Curriculum development in Liberia's first postgraduate psychiatry training programme.

This paper describes the implementation of curricula for Liberia's first-ever psychiatry training programme in 2019 and the actions of the only two Liberian psychiatrists in the country at the time in developing and executing a first-year postgraduate psychiatry training programme (i.e. residency) with support from international collaborators. It explores cultural differences in training models among collaborators and strategies to synergise them best. It highlights the assessment of trainees' (residents') basic knowledge on entry into the programme and how it guided immediate and short-term priority teaching objectives, including integrated training in neuroscience and neurology. The paper describes the strengths and challenges of this approach as well as opportunities for continued growth.

Validation of an ICD-Code-Based Case Definition for Psychotic Illness Across Three Health Systems.

BACKGROUND AND HYPOTHESIS: Psychosis-associated diagnostic codes are increasingly being utilized as case definitions for electronic health record (EHR)-based algorithms to predict and detect psychosis. However, data on the validity of psychosis-related diagnostic codes is limited. We evaluated the positive predictive value (PPV) of International Classification of Diseases (ICD) codes for psychosis. STUDY DESIGN: Using EHRs at 3 health systems, ICD codes comprising primary psychotic disorders and mood disorders with psychosis were grouped into 5 higher-order groups. 1133 records were sampled for chart review using the full EHR. PPVs (the probability of chart-confirmed psychosis given ICD psychosis codes) were calculated across multiple treatment settings. STUDY RESULTS: PPVs across all diagnostic groups and hospital systems exceeded 70%: Mass General Brigham 0.72 [95% CI 0.68-0.77], Boston Children's Hospital 0.80 [0.75-0.84], and Boston Medical Center 0.83 [0.79-0.86]. Schizoaffective disorder PPVs were consistently the highest across sites (0.80-0.92) and major depressive disorder with psychosis were the most variable (0.57-0.79). To determine if the first documented code captured first-episode psychosis (FEP), we excluded cases with prior chart evidence of a diagnosis of or treatment for a psychotic illness, yielding substantially lower PPVs (0.08-0.62). CONCLUSIONS: We found that the first documented psychosis diagnostic code accurately captured true episodes of psychosis but was a poor index of FEP. These data have important implications for the case definitions used in the development of risk prediction models designed to predict or detect undiagnosed psychosis.

Validation of an ICD-code-based case definition for psychotic illness across three health systems.

Background and Hypothesis: Early detection of psychosis is critical for improving outcomes. Algorithms to predict or detect psychosis using electronic health record (EHR) data depend on the validity of the case definitions used, typically based on diagnostic codes. Data on the validity of psychosis-related diagnostic codes is limited. We evaluated the positive predictive value (PPV) of International Classification of Diseases (ICD) codes for psychosis. Study Design: Using EHRs at three health systems, ICD codes comprising primary psychotic disorders and mood disorders with psychosis were grouped into five higher-order groups. 1,133 records were sampled for chart review using the full EHR. PPVs (the probability of chart-confirmed psychosis given ICD psychosis codes) were calculated across multiple treatment settings. Study Results: PPVs across all diagnostic groups and hospital systems exceeded 70%: Massachusetts General Brigham 0.72 [95% CI 0.68-0.77], Boston Children's Hospital 0.80 [0.75-0.84], and Boston Medical Center 0.83 [0.79-0.86]. Schizoaffective disorder PPVs were consistently the highest across sites (0.80-0.92) and major depressive disorder with psychosis were the most variable (0.57-0.79). To determine if the first documented code captured first-episode psychosis (FEP), we excluded cases with prior chart evidence of a diagnosis of or treatment for a psychotic illness, yielding substantially lower PPVs (0.08-0.62). Conclusions: We found that the first documented psychosis diagnostic code accurately captured true episodes of psychosis but was a poor index of FEP. These data have important implications for the development of risk prediction models designed to predict or detect undiagnosed psychosis.

Building a postgraduate psychiatry training program in Liberia through cross-country collaborations: initiation stages, challenges, and opportunities.

