Unlike MWH, WWH demonstrated a global impairment profile with spared verbal recognition. Consistently, previous findings regarding memory impairment among PWH found this impairment to be more dependent on frontal and subcortical structures with relatively normal memory retention but impaired memory retrieval . Even in the female-specific profile of relative weakness in learning and memory, recognition was less impaired compared to learning and recall. We can only speculate as to why the sparing of recognition in the global impairment profile was specific to WWH and to verbal vs. visual memory. It is possible that, in the context of cognitive impairment in HIV, the female advantage in verbal memory may be most salient for the least cognitively taxing memory component, recognition performance, and this advantage is not fully adjusted for in our demographically corrected T-scores. Despite the heterogeneity in cognitive profiles by sex, the sociodemographic/clinical/biological factors associated with these cognitive profiles were similar for MWH and WWH suggesting that, although the same factors confer increased vulnerability to cognitive dysfunction, the adverse effects of these factors impact brain function differently in men and women. In both MWH and WWH, WRAT-4 had the greatest discriminative value of profile class followed by HIV disease variables , depressive symptoms, age, race/ethnicity and years of education. WRAT-4 scores have been consistently identified as an important determinant of cognitive function among PWH, with lower WRAT-4 scores conferring risk for cognitive impairment . WRAT-4 performance may be particularly salient in this population, given that reading level may reflect education quality, above and beyond years of education, especially in lower socioeconomic populations because of the many factors impacting education quality . Additionally,vertical farming systems reading level is associated with health outcomes including hospitalizations and outpatient doctor visits and, thus, may be a proxy for bio-psychosocial factors underlying general health . HIV disease variables were also strong determinants of cognitive profiles in both men and women.

Aside from some instances of a shorter duration of HIV disease relating to more cognitive impairment in WWH and in the total sample, the more biologically-based HIV disease variables were associated with cognitive impairment in the expected direction; higher current and nadir CD4 count and lower viral load were protective against cognitive impairment. It is curious that the global weakness with spared verbal recognition profile in women was associated with more severe HIV-related variables yet with shorter duration of HIV infection. We speculate that the shorter HIV infection in WWH may reflect CNS effects of untreated and/or early course HIV infection. Alternatively, the self-reported shorter duration of infection may not have been accurate, to the extent that WWH lived longer with untested/undetected infections. Findings are consistent with a wealth of literature relating proxies of HIV disease burden and severity to cognitive function and suggests that, even in the era of effective ART when viral suppression is common, HIV disease burden can have adverse effects on the brain possibly due to poor penetration of ARTs into the CNS, ART resistance, poor medication adherence , and/or the establishment of viral reservoirs in the CNS reservoir . In line with hypotheses of mental health factors relating to cognitive impairment profiles more strongly in women, current diagnosis of MDD was a predictor of cognitive profiles only among WWH. Although the prevalence of a current or lifetime diagnosis of MDD did not differ between WWH and MWH, MDD was an important risk factor of demonstrating Global weaknesses with spared verbal recognitioncompared to the profile demonstrating only Weakness in motor function . Our work indicates that HIV comorbid with depression affects certain cognitive domains including cognitive control, and that these effects are largest in women. Specifically, WWH with elevated depressive symptoms had 5 times the odds of impairment on Stroop Trial 3, a measure of behavioral inhibition, compared to HIV-uninfected depressed women, and 3 times the odds of impairment on that test compared to depressed MWH. In a recent meta-analysis, small to moderate deficits in declarative memory and cognitive control were documented not only in individuals with current MDD but also in individuals with remitted MDD, leading to the conclusion that these deficits occur independently of episodes of low mood in individuals with “active” MDD .

Together these lines of work suggest that MDD would exacerbate cognitive difficulties in PWH, particularly in the cognitive domains of declarative memory and cognitive control in WWH. Our study has limitations. Although we were adequately powered within both WWH and MWH , the magnitude of power was discrepant by sex considering that women represented 20% of our sample. Larger-scale studies in WWH only are currently underway. The generalizability of our findings also warrant additional study as the profiles identified here may not represent the profiles among all PWH. Due to the unavailability of data, we were unable to explore certain psychosocial factors as potential determinants of cognitive profiles. Our analyses were cross-sectional which allows us to identify determinants associated with cognitive profiles but precludes us from determining the temporal relationships between these factors and cognitive function. Although many of the related factors may be risk factors for cognitive impairment, reverse causality is possible with some of the factors resulting from cognitive impairment . Additionally, interpretation of the machine learning results should be done with care as RF is an ensemble model that is inherently non-linear in nature. This means that the importance and predictive power of every variable is specified in the context of other variables. This can lead to situations where an important predictive variable in the RF model has no significant difference in the overall comparison but has dramatic differences when included with other variables in the model. As such, this model should be interpreted as hypothesis-generating and identifies variables in need of further investigation. Lastly, because our study was focused on sex differences in cognitive profiles within PWH, we did not include a HIV-seronegative comparison group. Thus, we cannot determine the degree to which HIV contributes to sex differences in cognitive profiles. However, the independent HIV-related predictors does suggest that HIV has a role. Despite these limitations, we selected RF over linear models such as lasso and ridge regression because RF models had more predictive power and higher accuracy in this data compared to the linear models, even linear models with tuning parameters such as ridge and lasso that can used for feature selection. The results from these models mirror the P-values for the univariate comparisons , which is expected since analysis of variance and t-tests are also linear models. Moreover, RF models are more optimal for handling missing data, the inclusion of categorical predictor variables, and the use of categorical outcome measures which was the case in the present study.

RF models also account for the complexity in the data that can arise from multi-collinearity often seen in large feature sets. In conclusion, our results also suggest that sex is a contributor to the heterogeneity in cognitive profiles among PWH and that cognitive findings from MWH or male-dominant samples cannot be wholly generalized to WWH. Whereas, MWH showed an unimpaired profile and even a cognitively advantageous profile, WWH only showed impairment profiles that included global and more domain-specific impairment,cannabis grow room which supports previous findings of greater cognitive impairment in WWH than in MWH . Although the strongest determinants of cognitive profiles were similar in MWH and WWH including WRAT- 4, HIV disease characteristics, age and depressive symptoms, the direction of these associations sometimes differed. This suggests that the effects of certain biological, clinical, or demographic factors on the brain and cognition may manifest differently in MWH and WWH and that sex may contribute to heterogeneity not only in cognitive profiles but in their determinants although studies with larger numbers of WWH areneeded to more definitively test these hypotheses. It is important to detect these differing cognitive profiles and their associated risk/protective factors as this information can help to identify differing mechanisms contributing to cognitive impairment and whether these mechanisms are related to HIV disease, neurotoxic effects of ART medications, and/or comorbidities that are highly prevalent among PWH . Given the longer lifespan of PWH in the era of effective antiretroviral therapy, cognitive profiling will also inform aging-related effects on cognition in the context of HIV and perhaps early clinical indicators of age-related neurodegenerative disease. By identifying cognitive profiles and their underlying mechanisms, we can ultimately improve our ability to treat by tailoring and directing intervention strategies to those most likely to benefit. Overall, our results stress the importance of considering sex differences in studies of the pathogenesis, clinical presentation, and treatment of cognitive dysfunction in HIV. Traumatic brain injury is a significant public health concern as it is a leading cause of mortality, morbidity and disability in the United States. According to the World Health Organization, TBI is expected to become the third leading cause of death and disability in the world by 2020. In the United States TBI contributes to a third of all injury-related deaths. The leading causes of injuries resulting in TBI prevalence are traffic related, such as motor vehicle crashes, or non-traffic related, such as falls. Notably, up to 51% of all TBI patients have substance use exposure at the time of injury. Substance use includes alcohol and drugs such as marijuana. Current existing research suggest that in general, substance-exposed patients may have worse TBI outcomes, including greater rates of mortality and severity of injury. Research has also shown that substance use exposed TBI patients suffer worse functional outcomes, which can result in socioeconomic burden to patients and the nation at large. This healthcare burden has been calculated to be approximately $76.5 billion in 2010 alone. There is a substantial body of research elucidating the role alcohol plays in injuries that lead to TBI prevalence and outcomes. Specifically, alcohol use results in impairments such as diminished motor control, blurred vision, and poor decision making, which has been shown to increase the risk of traffic related injury.

This research has been used to create public health policies and prevention programs that have made a significant health impact, such as reducing the number of alcohol-impaired drivers. Other substances have not been as well studied. For example, marijuana is a drug that despite being federally and legally regulated, remains the most widely used drug in the U.S. Marijuana use has been shown to result in similar cognitive impairments as alcohol use, such as lack of coordination, inability to pay attention, and decision-making abilities, suggesting marijuana users are similarly at increased risk for TBI. There is some indirect evidence of this, in that it has been shown that marijuana users in general are about 25% more likely to be involved in a motor vehicle crash and that the older adult marijuana users have a greater risk for falls. However, concrete data linking marijuana exposure at time of injury and TBI prevalence and severity is scarce. Adding to the concern, national surveys on drug use and health have documented an increase in individual daily marijuana use over the last 5 years. As the number of states legalizing marijuana for both medical and recreational use increases, it is imperative to resolve the ambiguity within the research available regarding the relationships between marijuana exposure at time of injury, mechanism of injury, and TBI prevalence and severity. This study found that the presence of THC was significantly associated with lower GCS scores and a potentially more severe TBI, but this relationship was significant without controlling for other predicting variables. Furthermore, a significant relationship was found between GCS scores, age, and blood alcohol levels at the time of presentation in the ED. Older participants were found to have higher GCS scores, indicating a less serious brain injury. Study participants who had higher blood alcohol levels were found to have lower GCS scores, indicating a more serious brain injury. Age and higher blood alcohol levels were found to be associated, with higher blood alcohol levels noted in younger patients. A linear regression showed different results when examining the relationship between the presence of THC and GCS scores, hence TBI severity. When controlling for all other variables, the presence of THC was not found to be an independent predictor of TBI severity.

In the oldest age decade, the H+/D− group had the highest positive psychological factors, suggesting an important relationship between these positive psychological factors and being able to live a relatively long, non-depressed life as a person living with HIV. Hence, positive psychological factors may be protective for PLWH. Individuals’ subjective health ratings may provide valuable insight to their overall well-being, as previous studies have shown an association between reported worse health ratings and an increased risk of mortality . This finding may also reflect a potential “survivor effect” given that these older individuals have had HIV for longer and as long-term survivors, may view living with HIV more positively compared to prior expectations. This study has strengths in its multi-cohort design methodology that allows us to examine the combined effects of HIV and depression on HRQoL across age cohorts; there are also some limitations, however. For example, we were not able to address questions regarding the onset of depressive symptoms in relation to HRQoL or the positive psychological factors. For instance, depression may lead to less resilience and grit or vice versa. Like prior studies , we found a higher proportion of elevated depressive symptoms among PLWH, and individuals with elevated depressive symptoms reported lower HRQoL and positive psychological factors. There may be other factors related to depression and acquiring HIV not captured by our present variables that may account for the difference in depressive symptoms by HIV status. Another limitation is the small sample size per group, especially within the H−/D+ group. Furthermore, the sample, particularly the within the PLWH groups, was predominantly male and these results may not be generalizable to females. However, within the United Sates the majority of middle-aged to older PLWH are male; thus, our study cohort is similar to the broader characteristics of PLWH in the U.S. . Given the negative consequences of depression in PLWH, it is important to identify those in greatest need of treatment.

Prior work has highlighted the usefulness of cognitive behavioral therapy for depression treatment among PLWH,rolling grow benches even in those with advanced HIV disease . Furthermore, meta-analytic work has shown psychotherapeutic interventions reduce depressive symptoms in PLWH, which in turn may lead to improved psychiatric and medical outcomes . With this said, older PLWH are less likely to be engaged in behavioral health treatment for depression than younger PLWH, highlighting the need to address underlying factors contributing to the lack of adequate mental health treatment among older PLWH . However, increasing or improving positive psychological factors may provide one potential avenue to mitigate depressive symptoms.Neisseria gonorrhoeae and Chlamydia trachomatis are the two most common bacterial sexually transmitted infections worldwide, estimated to have caused 87 and 127 million infections, respectively, in 2016. Men who have sex with men are disproportionately affected by STIs, including N. gonorrhoeae and C. trachomatis. Infections by N. gonorrhoeae and C. trachomatis can increase the risk of HIV transmission and acquisition, mediated through ulceration and mucosal inflammation. Extragenital chlamydia and gonorrhea infections are common among MSM and are of public health importance. Recent rectal gonorrhea or chlamydia infections have been associated with increased risk for HIV acquisition. Pharyngeal N. gonorrhoeae infections are also important, as they can serve as a reservoir for antimicrobial resistance. Extragenital infections are commonly asymptomatic and screening is necessary to make a diagnosis. The U.S. Centers for Disease Control and Prevention recommends at least annual screening for rectal and pharyngeal infections among sexually-active MSM. The World Health Organization guidelines also support periodic screening for rectal and urethral infections among MSM. Data regarding extragenital N. gonorrhoeae and C. trachomatis infections are primarily from high-resource settings. A recent meta-analysis of STIs in PrEP users found nearly one in four had chlamydia, gonorrhea, or syphilis at PrEP initiation. However, few reports from low resource settings were included in that meta-analysis, highlighting the need for additional data from these settings. In low-resource settings, there are significant infrastructure and cost barriers that limit the widespread availability of diagnostic tests needed to screen for extragenital N. gonorrhoeae and C. trachomatis.

