Digital mental health: challenges and next steps.

Digital innovations in mental health offer great potential, but present unique challenges. Using a consensus development panel approach, an expert, international, cross-disciplinary panel met to provide a framework to conceptualise digital mental health innovations, research into mechanisms and effectiveness and approaches for clinical implementation. Key questions and outputs from the group were agreed by consensus, and are presented and discussed in the text and supported by case examples in an accompanying appendix. A number of key themes emerged. (1) Digital approaches may work best across traditional diagnostic systems: we do not have effective ontologies of mental illness and transdiagnostic/symptom-based approaches may be more fruitful. (2) Approaches in clinical implementation of digital tools/interventions need to be creative and require organisational change: not only do clinicians and patients need training and education to be more confident and skilled in using digital technologies to support shared care decision-making, but traditional roles need to be extended, with clinicians working alongside digital navigators and non-clinicians who are delivering protocolised treatments. (3) Designing appropriate studies to measure the effectiveness of implementation is also key: including digital data raises unique ethical issues, and measurement of potential harms is only just beginning. (4) Accessibility and codesign are needed to ensure innovations are long lasting. (5) Standardised guidelines for reporting would ensure effective synthesis of the evidence to inform clinical implementation. COVID-19 and the transition to virtual consultations have shown us the potential for digital innovations to improve access and quality of care in mental health: now is the ideal time to act.

COVID-19 mortality among veterans with serious mental illness in the veterans health administration.

OBJECTIVE: Persons with serious mental illness (SMI: schizophrenia-spectrum disorders, bipolar disorder) experience increased risk of mortality after contracting COVID-19 based on the results of several international evaluations. However, information about COVID-19 mortality risk among patients with SMI in the Veterans Health Administration (VHA) has been limited, precluding identification of protective factors. The current evaluation was conducted to assess COVID-19 mortality risk among VHA patients with SMI and to evaluate potential protective factors in mitigating mortality risk following a positive COVID-19 diagnosis. METHODS: National VHA administrative data was used to identify all patients (N = 52,916) who received a positive COVID-19 test result between March 1, 2020, and September 30, 2020. Mortality risk was assessed by SMI status via bivariate comparisons and multivariate regression analyses. RESULTS: In unadjusted analyses, VHA patients with SMI overall and patients with bipolar disorder in particular did not experience increased mortality risk in the 30 days following a positive COVID test, although patients with schizophrenia had increased risk. Within adjusted analyses, patients with schizophrenia remained at increased mortality risk (OR = 1.38), but at reduced levels relative to previous evaluations in other healthcare settings. CONCLUSIONS: Within VHA, patients with schizophrenia, but not those with bipolar disorder, experience increased mortality risk in the 30 days following a positive COVID-19 test. Large integrated healthcare settings such as VHA may offer services which may protect against COVID-19 mortality for vulnerable groups such as persons with SMI. Additional work is needed to identify practices which may reduce the risk of COVID-19 mortality among persons with SMI.

[COVID-19 and Psychiatric Disorders in Minors: Changes in Inpatient Treatment According to Hospital Statistics]. / COVID-19 und psychische Störungen bei Minderjährigen: Veränderungen der Behandlungen nach der Krankenhausstatistik.

COVID-19 and Psychiatric Disorders in Minors: Changes in Inpatient Treatment According to Hospital Statistics Abstract: Increased rates of psychiatric disorders and psychiatric emergencies in children and adolescents stemming from the COVID-19 pandemic have been reported, with more children and adolescents suffering from internalizing disorders. This study analyzes whether the increased rates led to increased rates of inpatient treatment in child and adolescent psychiatric and pediatric hospitals in Germany as well as a change in diagnoses of the treated patients. We analyzed routine hospital data ("InEK" data, § 21 KHG data files) from a prepandemic (2019) and a pandemic (2021) half-year regarding changes in the number of cases, diagnoses, and length of stay (LoS) in child and adolescent psychiatry and pediatrics. We also investigated the development of psychiatric emergencies in minors. We found an increase in internalizing problems (depression, anorexia nervosa, trauma-related disorders) and a decrease in externalizing problems among the admitted psychiatric inpatients. Further, we observed a halving of cases treated for alcohol intoxication. However, we discovered no change for the frequency of psychiatric emergency treatments nationwide. A more detailed analysis revealed that, in areas with a low number of child and adolescent psychiatry inpatient beds, emergency care was prioritized and LoS decreased, whereas in areas with a fair bed-to-inhabitant ratio among minors, there was a trend toward increased LoS, also in pediatric departments. We recommend continued monitoring of inpatient care after the pandemic, with special attention paid to underprivileged children and adolescents such as those with externalizing problems.