Background: About 80% of the nearly 2 billion people experiencing psychiatric conditions worldwide do not have access to quality, affordable mental health care. In Africa, there are 0.004 psychiatrists per 10,000 people, with the shortage exacerbated by a limited number of postgraduate psychiatry training opportunities. As of 2018, there were only two psychiatrists in Liberia. Methods: This paper aims to offer a framework for developing postgraduate (i.e., residency) psychiatry training in resource-constrained settings to disseminate best practices and lessons learned. This article describes the approach to developing the formal global academic partnership that supported the initiation of Liberia's first postgraduate psychiatry training program in July 2019. Results: Authors describe strengths, challenges, and opportunities for improvement in the planning and initiation stages of the postgraduate program. Key strengths of the program planning process include: (1) collaboration with a coalition of local and national stakeholders committed to improving mental health care in Liberia; (2) early procurement of quality video conferencing equipment and internet service to facilitate remote learning and broaden access to digital materials; and (3) leveraging of intra-continental partnerships for subspecialty training. Challenges experienced include: (1) navigating the intricacies of local political and administrative processes; (2) recruiting candidates to a medical specialty with historically lower salaries; and (3) the added burden placed on the limited number of local specialists. Identified opportunities include building a monitoring, evaluation, and learning (MEL) framework, further diversifying subspecialty areas of psychiatric and neurological training, and obtaining full accreditation of the postgraduate psychiatry program through the West African College of Physicians (WACP). Conclusion: The successful launch of the postgraduate psychiatry training program in Liberia is attributed to several factors, including a long-standing academic collaboration of over 10 years and support for mental health capacity-building efforts at national and local levels.

Trauma, risk, and resilience: A qualitative study of mental health in post-conflict Liberia.

The Liberian civil wars led to widespread destruction and devastation for its individuals, communities, and economy. However, individuals' subjective trauma experiences and long-term psychological impact remain relatively understudied. This study aims to explore context-specific traumatic events and examine how risk and protective factors combine with traumas to influence trajectories of suffering and recovery over time. We conducted 43 semi-structured interviews with Liberian adults who were present during the Liberian civil wars, and we used line-by-line open coding, thematic analysis, and axial coding to analyze and contextualize the data. Eight key trauma themes emerged: Abuse (emotional, physical, and sexual), Captivity, Combat, Killings, Physical Illness, Resource Loss, Family Separation, and War Environment. The risk and protective factors that were reported as salient were: Age, Biological Sex, Socioeconomic Status, and Community Support. Further, key patterns emerged across interviews that indicated greater risk for long-term suffering: 1) exposure to multiple traumatic events, 2) certain types of traumatic events (like killing of a close family member), and 3) the combination of specific traumatic events and risk and protective factors (like older women witnessing the killing of their children). This study provides culturally relevant information on trauma, suffering, and resilience in post-conflict Liberia, with the aim of guiding the development of screening tools and targeted psychological interventions that improve well-being over time.

Long-Term Trends in Psychiatric Emergency Services Delivered by the Boston Emergency Services Team.

Rising psychiatric emergency department (ED) presentations pose significant financial and administrative burdens to hospitals. Alternative psychiatric emergency services programs have the potential to alleviate this strain by diverting non-emergent mental health issues from EDs. This study explores one such program, the Boston Emergency Services Team (BEST), a multi-channel psychiatric emergency services provider intended for the publicly insured and uninsured population. BEST provides evaluation and treatment for psychiatric crises through specialized psychiatric EDs, a 24/7 hotline, psychiatric urgent care centers, and mobile crisis units. This retrospective review examines the sociodemographic and clinical characteristics of 225,198 BEST encounters (2005-2016). Of note, the proportion of encounters taking place in ED settings decreased significantly from 70 to 58% across the study period. Findings suggest that multi-focal, psychiatric emergency programs like BEST have the potential to reduce the burden of emergency mental health presentations and improve patient diversion to appropriate psychiatric care.

"Making Room": A Thematic Analysis Study of the Process of Postpartum Maternal Adjustment.

