House Passes $1.3 Trillion Spending Package, Including Funding for Major MH Initiatives

APA Urges Senate Action

Today the U.S. House of Representatives approved $96.4 billion in funding for the Department of Health and Human Services by passing the Labor-Health and Human Services-Education FY 2021 appropriations bill. The bill is part of HR 7617, a $1.3 trillion spending package that funds most federal agencies throughout the next fiscal year.

The bill includes $6 billion for the Substance Abuse and Mental Health Services Administration (SAMHSA) for programs related to mental health and substance use, an increase of more than $100 million over the previous fiscal year. The impact of APA’s advocacy was evident in this increase, as the organization’s work with mental health partners resulted in a $35 million increase to the SAMHSA budget to improve mental health crisis systems and suicide prevention at the state and local levels, including $25 million for a national suicide prevention lifeline.

The bill also includes the following:

• $8 billion for the Centers for Disease Control and Prevention (CDC), an increase of over $250 million from the previous fiscal year.
• $66.95 million for the CDC Racial and Ethnic Approaches to Community Health (REACH) program, a 14% increase in funding for the Minority Fellowship Program (MFP), and a request that the National Institute of Mental Health develop a 10-year strategic plan to eliminate racial mental health disparities in youth by 2030.
• Funds for firearm injury and mortality prevention research: $30 million for the CDC and $25 million for the National Institutes of Health.
• An increase of over 40% in funding for the loan repayment program for the Substance Use Disorder Treatment Workforce Program through the Health Resources and Services Administration.
• $550 million for the National Institute on Alcohol Abuse and Alcoholism, $1.47 billion for the National Institute on Drug Abuse, and $2.06 billion for the National Institute of Mental Health, all of which represent increases from the previous fiscal year.

“We applaud the House for recognizing the critical need for funding for mental health, particularly the increased funding for suicide prevention and to address racial disparities in mental health care,” said APA President Jeffrey Geller, M.D., M.P.H., in a statement released by APA this afternoon. “The nation is struggling with a raging COVID-19 pandemic, the continued rise in suicides, racial inequities in health care, and the continued opioid epidemic—all reasons why a boost in federal funding is essential. We need a steady, long-term commitment by Congress to address these critical issues.”

APA CEO and Medical Director Saul Levin, M.D., M.P.A., added, “APA urges the Senate to support and build upon these investments to our nation’s mental health. Our members and our organization stand ready to work with members on both sides of the aisle on a sustained effort to better fund our nation’s mental health care needs.”

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Please Take a Few Moments to Complete APA Survey on Racism

The APA Presidential Task Force to Address Structural Racism Throughout Psychiatry invites you to complete the second in a series of surveys on how racism impacts the field of psychiatry. Your answers will be anonymous. They will be used to inform the Task Force’s work and may be anonymously cited in future work. The survey is open from July 23 to August 6.

APA Mourns Loss of Rep. John Lewis, Praises Trailblazing Legacy

As civil rights leader and longtime congressman Rep. John Lewis is laid to rest today in Atlanta, APA released a statement honoring his memory and celebrating his lifelong work to end racial inequality.

“We are mourning the loss of a leader who meant so much to the Black community and to all Americans who strive for equity and justice,” said APA President Jeffrey Geller, M.D., M.P.H., in APA’s statement. “For more than a half century, Rep. John Lewis showed what walking the walk truly means in promoting civil rights, even putting his own life at risk in service of the cause. His lesson to us is to continue that work through speaking up, taking tangible actions, exhibiting humility, and practicing perseverance. In taking on racial discrimination, we will do well if we take to heart his words: ‘I believe race is too heavy a burden to carry into the 21st century. It's time to lay it down. We all came here in different ships, but now we're all in the same boat.’”

Lewis began advocating for racial equality when he was just a teenager. At 23, he was the youngest speaker at the March on Washington in 1963, at which the Rev. Martin Luther King Jr., gave his iconic, “I Have a Dream,” speech. Lewis was also one of the original Freedom Riders, civil rights activists who rode buses between Southern states to challenge seating segregation.

