Sy Atezaz Saeed, MD, MS

Telepsychiatry has its roots in Europe. In the 1920s and into the 1940s radio consultations were performed between European countries and sailors onboard ships or people on isolated islands who were ill. In the 1950s, radiology images were being transmitted.

 In 1959, the Nebraska Psychiatric Institute was using early videoconferencing to provide group therapy, long-term therapy, and consultation-liaison psychiatry.

 By the 1980s, telepsychiatry was increasingly common.

The New Freedom Commission on Mental Health emphasized the need for prevention and treatment of mental illness so that patients with mental health conditions can receive the care they need and become functional participants in the community.

 The Commission discussed videoconferencing and telehealth as a means of access to care. In 2015, approximately 60 million people in the US were living in rural areas.

 The popularization of telemedicine has been secondary to a direct need to serve these areas.

Benefits and effectiveness of telepsychiatry

The use of telepsychiatry to provide mental health services has the potential to solve the provider shortage problem that directly affects access to care. Telepsychiatry is not only effective and well accepted; it can also increase administrative efficiency while providing positive outcomes in most clinical settings. Hilty and colleagues

 reviewed the published literature on effectiveness of telemental health compared to services provided face-to-face. Their findings suggest that telemental health is not only effective for diagnosis and assessment across many populations and disorders in many settings, but it appears to be comparable to face-to-face care. Telepsychiatry has also been found to be effective in providing access to care for inmates and veteran populations.

In a study that compared telepsychiatry with standard care, participants who received treatment via telepsychiatry had greater response and remission rates.

 Positive results were also seen in a study undertaken in a skilled nursing facility.

 The findings indicate that telepsychiatry provided efficient access to care compared with regular visits by a provider who would need to travel to the nursing home multiple times. A study by De Las Cuevas and colleagues

 also demonstrated the effectiveness of telepsychiatry and how it is equivalent to in-person evaluation. In a literature review of child and adolescent psychiatry articles, Diamond and Bloch

 found telepsychiatry to be equivalent to in-person consultations and no negative outcomes were reported. As evidence continues to emerge in support of telepsychiatry as a means to reach underserved patients, we hope to see it continue to evolve into a widely available method for delivering mental health services.

Despite empirical evidence for the effectiveness of telepsychiatry when compared with in-person care many psychiatrists are still not at ease with telepsychiatry. Including telepsychiatry in residency training curriculum can help increase the number of psychiatrists who will likely use it in caring for patients.

A recent review of the use of tele-psychiatry in graduate medical education concluded that there was a need for a more evidence-based approach to telepsychiatry training and that such a training, if done right, could not only improve clinical outcomes but also promote social accountability, cultural competence, and interprofessional care.

 There appears to be a clear practice gap in the US between resident/fellow interest in telepsychiatry and the didactic curriculum and clinical experiences offered in residency programs. Pedagogical approaches have been proposed that are likely to promote these competencies including an elective that is likely to advance residents’ competence to practice telepsychiatry.

In addition to the direct benefits of telepsychiatry for patients and providers, other benefits have also been identified, including reducing geographic and socioeconomic health disparities; better consumer compliance, education of mental health professionals, coordination of care across mental health systems; improving in recruiting and retaining mental health professionals to work in underserved or rural areas; and possible reduction of stigma associated with receiving mental health services.

Applications of telepsychiatry include both clinical and non-clinical uses such as education as well as administrative and research applications. Clinical outcomes of telepsychiatry interventions are comparable to face-to-face treatment delivered across diverse patient populations and diagnostic groups. For clinical applications, telepsychiatry can be used for both diagnostic and therapeutic applications across the life span. Common applications include diagnostic assessments, pre-hospitalization assessment and post-hospital follow-up care, medication management, psychotherapy, and consultation.

Telepsychiatry consultations can be used for routine as well as for crisis behavioral health cases. It can also be used in the development of clinical care plans, case management, psychological testing, forensic evaluations, and liaison services with other medical specialties. Points of delivery can include hospitals and their emergency departments, clinics, offices, homes, assisted living facilities, nursing homes, schools, and forensic settings. Professional users can include psychiatrists, resident physicians, nurses, social workers, psychologists, and other mental health providers. Practice models can vary from direct clinical service to consultation, as depicted in the 

Telepsychiatry can be effectively used for any number of psychiatric interventions. A review of telepsychiatry for suicide prevention found no difference between use of DBT via teleconferencing versus treatment as usual.

 Telepsychiatry has also been used for cognitive assessments of patients with dementia, and it has been effective in providing care to geriatric patients in rural nursing home facilities.

The department of Veterans affairs has conducted studies on the use of videoconferencing to provide CBT to veterans with PTSD.

 Videoconferencing did not affect compliance with CBT treatments. Study data also show that videoconferencing was a practical way to deliver care to veterans in remote areas without affecting the quality of care provided.

 examined the use of videoconferencing for anger management group therapy. Although the participants displayed decreased alliance towards the group leader, videoconferencing was deemed a practical and effective way of delivering care. Steel, Cox, and Garry

 looked at videoconferencing for the management of long-term conditions. Their data indicate that videoconferencing delivered similar outcomes to in-person care and was a practical way to provide care to rural communities.

Two-way audio-video communication in real time-videoconferencing-has become synonymous with telepsychiatry. A provider at a distant location evaluates and treats a patient at a local clinical site via live and interactive audiovisual conferencing systems. Historically telepsychiatry applications have used point-to-point network connections; with the rapid diffusion of Internet and Ethernet networks, Internet Protocol (IP) has largely replaced these older point-to-point networks.

