Heidi Anne Duerr, MPH

Between the Goldwater Rule and boundary issues, it can be tricky for the field and individual psychiatrists to address issues like politics and election anxiety.


A. I welcome conversations and aim to help people understand their own issues, anxieties, and reasons for voting.

B. I cautiously welcome patients and people in my life to discuss issues, but avoid making comments or sharing my opinions. 

C. I dissuade such conversations in my practice, but I am very engaged in my personal life.

D. I avoid all political conversations except for a close circle of family/friends.

Poll

Do you live by the old adage not to discuss religion or politics? Or, do you welcome controversy and let the chips fall where they may?

Poll: Psychiatrists and the 2020 Presidential Election

With the National Conventions upon us, election coverage has started to increase in the news. 

A.	Yes, especially compared to the last presidential election(s).

B.	Yes, but probably not more than past elections. 

C.	No, because I/we avoid discussing politics.

D.	No, people believe things will work out.

With the National Conventions upon us, election coverage has started to increase in the news. Are you noticing more election anxiety in family, friends, and your community?

Poll: Gauging Election Anxiety in the Community 

While racism is not new, the events of 2020 have emphasized the need to recognize and address the ways racism lurks in medicine, psychiatry, and society.

Seven Psychiatrists Against Racism (SPAR), a diverse and passionate group of professionals, have gathered to 

the issues and discuss what can be done to address the problems and inequities in our country. And, you are cordially invited to be part of the solution and the conversation.

Register for this dynamic Webinar on Thursday, August 20th, at 7:00 PM eastern/4:00 PM pacific by registering 

Articles

What can be done about racism? We're so glad you asked.

Hiding in Plain Sight: Racism and What You Can Do About It

Tensions continue to run high in the country due to record unemployment rates, the threat of the pandemic, and the rise of awareness of sociocultural issues.

B. No, my patients don’t seem to be bothered or concerned about the upcoming election

As cultural issues collide with science, what concerns do you have for the health of your patients?

Poll: Are Your Patients Reporting Election-Anxiety Symptoms?

As the fall approaches, so does election season. With so much uncertainty thanks to COVID-19 and other issues in this country, there is talk of “election anxiety.”

A. I am very worried, and I am doing something productive about it

B. I am very worried, but I am not doing anything 

Is anxiety related to the election a true phenomenon? 

Election Anxiety Poll—What Are Your Thoughts?

Slideshows

According to some estimates, nearly 2.3 million people in the US suffer from dementia-related psychosis. The Gerontological Society of America’s diagnostic and treatment considerations help shed light on this complicated condition.


Understanding Dementia-Related Psychosis

Suicide risk screening is especially challenging in the time of a pandemic. Data are not yet available to ascertain how COVID-19 will affect the suicide rate. However, the 3-tiered clinical pathway needed to be revised to accommodate mostly telehealth screening. Maryland Pao, MD, Annabelle M. Mournet, and Lisa M. Horowitz, PhD, MPH, revised the suicide risk screening clinical pathways published by Brahmbhatt and colleagues to reflect the need for phone screening and assessments. 

Learn more in the article "Implementation Challenges of Universal Suicide Risk Screening in Adult Patients in General Medical and Surgical Settings," to appear in the July 2020 issue of

Courtesy: National Institute of Mental Health

Suicide risk screening is especially challenging. Although data are not yet available to ascertain how COVID-19 will affect the suicide rate, the 3-tiered clinical pathway has been revised to accommodate mostly telehealth screening.

Youth Suicide Screening Pathway

How can telepsychiatry improve quality and access to care as well as reduce physician burnout? Telepsychiatry pioneers Peter Yellowlees, MMBS, MD, Chief Wellness Officer at 

 and Professor of General Psychiatry at the University of California, and Jay Shore, MD, MPH, Professor at the Department of Psychiatry and Family Medicine at 

, joined moderator Chris Aiken, MD, Director of the 

, to discuss tips and tricks in making telepsychiatry work in this era of COVID and beyond. The webinar, which was recorded live, is available at 

www.psychiatrictimes.com/career/resources-psychiatric-times-telepsychiatry-covid-webinar

There are a number of tools that can make telepsychiatry easier for the clinician, said Yellowlees, who authored on the 2009 telemental health guidelines. A noiseless keyboard, for example, will make it easier to take notes during a session without disrupting the flow of the conversation. This, in turn, makes post-appointment paperwork quicker and easier. Similarly, an echo-cancelling microphone improves audio quality.

