Thesis (M.S.)--Boston University

BACKGROUND: There is an urgent need to provide training and tools to frontline health workers in order for them to properly diagnose and treat mental illnesses in Latin-American communities, since the vast majority of people with a mental illness suffer in silence. A computer-assisted interview, the Global Mental Health Assessment Tool (GMHAT/PC) has been developed to assist general practitioners and other health professionals to make a quick, convenient, yet reasonably comprehensive and standardised mental health assessment. GMHAT/PC has been translated into various languages including German, Dutch, Chinese, Hindi and Arabic. This is the first study, of a GMHAT/PC Spanish version carried out in Latin America, to establish its validity in that culture and feasibility to be used in the health care setting. If proven a valid tool through this study, the GMHAT/PC Spanish version will be an important aid towards improving the mental health of Spanish-speaking communities within the Latin-American region. AIM: The study aims at assessing both the validity of a GMHAT/PC Spanish version, and the feasibility of utilising a computer assisted diagnostic interview by GPs. DESIGN: 1) Validation study was planned to establish whether the GMHAT/PC based diagnosis compares well with the consultants ICD-10 based diagnosis (Gold Standard) 2) Feasibility study was carried out to examine whether GMHAT/PC can be used in routine clinical care in a general health setting. MATERIALS AND METHODS: In the first study (validation), participants varied from those who were in remission i.e. without much psychopathology to those had symptoms of a severe mental illness. They were recruited from in-patient (82%) and out-patient (18%) mental health settings in Colombia. The participants were expected to have a wide range of psychiatric diagnoses (anxiety disorders, depression, psychosis, bipolar affective disorder, organic mental disorders, and other diagnoses). All consecutive patients were interviewed by GPs using GMHAT/PC and psychiatrists made an independent diagnosis applying ICD-10 criteria. The second study (feasibility) was carried out on patients hospitalised at medical, surgical and women’s wards during a period of one month in each service. The diagnosis of a medical illness was made by specialists in each service. A trained GP carried out psychiatric assessment of all participants using GMHAT/PC. RESULTS: First study (validity): two hundred ninety-nine patients (n=299) participated, 54.18% males and 45.81% females in the age range of 14-78. All patients were interviewed independently by seven psychiatrists with over five years of clinical experience. The mean duration of GMHAT/PC interview was 12.5 minutes. Most patients were pleased that they were asked about every aspect of their mental health. Psychiatrists made a single diagnosis in 183 (61%) cases, multiple (two) diagnosis in 112 (37%) cases and multiple (three) diagnosis in another four cases. GMHAT/PC in almost all cases gave additional multiple diagnoses. The results show an acceptable-to-good level of agreement between the GPs’ (GMHAT/PC) diagnoses and the psychiatrists’ (clinical) diagnoses of any mental illness, Kappa 0.58- 95% C.I (0.46, 0.72). There is a good level of sensitivity (81%) and specificity (92%), with GPs correctly identifying 242 out of the 250 participants diagnosed with a mental illness, and 27 out of 35 of those who do not present any whatsoever. The agreement (kappa value) between GMHAT/PC diagnosis and psychiatrists ICD-10 based diagnosis of specific disorders were as follows: Organic disorders-0.87; Psychosis- 0.56; Depression-0.53; Mania-0.6, Alcohol and drug misuse- 0.62, Learning disorder- 0.4; Personality Disorder- 0.39 and Anxiety disorders- 0.14. The sensitivity of different disorders ranged from 63% (Mania) to 100% (Anxiety) and specificity from 71% (Anxiety) to 100% (organic). The second study (feasibility): out of 455 medically-ill patients, 4.8% had a mental illness identified by GMHAT/PC interview. Anxiety, depression and organic disorders were the most frequently identified mental disorders in internal medicine and surgery. Cancer had a significantly higher prevalence of comorbid mental illness. CONCLUSION: GMHAT/PC -Spanish version used by GPs in this study detected mental disorders accurately and it was feasible to use GMHAT/PC in Colombia and Latin-American health settings. The findings of this study will have a big impact upon mental health service provision in Spanish-speaking nations within the Latin-American region as the Spanish version for GMHAT/PC will assist primary care physicians and other health workers in detecting and managing mental health disorders in the communities. There is no other comparable easy-to-use comprehensive mental health diagnostic tool available in Spanish.

<p>Abstract The increased prevalence of cognitive deterioration has increased the challenges of caring for older adults. This study?s project site offers a psychiatric program for older adults with customized care for complex geriatric mental health patients. Clinical assessment and care management are often overlooked in geriatric mental health patients diagnosed with behavioral and psychological symptoms of dementia (BPSD). The purpose of this project was to deliver an education program developed from the Staff Training in Assisted Living Residences-Veterans Administration, P.I.E.C.E.S ? model and the Castle framework to 42 nursing and allied health staff of the project site. The project question explored whether an education program on care of patients with BPSD increased staff members? perceived knowledge and competence in providing care to these patients. This education program focused on comprehensive assessment, individualized care planning, and individualized nonpharmacological interventions to manage older adults with dementia. Descriptive statistics were used to analyze performance outcomes data before and after staff education. In addition, care plans of patients were reviewed. Results included a 100% increase in recognition of core concepts of the education program; a 48% to 86% increase in staff willingness to use interdisciplinary care plans; and a 6.6% to 95% increase in documentation of key interventions in care plans for 6 behaviors of dementia. The results of this project might bring about social change by improving the skills and competence of nursing staff in managing the patients with dementia, thus positively impacting the quality of life of patients with BPSD by benefiting from nonpharmacological interventions.