Effect of COVID-19 pandemic on utilisation of community-based mental health care in North-East of Italy: A psychiatric case register study.

AIMS: WHO declared that mental health care should be considered one essential health service to be maintained during the coronavirus disease 2019 (COVID-19) pandemic. This study aims to describe the effect of lockdown and restrictions due to the COVID-19 pandemic in Italy on mental health services' utilisation, by considering psychiatric diagnoses and type of mental health contacts. METHODS: The study was conducted in the Verona catchment area, located in the Veneto region (northeastern Italy). For each patient, mental health contacts were grouped into: (1) outpatient care, (2) social and supportive interventions, (3) rehabilitation interventions, (4) multi-professional assessments, (5) day care. A 'difference in differences' approach was used: difference in the number of contacts between 2019 and 2020 on the weeks of lockdown and intermediate restrictions was compared with the same difference in weeks of no or reduced restrictions, and such difference was interpreted as the effect of restrictions. Both a global regression on all contacts and separate regressions for each type of service were performed and Incidence Rate Ratios (IRRs) were calculated. RESULTS: In 2020, a significant reduction in the number of patients who had mental health contacts was found, both overall and for most of the patients' characteristics considered (except for people aged 18-24 years for foreign-born population and for those with a diagnosis of schizophrenia. Moreover, in 2020 mental health contacts had a reduction of 57 096 (-33.9%) with respect to 2019; such difference remained significant across the various type of contacts considered, with rehabilitation interventions and day care showing the greatest reduction. Negative Binomial regressions displayed a statistically significant effect of lockdown, but not of intermediate restrictions, in terms of reduction in the number of contacts. The lockdown period was responsible of a 32.7% reduction (IRR 0.673; p-value <0.001) in the overall number of contacts. All type of mental health contacts showed a reduction ascribable to the lockdown, except social and supportive interventions. CONCLUSIONS: Despite the access to community mental health care during the pandemic was overall reduced, the mental health system in the Verona catchment area was able to maintain support for more vulnerable and severely ill patients, by providing continuity of care and day-by-day support through social and supportive interventions.

Forensic mental telehealth assessment (FMTA) in the context of COVID-19.

Due to the present COVID-19 pandemic, forensic mental telehealth assessment (FMTA) is an increasingly utilized means of conducting court-sanctioned psychiatric and psychological evaluations. FMTA is not a novel development, and studies have been published during the past two decades that opine on the positive and negative implications of conducting testing and interview procedures online, in forensic and traditionally clinical matters alike. The present article examines prospects for eventual legal challenges to FMTA, describes considerations for conducting FMTA in both institutional and residential settings, and concludes that FMTA is now-due to predicted accommodations on the part of courts, attorneys, institutions, and professional guilds-a permanent part of the forensic evaluation landscape, even once the present COVID-19 pandemic has subsided.

Mental health consequences of the COVID-19 pandemic: Results from a large-scale population-based study in Israel.

INTRODUCTION: Contemporary evidence notes the COVID-19 pandemic greatly impacted the utilization of physical and mental health services worldwide. The present study was therefore designed to evaluate the changes in the utilization of mental health services during the first year of the COVID-19 pandemic compared to previous years as well as to estimate the moderating role age had on these changes. MATERIALS AND METHODS: Psychiatric data was collected from n = 928,044 individuals living in Israel. Rates of receipt of psychiatric diagnoses and purchases of psychotropic medication were extracted for the first year of the COVID-19 pandemic and for two comparison years. The odds of receiving a diagnosis or of purchasing a psychotropic medication during the pandemic were compared to control years using uncontrolled logistic regression models and controlled and logistic regression that accounted for differences between ages. RESULTS: There was a general reduction of about 3-17% in the odds of receiving a psychiatric diagnosis or purchasing psychotropic medications during the pandemic year compared to control years. The bulk of tests conducted showed that reduction in the rates of receiving diagnoses and purchasing medications during the pandemic were evident or more profound in the older age groups. An analysis of a combined measure conclusive of all other measures revealed decreased rates of utilizing any service examined during 2020, with rates decreasing as age increases up to a decrease of 25% in the oldest age group (80-96). DISCUSSION AND CONCLUSION: Changes in utilization of mental health services reveal the interplay between psychological distress that has been documented to increase during the pandemic and people's reluctance to seek professional assistance. This appears to be especially prominent among the vulnerable elderly, who may have received even less professional help for their emerging distress. The results obtained in Israel are likely to be replicated in other countries as well, given the global impact of the pandemic on adults' mental health and individuals' readiness to utilize mental healthcare services. Future research on the long-term impact of the pandemic on utilization of mental healthcare services is warranted, with an emphasis on the response of different populations to emergency situations.