Yellowlees also likes to use multiple screens during telepsychiatry sessions. “I have one screen for the video, I have another screen to the EMR, and I typically have my email or something else going on the third screen,” he explained. “And it’s actually less tiring to have two or three screens, because you don’t have to constantly change the picture, or change the shape of your screen as you’re doing different functions; you literally use each screen for a different function. And that’s a much, much easier way of working.”

Choosing an appropriate telepsychiatry platform is also important. Despite the flexibility during COVID, both Shore and Yellowlees noted it is best to use platforms that are HIPAA-compliant. “You know, the government can easily change the rules and decide they want to come and prosecute people [for not being HIPAA-compliant].”

Choosing a HIPAA-compliant platform now will allow for a seamless transition in a post-COVID world. Just as it may take time for clinicians to learn new platforms, patients may have a similar adjustment period. Since the rules will likely change after the COVID crisis, they added, it makes sense to acclimate your patients to something you can use moving forward.

The speakers agreed that telepsychiatry requires a degree of flexibility and creativity. For instance, psychiatrists should aim to be more animated during a telepsychiatry visit, Yellowlees noted. “I normally say to people to be about 110% of normal—just slightly more lively, slightly more intonation in your voice. . . . And, that may be why some people also find telepsychiatry a little bit more tiring initially, because they’re actually having to speak and enunciate more loudly and more carefully.”

Similarly, clinicians may need to ask patients to be more creative. For example, clinicians can ask patients to weight themselves or use a blood pressure monitor during the video visit, sincemany of the tools used to assess patients’ vital signs can be obtained inexpensively online.

Shore also had some suggestions for patients worried about their privacy. “One of the places that many of my colleagues and I have found useful is car therapy. When the car is not moving and the patient is not driving, it provides a private secure space,” he explained.

opens up a world of possibilities. Yellowlees shared, “I’ll get them to deliberately use an iPad or a phone or mobile device, and I’ll have them show me around the house and walk me out in the garden. I’ll talk to them about their pictures or what they’re having for supper. I’ll get to see their pets, and potentially I’ll meet other members of the family—of course with appropriate discussion beforehand with a patient.”

This can be particularly helpful when doing therapy, explained Shore, Director of Telemedicine Programming for the Department of Psychiatry, University of Colorado Anschutz Medical Campus. “I think there’s a real power to move the treatment into the place where the patient lives.”

Telepsychiatry also allows for greater insights and ability to help patients with specific disorders. For instance, if you are working with someone with ADHD, you can see the state of their homes. In patients with eating disorders, clinicians can ask to see the pantry, and for patients with a hoarding disorder, you can monitor their progress as they sort through belongings.

Other special patient populations can also benefit from telepsychiatry, as it evens out the playing field and provides a more egalitarian approach. Patients with anxiety can meet with their physician in a more comfortable environment, which in turn allows them to share more freely. It also benefits children and adolescents, Aiken added. “It can be intimidating to be in an older doctor’s office when you’re an adolescent. In telepsychiatry, we are on their media—this is their domain, the electronic media, so they take it and run with it.”

According to the experts, the literature to date suggests very high levels of patient satisfaction, most likely due to its flexibility. It becomes easier for patients to show up for appointments, with minimal disruptions to their schedule.

The flexibility goes both ways. In the past, taking an extended vacation or attending a convention meant leaving your patients behind, finding coverage, and the like. With telepsychiatry, clinicians can schedule appointments around their travel schedules and leisure time.

Another perk of telepsychiatry is that patients may find it easier to divulge sensitive information. “There’s a big computer science literature showing that people tend to be more honest if they’re talking about sensitive topics to a computer, filling in a questionnaire, or to someone on video on a computer as opposed to in person,” Yellowlees said. “Imagine if you’re a female and you’ve been raped recently. It’s much easier to talk to someone like Jay or myself on video than to come into our clinics and see us there as sort of physically large males.”

With greater opportunities to connect with patients and high levels of patient satisfaction, all three experts agreed the future should consist of a balanced hybrid model as standard care.

“I tend to look at it like video and in-person visits, each has their own strengths and challenges, and it’s variable by the patient population,” Shore explained. “As Peter [Yellowlees] mentioned, I’ve worked with victims of domestic violence and see them first in video to establish a relationship where they feel safer and more comfortable. Now, there are other patients where you may want to see them in person first to establish the relationship, and then do video.”

