Telehealth and the Community SMI Population: Reflections on the Disrupter Experience of COVID-19.

The novel coronavirus pandemic and the resulting expanded use of telemedicine have temporarily transformed community-based care for individuals with serious mental illness (SMI), challenging traditional treatment paradigms. We review the rapid regulatory and practice shifts that facilitated broad use of telemedicine, the literature on the use of telehealth and telemedicine for individuals with SMI supporting the feasibility/acceptability of mobile interventions, and the more limited evidence-based telemedicine practices for this population. We provide anecdotal reflections on the opportunities and challenges for telemedicine drawn from our daily experiences providing services and overseeing systems for this population during the pandemic. We conclude by proposing that a continued, more prominent role for telemedicine in the care of individuals with SMI be sustained in the post-coronavirus landscape, offering future directions for policy, technical assistance, training, and research to bring about this change.

Impact of experience of psychiatrists and psychiatry residents regarding electronic communication and social networking on internet use patterns: a questionnaire survey for developing e-professionalism in South Korea.

BACKGROUND: The development of technology, novel communication, and social networking can positively or negatively affect the therapeutic alliance between patients and psychiatrists. We conducted this study to identify Internet use patterns of psychiatrists and psychiatry residents in South Korea and to provide basic data for developing e-professionalism. METHODS: In this questionnaire survey included a total of 250 participants, of which 195 (78%) completed the questionnaire. Questions included demographics, use of email, web searches, personal and professional use of websites and social networking, and negative and positive experiences of electronic communication and social networking. We confirmed the correlation between experience and use patterns of psychiatrists' electronic communication and social networking. RESULTS: A total of 129 participants (66.2%) reported that they posted their personal or professional content online, 112 (57.9%) had received patients' requests through electronic communication or social networking, and 120 (61.4%) had communicated with patients via electronic communication or social networking. In total, 170 participants (87.2%) reported that they were worried about the negative consequences of using electronic communication and social networking, and 180 (92.3%) indicated they were not educated about electronic communication or social networking. CONCLUSION: In order to reduce the negative effects of electronic communication and social networking, we need guidelines that are appropriate for the situation in South Korea. Furthermore, future research will need to identify and suggest solutions for negative experiences of electronic communication and social networking that may affect the relationship between patients and physicians.

How the DSM Is Used in Clinical Practice.

Despite widespread use, how clinicians use the DSM in psychiatric practice is not well understood. Recognizing public and professional attitudes toward the DSM are integral to future DSM development, to assess a commonly held assumption such as that the DSM is used primarily for coding, and to assess its clinical utility. A convenience sample of Psychiatric Times readers was surveyed to assess the DSM's use in clinical practice. A total of 394 behavioral health care practitioners fully completed the online survey. Results suggest that the DSM, beyond administrative and billing use, is used for communication with health care providers, for teaching diagnoses to trainees, and, importantly, as an educational tool to inform patients and caregivers alike.

Why We Need to Enhance Suicide Postvention: Evaluating a Survey of Psychiatrists' Behaviors after the Suicide of a Patient.

Suicide prevention efforts are increasing to enhance capabilities and better understand risk factors and etiologies. Postvention, or how clinicians manage the postsuicide aftermath, strengthens suicide prevention, destigmatizes the tragedy, operationalizes the confusing aftermath, and promotes caregiver recovery. However, studies regarding its efficacy are minimal. The Psychopathology Committee of the Group for the Advancement for Psychiatry surveyed a convenience sample of psychiatrists to better understand postvention activities. Ninety psychiatrists completed the survey; they were predominantly men (72%) with an average of 24.6 years of experience (SD, 16.7 years). Most had contact with the patient's family within 6 months of the suicide, and most psychiatrists sought some form of support. Few psychiatrists used a suicide postvention procedure or toolkit (9%). No psychiatrists stopped clinical practice after a patient suicide, although 10% stopped accepting patients they deemed at risk of suicide. Postvention efforts, therefore, should be improved to better address survivor care.

Ethical Challenges in Psychiatric Administration and Leadership.

