Suddenly Becoming a "Virtual Doctor": Experiences of Psychiatrists Transitioning to Telemedicine During the COVID-19 Pandemic

Coping strategies and psychological distress in postoperative recovery: A repeated-measures study in women undergoing breast-conserving surgery

Objective

Breast-conserving surgery (BCS) is the standard treatment for early-stage breast cancer, yet patients often experience significant psychological distress and physical symptoms during recovery. This study aimed to explore the relationships between antecedents, physical symptoms (pain and nausea), psychological distress, and coping strategies utilized by women recovering from BCS to improve management of postoperative challenges.

Methods

This repeated-measures descriptive study involved 75 women who underwent BCS with sentinel lymph node biopsy at a National Cancer Institute-designated center. Participants completed the National Comprehensive Cancer Network (NCCN) Distress Thermometer and Ways of Coping Instrument on Postoperative Day 1 (POD1) and POD14. Bivariate analyses, multiple linear regression, and structural equation modeling were conducted to evaluate associations between antecedents, coping strategies, and distress. Open-ended responses were qualitatively analyzed for thematic content.

Results

Seeking social support (POD1 mean ​= ​1.25; POD14 mean ​= ​1.20) and planful problem-solving (POD1 mean ​= ​1.19; POD14 mean ​= ​1.04) were the most frequently used coping strategies, while accepting responsibility and confrontive coping were least utilized. Overall coping strategy use decreased between POD1 and POD14, likely reflecting recovery adaptation. Significant predictors of distress included escape-avoidance coping (β ​= ​0.415, P ​< ​0.001), social support (β ​= ​0.270, P ​= ​0.02), history of nausea (β ​= ​0.517, P ​< ​0.001), and age (β ​= ​0.293, P ​= ​0.007). Coping strategies did not mediate the relationship between antecedents and distress.

Conclusions

Adaptive coping strategies such as social support and planful problem-solving play a critical role in mitigating distress during BCS recovery. Interventions should emphasize fostering these strategies and addressing high-risk groups, such as younger patients and those with a history of nausea. Despite limitations, this study underscores the importance of supporting adaptive coping to improve postoperative outcomes and provides a basis for future research.

Assessment of the Performance of an AI-Driven SpeechEnhancer Algorithm for Speech Enhancement Following Laryngeal Oncosurgery

OBJECTIVE

The present study aimed to evaluate the effectiveness of the performance of an AI-driven SpeechEnhancer algorithm speech synthesis following laryngeal oncosurgery.

METHODS

The original and synthesized speech samples from 77 patients after laryngeal oncosurgery were evaluated in this study. A panel of four experts conducted the auditory-perceptual speech evaluation using the IINFVo and the Similarity Mean Opinion Score (SMOS) scales. The acoustic analysis of speech samples was performed using the Average Voicing Evidence (AVE), Proportion of Voiced Frames (PVF), Proportion of Voiced Speech Frames (PVS) and Acoustic Substitution Voicing Index (ASVI) measures.

RESULTS

The synthesized speech samples outperformed the original speech in acoustic and auditory-perceptual evaluation. The mean total IINFVo scores were statistically significantly higher (P < 0.05) in the synthesized speech samples group [IINFVo = 5.59 (SD = 0.83)] when compared with the original speech samples [IINFVo = 4.18 (SD = 1.11)]. The mean SMOS score of 2.42 (SD = 1.19) demonstrated a modest level of similarity between the synthesized and original speech samples. A statistically significant (P < 0.05) improvement of acoustic AVE, PVF, and PVS parameters in synthesized speech samples was observed. The quality of the synthesized speech [ASVI = 19.22 (SD = 7.44)] statistically significantly (P = 0.001) surpassed the original substitution voicing speech quality (ASVI = 9.39 (SD = 4.34).

CONCLUSION

The AI-driven "SpeechEnhancer" algorithm is a promising tool for speech rehabilitation after laryngeal oncosurgery. It demonstrates the potential for use in clinical settings by healthcare professionals and patients following laryngeal carcinoma surgery.

The Impact of COVID-19 on the Division of Household Labor Among Women Physicians and Advanced Practice Providers

BACKGROUND

COVID-19 increased the burden of childcare on parents, leaving women vulnerable to increased disparities in the division of domestic labor. Women healthcare workers may be at heightened risk of worsening gender parity in the workplace as a result.

OBJECTIVE

To examine the impact of the COVID-19 pandemic on gender parity in the division of household responsibilities among women healthcare workers.

DESIGN

Cross-sectional survey assessing changes in the workplace and changes in the balance of domestic duties with partners via multiple open-ended and Likert-scale type questions. Data were analyzed descriptively, including thematic analysis of free-text responses.

PARTICIPANTS

This survey study included 1459 women healthcare workers and 244 of their partners.

MAIN MEASURES

Primary outcomes were levels of responsibility for domestic labor, including housework, childcare, and child education. Free-text questions focused on the impact of household responsibilities on the workplace.

KEY RESULTS

In total, 1459 healthcare workers identifying as women responded to this survey. Of them, 655 (45%) practice in an academic setting, and 1025 (70%) are physicians. Additionally, 244 self-identifying partners of women healthcare workers responded; the majority were men (204 [84%]), and over one-third (91 [38%]) work in healthcare. Among respondents overall, women reported doing most of the housework (52% of respondents [756/1459] versus 27% of partners [61/244]) and child education, compared with their partners (31% of respondents [451/1459] versus 23% of partners [55/244]). Thematic analysis of free-text questions revealed that women experienced worsened gender parity in the workplace because of increased household responsibilities.

CONCLUSIONS

We observed significant gender-based disparities in the division of household labor among healthcare workers, with negative impacts on work performance, focus, and academic productivity. Our results support the notion that the COVID-19 pandemic worsened gender parity in the homes of healthcare workers, thus negatively affecting gender parity in the medical workplace.

Implementing contingency management in family medicine: A qualitative inquiry on provider and patient preferences for a low magnitude reward program compatible with buprenorphine treatment

Background

Contingency management (CM) is an effective yet underutilized behavioral intervention that uses rewards to improve outcomes in medication for opioid use disorder (MOUD) treatment. Prior implementation attempts have focused on specialized addiction clinics, using intensive daily treatment with methadone and high reward values (e.g. >$200 total). However, many people get MOUD from less specialized, more accessible, family medicine clinics. These clinics could also benefit from CM, yet present unique challenges for CM. Family medicine clinics typically use buprenorphine as their primary medication, which requires less intensive dosing schedules and thus provides fewer CM opportunities. They may also have lower institutional willingness to use high-value rewards. As an initial step in user-centered design of a low value reward (<$75 total) CM program for the family medicine context, we conducted qualitative interviews with patients and staff in the buprenorphine treatment program of a family medicine department. We gathered and analyzed qualitative data on CM knowledge, preferred program parameters, and implementation considerations.

Method

Participants (N = 24) were buprenorphine treatment staff (n = 12) and patients (n = 12). Participants completed 30-50-minute semi-structured interviews, analyzed using rapid matrix analysis.

Results

Participants had little experience with CM, but generally viewed CM as acceptable, appropriate, and feasible. Interviewees coalesced around having staff who were not providers with prescription privileges conduct CM, consistent rather than escalating payments, and physical rewards delivered in-person. Potential challenges included medical record integration, demands on staff time, and confirmation of patients' goal completion.

Conclusions

Patient and staff feedback was well-aligned, especially regarding rewards as an opportunity for staff-patient connection and the need for simplicity. Some consensus suggestions (e.g. non-escalating rewards) conflict with extant CM literature. Implications for implementation of CM in this setting are presented. These findings inform user-centered design and iteration of a CM program for this accessible, non-specialized family medicine setting.

Telemedicine as an Approach to the Mental Health of Healthcare Workers in Angola

INTRODUCTION

African healthcare professionals face significant mental health challenges; therefore, telemedicine can overcome geographical barriers and improve access to mental healthcare.

OBJECTIVE

The objective of this study was to identify the key factors influencing the adoption of telemedicine as a tool to support healthcare workers' mental health in an Angolan healthcare network and develop a telemedicine model tailored to this context.

METHODOLOGY

This mixed-method study collected quantitative data from a questionnaire applied to healthcare workers (n = 275), which were analyzed using descriptive statistics and logistic regressions. Qualitative data were obtained through structured interviews (n = 5) with psychologists and psychiatrists, and analyzed using thematic analysis in MAXQDA (Version 2022, VERBI Software, Germany), to identify recurring patterns and themes. The data were triangulated to ensure the rigor and consistency of the findings. Participation was anonymous and voluntary, and informed consent was obtained from all participants.

RESULTS

Previous experiences with mental health consultations, perceptions of teleconsultations, and doctor-patient relationship were significant in influencing telemedicine adoption by workers. The thematic analysis revealed four themes: perception and ease of telemedicine use, intention to use, and the perception of mental health in Angola. The key adoption factors for providers included project feasibility, management support, training, payment policies, and adherence to legal, ethical, and deontological standards.

