The Use of Automated Machine Translation to Translate Figurative Language in a Clinical Setting: Analysis of a Convenience Sample of Patients Drawn From a Randomized Controlled Trial.

BACKGROUND: Patients with limited English proficiency frequently receive substandard health care. Asynchronous telepsychiatry (ATP) has been established as a clinically valid method for psychiatric assessments. The addition of automated speech recognition (ASR) and automated machine translation (AMT) technologies to asynchronous telepsychiatry may be a viable artificial intelligence (AI)-language interpretation option. OBJECTIVE: This project measures the frequency and accuracy of the translation of figurative language devices (FLDs) and patient word count per minute, in a subset of psychiatric interviews from a larger trial, as an approximation to patient speech complexity and quantity in clinical encounters that require interpretation. METHODS: A total of 6 patients were selected from the original trial, where they had undergone 2 assessments, once by an English-speaking psychiatrist through a Spanish-speaking human interpreter and once in Spanish by a trained mental health interviewer-researcher with AI interpretation. 3 (50%) of the 6 selected patients were interviewed via videoconferencing because of the COVID-19 pandemic. Interview transcripts were created by automated speech recognition with manual corrections for transcriptional accuracy and assessment for translational accuracy of FLDs. RESULTS: AI-interpreted interviews were found to have a significant increase in the use of FLDs and patient word count per minute. Both human and AI-interpreted FLDs were frequently translated inaccurately, however FLD translation may be more accurate on videoconferencing. CONCLUSIONS: AI interpretation is currently not sufficiently accurate for use in clinical settings. However, this study suggests that alternatives to human interpretation are needed to circumvent modifications to patients' speech. While AI interpretation technologies are being further developed, using videoconferencing for human interpreting may be more accurate than in-person interpreting. TRIAL REGISTRATION: ClinicalTrials.gov NCT03538860; https://clinicaltrials.gov/ct2/show/NCT03538860.

Perioperative Neurofilament Light Plasma Concentrations and Cognition before and after Cardiac Surgery: A Prospective Nested Cohort Study.

BACKGROUND: Neurofilament light is a marker of neuronal injury and can be measured in blood. Postoperative increases in neurofilament light have been associated with delirium after noncardiac surgery. However, few studies have examined the association of neurofilament light changes with postdischarge cognition in cardiac surgery patients, who are at highest risk for neuronal injury and cognitive decline. The authors hypothesized that increased neurofilament light (both baseline and change) would be associated with worse neuropsychological status up to 1 yr after cardiac surgery. METHODS: This observational study was nested in a trial of cardiac surgery patients, in which blood pressure during bypass was targeted using cerebral autoregulation monitoring. Plasma concentrations of neurofilament light were measured at baseline and postoperative day 1. Neuropsychological testing was performed at baseline, 1 month after surgery, and 1 yr after surgery. Primary outcomes were baseline and change from baseline in a composite z-score of all cognitive tests. RESULTS: Among 167 patients, cognitive outcomes were available in 80% (134 of 167) and 61% (102 of 167) at 1 month and 1 yr after surgery, respectively. The median baseline concentration of neurofilament light was 18.2 pg/ml (interquartile range, 13.4 to 28.1), and on postoperative day 1 was 28.5 pg/ml (interquartile range, 19.3 to 45.0). Higher baseline log neurofilament light was associated with worse baseline cognitive z-score (adjusted slope, -0.60; 95% CI, -0.90 to -0.30; P < 0.001), no change in z-score from baseline to 1 month (0.11; 95% CI, -0.19 to 0.41; P = 0.475), and improvement in z-score from baseline to 1 yr (0.56; 95% CI, 0.31 to 0.81; P < 0.001). Whereas some patients had an improvement in cognition at 1 yr and others a decline, an increase in neurofilament light from baseline to postoperative day 1 was associated with a greater decline in cognition at 1 yr. CONCLUSIONS: Higher baseline neurofilament light concentration was associated with worse baseline cognition but improvement in cognition at 1 yr. A postoperative increase in neurofilament light was associated with a greater cognitive decline at 1 yr.

Primary Care Physician Adherence to Telepsychiatry Recommendations: Intermediate Outcomes from a Randomized Clinical Trial.

