Trends in Telepsychiatry and In-Person Psychiatric Care for Depression in an Academic Health System, 2017-2022

OBJECTIVE

The authors aimed to assess differences in appointment completion rates between telepsychiatry and in-person outpatient psychiatric care for patients with depression in an academic health system.

METHODS

Electronic health records of encounters for patients (ages ≥10) with a depression diagnosis and at least one scheduled outpatient psychiatric appointment (N=586,266 appointments; November 2017-October 2022) were assessed for appointment volume and completion of telepsychiatry versus in-person sessions.

RESULTS

Telepsychiatry became the dominant care modality after the onset of the COVID-19 pandemic, although the number of telepsychiatry and in-person appointments nearly converged by October 2022. Logistic regression showed that telepsychiatry appointments (July 2020-October 2022) were more likely (OR=1.30, 95% CI=1.27-1.34) to be completed than in-person appointments.

CONCLUSIONS

Telepsychiatry appointments were less likely to be canceled or missed than in-person appointments, suggesting that telepsychiatry improved efficiency and continuity of care. As in-person operations resume following the pandemic, maintaining telepsychiatry services may optimize hospital-level and patient outcomes.

Use of Non-Psychiatric Medications With Potential Depressive Symptom Side Effects and Level of Depressive Symptoms in Major Depressive Disorder

Objective: To determine whether use of medications with potential depressive symptom side effects is associated with a higher level of depressive symptoms in adults with antidepressant-treated major depressive disorder (MDD).

Methods: The study was based on the 2013-2014, 2015-2016, and 2017-2018 National Health and Nutrition Examination Survey (NHANES)-a nationally representative cross-sectional survey of the US general population. In 885 adult participants from these NHANES cycles who reported receiving antidepressants for treatment of International Classification of Diseases, Tenth Revision, Clinical Modification MDD, the association between the number of medications with potential depressive symptom side effects and the level of depressive symptoms was assessed.

Results: A majority (66.7%, n = 618) of the participants with antidepressant-treated MDD used at least 1 non-psychiatric medication with potential depressive symptom side effects, and 37.3% (n = 370) used more than 1 such medication. The number of medications with depressive symptom side effects was significantly associated with lower odds of no to minimal depressive symptoms, defined as a Patient Health Questionnaire-9 (PHQ-9) score < 5 (adjusted odds ratio [AOR] = 0.75, 95% confidence interval [CI] = 0.64-0.87, P < .001), and higher odds of moderate to severe symptoms, defined as a PHQ-9 score ≥ 10 (AOR = 1.14, 95% CI = 1.004-1.29, P = .044). No such associations were found for medications without potential depressive symptom side effects.

Conclusions: Individuals treated for MDD frequently use non-psychiatric medications for comorbid medical conditions that are associated with an increased risk of depressive symptoms. In evaluating the response to antidepressant medication treatment, side effects of concomitantly used medications should be considered.

The relationship between social and environmental factors and symptom severity in the seriously mentally ill population

BACKGROUND

The goal of this article is to investigate the relationship of psychiatric symptom severity with internalised stigma, neighbourhood environment, and social support among individuals with serious mental illness.

METHOD

Using a longitudinal study design we examined the relationship between psychiatric symptom severity with internalised stigma, neighbourhood environment, and social support among 271 adults with serious mental illness recruited from new admissions to two urban mental health clinics.

RESULTS

After controlling for demographics increased stigma levels predicted greater symptom severity, as measured by the Positive and Negative Syndrome Scale (PANSS) Positive, Negative, and General Psychopathology scales over a 4-year period (p < .05). In adjusted models, individuals who reported living in more disadvantaged neighbourhoods also reported higher PANSS Negative and General scores over time (p < .05). Social support from friends and relatives was not significantly related to PANSS Positive, Negative, or General Psychopathology scores among individuals with serious mental illness.

CONCLUSIONS

Individuals with serious mental illness who experience internalised stigma and neighbourhood disadvantage experience greater symptom severity over time. Targeting stigma and housing during treatment could potentially impact symptom severity in this population.

