Decreased inpatient psychiatric admissions with telepsychiatry use during the COVID-19 pandemic.

Objective: This study examines the quality of care provided through telepsychiatry by comparing psychiatric hospitalization rates among patients receiving in-person psychiatric care prior to the COVID-19 pandemic with rates among patients receiving virtual psychiatric care during the COVID-19 pandemic. Methods: Mental health-related hospitalization rates among patients enrolled in a large academic hospital's outpatient psychiatry programs between March 1, 2018 and February 28, 2022 were retrospectively analyzed. Four time periods were created, spanning March 1 to February 28 of the following year. Demographic and clinical data were collected from the electronic health record, and descriptive statistics were calculated. Change in hospitalization rate between time periods was evaluated using McNemar's test. Results: In the 2018 time period, 7.38% of all enrolled patients were hospitalized, compared to 7.70% hospitalized in the 2019 period, 5.74% in the 2020 period, and 5.38% in the 2021 period. Patients enrolled in both the 2018 and the 2019 periods saw no difference in hospitalization rate between the 2 years (2.93% in 2018, 2.83% in 2019; p = 0.830); patients enrolled in both 2019 and 2020 saw significantly lower hospitalization rates in 2020 (5.47% in 2019, 4.58% in 2020; p = 0.022); and patients enrolled in both 2020 and 2021 saw no difference (3.34% in 2020, 3.23% in 2021; p = 0.777). Conclusion: Psychiatric hospitalization rates significantly decreased between the 2019 and the 2020 periods, suggesting a decrease in admissions associated with adoption of telepsychiatry. Future research should differentiate the roles played by telepsychiatry and COVID-19-related factors in reducing hospitalization rates during the pandemic.

Transformation of Outpatient Psychiatry.

Provision of psychiatric services during the pandemic required flexibility, innovation, and collaboration. Going forward, telepsychiatry will offer accessible and effective treatment options. Increased collaboration with multidisciplinary providers, a critical component of effective treatment during the pandemic, should augment future treatment relationships. Large practice organizations continue to develop and disseminate best practices, and providers and institutions must continuously adapt and improve services. An increased focus on the utility of novel and innovative technology's role in psychiatry has emerged during the pandemic, and although openness to innovation will be critical, as will adherence to use of scientifically validated tools and procedures.

Trends in Outpatient Psychotherapy Provision by U.S. Psychiatrists: 1996-2016.

OBJECTIVE: Previous work has demonstrated significant declines in the provision of outpatient psychotherapy by U.S. psychiatrists. The objective of this study was to characterize patterns and trends of psychotherapy by U.S. psychiatrists from 1996 to 2016. METHODS: A retrospective, nationally representative analysis of psychiatrist visits from 21 waves of the U.S. National Ambulatory Medical Care Survey between 1996 and 2016 (N=29,673) was conducted to assess rates of outpatient psychotherapy provision by U.S. psychiatrists. Provision was modeled as risk differences and adjusted by clinical, sociodemographic, geographic, and financial characteristics. RESULTS: Between 1996 and 2016, the weighted percentage of visits involving psychotherapy declined significantly from 44.4% in 1996-1997 to 21.6% in 2015-2016. Declines were most marked among patients diagnosed with social phobia (29% to 8%), dysthymic disorder (65% to 30%), and personality disorders (68% to 17%). For patients diagnosed with schizophrenia, psychotherapy provision remained stable (10%-12%). In the 2010-2016 period, about half of psychiatrists (53%) no longer provided psychotherapy at all. Antidepressant, antipsychotic, and sedative-hypnotic prescriptions were negatively associated with psychotherapy provision. During the study period, sociodemographic disparities grew, with older, White patients residing in metropolitan areas in the Northeast or West increasingly becoming the most likely to receive psychotherapy. Self-pay predicted access to solo-practice psychiatrists, who saw fewer patients but more frequently, and were more likely to provide psychotherapy. CONCLUSIONS: Previously reported declines in psychiatrist provision of psychotherapy continued through 2016, affecting nearly all clinical categories. In the 2010s, about half of psychiatrists practiced no psychotherapy at all, creating new challenges to the integration of neurobiological and psychosocial elements of clinical care.