In 1965, when Lewis was 25, he helped lead a march for voting rights across the Edmund Pettus Bridge in Selma, Ala. Alabama state troopers met the marchers at the end of the bridge and charged them when they stopped to pray. Lewis’s skull was fractured during the incident that day, which has since been dubbed “Bloody Sunday.”

As a member of Congress, Lewis was dedicated to advancing racial and ethnic equality and supported policies that ensured struggling families had access to safety nets. Just this year he had introduced legislation aimed at supporting the health and well-being of current and former foster care youth transitioning into adulthood (HR 7591), as well as a bill that would ensure minority and medically underserved communities have access to public health interventions and medically necessary services during the COVID-19 pandemic (HR 7546).

“Rep. John Lewis was a selfless, constant advocate for civil rights for Black Americans and other underrepresented groups and a shining example for the rest of all of us,” said APA CEO and Medical Director Saul Levin, M.D., M.P.A., in APA’s statement. “Rep. Lewis continually made his voice heard and pushed for change to help millions of Americans, whether it was during the struggle for voting rights or in fierce advocacy for the Affordable Care Act. His memory serves as an inspiration to us at APA to continue his legacy and to strive for the ideals he believed in.”

Lewis also cosponsored the George Floyd Justice in Policing Act (HR 7120), which includes a wide variety of policies meant to increase accountability among law enforcement and end discriminatory policing practices. In a floor statement Lewis made in support of the legislation, he said that, in making the call for racial equity and equality, young people today are “taking up the mantle in a movement that I know all too well.

“For far too long, equal justice and protection under the law have been deferred dreams for Black people and communities of color across our country,” Lewis said in his floor statement. “[A] democracy cannot thrive where power remains unchecked and justice is reserved for a select few. Ignoring these cries and failing to respond to this movement is simply not an option. For peace cannot exist where justice is not served.”

Medicare Data Show Disproportionate Effect of COVID-19 on Racial, Ethnic Minorities

Among Medicare beneficiaries, racial minorities—African Americans, Hispanics, and American Indians/Alaskan Natives—have been disproportionately affected by the global COVID-19 pandemic compared with white beneficiaries, according to a “Preliminary Medicare COVID-19 Snapshot” released this week by the Centers for Medicare and Medicaid Services (CMS).

The report was based on claims data from the Medicare Fee-for-Service (FFS) and Medicare Advantage programs received by July 17. COVID-19 cases were determined by an ICD-10 diagnosis code for COVID-19 on a claim or encounter record for any health care setting—for example, physician’s office, inpatient hospital, or laboratory.

According to the report, 549,414 Medicare beneficiaries were diagnosed with COVID-19 between January 1 and June 20. The CMS update reported the following trends about minority groups within the Medicare population:

• Black beneficiaries have been most severely affected by the pandemic, with 1,658 cases of COVID-19 per 100,000 beneficiaries and 670 COVID-19 hospitalizations per 100,000 beneficiaries.
• Among Hispanic beneficiaries, there have been 1,230 cases of COVID-19 and 401 COVID-19 hospitalizations per 100,000 beneficiaries.
• Among American Indian/Alaskan Native beneficiaries, there have been 1,125 cases of COVID-19 and 505 COVID-19 hospitalizations per 100,000 beneficiaries.

Dual Medicare and Medicaid beneficiaries and those with kidney disease have also been especially hard hit by the pandemic. Dual beneficiaries—who often have multiple chronic conditions (including mental and substance use disorders) and are typically in lower socioeconomic groups—have experienced 2,310 COVID-19 cases per 100,000 beneficiaries and 719 hospitalizations per 100,000 beneficiaries.

A total of 5,781 Medicare beneficiaries with end-stage renal disease per 100,000 beneficiaries have been diagnosed with COVID-19, and 1,911 have been hospitalized.