Assessing Self-reported Recovery in a Community Psychiatry Setting

OBJECTIVE

This study examined demographic and diagnostic characteristics associated with self-reported recovery in patients with serious mental illness.

METHODS

Patient demographics and diagnoses were obtained from a retrospective review of charts from 981 patients attending a community psychiatry outpatient program between January 2015 and December 2016. All patients completed the Recovery Assessment Scale-Revised (RAS-R), a self-report recovery questionnaire consisting of 5 subscales, approximately every 6 months. Generalized estimating equation models were used to assess change in RAS-R scores over time and to test for associations with demographic characteristics, clinical diagnoses, and appointment adherence.

RESULTS

RAS-R scores increased among all demographic and diagnostic groups during the study period. A primary diagnosis of a psychotic disorder (including schizophrenia) was associated with higher 2-year average RAS-R total scores and scores on the Personal Confidence and Hope, Goal and Success Orientation, and Not Dominated by Symptoms subscales. African American race was associated with higher 2-year average scores on the Personal Confidence and Hope subscale. Increasing age was associated with higher total RAS-R scores and multiple subscale scores. No significant associations were found between sex or appointment adherence and RAS-R total scores or any of the subscale scores.

CONCLUSIONS

While certain demographic and diagnostic groups were associated with higher RAS-R scores, study results suggest that time in treatment is itself associated with higher self-reported recovery among all demographic groups. Age, race, and diagnosis were all associated with higher scores on the Personal Confidence and Hope subscale, highlighting the need for individualized treatment that takes multiple patient characteristics into account.

Remission and Treatment Augmentation of Depression in the United States

Objective: To determine the proportion of adults treated for depression in the US who achieve remission and, among those not achieving remission, the proportion receiving augmentation treatment. Methods: Using data from the US National Health and Nutrition Examination Survey (NHANES) for years 2013-2014, 2015-2016, and 2017-2018, we identified 869 adults who reported using antidepressant medications for depression for at least 3 months. This sample was partitioned into remitted (score < 5) and non-remitted (score ≥ 5) respondents based on 9-item Patient Health Questionnaire (PHQ-9) score-a questionnaire based on the DSM-IV criteria for major depressive disorder. Among the non-remitted group, the proportion receiving antidepressant augmentation with another antidepressant medication of a different class or other medications was also assessed. Results: An estimated 43.5% of adults receiving antidepressant medications for depression were in remission when assessed. Among those not in remission, 28.1% were using augmentation treatment, which in most cases was another antidepressant medication from a different class. As compared to depressed adults without any mental health contact in the past year, those with such contact had significantly higher odds of using augmentation treatment (adjusted odds ratio = 2.72; 95% CI, 1.56-4.76; P = .001). Conclusions: The low percentage of US adults treated with antidepressants for depression that achieves remission represents a missed clinical and public health opportunity to optimize depression treatment. Closer monitoring of symptoms through measurement-based care and setting symptom remission as a goal can help improve outcomes for adults with depression.

Symptom Severity and Care Delay among Patients with Serious Mental Illness

PURPOSE

This study investigated associations between psychiatric symptom severity and delay in seeking general medical services among individuals with serious mental illness.

METHODS

The association of psychiatric symptom severity, measured by the Positive and Negative Syndrome Scale (PANSS), and general medical care delay was examined among 271 patients at two urban, outpatient psychiatric clinics.

RESULTS

Higher scores for PANSS paranoid/belligerence were associated with delays in accessing general medical care (adjusted odds ratio [AOR]=1.46, 95% confidence interval [CI]=1.04-2.01, p=.025). Higher scores on the depression symptom cluster were also associated with care delay (AOR=1.43, 95% CI=1.06-1.93, p=.018). Other symptom types showed no associations with care delay.

CONCLUSION

Severity of specific psychiatric symptoms was associated with delays in seeking general medical care among people with serious mental illness. Increased focus on psychiatric symptom management may reduce medical care delay, thereby reducing the elevated morbidity and mortality among this population.