CONCLUSIONS

The adoption of telemedicine for occupational mental health requires culturally adapted interventions and compliance with technological and data protection standards. Hospital management must address infrastructure challenges and mental health perceptions, and implement sustainable strategies that promote occupational well-being within the organization.

Evaluating the Mental Health (MH) impact of the COVID-19 pandemic for stable patients with HIV

People living with HIV (PLWH) have a higher prevalence of mental ill health compared to the general population. We aimed to understand the impact of the COVID-19 pandemic and omitting routine HIV appointments on the mental health (MH) of PLWH. Between April 2020 and March 2021, routine appointments for "stable" PLWH were replaced by virtual consultations. MH assessments using standardised questionnaires were compared before and during the pandemic. Full data were available for 426 individuals after excluding those with incomplete data and those requiring early review for non-MH-related issues. The results showed that 277 (65%) experienced no/minimal MH symptoms throughout, indicating robust MH. For depression, scores worsened in 59 (13.8%), improved in 62 (14.6%) and remained stable in 305 (71.6%). For anxiety, scores worsened in 55 (12.9%), improved in 64 (15%) and remained stable in 307 (72.1%). A total of 98.4% of individuals remained virally suppressed, with 7 developing a detectable viral load. One person stopped antiretroviral treatment secondary to an MH crisis. Findings suggest that the COVID-19 pandemic did not significantly impact the overall MH in our cohort of PLWH. It also demonstrates an effective implementation of virtual consultations. The complex nature of MH in PLWH highlights the need for individualised MH care.

A Qualitative Evidence Synthesis of Patient and Provider Attitudes Toward Audio-Only Telemental Health Care

Background: Audio-only (phone) telemental health care can increase access to care, but its lack of nonverbal information may negatively impact care quality as compared to video or in-person visits. The objective of this work was to understand patient and provider attitudes toward phone care via a review of qualitative research. Methods: A qualitative evidence synthesis was conducted of peer-reviewed qualitative research published between 2013 and 2023. Studies were required to include qualitative data regarding patient and/or provider attitudes toward audio-only telemental health care. Results pertinent to phone care were extracted and underwent coding followed by theme identification. Results: We identified 2,065 abstracts and 29 articles were ultimately included in the synthesis; 27 of these studies were conducted during the COVID-19 pandemic. Five themes described benefits of phone care, nine described drawbacks, and three themes were neutral. Phone care was seen as easy to use, particularly for briefer check-ins or as a back-up option if video calls failed, and some patients preferred the privacy of not being seen. However, the loss of visual information during phone visits was considered particularly challenging in the treatment of more complex or severe patients; providers questioned whether they were able to provide high quality care, and patients reported feeling less supported and understood by their providers. Conclusions: The relative benefits and drawbacks of audio-only telemental health care must be carefully weighed against the options of video or in-person treatment based on patient needs and severity. Future work should continue to examine patient and provider attitudes toward phone care as the mental health landscape evolves postpandemic.

Experience and attitudes in relation to telepsychiatry use among non-consultant doctors

INTRODUCTION

In order to minimise physical interaction during the COVID-19 pandemic, telepsychiatry became a key part of clinical practice for many psychiatrists.

METHODS

This study involved an exploratory, cross-sectional, opt-in online survey circulated to non-consultant doctors in psychiatry working in Ireland. It assessed experience and attitudes in relation to telepsychiatry use.

DISCUSSION

The response rate was 11.6% (n = 61). Forty-eight individuals (78.6%) had delivered clinical care using telepsychiatry. Fifty-nine individuals (96.7%) were unfamiliar with telepsychiatry prior to the pandemic. Most respondents had not received specific training around use of a telepsychiatry platform (86.9%, n = 63) and were unaware of published guidelines around its optimal use (54.1%, n = 33). Respondents' concerns included issues around connectivity, medico-legal uncertainty and clinical effectiveness.

CONCLUSION

Conclusions drawn are limited by the potential for selection bias in this study. Nonetheless the paper has highlighted important issues including the need for more research assessing telepsychiatry clinical and curricular experience. Additional curricular interventions during training could build skillset and confidence in telepsychiatry.

Perceived Barriers and Facilitators of Behavioral-Health Modality Change Adoption During the COVID-19 Pandemic: A Systematic Review

Introduction

During the Coronavirus Disease 2019 pandemic, there was a surge in demand for mental health services worldwide, presenting challenges for healthcare institutions as they navigated changes in policy and safety regulations. In the United States, this resulted in many behavioral health modality changes to remain in compliance with the Center for Disease Control guidelines. A growing body of literature has documented these, yet few explored barriers and facilitators affecting the adoption of these modality delivery changes. The researchers conducted a systematic review using the PRISMA method, focusing on service delivery changes across healthcare systems in the United States from March 2020 to May 2022.

Objective

The study objective was to identify barriers and facilitators affecting the adoption of changes to modality delivery of behavioral health services due to pandemic restrictions.

Methods

This was a systematic review that utilized the PRISMA method. The researchers identified 445 initial articles from eight databases using predetermined keywords and implemented a three-round screening process to select the most pertinent articles for this review. The researchers used a thematic analysis focused on user-related, program-related, technology, and environment-related constructs relevant to engagement with digital mental health interventions, and also addressed provider and administrative-related barriers and facilitators of virtual behavioral health modality changes. Barriers and facilitators were operationalized using the Borghouts Model.

Results

This systematic review revealed several common barriers and facilitators, including underdeveloped technology infrastructure, privacy and confidentiality concerns, poor technology literacy, availability of diverse technology options, provider technology training, and ease of integration into everyday life.

Conclusion

This review provides insights into barriers and facilitators of modality change adoption, which could inform the development and implementation of virtual mental healthcare services and may help optimize the application of these services by improving our understanding and ability to overcome barriers influencing their adoption.

Challenges and Facilitators in Implementing Remote Patient Monitoring Programs in Primary Care

BACKGROUND

The COVID-19 pandemic resulted in greater use of remote patient monitoring (RPM). However, the use of RPM has been modest compared to other forms of telehealth.

OBJECTIVE

To identify and describe barriers to the implementation of RPM among primary care physicians (PCPs) that may be constraining its growth.

DESIGN

We conducted 20 semi-structured interviews with PCPs across the USA who adopted RPM. Interview questions focused on implementation facilitators and barriers and RPM's impact on quality. We conducted thematic analysis of semi-structured interviews using both inductive and deductive approaches. The analysis was informed by the NASSS (non-adoption and abandonment and challenges to scale-up, spread, and sustainability) framework.

PARTICIPANTS

PCPs who practiced at least 10 h per week in an outpatient setting, served adults, and monitored blood pressure and/or blood glucose levels with automatic transmission of data with at least 3 patients.

KEY RESULTS

While PCPs generally agreed that RPM improved quality of care for their patients, many identified barriers to adoption and maintenance of RPM programs. Challenges included difficulties handling the influx of data and establishing a manageable workflow, along with digital and health literacy barriers. In addition to these barriers, many PCPs did not believe RPM was profitable.

CONCLUSIONS

To encourage ongoing growth of RPM, it will be necessary to address implementation barriers through changes in payment policy, training and education in digital and health literacy, improvements in staff roles and workflows, and new strategies to ensure equitable access.

Environmental Factors for Sustained Telehealth Use in Mental Health Services: A Mixed Methods Analysis

Background: The mental health service delivery gap remains high globally. Appropriate telehealth use may increase capacity through flexible remote care provision. Despite the historical lack of telehealth integration into publicly funded mental health services, during COVID-19 lockdowns, services rapidly switched to telephone and audiovisual care provision. In Aotearoa New Zealand (NZ), this was abandoned when no longer required by COVID-19 restrictions. This study explores environmental factors associated with telehealth implementation and ongoing use or discontinuation across a multiregional outpatient mental health service. This work contributes to understanding system-level factors influencing telehealth use and thus informs policy and practice in postpandemic environments. Methods: This mixed methods study applied an interpretive description methodology. Semistructured interviews with 33 mental health clinicians were thematically analysed. Qualitative findings were reframed and evaluated using time series analyses of population-level quantitative data (prior to and throughout the pandemic). Findings were synthesised with qualitative themes to develop an understanding of environmental factors contributing to telehealth use. Results: Findings highlighted an increase in clients assessed by mental health services and declining clinician numbers, contributing to pressure placed on clinicians. There was a lack of culture supporting telehealth, including limited awareness, leadership, and champions to facilitate implementation. Some teams provided services suited to telehealth; other subspeciality teams had limited applications for telehealth. There was a general lack of policy and guidelines to support telehealth use and limited technical support for clinicians unfamiliar with audiovisual software. Conclusion: Disorganised telehealth adoption in the study regions provides insight into wider environmental drivers affecting telehealth uptake. For telehealth to become a workable service delivery mode following COVID-19, stewardship and culture shifts are required, including policy development, technical support, and resources to support clinical teams. Telehealth may address growing service demand by improving interfaces with primary care and providing timely access to specialist input.