For related information, see the Psychiatric News articles “Black Community Especially Vulnerable to COVID-19,” “Hispanic Community and COVID-19: Addressing Health Inequalities Can No Longer Be Delayed,” “American Indians Face Special Hardships in Combating COVID-19 Pandemic.”

Lessons From Pandemic Could Advance Understanding of How Best to Support Vulnerable Families

The trauma and unpredictability of COVID-19 are likely to add stress in the lives of vulnerable children, including those who are abused, maltreated, and/or have a mental illness. There is much that can be learned from such stress to help vulnerable families in the future, according to an article published Monday in JAMA Pediatrics.

“Recent advancements across disciplines relevant to early child development (for example, pediatrics, neuroscience, epigenetics, psychology, and public health) can be used to understand the consequences of this pandemic and develop and scale empirically supported interventions for adversity-exposed children and families,” wrote Danielle Roubinov, Ph.D., Nicole R. Bush, Ph.D., and W. Thomas Boyce, M.D., of the University of California, San Francisco.

To understand the consequences of COVID-19 on child development, the authors advised researchers to carefully assess parents and children over time about family exposure to the pandemic and COVID-19–associated losses/strains, including the loss of housing, increased family conflict, and/or separation from a parent or the death of loved one. Collecting information about the mental health of parents and children and family access to supports are also essential for evaluating children’s response to the pandemic, they added.

The authors also recommended that researchers studying the consequences of COVID-19 on vulnerable families consider the following:

• Examine factors that promote resilience and positive adjustment.
• Assess biological markers of resiliency or recovery.
• Consider how best to analyze factors that mediate or moderate the association of the pandemic with parent, child, and overall family functioning.
• Collect data on health disparities.
• Evaluate ongoing efforts to meet COVID-associated mental health needs and other prevention and intervention efforts that have continued despite pandemic.

“[L]essons from COVID-19 have the potential to deepen rather than diminish the research agenda on adverse early experiences among children and families. The current global pandemic is an international tragedy; however, the greatest burden of morbidity, mortality, and misfortune will be borne by those with the fewest resources,” Roubinov, Bush, and Boyce concluded. “Our purpose is not to turn this tragedy into academic gain but rather to promote advancement in the science of child development as a means to reduce the chasm between advantaged and vulnerable families.”

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Have You Thought About Running for APA Office? Help Steer APA’s Future
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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HHS Renews Declaration of Public Health Emergency for COVID-19

Last week, U.S. Secretary of Health and Human Services (HHS) Alex Azar formally renewed the agency’s determination that the COVID-19 pandemic is a public health emergency. The extension of this public health emergency keeps many regulatory changes and waivers relevant to psychiatrists—such as relaxed telemedicine restrictions—in effect for the time being.

Secretary Azar first declared COVID-19 a public health emergency in late January and subsequently renewed that status on April 21. APA and other health organizations had urged the Trump administration to authorize another extension to help combat the ongoing COVID-19 pandemic. There have been over 4 million cases of COVID-19 and nearly 150,000 COVID-related deaths since the virus was first identified in the United States on January 20.

“APA recently surveyed its membership to understand the impact of easing telehealth regulations on practice during the PHE [public health emergency]. The survey found a major shift to the use of telehealth after the PHE was declared,” wrote APA CEO and Medical Director Saul Levin, M.D., M.P.A., in a letter to the HHS secretary. “While the changes were necessary to comply with physical distancing and self-isolation mandates, this shows that telehealth for treating psychiatric and substance use disorders can be adopted quickly, and efficiently, and that most barriers to doing so in the first place may have been regulatory in nature. These survey results mirror national research on telehealth that show improved access to care, reduced no-show rates, and a high rate of patient satisfaction.”

In addition to maintaining relaxed telemedicine guidelines, the continuation of the emergency determination allows the Food and Drug Administration to quickly authorize the use of unapproved COVID-19 medications for patients and provides state and local health departments more flexibility to reassign some emergency personnel to respond to virus outbreaks.

