Assessment of knowledge and perceptions of Tunisian psychiatrists regarding telepsychiatry.

INTRODUCTION: Telemedicine has become a fundamental pillar of the evolution of healthcare worldwide. In Tunisia, the challenges of the health system, amplified by the COVID-19 pandemic, have highlighted the urgency to adopt innovative solutions. In this regard, the publication of Presidential Decree No. 318/2022 on April 8 in the Official Journal of the Tunisian Republic represents a significant advance in the regulation of telemedicine. AIM: To assess the knowledge of Tunisian psychiatrists and child psychiatrists regarding telemedicine, its legal framework, and their perceptions of this new medical practice. METHODS: A descriptive cross-sectional study was conducted 8 months after the issuance of the presidential decree. The survey was conducted online through an electronic questionnaire on Google Forms. RESULTS: A total of 68 participants were included in this survey. The median number of professional years was 5±7 years. Among the participants, 82% worked in psychiatry and 18% worked in child psychiatry. The sector of practice was public in 69% and private in 31% of cases. Most of them (62%) did not know about the different telemedicine acts, and 57% of doctors were unaware of the existence of the presidential decree. The majority of doctors (84%) expressed a favorable opinion regarding the adoption of telepsychiatry, regardless of sex (p=0.69), professional status (p=0.512), specialty (p=1), years of experience (p=0.83), and practice sector (p=1). CONCLUSION: Despite a low level of knowledge regarding telemedicine, the study highlights the interest of the participants in integrating telepsychiatry into their clinical practices.

Peripandemic psychiatric emergencies: impact of the COVID-19 pandemic on patients according to diagnostic subgroup.

On March 11th, 2020, the outbreak of coronavirus disease 2019 (COVID-19) was declared a pandemic. Governments took drastic measures in an effort to reduce transmission rates and virus-associated morbidity. This study aims to present the immediate effects of the pandemic on patients presenting in the psychiatric emergency department (PED) of Hannover Medical School. Patients presenting during the same timeframe in 2019 served as a control group. A decrease in PED visits was observed during the COVID-19 pandemic with an increase in repeat visits within 1 month (30.2 vs. 20.4%, pBA = 0.001). Fewer patients with affective disorders utilized the PED (15.2 vs. 22.2%, pBA = 0.010). Suicidal ideation was stated more frequently among patients suffering from substance use disorders (47.4 vs. 26.8%, pBA = 0.004), while patients with schizophrenia more commonly had persecutory delusions (68.7 vs. 43.5%, pBA = 0.023) and visual hallucinations (18.6 vs. 3.3%, pBA = 0.011). Presentation rate of patients with neurotic, stress-related, and somatoform disorders increased. These patients were more likely to be male (48.6 vs. 28.9%, pBA = 0.060) and without previous psychiatric treatment (55.7 vs. 36.8%, pBA = 0.089). Patients with personality/behavioral disorders were more often inhabitants of psychiatric residencies (43.5 vs. 10.8%, pBA = 0.008). 20.1% of patients stated an association between psychological well-being and COVID-19. Most often patients suffered from the consequences pertaining to social measures or changes within the medical care system. By understanding how patients react to such a crisis situation, we can consider how to improve care for patients in the future and which measures need to be taken to protect these particularly vulnerable patients.

Similarities and Differences Between Rural and Urban Telemedicine Utilization.

Telemedicine has traditionally been used in rural areas, but the recent development of mHealth solutions has led to a growth in urban telemedicine services. The aim of this study was to determine whether urban and rural patients in a large academic medical center use telemedicine to access different healthcare specialties at different rates. This retrospective cohort study examined all telemedicine visits dated 2008-2017 at a large academic medical center. Visits were classified by clinical specialty. Teledermatology, child telepsychiatry, and adult telepsychiatry made up 97 percent of telemedicine visits. Rural patients were more likely to have multiple telehealth visits. A significant difference was observed between rural and urban use of telemedicine, both in terms of specialties and demographics. This suggests that health systems should consider adjusting resources and training to meet the different needs of these two populations. In particular, telemedicine may offer help for the nationwide maldistribution of adolescent psychiatry providers.