Objective:To compare clinical recommendations given by psychiatrists and the adherence to these recommendations by primary care physicians (PCP) following consultations conducted by asynchronous telepsychiatry (ATP) and synchronous telepsychiatry (STP).Materials and Methods:ATP and STP consultations were compared using intermediate data from a randomized clinical trial with adult participant enrollment between April 2014 and December 2017. In both study arms, PCPs received written recommendations from the psychiatrist after each encounter. Independent clinicians reviewed PCP documentation to measure adherence to those recommendations in the 6 months following the baseline consultation.Results:Medical records were reviewed for 645 psychiatrists' consult recommendations; 344 from 61 ATP consultations and 301 from 62 STP consultations. Of those recommendations, 191 (56%) and 173 (58%) were rated fully adherent by two independent raters for ATP and STP, respectively. In a multilevel ordinal logistic regression model adjusted for recommendation type and recommended implementation timing, there was no statistically significant difference in adherence to recommendations for ATP compared with STP (adjusted odds ratio = 0.91, 95% confidence interval = 0.51-1.62). The profiles of recommendation type were comparable between ATP and STP.Conclusions:This is the first PCP adherence study comparing two forms of telemedicine. Although we did not find evidence of a difference between ATP and STP; this study supports the feasibility and acceptability of ATP and STP for the provision of collaborative psychiatric care. Clinical Trial Identifier NCT02084979.

Clinical Outcomes of Asynchronous Versus Synchronous Telepsychiatry in Primary Care: Randomized Controlled Trial.

BACKGROUND: Asynchronous telepsychiatry (ATP; delayed-time) consultations are a novel form of psychiatric consultation in primary care settings. Longitudinal studies comparing clinical outcomes for ATP with synchronous telepsychiatry (STP) are lacking. OBJECTIVE: This study aims to determine the effectiveness of ATP in improving clinical outcomes in English- and Spanish-speaking primary care patients compared with STP, the telepsychiatry usual care method. METHODS: Overall, 36 primary care physicians from 3 primary care clinics referred a heterogeneous sample of 401 treatment-seeking adult patients with nonurgent psychiatric disorders. A total of 184 (94 ATP and 90 STP) English- and Spanish-speaking participants (36/184, 19.6% Hispanic) were enrolled and randomized, and 160 (80 ATP and 80 STP) of them completed baseline evaluations. Patients were treated by their primary care physicians using a collaborative care model in consultation with the University of California Davis Health telepsychiatrists, who consulted with patients every 6 months for up to 2 years using ATP or STP. Primary outcomes (the clinician-rated Clinical Global Impressions [CGI] scale and the Global Assessment of Functioning [GAF]) and secondary outcomes (patients' self-reported physical and mental health and depression) outcomes were assessed every 6 months. RESULTS: For clinician-rated primary outcomes, ATP did not promote greater improvement than STP at 6-month follow-up (ATP vs STP, adjusted difference in follow-up at 6 months vs baseline differences for CGI: 0.2, 95% CI -0.2 to 0.6; P=.28; and GAF: -0.6, 95% CI -3.1 to 1.9; P=.66) or 12-month follow-up (ATP vs STP, adjusted difference in follow-up at 12 months vs baseline differences for CGI: 0.4, 95% CI -0.04 to 0.8; P=.07; and GAF: -0.5, 95% CI -3.3 to 2.2; P=.70), but patients in both arms had statistically and clinically significant improvements in both outcomes. There were no significant differences in improvement from baseline between ATP and STP on any patient self-reported ratings at any follow-up (all P values were between .17 and .96). Dropout rates were higher than predicted but similar between the 2 arms. Of those with baseline visits, 46.8% (75/160) did not have a follow-up at 1 year, and 72.7% (107/147) did not have a follow-up at 2 years. No serious adverse events were associated with the intervention. CONCLUSIONS: This is the first longitudinal study to demonstrate that ATP can improve clinical outcomes in English- and Spanish-speaking primary care patients. Although we did not find evidence that ATP is superior to STP in improving clinical outcomes, it is potentially a key part of stepped mental health interventions available in primary care. ATP presents a possible solution to the workforce shortage of psychiatrists and a strategy for improving existing systems of care. TRIAL REGISTRATION: ClinicalTrials.gov NCT02084979; https://clinicaltrials.gov/ct2/show/NCT02084979.

