College student mental health, treatment utilization, and reduced enrollment: Findings across a state university system during the COVID-19 pandemic.

Objective: This study measured the rate of college student mental health concerns and mental health service utilization. The roles of mental health and seeking treatment regarding anticipated enrollment were explored. Methods: One thousand eight hundred thirty-one randomly selected students participated in this online survey. Results: Most students reported clinically significant symptoms (88.3%), and many sought treatment in the past year (28.8%). Most students had favorable attitudes toward telemental health. Barriers to seeking care included a preference for self-management of symptoms (68.8%) and limited time (43.3%). Mental health was the most commonly reported reason for anticipating reduced enrollment (ps < .001), and these individuals were more likely to seek treatment. Conclusions: Past and anticipated use of mental health treatment likely exceeds on-campus capacity. Student mental health and retention are linked, and treatment may support retention. Nontraditional services, including telemental health, could help address increasing symptom severity and demand for services.

A Graduate Medical Orientation Intervention Focused on Local Health Inequities.

Background: Residents must understand the social drivers of health in the communities they serve to deliver quality care. While resident orientation provides an opportunity to introduce residents to social and structural drivers of health, inequity, and care delivery relevant to the patient population in their new communities, many graduate medical education orientation curricula do not include this content. Objective: To report the development and implementation of a novel, patient-centered health equity orientation curriculum, including initial feasibility and acceptability data as well as preliminary self-reported outcomes. Methods: The curriculum was developed by academic faculty in collaboration with institutional and local health equity champions. Content centered on the history of inequities and racism within the local communities and included didactic presentations, asynchronous video, and virtual site visits to community resource groups. The curriculum was administered to all 2021 incoming Vanderbilt University Medical Center medical and surgical residents (N=270) over 2 half-days, both in-person and via Zoom. Data were collected anonymously via pre- and post-surveys. Results: A total of 216 residents (80% response rate) provided pre-survey response data, but only 138 residents (51.1%) provided post-survey data, including self-reported demographics (eg, underrepresented in medicine status) and level of agreement with 10 competency-based statements coded as pertaining to knowledge, skills, behaviors, or attitudes (KSBAs). Primary outcomes included improvement in residents' KSBAs from pre- to post-survey. The greatest increases in percentages occurred with content that was specific to local history and population. Conclusions: In a class of incoming residents, this study demonstrated feasibility, acceptability, and pre-post curriculum improvement in self-reported KSBAs when addressing health equity issues.

A Lifestyle Risk Reduction Model for Preventing High-Risk Substance Use Across the Lifespan.

While effective models of alcohol and drug prevention exist, they often focus solely on youth or young adults. This article describes the Lifestyle Risk Reduction Model (LRRM), an approach applicable across the lifespan. The intent behind the LRRM is to guide the development of prevention and treatment programs provided to individuals and small groups. The LRRM authors' goals are to help individuals reduce risk for impairment, addiction, and substance use's negative consequences. The LRRM identifies six key principles that conceptualize the development of substance-related problems by drawing parallels with health conditions, such as heart disease and diabetes, which often result from combined effects of biological risk and behavioral choices. The model also proposes five conditions that describe important steps for individuals as they progress toward greater perception of risk and lower risk behavior. One LRRM-based indicated prevention program (Prime For Life) shows positive results in cognitive outcomes and in impaired driving recidivism for people across the lifespan. The model emphasizes common elements across the lifespan, responds to contexts and challenges that change across the life course, complements other models, and is usable for universal, selective, and indicated prevention programs.

The measurement of college athletes' knowledge and behavior on pre- and post-workout nutrition utilizing a text message intervention.

Objective: The purpose of this study was to measure college student athletes' nutrition knowledge and behavior before and after a text message-based educational intervention. Participants: Athletes (n = 35) participated by completing a pre- and post-intervention survey. Methods: This survey gathered information on ability to identify carbohydrate and protein food sources, pre-and post-workout intake, and behavior. Text messages were sent during the 4-week intervention and included information regarding the importance of carbohydrate consumption before training, and a carbohydrate-protein mixture for recovery. Results: Dependent t-tests revealed a lack of statistically significant increases in total knowledge (p = 0.156) or behavior (p = 0.177), but an increase in the behavior questions regarding efficacy of carbohydrate before training (p = 0.026) and carbohydrate and protein after training (p = 0.016). Conclusion: This suggests the text message educational intervention did influence behavioral outcomes. Future research should focus on the effectiveness, length, and frequency of the text message intervention, and investigate the athletes' willingness to change dietary behaviors.

