Barriers to COVID-19 Prevention Measures Among People Experiencing Homelessness with Substance Use Disorder or Serious Mental Illness.

People experiencing homelessness (PEH) are at disproportionate risk of becoming infected and having severe illness from coronavirus disease 2019 (COVID-19), especially when residing in congregate settings like homeless shelters. Behavioral health problems related to substance use disorder (SUD) and severe mental illness (SMI) may have created additional challenges for PEH to practice prevention measures like mask wearing, physical distancing, handwashing, and quarantine and isolation. The study objective was to understand the perceived barriers PEH face regarding COVID-19 non-pharmaceutical prevention strategies and identify recommendations for overcoming barriers. From August-October 2020, qualitative phone interviews with 50 purposively selected behavioral health professionals across the United States serving PEH with SUD or SMI were conducted. Professionals described that PEH faced barriers to prevention that were structural (e.g., access to necessary resources), behavioral (related to SUD or SMI), or related to the priority of other needs. Recommendations to overcome these barriers included providing free prevention resources (e.g., masks and hand sanitizer), providing education about importance of prevention strategies, and prioritizing access to stable housing. Interviews took place before COVID-19 vaccines were available, so barriers to vaccination are not included in this paper. Findings can help support tailored approaches during COVID-19 and future public health threats.

Impact of Social Isolation during the COVID-19 Pandemic on Mental Health, Substance Use, and Homelessness: Qualitative Interviews with Behavioral Health Providers.

The United States is experiencing a syndemic of homelessness, substance use disorder, and mental health conditions, which has been further exacerbated by the COVID-19 pandemic. Although it is expected that mitigation strategies will curb community transmission of COVID-19, the unintended consequences of social isolation on mental health and substance use are a growing public health concern. Awareness of changing mental health and substance use treatment needs due to the pandemic is critical to understanding what additional services and support are needed during and post-pandemic, particularly among people experiencing homelessness who have pre-existing serious mental illness or substance use disorder. To evaluate these effects and support our understanding of mental health and substance use outcomes of the COVID-19 pandemic, we conducted a qualitative study where behavioral health providers serving people experiencing homelessness described the impact of COVID-19 among their clients throughout the United States. Behavioral health providers shared that experiencing social isolation worsened mental health conditions and caused some people to return to substance use and fatally overdose. However, some changes initiated during the pandemic resulted in positive outcomes, such as increased client willingness to discuss mental health topics. Our findings provide additional evidence that the social isolation experienced during the pandemic has been detrimental to mental health and substance use outcomes, especially for people experiencing homelessness.

Dialog Across Cultures: Therapy for Diverse Families.

Child and adolescent psychiatrists (CAPs) work at the intersections of families, cultures, and systems, which affect engagement in care, assessment, and treatment planning. There are several practical strategies that CAPs can apply to practice cultural humility, to join with families, to facilitate difficult conversations and to work through misalignment. Culturally inclusive family-based care can promote greater understanding and lead to stronger outcomes with families as well as help mitigate mental health impact of structural racism and social inequities.

Behavioral Health Providers' Experience with Changes in Services for People Experiencing Homelessness During COVID-19, USA, August-October 2020.

The COVID-19 pandemic caused disruptions in behavioral health services (BHS), essential for people experiencing homelessness (PEH). BHS changes created barriers to care and opportunities for innovative strategies for reaching PEH. The authors conducted 50 qualitative interviews with behavioral health providers in the USA during August-October 2020 to explore their observations of BHS changes for PEH. Interviews were transcribed and entered into MAXQDA for analysis and to identify salient themes. The largest impact from COVID-19 was the closure or limited hours for BHS and homeless shelters due to mandated "stay-at-home" orders or staff working remotely leading to a disconnection in services and housing linkages. Most providers initiated telehealth services for clients, yielding positive outcomes. Implications for BHS are the need for long-term strategies, such as advances in communication technology to support BHS and homeless services and to ensure the needs of underserved populations are met during public health emergencies.

Graduating With Honors in Resilience: Creating a Whole New Doctor.