Factors critical for the successful delivery of telehealth to rural populations: a descriptive qualitative study

BACKGROUND

The use of telehealth has proliferated to the point of being a common and accepted method of healthcare service delivery. Due to the rapidity of telehealth implementation, the evidence underpinning this approach to healthcare delivery is lagging, particularly when considering the uniqueness of some service users, such as those in rural areas. This research aimed to address the current gap in knowledge related to the factors critical for the successful delivery of telehealth to rural populations.

METHODS

This research used a qualitative descriptive design to explore telehealth service provision in rural areas from the perspective of clinicians and describe factors critical to the effective delivery of telehealth in rural contexts. Semi-structured interviews were conducted with clinicians from allied health and nursing backgrounds working in child and family nursing, allied health services, and mental health services. A manifest content analysis was undertaken using the Framework approach.

RESULTS

Sixteen health professionals from nursing, clinical psychology, and social work were interviewed. Participants mostly identified as female (88%) and ranged in age from 26 to 65 years with a mean age of 47 years. Three overarching themes were identified: (1) Navigating the role of telehealth to support rural healthcare; (2) Preparing clinicians to engage in telehealth service delivery; and (3) Appreciating the complexities of telehealth implementation across services and environments.

CONCLUSIONS

This research suggests that successful delivery of telehealth to rural populations requires consideration of the context in which telehealth services are being delivered, particularly in rural and remote communities where there are challenges with resourcing and training to support health professionals. Rural populations, like all communities, need choice in healthcare service delivery and models to increase accessibility. Preparation and specific, intentional training for health professionals on how to transition to and maintain telehealth services is a critical factor for delivery of telehealth to rural populations. Future research should further investigate the training and supports required for telehealth service provision, including who, when and what training will equip health professionals with the appropriate skill set to deliver rural telehealth services.

Distress, Pain, and Nausea on Postoperative Days 1 and 14 in Women Recovering From Breast-Conserving Surgery: A Repeated-Measures Study

OBJECTIVES

To determine the incidence and trajectory of distress, pain, and nausea and vomiting at postoperative day (POD) 1 and at POD 14 following breast-conserving surgery.

SAMPLE & SETTING

75 women aged 18 years or older receiving breast-conserving surgery with sentinel lymph node biopsy for treatment of early-stage primary breast cancer at an ambulatory surgery center.

METHODS & VARIABLES

This prospective, repeated-measures study assessed distress, pain, and nausea and vomiting using the National Comprehensive Cancer Network Distress Thermometer and Problem List on POD 1 and POD 14.

RESULTS

Pain and distress scores were highest on POD 1. The number of women who reported depression increased from POD 1 to POD 14. Thematic analysis revealed that family concerns, fears and worries, and postoperative issues contributed to pain and distress.

IMPLICATIONS FOR NURSING

Women experience pain and distress during recovery at home after breast-conserving surgery. Nurses can use these results to apply evidence-based practice to reduce this symptom burden. Future nursing research should focus on targeted interventions outside of the hospital setting.

A Scoping Review of Changes to Patient-Doctor Communication During COVID-19

Effective communication between patients and doctors is fundamental to high-quality healthcare, patient safety, and overall satisfaction. However, the onset of COVID-19 has prompted significant shifts in communication from in-room and face-to-face interactions to virtual consults. The impact of this pandemic-related change on patient-doctor communication goals, processes, attributes, and environment remains unclear. We undertook a scoping review involving the systematic search of seven academic databases for relevant articles published up to and including June 2021. In total, 47 articles were identified that met the inclusion criteria. We applied the patient-doctor communication framework to guide our deductive thematic analysis of articles included, sorting results from reported studies and position papers into themes and sub-themes. The theme of communication goals highlighted sub-themes related to patient safety, convenience, affordability, and satisfaction; preparation included sub-themes on technology interventions, workforce training, and digital literacy; participant attributes included compassion for doctors and rebuilding trust among patients; and communication process included issues related to telemedicine or video conferencing, challenges with diminished patient privacy, and distractions in the patient's home setting. Finally, the environment theme included insights into doctors' workload, isolation, and anxiety and how changes requiring increases in virtual consults iteratively altered confidence in care provision and communication with patients. Results of the scoping review provide important insights for strengthening virtual patient-doctor interactions, including target areas for training and professional development during and beyond the current pandemic.

Modality and terminology changes for behavioral health service delivery during the COVID-19 pandemic: a systematic review

Introduction

The COVID-19 pandemic prompted healthcare professionals to implement service delivery adaptations to remain in compliance with safety regulations. Though many adaptations in service delivery were reported throughout the literature, a wide variety of terminology and definitions were used.

Methods

To address this, we conducted a PRISMA review to identify service delivery adaptations across behavioral healthcare services in the United States from March 2020 to May 2022 and to identify variations in terminology used to describe these adaptations. We identified 445 initial articles for our review across eight databases using predetermined keywords. Using a two-round screening process, authors used a team approach to identify the most appropriate articles for this review.

Results

Our results suggested that a total of 14 different terms were used to describe service modality changes, with the most frequent term being telehealth (63%). Each term found in our review and the frequency of use across identified articles is described in detail.

Discussion

Implications of this review such as understanding modality changes during the COVID-19 pandemic and beyond are discussed. Our findings illustrate the importance of standardizing terminology to enhance communication and understanding among professionals.

Telemedicine from Home or the Office: Perceptions of Mental Health Providers

Introduction: The COVID-19 pandemic led to a rapid transition to telemedicine for mental health care and redefined many providers' work environments and practices. The purpose of the study was to investigate the impact of work location on telemental health (TMH) benefits, disruptions, and concerns to further understand the rapid implementation of telemedicine for mental health treatment. Methods: A sample of 175 practicing TMH providers completed an online survey between July and August 2020. Providers answered questions about personal demographics and practice characteristics. Next, they answered questions about benefits, disruptions, and concerns regarding the use of telemedicine in their practice. Chi-square and independent samples t-test were conducted to identify work location differences for personal demographics and clinical practice characteristics. Three multivariate analyses of covariance were conducted to examine overall differences in perceptions of telemedicine benefits, concerns, and disruptions based on work location while covarying for provider race, ethnicity, percentage of caseload seen through telemedicine, practice type, specialty, and primary method of reimbursement. Results: TMH providers who primarily work from an office reported more benefit of reduced costs/overhead (ηp2 = 0.039), less benefit of limiting the spread of the virus (ηp2 = 0.028), and more concern about reimbursement (ηp2 = 0.046) than those who primarily work from home. We observed no difference in disruptions, patient access to care, quality of care, and work-life balance. Discussion: Exploration into work location of TMH providers aids in understanding of clinical workflows and provider wellbeing. Our findings suggest that telemedicine may be easily integrated into different types of clinical workflows and work locations.

Optimizing methadone dose adjustment in patients with opioid use disorder

Introduction

Opioid use disorder is a cause for concern globally. This study aimed to optimize methadone dose adjustments using mixed modeling and machine learning.

Methods

This retrospective study was conducted at Taichung Veterans General Hospital between January 1, 2019, and December 31, 2020. Overall, 40,530 daily dosing records and 1,508 urine opiate test results were collected from 96 patients with opioid use disorder. A two-stage approach was used to create a model of the optimized methadone dose. In Stage 1, mixed modeling was performed to analyze the association between methadone dose, age, sex, treatment duration, HIV positivity, referral source, urine opiate level, last methadone dose taken, treatment adherence, and likelihood of treatment discontinuation. In Stage 2, machine learning was performed to build a model for optimized methadone dose.

Results

Likelihood of discontinuation was associated with reduced methadone doses (β = 0.002, 95% CI = 0.000-0.081). Correlation analysis between the methadone dose determined by physicians and the optimized methadone dose showed a mean correlation coefficient of 0.995 ± 0.003, indicating that the difference between the methadone dose determined by physicians and that determined by the model was within the allowable range (p < 0.001).

Conclusion

We developed a model for methadone dose adjustment in patients with opioid use disorders. By integrating urine opiate levels, treatment adherence, and likelihood of treatment discontinuation, the model could suggest automatic adjustment of the methadone dose, particularly when face-to-face encounters are impractical.

Healthcare Access for a Diverse Population with Schizophrenia Following the Onset of the COVID-19 Pandemic

COVID-19 has had a disproportionate impact on the most disadvantaged members of society, including minorities and those with disabling chronic illnesses such as schizophrenia. We examined the pandemic's impacts among New York State's Medicaid beneficiaries with schizophrenia in the immediate post-pandemic surge period, with a focus on equity of access to critical healthcare. We compared changes in utilization of key behavioral health outpatient services and inpatient services for life-threatening conditions between the pre-pandemic and surge periods for White and non-White beneficiaries. We found racial and ethnic differences across all outcomes, with most differences stable over time. The exception was pneumonia admissions-while no differences existed in the pre-pandemic period, Black and Latinx beneficiaries were less likely than Whites to be hospitalized in the surge period despite minorities' heavier COVID-19 disease burden. The emergence of racial and ethnic differences in access to scarce life-preserving healthcare may hold lessons for future crises.