As stipulated by law, the emergency extension—which began July 25—is valid for 90 days and thus due to expire at the end of October.

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Please Take a Few Moments to Complete APA Survey on Racism

The APA Presidential Task Force to Address Structural Racism Throughout Psychiatry invites you to complete the second in a series of surveys on how racism impacts the field of psychiatry. Your answers will be anonymous. They will be used to inform the Task Force’s work and may be anonymously cited in future work. This survey is open from July 23 to August 6.

Psychiatrists Still Not Reimbursed on Par With Primary Care Physicians

Medicaid often reimburses psychiatrists less than primary care physicians for treating mental or substance use disorders, according to a report published today in Psychiatric Services in Advance. This disparity in reimbursement may explain why psychiatrists are less likely to participate in Medicaid than primary care physicians and why some regions face a shortage of psychiatrists, the researchers wrote.

Tami L. Mark, Ph.D., M.B.A., and colleagues analyzed data from outpatient medical claims from 2014 for 11 states. The claims were for a primary behavioral health diagnosis such as a mental or substance use disorder and included evaluation and management procedure codes of 99213 (established patient office visit, low to moderate severity) or 99214 (established patient office visit, moderate severity). The states included were Georgia, Idaho, Michigan, Minnesota, Mississippi, New Jersey, Pennsylvania, South Dakota, Vermont, West Virginia, and Wyoming.

Primary care physicians were reimbursed more than psychiatrists for code 99213 in 10 of the states and for code 99214 in nine of the states. Primary care physicians were reimbursed $1 to $34 more than psychiatrists for code 99213 and $5 to $40 more for code 99214.

“The disparity in reimbursement rates between psychiatrists and primary care physicians is inconsistent with the Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA), which requires that provider reimbursement rates for treating mental and substance use disorders be based on criteria that are comparable to the criteria for setting reimbursement rates for medical providers and applied no more stringently,” the researchers wrote. However, although MHPAEA applied to Medicaid managed care plans and the Children's Health Insurance Program as of 2009, these health programs had until 2017 to comply, the researchers noted.

“A key implication of these findings is that reducing reimbursement disparities between psychiatrists and other medical doctors may increase the supply of psychiatrists willing to treat Medicaid patients,” the researchers wrote.

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HHS Extends COVID-19 Public Health Emergency

Health and Human Services Secretary Alex Azar on Thursday extended for an additional 90 days the current COVID-19 public health emergency, which was set to expire on July 25. APA has heard from many members expressing concern about the impending deadline and the implication for various regulatory waivers implemented because of the pandemic, including those pertaining to telemedicine.

Childhood Abuse Survivors With PTSD Benefit From DBT-PTSD and CPT Therapies

Women with posttraumatic stress disorder (PTSD) associated with childhood abuse improved significantly with both dialectical behavior therapy for PTSD (DBT-PTSD) and cognitive processing therapy (CPT), with DBT-PTSD resulting in slightly more favorable outcomes, according to a study published Wednesday in JAMA Psychiatry.

“Currently, treatment for [PTSD associated with childhood abuse] mostly relies on established treatments that were developed for survivors of adult-onset trauma,” wrote Martin Bohus, M.D., Ph.D., of Heidelberg University in Germany and colleagues. “Most treatment guidelines recommend prolonged exposure, cognitive processing therapy [CPT], or trauma-focused cognitive behavioral therapy, but there is debate on whether these treatments are sufficient for [these] patients.”

From January 2014 to October 2016, women who sought treatment were recruited from three sites in Germany and randomly assigned to receive DBT-PTSD or CPT. The participants were aged 18 to 65, were diagnosed with PTSD following sexual or physical abuse before age 18, and met three or more criteria for borderline personality disorder. Forty-eight percent of the participants also met the threshold for a diagnosis of borderline personality disorder.