As with all professional ethical principles, those in psychiatry have to evolve over time and societal changes. The current ethical challenges for psychiatric administration and leadership, especially regarding for-profit managed care, need updated solutions. One solution resides in the development by the American Association of Psychiatric Administrators (AAPA) of the first set of ethical principles designed specifically for psychiatric administrators. These principles build on prior Psychological Theories of leadership, such as those of Freud, Kernberg, and Kohut. Supplementing these theories are the actual real life models of psychiatrist leadership as depicted in the memoirs of various psychiatrists. Appreciating these principles, theories, and models may help emerging leaders to better recognize the importance of ethical challenges. A conclusion is that psychiatrists should have the potential to assume more successful leadership positions once again. In such positions, making the skills and well-being of all in the organization seems now to be the foremost ethical priority.

How do clinicians actually use the Diagnostic and Statistical Manual of Mental Disorders in clinical practice and why we need to know more.

The clinical use of the Diagnostic and Statistical Manual of Mental Disorders (DSM) is explicitly stated as a goal for both the DSM Fourth Edition and DSM Fifth Edition (DSM-5) revisions. Many uses assume a relatively faithful application of the DSM diagnostic definitions. However, studies demonstrate significant discrepancies between clinical psychiatric diagnoses with those made using structured interviews suggesting that clinicians do not systematically apply the diagnostic criteria. The limited information regarding how clinicians actually use the DSM raises important questions: a) How can the clinical use be improved without first having a baseline assessment? b) How can potentially significant shifts in practice patterns based on wording changes be assessed without knowing the extent to which the criteria are used as written? Given the American Psychiatric Association's plans for interim revisions to the DSM-5, the value of a detailed exploration of its actual use in clinical practice remains a significant ongoing concern and deserves further study including a number of survey and in vivo studies.

The evolution of public psychiatry fellowships.

OBJECTIVE: The growth of Public Psychiatry Fellowships (PPFs) has reached a new developmental stage, providing a wide array of academic partnerships and educational opportunities in psychiatric leadership and administration. The authors examine the evolution of these programs and illustrate three distinct models. METHODS: Data from yearly surveys and discussions with PPF directors were used to identify key similarities and areas of divergence as the programs have evolved. RESULTS: The first period of program expansion took place 8-10 years ago when new programs were modeled on the Columbia PPF, and key elements of that program and the American Association of Community Psychiatrists (AACP) guidelines were incorporated broadly. Examples of multiple source (Columbia), single source (Yale and UCSF), and grant-funded programs (Alabama and UCSD) are presented. CONCLUSIONS: A review of the current status of PPFs reveals a diversity of structures and strategies for success, which can be attributed to the range of their funding sources. The advantages and potential disadvantages of those models are outlined with respect to the educational experience and opportunities for growth and sustainability.

Psychiatrists' use of electronic communication and social media and a proposed framework for future guidelines.

BACKGROUND: Recent and ongoing advances in information technology present opportunities and challenges in the practice of medicine. Among all medical subspecialties, psychiatry is uniquely suited to help guide the medical profession's response to the ethical, legal, and therapeutic challenges--especially with respect to boundaries--posed by the rapid proliferation of social media in medicine. Ironically, while limited guidelines exist for other branches of medicine, guidelines for the responsible use of social media and information technology in psychiatry are lacking. OBJECTIVE: To collect data about patterns of use of electronic communications and social media among practicing psychiatrists and to establish a conceptual framework for developing professional guidelines. METHODS: A structured survey was developed to assess the use of email, texting, and social media among the active membership of the Group for the Advancement of Psychiatry (GAP) to gain insight into current practices across a spectrum of the field and to identify areas of concern not addressed in existing guidelines. This survey was distributed by mail and at an annual meeting of the GAP and a descriptive statistical analysis was conducted with SPSS. RESULTS: Of the 212 members, 178 responded (84% response rate). The majority of respondents (58%) reported that they rarely or never evaluated their online presence, while 35% reported that they had at some time searched for information online about patients. Only 20% posted content about themselves online and few of these restricted that information. Approximately 25% used email to communicate with patients, and very few obtained written consent to do so. CONCLUSION: Discipline-specific guidelines for psychiatrists' interactions with social media and electronic communications are needed. Informed by the survey described here, a review of the literature, and consensus opinion, a framework for developing such a set of guidelines is proposed. The model integrates four key areas: treatment frame, patient privacy, medico-legal concerns, and professionalism. This conceptual model, applicable to many psychiatric settings, including clinical practice, residency training, and continuing medical education, will be helpful in developing discipline-wide guidelines for psychiatry and can be applied to a decision-making process by individual psychiatrists in day-to-day practice.

