Racial and Ethnic Differences Among Active-Duty Service Members in Use of Mental Health Care and Perceived Mental Health Stigma: Results From the 2018 Health Related Behaviors Survey.

INTRODUCTION: The prevalence of mental health disorders is rising among US service members; however, research is limited on their use of mental health care. The objective of our study was to determine whether racial and ethnic disparities exist in the use of mental health care and perceived mental health stigma among active-duty service members. METHODS: We obtained data from a sample of 17,166 active-duty service members who participated in the 2018 Department of Defense Health Related Behavior Survey (HRBS). Racial and ethnic groups included Black, Hispanic, White, and other. Yes-no questions about use of mental health care and perceived mental health stigma were our outcome variables. We used multiple logistic regression to assess racial and ethnic differences in mental health care use and perceived mental health stigma by service members. Significance was set at P <.05. RESULTS: In 2018, approximately 25.5% of service members self-reported using mental health services, and 34.2% self-reported perceived mental health stigma. Hispanic service members (AOR = 0.78) and service members in the "other" racial and ethnic group (AOR = 0.81) were less likely than their White counterparts to have used mental health care. Black (AOR = 0.68) and Hispanic (AOR = 0.86) service members were less likely than their White counterparts to self-report perceived mental health stigma. CONCLUSION: The 2018 HRBS showed racial and ethnic differences in mental health care use and perceived stigma among US active-duty service members. Perceived stigma was a barrier to use of mental health care among service members with a mental health condition. Culture-sensitive programs customized for different racial and ethnic groups are needed to promote mental health care and reduce perceptions of stigma associated with its use.

Natural disasters and mental health.

Natural disasters are large-scale adverse events resulting from natural processes of the earth, often associated with death, trauma, and destruction of property. They threaten harm or death to a large group of people; cause disruption of services and social networks and a communal loss of resources; and involve identifiable mental and physical health outcomes, among those affected. While majority of individuals who experience a traumatic event due to natural disasters do not develop psychopathology, natural disasters can threaten our psychological well-being in many ways and they can result in both short and long-term psychological distress and thus create a significant burden of mental health conditions on individuals and the community affected by them. In this paper we provide a narrative review that focuses on the mental health effects of natural disasters. We discuss effective, evidence-based interventions that can help enhance the sense of safety, hope, and optimism, as well as serve to promote social connectedness for those who are impacted. We describe how these interventions, developed by keeping in mind the cultural context and the needs of the community, can be provided pre, peri and post-disaster period to improve the adverse mental health effects of the disaster.

COVID-19 and its impact on the brain and Mind- A conceptual model and supporting evidence.

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the novel coronavirus that is causing the ongoing coronavirus disease 2019 (COVID-19) pandemic, was first reported in late 2019. Since then, an unprecedented amount of new knowledge has emerged about this virus and its treatment. Although the reported symptoms of COVID-19 are primarily respiratory with acute respiratory distress syndrome, SARS-CoV-2 has also been shown to affect other organs, including brain, and there are growing reports of neuropsychiatric symptoms due to COVID-19. There are two suggested pathways for how COVID-19 can affect the brain and mind: the direct impact on the brain and impact mediated via stress. Direct impact on the brain is manifested as encephalitis/encephalopathy with altered mental status (AMS) and delirium. In this paper, we summarize evidence from studies of previous outbreaks and current data from the COVID-19 pandemic that describe how COVID-19 is associated with an increased prevalence of anxiety, stress, poor sleep quality, obsessive-compulsive symptoms, and depression among the general population during the pandemic. In addition, we summarize the current evidence that supports how COVID-19 can also impact the CNS directly and result in delirium, cerebrovascular events, encephalitis, unspecified encephalopathy, AMS, or peripheral neurologic disorders.

The Impact of NC Statewide Telepsychiatry Program (NC-STeP) on Cost Savings by Reducing Unnecessary Psychiatric Hospitalizations During a 6½ Year Period.

OBJECTIVE: To study the impact of the North Carolina Statewide Telepsychiatry Program in reducing unnecessary psychiatric hospitalizations and cost savings during a 6½ year period. METHODS: Patient encounter data was extracted from the NC-STeP database that captured records of 19,383 patients who received services over a 6½ -years' period. We analyzed the data to calculate the total number of patient encounters, the number of encounters with an IVC, and the number of encounters with an IVC that was overturned. For encounters with an overturned IVC, we also determined the patient discharge disposition. We estimated the cost of a typical mental health hospitalization to measure the savings generated by the overturned IVCs in the NC-STeP program. RESULTS: Over the 6½ year period there were 19,383 NC-STeP patient encounters at partner hospital emergency departments. There were 13,537 encounters where the patient had an IVC in place during the ED stay, and 4,627 where the IVC was overturned (34 %). For patients where there was an IVC that was overturned, 85.9 % of those patients were ultimately discharged home. Using the "three-way bed" cost estimate of $ 4,500 for each overturned IVC, the cost savings generated by the NC-STeP program from November 2013 to June 2020 were $ 20,821,500. CONCLUSIONS: Telepsychiatry consultation services in the emergency departments can decrease unnecessary psychiatric hospitalizations and contribute to significant cost savings to the healthcare system and society and improve the outcomes for patients and families by decreasing financial burden and stress associated with a hospital stay.

