Tuesday, July 14, 2020

Rules on Confidentiality of SUD Treatment Records Updated to Enhance Coordination of Care

The Substance Abuse and Mental Health Services Administration (SAMHSA) announced yesterday that it has revised regulations governing the disclosure of information about a patient’s history of substance use disorders (SUDs). The changes are intended to help advance coordination of treatment of patients under the care of multiple health care professionals.

The regulations that were revised fall under 42 CFR Part 2 and govern confidentiality of SUD treatment records.

The 42 CFR Part 2 regulations were designed to protect patient records created by federally assisted programs (“Part 2 programs”) for the treatment of SUD. With the revisions announced by SAMHSA yesterday, treatment records created by non-Part 2 health care professionals evaluating or caring for patients with SUD are explicitly not covered by Part 2, thereby allowing coordination of SUD care by non-Part 2 health care professionals.

Additionally, declared national emergencies (such as the COVID-19 pandemic) that disrupt treatment facilities and services are considered under the revised guidelines to be a “bona fide medical emergency” for the purposes of disclosing SUD records without patient consent.

HHS Assistant Secretary for Mental Health and Substance Use Elinore F. McCance-Katz, M.D., Ph.D., said the adoption of this rule means Americans will be better able to receive integrated and coordinated care in the treatment of their substance use disorders. “We are grateful to the individuals and organizations that contributed their input to the rule-making process,” she said. “This is great news for our nation’s families and communities.”

These regulations will be further revised next year to better align Part 2 with HIPAA per passage of the Coronavirus Aid, Relief, and Economic Security Act (CARES Act, HR 748) passed by Congress and signed into law by President Donald Trump on March 27.

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Monday, July 13, 2020

Delirium Found to Be Risk Factor for Long-Term Cognitive Decline

Hospitalized patients who experience delirium—an acute state of disorientation—have an elevated risk of long-term cognitive decline, according to a meta-analysis published today in JAMA Neurology. The risk was similar regardless of whether the patients were recovering from surgery or other serious conditions, such as sepsis or respiratory failure.

“From a public health standpoint, delirium represents a clear target to improve population health,” wrote Terry Goldberg, Ph.D., of Columbia University Irving Medical Center and colleagues. “Delirium is robustly associated with increases in mortality and, as shown here, long-term cognitive decline.”

The investigators combined data from clinical studies that looked at the rates of dementia or other objectively measured cognitive problems in patients at least three months after an episode of delirium. They identified 24 studies encompassing 3,562 patients who experienced delirium and 6,987 patients who did not experience delirium. (The mean age of the patients included in the meta-analysis was 75 years.)

Patients who had experienced delirium were 2.3 times as likely to show cognitive decline three months later compared with patients who had not experienced delirium. The circumstances of the delirium (following anesthesia, trauma, infection, and so on) did not affect the odds of future cognitive decline. This suggests that the underlying mechanisms of delirium may be similar and possibly associated with inflammatory processes common to both surgical and nonsurgical contexts, the investigators noted.

“While our analyses were consistent with a causal hypothesis, causality cannot be confirmed because these studies were designed as observational in demonstrating associations,” Goldberg and colleagues wrote. “Findings based on prospective randomized clinical trials, albeit difficult to implement, might help to resolve this issue.”

To read more on this topic, see the Psychiatric News article “Do Not Forget Delirium During the COVID-19 Scramble.”

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Friday, July 10, 2020

Some Young Breast Cancer Survivors Report PTSD Symptoms Years After Diagnosis

Posttraumatic stress disorder (PTSD) is known to affect a subset of cancer survivors. A study in Psycho-Oncology found that 6.3% of young survivors of non-metastatic breast cancer reported PTSD symptoms related to cancer more than two years after their diagnosis. Women who reported anxiety symptoms six months after being diagnosed with breast cancer were 12 times more likely than others to report PTSD symptoms two years later.

“We found similar rates of cancer-related PTSS [posttraumatic stress symptoms] in breast cancer survivors diagnosed at a young age compared with the general breast cancer population despite their well-documented increased risk of overall distress,” wrote Danny Vazquez, M.D., M.P.P., of Dana-Farber Cancer Institute and colleagues. “Nevertheless, factors associated with posttraumatic stress should be considered at diagnosis and in survivorship to identify young patients who may benefit from psychosocial resources.”

The findings were based on data collected as part of the Young Women’s Breast Cancer Study—an ongoing prospective cohort study of more than 1,300 women diagnosed with breast cancer at or before the age of 40. Study participants received a baseline survey within six months of diagnosis, and follow-up surveys were sent every six months for the first three years after diagnosis and yearly thereafter.

