School-Based Tele-Behavioral Health: A Scoping Review of the Literature.

BACKGROUND: Telehealth utilization exploded during the COVID-19 pandemic, including within school-based health programs. School-based tele-behavioral health can help programs overcome barriers of access to care, but the current state and effectiveness of such programs are unknown. METHODS: A scoping literature review was conducted. Studies were included if they described in-school behavioral health services delivered via telehealth for children ages 5 to 18. From the included studies, population, location, setting, intervention, telehealth modality, clinician type, and outcomes assessed were extracted. FINDINGS: Eighteen studies met inclusion criteria. All described psychotherapy or medication management delivered by psychologists (n = 7) and/or psychiatrists (n = 11). Treatment included psychotherapy (N = 8), psychiatric consultation (N = 7), medication management (N = 4), crisis stabilization (N = 1), and caregiver education (N = 1). Eight studies provide qualitative or quantitative outcomes, with 4 examining clinical effectiveness. CONCLUSIONS: Despite limited findings in the literature, school-based tele-behavioral health is feasible, effective, and acceptable for delivery of behavioral health care to children and adolescents.

Factors Associated with Reliance on Audio-Only Technology (Telephone) for Completion of Telepsychiatry Visits.

Introduction: The ability to access telepsychiatry through audio-video technology versus audio-only (telephone) technology potentially leads to inequitable outcomes. This study examines the characteristics of patients who relied on the telephone to complete outpatient telepsychiatry visits in a large health system. Methods: This is a retrospective analysis of all telepsychiatry outpatient visits conducted from May 1, 2020, to December 31, 2021. Demographic, clinical, and socioeconomic factors were extracted from the electronic health record. Two-sample t tests were used for continuous variables and χ2 tests for categorical variables for bivariate analyses. Multiple logistic regression was used to examine the association between only telephone visits and all input variables. Results: Eight hundred ninety-four (8.9%) patients completed all visits only by telephone during the study period. In bivariate analyses, factors associated with telephone-only visits included male sex, non-English primary language, Black race, unmarried status, non-Hispanic ethnicity, older age, Medicare enrollment, uninsured status, and higher social vulnerability index (SVI). Psychiatric diagnoses associated with only telephone visits included substance use disorders and psychotic disorders. In multivariate analyses, factors associated with higher odds of only telephone visits included older age, inactive patient portal, comorbid diabetes, higher SVI, and higher broadband adoption. Psychiatric diagnoses associated with higher odds of completing only telephone visits included psychotic disorders, substance use disorders, or intellectual/developmental disabilities. Conclusions: Several patient-level factors are associated with a reliance on the telephone to complete telepsychiatry appointments.

A Comprehensive Examination of Pediatric Behavioral Health Service Demand and Utilization in a Large, Academic Health System from 2019 to 2021.

Studies of the effects of COVID-19 on youth suggest a worsening in mental health globally. We performed a retrospective analysis of data from January 2019-November 2021 for all outpatient referrals, as well as outpatient, inpatient, and emergency department (ED) encounters for behavioral health (BH) reasons in children aged < 18 in a large academic health system in the United States. Mean weekly rates of outpatient psychiatry referrals, outpatient psychiatry visits, ED visits, and inpatient admissions for BH reasons were compared between pre-pandemic and pandemic periods. The average weekly rate of ambulatory referrals (8.0 ± 0.33 to 9.4 ± 0.31) and completed appointments (194.2 ± 0.72 to 213.1 ± 0.71) significantly increased during the pandemic, driven largely by teenagers. The weekly average of ED pediatric encounters for BH did not increase during the pandemic, although the percentage of all pediatric ED encounters that were for BH did increase from 2.6 to 4.1% (p < 0.001). Length of stay for pediatric BH ED patients increased from 1.59 ± 0.09 days pre-pandemic to 1.91 ± 0.11 days post-pandemic (p < 0.0001). Inpatient admissions for BH reasons overall decreased during the pandemic, due to a decrease in inpatient psychiatric bed capacity. However, the weekly percentage of inpatient hospitalizations for BH reasons that occurred on medical units increased during the pandemic (15.2% ± 2.8-24.6% ± 4.1% (p = 0.0006)). Taken together, our data suggest the COVID-19 pandemic had varying degrees of impact, depending on the setting of care.

