Determinants of experience & satisfaction in telehealth psychiatry during the COVID-19 pandemic for patients & providers.

Introduction: The objective of this study was to characterize the experiences and overall satisfaction of patients and providers with the March 2020 transition to telehealth in a psychiatric setting (telepsychiatry). The study also investigated how socio-demographic and clinical characteristics impact an individual's experiences and satisfaction with telepsychiatry. Methods: Responses were collected from 604 patients and 154 providers engaged in clinical care at one of three participating Johns Hopkins Medicine outpatient psychiatric clinics between January 2020-March 2021. Survey data were collected by self-report via Qualtrics or telephone follow-up. Results: Respondents were predominately female and White. Over 70% of patients and providers were generally satisfied with telepsychiatry. However, providers were more likely to favor in-person care over telepsychiatry for post-pandemic care 48% to 17% respectively, while 35% rated both modalities equivalently. Patients were more evenly divided with 45% preferring telepsychiatry compared to 42% for in-person care, and only 13% rating them equivalently. Among providers, technical difficulties were significantly associated with both less satisfaction and lower preference for telepsychiatry [odds ratio for satisfaction (ORS) = 0.12; odds ratio for preference (ORP) = 0.13]. For patients, factors significantly associated with both lower satisfaction and lower preference for telepsychiatry included technical difficulties (ORS = 0.20; ORP = 0.41), unstable access to the internet (ORS = 0.46; ORP = 0.50), worsening depression (ORS = 0.38; ORP = 0.36), and worsening anxiety (ORS = 0.41; ORP = 0.40). Factors associated with greater satisfaction and higher preference for telepsychiatry among patients included higher education (ORS = 2.13; ORP = 1.96) and a decrease in technical difficulties over time (ORS = 2.86; ORP = 2.35). Discussion: Patients and providers were satisfied with telepsychiatry. However, there were greater differences between them in preferences for continuing to use telepsychiatry post-pandemic. These findings highlight factors that influence patient and provider preferences and should be addressed to optimize the use of telepsychiatry in the future.

Healthcare Worker Mental Health After the Initial Peak of the COVID-19 Pandemic: a US Medical Center Cross-Sectional Survey.

BACKGROUND: There is a paucity of data on the mental health impact of the Coronavirus disease 2019 (COVID-19) pandemic on United States (US) healthcare workers (HCWs) after the first surge in the spring of 2020. OBJECTIVE: To determine the impact of the pandemic on HCWs, and the relationship between HCW mental health and demographics, occupational factors, and COVID-19 concerns. DESIGN: Cross-sectional survey in an urban medical center (September-November 2020) in Baltimore, MD, in the United States. PARTICIPANTS: A total of 605 HCWs (physicians, nurse practitioners, nurses, physician assistants, patient care technicians, respiratory therapists, social workers, mental health therapists, and case managers). MAIN MEASURES: Measures of mental health (Patient Health Questionnaire-2, Generalized Anxiety Disorder-7, PROMIS Sleep Disturbance 4a, Impact of Event Scale-Revised, Maslach Burnout Inventory-2 item, Connor-Davidson Resilience Scale-2 item), demographics, occupational factors, and COVID-19 related concerns. KEY RESULTS: Fifty-two percent of 1198 HCWs responded to the survey and 14.2% reported depression, 43.1% mild or higher anxiety, 31.6% sleep disturbance, 22.3% posttraumatic stress symptoms, 21.6% depersonalization, 46.0% emotional exhaustion, and 23.1% lower resilience. Relative to HCWs providing in-person care to COVID-19 infected patients none of their working days, those doing so all or most days were more likely to experience worse depression (adjusted odds ratio, 3.9; 95% CI, 1.3-11.7), anxiety (aOR, 3.0; 95% CI, 1.4-6.3), possible PTSD symptoms (aOR, 2.6; 95% CI, 1.1-5.8), and higher burnout (aOR, 2.6; 95% CI, 1.1-6.0). Worse mental health in several domains was associated with higher health fear (aORs ranged from 2.2 to 5.0), job stressors (aORs ranged from 1.9 to 4.0), perceived social stigma/avoidance (aORs ranged from 1.8 to 2.9), and workplace safety concerns (aORs ranged from 1.8 to 2.8). CONCLUSIONS: US HCWs experienced significant mental health symptoms eight months into the pandemic. More time spent providing in-person care to COVID-19-infected patients and greater COVID-19-related concerns were consistently associated with worse mental health.

