Exploring the Effects of Earthquakes in Nepal
On April 25, 2015 a magnitude 7.8 earthquake struck Nepal, killing more than 8,000 people and injuring over 21,000. As a result, hundreds of thousands of Nepalese were homeless and entire villages were flattened in many areas. Complicating matters, on May 12, 2015 the largest aftershock occurred (magnitude of 7.4) followed minutes later by a magnitude 6.3 shock. More than 450,000 people were displaced overall.
The horrific effects of earthquakes go far beyond immediate physical destruction. It is difficult to imagine the losses both physical and mental that can occur during such devastation. Until now there was limited knowledge regarding post-disaster psychopathology, and even mental health in general in the Nepali population. Through internal funding, Susan Santangelo, the Director of the Center for Psychiatric Research at MMCRI, was able to launch the Nepal PTSD Project in March 2016.
“The goals of the project are to determine the prevalence of PTSD, depression, resilience and factors associated with event impact among earthquake survivors,” says Santangelo. “In addition, we trained college students in Skills for Psychological Recovery (SPR) to enable the students to train villagers to ultimately help each other.”
As of 2019, the research team is currently analyzing data to determine the impact of teaching skills for psychological recovery to the villagers. They have just published a paper with another one under review. The published paper is:
Schwind, JS; Formby, CS; Santangelo, SL; Norman, SA; Brown, R; Hoffmann-Frances, R; Koss, E; Karmacharya, D. Earthquake Exposures and Mental Health Outcomes in Children and Adolescents from Phulpingdanda Village, Nepal: A Cross-Sectional Study. Child Adolesc Psychiatry Ment Health. 2018 Dec 20;12:54. doi: 10.1186/s13034-018-0257-9. PMID: 30598695
Above: Maine Behavioral Healthcare Trauma experts, Rebecca Hoffman-Frances and Rebecca Brown, lead discussion of earthquake aftermath with school children. Below: A destroyed home in Nepal and Nepalese family outside their temporary home.
+Innovative Trauma Research Helps Kids
Our Director of Clinical Innovation; Rebecca Hoffmann-Frances, is a busy lady. Busy and very passionate about improving the lives of Maine kids who have experienced trauma. One of several researchers at the Center for Psychiatric Research (CPR), Rebecca is integrally involved in two programs that will soon become connected in a way that has not been attempted by any other healthcare system of our size in the entire country. It is truly groundbreaking.
The Maine Children’s Trauma Response Initiative (MCTRI) is an MBH project that has trained over 250 clinicians in Trauma Focused Cognitive Behavioral Therapy (TF-CBT), meaning there are clinicians trained in every county in Maine. TF-CBT has been proven to help children who have experienced a traumatic event through individual and family therapy and teaching coping skills. “What we need to do now,” Rebecca says, “is understand the effectiveness of the model in a variety of settings and focus on implementation science – learning about the factors that support a clinician’s continued use of the model with fidelity.”
Coinciding with MCTRI is the Portland Defending Childhood project, a Department of Justice program that focuses on prevention and intervention. “Through research we’ve learned that levels of trauma in rural areas in Maine are almost double the rates in urban areas in part due to isolation and lack of services.” This knowledge highlights the importance of providing trauma screening on a routine basis for all children.
In November, Rebecca and colleagues at Maine Medical Center will be leading the implementation of a trauma screening tool that will be incorporated into the EPIC electronic health record. The tool will be used to screen all children from birth to 21 years of age during well child visits at every MaineHealth practice that uses EPIC. In addition to providing early intervention and an opportunity to collect data, kids can be easily connected to clinicians trained in TF-CBT. This type of quality improvement initiative is what will bring positive change for kids in Maine.
+Nationally Known Researcher Nurtures Early Intervention
Dr. William McFarlane, “father” of the Portland Identification and Early Treatment (PIER) program, has a long history of advocating early intervention treatment for youth with mental illness. The PIER program and its subsequent implementation throughout the U.S. is a great source of pride for him – and understandably so (see Now is The Time). It began almost 40 years ago when a teen he hired to do some construction had difficulty hammering nails. “He also exhibited behaviors associated with early onset schizophrenia like difficulty concentrating, recalling instructions and responding to things that weren’t there,” Dr. McFarlane explained. “Unfortunately, he did have a full-blown psychotic event a few years later. I’ll never forget him. He was the inspiration for our work on preventing the first episode.”