Integrated Care Education for General Psychiatry Residents in the US: a Review of the Literature.

OBJECTIVE: The purpose of this review was to synthesize published literature describing integrated care education available to general psychiatry residents in the United States (US) in order to better understand curricular models and summarize curriculum barriers and facilitators. METHODS: The authors searched electronic databases for articles describing integrated care education for general psychiatry residents. Minimum inclusion criteria were focus on an ambulatory integrated care curriculum, description of the study population and training program, publication in English, and program location in the US. Data extracted included trainee, faculty, or collaborator evaluations, educational model, level of care integration, and barriers or facilitators to implementation. RESULTS: The literature search identified 18 articles describing curricula at 26 residency programs for inclusion. Most programs offered clinical and didactic curricula to advanced trainees across a variety of care integration levels. Common barriers included fiscal vulnerability and difficulties identifying team members or clarifying team member roles. Common facilitators included institutional and interdepartmental support, dedicated space, and faculty supervision. No statistical analysis was able to be performed due to study heterogeneity. CONCLUSIONS: This review found a relatively small number of articles written about integrated care education for psychiatry residents. Resident evaluation suggests this training is valuable regardless of curriculum structure, training years, or level of care integration. Dedicated funding, staff, and space were crucial for successful curricula. This review highlights a need for more rigorous research characterizing and evaluating integrated care education.

Socially Distanced Emergencies: Clinicians' Experience with Tele-behavioral Health Safety Planning.

Psychiatry has experienced a rapid expansion in providing behavioral health services using virtual means; however, little is known regarding clinicians' experience in managing patient emergencies during virtual encounters. We present survey data from a large academic psychiatry department designed to better understand safety planning while delivering ambulatory tele-behavioral health services during the COVID-19 pandemic. Clinical faculty in the department were sent an anonymous electronic survey developed and distributed using the Qualtrics™ software. Departmental leadership provided a list of clinicians who performed ambulatory care. SAS 9.4 was used to conduct statistical analysis for associations between variables. Approximately one quarter (23.3%) of respondents engaged in proactive safety planning for most of their outpatient virtual visits, while a little over half (53.2%) of clinicians implemented emergent safety planning between just one to five visits. Clinicians who more frequently implemented emergency protocols were more likely to engage in proactive safety planning prior to emergencies (p = 0.0115). 10.8% of participants petitioned for civil commitment, though those that did identified numerous challenges. Our results reinforce the importance in appropriate training regarding best practices while providing tele-behavioral health care, with increased awareness for conducting safety planning and implementing emergent protocols. Furthermore, while petitioning for civil commitment is a relatively low base rate event in a large outpatient practice, these data and narrative feedback help to outline challenges and potential measures to improve this process for all parties. Increased attention to protocols and procedures are key as the utilization of virtual care within psychiatry continues.

Implementing Collaborative Care Management of Behavioral Health for Patients with Inflammatory Bowel Disease.

Background: Individuals with inflammatory bowel disease (IBD) are up to twice as likely to suffer from anxiety and/or depression. Collaborative care management (CoCM) is an evidence-based approach to treating behavioral health disorders that have proven effective for a range of conditions in primary care and some specialty settings. This model involves a team-based approach, with care delivered by a care manager (case reviews and behavioral therapy), psychiatrist (case reviews and psychopharmacological recommendations), and medical provider (ongoing care including psychopharmacological prescriptions). We assessed the feasibility and effectiveness of CoCM in reducing anxiety and depressive symptoms in patients with IBD. Methods: Patients with psychological distress identified by clinical impression and/or the results of the Patient Health Questionaire-9 (PHQ-9) and Generalized Anxiety Disorder-7 (GAD-7) were referred to the CoCM program. Data from our 9-month CoCM pilot were collected to assess depression and anxiety response and remission rates. We obtained provider surveys to assess provider acceptability with delivering care in this model. Results: Though the SARS-CoV2 COVID-19 pandemic interrupted screening, 39 patients enrolled and 19 active participants completed the program. Overall, 47.4% had either a response or remission in depression, while 36.8% had response or remission in anxiety. The gastroenterologists highly agreed that the program was a beneficial resource for their patients and felt comfortable implementing the recommendations. Discussion: CoCM is a potentially feasible and well accepted care delivery model for treatment of depression and anxiety in patients with IBD in a specialty gastroenterology clinic setting.