Predicting benzodiazepine prescriptions: A proof-of-concept machine learning approach.

Introduction: Benzodiazepines are the most commonly prescribed psychotropic medications, but they may place users at risk of serious adverse effects. Developing a method to predict benzodiazepine prescriptions could assist in prevention efforts. Methods: The present study applies machine learning methods to de-identified electronic health record data, in order to develop algorithms for predicting benzodiazepine prescription receipt (yes/no) and number of benzodiazepine prescriptions (0, 1, 2+) at a given encounter. Support-vector machine (SVM) and random forest (RF) approaches were applied to outpatient psychiatry, family medicine, and geriatric medicine data from a large academic medical center. The training sample comprised encounters taking place between January 2020 and December 2021 (N = 204,723 encounters); the testing sample comprised data from encounters taking place between January and March 2022 (N = 28,631 encounters). The following empirically-supported features were evaluated: anxiety and sleep disorders (primary anxiety diagnosis, any anxiety diagnosis, primary sleep diagnosis, any sleep diagnosis), demographic characteristics (age, gender, race), medications (opioid prescription, number of opioid prescriptions, antidepressant prescription, antipsychotic prescription), other clinical variables (mood disorder, psychotic disorder, neurocognitive disorder, prescriber specialty), and insurance status (any insurance, type of insurance). We took a step-wise approach to developing a prediction model, wherein Model 1 included only anxiety and sleep diagnoses, and each subsequent model included an additional group of features. Results: For predicting benzodiazepine prescription receipt (yes/no), all models showed good to excellent overall accuracy and area under the receiver operating characteristic curve (AUC) for both SVM (Accuracy = 0.868-0.883; AUC = 0.864-0.924) and RF (Accuracy = 0.860-0.887; AUC = 0.877-0.953). Overall accuracy was also high for predicting number of benzodiazepine prescriptions (0, 1, 2+) for both SVM (Accuracy = 0.861-0.877) and RF (Accuracy = 0.846-0.878). Discussion: Results suggest SVM and RF algorithms can accurately classify individuals who receive a benzodiazepine prescription and can separate patients by the number of benzodiazepine prescriptions received at a given encounter. If replicated, these predictive models could inform system-level interventions to reduce the public health burden of benzodiazepines.

Multidimensional Evaluation of Screening Brief Intervention and Referral to Treatment Training for Medical Students.

OBJECTIVE: Screening, Brief Intervention, and Referral to Treatment (SBIRT) is an evidence-based approach to identifying and addressing alcohol use in non-specialty settings. Many medical schools teach SBIRT, but most published evaluations of these efforts exclude rigorous skill assessments and teaching methods. METHODS: During the 2017-2018 academic year, 146 third-year medical students received classroom-based learning on SBIRT and motivational interviewing (MI) and at least two SBIRT practices with feedback as part of a 4-week psychiatry clerkship. The objective of this curriculum was to improve SBIRT knowledge, attitudes, and confidence and enable learners to skillfully deliver SBIRT. Outcomes evaluated included satisfaction, knowledge, attitudes and confidence, and clinical skill in delivering SBIRT to a standardized patient (rated by the actor, as well as an expert). RESULTS: Results indicated acceptable satisfaction at post-curriculum and significant improvements in attitudes and knowledge from pre- to post-curriculum. On the clinical skills exam, all students were rated as having mastered at least 80% of SBIRT elements by standardized patients and 91.8% were rated at this level by a faculty expert. Student attitudes and knowledge were unrelated to expert ratings, and standardized patient ratings had limited associations with expert ratings. CONCLUSIONS: These results suggest curriculum objectives were achieved and provide unique contributions to the SBIRT curricular outcome research for healthcare trainees. Other findings included that trainee knowledge and confidence may not relate to skill, and standardized patient feedback provides different information on SBIRT and MI skill than expert ratings.

Effects of video technology on cooking self-efficacy of college students.