Understanding the burden of gonorrhea and chlamydia in low-resource settings is also important for HIV prevention, as it can often be an entry point into HIV pre-exposure prophylaxis programs that are being scaled up worldwide. In Vietnam, the 2013 HIV/STI Integrated Biological and Behavioral Surveillance sampled 1587 MSM across the country and found a 5% prevalence of urethral chlamydia and <3% of urethral gonorrhea. That report found a 10% prevalence of rectal chlamydia and <3% of rectal gonorrhea, but oropharyngeal testing was not performed. Aside from that report, data regarding the prevalence and risk factors for extragenital chlamydia and gonorrhea infections among MSM in Vietnam are scarce. A better understanding of the prevalence and correlates of N. gonorrhoeae and C. trachomatis infections among MSM in Vietnam is needed to effectively plan for STI screening, diagnosis, and prevention programs in the setting of limited resources, especially in the context of the rapid scale-up of HIV PrEP programs. The objectives of this study were to determine the baseline prevalence of urethral, rectal, and pharyngeal N. gonorrhoeae and C. trachomatis infections within a cohort of HIVnegative MSM in Hanoi, the capital and second-largest city in Vietnam, and to examine the factors associated with N. gonorrhoeae and C. trachomatis infections. Between July 2017 and April 2019, MSM were recruited to participate in the Health in Men -Hanoi study, a prospective, observational cohort designed to investigate the prevalence and incidence of HIV and STIs, as well as the social and behavioral characteristics within this population. Participants were recruited from concurrent HIV and STI surveys among MSM that utilized time-location sampling, respondent-driven sampling, and internet-based sampling methods. Recruited individuals presented to the Sexual Health Promotion Clinic at Hanoi Medical University where informed consent and study enrollment were completed. Cohort inclusion criteria were: assigned male sex at birth, aged ≥ 16 years, having oral or anal sex with another man or transgender woman in the prior 12 months, living in Hanoi continuously for the prior 3 months and without a plan to move in the next two years, and serologically confirmed to be HIV-negative at baseline. At the time of the study, no participants were enrolled in a PrEP program, as PrEP was not available in Vietnam. Data collected at baseline in the sub-sample of HIV-negative MSM were used for this study.

Socio-demographics, substance use, sexual practices, history of STIs, and history pertaining to HIV counseling, testing, treatment, and care services, were collected through audio computer-assisted self-administered interviewing . Group sex was defined as more than one partner in a sexual encounter in the prior six months. Participants were asked about any rectal and genitourinary symptoms in the prior 6 months. Rectal symptoms were classified as any of the following: dyschezia, pruritis, bleeding, discharge, or ulcers. Genitourinary symptoms were classified as any of the following: dysuria, discharge, bleeding, pruritis, or ulcers. All participants received client-centered HIV and STI risk-reduction counseling. Urine samples, rectal swabs, and pharyngeal swabs were collected using cobas PCR urine sample kits and cobas PCR female swab collection kits and were tested for N. gonorrhoeae and C. trachomatis by NAAT on the cobas 4800 CT/NG v2.0 system . Blood was collected for HIV testing and was performed on the ARCHITECT HIV Ag/Ab Combo . Serologic testing for syphilis was done using the Architect Syphilis TP assay , with positive samples undergoing rapid plasma reagin testing and Treponema pallidum hemagglutination , as indicated . All participants with a positive NAAT for C. trachomatis or N. gonorrhoeae were considered to have an infection. Test results for C. trachomatis or N. gonorrhoeae were classified as missing if a specimen was not available for testing or if the testing had inconclusive results. Those with a positive T. pallidum-specific antibody and a measurable RPR were considered to have a syphilis infection. Descriptive statistics were applied to socio-demographic, behavioral,drying cannabis and clinical data. Predictive logistic regression modeling was used to evaluate factors associated with N. gonorrhoeae and C. trachomatis infections separately and the combined outcome of having either infection. Variables for consideration were selected a priori using an approach that included variables based on biologic basis, as well as known risk factors and confounders. The variables included in the bivariate analyses were: age, education, income, ATS use for sex, group sex, meeting sexual partners via mobile apps, prior diagnosis of STIs, and genitourinary orrectal symptoms. Symptom status was dichotomized for the logistic regression models. All variables in the bivariate analyses were also included in the multivariate analysis, with the exception of any substance use in the prior 3 months and amphetamine-type stimulantuse in the prior 3 months, which were excluded from the multivariate analysis due to high collinearity with ATS use to enhance sexual performance in the prior 6 months. Records with missing variable data were excluded from the logistic regression models. All data analyses were done using R version 3.61. There were 1498 participants in the baseline survey. Nine did not have any samples for N. gonorrhoeae and C. trachomatis testing and were excluded from the analysis. Among the remaining 1489 participants, the median age was 22 years . Income in the prior month was less than 5 million VND for 40.5% of participants and 30.8% had completed university education. Substance use in the prior 3 months was reported by 8.3% of participants and 6.5% reported using ATS to enhance sexual performance in prior 6 months. Among those reporting anal sex in the prior 6 months, 32.1% had insertive sex, 30.0% had receptive sex, and 29.5% had both.

Condomless anal intercourse in the prior 6 months was reported by 57.6% of participants. Anal sex with two or more partners in the prior month was reported by 31.8% of participants. Group sex in the prior 6 months was reported by 24.9% of participants. Over half of participants reported meeting sexual partners via websites or mobile apps in the prior 6 months. There were 841 participants who did not have genitourinary or rectal symptoms in the prior 6 months. There were 235 participants with a prior diagnosis of chlamydia, gonorrhea, or syphilis. The prevalence of syphilis was 18.3% . There were 1378 participants included in the analyses of factors associated with N. gonorrhoeae, C. trachomatis, or either N. gonorrhoeae or C. trachomatis infection, excluding those with missing variable data . In the multi-variable analysis of the combined N. gonorrhoeae or C. trachomatis outcome, those aged 25-34 years had lower odds of infection compared to those with ages 16-24 years . This was largely contributed to by C. trachomatis infection . Other independent factors associated with having either N. gonorrhoeae or C. trachomatis infections included having two or more recent sex partners , condomless anal intercourse in the prior six months , which was driven by C. trachomatis , and meeting sexual partners via mobile apps or the internet , which was driven by N. gonorrhoeae . Genitourinary or rectal symptoms in the prior 6months and group sex were associated with infections in bivariate analysis, but not in the multivariate model. A prior STI diagnosis and ATS use to enhance sexual performance were not associated with any infections in the multi-variable models. .In this study of young, HIV-negative MSM in Hanoi, Vietnam, we found a high prevalence of N. gonorrhoeaeand C. trachomatisinfections with more than one in four participants having one of these infections at baseline. Rectal infections occurred in 73.9% of those with chlamydia and 70.5% of gonorrhea infections occurred in the oropharynx. Limiting testing to the urethral site would have missed nearly three-quarters of C.trachomatis or N. gonorrhoeae infections within this cohort, as 27.4% of infections occurred in the urethra. Half of all persons with chlamydia or gonorrhea were asymptomatic, and reporting genitourinary or rectal symptoms were not associated with infections, highlighting the need for routine screening in this population. Prior surveys of urethral chlamydia or gonorrhea in Vietnam found a similar prevalence of C. trachomatisand N. gonorrhoeae , compared to the overall urethral prevalence of 7.1% and 1.3%, respectively, we reported here. While data on extragenital chlamydia and gonorrhea within Vietnam are very limited, surveys from Ho Chi Minh City, Hanoi, and Nha Trang including urethral, rectal, and pharyngeal testing among HIVnegative male sex workers, many of whom are MSM, found a high overall prevalence of N. gonorrhoeae, up to 29%, and up to 17% for C. trachomatis, although data stratified by anatomical site were not reported.

The potential applicability of the interest group mechanism identified in this paper across policy domains also has implications for fundamental models of lawmaking in American politics. Standard models conceive of lawmakers as primarily driven by the preferences of the median voters in their districts, which are generally taken as exogenous . Alternative perspectives suggest that lawmakers are primarily responsive to the pressures of organized interests seeking to advance policy goals, and moreover, that the ability of competing groups to influence politics is structured by the existing policy-scape . Findings presented here support the notion that existing policy, in part by shaping interest group capacities, affects congressional representation. This paper therefore provides quantitative empirical grounding for the difficult-to-test arguments in favor of the policy-focused approach— and one empirical framework for scholars working in this vein.Wealthy foundations have taken on increasingly prominent roles influencing education policy in the U.S. This paper uses a mix of qualitative and quantitative evidence to study the drivers and implications of the engagement of major foundations in the politics of charter schools. I show that states that adopted favorable charter laws, in addition to empowering charter schools as political actors, also drew wealthy foundations into the charter policy space by enabling them to make investments in developing new schools. Foundations later sought to protect those investments, leveraging strategic grant-making to drive the growth of a pro-charter advocacy network with national scope. Findings underscore the importance of state policy experimentation in catalyzing new interest group coalitions,commercial racks with implications for ideas about policy reform in American federalism.

In recent years, contests over policies governing charter schools have generated some of the most hard-fought battles in state politics. In 2016, Massachusetts voters rejected a ballot initiative that would have lifted the state’s cap on charter schools to allow 12 new schools each year after a $33 million campaign—at that point the most expensive in the state’s history. A few years later, in 2019, on the other side of the country, California Governor Newsom signed legislation adding restrictions to new charter schools after a big-money campaign pitting teachers unions against charter advocates. That teachers unions and other incumbent organized interests in the K-12 education sector would resist charter schools makes good sense. Teachers unions are some of the most active and well-resourced organized interests in American politics, particularly at the state and local levels where most education policy is made . Teachers at charter schools are much less likely to be unionized , so the rise of charter schools poses an acute threat to their continued strength. And while funding formulas vary across the states, broadly speaking, the more students enroll in charters the less funding is available to district schools, so the growth of charter schools also threatens union jobs in the long run. What is somewhat more surprising is the emergence of a well-resourced pro-charter advocacy coalition battling to defend and expand chartering. This coalition often includes charter schools themselves, who also are sometimes able to drum up grassroots support among the parents of their students. But, as of 2017, charter schools only enrolled about 6 percent of all public-school K-12 students . Even large charter networks like The Knowledge is Power Program do not have the resources to go toe-to toe with teachers unions in the political sphere. And charter school parents are usually lower income people of color—not a group seen as particularly powerful in American politics. More fundamental to the pro-charter political coalition than the schools themselves are wealthy philanthropists and the advocacy groups they fund.

For instance, Great Schools, which spent $23.6 million in 2016 to try to raise a cap on the number of charter schools in Massachusetts was bank-rolled primarily by the Walton family and Michael Bloomberg . Indeed, existing research has documented how the coordinated engagement of wealthy foundations has been fundamental to the emergence of a pro-charter coalition of interest groups combining a national scope with local on-the-ground presence . This paper traces the emergence and growth of this pro-charter coalition and studies its implications for the politics of education. I argue that the rise of the pro-charter education coalition depended fundamentally on early policy victories during a particular “window of opportunity” for the charter school movement. Advocates took advantage of the broad attention to education reform in the 90’s and early 2000’s to pass “charter laws” across a wide range of states. These laws provided a legal framework for new charter schools to be authorized. I show that, even though a majority of states adopted charter laws in this period, charter sector growth depended fundamentally on a smaller set of states with highly pro-charter policies. This growth, I argue, was essential for building a broader political coalition supported by foundations. In the 90’s and early 2000’s, foundations’ primary role was to provide financial and technical support to charter schools to get up-and-running. But the involvement of these foundations in directly supporting schools and other charter operations planted the seeds for subsequent political engagement. As charter schools grew and came under increasing pressure from hostile teachers unions, foundations recognized that the continued growth and viability of the charter school sector depended not just on their operational support— but also on the development of a pro-charter political coalition. Drawing on data submitted to the IRS by non-profit organizations , I document a shift in foundation grant-making towards greater political advocacy. Elite interviews suggest that key foundations recognized the importance of building political capacity through grant-making to defend earlier investments in the charter movement. The consequences of the rise of this foundation-funded, nationally scoped, political coalition have been profound.