<p> This study examined the communicative construction of mental health in correctional work. Using narrative interviews with 25 current and former correctional officers, I explore how macro, meso, and micro D/discourses both enable and constrain communication and action around mental health for correctional employees. The findings suggest that larger cultural Discourses related to masculinity, bounded rationality, and personal responsibility, meso discourses related to organizational expectations, and daily micro-talk about mental health and resources such as the Employee Assistance Program, primarily create and sustain communication barriers that limit correctional workers from communicating about or seeking help for mental health challenges. From a critical perspective, D/discourses related to power and control privileged the rational experiences of workers and marginalized the emotional/physical experiences, a practice I argue has significant implications for the health and well-being of workers. </p><p>

Thesis (M.S.)--Boston University

The dissertation aims to enhance knowledge about bereavement support-seeking among older adults with Complicated Grief (CG) and/or depression and to examine the outcomes of support received. This three-paper dissertation uses data from two studies of bereaved older adults: the Changing Lives of Older Couples (CLOC) Study and the Complicated Grief Treatment in Older Adults (CGTOA) Study. The dissertation draws upon Pescosolido and colleagues' Network Episode Model to frame the exploration of support-seeking. Paper 1 is based on qualitative interviews with eight older adults with CG who completed participation in a National Institute of Mental Health (NIMH) funded randomized clinical trial of CG treatment, the CGTOA study, and seeks to better understand the bereavement support- seeking process. Several primary themes arose, including observing that grief was causing a great deal of emotional distress and role impairment, grief not meeting their own or others' expectations of what grief "should be," influences of social relationships on support-seeking, and a lack of effectiveness of support groups and/or care from mental health professionals. Papers 2 and 3 use secondary analyses of longitudinal surveys from the CLOC Study, a representative community sample of widowed older adults. Paper 2 describes support sought for grief at 6, 18, and 48 months post-widowhood, including religious leader, support group, and family doctor support, and examines the influence of social network variables, the presence of CG and depression, and other demographic (gender, education, age, race, income, and home ownership) and clinical variables (health satisfaction, anxiety severity, attachment anxiety, attachment avoidance) on support sought. Approximately 20% of the sample sought multiple types of support concurrently. Social network, clinical and demographic variables also varied across types of support sought. For example, the presence of CG was associated with a greater likelihood of seeking support, and low instrumental support increased the odds of going to family doctors for support with grief. There were also significant associations between types of support sought. Paper 3 determined whether utilization of bereavement supports at 6 months post-loss was associated with reductions in emotional distress (grief, depression, or anxiety) at 18 months in widows with CG or depression in the CLOC sample. Using a self-help or support group reduced grief symptoms, but did not significantly alter depression or anxiety symptoms. Seeking support from a religious leader decreased depression, but not grief or anxiety. Seeking support from a family doctor did not impact anxiety, depression or grief. Discussion sections for each paper and a conclusion section for the entire dissertation summarize study findings, identify limitations, and detail implications for practice, research, and policy.

Bullying, harassment, and horizontal violence (BHHV) is commonly reported by student nurses during their clinical education. Despite decades of mention in the literature, no instrument is available to specifically measure the student nurse's experience of BHHV during clinical education. Purpose: The purpose of this dissertation is to examine the experience of BHHV in a population of student nurses matriculating during their clinical education in New York. The experience of BHHV is measured with the BEHAVE Survey, the instrument developed and tested for this purpose. Methods: This dissertation is presented in three manuscripts: (1) a comprehensive review of the literature using The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Statement as the methodological guide, (2) the initial psychometric testing of BEHAVE (Bulling, harassment, and HorizontAl ViolencE) for validity and reliability at a university-based school of nursing in New York, and (3) a descriptive, quantitative survey of baccalaureate nursing students at a university-based school of nursing in New York completed as a field test of the BEHAVE. Results: Despite variations in methodology, measurement, terms, definitions, and coding of behaviors and sources of BHHV, the findings of this literature review indicate that student nurses are common targets of BHHV during clinical education, regardless of demographic characteristics, disability, sexual orientation, geography location, academic institution or program type. Psychometric testing indicated: scale-level content validity index among experts 0.89, r = 0.97, a Cronbach's á 0.94, and percent agreement 93% in test-retest reliability. BEHAVE was administered to a total of 32 participants (96.7% participation rate). Approximately 72% reporting current experienced or observed BHHV with 46.8% (36/77) of incidents originated from a nurse. Conclusions: The evidence from both the literature and this field trial suggests that BHHV is a common experience among nursing students. This is significant because student nurses are vulnerable to BHHV and studies including students have been limited to date. Therefore, it behooves the research community to continue to explore the impact of BHHV on the student nurse's socialization into the professional nursing role. Further knowledge may inform targeted interventions to reduce BHHV and improve the ability of nursing students to minimize the impact of BHHV should it occur.

