Burnout and Moral Injury Among Black Psychiatrists and Other Black Mental Health Professionals.

This column discusses burnout and moral injury among Black psychiatrists and other Black mental health professionals and highlights the contribution of racism to these outcomes. In the United States, the COVID-19 pandemic and racial turmoil have revealed stark inequities in health care and social justice, and demand for mental health services has increased. To meet the mental health needs of communities, racism must be recognized as a factor in burnout and moral injury. The authors offer preventive strategies to support the mental health, well-being, and longevity of Black mental health professionals.

GAP-REACH: a checklist to assess comprehensive reporting of race, ethnicity, and culture in psychiatric publications.

Growing awareness of health and health care disparities highlights the importance of including information about race, ethnicity, and culture (REC) in health research. Reporting of REC factors in research publications, however, is notoriously imprecise and unsystematic. This article describes the development of a checklist to assess the comprehensiveness and the applicability of REC factor reporting in psychiatric research publications. The 16-item GAP-REACH checklist was developed through a rigorous process of expert consensus, empirical content analysis in a sample of publications (N = 1205), and interrater reliability (IRR) assessment (N = 30). The items assess each section in the conventional structure of a health research article. Data from the assessment may be considered on an item-by-item basis or as a total score ranging from 0% to 100%. The final checklist has excellent IRR (κ = 0.91). The GAP-REACH may be used by multiple research stakeholders to assess the scope of REC reporting in a research article.

Comparative effectiveness of standard versus patient-centered collaborative care interventions for depression among African Americans in primary care settings: the BRIDGE Study.

OBJECTIVE: To compare the effectiveness of standard and patient-centered, culturally tailored collaborative care (CC) interventions for African American patients with major depressive disorder (MDD) over 12 months of follow-up. DATA SOURCES/STUDY SETTING: Twenty-seven primary care clinicians and 132 African American patients with MDD in urban community-based practices in Maryland and Delaware. STUDY DESIGN: Cluster randomized trial with patient-level, intent-to-treat analyses. DATA COLLECTION/EXTRACTION METHODS: Patients completed screener and baseline, 6-, 12-, and 18-month interviews to assess depression severity, mental health functioning, health service utilization, and patient ratings of care. PRINCIPAL FINDINGS: Patients in both interventions showed statistically significant improvements over 12 months. Compared with standard, patient-centered CC patients had similar reductions in depression symptom levels (-2.41 points; 95 percent confidence interval (CI), -7.7, 2.9), improvement in mental health functioning scores (+3.0 points; 95 percent CI, -2.2, 8.3), and odds of rating their clinician as participatory (OR, 1.48, 95 percent CI, 0.53, 4.17). Treatment rates increased among standard (OR = 1.8, 95 percent CI 1.0, 3.2), but not patient-centered (OR = 1.0, 95 percent CI 0.6, 1.8) CC patients. However, patient-centered CC patients rated their care manager as more helpful at identifying their concerns (OR, 3.00; 95 percent CI, 1.23, 7.30) and helping them adhere to treatment (OR, 2.60; 95 percent CI, 1.11, 6.08). CONCLUSIONS: Patient-centered and standard CC approaches to depression care showed similar improvements in clinical outcomes for African Americans with depression; standard CC resulted in higher rates of treatment, and patient-centered CC resulted in better ratings of care.

Lessons learned: a "homeless shelter intervention" by a medical student.

OBJECTIVE: The authors explored the process of implementing a medical student-initiated program designed to provide computerized mental health screening, referral, and education in a homeless shelter. METHOD: An educational program was designed to teach homeless shelter staff about psychiatric disorders and culturally-informed treatment strategies. Pre- and post-questionnaires were obtained in conjunction with the educational program involving seven volunteer shelter staff. A computerized mental health screening tool, Quick Psycho-Diagnostics Panel (QPD), was utilized to screen for the presence of nine psychiatric disorders in 19 volunteer homeless shelter residents. RESULTS: Shelter staffs' overall fund of knowledge improved by an average of 23% on the basis of pre-/post-questionnaires (p=0.005). Of the individuals who participated in the mental health screening, 68% screened positive for at least one psychiatric disorder and were referred for further mental health care. At the 3-month follow-up of these individuals, 46% of those referred had accessed their referral services as recommended. CONCLUSIONS: Medical student-initiated psychiatric outreach programs to the homeless community have the potential to reduce mental health disparities by both increasing access to mental health services and by providing education. The authors discuss educational challenges and benefits for the medical students involved in this project.

