Effects of COVID-19 on Patients in Adult Ambulatory Psychiatry: Using Patient-Rated Outcome Measures and Telemedicine

Use of Patient-Reported Outcome Measures to Assess the Effectiveness of Hybrid Psychiatric Visits

OBJECTIVE

Little empirical evidence exists to support the effectiveness of hybrid psychiatric care, defined as care delivered through a combination of telephone, videoconferencing, and in-person visits. The authors aimed to investigate the effectiveness of hybrid psychiatric care compared with outpatient waitlist groups, assessed with patient-reported outcome measures (PROMs).

METHOD

Participants were recruited from an adult psychiatry clinic waitlist on which the most common primary diagnoses were unipolar depression, generalized anxiety disorder, and bipolar disorder. Patients (N=148) were randomly assigned to one of two waitlist groups that completed PROMs once or monthly before treatment initiation. PROMs were used to assess symptoms of depression (Patient Health Questionnaire-9 [PHQ-9]), anxiety (Generalized Anxiety Disorder-7 [GAD-7]), and daily psychological functioning (Brief Adjustment Scale-6 [BASE-6]). Patient measures were summarized descriptively with means, medians, and SDs and then compared by using the Kruskal-Wallis test; associated effect sizes were calculated. PROM scores for patients who received hybrid psychiatric treatment during a different period (N=272) were compared with scores of the waitlist groups.

RESULTS

PROM assessments of patients who engaged in hybrid care indicated significant improvements in symptom severity compared with the waitlist groups, regardless of the number of PROMs completed while patients were on the waitlist. Between the hybrid care and waitlist groups, the effect size for the PHQ-9 score was moderate (d=0.66); effect sizes were small for the GAD-7 (d=0.46) and BASE-6 (d=0.45) scores.

CONCLUSIONS

The findings indicate the clinical effectiveness of hybrid care and that PROMs can be used to assess this effectiveness.

Assessing the impact of COVID-19 on outpatient psychiatric population well-being and symptomology utilizing COVID-19 Events Checklist (CEC) and Measurement Based Care

BACKGROUND

This study examines the impact of SARS-CoV-2 (i.e., coronavirus, COVID, COVID-19) using data from a measurement-based care (MBC) system utilized in an outpatient psychiatric clinic providing telemedicine care. A novel Patient Rated Outcome Measure (PROM), the COVID-19 Events Checklist (CEC) was administered in a hospital system based ambulatory clinic beginning April 2020 to track COVID-19-19's impact on patients' mental, emotional, and health-related behaviors during the pandemic. The study (1) provides descriptive CEC data, and (2) compares CEC results with PROMs evaluating anxiety (Generalized Anxiety Disorder-7; GAD-7), depression (Patient Health Questionnaire; PHQ-9), and psychological distress (Brief Adjustment Scale-6; BASE-6).

METHODS

This retrospective observational study included patient intake data collected from April 2020 to March 2021. Patient (N = 842) reports on the CEC's five domain questions were aggregated to calculate average reports of COVID-19 related impacts at intake over the initial 12 months of the pandemic. Trends in COVID-19 related impacts were examined, and non-aggregated scores on the PHQ-9, GAD-7, and BASE-6 were compared to primary dichotomous (yes/no) CEC survey questions via Wilcoxon rand sum testing.

RESULTS

Results capture the relationship between COVID-19 exposure, COVID-19- related sequelae and behaviors, and psychological symptom severity. Specifically, Wilcoxon rank-sum tests indicate that social determinants of health (SDOH), negative mental health impacts, and positive coping skill use were significantly associated with psychological symptomatology including overall psychological functioning via the BASE-6, anxiety via the GAD-7, and depressive symptoms via the PHQ-9. Results regarding SDOH were as follows: BASE-6 (w = 44,005, p < 0.001), GAD-7 (w = 44,116, p < 0.001), and PHQ-9 (w = 43,299, p < 0.001). Regarding negative mental health outcomes, the results were: BASE-6 (w = 38,374, p < 0.001), GAD-7 (w = 39,511, p < 0.001), and PHQ-9 (w = 40,154, p < 0.001). As the initial year of the pandemic elapsed, incoming patients demonstrated increased rates of suspected or confirmed exposure to COVID-19, (+2.29%, t = 3.19, p = 0.01), reported fewer negative impacts of COVID-19 on SDOH (-3.53%, t= -2.45, p = 0.034), and less engagement in positive coping strategies (-1.47%, t = -3.14, p = 0.010).

CONCLUSIONS

Psychosocial factors related to COVID-19 are discussed, as well as opportunities for further research on the relationship between psychological symptomatology and the impact of COVID-19 on health-related behaviors.

