Patient and Provider Satisfaction with Asynchronous Versus Synchronous Telepsychiatry in Primary Care: A Secondary Mixed-Methods Analysis of a Randomized Controlled Trial.

Background: Asynchronous telepsychiatry (ATP) consultations are a novel form of psychiatric consultation. Studies comparing patient and provider satisfaction for ATP with that for synchronous telepsychiatry (STP) do not exist. Methods: This mixed-methods study is a secondary analysis of patients' and primary care providers' (PCPs) satisfaction from a randomized clinical trial of ATP compared with STP. Patients and their PCPs completed satisfaction surveys, and provided unstructured feedback about their experiences with either ATP or STP. Differences in patient satisfaction were assessed using mixed-effects logistic regression models, and the qualitative data were analyzed using thematic analysis with an inductive coding framework. Results: Patient satisfaction overall was high with 84% and 97% of respondents at 6 months reported being somewhat or completely satisfied with ATP and STP, respectively. Patients in the STP group were more likely to report being completely satisfied, to recommend the program to a friend, and to report being comfortable with their care compared with ATP (all p < 0.05). However, there was no difference between the patients in ATP and STP in perceived change in clinical outcomes (p = 0.51). The PCP quantitative data were small, and thus only summarized descriptively. Conclusions: Patients expressed their overall satisfaction with both STP and ATP. Patients in ATP reported more concerns about the process, likely because feedback after ATP was slower than that after STP consultations. PCPs had no apparent preference for STP or ATP, and reported implementing the psychiatrists' recommendations for both groups when such recommendations were made, which supports our previous findings. Trial Registration: ClinicalTrials.gov NCT02084979; https://clinicaltrials.gov/ct2/show/NCT02084979.

Depression.

Most psychiatric care is delivered in primary care settings, where depression is the most common presenting psychiatric symptom. Given the high prevalence of depression worldwide and the well-established consequences of untreated depression, the ability of primary care clinicians to effectively diagnose and treat it is critically important. This article offers up-to-date guidance for the diagnosis and treatment of major depressive disorder, including practical considerations for delivering optimal and efficient care for these patients.

Primary Care Physician Adherence to Telepsychiatry Recommendations: Intermediate Outcomes from a Randomized Clinical Trial.

Objective:To compare clinical recommendations given by psychiatrists and the adherence to these recommendations by primary care physicians (PCP) following consultations conducted by asynchronous telepsychiatry (ATP) and synchronous telepsychiatry (STP).Materials and Methods:ATP and STP consultations were compared using intermediate data from a randomized clinical trial with adult participant enrollment between April 2014 and December 2017. In both study arms, PCPs received written recommendations from the psychiatrist after each encounter. Independent clinicians reviewed PCP documentation to measure adherence to those recommendations in the 6 months following the baseline consultation.Results:Medical records were reviewed for 645 psychiatrists' consult recommendations; 344 from 61 ATP consultations and 301 from 62 STP consultations. Of those recommendations, 191 (56%) and 173 (58%) were rated fully adherent by two independent raters for ATP and STP, respectively. In a multilevel ordinal logistic regression model adjusted for recommendation type and recommended implementation timing, there was no statistically significant difference in adherence to recommendations for ATP compared with STP (adjusted odds ratio = 0.91, 95% confidence interval = 0.51-1.62). The profiles of recommendation type were comparable between ATP and STP.Conclusions:This is the first PCP adherence study comparing two forms of telemedicine. Although we did not find evidence of a difference between ATP and STP; this study supports the feasibility and acceptability of ATP and STP for the provision of collaborative psychiatric care. Clinical Trial Identifier NCT02084979.

Clinical Outcomes of Asynchronous Versus Synchronous Telepsychiatry in Primary Care: Randomized Controlled Trial.