Disparities in Health Care and the Digital Divide.

PURPOSE OF REVIEW: Disparities in health outcomes are a well documented and worrisome part of our health care system. These disparities persist in spite of, and are occasionally exacerbated by, new technologies that are intended to improve health care. This results in a "digital divide" in which populations that have poorer health outcomes continue to have poorer health outcomes despite technological improvements. RECENT FINDINGS: In many ways, the digitical divide is already shrinking via improved access to internet and technology/process improvements. For example, people with schizophrenia, PTSD, and bipolar disorder have had their care successfully augmented by new technology. However, problems persist- being impoverished, female, and black all correlate with decreased probability of completing a telehealth visit, and millions of americans have insufficient internet access to complete telehealth visits. We must continue to utilize new technology in health care to improve outcomes, but we must also be wary to ensure those outcomes are equitable across different populations.

The Impact of the North Carolina Statewide Telepsychiatry Program (NC-STeP) on Patients' Dispositions From Emergency Departments.

OBJECTIVE: The number of patients seeking treatment in emergency departments (EDs) for mental health reasons is rising, and these patients are often kept in the ED until they can be treated or discharged, leading to overcrowding. Telepsychiatry may alleviate overcrowding by increasing the rate of discharges home. METHODS: ED discharge records for 86,931 patients with psychiatric symptoms were examined to compare patient disposition and length of stay (LOS) between times when the North Carolina Statewide Telepsychiatry Program (NC-STeP) program was available or unavailable. RESULTS: For patients with a LOS of >2 days (N=3,144) and when NC-STeP was available, 62% (N=1,941) were discharged home, and 29% (N=922) were transferred to a psychiatric facility. When NC-STeP was unavailable (N=2,662), 43% (N=1,139) of these patients were discharged home, and 46% (N=1,230) were transferred to a psychiatric facility. For patients with a LOS of 1-2 days and when NC-STeP was available (N=41,713), 77.0% (N=32,131) were discharged home, and 15.4% (N=6,441) were transferred to a psychiatric facility, compared with 74.2% (N=29,237) discharged home and 13.9% (N=5,495) transferred to a psychiatric facility when NC-STeP was unavailable (N=39,412). The increases in discharges home and decreases in referrals to psychiatric facilities when NC-STeP was available were statistically significant for patients in both groups (p<0.001). CONCLUSIONS: Results suggest that telepsychiatry programs such as NC-STeP increase the number of discharges home and decrease transfers to psychiatric facilities, likely promoting patient satisfaction and improving ED efficiency.

Past Epidemics, Natural Disasters, COVID19, and Mental Health: Learning from History as we Deal with the Present and Prepare for the Future.

As cases of the coronavirus disease (COVID-19) continue to rise, psychological endurance is a challenge many people will face. For mental health, heightened stress responses to the pandemic, is likely to manifest in three ways: 1) development of a new episode of a disorder in those with a predisposition to a major psychiatric disorder or an acute exacerbation in those who already have such a disorder, 2) development of a trauma or stressor related disorder, such as acute stress disorder, Post Traumatic Stress Disorder (PTSD), or adjustment disorders, and 3) development of a symptomatic stress response that does not meet the diagnostic criteria of a psychiatric disorder. The authors reviewed existing literature on past epidemics, natural disasters, and COVID-19 with a focus on psychiatry and mental health. Psychological effects of past epidemics (Severe Acute Respiratory Syndrome CoV-1, Ebola, Middle East Respiratory Syndrome, the Anthrax threat), past natural disasters, and current COVID-19 data suggest numerous psychological effects following the pandemic. Alcohol use, PTSD, anxiety, anger, fear of contagion, perceived risk, uncertainty, and distrust are a few of the immediate and long-term effects that are likely to result from the COVID-19 pandemic. Identifying people in need of mental health care and determining the appropriate psychiatric services and therapy needed will be important. Increasing the use and availability of telehealth, group meetings, and online resources are some ways that health care workers can prepare for the increasing demand of psychiatric services during and following the pandemic.

Depression and Anxiety Disorders: Benefits of Exercise, Yoga, and Meditation.

