Impact of the Pandemic was Minor Compared to Systemic Decrease in Fidelity of Assertive Community Treatment Services- A Provincial Study in Ontario, Canada

Assertive Community Treatment (ACT) model is the gold standard in community psychiatry serving people with severe mental illness. With its outreach-based design, the pandemic has profoundly affected the operations and functioning of ACT. The Dartmouth ACT Scale (DACTS) provides a standardized comprehensive and quantitative way to evaluate ACT quality. Results could inform nature of impact and identify areas for improvement. Current online survey used DACTS during the pandemic in April-May 2021. Clinical and administrative leadership of the 80 ACT teams in Ontario, Canada cross-sectionally rated ACT quality one-year pre-Covid (2018-2019) and one-year post the start of Covid (2020-2021). The overall pre-Covid Ontario ACT DACTS fidelity was 3.65. The pandemic led to decreases in all domains of DACTS (Human Resources: -4.92%, p < 0.001, 95% CI [0.08-0.27]; Organizational Boundary: -1.03%, p < 0.013,95%CI [0.01-0.07]; and Nature of Services: -6.18%, p < 0.001, 95%CI [0.16-0.26]). These changes were accounted by expected lower face-to-face encounters, time spent with clients, reduction in psychosocial services, less interactions with hospitals and diminished workforces. The magnitude of change was modest (-3.84%, p < 0.001, 95%CI [0.09-0.19]). However, the Ontario ACT pre-Covid DACTS was substantially lower (-13.5%) when compared to that from a similar survey 15 years ago (4.22), suggestive of insidious systemic level loss of fidelity. Quantitative fidelity evaluation helped to ascertain specific pandemic impact. Changes were significant and specific, but overall relatively modest when compared to the larger system level drop over the last decade. There is both evidence for model adaptability and resilience during Covid disruption, and concerns over larger downward drift in ACT fidelity and quality.

"Trust in God, but tie your donkey": Holy water priest healers' views on collaboration with biomedical mental health services in Addis Ababa, Ethiopia

This exploratory qualitative study examines holy water priest healers' explanatory models and general treatment approaches toward mental illness, and their views and reflections on a collaborative project between them and biomedical practitioners. The study took place at two holy water treatment sites in Addis Ababa, Ethiopia. Twelve semi-structured interviews with holy water priest healers found eight notable themes: they held multiple explanatory models of illness, dominated by religious and spiritual understanding; they emphasized spiritual healing and empathic understanding in treatment, and also embraced biomedicine as part of an eclectic healing model; they perceived biomedical practitioners' humility and respect as key to their positive views on the collaboration; they valued recognition of their current role and contribution in providing mental healthcare; they recognized and appreciated the biomedical clinic's effectiveness in treating violent and aggressive patients; they endorsed the collaboration and helped to overcome patient and family reluctance to the use of biomedicine; they lamented the lack of spiritual healing in biomedical treatment; and they had a number of dissatisfactions and concerns, particularly the one-way referral from religious healers to the biomedical clinic. The study results show diversity in the religious healers' etiological understanding, treatment approaches and generally positive attitude and views on the collaboration. We present insights and explorations of factors affecting this rare, but much needed collaboration between traditional healers and biomedical services, and potential ways to improve it are discussed.

"It feels terrible that people are making decisions for me": Reflections and experiences of individuals with psychiatric disability who have substitute decision makers for treatment

OBJECTIVE

In Canada and elsewhere, making treatment decisions for a person with serious mental illness (SMI) who was found incapable for treatment decisions via a substitute decision maker (SDM) is the norm. This practice is often called into question from a rights-based perspective. The literature on the views of affected individuals is limited. We explore the experiences of adults with SMI who have had SDMs to gain more in-depth understanding.

METHOD

We conducted semistructured interviews with 11 consumers of psychiatric services who have had experiences with SDM (range 1-12 years) at an urban hospital in Toronto, Canada.

RESULTS

Thematic analysis showed five main themes and related subthemes, including: (1) strong dissatisfaction with and rejection of the SDM's role and purpose; (2) pervasive sense of stigma associated with having a SDM; (3) ongoing struggles to gain autonomy; (4) mixed changes in relationship with and views about SDM; and (5) views on how to improve SDM process.