Mental Health of Staff at Correctional Facilities in the United States During the COVID-19 Pandemic.

BACKGROUND: Although United States (US) correctional workers (correctional officers and health care workers at correctional institutions) have experienced unprecedented stress during the COVID-19 pandemic, to date, there are no systematic data on the mental health impact of COVID-19 on correctional workers. OBJECTIVE: To determine the perceived mental health burden of the COVID-19 pandemic on correctional workers and to explore the relationship between workers' mental health, social demographics, and environmental/work factors. In particular, the study sought to examine if occupational role (correctional officers vs. health care workers) or sex were associated with mental health status. METHODS: This cross-sectional survey was conducted in 78 correctional sites in Pennsylvania, Maryland, West Virginia and New York from November 1 to December 1, 2020. There were 589 participants, including 103 correctional officers and 486 health care workers employed at the correctional facilities. Measurements included the Patient Health Questionnaire-9, Generalized Anxiety Disorder-7, Adult PROMIS Short Form v.1.0-Sleep Disturbance, Impact of Event Scale-Revised, Maslach Burnout Inventory 2-item, and Connor-Davidson Resilience Scale 2-item. RESULTS: Approximately 48% of healthcare workers and 32% of correctional officers reported mild to severe depressive symptoms, 37% reported mild to severe anxiety symptoms, 47% of healthcare workers and 57% of correctional officers reported symptoms of burnout, and 50% of healthcare workers and 45% of correctional officers reported post-traumatic stress symptoms. Approximately 18% of healthcare workers and 11% of correctional officers reports mild to moderate sleep disturbance. Health care workers had significantly higher depression and sleep disturbance scores than did correctional officers, while correctional officers had significantly higher burnout scores. Female correctional workers scored significantly higher on anxiety than their male counterparts. Increased workload, workplace conflict, younger age of employees, trust in institutional isolation practices, and lower work position were associated with increased burnout. Despite experiencing high mental health burden, correctional workers showed high resilience (60%). CONCLUSION: We found a high level of psychological symptoms among health care workers in correctional settings, and this population may experience unique challenges, risks and protective factors relative to other health care workers outside of correctional settings. Understanding these factors is essential for developing effective interventions for correctional workers.

Provider perceived barriers and facilitators to integrating routine outcome monitoring into practice in an urban community psychiatry clinic: A mixed-methods quality improvement project.

BACKGROUND AND AIMS: Although mental health clinics are under increasing pressure to demonstrate value and routine outcome monitoring (ROM) has become a mandated component of care, providers have been slow to adopt ROM into practice, with some estimating that less than 20% of mental health clinicians use it consistently in the United States. This article explores perceived barriers and facilitators to integrating ROM into practice among clinicians and administrators in a large urban US community psychiatry clinic. METHOD: One hundred and thirty-eight clinical and administrative staff were administered an anonymous web-based survey to elicit attitudes towards ROM. Responses were summarized descriptively and qualitatively synthesized into a conceptual model using inductive thematic analysis. RESULTS: Common barriers to integration included insufficient time to collect and/or use measures, not knowing what measures to use, measures being difficult to access, and insufficient training. Facilitators included increased access/ease of use, training and support, measure relevance/validity, and accountability. CONCLUSIONS: In order for psychiatry clinics to successfully implement ROM into practice, they must diagnose organization-side barriers and translate this knowledge into actionable quality improvement initiatives ranging from the infrastructural to the cultural.