DBT-PTSD is based on the principles of DBT, which was originally developed to treat borderline personality disorder by giving patients skills to manage painful emotions and regulate their emotions. DBT-PTSD includes supplemental trauma-focused cognitive-behavioral interventions. CPT is an established, trauma-focused therapy that challenges patients to face dysfunctional emotions related to trauma.

The 193 participants received up to 45 weekly individual sessions of DBT-PTSD or CPT within one year, plus three additional sessions in the three following months. Both treatments included individual therapy, plus homework and telephone consultations as needed. Participants were assessed using the Clinician-Administered PTSD Scale for DSM-5 (CAPS-5) before the start of therapy and again after three, six, nine, 12, and 15 months.

Although the women in both groups showed significant improvements in CAPS-5 scores over the course of the study, the improvements were more pronounced in the group receiving DBT-PTSD, the authors noted. “The same results were seen for other aspects of psychopathology closely associated with a history of [childhood abuse], such as dissociation, self-harm, and high-risk behaviors,” they wrote. “[P]articipants in the DBT-PTSD group were more likely to achieve symptomatic remission, reliable improvement, and reliable recovery and were less likely to drop out of treatment,” the authors wrote.

“The study shows that even severe forms of [childhood abuse]-associated PTSD that include multiple co-occurring mental disorders and emotion dysregulation can be treated efficaciously,” the authors concluded. “Future studies should strive for a better definition of patient groups that might profit from current therapies.”

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Please Take a Few Moments to Complete APA Survey on Racism

The APA Presidential Task Force to Address Structural Racism Throughout Psychiatry invites you to complete the second in a series of surveys on how racism impacts the field of psychiatry. Your answers will be anonymous. They will be used to inform the Task Force’s work and may be anonymously cited in future work. This survey is open from July 23 to August 6.

Deaths From Illicit Opioids Rise Dramatically While Deaths From Prescription Opioids Fall

Deaths involving illicit opioids, stimulants (such as methamphetamine), heroin, and cocaine rose dramatically between 2015 and the end of 2019, according to a report released Monday by the AMA’s Opioid Task Force.

The report also showed a 37.1% decrease in opioid prescribing; wider use of state Prescription Drug Monitoring Programs; and increasing numbers of doctors trained to prescribe buprenorphine (a medication used for treating opioid use disorder).

The trends indicate that the nature of the nation’s drug overdose crisis has changed. “The nation’s drug overdose epidemic is now being driven predominantly by highly potent illicit fentanyl, heroin, methamphetamine, and cocaine, although mortality involving prescription opioids remains a top concern,” Patrice A. Harris, M.D., M.A., chair of the AMA Opioid Task Force, said in a press release. Harris is a psychiatrist and immediate past president of the AMA.

Harris emphasized the importance of naloxone, a drug that can be used to reverse an opioid overdose in an emergency. “If it weren’t for naloxone, there likely would be tens of thousands additional deaths,” she said.

Drawing on statistics from the Centers for Disease Control and Prevention, the AMA reported that from 2015 to 2019, deaths involving illicitly manufactured fentanyl and fentanyl analogs increased from 5,766 to 36,509; deaths involving stimulants increased from 4,402 to 16,279; deaths involving cocaine increased from 5,496 to 15,974; and deaths involving heroin increased from 10,788 to 14,079.

In contrast, deaths involving prescription opioids decreased from 12,269 to 11,904.

The AMA report encouraged policymakers to take the following actions to remove barriers to evidence-based care for patients with pain and those with substance use disorder:

• Remove prior authorization, step therapy, and other inappropriate administrative burdens or barriers that delay or deny care for FDA-approved medications used as part of medication-assisted treatment (MAT) for opioid use disorder.
• Enforce meaningful oversight and enforcement of state and federal mental and substance use disorder parity laws, including requiring health insurance companies to demonstrate compliance with parity laws.
• Support efforts to expand sterile needle and syringe services programs.
• Support reforms in the civil and criminal justice system that ensure access to high-quality, evidence-based care for opioid use disorder, including MAT.

