Ethical Obligations to Patients and Larger Community May Compete During COVID-19 Crisis

For most physicians, the needs of the individual patient in their office or clinic is the focus of their attention. But outside the setting of that single patient encounter is a larger community of patients in need, their families, and individuals who may later need care.

Even in the best of times there may be a tension between a physician’s ethical obligations to the individual patient and to the broader public. During a global pandemic such as COVID-19, that tension has been heightened and may come into play in many clinical scenarios, according to Rebecca Brendel, M.D., J.D., chair of the APA Committee on Ethics. She is director of the master’s degree program at the Harvard Medical School Center for Bioethics and a member of the AMA Council on Ethical and Judicial Affairs.

“For most of us, in our practices, what we are most commonly thinking about is the single patient before us. Now we are in the midst of an enormous public health crisis, and as physicians we have an ethical obligation to think as well about the greater good.”

She outlined two specific clinical scenarios that are liable to be common and in which competing ethical obligations to patient or public health will be at play:

Prescriptions and hoarding of medicines: Patients are bound to be anxious about having an adequate supply of their medications during a period when pharmacies are being deluged and may be experiencing shortages. These patients may be inclined to request an extra supply of medications. Psychiatrists should be certain their patients have an adequate supply of their medications (taking into account whether the risk of suicide exists), but Brendel advised that psychiatrists avoid prescribing refills that could lead a patient to hoard medications. “One way we can be absolutely sure there will be shortages of medications is by not thinking cautiously about how we prescribe.”

(Reimbursement for multiple months of prescriptions varies with health plans; many plans cover a maximum of a 60- or 90-day supply, but physicians could theoretically write scripts for even longer, and mail-order pharmacies could auto-fill them; moreover, some patients might be willing to pay out of pocket for extra supplies.)

Brendel said psychiatrists can help allay patients’ fears and should talk to them about planning ahead and not waiting until they are about to run out of a medication to request a refill.

Social distancing and scheduling appointments: Psychiatrists and mental health professionals are likely to have patients who prefer, expect, and may even insist upon face-to-face visits. “In normal times, psychiatrists have an obligation to put their patients’ needs and wants first and to accommodate them within established clinical boundaries to the best of their ability,” Brendel said. “We are not in normal times. Data very clearly show that the best way to contain the spread of COVID-19 is social distancing and that person-to-person contact is the major source of spread of the virus. Telephone and video teleconferencing may not be ideal in the course of routine care, but in the current circumstances are essential.”

Brendel emphasized that psychiatrists and health care professionals must also be mindful of their own health, for their own sake and the sake of their families, but also for the greater good. “Psychiatrists have a personal but also a professional responsibility to be healthy and available in this extraordinary new circumstance,” she said.

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Join APA-NABH Webinar on Caring for Patients Through COVID-19 Crisis: April 1

APA and the National Association for Behavioral Healthcare (NABH) will host a joint webinar on Wednesday, April 1, from 2 p.m. to 3 p.m. EDT with experts working in inpatient, residential, and other nonambulatory care settings about how they are assessing the current environment and developing new protocols to care for their patients during the COVID-19 crisis. Hear from experts about the management of different types of services, key messages to give your team leaders, unique challenges for people with serious mental illness (SMI), how to handle group therapy, and more. Questions can also be submitted via chat during the live session. A recording will be posted after the event. More information about the webinar, including how to register, is posted here.

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Register Now to Participate in 2020 Minority and Underrepresented Group Caucus Election

The Caucus of Asian-American Psychiatrists is holding an election for three leadership positions: president, Assembly representative, and Assembly deputy representative. To be eligible to vote in the election, APA members must join the caucus by Wednesday, April 1. Find more information on how to join the caucus here.

Supreme Court Upholds States’ Rights to Nullify Insanity Defense

The U.S. Supreme Court ruled last week that states can prevent criminal defendants from pleading insanity without violating their constitutional rights.

In the case Kahler v. Kansas, the justices ruled 6-3 in favor of the state. The defendant, James Kraig Kahler, had been sentenced to death for the murder of his family. His lawyers wanted to mount an insanity defense, but Kansas is one of four states that eliminated a defendant’s ability to plead not guilty by reason of insanity. (Idaho, Montana, and Utah are the others; Alaska substantially limits the insanity defense.)

Justice Elena Kagan wrote the majority opinion for the court, saying that Kansas takes into account a defendant’s mental health at both trial and sentencing, but the option of an insanity defense and the scope of its application are “for Kansas to make—and, if it wishes, to remake and remake again as the future unfolds.”

Experts in psychiatry and the law said that the decision could have significant consequences. “The most immediate impact of the case is on Kansas and the four other states that have elected to effectively get rid of their insanity defenses. Their laws will remain valid,” said Paul Appelbaum, M.D., a member of APA’s Committee on Judicial Action.

He said the longer-term impact of the case is more difficult to predict because states can make their own choices; 45 states and the federal government retain meaningful insanity defense laws. “Given the long-standing acceptance of insanity as a defense to criminal charges—dating back in the Anglo-American tradition to medieval times—most states will probably choose to retain that option [for defendants who want to plead insanity],” Appelbaum said. “Defendants in the states without an effective insanity defense will be most adversely impacted by the decision. More people with severe mental illness will spend decades in prison.”

Debra Pinals, M.D., chair of the APA Council on Psychiatry and Law, agreed. “Persons with serious mental illness who engage in criminal behavior living in states with narrower criteria for insanity, or in states with no insanity defense, will likely be found guilty and sentenced.”

For related information, see the Psychiatric News article “States Move to Exempt People With SMI From Death Penalty.”

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Join APA-NABH Webinar on Caring for Patients Through COVID-19 Crisis: April 1

APA and the National Association for Behavioral Healthcare (NABH) will host a joint webinar on Wednesday, April 1, from 2 p.m. to 3 p.m. EDT with experts working in inpatient, residential, and other nonambulatory care settings about how they are assessing the current environment and developing new protocols to care for their patients during the COVID-19 crisis. Hear from experts about the management of different types of services, key messages to give your team leaders, unique challenges for people with serious mental illness (SMI), how to handle group therapy, and more. Questions can also be submitted via chat during the live session. A recording will be posted after the event. More information about the webinar, including how to register, is posted here.