Effectiveness of telehealth versus in-person care during the COVID-19 pandemic: a systematic review

In this systematic review, we compared the effectiveness of telehealth with in-person care during the pandemic using PubMed, CINAHL, PsycINFO, and the Cochrane Central Register of Controlled Trials from March 2020 to April 2023. We included English-language, U.S.-healthcare relevant studies comparing telehealth with in-person care conducted after the onset of the pandemic. Two reviewers independently screened search results, serially extracted data, and independently assessed the risk of bias and strength of evidence. We identified 77 studies, the majority of which (47, 61%) were judged to have a serious or high risk of bias. Differences, if any, in healthcare utilization and clinical outcomes between in-person and telehealth care were generally small and/or not clinically meaningful and varied across the type of outcome and clinical area. For process outcomes, there was a mostly lower rate of missed visits and changes in therapy/medication and higher rates of therapy/medication adherence among patients receiving an initial telehealth visit compared with those receiving in-person care. However, the rates of up-to-date labs/paraclinical assessment were also lower among patients receiving an initial telehealth visit compared with those receiving in-person care. Most studies lacked a standardized approach to assessing outcomes. While we refrain from making an overall conclusion about the performance of telehealth versus in-person visits the use of telehealth is comparable to in-person care across a variety of outcomes and clinical areas. As we transition through the COVID-19 era, models for integrating telehealth with traditional care become increasingly important, and ongoing evaluations of telehealth will be particularly valuable.

Patient Reported Outcome and Experience Measures (PROMs and PREMs) in substance use disorder treatment services: A scoping review

BACKGROUND

Substance use disorders (SUD) pose significant challenges for healthcare systems, and there is a need to monitor the provision of effective, individualized care to persons accessing treatment. Patient-Reported Outcome Measures (PROMs) and Patient-Reported Experience Measures (PREMs) are increasingly used in healthcare services to measure treatment outcomes and quality of care as perceived by patients, and to guide service improvement.

OBJECTIVES

This review aims to identify and characterize international developments regarding the use and systematic implementation of PROMs and PREMs in SUD treatment services.

METHODS

A scoping review was conducted searching multiple databases to identify studies on the use and routine implementation of PROMs and PREMs in SUD treatment services.

RESULTS

23 articles were selected, all dating from 2016 onwards. There was large variation in the patient-reported measures that were used, how they were developed and how and when patient-reported data were collected. Treatment providers identified leadership support, the presence of an integrated electronic patient record, and regular feedback to be the most important facilitators of successful implementation of patient-reported measures into clinical practice, whilst treatment dropout and burden to staff and patients were the most important barriers to consider.

CONCLUSIONS

PROMs and PREMs are increasingly used in SUD treatment services, but guidance is needed to support researchers and clinicians in selecting and implementing valid, meaningful, and comparable measures if we want to understand the effects of PROM and PREM data collection and feedback on treatment quality and results.

Social media use for coping with stress and psychological adjustment: A transactional model of stress and coping perspective

Introduction

The psychological well-being of individuals has become an essential issue during the global pandemic. As a pervasive activity for individuals to pull through COVID-19, social media use may play a role in psychological well-being. Drawing on the transactional model of stress and coping, the current study investigated the relationships between COVID-19-related stressors and the use of social media to facilitate specific coping strategies. We further investigated how social media coping strategies impact users' psychological adjustment.

Methods

We collected the data from 641 quarantined residents through a two-wave survey that was conducted in two cities in China during government-mandated lockdowns.

Results

The results showed that perceived COVID-19 stress was related to the intensity of social media use for problem-focused coping, socioemotional coping, and mental disengagement. In addition, individuals' psychological adjustment was positively associated with social media use for socioemotional coping and mental disengagement while negatively related to problem-focused coping. Age was also found to be a moderator of the relationship between socioemotional coping and psychological adjustment.

Discussion

To relieve pandemic-related stress, individuals can actively utilize social media to implement various coping strategies. However, coping activities with social media may not always induce psychological benefits. By revealing the different levels of psychological adjustment among social media users with specific coping strategies, the current research enriched the literature on the effects of social media use on mental health. Findings from this study suggest the need for the prudent use of social media to cope with public health crises.

The Implementation of Measurement-Based Care in the Context of Telemedicine: Qualitative Study

BACKGROUND

The Measurement Based Care in Mental Health Initiative launched by the Department of Veterans Affairs in 2016 is an example of an evidence-based practice that uses patient-reported outcome measures (PROMs) to improve patient outcomes. The acceptance of measurement-based care (MBC) among Veterans Affairs providers is relatively high. However, there are barriers to MBC for telehealth providers. Health information technologies might afford opportunities to address some of the barriers related to the uptake of MBC.

OBJECTIVE

This paper reports on an implementation effort to integrate MBC into mental health care telehealth practice using eHealth solutions.