Typically, a telepsychiatry setup includes a video camera, microphone, speakers (or headset), and one or two displays at each end of the system. Often, separate displays or a picture-in-picture (if one display) are used to enable participants to see both outgoing and incoming video. A pan-zoom-tilt control of the video camera is preferred that allows the clinician to control his or her view of the patient’s site or locally control the view that is being transmitted to the patient.

When setting up a telepsychiatry service the following security measures need to be considered and addressed:

Personal computer or mobile device should have the latest security patches and updates applied to the operating system and any third-party applications being utilized for tele-psychiatry encounters.

Audio and video transmission should be secured by using point-to-point encryption that meets recognized standards. Unauthorized persons should not be allowed access to sensitive information stored on the device or use the device to access sensitive applications or network resources.

Protected health information and other confidential data must be backed up to or stored on secure data storage locations.

When using mobile devices, special attention needs to be given to: adequate restriction on access to any patient contact information stored on the device; a passphrase or equivalent security feature before the device can be accessed, preferably using multi-factor authentication; an inactivity timeout function that requires a passphrase or re-authentication to access the device after the timeout threshold has been exceeded (the American Telemedicine Association [ATA] recommends this timeout not to exceed 15 minutes); capability to remotely disable or wipe the device in the event it is lost or stolen.

ATA guidelines recommend providing services at a bandwidth of 384 Kbps or higher in each of the downlink and uplink directions and providing a minimum of 640 × 360 resolution at 30 frames per second.

Videoconference software should not allow multiple concurrent sessions to be opened by a single user.

The American Psychiatric Association (APA) has released a telepsychiatry toolkit as a resource for its members who want to learn about the various aspects of telepsychiatry. The toolkit covers topics from history, training, practice/clinical, reimbursement, and legal issues; it is available at 

https://www.psychiatry.org/psychiatrists/practice/telepsychiatry

. ATA practice guidelines are available at 

https://www.integration.samhsa.gov/operations-administration/practice-guidelines-for-video-based-online-mental-health-services_ATA_5_29_13.pdf

Potential barriers to the widespread use of telepsychiatry

 have summarized the benefits and constraints of using telepsychiatry within the current system of healthcare and have identified reimbursement, licensure, privacy, security, patient safety, and interoperability as challenges.

 A “fee-for-service” approach is used by Medicare for payment that reimburses the clinician providing the telepsychiatry service. Reimbursement is typically provided for a diagnostic interview, pharmacologic management, and individual psychotherapy provided by psychiatrists and clinical psychologists. Services provided by other mental health providers vary by the state and may not be covered.

 The costs associated with development of the infrastructure and maintenance are typically non-reimbursable. In limited situations, reimbursement might be obtained from individual contracts, managed care, third-party payers, and Medicaid and Medicare. A structure for reimbursement of collateral charges (eg, technician, line time) is needed. Funds from the Federal Communications Commission’s Universal Service Fund subsidies can reduce the cost of telepsychiatry network connections. Individual states have also developed various funding streams to support telemedicine.

 For a physician to conduct a telemedicine consultation with a facility in another state, that physician must be licensed by both states’ licensing boards. Likewise, nurses and other allied health professionals have similar state licensing constraints.

 A provider must be credentialed in the services that he or she provides, which in many cases necessitates credentialing in multiple systems. This significantly increases the burden on providers for completing applications, waiting for the review process to complete before services can start, and paying associated dues.

 Changes in a workplace requires restructuring the flow of daily work. If the goal of the organization is to promote the use of telepsychiatry, telepsychiatry must be integrated into the current process of patient care. Successful implementation requires that both clinicians and patients recognize that this approach to treatment is likely to improve outcomes by increasing access to care.

 Privacy considerations that are unique to telepsychiatry include the potential for non-clinical personnel to view telepsychiatry transactions and the off-camera presence of other clinical personnel. The increased use of IP videoconferencing over public networks also creates the potential for unauthorized access to protected health information. Technological solutions, such as in-codec encryption and virtual private networks, need to be implemented to address these issues, which necessitate training on secure storage and retrieval of data; medico-legal; and ethical issues related to maintaining patient privacy.

 The Ryan Haight Online Pharmacy Consumer Protection Act of 2008, requires any practitioner issuing a prescription for a controlled substance to conduct an in-person medical evaluation at least once every 24 months.

 Some malpractice providers cover telepsychiatry as part of their standard coverage while others may require additional coverage for providing telepsychiatry services.

The potential for telepsychiatry to improve access to mental health care is evident. The current technology is adequate for most uses and continued advances are in progress. There are numerous applications already defined and more are ripe for exploration. Barriers to implementation are primarily of the human variety and will require a combination of consumer, provider, and governmental advocacy to overcome. Given the challenges associated with disparity in access to psychiatric care, telepsychiatry can help provide access to mental health care to everyone who needs it.

Dr Saeed is Professor and Chairman, Dr Pastis is Clinical Assistant Professor, Department of Psychiatry and Behavioral Medicine, Brody School of Medicine, East Carolina University, Greenville, NC.

 Ryu S. History of telemedicine: evolution, context, and transformation. 

