We still cannot breathe: Applying intersectional ecological model to COVID-19 survivorship

PURPOSE/OBJECTIVE

Individuals with historically oppressed identities, such as disabled or racialized minorities, face inequities across all societal institutions, including education, criminal justice, and healthcare. Systems of oppression (e.g., ableism, racism) lead to inequities that have ultimately contributed to disproportionate rates of COVID-19 morbidity and mortality in the United States. In the midst of the COVID-19 pandemic, increased public attention regarding police brutality toward Black people and the reinvigoration of the national Black Lives Matter (BLM) movement further highlighted the detrimental effects of oppressive systems and the urgent need to promote equity in the United States. The disproportionate number of COVID-19-related deaths and police brutality are inextricably connected, as both are products of oppression toward minoritized communities. The co-occurrence of the pandemic and BLM movement protests also creates an opportunity for critical discourse on the intersection of ableism and anti-Black racism specifically within the field of rehabilitation psychology.

RESEARCH METHOD/DESIGN

The overarching goals of this review are to apply the Intersectional Ecological Model with the addition of the chronosystem to illustrate how systems of oppression lead to health disparity in COVID-19 survivorship and to provide recommendations to promote health equity. Conclusions/Implication: As the COVID-19 pandemic shifts to an endemic and efforts to eliminate oppressive systems continue, rehabilitation psychologists have an ongoing, evolving, and shared responsibility to employ socially-responsive solutions to promote optimal functioning for patients, families, and communities. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Longitudinal Trajectories of Post-Concussive Symptoms Following Mild Traumatic Brain Injury

BACKGROUND

Individuals recovering from mild traumatic brain injury (TBI) represent a heterogenous population that requires distinct treatment approaches. Identification of recovery trajectories improves our ability to understand the natural history of mild TBI recovery and develop targeted interventions.

OBJECTIVE

To utilize group-based trajectory modeling (GBTM) to identify distinct patterns of symptom recovery following mild TBI in the first 6 months after mild TBI.

METHODS

This study is comprised of 253 adults who presented to the emergency department with mild TBI and completed assessments for six-months post-injury. Patients were recruited for the prospective observational cohort study, HeadSMART. The primary outcome measure was the Rivermead Postconcussion Symptom Questionnaire. GBTM was used to identify longitudinal trajectories of recovery following mild TBI using Rivermead scores at baseline, one, three, and six months following diagnosis.

RESULTS

Findings identified four distinct trajectories of symptom recovery follwing mild TBI including 9% of participants who were categorized with minimal acute symptoms that decreased over time, 45% with mild acute symptoms that decreased over time, 33% with relatively higher acute symptoms that decreased over time, and 13% with relatively higher acute symptoms that increased over time.

CONCLUSIONS

GBTM identified four distinct trajectories of recovery following mild TBI and GBTM may be useful for research interventions that can alter recovery trajectories.

The feasibility of remotely monitoring physical, cognitive, and psychosocial function in individuals with stroke or chronic obstructive pulmonary disease

Objective

Clinical implementation of remote monitoring of human function requires an understanding of its feasibility. We evaluated adherence and the resources required to monitor physical, cognitive, and psychosocial function in individuals with either chronic obstructive pulmonary disease or stroke during a three-month period.

Methods

Seventy-three individuals agreed to wear a Fitbit to monitor physical function and to complete monthly online assessments of cognitive and psychosocial function. During a three-month period, we measured adherence to monitoring (1) physical function using average daily wear time, and (2) cognition and psychosocial function using the percentage of assessments completed. We measured the resources needed to promote adherence as (1) the number of participants requiring at least one reminder to synchronize their Fitbit, and (2) the number of reminders needed for each completed cognitive and psychosocial assessment.

Results

After accounting for withdrawals, the average daily wear time was 77.5 ± 19.9% of the day and did not differ significantly between months 1, 2, and 3 (p = 0.30). To achieve this level of adherence, 64.9% of participants required at least one reminder to synchronize their device. Participants completed 61.0% of the cognitive and psychosocial assessments; the portion of assessments completed each month didnot significantly differ (p = 0.44). Participants required 1.13 ± 0.57 reminders for each completed assessment. Results did not differ by disease diagnosis.

Conclusions

Remote monitoring of human function in individuals with either chronic obstructive pulmonary disease or stroke is feasible as demonstrated by high adherence. However, the number of reminders required indicates that careful consideration must be given to the resources available to obtain high adherence.