Artificial Intelligence in mental health and the biases of language based models.

BACKGROUND: The rapid integration of Artificial Intelligence (AI) into the healthcare field has occurred with little communication between computer scientists and doctors. The impact of AI on health outcomes and inequalities calls for health professionals and data scientists to make a collaborative effort to ensure historic health disparities are not encoded into the future. We present a study that evaluates bias in existing Natural Language Processing (NLP) models used in psychiatry and discuss how these biases may widen health inequalities. Our approach systematically evaluates each stage of model development to explore how biases arise from a clinical, data science and linguistic perspective. DESIGN/METHODS: A literature review of the uses of NLP in mental health was carried out across multiple disciplinary databases with defined Mesh terms and keywords. Our primary analysis evaluated biases within 'GloVe' and 'Word2Vec' word embeddings. Euclidean distances were measured to assess relationships between psychiatric terms and demographic labels, and vector similarity functions were used to solve analogy questions relating to mental health. RESULTS: Our primary analysis of mental health terminology in GloVe and Word2Vec embeddings demonstrated significant biases with respect to religion, race, gender, nationality, sexuality and age. Our literature review returned 52 papers, of which none addressed all the areas of possible bias that we identify in model development. In addition, only one article existed on more than one research database, demonstrating the isolation of research within disciplinary silos and inhibiting cross-disciplinary collaboration or communication. CONCLUSION: Our findings are relevant to professionals who wish to minimize the health inequalities that may arise as a result of AI and data-driven algorithms. We offer primary research identifying biases within these technologies and provide recommendations for avoiding these harms in the future.

Suddenly Becoming a "Virtual Doctor": Experiences of Psychiatrists Transitioning to Telemedicine During the COVID-19 Pandemic.

OBJECTIVE: In response to the COVID-19 pandemic, many psychiatrists have rapidly transitioned to telemedicine. This qualitative study sought to understand how this dramatic change in delivery has affected mental health care, including modes of telemedicine psychiatrists used, barriers encountered, and future plans. The aim was to inform the ongoing COVID-19 response and pass on lessons learned to psychiatrists who are starting to offer telemedicine. METHODS: From March 31 to April 9, 2020, semistructured interviews were conducted with 20 outpatient psychiatrists practicing in five U.S. states with significant early COVID-19 activity. Inductive and deductive approaches were used to develop interview summaries, and a matrix analysis was conducted to identify and refine themes. RESULTS: At the time of the interviews, all 20 psychiatrists had been using telemedicine for 2-4 weeks. Telemedicine encompassed video visits, phone visits, or both. Although many continued to prefer in-person care and planned to return to it after the pandemic, psychiatrists largely perceived the transition positively. However, several noted challenges affecting the quality of provider-patient interactions, such as decreased clinical data for assessment, diminished patient privacy, and increased distractions in the patient's home setting. Several psychiatrists noted that their disadvantaged patients lacked reliable access to a smartphone, computer, or the Internet. Participants identified several strategies that helped them improve telemedicine visit quality. CONCLUSIONS: The COVID-19 pandemic has driven a dramatic shift in how psychiatrists deliver care. Findings highlight that although psychiatrists expressed some concerns about the quality of these encounters, the transition has been largely positive for both patients and physicians.

A Survey of American Psychiatrists Concerning Medication Prior Authorization Requirements.

This study examined opinions of American psychiatrists regarding prior authorization (PA) requirements for third-party payer coverage of medications and quantified perceived impact of these requirements on clinical practice. One thousand selected psychiatrist members of the American Psychiatric Association were invited to participate in a survey. Response rate was 33.1%. Respondents predominantly believed the obligation to obtain PA reduces job satisfaction and negatively impacts patient care. A total of 59.9% of respondents reported employing either diagnosis modification or falsification of previous medication trials at least occasionally in order to obtain PA. A total of 66.6% refrained at least occasionally from prescribing preferred medications due to PA requirement or expectation of one. On multivariate analysis, risk factors for refraining at higher frequency included seeing 300 or more patients in the previous 3 months, engaging more frequently in diagnosis modification, and reporting increased perception that obtaining PA reduces time for patient care.