“What I’m hearing is that in the hybrid model patients might feel more secure in their connection with us, knowing that they can reach us when they’re at the beach, when their car is broken,” Aiken said. “We just have to turn it up a bit, 110%, in our own attunement and energy involvement, and we can actually connect to patients in different ways.” ❒

For full coverage of the webinar and more information, visit us at 

www.psychiatrictimes.com/telepsychiatry/making-telepsychiatry-work-you-and-your-patient

How can telepsychiatry improve quality and access to care as well as reduce physician burnout? Telepsychiatry pioneers joined Chris Aiken, MD to discuss tips and tricks in making it work for you. 

The Future of Telepsychiatry

How can telepsychiatry improve quality and access to care as well as reduce physician burnout? Telepsychiatry pioneers Peter Yellowlees, MMBS, MD, Chief Wellness Officer at UC Davis Health and Professor of General Psychiatry at the University of California, and Jay Shore, MD, MPH, Professor at the Department of Psychiatry and Family Medicine at Colorado School of Public Health, joined moderator Chris Aiken, MD, Director of the Mood Treatment Center and 

 Section Editor for Bipolar Disorder, to discuss tips and tricks in making telepsychiatry work in this era of COVID and beyond. The webinar, which was recorded live on May 18, 2020, is available online at 

https://event.on24.com/wcc/r/2359555/FAB61DFA865C680B16BE9C42AF7BAF30

Yellowlees, who has authored more than 80 articles on telepsychiatry and health informatics, has been conducting telemedicine since 1991. Recognizing the need to address mental health in more rural areas, his first session was with an Aboriginal women with depression in a distant part of Australia. Since then, he has refined his approach and gained much experience. In 2009, he was the lead author on the telemental health guidelines published by the American Telemedicine Association; he is a Fellow and Past President of the 

Although there are a number of things that can make telepsychiatry easier for the clinician, Yellowlees said a clinician could easily get a good setup for about $200. A noiseless keyboard, for example, will make it easier to take notes during a session without disrupting the flow of the conversation. This, in turn, makes post-appointment paperwork quicker and easier. Similarly, an echo-cancelling microphone improves audio quality-it can be easily connected to a desktop computer and eliminates the need for headphones. Throw in a camera, and you are good to go. Even simpler, forgo the desktop computer for a laptop or a tablet, which has a built in camera and speakers.

According to Yellowlees, clinicians often overlook things like proper lighting and video presentation issues. He suggested havinf a light overhead, almost directed between you and the camera screen, and to avoid having too much light behind you to avoid shadows. Always check to see that you are centered properly, with your head about two-thirds of the way up the screen. “You don’t want your eyes to be far away from the actual camera,” he explained. Since the camera is a few inches above the eyes, this placement allows the clinician to make “eye contact” with the patient in a more natural way.

Choosing an appropriate telepsychiatry platform is also important. Despite the flexibility being afforded to health care providers during COVID, both Shore and Yellowlees noted it is best to use platforms that are HIPAA-compliant. “You know, the government can easily change the rules and decide they want to come and prosecute people [for not being HIPAA-compliant]. They really haven’t changed the HIPAA rules at all; they’ve just decided that they weren’t going to prosecute.”

In addition, picking the best platform right off the bat will allow for a seamless transition in a post-COVID world. Just as it may take time for clinicians to learn new platforms, patients may have a similar adjustment period. Since the rules will likely change after the COVID crisis, they added, it makes sense to acclimate your patients to something you can use moving forward. Fortunately, there are a number of user-friendly platforms from which to choose (

Not surprisingly, many of the attendees’ questions surrounded reimbursement issues. Also not surprisingly, Shore, who also got his start in telemedicine to treat patients in rural areas noted the situation is complex, as insurance companies may have their own set of rules and CPT codes. Shore currently serves as the Director of Telemedicine Programming for the Department of Psychiatry, School of Medicine; as Director of Telemedicine for the Helen and Arthur E. Johnson Depression Center University of Colorado Anschutz Medical Campus; and as Chief Medical Officer of AccessCare, a provider of telemental health services of rural and underserved populations. As such, he is well aware of the intricacies of the reimbursement tango.

