to provide clinical supervision and services globally [1]. The use of videoconferencing-based clinical supervision has been reported in studies involving the teaching of medical students [2], psychiatry residents and fellows [3], and psychoanalysis candidates [4]. In addition, telemental health educational programs for psychologists and medical professionals are now being proposed [5]. In this report, we present a global telemental health system that provides clinical consultations and supervision to health care providers in the Syrian humanitarian setting, using storeand-forward technology, as an alternative to videoconferencing. Store-and-forward telemental health utilizes the indirect transmission of electronic text or recorded audio-visual material between parties. The Syrian TeleMental Health Network [6] uses a store-and-forward platform to provide training and education for health care workers, as well as clinical consultations, in Syrian conflict settings. The store-and-forward platform we use (Collegium Telemedicus) [7] is also used by nongovernmental organizations such asMédicines sans frontières to provide advice and consultations to their physicians in the field [8]. The platform is based in the UK and consists of a safe server through which referring providers can send clinical material about certain cases to specialists within the network. Collegium Telemedicus complies with European standards of information security by ensuring that “data traffic” from the user to the server is encrypted, in addition to an encrypted database and two firewalls to protect the server. The software is available on a secure server and can be accessed using any Internet browser. It provides “non-live” (i.e., asynchronous) means of communication, for transmitting clinical material and educational responses. The purpose of our network is to help health care providers (e.g., physicians, psychologists, nurses, and non-specialized health care workers) to obtain specialized consultation and then supervision about their cases. Many specialists of Arabic background (e.g., Syrian and Lebanese) are recruited from academic centers in the US, Canada, UK, and Middle East to provide the consultations and training. Clinics recruited for this network are either primary care centers staffed with physicians and nurses or mental health clinics staffed with Bachelor’s degree-level psychologists and psychiatrists. The medical director’s approval from each center is obtained prior to implementation. A needs assessment form is then filled out by the center’s coordinator, detailing the general capacity of the center, team members, their specialties, available medications (if any), and so on; this information will be available later to the specialists who will provide the consultations. Next, whenever possible, an initial meeting takes place via videoconferencing, during which all team members being recruited will meet with the network coordinators and some of the specialists to obtain an overview of the network and * Hussam Jefee-Bahloul hussam.jefeebahloul@gmail.com; hussam.bahloul@yale.edu

The association between depressive disorders and health care utilization: results from the São Paulo Ageing and Health Study (SPAH)

BACKGROUND Although depressive disorders are associated with increased health care utilization in the elderly living in high-income countries, few studies have examined this relationship in Latin America. METHOD The present study is part of the São Paulo Ageing and Health Study, a population-based epidemiological study of mental disorders in 2072 low-income adults ≥ 65 years old living in São Paulo, Brazil. Depressive disorders defined as major depressive disorder (MDD) and clinically relevant depressive symptoms (CRDS) were assessed with the Geriatric Mental State and the Neuropsychiatric Inventory. We examined the association between depressive disorders/symptoms and health care utilization (outpatient visits, hospital admissions and medication use in the past 3 months) using count models. RESULTS The prevalence of MDD and CRDS was 4.9% and 21.4%, respectively. In the fully adjusted model, older adults with MDD were 36% more likely to have one more outpatient visit (RM: 1.36, 95% CI: 1.11-1.67), while older adults with CRDS were 14% more likely to have one more outpatient visit (RM: 1.14, 95% CI: 1.02-1.28). Elderly individuals with MDD had a prevalence of hospital admissions in the previous 3 months that was twice that of those without depression (PR=2.02, 95% CI: 1.09-3.75). Significant differences were not found for medication use. CONCLUSION Among low-income older adults living in Brazil, those with MDD are more likely to have a recent hospital admission and outpatient service use than those without depression. Future studies are needed to examine the effectiveness of depression treatments for this population in order to both decrease the burden of illness as well as to minimize health care utilization related to depression.

Transforming Systems of Care Through a Novel Resident-Led Approach to Morbidity and Mortality Conferences.