METHODS

Qualitative data were generated from 22 semistructured interviews with psychiatrists (n=4), psychologists (n=3), social workers (n=3), nurses (n=6), a pharmacist (n=1), and administrative staff (n=5) who provide telemental health care through a community-based outpatient clinic in the rural Midwestern United States. The interviews were conducted during the pilot phase of an implementation initiative to increase the adoption of MBC by revising clinic workflows to integrate the use of eHealth technologies. Data were analyzed using thematic analysis.

RESULTS

Time burden and workflow issues were the most common barrier to provider adoption of MBC; sharing and reviewing pencil-and-paper measures and results in the same room was no longer possible in novel telehealth workflows necessitated by the COVID-19 pandemic. Providers voiced concerns about how long it would take to collect, adequately score, interpret, share, and document the PROMs during the telehealth visit. Concerns about time might also correspond to a gap in providers' familiarity with these assessments, greater comfort in assessing symptoms through clinical interviews, and being accustomed to using the assessments as screening tools more so than longitudinal outcome measures. Capacities associated with eHealth technologies may address workflow concerns and promote providers' understanding and use of the measures as tracking tools.

CONCLUSIONS

The need to use limited appointment time well was a top priority for telemental health providers. eHealth technologies provided operative supports that protect time in appointments by shifting when and how PROMs are collected. Bolstering providers' familiarity with how to use PROMs in the course of treatment may impact providers' buy-in by encouraging them to reconsider how sharing and acting on PROMs could be time well spent.

Brief Adjustment Scale-6 for Measurement-Based Care: Psychometric Properties, Measurement Invariance, and Clinical Utility

The Brief Adjustment Scale-6 (BASE-6) was recently developed for measuring general psychological functioning within measurement-based care (MBC). The present study further evaluated psychometric properties, generalizability to race/ethnic populations, and clinical utility of the BASE-6. Three adult samples, Sample 1: online community participants (n = 394); Sample 2: college students (n = 249); Sample 3: outpatient clinic clients (n = 80), were included. The results demonstrated a high level of internal consistency, good test-retest reliability, and convergent validity in all samples. The unidimensional structure of BASE-6 was confirmed and factorial invariance was established across groups. Finally, the BASE-6 captured change over time by demonstrating a large effect size of pre-post treatment changes and significant linear change in multilevel growth modeling. These results support the BASE-6 as a reliable and valid measure regardless of race/ethnicity and can sensitively detect clinical change over the course of the treatment. Thus, the BASE-6 appears to accurately monitor overall psychological adjustment.

Patients with affective disorders profit most from telemedical treatment: Evidence from a naturalistic patient cohort during the COVID-19 pandemic

BACKGROUND

During the COVID-19 pandemic telemedicine became essential in maintaining diagnostic procedures and treatment in psychiatry. However, it is still an open question if telemedicine is a feasible treatment option for all groups of psychiatric patients alike. This prospective monocentric observational trial was conducted to assess the general applicability of telemedical treatment in a naturalistic psychiatric outpatient cohort and to identify groups of disorders and clusters of psychopathology that respond particularly well to telemedical treatment considering sociodemographic characteristics and patients' perspectives.

METHODS

Patients were recruited April 2020-April 2021 and asked to fill out the WHO-5 and the SCL-90R at baseline, after 4-6 and 8-12 weeks and a feedback-survey. Additionally, medical records, psychopathology, psychosocial functioning, and socio-demographic data were analyzed. Primary outcomes were well-being, psychopathology and functioning during treatment. Secondly, diagnostic groups and psychopathology linked to a superior treatment-response were determined with respect to patients' subjective experiences.

RESULTS

Out of 1.385 patients, 254-mostly with hyperkinetic (35.3%) and depressive disorders (24.6%)-took part. Well-being and SCL-90R total scores improved substantially (both p < 0.001). CGI and GAF scores were worse in depressed subjects (both p < 0.05). Improvement was mainly seen in depressed patients; chronic disorders experienced a decline in well-being. Sociodemographic characteristics could not explain this difference. Particularly female (r = 0.413) patients found telepsychiatry equivalent to conventional treatment. The more virtual sessions participants attended the more likely they were to find telepsychiatry equal to conventional treatment (r = 0.231).

CONCLUSION

Telemedicine is an effective treatment for patients with depression under naturalistic conditions. Telemedical consultations are a simple and reliable way of monitoring symptom severity and directing treatment choices during the treatment of depressive disorders. Patients with depression benefited more from telemedical treatment compared to participants with chronic non-episodic psychiatric disorders. Future research needs to concentrate on improving telemedical treatment options suited for the latter conditions. Psychiatric telemedicine yielded overall high degrees of satisfaction among users.