Electronic health record adoption among US substance use disorder and other mental health treatment facilities

OBJECTIVE

This study examined Electronic Health Record (EHR) utilization among US substance use disorder (SUD) versus mental health (MH) treatment facilities.

METHODS

Data from the National Survey of Substance Abuse Treatment Services and the National Mental Health Services Survey were used to examine differences in clinical and administrative utilization of EHR.

RESULTS

EHR use was significantly less common among SUD facilities compared to MH facilities for both non-exclusive (mixed computer and paper) and exclusive (paper-free) use. Fewer than 25 % of facilities of either type reported exclusive EHR use for core clinical activities (progress notes, laboratory monitoring, and prescriptions) with wide variability among states. Being an inpatient facility, having Joint Commission accreditation, being a private-for-profit, or a public facility were significantly positively associated with exclusive EHR use for core clinical activities; these associations were stronger among SUD facilities than MH facilities. Accepting Medicare was associated with exclusive EHR use for core clinical activities in both facility types, while accepting private insurance was associated with such use only among SUD treatment facilities.

CONCLUSIONS

EHR adoption among SUD facilities lags behind MH facilities. However, exclusive EHR use for clinical purposes remains elusive for both types of facilities with no more than a quarter of facilities in any state reporting such use. Some of the factors associated with exclusive EHR use for clinical purposes among SUD treatment facilities-such as Joint Commission accreditation-may be policy leverage points to expedite EHR adoption in these facilities.

Symptom severity and medication-assisted treatment for individuals with serious mental illness and a history of heroin use

The study examined associations between medication assisted treatment (MAT) and psychiatric symptom severity, measured by Positive and Negative Symptom Scale (PANSS), among individuals with serious mental illness and a history of heroin use. Of 271 participants, 32% (n=87) reported a history of heroin use and, of those, 14.9% (n=13) reported MAT. Higher scores in PANSS Total, Negative, and Disordered subscales were associated with lower odds, while being on an antipsychotic with higher odds, of receiving MAT. This supports the greater need for clinician attention to different symptom clusters and targeted multidimensional interventions as a way to increase MAT participation.

Integrated dual diagnosis treatment among United States mental health treatment facilities: 2010 to 2018

OBJECTIVE

Little is known about the correlates of and recent trends in implementation of Integrated Dual Diagnosis model, an evidence-based approach for dual diagnosis services, in US mental health facilities between 2010 and 2018.

METHODS

Changes over time in Integrated Dual Diagnosis Treatment use were examined using multiple waves of a national survey of mental health treatment facilities that reported offering any substance use services. State and facility correlates of offering integrated dual diagnosis services among these facilities in 2018 were examined.

RESULTS

The proportion of mental health treatment facilities that reported offering any substance use services increased significantly from 50.1% in 2010 to 57.1% in 2018. Among these facilities, significantly fewer reported offering Integrated Dual Diagnosis Treatment in 2018 (74.8%) than in 2010 (79.6%). The prevalence of Integrated Dual Diagnosis Treatment use increased in more recent years in tandem with increase in substance use services, though the increases in Integrated Dual Diagnosis Treatment have not matched the expansion of substance use services. Mental health facilities with substance use services more commonly offered other mental health services and had more funding sources available. Facilities with any substance use disorder services that offered Integrated Dual Diagnosis Treatment were more commonly licensed by State Substance Agencies and more commonly offered psychotropics and group therapies. Facilities located in states that implemented the Integrated Dual Diagnosis Treatment model had a higher odds of offering this model.

CONCLUSIONS

The growth in the co-location of substance use treatment services within mental health treatment facilities has not been matched by true integration of these treatments, highlighting the need for further efforts to comprehensively address the complex needs of dually diagnosed patients.

Telepsychiatry Use in U.S. Mental Health Facilities, 2010-2017

OBJECTIVE

The study examined the use of telepsychiatry in U.S. mental health facilities between 2010 and 2017.