Exploring several mini-cases, I show how foundation-funded groups have been fundamental to efforts to expand charter schools to new locales—and seek to defend charter schools in places where they have gained a foothold. This analysis has implications for our understanding for how reforms challenging incumbent vested interests can unfold over time. As Finn, Manno, and Wright write: “Aside, perhaps, from mayoral control, chartering is by far the most significant manifestation of structural and governance innovation in public education…” . What is interesting about this case for the literature on public policy reform is that, unlike other durable reforms , the advent of charter schools—except in some extreme cases like New Orleans —has largely failed to dislodge incumbent education interests. While charter school policy reforms have, to an extent, politically empowered charter schools and charter networks themselves,greenhouse rolling benches these interests have been less important to the broader pro-charter coalition than foundations. More so than generating their own interest group supports by conferring benefits , early charter laws changed the politics by drawing previously sidelined political actors—in this case, foundations—into the charter coalition. The role of philanthropists in politics is a growing and important topic of study in political science . With greater inequality concentrating wealth at the top of society, foundations have developed ever-greater financial resources . In addition, a growing cadre of living donors have sought to leverage strategic grant-making and political engagement to accelerate structural change by driving policy shifts . But this paper shows the relationship also goes in the other direction: how foundations engage in politics is shaped by prior policy decisions through policy feedback dynamics . The paper unfolds as follows. I first provide background on the growth of charter schools in the U.S. and discuss the importance of state policy decisions for the charter school sector. I then trace the emergence of a pro-charter political coalition, highlighting the role of state experimentation with charter laws in building this coalition. I proceed to present several minicases that underline the importance of this pro-charter political coalition to expanding and defending charter laws. Finally, I discuss implications for understandings of policy reform over time in American federalism and conclude. Laws allowing for the establishment of public charters schools were adopted in 40 states in the 90’s and early 2000’s. The first to adopt was Minnesota, which passed its charter law in 1991. The federal government also adopted new charter school policy in this period. The Federal Charter School Program, initiated in 1994 by amendments to the Elementary and Secondary Education Act, directed critical funding to support the growth of charter schools in states that allowed them . The expansion of charter schools generally coincides with greater choice in K-12 education. Where charters have become established, parents can opt to send their children to either publicly funded charter schools or district schools tuition-free. Charter schools are publicly funded, but privately operated. Governance from authorizers under state jurisdiction, versus local school districts, generally allows them greater autonomy than traditional public schools Charter schools’ political momentum came in part from renewed attention to education policy in the 80’s and 90’s. Several reports were published in the early 1980’s highlighting major issues in the American K-12 education system.

The most famous of these was A Nation at Risk , which famously claimed that: “Our society and its educational institutions seem to have lost sight of the basic purposes of schooling, and of the high expectations and disciplined effort needed to attain them” . The report’s call for politicians to pay greater attention to education was heeded, even as the analysis underpinning its key findings were later disputed . In the 1980’s, the states and the federal government experimented with a wide range of education reforms ranging from teacher certification standards to more standardized testing to school-based management. Most of the reforms adopted in this period operated within the highly bureaucratic system established by progressives in the early 20th century. Indeed, new policies on standards and testing were designed to further bureaucratize and centralize the education system. These types of reforms, Chubb and Moe argued in their influential Politics, Markets, and America’s Schools, were destined to fail, since they failed to address the institutional problems underlying K-12 education’s woes. The most important factor determining a school’s performance, they proposed , was its level of autonomy. And a top-down bureaucratic management structure was anathema to holding schools accountable while maintaining school autonomy. Market control, versus democratic control, they argued, would allow for greater school autonomy and, as a result, improved academic performance. Chubb and Moe thus pushed for an alternative set of reforms aimed at decentralizing the education system, instilling choice, and leveraging market competition to achieve improvements. Similar ideas were also being promoted on the left side of the political spectrum. In 1988, University of Massachusetts professor Ray Budde released Education by Charter: Restructuring School Districts.Budde advocated for allowing innovative teachers to apply for special charters to create new programs, thus devolving authority down to teachers and enhancing their autonomy. American Federation of Teachers president Al Shanker latched onto the chartering concept and promoted it as a way for teachers and their unions to maintain their central role in the face of seemingly inevitable education reforms. Chartering thus emerged in this period as a “middle-path” between the highly rigid existing system and a privatized system of vouchers promoted by those on the far right of the political spectrum . Policy entrepreneurs first took chartering from concept to law in the state of Minnesota. The effort was led by Joe Nathan, a former Minnesota teacher who had written a book promoting the charter school concept and then worked for the National Governors Association’s education reform group commissioned by Lamar Alexander and Bill Clinton. Nathan partnered with Ted Kolderie from Citizens League, a moderate “good government” Minnesota think-tank, and former State Senator Ember Reichgott Junge to develop and enact a bill that would put in place a process for schools to apply for charters to operate independently of school districts. The Minnesota bill was ultimately supported by a minority of the Democratic party , but by enough Republicans to pass. Bipartisan support within the “window of opportunity” generated from attention to education reform was critical to overcoming opposition from teachers unions and school boards in Minnesota, and later, elsewhere . Contrary to Al Shanker’s hopes, charter laws generally did not establish a role for teachers unions in the chartering process, instead generally specifying that new charter schools could operate outside of negotiated collective bargaining contracts.

The model includes a linear time variable to account for broader trends like growth in lobbying from distributed solar. I estimate multilevel models with random effects at the firm, state, and year levels to account for the hierarchical structure of the data. In column of Table 2, the outcome variable is a binary measure of whether a firm lobbied in a particular state-year .In column , the outcome variable is the total number of lobbying registrations attributed to a particular firm . For this specification, I estimate a negative binomial model since the outcome is an over dispersed count variable . Finally, in column , the outcome is logged lobbying expenditures for the limited sample of states for which these data are available. Across specifications, results, presented in Table 2, indicate that firm lobbying in a state is increasing in its installed TPO capacity in that state and its installed capacity in other states . The coefficients in column indicate that a doubling of in-state capacity is associated with an 8-percentage point increase in the likelihood of an installer lobbying, while a doubling of out-of-state capacity is associated with a 5-percentage point increase likelihood of an installer lobbying in any particular state. Results from the negative binomial model also indicate that both in-state and out-of-state capacity matter for lobbying. The coefficient of .47 in column suggests that a 1 percent increase in in-state capacity installed for a firm is associated with a .47 percent increase in number of retained lobbyists in that state ; the coefficient of .48 indicates that a 1 percent increase in out-of-state capacity is associated with a .48 percent increase in number of retained lobbyists in a given state . I recover consistent results in the limited sample of states using logged lobbying expenditures as the outcome in a linear model. The coefficients suggest that a doubling of in-state capacity is associated with a 71 percent increase in lobbying expenditures,hydroponic shelf system while a doubling of out-of-state capacity is associated with an 85 percent increase in lobbying expenditures in any particular state.

By showing that firm lobbying in any particular state depends on firm economic strength both within that state and across the states, these findings also suggests that policy in one state affects lobbying in another. That’s because state policy affects installer business growth , which in turn drives installer lobbying across the states due to the horizontal mobilization of firms. A particularly important case of cross-state feedback is where firms apply growth in states with favorable policy environments to seek to shape policy in potential new markets. To examine this dynamic, I track the economic and political presence across the states over time for the two largest and most politically active rooftop solar firms over the period: Sunrun and SolarCity. As illustrated by Table 3, both firms significantly expanded their political and economic presence from 2014 to 2016. While there is certainly significant overlap in the states where the firms were economically and politically active, both firms hired lobbyists in a number of states in which they were not selling systems. In 2016, for instance, SolarCity lobbied in 10 states in which it was not actively selling systems; Sunrun lobbied in 11 states where it did not have an economic presence. In many cases, these firms hired lobbyists in advance of economic expansion to particular states . To summarize, I have shown that: 1) favorable rooftop solar policy leads to rooftop solar industry growth, 2) rooftop solar industry growth leads to greater lobbying from rooftop solar industry both in the states where growth takes place as well as in other states, 3) rooftop solar firms have in a number of cases sought to influence policy in states where they are not yet active, and 4) installer lobbying is associated with more favorable policy, particularly in places where the industry has less of an economic presence. Taken together, the empirical analyses trace out a causal process whereby adoption of favorable rooftop solar policies in leading states affected the interest group politics—and ultimately policy decisions—in other states. Of course, the empirical analysis is not without its limitations. In particular, establishing causal inference in policy feedback and interest group influence research is a major challenge . In this case, neither policy enactment nor interest group lobbying is randomly assigned, nor are there apparent natural experiments to leverage.

Yet, by bringing together a multitude of both state- and firm-level data, this paper provides evidence in support of the proposed theoretical framework, and an empirical setup on which scholars working across different policy areas can build. In addition, the evidence presented does not rule out that traditional diffusion mechanisms of learning and competition have also shaped state-level rooftop solar policy and politics. It clearly demonstrates, however, that these traditional mechanisms are not the whole story. An analysis of interdependent policy making in this case that failed to consider the effects of state policies on the resources installers had at their disposal to engage politically in other states would be incomplete. Moreover, it is likely that the dynamics of cross-state policy feedback on interest group politics studied here can also serve to facilitate mechanisms of learning and competition. For instance, when installers lobbied in states where they had yet to establish an economic presence, they likely initiated a learning process among state lawmakers. Future research building on this paper might seek to refine methods for distinguishing the types of policy feedback spillovers explored here from traditional diffusion mechanisms. The standard policy diffusion designs are limited in their ability to parse mechanisms , and the feedback dynamics studied here will not always lead to diffusion in a strict sense. Broadly speaking, studying intergovernmental policy feedback in a federal context requires close attention not just to patterns of policy adoption in different units, but also to the political engagement of organized interests across the federal system. Scholars might pay particularly attention to two particular types of groups: first, groups with federated structures that can swiftly leverage resources from one jurisdiction to influence policy in another; and second, business interests seeking to expand. Studying the intergovernmental effects of policies on interest group politics also likely requires examinations over longer periods of time than conventional policy diffusion approaches. Diffusion mechanisms like learning and competition might manifest quickly—since they depend only on the beliefs of lawmakers—while the intergovernmental feed backs studied here depends on long-run shifts to interest group systems.

Indeed, the case of rooftop solar examined here is likely an outlier in the speed by which state policies gave rise to new interests. By adopting this empirical approach, scholars can further extend the theoretical framework developed in this paper. A natural extension is vertical policy feedback . The organized interests that benefit from, and are strengthened by, particular state-level reforms might, in addition to advocating for the propagation of those reforms across the states, advocate for the national-level adoption of those or aligned reforms. These effects have likely been limited in the case of distributed solar, where key decisions are made at the state level. Indeed, while SolarCity, Sunrun, Vivint, SunPower, and SunEdison spent just under 9 million dollars lobbying in the 15 states that collected expenditure data between 2015 and 2017, they collectively spent just 2.25 million dollars lobbying the federal government over the same period . But there is some anecdotal evidence that the growth of the distributed solar lobby, driven in part by state-level decisions,cannabis drying racks commercial has been important to the national politics of issues like tariffs on solar panels and the Solar Investment Tax Credit . Future research might also consider the conditions under which strategic actors intentionally leverage state policy as a political tool in building a political coalition for broader reform—or seeking to dismantle opposing organized interests . Importantly, politicians often face a collective action problem in their efforts to use policy for political gain. Even when a broader party or interest group benefits from a particular policy, individual lawmakers can have incentive to defect . This collective action problem is particularly pronounced for politicians seeking to use state policy for national-level political gain . As a result, we might expect federated groups with political operations across sites and levels of government to be most equipped to strategically harness dynamics of intergovernmental policy feedback . While this paper demonstrates the force of intergovernmental feed backs on interest group politics, these mechanisms are likely more limited in other cases. The aggressive growth strategy of installers, combined with the crucial role of state policy in driving growth, provided a strong incentive for installers to mobilize politically across the states. At the same time, even as rooftop solar firms have mobilized, incumbent electric utilities have been able to prevent pro-solar reforms across a number of states, and in some cases, roll them back . Forward looking incumbents engaged across sites and levels of government in the federal system can, in this way, use the political system to prevent competitors from gaining strength. Moreover, in policy areas like immigration or marriage equality, where sub-national policy decisions are less likely to engender major shifts in the broader interest group landscape, we are unlikely to observe strong policy feedback spillovers operating through organized interests. But at the same time, there are a broad swath of policy issues for which the mechanisms I explore here are likely quite relevant. Indeed, the emergence of supportive interests with a stake in new policy regimes is a fundamental feature of sustainable policy reforms .