OBJECTIVE: The objective of this study was to test the effect of video technology on cooking self-efficacy in undergraduate college students living off-campus at a public Midwestern University. PARTICIPANTS: 71 undergraduate college students living off-campus at a large Midwestern University. METHODS: Online surveys assessing changes in self-efficacy, number of meals cooked per week, and barriers to cooking. RESULTS: There were statistically significant improvements from pretest to post-test cooking self-efficacy scores for participants but no statistically significant differences between pretest and post-test number of meals cooked per week. There were no statistical differences between recipe intervention groups. CONCLUSIONS: Students reported confidence in cooking skill, but lacked time and equipment associated with cooking healthy meals. Overall, the use of video technology was effective at improving self-efficacy for cooking if meals are simple and short, and videos are short to maintain viewer attention.

A controlled examination of acute warning signs for suicide attempts among hospitalized patients.

BACKGROUND: Near-term risk factors for suicidal behavior, referred to as 'warning signs' (WS), distinguish periods of acute heightened risk from periods of lower risk within an individual. No prior published study has examined, using a controlled study design, a broad set of hypothesized WS for suicide attempt. This study addressed this gap through examination of hypothesized behavioral/experiential, cognitive, and affective WS among patients recently hospitalized following a suicide attempt. METHODS: Participants were recruited during hospitalization from five medical centers across the USA including two civilian hospitals and three Veterans Health Administration facilities (n = 349). A within-person case-crossover study design was used, where each patient served as her/his own control. WS were measured by the Timeline Follow-back for Suicide Attempts Interview and were operationalized as factors that were present (v. absent) or that increased in frequency/intensity within an individual during the 6 h preceding the suicide attempt (case period) compared to the corresponding 6 h on the day before (control period). RESULTS: Select WS were associated with near-term risk for suicide attempt including suicide-related communications, preparing personal affairs, drinking alcohol, experiencing a negative interpersonal event, and increases in key affective (e.g. emptiness) and cognitive (e.g. burdensomeness) responses. CONCLUSIONS: The identification of WS for suicidal behavior can enhance risk recognition efforts by medical providers, patients, their families, and other stakeholders that can serve to inform acute risk management decisions.

Low-Burden Universal Substance Use Screening in a Primary Care Clinic to Lower Implementation Barriers.

Universal substance use screening in primary care can proactively identify patients for intervention, though implementation is challenging. This project developed a strategy for universal low time- and labor-cost screening, brief intervention, and referral for treatment (SBIRT) in an HIV primary care clinic at an academic medical center in the Southeastern USA. Screening was implemented using a tablet computer that calculated results in real time and suggested motivational language for provider response. A brief intervention (BNI) was conducted by a trained professional as needed, preventing the need for all clinic providers to be competent in motivational interviewing (MI). More than 1868 patients were screened in 12 months, with an MI intervention conducted for 101 patients with higher risk use. Forty-four patients were referred for in-clinic treatment, compared to nine in the previous year. Computer-based, self-administered screening with real-time linkage to a BNI can allow recommended screening with low provider burden.

Users of cannabis-only are less likely to accept brief interventions than other substance use profiles in a sample of people living with HIV/AIDS.

BACKGROUND AND OBJECTIVES: Research has shown that people living with HIV/AIDS (PLWHA) engage in increased rates of substance use, which has a number of potential negative health outcomes. Increased legalization of cannabis is likely to further increase the availability and use of cannabis in this population. Efforts have been made to integrate screening and intervention resources as part of an individual's routine healthcare visits. Though brief approaches such as Screening and Brief Intervention (SBIRT) have shown promise in addressing alcohol use, results are mixed in addressing cannabis use. The present study investigated how individuals reporting cannabis use responded to an invitation to engage in a brief negotiated intervention (BNI). METHODS: PLWHA participated in a self-administered tablet computer-based version of SBIRT. Patients screened as having at-risk, high-risk, or dependent substance use (N = 331) were eligible to receive the BNI. Of these patients, 101 reported cannabis-only use, with or without alcohol. RESULTS: Binary logistic regressions controlling for Alcohol Use Disorders Identification Test and Drug Abuse Screening Test score and demographics, found that cannabis-only use was significantly related to declining the BNI. DISCUSSION AND CONCLUSIONS: Cannabis-only engagement predicts lower BNI acceptance rates than other substance use profiles; inappropriate screening tools may be one reason for this discrepancy. Implications and directions for future research are discussed. SCIENTIFIC SIGNIFICANCE: Findings are relevant in modifying SBIRT for cannabis use. To our knowledge, this is the first work to evaluate acceptance of brief interventions for cannabis as compared to other substances and brief intervention acceptance in a sample of PLWHA.