CONCLUSION AND IMPLICATIONS FOR PRACTICE

Our study highlights substantial dissatisfaction with the current SDM system and approaches among adults with SMI who have had SDMs. Issues of stigma and struggles to regain autonomy are prevalent. We discuss the personal, clinical, and social-legal contexts in which they occur, particularly in light of the United Nations' Convention on the Rights of Persons with Disabilities that calls for replacing SDMs with supported decision making. Rights-based approaches to care carry substantial practice implications and call for thoughtful change management. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Impact of COVID-19 on the lives of people with severe mental illness-front-line community psychiatry workers observation from a provincial survey of assertive community treatment teams in Ontario, Canada

Using an online survey distributed to members of the provincial organization that represents the 88 Assertive Community Treatment (ACT) and Flexible ACT teams in Ontario, Canada, this descriptive study relied on the unique vantage points and observations of the front-line community psychiatry workers who maintained contact with patients through outreach and telecommunication during the height of COVID-19. The patients who suffer from serious mental illness (SMI) were uniquely affected by COVID-19 due to the changes, reduction or shut down of many essential clinical and community support services. Thematic and quantitative analyses of the workers' observations highlighted 6 main areas of note, including significant social isolation and loneliness, clinical course deterioration and life disruption, increased hospital and ER use, police and legal contacts, and substance abuse and related deaths. There were also encouraging signs of positive adaptations in terms of independence and resilience. Reflections of these impacts and potential ameliorating approaches are further discussed.

"Everyone means well but the one person who's really going to go to bat" - experiences and perspectives of substitute decision makers in caring for their loved ones with serious mental illness

In the era of on-going efforts to empower persons with mental illness to be independent decision makers as informed by the United Nations' Convention on the Rights of Persons with Disability (CRPD), family members acting as substitute decision makers (SDM) for people suffering from disabling serious mental illness (SMI) remain an integral part of the medical-legal system in psychiatric care in many parts of the world, including Canada; yet their experiences and perspectives are rarely studied. This explorative qualitative study examines the lived experiences and reflections of 14 family member SDMs in Toronto, Canada. Five key themes related to being SDM emerged: 1) Varied subjective understanding of the responsibility and authority of the SDM role; 2) Varied role demands and impact on SDMs' lives; 3) Challenges in dealing with the mental health system; 4) Leveraging decision making status to promote patient care; and 5) SDM role impact on family relationships. The need to improve SDM understanding of their role, acknowledging their value and care-taker burden, finding a balance for their involvement, and improving their support in efforts to enhance care for the patients are discussed.

A Leg to Stand On: Working With Marginal Decision-making Capacity in a Patient With a Severe Leg Infection and Schizophrenia

Assessment of a patient's capacity to make treatment decisions and working with the wishes of a patient with mental illness against the best medically indicated plan is a complex and dynamic task. It is particularly challenging when the course of deterioration of the illness is meandering and slow, and the time horizon for recovery is uncertain, providing no clear point of entry for definitive crisis intervention. High-impact decisions concerning body integrity, such as the amputation of a leg, further complicate the task. To highlight these challenges and complexities, we present the case of a man who suffered from schizophrenia, with a worsening diabetic foot ulcer and suboptimal acceptance of proper wound care. The patient died as a result of his refusal of a proposed amputation to address his life-threatening infection. Medical system and cultural issues are also considered.

Characteristics of psychomotor retardation distinguishes patients with depression using multichannel near-infrared spectroscopy and finger tapping task

BACKGROUND

Psychomotor retardation (PMR) is frequently noted as a characteristic feature of major depressive disorder (MDD). In patients with depression, it is characterized by retardation of speech, emotion, thinking, and cognition. This study explored the activation pattern of the prefrontal cortex (PFC) during the finger-tapping task (FTT) in subjects with MDD, aiming to provide additional understanding on the connection between PMR and PFC activation pattern in depression through the use of near-Infrared Spectroscopy (NIRS). We hypothesized that, through use of NIRS during the FTT, motor retardation in depression would generate a distinct PFC activation pattern, allowing for differentiation between patients with MDD and healthy controls (HCs).

METHODS

Thirty-five patients with MDD and thirty-nine HCs underwent NIRS evaluation during performance of the FTT. The FTT included both left-finger tapping and right-finger tapping performed by a computer screen. Each participant was assessed using a 45-channel NIRS and various clinical scales.

FINDINGS

During the left-FTT, the left orbitofrontal cortex (OFC) showed higher oxy-hemoglobin (Oxy-Hb) activation in the MDD group when compared to the HCs. During the right-FTT, the right dorsolateral prefrontal cortex (DLPFC) demonstrated lower Oxy-Hb activation, and the dorsomedial prefrontal cortex (DMPFC) showed higher Oxy-Hb activation in the MDD group versus the HC group.

CONCLUSION

Our results demonstrated different activation patterns of the PFC between the MDD and HC groups, using FTT as a motor performance task. In particular, the OFC, the DLPFC and the DMPFC areas hold promise as new useful sites for such differentiation in future investigations.

Decision-making biases in suicide attempters with major depressive disorder: A computational modeling study using the balloon analog risk task (BART)

BACKGROUND

In the last decade, suicidality has been increasingly theorized as a distinct phenomenon from major depressive disorder (MDD), with unique psychological and neural mechanisms, rather than being mostly a severe symptom of MDD. Although decision-making biases have been widely reported in suicide attempters with MDD, little is known regarding what components of these biases can be distinguished from depressiveness itself.