These mechanisms are particularly relevant to the politics of the energy transition, where liberal leaning states have led the way, but where there are significantly more greenhouse gas emissions to be abated in conservative-leaning areas. While rooftop solar is just a small piece of the energy transition, similar ideas apply to other elements like utility-scale renewables and energy efficiency . In general, policy feed backs in energy governance tend to be quite powerful, since policies that replace fossil fuel infrastructure with clean energy infrastructure also replace fossil fuel interests with clean energy interests . More broadly, states play important regulatory roles across a number of policy areas, and their decisions can affect the political resources of organized interests active in other states. For instance, in the education system, state policy has been instrumental to the steady growth of charter schools in recent years, which in many states and districts now pose a meaningful challenge to the traditional public-school model—as well as to the teachers unions that draw strength from that model. As charter schools have grown, so has the charter school lobby, as wealthy foundations have allied with charter networks to push forward policies across the states, and also in local and federal politics . The general scope conditions for these types of effects are quite broad. Sub-national policies must give rise to new organized interests or significantly influence the capacities of existing interests. And the organized interests affected by sub-national policies must leverage newfound strength to mobilize horizontally across the federal system. Though this paper focuses specifically on the effects of state policies on business interests, elements of the proposed perspective also likely apply to other types of organized interests , as well as to sub-national jurisdictions apart from the US states .There are reasons to think, in addition, that these types of dynamics are at play even in some areas where we do not observe shifts to policy or interest group landscapes: they can be baked into the status quo. The period of rooftop solar policy and politics I study saw massive policy and interest group changes over a relatively short period of time, which renders the dynamics of policy feedback across the states highly visible. Similar mechanisms, though, can enforce policy stability across the federal system. Many powerful organized interests draw strength from policies in place in jurisdictions across the federal system and use their resources to block threatening policies at multiple sites and levels of government . These dynamics are difficult to study since they tend to lead to non-action. But studying policy areas in flux like rooftop solar can provide insight into forces of stability. Drawing on policy feedback literature and literature on congressional representation, I argue that, because of this institutional configuration, sub-national policy adoption can affect national representation.

The second core mechanism is competition . Because federal units compete for mobile businesses and residents, sub-national governments can be pressured to adopt attractive policies pursued in other units—or risk losing tax revenue and economic activity.The policy diffusion perspective has been highly fruitful. It has shed light on the degree to which policy decisions by governments are interdependent and explored several compelling mechanisms that drive this interdependence. But, I argue, this perspective is incomplete. It fails to fully account for the role of interest groups in the policy process—and how prior policy decisions across the federal system shape interest group politics. Policy diffusion scholarship focuses primarily on re-election motivated lawmakers who learn and compete because they, broadly speaking, want to produce good policy outcomes for their constituents. Yet, we know that much more goes into policy decisions besides lawmakers seeking good policy. Significant policy reforms usually represent just the final outcomes at the tail end of hard-fought political battles—which generally continue post-enactment in the implementation phase. These battles can draw a diverse array of interest groups like businesses, unions, and citizens groups, as well as government bureaucrats. Painting a complete picture of policy interdependence in American federalism therefore requires considering how prior policy decisions adopted across the federal system construct and empower political actors engaging across the federal system. That is the approach taken in this dissertation. I focus primarily on organized economic interests,indoor vertical garden system whose engagement is among the strongest drivers of policy decisions in American politics broadly , and who are particularly important in considering policy reforms that affect sectors of the economy.

Literature studying “policy feedback” has demonstrated the powerful ways in which the public policy landscape affects the representation of organized economic interests in the political system . For instance, the public policy landscape shapes the types of firms that grow and prosper—and as a result, which have the capacity to influence politics . Similarly, public policies like collective bargaining rules affect the ability of unions to grow and maintain membership, which in turn influences their political sway . Shifts 1 In the international sphere, Elkins and Simmons similarly categorize diffusion as either “adaptation to altered conditions” and learning. in policy, therefore, can affect the power of different organized economic interests in the political system. In a federal system of government in which states have significant authority and interest groups are active at multiple sites and levels of government, I argue that policy feedback effects on interest group politics can also generate powerful policy inter dependencies—in some cases driving the spread of policies across jurisdictions. More specifically, state-level reforms can increase the political power of interest group coalitions supporting the geographic and jurisdictional expansion of those reforms. These dynamics can play out, first, horizontally across the states. State-level reforms that benefit existing organized interests, or give rise to new ones, also tend to strengthen them politically. The groups that benefit from particular state-level reforms are likely to also benefit from the propagation of those reforms to other states. Thus, these groups might apply newfound strength to propagate reforms horizontally through lobbying and other political activities. The political implications of state-level reforms are not restricted to other states. The groups that benefit, and are politically strengthened, by a state-level reform might also leverage newfound strength to advocate for aligned reforms at the federal level. The geographic structure of representation in Congress provides a key avenue for this type of vertical, state-national feedback. Members of Congress represent geographically demarcated districts that are embedded in state policy landscapes.

Shifts to those landscapes precipitated by state policy reforms can in turn affect the political pressures that members face. More specifically, to the extent that state policy reforms influence state political economies, this can affect the ability of organized economic interests to engage in politics and make demands on their representatives. Finally, reforms achieved at the state level can affect the national interest group politics by drawing new actors into pro-reform coalitions. This dynamic is particularly relevant in considering the engagement of philanthropists, a growing topic of study in political science . State policy experiments can provide a proof-of-concept of the legitimacy of some set of reforms, and thus draw philanthropic investment. Once invested, foundations might use their financial resources to fund advocacy groups working to propagate those new policies. In the empirical portion of the dissertation, I apply this new theoretical perspective on policy interdependence in American federalism to three policy cases: rooftop solar policy, marijuana policy, and charter school policy. These are each areas in which state governments have taken the lead on driving forward policy reforms with major implications for sectors of the economy, and where, as I show, state government action has had implications for the interest group politics in the broader federal system.Even more so than in the case of rooftop solar, state actions have precipitated a major shift in marijuana policy over the past 20 years. Since California pioneered legalization of marijuana for medical use in 1996, 32 other states and Washington D.C. have followed suit. As of 2020, 15 states had also legalized marijuana for recreational use. This represents a profound shift from the policy regime associated with the War on Drugs that was initiated in the 1970’s. And, like in the case of rooftop solar, these policy shifts have also engendered shifts in the interest group politics. In particular, the advent of adult-use legalization, pioneered by Colorado and Washington in 2012, has driven rapid growth in the marijuana industry from just 3.5 billion dollars of revenue in 2014 to over 13.5 billion dollars of revenue in 2019.

This has led the industry to develop a greater political presence, both in the states and at the federal level. The costs from federal prohibition have led the industry, unlike in the case of rooftop solar, to focus to a greater extent on federal policy than propagating reforms across the states. Federal lobbying from marijuana industry rose from just $45,000 in 2012 to $6 million in 2019. And members of Congress representing legalizing states have, I show, become critical allies in efforts to liberalize federal marijuana policy and resolve costly state-federal legal tension. Take Cory Gardner , for instance. There is little in Gardner’s record prior to 2012 that would indicate he would become an important marijuana proponent. Yet, during his tenure in the Senate , Gardner became a central figure in federal marijuana policy. In 2018, Gardner vowed to block judicial nominees in the Senate until he received a commitment that the federal government would not prosecute marijuana industry . In the 116th Congress, Gardner sponsored core marijuana-related legislation including the SAFE Banking Act and the STATES Act. It is no coincidence that Gardner represents the state of Colorado,clone rack which has one of the strongest marijuana industries in the country. Indeed, interview evidence suggests that the sway of marijuana industry and marijuana voters in Jared Polis’s successful 2018 bid for governor was a major reason why Gardner, who anticipated a tough re-election in 2020 , made marijuana such a priority. To test whether the relationship between state-level legalization and representation in Congress generalizes, I leverage exogenous variation in likelihood of legalization generated by variation across the states in ballot initiative rules. This exogenous variation is necessary due to the inferential challenges in estimating the effects of state policy on national representation. Broadly speaking, to the extent that state policy decisions and representation in Congress are both shaped by factors like a state’s overall ideology, I would expect a correlation between state policy and national representation without any causal relationship. Variation in the availability of citizen initiatives across the states helps to overcome this causal identification problem in the case of marijuana policy. A number of states adopted procedures allowing citizens to enact statutes or constitutional amendments directly through statewide ballot initiatives in the Progressive era of the early 20th century. In the current era, ballot initiatives have been a critical tool for marijuana policy reform. The ability to bypass state legislatures is important because, as one advocate told me, citizens tend to be much more liberal on marijuana issues than their representatives in state legislatures. As a result, legalization efforts have been concentrated in states that allow ballot initiatives, and whether states allow initiatives strongly predicts legalization both for medical and recreational use. At the same time, whether states allow initiatives is not correlated with other factors generally associated with congressional behavior such as measures of ideology. And more importantly, whether states allow initiatives is not associated with member behavior on marijuana issues prior to the wave of state legalization initiated by California in 1996. This suggests that availability of the initiative is a valid instrument for estimating the effect of state legalization on national representation in the contemporary period.

I study the 116th Congress, which, as one journalist put it, was “the first Congress in history where, going into it, it seem[ed] that broad marijuana reforms [were] actually achievable” . Broadly speaking, I find evidence that state legalization affected national representation. Members of Congress representing legalizing states were more likely to sponsor or co-sponsor key pro-marijuana pieces of legislation. They were also more likely to cast certain pro-marijuana roll-call votes. Bringing quantitative evidence and elite interviews together to investigate mechanisms, I find the most support for the role of growing industry influence in legalizing states, but also find some support for the role of the initiative vote in signaling constituent preferences. I find little support for the potential alternative hypothesis that effects were driven by positive shifts to public favorability wrought by legalization. Like in the other two cases, state policy decisions regarding charter schools have driven major shifts to a sector of the economy and society: K-12 education. Charter schools, independent but publicly funded, have grown steadily since the early 2000’s. As Finn, Manno, and Wright write: “Aside, perhaps, from mayoral control, chartering is by far the most significant manifestation of structural and governance innovation in public education…” . In 1999, there were just 507 charter schools operating. By 2017, nearly 7000 charter schools were enrolling over 3 million students—about 7 percent of overall public K-12 enrollment. Charter schools owe their existence to the adoption of “charter laws” across 40 states between 1991 and 2003, which allowed new schools to form apart from the traditional district structure. Unlike in the case of marijuana policy, but like the rooftop solar case, charter school growth presents an existential threat to powerful organized economic interests—teachers unions. Charter schools generally have much lower rates of unionization than traditional public schools. The charter sector’s growth, despite opposition from unions and other incumbent education interests, is notable. It has depended in part, I argue, on the development of a nationally-scoped network of pro-charter advocacy groups—which have on several occasions gone toe-to-toe with powerful teachers unions. In the paper, I examine the role of prior state policy decisions in seeding this pro-charter interest group network. A key difference between the charter school policy case and the other cases studied is in the types of organized interests driving the sustainability and spread of reforms. In rooftop solar policy and marijuana policy, the story is relatively straightforward: state policy decisions gave rise to new industries that leveraged their economic growth to develop greater political influence. While charter growth precipitated by state policies has similarly generated new political interests in the form of large charter networks like Success Academy and KIPP, the political power of these organizations is highly limited. Since charter schools are mostly non-profits with limited revenue streams generally funneled into operations, the political activity of these charter networks has been modest compared to large marijuana and rooftop solar firms. Given that limitation, the financial backing of philanthropists like the Gates Foundation and the Walton Family Foundation has been crucial to building the pro-charter advocacy network. But foundations’ investments in charter advocacy did not arise in a vacuum. Drawing on elite interviews, I show that state policy decisions in the 90’s promoting charter growth in leading states like Minnesota and California were instrumental to generating support from philanthropists and building the pro-charter group coalition.

The timing of follow-up visits was anchored to the date of the participant’s baseline assessment . “Pre-pandemic” observations were any assessment occurring between study entry and March 19, 2020, the date of the first state-issued stay-at-home order, so each youth could contribute multiple assessments. Among youth contributing pre-pandemic data to analyses , there were an average of 3.0 pre-pandemic assessments . During the COVID-19 pandemic, participants were invited to complete three web-based surveys in June 2020 , December 2020 , and June 2021 . Of the 348 participants included in analyses, 237 completed the June 2020 survey, 213 completed the December 2020 survey, and 195 completed the June 2021 survey. Completers of the prepandemic and during-pandemic assessments were sociodemographically similar . Among the youth contributing during pandemic data to analyses , there were an average of 2.2 during-pandemic observations. Altogether, 60 youth contributed only pre-pandemic data, 67 youth contributed only during pandemic data, and 221 youth contributed both pre- and during pandemic data. Analyses were conducted in R v4.1.2 . We estimated the impact of the COVID-19 pandemic by comparing observations of same-age youth assessed at four different time points: prepandemic , June 2020, December 2020, and June 2021. Conceptually, we used the prepandemic data to construct a reference curve for the expected drinking or nicotine use as a function of age, then compared that reference curve to the observed drinking and nicotine use as a function of age at each survey wave during the pandemic. In this way, we sought to distinguish the effects of the pandemic from age-related changes in drinking or nicotine use that would have occurred even outside the pandemic context. We restricted the sample to participants ≤ age 15.8 years at study entry to reduce potential cohort effects on drinking and nicotine use introduced by study entry criteria or by secular changes in drinking or nicotine use among U.S. young adults between 2016 and 2021 . If cohort effects were present, they would be confounded with the effect of the COVID-19 pandemic .