APA Praises Mental Health Provisions in COVID-19 Stimulus Aid Package

APA today praised Congress for approving a $2 trillion stimulus aid package to provide fiscal relief for Americans and businesses in the face of the COVID-19 pandemic. The legislation, known as the Coronavirus Aid, Relief, and Economic Security Act (CARES Act), includes many provisions supported by APA that will enable psychiatrists and mental health care professionals to better respond to the pandemic. President Donald Trump signed the legislation on March 27..

“You can’t have a healthy economy without healthy people—and that includes mental health,” said APA President Bruce Schwartz, M.D. “This stimulus bill will strengthen our ability to help the millions of Americans with existing mental illnesses or substance use disorders, and more with emerging mental health issues as the pandemic unfolds. This is a promising development in the nation’s efforts to fight the impact of COVID-19.”

Among the provisions of the CARES Act that APA supports are $425 million for Substance Abuse and Mental Health Services Administration programs (including $250 for Certified Community Behavioral Health Clinics and $50 million for suicide prevention programs) and $4 billion for community health centers. The bill further loosens restrictions governing telehealth services by repealing the Medicare requirement that allows only health care professionals to see a patient remotely if they have previously seen that patient within the past three years. The legislation also aligns 42 CFR Part II with the Health Insurance Portability and Accountability Act (HIPAA) to allow sharing of substance use disorder records between health care professionals. Additionally, the legislation suspends the 2% Medicare sequester cut through December 2020.

“As we respond to one of the largest public health threats facing our country in decades, funding for behavioral health initiatives and expanding telemedicine is critical,” said APA CEO and Medical Director Saul Levin, M.D., M.P.A. “We strongly believe that federal and state government will need to continue to support physicians, who will be working long hours and in many cases risking their own health, as we continue to address this pandemic.”

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APA’s COVID-19 Resource Center Keeps You Updated

APA’s COVID-19 Resource Center brings together a number of useful resources from APA and other authoritative sources to help you deal with the COVID-19 crisis.

Psychiatrists Can Take Proactive Steps to Help Patients During COVID-19 Crisis

As health care workers at hospitals and emergency departments (EDs) focus greater attention on diagnosing and treating patients with coronavirus (COVID-19), psychiatrists across the country are bracing for the inevitable impact on their patients. Psychiatric News asked experts in the field what psychiatrists can do to help identify and address the needs of patients experiencing a worsening of psychiatric symptoms before they seek care in the ED.

It’s not whether EDs have the capacity to conduct assessments and crisis evaluations for patients with psychiatric conditions that worries Scott Simpson, M.D., medical director of psychiatric emergency services at Denver Health and an associate professor of psychiatry at the University of Colorado Anschutz Medical Campus. It’s what will happen to patients after such assessments are made that worries him. “I think there are going to be [many] challenges coming up related to transitions of care,” he said.

To help reduce the need for crisis services, psychiatrists and mental health professionals working in outpatient services should be connecting with patients, particularly those most vulnerable, explained Kim Nordstrom, M.D., J.D., an associate clinical professor of psychiatry at the University of Colorado School of Medicine. “This is paramount. Outpatient psychiatrists may be able to prevent crisis stabilization unit and ED visits, which in turn may reduce secondary exposure to the virus.”

Physicians should anticipate which of their patients are at risk for acute exacerbations of their symptoms during the pandemic and reach out to them, said Jon Levenson, M.D., an associate professor of psychiatry at Columbia University and chair of APA’s Council on Consultation-Liaison Psychiatry. Physicians may want to consider scheduling more frequent visits with these patients or arranging for other clinical staff to reach out via telemedicine or phone, as well.

“People with pre-existing psychiatric disorders are even more vulnerable with the uncertainty associated with the COVID-19 pandemic,” he said. “Many patients with psychiatric disorders who are already somewhat stigmatized and marginalized will feel even further isolated with the enforced quarantine, and they may start having more active symptomatology.”

Some patients may benefit from a reassessment of their psychotropic medicines and dosage, as well, he continued. Those who are acutely symptomatic might need a dosage increase to effectively treat their symptoms, he said.

Despite these efforts, some patients will continue to experience psychiatric crises requiring hospitalization during the COVID-19 pandemic.

“[Physicians on] inpatient psychiatric units are going to have to make hard decisions about what kinds of patients they’re going to accept and how they’re going to handle patients with even suspected coronavirus,” Simpson said.

Physicians also need to be flexible about the types of patients they treat, Simpson said, and inpatient units must be prepared to accept patients they may not otherwise, as capacity throughout the health care system shifts to care for COVID-19 patients.

It’s better to figure out how to safely treat a patient experiencing manic episodes who is COVID-19 positive in an inpatient psychiatric unit, rather than in a medical bed where they may be under continuous restraints, Simpson pointed out.

“There are hard times ahead,” said Jack Rozel, M.D., M.S.L., president of the American Association for Emergency Psychiatry, medical director for resolve Crisis Services, and an associate professor psychiatry at the University of Pittsburgh. “But psychiatrists got into this work because we care about people, and we want to help people. Now, more than ever, we’re needed. If not us, then who?”

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DEA, FTC Issue Warning: Beware of Scammers

Be aware: Scammers posing as representatives from the Drug Enforcement Administration (DEA) and officials from other agencies are targeting physicians.

It was recently brought to the attention of the Massachusetts Board of Medicine that Massachusetts licensees have been receiving scam calls from individuals posing as investigators of the Massachusetts Board of Medicine of the DEA. In these cases, the impersonator falsely stated that the licensee is under investigation and that their medical license is in jeopardy or has been suspended. Impersonators may demand money and/or seek additional information about the licensee’s DEA registration number and financial information. Physicians from other states received similar scam calls from individuals purporting to be FBI and DEA. The DEA webpage includes information for reporting the threat online.