A Shift in Approach: Assessment and Treatment of Adults With Functional Neurological Disorder

Functional neurological disorder (FND) is a complex condition involving an interaction of psychological, physiological, and social factors. Despite high utilization of medical services, people with FND often suffer from poor long-term health and psychosocial outcomes, and experience stigmatization and marginalization within the medical community. Health service psychologists are well positioned to help patients with FND through the lens of the biopsychosocial model of health. Psychologists can facilitate appropriate assessment and treatment, and advocate for the needs of patients diagnosed with FND within multidisciplinary teams. This article reviews best practices for assessment and treatment of individuals diagnosed with or suspected of having FND and presents some clinical and ethical challenges associated with this complex population.

777 Use of the PHQ-2 as a Depression Screening Tool

Introduction

In 2015, the Burn Quality Improvement Program (BQUIP) guidelines recommended systematic screening of Major Depressive Disorder at all verified burn centers. Our level one trauma center rolled out a program to screen all patients entering the burn service starting in June 2018. This project evaluates the program after the first year of implementation.

Methods

All patients over age 12 admitted to the burn service were screened by bedside nurses using the 2-item Patient Health Questionnaire (PHQ-2). Exclusion for screening included those who were intubated and sedated and/or not alert or oriented. A reminder for the PHQ-2 screener automatically popped up in the nursing task list in the electronic medical record until it was given or patient was coded as not appropriate for screening.

Results

A total of 509 patients were admitted to the Burn Service between June 2018 and May 2019. Of those, 40 were identified as not being appropriate for screening due to prolonged mental impairment (e.g. not able to regain consciousness), and 116 (24%) were not screened for unknown reasons. The remaining patients (n=353, 77%) were screened with the PHQ-2 and 94% of these patients were screened on the same day of admit. Of the patients screened, 28 (8%) scored above the clinical cut-off for probable depression (PHQ-2 ³ 3) and 265 (75.1%) did not endorse any symptoms on the PHQ-2 (PHQ-2 = 0). Of the 28 that screened positive on the PHQ-2, 16 (57.1%) received psychological services. Of those that did not receive psychology services, the majority were admitted for less than 3 days (n=10, 76.9%).

Conclusions

In the first year of the program the vast majority of eligible patients were able to be screened by nursing staff with a 2-item measure within one day of admit to the burn service. This success is likely due to the automation of the task in the electronic medical record, the ease of use of the PHQ-2 and the dedication of the nursing staff. The 8% rate of a positive screen is higher than the general population. Given that most patients were screened within 24 hours of admission, we are capturing depressive symptoms that predate the injury. We know that depression can impair burn recovery (e.g. affect participation in therapy, impede wound healing) and lead to poorer long term outcomes. Systematic screening of depressive symptoms upon admission will allow us to intervene earlier and potentially reduce barriers to optimal recovery. Despite high screening rates, about 40% of patients did not receive psychological intervention. We will be discussing utilization of resources for providing inpatient services to patients with a positive screen.

Applicability of Research to Practice

The PHQ-2 is an effective screening tool for depressive symptoms for patients on an inpatient burn unit. These findings are important for hospital systems looking to screen for and treat the mental health needs of burn patients. Depression screening will be required for BQUIP starting in 2020.

Group Differences Among Caregivers of Civilians and Service Members or Veterans With Traumatic Brain Injury

OBJECTIVE

To examine group differences among caregivers of service members or veterans (SMVs) and civilians with traumatic brain injury (TBI).

DESIGN

An observational research study examining the group differences between caregivers of SMVs and civilians with TBI. The data presented was collected as part of a larger study that calibrated and validated the Traumatic Brain Injury-Care Quality of Life (TBI-CareQOL) item banks.

SETTING

Participants in this multicenter study completed an online survey via a study-specific website. Surveys were completed at the study site, at home, or via phone interview. Civilian caregivers were recruited from 4 rehabilitation hospitals and caregivers of SMVs were recruited through community outreach and collaboration with the Hearts of Valor.

PARTICIPANTS

Participants (N=473) consisted of 344 caregivers of civilians with TBI and 129 caregivers of SMVs with TBI.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Zarit Burden Interview Scale, TBI-CareQOL, and Mayo Portland Adaptability Inventory, 4th revision (MPAI-4).

RESULTS

Of the independent variables included in the logistic regression model that classified military-affiliated vs civilian caregivers, 5 were statistically significant: age, spousal status, time since injury, MPAI-4 Adjustment, and TBI-CareQOL Feeling Trapped.

CONCLUSIONS

The results indicate that caregivers of SMVs were more likely to report worse emotional and social adjustment among the individuals with TBI and caregivers of SMVs were more likely to report greater levels of feeling trapped by their caregiving duties.