The Association Between Adverse Childhood Experiences and Burnout in a Regional Sample of Physicians.

OBJECTIVE: Little research has occurred in physicians on the prevalence of adverse childhood experiences (ACEs) and their potential correlation with burnout. The authors hypothesized that there would be a relationship between burnout levels and ACE scores, with physicians reporting more burnout being likely to have higher ACE scores. METHODS: Three hundred physicians completed the ten-question ACE scale and two burnout scales, the Mini-Z, and two items from the Maslach Burnout Inventory. RESULTS: One hundred and thirty eight (46%) of the physicians were positive on one or the other of the two burnout measures, and 49% of the respondents were positive for at least one ACE, while 9% were positive for four or more ACEs. The most common ACEs reported by the group were having a family member being depressed, being mentally ill, or attempting suicide (22%). The burnout measures correlated strongly with each other (r = 0.68, p < .001), and separate logistic regression models revealed that the physicians with an ACE score of 4 or more had more than two and half times the risk of burnout on either burnout scale measured. CONCLUSIONS: In this group of physicians, almost half reported experiencing ACEs, and half reported symptoms of burnout. The research hypothesis, which physicians reporting more burnout would be more likely to have higher ACE scores, was supported. It is possible that ACEs are a vulnerability factor in physicians for the development of burnout. This possibility and potential protective factors should be further studied.

Asynchronous Telepsychiatry Interviewer Training Recommendations: A Model for Interdisciplinary, Integrated Behavioral Health Care.

Objective: Asynchronous telepsychiatry (ATP) is an integrative model of behavioral health service delivery that is applicable in a variety of settings and populations, particularly consultation in primary care. This article outlines the development of a training model for ATP clinician skills. Methods: Clinical and procedural training for ATP clinicians (n = 5) was provided by master's-level, clinical mental health providers developed by three experienced telepsychiatrists (P.Y. D.H., and J.S) and supervised by a tele-psychiatrist (PY, GX, DL) through seminar, case supervision, and case discussions. A training manual and one-on-one sessions were employed for initial training. Unstructured expert discussion and feedback sessions were conducted in the training phase of the study in year 1 and annually thereafter over the remaining 4 years of the study. The notes gathered during those sessions were synthesized into themes to gain a summary of the study telepsychiatrist training recommendations for ATP interviewers. Results: Expert feedback and discussion revealed three overarching themes of recommended skill sets for ATP interviewers: (1) comprehensive skills in brief psychiatric interviewing, (2) adequate knowledge base of behavioral health conditions and therapeutic techniques, and (3) clinical documentation, integrated care/consultation practices, and e-competency skill sets. The model of training and skill requirements from expert feedback sessions included these three skill sets. Technology training recommendations were also identified and included: (1) awareness of privacy/confidentiality for electronic data gathering, storage, management, and sharing; (2) technology troubleshooting; and (3) video filming/retrieval. Conclusions: We describe and provide a suggested training model for the use of ATP integrated behavioral health. The training needs for ATP clinicians were assessed on a limited convenience sample of experts and clinicians, and more rigorous studies of training for ATP and other technology-focused, behavioral health services are needed. Clinical Trials number: NCT03538860.

A Literature Review Comparing Clinicians' Approaches and Skills to In-Person, Synchronous, and Asynchronous Care: Moving Toward Competencies to Ensure Quality Care.

