The Role of Social Support in Perinatal Mental Health and Psychosocial Stimulation.

Social support refers to the help someone receives emotionally or instrumentally from their social network. Poor social support in the perinatal period has been associated with increased risk for symptoms of common mental disorders, including depression and posttraumatic stress symptoms (PTS), which may impact parenting behavior. Whether social support impacts parenting behaviors, independent of mental health symptomatology, remains unclear. Among N=309 participants of the Scaling Up Maternal Mental healthcare by Increasing access to Treatment (SUMMIT Trial), a large perinatal depression and anxiety treatment trial, we explored the relations between perceived social support, perinatal depressive and PTS symptoms, and psychosocial stimulation provided by the parent in their home environment. Social support was measured at baseline using the Multidimensional Scale of Perceived Social Support (MSPSS). Perinatal depressive symptoms were measured by the Edinburgh Postnatal Depression Scale (EPDS) and PTS symptoms were measured by the Abbreviated PTSD Checklist (PCL-6) at baseline, 3-, and 6-months post-randomization. Psychosocial stimulation was assessed by the Home Observation Measurement of the Environment (HOME) when the infant was between 6 to 24 months. Using stepwise hierarchical regressions, we found: (1) perceived social support at baseline significantly predicted both depressive and PTS symptoms at 3-months post-randomization, even when controlling for baseline depressive and PTS symptoms; and (2) while neither depressive nor PTS symptoms were significantly associated with psychosocial stimulation, perceived social support at baseline was a significant predictor. Clinical implications regarding treatment of perinatal patients are discussed.

Screening Accuracy of the Parent-Report Preschool Strengths and Difficulties Questionnaire in Primary Care.

OBJECTIVE: To evaluate the screening test accuracy and reliability of the parent-report preschool Strengths and Difficulties Questionnaire (P-SDQ) in primary care settings. METHODS: Children 24 to 48 months were recruited at scheduled primary care visits in Toronto, Canada. Parents completed the P-SDQ at baseline, 2, and 12 weeks. At 12 weeks, parents were invited to a semistructured diagnostic phone interview, the Preschool Age Psychiatric Assessment (PAPA). Criterion validity between baseline P-SDQ scores (Total Difficulties Score [TDS], internalizing and externalizing subscale) and Diagnostic and Statistical Manual, 5th edition diagnoses on PAPA was evaluated using area under the curve (AUC) and calculating screening test properties (sensitivity and specificity). Test-retest reliability at baseline and 2 weeks was evaluated using intraclass correlation coefficient. RESULTS: A total of 183 children were enrolled, mean age 39.3 (SD 7.4) months, 46.4% male, 120 (66%) completed P-SDQ at 2 weeks, 107 (58%) completed PAPA at 12 weeks. Of those with a PAPA, 26 (24%) had any psychiatric diagnosis, 17 (16%) had internalizing disorders and 4 (4%) had externalizing disorders. TDS identified any diagnosis with AUC = 0.67 (95% confidence intervals (CI): 0.55, 0.79); internalizing subscale identified internalizing disorders with AUC = 0.61 (95% CI: 0.47, 0.74); externalizing subscale identified externalizing disorders with AUC = 0.77 (95% CI: 0.60, 0.94). Sensitivity and specificity, and test-retest reliability were satisfactory for TDS and externalizing subscale, and less satisfactory for the internalizing subscale. CONCLUSIONS: The externalizing subscale has sufficient accuracy and reliability to identify children aged 2 to 4 years at risk for attention deficit/hyperactivity disorder and disruptive behavior disorders in primary care.

Understanding the Influence of the Junior Attending Role on Transition to Practice: A Qualitative Study.

BACKGROUND: The Junior Attending (JA) role is an educational model, commonly implemented in the final years of training, wherein a very senior resident assumes the responsibilities of an attending physician under supervision. However, there is heterogeneity in the model's structure, and data are lacking on how it facilitates transition to independent practice. OBJECTIVE: The authors sought to determine the value of the JA role and factors that enabled a successful experience. METHODS: The authors performed a collective case study informed by a constructivist grounded theory analytical approach. Twenty semi-structured interviews from 2017 to 2020 were conducted across 2 cases: (1) Most Responsible Physician JA role (general internal medicine), and (2) Consultant JA role (infectious diseases and rheumatology). Participants included recent graduates who experienced the JA role, supervising attendings, and resident and faculty physicians who had not experienced or supervised the role. RESULTS: Experiencing the JA role builds resident confidence and may support the transition to independent practice, mainly in non-medical expert domains, as well as comfort in dealing with clinical uncertainty. The relationship between the supervising attending and the JA is an essential success factor, with more productive experiences reported when there is an establishment of clear goals and role definition that preserves the autonomy of the JA and legitimizes the JA's status as a team leader. CONCLUSIONS: The JA model offers promise in supporting the transition to independent practice when key success factors are present.

