Kristopher Kaliebe

Telepsychiatry in juvenile justice settings.

Telepsychiatry is emerging as a valuable means of providing mental health care in juvenile justice settings. Youth in the juvenile justice system have high levels of psychiatric morbidity. State and local juvenile justice systems frequently struggle to provide specialized psychiatric care, as these systems have limited resources and often operate in remote locations. Case studies in the use of telepsychiatry to provide improved care in juvenile corrections in 4 states are described, along with a review of advantages and disadvantages of telepsychiatry in these settings.

The Future of Psychiatric Collaboration in Federally Qualified Health Centers

Federally qualified health centers (FQHCs) provide comprehensive care to underserved and disadvantaged populations. FQHCs now comprise the largest primary care network in the United States. Currently, many FQHCs provide limited access to psychiatric services; and when such services are available, most use traditional on-site psychiatric clinics. The author reviews the rationale for increasing access to behavioral health care in FQHCs by adopting collaborative models of care, describes challenges to adopting these models in FQHCs, and discusses ways to increase the primary care teams ability to support patient self-care and family functioning.

Rules of Thumb: Three Simple Ideas for Overcoming the Complex Problem of Childhood Obesity

hildhood obesity correlates with increased internalizing disorders, externalizing C disorders, attention-deficit/hyperactivity disorder, learning disorders, and academic underperformance. However, families rarely present to mental health practitioners to treat obesity directly, and minimal guidance exists regarding how to address this multifaceted problem during a time-limited office visit. Moreover, many behavior patterns associated with obesity, such as sedentary lifestyles, excessive media exposure, and inappropriate diets, also correlate with psychiatric diagnosis or psychological distress. Thus, clinicians may want to consider an approach that focuses on educating parents or other caregivers about some common factors driving these harmful modern lifestyles. The following method emphasizes to caregivers 3 simple family-oriented goals (authoritatively labeled “rules”) to assist navigating a complex, ever-evolving world that is often averse to healthy behaviors. The “rules” aim to lead caregivers toward decisions that promote physical health and mental health and are suitable as part of treatment and prevention (for a sample handout for caregivers, see Supplement 1, available online). This approach makes use of heuristics, or mental shortcuts, such as “rules of thumb.” Heuristics are a set of learned or hardwired internal cognitive biases that drive a surprisingly large amount of human choices. They have the advantage of being straightforward and practical, although imperfect, decision-making tools. Innate heuristics make us irrational in certain ways, including being susceptible to manipulation by

Collaborative Health Care and Emerging Trends in a Community-Based Psychiatry Residency Model.

ObjectiveThis paper provides a report of an academic department of psychiatry’s journey into the change process associated with addressing the new requirements in health-care delivery, the emphasis on person-centered treatment models, and the implications for residency training programs. Louisiana State University Health Sciences Center Department of Psychiatry’s experience is based on responding to real-world shifts in which academic departments can play a leadership role.MethodsImportantly, methods are based on person-centered collaboration being central to a successful change process and include a description of the training, with data supporting implementation of the model.ResultsThe model demonstrates increased access to care and improved behavioral health symptoms. It indicates that with proper training and supervision, psychiatry residents can be an agent of change.ConclusionThis brief review of our experience offers to other departments of psychiatry examples of collaborative strategies substantially informed by the needs and preferences of both persons accessing services and local communities.

Impact of Nutrition on Neurocognition.