Compared to the literature from our colleagues in other medical disciplines, the literature on Morbidity and Mortality (M&M) conferences in psychiatry is limited. In 2009, Goldman et al. found only nine reports over the past 40 years of psychiatric M&M endeavors [1]. Potential explanations for this dearth of M&M activities include the stigma and blaming culture sometimes associated with these forums, the relative rarity of mortality as a result of psychiatric illness, and the difficulty in clearly defining other adverse outcomes in mental health [2]. There is an increased understanding, however, that placing greater emphasis on issues of patient safety (PS) and quality improvement (QI) leads to improved patient care [3]. Regulatory bodies that oversee hospitals and graduatemedical education have begun to place greater emphasis on PS by focusing on decreasing “medical errors” and on QI through systems-level changes at healthcare institutions [4–6]. The Accreditation Council for Graduate Medical Education (ACGME) has included proficiency in QI and PS in their residency milestones and has created the Clinical Learning Environment Review (CLER) to engage residents in QI and PS initiatives [7]. Involving residents in this process is not only educational, but also pragmatic, given their position on the front lines of care and keen awareness of the factors adversely impacting clinical decision-making [8–10]. Some residencies are implementing QI curricula by utilizing experiential learning as a component of resident education [11–13]. A select few residencies encourage trainees to take on leadership roles in developing QI initiatives [14, 15]. Further, the Veterans Affairs (VA) Office of Academic Affiliation has funded Chief Resident in Quality and Patient Safety (CRQS) positions nationally to support QI initiatives during training [16]. Ideally, M&M conferences serve as a QI endeavor, providing peer review, adverse event reporting and analysis, and relevant education [17]. Numerous factors may impede successful implementation however, including a lack of structure, inadequate time, degeneration into lecture, or a perception that great ideas are “dismissed at the door” afterwards; but perhaps most salient is their association with a culture of blame, bullying, and disrespect [6, 18–20]. In 2012, Leape and collaborators described how this dysfunctional blaming culture is “a substantial barrier to progress in patient safety” despite 30 years of evidence that improved communication and discussion of errors leads to improved patient care [21, 22]. Patient safety forums can positively influence large healthcare organizations, by promoting institutional transparency and a non-punitive culture [23]. Further, shifting focus from individual to system-level factors that lead to errors enables identification of targets for improvement in care [24]. Charles Vincent described a framework for “systems analysis,” an approach founded in root cause analysis (RCA, a systematic process for identifying “root causes” of an adverse event) [25]. We therefore initiated a resident-led M&M-style conference series for the mental health service line at VA Connecticut Healthcare System (VACHS), entitled the “Mental Health Systems Improvement Series” (MHSIS). The MHSIS was established to create a safe, interdisciplinary forum for the structured discussion of unfavorable outcomes and “near misses” (an event where an adverse clinical outcome was narrowly avoided) using an RCA framework. Here, we describe the MHSIS, highlight the systemic and cultural changes that have resulted from its implementation, and demonstrate how such a forum can improve residency * Tobias Wasser tobias.wasser@yale.edu

Integration of Primary Care and Psychiatry: A New Paradigm for Medical Student Clerkships

BackgroundPublic health crises in primary care and psychiatry have prompted development of innovative, integrated care models, yet undergraduate medical education is not currently designed to prepare future physicians to work within such systems.AimTo implement an integrated primary care–psychiatry clerkship for third-year medical students.SettingUndergraduate medical education, amid institutional curriculum reform.ParticipantsTwo hundred thirty-seven medical students participated in the clerkship in academic years 2015–2017.Program DescriptionEducators in psychiatry, internal medicine, and pediatrics developed a 12-week integrated Biopsychosocial Approach to Health (BAH)/Primary Care–Psychiatry Clerkship. The clerkship provides students clinical experience in primary care, psychiatry, and integrated care settings, and a longitudinal, integrated didactic series covering key areas of interface between the two disciplines.Program EvaluationStudents reported satisfaction with the clerkship overall, rating it 3.9–4.3 on a 1–5 Likert scale, but many found its clinical curriculum and administrative organization disorienting. Students appreciated the conceptual rationale integrating primary care and psychiatry more in the classroom setting than in the clinical setting.ConclusionsWhile preliminary clerkship outcomes are promising, further optimization and evaluation of clinical and classroom curricula are ongoing. This novel educational paradigm is one model for preparing students for the integrated healthcare system of the twenty-first century.

Addressing the Cost of Health Care From the Front Lines of Psychiatry

TheescalatingcostofhealthcareintheUnitedStateshasbeendescribedasanunsustainablecrisis.Thishighcostdoesnotalwaystranslateintobetteroutcomes.Fi-nancial expenditures frequently outweigh the clinicalbenefits,resultinginlow-valuecare.Whilemedicalprofessionalsatlargehavebeguntoconsider potential solutions for addressing high costsand low-value care, psychiatrists have been relativelyinsulated from the discussion for 2 reasons: their infre-quent use of the costliest medical procedures and thediffusion of their highest cost factor, psychiatric medi-cations, across a wide number of medical specialists.The bulk of antidepressants and antianxiety medica-tions, along with half of antipsychotics, are prescribedby other health care providers and specialties.