Introduction: Research is increasing on asynchronous technologies used by specialist clinicians and primary care, including e-mail, text, e-consultation, and store-and-forward (asynchronous) options. Studies typically describe interventions and care outcomes rather than development of clinical skills for using technology. Methods: This article attempts to compare clinicians' approaches to, and skills for, asynchronous technologies versus in-person and synchronous (i.e., video) care. Literature from technology, health care, pedagogy, and business were searched from 2000 to 2019 for title words, including synchronous (e.g., video, telemental or behavioral health, telepsychiatry), asynchronous (e.g., app, e-consultation, e-mail, text, sensor in a wearable device), education, clinical, and consultation. Results: From a total of 4,812 potential references, two authors (D.M.H., J.T.) found 4,622 eligible for full text review and found 381 articles directly relevant to the concept areas in combination for full text review. However, exclusion criteria subtracted 305, leaving a total of 76 articles. While in-person and synchronous care are similar in many ways, the clinical approach to asynchronous care has many differences. As asynchronous technologies and models of care are feasible and effective, often for consultation, an outline of patient, primary care provider, and specialist clinician goals and skills are presented. Few studies specifically discuss skills or competencies for asynchronous care, but components from published clinical informatics, video, social media, and mobile health competencies were organized into Accreditation Council of Graduate Medical Education domains. Conclusions: Further implementation of science research is needed for asynchronous technology interventions, as well as clinician competencies using asynchronous technologies, to ensure optimal outcomes for patients in health care.

Cognitive Decline after Delirium in Patients Undergoing Cardiac Surgery.

WHAT WE ALREADY KNOW ABOUT THIS TOPIC: Cardiac surgery is associated with cognitive decline and postoperative delirium. The relationship between postoperative delirium and cognitive decline after cardiac surgery is unclear WHAT THIS ARTICLE TELLS US THAT IS NEW: The development of postoperative delirium is associated with a greater degree of cognitive decline 1 month after cardiac surgery. The development of postoperative delirium is not a predictor of cognitive decline 1 yr after cardiac surgery. BACKGROUND: Delirium is common after cardiac surgery and has been associated with morbidity, mortality, and cognitive decline. However, there are conflicting reports on the magnitude, trajectory, and domains of cognitive change that might be affected. The authors hypothesized that patients with delirium would experience greater cognitive decline at 1 month and 1 yr after cardiac surgery compared to those without delirium. METHODS: Patients who underwent coronary artery bypass and/or valve surgery with cardiopulmonary bypass were eligible for this cohort study. Delirium was assessed with the Confusion Assessment Method. A neuropsychologic battery was administered before surgery, at 1 month, and at 1 yr later. Linear regression was used to examine the association between delirium and change in composite cognitive Z score from baseline to 1 month (primary outcome). Secondary outcomes were domain-specific changes at 1 month and composite and domain-specific changes at 1 yr. RESULTS: The incidence of delirium in 142 patients was 53.5%. Patients with delirium had greater decline in composite cognitive Z score at 1 month (greater decline by -0.29; 95% CI, -0.54 to -0.05; P = 0.020) and in the domains of visuoconstruction and processing speed. From baseline to 1 yr, there was no difference between delirious and nondelirious patients with respect to change in composite cognitive Z score, although greater decline in processing speed persisted among the delirious patients. CONCLUSIONS: Patients who developed delirium had greater decline in a composite measure of cognition and in visuoconstruction and processing speed domains at 1 month. The differences in cognitive change by delirium were not significant at 1 yr, with the exception of processing speed.

Asynchronous Telepsychiatry: A Component of Stepped Integrated Care.

OBJECTIVE: Integrated behavioral healthcare models typically involve a range of consultation options for mental healthcare. Asynchronous telepsychiatry (ATP) consults may be an additional potential choice, so we are conducting a 5-year clinical trial comparing ATP with synchronous telepsychiatry (STP) consultations. METHODS: Patients referred by primary care providers are randomly assigned to one of the two treatment groups, ATP or STP. Clinical outcome, satisfaction, and economic data are being collected from patients for 2 years at 6-month intervals. RESULTS: Baseline characteristics for the first 158 patients and case examples of ATP are presented. CONCLUSION: Implementing ATP in existing integrated behavioral healthcare models could make mental healthcare more efficient.

Managing Psychiatrist-Patient Relationships in the Digital Age: a Summary Review of the Impact of Technology-enabled Care on Clinical Processes and Rapport.

