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With widespread adoption of telemedicine in response to the COVID-19 pandemic, psychiatrists must determine which visits are best conducted via telemedicine versus in person. Although some telepsychiatry guidelines and best practices have been developed, the literature has not described how psychiatrists make decisions about offering different care modalities. The authors explored how psychiatrists decide whether telemedicine is appropriate for a given patient.From June 25 to August 4, 2021, the authors conducted semistructured interviews with 20 outpatient psychiatrists. The authors used a critical incident technique and clinical vignettes to identify conscious and unconscious factors that influence psychiatrists' decision to offer telemedicine. Using inductive thematic analysis, the authors analyzed interview data.Psychiatrists perceived that most patients are good candidates for telemedicine visits in the context of hybrid care models. Patient preference and situational factors, such as access to private spaces, rather than any particular diagnosis or patient demographic characteristic, drove telemedicine versus in-person care. Psychiatrists described numerous factors affecting their decision to offer telemedicine, and they were driven to try telemedicine and adjust as needed to "meet patients where they are" and to improve engagement in care. Psychiatrists reported using telemedicine as a bargaining chip in negotiations with patients, leveraging the offer of telemedicine to improve treatment attendance and adherence.This detailed assessment of how psychiatrists choose different care modalities can inform clinical practice guidelines and reimbursement policies that often mandate in-person visits. The results show that psychiatrists did not perceive intermittent in-person visits as essential for high-quality care.

Adolescents with attention-deficit/hyperactivity disorder (ADHD) are at high risk for tobacco use, but tobacco use prevention strategies are not regularly incorporated into evidence-based ADHD interventions. We conducted a pilot randomized-controlled trial to determine the feasibility of integrating tobacco use prevention skills into a behavioral treatment for ADHD and to provide preliminary efficacy data comparing a combined (ADHD + tobacco) intervention (N = 40) to an ADHD only intervention (N = 23) on tobacco risk outcomes. Sixty-three adolescents (72% male; 13-17 years) with ADHD and their caregivers were randomly assigned to condition and families were masked to condition. Parent and adolescent ratings were collected at baseline, immediate post-intervention, and at 3- and 9-month follow-up assessments. The combined intervention was (1) implemented with high fidelity (94%), (2) well received by parents and adolescents as evidenced by high levels of treatment attendance (82%) and satisfaction with the intervention, and (3) associated with parent- and adolescent-reported reductions in tobacco use risk. Relative to the ADHD intervention, the combined intervention buffered against increases in tobacco risk, including reduced intentions to smoke and maladaptive social normative beliefs, and increased parental control, family cohesion, and family communication about substance use. Effect sizes at post-treatment were in the small to moderate range. Overall, this study provides preliminary support for a parent-adolescent behavioral treatment supplemented with family-based tobacco prevention strategies. This approach targets families already in treatment for ADHD, reducing barriers that occur when families attend multi-session prevention programs in addition to ADHD treatment.

In an increasingly connected world and in the midst of a global pandemic, digital trials offer numerous advantages over traditional trials that rely on physical study sites. Digital trials have the potential to improve access to research and clinical treatments for the most vulnerable and minoritized, including pregnant and postpartum individuals. However, digital trials are underutilized in maternal and child health research, and there is limited evidence to inform the design and conduct of digital trials. Our research collaborative, consisting of 5 research teams in the U.S. and Australia, aimed to address this gap. We collaborated to share lessons learned from our experiences recruiting and retaining pregnant and postpartum individuals in digital trials of social and behavioral interventions. We first discuss the promise of digital trials in improving participation in research during the perinatal period, as well as the unique challenges they pose. Second, we present lessons learned from 12 completed and ongoing digital trials that have used platforms such as Ovia, Facebook, and Instagram for recruitment. Our trials evaluated interventions for breastfeeding, prenatal and postpartum depression, insomnia, decision making, and chronic pain. We focus on challenges and lessons learned in 3 key areas: (1) rapid recruitment of large samples with a diversity of minoritized identities, (2) retention of study participants in longitudinal studies, and (3) prevention of fraudulent enrollment. We offer concrete strategies that we pilot-tested to address these challenges. Strategies presented in this commentary can be incorporated, as well as formally evaluated, in future studies.

UNSTRUCTURED In an increasingly connected world and in the midst of a global pandemic, digital trials offer numerous advantages over traditional trials that rely on physical study sites. Digital trials have the potential to improve access to research and clinical treatments for the most vulnerable and minoritized, including pregnant and postpartum individuals. However, digital trials are underutilized in maternal and child health research, and there is limited evidence to inform the design and conduct of digital trials. Our research collaborative, consisting of 5 research teams in the U.S. and Australia, aimed to address this gap. We collaborated to share lessons learned from our experiences recruiting and retaining pregnant and postpartum individuals in digital trials of social and behavioral interventions. We first discuss the promise of digital trials in improving participation in research during the perinatal period, as well as the unique challenges they pose. Second, we present lessons learned from 12 completed and ongoing digital trials that have used platforms such as Ovia, Facebook, and Instagram for recruitment. Our trials evaluated interventions for breastfeeding, prenatal and postpartum depression, insomnia, decision making, and chronic pain. We focus on challenges and lessons learned in 3 key areas: (1) rapid recruitment of large samples with a diversity of minoritized identities, (2) retention of study participants in longitudinal studies, and (3) prevention of fraudulent enrollment. We offer concrete strategies that we pilot-tested to address these challenges. Strategies presented in this commentary can be incorporated, as well as formally evaluated, in future studies.

