Impact of the Pandemic was Minor Compared to Systemic Decrease in Fidelity of Assertive Community Treatment Services- A Provincial Study in Ontario, Canada.

Assertive Community Treatment (ACT) model is the gold standard in community psychiatry serving people with severe mental illness. With its outreach-based design, the pandemic has profoundly affected the operations and functioning of ACT. The Dartmouth ACT Scale (DACTS) provides a standardized comprehensive and quantitative way to evaluate ACT quality. Results could inform nature of impact and identify areas for improvement. Current online survey used DACTS during the pandemic in April-May 2021. Clinical and administrative leadership of the 80 ACT teams in Ontario, Canada cross-sectionally rated ACT quality one-year pre-Covid (2018-2019) and one-year post the start of Covid (2020-2021). The overall pre-Covid Ontario ACT DACTS fidelity was 3.65. The pandemic led to decreases in all domains of DACTS (Human Resources: -4.92%, p < 0.001, 95% CI [0.08-0.27]; Organizational Boundary: -1.03%, p < 0.013,95%CI [0.01-0.07]; and Nature of Services: -6.18%, p < 0.001, 95%CI [0.16-0.26]). These changes were accounted by expected lower face-to-face encounters, time spent with clients, reduction in psychosocial services, less interactions with hospitals and diminished workforces. The magnitude of change was modest (-3.84%, p < 0.001, 95%CI [0.09-0.19]). However, the Ontario ACT pre-Covid DACTS was substantially lower (-13.5%) when compared to that from a similar survey 15 years ago (4.22), suggestive of insidious systemic level loss of fidelity. Quantitative fidelity evaluation helped to ascertain specific pandemic impact. Changes were significant and specific, but overall relatively modest when compared to the larger system level drop over the last decade. There is both evidence for model adaptability and resilience during Covid disruption, and concerns over larger downward drift in ACT fidelity and quality.

Guidelines and recommendations about virtual mental health services from high-income countries: a rapid review.

OBJECTIVES: This study reviewed existing recommendations for virtual mental healthcare services through the quadruple aim framework to create a set of recommendations on virtual healthcare delivery to guide the development of Canadian policies on virtual mental health services. DESIGN: We conducted a systematic rapid review with qualitative content analysis of data from included manuscripts. The quadruple aim framework, consisting of improving patient experience and provider satisfaction, reducing costs and enhancing population health, was used to analyse and organise findings. METHODS: Searches were conducted using seven databases from 1 January 2010 to 22 July 2022. We used qualitative content analysis to generate themes. RESULTS: The search yielded 40 articles. Most articles (85%) discussed enhancing patient experiences, 55% addressed provider experiences and population health, and 25% focused on cost reduction. Identified themes included: screen patients for appropriateness of virtual care; obtain emergency contact details; communicate transparently with patients; improve marginalised patients' access to care; support health equity for all patients; determine the cost-effectiveness of virtual care; inform patients of insurance coverage for virtual care services; increase provider training for virtual care and set professional boundaries between providers and patients. CONCLUSIONS: This rapid review identified important considerations that can be used to advance virtual care policy to support people living with mental health conditions in a high-income country.

Impact of COVID-19 on the lives of people with severe mental illness-front-line community psychiatry workers observation from a provincial survey of assertive community treatment teams in Ontario, Canada.

Using an online survey distributed to members of the provincial organization that represents the 88 Assertive Community Treatment (ACT) and Flexible ACT teams in Ontario, Canada, this descriptive study relied on the unique vantage points and observations of the front-line community psychiatry workers who maintained contact with patients through outreach and telecommunication during the height of COVID-19. The patients who suffer from serious mental illness (SMI) were uniquely affected by COVID-19 due to the changes, reduction or shut down of many essential clinical and community support services. Thematic and quantitative analyses of the workers' observations highlighted 6 main areas of note, including significant social isolation and loneliness, clinical course deterioration and life disruption, increased hospital and ER use, police and legal contacts, and substance abuse and related deaths. There were also encouraging signs of positive adaptations in terms of independence and resilience. Reflections of these impacts and potential ameliorating approaches are further discussed.

Health-related quality of life measures in incarcerated populations: protocol for a scoping review.