Preliminary analyses showed date of birth was not predictive of drinking or nicotine use in the restricted sample after controlling for age,vertical farming equipment suppliers suggesting any remaining cohort effects were minimal . In addition, we restricted observations to those of participants ages 18.8–22.4 years old at each time point, to ensure we had observations covering the same age span at each of the four assessment time points and avoid extrapolation beyond the common region of support . Outcomes included the proportion of young adults drinking or using nicotine, the number of days drinking or using nicotine among those reporting any use, and the typical number of drinks per drinking day . Regressions were fit in the geepack package , clustering observations on participant, specifying an exchangeable correlation structure, and using robust standard errors. For dichotomous dependent variables, a logistic link function was used. Model specification included fixed effects for sex, race, ethnicity, study site, age at observation, age-at-observation-squared, and time point of assessment. Participant sex, race, ethnicity, and study site were included as covariates given previous work has established they predict alcohol and nicotine use . Age at observation was included to implement our age-based identification strategy ; both linear and quadratic effects were included to account for nonlinear developmental changes in alcohol and nicotine use across this age range . Time point of assessment was a four-level categorical variable , represented by dummy variables with prepandemic as the reference level. Follow-up models investigated whether the effect of the COVID-19 pandemic varied as a function the impact of the pandemic on participants’ financial security. We expanded the primary model described above by adding the main effect of financial impact and terms capturing the interaction of financial impact with time point. We then tested the statistical significance of the interaction via a Wald test .

Regression models compared drinking and nicotine use at the three during-pandemic time points to drinking and nicotine use pre-pandemic. Fig. 1, Panel A graphs the model-estimated means for a 20-year-old participant across time points, which are interpreted next. Compared to pre-pandemic , significantly fewer participants reported any past-month drinking in June 2020 and December 2020 , with the difference no longer being statistically significant in June 2021 . Compared to pre-pandemic, those reporting any past-month drinking drank on 1.83 more days in June 2020 , with the difference no longer being statistically significant in December 2020 or June 2021 . Compared to pre-pandemic, there were no significant differences at any of the three during-pandemic time points in the number of drinks on a typical drinking day or the binge drinking or nicotine use outcomes . Tables 2 and 3 reports the corresponding effect sizes. Compared to pre-pandemic, 4–5% fewer participants engaged in past month binge drinking in June 2020 and December 2020, though neither difference was statistically significant . We did not find evidence that the degree to which the pandemic impacted participants’ financial security moderated the pandemic’s impact on drinking outcomes . We found evidence that the degree to which the pandemic impacted participants’ financial security moderated the pandemic’s impact on the number of days using nicotine among past-month users but not the prevalence of past-month nicotine use . Fig. 1, Panel B graphs the interactions for the nicotine use outcomes. Among those reporting any past-month nicotine use, participants who experienced moderate-to-extreme financial impact increased the number of days using nicotine while those with no financial impact decreased the number of days using nicotine in June 2020 . We investigated changes in drinking and nicotine use from prepandemic baseline over the first 15 months of the COVID-19 pandemic in a sample of 348 emerging adults ages 18–22 years old. Compared to pre-pandemic, in June 2020, fewer young adults reported past-month drinking, but those who did were drinking on more days. Compared to pre-pandemic, in December 2020, fewer young adults reported past-month drinking, but those who did were no longer drinking on significantly more days. By follow-up in June 2021, on average, there were no significant differences from pre-pandemic patterns of alcohol and nicotine use.

Findings are consistent with previous short-term studies showing a pandemic related increase in the number of days drinking. In our data, this change reflected a different distribution of drinking across the population: compared to pre-pandemic, fewer young adults were drinking, but those who did drank more frequently. While two previous studies found decreases in binge drinking , we did not find a statistically significant change in the number of days of binge drinking at any time point in the current study. However, the non-significant reduction we observed in binge drinking in June and December 2020 was directionally consistent with these previous studies. In addition, the time frame of measurement may explain the discrepancy: those two previous studies focused on changes earlier during the pandemic, in March and April 2020, whereas another study focusing on changes in June and July 2020 also found no significant change in binge drinking. As in one previous study , we did not find an average effect of the pandemic on nicotine use. However, this appeared to obscure opposing changes among those who suffered vs. did not experience impacts on their financial security. Relative to pre-pandemic, in June 2020, those with past-month nicotine use had increased the number of days using if they experienced financial impact and had stable or decreased number of days using if they denied experiencing financial impact . Loss of job or reduction in work hours could increase smoking during periods of boredom at home or to cope with the attendant stress . This pattern is consistent with the larger literature documenting how the pandemic may exacerbate health disparities based on pre-existing socioeconomic advantage . However, moderation of multiple outcomes was tested, so the current findings should be regarded as preliminary and await replication. This study had limitations. First,grow lights shelves findings may not generalize beyond emerging adults ages 18–22 years old . Second, for nicotine use, we did not measure the quantity used each day, which could have changed. Third, we did not consider other substances such as cannabis. Fourth, the mode of assessment differed from the prepandemic to during-pandemic assessments, potentially introducing differences.Fifth, secular changes in the rates of alcohol or nicotine use among young adults between 2016 and 2021 could be confounding the effect of the pandemic, potentially introducing bias.Sixth, pre-pandemic responses on a free-response scale had to be mapped onto the discrete response options , potentially limiting precision. Seventh, we assessed the degree to which the pandemic impacted individuals’ financial security but not the form of this impact . Eighth, pre-pandemic observations were not anchored to the months of June and December, so seasonal effects could explain part of the observed differences. We reported here the most extended follow-up to date of pandemic related changes in drinking and nicotine use in emerging adults. The study had several further strengths. We used seven years of prepandemic assessments and a rigorous age-based design to identify the pandemic’s impact over and above typical developmental changes. We incorporated three assessments spanning the first 15 months of the pandemic to study whether early changes in drinking and nicotine use persisted. Participants spanned five sites across the U.S and multiple racial and ethnic backgrounds. Finally, we focused on a critical developmental period associated with elevated risk for problematic use . In summary, in a heterogeneous group of young adults, pandemic related changes in drinking patterns were no longer detectable in June 2021. Pandemic-related increases in nicotine use occurred only for participants who reported greater impact of the pandemic on their financial security—these subgroup effects were no longer statistically significant in June 2021, though a large effect size for past-month nicotine use remained. Thus, those whose financial security has been adversely impacted by the pandemic may reflect a vulnerable group worth targeting for supports to manage drinking and nicotine use.

Continued follow-up beyond summer 2021 is necessary to verify that the pandemic’s effects on drinking and nicotine use have indeed faded and understand the pandemic’s long-run impacts of substance use trajectories into adulthood. Parkinson’s Disease treatment has been based on dopamine replacement therapy for 35 years. Yet, side effects resulting from long-term use of DA agonists, namely dyskinesias and on–off responses, are prompting investigations of alternative neurotransmitter manipulations to modulate basal ganglia function and normalize motor activity. Dyskinesias often result from lesion or disturbance affecting the transcortical loop or indirect pathway, with disruption of balance between excitation and inhibition in the globus pallidus pars externa-subthalamic nucleus-globus pallidus pars interna circuit. Thus, dyskinesias reflect altered patterns of neuronal firing in this circuit, which result in the improper selection of specific motor programs and, eventually, in the development of hyperkinetic movements . Endocannabinoids, the endogenous ligands of cannabinoid receptors, are synthesized upon demand by neurons in response to depolarization , and, once released, diffuse backwards across synapses to suppress pre-synaptic GABA or glutamate release . Because of these properties, the endocannabinoid system may offer new pharmacological targets for the treatment of neurologic conditions characterized by abnormal firing patterns. One application of cannabinoidbased therapeutics would be for dyskinetic syndromes, hyperkinetic disorders characterized by changes in pattern, synchronization, mean discharge rates, and somatosensory responsiveness of neurons in the direct and indirect extrapyramidal motor circuits . Further applications of cannabinoid-based therapeutics may extend to treatment of seizure disorders, changes in behavioral or cognitive state resulting from hypersynchronous excessive neuronal discharges in other, for example, limbic, cortical or thalamic circuits. To test the hypothesis that endocannabinoids act as endogenous antidyskinetic agents with modulatory effects on abnormal basal ganglia circuits, we examined endocannabinoid production in specific areas of the basal ganglia of rats infected with Borna disease virus and how cannabinoid agonists and antagonists affect their motor behaviors. Borna disease virus is a negative strand RNA virus epidemiologically linked to patients with neuropsychiatric disorders and Parkinson’s-plus syndromes . After infection, BD rats develop an extrapyramidal disorder with spontaneous dyskinesias, hyperactivity, stereotypic behaviors, partial DA deafferentation, DA agonist hypersensitivity, and Huntington’s-type striatal neuropathology . Our investigations revealed elevations in the endocannabinoid anandamide in the subthalamic nucleus of BD rats, associated with increased metabolic activity in this key basal ganglia relay nucleus.

A higher score on our composite measure was associated with being female, being unemployed, having greater medication load and lower mania symptomatology. Similarly, studies in BD show that poor sleep is associated with worsening BD symptoms , among other correlates. Based upon LASSO regression, TST and NA most contributed to the correlation with medication load which may be reflective of the sedating properties of many psychotropic medications . PS contributed most to the correlations with employment, and mania symptoms, which may relate to sleep fragmentation and variability that has previously been shown to be associated with these variables . Because wrist actigraphy is easily administered and is less invasive compared to an inlab sleep evaluation and is easier to get longitudinal measures over the span of weeks, it is important for future research to identify other approaches that could reduce these voluminous data to actionable insights, especially for treating patients with BD where management of sleep is paramount. Clinicians could utilize a composite measure to identify patients with poor sleep overall and triage these patients to appropriate sleep treatment options based upon their individual sleep metrics. In the future, as such accelerometry data becomes available in many different populations, it may soon be possible to identify when poor sleep begins to emerge with the possibility of predicting a mood episode to offer just-in-time clinical interventions. More research is needed to develop tools using these data for future prediction of events for clinical monitoring. Our study has some limitations. First, our analysis was cross-sectional and retrospective. Research should explore ways that changes in sleep quality longitudinally may be incorporated in this composite measure. Second, we focused on the means of sleep parameters as our main purpose was to examine an intuitive composite score for poor sleep. Future studies may want to identify whether night-to-night variability in sleep or circadian patterns can improve a composite measure . Third, in the absence of published norms for actigraphic sleep measures for healthy individuals of comparable age to our BD sample, we used our own HC sample as the normative group.

To the extent that our HC sample was relatively small and participants were not selected on the basis of having no reported sleep abnormalities,grow trays 4×4 this may have introduced some bias into the composite scores. It may be important for future studies to compare this method to other approaches which do not use a normative sample . Fourth, our sample size was small and given the number of correlates assessed with the composite score, there is a possibility of significant findings due to chance alone. However, our study evaluates a potential way to combine actigraphic measurements, and future studies with larger samples may help examine this further. Finally, we did not have measures of sleep apnea which may contribute to disturbed sleep . However, sleep apnea is often undiagnosed , and in a clinical setting, clinicians may need to base their assessment of sleep on wrist actigraphy alone. In conclusion, we found that while a sleep composite measure based upon actigraphy measures was correlated with patient characteristics similar to that in other studies, it does not add more information beyond individual sleep metrics alone and future research might benefit from selecting individual sleep metrics based on theory rather than use a composite measure approach. While our approach may have limited utility in BD, it may be important for research to examine this in other clinical groups, including those with other serious mental illnesses. As sleep becomes more frequently measured by actigraphy, efforts to improve the use and applicability of these unique data will be important for understanding the dynamics of sleep in those with BD.With the introduction of combination antiretroviral therapy mortality among HIV-infected patients diminished significantly. However, some patient subgroups have different survival patterns, and have shown less decline in death rates.These include patients with psychiatric or substance use disorders, which are highly prevalent among patients treated for HIV/AIDS.There is also a high cooccurrence between psychiatric and substance use disorders among the HIV-infected,as in other populations; and severity is greater in each type of disorder when there is cooccurrence.Together they place individuals at elevated risk for poor health outcomes. Because psychiatric and substance use disorders frequently co-occur, it is important to examine the combined impact of these disorders among people with HIV infection. Research among HIV-infected patients has shown an association between depression symptoms, HIV disease progression and mortality; and mental illness and substance abuse are barriers to optimal adherence to combination antiretroviral regimens.