Telehealth: Reducing Patients' Greenhouse Gas Emissions at One Academic Psychiatry Department.

OBJECTIVE: Academic and organizational leaders in psychiatry and all other medical fields are negatively impacted by climate change. The COVID-19 pandemic prompted a rapid shift to the use of more telehealth by behavioral health clinicians. The purpose of this study was to estimate the reduction of patients' greenhouse gas emissions during this rapid shift at one academic psychiatry institution. METHODS: The authors extracted data associated with all outpatient visits to all 26 psychiatry clinics from March 16, 2020, to December 31, 2020. Once the patients' travel miles saved by confirmed virtual visits were calculated, the authors used the standard ratio from the US Environmental Protection Agency (EPA) to calculate the total quantity of CO2 that would be emitted if the visits had occurred in person. RESULTS: During the study period, a total of 47,582 outpatient behavioral health visits with 3975 unique patients were completed. The majority of these departmental visits were telehealth (85%), with most of the telehealth visits conducted using real-time audio-video platforms (75.7%). Subtracting emissions from patient technology during telehealth visits from the estimated patient transport values produced a net savings of greenhouse gas emissions of 867,011 kg CO2. This amount is equal to the greenhouse gas emissions from 189 passenger vehicles driven for 1 year according to the EPA. CONCLUSIONS: This study shows that converting in person, face-to-face behavioral health visits to telehealth has the potential to increase both energy efficiency and conservation through a reduction in greenhouse gas emissions due to reduced patient travel. If these values were extrapolated to the total adult US population who have visits for behavioral health reasons, we estimate that conversion to virtual visits could save approximately 830,000 metric tons of CO2 annually. Organizational leaders should consider these societal benefits when making decisions regarding development and support of telehealth.

Adaptation of an Academic Inpatient Consultation-Liaison Psychiatry Service During the SARS-CoV-2 Pandemic: Effects on Clinical Practice and Trainee Supervision.

BACKGROUND: The SARS-CoV-2 pandemic has led to drastic changes in how psychiatric consultation-liaison (C-L) services conduct business and required rapid transition to telepsychiatry. We describe the practice changes implemented to rapid transition to virtual care in a large, academic psychiatry C-L service in response to the pandemic. OBJECTIVE: To describe clinical service structural changes, timelines and impacts on consultation volume as well as present quantitative and qualitative data regarding the experience of this transition from the standpoints of both psychiatric trainees and attending physicians. METHODS: We present the narrative descriptions of transition details based on focused interviews with inpatient C-L leadership. Inpatient consult volume and charge data were gathered using analysis of health system data. Attending and trainee experience of the transition to virtual care were assessed using anonymous, online surveys. RESULTS: During the pandemic, the average weekly consultation volume and average weekly charges were significantly lower compared with prepandemic. Both volume and charges were affected by addition of video consultation capability. Both attendings and trainees had moderate or high comfort and moderate satisfaction with telephone and video consultations. Overall, the trainee satisfaction with supervision, learning, and their consult psychiatry experience did not seem to be affected by the pandemic. CONCLUSIONS: Our results support the feasibility of the rapid implementation of virtual care in a psychiatric academic C-L service without negatively impacting the learner's consult psychiatry experience. This should provide comfort to academic C-L services that required rapid implementation of virtual care.

Psychiatric Case Review and Treatment Intensification in Collaborative Care Management for Depression in Primary Care.

OBJECTIVE: This study examined whether psychiatric case review was associated with depression medication modification in a large implementation program of collaborative care for depression in safety-net primary care clinics. METHODS: Registry data were examined from an implementation of the collaborative care model in Washington State. A total of 14,960 adults from 178 primary care clinics who initiated care between January 1, 2008, and September 30, 2014, and who had a baseline Patient Health Questionnaire-9 (PHQ-9) score of 10 or higher were included. Rates of psychiatric case reviews and receipt of new depression medications were extracted from the registry for all patients and for a subset of patients who did not improve by eight weeks of treatment (did not achieve a PHQ-9 score of less than 10 or a reduction in PHQ-9 score of 50% or more, compared with baseline). RESULTS: One-half of patients received a new depression medication. Psychiatric case review in any given month was associated with a doubling of the probability of receiving a new medication in the following month. Among patients who did not improve by eight weeks of treatment, a psychiatric case review during weeks 8-12 was associated with a higher rate of receipt of new medications during weeks 8-16 or weeks 8-20. CONCLUSIONS: In a collaborative care program, psychiatric case review was associated with higher rates of subsequent receipt of a new depression medication. This finding supports the importance of psychiatric case review in reducing clinical inertia in collaborative care treatment of depression.