Additionally, the Federal Trade Commission is warning the public on how best to avoid coronavirus scams, including recorded scam calls on “fake tests for Medicare recipients” and “free test kit scam.”

Many Americans Anxious Over COVID-19, APA Poll Finds

Many Americans are feeling anxious over the risk that the novel coronavirus (COVID-19) poses to their health, the health of their family and friends, their finances, and the long-term impact the virus will have on the economy, according to a national poll released today by APA.

“The stress and anxiety caused by the pandemic can and is having an effect on people’s physical and mental health,” APA President Bruce Schwartz, M.D., said in a press statement. “During this time, it is important to do what we can to maintain self-care and manage the stress. I would suggest this for everyone coping at home as well as those who are still in their workplaces by necessity, especially the health care professionals on the front lines of this pandemic.”

The findings were based on an online survey of a nationally representative sample of 1,004 U.S. adults aged 18 and older conducted on March 18 and 19.

Several takeaways from the poll include the following:

• Nearly half of respondents (48%) are anxious about getting coronavirus, and even more (62%) worry their family members and loved ones will catch coronavirus.
• More than half of respondents (57%) are concerned that the coronavirus will have a serious negative impact on their finances, and 68% fear that the coronavirus will have a long-lasting impact on the economy.
• More than a third of respondents (36%) reported that coronavirus is having a serious impact on their mental health, and more than half (59%) feel that coronavirus is having a serious impact on their day-to-day lives.
• Despite these concerns, only 19% of respondents reported that they are having trouble sleeping, and 12% reported they have been fighting more with a partner or loved ones.
• Nearly 40% of respondents said that they believe people are overreacting/being overly cautious about coronavirus, while nearly 40% said that they disagree with this statement.

“The poll highlights both the anxiety caused by the pandemic and the need for clear, consistent communications on how to prevent the spread of COVID-19,” said APA CEO and Medical Director Saul Levin, M.D., M.P.A. “In the disruption COVID-19 is causing, everyone needs to make sure they are taking the time to take care of their own physical and mental health, alongside with their families, friends, and work colleagues. Social isolation can be prevented by taking the time to use social media, letters, or simply the phone to communicate with loved ones and friends, particularly those we haven’t been in touch with over the years as we would have liked. Together, we will get through this.”

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APA’s COVID-19 Resource Center Keeps You Updated

APA’s COVID-19 Resource Center brings together a number of useful resources from APA and other authoritative sources to help you deal with the COVID-19 crisis.

FDA Loosens Restrictions on REMS for Medications, CMS Grants Exceptions on Quality Reporting

In response to the unfolding COVID-19 public health crisis, federal agencies have announced new changes intended to lighten the burden on health care systems and professionals working to respond to the crisis. These include separate announcements by the Food and Drug Administration (FDA) and the Centers for Medicare and Medicaid Services (CMS).

The FDA has released new guidance regarding Risk Evaluation and Mitigation Strategy (REMS) requirements for certain medications, including clozapine. According to the notice, the FDA does not intend to take action against health care professionals for failing to adhere to certain REMS requirements for these medications for the duration of the COVID-19 public health emergency. Clozapine is considered one of the most effective antipsychotics for serious mental illness, especially treatment of refractory schizophrenia.

The FDA guidance is posted along with other COVID-related items on the APA website.

According to the guidance, health care professionals prescribing and/or dispensing medications subject to REMS with laboratory testing (or imaging) requirements should consider whether there are compelling reasons not to complete or delay lab tests during this public health emergency. Health care professionals should discuss the benefits and risks of continuing treatment in the absence of laboratory testing with their patients.

The FDA guidance followed a separate and distinct announcement by CMS on granting exceptions for health care professionals enrolled in Medicare quality reporting programs. For those programs with data submission deadlines in April and May, submission of those data will be optional. In addition, no data reflecting services provided from January 1, 2020, through June 30, 2020, will be used in CMS’s calculations for the Medicare quality reporting and value-based purchasing programs.

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APA’s COVID-19 Resource Center Keeps You Updated

APA’s COVID-19 Resource Center brings together a number of useful resources from APA and other authoritative sources to help you deal with the COVID-19 crisis.

Survey Finds COVID-19 Takes Heavy Psychological Toll on Health Care Workers

As communities across the world continue to grapple with containing the spread of the novel coronavirus (COVID-19) and deal with the quickly proliferating number of cases, a study out of China reports troubling information on the psychological ramifications of COVID-19 on health care workers: A survey of more than 1,200 nurses and physicians working in hospitals in the Wuhan region (where the outbreak originated) and across mainland China revealed that more than 50% reported symptoms of depression, and more than 70% reported symptoms of psychological distress. The findings were published today in JAMA Network Open.

“Protecting health care workers is an important component of public health measures for addressing the COVID-19 epidemic. Special interventions to promote mental well-being in health care workers exposed to COVID-19 need to be immediately implemented, with women, nurses, and frontline workers requiring particular attention,” wrote Jianbo Lai, M.Sc., of Renmin Hospital of Wuhan University in China and colleagues.

The researchers surveyed health care workers from 34 hospitals in China with fever clinics or wards for COVID-19 between January 29, 2020, and February 3, 2020. (During this period, the total confirmed cases of COVID-19 exceeded 10,000 in China, according to the authors.) The researchers assessed the survey respondents’ depression, anxiety, insomnia, and distress using the Chinese versions of the Patient Health Questionnaire, the Generalized Anxiety Disorder scale, the Insomnia Severity Index, and the Impact of Event Scale–Revised.

