Pandemic Disrupted Mental Health Care for Medicare Beneficiaries With Severe Mental Illness

There was a significant drop in the rate of mental health care use among adults with severe mental illness during the first months of the pandemic, according to a report in JAMA Network Open. The findings were based data collected from more than 650,000 Medicare beneficiaries with schizophrenia or bipolar I disorder.

“Among individuals with psychotic disorders specifically, there are reports that the pandemic has been associated with increased symptom acuity,” wrote Alisa Busch, M.D., M.S., of Harvard Medical School and colleagues. “Thus, the decreased utilization we observed across all levels of care is even more concerning … considering the high prevalence of disability (>80%) and poverty (>75%) in this study population.”

Busch and colleagues compared the use of mental health services in the first nine months of 2019 and 2020 by Medicare beneficiaries aged 18 and older who had been diagnosed with schizophrenia disorder or bipolar I disorder. They compared the patients’ rates of mental health outpatient services, emergency department services, hospital admissions, and antipsychotic and mood stabilizer prescription fills in 2019 and 2020.

During the first month of the pandemic, the rates of outpatient services, emergency department services, hospital admissions, and prescription fills dropped by 20.3%, 27.7%, 27.9% and 20.3%, respectively, compared with 2019 levels. These drops occurred despite the robust availability of telemedicine, which accounted for nearly half of all mental health outpatient visits during the first month of the pandemic.

Within six months, the rates of health care use among adults with schizophrenia or bipolar I disorder began to recover. By the end of September 2020, the rate of outpatient visits and prescription fills were only 2.5% and 3.4% lower, respectively, than 2019 levels. Emergency department use and hospital admissions remained 14.1% and 12.4% lower, respectively, indicating a slower recovery.

Further analysis revealed that as the pandemic progressed in 2020, Medicare beneficiaries who were Black, were dually eligible for Medicaid, and/or were disabled had slightly lower odds of receiving outpatient mental health care relative to other groups, the researchers wrote.

“While these differential changes were small in magnitude, they are concerning because they represent incremental worsening of sizable preexisting disparities,” Busch and colleagues wrote. “Future work will be needed to understand the long-term consequences on health outcomes of these disruptions in care and how to address disparities in access to care for patients with severe mental illness.”

To read more about this topic, see the Psychiatric Services article “Experiences of Persons With Serious Mental Illness During the COVID-19 Pandemic.”

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Today Is Last Day to Vote in APA’s 2022 Election

Your voice is important in determining the future of APA and your profession. You can vote by using the ballot you were emailed or clicking on “Vote Today” here or on APA’s website. Take time to learn more about this year’s candidates on the same site and view the archived town halls in which candidates responded to key questions. The deadline to cast your vote is tonight—Monday, January 31, at 11:59 p.m. ET.

Illicit Ketamine Use Linked to Depression in Youth

Recreational ketamine use appears to be associated with depressive symptoms in youth, a study in the American Journal on Addictions has found. The study also suggests that the higher the dose of ketamine and more frequent use, the higher the risk of depression.

“Although recent trials suggest that ketamine administration in clinical settings is efficacious in treating treatment-resistant depression, our study demonstrates that past-year recreational ketamine use is actually a risk factor for reporting current depressive symptoms among adolescents,” wrote Joseph J. Palamar, Ph.D., of the New York University Grossman School of Medicine and colleagues.

The researchers examined data from 15,673 youth who participated in the Monitoring the Future survey, an annual survey administered to middle- and high-school students in approximately 130 public and private schools in the 48 contiguous states. Researchers drew their data from surveys administered from 2016 to 2019, and majority of the sample examined was at least 18 years old when they took the survey.

In the surveys, participants were asked how much they agreed with the following four statements:

• Life is often meaningless.
• The future often seems hopeless.
• I enjoy life as much as anyone.
• It feels good to be alive.

Participants rated their agreement as “agree,” “mostly agree,” “neither,” “mostly disagree,” or “disagree.” The researchers then scored the students’ responses and defined students with scores in the top 25th percentile as having a high level of depression.

Participants were also asked how often in the past year they had used alcohol, cannabis, cocaine, ketamine, and heroin and how often they engaged in nonmedical use of prescription amphetamine, opioids, sedatives, and tranquilizers.

The prevalence of high-level depression was 37%, 65%, and 70% greater among participants who took illicit ketamine 1-2 times, 3-9 times, or 10 times or more, respectively, in the previous year compared with participants who did not take illicit ketamine.

“These results begin to address the gap that exists in the literature regarding the association between depressive symptoms and nonmedical or recreational ketamine use, but further research needs to be conducted to investigate the temporal associations between depressive symptoms and ketamine use in both the adolescent and adult population,” Palamar and colleagues concluded.

For related information, see the American Journal of Psychiatry article “Efficacy of Intravenous Ketamine in Adolescent Treatment-Resistant Depression: A Randomized Midazolam-Controlled Trial.”

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You Have Till Monday to Vote in APA's 2022 Election!

The voting period for APA’s 2022 election closes next week. You can vote by using the ballot you were emailed or clicking on “Vote Today” here or on APA’s website. Take time to learn more about this year’s candidates on the same site and view the archived town halls in which candidates responded to key questions. The deadline to vote is Monday, January 31, at 11:59 p.m. ET.

Most Patients Considered Good Candidates for Telemedicine, Psychiatrists Report

Psychiatrists view telemedicine as a tool to facilitate engagement with care, encourage patients to keep appointments, and improve adherence with treatment, according to a report published yesterday in Psychiatric Services in Advance.

The pandemic has made telemedicine a permanent part of psychiatric practice, allowing psychiatrists to approach care through a hybrid model of in-person and virtual visits. “However, hybrid models add another layer of complexity, requiring clinicians to use their judgment to make individualized decisions about the appropriateness of different modalities,” wrote Lori Uscher-Pines, Ph.D., of the RAND Corporation and colleagues. “Understanding how clinicians make decisions about telemedicine versus in-person care is key to informing clinical practice guidelines and reimbursement policies that mandate in-person care with some frequency.”

From June 25 to August 4, 2021, Uscher-Pines and colleagues conducted semi-structured interviews with 20 psychiatrists treating adults in outpatient settings across the United States. Psychiatrists were eligible if they conducted both telemedicine and in-person visits in the previous month, with neither type of visit representing more than 90% of all visits (telemedicine was defined as the same as video visits).

Interviews involved the critical incident technique, which is a method that asks patients to reflect on real-life experiences, “to uncover unconscious factors that influence the decision to offer telemedicine,” the authors wrote. Participants were asked to describe an example of a telemedicine visit during which they thought the quality was equivalent to that of an in-person interaction, as well as an example in which they felt uncomfortable about the quality of the telemedicine visit. The researchers also provided the participants with four clinical vignettes and asked them to discuss their thoughts on the appropriateness of telemedicine in the cases the vignettes described.

