Insights into designing educational materials for persons living with dementia: a focus group study.

BACKGROUND: Persons living with dementia (PLWD) may experience communication difficulties that impact their ability to process written and pictorial information. Patient-facing education may help promote discontinuation of potentially inappropriate medications for older adults without dementia, but it is unclear how to adapt this approach for PLWD. Our objective was to solicit feedback from PLWD and their care partners to gain insights into the design of PLWD-facing deprescribing intervention materials and PLWD-facing education material more broadly. METHODS: We conducted 3 successive focus groups with PLWD aged ≥ 50 (n = 12) and their care partners (n = 10) between December 2022 and February 2023. Focus groups were recorded and transcripts were analyzed for overarching themes. RESULTS: We identified 5 key themes: [1] Use images and language consistent with how PLWD perceive themselves; [2] Avoid content that might heighten fear or anxiety; [3] Use straightforward delivery with simple language and images; [4] Direct recipients to additional information; make the next step easy; and [5] Deliver material directly to the PLWD. CONCLUSION: PLWD-facing educational material should be addressed directly to PLWD, using plain, non-threatening and accessible language with clean, straightforward formatting.

Psychotherapy Disruption Before and After the Transition to Virtual Mental Health Care Induced by the COVID-19 Pandemic.

OBJECTIVE: This study aimed to examine population-level disruption in psychotherapy before and after the rapid shift to virtual mental health care induced by the onset of the COVID-19 pandemic in the United States. METHODS: This retrospective study used electronic health record and insurance claims data from three U.S. health systems. The sample included 110,089 patients with mental health conditions who were members of the health systems' affiliated health plans and attended at least two psychotherapy visits from June 14, 2019, through December 15, 2020. Data were subdivided into two 9-month periods (before vs. after COVID-19 onset, defined in this study as March 14, 2020). Psychotherapy visits were measured via health records and categorized as in person or virtual. Disruption was defined as a gap of >45 days between visits. RESULTS: Visits in the preonset period were almost exclusively in person (97%), whereas over half of visits in the postonset period were virtual (52%). Approximately 35% of psychotherapy visits were followed by a disruption in the preonset period, compared with 18% in the postonset period. Disruption continued to be less common (adjusted OR=0.45) during the postonset period after adjustment for visit, mental health, and sociodemographic factors. The magnitude of the difference in disruption between periods was homogeneous across sociodemographic characteristics but heterogeneous across psychiatric diagnoses. CONCLUSIONS: This study found fewer population-level disruptions in psychotherapy receipt after rapid transition to virtual mental health care following COVID-19 onset. These data support the continued availability of virtual psychotherapy.

The rapid shift to virtual mental health care: Examining psychotherapy disruption by rurality status.

BACKGROUND: Given the low usage of virtual health care prior to the COVID-19 pandemic, it was unclear whether those living in rural locations would benefit from increased availability of virtual mental health care. The rapid transition to virtual services during the COVID-19 pandemic allowed for a unique opportunity to examine how the transition to virtual mental health care impacted psychotherapy disruption (i.e., 45+ days between appointments) among individuals living in rural locations compared with those living in nonrural locations. METHODS: Electronic health record and insurance claims data were collected from three health care systems in the United States including rurality status and psychotherapy disruption. Psychotherapy disruption was measured before and after the COVID-19 pandemic onset. RESULTS: Both the nonrural and rural cohorts had significant decreases in the rates of psychotherapy disruption from pre- to post-COVID-19 onset (32.5-16.0% and 44.7-24.8%, respectively, p < 0.001). The nonrural cohort had a greater reduction of in-person visits compared with the rural cohort (96.6-45.0 vs. 98.0-66.2%, respectively, p < 0.001). Among the rural cohort, those who were younger and those with lower education had greater reductions in psychotherapy disruption rates from pre- to post-COVID-19 onset. Several mental health disorders were associated with experiencing psychotherapy disruption. CONCLUSIONS: Though the rapid transition to virtual mental health care decreased the rate of psychotherapy disruption for those living in rural locations, the reduction was less compared with nonrural locations. Other strategies are needed to improve psychotherapy disruption, especially among rural locations (i.e., telephone visits).

