FRONTLINE REPORTS The Frontline Reports column features short descriptions of novel approaches to mental health problems or creative applications of established concepts in different settings. Material may be 350 to 750 words long, with a maximum of three authors (one is preferred) and no references, tables, or figures. Send material to Francine Cournos, M.D., New York State Psychiatric Institute (fc15@columbia. edu), or to Stephen M. Goldfinger, M.D., SUNY Downstate Medical Center ([email protected]).

Rural Psychiatrists Creating Value for Academic Institutions Rural areas comprise 98% of our nation’s territory but are typically isolated from larger academic medical centers. Collaborations between rural practitioners and such centers can serve to benefit providers, patients, and academicians. We report on a collaboration that turned an outpatient rural practice into a center providing clinical care, education, and research opportunities for the community and for distant academic medical centers. Challenges particular to rural psychiatry include patient confidentiality and therapeutic boundary issues, overlapping relationships, cultural and ethical demands, lack of subspecialty support, professional isolation, absence of academic collaboration, and difficulties in recruiting psychiatrists. We describe the highlights of our experience since 1994 at the Sun Valley Behavioral and Research Center in Imperial, California, a rural county where 160,600 mostly Hispanic and Latino people were residing when we launched our clinical and service initiatives. Among the successful programs is a linked outpatient and consultation liaison service for patients admitted to local general hospitals in a locale where the nearest inpatient unit is 120 miles away. This service has eliminated the need for psychiatric hospitalizations in PSYCHIATRIC SERVICES

Francine Cournos, M.D., and Stephen M. Goldfinger, M.D., Editors

about two-thirds of consultations. In a community that lacks a dementia unit, we established an adult day treatment center for the elderly population, which helps delay institutionalization. In 2008 we set up a clinical trials division that has collaborated in 38 research projects to date. Since 2011, cooperation between federally qualified health centers and county mental health services has allowed our psychiatrists to train a community clinic team to triage, identify at-risk-patients, follow patients in their homes, and assist with transportation. Our unsuccessful efforts included a partial hospitalization program that closed when Medicare no longer accepted the host hospital because it was in a different county and an electroconvulsive therapy service that never launched because of perceived stigma and controversy in the community. A National Alliance on Mental Illness chapter and a support group both failed after two sessions because participants were reluctant to disclose private information in this small, tightly interwoven community. Other programs ceased for lack of a large enough base to support group work—again, we believe, a function of the low-density population. We have learned that rural barriers can be overcome when the services launched are culturally sensitive, scientifically sound, dispensed by competent staff, affordable to the consumer, and have a priori advice from qualified people. Most of our unsuccessful initiatives lacked one or more of these components. A persistent difficulty is finding capable staff. The likelihood of low practice income and the challenges of a “rural lifestyle” seem to be the main obstacles to recruiting psychiatrists. To address concerns about professional isolation and lack of psychiatrist availability, we created our own supervision program to enhance recruitment of mid-level practitioners such as physician assistants, master’slevel trained therapists, and medical assistants.

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Having trained in a large academic center, we have maintained contact with our residency mentor by phone, e-mail, and in person, and we eventually became volunteer faculty at the same university. Collaborating with academicians has helped us understand the importance of publishing as a way of communicating with other psychiatrists, thereby decreasing our isolation, receiving constructive criticism, and stimulating ideas to create new clinical services or improve the existing ones. These collaborations have also resulted in numerous publications focusing on rural psychiatry. Being liaisons between large academic centers and our rural community has been both challenging and satisfying. The main obstacles to implementing funded research interventions include recruitment, transportation, and attrition. One challenge to recruitment is stigma that is partially overcome with extensive education. A second factor is our low-density population and poor public transportation, such that anyone applying for funds must include a larger-than-usual dedicated travel budget. Even after enrollment, some participants drop out for a variety of reasons, such as family illness, new employment, and time spent applying for benefits, such that flexible schedules for research activities should be considered. We believe that psychiatric leadership plays an essential role in initiating and implementing these efforts and can help disseminate the idea that rural psychiatry is not only a clinical placement but also an opportunity to perform research and academic activities. Both those already in rural practices and new recruits can be encouraged to collect data, present at meetings, find a mentor, foster online collaborations, and submit to journals. We recommend reaching out to neighboring departments of psychiatry to ignite interest in rural psychiatry and to build academic bridges; we are convinced that rural psychiatrists can create value for academic centers. 1177

FRONTLINE REPORTS Bernardo Ng, M.D. Alvaro Camacho, M.D., M.P.H. Joel Dimsdale, M.D. The authors are with the Department of Psychiatry, University of California, San Diego, and Dr. Camacho is also with the Department of Family and Preventive Medicine at the university. Dr. Ng and Dr. Camacho are also with the Sun Valley Behavioral and Research Center, 2417 Marshall Rd., Suite 1, Imperial, CA 92251 (e-mail: [email protected]).

