Wednesday, July 8, 2020

Daily Support Through Texting Potentially Effective for People With Serious Mental Illness

People with serious mental illness (SMI) may benefit from receiving text messages from a member of their assertive community treatment (ACT) team, suggests a report in Psychiatric Services in Advance. ACT is a widely accepted model of team-based care for people with SMI.

“Augmentation of care with [mobile texting] proved to be feasible, acceptable, safe, and clinically promising,” wrote Dror Ben-Zeev, Ph.D., of the University of Washington and colleagues. “When pandemics such as COVID-19 block the possibility of in-person patient-provider contact, evidence-based texting interventions can serve a crucial role in supporting continuity of care.”

A total of 49 patients with schizophrenia, bipolar disorder, or major depression were randomly assigned to receive texts on a regular basis from a trained member of their ACT team (n=37) or “usual care,” which involved ACT without the added intervention (n=12). ACT team members met with each participant receiving the experimental treatment to build rapport and review how the texting intervention would work. Patients also received a training session regarding basic phone functions and texting. After this visit, the ACT team members provided daily support via text messages for 12 weeks during the team’s hours of operation. They were encouraged to add their own “personal touch” so that the texts did not seem bland or robotic.

The intervention proved to be feasible: 95% of participants assigned to the mobile intervention commenced treatment by sending at least one text message. Those who engaged recorded an average of 41 days in which any texts were exchanged, representing approximately 69% of the days in which texting could have occurred. Patients sent an average of four daily messages and received an average of 3.6 daily messages from the ACT team member. A total of 91% of participants reported satisfaction with the intervention, and there were no adverse events reported.

At three months, patients receiving the text intervention showed greater improvement on scales measuring depression, paranoia, and thoughts of being persecuted compared with those who did not receive the intervention. The advantage for the texting condition diminished by the six-month follow-up, suggesting the intervention needs to be sustained to be effective.

“The findings of this study are encouraging given the relative ease of training ACT staff to serve as interventionists and supervising them, the low burden placed on both patients and practitioners over the intervention period, and the simplicity of the technology used,” the researchers wrote. “If future research replicates our findings in larger samples supporting the clinical utility of the intervention, the treatment could be disseminated broadly and rapidly.”

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Tuesday, July 7, 2020

Childhood Sleep Problems Associated With Psychotic, Personality Disorder Symptoms, Study Suggests

Young children who have irregular sleep routines and frequently wake up at night may be more likely to have psychotic symptoms in early adolescence, according to a report in JAMA Psychiatry. The report also noted that children who go to bed late and sleep for shorter periods at night may be at higher risk of developing borderline personality disorder (BPD) symptoms during early adolescence.

“Adequate sleep in childhood is essential for optimal cognitive and emotional functioning,” wrote Isabel Morales-Muñoz, Ph.D., of the University of Birmingham, United Kingdom, and colleagues. “[E]arly behavioral sleep problems may be modifiable risk factors associated with future psychopathologic symptoms.”

Morales-Muñoz and colleagues assessed data from the Avon Longitudinal Study of Parents and Children (ALSPAC), a large U.K. study that enrolled over 14,000 pregnant women from Avon between 1991 and 1992 and has been monitoring them and their children to examine how biology and environment influence health and disease as the children grow. As part of ALSPAC, parents reported on their children’s sleep behaviors at the ages of 6, 18, and 30 months and 3.5, 4.8, and 5.8 years. When the children in the study reached age 10, the researchers assessed their depressive symptoms; between age 11 and 12, the youth were asked about BPD symptoms; and between age 12 and 13, they were asked about psychotic symptoms.

Of the 6,333 youth who were evaluated for BPD, 472 reported BPD symptoms. Of the 7,155 youth evaluated for psychotic experiences, 376 reported symptoms.

Compared with youth with no psychotic symptoms, youth who reported psychotic symptoms had more frequent nightly awakenings at 18 months of age and less regular sleep routines at 6 and 30 months and 5.8 years of age. Youth who reported BPD symptoms went to bed later and slept less at 3.5 years of age compared with youth with no BPD symptoms.

The investigators also found that some of the associations between specific sleep problems and psychotic experiences were likely mediated by childhood depression; that is, children with more night awakenings or irregular sleep routines were at higher risk of depression at age 10, which then increased the risk of subsequent psychotic symptoms. Morales-Muñoz and colleagues did not find any mediating effect of depression between shorter sleep duration and BPD.

“These findings suggest that the associations between childhood sleep and psychotic experiences as well as childhood sleep and BPD symptoms in adolescence follow different pathways,” Morales-Muñoz and colleagues concluded.