Showing Up Is Half the Battle: The Impact of Telehealth on Psychiatric Appointment Attendance for Hospital-Based Intensive Outpatient Services During COVID-19.

Introduction: The COVID-19 pandemic accelerated telehealth to deliver psychiatric services. Continuation of psychiatric services for individuals with high clinical acuity was critical. This study examined attendance to rapidly deployed telehealth services for psychiatrically high-risk individuals receiving intensive outpatient program (IOP), primarily group-based psychotherapy services for adults and adolescents by race/ethnicity, insurance, and clinical treatment program within a large hospital-based outpatient psychiatric setting. Methods: Chi-square tests compared whether attendance rates for telehealth versus in-person IOP services varied by population group, race, insurance, and clinical program, using observational data of adolescent and adult patients treated between October 1, 2019, and July 31, 2020. Results: Appointment attendance increased for telehealth versus in-person services for adolescents (χ2 (df = 1) = 27.49, p < 0.0001) and adults (χ2 (df = 1) = 434.37, p < 0.0001). For adults, increased appointment attendance for telehealth was observed across insurance type (Medicaid: +11.5%; Medicare: +13.79%; Commercial: +6.94%), race/ethnicity (+6.23% to +15.76% across groups), and for IOP groups across all five diagnostic treatment programs (between 7.59% and 15.9% increases across groups). Adolescent results were mixed; increased appointment attendance for telehealth was observed among commercially insured youth (+7.11%), but no differences were observed for Medicaid-insured youth. Non-Hispanic white youth had increased attendance for telehealth (+8.38%) and no differences were observed for non-Hispanic black youth. Decreases were found in telehealth attendance for Hispanic/Latinx youth (-13.49%). Discussion: Rapidly deployed telehealth increased attendance to intensive services for psychiatrically high-risk individuals, particularly among adults and for adolescents with commercial insurance and non-Hispanic white youth. Trends among racial/ethnic and Medicaid-insured youth warrant further investigation regarding the potential for special challenges or vulnerabilities and advocacy needs. Findings highlight telehealth as an important tool in supporting availability of services for individuals with high levels of psychiatric acuity, particularly for group-based services, during the pandemic.

Staff experiences of encountering and treating outpatients with substance use disorder in the psychiatric context: a qualitative study.

BACKGROUND: High comorbidity exists between mental illness and substance use disorders (SUD). Patients in psychiatry living with problematic alcohol or drug consumption can experience a sense of exclusion, where seeking help for SUD can be perceived as stigmatizing. The aim of this study is to illuminate staff experiences of encountering patients with SUD within the psychiatric outpatient context. METHODS: The study was exploratory, with a qualitative design. Interviews with outpatient psychiatry managers and focus groups with clinical staff focused on the experience of encountering patients with SUD. Data were evaluated using content analysis inspired by phenomenological-hermeneutic methodology. RESULTS: Three themes were identified and each illuminated by two sub-themes. Bridging the organizational gap included sub-themes of having an established collaboration and facing difficulties in the collaboration; Having beliefs about the patient you encounter included sub-themes of working with patients who are exposed to prejudicial thoughts and expressing prejudicial thoughts about the patient. Striving to achieve a therapeutic alliance included sub-themes of having a feeling of developing together and supporting the patient towards recovery. CONCLUSION: A life-world perspective, used to interpret results, indicated that caring for patients with SUD in psychiatry was perceived as difficult, where collaboration between psychiatry and addiction care was often experienced as problematic. Based on these findings, we believe that the current gap between the psychiatry and addiction care could be reduced to some extent by offering patients digital treatment for SUD. In this way, patients could remain under the care of their regular psychiatric clinic without having to physically visit SUD services. Thus, a virtual bridge could be established to bring psychiatry and addiction care closer to each other for the patients' benefit.

On-Site Prescription Dispensing Improves Antidepressant Adherence among Uninsured Depressed Patients.