PURPOSE OF REVIEW: Participatory medicine and the availability of commercial technologies have given patients more options to view and track their health information and to communicate with their providers. This shift in the clinical process may be of particular importance in mental healthcare where rapport plays a significant role in the therapeutic process. RECENT FINDINGS: In this review, we examined literature related to the impact of technology on the clinical workflow and patient-provider rapport in the mental health field between January 2014 and June 2017. Thirty three relevant articles, of 226 identified articles, were summarized. The use of technology clinically has evolved from making care more accessible and efficient to leveraging technology to improve care, communication, and patient-provider rapport. Evidence exists demonstrating that information and communication technologies may improve care by better connecting patients and providers and by improving patient-provider rapport, although further research is needed.

A Multicenter Pilot Study Assessing Regional Cerebral Oxygen Desaturation Frequency During Cardiopulmonary Bypass and Responsiveness to an Intervention Algorithm.

BACKGROUND: The purpose of this multicenter pilot study was to: (1) determine the frequency of regional cerebral oxygen saturation (rScO2) desaturations during cardiac surgery involving cardiopulmonary bypass (CPB); (2) evaluate the accuracy of clinician-identified rScO2 desaturations compared with those recorded continuously during surgery by the near-infrared spectroscopy (NIRS) monitor; and (3) assess the effectiveness of an intervention algorithm for reversing rScO2 desaturations. METHODS: Two hundred thirty-five patients undergoing coronary artery bypass graft and/or valvular surgery were enrolled at 8 US centers in this prospective observational study. NIRS (Invos™ 5100C; Covidien) was used to monitor rScO2 during surgery. The frequency and magnitude of rScO2 decrements >20% from preanesthesia baseline were documented, and the efficacy of a standard treatment algorithm for correcting rScO2 was determined. The data from the NIRS monitor were downloaded at the conclusion of surgery and sent to the coordinating center where the number of clinician-identified rScO2 desaturation events was compared with the number detected by the NIRS monitor. RESULTS: The average rScO2 obtained at baseline (mean ± SD, 61% ± 11%; 99% confidence interval, 57%-65%) and during CPB (62% ± 14%; 57%-67%) was not different. However, rScO2 after separation from CPB (56% ± 11%; 53%-60%) was lower than measurements at baseline and during CPB (P < 0.001). During CPB, rScO2 desaturations occurred in 61% (99% confidence interval, 50%-75%) of patients. The area under the curve for product of magnitude and duration of the rScO2 was (mean ± SD, 145.2; 384.8% × min). Clinicians identified all patients with an rScO2 desaturation but identified only 340 (89.5%) of the 380 total desaturation events. Of the 340 clinician-identified rScO2 desaturation events, 115 resolved with usual clinical care before implementation of the treatment algorithm. For the remaining 225 events, the treatment algorithm resulted in resolution of the rScO2 desaturation in all but 18 patients. CONCLUSIONS: This multicenter pilot study found that 50% to 75% of patients undergoing cardiac surgery experience one or more rScO2 desaturations during CPB. Nearly 10% of desaturation events were not identified by clinicians, suggesting that appropriate alarming systems should be adopted to alert clinicians of such events. The intervention algorithm was effective in reversing clinically identified rScO2 desaturations in the majority of events.

The hybrid doctor-patient relationship in the age of technology - Telepsychiatry consultations and the use of virtual space.

The doctor-patient relationship is evolving and changing through the impact of many technological, social and environmental factors. These factors will be examined, especially the impact of changing attitudes among younger generations of physicians and patients who live in an information-driven networked world. Telepsychiatry is already over 50 years old and has a strong evidence base which suggests that it is a better form of practice compared with the traditional in-person consultation for certain patient groups. In particular, telepsychiatry encourages intimacy in relationships through the use of the 'virtual space' in the consultation, better collaboration between psychiatrists and primary care physicians, and improved patient satisfaction. The practice of psychiatry will change through the use of mobile devices, asynchronous consultations, and the opportunities that automated interpretation and translation bring to work across cultures. The future will likely bring many psychiatrists working increasingly in a hybrid model, both in-person, and online, using the strengths of both approaches to improve patient care.

Telepsychiatry Today.