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Monday, July 6, 2020

Changes Urged to Facilitate Telehealth in Treatment of Patients With Substance Use Disorders

Telehealth urgently needs to be adapted for the treatment of people with substance use disorders (SUDs) in light of the global COVID-19 pandemic, wrote Lewei (Allison) Lin, M.D., M.S., of the Veteran Affairs Center for Clinical Management Research, in Ann Arbor, Mich., and colleagues in an article in JAMA Psychiatry.

Relaxation of regulations in response to the pandemic has made telemedicine more accessible, but “compared with mental health, adoption of telehealth for SUDs has been limited because SUD treatment often relies on frequent visits, intense monitoring through urine toxicology, and other practices that pose additional barriers,” Lin and colleagues wrote.

They urged the following steps to help leverage telemedicine in the treatment of patients with SUDs:

  • Develop practice guidelines for telehealth-delivered SUD treatment. Overall guidelines for patient-centered, evidence-based care that incorporate some specific considerations for telehealth treatment of patients with SUDs are needed. Pertinent issues include how and how often urine toxicology screens should be obtained and coordination of care for patients with complex disorders.
  • Facilitate prescription of buprenorphine through telemedicine. Buprenorphine is a life-saving treatment, but there are not enough prescribers. To attract and train clinicians to deliver care via telehealth to patients taking buprenorphine, greater efforts should be made to increase awareness of telehealth technology and infrastructure, billing and reimbursement policies, changes in federal- and state-level regulations, and strategies to encourage adoption by clinics.
  • Incorporate psychosocial treatments into telemedicine. The stress and uncertainty brought on by COVID-19 emphasize the importance of patients having access to psychosocial resources, including psychotherapy, case management, crisis support, and community supports. Making resources accessible online and adapting evidence-based psychotherapy treatments to telehealth is key and would also support care after COVID-19.

“As we work fervently toward addressing the COVID-19 pandemic, we must also continue delivering ongoing treatment for patients, especially for those whom treatment disruptions may result in equally dire consequences,” Lin and colleagues wrote. “Telehealth can uniquely address capacity shortages, but much work is needed to support large-scale dissemination and adoption.”

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Thursday, July 2, 2020

APA Presidential Task Force to Address Structural Racism Throughout Psychiatry

APA has established the Presidential Task Force to Address Structural Racism Throughout Psychiatry.

The task force was initially described at a virtual APA Town Hall on June 15 amid rising calls from psychiatrists for action on racism and held its first meeting on June 27. The task force has distributed a survey on mental health care of Black patients throughout the APA membership and is planning a second virtual town hall for August 24.

Focusing on organized psychiatry, psychiatrists, psychiatric trainees, psychiatric patients, and others who work to serve psychiatric patients, the task force is initially charged with the following:

  • Providing education and resources on APA’s and psychiatry’s history regarding structural racism.
  • Describing the current impact of structural racism on the mental health of patients and colleagues.
  • Developing achievable and actionable recommendations for change to eliminate structural racism in APA and psychiatry.
  • Providing reports with its recommendations to the APA Board of Trustees at each of its meetings through May 2021.
  • Monitoring the implementation of this plan.

Chairing the task force is Cheryl D. Wills, M.D., an associate professor of psychiatry at Case Western Reserve University and APA Area 4 Board of Trustees member. Other members include Renée Binder, M.D.; Frank Clark, M.D.; Charles Dike, M.D., M.P.H.; APA Assembly Speaker-Elect Mary Jo Fitz-Gerald, M.D., M.B.A.*; Danielle Hairston, M.D., president of APA’s Black Psychiatrists Caucus; Hunter McQuistion, M.D.; Michele Reid, M.D.*; Steven Starks, M.D.; Richard Summers, M.D.*; and Sanya Virani, M.D., M.P.H.*

“The history of APA, going back to its very roots in the 1700s, is scarred with structural racism and racist ideas,” said APA President Jeffrey Geller, M.D., M.P.H. “While efforts have occurred over the years to rectify this problem, particularly by Black psychiatrists, as a field and organization, we still have a very long way to go. I believe in this moment, when all Americans are seeing the murders and trauma of many Black Americans, as well as an upswell of activism and change, we hope all our members will work with the task force to bring about actions that will make a difference for our organization and field with positive ripple effects far beyond.”

APA CEO and Medical Director Saul Levin, M.D., M.P.A., said this is a time for reflection, accountability, and action for APA. “We have not done enough in the past as a field or as an organization to ensure that Black people, as well as other minority communities, are treated fairly and equitably,” Levin said. “I am committed to ensuring that this task force, coupled with actions by our entire membership and administration, helps us dismantle the systemic racism that impacts so many of our colleagues and the patients we serve.”