The successful treatment of depressive disorders critically depends on adherence to prescribed treatment regimens. Despite increasing rates of antidepressant medication prescription, adherence to the full treatment course remains poor. Rates of antidepressant non-adherence are higher for uninsured patients and members of some marginalized racial and ethnic communities due to factors such as inequities in healthcare and access to insurance. Among patients treated in a free, student-run and faculty-supervised clinic serving uninsured patients in a majority Hispanic community in East Harlem, adherence rates are lower than those observed in patients with private or public New York State health insurance coverage. A prior study of adherence in these patients revealed that difficulty in obtaining medications from an off-site hospital pharmacy was a leading factor that patients cited for non-adherence. To alleviate this barrier to obtaining prescriptions, we tested the effectiveness of on-site, in-clinic medication dispensing for improving antidepressant medication adherence rates among uninsured patients. We found that dispensing medications directly to patients in clinic was associated with increased visits at which patients self-reported proper adherence and increased overall adherence rates. Furthermore, we found evidence that higher rates of antidepressant medication adherence were associated with more favorable treatment outcomes. All patients interviewed reported increased satisfaction with on-site dispensing. Overall, this study provides promising evidence that on-site antidepressant dispensing in a resource-limited setting improves medication adherence rates and leads to more favorable treatment outcomes with enhanced patient satisfaction.

Understanding the provision of a clinical service in mental health and the role of the pharmacist: a qualitative analysis / Compreendendo a provisão de um serviço clínico na saúde mental e o papel do farmacêutico: uma análise qualitativa / Comprender la prestación de un servicio clínico en salud mental y el papel del farmacéutico: un análisis cualitativo

Pharmacists have important roles in mental health disease; however, their performance in Brazilian Psychosocial Care Centers (CAPS) is unknown. This qualitative study was conducted in a CAPS, Brazil; using interviews and analyzes from the perspective of Bardin, in which categories arising from the perceptions of patients and the health team emerged in relation to the provision of the medication review with follow up (MR) service and the role of the pharmacist in mental health. According to the participants, the MR service is essential and important because it allows professional recognition, beyond the identification of professional attributes of the pharmacists. Moreover, there was a duality in the pharmacist's role between the logistic and clinical attributes of mental health. Thus, this perception helps to elucidate the pharmacist's process of work in mental health and supports future strategies of action in this area. (AU)

Farmacêuticos têm papéis importantes na área da saúde mental; entretanto, sua atuação nos Centros de Atenção Psicossociais (CAPS) brasileiros é desconhecida. Este estudo qualitativo foi realizado em um CAPS, Brasil; utilizando-se de entrevistas e análises sob a perspectiva de Bardin, no qual categorias em relação à prestação do serviço de acompanhamento farmacoterapêutico (AFT) e ao papel do farmacêutico na saúde mental emergiram através das percepções dos pacientes e equipe de saúde. Segundo os participantes, o serviço de AFT é essencial e importante porque permite o reconhecimento profissional, além da identificação dos atributos profissionais dos farmacêuticos. Além disso, houve uma dualidade no papel do farmacêutico em relação aos atributos logísticos e clínicos na saúde mental. Assim, essas percepções ajudam a elucidar o processo de trabalho do farmacêutico em saúde mental, subsidiando futuras estratégias de ação nesta área. (AU)

Los farmacéuticos tienen un papel importante en el área de la salud mental; sin embargo, se desconoce su desempeño en los Centros de Atención Psicosocial de Brasil (CAPS). Este estudio cualitativo se llevó a cabo en un CAPS, Brasil; utilizando entrevistas y análisis desde la perspectiva de Bardin, en las que de las percepciones de los pacientes y del equipo de salud surgieron categorías en relación a la prestación del servicio de seguimento farmacoterapéutico (SFT) y el papel del farmacéutico en la salud mental. Según los participantes, el servicio de SFT es fundamental e importante. Además, existía una dualidad en el rol del farmacéutico en relación a los atributos logísticos y clínicos en salud mental. Así, estas percepciones ayudan a dilucidar el proceso de trabajo del farmacéutico en salud mental, apoyando futuras estrategias de actuación. (AU)

COVID-19 and telepsychiatry: Early outpatient experiences and implications for the future.

