Risk factors for developing depressive symptoms in the immediate postoperative period after Mohs micrographic surgery.

PURPOSE: Mohs micrographic surgery (MMS) is a highly efficacious, tissue sparing method of skin cancer removal. Nevertheless, in the months to years after MMS, psychosocial distress has been described. The present study addressed the immediate period after MMS and assessed the frequency and risk factors for development of depressive symptoms. METHODS: Subjects undergoing MMS at two physician practices (JL, FS) were included in this prospective cohort study. Preoperatively, a standardized depression screening, the Patient Health Questionnaire-8 (PHQ-8), was administered. After MMS, the PHQ-8 was readministered at weeks 1, 2, 4, 6, and 12. Average PHQ-8 score by week and change from baseline PHQ-8 score were the primary outcomes. RESULTS: Sixty-three subjects were included of which 49 (78%) had a facial site. Twenty-two subjects (35%) had some increase in score during the 12-week follow-up period, of which 18 had a facial site. The oldest subjects (83-99 years, n = 14) had significantly higher PHQ-8 scores at week 4 (p < 0.01) and week 6 (p = 0.02) than all other age groups. There were no differences in scores between location groups. CONCLUSIONS: One-third of subjects had some increase in score during the follow-up period. Those in the oldest age cohort were at highest risk of increased score. In contrast to prior literature, those with facial sites were not at higher risk. This difference may be explained by increased masking during the ongoing COVID-19 pandemic. Ultimately, consideration of patients' psychologic status in the immediate postoperative period after MMS, particularly in the elderly population, may enhance perceived patient outcomes.

Integrating Behavioral Health and Serious Illness Care in a Post-COVID-19 Environment.

Individuals with serious medical illnesses experience high rates of comorbid behavioral health conditions. Behavioral health comorbidity affects outcomes in serious illness care. Despite this consequence, behavioral health remains siloed from serious illness care. Prior to the COVID-19 pandemic, the authors presented a conceptual model of behavioral health integration into serious illness care. In this column, the authors reflect on this model in the context of the challenges and opportunities posed by COVID-19.

Palliative Care Training for Consultation-Liaison Psychiatry Fellows: A National Survey Project.

BACKGROUND: Provision of palliative care is part of the standard of care for patients with serious, life-limiting medical illnesses. Patients in the palliative care setting have high rates of psychiatric co-morbidity. However, integration of mental health care into palliative care remains a significant gap. With appropriate training, consultation-liaison (C-L) psychiatrists are well-positioned to improve integration of mental health into palliative care. PURPOSE: To understand current palliative care training practices for C-L psychiatry fellows in the United States. METHOD: We invited all U.S. C-L psychiatry fellowship program directors to participate in a 17-item online structured survey aimed at understanding palliative care training in their fellowship programs. RESULTS: 37/61 (61%) of C-L psychiatry fellowship program directors responded to the survey. Eighty-six percent of programs provide some palliative care didactics, but the topics covered vary widely. Programs are closely split between offering a required, elective, or no clinical palliative care experiences. Only about half (45%) of programs identify formal opportunities for interaction between palliative care and C-L psychiatry fellows. Program directors identified topics such as goals-of-care discussions, systems issues in end-of-life care, and pain management as important for fellows to learn. Barriers to teaching these topics included time, lack of teaching faculty, and disciplinary siloes. CONCLUSIONS: Although C-L psychiatry fellowship program directors identify a number of key teaching topics in palliative care for C-L psychiatry fellows, there are wide discrepancies in the depth and content of existing palliative care didactic and clinical experiences in C-L psychiatry fellowships.

Bridging the Behavioral Health Gap in Serious Illness Care: Challenges and Strategies for Workforce Development.

Comorbidity with behavioral health conditions is highly prevalent among those experiencing serious medical illnesses and is associated with poor outcomes. Siloed provision of behavioral and physical healthcare has contributed to a workforce ill-equipped to address the often complex needs of these clinical populations. Trained specialist behavioral health providers are scarce and there are gaps in core behavioral health competencies among serious illness care providers. Core competency frameworks to close behavioral health training gaps in primary care exist, but these have not extended to some of the distinct skills and roles required in serious illness care settings. This paper seeks to address this issue by describing a common framework of training competencies across the full spectrum of clinical responsibility and behavioral health expertise for those working at the interface of behavioral health and serious illness care. The authors used a mixed-method approach to develop a model of behavioral health and serious illness care and to delineate seven core skill domains necessary for practitioners working at this interface. Existing opportunities for scaling-up the workforce as well as priority policy recommendation to address barriers to implementation are discussed.

A Model to Improve Behavioral Health Integration into Serious Illness Care.