Analysis of psychiatrists' prescription of opioid, benzodiazepine, and buprenorphine in Medicare Part D in the United States.

INTRODUCTION: The opioid epidemic is a severe problem in the world, especially in the United States, where prescription opioid overdose accounts for a quarter of drug overdose deaths. OBJECTIVE: To describe psychiatrists' prescription of opioid, benzodiazepine, and buprenorphine in the United States. METHODS: We conducted a retrospective cross-sectional study of the 2016 Medicare Part D claims data and analyzed psychiatrists' prescriptions of: 1) opioids; 2) benzodiazepines, whose concurrent prescription with opioids can cause overdose death; 3) buprenorphine, a partial opioid agonist for treating opioid addiction; 4) and naltrexone microsphere, a once-monthly injectable opioid antagonist to prevent relapse to opioid dependence. Prescribers with 11 or more claims were included in the analysis. RESULTS: In Medicare Part D in 2016, there were a total of 1,131,550 prescribers accounting for 1,480,972,766 total prescriptions and 78,145,305 opioid prescriptions, including 25,528 psychiatrists (2.6% of all prescribers) accounting for 44,684,504 total prescriptions (3.0% of all prescriptions) and 131,115 opioid prescriptions (0.2% of all opioid prescriptions). Psychiatrists accounted for 17.3% of benzodiazepine, 16.3% of buprenorphine, and 33.4% of naltrexone microsphere prescriptions. The opioid prescription rate of psychiatrists was much lower than that of all prescribers (0.3 vs 5.3%). The buprenorphine prescription rate of psychiatrists was much higher than that of all prescribers (2.3 vs. 0.1%). There was a substantial geographical variation across the United States. CONCLUSIONS: The results show that, proportionally, psychiatrists have lower rates of opioid prescription and higher rates of benzodiazepine and buprenorphine prescription.

Efficacy, patient-doctor relationship, costs and benefits of utilizing telepsychiatry for the management of post-traumatic stress disorder (PTSD): a systematic review.

INTRODUCTION: Post-traumatic stress disorder (PTSD) is one of the most common psychiatric disorders found among victims of disaster, kidnapping, accidents, sexual assaults and war in Indonesia. However, lacking and unequal distribution of psychiatric medical personnel remains a barrier to its management. This review aims to introduce and evaluate the potential contribution of telepsychiatry to the management of PTSD based on published literature. METHODS: Original studies were obtained from PubMed, Science Direct, ProQuest, High Wire, and Elsevier Clinical Key databases. RESULTS: A total of 125 articles were found, of which 15 articles (12 randomized controlled trials, 2 open trials and 1 pilot study) fulfilled the inclusion criteria. A total of 991 subjects were found with a follow-up period ranging between 5 weeks and 18 months. Telepsychiatry is an innovative use of technology to aid the delivery of PTSD treatments in areas difficult to reach. The quality of care given by telepsychiatry both through video conferencing as well as web- and application-based is comparable to that of face-to-face therapy. Patient satisfaction, quality of doctor-patient relationship also remains high, with lower costs and shorter therapeutic time when compared to face-to-face therapy. CONCLUSION: Various studies have shown that telepsychiatry is an effective solution for the management of PTSD. Studies have also reported that the quality of treatment through telepsychiatry is as effective as face-to-face therapy, with greater efficiency. Countries, especially those with a low patient-to-mental health professional ratio, should be encouraged to develop telepsychiatry systems to manage PTSD.