“We know that ending the drug overdose epidemic will not be easy, but if policymakers allow the status quo to continue, it will be impossible,” Harris said. “This is particularly important given concerns that the COVID-19 pandemic is worsening the drug overdose epidemic. Physicians will continue to do our part. We urge policymakers to do theirs.”

For related information, see the American Journal of Psychiatry article “New Challenges in Addiction Medicine: COVID-19 Infection in Patients With Alcohol and Substance Use Disorders—The Perfect Storm.”

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COVID-19 Fear, Food Insecurity May Worsen Depressive Symptoms, Survey Finds

The COVID-19 pandemic has created significant fear and stress for people around the world. A report in Depression & Anxiety now describes how COVID-19-related fear and food insecurity are likely contributing to higher levels of depression in U.S. adults.

“Early reports coming out of China, Europe, and North America confirm significant mental health consequences tied to heightened levels of fear, perceived health risks, and an overwhelming sense of dread that [are] tied to dramatic increases in virus‐related morbidity and mortality around the world,” wrote Kevin M. Fitzpatrick, Ph.D., of the University of Arkansas and colleagues.

The report by Fitzpatrick and colleagues focused on the responses of thousands of U.S. adults to an online survey in late March. The survey included questions about the respondents’ depressive symptoms (based on the Center for Epidemiological Studies Depression Scale, or CES‐D), fear of COVID-19 (on a scale of 0-10), access to healthy food, and physical symptoms. The respondents were also asked questions about their employment status, how connected they felt to others in their social network, the extent to which they felt in control of factors impacting their lives, and more.

Of the nearly 10,368 adults surveyed (average age 47 years), 19% reported they were unemployed, laid off, or furloughed. The authors noted that a CES-D score of 16 is considered the cutoff for depression; the average CES‐D score of the respondents was 16.9, and 28% of respondents had scores higher than 25. Respondents on average rated their fear as a 7 on a scale of 0-10; nearly 30% rated their fear of COVID-19 at 8 or above.

Respondents who identified as female, single, Hispanic, and/or not working reported higher depressive symptoms than other respondents. Those with higher levels of COVID‐19 fear and moderate-to-high levels of food insecurity reported more depressive symptoms than people with less fear and low or no food insecurity. In contrast, respondents who expressed greater optimism, control over factors impacting their lives, and greater connection with others reported fewer depressive symptoms.

The “results highlight the significance of vulnerability and individual stressors in the wake of the COVID‐19 pandemic,” Fitzpatrick and colleagues wrote. “In addition, the analysis affirms the importance of access to social and psychological resources to combat heightened fear and anxiety that persons report during the current pandemic.”

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Have You Thought About Running for APA Office? Help Steer APA’s Future
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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Psychiatrists Experience Substantial Burnout, APA Survey Finds

Nearly 80% of North American psychiatrists responding to an online survey reported burnout, and 16% reported symptoms consistent with major depression, according to a report in AJP in Advance.

“We believe that these findings have an important workforce policy implication,” wrote Richard Summers, M.D., of the University of Pennsylvania and colleagues. “Because burnout has been associated with a move to part-time status, increased leaves of absence, job change, and early retirement, interventions to decrease burnout are also interventions to enhance the psychiatric workforce.”

The survey was created by the Board of Trustees Workgroup on Psychiatrist Well-Being and Burnout and open from October 30, 2017, through December 10, 2018. The survey included the 16-item Oldenburg Burnout Inventory (OLBI) as well as the Patient Health Questionnaire-9 (PHQ-9), a common depression screening tool. Both APA members and nonmember psychiatrists were invited to participate, and 2,084 psychiatrists responded.

Seventy-eight percent of respondents reported OLBI scores above 35, indicating a positive screen for burnout. In addition, 16% of respondents reported PHQ-9 ≥10, consistent with moderate or severe depression. Of those reporting possible depression, 98% also reported burnout, suggesting a strong overlap of these two problems. However, the workgroup did not find any association between burnout and suicidal ideation after controlling for other depressive symptoms.

