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The dearth of child and adolescent mental health services (CAMHS) is a global problem. Integrating CAMHS in primary care has been offered as a solution. We sampled integrated care perspectives from colleagues around the world. Our findings include various models of integrated care namely: the stepped care model in Australia; shared care in the United Kingdom (UK) and Spain; school-based collaborative care in Qatar, Singapore and the state of Texas in the US; collaborative care in Canada, Brazil, US, and Uruguay; coordinated care in the US; and, developing collaborative care models in low-resource settings, like Kenya and Micronesia. These findings provide insights into training initiatives necessary to build CAMHS workforce capacity using integrated care models, each with the ultimate goal of improving access to care. Despite variations and progress in implementing integrated care models internationally, common challenges exist: funding within complex healthcare systems, limited training mechanisms, and geopolitical/policy issues. Supportive healthcare policy, robust training initiatives, ongoing quality improvement and measurement of outcomes across programs would provide data-driven support for the expansion of integrated care and ensure its sustainability.

This article focuses on potential neurological side effects secondary to psychotropic agents. Clinicians often have to manage these relatively commonly occurring neurological side effects. These potential side effects, if not managed in a timely manner, could be a significant negative factor impacting compliance and tolerability as well as efficacy. This article reviews mechanism of action, assessment, diagnosis, and management of extrapyramidal side effects including akathisia, acute dystonia, parkinsonism, and tardive dyskinesia, as well as motor tics, tremors, myoclonus, seizures, and delirium. Prescribing clinicians need to be cognizant of these potential side effects and knowledgeable in assessing and managing them. [ Psychiatr Ann . 2021;51(9):402–409.]

Pregnancy can be a colossal change for some women, with the commencement of motherhood possibly generating emotional health problems, including peripartum depression (PPD). PPD significantly affects the parent-child relationship, which is the foundation for the socioemotional development of the child. In this article, we reviewed the association between PPD and resilience, and identified their mediators and moderators. Eight studies were included after a rigorous screening process. There was a significant relationship between PPD and childhood resiliency, resulting in an increased risk of psychiatric disorders in children and adolescents. Maternal sensitivity and emotional availability were possible mediators. Maternal education, income level, maternal trauma, life adversities, marital conflicts, and perceived social support were reported moderators. This article highlights the need for timely recognition and treatment of PPD with targeted interventions to improve the parent-child relationship. [ Psychiatr Ann . 2021;51(7):322–330.]

Diversity provides better patient outcomes, reduces physician burnout, and therefore lessens the burden of the healthcare system. In this study, we explore the gender and racial trends in the recruitment of medical graduates into US psychiatry residency programs. Retrospective data analysis was performed utilizing the data from the Accreditation Council for Graduate Medical Education (ACGME) Data's annual Resource Books from the year 2007 to 2018. Demographic data, including gender and race, were extracted for psychiatry residents. Gender was categorized as Male, Female, and Not Reported. Race/ethnicity was categorized as White (Non-Hispanic), Asian/Pacific Islander, Hispanic, Black/African-American (Non-Hispanic), Native American/Alaskan, Others (not in the aforementioned categories), and Unknown. Female psychiatry residents relatively decreased by 2.6% whereas male psychiatry residents relatively increased by 15.5% from 2007 to 2018. Between the years 2011 and 2018, there was a relative increase in African American/Black and Native American/Alaskan psychiatry residents by 5.5% and 1%, respectively, whereas the Asian/Pacific Islanders, White (Non-Hispanic), and Hispanic/Latino psychiatry residents relatively decreased by 5.1%, 2.3%, and 1.7%, respectively. Despite the overall increase of women and ethnic minorities in US medical schools, women and racial minorities remain significantly under-represented in psychiatry residency programs in the US.