Understanding the uptake of virtual care for first and return outpatient appointments in child and adolescent mental health services: a mixed-methods study

OBJECTIVE

To describe patterns of virtual and in-person outpatient mental health service use and factors that may influence the choice of modality in a child and adolescent service.

DESIGN

A pragmatic mixed-methods approach using routinely collected administrative data between 1 April 2020 and 31 March 2022 and semi-structured interviews with clients, caregivers, clinicians and staff. Interview data were coded according to the Consolidated Framework for Implementation Research (CFIR) and examined for patterns of similarity or divergence across data sources, respondents or other relevant characteristics.

SETTING

Child and adolescent outpatient mental health service, Nova Scotia, Canada.

PARTICIPANTS

IWK Health clinicians and staff who had participated in virtual mental healthcare following its implementation in March 2020 and clients (aged 12-18 years) and caregivers of clients (aged 3-18 years) who had received treatment from an IWK outpatient clinic between 1 April 2020 and 31 March 2022 (n=1300). Participants (n=48) in semi-structured interviews included nine clients aged 13-18 years (mean 15.7 years), 10 caregivers of clients aged 5-17 years (mean 12.7 years), eight Community Mental Health and Addictions booking and registration or administrative staff and 21 clinicians.

RESULTS

During peak pandemic activity, upwards of 90% of visits (first or return) were conducted virtually. Between waves, return appointments were more likely to be virtual than first appointments. Interview participants (n=48) reported facilitators and barriers to virtual care within the CFIR domains of 'outer setting' (eg, external policies, client needs and resources), 'inner setting' (eg, communications within the service), 'individual characteristics' (eg, personal attributes, knowledge and beliefs about virtual care) and 'intervention characteristics' (eg, relative advantage of virtual or in-person care).

CONCLUSIONS

Shared decision-making regarding treatment modality (virtual vs in-person) requires consideration of client, caregiver, clinician, appointment, health system and public health factors across episodes of care to ensure accessible, safe and high-quality mental healthcare.

The Adoption of AI in Mental Health Care-Perspectives From Mental Health Professionals: Qualitative Descriptive Study

BACKGROUND

Artificial intelligence (AI) is transforming the mental health care environment. AI tools are increasingly accessed by clients and service users. Mental health professionals must be prepared not only to use AI but also to have conversations about it when delivering care. Despite the potential for AI to enable more efficient and reliable and higher-quality care delivery, there is a persistent gap among mental health professionals in the adoption of AI.

OBJECTIVE

A needs assessment was conducted among mental health professionals to (1) understand the learning needs of the workforce and their attitudes toward AI and (2) inform the development of AI education curricula and knowledge translation products.

METHODS

A qualitative descriptive approach was taken to explore the needs of mental health professionals regarding their adoption of AI through semistructured interviews. To reach maximum variation sampling, mental health professionals (eg, psychiatrists, mental health nurses, educators, scientists, and social workers) in various settings across Ontario (eg, urban and rural, public and private sector, and clinical and research) were recruited.

RESULTS

A total of 20 individuals were recruited. Participants included practitioners (9/20, 45% social workers and 1/20, 5% mental health nurses), educator scientists (5/20, 25% with dual roles as professors/lecturers and researchers), and practitioner scientists (3/20, 15% with dual roles as researchers and psychiatrists and 2/20, 10% with dual roles as researchers and mental health nurses). Four major themes emerged: (1) fostering practice change and building self-efficacy to integrate AI into patient care; (2) promoting system-level change to accelerate the adoption of AI in mental health; (3) addressing the importance of organizational readiness as a catalyst for AI adoption; and (4) ensuring that mental health professionals have the education, knowledge, and skills to harness AI in optimizing patient care.

CONCLUSIONS

AI technologies are starting to emerge in mental health care. Although many digital tools, web-based services, and mobile apps are designed using AI algorithms, mental health professionals have generally been slower in the adoption of AI. As indicated by this study's findings, the implications are 3-fold. At the individual level, digital professionals must see the value in digitally compassionate tools that retain a humanistic approach to care. For mental health professionals, resistance toward AI adoption must be acknowledged through educational initiatives to raise awareness about the relevance, practicality, and benefits of AI. At the organizational level, digital professionals and leaders must collaborate on governance and funding structures to promote employee buy-in. At the societal level, digital and mental health professionals should collaborate in the creation of formal AI training programs specific to mental health to address knowledge gaps. This study promotes the design of relevant and sustainable education programs to support the adoption of AI within the mental health care sphere.

"The best of a bad situation?" A mixed methods survey exploring patients' perspectives on physiotherapy-led online group exercise programmes

INTRODUCTION

The COVID-19 pandemic saw the migration of many physiotherapy-led group exercise programmes towards online platforms. This online survey aimed to ascertain the patients' views of online group exercise programmes (OGEP), including their satisfaction with various aspects of these programmes, the advantages and disadvantages and usefulness beyond the pandemic.

METHODS

A mixed-methods design was utilised with a cross-sectional national online survey of patients who had previously attended a physiotherapy-led OGEP in Ireland. The survey collected both qualitative and quantitative data. Descriptive statistics were used to summarise the ordinal and continuous data and conventional content analysis was used to analyse the free-text responses.

RESULTS

In total, 94 patients completed the surveys. Fifty percent of patients questioned would prefer in-person classes. Despite only a quarter of patient respondents preferring online classes going forward, satisfaction with the OGEPs was high with nearly 95% of respondents somewhat or extremely satisfied. Decreased travel and convenience were cited as the main benefits of OGEPs. Decreased social interaction and decreased direct observation by the physiotherapist were the main disadvantages cited.

CONCLUSION

Patients expressed high satisfaction rates overall with online classes, but would value more opportunities for social interaction. Although 50% of respondents would choose in-person classes in the future, offering both online and in-person classes beyond the pandemic may help to suit the needs of all patients and improve attendance and adherence.

Standardising the role of a digital navigator in behavioural health: a systematic review

As the number and availability of digital mental health tools increases, patients and clinicians see benefit only when these tools are engaging and well integrated into care. Digital navigators-ie, members of health-care teams who are dedicated to supporting patient use of digital resources-offer one solution and continue to be piloted in behavioural health; however, little is known about the core features of this position. The aims of this systematic review were to assess how digital navigators are implemented in behavioural health, and to provide a standardised definition of this position. In January, 2023, we conducted a systematic literature search resulting in 48 articles included in this systematic review. Results showed high heterogeneity between four attributes of digital navigators: training specifications, educational background, frequency of communication, and method of communication with patients. Reported effect sizes for depression and anxiety were medium to large, but could not be synthesised due to study heterogeneity and small study sample size. This systematic review was registered with PROSPERO (CRD42023391696). Results suggest that digital navigator support can probably increase access to, engagement with, and clinical integration of digital health technology, with standards for training and defined responsibilities now emerging.

Lockdown during the early phase of Covid-19 - effects on specialized mental health services and vocational activities for patients with psychotic disorders

PURPOSE

People with psychotic disorders may be particularly vulnerable to adverse effects from restrictions implemented to limit the COVID-19 pandemic. Mental health professionals may also be at risk of adverse effects. The aim of this study was to investigate the impact of potential changes in accessibility, quality of care and vocational activity on people with psychotic disorders and the impact on clinicians working in these conditions.

MATERIALS AND METHODS

Patients and clinicians in specialized mental health services for psychotic disorders answered questionnaires regarding changes in treatment, quality of treatment, vocational activity, and well-being. Data was analyzed with nonparametric tests.

RESULTS

Inpatients appeared more influenced by the restrictions than outpatients, however, quality of treatment was regarded relatively unaffected. Clinicians seemed satisfied working under these conditions, though a larger portion of clinicians reported changes in treatment compared to patients. The patients who reported being affected by changes in vocational activity tended to report negative effects, but the majority reported being unaffected.

CONCLUSION

Overall, patients and clinicians appeared to cope well with the changes they experienced in accessibility, quality of care and vocational activity during the early phases of the pandemic.

Understanding psychology students' perspective on video psychotherapy and their intention to offer it after graduation: a mixed-methods study

Introduction

Video psychotherapy (VPT) demonstrated strong clinical efficacy in the past, with patients and psychotherapists expressing satisfaction with its outcomes. Despite this, VPT only gained full recognition from the German healthcare system during the COVID-19 pandemic. As society increasingly relies on new media, it seems likely that VPT will become even more relevant. Previous studies surveyed practicing psychotherapists and patients about advantages and disadvantages of VPT. In contrast, our approach targets a younger generation, specifically psychology students intending to become licensed practitioners after graduation.

Methods

Our mixed-methods study was conducted in an online survey format and had two main objectives. Firstly, we investigated which person-related variables are associated with psychology students' behavioral intention to offer VPT after graduation, using a multiple regression analysis. Secondly, we explored psychology students' perception of advantages and disadvantages of VPT and identified their desired learning opportunities regarding VPT in their study program, using qualitative content analysis.