The COVID-19 pandemic has dramatically transformed the U.S. healthcare landscape. Within psychiatry, a sudden relaxing of insurance and regulatory barriers during the month of March 2020 enabled clinicians practicing in a wide range of settings to quickly adopt virtual care in order to provide critical ongoing mental health supports to both existing and new patients struggling with the pandemic's impact. In this article, we briefly review the extensive literature supporting the effectiveness of telepsychiatry relative to in-person mental health care, and describe how payment and regulatory challenges were the primary barriers preventing more widespread adoption of this treatment modality prior to COVID-19. We then review key changes that were implemented at the federal, state, professional, and insurance levels over a one-month period that helped usher in an unprecedented transformation in psychiatric care delivery, from mostly in-person to mostly virtual. Early quality improvement data regarding virtual visit volumes and clinical insights from our outpatient psychiatry department located within a large, urban, tertiary care academic medical center reflect both the opportunities and challenges of virtual care for patients and providers. Notable benefits have included robust clinical volumes despite social distancing mandates, reduced logistical barrieres to care for many patients, and decreased no-show rates. Finally, we provide clinical suggestions for optimizing telepsychiatry based on our experience, make a call for advocacy to continue the reduced insurance and regulatory restrictions affecting telepsychiatry even once this public health crisis has passed, and pose research questions that can help guide optimal utilization of telepsychiatry as mainstay or adjunct of outpatient psychiatric treatment now and in the future.

Rapid design and deployment of intensive outpatient, group-based psychiatric care using telehealth during coronavirus disease 2019 (COVID-19).

COVID-19 has demanded unprecedented actions in the delivery of outpatient psychiatric services, including the rapid shift of services from in-person to telehealth in response to public health physical distancing guidelines. One such shift was to convert group-level intensive outpatient psychiatric (IOP) interventions to telehealth. Historically, telehealth in psychiatric care has been studied in provider-patient interactions, but has not been as well studied for group telehealth service delivery. During the COVID-19 outbreak, providing group-based interventions was important in order to care for high-risk individuals who needed structured psychotherapy group support. However, the delivery of services via telehealth led to special challenges that were unable to be fully accommodated by the preexisting telehealth infrastructure. Rapid feasibility testing and adoption of technology was needed to support IOP services to minimize infectious spread while delivering group services to high-risk psychiatric patients. This article describes the processes and workflows for service delivery and early results of telehealth for IOP services in 2 adolescent treatment programs. In addition, the article highlights early observations around safety and quality and the role of telehealth policy and payment.

Neuropsychological features in patients with severe mental disorders and risk of violence: A prospective multicenter study in Italy.

In Severe Mental Disorders (SMDs) the most important cognitive deficits involve the Executive Functions (EFs). In this study we examined the association between EFs and aggressive behaviour in outpatients with SMDs. We included a total of 247 outpatients divided into two groups: 'cases', patients with a history of violence (N=126) and 'non-violent' (N=121). We compared their EFs score and then categorized the participants into four groups (Pathological Non-Violent comparison group; Non-Pathological Non-Violent comparison group; Pathological Violent cases and Non-Pathological Violent cases), based on the scores of a subtest assessing processing speed (i.e., Symbol-coding task) of the Brief Assessment of Cognition in Schizophrenia (BACS). We followed the 4 groups during a 1-year follow-up (FU) monitoring violent behaviour with the Modified Overt Aggression Scale (MOAS). According to the classification based on the BACS-Symbol Coding Task we found no statistically significant differences between subgroups in MOAS scores. We only found that the trend curve for PV was almost consistently over the other group curves in the MOAS 'aggression against people'. Our results suggested a worse performance in the violent compared to non-violent group in EFs. Despite this evidence, the score on the processing speed task was not associated with aggressive behaviour during FU.

Rapid Conversion of an Outpatient Psychiatric Clinic to a 100% Virtual Telepsychiatry Clinic in Response to COVID-19.