BACKGROUND: Asynchronous telepsychiatry (ATP; delayed-time) consultations are a novel form of psychiatric consultation in primary care settings. Longitudinal studies comparing clinical outcomes for ATP with synchronous telepsychiatry (STP) are lacking. OBJECTIVE: This study aims to determine the effectiveness of ATP in improving clinical outcomes in English- and Spanish-speaking primary care patients compared with STP, the telepsychiatry usual care method. METHODS: Overall, 36 primary care physicians from 3 primary care clinics referred a heterogeneous sample of 401 treatment-seeking adult patients with nonurgent psychiatric disorders. A total of 184 (94 ATP and 90 STP) English- and Spanish-speaking participants (36/184, 19.6% Hispanic) were enrolled and randomized, and 160 (80 ATP and 80 STP) of them completed baseline evaluations. Patients were treated by their primary care physicians using a collaborative care model in consultation with the University of California Davis Health telepsychiatrists, who consulted with patients every 6 months for up to 2 years using ATP or STP. Primary outcomes (the clinician-rated Clinical Global Impressions [CGI] scale and the Global Assessment of Functioning [GAF]) and secondary outcomes (patients' self-reported physical and mental health and depression) outcomes were assessed every 6 months. RESULTS: For clinician-rated primary outcomes, ATP did not promote greater improvement than STP at 6-month follow-up (ATP vs STP, adjusted difference in follow-up at 6 months vs baseline differences for CGI: 0.2, 95% CI -0.2 to 0.6; P=.28; and GAF: -0.6, 95% CI -3.1 to 1.9; P=.66) or 12-month follow-up (ATP vs STP, adjusted difference in follow-up at 12 months vs baseline differences for CGI: 0.4, 95% CI -0.04 to 0.8; P=.07; and GAF: -0.5, 95% CI -3.3 to 2.2; P=.70), but patients in both arms had statistically and clinically significant improvements in both outcomes. There were no significant differences in improvement from baseline between ATP and STP on any patient self-reported ratings at any follow-up (all P values were between .17 and .96). Dropout rates were higher than predicted but similar between the 2 arms. Of those with baseline visits, 46.8% (75/160) did not have a follow-up at 1 year, and 72.7% (107/147) did not have a follow-up at 2 years. No serious adverse events were associated with the intervention. CONCLUSIONS: This is the first longitudinal study to demonstrate that ATP can improve clinical outcomes in English- and Spanish-speaking primary care patients. Although we did not find evidence that ATP is superior to STP in improving clinical outcomes, it is potentially a key part of stepped mental health interventions available in primary care. ATP presents a possible solution to the workforce shortage of psychiatrists and a strategy for improving existing systems of care. TRIAL REGISTRATION: ClinicalTrials.gov NCT02084979; https://clinicaltrials.gov/ct2/show/NCT02084979.

An Update on Telepsychiatry and How It Can Leverage Collaborative, Stepped, and Integrated Services to Primary Care.

INTRODUCTION: In this era of patient-centered care, telepsychiatry (TP; video or synchronous) provides quality care with outcomes as good as in-person care, facilitates access to care, and leverages a wide range of treatments at a distance. METHOD: This conceptual review article explores TP as applied to newer models of care (e.g., collaborative, stepped, and integrated care). RESULTS: The field of psychosomatic medicine (PSM) has developed clinical care models, educates interdisciplinary team members, and provides leadership to clinical teams. PSM is uniquely positioned to steer TP and implement other telebehavioral health care options (e.g., e-mail/telephone, psych/mental health apps) in the future in primary care. Together, PSM and TP provide versatility to health systems by enabling more patient points-of-entry, matching patient needs with provider skills, and helping providers work at the top of their licenses. TP and other technologies make collaborative, stepped, and integrated care less costly and more accessible. CONCLUSION: Effective health care delivery matches the intensity of the services to the needs of a patient population or clinic, standardizes interventions, and evaluates both process and clinical outcomes. More research is indicated on the application of TP and other technologies to these service delivery models.

Telepsychiatry and other technologies for integrated care: evidence base, best practice models and competencies.