The Perinatal Depression Treatment Cascade: Baby Steps Toward Improving Outcomes.

OBJECTIVE: Perinatal depression is a common and costly health concern with serious implications for the mother and child. We sought to quantify the "Perinatal Depression Treatment Cascade"-the cumulative shortfalls in clinical recognition, initiation of treatment, adequacy of treatment, and treatment response for women with antenatal (AND) and postpartum depression (PPD). DATA SOURCES: A systematic search was conducted to identify articles about diagnostic rates, treatment rates, adequate treatment rates, and remission rates for AND and PPD. We searched PubMed and EMBASE through March 2015. STUDY SELECTION: Articles were included if they were in English and examined rates of detection, treatment, adequate treatment, or remission for AND or PPD. DATA EXTRACTION AND ANALYSIS: Mean rates of diagnosis, treatment, adequate treatment, and remission were calculated and weighted based on the number of subjects in each study. Search results were dually reviewed for confirmation of study eligibility and data abstraction. RESULTS: Decrements occur at each branch of the cascade. Data suggest that 49.9% of women with AND and 30.8% of women with PPD are identified in clinical settings; 13.6% of women with AND and 15.8% of women with PPD receive treatment; 8.6% of women with AND and 6.3% of women with PPD receive adequate treatment; and 4.8% of women with AND and 3.2% of women with PPD achieve remission. CONCLUSIONS: Application of the treatment cascade model suggests multiple opportunities for improving perinatal depression management, informing optimal allocation of resources, and providing adequate treatment to this underrecognized and undertreated population..

Idiopathic Hypersomnia and Hypersomnolence Disorder: A Systematic Review of the Literature.

BACKGROUND: Hypersomnia is a common complaint in medical offices. Often patients are given psychiatric diagnoses, but a primary sleep disorder may be present. The new diagnosis of "hypersomnolence disorder" (HD) in the Diagnostic and Statistical Manual of Mental Disorders, fifth edition is a primary sleep disorder most similar to the diagnosis "idiopathic hypersomnia" (IH) in sleep literature and can be missed in psychiatric settings. METHODS: A systematic review of the computerized databases PubMed, EMBASE, Web of Science, and Psychinfo using the search criteria "idiopathic AND (hypersomnolence OR hypersomnia)," as well as "hypersomnolence disorder was conducted." Articles were included if they were in English and included information regarding the epidemiology, diagnosis, pathophysiology, or treatment of IH or HD. Where relevant, weighted means and 95% CI were calculated based on the number of subjects in each study. RESULTS: A total of 143 articles discussed IH, whereas no articles were found regarding HD. Most articles were review articles, prospective studies, or studies of pathophysiology. IH is found in approximately 0.02%-0.010% of the general population, has a mean age of onset of 21.8 years, and is associated with several somatic symptoms. Alterations in histaminergic or dopaminergic signaling may be involved in IH. Treatment with modafinil or other stimulants appears moderately effective. IH can be differentiated from psychiatric hypersomnolence by formal polysomnography. CONCLUSIONS: IH and HD are relatively uncommon disorders and little is known about them. However, they are distinct from psychiatric disorders and respond well to treatment once properly identified.

Predictors of depression recovery in HIV-infected individuals managed through measurement-based care in infectious disease clinics.

