Integrated model of primary and mental healthcare for the refugee population served by an academic medical centre.

Refugees are at increased risk for developing mental health concerns due to high rates of trauma exposure and postmigration stressors. Moreover, barriers to accessing mental health services result in ongoing suffering within this population. Integrated care-which combines primary healthcare and mental healthcare into one cohesive, collaborative setting-may improve refugees' access to comprehensive physical and mental health services to ultimately better support this uniquely vulnerable population. Although integrated care models can increase access to care by colocating multidisciplinary services, establishing an effective integrated care model brings unique logistic (eg, managing office space, delineating roles between multiple providers, establishing open communication practices between specialty roles) and financial (eg, coordinating across department-specific billing procedures) challenges. We therefore describe the model of integrated primary and mental healthcare used in the International Family Medicine Clinic at the University of Virginia, which includes family medicine providers, behavioural health specialists and psychiatrists. Further, based on our 20-year history of providing these integrated services to refugees within an academic medical centre, we offer potential solutions for addressing common challenges (eg, granting specialty providers necessary privileges to access visit notes entered by other specialty providers, creating a culture where communication between providers is the norm, establishing a standard that all providers ought to be CC'ed on most visit notes). We hope that our model and the lessons we have learned along the way can help other institutions that are interested in developing similar integrated care systems to support refugees' mental and physical health.

Improving Depression Screening in Primary Care: A Quality Improvement Initiative.

The increase in depression during the COVID-19 pandemic underscores the importance of systematic approaches to identify individuals with mental health concerns. Primary care is often underutilized for depression screening, and it is not clear how practices can successfully increase screening rates. This study describes a quality improvement initiative to increase depression screening in five Family Medicine clinics. The initiative included four Plan-Do-Study-Act cycles that resulted in implementing a standardized workflow for depression screening, collaborative efforts with health information technology to prompt providers to perform screening via the medical record, delivering educational materials for providers and clinic staff and conducting follow-up education. Between September 2020 and April 2021 there were 23,745 clinic encounters with adult patients that were analyzed to determine whether patients were up-to-date on depression screening following their visit. A multi-level logistic regression model was constructed to determine the changes in likelihood of a patient being up-to-date on screening over the study period, while controlling for patient demographics and comorbidities. The average proportion of up-to-date patients increased from 61.03% in September 2020 to 82.33% in April 2021. Patients aged 65+ and patients with comorbidities were more likely to be up-to-date on screening; patients with telemedicine visits had lower odds of being up-to-date on depression screening. Overall, this paper describes a feasible, effective intervention to increase depression screening in a primary care setting. Additionally, we discuss lessons learned and recommendations to inform the design of future interventions.

Cultural Considerations in Caring for Refugees and Immigrants.

This article describes the different ways culture affects health care, in terms of patient-related factors, health care provider-related factors, and health care system-related factors. This article also reviews interventions and best practices that draw on the incorporation of culture into health care and that thus may be effective for building cross-cultural understanding between providers and their immigrant and refugee patients.

Perceived Psychological Control in Early Adolescence Predicts Lower Levels of Adaptation into Mid-Adulthood.

This study examined perceived parental psychological control in early adolescence as a critical stressor likely to be associated with lower levels of adaptation into mid-adulthood. A diverse sample of 184 adolescents was followed from age 13 through 32 to assess predictions to adult adaptation. Perceived parental psychological control at age 13 predicted relative decreases in observed support, lower likelihood of being in a romantic relationship, and lower academic attainment (after accounting for grade point average at baseline) by age 32. Many outcomes were mediated by lower levels of psychosocial maturity and peer acceptance in mid-adolescence. Overall, results suggest that perceived parental psychological control in early adolescence potentially undermines autonomy so as to lead to less favorable outcomes well into adulthood.

Interactions between anxiety subtypes, personality characteristics, and emotional regulation skills as predictors of future work outcomes.