OBJECTIVES: Mothers are especially vulnerable to the onset or recurrence of psychological symptoms during the postpartum period. However, protective psychosocial factors may provide a stress buffering effect and promote a positive adjustment trajectory. Previous research has demonstrated the importance of positive maternal adjustment for maternal mental health and child outcome. However, research is needed that explores (1) the psychosocial components of maternal adjustment, (2) the process of maternal adjustment as subjectively experienced by mothers, and (3) clinical targets that can help postpartum healthcare teams to facilitate positive adjustment during the perinatal period. METHODS: This qualitative study utilized thematic analysis in order to understand the dimensions and properties of themes related to maternal adjustment. Through narrative interviews, this study investigated processes associated with maternal adjustment in a sample of n = 23 mothers receiving obstetric care. RESULTS: Thematic analysis uncovered three key developmental processes: (1) "Stretching Identity; Transitioning Roles", (2) "Navigating Stressors; Approaching Self-Efficacy", and (3) "Changing Relationships; Strengthening Support." Negative maternal self-attributions emerged as a key target for supportive intervention. Each process is complex and susceptible to both downward and upward spirals, consistent with the broaden-and-build theory of positive emotion. CONCLUSIONS FOR PRACTICE: Negative maternal attributions of self are discussed as a key target precipitating postpartum adjustment trajectories. Given this, parenting interventions that teach cognitive reappraisal or mindfulness strategies may be especially beneficial for mothers in the perinatal period.

Orphans in post-conflict Liberia: Seeking care in fractured communities.

Orphans in post-conflict settings have unique needs that have not been well-characterized. In post-conflict Liberia, maternal orphans are more likely to be without care than paternal orphans. This study examined the experiences of maternal orphans in Liberia, as they attempted to care for themselves and seek care from others, and the barriers they faced. In-depth interviews were conducted with 75 post-conflict Liberian orphans. We performed a secondary narrative analysis of interview transcripts from all maternal or double orphans (n = 17). We identified similar elements across narratives: traumatic loss, disconnection from family and community, and the desire for a savior. Female high-risk orphans were more likely to have formal substitute caregiving arrangements in which they were living with someone who was a relative or had been selected by a relative. Male orphans more commonly lacked arranged substitute care, but this allowed them to form relationships with substitute caregivers of their choosing. Sex also played a role in the provision of caregiving; substitute care was provided by women. Findings highlighted the syndemic relationship between poverty, violence, transactional sex, trauma, and substance use that traps high-risk Liberian orphans. Interventions are needed to improve access to mental health care, sober communities, housing, and education support. The need to integrate these services into indigenous institutions and address barriers related to stigma is explored.

Experiences and practices of caregiving for older persons living with dementia in African countries: A qualitative scoping review.

BACKGROUND: The increasing awareness and diagnosis of dementia in Africa necessitate documentation of caregiving practices to understand local patterns and improve the quality of care. Caregiving in African communities is rooted in informal-communal social organization. This scoping review analyses caregiver characteristics and experiences, and practices of caregiving for persons living with dementia in Africa. METHODS: A total of 152 references were retrieved, with 64 references obtained from PubMed, 85 from AJOL, and three from Scopus. Based on the relevance of titles, 83 references were further retained from PubMed (64), AJOL (16), and Scopus (3). A rapid review of abstracts was done in Distiller SR, and finally, six relevant articles were content-analyzed using Atlas ti 8.4 qualitative analysis software. RESULTS: All six included studies were published between 2003 and 2018. Four themes were identified: article characteristics, caregiver characteristics, caregiver in context, and caregiver potentialities (challenges and opportunities). Studies reported findings from research conducted in four African countries: three from Nigeria, and one each from South Africa, Egypt, and Tanzania. Caregivers of persons living with dementia typically had eight years or less of formal education, were unpaid, and spent a daily average of 13 hours in caregiving. Cultural thresholds and individual caregiver differences underlie the interpretation of stressors across cultures. Caregivers lack the right training and information as well as support systems to improve their role performance and reduce accumulated stress. CONCLUSION: In African countries, informational and educational platforms are essential for improved individual dementia caregiving, vis-à-vis strengthened roles of governments, and religious/traditional leaders and organizations.

Developing a Dual Residency Program in Psychiatry and Neurology in an Area of Regional Conflict: The University of Hargeisa-Massachusetts General Hospital-Boston Medical Center Experience.