Online Mental Health Platform for MoroccanDutch in the Netherlands Migrants in various countries and cultures are at increased risk of developing psychopathology, tend to be underrepresented in mental health care, and drop out of care more frequently than the general population. This pattern applies to persons of Moroccan descent in the Netherlands, who constitute one of the largest migrant populations in the country. The underrepresentation of this population in mental health care is partly explained by cultural differences. There is a stronger taboo on showing and sharing psychiatric symptoms, and the disease narrative tends to differ from the native population. Apart from the standard medical disease model, mental problems are interpreted to result from evil influences or bewitchment (suffering from Djinns)—an unfamiliar domain for non-Moroccan mental health professionals. As a result, migrants experiencing mental health problems and their friends and family have difficulties integrating these different disease perspectives with the accompanying treatment approaches. The Internet offers new opportunities to communicate about psychiatric problems. The popular Web site www.marokko.nl reaches 75% of all young Moroccan-Dutch people (ages 15–35) living in the Netherlands. Protected by an anonymous pseudonym, visitors to this Web site openly discuss societal and personal issues, including mental health problems. An earlier search on Marokko.nl yielded 1178

23,700 hits using the word “crazy,” 2,440 hits for “hearing voices,” and 680 hits for “depression” and “depressive.” Lengthy discussions are posted, in which serious psychiatric symptoms are expressed, and participants give each other support and advice. In collaboration with the Webmasters of Marokko.nl, we created an add-on feature for the site that offers information from and exchange with both mental health professionals and specially trained imams who have knowledge about psychiatric disorders and can offer culturally sensitive support for social problems. This add-on was launched as the Web site ZiekOfBezeten.marokko.nl (which translates to English as “IllOrPossessed.morocco.nl”). The goals are to educate users about psychiatric disorders, Al-ayn (evil eye), Djinns (evil spirits), and addiction; describe the Dutch mental health care system and its providers; offer a platform for online forum discussions; provide self-rated screening instruments (in Dutch) for substance use and depression, including automatically generated feedback scores and advice for help; and offer direct contact with a mental health care worker or specially trained imam via e-mail and chat. ZiekOfBezeten.nl was officially launched on November 15, 2012, after a few months of beta testing. By February 2013, the site had been visited 11,696 times (9,856 unique visitors). On average, visitors viewed 1.9 pages per visit and stayed on the site for 1.51 minutes. A total of 81 forum discussions about psychiatryrelated topics are currently running on the site. The discussions add up to a total of 6,252 reactions (77 per discussion) and 270,132 views (3,335 per discussion). There is a wide variation in the length of the discussions; 18 discussions have over 100 reactions, and the most extensive discussion generated 947 reactions. In 2012, ZiekOfBezeten.nl received 208 visitors who e-mailed a question to a mental health care worker or specially trained imam. Questions concerned Djinns or other PSYCHIATRIC SERVICES

religious themes (50%), psychiatric topics (28%), substance abuse (6%), other topics (10% on puberty or relationships), and multiple topics (6%). The questions were very personal and often expressed the writer’s or a close relative’s emotional suffering. The site’s depression screen (the K10) has been completed 980 times in three months. Over 50% of the participants screened positive for depression at the conservative cutoff score of $30. Screening instruments for addictive behaviors were completed in 2012 as follows: tobacco (1,951 times), alcohol (143), cannabis (174), gambling (75), cocaine (31), Ecstasy (24), sedatives (8), and gaming (14). For most screens at least 30% of the participants were at high risk of abusive behavior, although the proportion of positive screens was lower for alcohol (15%) and gaming (7%) and higher for cocaine, sedatives, and gambling (.50%). Through the site we are able to provide support to a large migrant population at risk of psychiatric disorders. The Web site was first funded by Innovatiefonds Zorgverzekeraars, Skanfonds, and Fonds Voorzorg Utrecht and is now offered as part of Amsterdam’s regular mental health care, improving access to care for MoroccanDutch migrants. An online platform might be useful for other marginalized populations that are geographically dispersed and difficult to reach but whose members may assemble via specific online communities. Associations between psychiatric problems and environmental influences are being investigated in the MEDINA study (Migrants Examined for Determinants of psychopathology through INternet Assessment). Madelien Hermina van de Beek, M.D. Lian van der Krieke, M.Sc. Prof. Robert Anton Schoevers M.D., Ph.D. The authors are with the Department of Psychiatry, University of Groningen, and the University Medical Center Groningen, Hanzeplein 1, Entrance 24, Room kn1.14a, P.O. Box 30.001, 9700 RB Groningen, the Netherlands (e-mail: m.vandebeek@dimence. nl).

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Rural psychiatrists creating value for academic institutions.

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