 American Psychiatric Association. What is Telepsychiatry? January 2017. 

https://www.psychiatry.org/patients-families/what-is-telepsychiatry

 New Freedom Commission on Mental Health. Achieving the Promise: Transforming Mental Health Care in America. Final report; 2003. Rockville, MD. DHHS Pub. No. SMA-03-3832.

 US Census Bureau. New Census Data Show Differences Between Urban and Rural Populations; 2016. 

https://www.census.gov/newsroom/press-releases/2016/cb16-210.html

 Hilty DM, Ferrer DC, Parish MB, et al. The effectiveness of telemental health: a 2013 review. 

 Brodey BB, Claypoole KH, Brodey IS, et al. Satisfaction of forensic psychiatric patients with remote telepsychiatric evaluations. 

 Dunn BE, Choi H, Almagro UA, et al. Telepathology networking in VISN-12 of the Veterans Health Administration. 

 Yeung A, Martinson MA, Baer L, et al. The effectiveness of telepsychiatry-based culturally sensitive collaborative treatment for depressed Chinese American immigrants: a randomized controlled trial. 

 Johnston D, Jones III BN. Telepsychiatry consultations to a rural nursing facility: a 2-year experience. 

 De Las Cuevas C, Arredondo MT, Cabrera MF, et al. Randomized clinical trial of telepsychiatry through videoconference versus face-to-face conventional psychiatric treatment. 

 Diamond JM, Bloch RM. Telepsychiatry assessments of child or adolescent behavior disorders: a review of evidence and issues. 

 Sunderji N, Crawford A, Jovanovic M. Telepsychiatry in graduate medical education: a narrative review. 

 Saeed SA, Johnson TL, Bagga M, Glass O. Training residents in the use of telepsychiatry: Review of the literature and a proposed elective. 

 Farrell SP, McKinnon CFR. Technology and rural mental health. 

 Marasinghe RB, Kavanagh D, Edirippulige S, et al. Telehealth approaches to suicide prevention: a review of evidences. 

 Loh PK, Ramesh P, Mahe, S, et al. Can patients with dementia be assessed at a distance? The use of Telehealth and standardised assessments. 

 Morland LA, Greene CJ, Grubbs K, et al. Therapist adherence to manualized cognitive behavioral therapy for anger management delivered to veterans with PTSD via videoconferencing. 

 Greene CJ, Morland LA, Macdonald A, et al. How does tele-mental health affect group therapy process? Secondary analysis of a noninferiority trial. 

 Steel K, Cox D, Garry H. Therapeutic videoconferencing interventions for the treatment of long-term conditions. 

 Deslich S, Stec B, Tomblin S, Coustasse A. Telepsychiatry in the 21st century: transforming healthcare with technology. 

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3709879/

Articles

Findings suggest that telemental health is not only effective for diagnosis and assessment across many populations and disorders in many settings, but it appears to be comparable to face-to-face care.

Using Telehealth to Enhance Access to Evidence-Based Care

Here we present brief descriptions of 8 of the top 25 articles we have chosen for their relevance to clinical psychiatric practice, and their clinical applicability. The order in which the articles appear is arbitrary.

This study supports the indication that fluoxetine is more likely to be effective than other antidepressants in treating MDD in children younger than 18 years.

The study used network meta-analysis of 34 randomized controlled trials, which included 5260 participants, to compare the efficacy of 14 different antidepressants for acute MDD in children younger than 18 years. SSRIs, SNRIs, TCAs, and other medications were compared. A network meta-analysis allows for comparisons between different medications: although many have not been compared directly with each other, all have been compared with placebo.

Only fluoxetine was statistically superior to placebo in producing improvement. Fluoxetine was associated with fewer dropouts because of adverse effects than several SSRIs, TCAs, and SNRIs. Venlafaxine was statistically most likely to produce suicidal thoughts or behaviors. More patients were exposed to fluoxetine than to any of the other medications; thus, power may be a potential bias in that disparate numbers of patients have been exposed to the different medications.

Cipriani A, Zhou X, Del Giovane C, et al. Comparative efficacy and tolerability of antidepressants for major depressive disorder in children and adolescents: a network meta-analysis. 

This article adds to the positive support for omega-3 fatty acid preparations, especially those that are primarily eicosapentaenoic acid (EPA) or ethyl-EPA formulations. In this case, adding omega-3 fatty acids to antidepressant therapies for MDD enhanced the therapeutic effects.

This review of nutraceuticals as adjunctive therapy for depression finds several with repeated positive effects on depression. The nutraceuticals with enough trials to enable meta-analyses were examined. Findings for S-adenosylmethionine (SAMe), methylfolate, omega-3, and vitamin D as adjuncts to SSRI therapy for MDD were more positive than negative.

Creatine and an amino acid combination were studied less often but still showed occasional efficacy. Those that did not show much promise were zinc, vitamin C, tryptophan, and inositol.

Meta-analyses supported omega-3 fatty acids from fish oil as very likely to be effective as adjuncts to antidepressant medications. There was mixed support for folic acid and folate-related compounds, but their effects were not comparable to those of omega-3.

It is not yet clear what the optimal dose is, whether it is the same for all antidepressants, and what the optimal duration of adjunctive treatment would be. While safety remains to be determined, omega-3 fatty acid adjunctive treatment does not appear to increase the adverse effects of antidepressants and offers a relatively safe option compared with supplementation with antipsychotic medications or other nutraceuticals.

Sarris J, Murphy J, Mischoulon D, et al. Adjunctive nutraceuticals for depression: a systematic review and meta-analysis. 