METHODS

Changes over time in the availability of telepsychiatry were examined by using multiple waves of a national survey of mental health facilities. State and facility correlates of offering telepsychiatry in 2017 were examined.

RESULTS

The proportion of state facilities that self-reported offering telepsychiatry increased significantly from 15.2% in 2010 to 29.2% in 2017, with wide variability among states.. In 2017, facilities with telepsychiatry were more commonly publicly owned than to have others forms of ownership (odds ratio [OR]=2.72, 95% confidence interval [CI]=2.47-2.99, p<0.001), although the percentage of privately owned facilities offering telepsychiatry has increased significantly since 2010 (OR=2.94, 95% CI=2.14-4.05, p<.001). Facilities offering telepsychiatry had lower odds of receiving funding from Medicaid (OR=0.86, 95% CI=0.75-0.98, p<0.001) but higher odds of receiving funding from all other sources. Facilities in states that did not fund telepsychiatry had lower odds of offering these services in 2017 (OR=0.57, 95% CI=0.51-0.62, p<0.001). Telepsychiatry was more commonly offered in states with higher proportions of rural population (OR=1.64, 95% CI=1.45-1.85, p<0.001) and designated medically underserved areas (OR=1.36, 95% CI=1.25-1.47, p<0.001), compared with other states.

CONCLUSIONS

Nearly twice as many U.S. mental health facilities offered telepsychiatry in 2017 than in 2010. Medicaid funding lagged behind other funding sources, suggesting state administrative barriers. Telepsychiatry was commonly used by facilities in medically underserved and rural areas.

Availability of Assertive Community Treatment in the United States: 2010 to 2016

OBJECTIVE

The study examined change in availability of assertive community treatment (ACT) and associated services over time.

METHODS

Change over time in the availability of facilities in the United States offering ACT and its associated services was examined by using 2010 and 2016 data from the National Mental Health Services Survey.

RESULTS

The proportion of facilities that self-reported provision of ACT and its associated services declined between 2010 and 2016 (odds ratio [OR]=0.73, 95% confidence interval [CI]=0.63-0.86, p<0.001). Although a higher proportion of facilities that provided ACT reported offering all the required services in 2016 (OR=1.31, 95% CI=1.04-1.66, p=0.026) compared with 2010, this proportion accounted for less than 20% of the programs. Compared with 2010, in 2016 increases were observed in peer (OR=1.72, 95% CI=1.38-2.13, p<0.001) and co-occurring disorders services (OR=1.23, 95% CI=1.08-1.42, p=0.004) as well as in secondary services, such as tobacco cessation (OR=4.53, 95% CI=3.51-5.84, p<0.001) and telemedicine (OR=2.08, 95% CI=1.67-2.57, p<0.001). Continuous education for staff was required at more facilities with ACT in 2016 compared with 2010.

CONCLUSIONS

Although the proportion of facilities with ACT that offer all the required core services has increased in recent years, such programs remain a minority, and the overall number of facilities with ACT has declined.

Distribution and Correlates of Assertive Community Treatment (ACT) and ACT-Like Programs: Results From the 2015 N-MHSS

OBJECTIVE

The study examined the availability and characteristics of assertive community treatment (ACT) programs across mental health treatment facilities in the United States.

METHODS

Prevalence and correlates of facilities that reported offering ACT, broadly defined as intensive community services for serious mental illness provided by multidisciplinary teams in the clients' natural settings and including both ACT and "ACT-like" programs, were examined by using data from the National Mental Health Services Survey. Availability of services essential to the ACT model in these facilities was also examined.

RESULTS

Of the 12,826 surveyed facilities, 13.4% reported offering ACT, with significant variability among states. Of the facilities with ACT, 19.2% reported offering all core ACT services. Few facilities offered peer support, employment, and housing services. Compared with programs at facilities that did not offer all core ACT services, facilities with ACT programs that offered these services had higher odds of being publicly owned (odds ratio [OR]=2.12, 95% confidence interval [CI]=1.64-2.74) and of receiving federal (OR=3.60, CI=2.17-5.98) or grant funding (OR=1.87, CI=1.45-2.41). Facilities with ACT that offered all core services also had higher odds of offering other services important to individuals with serious mental disorders.

