Racial differences in pathways to care preceding first episode mania or psychosis: a historical cohort prodromal study.

Background: There is evidence suggesting racial disparities in diagnosis and treatment in bipolar disorder (BD) and schizophrenia (SZ). The purpose of this study is to compare psychiatric diagnoses and psychotropic use preceding a first episode of mania (FEM) or psychosis (FEP) in racially diverse patients. Methods: Using a comprehensive medical records linkage system (Rochester Epidemiology Project, REP), we retrospectively identified individuals diagnosed with BD or SZ and a documented first episode of mania or psychosis. Illness trajectory before FEP/FEM were characterized as the time from first visit for a mental health complaint to incident case. Pathways to care and clinical events preceding FEP/FEM were compared based on subsequent incident case diagnosis (BD or SZ) and self-reported race (White vs. non-White). Results: A total of 205 (FEM = 74; FEP = 131) incident cases were identified in the REP. Duration of psychiatric antecedents was significantly shorter in non-White patients, compared to White patients (2.2 ± 4.3 vs. 7.4 ± 6.6 years; p < 0.001) with an older age at time of first visit for a mental health complaint (15.7 ± 6.3 vs. 11.1 ± 6.0 years; p = 0.005). There were no significant differences by race in FEM pathway to care or age of first seeking mental health. Overall non-White patients had lower rates of psychotropic use. Conclusion: These data are unable to ascertain reasons for shorter duration of psychiatric antecedents and later age of seeking care, and more broadly first age of initial symptom presentation. If symptoms are confirmed to be earlier than first time seeking care in both groups, it would be important to identify barriers that racial minorities face to access timely psychiatric care and optimize early intervention strategies.

Comparison of Demographic and Clinical Features of Bipolar Disorder in Persons of African and European Ancestry.

AIM: This study quantified and compared demographic and clinical features of bipolar disorder (BD) in persons of African ancestry (AA) and European ancestry (EUR). METHODS: Participants enrolled in the Mayo Clinic Bipolar Biobank from 2009 to 2015. The structured clinical interview for DSM-IV was used to confirm the diagnosis of BD, and a questionnaire was developed to collect data on the clinical course of illness. Descriptive statistics and bivariate analyses were completed to compare AA versus EUR participants. Subsequently, clinical outcomes were compared between AA and EUR participants using linear regression for continuous outcomes or logistic regression for binary outcomes while controlling for differences in age, sex, and recruitment site. RESULTS: Of 1865 participants enrolled in the bipolar biobank, 65 (3.5%) self-identified as AA. The clinical phenotype for AA participants, in comparison to EUR participants, was more likely to include a history of PTSD (39.7% vs. 26.2%), cocaine use disorder (24.2% vs. 11.9%), and tardive dyskinesia (7.1% vs. 3%). CONCLUSION: The low rate of AA enrollment is consistent with other genetic studies. While clinical features of bipolar disorder are largely similar, this study identified differences in rates of trauma, substance use, and tardive dyskinesia that may represent health disparities in bipolar patients of African ancestry. Future bipolar biomarker studies with larger sample sizes focused on underrepresented populations will provide greater ancestry diversity in genomic medicine with greater applicability to diverse patient populations, serving to inform health care policies to address disparities in bipolar disorder.

The Interplay Between Group Identity, Suicidality, and Bullying in Midwestern Middle School Youth, 18-42.

Bullying peaks in middle school and is a risk factor for negative mental health outcomes, including suicidality. Suicide rates are higher in nonmetropolitan/rural areas and for American Indian/Alaska Natives compared to other racial/ethnic groups. Stigma-related bullying, a type of interpersonal discrimination, is increasingly considered an important driver of peer victimization. This study centers on the group identity characteristics of race/ethnicity, weight status, and sex to explore how school-based and electronic-bullying victimization mediate suicidality amongst a cohort of middle school students in North Dakota. Bivariate, multivariate, and structural equation modeling were performed using data from the 2015 North Dakota Middle School Youth Risk Behavior Survey. Minoritized race/ethnicity, very overweight, and female students all experienced statistically higher suicidality than comparison groups, mediated in some instances by bullying. Group identity, stigma, and discrimination may influence suicidality in North Dakota middle school youth. More information is needed on stigma and discrimination, including intersections of identity, as drivers of bullying and suicidality in minoritized youth in nonmetropolitan/rural areas.