Shore reported that there is a loosening of requirements in the federal programs, including additional codes in Medicare and Medicaid. Yet, there have been weekly if not daily changes in coding, so he suggests clinicians check for specific directions on insurance company websites. Similarly, the American Psychiatric Association’s telepsychiatry page has many resources to help clinicians.

Certainly, as the COVID pandemic evolves, both Shore and Yellowless expect the reimbursement rules to change and evolve. Before the pandemic, Yellowlees routinely obtained prior authorization for telepsychiatry visits for each new patient. He noted this would be good practice moving forward for all clinicians to consider.

All speakers agreed that telepsychiatry requires a degree of flexibility and creativity to make it work. For instance, psychiatrists should aim to be more animated during a telepsychiatry visit, Yellowlees noted. “Try to be lively and be reasonably friendly, you know, perhaps a bit more than you necessarily would in your own clinic. I normally say to people to be about 110% of normal-just slightly more lively, slightly more intonation in your voice. . . . And, that may be why some people also find telepsychiatry a little bit more tiring initially, because they’re actually having to speak and enunciate more loudly and more carefully.”

Similarly, clinicians may need to ask patients to be more creative. For example, clinicians can ask patients to weight themselves or use a blood pressure monitor during the video visit-many of the tools used to assess patients’ vital signs can be obtained inexpensively online. Patients with limited funds might be able to visit a local drug store to assess blood pressure and pulse readings.

Shore also had some suggestions for patients worried about their privacy. “One of the places that many of my colleagues and I have found useful is car therapy. When the car is not moving and the patient is not driving, it provides a private secure space,” he explained. “I actually have patients who park near places like a local library or health care center with good bandwidth . . . I have had patients park in front of their relatives’ houses and use their WiFi passwords.”

On the other hand, telepsychiatry opens up a world of possibilities. Yellowlees shared, “I’ll get them to deliberately use an iPad or a phone or mobile device, and I’ll have them show me around the house and walk me out in the garden. I’ll talk to them about their pictures or what they’re having for supper. I’ll get to see their pets, and potentially I’ll meet other members of the family-of course with appropriate discussion beforehand with a patient.”

This can be particularly helpful when doing therapy, Shore explained. “You’re doing [therapy] in this artificial environment, not in the environment where they live and they’re dealing with their symptoms. And so, I think there’s a real power to move the treatment into the place where the patient lives.”

Similarly, telepsychiatry also allows for greater insights and ability to help patients with specific disorders. For instance, if you’re working with someone with ADHD, you can see the state of their homes. In patients with eating disorders, clinicians can ask to see the pantry to see what might tempt them. For patients with a hoarding disorder, you can monitor their progress and watch as they sort through things.

Other special patient populations can also benefit from telepsychiatry. The most obvious group includes older and immunosuppressed patients during the COVID environment, who benefit from care that does not endanger their lives. Telepsychiatry also evens out the playing field and provides a more egalitarian approach. Patients with anxiety can meet with their physician in a more comfortable environment, which in turn allows them to share more freely. It also benefits children and adolescents, Aiken added. “It can be intimidating to be in an older doctor’s office when you’re an adolescent. In telepsychiatry, we are on their media-this is their domain, the electronic media, so they take it and run with it.”

The flexibility goes both ways. In the past, taking an extended vacation or attending a convention meant leaving your patients behind, finding coverage, and the like. With telepsychiatry, clinicians can schedule appointments around their travel schedules, appointments, and leisure time and still be able to monitor their patients.

With greater opportunities to connect with patients and high levels of patient satisfaction, all three experts agreed the future of psychiatry should consist of a hybrid model of care. Aiken noted, “As we emerge [from this pandemic], psychiatry will have this tremendous opportunity to figure out the right balance [of telepsychiatry and in-person care].” This balanced hybrid approach should really be the standard of care, he added.

“What I’m hearing is that in the hybrid model patients might feel more secure in their connection with us, knowing that they can reach us when they’re at the beach, when their car is broken,” Aiken said. “We just have to turn it up a bit, 110%, in our own attunement and energy involvement, and we can actually connect to patients in different ways.”

Telepsychiatry and Health Technologies A Guide for Mental Health Professionals

Telepsychiatry and Health Technologies: A Guide for Mental Health Professionals.

 American Psychiatric Association Publishing; 2018.

