The Need to Adapt the Psychiatric Clinical Assessment to the Digital Age: A Practical Approach.

The use of electronic devices and social media is becoming a ubiquitous part of most people's lives. Although researchers are exploring the sequelae of such use, little attention has been given to the importance of digital media use in routine psychiatric assessments of patients. The nature of technology use is relevant to understanding a patient's lifestyle and activities, the same way that it is important to evaluate the patient's occupation, functioning, and general activities. The authors propose a framework for psychiatric inquiry into digital media use, emphasizing that such inquiry should focus on quality of use, including emotional and behavioral consequences, rather than simply the amount of use.

Before and During the First COVID-19 Surge: Work Conditions, Burnout, and Mental Health Among Resident Physicians in a Department of Psychiatry in the USA.

OBJECTIVE: Resident physicians are critical frontline workers during pandemics, and little is known about their health. The study examined occupational and mental health risks among US psychiatry residents before and during the first COVID-19 surge. METHODS: Longitudinal data were collected from a cohort of US psychiatry residents at one academic medical center in October 2019, before the pandemic, and April 2020 after the initiation of a state-level stay-at-home order. Primary outcome measures were psychological work empowerment, defined as one's self-efficacy towards their work role, and occupational burnout. A secondary outcome was mental health. In May and June 2020, resident engagement sessions were conducted to disseminate study findings and consider their implications. RESULTS: Fifty-seven out of 59 eligible residents participated in the study (97%). Half the study sample reported high burnout. From before to during the first COVID-19 surge, psychological work empowerment increased in the total sample (p = 0.03); and mental health worsened among junior residents (p = 0.004), not senior residents (p = 0.12). High emotional exhaustion and depersonalization were associated with worse mental health (p < 0.001). In engagement sessions, themes related to residents' work conditions, COVID-19, and racism emerged as potential explanations for survey findings. CONCLUSIONS: The study is exploratory and novel. During early COVID, psychiatry residents' well-being was impacted by occupational and societal factors. Postpandemic, there is a growing psychiatrist shortage and high demand for mental health services. The findings highlight the potential importance of physician wellness interventions focused on early career psychiatrists who were first responders during COVID.

Revisiting Research Safety Protocols: The Urgency for Alternatives to Law Enforcement in Crisis Intervention.

Research safety protocols are ubiquitous in mental health research involving human subjects and have the potential to harm research participants from racial-ethnic minority populations. For mental health emergencies, such protocols commonly rely on law enforcement for crisis intervention. The authors review inequities experienced by individuals with mental illness in law enforcement encounters, especially Black, Latinx, and other minoritized populations. They then describe the development of a research safety protocol that uses community-based crisis intervention programs as alternatives to law enforcement and provide a roadmap for researchers and institutional review boards to revisit and revise their human subjects safety protocols.

Long-Acting Injectable Therapy for People with HIV: Looking Ahead with Lessons from Psychiatry and Addiction Medicine.

Long-acting injectable antiretroviral medications are new to HIV treatment. People with HIV may benefit from a treatment option that better aligns with their preferences, but could also face new challenges and barriers. Authors from the fields of HIV, substance use treatment, and mental health collaborated on this commentary on the issues surrounding equitable implementation and uptake of LAI ART by drawing lessons from all three fields. We employ a socio-ecological framework beginning at the policy level and moving through the community, organizational, interpersonal, and patient levels. We look at extant literature on the topic as well as draw from the direct experience of our clinician-authors.

Client Outreach in Los Angeles County's Assisted Outpatient Treatment Program: Strategies and Barriers to Engagement.

Purpose: Assisted Outpatient Treatment (AOT) programs can compel treatment-refusing individuals to participate in mental health treatment via civil court order. In California's AOT programs, individuals first must be offered 30 days of outreach services and can accept services voluntarily. This study examines the use of outreach strategies in an AOT program with the potential for voluntary or involuntary enrollment. Methods: Outreach staff completed a survey in which they reported and rated outreach strategies and barriers to treatment for 487 AOT-referred individuals. Results: Outreach staff reported using a broad array of strategies to persuade and engage clients. Supportive and persuasive strategies were most common. More coercive strategies, including court order, were used when needed. More clients enrolled voluntarily (39.4%) than involuntarily (7.2%). Conclusions: Outreach, coupled with the strategic used of potential court involvement, can lead to voluntary enrollment of treatment-refusing individuals with many, often severe, barriers to engaging in outpatient treatment.

Multi-Sector Assessment and Client-Perception of Social Need at Long-Term Follow-Up of a Group-Randomized Trial of Community-Engaged Collaborative Care for Adults with Depression.

