Abstract Background How can psychiatrists best provide care in complex, sometimes overwhelming disasters? COVID-19 strained every aspect of health care to the breaking point, from finances to pharmaceutical supply lines. We can expect more challenges to prescribing in the future, as shown by recent hurricanes in Puerto Rico, fires in California, and ice storms in Texas. When medications become scarce or inaccessible, then clinicians need to make difficult prescribing decisions. We suggest that a culture of deprescribing, a systematic approach to reducing or simplifying medications, could be applied to a wide variety of crises. Deprescribing is defined as the planned reduction of medications to improve patient health or to reduce side effects (see deprescribing.org). It has been used to reduce polypharmacy in geriatric and other complex populations. It provides evidence-based guidance for phasing out many classes of medications. It is part of the larger program to reduce waste in health care and to make pharmacy more rational. Disasters and resource scarcity, however, require a different approach. In contrast to routine care focused on individual patients, crisis standards of care (CSC) shift the clinical focus to the community. Instead of deprescribing guidelines for individual clinicians, CSC deprescribing would be national policies addressing shortages of important medications. We did a scoping review looking for studies of deprescribing in a crisis. Methods/Results We extracted 1340 references in Google Scholar 2016 to 2021 using (deprescribing) AND (disaster OR crisis OR climate OR pandemic OR supply lines ). A scan of texts found 160 references matching our criteria, and only 19 of them addressed deprescribing as a strategy to strengthen health systems or providers in an emergency. Most of those were related to scarce supplies during COVID, and a few addressed the carbon impact of medications. We also reviewed related literatures on medication supply chain vulnerabilities, WHO Essential Medicines, and healthcare rationing. Implications Deprescribing gained attention during the COVID pandemic, responding to both disrupted supply lines and improving patient safety. Writers concerned with climate change support deprescribing to reduce the carbon impact of medications. Deprescribing as crisis policy could help streamline national stockpiles, supply chains, and manufacturing. Education could make deprescribing second nature for clinicians, potentially decreasing stress and increasing flexibility in future emergencies. Barriers to deprescribing generally include cultural inertia, industry lobbyists, education, and malpractice fears. In a crisis, deprescribing guidelines could provide clinicians with confidence and flexibility while conserving scarce resources. Research is needed to evaluate deprescribing guidelines for crises, especially ensuring equity in how they reduce polypharmacy and save money. Funding No funding

It may be too late to avoid the climate crisis, likely to be humanity's most expensive, widespread, and enduring catastrophe. This is a qualitatively different kind of catastrophe, in which increased costs, decreased revenue, and no possibility of bailout force communities to harshly cut budgets, especially in health care. Little is known about making such brutal cuts fair or efficient, nor how to help the public accept them. The crisis presents an opportunity for bioethicists to play a crucial role, but one for which traditional approaches are inherently inadequate. Although often dismissed as heartless, Garrett Hardin's "lifeboat ethics" started a conversation about making ethical choices in global disasters-where all options are painful and unacceptable-and may provide guidance. Bioethics during the climate crisis must focus on communities rather than individuals and help survivors grieve the terrible consequences. Because today's choices will affect many generations, with the burdens falling most heavily on poor communities, we have to construct a radical bioethics to help tomorrow's health care become green, efficient, and fair.