Based on a review of the literature by a consensus panel, this guideline strongly recommends cognitive-behavioral therapy for chronic insomnia (CBT-I) in adults as the first-line treatment.

The quality of evidence supporting this recommendation was judged to be moderate for a wide variety of outcomes from remission to improved sleep quality. In addition, CBT-I was effective with delivery methods ranging from in-person delivery to telephone or Internet delivery.

If CBT-I does not prove successful, the guidelines weakly recommend sleep medications for a suggested maximum duration of 4 or 5 weeks. The evidence of medication efficacy was weak, with a narrower range of positive effects and with considerably greater adverse-effect burdens. There was insufficient evidence of efficacy for complementary and alternative approaches.

Qaseem A, Kansagara D, Forciea MA, et al, for the Clinical Guidelines Committee of the American College of Physicians. Management of chronic insomnia disorder in adults: a clinical practice guideline from the American College of Physicians. 

This article supports the greater use of clozapine in general practice when managing treatment-compliant patients who continue to require hospitalizations and medication changes.

Because of the risk of agranulocytosis, clozapine has come to be viewed in general practice as a last resort for treatment-resistant schizophrenia. This, in turn, has led to possible underutilization.

This article reports on the effects in general practice of switching to clozapine after an inadequate response to standard antipsychotics, such as olanzapine or risperidone. A retrospective cohort design employing Medicaid data was used to compare 2 groups of 3123 patients with treatment-resistant schizophrenia. One group had been switched to clozapine after showing signs of treatment resistance. The other group had been switched to a different non-clozapine antipsychotic after showing comparable signs of treatment resistance, such as hospitalization and at least 2 antipsychotic medications prescribed while maintaining medication compliance.

The 2 groups were selected to enable tight matching on gender, race, and age. Medical and psychiatric symptoms were also matched using a scoring system to reduce the likelihood that the clozapine group had more severe symptoms.

Intent-to-treat analysis demonstrated that the group switched to clozapine had significantly fewer hospitalizations, medication discontinuations, or new antipsychotics initiated, while showing no differences from the non-clozapine group in mortality. The clozapine group had higher rates of diabetes, bowel obstruction, and hyperlipidemia. However, the rates of these adverse effects were relatively low. Other medical adverse effects were not different between groups.

Stroup TS, Gerhard T, Crystal S, et al. Comparative effectiveness of clozapine and standard antipsychotic treatment in adults with schizophrenia. 

The study shows that it is likely that tDCS is superior to placebo and that the higher the tDCS dose, the better the response.

The data that support the efficacy of transcranial direct current stimulation (tDCS) for MDD have been mixed Most studies show positive trends toward better responsiveness and remission rates with tDCS than with sham controls. However, meta-analytic attempts to combine trials have led to mixed results because of the low numbers of randomized trials and participants.

This article presents a different meta-analytic approach that emphasizes individual patient data over group comparisons. One issue with this approach, however, is that not all randomized clinical trials (RCTs) allow for the inclusion of individual patient data, so some caution is appropriate.

Six RCTs were included in the meta-analysis. The results indicated that the response to tDCS was more positive than to sham procedures. The overall efficacy of tDCS was comparable to that seen in response to repetitive transcranial stimulation, and perhaps even to SSRI antidepressants.

This study was not a comparison between tDCS and a validated antidepressant treatment, so comparability has to be assumed. In those circumstances in which access to tDCS is available and patients have a poor response to antidepressant medications or prefer nonmedication treatment, tDCS could reasonably be considered.

Brunoni AR, Moffa AH, Fregni F, et al. Transcranial direct current stimulation for acute major depressive episodes: meta-analysis of individual patient data. 

Clinicians who are considering omega-3 fatty acids for their patients with MDD should ensure that EPA-predominant PUFAs are used. Similarly, when PUFAs are being considered as adjunctive treatment to antidepressants, EPA-predominant preparations should be recommended.

Meta-analyses in multiple steps were used to assess several hypotheses regarding the potential antidepressant effects of omega-3 polyunsaturated fatty acids (PUFAs), either alone or as an adjunct to antidepressant medications. Previous meta-analyses had yielded mixed results with no clear positive effects of omega-3 PUFAs on depression symptoms.

In this article, results of separate meta-analyses on EPA-predominant
PUFAs versus docosahexaenoic acid (DHA)-predominant PUFAs were reported. In addition, results of separate meta-analyses for the effects of omega-3 on patients with clinically diagnosed MDD versus depressed persons who did not meet clinical diagnostic criteria were reported. As hypothesized, omega-3 PUFAs that were predominantly EPA significantly reduced depressive symptoms in patients who had received a clinical diagnosis. Neither EPA- nor DHA-predominant omega-3s produced significant improvement in depressed patients who did not have clinically diagnosed MDD.

Hallahan B, Ryan T, Hibbeln JR, et al. Efficacy of omega-3 highly unsaturated fatty acids in the treatment of depression. 

The efficacy of interpersonal psychotherapy (IPT) increases the range of evidence-based psychotherapies that can reasonably be recommended for depression, anxiety disorders, and eating disorders, perhaps making referral for psychotherapy easier.

This study compared IPT with other forms of therapy or with some form of placebo for a range of clinical disorders ranging from MDD to eating disorders. The efficacy of IPT in combination with antidepressant medications, IPT for prevention of depression in patients at risk, and IPT for prevention of relapse were also examined. The efficacy of IPT for the treatment of depression has been long recognized, although its relative efficacy compared with CBT or antidepressant medications was less certain.

