Incorporating Digital Interventions into Mental Health Clinical Practice: a Pilot Survey of How Use Patterns, Barriers, and Opportunities Shifted for Clinicians in the COVID-19 Pandemic

Although many digital mental health interventions are available, clinicians do not routinely use them in clinical practice. In this pilot survey, we review the factors that supported the rapid transition to televisits during the COVID-19 pandemic, and we explore the barriers that continue to prevent clinicians from using other digital mental health interventions, such as mindfulness applications, mood trackers, and digital therapy programs. We conducted a pilot survey of mental health clinicians in different practice environments in the USA. Survey respondents (n = 51) were primarily psychiatrists working in academic medical centers. Results indicated that systemic factors, including workplace facilitation and insurance reimbursement, were primary reasons motivating clinicians to use televisits to provide remote patient care. The shift to televisits during the pandemic was not accompanied by increased use of other digital mental health interventions in patient care. Nine clinicians reported that they have never used digital interventions with patients. Among the 42 clinicians who did report some experience using digital interventions, the majority reported no change in the use of digital applications since transitioning to televisits. Our preliminary findings lend insight into the perspective of mental health clinicians regarding the factors that supported their transition to televisits, including institutional support and insurance reimbursement, and indicate that this shift to virtual patient care has not been accompanied by increased use of other digital mental health interventions. We contend that the same systemic factors that supported the shift toward virtual visits in the COVID-19 pandemic may be applied to support the incorporation of other digital interventions in mental healthcare.

Supplementary Information

The online version contains supplementary material available at 10.1007/s41347-022-00260-8.

Past Psychiatric Conditions as Risk Factors for Postpartum Depression: A Nationwide Cohort Study

OBJECTIVE

To compare risk for postpartum depression across prior psychiatric diagnoses.

METHODS

The deidentified Optum© Clinformatics Data Mart of national commercial insurance claims was used to identify 1,166,577 women of reproductive age with first-observed incidence of pregnancy across all 50 United States from 2003 to 2016. Women with insurance coverage for at least 6 months prior to conception and following delivery were eligible (n = 336,522). Psychiatric diagnoses prior to pregnancy were identified by ICD-9-CM and ICD-10-CM codes, including depression, anxiety and panic disorders, bipolar disorder, obsessive-compulsive disorder, posttraumatic stress disorder, and eating disorders. Primary outcomes included postpartum depression diagnosis at 2 months and 1 year after delivery. Multiple variable logistic regression analysis assessed for independent associations between predictors and outcomes.

RESULTS

Among 336,522 pregnancies, 9.4% of women were diagnosed with postpartum depression (n = 31,610). Five percent of women with no depression history developed postpartum depression, compared to 65% of women with depression prior to and during pregnancy. Among women with history of depression who were euthymic during pregnancy, 20% were diagnosed with postpartum depression. A major risk factor was a history of depression (OR = 2.7; 95% CI, 2.6-2.8; P < .001), and depression in pregnancy was a risk factor for continued depression in the postpartum period (OR = 13.1; 95% CI, 12.6-13.6; P < .001). All other psychiatric conditions, including anxiety and panic disorders, bipolar disorder, obsessive-compulsive disorder, posttraumatic stress disorder, and eating disorders, conferred risk for postpartum depression, independent of a comorbid depression history.

CONCLUSIONS

We report that all psychiatric diagnoses investigated independently increase risk for postpartum depression and suggest that care providers inquire about psychiatric history to identify and closely monitor women at increased risk for postpartum depression.

Management of perinatal depression with non-drug interventions

Perinatal depression is a common disorder that has been associated with serious risks to mother and child. Recently, screening for depression in pregnant and postpartum women has increased, as has the development of new psychotherapy and non-drug treatment modalities. Matching patients to treatments can be challenging, and although research into personalized treatment of major depression in the general population has increased, no published guidelines focus on personalized treatment approaches to perinatal depression. In particular, guidelines on non-drug treatments are lacking. This review summarizes the evidence on personalized non-drug treatment of perinatal depression, how to incorporate patients' preferences, novel treatments under investigation, and the potential role of biomarkers in matching patients to treatment. The review provides recommendations for future research in personalized care of perinatal depression.

Contraceptive counseling in reproductive-aged women treated for breast cancer at a tertiary care institution: a retrospective analysis

OBJECTIVE

The objective was to assess the frequency of documented contraceptive and fertility preservation counseling for women treated for breast cancer.

STUDY DESIGN

We conducted a chart analysis of female breast cancer patients (n=211) ages 18-45 years receiving chemotherapy treatment at Stanford Comprehensive Cancer Center from 2010 to 2014. Primary outcomes of contraceptive counseling and fertility preservation counseling documentation were assessed for frequency. Secondary outcomes included pregnancy testing, contraception use and pregnancy during treatment.