How can telepsychiatry improve quality and access to care as well as reduce physician burnout? Telepsychiatry pioneers

Making Telepsychiatry Work for You and Your Patients

Before the pandemic took front and center stage, the US Food and Drug Administration was busy in the field of psychiatry. With a number of medications in the pipeline, new indications for old familiar faces, and the industry’s desire to share information with clinicians and patients alike, the FDA will likely remain busy, both policing the field and making approvals.

Pharmaceutical company makes the FDA’s naughty list

A warning letter was sent from the FDA’s Office of Prescription Drug Promotion (OPDP) for misleading advertising for the drug ProCentra, an oral solution used to treat attention-deficit/hyperactivity disorder.

 The warning letter was in response to a sponsored link on Google.com that failed to include risk information and use the medication’s established name. The letter also noted that the FDA Bad Ad Program received complaints.

The OPDP explained that the ad suggested the drug’s efficacy and ease use by pointing out its “Bubblegum Flavor” and “Liquid Treatment Option,” all of which easily would appeal to parents as desirable for children, without including any risk information.

These violations are especially concerning from a public health perspective because they create a misleading impression about the safety of ProCentra, a drug that is a schedule II controlled substance used in the vulnerable pediatric patient population, and bears a Boxed Warning that describes the high potential for abuse, that administration of amphetamines for prolonged periods of time may lead to drug dependence, and states that misuse may cause sudden death and serious cardiovascular adverse events.

The letter was sent to Stefan Antonsson, CEO of Outlook Pharmaceuticals, with specific corrective actions requested. For starters, the company was told to “immediately cease misbranding.” In addition, they must respond in a letter detailing not only how they will comply with this request, but, since the violations are deemed serious, they must include “a comprehensive plan of action to disseminate truthful, nonmisleading, and complete corrective messages about the issues discussed in this letter to the audience(s) that received the violative promotional materials.”

According to Regulatory Focus, the ad has been removed and the CEO will respond.

Meanwhile, its likely Outlook is not alone in such missteps. According to AdComplyRx, more than 30 major prescription brands inadvertently ran 

 Nonetheless, the warning letter, which is the first of its kind for this calendar year, showed that the FDA is watching and will hold companies responsible for irresponsible action.

On a more positive note, the FDA reviewed and accepted the New Drug Application (NDA) for LY03005, a serotonin-norepinephrine-dopamine triple reuptake inhibitor (SNDRI). Developed under Luye Pharma’s New Chemical and Therapeutic Entities Research and Development platform, the company has 

patents covering the chemical compound, crystal form, and formulation of LY03005.

Unlike other available antidepressants, it is believed the SNDRI class of medications will be relatively beneficial in preserving patients’ sexual functions. Data also suggests SNDRIs will have a better safety profile, produce a more rapid onset, and provide better efficacy.

SNDRIs fall under the category of triple reuptake inhibitors (TRIs), since they simultaneously target serotonin transporters, norepinephrine transporters, and dopamine transporters. TRIs are emerging as a promising class of antidepressants. It is theorized that, compared with monoamine transporters, their broader spectrum inhibition would lead to 

 and faster antidepressant response while also addressing a broader range of symptoms (including anhedonia).

The company originally filed for the NDA in late December 2019 after consensus was reached with the FDA under End-Of-Phase 2-CMC meeting and Pre-NDA meeting.

 Luye Pharma has made a commitment to their central nervous system pipeline; they currently are working on compounds for the treatment of schizophrenia, bipolar disorder, and Alzheimer disease.

“The global patient population affected by depression and other CNS diseases is large and growing, with serious distress caused by these diseases greatly affecting both patients and their families. We look forward to bringing more high-quality and innovative drugs to the market, helping these patients in need,” a senior management representative from Luye Pharma Group said in a press statement.

1. Haffer AST. Warning Letter: Re: ANDA 040776 PROCENTRA® (dextroamphetamine sulfate) oral solution, CII MA 60. US Food and Drug Administration. February 21, 2020.

2. AdComplyRx. Homepage: 2018 Brand Safety Report. 

OPDP Warns Pharma Company for Sponsored Link on Google. Regulatory Focus

NDA Filing for Luye Pharma’s Antidepressant Drug LY03005 Accepted by the U.S. FDA

Triple reuptake inhibitors as potential next-generation antidepressants: a new hope?

Release. Luye Pharma Submits New Drug Application in the U.S. for Its Antidepressant Drug LY03005. December 26, 2019

New hope for depression on the horizon and other updates.

Author | Heidi Anne Duerr, MPH

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