On average, the participants reported providing 59% of their visits in the previous month via telemedicine. They also reported being able to make decisions about offering telemedicine to patients using their own clinical judgment, without constraints from their organizations or practice settings. Additional findings included the following:

• Patient preference drove a significant percentage of in-person care, with psychiatrists repeatedly mentioning during interviews that they tried to accommodate patient preference when determining whether visits should be conducted via telemedicine or in-person.
• Psychiatrists also reported that almost all patients are good candidates for telemedicine. Some psychiatrists felt telemedicine was less appropriate when treating patients with substance use disorders, suicidal ideation, psychotic disorders, eating disorders, intimate partner violence, or trauma. Other psychiatrists disagreed, however, and countered that telemedicine offered unique benefits even in these cases (for example, improved patient safety and reduced likelihood of escalation).
• Some psychiatrists thought that some patients could be treated exclusively through telemedicine, while others believed that it is necessary to offer hybrid models that mix telemedicine with in-person visits to ensure high-quality care.
• Psychiatrists used telemedicine as a tool “to meet patients where they are,” and they offered it as a way to facilitate keeping appointments and adhering to treatment.

“[O]ffering the option of telemedicine, with its added convenience and potential for privacy, could help individuals expressing ambivalence about treatment or behavior change overcome their personal activation barriers to engagement,” the authors wrote.

For related information, see the Psychiatric News article “Telemental Health Use Remains Robust, But What Does Future Hold?”

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One Week Left to Vote in APA’s 2022 Election!

The voting period for APA’s 2022 election closes next week. You can vote by using the ballot you were emailed or clicking on “Vote Today” here or on APA’s website. Take time to learn more about this year’s candidates on the same site and view the archived town halls in which candidates responded to key questions. The deadline to vote is Monday, January 31, at 11:59 p.m. ET.

People With Depression More Likely to Endorse Misinformation About COVID Vaccines

Individuals with moderate to severe depressive symptoms are more likely to say they believe misinformation about COVID-19 vaccines than those without depressive symptoms, according to a report in JAMA Open Network. Moreover, individuals who believed misinformation about COVID vaccines were less likely to be vaccinated or be willing to get the vaccine.

“As such, individuals already burdened with depression may be at a higher risk of COVID-19,” wrote lead author Roy H. Perlis, M.D., M.Sc., of Massachusetts General Hospital and colleagues.

The researchers analyzed data from U.S. adults who responded to at least one of two online surveys conducted between April 1 and May 3, 2021, and between June 9 and July 7, 2021. The surveys were part of The COVID States Project, which has issued surveys approximately once every six weeks since April 2020.

As part of these surveys, the respondents were asked to indicate whether they believed the following statements to be accurate or inaccurate: “The COVID-19 vaccines will alter people’s DNA,” “The COVID-19 vaccines contain microchips that could track people,” “The COVID-19 vaccines contain the lung tissue of aborted fetuses,” and “The COVID-19 vaccines can cause infertility, making it more difficult to get pregnant.”

Survey participants also completed the Patient Health Questionnaire 9-item (PHQ-9) to assess whether they had major depressive symptoms over the preceding two weeks, with a score of 10 indicating at least moderate depression.

Among 15,464 survey respondents (64% of whom were women), 4,164 (26.9%) had at least moderate depressive symptoms on the PHQ-9, and 2,964 respondents (19.2%) indicated they believed at least one vaccine-related statement of misinformation. People with depressive symptoms were 2.33 times more likely to endorse misinformation than those who did not have depressive symptoms.

The researchers also analyzed a subset of 2,809 individuals who answered both surveys. They found that people who reported depressive symptoms in the first survey were more likely to mark more vaccine-related statements of misinformation as true in the second survey.

The association between depression and endorsement of misinformation “persisted with adjustment for sociodemographic features as well as self-reported ideology and political party affiliation,” according to the authors.

They concluded, “While this study design cannot address causation, the association between depression and spread and impact of misinformation merits further investigation.”

For related information, see the Psychiatric News article “Vaccination Conversations: Influencing Critical Health Behaviors in COVID-19.”

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One Week Left to Vote in APA’s 2022 Election!

The voting period for APA’s 2022 election closes next week. You can vote by using the ballot you were emailed or clicking on “Vote Today” here or on APA’s website. Take time to learn more about this year’s candidates on the same site and view the archived town halls in which candidates responded to key questions. The deadline to vote is Monday, January 31, at 11:59 p.m. ET.

Stigmatizing Words Found More Common in Black Patients’ Electronic Health Records

Health care professionals may be more likely to use such terms as “agitated,” “aggressive,” and “not compliant” to describe Black patients in their medical notes than White patients, a report in Health Affairs suggests.

“Our findings suggest disproportionate use of negative patient descriptors for Black patients compared with their White counterparts, which raises concerns about racial bias and possible transmission of stigma in the medical record,” wrote Michael Sun and Elizabeth L. Tung, M.D., of the University of Chicago and colleagues.

Numerous studies point to evidence of unequal treatment by race in the U.S. health care system and its negative impact on patients, according to the researchers. For the current study, the researchers used machine learning techniques to analyze medical providers’ use of negative patient descriptors in the history and physical notes in the electronic health records (EHRs) of patients seen at a large urban academic medical center in Chicago. These data included health records for patients who received treatment in an emergency department, inpatient setting, or outpatient setting between January 1, 2019, and October 1, 2020.

The final sample consisted of 18,459 patients (average age 47 years; 56% women) with 40,113 history and physical notes for analysis. The majority of the patients in the sample were Black (61%), followed by White (30%), Hispanic or Latino (6%), and other (3.5%). In total, 8.2% of patients had one or more negative descriptors recorded in the electronic history and physical notes.

After controlling for sociodemographic and health characteristics, the researchers found that Black patients had 2.54 times the odds of being described with one or more negative descriptors in the EHR compared with White patients. Patients with Medicaid or Medicare insurance also had over twice the odds of a negative descriptor compared with patients with private or employer-based insurance. In contrast, notes written during outpatient encounters were less likely to include a negative descriptor compared with those written during inpatient encounters.

Sun, Tun, and colleagues noted several limitations of the study, including its focus on data drawn from a single urban academic medical center during the COVID-19 pandemic.

Nonetheless, the authors cautioned, “History and physical notes provide key information frequently drawn on by other care providers. Negative descriptors written in the admission history and physical may be likely to be copied into subsequent notes, recommunicating and amplifying potential biases. … Future research is needed to investigate the longitudinal consequences of a negative descriptor in a patient’s medical record.”

For related information, see the Psychiatric News article “Special Report: Racism and Inequities in Health Care for Black Americans.”

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Teens Found to Benefit From Social Support, Healthy Activities During Pandemic

Adolescents who had strong social supports and engaged in healthy behaviors including exercise were emotionally more healthy during the first months of the COVID-19 pandemic, according to a media release from the National Institute on Drug Abuse (NIDA). The release describes data from the Adolescent Brain Cognitive Development (ABCD) Study in press with the Journal of Adolescent Health.