Group Treatment with French-Speaking African Survivors of Torture and Its Effects on Clinical Engagement: Can Hope Be Operationalized?

This study examines the clinical engagement of French-speaking African survivors of torture by measuring how often they utilize adjunctive programmatic services (i.e., mental health, social, and legal services) in relation to their involvement with the Francophone support group. Thirty-two clients who attended at least five Francophone group therapy sessions were identified and matched with their counterparts who never attended the Francophone group. We compared the number of services the clients in the Francophone group and the control group utilized, controlling for the number of services the clients utilized before attending the Francophone group. We found that the Francophone group showed significantly greater overall programmatic engagement. For the types of services utilized, the Francophone group sought out more mental health services, but there was no significant difference in social and legal services. These findings suggest that involvement with the Francophone group can be linked to increased levels of programmatic engagement.

Persecution Experiences and Mental Health of LGBT Asylum Seekers

Asylum seekers are a unique population, particularly those who have endured persecution for their sexual orientation or gender identity. Little data exist about the specific experiences and needs of asylum seekers persecuted due to lesbian, gay, bisexual, or transgender (LGBT) identity. Quantitative data were gathered regarding demographics, persecution histories, and mental health of 61 clients from a torture survivors program in New York City who reported persecution due to LGBT identity. Thirty-five clients persecuted due to their LGBT identity were matched by country of origin and sex with clients persecuted for other reasons to explore how persecution and symptoms may differ for LGBT clients. LGBT asylum seekers have a higher incidence of sexual violence, persecution occurring during childhood, persecution by family members, and suicidal ideation. Understanding the type of persecution experiences and how these influence mental health outcomes is an essential step toward designing and delivering effective treatments.

Cognitive-Affective Verbal Learning Test: An integrated measure of affective and neutral words

Despite growing affective-memory research, only 2 potential clinical measures have been published, each with limitations. We describe the development and piloting of an integrated memory measure for neutral and affectively valenced words, the Cognitive-Affective Verbal Learning Test (C-AVLT). The C-AVLT and mood self-report measures were administered to 124 healthy university students in Study 1, with readministration to 40 students after 1 week. In Study 2, the C-AVLT and other neuropsychological measures of memory and emotion were administered to 61 patients referred for polysomnogram evaluation of obstructive sleep apnea (OSA). Study 1 supported the C-AVLT's internal and test-retest reliabilities, as well as concurrent validity, that is, the affective-bias scores but not performance scores correlated with self-reported mood. In Study 2, convergent, criterion (specifically cross-sectional concurrent validity), and incremental validity were supported with regard to both performance and affective-bias scores within the OSA sample. We demonstrated the C-AVLT is a reliable and clinically useful measure of both memory and affective-processing bias in 2 samples. Future clinical and research recommendations for the C-AVLT are discussed, including broadening normative data and criterion validity data in psychiatric and neurological samples. (PsycINFO Database Record

Predictors of suicidal ideation in treatment-seeking survivors of torture

In this study, we examined sociodemographic, persecutor identity, torture, and postmigration variables associated with suicidal ideation in a clinical sample of 267 immigrant survivors of torture who have resettled in New York City. The purpose of this study was to identify variables associated with increased risk for suicidal ideation in survivors of torture before they receive legal, psychological, or medical services for torture-related needs. Results from a binary logistic regression model identified a combination of 3 variables associated with current suicidal ideation at intake into the program. Being female, having not submitted an application for asylum, and a history of rape or sexual assault were significantly associated with suicidal ideation at intake, when also controlling for several other important variables. The final model explained 21.4% of variation in reported suicidal ideation at intake. The discussion will focus on the importance of conducting a thorough assessment of suicidal ideation in refugees and survivors of torture.

Posttraumatic stress in emergency settings outside North America and Europe: a review of the emic literature

Mental health professionals from North America and Europe have become common participants in postconflict and disaster relief efforts outside of North America and Europe. Consistent with their training, these practitioners focus primarily on posttraumatic stress disorder (PTSD) as their primary diagnostic concern. Most research that has accompanied humanitarian aid efforts has likewise originated in North America and Europe, has focused on PTSD, and in turn has reinforced practitioners' assumptions about the universality of the diagnosis. In contrast, studies that have attempted to identify how local populations conceptualize posttrauma reactions portray a wide range of psychological states. We review this emic literature in order to examine differences and commonalities across local posttraumatic cultural concepts of distress (CCDs). We focus on symptoms to describe these constructs - i.e., using the dominant neo-Kraepelinian approach used in North American and European psychiatry - as opposed to focusing on explanatory models in order to examine whether positive comparisons of PTSD to CCDs meet criteria for face validity. Hierarchical clustering (Ward's method) of symptoms within CCDs provides a portrait of the emic literature characterized by traumatic multifinality with several common themes. Global variety within the literature suggests that few disaster-affected populations have mental health nosologies that include PTSD-like syndromes. One reason for this seems to be the almost complete absence of avoidance as pathology. Many nosologies contain depression-like disorders. Relief efforts would benefit from mental health practitioners getting specific training in culture-bound posttrauma constructs when entering settings beyond the boundaries of the culture of their training and practice.

