Mental Health Community and Health System Issues in COVID-19: Lessons from Academic, Community, Provider and Policy Stakeholders.

The coronavirus pandemic of 2019 (COVID-19) has created unprecedented changes to everyday life for millions of Americans due to job loss, school closures, stay-at-home orders and health and mortality consequences. In turn, physicians, academics, and policymakers have turned their attention to the public mental health toll of COVID-19. This commentary reporting from the field integrates perceptions of academic, community, health system, and policy leaders from state, county, and local levels in commenting on community mental health needs in the COVID-19 pandemic. Stakeholders noted the broad public health scope of mental health challenges while expressing concern about exacerbation of existing disparities in access and adverse social determinants, including for communities with high COVID-19 infection rates, such as African Americans and Latinos. They noted rapid changes toward telehealth and remote care, and the importance of understanding impacts of changes, including who may benefit or have limited access, with implications for future services delivery. Needs for expanded workforce and training in mental health were noted, as well as potential public health value of expanding digital resources tailored to local populations for enhancing resilience to stressors. The COVID-19 pandemic has led to changes in delivery of health care services across populations and systems. Concerns over the mental health impact of COVID-19 has enhanced interest in remote mental care delivery and preventive services, while being mindful of potential for enhanced disparities and needs to address social determinants of health. Ongoing quality improvement across systems can integrate lessons learned to enhance a public mental well-being.

Post-traumatic stress disorder: the neurobiological impact of psychological trauma.

The classic fight-or-flight response to perceived threat is a reflexive nervous phenomenon thai has obvious survival advantages in evolutionary terms. However, the systems that organize the constellation of reflexive survival behaviors following exposure to perceived threat can under some circumstances become dysregulated in the process. Chronic dysregulation of these systems can lead to functional impairment in certain individuals who become "psychologically traumatized" and suffer from post-traumatic stress disorder (PTSD), A body of data accumulated over several decades has demonstrated neurobiological abnormalities in PTSD patients. Some of these findings offer insight into the pathophysiology of PTSD as well as the biological vulnerability of certain populations to develop PTSD, Several pathological features found in PTSD patients overlap with features found in patients with traumatic brain injury paralleling the shared signs and symptoms of these clinical syndromes.

Barriers and strategies for improving communication between inpatient and outpatient mental health clinicians.

OBJECTIVES: To explore hospital leaders' perceptions of organisational factors as barriers and/or facilitators in improving inpatient-outpatient (IP-OP) communication. DESIGN: Semistructured in-person interviews. ANALYSIS: Constant comparative method of qualitative data. SETTING: Inpatient psychiatry units in 33 general medical/surgical and specialty psychiatric hospitals in California and Massachusetts (USA). PARTICIPANTS: Psychiatry chair/chief, service director or medical director. VARIABLES: Importance to leadership, resources, organisational structure and culture. RESULTS: A majority of hospital leaders rated the IP-OP communication objective as highly or moderately important. Hospitals with good IP-OP communication had structures in place to support communication or had changed/implemented new procedures to enhance communication, and anticipated clinicians would 'buy in' to the goal of improved communication. Hospitals reporting no improvement efforts were less likely to have structures supporting IP-OP communication, anticipated resistance among clinicians and reported a need for technological resources such as electronic health records, integrated IT and secure online communication. Most leaders reported a need for additional staff time and information, knowledge or data. CONCLUSIONS: For many hospitals, successfully improving communication will require overcoming organisational barriers such as cultures not conducive to change and lack of resources and infrastructure. Creating a culture that values communication at discharge may help improve outcomes following hospitalisation, but changes in healthcare delivery in the past few decades may necessitate new strategies or changes at the systems level to address barriers to effective communication.

Classification of spatially unaligned fMRI scans.

The analysis of fMRI data is challenging because they consist generally of a relatively modest signal contained in a high-dimensional space: a single scan can contain millions of voxel recordings over space and time. We present a method for classification and discrimination among fMRI that is based on modeling the scans as distance matrices, where each matrix measures the divergence of spatial network signals that fluctuate over time. We used single-subject independent components analysis (ICA), decomposing an fMRI scan into a set of statistically independent spatial networks, to extract spatial networks and time courses from each subject that have unique relationship with the other components within that subject. Mathematical properties of these relationships reveal information about the infrastructure of the brain by measuring the interaction between and strength of the components. Our technique is unique, in that it does not require spatial alignment of the scans across subjects. Instead, the classifications are made solely on the temporal activity taken by the subject's unique ICs. Multiple scans are not required and multivariate classification is implementable, and the algorithm is effectively blind to the subject-uniform underlying task paradigm. Classification accuracy of up to 90% was realized on a resting-scanned schizophrenia/normal dataset and a tasked multivariate Alzheimer's/old/young dataset. We propose that the ICs represent a plausible set of imaging basis functions consistent with network-driven theories of neural activity in which the observed signal is an aggregate of independent spatial networks having possibly dependent temporal activity.

In vivo evidence of differential impact of typical and atypical antipsychotics on intracortical myelin in adults with schizophrenia.

CONTEXT: Imaging and post-mortem studies provide converging evidence that patients with schizophrenia have a dysregulated developmental trajectory of frontal lobe myelination. The hypothesis that typical and atypical medications may differentially impact brain myelination in adults with schizophrenia was previously assessed with inversion recovery (IR) images. Increased white matter (WM) volume suggestive of increased myelination was detected in the patient group treated with an atypical antipsychotic compared to a typical one. OBJECTIVE: In a follow-up reanalysis of MRI images from the original study, we used a novel method to assess whether the difference in WM volumes could be caused by a differential effect of medications on the intracortical myelination process. DESIGN, SETTING, AND PARTICIPANTS: Two different male cohorts of healthy controls ranging in age from 18-35 years were compared to cohorts of subjects with schizophrenia who were treated with either oral risperidone (Ris) or fluphenazine decanoate (Fd). MAIN OUTCOME MEASURE: A novel MRI method that combines the distinct tissue contrasts provided by IR and proton density (PD) images was used to estimate intracortical myelin (ICM) volume. RESULTS: When compared with their pooled healthy control comparison group, the two groups of schizophrenic patients differed in the frontal lobe ICM measure with the Ris group having significantly higher volume. CONCLUSIONS: The data suggest that in adults with schizophrenia antipsychotic treatment choice may be specifically and differentially impacting later-myelinating intracortical circuitry. In vivo MRI can be used to dissect subtle differences in brain tissue characteristics and thus help clarify the effect of pharmacologic treatments on developmental and pathologic processes.