“Focusing on what you can do to support young people, like maintaining as much of a routine as possible, walking at least 10 minutes a day, and strengthening family relationships, really matters during times of stress.” said Fiona C. Baker, Ph.D., director of the Center for Health Sciences at SRI International in Menlo Park, Calif., and principal investigator of the ABCD study site at SRI.

Baker together with Orsolya Kiss, Ph.D., of SRI International and colleagues analyzed data from more than 3,000 youth aged 11 to 14 who are enrolled in the NIH’s ABCD Study, a nationwide study that has been tracking the biological and behavioral development of a cohort of children since 2015. As part of the ABCD Study, youth and their families periodically complete comprehensive behavioral and lifestyle questionnaires, which have included COVID-related questions as of May 2020.

The investigators analyzed data collected from pre-pandemic assessments (that is, before February 2020) and three online surveys conducted between May and August 2020. The surveys assessed over 200 characteristics of the youth, including demographics, physical activities, family relationships, and screen time.

Kiss and colleagues found that youth who discussed plans for the day with their parents, participated in family activities, and went outside for exercise were more likely to report positive well-being during the first months of the pandemic. Overall, eight of the top 20 features associated with positive well-being in adolescents involved social support from family or friends.

Adolescents who were female and/or had internalizing symptoms (for example, being sad or withdrawn) or sleep problems before the start of the pandemic were more likely to experience psychological distress including stress, anxiety, and/or depression. Adolescents who experienced or witnessed discrimination in relation to COVID-19 were also more likely to have stress, anxiety, and/or depression.

“Early adolescence is a time when youth are already experiencing rapid change physically, emotionally, and socially, and the COVID-19 pandemic has caused immense disruption to this sensitive stage in life,” Nora D. Volkow, M.D., director NIDA, the lead institute for ABCD, said in the release. “This study helps us understand how modifiable lifestyle factors affect the mental health and well-being of adolescents, and it can inform the development of interventions to protect youth during a major life stress. This is important now, as we continue to grapple with the pandemic, and also in future crisis response at the local or national level.”

To read more on this topic, see the Psychiatric News article “Long-Term Impact of COVID-19 on Children, Adolescents Constitutes Public Health Emergency.”

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One Week Left to Vote in APA’s 2022 Election!

The voting period for APA’s 2022 election closes next week. You can vote by using the ballot you were emailed or clicking on “Vote Today” here or on APA’s website. Take time to learn more about this year’s candidates on the same site and view the archived town halls in which candidates responded to key questions. The deadline to vote is Monday, January 31, at 11:59 p.m. ET.

Pandemic Sparks Increase in Mental Health, Substance Use Outpatient Visits Among Physicians

The number of outpatient visits for mental health and substance use by physicians jumped 27% in the first year of the COVID-19 pandemic, a study published today in JAMA Network Open has found.

“We observed increases in mental health and substance use visits during the COVID-19 pandemic that, consistent with surveys finding high levels of self-reported anxiety, depression, and stress in physicians during the pandemic, may indicate worsening physician mental health,” wrote Daniel T. Myran, M.D., M.P.H., of the Ottawa Hospital Research Institute in Canada and colleagues.

The researchers analyzed data from the records of 34,055 practicing physicians in the Ontario Health Insurance Plan from March 1, 2017, to March 10, 2021, to determine the participants’ rates of in-person or virtual outpatient visits to a psychiatrist or family medicine and general practice clinicians related to mental health and substance use. They compared the physicians’ visits during the first year of the pandemic in Ontario (March 11, 2020, to March 10, 2021) with those recorded before the pandemic.

The annual crude number of visits per 1,000 physicians rose from 816.8 before the pandemic to 1,375.5 during the pandemic. After adjusting for demographic and physician characteristics and a history of health care use related to mental health, visits increased by an average of 13% per physician. The largest relative increases in the rate of visits occurred among physicians who did not have a history of mental health problems or substance use.

“[T]hese findings suggest that generally, physicians have displayed resiliency during the pandemic, but a small group of physicians may have developed very high new mental health care needs during the pandemic, which are possibly related to pandemic-specific stressors,” Myran and colleagues wrote.

The proportion of physicians with one or more mental health and substance use visits within a year increased from 12.3% before the pandemic to 13.4% during the pandemic. Psychiatrists had the highest rate of visits (3,441.5 visits per 1,000 physicians) and surgeons had the lowest rates of visits (370.9 visits per 1,000 physicians). Overall, visits related to anxiety and adjustment reactions had the largest increases during the pandemic.

The researchers noted that the increase in visits may be explained by reduced barriers to health and mental health care, including an expansion in virtual care options in Ontario.

“It is possible that physicians with both physical and mental health concerns that predated the pandemic increased their health services use owing to this change (e.g., appointments are easier to schedule and less visible and thus less stigmatized),” they wrote.

For related information, see the Psychiatric News article “Physician Mental Health During COVID-19: A Call to Action.”

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Don’t Put Off Voting in APA’s 2022 Election!

The voting period for APA’s 2022 election closes in less than two weeks. You can vote by using the ballot you were emailed or clicking on “Vote Today” on APA’s website. Take time to learn more about this year’s candidates by reading the Special Edition APA Election Newsletter and viewing the archived town halls in which candidates responded to key questions. The deadline to vote is Monday, January 31, at 11:59 p.m. ET.

Veterans With and Without SMI Equally Likely to Receive COVID-19 Vaccine

Veterans with serious mental illness (SMI) are just as likely as veterans without SMI to be vaccinated against COVID-19, according to a study published this week in Psychiatric Services in Advance.

“Because individuals with [SMI] are at higher risk for COVID-19 infection and death, COVID-19 vaccine uptake in this population is a key concern,” wrote Taona P. Haderlein, Ph.D., M.A., of the Veterans Emergency Management Evaluation Center in North Hills, Calif., and colleagues. “Researchers have noted that fear of contracting COVID-19 via COVID-19 vaccination, as well as the ‘infodemic’ of misinformation from media outlets regarding the COVID-19 pandemic and vaccine rollout, may exacerbate preexisting mistrust among some individuals with [SMI] and increase vaccine hesitancy.”

Haderlein and colleagues analyzed Veterans Health Administration (VHA) electronic health record data, identifying over 4.8 million veterans aged 18 and older who had an outpatient visit from March 1, 2018, through February 29, 2020. These records included information on veterans who had an SMI diagnosis (diagnoses included schizophrenia, schizoaffective disorder, or bipolar disorder) as well as veterans without an SMI diagnosis. Veterans who received COVID-19 vaccinations were identified from December 1, 2020, to June 1, 2021. The authors also looked at other health behaviors noted in the electronic health record data, such as history of smoking or influenza vaccinations.