Background Medical students have faced an enormous disruption to their lives due to the COVID-19 pandemic. The study aimed to assess the impact of COVID-19 on medical student’s psychological well-being in Pakistan. Following ethical approval, an online survey developed in collaboration with World Psychiatric Association (WPA) was distributed among medical students of 5 Medical colleges in the Punjab province of Pakistan between August and September 2020. Patient Health Questionnaire (PHQ-9), Generalized Anxiety Disorder Scale (GAD-7), and Risk Assessment Suicidality Scale (RASS) were used to assess psychological well-being. Data was analyzed using SPSS 26.0. Results Eleven hundred medical students responded, 756 (69%) being females. More than 2/3rd admitted that their emotional state got worse in relation to appearance of anxiety, insecurity, and sadness, compared to before the outbreak of COVID-19. Prevalence of anxiety and depressive symptoms were 48.6% and 48.1%, respectively. Female medical students, pre-clinical students, and those with a previous psychiatric history reported experiencing more anxiety and depression symptoms (P value Conclusion Our findings underscore that the impact of COVID-19 on medical students has been significant; hence, it is crucial for medical colleges to employ strategies to maintain the student’s well-being with safeguards like reassurance, support, and confidential student-centered psychiatric services. The use of virtual platforms (websites, email) to educate and screen students by staff members can create a positive impact. The limitations of this study include cross-sectional design, the possibility of selective participation being web-based survey, response bias, and the possibility of reluctance of students to report mental health problems due to stigma.

Autism is a fascinating topic that has attracted the interest of researchers and the lay public alike. The history of autism is filled with accomplishments of people who were astute observers of childhood psychopathology. Autism spectrum disorder affects a diverse group of children who share certain commonalities. There are ongoing attempts to understand its etiology and to refine diagnostic criteria for improved and timely recognition. In recent years, rapidly evolving research has highlighted the limits of our understanding of a disorder that at one time was considered rare, but now presents itself in 1 in every 59 children in the United States. This article particularly focuses on the history of autism as well as the changing criteria in the Diagnostic and Statistical Manual of Mental Disorders . [ Psychiatr Ann . 2019;49(3):103–108.]

The study investigated behavioral measures of social distance (i.e., desired proximity between self and others in social contexts) as an index of stigma against those with mental illness among medical students in the Republic of North Macedonia, Turkey, Azerbaijan, Kazakhstan, and Poland, using the Reported and Intended Behavior Scale (RIBS), a standardized, self-administered behavioral measure based on the Star Social Distance Scale. The students' responses to standardized clinical vignettes on schizophrenia, and depression with suicidal ideation, were also assessed. A total of 257 North Macedonian (females, 31.5%; 1-4 grades, 189; 5-6 grades, 68); 268 Turkish (females, 43.3%; 1-4 grades, 90; 5-6 grades, 178); 450 Kazakh (females, 28.4%, 71.6%; 1-4 grades, 312; 5-6 grades, 138); 512 Azerbaijani (females, 24%; 1-4 grades, 468; 5-6 grades, 44; females, 24%), and 317 Polish (females, 59.0%; 1-4 grades, 208; 5-6 grades, 109) students were surveyed. The responses on the RIBS social distance behavior measures did not improve with advancing medical school grade, but students across all sites viewed schizophrenia and depression as real medical illnesses. The results support the development of enhanced range of integrated training opportunities for medical student to socially interact with persons with mental illness sharing their experiences with them.

Autism spectrum disorder (ASD) is a neurological and developmental disorder characterized by social impairment and restricted interactive and communicative behaviors. It may occur as an isolated disorder or in the context of other neurological, psychiatric, developmental, and genetic disorders. Due to rapid developments in genomics and imaging technologies, imaging genetics studies of ASD have evolved in the last few years. Increased risk for ASD diagnosis is found to be related to many specific single-nucleotide polymorphisms, and the study of genetic mechanisms and noninvasive imaging has opened various approaches that can help diagnose ASD at the nascent level. Identifying risk genes related to structural and functional changes in the brain of ASD patients provide a better understanding of the disease’s neuropsychiatry and can help identify targets for therapeutic intervention that could be useful for the clinical management of ASD patients.

Generalized anxiety disorder (GAD), despite being among the most common psychopathology of children and adolescents, often goes undetected and untreated. GAD is characterized by excessive worry for more than 6 months about a variety of situations, events, or activities (especially school performance among children), inability to control the worry, and presence of at least one physical symptom. The interplay of various risk factors (genetic, environmental, and psychosocial) and protective factors is seen in youth with GAD, and comorbidity is common. GAD is associated with significant distress and disability independent of comorbid disorders. A multimodal approach that includes psychoeducation, psychological therapies (in particular cognitive-behavioral therapy), family therapy, and pharmacological treatment provides the best outcome for children and adolescents with GAD. [ Psychiatr Ann. 2017;47(10):497–501.]