BACKGROUND: Treatment of comorbid chronic disease, such as depression, in people living with HIV/AIDS (PLWHA) increasingly falls to HIV treatment providers. Guidance in who will best respond to depression treatment and which patient-centered symptoms are best to target is limited. METHODS: Bivariable analyses were used to calculate hazard ratios for associations between baseline demographic, mental health-related, and HIV-related factors on time to first depression remission among PLWHA enrolled in a randomized trial of measurement-based antidepressant management. Time-updated factors also were analyzed at time of antidepressant (AD) initiation/adjustment and 8 weeks post AD initiation/adjustment. RESULTS: Baseline comorbid depression and anxiety; comorbid depression, anxiety and substance abuse; and generalized anxiety disorder predicted a slower time to first remission. Being on ART but non-adherent, having panic disorder, having a history of a major depressive episode, or having been in HIV care for >10 years prior to study initiation predicted a faster time to first remission. Sleep difficulty or fatigue at the time of AD initiation/adjustment predicted a slower time to remission. In non-remitters at 8 weeks post AD initiation/adjustment, sleep difficulty, anxiety, and fatigue each predicted a slower time to remission. LIMITATIONS: Remission was determined by PHQ-9 scores, not diagnostic criteria. The results may apply only to depression recovery in this particular model of treatment. We conducted only exploratory analyses to determine magnitude of effects. CONCLUSIONS: Baseline comorbid anxiety with or without substance abuse predicts slower time to depression remission among PLWHA treated in HIV clinics. Targeting anxiety or fatigue at the time of AD initiation/adjustment or sleep difficulty, anxiety, and fatigue at 8 weeks post AD initiation/adjustment could shorten time to depression remission in this model.

Perinatal depression in HIV-infected African women: a systematic review.

OBJECTIVE: To systematically review the literature on prevalence and incidence of perinatal depression in human immunodeficiency virus (HIV)-infected African women. DATA SOURCES: We searched 17 databases, including PubMed, PsycINFO, Cochrane, EMBASE, Web of Science, ClinicalTrials.gov, Google Scholar, and OpenGrey, from inception through August 2014 using the search strategy ((antenatal OR peripartum OR perinatal OR postnatal OR postpartum) AND (depression OR mental disorder) AND HIV AND Africa NOT (-) American). STUDY SELECTION: We included English-language articles on studies conducted in Africa with prevalence or incidence rates of diagnostically confirmed depression or suspected depression in HIV-infected women during pregnancy through 12 months postpartum. DATA EXTRACTION: We examined details of study design, location, means of measurement, incidence and prevalence rates of diagnostically confirmed depression or suspected depression and any associated risk factors for development of depression. Mean prevalence rates were calculated and weighted based on study size. RESULTS: Twenty-two articles met inclusion criteria. Two reported diagnostically confirmed antenatal depression, and 9 reported suspected antenatal depression prevalence. Two reported diagnostically confirmed postnatal depression, and 10 reported suspected postnatal depression prevalence. Weighted mean prevalence of antenatal depression was 23.4%, and suspected antenatal depression was 43.5%. Weighted mean prevalence of postnatal depression was 22.5%, and suspected postnatal depression was 31.1%. No studies reported incidence rates. CONCLUSIONS: Few studies have examined the rate of perinatal depression in HIV-infected African women. Existing studies show a high prevalence of perinatal depression, with even higher prevalence rates of suspected depression. No data on the incidence of perinatal depression in this population exist.

TNAP and Pain Control.

Chronic pain is one of the most debilitating and expensive diseases, yet current therapies are often insufficient in bringing about long-term relief. Further, many treatments for chronic pain also carry significant side effects. The molecule adenosine has long been identified as a potent inhibitor of nociceptive circuits in the spinal cord; however, the widespread expression of adenosine receptors in many organ systems has limited its use as an analgesic. Recently several 5' ectonucleotidases, including tissue non-specific alkaline phosphatase (TNAP), have been characterized for their ability to generate endogenous adenosine in nociceptive circuitry of the dorsal spinal cord. These ectonucleotidases have the ability to hydrolyze the endogenous pronociceptive nucleotides like adenosine triphosphate (ATP) into the antinociceptive nucleoside adenosine. This chapter discusses the role of TNAP and other ectonucleotidases in nociceptive circuits, and their potential as future targets of new therapeutics to treat chronic pain.

Medically necessary sterilization of a minor with intellectual disability: a case report and historical perspective.

Medical necessity may lead to secondary sterilization of individuals with intellectual disabilities, but legal statutes mandate that certain procedures be followed in these cases. In this article, we present a case of medically necessary sterilization of an individual with intellectual disability, and we discuss important legal statutes that guide this practice in North Carolina.