INTRODUCTION: Incarcerated populations represent a vulnerable and marginalised segment of society, with increased health needs and a higher burden of communicable and non-communicable diseases. Traditional population health outcomes do not capture physical, mental, emotional and social well-being. Health-related quality of life (HRQoL) outcomes attempt to measure these important parameters. To date, there has not been a scoping review to summarise the HRQoL literature in the incarcerated population. Thus, we aim to perform such a review to inform health policy decisions in incarcerated populations and support health economic evaluations of interventions in incarcerated populations. METHODS AND ANALYSIS: We will conduct a scoping review of the literature on the HRQoL in the incarcerated population informed by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) and the corresponding PRISMA Extension for Scoping Reviews. The submissions records of six electronic databases with peer-reviewed literature and three health technology assessment agencies will be searched. The search strategy was informed by recommendations for HRQoL reviews. We will include studies that report HRQoL, health state utility values or reference to quality adjusted life years or quality-adjusted life expectancies of incarcerated populations. No assessments of items' quality will be made, as the purpose of this scoping review is to synthesise and describe the coverage of the evidence. We will also identify knowledge gaps on the HRQoL in the incarcerated population. ETHICS AND DISSEMINATION: Research ethics approval is not required as primary data will not be collected. The findings of this scoping review will be used to inform health economic analyses for the incarcerated population and will be disseminated through peer-reviewed publications and conference presentations.

Cost-Effectiveness of Early Intervention in Psychosis: A Modeling Study.

OBJECTIVE: Programs for early intervention in psychosis have shown clinical efficacy. The authors aimed to evaluate the cost-effectiveness of early intervention programs compared with standard care for the treatment of first-episode psychosis in the United States. METHODS: A decision-analytic model integrating published data on clinical efficacy, costs, and health utilities was developed to evaluate early intervention versus standard care over the lifetime of patients after their first psychotic episode. Model input data were derived from meta-analyses, clinical trials, and U.S. national data. The main outcomes included hospitalizations, employment rate, quality-adjusted life years (QALYs), lifetime health care costs, and incremental cost-effectiveness ratios (ICERs). RESULTS: Compared with patients receiving standard care, patients in the early intervention strategy had 3.2 fewer hospitalizations and 2.7 more years of employment over the course of their remaining life expectancy. From a health care perspective, early intervention had an ICER of approximately $51,600 per QALY. From a societal perspective, early intervention saved costs (i.e., yielded greater health benefits and had lower costs compared with standard care). Results were sensitive to the effect of early intervention on suicide, cost of standard care, cost of early intervention, and the effect (relative risk) of early intervention on employment. A scenario analysis that excluded the effect (i.e., hazard ratio) of early intervention on suicide yielded an ICER of approximately $197,000 per QALY. CONCLUSIONS: These results suggest that it is economically beneficial to fund early intervention in psychosis programs in the United States. The findings indicate that early intervention in psychosis saves costs (from the societal perspective) and is cost-effective (health care sector perspective).

Intergenerational Decision Making: The Role of Family Relationships in Medical Decision Making.

A symposium held at the 42nd annual Society for Medical Decision Making conference on October 26, 2020, focused on intergenerational decision making. The symposium covered existing research and clinical experiences using formal presentations and moderated discussion and was attended by 43 people. Presentations focused on the roles of pediatric patients in decision making, caregiver decision making for a child with complex medical needs, caregiver involvement in advanced care planning, and the inclusion of spillover effects in economic evaluations. The moderated discussion, summarized in this article, highlighted existing resources and gaps in intergenerational decision making in four areas: decision aids, economic evaluation, participant perspectives, and measures. Intergenerational decision making is an understudied and poorly understood aspect of medical decision making that requires particular attention as our society ages and technological advances provide new innovations for life-sustaining measures across all stages of the lifespan.

Involuntary isolation: interpreting mental health legislation during the COVID-19 pandemic.

The coronavirus disease 2019 (COVID-19) pandemic poses new and unprecedented challenges to the interpretation of mental health law. The authors present pragmatic and ethical considerations in the psychiatric safety assessment at the intersection of COVID-19 and severe mental illness.

Expression and resilience of a cocaine-conditioned locomotor response after brief and extended drug-free periods.

Conditioned associations between drug experience and its context are maintained long after drug use ceases, and may contribute to relapse after extended abstinence. These include operantly conditioned associations directed toward seeking drug, but also Pavlovian conditioned associations between drug reward and contextual cues present at the time of drug administration. The present study sought to determine whether expression of a Pavlovian conditioned locomotor (CL) response to a cocaine-associated context increases over time in the same manner observed for instrumental responses, and whether the CL memory is differentially susceptible to extinction and recovery after brief versus extended abstinence. Male rats received injections of cocaine (30mg/kg, i.p.) or vehicle once per day for 6 days. In Exp. 1, CL activity was measured 1, 7, 21, or 42 days later. Rats that had received cocaine injections displayed robust CL, regardless of when testing occurred. In Exp. 2, extinction and recovery of CL were assessed after 1 or 42 days. The CL response was more readily extinguished in rats tested 1 day after drug exposure, as compared to rats tested 42 days later. Exp. 3 confirmed that conditioning in the testing context was necessary for expression of CL. Overall, our results indicate that Pavlovian associations underlying the CL response are maintained long after drug experience. Although the expression of CL does not change with the passage of time, as has been observed for instrumental drug-related responses, the memory trace does appear to become more resilient over time.