AbstractBackgroundHow can psychiatrists best provide care in complex, sometimes overwhelming disasters? COVID-19 strained every aspect of health care to the breaking point, from finances to pharmaceutical supply lines. We can expect more challenges to prescribing in the future, as shown by recent hurricanes in Puerto Rico, fires in California, and ice storms in Texas. When medications become scarce or inaccessible, then clinicians need to make difficult prescribing decisions. We suggest that a culture of deprescribing, a systematic approach to reducing or simplifying medications, could be applied to a wide variety of crises. Deprescribing is defined as the planned reduction of medications to improve patient health or to reduce side effects (see deprescribing.org). It has been used to reduce polypharmacy in geriatric and other complex populations. It provides evidence-based guidance for phasing out many classes of medications. It is part of the larger program to reduce waste in health care and to make pharmacy more rational. Disasters and resource scarcity, however, require a different approach. In contrast to routine care focused on individual patients, crisis standards of care (CSC) shift the clinical focus to the community. Instead of deprescribing guidelines for individual clinicians, CSC deprescribing would be national policies addressing shortages of important medications. We did a scoping review looking for studies of deprescribing in a crisis.Methods/ResultsWe extracted 1340 references in Google Scholar 2016 to 2021 using (deprescribing) AND (disaster OR crisis OR climate OR pandemic OR supply lines). A scan of texts found 160 references matching our criteria, and only 19 of them addressed deprescribing as a strategy to strengthen health systems or providers in an emergency. Most of those were related to scarce supplies during COVID, and a few addressed the carbon impact of medications. We also reviewed related literatures on medication supply chain vulnerabilities, WHO Essential Medicines, and healthcare rationing.ImplicationsDeprescribing gained attention during the COVID pandemic, responding to both disrupted supply lines and improving patient safety. Writers concerned with climate change support deprescribing to reduce the carbon impact of medications. Deprescribing as crisis policy could help streamline national stockpiles, supply chains, and manufacturing. Education could make deprescribing second nature for clinicians, potentially decreasing stress and increasing flexibility in future emergencies. Barriers to deprescribing generally include cultural inertia, industry lobbyists, education, and malpractice fears. In a crisis, deprescribing guidelines could provide clinicians with confidence and flexibility while conserving scarce resources. Research is needed to evaluate deprescribing guidelines for crises, especially ensuring equity in how they reduce polypharmacy and save money.FundingNo funding

Study Objective The COVID-19 crisis has severely stressed our healthcare system and pushed our economy to the brink. This long emergency will probably cause years of severe suffering in every region. Health expenses greatly increased, supply chains were disrupted, and governments coped with much less revenue. Good clinicians plan for ALL contingencies, and we need to consider that the current disaster may get much worse. How can we adapt psychiatry to a long emergency? This goes far beyond previous work on crisis standards of care because the emergency is severe, prolonged, and widespread. If we had to spend much less on psychotropics, which meds stay on the formulary? If we have to close hospitals, which patients get a bed? What adaptations could be used if demand exceeds the supply of providers? Very little is known about how to make severe, permanent cuts to healthcare. Our previous systematic review found no scholarship addressing the ethics of severe and prolonged healthcare rationing. Global catastrophes need a global health policy, but this one has no experts. The present study starts the project by surveying experts with related experience that could be useful in future plans. Method We used purposive sampling to find 18 professionals with experience in healthcare rationing from underserved, indigenous communities, homeless programs, and African nations. We also interviewed ethicists, pharmacists, administrators, NGO clinicians, and military. Interviews were transcribed and coded using basic inductive techniques. Because so little is known about this topic, we used grounded theory, an iterative approach to guide further sampling, refine interviews, and make some preliminary conclusions. Results Participants all agreed this crisis planning is extremely important and complex. They described diverse concerns regarding ethical decision making, with some having confidence with top-down government policy, and others recommending a grassroots approach. Minority participants had less confidence in government. There was no consensus on any best ethical framework. Most had confidence that clinicians will ultimately do the right thing. Native American leaders had confidence in a holistic, preventive approach. All agreed that social justice should be central in measuring economic impact of long emergencies and choosing ethical options. We collected suggestions for innovative approaches to rationing. Conclusions This research program illuminates the difficult ethical questions about adapting psychiatry to a prolonged, widespread, and severe emergency. Our interviews identify areas where severe but ethical cuts can be made in medications, hospitals, clinical staff, and administration. Next steps include evidence-based formularies, utilitarian staff cuts, and ethical standards for closing beds or revamping state hospitals. Underserved and diverse communities with rationing experience must have a voice in the discussion.