Noncommunicable diseases are the leading cause of worldwide death and disability and continue to increase in both developed and developing countries. There is a need to address and treat neuropsychiatric disorders in low-income countries, especially in the Horn of Africa. Capacity building by training local doctors and health care workers is a laborious endeavor, with challenges piling up along the way. Nevertheless, the rewards are great when brain specialists who are able to address the needs in their country and treat their fellow citizens receive the training needed to do so effectively. The present article describes a coordinated administrative, educational, and clinical effort to develop and implement a dual residency program in psychiatry and neurology at the University of Hargeisa in Somaliland. The authors highlight the foundations of the program and the challenges faced during its development and implementation in an area of regional conflict. The program provides evidence that this aim is achievable and serves as a model for others seeking to replicate it in other low- and middle-income countries.

Development of the South Sudan Mental Health Assessment Scale.

This study developed and validated a measure that captures variation in common local idioms of distress and mental health problems experienced by women in South Sudan, a country which has experienced over 50 years of violence, displacement, and political, social, and economic insecurity. This measure was developed during a randomized controlled trial of the Adolescent Girls Initiative (AGI) and used qualitative Free Listing (n = 102) and Key Informant interviews (n = 27). Internal reliability and convergent validity were assessed using data from 3,137 randomly selected women (ages 14-47) in 100 communities in South Sudan. Test-retest and inter-rater reliability were assessed using responses from 180 women (ages 15-58) who completed the measure once, and 129 of whom repeated the measure an average of 12 days (SD = 8.3) later. Concurrent validity was assessed through the ratings of 22 AGI leaders about the presence or absence of mental health symptoms in the 180 women in the test-retest sample. The study resulted in the development of the South Sudan Mental Health Assessment Scale, a 24-item measure assessing six idioms of distress. The scale consisted of one factor and had excellent internal, test-retest, and interrater reliability. The scale also demonstrated good convergent and concurrent validity and performed well psychometrically. Moreover, its development provides an example for other organizations, working in environments where mental health measures have not yet been developed and validated, to create and validate measures relevant to their populations. In this way, the role of mental health in development settings can be more rapidly assessed.

Prevalence of metabolic syndrome among patients with schizophrenia in Ethiopia.

BACKGROUND: Globally, the prevalence of metabolic syndrome (MetS) is higher among patients with schizophrenia than the general population, and this leads to higher morbidity and mortality in this population. The aim of this study was to investigate the MetS prevalence among patients with schizophrenia in Ethiopia. METHODS: We conducted a cross-sectional analysis of baseline data of 200 patients with schizophrenia recruited from Amanuel Mental Specialized Hospital, Addis Ababa, Ethiopia. Lipid profile and blood glucose levels were measured using Roche Cobas 6000 clinical chemistry analyzer. The prevalence of MetS was assessed based on National Cholesterol Education Program Adult Treatment Panel III criteria. Patients' demographic information, clinical and laboratory data, lifestyle habits, particularly smoking and Khat chewing, were evaluated vis-à-vis MetS. RESULTS: The overall prevalence of MetS in patients with schizophrenia was 21.5% (17.1% male, 29.6% female) where Low HDL-cholesterol value was the most common metabolic disorders components in both males and females subgroups. In the multivariate analysis, the positive and negative symptoms score (PANSS, AOR = 1.03, 95% CI 1.001-1.054) was associated factors with MetS. CONCLUSION: In Ethiopia, patients with schizophrenia were found to have higher prevalence of MetS than the general population. Physicians/health care providers should routinely screen patients with schizophrenia for MetS and initiate timely management of those who develop the syndrome to reduce the health cost from caring for NCDs, improve the patients' quality of life, and prevent premature mortality.

Exploration of alcohol use disorder-associated brain miRNA-mRNA regulatory networks.