The utility of PHQ-9 and CGI-S in measurement-based care for predicting suicidal ideation and behaviors.

BACKGROUND: Measurement-based care (MBC) has emerged as an effective strategy for improving outcomes in patients with mood disorders. Suicide is a particularly devastating outcome of mood disorders. Using data from a new MBC program from the National Network of Depression Centers (NNDC), we examined whether capturing a patient-rated symptom measure, the patient health questionnaire (PHQ-9), along with a provider-rated global functioning measure, the clinical global impression scale (CGI-S), improves identification of patients at risk of suicide over using either measure alone. METHODS: A total of 126 adults with mood disorders from nine sites in the NNDC completed the PHQ-9 and CGI-S and had at least one subsequent visit where they completed the Columbia-suicide severity rating scale (C-SSRS). The PHQ-9 (≥10) and CGI-S (≥4) were dichotomized at commonly accepted severity thresholds. Associations of the PHQ-9 and CGI-S with suicidal ideation or behavior were examined using Firth's logistic regression to accommodate small samples while controlling for age, sex, race, and diagnosis. RESULTS: Patients who scored higher on only the PHQ-9 or CGI-S were not significantly more likely to experience subsequent suicidal ideation or behaviors. However, patients who scored higher on both the PHQ-9 and CGI-S were significantly more likely to experience suicidal ideation (OR = 4.70, p = 0.0005) and suicidal behaviors (OR = 25.38, p = 0.0003). DISCUSSION: Information from both patient and clinician-rated measures was better able to identify patients with mood disorders at risk for suicidal ideation and behaviors. Using both together may help reduce the risk of suicide by identifying those patients at greatest risk and allowing for more targeted interventions.

Measuring the time course of selection during visual search.

In visual search tasks, observers can guide their attention towards items in the visual field that share features with the target item. In this series of studies, we examined the time course of guidance toward a subset of items that have the same color as the target item. Landolt Cs were placed on 16 colored disks. Fifteen distractor Cs had gaps facing up or down while one target C had a gap facing left or right. Observers searched for the target C and reported which side contained the gap as quickly as possible. In the absence of other information, observers must search at random through the Cs. However, during the trial, the disks changed colors. Twelve disks were now of one color and four disks were of another color. Observers knew that the target C would always be in the smaller color set. The experimental question was how quickly observers could guide their attention to the smaller color set. Results indicate that observers could not make instantaneous use of color information to guide the search, even when they knew which two colors would be appearing on every trial. In each study, it took participants 200-300 ms to fully utilize the color information once presented. Control studies replicated the finding with more saturated colors and with colored C stimuli (rather than Cs on colored disks). We conclude that segregation of a display by color for the purposes of guidance takes 200-300 ms to fully develop.

Mobile technology for medication adherence in people with mood disorders: A systematic review.

BACKGROUND: Medication non-adherence is a critical challenge for many patients diagnosed with mood disorders (Goodwin and Jamison, 1990). There is a need for alternative strategies that improve adherence among patients with mood disorders that are cost-effective, able to reach large patient populations, easy to implement, and that allow for communication with patients outside of in-person visits. Technology-based approaches to promote medication adherence are increasingly being explored to address this need. The aim of this paper is to provide a systematic review of the use of mobile technologies to improve medication adherence in patients with mood disorders. METHODS: A total of nine articles were identified as describing mobile technology targeting medication adherence in mood disorder populations. RESULTS: Results showed overall satisfaction and feasibility of mobile technology, and reduction in mood symptoms; however, few examined effectiveness of mobile technology improving medication adherence through randomized control trials. LIMITATIONS: Given the limited number of studies, further research is needed to determine long term effectiveness. CONCLUSIONS: Mobile technologies has the potential to improve medication adherence and can be further utilized for symptom tracking, side effects tracking, direct links to prescription refills, and provide patients with greater ownership over their treatment progress.