Results

A sample of 255 psychology students participated. The multiple regression model explains 73% of inter-individual variance in the intention to offer VPT, with attitudes toward VPT showing the strongest relationship with intention to offer VPT. Expected usefulness, satisfaction with video conferencing, and subjective norm also showed significant relations. The students provided 2,314 statements about advantages, disadvantages, and desired learning opportunities, which we coded by means of three category systems. In terms of advantages, the most frequently mentioned categories were low inhibition threshold, flexibility in terms of location, and no need to travel. For disadvantages, the predominant categories included lack of closeness between patient and psychotherapist, lack of nonverbal cues, and problems with technology or internet connection. Regarding desired learning opportunities, training for technical skills, practical application through role-playing and self-experience, and general information about VPT were the most mentioned categories. In addition, we identified numerous other aspects related to these topics, reflecting a differentiated and balanced assessment of VPT.

Discussion

We discuss the theoretical and practical implications of our findings for training the next generation of psychotherapists and outline a specific five-step plan for integrating VPT into study programs.

Pareto-Optimized Non-Negative Matrix Factorization Approach to the Cleaning of Alaryngeal Speech Signals

The problem of cleaning impaired speech is crucial for various applications such as speech recognition, telecommunication, and assistive technologies. In this paper, we propose a novel approach that combines Pareto-optimized deep learning with non-negative matrix factorization (NMF) to effectively reduce noise in impaired speech signals while preserving the quality of the desired speech. Our method begins by calculating the spectrogram of a noisy voice clip and extracting frequency statistics. A threshold is then determined based on the desired noise sensitivity, and a noise-to-signal mask is computed. This mask is smoothed to avoid abrupt transitions in noise levels, and the modified spectrogram is obtained by applying the smoothed mask to the signal spectrogram. We then employ a Pareto-optimized NMF to decompose the modified spectrogram into basis functions and corresponding weights, which are used to reconstruct the clean speech spectrogram. The final noise-reduced waveform is obtained by inverting the clean speech spectrogram. Our proposed method achieves a balance between various objectives, such as noise suppression, speech quality preservation, and computational efficiency, by leveraging Pareto optimization in the deep learning model. The experimental results demonstrate the effectiveness of our approach in cleaning alaryngeal speech signals, making it a promising solution for various real-world applications.

Prescribing Medications for Alcohol Use Disorder: A Qualitative Study of Primary Care Physician Decision Making

PURPOSE

Over 29 million Americans have alcohol use disorder (AUD). Though there are effective medications for AUD (MAUD) that can be prescribed within primary care, they are underutilized. We aimed to explore how primary care physicians familiar with MAUD make prescribing decisions and to identify reasons for underuse of MAUD within primary care.

METHODS

We conducted semistructured interviews with 19 primary care physicians recruited from a large online database of medical professionals. Physicians had to have started a patient on MAUD within the last 6 months in an outpatient setting. Inductive and deductive thematic analysis was informed by the theory of planned behavior.

RESULTS

Physicians endorsed that it is challenging to prescribe MAUD due to several reasons, including: (1) somewhat negative personal beliefs about medication effectiveness and likelihood of patient adherence; (2) competing demands in primary care that make MAUD a lower priority; and, (3) few positive subjective norms around prescribing. To make MAUD prescribing a smaller component of their practice, physicians reported applying various rules of thumb to select patients for MAUD. These included recommending MAUD to the patients who seemed the most motivated to reduce drinking, those with the most severe AUD, and those who were also receiving other treatments for AUD.

CONCLUSIONS

There is a challenging implementation context for MAUD due to competing demands within primary care. Future research should explore which strategies for identifying a subset of patients for MAUD are the most appropriate and most likely to improve population health and health equity.

Stakeholder perspectives and experiences of the implementation of remote mental health consultations during the COVID-19 pandemic: a qualitative study

BACKGROUND

Remote mental health consultations were swiftly implemented across mental health services during the COVID-19 pandemic. Research has begun to inform future design and delivery of telemental health services. Exploring the in-depth experiences of those involved is important to understand the complex, multi-level factors that influence the implementation of remote mental health consultations. The aim of this study was to explore stakeholder perspectives and experiences of the implementation of remote mental health consultations during the COVID-19 pandemic in Ireland.

METHODS

A qualitative study was conducted whereby semi-structured, individual interviews were undertaken with mental health providers, service users, and managers (n = 19) to acquire rich information. Interviews were conducted between November 2021 and July 2022. The interview guide was informed by the Consolidated Framework for Implementation Research (CFIR). Data were analysed thematically using a deductive and inductive approach.

RESULTS

Six themes were identified. The advantages of remote mental health consultations were described, including convenience and increased accessibility to care. Providers and managers described varying levels of success with implementation, citing complexity and incompatibility with existing workflows as barriers to adoption. Providers' access to resources, guidance, and training were notable facilitators. Participants perceived remote mental health consultations to be satisfactory but not equivalent to in-person care in terms of quality. Views about the inferior quality of remote consultations stemmed from beliefs about the inhibited therapeutic relationship and a possible reduction in effectiveness compared to in-person care. Whilst a return to in-person services was mostly preferred, participants acknowledged a potential adjunct role for remote consultations in certain circumstances.

CONCLUSIONS

Remote mental health consultations were welcomed as a means to continue care during the COVID-19 pandemic. Their swift and necessary adoption placed pressure on providers and organisations to adapt quickly, navigating challenges and adjusting to a new way of working. This implementation created changes to workflows and dynamics that disrupted the traditional method of mental health care delivery. Further consideration of the importance of the therapeutic relationship and fostering positive provider beliefs and feelings of competence are needed to ensure satisfactory and effective implementation of remote mental health consultations going forward.

Clinicians' and Users' Views and Experiences of a Tele-Mental Health Service Implemented Alongside the Public Mental Health System during the COVID-19 Pandemic

A tele-mental health model called Head to Health was implemented in the state of Victoria, Australia to address the crisis caused by the COVID-19 pandemic. It was a free centralized intake service that adopted a targeted approach with several novel elements, such as stepped care and telehealth. This study examines the views and experiences of clinicians and service users of the tele-mental health service in the Gippsland region of Victoria during the COVID-19 pandemic. Data from clinicians were obtained via an online 10-item open-ended survey instrument and from service users through semi-structured interviews. Data were obtained from 66 participants, including 47 clinician surveys and 19 service user interviews. Six categories emerged from the data. They were: 'Conditions where use of tele-mental health is appropriate', 'Conditions where tele-mental health may not be useful', 'Advantages of tele-mental health', 'Challenges in using tele-mental health', 'Client outcomes with tele-mental health', and 'Recommendations for future use'. This is one of a few studies where clinicians' and service users' views and experiences have been explored together to provide a nuanced understanding of perspectives on the efficacy of tele-mental health when it was implemented alongside public mental health services.

Provider Perspectives on Sleep as a Determinant of Health and Housing Outcomes among Veterans Experiencing Homelessness: An Exploratory, Social-Ecological Study

Sleep problems are common among United States (U.S.) veterans and are associated with poor health, mental health, and functioning. Yet, little is known about insufficient sleep and factors contributing to sleep disparities among veterans experiencing homelessness. We conducted semi-structured interviews to better understand the clinical, environmental, and structural factors contributing to insufficient sleep among veterans and to improve care for this population. Interviews were conducted with 13 providers caring for veterans experiencing homelessness, including physicians, psychologists, nurses, social workers, and peer support specialists. Providers worked at a West Coast VA institution serving a large population of veterans experiencing homelessness. Interviews were analyzed for themes pertaining to sleep using the social-ecological model as a framework. On an individual level, factors influencing sleep included psychiatric disorders and use of substances. On an interpersonal level, factors included safety concerns while sleeping. On an environmental level, factors included noise and proximity to others as barriers to sleep. On the organizational level, logistical issues scheduling sleep clinic appointments and lack of transportation to attend sleep clinic appointments were identified as treatment barriers. These findings can inform future research studying the impact of sleep on health and housing outcomes and interventions addressing sleep among veterans experiencing homelessness.

Barriers and Facilitators to Psychologists' Telepsychology Uptake during the Beginning of the COVID-19 Pandemic

The COVID-19 pandemic transformed the delivery of psychological services as many psychologists adopted telepsychology for the first time or dramatically increased their use of it. The current study examined qualitative and quantitative data provided by 2619 practicing psychologists to identify variables facilitating and impeding the adoption of telepsychology in the U.S. at the beginning of the COVID-19 pandemic. The top five reported barriers were: inadequate access to technology, diminished therapeutic alliance, technological issues, diminished quality of delivered care or effectiveness, and privacy concerns. The top five reported facilitators were: increased safety, better access to patient care, patient demand, efficient use of time, and adequate technology for telepsychology use. Psychologists' demographic and practice characteristics robustly predicted their endorsement of telepsychology barriers and facilitators. These findings provide important context into the implementation of telepsychology at the beginning of the pandemic and may serve future implementation strategies in clinics and healthcare organizations attempting to increase telepsychology utilization.