Meta-analysis of 90 studies including over 11,000 patients again showed that IPT was more effective than placebo or waiting list controls for the treatment of MDD. The results also showed that IPT was comparable in efficacy to CBT and to pharmacotherapies. The combination of IPT with antidepressant medications produced greater improvement in depression than IPT alone. Moreover, IPT was efficacious for anxiety disorders and for eating disorders.

There were no important differences in the efficacy of IPT and CBT or pharmacotherapies for depression, anxiety, or eating disorders. The lack of availability of therapists and evidence-based psychotherapies can be a significant problem, however.

Cuijpers P, Donker T, Weissman MM, et al. Interpersonal psychotherapy for mental health problems: a comprehensive meta-analysis. 

This study strongly suggests that less caution is needed in first-term use of sertraline, but increased caution is needed for fluoxetine in pregnant women. Continued caution should be used when considering paroxetine.

This case-control study is based on a very large multistate US dataset. It allowed individual birth defect risk to be associated with 5 SSRI exposures. The odds found in the dataset were used to modify the odds that already existed in other studies. The authors conducted a meta-analysis to determine the a priori odds and then in conjunction with the dataset determined the posterior odds.

A group of almost 18,000 women who gave birth to infants with birth defects were compared with almost 10,000 women whose infants had no birth defects. All women were asked about their SSRI use in the month before pregnancy and during the first trimester of their pregnancy.

Because of the study design, the odds of each SSRI exposure were associated with specific defect identification, rather than the other way around. In addition, no causal conclusions could be made. Despite these limitations, the large number of defects and exposures allowed for more precise estimates of the associations between defects and first-trimester exposure to each SSRI. The large dataset found that most previously reported associations were not supported. Perhaps most importantly, no birth defects were associated with sertraline exposures.

Many of the previously reported associations of defects with paroxetine were replicated. Two defects were associated with fluoxetine exposure.
Defects were not associated with citalopram, escitalopram, or sertraline.

Reefhuis J, Devine O, Friedman JM, et al, on behalf of the National Birth Defects Prevention Study. Specific SSRIs and birth defects: bayesian analysis to interpret new data in the context of previous reports. 

Dr. Saeed is Professor and Chairman of the Department of Psychiatry and Behavioral Medicine at the Brody School of Medicine at East Carolina University, Director of the ECU Center for Telepsychiatry and e-Behavioral Health as well as of the North Carolina Statewide Telepsychiatry Program (NC-STeP), and Chief of Psychiatry at Vidant Health in Greenville, NC. Dr. Bloch is Professor and Director of Research in the Department of Psychiatry and Behavioral Medicine at Brody School of Medicine at East Carolina University.

The psychiatric literature is overwhelming. So these authors have culled 25 "top" articles based on their relevance to clinical practice. Here's a quick synopsis of 8 top articles. 

Top Papers That Can Change Your Practice

Psychiatrists and other clinicians are under increasing pressure to stay up to date with the medical literature. With the rapid growth of knowledge, the challenge to keep up with the ever-growing body of information is greater than ever.

There is now an emerging realization that, as clinical providers, we need an efficient and effective system to help us sort and evaluate the quality of information before we can apply it to clinical care. Without such a system, when faced with an overload of information, most of us tend to take the first or the most easily accessed information-without consideration of the quality of such information. As a result, such poor-quality information affects the quality of care we provide and costs billions of dollars annually because of underuse, overuse, and misuse.

To sort and evaluate published research that is ready for clinical utilization, we used the following 3-step methodology:

 Search literature for research findings published between July 1, 2015, and June 30, 2016, that suggest readiness for clinical use.

 Members of the American Association of Chairs of Departments of Psychiatry; the American Association of Community Psychiatrists; the American Association of Psychiatric Administrators; the North Carolina Psychiatric Association; and the Group for the Advancement of Psychiatry (GAP), as well as colleagues, were asked: Among the articles published from July 1, 2015, to June 30, 2016, which ones in your opinion have (or are likely to have or should have) affected/changed the clinical practice of psychiatry?

 Look for appraisals in post-publication reviews, such as 

Faculty of 1000 Factor, Evidence-Based Mental Health

, and commentaries in peer-reviewed journals.

The top 25 articles were selected based on their clinical relevance/applicability. Here, we present brief descriptions of the first 8 papers chosen by this methodology-the order in which the articles appear in the list is arbitrary. We will present descriptions of the remaining papers in upcoming issues. Abstracts are available on PubMed.

Amminger GP, SchÃ¤fer MR, SchlÃ¶gelhofer M, et al. Longer-term outcome in the prevention of psychotic disorders by the Vienna omega-3 study. 

» This follow-up of a randomized clinical trial (RCT) demonstrated that omega-3 fatty acids were effective in preventing new-onset psychotic disorders in high-risk individuals. The current study compared oral administration of daily fish oil capsules containing 700 mg of eicosapentaenoic acid and 480 mg of docosahexaenoic acid with placebo for 12 weeks in individuals at similar risk for a new-onset psychotic disorder. Follow-up was extended to 7 years.

Participants (N = 81) between the ages of 13 and 25 who sought treatment for attenuated psychotic behaviors, transient psychosis, or decreased functioning in the presence of genetic risk for psychotic disorders were randomly assigned to omega-3 and placebo. At the 7-year follow-up, patients in the omega-3 group were 32% less likely to have converted to a psychotic diagnosis or to have been treated with antipsychotic medications.