Depressive disorders in children and adolescents constitute a significant burden on social and public health. The impairment can affect several domains of functioning including family, school, and social. Depression is also a significant risk factor in suicide and other psychiatric disorders. The prevalence of major depressive disorder is estimated to be 2% in children and 4% to 8% in adolescents. The rates are much higher in subsyndromal depression, which also affects the functioning of youth. Most youth do recover; however, recurrence is common, with 40% to 70% of youth experiencing relapse within 3 to 5 years. Biopsychosocial assessment of depression requires gathering information from multiple informants and synthesizing the information to diagnose depression. Treatment of pediatric depression consists of social, psychological, and pharmacological interventions. [ Psychiatr Ann. 2017;47(10):502–506.]

Pediatric obsessive-compulsive disorder (OCD) is a complex neuropsychiatric disorder that is characterized by the presence of distressing and impairing recurrent obsessions and/or compulsions. OCD affects up to 4% of children and adolescents, and constitutes a significant societal burden and causes marked distress and functional impairments in affected people and their families. The assessment of pediatric OCD should comprehensively capture comorbid conditions. Cognitive-behavioral therapy (CBT) is the first-line treatment for pediatric OCD. For moderate to severe cases, CBT may be combined with pharmacological treatment. First-line medications for pediatric OCD are selective serotonin reuptake inhibitors, and the US Food and Drug Administration has approved fluoxetine, sertraline, and fluvoxamine for use in pediatric OCD. Most children with OCD achieve remission or significant improvement in their symptoms. [ Psychiatr Ann. 2017;47(10):512–518.]

Children and adolescents are susceptible to developing posttraumatic stress disorder (PTSD), which has serious consequences for their emotional, physical, social, and cognitive development. Sources of traumatic stress in children are many, such as loss of a loved one, accidents, community or school violence, domestic violence, physical or sexual abuse, man-made or natural disasters, and terrorism. Due to the wide range of reactions seen in children according to their age and developmental levels, it is not possible to directly apply adult PTSD criteria to them. This article discusses issues related to etiology, assessment, and diagnosis of PTSD in children and adolescents. It describes the comorbidities and the neurobiological basis of PTSD symptomatology and critically evaluates current psychological and pharmacological treatments of PTSD in the pediatric population. [ Psychiatr Ann . 2017;47(3):139–144.]

Mental health disorders are a burgeoning global public health challenge, and disproportionately affect the poor. Low- and middle-income countries (LMICs) bear 80 % of the mental health disease burden. Stigma associated with mental health results in delayed help seeking, reduced access to health services, suboptimal treatment, poor outcomes and an increased risk of individuals' human rights violations. Moreover, widespread co-occurrence of physical comorbidities such as noncommunicable diseases with mental health disorders makes the treatment of both conditions challenging and worsens prognosis. This paper explores various aspects of stigma towards mental health with a focus on LMICs and assesses measures to increase help-seeking and access to and uptake of mental health services. Stigma impacts persons living with mental illness, their families and caregivers and healthcare professionals (mental health professionals, non-psychiatric specialists and general practitioners) imparting mental health care. Cultural, socio-economic and religious factors determine various aspects of mental health in LMICs, ranging from perceptions of health and illness, health seeking behavior, attitudes of the individuals and health practitioners and mental health systems. Addressing stigma requires comprehensive and inclusive mental health policies and legislations; sustainable and culturally-adapted awareness programs; capacity building of mental health workforce through task-shifting and interprofessional approaches; and improved access to mental health services by integration with primary healthcare and utilizing existing pathways of care. Future strategies targeting stigma reduction must consider the enormous physical comorbidity burden associated with mental health, prioritize workplace interventions and importantly, address the deterioration of population mental health from the COVID-19 pandemic.

Mental health is a key component of health, yet appropriate care is limited. Evidence concerning child and adolescent mental health has predominantly come from western countries, while the Middle East region, with a large youth population, has reported very little on it. This original, cross-sectional study of child and adolescent psychiatry in the Middle East provides an assessment of current postgraduate programs, services and what is needed to build workforce capacity. Academic psychiatrists from 16 Middle East countries were invited to form a Consortium to map current postgraduate training as one of the determinants of available child and adolescent psychiatry services, identify gaps in the distribution of child and adolescent psychiatrists, and propose potential steps to improve access to child and adolescent mental health care. The study collected data from 15 of the 16 countries invited (no data provided from Yemen). The study revealed underdeveloped child and adolescent psychiatry academic systems throughout the region. Despite recognition of the specialty in a majority of the countries (11/15), only six countries had established a designated child and adolescent psychiatry training program. The overall shortage of child and adolescent mental health specialists varied, yet all Consortium members reported a need for additional child and adolescent psychiatry specialists and allied professionals. Lack of child and adolescent psychiatry specialized programs in place throughout the region has evidently contributed to the shortage of qualified child and adolescent mental health workforce in the Middle East.