According to Which Criteria Should Telemental Health Be Deemed Elder Inclusive?

Telepsychiatry offers opportunities to provide better access to and higher quality of psychiatric care for some patients. This commentary on a case considers an analysis of clinical and ethical barriers to equitable telehealth for elders with mental health needs.

Cancer and psychiatric diagnoses in the year preceding suicide.

BACKGROUND: Patients with cancer are known to be at increased risk for suicide but little is known about the interaction between cancer and psychiatric diagnoses, another well-documented risk factor. METHODS: Electronic medical records from nine healthcare systems participating in the Mental Health Research Network were aggregated to form a retrospective case-control study, with ICD-9 codes used to identify diagnoses in the 1 year prior to death by suicide for cases (N = 3330) or matching index date for controls (N = 297,034). Conditional logistic regression was used to assess differences in cancer and psychiatric diagnoses between cases and controls, controlling for sex and age. RESULTS: Among patients without concurrent psychiatric diagnoses, cancer at disease sites with lower average 5-year survival rates were associated with significantly greater relative risk, while cancer disease sites with survival rates of >70% conferred no increased risk. Patients with most psychiatric diagnoses were at higher risk, however, there was no additional risk conferred to these patients by a concurrent cancer diagnosis. CONCLUSION: We found no evidence of a synergistic effect between cancer and psychiatric diagnoses. However, cancer patients with a concurrent psychiatric illness remain at the highest relative risk for suicide, regardless of cancer disease site, due to strong independent associations between psychiatric diagnoses and suicide. For patients without a concurrent psychiatric illness, cancer disease sites associated with worse prognoses appeared to confer greater suicide risk.

Detecting and distinguishing indicators of risk for suicide using clinical records.

Health systems are essential for suicide risk detection. Most efforts target people with mental health (MH) diagnoses, but this only represents half of the people who die by suicide. This study seeks to discover and validate health indicators of suicide death among those with, and without, MH diagnoses. This case-control study used statistical modeling with health record data on diagnoses, procedures, and encounters. The study included 3,195 individuals who died by suicide from 2000 to 2015 and 249,092 randomly selected matched controls, who were age 18+ and affiliated with nine Mental Health Research Network affiliated health systems. Of the 202 indicators studied, 170 (84%) were associated with suicide in the discovery cohort, with 148 (86%) of those in the validation cohort. Malignant cancer diagnoses were risk factors for suicide in those without MH diagnoses, and multiple individual psychiatric-related indicators were unique to the MH subgroup. Protective effects across MH-stratified models included diagnoses of benign neoplasms, respiratory infections, and utilization of reproductive services. MH-stratified latent class models validated five subgroups with distinct patterns of indicators in both those with and without MH. The highest risk groups were characterized via high utilization with multiple healthcare concerns in both groups. The lowest risk groups were characterized as predominantly young, female, and high utilizers of preventive services. Healthcare data include many indicators of suicide risk for those with and without MH diagnoses, which may be used to support the identification and understanding of risk as well as targeting of prevention in health systems.

The Impact of Socioeconomic Status, Race/Ethnicity, and Patient Perceptions on Medication Adherence in Depression Treatment.