Decades later, Dr. McFarlane became the lead investigator for the Mental Health Attitudes of Youth (MAY) study with some exciting initial results to report.
Early analysis, reflecting over half the sample (120 out of 200), supports the notion that the subject’s awareness of symptoms (internal stigma) has more impact than the “labeling” they experience from those around them. Their internal struggles with memory loss or even mild hallucinations can make them think they’re defective and become stigmatizing. Despite being scared, they are still at an earlier stage where psychosis has not set in, so they are able to respond to early treatment.
More importantly, they are able to engage in that treatment, as they are hopeful to reverse what is happening to them. Early intervention means both the subject and family members have not become exhausted by the illness. Everyone — including parents, school staff, family members and clinicians — can work together to reduce the symptoms sooner.
“The good news”, said Dr. McFarlane is that “the relationships between shame, stigma and symptoms may be affected by therapy. We believe that when the symptoms are treated, the shame and stigma will go away.”
+Learning from Buddies
Sandra Fritsch, M.D. child and adolescent psychiatry training director at MMC is in the finishing stages of submitting data for publication on the results of a collaborative learning model called “The Buddy System.” The training model was put in place in 2012 to develop a collaborative learning model by pairing pediatric and medical pediatric (med ped) residents with child psychiatry fellows
As health care models such as Behavioral Health Homes, Behavioral Health Integration and Accountable Care Organizations emerge, it is important to foster a collaborative environment among behavioral and medical health. Traditional education leaves pediatric and med peds residents with little formalized mental health training or appropriate resources. In addition, many child and adolescent psychiatry fellows have limited postgraduate training in pediatric primary care. The Buddy System is filling a significant need in the transformation of integrated health care.
“I’m particularly interested in understanding what fosters and promotes learning,” explained Dr. Fritsch. Collaborative care/shared care with pediatric primary care represents a significant focus of her career and led to the development of the Child Psychiatry Access Program (CPAP). This program fosters a collaborative work environment where professionals from behavioral and medical health can learn from each other. Developing the Buddy System was a natural extension of CPAP “I want to understand the attitudes of primary care providers and how they perceive access to child psychiatry and mental healthcare. Participants have an opportunity to explore potential barriers they may experience and give feedback. This is truly a quality improvement model that can change behaviors.”
Dr. Fritsch and her colleagues at Tufts present the model to peers throughout the nation and are receiving interest by other programs (e.g. Arizona and the State of University of New York) that plan to implement it. You can read more about this valuable program in Psychiatric News.
+Primary Care Integration for Treatment of Substance Abuse
The newest member of the Center for Psychiatric Research (CPR), Jonathan Fellers, MD has hit the ground running. Although he only joined the Maine Medical Center psychiatry staff in September, he is has already begun working with primary care integration to expand access to treatment for individuals addicted to heroin and other substances. In October, he and Dr. Susan Santangelo, Director of the Center for Psychiatric Research, participated in the inaugural meeting of the Northeast Node of the Clinical Trials Network (CTN) at Dartmouth College. Funded by the National Institute on Drug Abuse, the CTN was established as a way to improve treatment for patients suffering from substance abuse based on evidence from clinical trials research.
“Data suggest that poor decision making is part of the illness,” explained Dr. Fellers. “Delayed discounting (an inability to delay gratification) is different in addiction and serves as a biomarker we can measure. Partnering with the Northeast Node will be a great opportunity to allow our patients to participate in treatment trials for substance abuse.”