METHODS

Ninety-three patients with current MDD (40 with suicide attempts [SA group] and 53 without suicide attempts [NS group]) and 65 healthy controls (HCs) completed psychometric assessments and the balloon analog risk task (BART). To analyze and compare decision-making components among the three groups, we applied a five-parameter Bayesian computational modeling.

RESULTS

Psychological assessments showed that the SA group had greater suicidal ideation and psychological pain avoidance than the NS group. Computational modeling showed that both MDD groups had higher risk preference and lower ability to learn and adapt from within-task observations than HCs, without differences between the SA and NS patient groups. The SA group also had higher loss aversion than the NS and HC groups, which had similar loss aversion.

CONCLUSIONS

Our BART and computational modeling findings suggest that psychological pain avoidance and loss aversion may be important suicide risk factor that are distinguishable from depression illness itself.

977 Breaking Out of Tradition: Designing Escape Rooms as Novel Simulation

Aim

The emerging field of gamification, the addition of game play elements to non-game settings, is widely used in business and is increasingly being used in education. Successful methods have included live leader boards and a web-based game solving a protein folding conundrum.

Method

We designed an escape room (ER), incorporating gaming elements, focussing on communication in a surgical environment. A cross over study was delivered to 4th year medical students, comparing traditional simulation. The ER included logic puzzles, hidden clues, padlocked boxes, and surgical skills appropriate to their level. Self-reported engagement and teamwork were recorded, as was observed teamwork and communication skills.

Results

Self-reported engagement was very high for the students compared to more traditional simulation, including better understanding of effective communication strategies. The ER group were less likely to self-identify learning points but structured debrief mitigated this difference.

Conclusions

Gamification techniques can be integrated with good engagement and educational outcomes and should be considered as an adjunct to existing simulation strategy.

971 Gamification of Education; Can Playable Education Result in Better Learning Outcomes?

Aim

Combining traditional simulation (TS) and the emerging field of gamification, to create medical Escape Rooms (ERS) has been used in Nursing to good results but is yet to be widely adopted in medical education. We conducted a pilot study to create ERS for undergraduates to assess their educational value.

Method

Existing Simulation themes of sepsis, post-operative bleeding, trauma, burns and communication in the theatre environment were developed into Escape Rooms by a multidisciplinary team. A cross over study for 4th year students was carried out. Questionnaires were used to evaluate the experience, learning assessed by pre and post quiz and observational tools for teamwork, communication and leadership were utilised.

Results

Qualitative data demonstrated overall good feedback on enjoyment an engagement. Quantitative data collected as pre- and post-exposure learning demonstrated equivocal benefit. Self-assessed teamwork showed equal in all domains and improved in contribution of knowledge and maintaining team focus on the ER group.

Conclusions

Participants find ER enjoyable have similar educational benefits of traditional simulation with the benefits on enhancing non-technical skills amongst a novice group. Escape rooms may be useful as an adjunct to TS particularly at developing non-technical skills.

961 ‘WE CARE!’: CARE WORKERS’ SELF-PERCEIVED MEANING OF RESIDENTIAL AGED CARE WORK

Introduction

Aged care workers in residential care homes of the elderly (RCHEs) are socially devalued as less skilled, low-paid, and doing ‘dirty work’. Care workers’ insider experiences with the meaning of residential aged care work are largely absent from the community and the literature.

Method

A qualitative study was conducted to examine the self-perceived meaning of work (MOW) among care workers in RCHEs in Hong Kong, an East Asian metropolis with a rapidly aging population, and unique socio-cultural meanings of elderly care. Adopting the Grounded Theory Method, in-depth interviews with 27 care workers in 6 RCHEs were conducted.

Results

Findings suggest that regardless of the job requirements of carrying out ‘dirty tasks’ and shared experiences of public devaluations, RCHE care workers find positive meanings in their work including: contributing to the greater good of helping the elderly; establishing meaningful relationships; forming a professional identity of geriatric care; achieving personal growth; ensuring job security and benefits in the aged care job market. Care workers find their work meaningful primarily because it is essential to maintain the elderly’s health and quality of life, which echoes with the Chinese cultural values of ‘accumulating fortune’ and ‘respecting the elderly’. Engaging in residential care work allows care workers to build long-term relationships with the elderly, through which they found joys and knowledge of life such as letting go. Care workers propose that geriatric care is highly skillful and professional, requiring communication, coordination, and chronic illness care skills. Care workers identify several inhibitors of attaining MOW, including heavy workloads, manpower shortage, and dehumanizing bureaucratic practices.

Conclusion

Care workers offer counter-narratives of public devaluation and reframe the meaning of care work in RCHEs. These findings have broader implications on policy, professional, and education interventions in promoting the public recognition of aged care work.

The work described in this paper was fully supported by a grant from the Research Grants Council of the Hong Kong Special Administrative Region, China (UGC/FDS16/M12/20).