Progress in workforce development since 2000: advanced training opportunities in public and community psychiatry.

A crisis in the behavioral health care workforce has drawn considerable attention from consumers, families, advocates, clinical professionals, and system administrators at local, state, and federal levels in the past decade. Its effects have been felt in the recruitment, retention, and performance of psychiatrists in the public sector, where a focus on biological aspects of illness and efforts to cut costs have made it difficult for public psychiatrists to engage meaningfully in leadership, consultation, prevention, and psychosocial interventions. An array of training opportunities has recently been created to meet the needs of community psychiatrists at various stages of their careers, from psychiatrists just beginning their careers to those who have been working as medical directors for several years. This article describes the development of these initiatives and their impact on public psychiatry in four key areas--training of experienced psychiatrists, ensuring retention of psychiatrists in community programs, providing fellowship training, and creating professional identity and pride. Although these programs constitute only initial steps, opportunities for psychiatrists to obtain advanced training in community psychiatry are much greater now than they were ten years ago. These initiatives will enhance the professional identity of community psychiatrists and provide a solid foundation for future development of public service psychiatry in the behavioral health workforce.

Trauma and diverse child populations.

It has been estimated that as many as two-thirds of American youth experience a potentially life-threatening event before 18 years of age and that half have experienced multiple potentially traumatic events. Race, ethnicity, and culture influence the frequency and nature of these traumas and also the ways in which children react to traumatic events. The authors discuss the varied influences of cultural background on these reactions to trauma, the varying presentations of diverse children experiencing troubling reactions, and the need to provide treatment to children and their families in a fashion that is culturally sensitive and acceptable to diverse families.

A cluster randomized trial of standard quality improvement versus patient-centered interventions to enhance depression care for African Americans in the primary care setting: study protocol NCT00243425.

BACKGROUND: Several studies document disparities in access to care and quality of care for depression for African Americans. Research suggests that patient attitudes and clinician communication behaviors may contribute to these disparities. Evidence links patient-centered care to improvements in mental health outcomes; therefore, quality improvement interventions that enhance this dimension of care are promising strategies to improve treatment and outcomes of depression among African Americans. This paper describes the design of the BRIDGE (Blacks Receiving Interventions for Depression and Gaining Empowerment) Study. The goal of the study is to compare the effectiveness of two interventions for African-American patients with depression--a standard quality improvement program and a patient-centered quality improvement program. The main hypothesis is that patients in the patient-centered group will have a greater reduction in their depression symptoms, higher rates of depression remission, and greater improvements in mental health functioning at six, twelve, and eighteen months than patients in the standard group. The study also examines patient ratings of care and receipt of guideline-concordant treatment for depression. METHODS/DESIGN: A total of 36 primary care clinicians and 132 of their African-American patients with major depressive disorder were recruited into a cluster randomized trial. The study uses intent-to-treat analyses to compare the effectiveness of standard quality improvement interventions (academic detailing about depression guidelines for clinicians and disease-oriented care management for their patients) and patient-centered quality improvement interventions (communication skills training to enhance participatory decision-making for clinicians and care management focused on explanatory models, socio-cultural barriers, and treatment preferences for their patients) for improving outcomes over 12 months of follow-up. DISCUSSION: The BRIDGE Study includes clinicians and African-American patients in under-resourced community-based practices who have not been well-represented in clinical trials to improve depression care. The patient-centered and culturally targeted approach to depression care is a relatively new one that has not been tested in most previous studies. The study will provide evidence about whether patient-centered accommodations improve quality of care and outcomes to a greater extent than standard quality improvement strategies for African Americans with depression. TRIAL REGISTRATION: ClinicalTrials.gov NCT00243425.