Experiencing mental health difficulties during pregnancy predicts a variety of quality-of-life (QoL) outcomes for Black women. However, one area of prenatal mental health remains underresearched: attention-deficit/hyperactivity disorder (ADHD). Given the impairments reported by adults with significant symptoms of ADHD and the linkages between depression and ADHD in nonpregnant samples, the current study aimed to examine the relationships among ADHD symptoms, depression, and QoL in Black pregnant women.Participants for this study were 116 pregnant Black women aged 18-43 years (mean age = 27.14, standard deviation = 5.67) presenting to an urban women's health clinic. We investigated associations among maternal ADHD symptoms, risk of maternal depression, and different aspects of QoL, including relationships, life outlook, and life productivity.Linear hierarchical regressions were performed to investigate the ability of maternal depression risk to mediate the relationship between maternal ADHD symptoms and QoL. Moderate to large negative correlations were found between maternal ADHD symptoms, depression risk, and quality of life (p's ≤ 0.001). Furthermore, maternal depression risk either partially or fully explained the relationship between ADHD symptoms and the different QoL variables.This study illustrates that symptoms of both ADHD and depression are important clinical considerations for Black women during pregnancy. As significant ADHD symptoms can lead to the development of depression, future research should investigate the temporal relationship between depression and QoL in pregnant women diagnosed with ADHD, as well as study whether ADHD treatment results in improvements in depressive symptoms.

The abundance of butternut (Juglans cinerea L.) trees has severely declined rangewide over the past 50 years. An important factor in the decline is butternut canker, a disease caused by the fungus Ophiognomonia clavigigenti-juglandacearum, which has left the remaining butternuts isolated and sparsely distributed. To manage the remaining populations effectively, information regarding how butternut’s population genetic structure is affected by environmental and historical factors is needed. In this study, we assessed genetic structure and diversity of 161 butternut trees from 19 adjacent watersheds in the southern portion of butternut’s range using 12 microsatellite markers. We assessed the genetic diversity and genetic differentiation among trees grouped at various spatial scales. Our goal was to use historical abundance and land use data for these watersheds, which are now all a part of the Great Smoky Mountains National Park (GSMNP), to understand the ecological and evolutionary forces that challenge the conservation and management of butternut. In general, butternuts within the 19 neighboring watersheds were all part of one continuous population, with gene flow throughout. Significant genetic differentiation was detected between some groups of trees, but the differentiation was quite small and may not represent an ecologically significant distinction. The mean heterozygosity in all watersheds remained high, despite extensive mortality. Overall, genetic diversity and rare alleles were evenly distributed across all watersheds, with some variability in subpopulations containing butternut-Japanese walnut hybrids (Juglans x bixbyi or buarts). These results indicate that management of this species should focus on protection from future hybridization with Japanese walnut, promotion of regeneration, and persistence of all remaining butternut trees, which still retain high levels of genetic diversity.

To mitigate the loss of native tree species threatened by non-native pathogens, managers need to better understand the conservation status of remaining populations and the conditions that favor successful regeneration. Populations of Juglans cinerea L. (butternut), a wide-ranging riparian species, have been devastated by butternut canker, a disease caused by a non-native fungal pathogen. We assessed J. cinerea within Great Smoky Mountains National Park (GSMNP) to determine post-disease survivorship and health, recruitment history, environmental conditions associated with survival, and the extent of hybridization with a non-native congener. Monitoring records were used to locate and collect data for 207 J. cinerea trees in 19 watersheds. Tree cores were collected from a subset of individuals to assess recruitment history. We sampled vegetation plots within areas that contained J. cinerea to assess site conditions and overstory species composition of characteristic habitat. We collected leaf samples for genetic analysis to determine the frequency of hybridization. Our reassessment of monitoring records suggests that J. cinerea abundance in GSMNP has declined due to butternut canker and thirty years of poor regeneration. Populations displayed continuous recruitment following Park establishment (1934) until around 1980, after which regeneration declined drastically. Ordination analysis revealed that J. cinerea in the contemporary forest was associated with greater distance from homesites and reduced basal area of competing species. Hybrids comprised a small portion of sampled trees. The presence of healthy trees and low rate of hybridization suggest that these trees may contribute to the development of disease-resistant genotypes for future restoration efforts.

Objective To date, most investigations of mental health in pregnant women have focused on depression or substance use. This study aimed to (a) delineate the relationships between symptoms of attention-deficit/hyperactivity disorder (ADHD) and prenatal health behaviors and (b) explore whether the symptom clusters of ADHD differentially predict prenatal health behaviors (e.g., physical strain, healthy eating, prenatal vitamin use). Method A total of 198 pregnant women (mean age = 27.94 years) completed measures of ADHD symptoms, prenatal health behaviors, and depression. Results Inattention, hyperactivity, and impulsivity/emotional lability all evidenced significant relationships with the prenatal health behaviors, each differentially predicting different prenatal health behaviors. Conclusion As decreased engagement in adequate prenatal health behaviors puts both the mother and fetus at risk for negative birth outcomes, future research should work to develop a brief ADHD screen to be used in obstetric clinics and should investigate these relationships within a sample of women with a diagnosis of ADHD.