Understanding client perceptions of need for underlying social determinant support may improve services for depression care. This secondary analysis examines perceptions of "social needs" related to housing and employment, financial, and legal (EFL) concerns among individuals with depression. Data were analyzed from Community Partners in Care, a randomized comparative effectiveness trial of multi-sector collaborative care for depression among a sample of people who were predominantly racial/ethnic minorities and low-income. Adults with depression (n = 980) in both interventions were surveyed at 36-month follow-up for (1) being asked about and (2) having social needs for housing or EFL concerns. In multivariate models, life difficulty and mental health visits in non-healthcare sectors predicted being asked about housing and EFL. Lower social determinants of health-related life satisfaction increased the odds of having unmet housing and EFL needs. These findings underscore the role of non-healthcare organizations as community resources for depression care and in screening and addressing social needs.

Mental Health Conservatorship Among Homeless People With Serious Mental Illness.

OBJECTIVE: The purpose of this study was to examine associations between homelessness and length of psychiatric hospitalization and to explore the role of mental health conservatorship in determining discharge location for patients who are homeless and have a grave disability from serious mental illness. METHODS: This observational study used administrative data from a safety-net psychiatric hospital in Los Angeles. The sample included 795 adults (≥18 years) who were hospitalized on an involuntary psychiatric hold between 2016 and 2018. The outcome variables were length of stay (days) and discharge location (home, locked psychiatric facility, unlocked psychiatric facility, unhoused). The predictor variables were homelessness status and whether a mental health conservatorship was initiated during hospitalization. Multiple regression models were used to estimate associations between variables. RESULTS: Homelessness status was associated with 27.5 additional days (SE=3.5 days) of hospitalization in adjusted models. Homeless patients for whom conservatorship was initiated comprised 6% of the sample but 41% of total inpatient days. Among people who were homeless, initiation of a conservatorship was associated with significantly longer length of inpatient stay (mean=154.8 days versus 25.6 days for the whole sample) but also with lower odds of being unhoused at the time of discharge (risk ratio=0.19, 95% confidence interval=0.09-0.34). CONCLUSIONS: A mental health conservatorship can be a mechanism for helping homeless people with a grave disability from mental illness to transition from the streets to residential psychiatric treatment, but it requires substantial resources from facilities that initiate such conservatorships and does not guarantee resolution of long-term supportive housing needs.

How Pharmaceuticals Mask Health and Social Inequity.

Medications, like all interventions, shape the ways in which physicians see disease, provide care, define successful outcomes, and organize health care systems. Pharmaceuticals make symptoms and biological drug targets more visible while rendering individuals and their social suffering invisible, thereby focusing our profession on the intracellular effects of an unequal society. This article uses psychopharmacology as a probe to trace a more general problem within contemporary medicine: the pervasive influence of biomedical narratives and therapeutic rationales extending from clinical practice, to medical education, to health care finance.

Directing Research Toward Health Equity: a Health Equity Research Impact Assessment.

Despite medical research advancements, inequities persist, as research has enhanced the health of some while leaving many communities untouched. Reforms are needed to direct research toward health equity, both during this pandemic and beyond. All research must currently pass scientific and ethical review processes, but neither may adequately examine a project's potential impact on inequities and local communities. Research stakeholders need practical tools to help review and examine any given study's impact on health equity. We articulate a health equity research impact assessment, which draws from existing research impact assessments and health disparities research measures and frameworks. We describe how this tool was developed and how it may be used by research reviewers, researchers, academic institutions, and funding agencies to elevate health equity in medical science.

Recovery in Context: Thirty Years of Mental Health Policy in California.

Over the past quarter century, Recovery has become the hegemonic model guiding mental health policy. Advocates presented Recovery as a radical departure from the past, with the promise of dramatically improved outcomes for those with serious mental illness. This article looks at the implementation of Recovery-based policies in California from the 1990s to the present and interrogates the ways these policies emerged out of and reinforced many of the problems they were intended to solve. Against the backdrop of welfare reform, managed care, and a growing belief in market forces and individual responsibility, California policymakers pivoted from rigorously studied pilot programs that were intended to provide intensive, long-term treatment to Recovery-oriented programs that, while initially intensive, promised to "flow" increasingly independent and self-sufficient patients to less-intensive services. Moreover, these new programs promised to produce cost savings by reducing homelessness, hospitalization, and incarceration. Reported outcomes from these programs have been overwhelmingly positive but are based on flawed evaluations that lean more heavily on belief than on evidence. While proclaiming a comprehensive, patient-centered approach, Recovery's embrace of independence over long-term care and social supports has justified a system of care that systematically fails the sickest patients by abandoning them to the streets and jails.