Autism spectrum disorder (ASD) is characterized by early-onset socialization and communication difficulties associated with restricted interests and behavioral rigidities. Recent epidemiologic studies show that 1 in 68 children has autism. This complex condition is among the least-understood developmental disorders of childhood but there is a growing body of research on ASD, making it critically important that clinicians are well informed about these conditions. Recent changes in the Diagnostic and Statistical Manual of Mental Disorders , fifth edition, regarding ASD criteria can affect how the diagnosis is made. Various comorbidities can have a huge impact on assessment and management. There are various behavioral and pharmacologic strategies focusing on cluster symptoms of hyperactivity/inattention, irritability, aggression, self-injurious behaviors, and ritualistic behaviors. In the past few years, the US Food and Drug Administration has approved psychotropic medications for treating irritability associated with autism. Speech and language assessment and interventions, parent education, and appropriate educational programs are integral parts of management. [ Psychiatr Ann . 2016;46(1):58–62.]

The recent advances in the field of pharmacogenetics have led to personalized medicine in pediatric psychiatry. Currently, the US Food and Drug Administration reports more than 100 prescription medications, of which approximately 30% are psychotropic, have pharmacogenomic information on their product labels. A high percentage of psychotropic medications are metabolized by the cytochrome P450 enzymes (CYP450). Enzymes that are most relevant include CYP450, 1A2, 2B6, 2C9, 2C19, 2D6, and 3A4. Psychopharmacogenomics offers personalized psychiatry leading to individually adapted plans after taking into consideration the genetic variability in drug metabolism. For clinicians, it results in a better-informed decision for the patient's clinical care. CYP450 testing can also predict individual response to treatment while minimizing side effects or avoiding poor outcome by avoiding metabolism through the polymorphic pathway. This review focuses on the current state regarding pharmacogenomics in pediatric psychiatry with discussion about metabolism of psychotropic medications and understanding of the CYP450 enzymes. [ Psychiatr Ann . 2016;46(1):52–57.]

Sleep problems are common among children and adolescents, with up to 50% of children experiencing sleep difficulties and as many as 4% receiving a formal sleep disorder diagnosis. Early identification of sleep problems may prevent negative consequences, such as daytime sleepiness, misdiagnosis, learning difficulties, or poor academic performance. This article provides an overview of common sleep disorders in children and adolescents, including common presenting symptoms, diagnosis, and treatment. [ Psychiatr Ann . 2016;46(1):39–44.]

Background Restraints are used as one of the safety interventions for children and adolescents in various community, hospital, and treatment settings. Although considered safety interventions, restraints are known to have many adverse effects on children and staff, including injuries; even reports of death are noted in the literature. Objective In an effort to reduce the use of restraints and to provide trauma-informed care in a 52-bed Pediatric Psychiatric Hospital, a quality improvement project was launched. Interventions Primary prevention principles based on trauma-informed and strength-based care were utilized to provide care for children and adolescents. Hospital leadership played an instrumental role in bringing positive culture change. Staff involvement and training in restraint reduction and prevention tools played a key role in this project. Debriefing and problem solving were effective interventions for the prevention of restraints. Involvement of youth and family in treatment planning built stronger relationships with staff and paved the way for better communication and trust, and improved understanding of strengths and needs of children and adolescents. Results Over a 10-year period, mechanical restraints decreased by 100%, from 485 in 2005 to “zero” in 2014 and none in the last 3 years. Physical restraints decreased by 88%, from 3,033 in 2005 to 379 in 2014.

Aims and methodTo assess adolescents' perceptions of their psychiatric illness and the role of various demographic factors in a Pakistani setting. Adolescents with various psychiatric diagnoses were interviewed using a structured questionnaire including the Illness Perceptions Questionnaire–Revised (IPQ-R).ResultsFifty-two adolescents with various psychiatric illnesses were interviewed; their mean age was 12.7 years and the majority (67%) were female. Males had significantly higher scores on timeline and emotional representation (PClinical implicationsDespite the importance of early intervention in psychiatric problems, engaging youth in the treatment process in Pakistan remains difficult. Better understanding of how adolescents perceive their psychiatric difficulties may play a significant role in developing culturally sensitive interventions and better utilisation of services.