The researchers found that 48% of those diagnosed with SMI received a COVID-19 vaccination, compared with 46% of those without SMI. "[A]fter weighting based on demographic and clinical characteristics, we found that patients diagnosed as having serious mental illness and those diagnosed as having no serious mental illness were equally likely to receive a VHA COVID-19 vaccination,” the authors wrote. They also found that patients with SMI were more likely than those without to be current smokers and to have a history of influenza vaccination.

“VHA outreach activities may have helped address COVID-19 vaccine access barriers that are common in the population of individuals with serious mental illness,” the authors wrote, pointing to VHA efforts such as calling eligible patients to schedule vaccination appointments, disseminating educational information, and allowing flexibility in appointment scheduling. “Similar approaches might improve vaccine uptake for individuals outside the VHA,” they wrote.

For related information, see the Psychiatric Services article “Access to Care for Veterans With Serious Mental Illness During the COVID-19 Pandemic.”

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Don’t Put Off Voting in APA’s 2022 Election!

The voting period for APA’s 2022 election closes in less than two weeks. You can vote by using the ballot you were emailed or clicking on “Vote Today” on APA’s website. Take time to learn more about this year’s candidates by reading the Special Edition APA Election Newsletter and viewing the archived town halls in which candidates responded to key questions. The deadline to vote is Monday, January 31, at 11:59 p.m. ET.

Psoriatic Arthritis Linked to Depression, Anxiety, and Anhedonia

Individuals with psoriatic arthritis (a form of psoriasis characterized by chronic inflammation of joints, tendons, and ligaments) have higher rates of depression than those with non-arthritic psoriasis (a skin disease that causes red, itchy patches), according to a report in the Journal of Consultation-Liaison Psychiatry. Although there was no significant difference in suicidal thinking between psoriasis patients with and without arthritis, all psoriasis patients reported higher rates of suicidality than the general population.

“We recommend routine depression screening among psoriasis patients, in particular when psoriatic arthritis is present, as well as suicidality monitoring,” wrote Georgia Lada and Elise Kleyn, Ph.D., both of the University of Manchester, United Kingdom, and colleagues.

They conducted a survey of 219 adults aged 18 to 65 who were attending specialist psoriasis and psoriatic arthritis clinics in Greater Manchester in the United Kingdom. Adults were included in the analysis if they had a dermatologist-confirmed diagnosis of chronic plaque psoriasis and/or if they had a rheumatologist-confirmed diagnosis psoriatic arthritis. Of the 219 psoriasis patients, 84 had psoriatic arthritis.

Participants completed several self-report questionnaires—including the Hospital Anxiety and Depression Scale (HADS) and the Snaith-Hamilton Pleasure Scale (assesses ability to experience pleasure)—and answered questions about their medical and psychiatric history. Patients with psoriatic arthritis also completed the Psoriatic Arthritis Impact of Disease Questionnaire.

Even when adjusting for other medical problems, those with psoriatic arthritis were 2.92 times more likely to have depression than those with non-arthritic psoriasis, as defined by a score of 8 or higher on the HADS. “[Psoriatic arthritis] patients also had significantly lower hedonic tone and higher anxiety, after controlling for presence of psychiatric disorder,” the authors wrote.

There was no significant difference between patients with psoriatic arthritis and those with psoriasis only in terms of reported lifetime suicidal ideation (52.5% vs 46.6%), although the authors noted that both of those rates were higher than those of the general population. The prevalence of past-week suicidal ideation was higher in patients with psoriatic arthritis than those with psoriasis only (22.5% vs 13.4%).

“Suicidality monitoring and identification of risk factors in psoriasis patients is critical to tackle this major, yet preventable, public health issue,” the researchers wrote. “Future studies should aim to identify risk and protective factors for suicidality as well as inflammatory and neurobiological correlates of depression among patients with psoriasis and psoriatic arthritis.”

For related information, see the Psychiatric News article “Psychiatrists Work to Tease Apart Psychosomatic Aspects of Skin Disease.”

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Time to Vote in APA’s 2022 Election!

The voting period for APA’s 2022 election is now open. You can vote by using the emailed ballot you should have received by now or clicking on “Vote Today” on APA’s website. Take time to learn more about this year’s candidates by reading the Special Edition APA Election Newsletter and viewing the archived town halls in which candidates responded to key questions. The deadline to vote is January 31 at 11:59 p.m. ET. Your vote matters to the future of APA and psychiatry!

More Behavioral Issues Reported in Children When School Is Virtual

The behavior of children forced to switch learning formats during the pandemic was worse when their learning was remote, according to surveys of their parents. The findings were published in JAMA Pediatrics.

“The COVID-19 pandemic has interrupted the education of more than 1 billion children worldwide, with many experiencing shifts between remote, hybrid, and in-person learning,” wrote Emily C. Hanno, Ph.D., of Harvard University and colleagues. To assess the impact of these changes on youth’s behavior, the researchers asked 405 parents of children (average age 7.5 years) who were participating in the broader Early Learning Study at Harvard to complete four online surveys between January 4, 2021, and May 23, 2021.

For each survey, parents were asked to indicate their child’s current learning format (for example, in person, remote, or hybrid). They also were asked to report on their child’s behavioral health using the following three measures:

• General behavioral health: Parents were asked to rate their child’s behavior in the past month on a five-point scale, ranging from “much worse than usual” to “much better than usual.”
• Emergence of maladaptive behaviors: Parents were asked to indicate if they had witnessed maladaptive behaviors, such as more aggression and/or tantrums, in the past month.
• Frequency of dysregulated behaviors: Parents were asked how often they had seen 11 dysregulated behaviors, such as difficulty switching activities or limited attention, in their child in the past month.

Of 405 parents included in the analysis, 348 (85.9%) reported on 356 children’s behaviors in at least one of the four surveys. Nearly 60% of the children switched learning formats at least once during the nearly five-month period. “Parents reported that when learning remotely, their child exhibited worse general behavior, more maladaptive behavioral changes, and more dysregulated behaviors than when learning in person,” the authors wrote. Children experiencing hybrid learning exhibited better general behavior than when remote, but worse behavior than when in person, they added.

“[O]ur analyses … did not account for all time-varying factors that might explain children’s learning format and parents’ perception of their well-being at any given time,” Hanno and colleagues wrote. “Therefore, [the] results should not be interpreted to mean that remote learning caused worse behavioral health; rather, the results illustrate that parents perceived their children’s behaviors as having shifted systematically through the COVID-19 pandemic’s educational interruptions.”

Also appearing in JAMA Pediatrics is a review of 36 studies from 11 countries revealing that school closures and social lockdown during the first COVID-19 wave were associated with adverse mental health symptoms (such as distress and anxiety) and health behaviors (such as higher screen time and lower physical activity) among children and adolescents.