The experience of moral injury is of increased concern to child welfare professionals. This ethnographic study uses Akan (Ghanaian) women who are widowed and their children as an exemplary case study to consider the cultural shaping of moral injury, and implications for culturally-sensitive child welfare practice. We conducted in-depth, semi-structured, audio-recorded interviews. Twenty-one widows, 14 religious professionals providing services to widows, and one secular professional participated. Participants identified some morally injurious events and responses consistent with the Western literature, for example, events involving betrayal of widows and their children were associated with feelings of intense sadness, rage, and spiritual or existential crises. Other events and responses were culturally nuanced. Women's vulnerability to morally injurious events was enhanced due to culturally-based gender roles, widowhood rituals and customary laws involving inheritance. In addition, these events were interpreted and experienced through Akan spirituality in which the self is comprised of the soul, spirit and body; and moral injury, or "soul killing," involves the dissolution of this trinity and embitterment of the soul. The Akan cultural context also provided resources for healing. Akan women who were widowed articulated the empowerment and restoration they felt from coming together in a community both to address a common challenge (supporting themselves and their children financially), and to receive spiritual and psychosocial support from peers and professionals. This paper provides both a conceptual framework for the empirical examination of the cultural shaping of moral injury, and empirical data within a non-Western cultural context.

This study examines how Child Protection Services (CPS) – involved parents and professionals describe coping with moral injury through resources available within their everyday lives. Moral injury refers to the lasting harm caused by one's own or another's actions in high-stakes situations that transgress deeply held moral beliefs and expectations. This harm can occur at multiple, interacting psychological, social and spiritual levels. We administered a modified version of the Moral Injury Events Scale (MIES) (Nash et al., 2013) to 38 CPS-involved professionals and 10 parents. We then conducted in-depth, semi-structured, audio-recorded individual interviews with them to elaborate their responses to the MIES, and reflect on scenarios involving moral injury. For the current study we analyzed the responses of those in the sample who reported moral injury (eight CPS-involved parents and 35 professionals.) None had received professional support to address their moral injury. Participants' described coping with moral injury through a variety of resources available in their everyday lives. Their coping strategies reflected multiple, interacting levels of the ecology. Participants contributed vivid and detailed accounts of coping through drawing upon and strengthening their: (a) psychological resources through stress reducing and meaning-making activities, mental toughness, agency, acceptance, strong values, self-reflection and forgiveness; (b) microsystems through social support and corrective experiences; (c) macrosystems through engagement in advocacy and social programs to support other parents; and (d) spiritual engagement. Our aim is to identify potential models of successful coping with moral injury in everyday life in order to identify viable targets for formal prevention and intervention efforts.

Social workers are increasingly embracing international perspectives and roles to address persistent human rights issues. This study examines solutions to property rights disputes involving Ghanaian women who are widowed from the perspectives of Akan men and women in four communities. Property ownership is fundamental to the economic survival of women and their children, but millions of women around the world lose their rights to property following the deaths of their husbands. We conducted focus groups with 102 participants in four Akan communities to generate local, culturally viable solutions for preventing property rights violations and resolving them when they do occur.

This study considers any “moral injury” occurring among parents involved with the Child Protection System (CPS). Moral injury refers to the lasting psychological, spiritual and social harm caused by one's own or another's actions in a high stakes situation that transgress deeply held moral beliefs and expectations. The existing literature focuses on military contexts, but moral injury also may play a role in increasing the vulnerability of CPS clients who are threatened with loss of their parental rights and dissolution of their families. We administered a modified version of the Moral Injury Events Scale (MIES) (Nash et al., 2013) to 10 CPS involved parents. We then conducted in-depth, semi-structured, audio recorded individual interviews with parents to elaborate their responses to the MIES. Parents' MIES scores and interview elaborations suggest that some CPS-involved parents do experience moral injury. Moral injury was reported as a result of their own parenting behaviors, but also as a result of parents' involvement with professionals and within social systems that are charged with providing assistance to struggling families. For instance, some parents perceived professionals to be shaming, social services to be harmful and legal proceedings stigmatizing. Parents' reported reactions to morally injurious events included lasting feelings of guilt, shame and anger; and loss of trust in professionals. These responses impeded their perceived abilities to fully engage in services. If involvement in CPS places parents at increased risk of moral injury, then moral injury is a critically important construct for child welfare policy makers and workers to understand and address in the conduct of effective, ethical child welfare practice.

