Authors: Derek Baughman, MD, et al.

Abstract: Telemedicine offers great potential for promoting the quadruple aim in health care delivery: patient experience, clinician experience, cost, and quality. Studies on patient experience have shown high satisfaction with telemedicine, citing convenience, higher levels of comfort, and decreased costs.

Studies on clinician experience have shown improved intra-office effectiveness, patient-clinician communication, and improved outcomes (notably in medication adherence). Regarding health care costs, telemedicine has been shown to favorably affect office management costs, revenue (by decreased staffing requirements and extending office hours), and no-show rates.

Telemedicine has also shown potential for improving clinical outcomes, especially in managing chronic diseases like diabetes and hypertension, reducing diagnostic times, and reducing infection risk.

An unanswered question remained, however: given the unprecedented increase in telemedicine use, does exposure to this type of care affect quality?

The authors therefore set out to compare the quality of telemedicine and in-office visits using standardized performance measures during the COVID-19 telemedicine surge.

In this cohort study of 526,874 patients, telemedicine exposure was associated with significantly better performance, or no difference, in 13 of 16 performance measures. “Findings suggest that telemedicine exposure in primary care poses a low risk for negatively affecting quality performance, highlighting its potential to suitably augment care capacity… especially in chronic disease management and preventive care,” conclude the authors.

Importance: The study also identifies a need to understand relationships between the optimal blend of telemedicine and in-office care in different populations. For policy-makers, the findings support telemedicine’s continued funding. For practices and health systems, the study demonstrates telemedicine’s value in appropriate populations: augmenting primary care capacity without negatively affecting care quality.

Availability: Published by JAMA Network

Authors: Mark Zimmerman, MD, et al.

Abstract: Determinations of the efficacy of treatments for depression most commonly are based on changes in scores on symptom severity scales. “This narrow symptom-focused approach towards evaluating outcome is at variance with patients’ broader conceptualization of the factors deemed important in evaluating the outcome of depression treatment,” say the authors.

Here they examine factors associated with depressed patients’ global ratings of improvement after a treatment intervention. 503 patients with major depressive disorder completed the Remission from Depression Questionnaire (RDQ), a self-report measure that assesses multiple constructs considered by patients to be relevant to assessing treatment outcome.

The patients completed the RDQ at admission and discharge from the treatment program. At discharge, the patients made a global rating of the effectiveness of treatment.

The patients significantly improved from admission to discharge on each RDQ subscale. Changes in the well-being/life satisfaction and coping subscales were the only two subscales that were independently associated with the patients’ ratings of improvement.

“These results suggest that when evaluating outcome in the treatment of depression a focus on symptom improvement is too narrow,” say the authors. “Consideration of a broader perspective in measuring outcome in treatment studies of depression is more consistent with a biopsychosocial conceptualization.”

Importance: When measuring outcome in treatment of depression, considering symptom improvement alone is shown to be a too narrow focus.

Availability: Published in Psychiatry Research

Authors: Kate Helingoe, psychiatry registrar, Waikato District Health Board, Hamilton, New Zealand, et al.

Abstract: Among research selected for the latest edition of Annotations, this study says stigma experienced by trainee psychiatrists completing C-L Psychiatry rotations may lead to them feeling devalued and perceiving service-users to experience poorer care. But multidisciplinary education may potentially combat stigma and contribute to improved integration of services.

The research explores experiences of stigma from the perspectives of six trainee psychiatrists across four hospitals in New Zealand and suggests interventions to tackle it within a hospital environment. Some trainees felt isolated and undervalued. Education, integration, and role clarification within the hospital were identified as ways to reduce stigma.

Jai Gandhi, MD, who selected the Annotation, says the qualitative study points to the impact trainees’ perceptions of stigma had on patient care, patient ability to effectively liaise with medical colleagues, trainee well-being, and the training experience as a whole.

“The study found stigmatizing attitudes left trainees feeling isolated and undervalued, discouraged their desire to pursue careers in C-L Psychiatry, and concerned that patients with psychiatric issues would have worse care,” says Dr. Gandhi. “Trainees expressed beliefs that improved integration and communication with general hospital services could improve collegiality and improved education could combat stigmatizing attitudes.”

Importance: Dr. Gandhi adds: “C-L psychiatrists work in a variety of diverse settings, with colleagues from diverse specialties and backgrounds, and with trainees of various levels of experience. This study highlights the importance of ensuring the lead psychiatrist of a team, whether inpatient or outpatient, is consistently checking in with trainees on their experience of interaction with medical and surgical colleagues, and the influence this may have on their training experience.

“C-L psychiatrists, by nature of their training and experience, may be less sensitive to stigmatizing attitudes that are experienced as novel and shocking to trainees. This study highlights the various impacts this may have, not only on recruiting psychiatrists into C-L Psychiatry but on our patients as well.”

Availability: The latest quarterly Annotations are published on the ACLP website.

Authors: Philip Baiden, PhD, et al.

Abstract: Perceived racial discrimination is a major determinant of health— and among adolescents it is a higher determinant of suicidal ideation than more established risk behaviors.

Those are the findings from a study of perceived racial discrimination in US schools among racial/ethnic minority adolescents.

Data from a sample of 3,241 racial/ethnic minority adolescents from the 2021 Adolescent Behaviors and Experiences Survey were analyzed using binary logistic regression.

Controlling for other factors, racial/ethnic minority adolescents who experienced perceived racial discrimination had 1.57 times higher odds of experiencing suicidal ideation.

 Other more established factors associated with suicidal behavior included:

• Self-identifying as lesbian/gay, bisexual, or other.
• Experiencing cyberbullying.
• Feeling sad or hopeless.
• Poor mental health during the pandemic.

“The findings extend past research and demonstrate that racial/ethnic minority adolescents who experienced perceived racial discrimination were more likely to report suicidal behaviors over and above other well-established risk factors for suicidal behaviors,” report the authors.

Importance: Racial discrimination is shown here to have a higher rating among adolescents leading to suicidal ideation than other well-established risk factors. As the authors say, further studies employing longitudinal frameworks are needed to elucidate mechanisms underlying these associations.

Availability: Published in Psychiatry Research

Authors: Lynsay Ayer, PhD, et al.

Abstract: Utilizing a clinical pathway to identify and effectively manage those at risk of suicide can provide a roadmap for sustainable and feasible suicide prevention. Similar pathways assist providers in screening and treating conditions like lung cancer and substance use disorders. “However, comparable guidance for suicide risk screening in adult primary care practice is less developed and tends to focus on a specific screening tool,” say the authors.

To support ongoing efforts to standardize screening in primary care settings, the authors formed a workgroup to create a detailed, evidence-based clinical pathway to help clinicians identify suicide risk in adults. All workgroup members were experts in suicide prevention and/or primary care. Most have led or participated in clinical trials involving identification and treatment of suicide risk and implementation of specific suicide-prevention and other mental health interventions in general medical settings. The workgroup drew on input from additional experts.

The workgroup ultimately produced three documents designed to provide guidance for primary care practices interested in implementing suicide risk screening.

“With increasing interest in and demand for suicide risk screening and assessment in primary care, we see practical and clinical value in offering evidence-informed guidance on how suicide prevention can be implemented systematically, particularly for practices which may not have the same infrastructure and resources as larger hospital systems,” say the authors.

Importance: 80% of suicide decedents had contact with primary care within one year of their suicide. This and other research underscore the importance of screening for suicide risk within primary care settings, and implementation of suicide risk screening is already underway in many practices— but without established, evidence-based clinical pathways.

Availability: Published in the Journal of the  Academy of Consultation-Liaison Psychiatry