Ensuring privacy in telemedicine: Ethical and clinical challenges

Data privacy in telemedicine has been extensively considered and reviewed in the literature, such as explorations of consent, who can access information, and the security of electronic systems. However, privacy breaches are also a potential concern in the physical setting and surroundings of the patient. Here we review clinical situations in which there is unanticipated loss of privacy, as well as potential physical and psychological safety concerns for the patient and others when privacy is limited. We identify ethical concerns and explore the challenges of supporting full true autonomous decision-making in this situation. We close with preliminary recommendations at the patient, clinician, and systems levels to help ensure privacy is maintained.

Frontline experiences of delivering remote mental health supports during the COVID-19 pandemic in Scotland: innovations, insights and lessons learned from mental health workers

COVID-19 restrictions drove rapid adaptations to service delivery and new ways of working within Scotland's mental health sector. This study explores mental health workers' (MHWs') experiences of delivering their services remotely. Twenty participants, who had worked in mental health professions in the National Health Service (NHS) in Scotland throughout the COVID-19 pandemic, took part in online semi-structured interviews. Data was transcribed then analysed using an inductive thematic analysis. Two major themes are reported: (1) 'Improved Flexibility for both MHWs and Service Users' and (2) 'Teletherapies Challenge Therapeutic Boundaries'. In relation to (1) virtual platforms were seen as vital in maintaining patient care throughout the COVID-19 pandemic and a valuable resource for service users (SUs) who had previously struggled with mobility or social anxieties when accessing face-to-face services. Some MHWs' also noted benefits for their productivity and comfort. Regarding (2) MHWs highlighted that whilst conducting teletherapies from home, work-life boundaries became blurred and, in some instances, typically comforting spaces became associated with the traumatic content discussed by SUs. These stressors seemed to be compounded by MHWs' isolation, as they were less able to draw upon their colleagues for support. Further, confidentiality could not be assured, as MHWs and SUs alike had to accommodate their family members. These findings highlight important insights from MHWs in adapting to rapid changes in mental health working practices, particularly in relation to the challenges of delivering quality, safe and equitable services and the increased use of teletherapies. Such insights are vital in informing service developments and supporting future pandemic preparedness across a range of healthcare contexts and countries seeking to adopt hybrid models of mental health service delivery.

Long-Term Prospects for Telemedicine in Opioid Use Disorder (OUD) Treatment: Results from a Longitudinal Survey of OUD Clinicians

BACKGROUND

During the pandemic, there was a dramatic shift to telemedicine for opioid use disorder (OUD) treatment. Little is known about how clinician attitudes about telemedicine use for OUD treatment are evolving or their preferences for future use.

OBJECTIVE

To understand OUD clinician views of and preferences regarding telemedicine.

DESIGN

Longitudinal survey (wave 1, December 2020; wave 2, March 2022).

SUBJECTS

National sample of 425 clinicians who treat OUD.

MAIN MEASURES

Self-reported proportion of OUD visits delivered via telemedicine (actual vs. preferred), comfort in using video visits for OUD, impact of telemedicine on work-related well-being.

KEY RESULTS

The mean reported percentage of OUD visits delivered via telemedicine (vs. in person) dropped from 56.9% in December 2020 to 41.5% in March 2022; the mean preferred post-pandemic percentage of OUD visits delivered via telemedicine was 34.8%. Responses about comfort in using video visits for different types of OUD patients remained similar over time despite clinicians having substantially more experience with telemedicine by spring 2022 (e.g., 35.8% vs. 36.0% report being comfortable using video visits for new patients). Almost three-quarters (70.9%) reported that most of their patients preferred to have the majority of their visits via telemedicine, and 76.7% agreed that the option to do video visits helped their patients remain in treatment longer. The majority (58.7%) reported that telemedicine had a positive impact on their work-related well-being, with higher rates of a positive impact among those who completed training more recently (68.5% of those with < 10 years, 62.1% with 10-19 years, and 45.8% with 20 + years, p < 0.001).

CONCLUSIONS

While many surveyed OUD clinicians were not comfortable using telemedicine for all types of patients, most wanted telemedicine to account for a substantial fraction of OUD visits, and most believed telemedicine has had positive impacts for themselves and their patients.

"Working Together": Perspectives of Healthcare Professionals in Providing Virtual Care to Youth with Chronic Pain during the COVID-19 Pandemic

BACKGROUND

The onset of the coronavirus disease in 2019 necessitated a rapid transition to virtual care for chronic pain treatment.

METHODS

A mixed methods design was implemented using qualitative interviews and quantitative satisfaction surveys. Interviews were conducted in February 2021 with a sample of healthcare professionals (HCPs; n = 6) who had provided multidisciplinary treatment (MDT) through an outpatient hospital pediatric chronic pain program. Satisfaction surveys were distributed to all MDT professionals employed by the clinic in April 2021 (n = 13 of 20 eligible; 65% response rate). Participants represented medicine, rehabilitation, and mental health professionals.

RESULTS

Analysis of interviews generated five themes: (1) adaptation to virtual care, (2) benefits of virtual care, (3) limitations of virtual care, (4) shifting stance on virtual care over time, and (5) considerations for implementing virtual care. The satisfaction survey data revealed that respondents were able to effectively provide appropriate diagnoses, recommendations, and/or care plans for pediatric chronic pain via virtual care (n = 12, 92.3%). Detailed survey responses are presented by discipline.

CONCLUSIONS

This study provides a rich exploration of HCPs' experiences in providing MDT for pediatric chronic pain within a virtual care model. The current results may contribute to the future development of guidelines for virtual care delivery with pediatric chronic pain populations.

Perceptions of Pediatric Endocrinologists and Neurologists on the Drivers of Telehealth Use

OBJECTIVE

To assess the extent and drivers of telehealth use variation across clinicians within the same pediatric subspecialties.

METHODS

In this mixed methods study, 8 pediatric medical groups in California shared data for eleven subspecialties. We calculated the proportion of total visits delivered via telehealth by medical group for each subspecialty and identified the 8 most common International Classification of Diseases 10 diagnoses for telehealth and in-person visits in endocrinology and neurology. We conducted semi-structured interviews with 32 pediatric endocrinologists and neurologists and applied a positive deviance approach comparing high versus low utilizers to identify factors that influenced their level of telehealth use.

RESULTS

In 2019, medical groups that submitted quantitative data conducted 1.8 million visits with 549,306 unique pediatric patients. For 3 subspecialties, there was relatively little variation in telehealth use across medical groups: urology (mean: 16.5%, range: 9%-23%), orthopedics (mean: 7.2%, range: 2%-14%), and cardiology (mean: 11.2%, range: 2%-24%). The remaining subspecialties, including neurology (mean: 58.6%, range: 8%-93%) and endocrinology (mean: 49.5%, range: 24%-92%), exhibited higher levels of variation. For both neurology and endocrinology, the top diagnoses treated in-person were similar to those treated via telehealth. There was limited consensus on which clinical conditions were appropriate for telehealth. High telehealth utilizers were more comfortable conducting telehealth visits for new patients and often worked in practices with innovations to support telehealth.

CONCLUSIONS

Clinicians perceive that telehealth may be appropriate for a range of clinical conditions when the right supports are available.

Caregiver and Clinician Experience With Virtual Services for Children and Youth With Complex Needs During COVID-19

INTRODUCTION

During the COVID-19 pandemic, support services for children and youth quickly shifted to virtual means. To continue delivering essential, trauma-informed, specialized services, the center transitioned to providing most services by phone/video conference.

METHOD

A quality improvement project using survey methods was conducted to determine if virtual delivery was timely and satisfactory for inpatient and outpatient care.

RESULTS

Findings indicated services were timely. Caregivers appreciated the support, felt a personal connection with staff, and confirmed services met their goals and expectations. However, challenges faced by staff included engaging the child/youth by phone/video, loss of collaboration with colleagues, and concerns about fulfilling their role through virtual means.

DISCUSSION

Understanding stakeholder experiences illuminated the path of quality improvement during this major shift in service delivery. Benefits were shown for a blended model of in-person and virtual services on the basis of clinical judgment and the unique needs of clients and families in considering future service model options.

Mental health professionals and telehealth in a rural setting: a cross sectional survey

BACKGROUND

Telehealth usage has been promoted in all settings but has been identified as a panacea to issues of access and equity in the rural context. However, uptake and widespread integration of telehealth across all parts of the health system has been slow, with a myriad of barriers documented, including in rural settings. The crisis of the COVID-19 pandemic, saw barriers rapidly overturned with the unprecedented and exponential rise in telehealth usage. The uniqueness of the crisis forced telehealth adoption, but as the urgency stabilises, pandemic learnings must be captured, utilised, and built upon in a post-pandemic world. The aim of this study was to document staff experiences and perceptions of delivering rural psychological therapies via telehealth during the pandemic and to capture learnings for future rural telehealth delivery.

METHODS

An online cross-sectional survey that explored mental health professional's experiences, use, and perceptions of telehealth before and after pandemic-enforced changes to service delivery.