The role of public health in addressing racial and ethnic disparities in mental health and mental illness.

Racial/ethnic minority populations are underserved in the American mental health care system. Disparity in treatment between whites and African Americans has increased substantially since the 1990s. Racial/ethnic minorities may be disproportionately affected by limited English proficiency, remote geographic settings, stigma, fragmented services, cost, comorbidity of mental illness and chronic diseases, cultural understanding of health care services, and incarceration. We present a model that illustrates how social determinants of health, interventions, and outcomes interact to affect mental health and mental illness. Public health approaches to these concerns include preventive strategies and federal agency collaborations that optimize the resilience of racial/ethnic minorities. We recommend strategies such as enhanced surveillance, research, evidence-based practice, and public policies that set standards for tracking and reducing disparities.

Using non-feature films to teach diversity, cultural competence, and the DSM-IV-TR outline for cultural formulation.

OBJECTIVE: Feature films have been used for teaching in psychiatry for many years to demonstrate diagnoses, but the use of documentary and instructional films in resident and staff cultural competence training have not been extensively written about in the medical and psychological literature. This article will describe the films that have been used by the authors and suggest methods for their use in cultural competence and diversity training. METHODS: A literature search was done using MEDLINE and PsychINFO and the authors were asked to describe their teaching methods. RESULTS: One article was found detailing the use of videotapes as a stimulus but not for cultural competence education, and two articles were found documenting the use of The Color of Fear as a stimulus for the discussion of racism. However, many educators use these films all across the country for the purpose of opening discussion about racism. CONCLUSION: Documentary, instructional, and public service announcements can be useful in teaching culturally competent assessment and treatment.

Beyond misdiagnosis, misunderstanding and mistrust: relevance of the historical perspective in the medical and mental health treatment of people of color.

In this article, we discuss the relationship and relevance of the historical interaction primarily between African-American culture and the medical and mental health communities, and explore the role of historical experience in contributing to mistrust and underutilization of services by people of color. We conclude that failure on the part of practitioners to go beyond clinical history gathering to recognize and acknowledge the larger historical perspectives from which they and their patients of color draw conclusions and make decisions contributes to the mistrust of the medical and mental health communities and to perpetuation of the current climate of healthcare disparities.

Reconsideration of the training of psychiatrists and mental health professionals: helping to make soup.

For many years, we have known of deficits in our system of training mental health professionals, particularly in recognizing and integrating diversity. Recently, we have begun to understand that our literature must more authentically reflect the experiences of all people that we serve. The current paper suggests that a comprehensive biopsychosocial conceptualization of normal and abnormal behavior for all individuals is necessary to truly begin to reduce mental health disparities. The authors argue that factors such as racial, ethnic and cultural differences must be integrated into research before the literature will begin to change in a fashion that is beneficial to the mental health training process.

Mental health disparities, diversity, and cultural competence in medical student education: how psychiatry can play a role.

OBJECTIVE: The authors review recent developments in healthcare policy, including eliminating disparities in mental healthcare, increasing diversity in the healthcare workforce, and cultural competence. Following a discussion of the Liaison Committee on Medical Education (LCME) standards, as they relate to disparity, cultural competence, and diversity, the authors discuss an action plan describing the role of psychiatry in addressing these issues. METHODS: Key policy documents are reviewed for disparities, cultural competence, and diversity in healthcare and then in mental health specifically. RESULTS: Important developments in healthcare policy regarding these areas have occurred. CONCLUSION: Psychiatry can play a vital role in addressing disparities, cultural competence, and diversity in medical student education.

Race and ethnicity, mental health services and cultural competence in the criminal justice system: are we ready to change?