Behavioral health problems are highly prevalent among people with serious medical illness. Individuals living with these comorbidities have complex clinical and social needs yet face siloed care, high health care costs, and poor outcomes. Interacting factors contribute to these inequalities including historical separation of behavioral and physical health provision. Several care models for integrating behavioral health and general medical care have been developed and tested, but the evidence base focuses primarily on primary care populations and settings. This article advances that work by proposing a Behavioral Health-Serious Illness Care model. Developed through a mixed methods approach combining literature review, surveys, interviews, and input from an expert advisory panel, it provides a conceptual framework of building blocks for behavioral health integration tailored to serious illness care populations and the range of settings in which they receive care. The model is intended to serve as foundation to support the development and implementation of integrated behavioral health and serious illness care. The key components of the model are described, barriers to implementation discussed, and recommendations for policy approaches to address these barriers presented.

A randomized trial of interpersonal psychotherapy, problem solving therapy, and supportive therapy for major depressive disorder in women with breast cancer.

PURPOSE: Breast cancer (BC) is a risk factor for major depressive disorder (MDD), yet little research has tested the efficacy of different psychotherapies for depressed women with BC. This study, the largest to date, compared outcomes of three evidence-based, 12-week therapies in treating major depressive disorder among women with breast cancer. METHODS: This randomized trial compared interpersonal psychotherapy (IPT), problem solving therapy (PST), and brief supportive psychotherapy (BSP). Conducted at the outpatient clinic of the New York State Psychiatric Institute/Columbia University, the trial offered bilingual treatment by treatment-specific psychotherapists supervised by treatment experts. The primary outcome was change in the Hamilton Depression Rating Scale (HAM-D) at 12 weeks. Secondary outcomes included other validated patient-reported outcomes for depression and quality of life. RESULTS: Of 179 women with breast cancer screening positive for depression at the Columbia Cancer Center, 134 eligible patients signed informed treatment consent. Half of patients were Hispanic and economically disadvantaged. Most women had stage I (35.2%) or II (36.9%) BC; 9% had stage IV. The three brief psychotherapies showed similar improvements on the HAM-D, with large pre-post effect sizes (d ~ 1.0); a priori defined response rates were 35% for IPT, 50% for PST and 31% for BSP, and remission rates 25%, 30% and 27%, respectively. The three treatments also showed similar improvements in the Quality of Life Enjoyment and Satisfaction Questionnaire. Dropout was high, ranging from 37 to 52% across treatments. Predictors of dropout included having < 16 years of education and annual family income < $20,000. CONCLUSIONS: Among patients who completed treatment, all three psychotherapies were associated with similar, meaningful improvements in depression. Physical distance between the oncology and psychiatric treatment sites might have contributed to high dropout. This study suggests various psychotherapy approaches may benefit patients with breast cancer and major depression.

A Pilot Study of Interpersonal Psychotherapy for Depressed Women with Breast Cancer.

This study sought to examine the feasibility and preliminary efficacy of interpersonal psychotherapy (IPT) in the treatment of major depressive disorder (MDD) among women with breast cancer. Seven women with breast cancer and MDD received 12 sessions of IPT. Outcome measures included changes in depression severity, as measured by the Hamilton Rating Depression Scale (HAM-D), and global functioning, as measured by the Global Assessment Scale (GAF). Mixed linear models were used to examine whether change in depressive symptoms mediated change in global functioning. The HAM-D decreased from 21.3 (SD 8.1) to 11.1 (9.6) (p 0.02), whereas the GAF improved from 56.7 (5.5) to 70.3 (15.6) (p 0.049). A mixed regression model indicated that change in HAM-D scores predicted change in GAF scores (p 0.03). These results suggest that IPT is a promising treatment for depression in women with breast cancer. Randomized controlled trials are warranted to confirm the results of this study.

How do you know your consult service is doing a good job? Generating performance measures for C-L service effectiveness.

BACKGROUND: There is no consensus in the literature on measures for evaluating the performance of general hospital Consultation-Liaison psychiatry services. OBJECTIVE: The purpose of this study was to investigate what indicators might be used to this end. METHODS: We surveyed United States Psychosomatic Medicine fellowship directors (n = 53) about the use of performance measures for their psychiatric consultation services. Results of this survey led to the construction of a second survey, which was distributed to the representatives of services calling for psychiatric consultations at our hospital (n = 21); this survey sought to determine the importance of various performance parameters to overall consultee satisfaction. RESULTS: Sixty-three percent of responding psychiatric consult services do not use any of the parameters identified in the literature as performance measures. Consultee satisfaction was endorsed as a valuable performance indicator by 67.7% of them, but no satisfaction rating instrument was identified. The internal survey of consultees identified 11 of 16 candidate parameters as important or very important to consultee satisfaction, of which "consultant understands the core situation and the core question being asked" received the highest rating. CONCLUSIONS: Consultee satisfaction is perceived as a useful global measure of the effectiveness of a psychiatric consult service. We elicited parameters that can be used to create a measurement tool for consultee satisfaction with Consultation-Liaison services. The use of such a tool merits testing in a larger multicenter study.