Omega-3 polyunsaturated fatty acids have negligible adverse effects and are relatively inexpensive. This study replicated and extended the duration of positive effects of a 12-week course of polyunsaturated fatty acids on preventing psychotic disorders and improving symptomatic behaviors to 7 years.

Samara MT, Leucht C, Leeflang MM, et al. Early improvement as a predictor of later response to antipsychotics in schizophrenia: a diagnostic test review. 

» This systematic review used positive predictive value to test the hypothesis that a poor response to antipsychotic medication by week 2 would predict poor treatment effects by the end of the trial. Studies in which antipsychotics were used for 4 to 12 weeks to treat schizophrenia, schizophreniform psychosis, or schizoaffective psychosis were combined.

Less than a 20% improvement on the Positive and Negative Syndrome Scale by 2 weeks was used as the measure of lack of early responsiveness; endpoint lack of response was less than 50% improvement. The primary result was an overall positive predictive value of 0.90 or 90%. Patients who exhibited less than 20% improvement by 2 weeks were 90% likely to show less than 50% improvement by the end of their medication trial.

The primary clinical conclusion is that patients who have had at least 1 previous schizophrenia episode and who show at least 20% improvement after 2 weeks of targeted antipsychotic dose treatment should not have their medication changed early.

Kane JM, Robinson DG, Schooler NR, et al. Comprehensive versus usual community care for first-episode psychosis: 2-year outcomes from the NIMH RAISE early treatment program. 

» An RCT utilized the outcome data at the end of a 2-year intervention to compare quality of life and psychopathology scores for a multimodal multidisciplinary team approach (Navigate) versus usual community care for the treatment of first-episode psychosis. The team approach included personalized medication management, family psychoeducation, resilience-focused psychotherapy, and supported employment and education.

First-episode psychotic patients (N = 404), aged 15 to 40 years, were randomized to either treatment approach. Affective psychosis and medically related psychoses were not included. Participants in the Navigate team approach showed greater improvement in quality of life and reduction of psychopathology than those in the treatment as usual group. These differences were greater for participants whose untreated psychotic disorders were of shorter duration.

It is not clear whether the benefits of the intensive team approach will last beyond the 2-year treatment interval. Follow-up studies will tell whether outcome benefits of the intensive team approach persist after the end of the trial.

Jarde A, Morais M, Kingston D, et al. Neonatal outcomes in women with untreated antenatal depression compared with women without depression: a systematic review and meta-analysis. 

» This meta-analysis combined 23 observational studies, 22 prospective cohort studies, and 1 retrospective cohort study to examine the association of untreated prenatal depression with low birth weight, premature birth, and admission to neonatal intensive care units. Increased odds of both low birth weight (odds ratio [OR] = 1.96; 95% confidence interval [CI], 1.24-3.10) and preterm birth (OR = 1.56; 95% CI, 1.25-1.94) were seen in studies that reported conflicts of interest. More clinically relevant, the preterm birth rate OR when there were no conflicts of interest was 1.34 (95% CI, 1.08-1.66).

This study is important for decision-making discussions between clinicians and their depressed pregnant patients. Findings suggest that untreated depression during pregnancy is associated with an increased risk of low birth weight as well as preterm birth.

D’Onofrio G, O’Connor PG, Pantalon MV, et al. Emergency department- initiated buprenorphine/naloxone treatment for opioid dependence: a randomized clinical trial. 

» Patients (N = 329) with opioid dependence who presented to the ED were randomized into 3 treatment groups: referral only, brief intervention and referral, brief intervention and referral plus buprenorphine. Enrollment and participation in addiction treatment 30 days after randomization was the primary outcome.

Patients in the buprenorphine group (78%) who met the primary outcome far exceeded those in the referral-only group (37%) as well as those in the brief treatment and referral group (45%). This finding strongly suggests that active referral, a link to outpatient services, and buprenorphine treatment are far more successful in motivating patients to participate in longer-term addiction care. ED physicians and consultants should recognize the value of initiating treatment in the ED that is actively linked with ongoing outpatient services. The role of buprenorphine is not clear. Although several benefits were seen for buprenorphine treatment, no significant decreases were observed in the rates of urine samples that tested positive for opioids or in the risk of HIV infection.

Phillips KA, Keshaviah A, Dougherty DD, et al. Pharmacotherapy relapse prevention in body dysmorphic disorder: a double-blind placebo- controlled trial. 

» Adults (N = 100) with body dysmorphic disorder were given open-label escitalopram for 14 weeks, followed by random assignment of 58 responders to either a 6-month continuation of escitalopram or placebo. During the blinded continuation phase, the primary outcome was the comparison of relapse rates in patients who were receiving active treatment and those in the placebo group. Relapse during the 6-month continuation phase was greater in the placebo group. Continuing improvements were seen during the additional 6 months of escitalopram treatment: time to relapse increased, and compared with those who received placebo, fewer patients relapsed.

Guo T, Xiang YT, Xiao L, et al. Measurement-based care versus standard care for major depression: a randomized controlled trial with blind raters. 

» In this 24-week trial, 120 moderately to severely depressed patients were randomly assigned to either measurement-based care or standard treatment. With measurement-based care, antidepressant titration decisions were based on each patient’s Quick Inventory of Depressive Symptomatology-Self Report (QIDS-SR) score and on the adverse effects the patient experienced. Standard treatment was guided by psychiatrist evaluations without access to scale scores. Both groups were limited to either paroxetine or mirtazapine.

