Patient Satisfaction and Recommendations for Delivering a Group-Based Intensive Outpatient Program via Telemental Health During the COVID-19 Pandemic: Cross-sectional Cohort Study.

BACKGROUND: Although group-based intensive outpatient programs (IOPs) are a level of care commonly utilized by adults with serious mental illness, few studies have examined the acceptability of group-based IOPs that required rapid transition to a telemental health (TMH) format during the COVID-19 pandemic. OBJECTIVE: The aim of this study was to evaluate patient satisfaction and future recommendations for a group-based IOP that was transitioned to a TMH format during the COVID-19 pandemic. METHODS: A 17-item patient satisfaction questionnaire was completed by patients at discharge and covered 3 areas: IOP TMH satisfaction, future recommendations, and video technology challenges. Descriptive and content analyses were conducted for the quantitative and open-ended questions, respectively. RESULTS: A total of 76 patients completed the program in 2020. A subset of patients (n=40, 53%) responded to the survey at program discharge. The results indicated that the patients were satisfied overall with the TMH program format; 50% (n=20) of the patients preferred the program continue offering the TMH format, and the rest preferred returning to in-person formats after the pandemic. The patients indicated the elements of the program that they found most valuable and provided recommendations for future program improvement. CONCLUSIONS: Overall, adults with serious mental illness reported high satisfaction with the group-based IOP delivered via TMH. Health care systems may want to consider offering both TMH and in-person formats regardless of the state of the pandemic. Patients' feedback on future improvements should be considered to help ensure long-term success.

Gender-Affirming Telepsychology During and After the COVID-19 Pandemic: Recommendations for Adult Transgender and Gender Diverse Populations.

The implementation of telepsychology soared in response to the 2019 novel coronavirus (COVID-19) pandemic. For most health service psychologists, this surge preceded formal training in telepsychology. Transgender and gender diverse (TGD) individuals reported significant vulnerabilities and health disparities during the COVID-19 pandemic. To ensure the health and well-being of adult transgender and gender diverse individuals during the COVD-19 pandemic and beyond, it is critical to promote the delivery of gender-affirming telepsychology. This article highlights clinical issues observed by health service psychologists at a high-volume gender clinic during the COVID-19 pandemic. The authors provide anticipatory guidance and recommendations to promote gender-affirming telepsychology.

Rapid Adoption and Implementation of Telehealth Group Psychotherapy During COVID 19: Practical Strategies and Recommendations.

Behavioral health services have been tasked with rapidly adopting and implementing teletherapy during the SARS-CoV-2/COVID-19 pandemic to assure patient and staff safety. Existing teletherapy guidelines were developed prior to the pandemic and do not capture the nuances of rapidly transitioning in-person individual and group-based treatments to a teletherapy format. In this paper, we describe our approach to quickly adapting to a teletherapy technology platform for an intensive outpatient program (IOP) guided by cognitive and behavioral modular principles for adults with serious mental illness. A review of existing guidelines was conducted and the staged approach for teletherapy implementation (Muir et al., 2020) was selected as the most appropriate model for our organizational context. We describe the most pertinent implementation strategies and report our preliminary findings detailing the feasibility of IOPs delivered via telehealth. This model of rapid teletherapy implementation offers practical clinical guidelines for administrators and clinicians seeking to transition traditional in-person behavioral health services to a teletherapy format.

LGBTQ-Affirmative Behavioral Health Services in Primary Care.

Behavioral health concerns related to sexual and gender minority stress impair functioning and limit quality of life. With greater interest in implementing LGBTQ-affirmative health care practices, primary care providers likely will see larger numbers of LGBTQ individuals presenting with behavioral health concerns. Behavioral health and medical providers may not feel prepared to address the biological, psychological, social, and cultural minority stress factors that have an impact on LGBTQ patients. LGBTQ-affirmative behavioral health providers in primary care can offer a unique service by conducting tailored evaluations and individualized interventions targeting multifactorial influences that cause and perpetuate psychological distress in LGBTQ patients.

Feasibility and Initial Outcomes of a Group-Based Teletherapy Psychiatric Day Program for Adults With Serious Mental Illness: Open, Nonrandomized Trial in the Context of COVID-19.