Of the 1,257 surveyed (493 physicians and 764 nurses), 634 (50.4%) reported depression symptoms, 560 (44.6%) reported anxiety, 427 (34.0%) reported insomnia, and 899 (71.5%) reported distress. Health care workers engaged in the direct diagnosis, treatment, and care of patients with COVID-19 were more likely to report symptoms of depression (odds ratio, 1.52), anxiety (odds ratio, 1.57), insomnia (odds ratio, 2.97), and distress (odds ratio, 1.60) compared with those not involved in the diagnosis, treatment, and care of patients with COVID-19.

“These findings, consistent with those observed in the 2003 severe acute respiratory system (SARS) epidemic, may help to guide strategies for responding to mental health sequelae of this and future epidemics,” wrote Roy Perlis, M.D., a professor of psychiatry at Harvard Medical School, in an accompanying commentary.

“While the peak of the COVID-19 epidemic remains to be seen, it will ultimately subside. The work of Lai et al. provides a reminder of the toll that will likely linger: the consequences of chronic stress, including major depression and anxiety disorders. … [J]ust as the world has joined efforts to manage COVID-19 infection, it will be critical not to neglect the mental health consequences of the fight against the epidemic.”

For related information, see “Coronavirus and Mental Health: Taking Care of Ourselves During Infectious Disease Outbreaks,” by Joshua Morganstein, M.D., chair of the APA Committee on Psychiatric Dimensions of Disasters.

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APA’s COVID-19 Resource Center Keeps You Updated

APA’s COVID-19 Resource Center brings together a number of useful resources from APA and other authoritative sources to help you deal with the COVID-19 crisis.

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How to Participate in 2020 Minority and Underrepresented Group Caucus Election

The Caucus of Asian-American Psychiatrists is holding an election for three leadership positions: president, Assembly representative, and Assembly deputy representative. To be eligible to vote in the election, APA members must join the caucus by Wednesday, April 1. Find more information on how to join the caucus here.

SAMHSA Issues Additional Guidance on OUD Treatment, Privacy, Telehealth During COVID-19 Pandemic

Yesterday the Substance Abuse and Mental Health Services Administration (SAMHSA) released further guidance on the treatment of opioid use disorder (OUD) during the COVID-19 pandemic, specifically with respect to privacy and sharing of medical records related to substance use treatment. It has also clarified, with FAQs, guidance it released earlier this week about opioid treatment programs’ (OTPs’) ability to provide medications via telehealth during the pandemic.

Regarding privacy, SAMHSA has acknowledged that treatment providers may not be able to obtain written patient consent for disclosure of substance use disorder records during the pandemic. Therefore, “[t]he prohibitions on use and disclosure of patient identifying information under 42 C.F.R. Part 2 would not apply in these situations to the extent that, as determined by the provider(s), a medical emergency exists” and “patient identifying information may be disclosed by a Part 2 program or other lawful holder to medical personnel, without patient consent, to the extent necessary to meet a bona fide medical emergency in which the patient’s prior informed consent cannot be obtained,” the guidance states.

The guidance also includes a reminder that the regulations require programs to “document certain information in their records after a disclosure is made pursuant to the medical emergency exception.”

In its FAQs, SAMHSA noted that under 42 CFR Section 8.11(h), it has chosen to exempt OTPs from certain requirements. For the duration of the national emergency, OTPs are exempt “from the requirement to perform an in-person physical evaluation (under 42 C.F.R. § 8.12(f)(2)) for any patient who will be treated by the OTP with buprenorphine if a program physician, primary care physician, or an authorized health care professional under the supervision of a program physician, determines that an adequate evaluation of the patient can be accomplished via telehealth.”

However, this exemption does not apply to new OTP patients treated with methadone. These patients must still be evaluated in person.

Other key points in the SAMHSA FAQs include the following:

• OTPs may use telehealth, including care provided over the telephone, to continue treatment of existing OTP patients who use methadone or buprenorphine.
• Health care professionals who are qualified with a waiver under the Drug Addiction Treatment Act of 2000 (“DATA waiver,” “X waiver”) and who are working outside the context of an OTP may treat new and existing patients with buprenorphine via telehealth.
• OTPs may dispense either methadone or buprenorphine medications based on a telehealth evaluation. They may provide medication under a blanket exception: up to 14 doses for clinically less stable patients and 28 doses for clinically stable patients.
• Mid-level practitioners in OTPs can administer and dispense medications for treating OUD without the direct supervision of an OTP physician, if the mid-level practitioner is “licensed under the appropriate state law and registered under the appropriate state and federal laws to administer or dispense opioid drugs.” However, the OTP medical director still must assume responsibility for administering all medical services provided by the OTP.

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APA’s COVID-19 Resource Center Keeps You Updated

APA’s COVID-19 Resource Center brings together a number of useful resources from APA and other authoritative sources to help you deal with the COVID-19 crisis.

Due to COVID-19 Outbreak, Patients Can Take OUD Medications Home

In light of the coronavirus (COVID-19) outbreak, some patients receiving treatment for opioid use disorder (OUD) may take a 28-day supply of their medications home to avoid daily trips to their clinic, the Substance Abuse and Mental Health Services Administration (SAMHSA) stated in a guidance issued on Monday.

Under SAMHSA’s guidance, those states that have declared a state of emergency may make a blanket request to allow all opioid treatment programs (OTPs) to provide stable patients with four weeks of medication to take home. Those who are not considered stable “but who the OTP believes can safely handle this level of Take-Home medication,” the guidance states, may receive two weeks, or 14 days, of their medication.

OTPs operating in states that have not declared a state of emergency may also take advantage of the same guidance by requesting a blanket exemption request for its clinic.

SAMHSA stipulates that programs and states should use “appropriate clinical judgment and existing procedures to identify stable patients.” The administration also notes that the requests to take advantage of the new guidance do not need to be made on a per-patient basis.

Patients with OUD are often treated with methadone, buprenorphine, or, in some cases, the opioid antagonist naltrexone, explained Smita Das, M.D., Ph.D., M.P.H., a clinical assistant professor of psychiatry and behavioral health sciences at Stanford University School of Medicine and member of APA’s Council on Addiction Psychiatry. When patients initially start OUD treatment with such medications, they must make daily trips to their OTP to get their dose.