*Current member, APA Board of Trustees



Contribute to Determining the Future of APA
Nominate yourself or a colleague


As chair of APA’s Nominating Committee, Immediate Past President Bruce Schwartz, M.D., is seeking to diversify the elected leadership of APA and invites all members to consider running for one of the open Board of Trustee offices in APA’s 2021 election: president-elect; secretary; early-career psychiatrist trustee-at-large; minority/underrepresented representative trustee; Area 1, 4, and 7 trustees; and resident-fellow member trustee-elect. You may nominate yourself or a colleague—the important point is that you get involved! The deadline is Tuesday, September 1.

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Wednesday, July 1, 2020

COVID-19 May Lead to Uptick in Cases of Prolonged Grief Disorder

Many experts agree that the mental health effects of COVID-19 will continue to be felt long after the pandemic ends. In a commentary in the American Journal of Geriatric Psychiatry, Joseph S. Goveas, M.D., of the Medical College of Wisconsin and M. Katherine Shear, M.D., of Columbia University outlined why they believe cases of prolonged grief disorder are likely to rise and suggested ways to mitigate this emerging problem.

Prolonged grief disorder is characterized by intense yearning/longing for the deceased person or a preoccupation with thoughts or memories of the deceased person accompanied by significant distress or impairment.

COVID-19 has claimed the lives of more than 500,000 people worldwide. Additionally, physical distancing measures to contain the virus have changed the experience of dying from COVID-19 and other causes and disrupted the grieving process, which may increase the risk of prolonged grief disorder:

  • Few, if any, family members can be at the sides of those dying from COVID-19. “Comprehending the reality of a loss is difficult under any circumstances, but even more so when the death is sudden and a loved one is left to die alone,” they wrote.
  • Cultural and religious rituals have been largely disrupted. For instance, private viewings are not often possible, in-person funerals can have only a few guests, and hugging and/or other physical contact between mourners is discouraged.
  • The closure of schools, workplaces, places of worship, and limits on informal gatherings “can intensify the sense of social isolation and loneliness that is a part of the natural experience of many grieving individuals,” they wrote.

“The dramatic upheaval caused by the death of a loved one often triggers troubling feelings and thoughts,” Goveas and Shear wrote. “In addition to yearning and sadness, most people feel anxiety, guilt, or anger. Bereaved people are inclined to protest the death and have a natural tendency to imagine alternative scenarios in which their loved one did not die. Most feel survivor guilt. Although there is little research on the topic of survivor guilt, we believe that it is a universal human feeling.”

To lessen the adverse consequences of the death of a loved one during the pandemic, the authors recommended that clinicians learn more about the natural grieving process and how they might assist grieving patients in modulating their emotional pain; the thoughts, feelings, and behaviors that can stall or halt the grieving process; the unique challenges faced by the bereaved during the pandemic; and available treatments for caring for patients with prolonged grief disorder. The authors also called for the continuance of relaxed regulations that have permitted the expansion of telehealth services across the country to ensure continued access to much-needed care for bereaved individuals after the pandemic ends.

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Tuesday, June 30, 2020

Geller Testifies on Mental Health Needs During Pandemic and Beyond

During a virtual U.S. House subcommittee hearing today, APA President Jeffrey Geller, M.D., M.P.H., urged Congress to take action to curb the mental health impact of the COVID-19 pandemic.

“We expect that, even after the infectious aspect of this pandemic is over, we’re going to have a mental health pandemic that could go on for quite some time,” Geller told the U.S. House Committee on Energy & Commerce’s Subcommittee on Health.

The hearing, titled “High Anxiety and Stress: Legislation to Improve Mental Health During Crisis,” addressed 22 pieces of legislation related to mental health care pending before Congress. Geller expressed APA’s support for legislation that would achieve the following:

  • Require the Department of Health and Human Services to collect, analyze, and make publicly available data on race and ethnicity related to COVID-19 testing, hospitalization, and mortality as well as the mental health effects of the pandemic.
  • Enforce the parity law, which requires insurers to cover mental health at the same levels as physical health.
  • Continue expanded telehealth rules beyond the COVID-19 emergency.
  • Strengthen congressional efforts to prevent suicide.
  • Ensure that patients who present in the Emergency Department with suicidal ideation or who have attempted suicide are screened and referred to appropriate mental health treatment.
  • Boost resources for call centers, 24/7 mobile crisis units, and crisis stabilization programs.