BACKGROUND: In the context of the COVID-19 pandemic, many behavioral health services have transitioned to teletherapy to continue delivering care for patients with mental illness. Studies that evaluate the outcome of this rapid teletherapy adoption and implementation are pertinent. OBJECTIVE: This single-arm, nonrandomized pilot study aimed to assess the feasibility and initial patient-level outcomes of a psychiatric transitional day program that switched from an in-person group to a video teletherapy group during the COVID-19 pandemic. METHODS: Patients with transdiagnostic conditions who were at risk of psychiatric hospitalization were referred to the Adult Transitions Program (ATP) at a large academic medical center in the United States. ATP was a 3-week intensive outpatient program that implemented group teletherapy guided by cognitive and behavioral principles delivered daily for 3 hours per day. Feasibility was assessed via retention, attendance rate, and rate of securing aftercare appointments prior to ATP discharge. Patients completed standardized patient-reported outcome measures at admission and discharge to assess the effectiveness of the program for improving quality of mental health, depression, anxiety, and suicide risk. RESULTS: Patients (N=76) started the program between March and August of 2020. Feasibility was established, with 70 of the 76 patients (92%) completing the program and a mean attendance of 14.43 days (SD 1.22); also, 71 patients (95%) scheduled at least one behavioral health aftercare service prior to ATP discharge. All patient-level reported outcomes demonstrated significant improvements in depression (95% CI -3.6 to -6.2; Cohen d=0.77; P<.001), anxiety (95% CI -3.0 to -4.9; Cohen d=0.74; P<.001), overall suicide risk (95% CI -0.5 to -0.1; Cohen d=0.41; P=.02), wish to live (95% CI 0.3 to 1.0; Cohen d=0.39; P<.001), wish to die (95% CI -0.2 to -1.4; Cohen d=0.52; P=.01), and overall mental health (95% CI 1.5 to 4.5; Cohen d=0.39; P<.001) from admission to discharge. CONCLUSIONS: Rapid adoption and implementation of a group-based teletherapy day program for adults at risk of psychiatric hospitalization appeared to be feasible and effective. Patients demonstrated high completion and attendance rates and reported significant improvements in psychosocial outcomes. Larger trials should be conducted to further evaluate the efficacy and effectiveness of the program through randomized controlled trials.

Perinatal Mood and Anxiety Disorder Management in Multicenter Community Practices: Clinicians' Training, Current Practices and Perceived Strategies to Improve Future Implementation.

BACKGROUND: This study aimed to explore clinicians' perspectives on the current practice of perinatal mood and anxiety disorder (PMAD) management and strategies to improve future implementation. METHODS: This study had a cross-sectional, descriptive design. A 35-item electronic survey was sent to clinicians (N = 118) who treated perinatal women and practiced at several community clinics at an academic medical center in the United States. RESULTS: Among clinicians who provided care for perinatal women, 34.7% reported never receiving PMAD management training and 66.3% had less than 10 years of experience. Out of 10 patients who reported psychiatric symptoms, 47.8% of clinicians on average reported providing PMAD management to 1 to 3 patients and 40.7% noted that they conducted screening only when patient expresses PMAD symptoms. Suggested future improvements were providing training, developing a referral list, and establishing integrated behavioral health services. CONCLUSIONS: Results from this study indicated that while PMAD screening and management was implemented, improvements are warranted to meet established guidelines. Additionally, clinicians endorsed providing PMAD management to a small percentage of perinatal patients. Suggested strategies to increase adoption and implementation of PMAD management should be explored to improve access to behavioral health services for perinatal women.

Initial outcomes of a real-world multi-site primary care psychotherapy program.

OBJECTIVE: Although anxiety, mood, and adjustment disorders are commonly treated in primary care, little evidence exists regarding psychotherapy outcomes within this setting. The primary objective of this study was to describe outcomes of a large-scale primary care psychotherapy program. METHODS: Patients (N = 2772) participated in cognitive behavioral therapy (CBT) as part of a multi-site primary care program. A tracking system was utilized to collect data on demographics, diagnoses, course of care, anxiety and depressive symptoms, and frequencies of psychotherapy principles used over the course of primary care CBT. RESULTS: Anxiety disorders were most frequent, often comorbid with depression. Over two-thirds of the sample participated in at least one CBT session. Case formulation, cognitive interventions, exposure, and behavioral activation were frequently utilized approaches. Significant improvements on the GAD-7 and PHQ-9 occurred for all groups, yielding medium effect sizes (d = 0.50-0.68). Rates of reliable change (48-80%), response (35-53%), and remission (21-36%) were noted for those scoring in the moderate range of severity. CONCLUSION: Patients suffering from anxiety, depression, and adjustment disorders can be effectively treated in primary care with CBT. Future efforts are needed to match patient characteristics with the types and timing of therapy interventions to improve clinical and functional outcomes.