Clinical Phenotype of Tardive Dyskinesia in Bipolar Disorder.

PURPOSE: Recognizing the negative impact that antipsychotic-induced movement disorders have on the quality of life and treatment outcomes in bipolar disorder (BD), this study aimed to assess clinical correlates and antipsychotic use patterns of tardive dyskinesia (TD+) in BD. MATERIALS AND METHODS: Participants with and without TD were included. Clinical variables were compared using t-test and χ2 test. Antipsychotic use patterns in TD+, including number of trials, mean doses, and estimated cumulative exposure, were assessed in a case-only analysis. RESULTS: The prevalence rate of TD was 5.1%. In comparison to the TD- group (n = 1074), TD+ participants (n = 58) were older, more likely to be female and have type I bipolar illness. There were 60.3% of the TD+ group that continued using antipsychotics at study entry and had a mean cumulative exposure to antipsychotics of 18.2 ± 15.6 years. Average dose, in haloperidol equivalents, was 5.9 ± 3.5 mg and 77.7% of the trials were second-generation antipsychotics. CONCLUSIONS: This study confirms previously identified TD risk factors, such as age, sex, and bipolar subtype in a large BD cohort. Limitations included a cross-sectional design and the lack of tardive illness severity assessment. As atypical antipsychotics continue to be primary mood stabilization treatment, attempting to harmonize large data sets to identify additional biomarkers of tardive risk will optimize individualized care for patients with BD.

Patient Satisfaction and Recommendations for Delivering a Group-Based Intensive Outpatient Program via Telemental Health During the COVID-19 Pandemic: Cross-sectional Cohort Study.

BACKGROUND: Although group-based intensive outpatient programs (IOPs) are a level of care commonly utilized by adults with serious mental illness, few studies have examined the acceptability of group-based IOPs that required rapid transition to a telemental health (TMH) format during the COVID-19 pandemic. OBJECTIVE: The aim of this study was to evaluate patient satisfaction and future recommendations for a group-based IOP that was transitioned to a TMH format during the COVID-19 pandemic. METHODS: A 17-item patient satisfaction questionnaire was completed by patients at discharge and covered 3 areas: IOP TMH satisfaction, future recommendations, and video technology challenges. Descriptive and content analyses were conducted for the quantitative and open-ended questions, respectively. RESULTS: A total of 76 patients completed the program in 2020. A subset of patients (n=40, 53%) responded to the survey at program discharge. The results indicated that the patients were satisfied overall with the TMH program format; 50% (n=20) of the patients preferred the program continue offering the TMH format, and the rest preferred returning to in-person formats after the pandemic. The patients indicated the elements of the program that they found most valuable and provided recommendations for future program improvement. CONCLUSIONS: Overall, adults with serious mental illness reported high satisfaction with the group-based IOP delivered via TMH. Health care systems may want to consider offering both TMH and in-person formats regardless of the state of the pandemic. Patients' feedback on future improvements should be considered to help ensure long-term success.

Further Adaptations and Reflections by an Assertive Community Treatment Team to Serve Clients with Severe Mental Illness During COVID-19.

In September of 2020, Guan and colleagues wrote about their experience of an Assertive Community Psychiatry Program responding to the COVID-19 pandemic. We describe our own experience as an Assertive Community Treatment team in Minnesota responding to challenges of effectively and safely delivering service to clients. As the pandemic has progressed since last year, so has the literature, and updated references are highlighted. Common threads are woven between our experience, the experience of Guan and colleagues, and others to suggest the beginnings of a template to adapt services to a new post-pandemic world.