Many people with depression or anxiety turn to nonpharmacologic and nonconventional interventions, including exercise, yoga, meditation, tai chi, or qi gong. Meta-analyses and systematic reviews have shown that these interventions can improve symptoms of depression and anxiety disorders. As an adjunctive treatment, exercise seems most helpful for treatment-resistant depression, unipolar depression, and posttraumatic stress disorder. Yoga as monotherapy or adjunctive therapy shows positive effects, particularly for depression. As an adjunctive therapy, it facilitates treatment of anxiety disorders, particularly panic disorder. Tai chi and qi gong may be helpful as adjunctive therapies for depression, but effects are inconsistent. As monotherapy or an adjunctive therapy, mindfulness-based meditation has positive effects on depression, and its effects can last for six months or more. Although positive findings are less common in people with anxiety disorders, the evidence supports adjunctive use. There are no apparent negative effects of mindfulness-based interventions, and their general health benefits justify their use as adjunctive therapy for patients with depression and anxiety disorders.

Successfully Navigating Multiple Electronic Health Records When Using Telepsychiatry: The NC-STeP Experience.

Telepsychiatry is a viable option for providing psychiatric care to those who are currently underserved or who lack access to services, but barriers to its widespread utilization remain. Use of different electronic health record systems (EHRs) by various health care systems is one such barrier. Utilization of different EHRs makes it difficult for providers to review patient data and to document clinical encounters. This column describes a Web portal developed by the North Carolina Statewide Telepsychiatry Program that connects participating hospital emergency departments and remote psychiatric providers, allowing them to share secure electronic health information regarding patient encounters across different EHRs.

Psychiatric Management, Administration, and Leadership: a Continuum or Distinct Concepts?

To clarify the relationship between the concepts of management, administration, and leadership in psychiatry. The authors provide a review of the conceptual evolution of administrative psychiatry and develop operational definitions of these three domains. Based upon their experiences, they discuss relevant core competencies and personal attributes. The authors found that the terms psychiatric management, psychiatric administration, and psychiatric leadership are often used interchangeably, yet they each have a different and distinct focus. Additionally, some in the field consider the concepts overlapping, existing on a continuum, while others draw distinct conceptual boundaries between these terms. Psychiatrists in leadership positions function in all three domains. While these are distinct concepts, the authors recommend that administrative psychiatrists integrate all three in their everyday work. The authors suggest the distinctions among these concepts should inform training and identify core competencies related to these distinctions. Mentoring should focus on the practical integration of the concepts of management, administration, and leadership in administrative psychiatry. The authors present a cohesive framework for future development of a curriculum for education and research.

Tower of Babel Problem in Telehealth: Addressing the Health Information Exchange Needs of the North Carolina Statewide Telepsychiatry Program (NC-STeP).

Telepsychiatry is a viable option for providing psychiatric care to those who are currently underserved or who lack access to services. While the current technology is adequate for most uses, and continues to advance, there remain barriers to its widespread utilization. One such barrier when working with different healthcare systems is that they utilize different electronic medical record systems (EMRs). This paper describes the experience of the North Carolina Statewide Telepsychiatry Program (NC-STeP) with this problem and how the program successfully resolved it by establishing a web portal that connects participating hospital emergency departments and remote psychiatric providers to share secure electronic health information regarding patient encounters across different EMRs. The Portal also facilitates scheduling, status tracking, and reporting on each patient encounter, as well as delivers the necessary data for the billing to process charges for each consult and to administrators for the operation of the program. The portal effectively bridges the needs of the multiple actors in the telepsychiatry virtual encounter. It provides an efficient experience for the patient and the point-of-care provider, a reliable document exchange for the psychiatric provider, and effective record keeping for the billing and government entities.

The Changing World of Psychiatric Education: Challenges and Opportunities.

This special section of the journal focuses on the expanding horizons, challenges, and opportunities for the psychiatric educators. In the six papers that comprise this special section, the authors have covered a broad range of topics in both undergraduate medical education and graduate medical education including topics such as accreditation, technology, how providers can locate education resources, how trainees are taught about professionalism in the digital age, telepsychiatry, manualized psychotherapy treatments, and cultural competence. We hope that psychiatric educators, and others interested in this field, will find these papers helpful.

Training Psychiatry Residents in Psychotherapy: The Role of Manualized Treatments.

Evidence-based treatment and manualized psychotherapy have a recent but rich history. As interest and research have progressed, defining the role of treatment manuals in resident training and clinical practice has become more important. Although there is not a universal definition of treatment manual, most clinicians and researchers agree that treatment manuals are an essential piece of evidence-based therapy, and that despite several limitations, they offer advantages in training residents in psychotherapy. Requirements for resident training in psychotherapy have changed over the years, and treatment manuals offer a simple and straightforward way to meet training requirements. In a search limited to only depression, two treatment manuals emerged with the support of research regarding both clinical practice and resident training. In looking toward the future, it will be important for clinicians to remain updated on further advances in evidence based manualized treatment as a tool for training residents in psychotherapy, including recent developments in online and smartphone based treatments.