INTRODUCTION: This study examined long-term predictive links between different types of anxiety in late adolescence and work-related outcomes in young adulthood. The presence of adaptive personality traits and positive emotion regulation and coping skills were hypothesized to buffer these associations, reducing the negative effects of anxiety on future work outcomes. METHODS: Hypotheses were tested using multi-reporter data from a community sample of 184 youth in the United States followed from ages 17-30. Trait anxiety, anxious arousal, rejection sensitivity, and implicit rejection were each examined in late adolescence as predictors of work-related ambition, work performance, job satisfaction, and career satisfaction in young adulthood. Conscientiousness, grit, emotion regulation (ER) and coping skills were examined as potential moderators. RESULTS: Although trait anxiety was the only anxiety variable directly predictive of work outcomes in regression analyses, personality variables and ER skills interacted with multiple types of anxiety to predict work outcomes. Interestingly, findings reflected a pattern in which a combination of greater conscientiousness and greater anxiety, and greater ER skills and greater anxiety, predicted more positive work outcomes. CONCLUSIONS: These findings not only suggest that the development of traits such as conscientiousness and ER skills may be helpful for youth with higher levels of anxiety, but also that higher levels of anxiety, when appropriately balanced by other qualities, may be adaptive for promoting positive career development for some youth.

The Intensity Effect in Adolescent Close Friendships: Implications for Aggressive and Depressive Symptomatology.

This study examined the effect of close friendship intensity as a potential amplifier of an adolescent's preexisting tendencies toward depressive and aggressive symptoms. A diverse community sample of 170 adolescents and their closest friends was assessed via multiple methods, and adolescents were followed from age 16 to 17. Results supported the hypothesized effect, with more intense close friendships interacting with higher baseline levels of behavioral symptoms to predict greater relative increases in symptoms over time. Effects were observed for both depressive and aggressive symptoms, and appeared with respect to multiple observational measures of friendship intensity. Findings are interpreted as suggesting that seemingly disparate phenomena (e.g., co-rumination for depression and deviancy-training for aggression) may both be dependent upon the intensity of the adolescent's social connections.

Social determinants of sleep disturbance in safety-net primary care: unmet needs, classist discrimination, and anxiety.

BACKGROUND: The 3P model proposes that predisposing, precipitating, and perpetuating factors all play a role in sleep disturbance. OBJECTIVE: The purpose of the current study is to investigate social determinants of sleep disturbance by applying the 3P model to a safety-net primary care setting, specifically by evaluating the role of classism and unmet needs as precipitating factors for sleep disturbance, and anxiety as a perpetuating factor for sleep disturbance. METHODS: Participants (N = 210) were a convenience sample of racially/ethnically diverse adults over the age of 18 (age M = 44.7 years) recruited from a safety-net primary care clinic in an urban area. The study employed a cross-sectional design. Participants completed a survey assessing sleep disturbances, anxiety, unmet needs, classism, social support, and a researcher-generated demographic form. RESULTS AND CONCLUSIONS: The unmet need for affordable long-term housing and greater experiences of classism were associated with more sleep disturbance, suggesting that both acted as precipitating factors. In a structural equation model with adequate fit indices, anxiety mediated the relationships with sleep disturbance for both the unmet need for affordable long-term housing and classism, suggesting that it serves as a perpetuating factor. Medical providers are recommended to explore these potential needs in safety-net primary care when patients present with sleep disturbance or anxiety. Assisting with connections to long-term housing and helping patients counteract and cope with classist discrimination may be effective in improving sleep in safety-net primary care.

Close Friendship Strength and Broader Peer Group Desirability as Differential Predictors of Adult Mental Health.

Middle adolescents' close friendship strength and the degree to which their broader peer group expressed a preference to affiliate with them were examined as predictors of relative change in depressive symptoms, self-worth, and social anxiety symptoms from ages 15 to 25 using multimethod, longitudinal data from 169 adolescents. Close friendship strength in midadolescence predicted relative increases in self-worth and decreases in anxiety and depressive symptoms by early adulthood. Affiliation preference by the broader peer group, in contrast, predicted higher social anxiety by early adulthood. Results are interpreted as suggesting that adolescents who prioritize forming close friendships are better situated to manage key social developmental tasks going forward than adolescents who prioritize attaining preference with many others in their peer milieu.

Brief behavioral interventions at free medical fairs.