962 FROM DIRTY WORK TO MEANINGFUL WORK: A PHOTOVOICE STUDY OF RESIDENTIAL AGED CARE IN HONG KONG

Introduction

Caregiving work in ‘residential care homes for the elderly’ (RCHEs) has long been devalued as ‘dirty work’, which contributes to RCHE’s acute shortages of health care staff in Hong Kong. This study aims to unearth the voice of the RCHEs workers by delineating their insider perspectives of RCHE work.

Method

Adopting the Photovoice method, a participatory methodology, 30 RCHEs care workers (i.e. Registered Nurses, Enrolled Nurses, Health Workers, and Personal Care Workers) were invited to take photos that showcase their perspectives of doing aged care work. Two in-depth interviews were conducted with each research participant before and after the photo-taking procedure. Thematic analysis is then conducted to analyse the visual and verbal data.

Results

Findings show that RCHEs care workers perceive and revitalize the nature and meaning of their work in four ways: conducting ‘dirty tasks’ to help the elderly; valuing and engaging in long-term relationships; learning in work; and cultural meaning of working with the elderly. Contrary to public devaluation, RCHE care workers normalize the delivery of ‘dirty tasks’ (i.e. handling human excreta and wounds) as being helpful to both the elderly and the family members. Besides the routine caring tasks on paper, care workers highlight that they spend a lot of unrecognized labor to build rapport and provide emotional support to the elderly and their family members in their work. They also report that learning and self-development are an important part of residential care work, both in terms of professional knowledge and personal growth. Taking care of the elderly also conveys positive cultural meanings in Chinese society.

Conclusion

Policy, professional and educational initiatives of geriatric care primarily emphasize the delivery of clinical tasks (caring for), while undermining the emotional and relational aspects of aged care work.

The work described in this paper was fully supported by a grant from the Research Grants Council of the Hong Kong Special Administrative Region, China. (UGC/FDS16/M12/20).

"I thought that I had to be alive to repay my parents": Filial piety as a risk and protective factor for suicidal behavior in a qualitative study of Chinese women

Filial piety involves the Confucian view that children always have a duty to be obedient and to provide care for their parents. Filial piety has been described as both a risk and a protective factor in depression and suicide. This qualitative study aimed to explore the role of filial piety in the suicidal behavior of Chinese women. Qualitative interviews were conducted with Chinese women with a history of suicidal behavior living in the Beijing area (n = 29). Filial piety data were extracted and analyzed in accordance with constructivist grounded theory. The women described five specific family and filial piety factors and how they influenced their ability to fulfill family role obligations, which was described as a nexus connecting these factors to depression, suicidal behavior, and recovery. The five factors were: 1) rigidity of parental filial expectations, 2) perception of family relationships as positive/supportive or negative/harsh, 3) whether filial piety is of high or low personal value in the woman's life, 4) any experiences of rebellion leading to punitive consequences, and 5) how much filial piety she receives from her children. These factors could inform suicide risk assessments in this population. They can be harnessed as part of recovery and protect against future suicidal behavior.

Transformative learning in the setting of religious healers: A case study of consultative mental health workshops with religious healers, Ethiopia

OBJECTIVE

Psychiatric interventions that consider the socio-cultural and spiritual traditions of patients are needed to address stigma and improve access to mental health services. Productive collaboration between traditional healers and biomedical practitioners hold promise in such efforts, and applying tenets of transformative learning hold potential for mitigating an overemphasis on biomedical models in such collaboration. We present a framework for how to engage in health system reform to enhance mental health services in communities that are distrustful of, or unfamiliar with biomedical approaches. Our research question was how to bridge two seemingly opposing paradigms of mental health care, and we sought to understand how the theory of transformational learning (TLT) can be applied to learning among Religious healers and biomedical practitioners in culturally appropriate ways to improve collaboration.

METHODS

TLT informed the development, implementation, and evaluation of an educational intervention in Addis Ababa, Ethiopia that aimed to improve delivery of mental health services at two Holy water sites. The initiative involved both psychiatrists and religious healers with extensive experience providing care to mentally ill patients. Using a focused ethnographic approach that incorporates document analysis methodology, this qualitative study examined recordings and minutes of stakeholder meetings, workshops and informal interviews with participants, analyzed for evidence of Mezirow's 11 stages of transformative learning. A participatory action approach was used to encourage practice change.

RESULTS

All participants exhibited a high degree of engagement with the of the collaborative project and described experiencing "disorienting dilemmas" by Mezirow's classic description. Opportunities to reflect separately and in large groups encouraged a re-examination of attitudes previously contributing to siloed approaches to care and led to instrumental changes in mental health care delivery and a higher degree of coordination and collaboration between psychiatrists and traditional healers.

CONCLUSION

Our study demonstrates the utility of TLT in both the design and evaluation of initiatives aiming to bridge cross-cultural and cross-professional divides. The learning process was further enhanced by a collaborative participatory action model adjusted to accommodate Ethiopian socio-political and cultural relations.