After adjusting for mediating factors, the APA workgroup found that women psychiatrists; those reporting a lack of control over their professional schedule; and those working in inpatient, community, or government settings were more likely to report burnout than others. Women psychiatrists and psychiatrists working in nonacademic settings were also more likely to report high PHQ-9 scores, as were residents and early-career psychiatrists.

“Health care organizations can easily identify those at higher risk by screening for burnout and preferentially allocating their scarce resources toward these individuals,” Summers and colleagues wrote. “Health care organizations should also consider devoting resources to interventions focused on decreasing burnout among minority psychiatrists because of their potential increased risk and essential participation in the workforce.”

They added, “An important area of investigation is identifying individual and workplace factors that could predict burnout, depression, and suicide risk among psychiatrists so that preventive interventions can be developed and employed. Potentially important individual and workplace factors include work-home balance, such as family status and caregiver burden for family members, sense of belonging to the physician community, efficiency of the workplace, ease of use of electronic health records, perception of response to medical errors, and other psychiatry-specific factors (for example, out-of-network practice).”

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Now in Psychiatric News

Psychiatric News continues to report news and information relevant to psychiatrists about the COVID-19 pandemic. We will highlight these articles for you as they become available online:

COVID-19 and Psychotherapy: Addressing Blocked Mourning

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FCC Approves 988 as Suicide Prevention, Mental Health Crisis Number

Yesterday the Federal Communications Commission (FCC) unanimously approved 988 as a nationwide, three-digit phone number that people in crisis can call to speak with suicide prevention and mental health crisis counselors. All phone service providers are required to direct all 988 calls to the existing National Suicide Prevention Lifeline (1-800-273-TALK) by July 16, 2022. This includes all telecommunications carriers and interconnected and one-way Voice over Internet Protocol (VoIP) service providers. The National Suicide Prevention Lifeline will remain operational during and after the two-year transition to 988.

“If an individual or a loved one is experiencing intense emotional distress, the last thing we want is the stress of having to remember a long phone number to reach help. [That] can be a barrier to reaching out to someone,” said Assistant Secretary for Mental Health and Substance Use Elinore F. McCance-Katz, M.D., Ph.D., in comments before the vote. “With the implementation [of 988], we anticipate that many more Americans will receive help for suicide prevention, and many more lives will be saved.”

In December 2018, APA wrote a letter to the FCC, pointing out that a three-digit number could improve access to care and “reduce the prevalence of psychiatric boarding that is plaguing our emergency departments.” The letter also emphasized the need for an outreach campaign to educate members of the public about the new number so they understand when to dial it versus 911.

During the transition to 988, Americans who need help should continue to contact the National Suicide Prevention Lifeline by calling 1-800-273-8255 (1-800-273-TALK) and through online chats. Veterans and service members may reach the Veterans Crisis Line by pressing 1 after dialing, chatting online at http://www.veteranscrisisline.net, or texting 838255. A transcript of the vote is posted here.

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Now in Psychiatric News

Psychiatric News continues to report news and information relevant to psychiatrists about the COVID-19 pandemic. We will highlight these articles for you as they become available online:

Reopening Your Practice During Pandemic

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APA, AACAP Outline Plan for School Reopening That Emphasizes Safety, Optimizes Mental Health

APA and the American Academy of Child and Adolescent Psychiatry (AACAP) on Wednesday issued recommendations for schools and communities as they move to safely reopen schools in the COVID-19 era. APA members may want to share these recommendations with their local school boards or other government entities.

“In these uncertain times, making educational decisions based on science and community circumstances ensures the mental health needs of our children and adolescents are being addressed, allowing them to feel engaged, safe, secure, supported, and loved,” APA and AACAP stated in a news release.