One study of U.S. veterans found that survival was associated with greater number of mental health visits.Yet few studies have examined survival patterns for HIV-infected individuals who use alcohol or illicit drugs, but are generally not injection drug users, and have been diagnosed with psychiatric or SU disorders from a private health plan; nor have studies examined both psychiatric and SU disorders in relation to mortality. Previous research has shown that access to psychiatric and SU disorder care among HIV-infected patients varies based on sociodemographic factors and HIV illness severity.The current study compares mortality in HIV-infected patients diagnosed with psychiatric disorders and/or SU disorders to patients without either diagnosis receiving medical care from a private, fully integrated health plan where access to care andability to pay for care are not significant factors. We also examine the effects of accessing psychiatric or SU treatment services. Improvement in depression has been associated with better adherence to combination antiretroviral therapy and increased CD4 cell counts.Therefore, we hypothesize that accessing services is associated with decreased mortality among patients with HIV infection.We conducted a retrospective observational cohort study for years 1996 to 2007 among HIV-infected patients who were members of the Kaiser Permanente Northern California health plan. The KPNC is an integrated health care system with a membership of 3.5 million individuals, representing 34% of the insured population in Northern California. The membership is representative of the northern California population with respect to race/ethnicity, gender, and socioeconomic status, except for some under representation of both extremes of the economic spectrum.HIV infected patients are seen at medical centers throughout the KPNC 17-county catchment region. The study population consisted of 11,132 HIV-infected patients who received health care at KPNC at some time between January 1, 1996 and December 31, 2006. The study sample included all HIV-infected patients who were 14 years of age or older on or after January 1, 1996 and had at least 6 months membership during the first year of study observation .

This minimum age was chosen because the KPNC membership has very few HIV patients under age 14, children are likely to receive different psychiatric diagnoses than adolescents and adults , diagnosis of SU problems generally occurs later than age 13, and children are likely to receive services for these disorders in pediatrics departments rather than in the health plan’s specialty psychiatry and SU treatment programs. Patients could enter the study until December 31, 2006. In the data analyses, we also excluded 83 patients whose SU disorder diagnosis status was unclear . This resulted in a study analysis sample of 9751 patients.Since 1988, the KPNC Division of Research has maintained a surveillance system of patients who are HIV-1– seropositive,horticulture products ascertained through monitoring electronic inpatient, outpatient, laboratory testing, and pharmacy dispensing databases for sentinel indicators of probable HIV infection. HIV-1 seropositivity is then confirmed through review of patient medical records. Ascertainment of HIV infected patients by this registry has been shown to be at least 95% complete. The HIV registry contains information on patient demographics , HIV transmission risk group , dates of known HIV infection, and AIDS diagnoses. KPNC also maintains complete and historical electronic databases on hospital admission/discharge/transfer data, prescription dispensing, outpatient visits, and laboratory tests results, including CD4 T-cell counts and HIV-1 RNA levels. Mortality information including date and cause of death are obtained from hospitalization records, membership files, California death certificates, and Social Security Administration databases. Mortality data were complete through December 31, 2007. Antiretroviral medication prescription data were obtained from KPNC pharmacy databases. Approximately 97% of members fill their prescriptions at KPNC pharmacies, including patients whose prescriptions are obtained through the Ryan White AIDS Drug Assistance Program. ARV medication data included date of first fill, dosage, and days supply, as well as data on all refills. Patients were classified as: currently receiving combination-ARV , current dual NNRTI/NRTI ARV use, past ARV use, or never users .Psychiatric diagnoses were assigned by providers. One or more diagnoses can be coded by ICD-9 in the KPNC administrative databases.Psychiatric diagnoses selected for this study were the most common and serious psychiatric disorders diagnosed among health plan members including schizophrenic disorders , major depressive disorder, bipolar affective disorder, neurotic disorders , hysteria, phobic disorders, obsessive-compulsive disorder, anorexia nervosa, and bulimia. We examined the impact of having one or more of these psychiatric disorders in aggregate, as in prior HIV studies.31 Within the health plan, psychiatry can be accessed directly by patients. Mild cases of depression and anxiety may be addressed in primary care with medication but moderate to severe cases are referred to psychiatry. Treatment in psychiatry includes assessment, psychotherapy and medication management. Patients diagnosed with a psychiatric disorder generally return to psychiatry for individual and/or group psychotherapy and/or medication evaluations. Our measure of psychiatric treatment was whether or not a patient had visits to a psychiatric clinic after a psychiatric diagnosis,obtained from automated databases.A diagnosis of ICD-9 substance dependence or abuse can be made by the patient’s clinician in primary care, SU disorder treatment, or psychiatry as a primary or secondary diagnosis.Diagnostic categories include all alcoholic psychoses, drug psychoses, alcohol dependence syndrome, drug dependence , alcohol abuse, cannabis abuse, hallucinogen abuse, barbiturate abuse, sedative/tranquilizer abuse, opioid abuse, cocaine abuse, and amphetamine abuse; as well as multiple substance abuse and unspecified substance abuse. In our analyses we classified patients as having one or more diagnoses of substance abuse and/or dependence versus no diagnosis.KPNC provides comprehensive outpatient SU treatment available to all members of the health plan. Services include both day hospital and traditional outpatient programs,both of which include eight weeks of individual and group therapy, education, relapse prevention, family therapy, with aftercare visits once a week for ten months. In addition to these primary services, ambulatory detoxification and residential services are available, as needed. A small proportion of patients engage in residential SU treatment, conducted by contractual agreement with outside institutions. These data are available in the KPNC referrals and claims databases. As with psychiatric treatment, in the current study SU treatment initiation was measured as having one or more visits to an outpatient program or a stay in a residential SU treatment unit following diagnosis.Analyses focused on diagnoses of psychiatric disorders with and without co-occurring SU diagnoses as the primary predictors of interest. The distribution of demographic, clinical and behavioral characteristics was compared between patients with and without a major psychiatric diagnosis; statistical significance was assessed using the w2 test. The distribution of cause of death was examined by psychiatric diagnostic status ; statistical significance was assessed using the w2 test or Fisher’s exact test where table cells were sparsely populated. Cox proportional hazards regression was used to obtain point and interval estimates of mortality relative hazards associated with psychiatric diagnosis/treatment status and SU problems diagnosis/treatment status, with each of these two time dependent covariates measured at three levels: no diagnosis, diagnosis with treatment, diagnosis without treatment. With the goal of examining the joint effects of these two covariates on mortality, results are expressed as hazard ratios for combinations of psychiatric diagnosis/treatment and SU diagnosis/treatment levels, with no diagnosis of either comorbidity as the referent. These estimates were adjusted for an a priori chosen set of available covariates, including age at entry into study, race/ethnicity, gender, HIV transmission risk group, CD4 T-cell counts and HIV RNA levels and ARV treatment modeled as time-dependent covariates, year of known HIV infection, AIDS diagnosis prior to entry into study, and evidence of hepatitis C viral infection. Initial modeling results demonstrated a significant interaction between psychiatric and SU diagnosis/treatment status in Cox regression models . Therefore, relative hazard estimates of interest were obtained via appropriate linear combinations of parameter estimates from a fully saturated model .

Anatomical studies of endocannabinoid transport are greatly limited by the lack of transporter-specific markers. Nevertheless, biochemical experiments have documented the existence of [3 H]anandamide uptake in primary cultures of rat cortical neurons and astrocytes , rat cerebellar granule cells , human neuroblastoma cells , and human astrocytoma cells . The CNS distribution of endocannabinoid transport was investigated by exposing metabolically active rat brain slices to [14C]anandamide and analyzing the distribution of radioactivity in the tissue by autoradiography . A receptor antagonist was included in the incubations to prevent the binding of [14C]anandamide to CB1 receptors, which are very numerous in certain brain regions , and AM404 was used to differentiate transportmediated [14C]anandamide reuptake from nonspecific binding . Substantial levels of AM404-sensitive [14C]anandamide reuptake were observed in the somatosensory, motor, and limbic areas of the cortex and in the striatum. Additional brain regions showing detectable [14C]anandamide accumulation included the hippocampus, thalamus, septum, substantia nigra, amygdala, and hypothalamus . Thus, endocannabinoid transport may be present in discrete regions of the rat brain that also express CB1 receptors . Distribution of Endocannabinoid Transport Outside the CNS. The endocannabinoid system is not confined to the brain, and it is reasonable to anticipate that mechanisms of endocannabinoid inactivation may also exist in peripheral tissues. In keeping with this expectation,industrial rolling racks carrier-mediated [ 3 H]anandamide transport was demonstrated in J774 macrophages , RBL-2H3 cells , and human endothelial cells .

Although the kinetic and pharmacological properties of endocannabinoid uptake in peripheral cells appear to be generally similar to those reported in the CNS, some important difference have been observed. For example, in contrast to neurons, [3 H]anandamide uptake in RBL-2H3 cells is inhibited by arachidonic acid . Such disparities might reflect the existence in non-neural tissues of mechanisms of endocannabinoid internalization that are distinct from those found in the CNS. Inhibition of Endocannabinoid Transport: Molecular Tools. A variety of compounds have been tested for their ability to interfere with [3 H]anandamide internalization . Amongthem, the anandamide analog AM404 stands out for its relatively high potency and its ability to block endocannabinoid transport both in vitro and in vivo. AM404 inhibits [ 3 H]anandamide uptake in rat brain neurons and astrocytes , human astrocytoma cells , rat brain slices , and RBL-2H3 cells . AM404 does not directly activate cannabinoid receptors in vitro , but it augments several CB1 receptor-mediated effects of anandamide. For example, AM404 enhances anandamideevoked inhibition of adenylyl cyclase activity in cortical neurons, an effect that is reversed by the CB1 antagonist SR141716A . Likewise, AM404 potentiates the inhibitory actions of anandamide on GABA-ergic neurotransmission in the periaqueductal gray matter . These findings are consistent with the hypothesis that AM404 protects anandamide from inactivation and, by doing so, magnifies the biological effects of this short-lived lipid mediator. It is important to point out, however, that AM404 is readily transported inside cells , where it can reach concentrations that may be sufficient to inhibit anandamide hydrolysis . To what extent this effect contributes to the ability of AM404 to prolong anandamide’s life span is at present unclear. An initial screening found that AM404 has no affinity for a panel of 36 different pharmacological targets, including G protein-coupled receptors and ligand-gated ion channels .

However, additional studies revealed that AM404 activates capsaicin receptor channels at concentrations similar to those necessary to inhibit endocannabinoid transport . The fact that AM404 can produce undesired effects underscores the need to introduce appropriate controls in the design of in vivo experiments with this compound. In particular, the effects of a cannabinoid receptor antagonist should be routinely tested to verify that endogenously produced anandamide and 2-AG are involved in the response to AM404 . Inhibition of Endocannabinoid Transport: Functional Studies. AM404 does not display a typical cannabimimetic profile when administered in vivo; this is consistent with its poor affinity for cannabinoid receptors. For example, AM404 has no antinociceptive effect in mice or rats and causes no hypotension in guinea pigs . Nevertheless, in the same models, AM404 increases the responses elicited by exogenous anandamide, and this potentiation is reversed by the CB1 antagonist SR141716A . Despite the absence of overt cannabimimetic properties, AM404 resembles anandamide and other cannabinoid receptor agonists in certain respects. For example, when administered alone, AM404 causes a reduction in motor activity, which is prevented by the CB1 antagonist SR141716A . Furthermore, AM404 reduces the yawning evoked by low doses of the mixed D1/D2 dopamine agonist apomorphine and inhibits the hyperactivity elicited by the selective D2 agonist quinpirole . AM404 also decreases the levels of circulating prolactin, but the role of CB1 receptors in this response is unknown . Can the effects of AM404 be explained by its in vitro affinity for vanilloid receptors ? The fact that SR141716A, a selective CB1 antagonist, blocks the motor inhibitory effects produced by AM404 argues against this possibility. Furthermore, vanilloid agonists such as capsaicin have very different, in some cases even opposite, effects. For example, capsaicin causes hyperkinesia and pain , whereas AM404 elicits hypokinesia and enhances anandamide’s analgesic properties .