Telehealth facilitates integrated, patient-centred care. Synchronous video, telepsychiatry (TP), or telebehavioural health provide outcomes as good as in-person care. It also improves access to care, leverages expertise at a distance, and is effective for education and consultation to primary care. Other technologies on an e-behavioural health spectrum are also useful, like telephone, e-mail, text, and e-consults. This paper briefly organizes these technologies into low, mid and high intensity telehealth models and reviews the evidence base for interventions to primary care, and, specifically, for TP and integrated care (IC). Technology, mobile health, and IC competencies facilitate quality care. TP is a high intensity model and it is the best-studied option. Studies of IC are preliminary, but those with collaborative and consultative care show effectiveness. Low- and mid-intensity technology options like telephone, e-mail, text, and e-consults, may provide better access for patients and more timely provider communication and education. They are also probably more cost-effective and versatile for health system workflow. Research is needed upon all technology models related to IC for adult and paediatric primary care populations. Effective healthcare delivery matches the patients' needs with the model, emphasizes clinician competencies, standardizes interventions, and evaluates outcomes.

Depression.

This issue provides a clinical overview of depression, focusing on screening, diagnosis, treatment, and practice improvement. The content of In the Clinic is drawn from the clinical information and education resources of the American College of Physicians (ACP), including MKSAP (Medical Knowledge and Self-Assessment Program). Annals of Internal Medicine editors develop In the Clinic in collaboration with the ACP's Medical Education and Publishing divisions and with the assistance of additional science writers and physician writers.

General and Child and Adolescent Psychiatry Resident Training in Integrated Care: a Survey of Program Directors.

OBJECTIVE: Integrated care models are an evidence-based approach for integrating physical and behavioral health services. The American Association of Directors of Psychiatric Residency Training Integrated Care Task Force sought to describe current practices for providing training in integrated care to general and child and adolescent psychiatry residents. METHODS: Directors of US general and child and adolescent psychiatric residency training programs were anonymously surveyed to examine current practices in educating their residents in integrated care. Based on themes that emerged from the survey, the authors make recommendations for integrated care education of general and child and adolescent psychiatry residents. RESULTS: Fifty-two of 197 (26%) general and 36 of 111 (32%) child and adolescent program directors responded. Results demonstrate that a majority of responding general psychiatry (78%) and child and adolescent psychiatry (CAP) (72%) training programs offer integrated care rotations, many of which are electives for senior residents. The Veterans Health Administration (VA) and Federally Qualified Health Centers are common venues for such rotations. Sustainable funding of these rotations is a concern. Fewer than half of programs offer integrated care didactics. CONCLUSIONS: This report is intended to help program directors consider options for starting or optimizing their own integrated care curricula. Future research should examine the educational value, and the overall value to health care systems, of training in the integrated care model.

Teaching psychiatry residents to work at the interface of mental health and primary care.

The authors present examples of programs educating psychiatry residents to work in integrated healthcare settings.

Train New Trainers Primary Care Psychiatry Fellowship-Optimizing Delivery of Behavioral Health Care Through Training for Primary Care Providers.

OBJECTIVE: To expand and optimize the behavioral health workforce, it is necessary to improve primary care providers' (PCPs) overall knowledge and clinical skills in primary care-based psychiatry. Studies on the effects of postgraduate psychiatric education programs for PCPs on psychiatric knowledge are limited. METHODS: A total of 251 PCPs completed a 1-year fellowship. Data from program development and evaluation were analyzed for 4 fellowship years (2016-2019). Fellows were surveyed at baseline, midpoint, and postfellowship about mental health stigma, perceived competency, attitudes about psychiatry, satisfaction with current psychiatric knowledge, confidence and comfort to treat psychiatric illnesses, and program satisfaction. Psychiatric knowledge was evaluated at baseline, midpoint, and postfellowship. RESULTS: Large effects were noted on perceived competency/self-efficacy and confidence in the treatment of common psychiatric disorders encountered in primary care settings. Positive effects were observed on attitudes of mental health stigma, and even more robust effects were found with improvement in psychiatry clinical knowledge. Knowledge improved by 12% at postfellowship (P < .0001). Correlations of the degree of change in attitude with improved psychiatric literacy demonstrated significant relationships with reduction of stigma total score (r = -0.2133, P = .0043), increased willingness (r = 0.1941, P = .0096), and increased positive attitudes (r = 0.1894, P = .0111). CONCLUSION: Innovative initiatives to improve and expand psychiatric knowledge and clinical skills among those who provide the most behavioral health care (PCPs) can have marked impacts on attitudes toward mental health care delivery, stigma, and competency/self-efficacy. Future studies are necessary to consider the impact of this program on clinical practice pattern outcomes on a larger scale.