Removing a Disabled Person from Her Treasured Independent Living

Ms. X is a person with cerebral palsy and schizophrenia. She has intractable bedsores that are a result of her immobility and to poor wound care related to her delusional thinking. Despite intensive community support, the wounds have worsened to the point that she has needed multiple hospitalizations to prevent systemic sepsis, a life-threatening condition. She is capable of placement decisions and wishes for independence at home but is incapable of making wound care decisions and does not appreciate that immediately returning home from the hospital, instead of going into a special care facility, would likely result in sepsis. The resulting dilemma about discharge planning highlights the complexity involved in weighing concerns around mental illness and capacity for treatment and placement of care. The extent of the care that is required and available in a community or health care system and the slow but relatively certain progression of the symptoms also make the decision challenging. Two commentaries take very different approaches in exploring the question whether Ms. X should be supported to go home or to a special care facility.

Prefrontal cortex alterations in major depressive disorder, generalized anxiety disorder and their comorbidity during a verbal fluency task assessed by multi-channel near-infrared spectroscopy

Major depressive disorder (MDD) and generalized anxiety disorder (GAD) are frequently comorbid with each other, and both associated with substantial cognitive impairments; however, it is still unclear whether their impairments are neurobiologically similar or distinct. This study aims to investigate the cognitive functions of the prefrontal cortex (PFC) in patients with MDD and GAD during the verbal fluency task (VFT) using functional near-infrared spectroscopy (fNIRS). Fifty-two patients with MDD, fifty-one patients with GAD, fifty-two patients with the comorbidity of MDD and GAD (CMG), and forty-seven healthy controls (HC) participated in the study. Significant hypoactivation in the left ventrolateral and the left dorsolateral PFC was common in all patient groups when compared to HCs, suggesting a shared etiology. Furthermore,  MDD patients showed significant hypoactivation at the right frontal pole cortex (FPoC) when compared to HCs and significant hypoactivation at the middle FPoC when compared to the CMG patients. Our work is the first fNIRS study to reveal the shared and unique neurobiological profiles of MDD, GAD and their comorbidity under the same standard experimentation condition, suggesting fNIRS holds promise as an adjutant to assist clinical diagnosis.

Experiences of Family Burden in Caring for the Severely Mentally Ill in a Foreign Land: A Qualitative Study of Chinese Immigrant Families in Toronto, Canada

There is a relative dearth of qualitative studies on the actual experiences of families caring for members suffering from serious mental illness, and even less is known about disadvantaged ethnic minority immigrant families. This explorative qualitative study examines the burden experienced by 15 family members of Chinese immigrant background in Toronto, Canada. Six common themes emerged from the study: 1) significant worries about not being able to take care of ill members in the future; 2) on-going strain and changed family life; 3) pervasive social stigma, discrimination and lack of resources; 4) general appreciation of Canadian health and welfare systems and opportunities; 5) cultural factors and beliefs uniquely shape families' support and caring commitment; and 6) families find various ways to cope and help themselves. Opportunities for improved care delivery based on these understandings are discussed.

Highlighting psychological pain avoidance and decision-making bias as key predictors of suicide attempt in major depressive disorder-A novel investigative approach using machine learning

OBJECTIVE

Predicting suicide is notoriously difficult and complex, but a serious public health issue. An innovative approach utilizing machine learning (ML) that incorporates features of psychological mechanisms and decision-making characteristics related to suicidality could create an improved model for identifying suicide risk in patients with major depressive disorder (MDD).

METHOD

Forty-four patients with MDD and past suicide attempts (MDD_SA, N = 44); 48 patients with MDD but without past suicide attempts (MDD_NS, N = 48-42 of whom with suicide ideation [MDD_SI, N = 42]), and healthy controls (HCs, N = 51) completed seven psychometric assessments including the Three-dimensional Psychological Pain Scale (TDPPS), and one behavioral assessment, the Balloon Analogue Risk Task (BART). Descriptive statistics, group comparisons, logistic regressions, and ML were used to explore and compare the groups and generate predictors of suicidal acts.

RESULTS

MDD_SA and MDD_NS differed in TDPPS total score, pain arousal and avoidance subscale scores, suicidal ideation scores, and relevant decision-making indicators in BART. Logistic regression tests linked suicide attempts to psychological pain avoidance and a risk decision-making indicator. The resultant key ML model distinguished MDD_SA/MDD_NS with 88.2% accuracy. The model could also distinguish MDD_SA/MDD_SI with 81.25% accuracy. The ML model using hopelessness could classify MDD_SI/HC with 94.4% accuracy.

CONCLUSION

ML analyses showed that motivation to avoid intolerable psychological pain, coupled with impaired decision-making bias toward under-valuing life's worth are highly predictive of suicide attempts. Analyses also demonstrated that suicidal ideation and attempts differed in potential mechanisms, as suicidal ideation was more related to hopelessness. ML algorithms show useful promises as a predictive instrument.