Measuring stigma affecting sex workers (SW) and men who have sex with men (MSM): A systematic review.

BACKGROUND: Stigma involves discrediting a person or group based on a perceived attribute, behaviour or reputation associated with them. Sex workers (SW) and men who have sex with men (MSM) are key populations who are often at increased risk for the acquisition and transmission of HIV and who are affected by stigma that can negatively impact their health and well-being. Although stigma was included as an indicator in the US National HIV/AIDS Strategic Plan and there have been consultations focused on adding a stigma indicator within PEPFAR and the Global Fund in relation to potentiating HIV risks among key populations, there remains limited consensus on the appropriate measurement of SW- or MSM-associated stigma. Consequently, this systematic review summarizes studies using quantitative, qualitative, or mixed methods approaches to measure stigma affecting sex workers and men who have sex with men. METHODS AND FINDINGS: This systematic review included English, French, and Spanish peer-reviewed research of any study design measuring SW- or MSM-associated stigma. Articles were published from January 1, 2004 to March 26, 2014 in PsycINFO, PubMed, EMBASE, CINAHL Plus, Global Health, and World Health Organization Global Health Library Regional Indexes. Of the 541 articles reviewed, the majority measured stigma toward MSM (over 97%), were conducted in North America, used quantitative methods, and focused on internalized stigma. CONCLUSIONS: With the inclusion of addressing stigma in several domestic and international HIV strategies, there is a need to ensure the use of validated metrics for stigma. The field to date has completed limited measurement of stigma affecting sex workers, and limited measurement of stigma affecting MSM outside of higher income settings. Moving forward requires a concerted effort integrating validated metrics of stigma into health-related surveys and programs for key populations.

Implementing and Evaluating a Counseling Program in Partnership With a Community-based Domestic Violence Service Provider.

BACKGROUND: Given the burden of intimate partner violence (IPV), effective counseling interventions that are accessible to women in their own communities are needed. OBJECTIVES: To describe the collaborative process of implement ing and evaluating a new counseling program for IPV-the Women's Initiative for Safety and Health (WISH)-in a community setting and present results of its Thrst pilot test. METHODS: WISH is a stage-tailored, eight-session counseling program based on the transtheoretical model. Imple men tation evaluation addressed program exposure/Thdelity, counselor experience, and client experience. Outcome evaluation measured change in IPV-related incidents, self-efficacy, decisional balance, overall health, quality of life, and stage of change among 19 women. RESULTS: Both counselors and clients perceived the WISH intervention positively. Across all outcomes, there were improvements among some women, most notably in perceived self-efficacy, decisional balance, and stage of change. CONCLUSIONS: Academic-community partnerships can facilitate the translation of theory-based interventions for use in community-based settings.

Academic physicians' and medical students' perceived barriers toward bystander administered naloxone as an overdose prevention strategy.

AIMS: To identify perceived barriers to the prescription of naloxone to third-party contacts of opiate users. DESIGN: Qualitative descriptive study. SETTING: Two academic hospitals in Baltimore, MD, USA. PARTICIPANTS: Thirty medical providers, including both physicians and medical students. MEASUREMENTS: Qualitative; in-depth interviews and focus groups analyzed using line-by-line, focused, and axial coding based on methods adapted from grounded theory. FINDINGS: Academic physicians and medical students cited three categories of barriers to naloxone prescription related to drug, provider, and patient characteristics. Concerns about naloxone itself included inability to prevent addictive behaviors, duration of action, medical risks, expiration date, and route of administration. Concerns about medical providers included lack of knowledge or experience, medical community common practices and norms, insufficient provision of third-party education, physician and clinic scheduling practices, worry about insulting patients, and fear of being viewed as enabling drug abuse. Concerns about patients included increased risk-taking behaviors, opiate withdrawal symptoms, potential repeat overdose related to withdrawal-discomfort, decreased contact with medical providers, and stigma. CONCLUSIONS: Minimizing barriers to naloxone provision may increase acceptability and prescription practice in the medical community. Addressing these barriers from multiple provider perspectives is critical to advance naloxone prescription as a harm reduction strategy, which has the potential to prevent opiate overdoses.