The use of video-based telepsychiatry is increasing in response to consumer demand for convenient, inexpensive, and readily accessible services; improved financial reimbursement; and a robust body of evidence-based literature. Telepsychiatry leads to high patient and provider satisfaction ratings, and outcomes equivalent to in-person care, while younger generations often prefer telepsychiatry over face-to-face encounters. The evidence base for telepsychiatry is especially strong with respect to the treatment of post-traumatic stress disorder (PTSD), depression, and ADHD, while its use in underserved ethnic groups is well described in the American Indian, Hispanic, and Asian populations. Despite this, telepsychiatry barriers still persist. These include personal bias-especially in leadership-and insufficient training; the challenging business environment and legislative processes; and inconsistent reimbursement, licensing, and prescription policies. Technology is now less of a barrier, and it is clear that telepsychiatry overall is flourishing and changing the way that providers are working and patients are being treated.

Psychiatrists with substance use disorders: positive treatment outcomes from physician health programs.

OBJECTIVE: The objective of this study was to compare outcomes of psychiatrists and nonpsychiatrist physicians enrolled in state physician health programs for substance use disorders. METHODS: The study used the data set from a five-year, longitudinal cohort study of 904 physicians, including 55 psychiatrists, with diagnoses of substance abuse or dependence consecutively admitted to one of 16 state physician health programs between 1995 and 2001. RESULTS: There was a higher proportion of women among psychiatrists than among other physicians, but there were no other significant differences between the cohorts. Five-year outcomes were similar between psychiatrists and the other physicians, with at least 75% of psychiatrists continuing their medical practice after five years of monitoring and treatment. CONCLUSIONS: Psychiatrists were not overrepresented compared with other physician groups and had similar clinical outcomes at the five-year follow-up. Physician health programs appeared to be effective treatment programs for psychiatrists with substance use disorders.

The effectiveness of telemental health: a 2013 review.

INTRODUCTION: The effectiveness of any new technology is typically measured in order to determine whether it successfully achieves equal or superior objectives over what is currently offered. Research in telemental health-in this article mainly referring to telepsychiatry and psychological services-has advanced rapidly since 2003, and a new effectiveness review is needed. MATERIALS AND METHODS: The authors reviewed the published literature to synthesize information on what is and what is not effective related to telemental health. Terms for the search included, but were not limited to, telepsychiatry, effectiveness, mental health, e-health, videoconferencing, telemedicine, cost, access, and international. RESULTS: Telemental health is effective for diagnosis and assessment across many populations (adult, child, geriatric, and ethnic) and for disorders in many settings (emergency, home health) and appears to be comparable to in-person care. In addition, this review has identified new models of care (i.e., collaborative care, asynchronous, mobile) with equally positive outcomes. CONCLUSIONS: Telemental health is effective and increases access to care. Future directions suggest the need for more research on service models, specific disorders, the issues relevant to culture and language, and cost.

Transcultural psychiatry made simple--asynchronous telepsychiatry as an approach to providing culturally relevant care.

OBJECTIVE: To examine the feasibility and diagnostic reliability of asynchronous telepsychiatry (ATP) consultations in Spanish and ATP consultation with Spanish-to-English translation. SUBJECTS AND METHODS: Twenty-four interviews of Spanish-speaking patients were videorecorded by a bilingual clinician who also collected patient history data and gave the Structured Clinical Interview for DSM-IV Axis I Disorders (SCID-I) to each patient. The ATP data (video of the interview and patient history) were forwarded for psychiatric consultation and a diagnostic assessment by the investigators. The ATP data were then examined separately by two Spanish-speaking psychiatrists, before being translated into English and then re-examined by two English-speaking psychiatrists. Agreement between the expert diagnoses of the investigators and the diagnoses from the Spanish consultations, the Spanish-to-English translated consultations, and the SCID-I results was assessed using kappa statistics. RESULTS: We found acceptable levels of agreement for major diagnostic groupings among the Spanish- and English-speaking psychiatrists. Kappa values for diagnostic agreement between the expert and the translated consultations, the original language consultations, and the SCID-I were at least 0.52 (percentage agreement, 79%) and higher. CONCLUSIONS: ATP consultations in Spanish, and those translated from Spanish to English, are feasible, and broad diagnostic reliability was achieved. The ATP process allows for rapid language translation. This approach could be useful across national boundaries and in numerous ethnic groups. Cross-language ATP may also offer significant benefits over the use of real-time interpreting services and has the potential to improve the quality of care by allowing for the addition of culturally relevant information.