Training Residents in the Use of Telepsychiatry: Review of the Literature and a Proposed Elective.

Many regions in the United States are deficient in mental health services, especially those in rural areas. As a result of these deficiencies, many patients in need of psychiatric services are often left untreated. Although it is clear that telepsychiatry has great potential in improving patient access to mental health care in areas where psychiatric services are deficient, the lack of familiarity with the technology and inadequate training are current barriers to expanding the use of telepsychiatry. A review of telepsychiatry, its clinical applications, and evidence-based literature regarding competencies in graduate medical education related to telepsychiatry are provided. An approach to implementing telepsychiatry into a curriculum is suggested. We also propose an elective clinical experience with resources for didactics or independent study that will enable residents to develop a knowledge base and competence in the practice of telepsychiatry.

Use of Telepsychiatry in Psychodynamic Psychiatry.

This article reviews the organization, infrastructure basics, applications, effectiveness, outreach, and implementation barriers related to telepsychiatry. We highlight the tremendous potential and promise that this technology holds and also discuss the importance that telepsychiatry may play in the field of psychodynamic psychiatry. Given the growing effectiveness evidence base for therapy delivered over the Internet, telepsychiatry holds a large unexplored territory to help psychodynamically minded patients connect with psychodynamically oriented psychiatrists. This economically advantageous medium can be utilized to deliver psychodynamically guided approaches to the patient, alone or in combination with pharmacological and other psychosocial interventions. We hope, this article will help psychodynamically trained psychiatrists to consider bridging the gap with the remotely located, chronically mentally ill population which oftentimes has scarcity of resources.

Career Paths and Trends: How Does One Become a Leader in Psychiatric Administration? Implications for Residency Training.

In the changing landscape of healthcare the number of psychiatrists entering leadership positions has declined steadily over the years. One factor contributing to this appears to be lack of leadership training during residency training. International competency frameworks have addressed this and some programs, both national and international, have designed innovative curricula to provide didactic and experiential learning in administration during and after residency. Despite guidelines by the Accreditation Council for Graduate Medical Education regarding competency in administrative aspects of health care delivery, most psychiatrists feel ill-equipped to assume a leadership position after residency training. Inculcating comprehensive administrative training into residency faces many challenges related to funding and saturation of existing curricula. Administrative training should be a mandatory element in the training of all residents irrespective of the setting in which they intend to practice. Accreditation Council for Graduate Medical Education should consider taking a prescriptive approach in shaping competency frameworks to address the need for residents to be fluent in administrative aspects of practice. Training psychiatrist-administrators will be crucial in the future of mental health-care, both from the perspective of consumers as well as psychiatry as a specialty.

Role of Leadership in Narrowing the Gap between Science and Practice: Improving Treatment Outcomes at the Systems Level.

It's been well documented that health care does not reliably transfer what we know from science into clinical practice. As a result, Americans do not always receive the care suggested by the scientific evidence. Despite the best intentions of a dedicated and skilled healthcare workforce, this can often lead to poor clinical outcomes. As research and technology rapidly advance, this gap between science and practice appears to be widening. There is an increasing public concern about a lack of access to appropriate treatment, pervasiveness of unsafe practices, and wasteful uses of precious health care resources leading to suboptimum treatment outcomes. Leadership has a critical role in creating and sustaining the environment that supports health services for individuals and populations that increase the likelihood of desired health outcomes and are consistent with current professional knowledge. Leadership has some responsibility to improve outcomes by insuring effective use of evidence-based treatment guidelines; measurement-based care; knowledge and skills management; care coordination; and information technologies. This paper addresses leadership issues in these components of a system's ability to improve treatment outcomes.

Ethical Challenges in Psychiatric Administration and Leadership.

As with all professional ethical principles, those in psychiatry have to evolve over time and societal changes. The current ethical challenges for psychiatric administration and leadership, especially regarding for-profit managed care, need updated solutions. One solution resides in the development by the American Association of Psychiatric Administrators (AAPA) of the first set of ethical principles designed specifically for psychiatric administrators. These principles build on prior Psychological Theories of leadership, such as those of Freud, Kernberg, and Kohut. Supplementing these theories are the actual real life models of psychiatrist leadership as depicted in the memoirs of various psychiatrists. Appreciating these principles, theories, and models may help emerging leaders to better recognize the importance of ethical challenges. A conclusion is that psychiatrists should have the potential to assume more successful leadership positions once again. In such positions, making the skills and well-being of all in the organization seems now to be the foremost ethical priority.