“The toll of school closures and social isolation on children’s mental health cannot be overstated and will require both immediate- and long-term investigation and action to fully assess and address the impact,” wrote Danielle G. Dooley, M.D., M.Phil., of Children’s National Hospital and colleagues in an accompanying editorial.

For related information, see the Psychiatric News article “Building Resilience in Our Children for the Aftereffects of COVID-19.”

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Webinar on No Surprises Act Addresses What Law Means to You

Register to join the AMA webinar “Implementing the No Surprises Act” on Thursday, January 20, at 1 p.m. ET. The law, now in effect, protects patients from the financial impact of surprise medical billing. Learn what you need to do immediately to comply with the law. Experts will also address enforcement challenges and the interaction between state and federal surprise billing requirements. The moderator is Bobby Mukkamala, M.D., chair of the AMA Board of Trustees.

FDA Issues Warning About Dental Risk With Transmucosal Buprenorphine

The U.S. Food and Drug Administration (FDA) has issued a Drug Safety Communication about dental problems associated with the use of buprenorphine products that dissolve in the mouth (transmucosal) and is requiring that a new warning about the risk of dental problems be added to the prescribing information and patient medication guides for these products. The dental problems include tooth decay, cavities, dental abscesses/infection, tooth erosion, or tooth loss.

The warnings come after an FDA review of cases reported to the agency or published in the medical literature revealed 305 cases of dental problems, 131 of them classified as serious, among patients who take transmucosal buprenorphine. Most of the dental problems occurred in patients who used the medication to treat opioid use disorder (OUD), although 28 cases occurred in patients who used the medication to treat pain. The most common treatment for these dental problems was tooth extraction or removal, reported in 71 cases. Other cases involved root canals, dental surgery, or other procedures such as crowns and implants.

“It would be useful to learn more about these reports and understand what proportion of total people using these specific formulations may be affected,” said Smita Das, M.D., Ph.D., M.P.H., chair of APA’s Council on Addiction Psychiatry. She noted that 305 is a relatively low number of cases given the number of people who take transmucosal buprenorphine among the approximately 1.7 million people who use buprenorphine as prescribed.

“Of course, for those individuals who are affected by dental problems, the impact is certainly considerable in their daily lives,” Das said. “With any medication, if there is a risk, it is important to consider the likelihood of that risk and how that risk compares to the benefit. In the case of buprenorphine, it is a lifesaving medication for many people and a core part of treatment for opioid use disorder.”

The FDA Drug Safety Communication advises health care professionals to ask patients about their oral health history before prescribing treatment with a transmucosal formulation of buprenorphine and to refer patients to a dentist as soon as possible after starting treatment. Patients should be instructed to gently rinse their teeth and gums with water and swallow after the medication has completely dissolved, then wait at least an hour to brush their teeth. The FDA also cautions patients not to stop taking their medications without consulting a health care professional.

Miriam Delphin-Rittmon, Ph.D., assistant secretary for mental health and substance use and the head of the Substance Abuse and Mental Health Services Administration (SAMHSA), issued the following statement in response to the FDA guidance: “SAMHSA urges patients and providers to weigh the lifesaving benefits of buprenorphine with this identified risk in making decisions about starting and ongoing use of buprenorphine.” She added that SAMHSA supports the FDA’s recommendations regarding the steps patients can take to care for their teeth and minimize their risk.

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Public Health Emergency Again Extended

Today Health and Human Services Secretary Xavier Becerra extended the Public Health Emergency determination for an additional 90 days, effective January 16. This is the eighth such extension since the original declaration was issued at the start of the COVID-19 pandemic and is not expected to be the last.

Absence of Mood Improvement in Two Weeks May Predict Failure to Respond to TMS

If patients with major depressive disorder (MDD) demonstrate only limited mood improvements after two weeks of repetitive transcranial magnetic stimulation (rTMS), it may be a sign their treatment plans should be adjusted, suggests a study published in Depression & Anxiety.

“Insurers typically approve 36 [rTMS] sessions for patients with MDD. ... It is imperative to maximize benefit from the finite number of treatments [that] most patients can access,” wrote Alex Mirman, M.D., of the UCLA Semel Institute for Neuroscience and Human Behavior and colleagues. “Early, accurate prediction of nonresponse could allow clinicians to change treatment approach, with potentially better outcomes.”

Researchers recruited 329 participants receiving six weeks of rTMS treatment for an episode of nonpsychotic MDD. All participants had a primary MDD diagnosis and previously tried at least three antidepressant trials without achieving adequate improvements. Participants received 30 rTMS treatment sessions over the six-week period. Symptoms were assessed at baseline, after one and two weeks, and at the end of treatment using the 30-item Inventory of Depressive Symptomatology Self Report (IDS-SR). In addition to the IDS-SR score, the researchers analyzed three symptom subscales: sleep, mood, and anxiety. Response to rTMS was defined as a decline in pre- to posttreatment IDS-SR scores of at least 50%.

In total, 94 of the participants responded to rTMS. After one week, improvement in the IDS-SR mood subscale was the only significant predictor of total IDS-SR improvement by the end of the study.

Participants with severe or very severe depression symptoms at the start of the study whose mood improved by less than 20% after one week were highly unlikely to show a response to rTMS by the end of the study. None of the 19 participants with very severe symptoms at baseline who failed to show any improvement in mood after two weeks reached the criteria for response by the end of the study. Lack of improvement in sleep at two weeks was also a significant predictor of nonresponse.

“Our prior work suggests that in subjects showing limited improvement after [two] weeks of treatment, changing rTMS approach improved outcomes,” the authors concluded. “Together, these studies provide a rationale for TMS clinicians to consider changing rTMS approach in people with severe baseline depression showing no mood improvements after one week. This approach could lessen the burden of futile treatment and optimize efficacy in those severely depressed individuals who have most to gain from rTMS.”

For related information, see the Psychiatric News article “New Stanford Protocol for TMS Found to Achieve Fast Remission.”

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Time to Vote in APA’s 2022 Election!

The voting period for APA’s 2022 election is now open. You can vote by using the emailed ballot you should have received by now or clicking on “Vote Today” on APA’s website. Take time to learn more about this year’s candidates by reading the Special Edition APA Election Newsletter and viewing the archived town halls in which candidates responded to key questions. The deadline to vote is January 31 at 11:59 p.m. ET. Your vote matters to the future of APA and psychiatry!

FDA Approves Novel Drug to Treat Insomnia

The U.S. Food and Drug Administration (FDA) has approved Quviviq (daridorexant) 25 mg and 50 mg for the treatment of adult patients with insomnia.

The FDA has recommended that Quviviq be classified as a controlled substance, and it is expected to be available to patients in May 2022, following scheduling by the U.S Drug Enforcement Administration, according to a media release by Idorsia Ltd, maker of Quviviq.

Unlike many insomnia medications that act to sedate the brain, Quviviq is a dual orexin receptor antagonist, which works to reduce overactive wakefulness.