OBJECTIVE: Nonadherence to pharmacotherapy for psychiatric conditions is associated with poor outcomes, including increased risk of relapse, increased health care costs, and reduced quality of life. The objective of this study was to investigate the strength of association between socioeconomic factors, race/ethnicity, and patient perceptions with medication adherence in individuals with depression. METHODS: Baseline surveys were sent out in 2012 to 4,216 adult patients within a large health system who presented with a clinical diagnosis of major depressive disorder (ICD-9), recorded at least twice in the electronic medical record in the year 2011. A total of 1,573 patients responded to the baseline survey. Of those, 1,209 patients who completed the survey and had used antidepressants in the last 12 months were recruited for the study. Perception of medication risk was assessed using the Beliefs About Medicines Questionnaire, and adherence to medications was assessed using the Morisky Medication Adherence Scale. Logistic regression was used to investigate the relationship between perception of medicine risk and treatment adherence. RESULTS: For non-Hispanic white individuals, medication adherence was higher among those who were least concerned about the risk of medications (64%; 95% CI, 58-70) compared to those who were most concerned (34%; 95% CI, 26-43). In the logistic regression model, less concern about medications and their side effects was associated with higher medication adherence (odds ratio = 2.6; 95% CI, 1.77-3.84; P < .0001). This association remained significant after adjustment for age, race, education level, and extramedical use of other medications or substances. Moreover, patients with older age and lower education level as well as those who were non-Hispanic white and had no extramedical use of other medications/substances were more likely to be adherent to medications. CONCLUSIONS: This study contributes quantitative data on factors that impact treatment adherence. Identifying patients at increased risk of nonadherence, having discussions with patients early in the treatment process to understand their concerns regarding treatment options, being sensitive to cultural beliefs, and patiently proceeding with the decision-making process could help ensure better outcomes.

Current and Future Challenges in the Delivery of Mental Healthcare during COVID-19.

The USA is in the midst of the COVID-19 pandemic. We assess the impact of COVID-19 on psychiatric symptoms in healthcare workers, those with psychiatric comorbidities, and the general population. We highlight the challenges ahead and discuss the increased relevance of telepsychiatry. We analyzed all available literature available as of March 25, 2020, on PubMed, Ovid Medline, and PsychInfo. We utilized the MeSH term "covid AND (psychiatry OR mental health)" and included all articles. Duplicates were removed resulting in 32 articles, of which 19 are cited. Four additional references are included to examine suicide data. During the review process, an additional 7 articles were identified which are also included. Frontline healthcare workers are currently experiencing increased psychiatric symptoms and this is more severe in females and nurses. Non-frontline healthcare workers, as well as the general population, are experiencing vicarious traumatization. People with psychiatric comorbidities, and the general population, face increased psychiatric symptom burden. Migrant workers, the elderly, children, and the homeless may be disproportionately impacted. Suicide rates may be impacted. The COVID-19 pandemic has resulted in a severe disruption to the delivery of mental healthcare. Psychiatric facilities are facing unprecedented disruptions in care provision as they struggle to manage an infected population with comorbid psychiatric symptoms. Telepsychiatry is a flawed but reasonable solution to increase the availability of mental healthcare during COVID-19.

A qualitative comparison of DSM depression criteria to language used by older church-going African-Americans.

OBJECTIVE: Depression in late life is associated with substantial suffering, disability, suicide risk, and decreased health-related quality of life. According to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV), a depression diagnosis is derived from a constellation of symptoms that may be described differently by different people. For example, the DSM language may be inadequate in capturing these symptoms in certain populations such as African-Americans, whose rates of depression misdiagnosis is high. METHODS: This study reports the findings from a church-based, qualitative study with older African-Americans (n = 50) regarding the language they use when discussing depression and depression treatment, and how this compares to the DSM-IV depression criteria. Content analyses of the in-depth discussions with African-American male and female focus group participants resulted in a deeper understanding of the language they used to describe depression. This language was then mapped onto the DSM-IV depression criteria. RESULTS: While some words used by the focus group participants mapped well onto the DSM-IV criteria, some of the language did not map well, such as language describing irritability, negative thought processes, hopelessness, loneliness, loss of control, helplessness, and social isolation. CONCLUSIONS: The focus group setting provided insight to the language used by older, church-going African-Americans to describe depression. Implications include the advantages of using qualitative data to help inform clinical encounters with older African-Americans.