Mental disorders, COVID-19-related life-saving measures and mortality in France: A nationwide cohort study.

BACKGROUND: Meta-analyses have shown that preexisting mental disorders may increase serious Coronavirus Disease 2019 (COVID-19) outcomes, especially mortality. However, most studies were conducted during the first months of the pandemic, were inconclusive for several categories of mental disorders, and not fully controlled for potential confounders. Our study objectives were to assess independent associations between various categories of mental disorders and COVID-19-related mortality in a nationwide sample of COVID-19 inpatients discharged over 18 months and the potential role of salvage therapy triage to explain these associations. METHODS AND FINDINGS: We analysed a nationwide retrospective cohort of all adult inpatients discharged with symptomatic COVID-19 between February 24, 2020 and August 28, 2021 in mainland France. The primary exposure was preexisting mental disorders assessed from all discharge information recorded over the last 9 years (dementia, depression, anxiety disorders, schizophrenia, alcohol use disorders, opioid use disorders, Down syndrome, other learning disabilities, and other disorder requiring psychiatric ward admission). The main outcomes were all-cause mortality and access to salvage therapy (intensive-care unit admission or life-saving respiratory support) assessed at 120 days after recorded COVID-19 diagnosis at hospital. Independent associations were analysed in multivariate logistic models. Of 465,750 inpatients with symptomatic COVID-19, 153,870 (33.0%) were recorded with a history of mental disorders. Almost all categories of mental disorders were independently associated with higher mortality risks (except opioid use disorders) and lower salvage therapy rates (except opioid use disorders and Down syndrome). After taking into account the mortality risk predicted at baseline from patient vulnerability (including older age and severe somatic comorbidities), excess mortality risks due to caseload surges in hospitals were +5.0% (95% confidence interval (CI), 4.7 to 5.2) in patients without mental disorders (for a predicted risk of 13.3% [95% CI, 13.2 to 13.4] at baseline) and significantly higher in patients with mental disorders (+9.3% [95% CI, 8.9 to 9.8] for a predicted risk of 21.2% [95% CI, 21.0 to 21.4] at baseline). In contrast, salvage therapy rates during caseload surges in hospitals were significantly higher than expected in patients without mental disorders (+4.2% [95% CI, 3.8 to 4.5]) and lower in patients with mental disorders (-4.1% [95% CI, -4.4; -3.7]) for predicted rates similar at baseline (18.8% [95% CI, 18.7-18.9] and 18.0% [95% CI, 17.9-18.2], respectively). The main limitations of our study point to the assessment of COVID-19-related mortality at 120 days and potential coding bias of medical information recorded in hospital claims data, although the main study findings were consistently reproduced in multiple sensitivity analyses. CONCLUSIONS: COVID-19 patients with mental disorders had lower odds of accessing salvage therapy, suggesting that life-saving measures at French hospitals were disproportionately denied to patients with mental disorders in this exceptional context.

Clinical and psychopathological profiles of children with somatic symptom disorders in a pediatric emergency unit: an observational study before and during the SARS-CoV-2 pandemic.