The social ecology of resolving family conflict among West African immigrants in New York: a grounded theory approach

The current study employs a grounded theory approach to examine West African immigrants' resolution of parent-child conflict and intimate partner conflict. Data from 59 participants present an interactive social ecological framework, where a lack of resolution at one level results in attempts to resolve problems at higher levels. Four levels are identified within West African immigrants' problem solving ecology, each with specific actors in positions of authority: individual/dyadic (parents and spouses), extended family (which includes distant relatives and relatives living in home countries), community leadership (non-family elders and religious leaders), and state authorities. From participants' descriptions of family challenges emerged a picture of a social ecology in flux, with traditional, socially conservative modes of resolving family conflict transposed across migration into the more liberal and state-oriented familial context of the United States. This transposition results in a loss spiral for the traditional social ecology, differentially affecting individual actors within families. Implications for helping professionals working with new immigrant communities include identifying variability in openness to adapting structures that are not working well (e.g., patriarchal protection of abusive husbands) and supporting structures known to be associated with well being (e.g., collective monitoring of youth).

Intimate Partner Violence among West African Immigrants

Although the number of African immigrants arriving to the United States has increased significantly, there has been little investigation regarding their experiences of intimate partner violence or coping strategies. This study used focus groups and individual interviews to explore intimate partner violence among 32 heterosexual West African immigrants. Results suggest that although cultural expectations influence their coping strategies, West African-born men and women face different realities, with women reporting multiple instances of abuse and a sense of frustration with the existing options for assistance. Although participants discussed multilevel support structures within the immediate West African community to address intimate partner violence, all of these options maintained a gender hierarchy, leaving women dissatisfied. Challenges and barriers to partner violence resolution and coping strategies are identified. Results are examined in terms of their implications for addressing the needs of this underserved population. Implications for future research and services are discussed and highlighted.

Responding to secondary traumatic stress: a pilot study of torture treatment programs in the United States

Providers who care for torture survivors may be at risk for secondary traumatic stress, yet there has been little documentation of the effects of repeated exposure to traumatic issues on their emotional health or exploration of the support systems and resources available to address their emotional needs. This study assessed the secondary stress experiences of service providers (N = 43) within the National Consortium of Torture Treatment Programs in the United States and examined the supports offered by their organizations. The study found a significant correlation between rates of anxiety and depression among providers, r(34) = .49, p = .003. Although these participants reported that their work with survivors of torture was stressful, 91% indicated that their organizations offered a variety of stress-reduction activities. Overall, participants reported that their own personal activities were the most-effective stress reducers. The results are discussed in light of challenges that professionals who work with this population face and the effectiveness of support systems available to support their work.

Depression in children and adolescents in the first 6 months after traumatic brain injury

The objective was to assess the nature, rate, predictive factors, and neuroimaging correlates of novel (new-onset) depressive disorders, both definite and subclinical, after traumatic brain injury (TBI). Children with TBI from consecutive admissions were enrolled and studied with psychiatric interviews soon after injury (baseline), and again 6 months post-injury. Novel definite/subclinical depressive disorders at 6-month follow up occurred in 11% (n=15) of the children and subsets of children with non-anxious depression (n=9) and anxious depression (n=6) were identified. Novel definite/subclinical depressive disorder was significantly associated with older age at the time of injury, family history of anxiety disorder, left inferior frontal gyrus (IFG) lesions, and right frontal white matter lesions. Non-anxious depressions were associated with older age at injury, left IFG and left temporal pole lesions. Anxious depressions were associated with family history of anxiety disorder, Personality Change due to TBI, right frontal white matter lesions, and left parietal lesions. These findings, which are similar to those reported after adult TBI, identify both similarities and differences in non-anxious and anxious depression following childhood TBI with respect to lesion laterality, genetic factors (in the form of family psychiatric history of anxiety disorder), age at injury, and more generalized affective dysregulation.