We're Not Sure We Like It but We Still Want More: Trainee and Faculty Perceptions of Remote Learning During the COVID-19 Pandemic.

OBJECTIVE: In this study, the authors aim to compare perceptions of remote learning versus in-person learning among faculty and trainees at a single institution during the COVID-19 pandemic and to evaluate the impact that a brief faculty training on best practices in online teaching would have on faculty attitudes towards remote learning. METHODS: The authors conducted an attitude survey on remote learning among trainees and faculty members approximately 3 months after the transition from in-person to remote learning. The authors then conducted a faculty training on best practices in online teaching followed by an evaluation survey. Study findings were examined descriptively and by Fisher's exact testing. RESULTS: The response rates for the attitudes survey were 68% among trainees and 61% among faculty. Trainees and faculty perceived in-person learning more favorably than remote learning across a variety of domains, including overall enjoyment, interpersonal connection, ability to communicate, and concentration. Despite these trends, only 10% of trainees and 14% of faculty felt that all lectures would be most effectively delivered in-person when this becomes possible again. The response rate for the faculty training evaluation survey was 16%. Compared to non-attendees, faculty attendees reported more confidence in their ability to teach remotely (89% vs 56%, p=0.02) but not increased optimism (89% vs 63%, p=0.06). CONCLUSIONS: The study findings suggest that both trainees and faculty perceive remote learning negatively compared to in-person learning but still feel that some lectures should be delivered remotely even after a return to in-person learning is possible.

Reconsidering Systems-Based Practice: Advancing Structural Competency, Health Equity, and Social Responsibility in Graduate Medical Education.

Health inequities stem from systematic, pervasive social and structural forces. These forces marginalize populations and create the circumstances that disadvantage these groups, as reflected in differences in outcomes like life expectancy and infant mortality and in inequitable access to and delivery of health care resources. To help eradicate these inequities, physicians must understand racism, sexism, oppression, historical marginalization, power, privilege, and other sociopolitical and economic forces that sustain and create inequities. A new educational paradigm emphasizing the knowledge, skills, and attitudes to achieve health equity is needed.Systems-based practice is the graduate medical education core competency that focuses on complex systems and physicians' roles within them; it includes topics like multidisciplinary team-based care, patient safety, cost containment, end-of-life goals, and quality improvement. This competency, however, is largely health care centric and does not train physicians to engage with the complexities of the social and structural determinants of health or to partner with systems and communities that are outside health care.The authors propose a new core competency centered on health equity, social responsibility, and structural competency to address this gap in graduate medical education. For the development of this new competency, the authors draw on existing, innovative undergraduate and graduate medical pedagogy and public health, health services research, and social medicine frameworks. They describe how this new competency would inform graduate medical education and clinical care and encourage future physicians to engage in the work of health equity.

Community Interventions to Promote Mental Health and Social Equity.

(Reprinted with permission from Current Psychiatry Reports (2020) 21: 35).

Outcomes of two quality improvement implementation interventions for depression services in adults with substance use problems.

Background: Comorbid depression and substance use disorders (SUDs) are associated with poor health and social outcomes disproportionately affecting under-resourced communities.Objectives: To test the hypothesis that a coalition approach to collaborative care (CC) for depression would improve outcomes of hazardous drinking and behavioral health hospitalizations, relative to technical assistance, for individuals with comorbid substance use problems. Substance use problems were defined by meeting criteria for DSM-IV substance abuse or dependence, hazardous drinking by AUDIT-C, or treatment in a SUD program within the prior 6 months.Methods: Two depression CC implementation approaches were compared: Resources for Services (RS) provided expert technical support for CC toolkits to individual programs. Community engagement and planning (CEP) supported multi-sector coalitions in collaborating in planning, adapting, implementing and monitoring CC toolkits. One thousand eighteen individuals with depression (PHQ-8 ≥10) enrolled. Regression analyses estimated intervention effects in participants with comorbid substance use problems (n = 588, 281 females, 307 males). Substance use problems were defined by meeting criteria for DSM-IV substance abuse or dependence, hazardous drinking by AUDIT-C, or treatment in a SUD program within the prior 6 months.Results: There were no significant baseline differences by intervention status among participants with depression and substance use problems. Intervention effects on primary outcomes including depression were not significant at 6 months. Compared to RS, CEP significantly reduced alcohol consumption (CEP = 1.6, RS = 2.1, p = .038), probability of behavioral health hospitalizations (OR = 0.50, p = .036), and use of specialty mental health visits (IRR = 0.52, p = .027), while increasing use of faith-based depression services (IRR = 3.4, p = .001).Conclusions: Given feasibility and possible benefits, CEP should be considered a promising approach to implementing depression CC with potential benefits to adults with comorbid substance use problems.