“Patients often have to take public transit to get to the clinic in the morning, wait in line, get dosed at a window, and then go on with their day,” Das told Psychiatric News in an email. “Some patients may have medical conditions or may be older, putting them at increased risk of severe illness and death if they contract COVID-19.”

The Drug Enforcement Administration (DEA) on Monday also announced in a letter that it has eased restrictions of who can dispense medications in cases when a patient is quarantined due to the coronavirus. During such times, treatment program staff members, as well as law enforcement officers and national guard personnel, can deliver the medications to an approved lockbox at the patient’s home. The change applies only while the country’s public health emergency, declared on January 31, lasts. Typically, only licensed practitioners can dispense or administer medications to patients.

“Using public transit daily and going to a full waiting room may put everyone at risk,” Das said. “In light of COVID-19, we need to consider the health and safety of those patients and the community.”

For related information, see the Psychiatric News article “Stigma, Misunderstanding Among the Barriers to MAT Treatment.”

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APA’s COVID-19 Resource Center Keeps You Updated

APA’s COVID-19 Resource Center brings together a number of useful resources from APA and other authoritative sources to help you deal with the COVID-19 crisis.

CMS Loosens Telehealth Restrictions After COVID-19 Declared National Emergency

Medicare patients seeking certain medical services—including mental health services—can now be seen using live videoconferencing in their homes. They do not need to travel to a qualifying “originating site” for Medicare telehealth encounters, regardless of geographic location, according to a guidance issued yesterday by the Centers for Medicare and Medicaid Services (CMS).

CMS is temporarily expanding Medicare telehealth services and waiving existing restrictions on those services under authority granted to the secretary of Health and Human Services in the bipartisan Coronavirus Preparedness and Response Supplemental Appropriations Act approved by Congress and signed by President Trump on March 6. The new policy is intended to protect patient health and slow the transmission of COVID-19 by allowing patients to receive care without leaving home.

Through an emergency declaration under the Stafford Act and the National Emergencies Act, Medicare coverage will now include three types of virtual services: Medicare telehealth visits, virtual check-ins, and e-visits. The temporary rules apply to all Medicare providers.

Additionally, for the duration of the emergency, HHS will waive HIPAA penalties for using non-HIPAA compliant videoconferencing software. This will allow physicians and other health care professionals to use popular technology, such as Skype (basic) and FaceTime, to conduct telehealth sessions. The federal Office of Civil Rights has released further guidance about the waiver of HIPAA penalties.

When conducting a telemedicine encounter, health care professionals should use the same CPT codes as they use for in-person services, but with the Place of Service (POS) code 02 to indicate the care was provided via telemedicine. Psychiatrists considering transitioning patients to telepsychiatry in place of in-person appointments should consult APA’s Telepsychiatry Toolkit, which contains more than 60 pages of guidance on topics related to telepsychiatry, including clinical considerations, administrative and technical requirements for software issues, and reimbursement.

Physicians providing telepsychiatry services need a license in the state in which the patient is located at the time services are provided. However, many governors are declaring states of emergency that may alter or waive these restrictions, and the Federation of State Medical Boards lists states that have declared emergencies and have waived various licensing restrictions. APA is monitoring state-level activities and will disseminate information as soon as there is definitive guidance for members in those states.

Finally, the Drug Enforcement Administration yesterday lifted requirements that health care professionals must conduct an initial, in-person examination of a patient—thereby establishing a doctor-patient relationship—before electronically prescribing a controlled substance. For the duration of the emergency, that requirement will not apply.

Prior to passage of the bipartisan coronavirus bill, APA CEO and Medical Director Saul Levin, M.D, M.P.A., urged Congress to remove restrictions on using telehealth for mental health services. The bill granted authority to HHS Secretary Alex Azar to do so, but did not actually lift the restrictions. Yesterday’s guidance by HHS does so.

“We are in an extraordinary crisis, and the administration has done the right thing,” Levin said. “Now, Medicare beneficiaries who may be at risk of contracting COVID-19 can be seen in their homes via telepsychiatry and maintain their regular course of therapy without disruption. This will also minimize future infections.”

Additional information is posted on APA’s website. APA members with questions related to the new telehealth policy should send an email to practicemanagement@psych.org.

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Video, Written Patient Education Improves Understanding of Electroconvulsive Therapy

Brief education using videos or brochures improves patients’ understanding and willingness to consider electroconvulsive therapy (ECT), suggests a study in Psychiatric Services in Advance.

“ECT remains a maligned, underutilized treatment, and psychoeducation may be important in improving access to those who may benefit from it,” wrote Jack Tsai, Ph.D., of Yale School of Medicine and colleagues.

The researchers randomly assigned 556 adults who screened positive for depression on the Patient Health Questionnaire-9 to one of two education groups. One group watched an eight-minute video about ECT and the other group read a four-page online brochure that presented the same information as the video. The video featured members of the public, subject matter experts, and patient testimonials. The brochure consisted of a transcript of the video and did not include any images. Using the ECT-PK scale, the researchers measured the participants’ knowledge and perception of ECT both before and after the participants received their education. The researchers also asked participants about their willingness to receive ECT, both before and after their education.

The proportion of participants who would be willing to receive ECT increased from 31% to 63% in the video group and from 29% to 56% in the brochure group. The brochure group had a significantly greater reduction in concerns about ECT-related memory loss than the video group. However, the video group had a significantly greater reduction in fear of ECT than the brochure group.

“Thus, whereas both formats were effective, video psychoeducation may have some advantages in allaying fears about ECT and demonstrating the modernity of ECT through presentation of images, patient testimonials, and credible commentary from subject matter experts,” Tsai and colleagues wrote, adding that further research is needed.

For related information, see the Psychiatric News article “When Is ECT Right for Your Patients With Depression?”