Transcriptomic changes in specific brain regions can influence the risk of alcohol use disorder (AUD), but the underlying mechanism is not fully understood. We investigated AUD-associated miRNA-mRNA regulatory networks in multiple brain regions by analyzing transcriptomic changes in two sets of postmortem brain tissue samples and ethanol-exposed human embryonic stem cell (hESC)-derived cortical interneurons. miRNA and mRNA transcriptomes were profiled in 192 tissue samples (Set 1) from eight brain regions (amygdala, caudate nucleus, cerebellum, hippocampus, nucleus accumbens, prefrontal cortex, putamen, and ventral tegmental area) of 12 AUD and 12 control European Australians. Nineteen differentially expressed miRNAs (fold-change>2.0 & P < 0.05) and 97 differentially expressed mRNAs (fold-change>2.0 & P < 0.001) were identified in one or multiple brain regions of AUD subjects. AUD-associated miRNA-mRNA regulatory networks in each brain region were constructed using differentially expressed and negatively correlated miRNA-mRNA pairs. AUD-relevant pathways (including CREB Signaling, IL-8 Signaling, and Axonal Guidance Signaling) were potentially regulated by AUD-associated brain miRNA-mRNA pairs. Moreover, miRNA and mRNA transcriptomes were mapped in additional 96 tissue samples (Set 2) from six of the above eight brain regions of eight AUD and eight control European Australians. Some of the AUD-associated miRNA-mRNA regulatory networks were confirmed. In addition, miRNA and mRNA transcriptomes were analyzed in hESC-derived cortical interneurons with or without ethanol exposure, and ethanol-influenced miRNA-mRNA regulatory networks were constructed. This study provided evidence that alcohol could induce concerted miRNA and mRNA expression changes in reward-related or alcohol-responsive brain regions. We concluded that altered brain miRNA-mRNA regulatory networks might contribute to AUD development.

Psychotherapy in a resource-constrained setting: Understanding context for adapting and integrating a brief psychological intervention into primary care.

Low- and middle-income countries have few mental health professionals, and efforts to increase access to treatment are a global priority. A key gap is the lack of integration of psychotherapy interventions as a part of accessible evidence-based care. Current recommendations suggest that the integration of mental health treatments, including psychotherapy, into existing primary care pathways may serve as a means to address this disparity. Understanding the cultural and contextual factors that affect this process is a critical step in identifying necessary adaptations. The aim of this qualitative study was to identify contextual factors associated with integrating psychotherapy in primary care in a predominantly rural district in south-central Ethiopia. Purposive sampling was used to recruit 48 mental health service users, caregivers, health care providers, and community leaders. Semistructured interviews were conducted, recorded, and transcribed in Amharic and translated into English. Although challenges (e.g., stigma, job strain, lack of belief in formal treatments) are present, other existing strengths (e.g., openness to seeking treatment, increasing knowledge about mental health treatment, familiarity with practices similar to therapy) support subsequent psychotherapy adaptation and implementation. These findings suggest possible mechanisms to improve delivery and adaptation in the effort to lower the existing global treatment gap. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Treatment Effect With Paliperidone Palmitate Compared With Oral Antipsychotics in Black/African American Patients With Schizophrenia and a History of Criminal Justice System Involvement: A Post Hoc Analysis of the PRIDE Study.

OBJECTIVE: To examine the efficacy and safety of paliperidone palmitate once-monthly (PP1M) versus oral antipsychotics (OAPs) in Black/African American patients with schizophrenia and a history of criminal justice system involvement. METHODS: This was a post hoc analysis of a 15-month prospective, randomized, open-label, parallel-group, multicenter US study conducted from May 2010 to December 2013 that examined a subpopulation of Black/African American patients with schizophrenia (Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition criteria). The primary objective was to compare time to first treatment failure in patients treated with PP1M versus OAPs. Secondary objectives were to compare time to first institutionalization (psychiatric hospitalization or arrest/incarceration) and mean number of treatment failure events and institutionalizations over 15 months in PP1M-treated and OAP-treated patients. RESULTS: The intention-to-treat population included 275 Black/African American patients (PP1M, n = 145; OAPs, n = 130). Median time to first treatment failure was not reached for PP1M-treated patients and was 270 days for OAP-treated patients; hazard ratio (HR) was 1.39 (95% CI, 0.97-1.99; P = .075). Median time to first institutionalization was not reached for PP1M-treated patients and was 304 days for OAP-treated patients; HR was 1.49 (95% CI, 1.01-2.19; P = .043). Mean numbers of treatment failure events and institutionalizations were lower with PP1M than OAPs. The safety profile of PP1M was consistent with that of previous PP1M studies. CONCLUSIONS: In a Black/African American subpopulation of patients with schizophrenia and prior criminal justice system involvement, PP1M reduced the number of treatment failures, thereby reducing the number of psychiatric hospitalizations and/or arrests/incarcerations compared with daily OAPs. TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT01157351.