General-medical hospital admissions from a public inpatient psychiatric health facility: a review of medical complications over 30 months.

BACKGROUND: Medical comorbidity and mortality disproportionately affect adults with serious mental illness, as compared with the general population. OBJECTIVE: This study examined the medical diagnoses of patients transferred from a psychiatric health facility to general-medical hospitals. METHOD: The authors retrospectively reviewed the charts of 81 adult patients admitted to an inpatient psychiatric facility who were subsequently transferred to local general-medical hospitals from January 2005 to June 2007. RESULTS: Of 6,688 separate inpatient admissions, 81 patients (2.1%) were admitted to general-medical hospitals a total of 93 times, and had 108 admitting medical diagnoses. The leading admission indications were infections (N=33; 34%), electrolyte or nutritional abnormalities (N=12; 11%), and cardiovascular disorders (N=12; 11%). Iatrogenic causes related to psychiatric medications accounted for a small proportion of medical admissions (N=8; 7.5%). Over 90% of the patients had chronic medical disorders, and 80% of the patients had a psychotic or bipolar disorder. CONCLUSION: Patients with severe mental illness and chronic medical disorders may experience significant acute medical complications during inpatient psychiatric treatment. Given the complex care issues involved, continued vigilance in treating or preventing these conditions is warranted.

Psychiatrists for medically complex patients: bringing value at the physical health and mental health/substance-use disorder interface.

BACKGROUND: In their current configuration, traditional reactive consultation-liaison services see a small percentage of the general-hospital patients who could benefit from their care. These services are poorly reimbursed and bring limited value in terms of clinical improvement and reduction in health-service use. METHOD: The authors examine models of cross-disciplinary, integrated health services that have been shown to promote health and lower cost in medically-complex patients, those with complicated admixtures of physical, mental, social, and health-system difficulties. CONCLUSION: Psychiatrists who specialize in the treatment of medically-complex patients must now consider a transition from traditional consultation to proactive, value-added programs and bill for services from medical, rather than behavioral, insurance dollars, since the majority of health-enhancement and cost-savings from these programs occur in the medical sector. The authors provide the clinical and financial arguments for such program-creation and the steps that can be taken as psychiatrists for medically-complex patients move to the next generation of interdisciplinary service.

Management of mental illness in patients with diabetes.

Patients who have diabetes commonly have mood, anxiety, and psychotic disorders. These disorders may have multiple biologic underpinnings. Without treatment, care becomes complicated and outcomes are poor. Early diagnosis and biopsychosocial treatment that integrates medical and psychiatric interventions is highly desirable. Medications have a major role in treatment, although caution must be exercised because of potential side effects. Psychiatric consultation or management may be required for urgent or severe cases. An appreciation of culture, both ethnic and beyond, is a foundation for enhancing physician-patient relations and developing realistic expectations for treatment.

Use of Preventive Health Services in People With Serious Mental Illness: Consumer Perspectives on Barriers and Solutions.

OBJECTIVE: This study asked 350 consumers with serious mental illness (DSM-IV) (who are using community mental health services in Sacramento County, California) for their perspective about barriers and solutions to use of preventive health services. METHODS: Two questions were posed: (1) What do you think keeps you from getting preventive tests? (2) What do you think would help you complete the recommended tests? Participants were interviewed between October 2010 and December 2012. A mixed qualitative and quantitative data analysis method was used to examine participant responses. RESULTS: Perceived barriers included low priority (n = 64, 20%), doctor (did not order) (n = 55, 17%), finances/insurance barriers (n = 45, 14%), fear (n = 39, 12%), and knowledge about the services (n = 31, 10%). Common solutions included doctor-related interventions (n = 75, 23%), information (n = 61, 19%), insurance coverage (n = 49, 15%), transportation (n = 36, 11%), and use of reminders (n = 28, 9%). CONCLUSIONS: Consumers suggest that interventions may include providing more information and reminding doctors to order the tests and patients to complete the tests.