In anticipation of a surge of COVID-19 cases in Northern California, the outpatient psychiatric clinic at UC Davis Health, in which 98% of visits initially occurred in person, was converted to a telepsychiatry clinic, with all visits changed to virtual appointments within 3 business days. The clinic had 73 virtual appointments on its first day after full conversion. This column describes the process, challenges, and lessons learned from this rapid conversion. Patients were generally grateful, providers learned rapidly how to work from home, and the clinic remained financially viable with no immediate losses.

Workloads in Clinical Psychiatry: Another Way.

Caseload and daily volume requirements present clinical and administrative challenges in organized settings primarily serving the public sector. These challenges are examined through lenses of systems-level fiscal viability, population health, and patient experience. Framed by previous efforts in caseload methodology, illustrative data collected from members of the American Association of Community Psychiatrists are discussed, with consideration of issues of professional effort and burnout. A systematic effort is needed to develop guidelines for caseload and volume expectations that support recovery outcomes, account for practitioner skills, and promote high-quality clinical encounters.

PTSD in mental health outpatient settings: highly prevalent and under-recognized

Objectives: To estimate the current prevalence of posttraumatic stress disorder (PTSD) and the diagnosis rate of this disorder ascertained by psychiatrists in training. Methods: We interviewed 200 adults under treatment in a university mental health outpatient clinic. The PTSD diagnoses obtained using the Structured Clinical Interview for DSM-IV (SCID-IV) were compared with the patients' medical records. Results: Forty-one patients (20.5%) were diagnosed with current PTSD, but only one of them (2.4%) had previously received this diagnosis. This study confirms that although PTSD is highly prevalent among mental health outpatients, it is remarkably underdiagnosed in teaching hospitals. Conclusions: These findings suggest that psychiatrists in training may be failing to investigate traumatic events and their consequences and strongly indicate that trauma-related issues should be given more prominence in psychiatry curricula and psychiatrist training.

Improving Ambulatory Care Resident Training: Preparing for Opportunities to Treat Mental Illness in the Primary Care Setting.

PURPOSE: The development of an outpatient psychiatry clinical practice learning experience for PGY2 ambulatory care pharmacy residents in preparation for the treatment of psychiatric disorders in the primary care setting is described. SUMMARY: With the increased prevalence of psychiatric disorders, significant mortality, and limited access to care, integration of mental health treatment into the primary care setting is necessary to improve patient outcomes. Given the majority of mental health treatment occurs in the primary care setting, pharmacists in patient-centered medical homes (PCMHs) are in a unique position with direct access to patients to effectively manage these illnesses. However, the increased need for pharmacist education and training in psychiatry has prompted a large, Midwestern academic health system to develop an outpatient psychiatry learning experience for PGY2 (Postgraduate Year 2) ambulatory care pharmacy residents in 2015. The goal of this learning experience is to introduce the PGY2 ambulatory care residents to the role and impact of psychiatric clinical pharmacists and to orient the residents to the basics of psychiatric pharmacotherapy to be applied to their future practice in the primary care setting. CONCLUSION: The development of an outpatient psychiatry learning experience for PGY2 ambulatory care pharmacy residents will allow for more integrated and comprehensive care for patients with psychiatric conditions, many of whom are treated and managed in the PCMH setting.

Suicidal ideation and subsequent completed suicide in both psychiatric and non-psychiatric populations: a meta-analysis.

AIMS: Several authors claimed that expression of suicidal ideation is one of the most important predictors of completed suicide. However, the strength of the association between suicidal ideation and subsequent completed suicide has not been firmly established in different populations. Furthermore, the absolute suicide risk after expression of suicidal ideation is unknown. In this meta-analysis, we examined whether the expression of suicidal ideation predicted subsequent completed suicide in various populations, including both psychiatric and non-psychiatric populations. METHODS: A meta-analysis of cohort and case-control studies that assessed suicidal ideation as determinant for completed suicide in adults. Two independent reviewers screened 5726 articles for eligibility and extracted data of the 81 included studies. Pooled risk ratios were estimated in a random effects model stratified for different populations. Meta-regression analysis was used to determine suicide risk during the first year of follow-up. RESULTS: The risk for completed suicide was clearly higher in people who had expressed suicidal ideation compared with people who had not, with substantial variation between the different populations: risk ratio ranging from 2.35 (95% confidence interval (CI) 1.43-3.87) in affective disorder populations to 8.00 (95% CI 5.46-11.7) in non-psychiatric populations. In contrast, the suicide risk after expression of suicidal ideation in the first year of follow-up was higher in psychiatric patients (risk 1.40%, 95% CI 0.74-2.64) than in non-psychiatric participants (risk 0.23%, 95% CI 0.10-0.54). Past suicide attempt-adjusted risk ratios were not pooled due to large underreporting. CONCLUSIONS: Assessment of suicidal ideation is of priority in psychiatric patients. Expression of suicidal ideation in psychiatric patients should prompt secondary prevention strategies to reduce their substantial increased risk of suicide.