Introduction Self-stigma has a negative impact on the lives of children with mental health illnesses. It is a massive obstacle in the way of seeking professional help and poses a challenge to clinician's efforts to timely intervene and provide treatment. Aim The aim of our study was to measure the stigma associated with mental illness in children with a variety of psychiatric diagnoses. Methods Following Institutional Review Board approval, an interviewer-based questionnaire was administered to children (aged 8–12 years), receiving treatment in Child Psychiatry Department at a tertiary care hospital in Lahore. The questionnaire comprised of Demographic Information Form and Paediatric Self-Stigmatization Scale (PaedS). In addition, parent / caregiver also completed a modified sub scale of the PaedS measuring the children’s rejection by others due to their mental health difficulties. Results 110 children with various psychiatric problems, were interviewed with a mean age of 10 years + 1.7. Widespread presence of self-stigmatization was found in these children with particularly high scores for the scales of Societal Devaluation (2.6 + 0.54), Secrecy (2.85 + 0.59) and Self stigma (2.7 + 0.70). Almost two third of parents also answered in affirmative to statements about their children rejection by others due to their mental health difficulties. Children with emotional/ behavioral difficulties had statistically significant scores on secrecy and personal rejection subscales (P value Conclusions Significant self-stigmatization amongst the children diagnosed with mental health illnesses in Lahore, Pakistan emphasize negative societal attitudes, which need to be addressed effectively in a timely manner.

OBJECTIVE: The purpose of the study was to determine the effectiveness of six core strategies based on trauma informed care in reducing the use of seclusion and restraints with hospitalized youth. METHODS: The hospital staff received training in March 2005 in six core strategies that are based on trauma informed care. Medical records were reviewed for youth admitted between July 2004 and March 2007. Data were collected on demographics, including age, gender, ethnicity, number of admissions, type of admissions, length of stay, psychiatric diagnosis, number of seclusions, and restraints. RESULTS: Four hundred fifty-eight youth (females 276/males 182) were admitted between July 2004 and March 2007. Seventy-nine patients or 17.2% (females 44/males 35) required 278 seclusions/restraints (159 seclusions/119 restraints), with average number of episodes 3.5/patient (range 1–28). Thirty-seven children and adolescents placed in seclusion and/or restraints had three or more episodes. In the first six months of study, the number of seclusions/restraints episodes were 93 (73 seclusions/20 restraints), involving 22 children and adolescents (females 11/males 11). Comparatively, in final six months of study following the training program, there were 31 episodes (6 seclusions/25 restraints) involving 11 children and adolescents (females 7/males 4). The major diagnoses of the youth placed in seclusion and/or restraints were disruptive behavior disorders (61%) and mood disorders (52%). CONCLUSIONS: This study shows downward trend in seclusions/restraints among hospitalized youth after implementation of National Association of State Mental Health Program Directors six core strategies based on trauma informed care.

Background Studies have shown higher rate of various psychiatric disorders among individuals with substance abuse / dependence. There is little data in developing countries, such as Pakistan, on prevalence of psychiatric co-morbidity in this population and impact on treatment. Objective To assess the psychiatric co-morbidity among individuals with substance dependence and to determine its demographic associations in patients with substance dependence in Pakistan. Method This was a descriptive study conducted at a tertiary care hospital in Pakistan. Participants were 588 individuals with substance dependence admitted to a tertiary care hospital in Pakistan, mainly in male inpatient substance dependence unit. The patients were assessed for psychiatric co-morbidity using DSM IV criteria. Informed consent was obtained. The study was approved by the Institutional Research Committee. The results were obtained by using chi square test on SPSS 17. Results Out of 588, 200 patients (34%) were found co-morbid with other psychiatric disorders along with substance dependence. Reason of first substance use and history of previous substance dependence were observed to be significantly associated with co-morbid psychiatric disorders, x2 (48, n = 549) = 112.396, p Conclusion 1. There was high rate of psychiatric co-morbidity among individuals with substance dependence in this sample. 2. Depression, personality disorders and anxiety disorders were the major co-morbid diagnosis among this population.