Analysis of psychiatrists' prescription of opioid, benzodiazepine, and buprenorphine in Medicare Part D in the United States

Abstract Introduction The opioid epidemic is a severe problem in the world, especially in the United States, where prescription opioid overdose accounts for a quarter of drug overdose deaths. Objective To describe psychiatrists' prescription of opioid, benzodiazepine, and buprenorphine in the United States. Methods We conducted a retrospective cross-sectional study of the 2016 Medicare Part D claims data and analyzed psychiatrists' prescriptions of: 1) opioids; 2) benzodiazepines, whose concurrent prescription with opioids can cause overdose death; 3) buprenorphine, a partial opioid agonist for treating opioid addiction; 4) and naltrexone microsphere, a once-monthly injectable opioid antagonist to prevent relapse to opioid dependence. Prescribers with 11 or more claims were included in the analysis. Results In Medicare Part D in 2016, there were a total of 1,131,550 prescribers accounting for 1,480,972,766 total prescriptions and 78,145,305 opioid prescriptions, including 25,528 psychiatrists (2.6% of all prescribers) accounting for 44,684,504 total prescriptions (3.0% of all prescriptions) and 131,115 opioid prescriptions (0.2% of all opioid prescriptions). Psychiatrists accounted for 17.3% of benzodiazepine, 16.3% of buprenorphine, and 33.4% of naltrexone microsphere prescriptions. The opioid prescription rate of psychiatrists was much lower than that of all prescribers (0.3 vs 5.3%). The buprenorphine prescription rate of psychiatrists was much higher than that of all prescribers (2.3 vs. 0.1%). There was a substantial geographical variation across the United States. Conclusions The results show that, proportionally, psychiatrists have lower rates of opioid prescription and higher rates of benzodiazepine and buprenorphine prescription.

Efficacy, patient-doctor relationship, costs and benefits of utilizing telepsychiatry for the management of post-traumatic stress disorder (PTSD): a systematic review

Abstract Introduction Post-traumatic stress disorder (PTSD) is one of the most common psychiatric disorders found among victims of disaster, kidnapping, accidents, sexual assaults and war in Indonesia. However, lacking and unequal distribution of psychiatric medical personnel remains a barrier to its management. This review aims to introduce and evaluate the potential contribution of telepsychiatry to the management of PTSD based on published literature. Methods Original studies were obtained from PubMed, Science Direct, ProQuest, High Wire, and Elsevier Clinical Key databases. Results A total of 125 articles were found, of which 15 articles (12 randomized controlled trials, 2 open trials and 1 pilot study) fulfilled the inclusion criteria. A total of 991 subjects were found with a follow-up period ranging between 5 weeks and 18 months. Telepsychiatry is an innovative use of technology to aid the delivery of PTSD treatments in areas difficult to reach. The quality of care given by telepsychiatry both through video conferencing as well as web- and application-based is comparable to that of face-to-face therapy. Patient satisfaction, quality of doctor-patient relationship also remains high, with lower costs and shorter therapeutic time when compared to face-to-face therapy. Conclusion Various studies have shown that telepsychiatry is an effective solution for the management of PTSD. Studies have also reported that the quality of treatment through telepsychiatry is as effective as face-to-face therapy, with greater efficiency. Countries, especially those with a low patient-to-mental health professional ratio, should be encouraged to develop telepsychiatry systems to manage PTSD.

Characteristics of Office-Based Buprenorphine Prescribers for Medicare Patients.

INTRODUCTION: Opioid use disorder (OUD) is a major and growing public health concern, and Medicare patients have nearly double the proportion of OUD prevalence compared with those with commercial insurance. This study examines provider-level characteristics to delineate the wide variation behind buprenorphine provision, which is the mainstay of medication-assisted treatment for OUD. METHODS: Using Medicare Part D Public Use Files claims data from 2013 to 2016 in all states, we assessed prescribing patterns of buprenorphine formulations for the specialties of family medicine, internal medicine, psychiatry, and general practice. We incorporated data from 2013 to 2016 American Medical Association Physician Masterfile to model various provider- and area-level characteristics as predictors of buprenorphine prescriber status. RESULTS: Family medicine and internal medicine comprise nearly two-thirds of the outpatient buprenorphine prescriber population for Medicare beneficiaries. Yet, both specialties also have the lowest proportion of active buprenorphine prescribers compared with psychiatrists and general practitioners. Additional characteristics associated with buprenorphine provision include male sex, osteopathic training, Northeast region, US undergraduate medical education, more years in practice, and a higher proportion of dual-eligible patients. CONCLUSIONS: Primary care specialties, such as family medicine and internal medicine, currently comprise a significant majority of the US buprenorphine prescriber population for Medicare beneficiaries. Future policies should target specific demographics to enable greater patient access from physicians who are characteristically less likely to prescribe buprenorphine to increase overall capacity.