How to tell a happy from an unhappy schizotype: personality factors and mental health outcomes in individuals with psychotic experiences

Objective: It is unclear why some individuals reporting psychotic experiences have balanced lives while others go on to develop mental health problems. The objective of this study was to test if the personality traits of harm avoidance, self-directedness, and self-transcendence can be used as criteria to differentiate healthy from unhealthy schizotypal individuals. Methods: We interviewed 115 participants who reported a high frequency of psychotic experiences. The instruments used were the Temperament and Character Inventory (140), Structured Clinical Interview for DSM-IV, and the Oxford-Liverpool Inventory of Feelings and Experiences. Results: Harm avoidance predicted cognitive disorganization (β = 0.319; t = 2.94), while novelty seeking predicted bipolar disorder (β = 0.136, Exp [β] = 1.146) and impulsive non-conformity (β = 0.322; t = 3.55). Self-directedness predicted an overall decrease in schizotypy, most of all in cognitive disorganization (β = -0.356; t = -2.95) and in impulsive non-conformity (β = -0.313; t = -2.83). Finally, self-transcendence predicted unusual experiences (β = 0.256; t = 2.32). Conclusion: Personality features are important criteria to distinguish between pathology and mental health in individuals presenting high levels of anomalous experiences (AEs). While self-directedness is a protective factor, both harm avoidance and novelty seeking were predictors of negative mental health outcomes. We suggest that the impact of AEs on mental health is moderated by personality factors.

Mental health service availability and delivery at the global level: an analysis by countries' income level from WHO's Mental Health Atlas 2014.

AIMS: The World Health Organization (WHO)'s Mental Health Atlas series has established itself as the single most comprehensive and most widely used source of information on the global mental health situation. The data derived from the latest Mental Health Atlas survey carried out in 2014 describes the availability and delivery of mental health services in the WHO's Member States, focussing on differences by country's income level. METHODS: The data contained in this paper are mainly derived from questions relating to mental health service availability and uptake, as well as on financial and human resources for mental health. Results are presented as median values and analysed by World Bank income group. Interquartile ranges are also provided as measures of statistical dispersion. RESULTS: In total, 171 out of WHO's 194 Member States were able to at least partially complete the Atlas questionnaire. The results highlight a wide gap between high and low-medium income countries in a number of areas: for example, high-income countries have 20 times more beds in community-based inpatient units and 30 times more admissions; the rate of patients cared by outpatient facilities is 40 times higher; and there are 66 times more community outpatient contacts and 15 times more mental health staff at outpatient level. Overall resources for mental health are not distributed efficiently: globally about 60% of financial resources and over two-thirds of all available mental health staff are concentrated in mental hospitals, which serve only a small proportion of patients. Results indicate that outpatient care is the only effective means of increasing the coverage for mental disorders and is expanding, but it is strongly influenced by country income level. Two elements of the network of mental health facilities are particularly scarce in low- and middle-income countries: day treatment facilities and community residential facilities. CONCLUSIONS: The WHO Mental Health Atlas 2014 survey provides basic mental health information at the level of WHO's Member States, concerning mental health resources and activities. Atlas promotes the use of information, usually underestimated not only in low- and middle-income countries but also in high-income countries. Information is needed not only for monitoring the scaling up of the mental health system at country level, but also for improving transparency and accountability for users, families and the public.