Impact of Personality Disorder Cluster on Depression Outcomes Within Collaborative Care Management Model of Care.

BACKGROUND: Previous studies have suggested that having a comorbid personality disorder (PD) along with major depression is associated with poorer depression outcomes relative to those without comorbid PD. However, few studies have examined the influence of specific PD cluster types. The purpose of the current study is to compare depression outcomes between cluster A, cluster B, and cluster C PD patients treated within a collaborative care management (CCM), relative to CCM patients without a PD diagnosis. The overarching goal was to identify cluster types that might confer a worse clinical prognosis. METHODS: This retrospective chart review study examined 2826 adult patients with depression enrolled in CCM. The cohort was divided into 4 groups based on the presence of a comorbid PD diagnosis (cluster A/nonspecified, cluster B, cluster C, or no PD). Baseline clinical and demographic variables, along with 6-month follow-up Patient Health Questionnaire-9 (PHQ-9) scores were obtained for all groups. Depression remission was defined as a PHQ-9 score <5 at 6 months, and persistent depressive symptoms (PDS) was defined as a PHQ-9 score ≥10 at 6 months. Adjusted odds ratios (AORs) were determined for both remission and PDS using logistic regression modeling for the 6-month PHQ-9 outcome, while retaining all study variables. RESULTS: A total of 59 patients (2.1%) had a cluster A or nonspecified PD diagnosis, 122 patients (4.3%) had a cluster B diagnosis, 35 patients (1.2%) had a cluster C diagnosis, and 2610 patients (92.4%) did not have any PD diagnosis. The presence of a cluster A/nonspecified PD diagnosis was associated with a 62% lower likelihood of remission at 6 months (AOR = 0.38; 95% CI 0.20-0.70). The presence of a cluster B PD diagnosis was associated with a 71% lower likelihood of remission at 6 months (AOR = 0.29; 95% CI 0.18-0.47). Conversely, having a cluster C diagnosis was not associated with a significantly lower likelihood of remission at 6 months (AOR = 0.83; 95% CI 0.42-1.65). Increased odds of having PDS at 6-month follow-up were seen with cluster A/nonspecified PD patients (AOR = 3.35; 95% CI 1.92-5.84) as well as cluster B patients (AOR = 3.66; 95% CI 2.45-5.47). However, cluster C patents did not have significantly increased odds of experiencing persistent depressive symptoms at 6-month follow-up (AOR = 0.95; 95% CI 0.45-2.00). CONCLUSIONS: Out of the 3 clusters, the presence of a cluster B PD diagnosis was most significantly associated with poorer depression outcomes at 6-month follow-up, including reduced remission rates and increased risk for PDS. The cluster A/nonspecified PD group also showed poor outcomes; however, the heterogeneity of this subgroup with regard to PD features must be noted. The development of novel targeted interventions for at-risk clusters may be warranted in order to improve outcomes of these patients within the CCM model of care.

Collaborative Care Management Associated With Improved Depression Outcomes in Patients With Personality Disorders, Compared to Usual Primary Care.

BACKGROUND: The use of a collaborative care management (CCM) model can dramatically improve short- and long-term treatment outcomes for patients with major depressive disorder (MDD). Patients with comorbid personality disorder (PD) may experience poorer treatment outcomes for MDD. Our study seeks to examine the differences in MDD treatment outcomes for patients with comorbid PD when using a CCM approach rather than usual care (UC). METHODS: In our retrospective cohort study, we reviewed the records of 9614 adult patients enrolled in our depression registry with the clinical diagnosis MDD and the diagnosis of PD (Yes/No). Clinical outcomes for depression were measured with Patient Health Questionnaire-9 (PHQ-9) scores at 6 months. RESULTS: In our study cohort, 59.4% of patients (7.1% of which had comorbid PD) were treated with CCM, as compared with 40.6% (6.8% with PD) treated with UC. We found that the presence of a PD adversely affected clinical outcomes of remission within both groups, however, at 6 months patients with PD had significantly lower MDD remission rates when treated with UC as compared with those treated with CCM (11.5% vs 25.2%, P = .002). Patients with PD in the UC group were also noted to have an increased rate of persistent depressive symptoms (PHQ-9 score ≥10) at 6 months as compared with those in the CCM group (67.7% vs 51.7%, P = .004). CONCLUSIONS: In patients with comorbid MDD and PD, clinical outcomes at 6 months were significantly improved when treated with CCM compared with UC. This finding is encouraging and supports the idea that CCM is an effective model for caring for patients with behavioral concerns, and it may be of even greater benefit for those patients being treated for comorbid behavioral health conditions.