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Mental Health Resources for Dealing With COVID-19

APA has posted information and links to numerous resources to help psychiatrists and the public deal with issues related to the COVID-19 pandemic. Information will continue to be added as more details are known.

APA Offers Resources to Cope with COVID-19

Coronavirus and Mental Health: Taking Care of Ourselves During Infectious Disease Outbreaks

COVID-19 Mental Health Impacts: Resources for Psychiatrists

National Study of 9-,10-Year-Olds Reveals Up to 8% Have Suicidal Thoughts, Behaviors

About 8% of 9- and 10-year-olds in the United States who are participating in a national study reported that they have had suicidal thoughts and about 1% have attempted suicide, according to a study in Lancet Psychiatry. Children who are more impulsive or disruptive and/or those who reported greater family conflict were more likely to report suicidal thoughts and behaviors than those without these tendencies or family conflict.

“The findings reported here have immediate and practical implications as risk factors (childhood psychopathology, family conflict, and screen use), and protective influences (higher parental supervision and positive school engagement) are actionable and modifiable,” wrote Delfina Janiri, M.D., of the Icahn School of Medicine at Mount Sinai and colleagues. “Increasing school and parental awareness of child psychopathology and providing parenting education and family support could be clear and attainable targets for early intervention and prevention strategies.”

Janiri and colleagues analyzed baseline data from the National Institutes of Health’s Adolescent Brain and Cognitive Development (ABCD) study. (The study has enrolled 10,000 children aged 9 and 10 from across the United States and will follow them for a decade to study their brain development.) As part of the baseline ABCD assessments, children and their parents reported separately on the child’s current or past suicidal thoughts and behaviors. Complete data for both child and parental suicidality reports were available for 7,994 ABCD participants.

Overall, 673 (8.4%) children reported any past or current suicidal ideation, 107 (1.3%) reported past or current suicidal attempts, and 75 (0.9%) reported any past or current suicidal plans. According to caregivers, 650 (8.1%) children reported suicidal ideation, 39 (0.5%) reported suicidal attempts, and 46 (0.6%) reported suicidal plans. The agreement between children and parents was low, however; only 198 children who reported suicidal ideation were also identified as having these thoughts by their parents, for example. 

The researchers found that the presence of child psychopathology (disruptive or impulsive behaviors), child-parental conflicts, and elevated weekend screen time were all associated with an increased risk of child-reported suicidality (74%, 47%, and 37% increased risk, respectively). Conversely, higher levels of parental supervision and more positive school experiences appeared to reduce the risk of a child having current or past suicidal thoughts or behaviors.

“Too often, studies in the suicide prevention field have focused on risk factors and, as a result, it is often difficult to identify protective factors to target in psychosocial interventions. Therefore, it is rewarding that the focus of this study includes potential buffers, and it is valuable to see parental and positive school involvement emerge as robust factors associated with reduced suicide risk in children,” wrote Rory O’Connor, Ph.D., and Kathryn Robb, Ph.D., of the University of Glasgow in an accompanying editorial. They added that further work is needed to identify which aspects of parental involvement help reduce children’s suicidality risks.

To read more on this topic, see the Psychiatric News article “Preteen Suicides: Rare, Mysterious, and Devastating.” 

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How to Participate in 2020 Minority and Underrepresented Group Caucus Election

The Caucus of Asian-American Psychiatrists is holding an election for three leadership positions: president, Assembly representative, and Assembly deputy representative. To be eligible to vote in the election, APA members must join the caucus by Wednesday, April 1. Find more information on how to join the caucus here.

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Stress-Related Disorders May Raise Risk of Neurodegenerative Disease

People who have stress disorders such as posttraumatic stress disorder (PTSD) may have a higher risk of neurodegenerative diseases, suggests a study in JAMA Neurology. The risk appears to be stronger for vascular neurodegenerative diseases (such as vascular dementia), which are caused by changes in the blood vessels, than for primary neurodegenerative diseases (such as Alzheimer’s disease).

Huan Song, M.D., Ph.D., of Sichuan University in China and colleagues used data from several Swedish registers to follow people aged 40 years or older who received their first diagnosis of a stress-related disorder between January 1987 and December 2008. Follow-up began when people were 40 years old or five years after they had been diagnosed with a stress-related disorder, whichever came later. Follow-up ended in December 2013 or when people were diagnosed with a neurodegenerative disease, died, or moved away from Sweden, whichever came first. The researchers matched 61,748 people who had a stress-related disorder with 595,335 people who did not have a stress-related disorder.

Compared with those who did not have a stress-related disorder, those with a stress-related disorder had a 57% increase in risk of neurodegenerative diseases overall. They had an 80% increase in risk for vascular neurodegenerative diseases, and a 31% increase in risk for primary neurodegenerative diseases.

“[C]ardiovascular diseases are among the most well-established long-term physiological health consequences of stress-related disorders,” the researchers wrote. “Therefore, vascular factors could underlie the association of stress-related disorders with neurodegenerative diseases and may explain the relatively stronger association for vascular neurodegenerative diseases compared with primary neurodegenerative diseases.”

For related information, see the Journal of Neuropsychiatry and Clinical Neurosciences article “Neurodegenerative Dementias: Improving Brain Health to Decrease Risk.”

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Alcohol Use Disorder Is Significant Risk Factor for Suicide, Study Finds

Even after accounting for additional psychiatric diagnoses, people with alcohol use disorder (AUD) have a substantially increased risk of dying by suicide, according to a study of the Swedish population published today in AJP in Advance.

“While this association is strongest during the period close to an AUD registration, the effect persists for decades,” wrote Alexis C. Edwards, Ph.D., of Virginia Commonwealth University and colleagues.

The researchers analyzed population registry data of all Swedish citizens born between 1950 and 1970, including inpatient and outpatient records and criminal records of individuals beginning at age 15. They gathered information on AUD diagnoses and other psychiatric diagnoses, as well as cause of death. Deaths of undetermined intent were included as suicides.