RESULTS

Sixty-two respondents completed the questionnaire (response rate 68%). Both the delivery of telehealth via telephone and online video conferencing significantly increased during the pandemic (66% vs 98%, p < .001 for telephone and 10% vs 89%, p < 0.001 for online video). Respondents indicated that client's access to services and attendance had improved with telehealth use but their attention and focus during sessions and non-verbal communication had been negatively affected. The challenges for older adults, people with learning and sensory disabilities, and residents in remote areas with poorer mobile/internet connectivity were identified. Despite these challenges, none of the respondents indicated a preference to return to fully face-to-face service delivery with most (86%) preferring to deliver psychological therapies fully or mostly via telehealth.

CONCLUSIONS

This study addresses three major gaps in knowledge: the experience of delivering local telehealth solutions to address rural mental health needs, the provision of strong rural-specific telehealth recommendations, and the dearth of rural research emanating from the United Kingdom. As the world settles into a living with COVID-19 era, the uniqueness of the rural telehealth context may be forgotten as urban myopia continues to dominate telehealth policy and uptake. It is critical that rural resourcing and digital connectivity are addressed.

The impact of COVID-19 on the mental health and substance use health (MHSUH) workforce in Canada: a mixed methods study

BACKGROUND

The increased need for mental health and substance use health (MHSUH) services during the COVID-19 pandemic underscores the need to better understand workforce capacity. This study aimed to examine the pandemic's impact on the capacity of MHSUH service providers and to understand reasons contributing to changes in availability or ability to provide services.

METHODS

We conducted a mixed method study including a pan-Canadian survey of 2177 providers of MHSUH services and semi-structured interviews with 13 key informants. Survey participants answered questions about how the pandemic had changed their capacity to provide services, reasons for changes in capacity, and how their practice had during the pandemic. Thematic analysis of key informant interviews was conducted to gain a deeper understanding of the impact of the pandemic on the MHSUH workforce.

RESULTS

Analyses of the survey data indicated that the pandemic has had diverse effects on the capacity of MHSUH workers to provide services: 43% indicated decreased, 24% indicated no change, and 33% indicated increased capacity. Logistic regression analyses showed that privately funded participants had 3.2 times greater odds of increased capacity (B = 1.17, p < 0.001), and participants receiving funding from a mix of public and private sources had 2.4 times greater odds of increased capacity (B = 0.88, p < 0.001) compared to publicly funded participants. Top reasons for decreases included lockdown measures and clients lacking access or comfort with virtual care. Top reasons for increases included using virtual care and more people having problems relevant to the participant's skills. Three themes were constructed from thematic analysis of key informant interviews: the differential impact of public health measures, long-term effects of pandemic work conditions, and critical gaps in MHSUH workforce data.

CONCLUSIONS

The COVID-19 pandemic has had a substantial impact on the capacity of the MHSUH workforce to provide services. Findings indicate the importance of increasing and harmonizing funding for MHSUH services across the public and private sectors, developing standardized datasets describing the MHSUH workforce, and prioritizing equity across the spectrum of MHSUH services.

Telephone treatments in Improving Access to Psychological Therapies services: an analysis of use and impact on treatment uptake

BACKGROUND

There is debate about how best to increase access to psychological therapy and deliver mental healthcare effectively and efficiently at a national level. One trend is the increased use of the telephone to deliver therapy. However, there is the potential to disadvantage certain patient groups and/or impact on uptake of help. This study aims to answer three questions: (i) Which factors are associated with being offered an assessment by telephone? (ii) Which factors are associated with attendance at assessment? and (iii) What is the impact of an assessment by telephone on subsequent treatment appointment?

METHODS

Routine outcome data was provided by seven UK Improving Access to Psychological Therapy services. The analysis sample comprised 49,923 patients who referred to 615 general practices in 2017. Multilevel modelling, including service and GP practice as random factors, was used to answer the three research questions.

RESULTS

The offer of an initial assessment by telephone was strongly associated with local service configuration. Patient self-referral, a shorter wait, greater age and lower deprivation were associated with attendance at assessment and subsequent treatment session. Telephone mode assessment had no impact on the uptake of the assessment but may influence the uptake of further treatment if this was also by telephone. The practitioner carrying out the assessment had a significant effect on subsequent treatment uptake.

CONCLUSION

Offering telephone assessments does not have a negative impact on uptake of assessment and services may benefit by facilitating and integrating telephone assessments into their systems. The COVID-19 pandemic has accelerated the use of telephone and other remote means of delivery, and results from this study can inform services to consider how best to re-configure post-pandemic.

Benefits and Challenges of Video Consulting for Mental Health Diagnosis and Follow-Up: A Qualitative Study in Community Care

Mental health services continue to experience rising demand that exceeds capacity. The COVID-19 pandemic exacerbated this crisis, with access to services being reduced. Although video consultations (VCs) are a solution, usage in UK community mental healthcare settings remains limited. This study aims to investigate psychiatrists' and general practitioners' (GPs) perceptions of the benefits and challenges of VC for the diagnosis and follow-up of general adult mental health patients in the community during the COVID-19 pandemic. Semi-structured interviews in NHS community mental healthcare settings were conducted. Psychiatrists (n = 11) and GPs (n = 12) were recruited through purposive sampling. An explorative qualitative approach was employed. Data were analysed using thematic analysis. Four key themes were identified: (1) patient access to VC, (2) suitability of VC for mental health consultations, (3) information gathering with VC and (4) clinician satisfaction with VC. This study provides valuable insights into the experiences of psychiatrists and GPs working in the UK during the COVID-19 pandemic. To facilitate a digital-first future for the NHS, greater investment in remote technologies is required, particularly in the context of growing mental healthcare demand. Though face-to-face consultations remain the gold standard, VC provides an efficient way of communicating with patients, particularly those with less severe forms of mental illness.

To introduce or not? Strategic analysis of hospital operations with telemedicine

Despite its efficiency in reducing the impact of pandemics (e.g., the COVID-19), whether to introduce telemedicine as an additional way to serve chronically ill patients remains controversial for hospitals in many countries. This paper builds a stylized model to investigate a hospital's telemedicine strategy and the corresponding impacts on its operations regarding outpatient management of chronic diseases. We implement our analysis from three key concerns of the hospital in the presence of a pandemic: the differences in medical consumption and reimbursement between in-person and telemedicine modalities and the effort cost of infection reduction resulting from the pandemic. We find that in the absence of the pandemic, the hospital prefers to introduce telemedicine when the differences in medical consumption and reimbursement are both small. In the presence of the pandemic, we find that the introduction of telemedicine does not always benefit the hospital and that it is better not to introduce telemedicine in some cases since it may exacerbate the negative influence of the pandemic on the hospital's total costs. Furthermore, we surprisingly find that the hospital may set greater in-person capacity but less telemedicine capacity in response to the outbreak of the pandemic under certain conditions, which contradicts public beliefs. Finally, we show that social welfare can be improved by introducing telemedicine when the effort cost of infection reduction and the difference in reimbursement are both of moderate size. The condition under which social welfare is improved tightens with a greater difference in medical consumption.

Consultation-Liaison Telepsychiatry: A Coded Thematic Analysis of Clinicians' Reported Experiences

BACKGROUND

Telepsychiatry is now common practice. Within consultation-liaison psychiatry (CLP), previous work has shown that telepsychiatry is feasible and satisfactory. To date, there has not been qualitative work done within CLP to describe the clinician's experience with telepsychiatry.

OBJECTIVE

This study aimed to perform a thematic analysis of clinicians' perceived benefits and limitations of providing telepsychiatry in CLP.

METHODS

An anonymous clinician survey querying demographics, education, training, technological experience, and practice characteristics was distributed via social media and professional listservs, the quantitative results of which are presented elsewhere. Two questions (What was the best/worst aspect of adapting to telepsychiatry?) required free-text responses; comments were allowed elsewhere. We performed a thematic analysis of the text responses because of its flexibility and ability to develop new insights. We synthesized and generated a codebook iteratively. Initial coding was completed by 3 co-authors independently, followed by discussion to build consensus. We used qualitative content analysis to better understand common trends and frequencies in the data. Saturation of themes was reached.

RESULTS

A total of 333 behavioral health clinicians completed the survey, including 197 CLP participants. Most respondents (98.5%) responded to at least 1 open-answer question, with 314 reporting the worst aspects of telepsychiatry and 315 reporting the best aspects. Respondents made insightful comments about boundaries, public health implications, and the need for training. We categorized the results into implications for practice, therapeutic relationship, and uniquely affected populations.

CONCLUSIONS

These results show that telepsychiatry has both unique benefits and limitations within CLP. Our work examines and describes these nuances. We believe that future use of telepsychiatry will be synergistic with in-person care and that the 2 modalities will be used together to maximize benefits. A public health focus on improving Internet access and simplifying interstate licensure would improve equitable access and utilization of outpatient telepsychiatry. Telepsychiatry can be successful for inpatient Consultation-Liaison work but requires thoughtful triage and teamwork.

Investigating the Association Between Telemedicine Use and Timely Follow-Up Care After Acute Cardiovascular Hospital Encounters

Background

Telemedicine use increased dramatically during the COVID-19 pandemic; however, questions remain as to how telemedicine use impacts care.

Objectives

The purpose of this study was to examine the association of increased telemedicine use on rates of timely follow-up and unplanned readmission after acute cardiovascular hospital encounters.