Geller especially expressed APA’s support for the Telemental Health Expansion Act of 2019 (HR 5201), introduced by Reps. Doris Matsui (D-Calif.) and Bill Johnson (R-Ohio). The legislation would permanently exempt tele-mental health services from Medicare’s geographic restrictions, such as requiring patients to travel to a qualifying “originating site” for appointments.

He also highlighted the Mental Health Parity Compliance Act (HR 3165), sponsored by Reps. Katie Porter (D-Calif.), Gus Bilirakis (R-Fla.), and Rep. Donald Norcross (D-N.J.). This legislation would ensure that health insurance plans comply with the Mental Health Parity and Addiction Treatment Act of 2008.

During the question-and-answer portion of the hearing, Geller stressed that he believes a campaign is urgently needed to reduce prejudice and discrimination toward people with mental illness and called on Congress to help such an effort.

The only bill addressed during the hearing that APA opposed was the Medicare Mental Health Access Act (HR 884), introduced by Rep. Judy Chu (D-Calif.), which would define psychologists as physicians under Medicare. In his written testimony, Geller noted that the bill “would further fragment care by creating unnecessary and dangerous silos between all health care providers who should be working collaboratively.”

Geller testified along with former Rep. Patrick Kennedy, founder of the Kennedy Forum; Arthur C. Evans Jr., Ph.D., CEO of the American Psychological Association; and Arriana Gross, a member of the National Youth Advisory Board of the Sandy Hook Promise Students Against Violence Everywhere Promise Club.



Get Off the Sidelines: Serve Your Profession as APA Trustee
Nominate yourself or a colleague


As chair of APA’s Nominating Committee, Immediate Past President Bruce Schwartz, M.D., is seeking to diversify the elected leadership of APA and invites all members to consider running for one of the open Board of Trustee offices in APA’s 2021 election: president-elect; secretary; early-career psychiatrist trustee-at-large; minority/underrepresented representative trustee; Area 1, 4, and 7 trustees; and resident-fellow member trustee-elect. You may nominate yourself or a colleague—the important point is that you get involved! The deadline is Tuesday, September 1.

Access Nomination Requirements and Form

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Monday, June 29, 2020

Study Documents Neurological, Psychiatric Complications From COVID-19

While previous studies and case reports have found that COVID-19 patients have experienced vascular and neurological problems, a new study in the Lancet Psychiatry reports that patients are also showing symptoms of psychiatric disorders, including psychosis and depression.

The study was the result of a collaborative effort of specialists in the United Kingdom to document COVID-19 complications.

“To our knowledge, this is the first systematic, nationwide U.K. surveillance study of the breadth of acute complications of COVID-19 in the nervous system,” wrote Aravinthan Varatharaj, M.R.C.P., of University Hospital Southampton and colleagues.

Earlier this year, researchers created a U.K.-wide online portal through which specialists in neurology, psychiatry, stroke medicine, and neurointensive care could enter clinical data on COVID-19 patients who developed nervous system–related complications. The complications were classified in four broad areas: a cerebrovascular event (such as a stroke or brain hemorrhage), altered mental status (a change in behavior, cognition, or consciousness), peripheral neurological issue (weakness and/or pain in body nerves or muscles), or other.

The researchers focused on data entered between April 2 and April 26—the first three weeks that the portal accepted submissions. Full clinical details on 125 patients were analyzed.

Of this group, 77 patients experienced a cerebrovascular event (primarily stroke), 39 experienced altered mental status, six experienced peripheral problems, and three experienced other nervous system–related complications. Among the 39 patients with altered mental status, 16 were diagnosed with encephalopathy (brain inflammation), and 23 were diagnosed with a psychiatric disorder. Ten of these 23 patients developed psychosis, six developed cognitive problems, and seven developed mood problems including depression and mania.

A greater percentage of younger patients were affected by altered mental status than cerebrovascular events, Varatharaj and colleagues noted. For instance, 49% of the patients who experienced altered mental status were under age 60, whereas 18% of patients who experienced a cerebrovascular event were under 60.

“Our study population represents a snapshot of hospitalized patients with acute neurological or psychiatric complications associated with COVID-19. Larger, ideally prospective, studies should identify the broader cohort of COVID-19 patients both in and outside hospitals ... to determine clearer estimates of the prevalence of these complications and individuals at risk,” the authors concluded.

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The content of Psychiatric News does not necessarily reflect the views of APA or the editors. Unless so stated, neither Psychiatric News nor APA guarantees, warrants, or endorses information or advertising in this newspaper. Clinical opinions are not peer reviewed and thus should be independently verified.