Epidemiology and Economic Burden of Serotonin Syndrome With Concomitant Use of Serotonergic Agents: A Retrospective Study Utilizing Two Large US Claims Databases.

OBJECTIVE: Serotonin syndrome (SS) is an adverse drug reaction occurring among patients receiving serotonergic agents (SAs), and although SAs are commonly prescribed, the epidemiology and economic burden of SS with concomitant SA use have not been comprehensively examined. The objective of this study was to investigate the prevalence, incidence, and economic burden of SS with SA use. METHODS: A retrospective cohort study was conducted using Veterans Health Administration (VHA) records (identification period: October 1, 2008-September 30, 2012) and commercially insured patient records (Intercontinental Marketing Services PharMetrics Plus; identification period: January 1, 2010-December 31, 2013). Cohorts were based on drug classification and exposure: single monoamine oxidase inhibitor (MAOI), MAOIs in combination with SAs, single non-MAOI SA, and multiple non-MAOI SAs (2, 3, 4, ≥ 5). Participants were aged ≥ 18 years with continuous health plan enrollment for 12 months prior to the first SA claim. Outcomes were SS events (ICD-9-CM: 333.99), annual incidence and prevalence, related health care utilization and costs, and SS incidence relative risk. RESULTS: Over 15 million patients were identified and categorized by SA prescription type. SS incidence in both populations decreased: 0.19%-0.07% (VHA) and 0.17%-0.09% (commercially insured). Overall SS prevalence decreased during the study period. Compared to single non-MAOI SA patients, SS incidence relative risk was highest among patients prescribed ≥ 5 non-MAOI SAs. Inpatient stays accounted for 4.35% (VHA) and 0.88% (commercially insured) of all SS events. Of SS-related inpatient stays, median costs were $8,765 (VHA) and $10,792 (commercially insured). CONCLUSIONS: SS incidence and prevalence and SS-related hospitalization risk among patients prescribed SAs were low in both populations. This study provides additional information regarding SS risk associated with SA use.

Integrated Care at the Interface of Psychiatry and Primary Care: Prevention of Cardiovascular Disease.

Patients with mental illness, particularly serious mental illness, are more likely to suffer from common disorders without optimal treatment. Changes in preventive practice patterns cannot be fully realized on a large scale until clinicians are trained how to routinely provide this care. Psychiatrists may consider using preventive care strategies in the area of cardiovascular health, as cardiovascular disease is the most common cause of death and disproportionately affects patients with mental illness. At minimum, psychiatrists are well positioned to work collaboratively with primary care providers to address psychopathology that may interfere with adherence to the treatment plan.

Understanding preventive health screening services use in persons with serious mental illness: how does integrated behavioral health primary care compare?

OBJECTIVE: People with serious mental illness have reduced life expectancy, in large part due to reduced access to medical services and underutilization of preventive health services. This is a cross-sectional study that compared preventive services use in an integrated behavioral health primary care clinic (IBHPC) with two existing community mental health programs. METHODS: Participants completed questionnaires about preventive health services use that contained 33 questions about demographic clinical information, and use of preventive health services, from October 2010 to December 2012. Services examined included mammogram, Papanicolaou Test, prostate specific antigen, digital rectal exam, fecal occult blood test, and flexible sigmoidoscopy or colonoscopy; blood pressure, height and weight, cholesterol, and blood sugar for diabetes; and influenza immunization, Hepatitis C Virus (HCV), and Human Immunodeficiency Virus (HIV) antibodies. A health service utilization score was developed and used as primary outcome for data analyses. RESULTS: In the multivariate analyses female gender (p < 0.05), race/ethnicity (p = 0.01 for Asian, p = 0.04 for Hispanic/Latino, both compared to White), program type (p < 0.001), and having a primary care provider (p < 0.001) were significant predictors of higher services use. IBHPC was associated with higher overall service utilization compared to one community mental health program (p < 0.001) but was similar when compared another (p = 0.34). There was high variability in use of individual services among the clinical programs. CONCLUSION: More studies are needed to examine the effectiveness of integrated care in improving use of health screening services. Characteristics of the clinic in relation to use of preventive services deserve further study.