At baseline, all participants filled out questionnaires assessing symptoms of anxiety and depression, fear of cancer recurrence, and presence of social support; participants were also asked about psychiatric comorbidities and use of psychiatric medications. At 30 months, the participants were asked to fill out the 17- item PTSD Checklist-Specific Version questionnaire and rate the severity of PTSD symptoms they had experienced over the prior month specifically related to “cancer treatment or your experience with cancer” on a scale from 1 (“not at all”) to 5 (“extremely”). A score ≥ 50 was considered positive for clinically significant posttraumatic stress symptoms. Women diagnosed with stage 0 or stage 4 cancer, those with missing PTSD data, and those who experienced a recurrence within 12 months of the PTSD survey were excluded from the analysis.

Of the 700 women who had been diagnosed with stage 1-3 breast cancer included in the analysis, about 2% had psychiatric comorbidities and 3% reported taking psychiatric medications. Additionally, 8% screened positive for depression, 23% screened positive for anxiety, and 23% of women reported substantial fears of recurrence at baseline.

Clinically significant posttraumatic stress symptoms at 30 months were significantly associated with anxiety (odds ratio=12.43) and stage 2 vs. stage 1 disease (odds ratio= 2.26), the authors reported. There was no increased risk seen with stage 3 vs. stage 1 disease, but the authors noted that this might be due to the low number of women with stage 3 breast cancer (99 of 700) in the analysis. Women with a college degree and greater social support were less likely to report posttraumatic stress symptoms at 30 months.

“Early identification of those at risk could facilitate individualized screening strategies for the development of PTSS, as well as targeted medical interventions to improve [the] mental health and quality of life of breast cancer survivors diagnosed at a young age,” Vazquez and colleagues wrote.

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Thursday, July 9, 2020

Racial, Ethnic Minorities in United States More Likely to Experience COVID-19 Discrimination

COVID-19–associated discrimination disproportionately impacted members of racial and ethnic minorities in the United States in March and April, and those individuals experienced increased mental distress, according to a study published in the American Journal of Preventive Medicine.

“Anecdotal discriminatory acts amid the COVID-19 pandemic have been widely documented in media reports,” wrote Ying Liu, Ph.D., of the University of Southern California, Los Angeles, and colleagues. This study “provides the first systematic assessment on how perceived CAD [COVID-19–associated discrimination] is associated with potential risk factors … and mental distress.”

The researchers invited a random sample of U.S. adults aged 18 and older who were part of the Understanding America Study to participate in the survey. The participants used a computer, tablet, or smartphone (they were provided a tablet and broadband internet if necessary) to answer questions about whether they felt they had experienced discrimination due to people thinking they might have COVID-19 in March and then again in April.

COVID-19–associated discrimination was assessed using a four-item scale that was adapted from the Everyday Discrimination Scale Short Version. Respondents were asked if they had perceived the following actions due to others thinking they might have COVID-19: received less courtesy or respect, received poorer service at restaurants or stores, were threatened or harassed, or felt that people acted as if they were afraid of them. Possible responses included yes, no, or unsure.

Mental distress was assessed using the Patient Health Questionnaire, in which respondents were asked how often in the past 14 days they felt bothered by feeling anxious, feeling depressed, having little interest in doing things, and not being able to stop or control worrying. Respondents were also asked whether they had worn a face mask or covering in the past seven days and if they had experienced COVID-19 symptoms.

Of the 3,665 participants who took both the March and April surveys, the overall percentage who said they had experienced COVID-19–associated discrimination doubled from 4% in March to 10% in April. In both months, those who experienced discrimination were more likely to be members of racial/ethnic minorities, immigrants, and/or younger; have disease-related symptoms; have used face masks; and have experienced prior discrimination.

Asian Americans were at higher risk of COVID-19–associated discrimination in March, and the risk of COVID-19 discrimination among Black individuals increased from March to April, the authors wrote. Wearing face masks was also a persistent risk factor for discrimination. Mental distress, both during and prior to the pandemic, was higher for those who perceived COVID-19–associated discrimination.

“The relationship between COVID-related discrimination and worsening anxiety and depression is particularly pertinent during this pandemic, as it compounds mental health distress attributable to concerns of disease spread, social restrictions, and financial stress,” said co-author PhuongThao Le, Ph.D., M.P.H., in a news release.

For related information, see the Psychiatric News article “Asian American Hate Incidents: A Co-occurring Epidemic During COVID-19.”

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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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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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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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