The efficacy of Quviviq was evaluated in two multicenter, randomized, double-blind, placebo-controlled studies. A total of 1,854 adults with insomnia (as defined by DSM-5) were randomized to receive Quviviq or placebo once daily in the evening for three months. The first study included 930 adults randomized to Quviviq (50 mg or 25 mg) or placebo. The second study included 924 adults randomized to Quviviq (25 mg or 10 mg) or placebo.

In both trials, the researchers compared changes in Latency to Persistent Sleep (a measure of how long it takes to fall asleep) and Wake After Sleep Onset (a measure of sleep maintenance), as indicated by polysomnography in a sleep laboratory. The study participants also reported their total sleep times, based on their recordings in a sleep diary throughout the trial. Study participants who took Quviviq (25 and 50 mg) showed a statistically significant improvement over placebo on sleep maintenance and total time sleeping after taking the medication for one and three months. Study participants who took the 10 mg dose of did not show a statistically significant improvement over those who took placebo on either measure or on total sleep time.

According to the Quviviq label, several studies evaluated the abuse potential of the medication. One study of 63 recreational sedative drug users who were given a single dose of the medication revealed high “drug liking,” suggesting potential for abuse.

Philip R. Muskin, M.D., M.A., a professor of psychiatry at Columbia University Irving Medical Center and senior consultant in consultation-liaison psychiatry at New York-Presbyterian Hospital/Columbia University Irving Medical Center, said the new medication will be an effective addition to the tools available to treat patients with insomnia. “We certainly need new drugs for insomnia,” he told Psychiatric News. “It’s a very common problem, even among people who don’t meet DSM criteria for insomnia, and insomnia is a component of so many other psychiatric disorders—depression, anxiety, trauma, among others.”

He advised psychiatrists to be cautious about prescribing to patients with a history of addiction.

“No one drug works for everyone,” Muskin said. “Many of the existing drugs that sedate the brain help people fall asleep but don’t help them stay asleep. This new medication tunes down the biological signal in our brain to stay awake. There is a need for drugs that use a different mechanism of action than sedating the brain.”

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People With AUD May Benefit From Combination of Ketamine, Mindfulness Therapy

Treating people with alcohol use disorder (AUD) with a combination of ketamine and mindfulness-based therapy may lead to greater abstinence from alcohol than educating people with AUD about their disorder, suggests a report published today in AJP in Advance.

“The results showed that [three infusions of] ketamine increased the number of days abstinent from alcohol at three and six months compared with placebo,” wrote Meryem Grabski, Ph.D., and Amy McAndrew, Ph.D., of the University of Exeter and colleagues. “The greatest difference in percentage of days abstinent from alcohol was between patients given ketamine and therapy and those given placebo and education.”

The study included adults aged 18 to 65 years who met DSM-5 criteria for moderate to severe AUD or DSM-IV criteria for AUD and had been abstinent from alcohol for at least 24 hours. Individuals were excluded from the trial if they had uncontrolled hypertension, were taking antihypertensives or antidepressants, and/or had current suicidal ideation. Other exclusion criteria included a diagnosis of any current or past psychiatric disorder (except depression, anxiety, AUD, or alcohol dependence) or of substance dependence other than AUD or ever seeking professional help for dependence on an illicit substance.

Ninety-six adults with AUD (35 women; average age 44 years) were randomly assigned to one of four treatment groups: (1) ketamine and therapy, (2) ketamine and alcohol education, (3) saline (placebo) and therapy, and (4) saline and alcohol education. The participants were encouraged to attend 10 study visits.

Beginning at visit 2, all participants received either 90-minute therapy or alcohol-education sessions. The therapy sessions focused on relapse prevention, mindfulness, and the promotion of well-being. The alcohol education sessions focused on the biology of addiction and steps to improve and maintain a healthy lifestyle. Also beginning at visit 2 and repeated at visits 4 and 6, the participants received infusions of either ketamine or saline. All participants participated in therapy or alcohol-education sessions prior to receiving their infusion and 24 hours later for a total of seven sessions. On average, it took participants 190 days to complete the trial (from randomization to visit 10).

The participants reported on alcohol use at each study visit and wore alcohol-monitoring bracelets through the end of treatment (visit 8). After the alcohol-monitoring bracelets were removed, the participants were asked to record alcohol use in a diary until the end of the trial.

Participants in the ketamine group reported a significantly greater number of days abstinent from alcohol compared with those in the placebo group at six-month follow-up (mean difference=10.1%), with the greatest difference in the ketamine plus therapy group compared with the saline plus education group (mean difference=15.9%), Grabski, McAndrew, and colleagues reported. There was no significant difference in relapse (recurrent heavy alcohol use) at six months between the ketamine and placebo groups.

“This study demonstrated that treatment with three infusions of ketamine was well tolerated in patients with alcohol use disorder and was associated with more days of abstinence from alcohol at six-month follow-up. The findings suggest a possible beneficial effect of adding psychological therapy alongside ketamine treatment,” the authors concluded.

For related information, see the American Journal of Psychiatry article “A Single Ketamine Infusion Combined With Motivational Enhancement Therapy for Alcohol Use Disorder: A Randomized Midazolam-Controlled Pilot Trial.”

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CMS Field Tests Psychiatry Cost Measures, Invites Comments

The Centers for Medicare & Medicaid Services (CMS) is conducting field testing for five episode-based cost measures for the Merit-based Incentive Payment System (MIPS). The goal is to collect feedback on these cost measures for major depressive disorder and psychoses/related conditions. Testing will include assessment of the measures’ importance, scientific acceptability, and clinical validity. Clinicians and clinician groups with at least 20 episodes for at least one measure will receive a Field Test Report with information about their cost performance; feedback will be used to consider potential measure refinements. Draft specifications for each measure are available on the CMS website. The field testing ends Thursday, February 25.

APA is interested in reviewing Field Test Reports with APA members to inform our feedback to CMS. If you have received a cost report and are open to discussing it with APA staff, please contact Andrew Lyzenga at alyzenga@psych.org. Also, reach out if you have any questions, comments, or input on episode-based cost measures or the field testing process.

Failure to Respond to Antipsychotics Early May Predict Long-Term Outcomes in Youth With Psychosis

Adolescents with first-episode psychosis who do not respond to aripiprazole or quetiapine within four weeks appear unlikely to respond to the medications eight weeks later, reports a study in the Journal of the American Academy of Child and Adolescent Psychiatry.

“[Y]oung people with psychosis usually face years of psychiatric treatment, and pharmacotherapy is essential for recovery. Yet, antipsychotics should be administered with caution in adolescents due to an increased risk of side effects,” wrote Anne Katrine Pagsberg, M.D., Ph.D., of the University of Copenhagen, Denmark, and colleagues. “Being able to identify non-response early facilitates quicker decision-making to change treatment and, thus, diminishes the risk of prolonged exposure and adverse events associated with an ultimately ineffective medication.”