Addressing spirituality within the care of patients at the end of life: perspectives of patients with advanced cancer, oncologists, and oncology nurses.

PURPOSE: Attention to patients' religious and spiritual needs is included in national guidelines for quality end-of-life care, but little data exist to guide spiritual care. PATIENTS AND METHODS: The Religion and Spirituality in Cancer Care Study is a multi-institution, quantitative-qualitative study of 75 patients with advanced cancer and 339 cancer physicians and nurses. Patients underwent semistructured interviews, and care providers completed a Web-based survey exploring their perspectives on the routine provision of spiritual care by physicians and nurses. Theme extraction was performed following triangulated procedures of interdisciplinary analysis. Multivariable ordinal logistic regression models assessed relationships between participants' characteristics and attitudes toward spiritual care. RESULTS: The majority of patients (77.9%), physicians (71.6%), and nurses (85.1%) believed that routine spiritual care would have a positive impact on patients. Only 25% of patients had previously received spiritual care. Among patients, prior spiritual care (adjusted odds ratio [AOR], 14.65; 95% CI, 1.51 to 142.23), increasing education (AOR, 1.26; 95% CI, 1.06 to 1.49), and religious coping (AOR, 4.79; 95% CI, 1.40 to 16.42) were associated with favorable perceptions of spiritual care. Physicians held more negative perceptions of spiritual care than patients (P < .001) and nurses (P = .008). Qualitative analysis identified benefits of spiritual care, including supporting patients' emotional well-being and strengthening patient-provider relationships. Objections to spiritual care frequently related to professional role conflicts. Participants described ideal spiritual care to be individualized, voluntary, inclusive of chaplains/clergy, and based on assessing and supporting patient spirituality. CONCLUSION: Most patients with advanced cancer, oncologists, and oncology nurses value spiritual care. Themes described provide an empirical basis for engaging spiritual issues within clinical care.

Varying target prevalence reveals two dissociable decision criteria in visual search.

Target prevalence powerfully influences visual search behavior. In most visual search experiments, targets appear on at least 50% of trials [1-3]. However, when targets are rare (as in medical or airport screening), observers shift response criteria, leading to elevated miss error rates [4, 5]. Observers also speed target-absent responses and may make more motor errors [6]. This could be a speed/accuracy tradeoff with fast, frequent absent responses producing more miss errors. Disproving this hypothesis, our experiment one shows that very high target prevalence (98%) shifts response criteria in the opposite direction, leading to elevated false alarms in a simulated baggage search. However, the very frequent target-present responses are not speeded. Rather, rare target-absent responses are greatly slowed. In experiment two, prevalence was varied sinusoidally over 1000 trials as observers' accuracy and reaction times (RTs) were measured. Observers' criterion and target-absent RTs tracked prevalence. Sensitivity (d') and target-present RTs did not vary with prevalence [7-9]. These results support a model in which prevalence influences two parameters: a decision criterion governing the series of perceptual decisions about each attended item, and a quitting threshold that governs the timing of target-absent responses. Models in which target prevalence only influences an overall decision criterion are not supported.

The impact of multiple types of child maltreatment on subsequent risk behaviors among women during the transition from adolescence to young adulthood.

The purpose of this study was to investigate how different types of child maltreatment, independently and collectively, impact a wide range of risk behaviors that fall into three domains: sexual risk behaviors, delinquency, and suicidality. Cumulative classification and Expanded Hierarchical Type (EHT) classification approaches were used to categorize various types of maltreatment. Data were derived from Wave III of the National Longitudinal Study of Adolescent Health (Add Health). Our sample consisted of White, Black, Hispanic, and Asian females ages 18 to 27 (n = 7,576). Experiencing different kinds of maltreatment during childhood led to an extensive range of risk behaviors within the three identified domains. Women experiencing sexual abuse plus other maltreatment types had the poorest outcomes in all three domains. These findings illustrate that it may no longer be appropriate to assume that all types of maltreatment are equivalent in their potential contribution to negative developmental sequelae.