CONCLUSIONS

Substantial differences existed in availability of ACT and ACT-like programs among states, with evidence of a large unmet need overall, even when a very broad and inclusive definition of ACT was used. Few ACT programs offered all core services. Legislative, administrative, and funding differences may explain some of the variability.

Prescription opioid use among individuals with serious mental illness

Prevalence and correlates of prescription opioid use were explored in individuals with serious mental illness (SMI) by examining a sample of adults from two inner city community psychiatry clinics. Of 271 participants, 12.9% (n = 35) were on a prescribed opioid. Being on an opioid was significantly associated with history of heroin use and active prescription sedative-hypnotic use, including benzodiazepine use. Concurrent use of opioids with sedative-hypnotics was significantly associated with suicidal ideation. The results highlight risks of prescription opioid use in those with SMI, particularly in combination with prescription sedative-hypnotics.

Delays in Seeking General Medical Services and Measurable Abnormalities Among Individuals With Serious Mental Illness

OBJECTIVE

The study explored the association of delays in seeking general medical care with elevated blood pressure and metabolic abnormalities among individuals with serious mental illness.

METHODS

Association of delays in medical care with blood pressure, serum hemoglobin A1c (HbA1C), and lipids was assessed among patients at two inner-city community mental health centers.

RESULTS

Of 271 participants, 62% reported delays in seeking general medical care due to attitudinal and financial barriers. Care delay was associated with abnormalities in measured blood pressure (adjusted odds ratio [AOR]=2.14, p=.029) and HbA1c (AOR=3.18, p=.026). Care delay was not associated with abnormalities in lipid profiles.

CONCLUSIONS

This study found that delays in seeking general medical care are common and are associated with clinical markers linked with common medical conditions. The results may help to explain the elevated morbidity and mortality associated with serious mental illness.

Exposure to Direct-to-Consumer Pharmaceutical Advertising and Medication Nonadherence Among Patients With Serious Mental Illness

OBJECTIVE

This study explored the association of exposure to direct-to-consumer advertising (DTCA) with medication nonadherence among individuals with serious mental disorders.

METHODS

Results of an anonymous survey administered at an inner-city mental health clinic were examined by using logistic regression. Nonadherence was defined as not taking prescribed medications for at least two out of seven days.

RESULTS

Of 246 respondents, 48% reported DTCA exposure and 43% reported nonadherence. Sixty-one percent of those exposed to DTCA reported nonadherence, compared with 26% of those not exposed (adjusted odds ratio=4.96, 95% confidence interval=2.64-9.33, p<.001). Among those exposed to advertisements and reporting nonadherence, 59% reported changing medication-taking behaviors or stopping prescribed medications because of side effect information in advertisements. Only a minority communicated with providers before becoming nonadherent.

CONCLUSIONS

This study found an association between self-report of DTCA exposure and self-reported nonadherence. These results support further research on DTCA as a possible risk factor for nonadherence.

The Association of Alcohol Use Disorders with Suicidal Ideation and Suicide Attempts in a Population-Based Sample with Mood Symptoms

Using population-based data, we examined associations between alcohol use disorders (AUD) and suicidality, assessing effect modification by mood disorders, and mediation by drinking level. Suicidality was assessed among current drinkers with 2-weeks of low mood (n = 9,173) in the National Epidemiologic Survey on Alcohol and Related Conditions. Independent of mood disorder, alcohol dependence, was associated with suicidal ideation (adjusted odds ratio [AOR] = 1.64; 95% confidence interval [CI] = 1.25-2.14), and suicide attempts (AOR = 2.02; CI = 1.43-2.85) relative to those without AUD. Findings indicate partial mediation by consumption. Associations between AUD and suicidality among those with low mood are not explained by comorbid mood disorder, but are partially mediated by drinking level. Future studies should evaluate transitions in suicidality with change in consumption.