Therefore, a more plausible interpretation of the available data is that, by inhibiting anandamide clearance, AM404 may cause this lipid to accumulate outside cells and activate local cannabinoid receptors. In further support of this possibility, the systemic administration of AM404 in rats was found to cause a time-dependent increase in circulating anandamide levels . Finally, it is important to point out that several anandamide responses are not affected by AM404. One example is the inhibition of intestinal motility, which anandamide may produce in rodents by activating CB1 receptors on the surface of enteric neurons . This effect is not enhanced by AM404, suggesting that the predominant pathway of endocannabinoid inactivation in the intestine may be through enzymatic hydrolysis, not transport . The fact that rat intestinal tissue contains high AAH levels is in agreement with this possibility . Alternatively, anandamide transport may occur in the intestine through transport mechanisms that are insensitive to AM404.Mechanisms and Kinetics. Long before the discovery of anandamide, Schmid and coworkers identified in rat liver an amidohydrolase activity, which catalyzes the hydrolysis of fatty acid ethanolamides to free fatty acid and ethanolamine . That anandamide may serve as a substrate for this activity was first suggested on the basis of biochemical evidence and then demonstrated by molecular cloning and heterologous expression of the enzyme involved . AAH is an intracellular membrane-bound protein whose primary structure displays significant similarities with a group of enzymes known as “amidase signature family” . AAH may act as a general hydrolytic enzyme not only for fatty acid ethanolamides but also primary amides  and even esters . Site-directed mutagenesis experiments indicate that this unusually wide substrate preference may be underpinned by a novel catalytic mechanism involving the amino acid residue lysine 142. This residue may act as a general acid catalyst, favoring the protonation and consequent detachment of reaction products from the enzyme’s active site . Three serine residues that are conserved in all amidase signature enzymes may also be essential for enzymatic activity: serine 241 may serve as the enzyme’s catalytic nucleophile, while serine 217 and 218 may modulate catalysis through an as-yet-unidentified mechanism . Like other hydrolase enzymes, AAH may act in reverse, catalyzing the synthesis of anandamide from free arachidonate and ethanolamine . The high KM values reported for anandamide synthase activity suggest, however, that under normal circumstances AAH acts predominantly as a hydrolase. One exception is represented by the rat uterus, where substrate concentrations in the micromolar range are required for the synthase reaction to occur, implying that in this tissue AAH could contribute to anandamide biosynthesis . In addition to AAH, other ill-characterized enzyme activities may participate in the breakdown of anandamide and 2-AG. A fatty acid ethanolamide-hydrolyzing activity catalytically distinct from AAH was described in rat brain membranes and human megakaryoblastic cells . Furthermore, evidence indicates that 2-AG degradation may be predominantly catalyzed by an enzyme different from AAH,marijuana drying rack possibly a monoacylglycerol lipase . Structure-Activity Relationship Studies. Modifications in three potential pharmacophores have helped define several general requisites for endocannabinoid hydrolysis by AAH. First, reducing the number of double bonds in the hydrophobic carbon chain causes a gradual increase in metabolic stability .

Thus, [3 H]anandamide hydrolysis is inhibited by fatty acid ethanolamides in the 20 carbon atom series with the following rank order of potency: 20:4  20:3 20:2 20:1 20:0  no effect . Second, replacing the ethanolamine moiety with a primary amide leads to good AAH substrates. For example, the rate of hydrolysis of arachidonylamide is approximately twice that of anandamide . Third, anandamide congeners containing a tertiary nitrogen in the ethanolamine moiety are poor AAH substrates . Fourth, introduction of a methyl group at the C2, C1, or C2 positions of anandamide yields analogs that are resistant to hydrolysis, likely as a result of increased steric hindrance around the carbonyl group . Fifth, substrate recognition at the AAH active site is stereoselective, at least with fatty acid ethanolamide congeners containing a methyl group in the C1_x0007_or C2 positions . Finally, as a result of AAH’s remarkable “directed nonspecificity” , fatty acid esters also serve as substrates for this enzyme. Thus, 2-AG is hydrolyzed by AAH at a rate that is about 4 times faster than anandamide is . AAH Distribution in the CNS. AAH is widely distributed in the brain, with particularly high levels in cortex, hippocampus, cerebellum, amygdala, thalamus, and pontine nuclei . Immunohistochemical studies suggest that neurons, not glia, are the predominant cell type expressing AAH , although astrocytes in primary culture have been shown to contain AHH activity . CB1 cannabinoid receptors are present in various brain regions that also express AAH, but there appears to be no direct correlation between the concentrations of these two proteins . This discrepancy may reflect the participation of AAH in the degradation of non-cannabinoid lipid amides, such as oleamide and OEA. AAH Distribution outside the CNS. AAH mRNA and enzyme activity have been measured in a variety of nonneural cells lines, including lung carcinoma , human breast carcinoma , leukemia basophils , human monocytic leukemia , rat renal endothelial and mesangial cells , rat macrophages , human platelets , and human lymphocytes . Furthermore, high AAH levels have been found in rat liver, testis, kidney, lung, spleen, uterus, small intestine, and stomach; whereas lower levels were observed in heart and skeletal muscle . The distribution of AAH in human tissues is somewhat different from the rat, with expression levels that are reportedly higher in pancreas, brain, kidney, and skeletal muscle than in liver . Inhibition of AAH Activity: Molecular Tools. The armamentarium of AAH inhibitors available to the experimentalist has been recently enriched by two important groups of molecules. The first are fatty acid sulfonyl fluorides, such as the compound AM374 . AM374 irreversibly inhibits AAH activity with an IC50 value in the low nanomolar range and displays a 50-fold preference for AAH inhibition versus CB1 cannabinoid receptor binding . In superfused hippocampal slices, AM374 augments anandamide’s ability to inhibit [3 H]acetylcholine release, although it does not affect release when it is applied alone . The second group of AAH inhibitors is represented by a series of substituted  -keto-oxazolopyridines , which are reversible and extremely potent . Little information is as yet available on the pharmacological selectivity and in vivo properties of these interesting compounds. AAH Inhibition: Functional Studies. Systemic administration of the potent AAH inhibitor AM374 does not produce clear cannabimimetic effects in rats but enhances the operant leverpressing response evoked by anandamide administration . These results suggest that AM374 protects exogenous anandamide from degradation but does not cause a significant accumulation of endogenously generated anandamide. This idea is consistent with the finding that, in contrast to the transport inhibitor AM404 , AM374 does not increase circulating anandamide levels in rats . Further studies will be required to fully evaluate the behavioral impact of AAH inhibitors and to assess the biological availability and pharmacokinetics of these molecules.In Search of a Role. What place will inhibitors of endocannabinoid clearance occupy in medicine, if any, will largely depend on the answers to two key questions.

A quiz competition with questions on various aspects of mental illness also took place between four Junior High Schools in Tamale and was broadcast on the radio. In addition, BasicNeeds Ghana conducted research on mental health financing, lobbied Ghana’s Parliament to promote a speedy passage of the Mental Health Bill, and helped build a multipurpose psychiatric facility in the Upper West regional capital, Wa, with the help of Ghana Health Services and three other charities. The past ten years have seen the most significant increase in awareness of mental illnesses, which MindFreedom attributes to the birth of mental health NGOs. The first street march MindFreedom organized in 2006 presented neatly dressed, seemingly normal mentally ill patients and survivors, which subsequently shocked citizens and helped bring media attention to the plight of the mentally ill. When the executives were younger, mental illness was not talked about and one of the executives mentioned that he fearfully walked on the other side of the street when passing by the psychiatric hospital to avoid the mad people and the evils associated with them. Anyone seen walking into the psychiatric hospital also became the talk of the town in a negative way. MindFreedom dreams that Ghana will have mental health care as reliable as in the West in regards to human rights, access to treatment, and access to medication. They want everyone to know that anybody can be stricken by a mental illness, and they kept mentioning a proverb: “You shouldn’t wash your dirty linens outdoors, but if you keep them inside,clone rack the room will stink. By this they meant that families should not keep their disabled ones hidden in a room but should bring them out and not be ashamed of them.

Like in most developing countries, access to mental health in Ghana, where schizophrenia, depression, alcohol and cannabis abuse, and epilepsy are the most common diagnoses, remains low because of the limited number of treatment centres and the high mental patient to mental doctor ratio. Due to the discriminatory stigma, the low fatality of mental illness, and the alleged significance or discrepancy of physical health over mental health, the government in Ghana holds mental illness as a very low priority even though it is a leading component of the global burden of disease. The lack of priority lead to insufficient funding and outdated mental health policies which in turn caused a severe lack of mental health personnel and incentives to gain personnel, low employee morale, shortages of psychotropic medicine, human rights violations, congestion of institutionalized hospitals, poor condition of decaying facilities and inadequate equipment, lack of community care, lack of preventative and rehabilitative services, absence of research-based evidence, and the lack of an aggressive education and awareness campaign. All of these challenges need to be addressed in order to decrease the number of relapses and increase prevention and the rate of recover but unfortunately mental health professionals are often too busy to lobby for the implementation of change. Most importantly the psychiatric hospitals need to be decongested, the mental health staff strength needs to increase, community care and rehabilitation needs to be emphasized, and the Mental Health Bill needs to be passed. Despite Ghana’s challenges, much progress has been displayed through MindFreedom and BasicNeeds’ community and awareness work, Dr. Dzadey’s implementation of therapy and creation of the Drug Rehabilitation Unit, and Dr. Osei’s repatriation of the Accra Psychiatric Hospital. Though MindFreedom commended the repatriation of patients, BasicNeeds is arguing that there should have been a half-way home or reintegration centre set up to prepare the patients, who might have spent 20 or more years at the hospital, to live an independent life before being returned home. That would have been ideal; however, it is unrealistic because it would have taken a long time to create the rehabilitation centre and the hospital needed to be decongested as quickly as possible. The Castle Road Special School, built in 1968 and directed by Isaac Ben Roosevelt Gadoter, is the only special needs school in Ghana that is located in a Psychiatric Hospital.

The school provides hands-on therapy, art, reading, music, outdoor activities for the mentally ill or disabled in the Children’s Ward at the Accra Psychiatric Hospital. The teachers there represented one of the very few instances when I saw true compassion for the mentally ill/disabled during my time in Ghana and one of the even rarer instances when I heard that someone loved their occupation at the psychiatric hospital. After volunteering at another special needs school for children with autism, learning delays, hearing and speech problems, SENCDRAC, I luckily witnessed even more sympathy and care for the unique children in Ghana. There are 14 other registered special needs schools in Ghana, and they are at the forefront of displaying empathy for the mentally ill and disabled in the country. Hopefully, this sympathy will spread to mainstream schools and then to the entire public. The infrastructure of mental health services is reliant on satisfactory funding and allotting sufficient finances to allow for the delivery of notable mental health services, the effectual training of staff, and the development of collaborations and consultations which will make mental health service much more accessible. Though the health sector in general is underfunded, it is imperative that the Ministry of Health allocates funding to community mental health care and that the financing of the psychiatric hospitals becomes based on need, rather than unjustified ceilings, due to the vulnerable nature of the mentally ill. The Mental Health Bill will guarantee that at least eight percent of the total health budget will be apportioned to mental healthcare. The government is responsible for addressing the needs of its citizens by formulating suitable legislations and the Mental Health Bill offers the government a chance to enhance the delivery and accessibility of mental health services. The World Health Organization is calling the bill one of the best mental health laws in the developing world and believes that when it is passed it can serve as a model for other countries. The bill needs to be passed in order to avoid the collapse of a currently unstable mental health care system. The Mental Health Bill, Dr. Osei, MindFreedom, and BasicNeeds all promote the extension of psychiatric services into community district and regional hospitals.

This integration will also help improve access to mental health services in remote areas where patients presently travel a great number of miles for psychiatric treatment. Currently, care is mainly restricted to the institutional administration of psychotropic drugs instead of preventative or rehabilitative psychosocial interventions, due to the dearth of allied mental health personnel and the limited number of community psychiatric nurses. An accelerated, specialist training program should be locally established in order to increase the number of allied mental health personnel. The problematic brain drain of staff could be alleviated by providing satisfactory remuneration and incentives to encourage trained personnel to stay in Ghana or to return home from overseas. If a mental illness goes untreated, there are three possible consequences for the victim. The first is living with the sickness and underachieving or having low productivity because the person is not performing properly or to their highest potential. Secondly, the untreated person could engage in social vices such as drugs, armed robbery, and paedophilia. The third possibility is to die from complications of the illness, i.e. committing suicide due to depression, engaging in risky activities due to bi-polar disorder, not eating because of schizophrenia, or dying from a tumour that initially caused the illness. Each day that the bill remains before Parliament, Ghana is officially allowing the rights of the vulnerable to be abused by placing patients in overly congested institutions with little doctor-patient contact. A society of acceptance makes a much more favourable environment for recovery from mental illnesses, with stigma representing a large barrier to recovery [8]. Even in developed countries,4×8 tray grow people who are misinformed about mental illnesses can respond negatively to a friend or relative’s mental illness. Mental illness is not caused by poor decisions or by offending the gods, but can affect anyone no matter what ethnicity, background, age, or gender. The mentally ill can benefit from psychotherapy, group therapy, medication, self therapy, rehabilitation, and the acceptance and understanding from friends and family. Programs that encourage understanding and awareness of mental health issues and demystify mental illness should be forcefully undertaken for communities to further tolerate and acknowledge the mentally ill. Overcoming these widely prevalent traditional myths on mental illness will help lead more patients to seek professional treatment early on. Public health officers and the health promotion unit should integrate mental health into their awareness and advocacy programs. Mental health needs to be recognized and integrated into both primary and secondary care, social and health policy, and health system organization. The delivery of mental health care can also be improved by concentrating on currently active programs dealing with the prevention and treatment of tuberculosis, malaria, HIV, domestic violence, and maternal care.