BACKGROUND: Although coaching programs have become a prominent piece of graduate medical education, they have yet to become an integral part of undergraduate medical education. A handful of medical schools have utilized longitudinal coaching experiences as a method for professional identity formation, developing emotional intelligence and leadership. OBJECTIVE: We developed A Whole New Doctor (AWND), a medical student leadership development and coaching program at Georgetown University, with the aim of fostering resilience, leadership, and emotional intelligence at the nascent stage of physician training. To our knowledge, ours is the only program that is largely student-managed and uses certified executive coaches in the medical student population. METHODS: Cohort 1 of AWND started in October 2016. For each cohort, we hold a kickoff workshop that is highly interactive, fast-paced and covers coaching, complex thinking, reflective writing, and a coaching panel for Q&A. Following the workshop, students work with coaches individually to address self-identified weaknesses, tensions, and areas of conflict. We believe the program's student-driven nature provides a new structural approach to professional development and leadership programs, offering students a simultaneously reflective and growth-oriented opportunity to develop essential non-technical skills for physician leaders. RESULTS: Of the 132 students in the program, 107 have worked with one of our coaches (81%). Student testimonials have been uniformly positive with students remarking on an increased sense of presence, improvements in communication, and more specific direction in their careers. CONCLUSION: Our pilot coaching program has received positive feedback from students early in their medical training. It will be important to further scale the program to reach an increasing number of students and quantitatively evaluate participants for the long-term effects of our interventions.

Carisoprodol withdrawal induced delirium: A case study.

A 43-year-old woman with chronic back pain found relief by taking carisoprodol, a centrally acting skeletal muscle relaxant. She had acquired large amounts of the prescription medication through the Internet and was taking approximately three hundred 350 mg tablets each week, at times up to fifty tablets per day. She then abruptly stopped the medication and presented to the emergency room one week later with waxing and waning attention, confusion, disorientation and visual hallucinations. Oral lorazepam was dosed according to a protocol employing the Clinical Institute Withdrawal Assessment of Alcohol Scale (CIWA). Her symptoms of delirium resolved rapidly and she was discharged home on day three. A review of the literature did not show any other reports of carisoprodol withdrawal induced delirium. Such withdrawal symptoms could be expected as the mechanism of action of carisoprodol is similar to that of hypnotic sedatives. Its availability and ease with which it can be acquired through the Internet puts it at great risk for a drug of abuse.

Efficacy and tolerability of doxazosin and finasteride, alone or in combination, in treatment of symptomatic benign prostatic hyperplasia: the Prospective European Doxazosin and Combination Therapy (PREDICT) trial.

OBJECTIVES: To evaluate the efficacy and tolerability of the selective alpha(1)-adrenergic antagonist doxazosin and the 5-alpha-reductase inhibitor finasteride, alone and in combination, for the symptomatic treatment of benign prostatic hyperplasia. METHODS: In a prospective, double-blind, placebo-controlled trial, 1095 men aged 50 to 80 years were randomized to treatment for 52 weeks with doxazosin, finasteride, the combination of doxazosin and finasteride, or placebo. The dose of finasteride (or its matched placebo) was 5 mg/day. Doxazosin (or its matched placebo) was initiated at 1 mg/day, and titrated up to a maximum of 8 mg/day over approximately 10 weeks according to the response of the maximal urinary flow rate (Qmax) and International Prostate Symptom Score (IPSS). The IPSS and Qmax were assessed at baseline and at weeks 10, 14, 26, 39, and 52 or at the endpoint. RESULTS: An intent-to-treat analysis of 1007 men showed doxazosin and doxazosin plus finasteride combination therapy produced statistically significant improvements in total IPSS and Qmax compared with placebo and finasteride alone (P <0.05). Finasteride alone was not significantly different statistically from placebo with respect to total IPSS and Qmax. All treatments were generally well tolerated. CONCLUSIONS: Doxazosin was effective in improving urinary symptoms and urinary flow rate in men with benign prostatic hyperplasia, and was more effective than finasteride alone or placebo. The addition of finasteride did not provide further benefit to that achieved with doxazosin alone.