Anxiety disorders in children and adolescents in the first six months after traumatic brain injury

The study's objective was to assess the nature, rate, predictive factors, and neuroimaging correlates of novel (new-onset) definite anxiety disorders and novel definite/subclinical anxiety disorders (in a broader group of children with at least subclinical anxiety disorders) after traumatic brain injury (TBI). Children with TBI from consecutive admissions to five trauma centers were enrolled and studied with psychiatric interviews soon after injury (baseline) and again 6 months post-injury. Novel definite anxiety disorder and novel definite/subclinical anxiety disorders were heterogeneous and occurred in 8.5% (N=12) and 17% (N=24) of participants, respectively, in the first 6 months after injury. Novel definite anxiety disorder was significantly associated with younger age at injury and tended to be associated with novel depressive disorder, as well as lesions of the superior frontal gyrus. Novel definite/subclinical anxiety disorder was significantly associated with concurrent psychiatric problems of personality change due to TBI and novel definite/subclinical depressive disorder, as well as with lesions of the superior frontal gyrus and a trend-association with frontal lobe white-matter lesions. These findings suggest that anxiety after childhood TBI may be part of a broader problem of affective dysregulation related to damaged dorsal frontal lobe and frontal white-matter systems, with younger children being at greatest risk for developing novel anxiety disorder after TBI.

Screening for Torture: A Narrative Checklist Comparing Legal Definitions in a Torture Treatment Clinic

Torture has been defined most precisely in legal contexts. Practitioners who work with torture survivors and researchers who study torture have frequently cited legal definitions, particularly those in the United States' Torture Victims Relief Act, the United Nations Convention against Torture, or the World Medical Association's Declaration of Tokyo. Few practitioners have operationalized these definitions and applied them in their practice. We describe how a New York City torture treatment clinic used a coding checklist that operationalizes the definitions, and present results. We found that in practice these definitions were nested; that using guidelines for applying the definitions in practice altered the number of cases meeting criteria for these definitions; and that the severity of psychological symptoms did not differ between those who were tortured and those who were not under any definition. We propose theoretical and practical implications of these findings.

Pediatric stroke: plasticity, vulnerability, and age of lesion onset

The authors aim to investigate brain plasticity and vulnerability through the study of the relationship of age at the time of brain injury and neurocognitive and psychiatric outcome. Children with early stroke performed more poorly compared with children with late stroke in a wide variety of domains including intellectual function, language, memory, visuospatial function, academic function, and psychiatric problems. The exception to this pattern was that children with late stroke performed more poorly in two of three executive function tests. These findings suggest that in children with focal brain injury, as in those with more diffuse brain insults, younger age at injury predicts worse neurocognitive outcomes, although this may not apply to selected executive function outcomes. Adverse psychiatric outcome after early stroke is less direct but is evident in terms of severity in affected cases.

Fluoroscopic evaluation of diaphragmatic motion reduction with a respiratory gated radiotherapy system

We report on initial patient studies to evaluate the performance of a commercial respiratory gating radiotherapy system. The system uses a breathing monitor, consisting of a video camera and passive infrared reflective markers placed on the patient's thorax, to synchronize radiation from a linear accelerator with the patient's breathing cycle. Six patients receiving treatment for lung cancer participated in a study of system characteristics during treatment simulation with fluoroscopy. Breathing synchronized fluoroscopy was performed initially without instruction, followed by fluoroscopy with recorded verbal instruction (i.e., when to inhale and exhale) with the tempo matched to the patient's normal breathing period. Patients tended to inhale more consistently when given instruction, as assessed by an external marker movement. This resulted in smaller variation in expiration and inspiration marker positions relative to total excursion, thereby permitting more precise gating tolerances at those parts of the breathing cycle. Breathing instruction also reduced the fraction of session times having irregular breathing as measured by the system software, thereby potentially increasing the accelerator duty factor and decreasing treatment times. Fluoroscopy studies showed external monitor movement to correlate well with that of the diaphragm in four patients, whereas time delays of up to 0.7 s in diaphragm movement were observed in two patients with impaired lung function. From fluoroscopic observations, average patient diaphragm excursion was reduced from 1.4 cm (range 0.7-2.1 cm) without gating and without breathing instruction, to 0.3 cm (range 0.2-0.5 cm) with instruction and with gating tolerances set for treatment at expiration for 25% of the breathing cycle. Patients expressed no difficulty with following instruction for the duration of a session. We conclude that the external monitor accurately predicts internal respiratory motion in most cases; however, it may be important to check with fluoroscopy for possible time delays in patients with impaired lung function. Furthermore, we observe that verbal instruction can improve breathing regularity, thus improving the performance of gated treatments with this system.