This paper presents a scoping study of moral injury that identified directions for social work research. “Moral injury” refers to lasting psychological, spiritual and social harm caused by one's own or others' actions in a high stakes situation that transgress deeply held moral beliefs and expectations. A “scoping study” is a type of systematic review and knowledge synthesis useful when considering complex, emerging areas of research. Results revealed an increasing interest in moral injury over the past five years primarily in psychology/psychiatry. The majority of published articles are conceptual. Empirical studies aim to better understand the experience of moral injury, qualitatively; and develop and evaluate instruments to assess moral injury, quantitatively. Most empirical studies of moral injury involve US war veterans with little attention to moral injury in other groups, sociocultural contexts, or at different times in development. Failure to address issues of moral injury in social work may leave vulnerable clients struggling with issues of guilt, shame, moral confusion, and an absence of meaning that may persist for years and create obstacles to positive change. In addition, social workers may experience moral injury as they witness morally injurious behavior of others and of systems. If unaddressed, such injuries may diminish effectiveness, or lead to burn out. Social workers need relevant research to understand the extent to which moral injury affects them and their clients, and how to identify and address it.

This mixed method study describes the cultural adaptation, implementation and impact of a mental health intervention for individual rural children aged 7–17 from methamphetamine-involved families who are in foster care. Features of the culturally-shaped intervention include: 1) close collaboration with local professionals who provide the intervention over a seven month period; 2) provision of the intervention in and around children's homes; and 3) the use of local storytelling traditions in a narrative- and relationship-based intervention. As a group, children (N=15) showed problematic levels of Childhood Behavior Checklist (CBCL) externalizing and total problem behaviors and symptoms of PTSD/dissociation during the pretest. Children were randomly assigned to an experimental group who received the intervention immediately (n=8), or a wait-list control group (n=7) who received the intervention at the end of the study. There was a significant interaction effect of time (pre and post test) and group on externalizing behavior with the trajectory of the experimental group improving while that of the control group worsened. Gains made by the experimental group were maintained over a seven month follow-up period. Comparative case studies, individual qualitative interviews and open-ended questionnaires provided rich elaboration of participants' experiences and illuminated complexities and challenges of the intervention.

This mixed method study examines the mental health and experiences of physical aggression in 41 children aged six to 14 years from rural families involved with methamphetamine misuse and the child welfare system. Each child was seen for a minimum of 3 h total by experienced clinicians on at least three sessions conducted at the child's home. Fifty percent of children scored in the clinical range (98th percentile and above) on externalizing and 26% on aggression scales of the Child Behavior Checklist (CBCL). More girls (75%) scored in the clinical range on CBCL externalizing behaviors than did boys (32%). During individual, semi-structured interviews, 17 children spontaneously produced 58 narratives of past physical aggression. These were primarily set at home and involved adults and the children themselves. Children primarily attributed physical aggression to anger and adult substance misuse, and described negative outcomes of the aggression. In contrast, a subgroup of girls with clinically significant levels of CBCL externalizing behaviors characterized their own physical aggression as appropriate retaliation with emotionally satisfying consequences. Many of these girls also scored in the clinically significant range on CBCL internalizing behaviors and total problems. Clinicians who collected the data expressed concern about these girls, in particular because they were ostracized from non delinquent peer groups, viewed others' continuing physical aggression against them as an inevitable part of their future, and described their own physical aggression as unavoidably driven by that violence. The perspectives of this subgroup of girls are elaborated through a case study of a physically aggressive 12-year-old. Implications for intervention are discussed.

Objective: Varenicline is a novel antismoking agent that reduces cravings and blocks pleasure of nicotine by serving as a partial agonist to the nicotinic receptor. Varencicline was initially described as easily tolerated and without any special psychiatric precautions, but it was studied exclusively in normal Populations. We report on a bipolar patient who developed a manic episode after treatment with varenicline.Methods: The patient was interviewed and examined, and additional information was obtained from the medical record. The Naranjo adverse drug reaction scale was applied. Relevant literature was reviewed.Conclusion: Postmarketing reports of neuropsychiatric problems have recently led to a general warning to monitor for such symptoms. The bipolar patient described here became manic shortly after treatment with varenicline. We suggest close observation of patients with bipolar disorder on varenicline and further study varenicline-induced neuropsychiatric symptoms among mentally ill patients.