Rural Residents With Mental Health Needs Have Fewer Care Visits Than Urban Counterparts.

Analysis of a nationally representative sample of adults with mental health needs shows that rural residents have fewer ambulatory mental health visits than their urban counterparts do. Even among people already on prescription medications for mental health conditions, rural-urban differences are large.

Longitudinal analysis of dementia diagnosis and specialty care among racially diverse Medicare beneficiaries.

INTRODUCTION: There is insufficient understanding of diagnosis of etiologic dementia subtypes and contact with specialized dementia care among older Americans. METHODS: We quantified dementia diagnoses and subsequent health care over five years by etiologic subtype and physician specialty among Medicare beneficiaries with incident dementia diagnosis in 2008/09 (226,604 persons/714,015 person-years). RESULTS: Eighty-five percent of people were diagnosed by a nondementia specialist physician. Use of dementia specialists within one year (22%) and five years (36%) of diagnosis was low. "Unspecified" dementia diagnosis was common, higher among those diagnosed by nondementia specialists (33.2%) than dementia specialists (21.6%). Half of diagnoses were Alzheimer's disease. DISCUSSION: Ascertainment of etiologic dementia subtype may inform hereditary risk and facilitate financial and care planning. Use of dementia specialty care was low, particularly for Hispanics and Asians, and associated with more detection of etiological subtype. Dementia-related professional development for nonspecialists is urgent given their central role in dementia diagnosis and care.

Factors Associated with Psychiatrist Opt-out from US Medicare: an Observational Study.

BACKGROUND: Concerns exist about availability and access to psychiatric services in the USA. For Medicare beneficiaries, one impediment to psychiatric services is the extent to which psychiatrists have opted out of the Medicare program. OBJECTIVE: This study describes geographic variation in rates that psychiatrists opt out of Medicare, and assesses physician-level and geographic-level predictors of opt-out. DESIGN: Retrospective cross-sectional analysis of data describing psychiatrists' opt-out status as of March 2017 linked to data on psychiatrist location, psychiatrist characteristics (obtained from a comprehensive US physician database), and market area-level characteristics. PARTICIPANTS: 27,838 psychiatrists in the USA MAIN MEASURES: Whether a psychiatrist had opted out of Medicare as of March 2017. KEY RESULTS: Overall, 7.0% of psychiatrists (1940/27,838) opted out of Medicare as of March 2017. Opt-out rates varied substantially across states and within states. Physician-level factors independently associated with opt-out included: older age (psychiatrists > 65 years were 2.6 percentage points more likely to opt vs. psychiatrists < 35 years old, p = 0.03), greater years of experience, female gender (female psychiatrists were 2.6 percentage points more likely to opt out than male psychiatrists, p < 0.001), graduation from a top-20 ranked medical school (1.7 percentage points more likely to opt out of Medicare, p < 0.001), and domestic medical graduate (domestic graduates were 7.3 percentage points more likely to opt out of Medicare vs. foreign graduates, p < 0.001). Adjusting for other individual- and geographic-level factors, psychiatrists who practiced in areas with more psychiatrists per Medicare beneficiary were less likely to opt out (p < 0.001). CONCLUSIONS: The overall likelihood that psychiatrists opt out of Medicare is significant and varies considerably across regions and by characteristics of psychiatrists.