Methods

We examined hospital encounters for acute coronary syndrome, arrhythmia disorders, heart failure (HF), and valvular heart disease from a large U.S., multisite, integrated academic health system among patients with established cardiovascular care within the system. We evaluated 14-day postdischarge follow-up and 30-day all-cause unplanned readmission rates for encounters from the pandemic "steady state" period from May 24, 2020 through December 31, 2020, when telemedicine use was high and compared them to those of encounters from the week-matched period in 2019 (May 26, 2019, through December 31, 2019), adjusting for patient and encounter characteristics.

Results

The study population included 6,026 hospital encounters. In the pandemic steady-state period, 40% of follow-ups after these encounters were conducted via telemedicine vs 0% during the week-matched period in 2019. Overall, 14-day follow-up rates increased from 41.7% to 44.9% (adjusted difference: +2.0 percentage points [pp], 95% CI: -1.1 to +5.1 pp, P = 0.20). HF encounters experienced the largest improvement from 50.1% to 55.5% (adjusted difference: +6.5 pp, 95% CI: +0.5 to +12.4 pp, P = 0.03). Overall 30-day all-cause unplanned readmission rates fell slightly, from 18.3% to 16.9% (adjusted difference -1.6 pp; 95% CI: -4.0 to +0.8 pp, P = 0.20).

Conclusions

Increased telemedicine use during the COVID-19 pandemic was associated with earlier follow-ups, particularly after HF encounters. Readmission rates did not increase, suggesting that the shift to telemedicine did not compromise care quality.

Patient and provider perspectives of the implementation of remote consultations for community-dwelling people with mental health conditions: A systematic mixed studies review

Remote, or tele-, consultations became a necessary form of mental healthcare provision during the COVID-19 pandemic. As the prevalence of mental health problems rises, they may have a role in future mental health services. We aimed to review the literature on patient and provider perspectives on factors influencing the implementation of remote consultations for community-dwelling people with mental health conditions. We searched five electronic databases (PubMed, EMBASE, Web of Science, CINAHL, and PsycINFO) for empirical research up to July 13th, 2022. Only studies of synchronous, interactive remote consultations conducted via video, phone, or live-messaging between patients and providers were included. Two reviewers independently assessed the quality of included studies using the Mixed Methods Appraisal Tool. We integrated qualitative and quantitative data from 39 studies into a single mixed-methods synthesis. We mapped reported factors to the domains of the Consolidated Framework for Implementation Research (CFIR). Acceptability was generally high among participants, despite concerns about the quality of care and the perceived impeded therapeutic relationship. A prominent facilitator was the increased accessibility and convenience of remote consultations, while lack of appropriate infrastructure and low patient comfort and competence were among the most prevalent barriers. This review highlights the importance of patient preferences and provider buy-in to the future of remote consultations.

Digital Technology in Psychiatry: Survey Study of Clinicians

BACKGROUND

Digital technology has the potential to transform psychiatry, but its adoption has been limited. The proliferation of telepsychiatry during the COVID-19 pandemic has increased the urgency of optimizing technology for clinical practice. Understanding clinician attitudes and preferences is crucial to effective implementation and patient benefit.

OBJECTIVE

Our objective was to elicit clinician perspectives on emerging digital technology.

METHODS

Clinicians in a large psychiatry department (inpatient and outpatient) were invited to complete a web-based survey about their attitudes toward digital technology in practice, focusing on implementation, clinical benefits, and expectations about patients' attitudes. The survey consisted of 23 questions that could be answered on either a 3-point or 5-point Likert scale. We report the frequencies and percentages of responses.

RESULTS

In total, 139 clinicians completed the survey-they represent a variety of years of experience, credentials, and diagnostic subspecialties (response rate 69.5%). Overall, 83.4% (n=116) of them stated that digital data could improve their practice, and 23.0% (n=32) of responders reported that they had viewed patients' profiles on social media. Among anticipated benefits, clinicians rated symptom self-tracking (n=101, 72.7%) as well as clinical intervention support (n=90, 64.7%) as most promising. Among anticipated challenges, clinicians mostly expressed concerns over greater time demand (n=123, 88.5%) and whether digital data would be actionable (n=107, 77%). Furthermore, 95.0% (n=132) of clinicians expected their patients to share digital data.

CONCLUSIONS

Overall, clinicians reported a positive attitude toward the use of digital data to not only improve patient outcomes but also highlight significant barriers that implementation would need to overcome. Although clinicians' self-reported attitudes about digital technology may not necessarily translate into behavior, our results suggest that technologies that reduce clinician burden and are easily interpretable have the greatest likelihood of uptake.

Synthesis of the Evidence on What Works for Whom in Telemental Health: Rapid Realist Review

BACKGROUND

Telemental health (delivering mental health care via video calls, telephone calls, or SMS text messages) is becoming increasingly widespread. Telemental health appears to be useful and effective in providing care to some service users in some settings, especially during an emergency restricting face-to-face contact, such as the COVID-19 pandemic. However, important limitations have been reported, and telemental health implementation risks the reinforcement of pre-existing inequalities in service provision. If it is to be widely incorporated into routine care, a clear understanding is needed of when and for whom it is an acceptable and effective approach and when face-to-face care is needed.

OBJECTIVE

This rapid realist review aims to develop a theory about which telemental health approaches work (or do not work), for whom, in which contexts, and through what mechanisms.

METHODS

Rapid realist reviewing involves synthesizing relevant evidence and stakeholder expertise to allow timely development of context-mechanism-outcome (CMO) configurations in areas where evidence is urgently needed to inform policy and practice. The CMO configurations encapsulate theories about what works for whom and by what mechanisms. Sources included eligible papers from 2 previous systematic reviews conducted by our team on telemental health; an updated search using the strategy from these reviews; a call for relevant evidence, including "gray literature," to the public and key experts; and website searches of relevant voluntary and statutory organizations. CMO configurations formulated from these sources were iteratively refined, including through discussions with an expert reference group, including researchers with relevant lived experience and frontline clinicians, and consultation with experts focused on three priority groups: children and young people, users of inpatient and crisis care services, and digitally excluded groups.

RESULTS

A total of 108 scientific and gray literature sources were included. From our initial CMO configurations, we derived 30 overarching CMO configurations within four domains: connecting effectively; flexibility and personalization; safety, privacy, and confidentiality; and therapeutic quality and relationship. Reports and stakeholder input emphasized the importance of personal choice, privacy and safety, and therapeutic relationships in telemental health care. The review also identified particular service users likely to be disadvantaged by telemental health implementation and a need to ensure that face-to-face care of equivalent timeliness remains available. Mechanisms underlying the successful and unsuccessful application of telemental health are discussed.

CONCLUSIONS

Service user choice, privacy and safety, the ability to connect effectively, and fostering strong therapeutic relationships need to be prioritized in delivering telemental health care. Guidelines and strategies coproduced with service users and frontline staff are needed to optimize telemental health implementation in real-world settings.

TRIAL REGISTRATION

International Prospective Register of Systematic Reviews (PROSPERO); CRD42021260910; https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42021260910.

Socially Distanced Emergencies: Clinicians' Experience with Tele-behavioral Health Safety Planning

Psychiatry has experienced a rapid expansion in providing behavioral health services using virtual means; however, little is known regarding clinicians' experience in managing patient emergencies during virtual encounters. We present survey data from a large academic psychiatry department designed to better understand safety planning while delivering ambulatory tele-behavioral health services during the COVID-19 pandemic. Clinical faculty in the department were sent an anonymous electronic survey developed and distributed using the Qualtrics™ software. Departmental leadership provided a list of clinicians who performed ambulatory care. SAS 9.4 was used to conduct statistical analysis for associations between variables. Approximately one quarter (23.3%) of respondents engaged in proactive safety planning for most of their outpatient virtual visits, while a little over half (53.2%) of clinicians implemented emergent safety planning between just one to five visits. Clinicians who more frequently implemented emergency protocols were more likely to engage in proactive safety planning prior to emergencies (p = 0.0115). 10.8% of participants petitioned for civil commitment, though those that did identified numerous challenges. Our results reinforce the importance in appropriate training regarding best practices while providing tele-behavioral health care, with increased awareness for conducting safety planning and implementing emergent protocols. Furthermore, while petitioning for civil commitment is a relatively low base rate event in a large outpatient practice, these data and narrative feedback help to outline challenges and potential measures to improve this process for all parties. Increased attention to protocols and procedures are key as the utilization of virtual care within psychiatry continues.

Mental Health Act 1983 assessments: The use of video technology

Covid-19 requires practitioners to reflect on how they deliver health services. Using technology, in particular video technology, has increased, especially in primary care. This article considers the implications of technology for assessments under the Mental Health Act 1983. NHS Covid-19 guidance anticipated its use in assessments, but this was held to be unlawful. Is this the right decision or is it too restrictive an interpretation of the 1983 Act? The article argues that consideration should be given to the potential role, if any, of video technology in assessments and identifies some issues that need to be addressed. Use of these technologies should be part of the current review of the 1983 legislation.