Abstract This chapter provides an overview of the mixed methods research strategy. The site of the research is predominantly white, working-class, rural Illinois in the early 21st century. Participants were twenty-nine children in foster care because of parent methamphetamine misuse, four mothers recovering from methamphetamine addiction, seven foster parents of children from methamphetamine-involved families, and twenty-eight knowledgeable rural professionals (child welfare and law enforcement professionals, substance abuse and mental health providers and educators). Methods included extensive participant observation primarily shadowing child welfare investigators; in-depth, audiotaped individual interviews with adults and children; and standardized psychological testing of children.

AbstractThis chapter describes the conceptual and empirical bases of Life Story Intervention: a six- to eight-month-long, individualized program for school-aged children. It is evidence-based and draws on the American Association of Child and Adolescent Psychiatry guidelines for intervention with children who have experienced trauma, clinical discussions of substance-involved families, narrative therapy, and research on community- and relationship-based interventions. It also draws upon indigenous, oral narrative traditions in rural Illinois. It provides children with an opportunity to develop a supportive relationship with a healthy, reliable adult who can help them to express their feelings, and interpret and contextualize their experiences, including troubling or traumatic memories. It is delivered to children in their homes and communities by local professionals (e.g., social workers, child welfare workers, educators) who take on one child or two siblings and who are supervised by PhD- or MD-level licensed clinicians experienced in working with traumatized children.

Abstract This chapter describes the importance of thick, case-based research in understanding complex social phenomenon as they occur in everyday life, and grounding the design, implementation, and assessment of relevant, effective interventions. The research program described in this book presented the perspectives and voices of individuals who encountered methamphetamine misuse on a regular basis to understand this social problem from the perspectives of those involved, and in the complexities of their everyday lives. This information, in conjunction with existing research and clinical expertise, was used to design and implement a mental health intervention for rural children from methamphetamine-involved families. This research program illustrates the importance of meaning for child welfare practice and research; the importance of context in intervention, practice, and research; and the use of evidence in social work practice.

AbstractThis chapter provides an introductory discussion of the history and epidemiology of methamphetamine. Despite intense publicity in the popular press in the 1990s and early 2000s, methamphetamine is not a new drug, nor are problems with its misuse. Crises of methamphetamine misuse have occurred in diverse cultural and historical contexts from post World War II urban Japan to turn-of-the-century, rural Midwest. The social impact of these crises has been related to the quality of the drug, its means of distribution, population of users, methods of administration, and legal sanctions, all of which have varied widely across time and place.

Abstract This chapter focuses on the perspectives and experiences of knowledgeable adults. Child welfare workers, other community professionals (educators, counselors, law enforcement personnel, and substance misuse treatment providers), and foster parents described their experiences with families involved with methamphetamine. They described children's exposure to environmental danger, chaos, neglect, abuse, loss, and isolation. They believe that children develop anti-social beliefs and practices such as lying and stealing, drug misuse and violence. They described children as displaying psychological, emotional, and social disturbances. They also described individual variation in functioning across children that they attributed, in part, to individual, familial, and community characteristics. They noted a need for effective child mental health services in rural areas, and substance misuse treatment for their parents.

Abstract The design and implementation of Life Story Intervention involved close collaborations with rural adults who worked in a professional capacity with children. This chapter presents the account of a community professional's experiences in conducting Life Story Intervention with two young adolescent boys in foster care because of their parents' methamphetamine misuse.

AbstractEvaluation of Life Story Intervention using a quasi-experimental, longitudinal design is ongoing. This chapter describes the intervention's pilot tests, and presents several contrasting case studies of children's responses. The children depicted are similar in age, length of time in foster care, past experiences, and history of involvement with parental methamphetamine misuse. They illustrate a variety of child responses to Life Story Intervention, their struggles, and attempts to help. Life Story Intervention provided a bridge, bringing needed intervention to children at a critical time in their lives characterized by impermanence and flux, prior to engagement in a longer-term mental health intervention.