Somatic symptom disorders (SSDs) are a group of clinical conditions characterized by heterogeneous physical symptoms, not directly supported by a demonstrable organic process. Despite representing a growing problem in the pediatric age, the literature lacks studies assessing the psychopathological and clinical features of subjects with SSD, particularly during the SARS-CoV-2 pandemic. This is a retrospective, observational study, involving two historical cohorts of children admitted to a tertiary referral Italian hospital over the 2 years preceding and following the start of the SARS-CoV-2 pandemic. Demographic, clinical, socio-economical, and psychological variables were investigated. Standardized tests for the developmental age were administered to assess psychopathological variables. Overall rates and trends of accesses for SSD, as compared to the total accesses for any cause at the Pediatric Emergency Room during the same periods, were reported as well. Fifty-one (pre-pandemic, 29; pandemic, 22) children with SSD were enrolled (age, 11.4 ± 2.4 years, F = 66.7%). Subjects in the pandemic historical cohort reported more frequently fever (p < 0.001), headache (p = 0.032), and asthenia (p < 0.001), as well as more chronic conditions in personal and family history, and fewer previous hospital accesses, as compared to the pre-pandemic cohort. Depressed mood and anxious traits were documented in both samples. None of them had an ongoing or a previously reported SARS-CoV-2 infection. During the pandemic, a clinical psychologist was more frequently consulted before the hospital discharge to mental health services, to support the diagnosis.  Conclusion: This study showed the significant burden of SSD in children, highlighting the need to implement pediatricians' education to optimize the management of these patients. Children with SSD who accessed during the SARS-CoV-2 pandemic presented specific clinical features. Future studies, conducted on longitudinal and controlled samples, are indicated to further investigate children with these conditions. What is Known:    â€¢ Somatic symptoms disorders (SSDs) are frequent in the pediatric age, especially in early adolescence.    â€¢ Evidence remains scarce on the impact of the SARS-CoV-2 pandemic on SSDs in children. What is New:    â€¢ Children with SSD who accessed during the SARS-CoV-2 pandemic presented specific clinical features.    â€¢ The implementation of pediatricians' education and a multidisciplinary approach are needed to optimize the management of SSDs.

Telehealth Treatment of Patients in an Intensive Acute Care Psychiatric Setting During the COVID-19 Pandemic: Comparative Safety and Effectiveness to In-Person Treatment.

BACKGROUND: Most research evaluating telehealth psychiatric treatment has been conducted in outpatient settings. There is a great lack of research assessing the efficacy of telehealth treatment in more acute, intensive treatment settings such as a partial hospital. In the face of the COVID-19 pandemic, much of behavioral health treatment has transitioned to a virtual format. In the present report from the Rhode Island Methods to Improve Diagnostic Assessment and Services (MIDAS) project, we examined the effectiveness of our partial hospital program (PHP). METHOD: The sample included 207 patients who were treated virtually from May 2020 to September 2020 and a comparison group of 207 patients who were treated in the in-person partial program a year earlier. Patients completed self-administered measures of patient satisfaction, symptoms, coping ability, functioning, and general well-being. RESULTS: For both the in-person and telehealth methods of delivering partial hospital level of care, patients were highly satisfied with treatment and reported a significant reduction in symptoms and suicidality from admission to discharge. On the modified Remission from Depression Questionnaire, the primary outcome measure, both groups reported a significant (P < .01) improvement in functioning, coping ability, positive mental health, and general well-being. A large effect size of treatment (Cohen d > 0.8) was found in both treatment groups. The only significant difference in outcome between the patients treated in the different formats was a greater length of stay (mean ± SD of 13.5 ± 8.1 vs 8.5 ± 5.0 days, t = 7.61, P < .001) and greater likelihood of staying in treatment until completion (72.9% vs 62.3%, χ2 = 5.34, P < .05) in the virtually treated patients. CONCLUSIONS: Telehealth partial hospital treatment was as effective as in-person treatment in terms of patient satisfaction, symptom reduction, suicidal ideation reduction, and improved functioning and well-being. The treatment completion rate was higher in the telehealth cohort, and several patients who were treated virtually commented that they never would have presented for in-person treatment even if there was no pandemic. Telehealth PHPs should be considered a viable treatment option even after the pandemic has resolved.

Changes in Diagnostic and Demographic Characteristics of Patients Seeking Mental Health Care During the Early COVID-19 Pandemic in a Large, Community-Based Health Care System.