Pagsberg and colleagues analyzed data from the Tolerance and Effect of Antipsychotics in Children and Adolescents With Psychosis (TEA) study, a 12-week randomized, controlled trial in Denmark that compared the efficacy of aripiprazole to extended-release quetiapine in 113 adolescents (under age 18) diagnosed with first-episode psychosis. The researchers examined whether adolescents’ response to their assigned antipsychotic at two and four weeks could predict their response to the medications at 12 weeks. Non-response at Weeks 2 and 4 was defined as <20% decrease in the 30-item Positive and Negative Symptom Scale (PANSS-30) total score; non-response at the end of the trial was defined as <50% decrease in PANSS-30 at week 12. The analysis included 84 adolescents who adhered to their medication for all 12 weeks of the trial.

The researchers found that adolescents who did not respond to their assigned antipsychotic at Weeks 2 and 4 were about 80% and 90% likely, respectively, to not respond to the medication by the end of the trial. When adjusting for other variables, they found that non-response at Week 4 remained a statistically significant predictor of future non-response. They also examined other cutoff ranges and found that using a <30% symptom reduction at Week 4 offered the best predictive value for non-response at Week 12.

There were no significant differences between the two medications in terms of early and long-term response rates.

“In youth with first-episode psychosis showing early non-response to aripiprazole or quetiapine-extended-release, switching antipsychotic drug should be considered,” Pagsberg and colleagues concluded.

For related information, see the American Journal of Psychiatry article “A Population-Based Cohort Study Examining the Incidence and Impact of Psychotic Experiences From Childhood to Adulthood, and Prediction of Psychotic Disorder.”

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Time to Vote in APA’s 2022 Election!

The voting period for APA’s 2022 election is now open. You can vote by using the emailed ballot you should have received by now or clicking on “Vote Today” on APA’s website. Take time to learn more about this year’s candidates by reading the Special Edition APA Election Newsletter and viewing the archived town halls in which candidates responded to key questions. The deadline to vote is January 31 at 11:59 p.m. ET. Your vote matters to the future of APA and psychiatry!

Social Workers in Primary Care Practices Found to Increase Access to MH Care

Deploying behavioral health social workers in primary care settings can increase the likelihood that patients with depression or anxiety will receive treatment within 30 days of their diagnosis, a study published today in Psychiatric Services in Advance has found.

Elizabeth R. Pfoh, Ph.D., M.P.H., of the Cleveland Clinic’s Center for Value-Based Care Research and colleagues examined data from 68,659 adults who had at least one primary care visit between 2016 and 2019 and a new diagnosis of depression, anxiety, or both. Behavioral health social workers were deployed in 40 practices between 2017 and 2019. Patients were grouped according to whether they were diagnosed before or after the social workers were deployed. Patients were followed for 35 days after their diagnosis.

In May 2018, changes were made to the electronic health record (EHR) system enabling physicians to more easily refer patients to the behavioral health social workers, who would then call patients within seven days of receiving the referral. The social workers screened patients using tools such as the Patient Health Questionnaire-9 and asked patients about current substance use and anxiety as well as any history of psychiatric disorders. The social workers also offered community resources or referred patients to mental health professionals such as a psychiatrist, psychologist, or licensed independent social worker.

Compared with those diagnosed with depression or anxiety before the social workers began working with the primary care practices, patients diagnosed with depression or anxiety had the following:

• 4.35 times the odds and 4.27 times the odds, respectively, of having a behavioral health visit within 30 days of diagnosis.
• 5 times the odds of having a visit with a non-psychiatrist therapist.
• 1.82 times and 1.58 times the odds, respectively, of having a visit with a psychiatrist.

“Other health systems that have advanced EHR systems should consider introducing social workers trained in behavioral health to triage patients receiving new diagnoses of depression, anxiety, or both and systematically link them to appropriate care,” Pfoh and colleagues concluded.

For related information, see the Psychiatric Services article “Characteristics of Patients Who Attended Behavioral Health Services After Primary Care Referral With Referral Management Support.”

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Biomarker May Predict Patient Response to Antidepressants

Researchers have identified a biomarker that may be capable of predicting within one week whether patients with major depressive disorder (MDD) will respond to antidepressants. The findings were published yesterday in Molecular Psychiatry.

For the small pilot study, Steven Targum, M.D., of Signant Health in Boston, Mark Rasenick, Ph.D., of the University of Illinois College of Medicine in Chicago, and colleagues analyzed how antidepressants impact the protein Gs alpha, which allows neurotransmitters to make the molecule adenylyl cyclase. Previous research has shown that adenylyl cyclase is low in patients with MDD because Gs alpha is predominantly stuck in membranes called lipid rafts. Antidepressants may be able to move Gs alpha out of those rafts, the authors wrote.

Targum, Rasenick, and colleagues analyzed data from a study at the Emory University School of Medicine involving 49 participants with MDD and no psychosis and 59 controls with no history of MDD; participants ranged in age from 30 to 64 years. They were screened using the 17-item Hamilton Rating Scale for Depression (HAM-D) and completed at least two visits with researchers, scheduled one week apart, at which blood draws occurred to assess Gs alpha.

Nineteen of the participants with MDD went on to complete six weeks of treatment with antidepressants. Blood was drawn from these participants a third time six weeks after initiating medication treatment. Eleven participants responded to the antidepressants (defined as ≥50% improvement on HAM-D score) after six weeks.

Analysis of the blood draws revealed that during the initial screening visit, participants with MDD had significantly lower adenylyl cyclase activity compared with healthy controls. At the third visit, participants who responded to their antidepressant treatment experienced significant increases in adenylyl cyclase compared with those who did not respond to the medications.

“What we have developed is a test that can not only indicate the presence of depression but … also indicate therapeutic response with a single biomarker, and that is something that has not existed to date,” Rasenick said in a University of Illinois at Chicago news release.

According to the release, the biomarker blood test could indicate if Gs alpha is out of the lipid raft within one week. “Because platelets turn over in one week, you would see a change in people who were going to get better,” Rasenick said.

For related information, see the Psychiatric News article “Blood May Hold Secret to Biomarkers for Depression.”

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Some Neuropsychiatric Symptoms Increase Dementia Risk for Those With Mild Cognitive Impairment

Older individuals with mild cognitive impairment (MCI) who have depressive, hyperactive, and/or psychotic symptoms are at higher risk of developing dementia than are older people with MCI with mild or no neuropsychiatric symptoms, according to a report in the American Journal of Geriatric Psychiatry. Those with psychotic symptoms (delusions and hallucinations) had the greatest risk of developing dementia.

“Our results suggest that the structure of neuropsychiatric symptoms warrants further consideration in classification models of mild cognitive impairment to better predict the risk of disease progression,” wrote John Hanfelt, Ph.D., of the Goizueta Alzheimer’s Disease Research Center at Emory University School of Medicine and colleagues.