Intraoperative characterization of interventricular mechanical dyssynchrony using electroanatomic mapping system--a feasibility study.

BACKGROUND: Interventricular mechanical dyssynchrony (VVMD) is a strong predictor of cardiac resynchronization therapy (CRT) response. However, no simple and reliable clinical method of measuring VVMD during CRT implant is currently available. We tested the hypothesis that the EnSite™ NavX™ system (St. Jude Medical, St. Paul, MN, USA) can be used intraoperatively to determine VVMD, thereby facilitating CRT optimization. METHODS: During CRT implant, the leads in the right atrium (RA), right ventricle (RV), and left ventricle (LV) were connected to the EnSite™ NavX™ system to record the real-time 3D motion of the lead electrodes. The distances from RA to RV lead electrodes (RA-RV) and RA to LV lead electrodes (RA-LV) were computed over ten cardiac cycles during each of RV pacing and biventricular (BiV) pacing, respectively. The degree of synchrony was computed from the distance waveforms between RA-RV and RA-LV by a cross-covariance method to characterize VVMD. Septal-to-posterior wall motion delay (SPWMD) from M-mode echocardiography (echo) was measured for reference at each pacing intervention. VVMD was present in all five patients undergoing CRT implant. RESULTS: Four of the five patients demonstrated clear improvement in EnSite™ NavX™-derived VVMD during BiV versus RV pacing, which corresponded to the SPWMD results by echo. CONCLUSIONS: It is feasible to characterize VVMD and resynchronization in CRT patients with the EnSite™ NavX™ system during implant, demonstrating its potential as a tool for intraoperative CRT optimization.

Public's view of mental health services for the elderly: responses to Dear Abby.

The need for adequate mental health services for older adults is an increasingly urgent issue as the life expectancy of Americans continues to extend; yet there are unresolved questions regarding the public's perception of service needs. The Group for the Advancement of Psychiatry collaborated with advice columnist Jeannie Phillips of "Dear Abby" to invite public feedback on mental health services for the elderly. Feedback was invited on access to services as well as perceived need for improvement in the quality or quantity of those services. The effort resulted in 800 responses that identified three primary issues: problems in accessing care, inadequate detection of mental health conditions by general practitioners, and a need for more psychotherapy services. It is hoped that this Open Forum will stimulate discussion throughout the country for the benefit of older persons with mental health needs as the country grapples with changes to come after the passage of health care reform.

Identification of a biologically active component in minimally oxidized low density lipoprotein (MM-LDL) responsible for aortic smooth muscle cell proliferation.

Although low concentrations (10 microg/ml) of oxidized LDL density lipoproteins (Ox-LDL) and minimally modified LDL (MM-LDL) can stimulate the proliferation of aortic smooth muscle cells the biologically active component responsible for this phenomena has not been identified. Here we report that the 1-palmitoyl-2-(5-oxovaleroyl)-sn-glycero-4-phosphocholine (m/e594.3) (POVPC) present in MM-LDL but not 1-palmitoyl-2-glutaryl-sn-glycero-3-phophochline (m/e610.2)(PGPC) can stimulate the activity of UDP-galactose:glucosylceramide (beta 1-->4) galactosyltransferase (GalT-2) and produce lactosyceramide (LacCer). LacCer, in turn, generated superoxide radicals (O(2)(.-)). This is accompanied by the phosphorylation/activation of a cytosolic transcriptional factor p(44) MAPK and the subsequent proliferation of human aortic smooth muscle cells. D-threo-1-phenyl-2-decanoylamino-3-morpholino-1-propanol (D-PDMP), an inhibitor of GalT-2, impaired the induction of GalT-2 activity, O(2)(.-)generation, and cell proliferation. Thus POVPC may serve as a surrogate in MM-LDL mediated induction of aortic smooth muscle cells (A-SMC) proliferation via GalT-2 activation. The LacCer produced as a consequence of GalT-2 activation may serve as a lipid second messenger in the activation of an oxidant sensitive transcriptional pahtway that ultimately leads to cell proliferation and may contribute to the pathophysiology of atherosclerosis.