This should spark the interest of the government because advancing the mental health system could help the country reach the Millennium Development Goals which address HIV/AIDs, malaria, tuberculosis, child mortality, maternal health, and the empowerment of women. It has been consistently reported that HIV is associated with poor mental health due to psychological trauma and the causing of neuropsychiatric complications such as depression, cognitive disorder, mania, and dementia due to effects on the central nervous system. Strong evidence from developed countries also shows that depression, alcohol and substance abuse disorders, and cognitive impairment negatively affect adherence to antiretrovirals. In the US, those treated for depression for six months showed improvement in HAART adherence compared to those who did not take antidepressants. Some studies have also shown that the incidence of tuberculosis infection is high in people with serious mental illnesses or substance use disorders. Heavy drinkers had double the risk of being infected with tuberculosis compared to non-drinkers, according to a study in the US. Though there is little evidence, depression might also cause low adherence to anti-tuberculosis medication, which makes it very difficult for a country to control the disease. With gynaecological health being greatly affected by depression, anxiety, sexual and domestic abuse, and substance and alcohol use, many studies have also linked reproductive morbidity with mental illnesses. Depression is more common among women, especially poor women, due to domestic violence and lack of autonomy. Maternal psychosis increases the risk of infant mortality while maternal schizophrenia can result in low birth weight or premature delivery. Postpartum depression also leads to poor mother-infant interaction and little devotion to the health of the child. Mental disorders increase the risk for transmission of infectious disease and the development of non-communicable diseases and communicable diseases, while other sicknesses increase the risk for mental illnesses. Because of this co-morbidity, mental health policies should be integrated into different levels of care, with primary care physicians trained in treating mental disorders. Current community and public health programs or campaigns should become familiar with mental disorders in order to help improve both the physical and mental health of their targeted patients, which will lead to lead to quicker recoveries. If general physicians and prominent health-related NGOs start to increase awareness and encourage or participate in the treatment of mental disorders, a great deal of pressure will be taken off of the limited mental health staff in Ghana.It is estimated that there were 35 million people worldwide living with HIV/AIDS by the end of 2013, of whom 16 million were women and 19 million were men. Among men, people who inject drugs and men who have sex with men were recognized as high-risk groups in many countries. MSM bear a disproportionately higher burden of HIV infection than the general population. In Asia, MSM are as much as 18.7 times more likely to be infected with HIV than the general adult population. Adult men who report having sex with men account for 3–5 % of male cases in East Asia, 6–12 % in South and Southeast Asia, 6–15 % in Eastern Europe, and 6–20 % in Latin America. By the end of 2012, there were approximately 209,000 people living with HIV in Vietnam.

The official language is English but there are about 100 linguistic and cultural groups in Ghana, and English only accounts for 36.1% of the population’s primary language. The 2010 GDP, purchasing power parity, was $38.24 billion dollars, with one-third produced agriculturally. Gold, cocoa, and timber are the country’s main exports and recent oil production is expected to heighten economic growth. Twenty-eight and one half percent of Ghanaians live below the poverty line and 11% are unemployed . Ghana’s health expenditure is roughly 4.5% of the Gross National Product, compared to 15.2% in the US . Ghana is divided 10 regions and 170districts. Due to the proximity to the University of Ghana, Legon Campus, interviews were conducted in the metropolitan capital city, Accra , and in the surrounding Greater Accra Region, which lies on the south-east coast. In order to gain first-hand information and opinions on the current mental health situation in Ghana, 1.5-3 hour interviews were conducted with prodigious psychiatrists and a mental health NGO during spring of 2011. The first two interviews were with Dr. Akwasi Osei, the acting Chief Psychiatrist of the Ghana Health Service and Administrative Head of the Accra Psychiatric Hospital, the oldest and main psychiatric hospital in Ghana. In addition to holding these positions for the past six years, Dr. Osei is also a senior lecturer, researcher, and spokesperson for Ghana’s mental health care. The first interview dealt with matters based on Ghana’s mental health system and the stigma of mental illness, while the second interview addressed the logistics and condition of the Accra Psychiatric Hospital. Dr. Anna Dzadey, a psychiatrist from Poland, was the second interviewee. She has been the Medical Director and Psychiatric Specialist in charge of the Pantang Mental Hospital since 2005. Dr. Dzadey provided ample amounts of information on the Pantang Hospital, one of the three psychiatric hospitals in Ghana.

One of the most prominent mental health NGOs in Ghana, MindFreedom, was also interviewed to learn how they are helping to improve the care available to the mentally ill, and to see if they are noticing signs of advancement. The interview with MindFreedom involved Janet Amegatcher, Nii Lartey Adico, and Dan Taylor,plant growing trays the executives and founders of the NGO.In all of Ghana, there are only three public psychiatric hospitals and four private psychiatric hospitals. The three public hospitals, Accra Psychiatric Hospital, Pantang Hospital, and Ankaful Psychiatric Hospital, are all located in the South, with two in the Greater Accra Region and one about three hours away in Cape Coast in Ghana’s central region. Treatment for mental health care in government hospitals is free and is funded by the Ghana Health Service, which allocates a mere, debatable 0.5–3.4% of the health budget to the mental health sector. There are also four private psychiatric hospitals, two in Kumasi, one in Accra, and one in Tema . Although Kumasi is not along the coast, it is still in the southern half of Ghana. The private hospitals are criticized for being too expensive, and it is said that their patients usually end up at a public hospital once their resources are drained. It is uncertain whether the quality of care at a private psychiatric hospital is superior to that of a public hospital, but there are most likely better accommodation, less congestion, and more doctor-patient contact time. The Accra Psychiatric Hospital offers in-patient and outpatient services, limited counselling and therapy, and clinical training for doctors, psychologists, and psychiatric nurses. Technically, all services are free to the Ghanaian public, but some small fees are charged in order to help keep the hospital running. New patients are obliged to pay four Ghana cedis for a hospital records folder, ID card, and some forms. Patients are also asked to pay about 80 pese was for their medication, which can cost up to 400 Ghana cedis. In turn, this helps the patient to value the medicine on top of providing money for the hospital.

Typically two psychiatric nurses and two aids work in each ward on a daily basis, taking care of an unbelievable amount of patients by dispensing medication, noting observations, feeding, washing, and offering group therapy if there is any time or motivation left. The nurses write down the progress of each patient almost every day, but when asked how often the doctors review these notes, the nurses laughed and encouraged me to ask the medical director of the Accra Psychiatric Hospital. Although doctors should be checking in on their inpatients every day, in actuality, it happens about every two weeks due to the overload of outpatients and inpatients. A nurse will usually only report to a doctor if the condition of the patient has become very poor or if they believe the patient is well enough to be discharged. The Pantang Hospital, the largest of the three psychiatric hospitals, was commissioned in the rural Pantang Village in the Greater Accra Region in 1975 in order to reduce the congestion at the Accra Psychiatric Hospital. It was planned to be a regional psychiatric hospital with a 500 bed capacity, but in addition to the original psychiatric services, the hospital now offers primary health care, reproductive and child health services, and, under the National Health Insurance Scheme, HIV counselling, screening, and ART service. The psychiatric services are free by description, but similar to the Accra Psychiatric Hospital, Pantang asks patients to pay a small fee for their folders and medication if they can afford it. Nurses, nursing students, Health Assistant Training School students, and Community Health Mental Officers also gain clinical psychiatric experience at the Pantang Hospital. Community mental health care exists in Ghana, however, it is not well developed. A Community Psychiatry Nursing Programme began in 1975, and there are currently 120 Community Psychiatric Nurses working in all ten regions, but some regions may have just one or two CPNs. The nurses are not distributed evenly throughout the country, and only 70 districts out 170 are covered by at least one CPN. To become a CPN, a psychiatric nurse only has to train for three to six weeks after their completion of the mental nursing program but soon there will be an official degree program that spans over one or two years. Dr. Osei believes that there should be at least 2,000 CPNs working in the country in order to provide adequate community based psychiatric care.

CPNs are responsible for identifying and managing cases, referring cases to the next level of care, counselling, providing after-care services , and creating awareness and promoting mental health in the community. In addition to institutional care and community mental health, another key component of treatment is traditional healing. Due to the nation-wide presence of unorthodox healthcare and the Ghanaian belief that mental illness is caused by spiritual forces, traditional and spiritual healers tend to the largest sum of mentally ill sufferers in the country. Even urban people who live near the three psychiatric hospitals frequently visit spiritualists. Dr. Osei believes that traditional or faith healing, which uses herbal preparations and/or spiritual incantations/invocations, could be valuable if the administrators recognized their limits. Minor disorders like anxiety, minor depression, neurosis, phobias, or OCD, which might not require medication for treatment, can sometimes benefit from the therapy provided by healers. A healer is typically well trusted and has considerable influence over one’s emotions, so a patient might subsequently change their way of thinking after treatment, or receive reassurance that whatever provoked the problem has been removed in a spiritual manner. However, except for the occasional use of anti-psychotic herbs prescribed by herbalists,rolling grow tables traditional healers generally cannot help a person suffering from a severe mental disorder. It is well reported that abuse of the mentally ill occurs at prayer camps. In a documentary released by Mind Freedom Ghana, the mentally ill are chained to trees, exposed to the sun and rain, deprived of food and/or water, and even chained or flogged in an attempt to exorcise the supposed demons. The violations of a mentally ill person’s human rights have yet to be curbed because there are no laws governing mental health care outside of the psychiatric hospitals. Nonetheless, seeing a faith healer is seemingly less stigmatizing than visiting a psychiatric hospital. A mentally ill person is usually shown some sympathy from the community if they attend therapy from a traditional healer while no empathy is given to one who visits a mental hospital. The executives of Mind Freedom encourage a balance between faith healing and physical treatment when necessary, agreeing that seeing a traditional or faith healer brings fewer stigmas and is more convenient transport wise. Because of this, the normal pattern for Ghanaians involves utilizing traditional care first and then going to a psychiatric hospital if the problem was not cured. Twenty to thirty percent of the Accra Psychiatric Hospital’s patients try spiritual or traditional healing before a family member or the court brings them to the psychiatric hospital. About 20% of patients use faith healing after leaving the hospital for spiritual reinforcement. Patients at the Accra Psychiatric Hospital and Pantang Hospital travel from all over the country and surrounding countries such as Togo, Cˆote d’Ivoire, Benin, Burkina Faso, and Nigeria. On an ordinary day at the Accra Psychiatric Hospital, around 100 to 400 outpatients are seen, ten patients are admitted, and nine patients are discharged from the hospital wards. Dr. Osei extrapolates that about 40,000 outpatients were seen in 2010, but this number might not be very accurate due to faulty forms. Outpatient attendance has reportedly shown an increasing trend since 1995. The number of inpatient admissions is no longer increasing because the hospital’s psychiatrists are now more stringent on their criteria for admittance. Patients are admitted into a ward if they are a danger to themselves or others, if they require medication that cannot be administered on an outpatient basis , or if they are ordered into a psychiatric hospital by the court. The maximum occupancy of the hospital is 600 but there are currently 1,000 inpatients living in the wards, and there were 1,200 inpatients in January 2011. Table 1 and Table 2 reveal the numbers and ages of patients admitted and discharged in the year 2010. In 2010, Pantang Hospital assessed 18,503 psychological outpatients; 9,143 were male and 9,360 were female.

There was a 4.9% increase in outpatients from 2009, when only 17,636 patients were seen. According to data collected from 2004 to 2010, the hospital sees on average a total of 33,410 outpatients per year for both general and psychological causes, with just 15,894 of that number owing to psychological purposes. A range of 20 to 100 psychological outpatients can be seen a day. One thousand five hundred and thirty-nine patients were admitted into the Pantang Hospital in 2010, which reveals a 5.9% decrease in the number of inpatients from 2009. Usually, the number of patients admitted increases between 2.2% to 33% from year to year, though a decrease in attendance was also observed between 2006 and 2007. Over the past seven years, the hospital on average admits 1,371 patients per year, and about ten to twelve patients a day. Table 3 shows the number of patients who were admitted, discharged, and died according to each year. The dashes symbolize a lack of information. It is hard to tell whether there has been an increase in the number of diagnoses of a certain mental disorder within the past decade. The rise in numbers could be a result of increased awareness or a larger population. In addition, it is difficult for Ghanaian psychiatrists to ensure uniformity in diagnosis because of different backgrounds in training and cultural perspectives. Several years ago, the Pantang Hospital, along with the other two psychiatric hospitals, began using the International Classification of Mental and Behavioural Disorders— Tenth Revision , which groups mental disorders into categories and subcategories and assigns each disorder a code number. Even though the ICD- 10 helps systemize and standardize diagnosis, speeds up the digitalization of record, and simplifies comparisons between years, hospitals, and countries, many Ghanaian medical professionals have not been consistent in their usage of the classification system. Old patients should also be re-diagnosed using ICD-10 but because of the additional time this takes, it rarely happens.