This dissertation presents an ethnography of equine-assisted psychotherapy (EAP) based on nine months of fieldwork at "Equine Healers," a non-profit organization in central Colorado that specialized in various therapeutic modalities associated with EAP. In bridging scholarly work around animals, a literature suffused with the notion of "companion species," as well as scholarly work around psychotherapy, and most especially the idea of "psychotherapy as conversation," the connective conflict these two interests share, and from which this dissertation emerges, is over questions of language and communication. Specifically, the overarching problem that this dissertation addresses is: what counts as talking, in the context of "the talking cure," when beings that do not share human language are necessarily implicated in human conversations. Beginning with Das' (1997) encouragement to understand "pain as the beginning of a language game," most of this dissertation will therefore be about dropping the reader into the silences between the humans and the horses, and between the words the humans use to talk about their experiences with the horses, thereby raising fundamental questions about the communicational dialectics that can transform human experiences. I argue that anthropologists must re-arrange our analytical frames around humans and animals, beginning with how we understand language, in the context of communication, to be organized. Rather than privileging subjects and objects, I suggest returning to Bateson (1972) and attempting to privilege relationships. To explore these ideas, this dissertation will attend to a particular therapeutic modality employed at Equine Healers, a set of practices called a "group sculpture." To set up and make it possible to appreciate the complexity of this modality, this dissertation will first consider framing conversations among humans and horses as rhythmically ordered interactions. To do this, I generate a model of conversation based less on grammatical rules derived from the use of words, or the possibilities offered by subject-object "thing" relationships, and instead lean on musical relationships of rhythm. Initially emerging through conversation, I then trace out rhythms carried between horses and humans by particular physical, material pieces of their world. These brushes, clickers, and bridles ultimately bridge vocal and pneumatic rhythms; and it is movement along this connection, an ebb and flow of voice and breath that, in aligning, generate opportunities for iconic relationships with one's self.

Prenatal maternal depression and anxiety are associated with poor infant health, behavioral and achievement outcomes. The impacts of prenatal maternal mental health on the development of particular brain-based neurocognitive systems in children are less clear. This dissertation examines the association between prenatal maternal depression and anxiety and infant memory and language outcomes. 179 infant mother dyads were recruited in South Dakota. Ninety infants were followed at 9- and 15-months, and 89 were followed at 15- and 21-months of age. These data were used to understand more clearly the association between prenatal maternal depression and anxiety and changes in infant memory and language over the first two years of life. Additionally, by measuring the interaction between prenatal mental health and parenting and the direct association of parenting on changes in infant memory and language, we can better understand if the pathway between prenatal maternal mental health and infant memory and language is biological, social or both. Results demonstrated no significant direct association between prenatal maternal depression and anxiety symptoms and changes in infant memory or language from 9 to 21 months. The HOME language and literacy subscale was associated with changes in memory and language from 9 to 21 months; the HOME parental warmth subscale was associated with changes in language from 9 to 21 months. These results were independent of prenatal maternal social risk. Implications for additional screening measures, interventions, and considerations for future research are discussed.

Working with HIV-positive individuals may present a particular challenge to clinicians because of the phenomenon of stigma. Researchers have proposed that HIV stigma is layered with people's prejudiced attitudes toward already-stigmatized groups (e.g., sexual orientation, gender, race and ethnicity) in which people living with HIV/AIDS may have membership. Previous research has suggested that, clinicians' attitudes and reactions toward HIV and sexual orientation may significantly impact their therapeutic impressions, yet questions remain with regard to how clients' HIV status and racial identity may operate in confluence to influence clinicians' therapeutic impressions. This question may be particularly significant with regard to mental health professionals, as research also suggests that racial/ethnic minority clients can be perceived by their clinicians as more disturbed as a result of clinicians' biased racial attitudes. In the present study, case vignettes featuring hypothetical Black or White men who are either HIV-positive or HIV-negative were presented to participants to explore the influence of a client's HIV status and race upon participants' therapeutic impressions. Results indicated that participants' expectations of therapeutic process and evaluations of the clients' symptomatology were influenced by the clients' race and HIV status. Participants expected slightly greater session depth for the Black clients than the White clients in the vignettes, and their initial impressions of symptomatology were also slightly more negative toward the White clients in the vignettes. With regard to the main effect of client HIV status, participants expected slightly greater session depth for the HIV-positive clients than the HIV-negative clients in the vignettes. However, participants expected slightly less session smoothness for the HIV-positive clients in the vignettes, and they also reported lower assessment of psychological, occupational, and social functioning toward the HIV-positive clients in the vignettes. The potential interaction of the hypothetical client's race and HIV status and its effect upon participants' clinical impressions was not found significant. Implications for research and practice are discussed.