Even in correctable search, some types of rare targets are frequently missed.

Socially important visual search tasks, such as airport baggage screening and tumor detection, place observers in situations where the targets are rare and the consequences of failed detection are substantial. Recent laboratory studies have demonstrated that low target prevalence yields substantially higher miss errors than do high-prevalence conditions, in which the same targets appear frequently (Wolfe, Horowitz, & Kenner, 2005; Wolfe et al., 2007). Under some circumstances, this "prevalence effect" can be eliminated simply by allowing observers to correct their last response (Fleck & Mitroff, 2007). However, in three experiments involving search of realistic X-ray luggage images, we found that the prevalence effect is eliminated neither by giving observers the choice to correct a previous response nor by requiring observers to confirm their responses. This prevalence effect, obtained when no trial-by-trial feedback was given, was smaller than the effect obtained when observers searched through the same stimuli but were given trial-by-trial feedback about accuracy. We suggest that low prevalence puts pressure on observers in any search task, and that the diverse symptoms of that pressure manifest themselves differently in different situations. In some relatively simple search tasks, misses may result from motor or response errors. In other, more complex tasks, shifts in decision criteria appear to be an important contributor.

In visual search, guidance by surface type is different than classic guidance.

Visual search for targets among distractors is more efficient if attention can be guided to targets by attributes like color. In real-world search, we guide attention using information about surfaces (e.g., paintings are on walls). We compare "classic" color guidance to surface guidance in "scenes" of cubes. When a target can lie on one of many surfaces, color guidance is effective but surface guidance is not (Experiments 1-3). Surface guidance works when cued surfaces are coplanar (Experiment 4) or few in number (Experiment 5). We speculate that surface guidance is slow and limited to very few surfaces at one time.

Why do we miss rare targets? Exploring the boundaries of the low prevalence effect.

Observers tend to miss a disproportionate number of targets in visual search tasks with rare targets. This 'prevalence effect' may have practical significance since many screening tasks (e.g., airport security, medical screening) are low prevalence searches. It may also shed light on the rules used to terminate search when a target is not found. Here, we use perceptually simple stimuli to explore the sources of this effect. Experiment 1 shows a prevalence effect in inefficient spatial configuration search. Experiment 2 demonstrates this effect occurs even in a highly efficient feature search. However, the two prevalence effects differ. In spatial configuration search, misses seem to result from ending the search prematurely, while in feature search, they seem due to response errors. In Experiment 3, a minimum delay before response eliminated the prevalence effect for feature but not spatial configuration search. In Experiment 4, a target was present on each trial in either two (2AFC) or four (4AFC) orientations. With only two response alternatives, low prevalence produced elevated errors. Providing four response alternatives eliminated this effect. Low target prevalence puts searchers under pressure that tends to increase miss errors. We conclude that the specific source of those errors depends on the nature of the search.

Low target prevalence is a stubborn source of errors in visual search tasks.

In visual search tasks, observers look for targets in displays containing distractors. Likelihood that targets will be missed varies with target prevalence, the frequency with which targets are presented across trials. Miss error rates are much higher at low target prevalence (1%-2%) than at high prevalence (50%). Unfortunately, low prevalence is characteristic of important search tasks such as airport security and medical screening where miss errors are dangerous. A series of experiments show this prevalence effect is very robust. In signal detection terms, the prevalence effect can be explained as a criterion shift and not a change in sensitivity. Several efforts to induce observers to adopt a better criterion fail. However, a regime of brief retraining periods with high prevalence and full feedback allows observers to hold a good criterion during periods of low prevalence with no feedback.