How Do the Urban Poor Survive? A Comparative Ethnography of Subsistence Strategies in Argentina, Ecuador, and Mexico

Drawing on ethnographic data collected in three informal communities, one in Argentina, one in México, and one in Ecuador, we address the long-standing question posed by Larissa Lomnitz's and Carol Stack's now-classic studies of how impoverished people not only survive but what strategies they adopt in an attempt to build a dignified life. By focusing on the diversity of strategies by which the urban poor solve the everyday problems of individual and collective reproduction, we move beyond the macro-level analysis of structural constraint and material deprivation. Our findings show a remarkable continuity in the difficulties residents of these informal communities confronted and the problem-solving strategies they resorted to. We found that networks of kin and friends continue to play a crucial role in how poor people not only survive but attempt to get ahead. Additionally, we highlight the role of patronage networks and collective action as central to strategies by which the urban poor cope with scarcity and improve their life chances, while also paying close attention to ways in which they deal with pressing issues of insecurity and violence. The paper shows that poor people's survival strategies are deeply imbricated in routine political processes.

From motivation, decision-making to action: An fMRI study on suicidal behavior in patients with major depressive disorder

OBJECTIVE

We explored the neural mechanisms underlying disadvantageous risk decision making in un-medicated major depressive disorder patients who had recent suicide attempts.

METHODS

53 patients with major depressive disorder (MDD), including 23 with a history of suicide attempts (SA) and 30 without (NS), and 30 healthy controls (HCs) completed pertinent psychometric assessments, and the dynamic decision making balloon analogue risk task (BART) under fMRI. We also built a 4-parameter Bayesian computational modeling for decision making analyses.

RESULTS

Several distinct findings emerged. First, SA patients had no depression intensity difference but higher pain avoidance in psychometrics, and more risk aversion in the BART when compared to the NS patients, with computational modeling confirming such reduced risk-taking propensity. Second, SA patients showed smaller left insular cortex activation than NS patients during the high risk, decisional phase of BART, and the modulation correlated with pain avoidance in both SA and NS groups. Third, during feedback phase of loss trials of the BART, SA patients had greater activation in the left dorsolateral prefrontal cortex (dlPFC) than NS patients.

CONCLUSION

Taken together, we present novel findings and propose interpretations that the differential insula activation likely relates to high uncertainty-aversion in SA patients, contrary to the typical view that they are impulsive and risk prone. The differential left dlPFC activation likely suggests hypersensitivity to loss, contributing to conservative decision-making at large, and extreme choices such as suicide when value estimations are compromised and emotionally overwhelmed. The interactive interpretation places a renewed focus on psychological pain avoidance as a robust motivator for suicidal behavior.

Core outcome set for surgical trials in gastric cancer (GASTROS study): international patient and healthcare professional consensus

BACKGROUND

Surgery is the primary treatment that can offer potential cure for gastric cancer, but is associated with significant risks. Identifying optimal surgical approaches should be based on comparing outcomes from well designed trials. Currently, trials report different outcomes, making synthesis of evidence difficult. To address this, the aim of this study was to develop a core outcome set (COS)-a standardized group of outcomes important to key international stakeholders-that should be reported by future trials in this field.

METHODS

Stage 1 of the study involved identifying potentially important outcomes from previous trials and a series of patient interviews. Stage 2 involved patients and healthcare professionals prioritizing outcomes using a multilanguage international Delphi survey that informed an international consensus meeting at which the COS was finalized.

RESULTS

Some 498 outcomes were identified from previously reported trials and patient interviews, and rationalized into 56 items presented in the Delphi survey. A total of 952 patients, surgeons, and nurses enrolled in round 1 of the survey, and 662 (70 per cent) completed round 2. Following the consensus meeting, eight outcomes were included in the COS: disease-free survival, disease-specific survival, surgery-related death, recurrence, completeness of tumour removal, overall quality of life, nutritional effects, and 'serious' adverse events.

CONCLUSION

A COS for surgical trials in gastric cancer has been developed with international patients and healthcare professionals. This is a minimum set of outcomes that is recommended to be used in all future trials in this field to improve trial design and synthesis of evidence.

Holy water and biomedicine: a descriptive study of active collaboration between religious traditional healers and biomedical psychiatry in Ethiopia

BACKGROUND

Religious and traditional healers remain the main providers of mental healthcare in much of Africa. Collaboration between biomedical and traditional treatment modalities is an underutilised approach, with potential to scale up mental healthcare.

AIMS

To report the process and feasibility of establishing a collaboration between religious healers and psychiatrists in Addis Ababa, Ethiopia. To gain insight into the collaboration through studies of patient demographics, help-seeking patterns, nature of illness and receptivity of the project.

METHOD

This case study describes the process and challenges in establishing a collaborative psychiatric clinic for patients who are simultaneously receiving treatment with holy water, including an examination of basic clinical records of 1888 patients over a 7-year period.