In the final cohort of 2,229,880 individuals, the suicide rate for those without AUD was 0.29% for women and 0.76% for men. For those with AUD, the rate was 3.54% for women and 3.94% for men.

The association between AUD and suicide was most pronounced in individuals who did not have other psychiatric disorders, the researchers noted. Women with AUD had a substantially higher risk of suicide than men before accounting for other psychiatric disorders. “Our findings indicate that psychiatric comorbidity attenuates the AUD-suicide association, particularly among women,” they wrote.

In particular, AUD was the strongest predictor of suicide death in the first five years of observation for both men and women. The findings suggest that “prevention and intervention efforts may be most effective when directed toward individuals facing a relatively recent AUD-related incident” and for those with early onset of AUD, the authors wrote.

“These findings underscore the nuanced role of AUD in suicide risk and have implications for efforts aimed at reducing suicide and characterizing risk potential as a function of coexisting conditions,” the authors concluded.

For related information, see the American Journal of Psychiatry article “A Closer Look at Substance Use and Suicide.”

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Endometriosis, Psychiatric Disorders May Raise the Risk of One Another

Women who have endometriosis have a higher risk of mental illnesses such as depression, anxiety, and substance use disorders (SUDs), suggests a study in the American Journal of Obstetrics and Gynecology. The study also revealed that the opposite may be true: Women who have depression, anxiety, or other mental illnesses may have a higher risk of endometriosis. Endometriosis is an often painful condition that occurs when tissue similar to the lining of the uterus, called the endometrium, grows in other places, such as the fallopian tubes and ovaries.

Menghan Gao, M.Sc., of the Karolinksa Institute in Stockholm and colleagues analyzed data from several Swedish registers to follow all women who were born in Sweden between 1973 and 1990 and who were diagnosed with psychiatric disorders and endometriosis between age 14 years and the year 2016. They found that women with a previous diagnosis of endometriosis had higher rates of bipolar disorder, depressive disorders, anxiety and stress-related disorders, eating disorders, SUDs, personality disorders, and attention-deficit/hyperactivity disorder (ADHD) compared with women who did not have endometriosis. The greatest risk appeared to be for SUDs and depressive disorders: Women with endometriosis had nearly twice the rate of these conditions than their peers without endometriosis.

Women with a history of psychiatric disorders were more likely than those without a such a history to be later diagnosed with endometriosis. Those with anxiety and stress-related disorders had nearly twice the rate of endometriosis as those without these disorders. Those with a history of personality disorders, ADHD, or depressive disorders were also more likely to have endometriosis than those without such a history.

Abnormalities in the immune system may partly explain the relationship between psychiatric disorders and endometriosis, the researchers wrote. “It is believed that immune dysfunctions followed by inflammatory response to the [endometriosis] lesions are key factors in the pathogenesis of endometriosis, and mounting evidence implicates immune dysregulation in the causation of psychiatric disorders,” they wrote.

The researchers added that the psychological and physical suffering caused by endometriosis could amplify mental distress and that medications used to treat endometriosis may influence mental health. They also stated that women with psychiatric disorders are already receiving health care services, which may increase detection of endometriosis, and that undiagnosed symptoms of endometriosis, such as pain that causes psychological distress, may be misdiagnosed as psychiatric disorders.

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Digital Monitoring, Motivational Coaching May Decrease Depression in Older Bereaved Adults

The death of a spouse can disrupt routine daily activities, such as sleeping and eating, and increase risk of mood disorders, such as major depressive disorder (MDD). A small study published in the American Journal of Geriatric Psychiatry suggests that an intervention combining digital monitoring and motivational coaching may help older bereaved adults to better track and improve their sleeping, eating, and physical activity.

Evidence suggests that some 20% to 30% of older adults meet criteria for MDD in the year following the death of a spouse, but “[h]igh regularity in the timing of daily activities may protect against MDD,” wrote Sarah Stahl, Ph.D., of the University of Pittsburgh and colleagues.

Stahl and colleagues recruited adults aged 60 or older whose spouse had died within the past eight months and were identified by the researchers as being at high risk for MDD. (The researchers considered the following factors in assessing the participants’ risk of MDD: general medical comorbidities; subthreshold symptoms of depression, anxiety, and/or complicated grief; and low social support.)

Of the 152 people screened for the study, 57 were randomly assigned to one of three interventions: digital monitoring of sleep, meals, and physical activity; digital monitoring of sleep, meals, and physical activity plus motivational health coaching; or enhanced usual care. Those in the enhanced care group were followed on the same assessment schedule as the other participants and were referred to medical and or grief specialty care as necessary.

Participants who were assigned to digital monitoring recorded information on their sleep, meals, and physical activity twice daily in a diary-like app on a tablet for 12 weeks. Participants who were assigned to also receive motivational coaching received a weekly phone call from a health coach who used motivational interviewing techniques to motivate participants to engage in a regular routine. All participants wore an actigraphy watch on weeks 1 and 12 of the study and were assessed for depression at baseline, directly after the intervention period (12 weeks after baseline), and then three, six, and nine months later.

“We observed high levels of adherence in both digital monitoring (90%) and health coaching (92%),” Stahl and colleagues wrote. “Depression symptoms decreased from pre- to post-intervention; however, our sample was small, which affected power to detect differences between the three treatment arms.”

They concluded, “This pilot study demonstrated feasibility and acceptability of digital monitoring and motivational health coaching in older spousally bereaved adults at high risk for MDD.”

For related information, see the Psychiatric Services article “Toward Cultural Assessment of Grief and Grief-Related Psychopathology.”

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Gabapentin Found to Work Best for Those With Severe Alcohol Withdrawal Syndrome

Gabapentin is effective at reducing heavy drinking and promoting abstinence among people with alcohol use disorder (AUD), especially those with strong withdrawal symptoms, reports a study published today in JAMA Internal Medicine.

Previous studies suggest that gabapentin can help reduce short-term symptoms of alcohol withdrawal syndrome, which can include irritability, anxiety, sweating, and insomnia. The research on gabapentin’s ability to promote long-term reductions in drinking has been mixed, however.