RESULTS

Among the total sample (n=211), sexual activity was documented in 24% of patients (n=51). Fifty-one percent (n=108) of patients received pregnancy testing prior to initiation of treatment. Past contraception use was documented in 74% of patients (n=156) and current contraception use in 25% (n=53). Twenty-six percent of patients received fertility preservation counseling alone (n=54), 10% received contraceptive counseling alone (n=22), and 12% received both types of counseling (n=25). Patients were three times more likely to receive contraceptive counseling if using contraception at diagnosis [odds ratio (OR) 3.1, confidence interval (CI) 1.1-9.1, p=.04], and older women were significantly less likely to receive counseling (OR 0.2, CI 0.1-1.0, p=.04). Two patients became pregnant and had an abortion during treatment (1%), and neither patient was using contraception nor received contraceptive or fertility preservation counseling.

CONCLUSIONS

Documentation of fertility preservation counseling occurs more frequently than contraceptive counseling, but both occur suboptimally. Lack of documentation does not allow us to conclude that counseling did not occur, but it suggests the need to improve documentation and increase awareness of contraceptive needs and counseling.

IMPLICATIONS

Women undergoing breast cancer treatment do not consistently receive counseling on contraception or fertility preservation as a part of their care. Efforts are needed to ensure that women treated for breast cancer routinely receive counseling about fertility preservation and contraceptive options.

Isoflurane causes concentration-dependent inhibition of medullary raphé 5-HT neurons in situ

BACKGROUND

Anesthetics have a profound influence on a myriad of autonomic processes. Mechanisms of general anesthesia, and how these mechanisms give rise to the multifaceted state of anesthesia, are largely unknown. The ascending and descending serotonin (5-HT) networks are key modulators of autonomic pathways, and are critically involved in homeostatic reflexes across the motor, somatosensory, limbic and autonomic systems. These 5-HT networks are thought to contribute to anesthetic effects, but how anesthetics affect 5-HT neuron function remains a pertinent question. We hypothesized that the volatile anesthetic isoflurane inhibits action potential discharge of medullary raphé 5-HT neurons.

METHODS

We conducted extracellular recordings on individual neurons in the medullary raphé region of the unanesthetized in situ perfused brainstem preparation to determine how exposure to isoflurane affects 5-HT neurons. We examined changes in 5-HT neuron baseline firing in response to treatment with either 1, 1.5, or 2% isoflurane. We measured isoflurane concentrations by gas chromatography-mass spectrometry (GC-MS) analysis.

RESULTS

Exposure to isoflurane inhibited action potential discharge in raphé 5-HT neurons. We document a concentration-dependent inhibition over a range of concentrations approximating isoflurane MAC (minimum alveolar concentration required for surgical anesthesia). Delivered concentrations of isoflurane were confirmed using GC-MS analysis.

CONCLUSIONS

These findings illustrate that halogenated anesthetics greatly affect 5-HT neuron firing and suggest 5-HT neuron contributions to mechanisms of general anesthesia.

Isoflurane abolishes spontaneous firing of serotonin neurons and masks their pH/CO₂ chemosensitivity

Serotonin (5-hydroxytryptamine, 5-HT) neurons from the mouse and rat rostral medulla are stimulated by increased CO2 when studied in culture or brain slices. However, the response of 5-HT neurons has been variable when animals are exposed to hypercapnia in vivo. Here we examined whether halogenated inhalational anesthetics, which activate TWIK-related acid-sensitive K(+) (TASK) channels, could mask an effect of CO2 on 5-HT neurons. During in vivo plethysmography in mice, isoflurane (1%) markedly reduced the hypercapnic ventilatory response (HCVR) by 78-96% depending upon mouse strain and ambient temperature. In a perfused rat brain stem preparation, isoflurane (1%) reduced or silenced spontaneous firing of medullary 5-HT neurons in situ and abolished their responses to elevated perfusate Pco2. In dissociated cell cultures, isoflurane (1%) hyperpolarized 5-HT neurons by 6.52 ± 3.94 mV and inhibited spontaneous firing. A subsequent decrease in pH from 7.4 to 7.2 depolarized neurons by 4.07 ± 2.10 mV, but that was insufficient to reach threshold for firing. Depolarizing current restored baseline firing and the firing frequency response to acidosis, indicating that isoflurane did not block the underlying mechanisms mediating chemosensitivity. These results demonstrate that isoflurane masks 5-HT neuron chemosensitivity in vitro and in situ and markedly decreases the HCVR in vivo. The use of this class of anesthetic has a particularly potent inhibitory effect on chemosensitivity of 5-HT neurons.

Differential gene expression during compensatory sprouting of dendrites in the auditory system of the cricket Gryllus bimaculatus

Neurones that lose their presynaptic partners because of injury usually retract or die. However, when the auditory interneurones of the cricket Gryllus bimaculatus are denervated, dendrites respond by growing across the midline and forming novel synapses with the opposite auditory afferents. Suppression subtractive hybridization was used to detect transcriptional changes 3 days after denervation. This is a stage at which we demonstrate robust compensatory dendritic sprouting. Whereas 49 unique candidates were down-regulated, no sufficiently up-regulated candidates were identified at this time point. Several candidates identified in this study are known to influence the translation and degradation of proteins in other systems. The potential role of these factors in the compensatory sprouting of cricket auditory interneurones in response to denervation is discussed.