RESULTS

The collaboration is feasible and has been successfully implemented for 8 years. A majority (54%) of the clinic's patients were seeing biomedical services for the first time. Patients were brought in largely by families (54%); 26% were referred directly by priest healers. Most patients had severe mental illness, including schizophrenia (40%), substance misuse (24%) and mood disorders (30%). A vast majority (92.2%) of patients reported comfort in receiving treatment with holy water and prayers simultaneously with medication, and 73.6% believed their illness was caused by evil spirit possession.

CONCLUSIONS

A cross-system collaborative model is a feasible and potentially valuable model to address biomedical resource limitations. Provider collaboration and mutual learning are ultimately beneficial to patients with severe mental illness. Open-minded acceptance of cultural benefits and strengths of traditional healing is a prerequisite. Further study on outcomes and implementation are warranted.

Differentiating between bipolar and unipolar depression using prefrontal activation patterns: Promising results from functional near infrared spectroscopy (fNIRS) findings

BACKGROUND

Bipolar depression (BD) is a unique, severe and prevalent mental illness that shares many similarities in symptoms with unipolar depression (UD). Improving precision of their diagnoses would enhance treatment outcome and prognosis for both conditions. This study aims to provide evidence from functional Near-Infrared Spectroscopy (fNIRS) as a potential tool to differentiate UD and BD based on their differences in hemodynamic change in the prefrontal cortex during verbal fluency tasks (VFT).

METHODS

We enrolled 179 participants with clinically confirmed diagnoses, including 69 UD patients, 68 BD patients and 42 healthy controls(HC). Every participant was assessed using a 45-channel fNIRS and various clinical scales.

FINDINGS

Compared with HC, region-specific fNIR leads show UD patients had significant lower hemodynamic activation in 4 particular pre-frontal regions: 1) the left dorsolateral prefrontal cortex (DLPFC), 2) orbitofrontal cortex (OFC), 3) bilateral ventrolateral prefrontal cortex (VLPFC) and 4) left inferior frontal gyrus (IFG). In contrast, BD vs. HC comparisons showed only significant lower hemodynamic activation in the LIFG area. Furthermore, compared to BD patients, UD patients showed decreased hemodynamic activation changes in the VLPFC region.

CONCLUSION

Our results show significant frontal lobe activation pattern differences between UD and BD groups. fNIRS can be a potential tool to increase diagnostic precision for these conditions. In particular, the VLPFC area holds promise to be a useful site for such differentiation for further investigations.

Nasal septal angiofibroma: less vascular behaviour than observed in radiological imaging, a rare case in a 51-year-old woman

Angiofibroma of the head and neck is classically found in the nasopharynx of an adolescent male. We present a rare case where an angiofibroma was diagnosed in the anterior nasal septum of a 51-year-old woman, the eighth nasal septal angiofibroma reported in a female. This case highlights how an angiofibroma in an older woman has a less vascular behaviour than one in an adolescent male, even though radiological enhancement may suggest that the lesion is highly vascularised. Nasal septal angiofibromas can be managed by biopsy and removed by simple endoscopic resection with minimal haemorrhage. Although very rare, extranasopharyngeal angiofibroma/nasal septal angiofibroma should be included in the differential diagnosis when patients of all ages present with nasal obstruction secondary to a nasal mass, with or without epistaxis.

Adaptations and Innovations to Minimize Service Disruption for Patients with Severe Mental Illness during COVID-19: Perspectives and Reflections from an Assertive Community Psychiatry Program

Changes to community psychiatry during COVID-19 are unprecedented and without clear guidelines. Minimizing disruption, ensuring quality care to the already vulnerable people with serious mental illness is crucial. We describe and reflect our adaptations and innovations at one community psychiatry program, based on three key principles. In (i) Defining and maintaining essential services while limiting risk of contagion, we discuss such strategies and ways to assess risks, implement infection control, and other creative solutions. In (ii) Promoting health and mitigating physical and mental health impacts, we reflect on prioritizing vulnerable patients, dealing with loss of community resources, adapting group programs, and providing psychoeducation, among others. In (iii) Promoting staff resilience and wellness, we describe building on strength of the staff early, addressing staff morale and avoiding moral injury, and valuing responsive leadership. We also identify limitations and potential further improvements, mindful that COVID-19 and similar crises are likely recurring realities.

Lessons from a Canada-China cross-national qualitative suicide research collaboration

A cross-national qualitative suicide study was conducted by Tsinghua University and the University of Toronto with two samples of Chinese women in Beijing and Toronto. The aim of this article is to reflect on lessons learned from this collaborative study. A literature review guided the analysis. A focus group was conducted with members of both research teams. A semi-structured interview guide was developed to explore the researchers' experiences of participating in the cross-national study. Focus group transcript data and observations from authors informed the analysis, situated in the existing literature on cross-national qualitative health research and guided by Baistow's cross-national research frame. Our study highlights how cross-national research involves conceptual and practical challenges that require negotiation. Such research also holds many opportunities, including (1) using a different cultural lens to understand differences and clarify similarities cross-culturally; (2) co-constructing knowledge through collaboration; (3) deconstructing one's own assumptions; and (4) engaging in an inspiring and empowering experience in collaboration.