In the meantime, Dr. Fellers is working with a team to set up a new treatment program that will provide Buprenorphine to treat opioid addiction. Maine Medical Center is spending $800,000 to launch the new treatment program, which will expand drug treatment options by having addiction specialists and counselors travel to doctor’s offices to help addicts they are caring for. The program will support adoption of a consistent method to treat heroin addiction through medication, therapy and providing “curbside” support to physicians. “Primary care doctors and clinical staff will be welcome to reach out to me directly with any questions.” The program is scheduled to begin in primary care offices in Portland in February with plans to expand to Westbrook and Scarborough thereafter.
Dr. Fellers considers himself to be a “matchmaker” between available clinical trials and the population for which we provide care. And he is in the perfect position to do this by working with primary care offices, expanding treatment for substance abuse and addiction and partnering with the Northeast Node of the CTN. “My primary goal is to expand access to treatment and promote research.” The Center for Psychiatric Research is excited to welcome Dr. Fellers to Portland, Maine (from Portland, Oregon) and eager to collaborate with him on research that will ultimately improve treatment options for all those suffering from addiction.
+How Do Young People View Mental Illness?
Researchers for the Mental Health Attitudes of Youth (May) study are gathering perceptions by youth on what symptoms of mental illness mean to them. The study is a collaboration with Maine Medical Center and Tufts University. Research Coordinator Donna Downing has immersed herself wholeheartedly in the project.
“I get to work with these young people and their families by making lifestyle suggestions,” Donna explains. “I’m not only here to gather data but also act as a referral source when a family has hit a barrier for treatment. It’s very rewarding.”
The May study includes participants aged 12-35 who are experiencing emerging signs of psychotic illness such as difficulty thinking clearly, withdrawal from friends and family or mistaking noise for voices or messages. “The individual is still able to recognize that these symptoms are not real – and in their words – think they are going crazy,” Donna elaborated.
The study will be accepting referrals through June 2016. Early results have indicated that young people are most upset by terms such as depression and anxiety. They don’t understand the term psychosis, which is a loss of touch with reality. Fortunately, these anxious young people have the opportunity to discuss their fears with Donna who is there to help them get through it together.
+Groundbreaking Study on Vasopressin
Monthly meetings of the Center for Psychiatric Research are filled with promise that groundbreaking research may ultimately improve the lives of those living with mental illness. We recently spoke with Dr. Daniel Price, Clerkship Director for Psychiatry at Maine Medical Center with an office at McGeachey Hall Medical Center, Portland who is in the midst of a five-year study* on the impact of vasopressin that may prove useful in the treatment of autism, schizophrenia and depression/anxiety.
Sure, you’re thinking “vaso…what?” As Dr. Price explained it, “Vasopressin is a nonapeptide (a nine amino-acid molecule) that is released into the body by the pituitary as a hormone that regulates water metabolism. It is an FDA-approved drug for Diabetes Insipidus and abdominal distension. However, it is also released within the brain where it can regulate emotions and social interactions. It is these latter effects which we are studying.”
Research first began by studying voles (think of a stubby looking mouse) and has moved to humans. Dr. Price serves as the medical monitor to make sure all human subjects are physically sound and understand the impact of the testing. The study is being managed through Bowdoin under the direction of Professor Rick Thompson and Dr. Price was identified as an ideal partner.
“I just happened to be at the right place at the right time,” described Dr. Price. “I’m very pleased that Maine Medical Center was able to facilitate my role through the Maine Medical Center Research Institute (MMCRI). I can’t understate the importance of MMCRI in providing great coordinators who are the workhorses of the study and this collaborative effort with Bowdoin.”
The medical portion of the study takes place at McGeachey where subjects aged 18 to 30 years volunteer to participate during three, day-long trials. During the testing, participants are given either a placebo, or the drug, and asked to view a series of socially relevant photos. Subjects are “hooked up” to a monitor that is similar to a lie-detector where their responses are documented. The study will conclude this summer and will ultimately include findings from 250 subjects. Results will be analyzed well beyond that timeframe.
Volunteer subjects are being recruited and participation does include some compensation.
FMI: Contact Anna Cloutier, Study Coordinator at firstname.lastname@example.org or (207) 396-8304
This IRB-approved study was made possible through a National Institute of Mental Health (NIMH) grant.