Psychotherapy Patients of Psychiatry Residents: A Descriptive Study.

OBJECTIVE: Psychiatry residents learn psychodynamic psychotherapy for generalizable skills and as a transdiagnostic, long-term treatment indicated for patients with chronic mood, anxiety, or personality disorders. It is unknown how these indications align with actual patients of trainees. The aim of this descriptive study was to define characteristics of outpatients receiving psychodynamic psychotherapy from psychiatry residents. METHODS: Case reports (N=204) from 184 psychiatry residents were analyzed for patients' diagnoses and past treatments. RESULTS: Eighty-six percent of patients had prior psychiatric medication or treatment, 31% had three or more past courses of psychotherapy, and 48% had two or more diagnoses, including depression (62%), anxiety (46%), and personality disorders or traits (27%). CONCLUSIONS: Patients receiving psychodynamic psychotherapy from psychiatry residents had multiple psychiatric illnesses and a history of prior treatments that had not achieved or sustained recovery, suggesting complex and chronic illness. Consistent with community-based findings, these patient characteristics correspond with psychodynamic psychotherapy treatment indications.

Integrating Evidence-Supported Psychotherapy Principles in Mental Health Case Management: A Capacity-Building Pilot.

OBJECTIVES: Mental health case managers comprise a large workforce who help patients who struggle with complex mental illnesses and unmet needs with respect to the social determinants of health. This mixed-methods capacity-building pilot examined the feasibility, experiences, and outcomes of training community-based mental health case managers to integrate evidence-based psychotherapy principles into their case conceptualization and management practices. METHODS: Case-based, once-weekly, group consultations and training in applied therapeutic principles from mentalizing, interpersonal psychotherapy, motivational interviewing, and other evidence-based psychotherapies were provided to case managers over 8 months. A trauma-informed and culturally sensitive approach was emphasized to improve therapeutic alliances and to foster adaptive expertise and an appreciation of individual patient differences. RESULTS: Qualitative analyses of focus groups and individualized interviews identified a shift toward being more reflective rather than reactive, with improved empathy, patient engagement, morale, and confidence resulting from the training (N = 16). Self-reported pre-post counseling self-efficacy changes revealed significant improvements overall, driven by improved microskills and an ability to deal with challenging client behaviors (N = 10; P < 0.05). CONCLUSIONS: This pilot demonstrated that case-based consultations and training of mental health case managers within a community-of-practice in trauma-informed, culturally sensitive application of evidence-supported psychotherapy principles were feasible and acceptable with scalable potential to improve case managers' counseling self-efficacy, reflective capacity, empathy, and morale. Further research in this area is needed with a larger sample, and patient and health systems outcomes.

Reassurance seeking in the anxiety disorders and OCD: Construct validation, clinical correlates and CBT treatment response.

BACKGROUND: Reassurance seeking has been hypothesized to be a key factor in the maintenance of anxiety and obsessive-compulsive disorders according to contemporary cognitive-behavioural therapy (CBT) approaches. The present study sought to examine the structure, clinical correlates, and malleability of reassurance seeking in the context of CBT treatment. METHODS: Treatment-seeking participants (N = 738) with DSM-IV-TR (American Psychiatric Association, 2000) panic disorder with agoraphobia (PD/A), social anxiety disorder (SAD), generalized anxiety disorder (GAD), and obsessive compulsive disorder (OCD) completed the Reassurance Seeking Scale (RSS) with other symptom measures prior to and following CBT treatment. RESULTS: A confirmatory factor analysis supported a three factor solution: the need to seek excessive reassurance regarding decisions, attachment and the security of relationships, and perceived general threat and anxiety. The RSS was moderately correlated with general measures of anxiety and depression as well as disorder-specific symptom scales. Further, CBT was found to produce changes in reassurance seeking across CBT treatments and these reductions were significantly associated with disorder-specific clinical improvement. CONCLUSION: Reassurance seeking appears to be a common factor across anxiety disorders and its reduction in CBT treatment is associated with improved clinical outcomes.