The Rich Nonprofits Get Richer: Centering Psychiatric Grant Funding at the Margins.

Community psychiatrists serve multiple institutional roles, and at times these roles may include the review of grant proposals from nonprofit organizations. In this column, the authors argue that privilege and social capital can easily become concentrated among a small group of centralized model organizations and influence the grant review process. Established and wealthy nonprofits can co-opt the growing interest in health equity by leveraging their existing resources, thereby excluding emerging organizations within communities in need. By applying a structural lens to this problem, funding entities can identify approaches that more effectively promote equity throughout the grant life cycle.

Racial Disparities in the Administration of ECT in Texas, 1998-2013.

OBJECTIVE: Electroconvulsive therapy (ECT) is a treatment of choice for severe depression but has been underutilized among black patients. This study investigates racial disparities in the administration of ECT in the state of Texas between 1998 and 2013 using population data. DESIGN: Data from the Texas Department of State Health Services were obtained corresponding to the use for all ECT conducted in nonfederal settings during the period from January 2, 1998, to August 30, 2013. The data set comprised quarterly reports generated for each patient, totaling 27,931 patient quarters. Using year-by-year intercensal population estimates for the state of Texas, ECT treatments per capita were compared among black, white, Latina/Latino, and other individuals during this time period. RESULTS: Significantly more white patients were treated each quarter than minority patients (P < 0.001), with Latina/Latino patients recording fewer treatment quarters than any other racial group (P < 0.005). Large discrepancies in diagnosis by race were observed. Black patients were less likely than white and Latina/Latino patients to be diagnosed with depression and 4 times as likely as white patients to carry a diagnosis of schizophrenia. CONCLUSIONS: Concordant with previous data, large racial disparities in the administration of ECT were found in this Texas data set. Despite the limited nature of this data set, these results suggest that continued investigation is required to determine factors responsible for these disparities.

Moral transgression during the Vietnam War: a path analysis of the psychological impact of veterans' involvement in wartime atrocities.

BACKGROUND AND OBJECTIVES: Involvement in wartime combat often conveys a number of deleterious outcomes, including posttraumatic stress disorder (PTSD), depression, hostility, aggression, and suicidal ideation. Less studied is the effect of engagement in wartime atrocities, including witnessing and perpetrating abusive violence. DESIGN AND METHODS: This study employed path analysis to examine the direct effects of involvement in wartime atrocities on hostility, aggression, depression, and suicidal ideation independent of combat exposure, as well as the indirect effects via guilt and PTSD symptom severity among 603 help-seeking male Vietnam War veterans. RESULTS: Involvement in wartime atrocities was predictive of increased guilt, PTSD severity, hostility, aggression, depressive symptoms, and suicidal ideation after controlling for overall combat exposure. Combat-related guilt played a minor role in mediating the effect of atrocity involvement on depression and suicidal ideation. PTSD severity had a larger mediational effect. However, it still accounted for less than half of the total effect of involvement in wartime atrocities on hostility, aggression, and suicidal ideation. CONCLUSIONS: These findings highlight the heightened risk conveyed by involvement in wartime atrocities and suggest that the psychological sequelae experienced following atrocity involvement may extend well beyond guilt and PTSD.

Electroconvulsive Therapy and All-Cause Mortality in Texas, 1998-2013.

INTRODUCTION: Electroconvulsive therapy (ECT) remains an effective treatment for major depressive disorder. Since 1995, Texas has maintained an ECT database including patient diagnoses and outcomes, and reporting any deaths within 14 days of receiving an ECT treatment, encompassing a total of 166,711 ECT treatments administered in Texas over the previously unreported period of 1998 to 2013. METHODS: Descriptive analysis summarized information on deaths reported during the 16-year period-cause of death, type of treatment (index or maintenance) and patient demographics. Multiple logistic regression of death incidence by treatment session was performed to determine whether patient age, sex, race, diagnosis, or year of treatment was associated with death after ECT. RESULTS: Of those deaths occurring within 1 day of an ECT treatment, the death rate was 2.4 per 100,000 treatments. Looking at all deaths within 14 days of an ECT treatment, the death rate increased to 18 per 100,000 treatments but included all deaths regardless of likelihood of causal association with ECT, for example, accidents and suicides, the latter a leading cause of death among individuals with severe major depression or other disorders for which ECT is indicated. Death rate increased significantly with increasing patient age (P = 0.001) and male sex (P = 0.009), and there was a nonsignificant trend toward increased death amongst patients with bipolar disorder or schizophrenia (P = 0.058) versus depression. CONCLUSIONS: Our data indicate that ECT is in general a safe procedure with respect to the likelihood of immediate death. Suicide remains a significant risk in ECT patients, despite evidence that ECT reduces suicidal ideation.

Emergency Psychiatry Experience, Resident Burnout, and Future Plans to Treat Publicly Funded Patients.

OBJECTIVE: This study examined psychiatry resident burnout in emergency departments and its association with residents' posttraining plans to care for Medicaid patients and others publicly insured. METHODS: Between November and December 2013, psychiatry residents in North Carolina were recruited for a cross-sectional, Internet-based survey concerning emergency department experiences, attitudes about their roles, feelings of burnout, and posttraining intentions to treat Medicaid patients. The completion rate was 51% (N=91). RESULTS: In bivariate analyses (N=82 with an emergency psychiatry rotation), burnout was positively associated with frequent exhaustion (p<.001) and perceived suboptimal supervision by the attending physician (p<.01). Compared with other residents, residents planning to accept Medicaid after training had significantly lower burnout scores (p<.05). Experiencing assault in the emergency department indicated decreased likelihood of treating publicly insured patients after training (Medicaid, odds ratio=.09, p<.05). CONCLUSIONS: Adverse experiences with patient care in the emergency department during psychiatry residency appear to be linked to professional burnout and threaten to shape long-term plans regarding care for publicly insured patients.

A 19-year retrospective investigation of maternal mortality at Point G National Hospital, Bamako, Mali.

OBJECTIVE: To determine the changes in maternal mortality rates over the 19-year period from 1985 to 2003 at Point G National Hospital, Bamako, Mali. METHODS: Data on all pregnant women admitted from January 1, 1985 to December 31, 2003 were collected from all hospital services. Records were entered into a database, and maternal mortality rates and cause-specific fatality rates were analyzed. RESULTS: Significant declines in the fatality rates due to uterine rupture (odds ratio [OR] 0.086; 95% confidence interval [CI], 0.011-0.70) and postpartum infection (OR 0.22; 95% CI, 0.085-0.55) were noted when the period from 1985-1987 was compared with 2001-2003. Overall, there was a significant reduction in the odds of maternal death in the period between 1985-1987 and 2001-2003 (OR 0.529; 95% CI, 0.341-0.821), when adjustments were made for cesarean delivery, complications, and patient age. CONCLUSIONS: Although the crude maternal mortality rate remained high, shifts in the patient population that led to more patients with complications being admitted masked improvements in the odds of death for obstetric patients.

Schistosomiasis and vesicovaginal fistula.

Schistosoma haematobium is presented as a cause of vesicovaginal fistula in a nulliparous adolescent. The possible role of S. haematobium in failure of fistula repair and the importance of screening and treatment in endemic areas prior to repair are discussed.