The 2 primary outcome measures were time to response and to remission measured by Hamilton Depression Scale (HAM-D) scores. Response was a decrease of 50% or more on the HAM-D; remission was 7 or lower on the HAM-D. If the QIDS-SR score was not below 9 by week 8, medications were switched. Medications could be switched earlier based on psychiatrist decisions about adverse effects and efficacy.

The measurement-based care group showed higher rates of improvement (86.9%) and remission (73.8%) than the standard care group (62.7% and 28.8%, respectively). Average times to achieve these levels was almost twice as long with standard care. The measurement-care group received more dosage adjustments and ended at higher doses than the standard care group.

The results strongly suggest that better, quicker, and more frequent responses and remission are obtained with measurement-based treatment.

Leonpacher AK, Peters ME, Drye LT, et al. Effects of citalopram on neuropsychiatric symptoms in Alzheimer dementia: evidence from the Cit AD study. 

» The Citalopram for Agitation in Alzheimer’s Disease study (Cit AD) examined the efficacy of citalopram in reducing the incidence and intensity of aggressive behavior in patients with Alzheimer disease. Patients (N = 189) with Alzheimer disease and aggression were randomized to citalopram or placebo. Primary outcome variable was the aggression subscale score on the Neuropsychiatric Inventory (NPI).

After an earlier trial, no statistically significance difference was seen between citalopram and placebo. The current study is a secondary analysis of caregiver reports and other NPI subscales at 9 weeks to gauge whether citalopram reduced other neuropsychiatric symptoms besides aggression.

Citalopram lowered levels of reported delusions, anxiety, and irritability but may have increased sleep/night time behavior disorders. It is not clear whether the strongly serotonergic effects of citalopram offered any benefits compared with other SSRIs, but compared with placebo, neuropsychiatric benefits were seen.

Dr. Saeed is Professor and Chairman of the Department of Psychiatry and Behavioral Medicine at the Brody School of Medicine at East Carolina University, Director of the ECU Center for Telepsychiatry and e-Behavioral Health as well as of the North Carolina Statewide Telepsychiatry Program (NC-STeP), and Chief of Psychiatry at Vidant Health in Greenville, NC. Dr. Bloch is Professor and Director of Research in the Department of Psychiatry and Behavioral Medicine at Brody School of Medicine at East Carolina University. 

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Research Findings That Can Change Clinical Practice: Part 1

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A summary of important CBT studies with the most current evidence-based information, chosen for their relevance and clinical utility. 

5 Clinically Relevant Studies on CBT

This month, we have selected 9 articles on cognitive behavioral and mindfulness-based treatments based on their clinical relevance and applicability, as well as their quality. Our goal is to help you stay up to date with the most current evidence-based information in the face of an overwhelming literature.

Brent DA, Brunwasser SM, Hollon SD, et al. Effect of a cognitive- behavioral prevention program on depression 6 years after implementation among at-risk adolescents: a randomized clinical trial. 

http://www.ncbi.nlm.nih.gov/pubmed/26421861

A family history of psychiatric disorders is an important component of history taking. It is now known that parents’ depression can increase the risk of depression in their children.

This randomized study evaluated the usefulness of a cognitive-behavioral prevention (CBP) program in reducing the incidence of depression in adolescents. The program held 90-minute group sessions once a week for 8 weeks, then once monthly for 6 months. CBP plus usual care (family-initiated mental health treatment) was compared with usual care alone.

The 316 participants were aged 13 to 17 years and had at least 1 parent with current or previous depressive episodes. The study included patients with so-called “subsyndromal” depressive symptoms or a previous depressive episode in remission, but it excluded those in a current depressive state. Follow-up was 75 months after the intervention. The Depression Symptoms Rating scale was used to evaluate the participants.

 CBP is a promising intervention for the prevention of depression. Although participants received the most benefit from CBP in the early months of the study, at 75-month follow-up the incidence of depression was still lower among adolescents in the CBP group than among those who received usual care alone. Whether additional “booster” CBP sessions would provide further protection remains to be determined.

Kuyken W, Hayes R, Barrett B, et al. Effectiveness and cost-effectiveness of mindfulness-based cognitive therapy compared with maintenance antidepressant treatment in the prevention of depressive relapse or recurrence (PREVENT): a randomised controlled trial. 

http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(14)62222-4/fulltext

Although maintenance antidepressant therapy is important to prevent recurrent depressive episodes, many patients may be interested in alternative treatments.

This study looked at whether mindfulness-based cognitive therapy with discontinuation of antidepressant treatment (MBCT-TS) was superior to maintenance antidepressant treatment. Participants were eligible if they had 3 or more previous major depressive episodes and were receiving therapeutic dosages of maintenance antidepressants. A total of 424 patients were enrolled: 212 were assigned to MBCT-TS and 212 received maintenance antidepressant therapy. The duration of this single-blind, parallel, randomized, controlled trial was 24 months. The participants were evaluated with the Structured Clinical Interview for DSM-IV (SCID), GRID-Hamilton Rating Scale for Depression, and 21-item self-report Beck Depression Inventory. Psychiatric comorbidity was assessed with the relevant SCID modules; medical comorbidities with the Medical Symptom Checklist; quality of life with the WHO Quality of Life instrument (WHOQOL-BREF); and health-related quality of life with the EQ-5D-3L.