They analyzed data on neuropsychiatric symptoms (NPS) among 7,971 patients (average age: 73 years) diagnosed with MCI who were enrolled in the National Institutes of Health’s Alzheimer’s Disease Centers between June 2005 and December 2019. Neuropsychiatric features were evaluated using the Neuropsychiatric Inventory Questionnaire, a rating of 12 behaviors including delusions, hallucinations, agitation/aggression, depression/dysphoria, apathy/indifference, elation/euphoria, anxiety, disinhibition, irritability/lability, aberrant motor behavior, nighttime behaviors, and appetite/eating. Each neuropsychiatric feature was scored as either absent or present if it occurred in the previous month. Participants had follow-up assessments annually, and the time from initial visit to onset of dementia and time to death was recorded.

The researchers categorized participants into four subgroups based on their symptoms:

• Mild or no NPS: 50% reported mild or no neuropsychiatric symptoms.
• Affect or negative mood: 27% reported depression, anxiety, apathy, nighttime disturbance, and/or change in appetite.
• Hyperactive: 14% reported agitation, irritability, and/or disinhibition.
• Psychotic with additional severe NPS: 9% reported delusions and/or hallucinations, as well other NPS.

A total of 2,346 patients (29% of the total sample) eventually developed dementia. Individuals with psychotic symptoms had a 64% higher chance of developing dementia than did those with mild neuropsychiatric symptoms. Those with negative mood symptoms had a 39% greater risk, and those with hyperactive symptoms had a 35% greater risk.

“Our findings and the results of other studies suggest the value of considering neuropsychiatric symptoms in addition to cognitive features in classification models of MCI,” the researchers wrote. “Future research is needed to further understand the mechanisms contributing to the presence of NPS and their role in disease progression.”

For related information, see the American Journal of Psychiatry article “Predicting Dementia: Is it Ready for the Clinic?”

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Time to Vote in APA’s 2022 Election!

The voting period for APA’s 2022 election is now open. You can vote by using the emailed ballot you should have received by now or clicking on “Vote Today” on APA’s website. Take time to learn more about this year’s candidates by reading the Special Edition APA Election Newsletter and viewing the archived town halls in which candidates responded to key questions. The deadline to vote is January 31 at 11:59 p.m. ET. Your vote matters to the future of APA and psychiatry!

Breast Cancer Patients Benefit From Tailored Approach to Depression Screening

Developing tailored strategies that encourage staff at oncology clinics to routinely screen patients with breast cancer for depression can help increase the number of patients connected with behavioral health services, suggests a report published today in JAMA.

Depression is known to be associated with worse outcomes in cancer patients, including decreased social and physical functioning and poor quality of life. The American College of Surgeons Commission on Cancer recommends that health professionals screen cancer patients for distress; however, patients with breast cancer are often underdiagnosed and undertreated for depression and depressive symptoms, wrote Erin E. Hahn, Ph.D., M.P.H., of Kaiser Permanente Southern California and colleagues.

Hahn and colleagues wanted to know whether a depression screening program tailored to individual oncology clinics might increase the proportion of patients receiving referrals to behavioral health services compared with an education-only strategy. They randomized six medical centers within Kaiser Permanente Southern California that were treating patients diagnosed with a new primary breast cancer to one of two interventions: three centers received a tailored intervention; the other three received general education about the program. All centers were encouraged to screen newly diagnosed patients with the nine-item Patient Health Questionnaire (PHQ-9) and, as indicated based on PHQ-9 scores, refer patients for additional behavioral health services.

The clinical teams at tailored intervention sites were educated about the PHQ-9 and the scoring-referral algorithm, engaged in regular check-ins with a nurse researcher, and received tailored audit and feedback reports of progress compared with those of the other intervention sites throughout the study. The teams at the education-only sites were provided with general information about the screening program, including the PHQ-9 questionnaire and scoring-referral algorithm.

The trial included 1,436 patients diagnosed with new primary breast cancer who had a consultation with medical oncology between October 1, 2017, through September 30, 2018; these patients were followed up to May 31, 2019, insurance disenrollment, or death. Regardless of PHQ-9 screening, a significantly greater number of patients in the tailored intervention group received a referral for any behavioral health service compared with patients treated at the education-only clinics during the study period: 135 patients (18%) vs. 74 (11%), the authors reported.

“Given the high burden of depression in patients with breast cancer, effective screening and referral programs are needed. In the current era of heightened health-related concerns due to SARS-CoV-2, which may disproportionately affect patients with cancer and survivors, systematic depression screening and referral for patients with cancer may be even more important,” Hahn and colleagues concluded.

For related information, see the Psychiatric Services article “Factors Influencing Receipt of Mental Health Services Among Medicaid Beneficiaries With Breast Cancer.”

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No Surprises Act Takes Effect: Sets New Billing Limits and Fee Disclosures for Doctors

Key provisions of the No Surprises Act took effect January 1, and with it comes new billing limits and fee disclosures for physicians.

The law was intended to protect insured patients from large bills that can arise when they receive care from out-of-network doctors they did not choose. Last year, federal agencies published two interim final rules and another proposed rule to implement the law.

The rules apply to emergency or hospital-based care: For insured patients at network facilities, plans must cover such care at in-network rates. The law also prohibits out-of-network doctors in such cases from billing patients more than the in-network cost-sharing amount allowed by their plans. The regulations set a penalty of up to $10,000 for each violation.

New Fee Disclosure Rules for Office-Based Care

The rules also create new paperwork requirements for psychiatrists and other health care professionals providing office-based care: They must now provide a “good faith estimate” of expected charges to all uninsured patients or those who intend to self-pay. Such estimates must be provided whenever services are scheduled or whenever a patient requests an estimate.

Physicians’ fee estimates must be in a written document that is clear and understandable. Physicians must also post a notice on their website informing patients of their right to a good faith estimate. The Centers for Medicaid and Medicare Services (CMS) has created a template for both disclosures. The regulations establish a new patient-provider dispute-resolution process for cases in which the billed charges exceed by $400 or more the good faith estimate.

Physicians, Hospitals File Suit

What happens when plans and physicians providing emergency or hospital-based care at in-network facilities cannot come to terms on payments? The regulations specify that when disputes arise, the payment should be based on health plans’ median rate paid to in-network providers in their geographic area.

The AMA and American Hospital Association (AHA) filed a lawsuit against the federal government in December, charging that the new regulations governing disputes unfairly limits consideration of other factors and benefits commercial health insurance companies.

“The lawsuit argues that the regulations are a clear deviation from the law as written and all but ensure that hospitals, physicians, and other providers will routinely be undercompensated by commercial insurers, and patients will have fewer choices for access to in-network services,” according to a joint AMA/AHA statement.

For more information, see the Psychiatric News article “No Surprises Act Brings New Billing Rules, Disclosures; Doctors Sue” and APA’s guidance for psychiatrists on the No Surprises Act.

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