By the end of 2003, 3.2% of the U.S. adult population or 6.9 million adults were incarcerated, on probation or on parole. While non-whites constitute approximately 25% of the general U.S. population, they represent the majority of the prison (62%) and jail population (57%), a 33% increase since 1980. Approximately 15% of this prison and jail population has active symptoms of serious mental illness with two-thirds likely to have a co-occurring substance use disorder diagnosis. Meanwhile, the lack of adequate mental health and substance abuse treatment within all levels of the criminal justice system continues to exist. This is further exaggerated by the dearth of evidence showing appropriate cultural awareness and competence in delivery of these much needed services to a majority non-white population. This article will review the existing racial disparities present in the criminal justice system, the lack of appropriate psychiatric services, and the effect of cultural dissonance in service provision when services do exist. Policy implications and recommendations are included in the conclusion with a call for action to all agencies directly and indirectly affected by this multifaceted problem.

Outpatient prescriptions for atypical antipsychotics for African Americans, Hispanics, and whites in the United States.

BACKGROUND: New antipsychotic medications introduced during the past decade-clozapine (1990), risperidone (1994), olanzapine (1996), and quetiapine fumarate (1997)-offer a decrease in serious adverse effects compared with traditional antipsychotic medications, but at up to 10 times the cost. We examined whether ethnic minorities achieve access to these new advanced treatments. METHODS: Using national data on physician office and hospital outpatient department visits from the National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey from 1992 through 2000, we selected all patient visits at which an antipsychotic medication (atypical or traditional) was prescribed or continued and the patient was aged between 18 and 69 years. We performed a series of cross-sectional logistic regression analyses to determine the association of ethnic group and receipt of an atypical antipsychotic prescription over time, adjusted for potential confounders such as age, diagnosis, and health insurance type. RESULTS: Antipsychotic medication was prescribed or continued in 5032 visits; 33% of overall visits involved an atypical antipsychotic prescription. During 1992 to 1994, the adjusted relative odds of receipt of an atypical antipsychotic prescription for African Americans was 0.50 (95% confidence interval [CI], 0.26-0.96) and for Hispanics was 0.43 (95% CI, 0.16-1.18) compared with whites. During 1995 to 1997, the odds of receipt of a prescription for atypical antipsychotics increased for African Americans (odds ratio [OR], 0.69; 95% CI, 0.54-0.85) and for Hispanics (OR, 0.84; 95% CI, 0.65-1.07) compared with whites; and during 1998 to 2000, the relative odds continued to increase for African Americans (OR, 0.88; 95% CI, 0.78-0.97) and for Hispanics (OR, 1.05; 95% CI, 0.92-1.16) compared with whites. For visits specified for psychotic disorders, receipt of atypical antipsychotics was still lower for African Americans by 1998 to 2000 (adjusted OR, 0.74; 95% CI, 0.61-0.89) compared with whites, while for Hispanics the relative odds was equivalent (adjusted OR, 1.05; 95% CI, 0.87-1.19). CONCLUSION: Early gaps between ethnic groups in receipt of atypical antipsychotic prescriptions decreased throughout the 1990s but persisted for African Americans with psychotic disorders.

The acceptability of a culturally-tailored depression education videotape to African Americans.

The aim of this project was to determine the acceptability and usefulness of an educational videotape for African Americans with depression. Four focus groups were held in two community settings and at a historically black university. Subjects included 24 African Americans, aged 18-76 years, who screened positive for depression. Focus group questions addressed the usefulness of the videotape to understand depression and its treatment, the most and least effective parts of the videotape, and the cultural appropriateness of the information presented. Participants took pre- and post-tests on attitudes about depression. Discussions were audiotaped, transcribed, and reviewed independently by two investigators to identify and group comments into specific themes. Two other investigators reviewed the themes and comments for consistency and relevance. The videotape was generally well received and was rated effective in improving knowledge about depression and its treatment. After watching the videotape, attitudes improved in several areas, including depression as a medical illness, effectiveness of treatment, negative perceptions of antidepressant medication and reliance upon spirituality to heal depression. This culturally tailored videotape about depression is deemed acceptable and effective for most African Americans with depression participating in focus groups. It also improved knowledge and several attitudes about depression.