 In participants with a history of recurrent depressive episodes, MBCT-TS was not superior to maintenance antidepressant treatment in the prevention of relapse.

Both treatments did, however, seem to have a similar effect on participants’ quality of life and residual depressive symptoms, and they decreased relapse or recurrence. MBCT-TS can be further investigated as a potential alternative to pharmacotherapy for depression maintenance treatment.

Weck F, Neng JM. Response and remission after cognitive and exposure therapy for hypochondriasis. 

http://www.ncbi.nlm.nih.gov/pubmed/26513512

CBT can be used for a variety of psychiatric disorders, including hypochondriasis; in this setting, it has significant efficacy. This study was based on the results of a randomized controlled trial that focused on patients with hypochondriasis (N = 75) and their rates of response and remission after they received CBT or exposure therapy. The cognitive therapy group had 38 patients, and the exposure therapy group included 37 patients. After treatment 36.8% of the CBT group went into remission, compared with 54.1% of the exposure therapy group. At 12-month follow-up, 57.9% of CBT patients were in remission vs 51.4% in the exposure therapy group.

 After treatment, when the whole sample was combined (patients who underwent CBT and those who had exposure therapy), 45.3% of patients went into remission and 72.0% responded to treatment. At 12 months, the whole sample remission rate was 54.7% and the response rate was 68.0%. The differences between exposure therapy and CBT were not significant. In general, patients’ and therapists’ evaluations of clinical improvement were more comparable to remission rates than to response rates.

Brenes GA, Danhauer SC, Lyles MF, et al. Telephone-delivered cognitive behavioral therapy and telephone-delivered nondirective supportive therapy for rural older adults with generalized anxiety disorder: a randomized clinical trial. 

http://www.ncbi.nlm.nih.gov/pubmed/26244854

Patients in late life can experience generalized anxiety disorder (GAD), but there appear to be age-related differences in its manifestation. Access to psychiatric treatment for older adults may be limited in rural areas, and this problem may worsen as the so-called “baby boomers” continue to age.

This randomized clinical trial evaluated the efficacy of CBT delivered by telephone versus telephone-delivered nondirective supportive therapy (NST) in 141 rural older adults with GAD. Participants were age 60 years and older and had a principal diagnosis of GAD. The study took place in their homes. The telephone CBT group participated in 11 sessions; the telephone NST group had 10 sessions. The participants were evaluated by the Hamilton Anxiety Rating Scale and the Penn State Worry Questionnaire-abbreviated. Follow-up occurred at 2 and 4 months.

 Both treatments reduced symptoms of worry, depression, and GAD. However, telephone CBT produced superior results. Implementation of telephone CBT may decrease structural barriers that many older adults experience in mental health care.

Rohan KJ, Mahon JN, Evans M, et al. Randomized trial of cognitive- behavioral therapy versus light therapy for seasonal affective disorder: acute outcomes. 

http://www.ncbi.nlm.nih.gov/pubmed/25859764

Light therapy is effective in treating seasonal affective disorder (SAD) and may also be beneficial for non-seasonal MDD. The evidence regarding CBT for SAD is limited, however.

This randomized clinical trial compared CBT and light therapy in the treatment of SAD. The study enrolled 177 participants: 88 in the CBT group and 89 in the light therapy group. The CBT group underwent 12 sessions over 6 weeks, and the light therapy group received 30-minute morning treatments over a 6-week period. The participants were evaluated with the Structured Interview Guide for the Hamilton Rating Scale for Depression-SAD version (SIGH-SAD) and Beck Depression Inventory-Second Edition (BDI-II).

 CBT and light therapy may both be considered as options for an acute episode of SAD.

Philipsen A, Jans T, Graf E, et al. Effects of group psychotherapy, individual counseling, methylphenidate, and placebo in the treatment of adult attention-deficit/hyperactivity disorder: a randomized clinical trial. 

http://www.ncbi.nlm.nih.gov/pubmed/26536057

While ADHD is commonly associated with children and adolescents, its prevalence in adulthood is high. This 6-year randomized clinical trial examined the efficacy of nonpharmacological treatments (cognitive behavioral group psychotherapy [GPT] versus individual clinical management [CM]) in combination with methylphenidate or placebo in the treatment of adult ADHD. Seven centers in Germany participated in this prospective study. Investigators deemed 518 patients eligible and centrally randomized 433. The GPT and CM sessions occurred weekly for the first 3 months, then monthly for 9 months. Patients received either methylphenidate or placebo for 1 year. The ADHD Index of the Conner’s Adult ADHD Rating Scale was used to assess the primary outcome.

 After 3 months, there was no significant difference between the GPT and CM groups, but methylphenidate was superior to placebo. This finding contrasts with results of previous studies in which preliminary evidence suggested the superiority of structured disorder-oriented GPT over non- specific group control conditions. After 1 year, the treatment effects remained stable. At 1 year, the outcomes were better when CM or GPT was combined with methylphenidate.

Sibinga EM, Webb L, Ghazarian SR, Ellen JM. School-based mindfulness instruction: an RCT. 

http://www.ncbi.nlm.nih.gov/pubmed/26684478

Here's a summary of 9 recent articles on cognitive behavioral and mindfulness-based treatments, selected for their their clinical relevance, applicability, and quality.

Author | Sy Atezaz Saeed, MD, MS

Articles

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Key Studies That Inform Clinical Practice: Child and Adolescent Psychiatry

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