Today’s media-saturated environment bombards us with a constant stream of information about the latest diet ‘‘do’s and don’ts.’’ The 2015Y2020 US Department of Agriculture and Department of Health and Human Services’ Dietary Guidelines for Americans have generated much online attention for both stated and unstated recommendations. Simply described, these guidelines focus on healthful eating patterns, emphasizing a variety of whole foodsVvegetables and fruits, whole grains, and lean dairy or soy productsVin recognition of the impact that nutrition choices can have on health throughout the lifespan. Furthermore, the guidelines acknowledge the detrimental role of saturated and trans fats, as well as added sugars and sodium on diet-related chronic diseases. We as physicians should note the evidence base demonstrating the profound effects of nutrition on mental health and neurocognition. Nutrition counseling needs to play a larger role in our discussions with patients. The guidelines state: ‘‘All food and beverage choices matter.’’ As of 2012, more than one-third of the US population was classified as obese, and as such, the health and economic costs of obesity and obesity-related conditions are staggering. The five states with the highest prevalence of obesity are located in the South: Arkansas, West Virginia, Mississippi, Louisiana, and Alabama. Hypertension, dyslipidemia, type 2 diabetes mellitus, coronary heart disease, and certain cancers are leading causes of obesity-related deaths that can be prevented. The National Heart, Lung, and Blood Institute in conjunction with the National Institute of Diabetes and Digestive and Kidney Diseases convened an expert review panel to publish approachable treatment guidelines for physicians treating overweight and obesity. In this publication, lifestyle therapy, specifically dietary therapy and physical exercise, was featured prominently in effective treatment strategies. The evidence behind how diet affects health cannot be ignored. Specifically, calorie restriction and reduction of saturated fats were said to be effective in assisting with weight loss. These strategies need to be tailored to each individual, taking into account other factors such as patient readiness and environmental and cultural factors. In this Perspective we discuss the impact of nutrition on health and neurocognition; physical activity is outside the scope of our discussion. An increased focus on nutrition in clinical assessment and treatment is required in populations that consume more harmful diets. The southern dietary pattern is characterized by added fats, fried food, eggs, organ meats, processed meats, and sugar-sweetened beverages. The southeastern United States has been called the ‘‘Stroke Belt’’ because of its higher stroke risk and earlier cognitive decline than in other regions. Individuals who consume primarily a southern-style diet are highly likely to have hypertension, dyslipidemia, and diabetes mellitus. The US Southeast also has the highest rates of childhood attention-deficit/hyperactivity disorder (ADHD) and early-onset dementia. Although geographic data on adult ADHD are limited, the 2014 Express Scripts report indicates that Louisiana has the highest rate. As such, clinicians in the Stroke Belt should be especially attentive to dietary assessment and counseling because they are treating a population with the highest rates of ADHD, obesity, coronary artery disease, stroke, and dementia. To prevent unnecessary brain damage, physicians must emphasize the consumption of high-quality nutrition throughout the lifespan. Rates of childhood ADHD are increasing, particularly in the southeastern United States. Severity of ADHD symptoms is associated with diets high in simple sugars and processed and packaged foods. Trans fats and a number of additives and preservatives have been shown to cause ADHD symptoms, and their removal from the diet is an effective treatment. ADHD also is highly correlated with obesity. States with higher childhood obesity rates have a higher prevalence of childhood ADHD. Diets that are high in saturated fats are associated with inattention and hyperactivity, whereas diets that are high in omega-3 fatty acids have been shown to reduce symptoms of ADHD inattention and hyperactivity. Because of the strong correlation observed between obesity and ADHD, assessment and treatment of ADHD symptoms should include a nutritional assessment and recommendations for a brain-healthy diet, one that emphasizes whole foods. There is ample evidence that certain foods have positive effects on brain health, specifically berries and tree nuts. These food items can be introduced and encouraged during patient encounters. Cost and access often are concerns and barriers to adopting new behaviors; these can be addressed on an individual basis. Referrals to dietitians for assistance with meal planning also can facilitate dietary change for a healthier lifestyle, depending on patient readiness. Individuals living in the Stroke Belt states of Alabama, Arkansas, Georgia, Indiana, Kentucky, Louisiana, Mississippi, North and South Carolina, Tennessee, and Virginia are 34% more likely to have a stroke and 18% more likely than individuals from nonYStroke Belt states to exhibit earlier signs of memory and orientation problems. The results of the Perspective

Dr. Kaliebe replies.

Dr. Kaliebe replies: I thank Dr. Saul for her interest in my article and for raising important psychosocial issues regarding health and wellness. This included a discussion of weight bias, which can be a significant clinical issue. It is counterproductive and irrational to blame those, especially children, whose health is victim to obesogenic environments. Weight bias is one of many distorted messages strongly reinforced by the modern media milieu, and this underscores the importance of limiting media exposure. Furthermore, for decades medicine has overemphasized blood lipids, dietary fats, and body mass index, contributing to the preoccupation with fat and weight and thus displacing critical aspects of health, such as cardiorespiratory fitness. It also should be acknowledged that the perception of the ideal human form is largely genetically determined, and unhealthy appearances are instantly and automatically noticed. Thus, weight bias is a problem that should be addressed, but it cannot be eradicated. Regarding disordered eating, Schwartz and Henderson’s review “Does Obesity Prevention Cause Eating Disorders?” contains a thoughtful discussion and concludes obesity prevention does not increase it. Excessively restrictive eating seems to arise in response to the enormous discipline needed in hyper-palatable food environments. Disordered overeating appears to arise from tension between what our “slow” rational brains understand is healthy and what ubiquitous cues, our habits, and “fast” instincts drive us toward. “Eating food” is critical in either regard: unprocessed natural foods trigger the body’s evolved satiety signals, obviating restriction. Rarely, if ever, do teens binge on real foods such as walnuts, carrots, or broccoli.