The Status of SBIRT Training in Health Professions Education: A Cross-Discipline Review and Evaluation of SBIRT Curricula and Educational Research.

PURPOSE: To assess the quality of curricular research on the Screening Brief Intervention and Referral to Treatment (SBIRT) approach and determine the presence of useful training modalities, particularly motivational interviewing (MI) training, across health care training curricula. METHOD: The authors conducted a systematic review of published, peer-reviewed studies in PubMed, ERIC, CINAHL, Ovid HealthSTAR, and PsycINFO databases through March 2021 for English-language studies describing SBIRT, a curriculum for health care trainees, and curricular intervention outcomes. After the records were independently assessed, data were extracted and 20% of the studies were double-coded for interrater reliability. RESULTS: Of 1,856 studies, 95 were included in the review; 22 had overlapping samples and were consolidated into 10 nested studies, leaving 83 total. Interrater reliability ranged from moderate (κ = .74, P < .001) to strong (κ = .91, P < .001) agreement. SBIRT training was delivered to trainees across many professions, including nursing (n = 34, 41%), medical residency (n = 28, 34%), and social work (n = 24, 29%). Nearly every study described SBIRT training methods (n = 80, 96%), and most reported training in MI (n = 54, 65%). On average, studies reported 4.06 (SD = 1.64) different SBIRT training methods and 3.31 (SD = 1.59) MI training methods. Their mean design score was 1.92 (SD = 0.84) and mean measurement score was 1.89 (SD = 1.05). A minority of studies measured SBIRT/MI skill (n = 23, 28%), and 4 studies (5%) set a priori benchmarks for their curricula. CONCLUSIONS: SBIRT training has been delivered to a wide range of health care trainees and often includes MI. Rigor scores for the studies were generally low due to limited research designs and infrequent use of objective skill measurement. Future work should include predefined training benchmarks and validated skills measurement.

Treatment-resistant depression with anhedonia: Integrating clinical and preclinical approaches to investigate distinct phenotypes.

In our clinical work with treatment-resistant depressed (TRD) patients, certain patterns have emerged in terms of patients' presentations of anhedonia. Multiple studies have investigated anhedonia either as a state or a trait variable in depression, but anhedonia is a multifaceted construct and, as we better understand anhedonia, we increase our ability to measure and treat it. With the aim of personalizing medicine for more efficacious treatments, this paper focuses on clinical patterns we have seen in anhedonic TRD and argues for studies to be done in support of translational, face, and construct validity. Three representative clinical presentations of TRD with anhedonia are described: a congenital type, a stress-induced type, and a type exacerbated by medication. Each case is followed with discussion relating the clinical features to clinical and preclinical research relevant to putative mechanisms for the case. Animal models that are best suited to investigate and validate the existence of etiologies and mechanisms underlying anhedonia constructs unique to each case are proposed, as are potential directions for research in humans.

Predicting Posttraumatic Stress Disorder Among Survivors of Recent Interpersonal Violence.

A substantial minority of women who experience interpersonal violence will develop posttraumatic stress disorder (PTSD). One critical challenge for preventing PTSD is predicting whose acute posttraumatic stress symptoms will worsen to a clinically significant degree. This 6-month longitudinal study adopted multilevel modeling and exploratory machine learning (ML) methods to predict PTSD onset in 58 young women, ages 18 to 30, who experienced an incident of physical and/or sexual assault in the three months prior to baseline assessment. Women completed baseline assessments of theory-driven cognitive and neurobiological predictors and interview-based measures of PTSD diagnostic status and symptom severity at 1-, 3-, and 6-month follow-ups. Higher levels of self-blame, generalized anxiety disorder severity, childhood trauma exposure, and impairment across multiple domains were associated with a pattern of high and stable posttraumatic stress symptom severity over time. Predictive performance for PTSD onset was similarly strong for a gradient boosting machine learning model including all predictors and a logistic regression model including only baseline posttraumatic stress symptom severity. The present findings provide directions for future work on PTSD prediction among interpersonal violence survivors that could enhance early risk detection and potentially inform targeted prevention programs.