"I think I am worth it. I can give up committing suicide": Pathways to recovery for Chinese-Canadian women with a history of suicidal behaviour

This qualitative study explored the experiences and patterns of recovery of Chinese-born women living in Canada with a history of suicidal behaviour. It explores a number of dimensions of recovery including clinical, existential, functional, physical, and social. The women described engaging in "survival" recovery in the short term and "thriving" recovery in the long term, with survival strategies extending into the thriving phase of recovery during their complex path to it. The survival recovery phase included accessing culturally sensitive mental health care and obtaining social and instrumental support to help ensure safety, manage stress, and treat psychiatric symptoms. The thriving phase of recovery was described as involving six components: developing an explanatory model with their health care provider; undertaking a process of narrative reflection and prioritizing self-care; engaging in interdisciplinary care team support; engaging the support of family and friends; exploring spiritual and existential supports; and creating goals for the future and a sense of mastery. Through these six avenues, the women began to experience a sense of self-efficacy and agency that improved their ability to cope with stress and pressure, leading to building a life with meaning. The interviews provided insights into how clinical care can be improved and how practitioners can implement a more recovery-oriented approach to practice.

Exploring experiences with compulsory psychiatric community treatment: A qualitative multi-perspective pilot study in an urban Canadian context

As medical, ethical and clinical effectiveness debates about the use of compulsory psychiatric treatment continues, it is important to further explore the actual experiences and perspectives of all relevant stakeholders in community treatment orders (CTOs). This qualitative pilot study engaged a total of twenty-seven clients, their family members, and care providers in Toronto, Canada. Semi-structured, one-on-one interviews were conducted between February and July 2013 and analyzed using thematic analysis. Top key themes from all the participants identified include, among others: 1) clients' experiences of coercion while treated under CTO, but a preference for CTOs compared to involuntary hospitalization, nevertheless; 2) limited real opportunities for collaboration in treatment decisions expressed by clients and family members; 3) acceptance of the potential for clinical recovery on CTOs while debating the role of CTO in a broader recovery journey by all stakeholders; 4) general preservation of therapeutic relationships between clients and care providers, while acknowledging the tension of taking on an "enforcer" role by providers; and 5) existence of different avenues for asserting agency by clients. The findings of this research illuminate the nuanced, complex, and adaptive perspectives held by different stakeholders, point to the importance of preserving and enhancing procedural justice in their use, and alert the field to incorporate recovery-based approaches in this controversial practice that is a widely and commonly used clinical tool across many jurisdictions.

Prognostic Value of Brain Magnetic Resonance Imaging in Neonatal Hypoxic-Ischemic Encephalopathy: A Meta-analysis

OBJECTIVE

To quantify the prognostic value of neonatal brain magnetic resonance imaging (MRI) in neonatal hypoxic-ischemic encephalopathy.

METHODS

Meta-analysis of studies with ≥35-week neonates with hypoxic-ischemic encephalopathy who underwent brain MRI within age 4 weeks and had neurodevelopmental follow-up for at least 12 months.

RESULTS

An abnormal neonatal brain MRI was more frequent among patients with unfavorable neurodevelopmental outcome: odds ratio = 18.2 (95% confidence interval: 9.4-34.9), P <.0001. The prognostic value of neonatal brain MRI in moderate hypoxic-ischemic encephalopathy had an odds ratio of 17.7 (95% confidence interval: 5.3-59.3) and in severe hypoxic-ischemic encephalopathy, the odds ratio was 125.0 (95% confidence interval: 2.0-7917.1). Therapeutic hypothermia did not change the prognostic value of neonatal brain MRI (odds ratio for hypothermia, 14.0 [95% confidence interval: 3.1-63.6], vs no hypothermia, 18.1 [95% confidence interval: 10.0-33.1], P = .7525).

CONCLUSION

Neonatal brain MRI provides prognostic information on outcome beyond early infancy in hypoxic-ischemic encephalopathy and therapeutic hypothermia does not change its prognostic value.

The value of neck drain in esophageal surgery: a randomized trial

The use of surgical drains in certain clean elective operations remains controversial. To evaluate the role of closed-suction drain for an esophageal anastomosis in the neck, we conducted a randomized, controlled study in 40 patients with esophageal carcinoma who underwent esophagectomy with an esophageal anastomosis in the neck, half of whom had a neck drain inserted at the end of operation. The median (range) duration of drainage was 46 hours (36 to 88 hours). The median (range) amount of drainage was 63 ml (15 to 210 ml). There was no incidence of haematoma or seroma formation in both the drained and non-drained groups. Anastomotic leakage did not occur in any patient. The benefits of closed suction neck drain could not be demonstrated. Routine use of neck drain for esophageal anastomosis in the neck is not necessary.