The organizations urged schools and communities to keep the following precautions in mind when considering reopening:

• Public health agencies should base their recommendations on returning students, teachers, and staff to classrooms on scientific evidence and local community circumstances, not politics. APA and AACAP noted that one solution may not be appropriate for all school systems.
• The return to school must include appropriate protections for all children, families, school personnel, and other members of the community.
• When in-person classroom education is not possible, schools should prioritize techniques that optimize social interactions among students alongside educational objectives.
• The education of children with special needs requires additional resources to adapt instructional techniques. This population includes children with emotional, learning, and physical disabilities as well as those who are in foster care, who live in poverty, and for whom English is a second language, among others.
• The mental health of students, educators, school staff, and parents teaching at home must be continually addressed because mental health is an intrinsic part of overall health and well-being.
• Schools should provide students who have experienced systemic or cultural disadvantages in education and mental health support with sufficient access to equipment, services, and technology.
• Schools and communities should receive additional financial support to address the structural requirements necessary to create safe environments that ensure a full array of education and mental health supports.
• Systems to identify and provide interventions for the increased number of high-risk students as a result of the pandemic should be in place.

APA and AACAP “recognize that education, including school attendance, is an essential component of successful and healthy development for all children and adolescents,” the news release stated. “Access to universal, high-quality education is always the goal, but is especially true in the COVID-19 era, when many have had their education compromised and may be experiencing higher levels of stress from social isolation.”

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Have You Thought About Running for APA Office? Help Steer APA’s Future
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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How Psychiatrists Can Support Maternal Mental Health During Pandemic

Pregnant and postpartum women are likely to face significant challenges due to COVID-19 that may increase their risk of mental health problems. In an article appearing today in JAMA Psychiatry, several psychiatrists describe strategies for helping both women in treatment for psychiatric disorders and those not in treatment.

“Pregnant and postpartum women, already vulnerable owing to mood and anxiety disorders, have faced intensified harms as public health measures have interfered with crucial psychosocial needs specific to the peripartum period,” wrote Alison Hermann, M.D., Elizabeth M. Fitelson, M.D., and Veerle Bergink, M.D., Ph.D. “Maternal mental health is a bellwether in the COVID-19 pandemic, and we must address it expeditiously. Solutions are required on all levels, and systemwide efforts must be well organized and strategic.”

Obstetric Department infection control procedures for maternity wards—including the use of personal protective equipment, surgical masks during active labor, visitor restrictions, and truncated hospital stays postdelivery—may increase the risk of maternal distress at time of delivery and limit the opportunity to address the needs of women after they have given birth, they wrote. Once discharged from the hospital, these women may face additional challenges, as “many previously reliable interventions for postpartum mood regulation have not been available or are severely compromised.” For example, grandparents and overnight infant caregivers may not be able to provide in-person assistance due to physical distancing practices.

To mitigate these challenges for women who are already in psychiatric treatment, Hermann, Fitelson, and Bergink suggested that psychiatrists and mental health professionals take the following actions:

• Anticipate and plan for circumstances that might negatively impact these women’s mental health, particularly related to postpartum sleep and separation from personal supports. “Clinicians should discuss with patients and their families a plan for symptom monitoring and pandemic-specific contingency responses, including safety planning that considers temporary relocations for women avoiding crowded urban areas or seeking to co-quarantine with personal supports.”
• Use virtual health platforms to provide preventive psychotherapies, such as cognitive-behavioral therapy or interpersonal psychotherapy.
• Continue to encourage use of psychoactive medication during pregnancy and while nursing. “[T]he risk of untreated or undertreated illness must loom larger than in nonpandemic conditions, and the discontinuation of successful medication maintenance treatment is discouraged for most medications. For women taking medication that requires blood monitoring, prescribers need to make extra efforts to coordinate blood draws with other planned in-person medical appointments.”

“It is encouraging that many professional societies and treatment centers are developing written, web-based, or app-based psychoeducational materials, which may be particularly important for women not yet engaged with treatment,” the authors noted. “It is essential that these groups coordinate effectively and streamline these efforts so local health care systems can focus on efficient implementation.”

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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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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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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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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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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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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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