Free medical fairs have emerged to compensate for the lack of access to affordable health care in rural areas of the United States. Mental health services are offered less frequently than other medical services, despite a documented need, perhaps due to a belief that mental health interventions could not be effective in a single session. We examined the types of problems presented at three rural medical fairs, and whether single session mental health interventions affected participants' health confidence, distress, or progress toward health-related goals. Problems presented included mental health, legal, financial, tobacco cessation, and relationship problems. Findings indicated that, on average, participants gained health confidence and reduced distress and found the service very helpful. The majority of those reached for phone follow-up reported progress on one or more health goals. Goals that involved manageable steps within the participants' own control, such as gratitude practices or progressive muscle relaxation, were the most likely to be completed. Implementation lessons included the importance of learning about the fairs' cultures, advertising the services, location of services, being proactive in connecting with patients, and preparing resources for community referrals. Overall, findings suggest that mental health interventions can have a positive impact on some people at free medical fairs. Given that tens of thousands of people attend each year, the fairs offer a fruitful opportunity to reach some of our most underserved citizens.

Getting What You Expect: Negative Social Expectations in Early Adolescence Predict Hostile Romantic Partnerships and Friendships Into Adulthood.

Adolescents' negative expectations of their peers were examined as predictors of their future selection of hostile partners, in a community sample of 184 adolescents followed from ages 13 to 24. Utilizing observational data, close friend- and self-reports, adolescents with more negative expectations at age 13 were found to be more likely to form relationships with observably hostile romantic partners and friends with hostile attitudes by age 18 even after accounting for baseline levels of friend hostile attitudes at age 13 and adolescents' own hostile behavior and attitudes. Furthermore, the presence of friends with hostile attitudes at age 18 in turn predicted higher levels of adult friend hostile attitudes at age 24. Results suggest the presence of a considerable degree of continuity from negative expectations to hostile partnerships from adolescence well into adulthood.

The body remembers: Adolescent conflict struggles predict adult interleukin-6 levels.

Struggles managing conflict and hostility in adolescent social relationships were examined as long-term predictors of immune-mediated inflammation in adulthood that has been linked to long-term health outcomes. Circulating levels of interleukin-6 (IL-6), a marker of immune system dysfunction when chronically elevated, were assessed at age 28 in a community sample of 127 individuals followed via multiple methods and reporters from ages 13 to 28. Adult serum IL-6 levels were predicted across periods as long as 15 years by adolescents' inability to defuse peer aggression and poor peer-rated conflict resolution skills, and by independently observed romantic partner hostility in late adolescence. Adult relationship difficulties also predicted higher IL-6 levels but did not mediate predictions from adolescent-era conflict struggles. Predictions were also not mediated by adult trait hostility or aggressive behavior, suggesting the unique role of struggles with conflict and hostility from others during adolescence. The implications for understanding the import of adolescent peer relationships for life span physical health outcomes are considered.

Natural Mentoring Relationships and the Adjustment to College among Underrepresented Students.

This study investigated associations between natural mentoring relationships and academic performance via psychological distress among underrepresented college students attending an elite predominantly White institution (PWI). Specifically, this study explored whether the quantity of natural mentors possessed upon college entry, the retention of natural mentors across the first year of college, and overall changes in the number of natural mentors possessed during the first year of college predicted improvements in students' semester grade point averages (GPAs) via reductions in psychological distress. Participants in this study included 336 first-year undergraduate students attending a selective PWI. Students were eligible to participate in this study if they were first-generation college students, students from economically disadvantaged backgrounds, or students from underrepresented racial/ethnic minority groups. Results of this study indicated that a greater number of retained natural mentoring relationships across the first year of college were associated with improvements in students' GPAs via reductions in symptoms of depression from the Fall to Spring semester. The results of this study suggest that institutional efforts to support the maintenance of preexisting mentoring relationships may be an effective approach to promoting the academic success of underrepresented college students during the first year of college.

Long-Term Predictions from Early Adolescent Attachment State of Mind to Romantic Relationship Behaviors.

Attachment state of mind was investigated as a long-term predictor of romantic relationship competence. A secure early adolescent attachment state of mind was hypothesized to predict more constructive dyadic behaviors during conflict discussions and support seeking interactions in late adolescence and early adulthood. Utilizing multi-method data from a community sample of 184 individuals, followed from ages 14 to 21, adolescents with a secure attachment state of mind at age 14 were found to be in relationships that displayed more constructive dyadic conflict discussion behaviors and dyadic supportive behaviors at both ages 18 and 21. Results suggest substantial links between early adolescent attachment state of mind and the adult romantic relationship atmosphere an individual creates and experiences.