+The Future of Behavioral Health Integration through Research
Neil Korsen, MD has a vision. It calls for a healthcare system in which a behavioral health clinician is an integral care member of all primary care offices, not just some. As the medical director for the behavioral health integration program, Neil is also a member of the Maine Medical Center Research Institute (MMCRI) where ideas are shared and connections formed. Neil’s goal is to gain support for research that will confirm that Behavioral Health Integration (BHI) improves outcomes for clinicians and patients.
As background, our BHI program is one of the most successful integration programs in the country. There are approximately 40 clinicians providing care at over 50 primary care locations and almost 10 specialty offices throughout Maine. The program began with grant funding but under the expert eye of Mary Jean Mork, VP Integrated Programming, has become financially self-sustaining. “Mary Jean understands the fee for service system and the rules for reimbursement of behavioral health services at a level that is truly amazing,” Neil stated. “As one of the largest BHI programs in the nation, we are continually asked for advice from organizations working on developing similar integration services. Any research we can provide will help others across the country.”
The Institute for Clinical and Economic Review has released an action guide that supports the need for further research in this area. The guide includes several references to our program in Maine that highlights our commitment to the Triple Aim. “Through research we will be able to prove BHI has a positive impact on quality and cost that will ultimately provide value for consumers and providers” Neil explained.
A recent informal study provided insight into provider satisfaction with the program. Providers gave the program high marks and reinforced the importance of making behavioral health clinicians available to patients through their trusted primary care offices. One quote highlighted the “boundary-less care between medical and behavioral issues.”
One research area of particular to the group involves substance problems in the primary care setting. In fact, MaineHealth, MBH, and the BHI program have recently been invited to become part of the National Institute on Drug Abuse Clinical Trials Network based at the Dartmouth Psychiatric Research Center. Membership means we have an opportunity to participate in studies and share ideas for research.
The BHI program is an excellent example of the seamless care we strive to provide for our patients and clients. We look forward to sharing more information about this program in future issues.
+Can Video Improve Patient Engagement?
Dr. Colin Lamb, who has been part of the MaineHealth system for several years during his training, recently moved to Spring Harbor Hospital as an attending psychiatrist on the child and adolescent units. He has brought with him a very intriguing research project that could change the way we treat adolescents and young adults diagnosed with psychosis (a loss of contact with reality).
When complete, the study hopes to enroll around 40 individuals aged 13 to 25, who have been diagnosed with psychosis and have been admitted to Spring Harbor Hospital. The subjects are randomly placed into the experimental or control group. Subjects in the experimental group are videotaped during an interview designed to display current mental status and insight into their illness. During the study, each subject is assessed through a series of general symptom, mood and insight rating scales. After one week, patients in the experimental group are offered the opportunity to view their video and then participate in a structured debriefing session with a study investigator. Dr. Lamb explains, “In a sense, the patients are essentially having a therapeutic encounter with themselves and learning about their own illness presentation.”
This may be a valuable way for providers to help increase insight in a patient population that traditionally has little insight. Having minimal or no insight into one’s own psychotic illness is a large driver in treatment noncompliance and poor outcomes. Dr. Lamb reports that “so far, the individuals we have interviewed have responded positively and felt it was a worthwhile exercise. This is very intriguing from a clinical perspective and may offer another tool to help this challenging patient population.”
Dr. Lamb and his team are working diligently to make sure their study is known so they can identify more potential subjects.
If you would like more information about this study or have a potential candidate, please contact Dr. Lamb or one of the co-investigators (Dr. Doug Robbins, Dr. Kevin Coughlin, Dr. William Brennan or Sarah Maxner, LCSW). Additional members of the study include: Dr. Sandra Fritsch (mentor and safety monitor), Anna Cloutier, RN (research coordinator), and Susan Santangelo, PhD (research mentor).
This project is funded through a Maine Medical Center Research Institute (MMCRI) Mentored Research Grant and has received full IRB approval. Great care is being taken at each step in the process to ensure patient privacy and safety and maintain study integrity.