Ice-Cream Substitute for Patients With Kidney Failure.

OBJECTIVE: Quality of life for patients with kidney failure is less than similar-aged, general population counterparts. A large part of the decrease in quality of life is from the change of diet and nutritional restrictions. One way to combat this decrease in quality of life is through oral nutrition supplements. METHODS: An ice-cream substitute product was developed for patients with kidney failure on peritoneal dialysis. The product consisted of an ice-cream-like base of rice milk, egg whites, evaporated coconut milk, sugar, and vanilla bean paste. Two flavors were then created: cinnamon and lemon. Both flavors were tested subjectively and objectively. Sensory taste testing was with peritoneal dialysis patients using a Likert scale ballot with a comment section. Texture analysis was completed using a CT3 Brookfield texture analyzer. The results from the sensory testing (taste, texture, overall acceptability) and the texture analysis were analyzed using paired-samples t-tests. Nutritional analysis for the product was calculated. RESULTS: The sensory test of taste, texture, and overall acceptability between the two flavors was not found to be statistically different between the cinnamon and lemon. Similarly, the objective results were also not statistically significant between the two flavors. CONCLUSION: Based on the nutritional analysis, both the lemon and the cinnamon flavors were found to be "good" sources of protein when compared with the Food and Drug Administration's definition of a "good" source of protein. In addition, patients found the sensory aspects of both flavors to be slightly to moderately likable.

Practice and Dissemination of Motivational Interviewing: A Psychology Internship Curriculum.

Sufficient training in substance use issues has been identified as a common gap in professional psychology graduate training. Satisfactory training in evidence-based practices has also been identified as a common gap for providers who care for individuals with substance use problems. The "practice and dissemination" curriculum we developed seeks to address both of these gaps during the predoctoral internship training year by first training psychology interns to competently deliver motivational interviewing (MI) to individuals with substance use problems and then train community providers and volunteers to do so. From 2012-2013, a total of 55 community providers and volunteers from a homeless shelter, a substance use treatment facility, and a community mental health facility received training in MI through this curriculum by attending continuing education events delivered by 17 psychology interns. Evaluation of the dissemination portion of the curriculum as part of an exempt educational research project revealed that community providers were able to achieve significant increases in MI knowledge, readiness to implement MI, and MI skill as assessed with a video analogue measure by the end of the workshop. They also reported satisfaction with the workshop. These evaluation findings provide preliminary support for the curriculum as a novel and efficacious way to disseminate MI to community providers. Research is necessary to determine long-term outcomes of such training and to identify strategies to overcome potential barriers such as the substantial faculty effort necessary to implement the intensive curriculum.

Dynamics and determinants of cortisol and alpha-amylase responses to repeated stressors in recent interpersonal trauma survivors.

BACKGROUND: Alterations in major stress response systems are present during the immediate aftermath of trauma and may play a role in determining risk for developing posttraumatic stress disorder (PTSD). However, the dynamics and determinants of stress responses during this acute recovery phase, and their relevance for longitudinal clinical course and prognosis, have yet to be fully examined. The objectives of the present study were to characterize stress response and habituation patterns to repeated social stressors in women who recently experienced interpersonal trauma and to determine the extent to which these stress responses were associated with PTSD during prospective follow-up. METHOD: This longitudinal study examined salivary cortisol and alpha-amylase and heart rate (HR) responses to repeated stressors in 98 young women (ages 18-30). Participants included women who had experienced an incident of interpersonal trauma (i.e., physical and/or sexual assault) in the three months prior to their baseline assessment (n = 58) and a comparison group of healthy, non-traumatized women (n = 40). Women completed the Trier Social Stress Test (TSST), clinical interviews to evaluate posttraumatic stress symptom severity at the baseline assessment and again at 1-, 3-, and 6-month follow-ups. RESULTS: Multilevel models revealed a pattern of robust initial cortisol TSST responses and habituation across successive TSSTs; alpha-amylase and HR responses showed no evidence of habituation across TSSTs. Among interpersonal trauma survivors, current PTSD status was associated with more pronounced cortisol responses to the first TSST. Survivors exhibited similarly blunted cortisol responses across follow-up TSSTs regardless of PTSD status, suggesting habituation of cortisol responses among survivors who developed PTSD. PTSD re-experiencing symptoms were uniquely associated with blunting of cortisol TSST responses. CONCLUSION: Findings suggest that PTSD as a diagnostic entity is meaningfully associated with cortisol responses to repeated social stressors. Social-evaluative threat is a salient form of danger for interpersonal trauma survivors. Identifying the determinants of cortisol (non)habituation to repeated social-evaluative threat among interpersonal trauma survivors could inform the development of early interventions for PTSD.