OBJECTIVE: The early COVID-19 pandemic resulted in great psychosocial disruption and stress, raising speculation that psychiatric disorders may worsen. This study aimed to identify patients vulnerable to worsening mental health during the COVID-19 pandemic. METHODS: This retrospective observational study used electronic health records from March 9 to May 31 in 2019 (n = 94,720) and 2020 (n = 94,589) in a large, community-based health care system. Percent change analysis compared variables standardized to the average patient population for the respective time periods. RESULTS: Compared to 2019, psychiatric visits increased significantly (P < .0001) in 2020, with the majority being telephone/video-based (+264%). Psychiatric care volume increased overall (7%), with the greatest increases in addiction (+42%), behavioral health in primary care (+17%), and adult psychiatry (+5%) clinics. While patients seeking care with preexisting psychiatric diagnoses were mainly stable (−2%), new patients declined (−42%). Visits for substance use (+51%), adjustment (+15%), anxiety (+12%), bipolar (+9%), and psychotic (+6%) disorder diagnoses, and for patients aged 18­25 years (+4%) and 26­39 years (+4%), increased. Child/adolescent and older adult patient visits decreased (−22.7% and −5.5%, respectively), and fewer patients identifying as White (−3.8%) or male (−5.0) or with depression (−3%) or disorders of childhood (−2%) sought care. CONCLUSIONS: The early COVID-19 pandemic was associated with dramatic changes in psychiatric care facilitated by a rapid telehealth care transition. Patient volume, demographic, and diagnostic changes may reflect comfort with telehealth or navigating the psychiatric care system. These data can inform health system resource management and guide future work examining how care delivery changes impact psychiatric care quality and access.

Trajectories of common mental disorders symptoms before and during the COVID-19 pandemic: findings from the ELSA-Brasil COVID-19 Mental Health Cohort.

AIM: Evidence indicates most people were resilient to the impact of the COVID-19 pandemic on mental health. However, evidence also suggests the pandemic effect on mental health may be heterogeneous. Therefore, we aimed to identify groups of trajectories of common mental disorders' (CMD) symptoms assessed before (2017-19) and during the COVID-19 pandemic (2020-2021), and to investigate predictors of trajectories. METHODS: We assessed 2,705 participants of the ELSA-Brasil COVID-19 Mental Health Cohort study who reported Clinical Interview Scheduled-Revised (CIS-R) data in 2017-19 and Depression Anxiety Stress Scale-21 (DASS-21) data in May-July 2020, July-September 2020, October-December 2020, and April-June 2021. We used an equi-percentile approach to link the CIS-R total score in 2017-19 with the DASS-21 total score. Group-based trajectory modeling was used to identify CMD trajectories and adjusted multinomial logistic regression was used to investigate predictors of trajectories. RESULTS: Six groups of CMD symptoms trajectories were identified: low symptoms (17.6%), low-decreasing symptoms (13.7%), low-increasing symptoms (23.9%), moderate-decreasing symptoms (16.8%), low-increasing symptoms (23.3%), severe-decreasing symptoms (4.7%). The severe-decreasing trajectory was characterized by age < 60 years, female sex, low family income, sedentary behavior, previous mental disorders, and the experience of adverse events in life. LIMITATIONS: Pre-pandemic characteristics were associated with lack of response to assessments. Our occupational cohort sample is not representative. CONCLUSION: More than half of the sample presented low levels of CMD symptoms. Predictors of trajectories could be used to detect individuals at-risk for presenting CMD symptoms in the context of global adverse events.

[Mental Disorders in German Pediatric Practices Before and During the COVID-19 Pandemic]. / Psychische Störungen in deutschen pädiatrischen Praxen vor und während der COVID-19-Pandemie.

BACKGROUND: Field studies show an increased mental distress in children and adolescents during the COVID-19 pandemic. This health care data based study investigates, whether this corresponds with an increased number of diagnosed mental disorders in pediatric practices during the COVID-19 pandemics. METHODS: Data are based on children aged 2-17 years who visited one of 154 pediatric practices (Disease Analyzer database/IQVIA) at least once. Descriptive analyses were conducted. RESULTS: In 2020 and 2021, significantly more mental disorders were diagnosed compared to the two previous years (chi2 p < 0.001). An increase was particularly evident in affective disorders, although absolute numbers were small with an average increase of 7 patients per practice per year. DISCUSSION: The pandemic-associated increase in mental disorders in children and adolescents is reflected in the physician-diagnosed cases in pediatric practices, but is small in terms of numbers in individual practices.