Raymond Anton, M.D., and colleagues at the Medical University of South Carolina enrolled 96 adults who met the DSM-5 diagnosis for AUD, including alcohol withdrawal. After three days of alcohol abstinence, the participants were randomly assigned to receive either gabapentin (starting at 300 mg/day and titrated up to 1,200 mg/day) or placebo pills for 16 weeks. Participants also received nine medical management sessions, consisting of 15- to 20-minute appointments with a medical professional during which they were assessed on daily drinking since their last visit.

At the end of the study, 27% of the participants taking gabapentin reported no heavy drinking days (defined as consuming five or more drinks a day for men, four or more for women) compared with 9% of the participants taking placebo. In addition, 21% of the gabapentin participants reported total abstinence during the study, compared with 4% of the participants in the placebo group. Reduced drinking was especially prominent among participants who had higher alcohol withdrawal scores at baseline. Participants with low withdrawal scores at baseline had similar outcomes regardless of whether they took gabapentin or placebo.

“The weight of the evidence now suggests that gabapentin might be most efficacious after the initiation of abstinence to sustain it and that it might work best in those with a history of more severe alcohol withdrawal symptoms,” Anton and colleagues wrote. “Armed with this knowledge, clinicians may have another alternative when choosing a medication to treat AUD and thereby encourage more patient participation in treatment with enhanced expectation of success.”

To read more on this topic, see the Psychiatric News article “APA Releases Practice Guideline for AUD Pharmacotherapy” and APA’s Practice Guideline for the Pharmacological Treatment of Patients With Alcohol Use Disorder.

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Patients With and Without Psychotic Disorders Have Similar OUD Treatment Rates, Study Finds

People with a psychotic disorder and opioid use disorder (OUD) are as likely to stay in methadone treatment for OUD as those with other psychiatric disorders, according to a study published in Schizophrenia Bulletin.

“These findings are in contrast to commonly held beliefs that patients with psychotic disorders have worse treatment outcomes,” wrote Rachel Lamont, M.D., of McMaster University in Ontario, Canada, and colleagues. “Our findings also raise questions about the routine exclusion of persons with psychotic disorders from trials of opioid substitution therapy, which may not be warranted or helpful.”

Lamont and colleagues analyzed data from 415 adults with OUD enrolled in community-based outpatient methadone maintenance treatment across Ontario. They used the Mini-International Neuropsychiatric Interview to identify participants with psychiatric comorbidities, including psychotic disorders on the schizophrenia spectrum, as well as other nonpsychotic disorders, such as major depression, anxiety, and bipolar affective disorder. Urine drug screening took place at three, six, nine, and 12 months.

Thirty-seven participants were identified as having a comorbid psychotic disorder, while 378 had at least one comorbid nonpsychotic disorder.

The authors found that 81% of the patients with psychotic disorders remained in treatment for OUD at 12 months, a rate comparable to the 84% of patients with nonpsychotic disorders. They also found that having a psychotic disorder was associated with fewer positive opioid drug screenings.

Additional findings include the following:

• Participants with psychotic disorders on average received a higher dose of methadone than those with other psychiatric disorders.
• Participants with psychotic disorders were more likely to also be taking antidepressants, antipsychotics, benzodiazepines, and/or mood stabilizing medications compared with participants with other psychiatric disorders.
• Less than 50% of participants with psychotic disorders were prescribed antipsychotics.

Methadone maintenance therapy, the authors noted, “is not without risks,” and the use of higher doses of methadone among those with psychotic disorders “has important safety implications.” Additionally, “the low rate of prescription of antipsychotic medications may also point to unmet diagnostic or treatment needs.”

For related information, see the Psychiatric News article “Medications Can Help Patients With Substance Use, Psychotic Disorders.”

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How to Participate in 2020 Minority and Underrepresented Group Caucus Election

The Caucus of Asian-American Psychiatrists is holding an election for three leadership positions: president, Assembly representative, and Assembly deputy representative. To be eligible to vote in the election, APA members must join the caucus by Wednesday, April 1. Find more information on how to join the caucus here.

APA Praises Congress for Passing Emergency COVID-19 Funding, Authorizing Lifting of Telemedicine Restrictions

APA is hailing a bipartisan $8 billion emergency spending bill approved by the Senate today to address the spread of COVID-19. The measure was passed by the House of Representatives yesterday and is expected to be signed by President Trump.

Among the bill’s provisions is one that will allow the secretary of Health and Human Services to temporarily lift restrictions on Medicare access to telehealth services, such as live videoconference consultations with physicians.

In a March 2 letter to leaders in the House and Senate, APA CEO and Medical Director Saul Levin, M.D., M.P.A., urged Congress to take this action. “We recommend that these restrictions be waived, so that Medicare beneficiaries, who appear to be at particular risk of contracting COVID-19, may be ‘seen’ in the home via telepsychiatry and maintain their regular course of therapy without disruption,” Levin wrote. “This would also minimize future infections.”

APA President Bruce Schwartz, M.D., said in a statement APA released today that removing the restrictions will be especially beneficial to populations most susceptible to infection. “Telehealth and telepsychiatry in ordinary times can help more people access services that are critical to their well-being,” Schwartz said. “But it is especially important now, given the nature of COVID-19. Particularly for some groups, like senior citizens and other vulnerable populations, access to telepsychiatry and telehealth could be vital. We thank Congress for including this important provision in the funding package.”

In the statement Levin added, “Epidemics can cause people to experience stress and anxiety. Having tools and access to solutions like telepsychiatry, as well as clear communications from the media and government, will go a long way toward mitigating that stress.”

For additional APA resources on COVID-19, see the following:

A Message From APA on COVID-19

How Psychiatrists Can Help Patients During Coronavirus Outbreak

Coronavirus and Mental Health: Taking Care of Ourselves During Infectious Disease Outbreaks