Motivational interviewing quality assurance: A systematic review of assessment tools across research contexts.

The need for sustained skill development and quality assurance when executing behavioral interventions is best demonstrated in the empirical evolution of Motivational Interviewing (MI). As a brief behavioral intervention that identifies the therapeutic process as an active treatment ingredient, it is critical for researchers, trainers, and administrators to use psychometrically sound and theoretically congruent tools to evaluate provider skills and fidelity when executing MI. Yet, no prior work has evaluated the breadth of MI tools employed across research contexts. Therefore, this review identified MI fidelity and skill development tools across measurement, training and efficacy/effectiveness studies and evaluated their psychometric strength and fit with current MI theory. We identified 199 empirical studies that employed an MI fidelity/skill tool and we found 21 tools with varying degrees of empirical support and theoretical congruence. Specifically, we identified five observer-, two trainee- and one client-rated tool with strong empirical support, and nine observer- and two client-rated tools with preliminary empirical support. We detailed the empirical strength, including the extent to which tools were linked to trainee/client outcomes across research contexts and offer recommendations on which MI tools to use in training, efficacy, and effectiveness trials.

Post-sexual assault cigarette smoking: Findings from a randomized clinical trial of a video-based intervention.

Sexual assault (SA) is associated with elevated risk for cigarette smoking. The current study tested whether a brief video intervention delivered in the emergency department was effective at reducing smoking following SA. Participants were 233 girls and women (age 15+) who received a SA medical forensic examination (SAMFE) and were randomized to one of three conditions: 1) Prevention of Post-Rape Stress (PPRS), a brief video designed to reduce post-SA psychopathology; 2) Pleasant Imagery and Relaxation Information (PIRI), an active control video involving relaxation training; and 3) treatment as usual (TAU). Among those who participated at baseline, 154 participants completed at least one follow-up at 1.5, 3, and 6 months after the SAMFE. Participants reported the number of days of smoking and the average number of cigarettes smoked per day in the two weeks prior to the sexual assault as well as in the two weeks prior to each follow-up. Two-thirds (68.8%) of participants smoked prior to the SA or during any follow-up. One-fifth of participants who did not smoke prior to the SA smoked at one or more follow-ups. Smoking declined on average over follow-up although TAU was associated with increased initial smoking compared to PPRS; PPRS and PIRI did not differ. SA contributes to increases in smoking and the PPRS, a brief and cost-effective video-based intervention delivered during the SAMFE, can protect against increases in post-SA smoking. Trial registration: NCT01430624.

Registered dietitian nutritionists and perceptions of liberalizing the hemodialysis diet.

BACKGROUND/OBJECTIVES: The objective of this study was to assess the level of awareness, comfort, and likelihood of liberalizing the hemodialysis diet in practicing renal registered dietitian nutritionists (RDN). SUBJECTS/METHODS: An original, cross-sectional survey was sent to the Academy of Nutrition and Dietetics' Renal Practice Group in May 2017, consisting primarily of renal dietitians. RESULTS: A total of 187 renal dietitians responded to the survey designed to assess their current practices regarding the renal diet for hemodialysis patients and how comfortable they would be liberalizing the current restrictions. On average, 16.3% of dietitians are extremely likely to liberalize the restrictions on various food groups including fruits and vegetables, beans and legumes, and whole grains. CONCLUSIONS: RDN feel confident in their ability to interpret and apply evidence-based literature into practice, and they are moderately comfortable liberalizing the renal diet. The participants were generally more comfortable liberalizing the phosphorus restriction than the potassium restriction, and the sodium restriction remains important to control interdialytic weight gain and hypertension. Future research is needed to establish efficacy of a liberalized diet as well as interventions to help RDN feel more comfortable implementing a liberalization of the renal diet.

It's time to start asking all patients about intimate partner violence.

Many people endure a menacing or violent romantic partner--yet few physicians ask about this risk, or actual harm. Here is a roadmap for screening.