Relationship between quality of life and social integration among patients with schizophrenia attending a Nigerian tertiary hospital.

BACKGROUND: Despite decades of de-institutionalization and the best efforts of community mental health services, individuals with schizophrenia living outside the hospital may be described as in the community but not of the community, and remain in a very real sense socially excluded. AIM AND OBJECTIVES: To determine the relationship between social integration and quality of life among patients with schizophrenia attending the outpatient clinic of the Neuropsychiatric Hospital Abeokuta in Nigeria. METHODS: One hundred and fifty-one patients were recruited. Sociodemographic questionnaire, MINI-PLUS, WHOQOL-BREF, Social Integration Scale and PANSS were administered. Multivariable regression analyses were performed to identify the determinants of quality of life and the relationship with social integration. RESULTS: The mean (± SD) age of the respondents was 40.00 (± 10.23), 56.3% were males, 37.1% were single. Independent predictors of lower quality of life were: (1) more severe psychopathology for the domains of general health (p = 0.003), social relationship (p = 0.019) and environment (p = 0.008); (2) longer duration of illness for the social relationship (p = 0.028) and environment (p = 0.015) domains; and (3) negative symptoms (p = 0.034) for the physical domain. CONCLUSION: There is a need to pay closer attention to social outcome measures such as quality of life and level of social integration among patients with schizophrenia who come in contact with psychiatry services, and not just on symptom remission only.

Using local terminology to measure substance use behaviours among youth in post-conflict Liberia: a mixed methods study.

This mixed methods study aimed to use local terminology to accurately characterize the prevalence and risk factors associated with substance use and risky health behaviors among school-based youth in Monrovia, Liberia. An 86-question survey was validated using qualitative data obtained from focus groups at two secondary schools in central and greater Monrovia. The revised survey was then administered to 400 students from eight different secondary schools in this region. The observed prevalence estimates for lifetime and current substance use were considerably higher than previously reported among adolescents in the West African region. Among students who were former child soldiers, the rates of current substance use were 5.8-33.8% higher compared to the overall study sample. Male gender, academic seniority, and peer approval of substance use were all found to be strong predictors of current substance use among secondary students. Results suggest the need for targeted, trauma-informed interventions to reduce rates of substance use and risky health behaviors among youth in Liberia and similar post-conflict settings.

Towards a better understanding of attitudes and beliefs held by traditional healers and recipients of traditional medicine concerning mental health conditions in post-conflict Liberia: a qualitative investigation.

BACKGROUND: A better understanding of attitudes and beliefs held by traditional healers and utilizers of traditional medicine concerning mental health conditions in Liberia is important as Liberia seeks to improve its delivery of mental healthcare in the context of scarce resources and recovery from civil war. METHODS: A qualitative research design was used to collect data from 24 Liberian traditional healers, and 11 utilizers of Liberian traditional medicine. Participants were queried about mental health problems in Liberia, treatments, and attitudes towards modern healthcare. Qualitative data were probed and aggregated using content analysis. RESULTS: Mental health problems described by study participants included: Open Mole, African Science, Epilepsy, Depression and Mental Illness (trauma/substance use). Mental health problems were often associated with socioeconomic distress, and participants described their attitudes and beliefs concerning mental healthcare, traditional medicine, and modern healthcare. CONCLUSION: Traditional medicine is an important part of mental healthcare in Africa. Mental illness, social factors, and healthcare access were important problems in Liberia. Mental health problems blended local cultural beliefs with Westernized nosology and social factors. Traditional healer's attitudes towards Western medicine reflected ambivalence. There is a desire for collaboration with 'modern' health care providers, but this will require reciprocal trust-building.