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 covered a wide variety of psychiatric issues and industry updates, from the cardiac adverse effects of lithium to the road to over-the-counter naloxone. Here are some highlights from the week.

Harnessing the Power of AI Technology for Drug Discovery Treatments

The buzz about the power of artificial intelligence (AI) to either save or doom humanity is rather deafening. A way to explain what people mean by AI is that it comprises the technologies we employ to have computers comb through large datasets using programs (“algorithms”) to find and extract patterns, help humans understand those patterns, suggest decisions regarding future choices, and predict future events or suggest outcomes not previously conceived.

Although some expect AI to mimic human intelligence, some AI systems show performance superior to that of humans (eg, AlphaGo). On the other hand, unlike humans, most AI systems need considerable data and training to achieve acceptable performance (eg, we only need to taste strawberries once to know if we like them or not). 

The Road to Over-the-Counter Naloxone: FDA Releases Federal Register Notice

To encourage sponsor application for over-the counter naloxone, the US Food and Drug Administration (FDA) today issued a Federal Register notice, “Safety and Effectiveness of Certain Naloxone Hydrochloride Drug Products for Nonprescription Use,” that could help facilitate the development and potential approval of nonprescription naloxone drugs.

“Today’s action supports our efforts to combat the opioid overdose crisis by helping expand access to naloxone,” said FDA Commissioner Robert M. Califf, MD. “The agency will keep overdose prevention and reduction in substance use disorders as a key priority and area of intense strategic focus for action as rapidly as possible.” 

Lithium: Cardiac Adverse Effects and When to Get an ECG

A recent consultation motivated an evaluation of the evidence on when one should monitor electrocardiograms (ECGs) in patients taking lithium. Opinions vary and tend to be vague about when and how often to measure the ECG. Mogens Schou, MD, who was perhaps the world’s foremost expert on lithium and a passionate advocate for its use, observed that lithium occasionally changes the function or electrical activity of the heart, but the presence of heart disease rarely should prevent lithium treatment. 

If heart disease was present, however, he recommended a consultation with a cardiologist and serial ECGs might be considered. Much more recently, The Maudsley Prescribing Guidelines in Psychiatry from the United Kingdom recommended getting an ECG if there are risk factors for, or preexisting, cardiac disease—but offered no further details. 

The Race Is On to Nurture Resilient People for a Resilient Planet

The scale and devastation of climate change is increasingly apparent. As we witness tenuous and inadequate movement toward effective responses, one thing is clear: 

 are also falling apart, in addition to the places where they live. The rapidly growing human emotional suffering from climate change is alarming from more than a humanitarian perspective: Social and emotional bandwidth is vital to tackle climate change itself.

People must adapt, care, endure, transform, and find hope through these challenges if we are to humanely and effectively make it through at all. The emotional and social challenges of these tasks—our psychiatric work—have been a neglected part of climate efforts. 

. And be sure to stay up-to-date by subscribing to the 

Do you have a comment on any of these or other articles? Have a good idea for an article and want to write? Interested in sharing your perspectives? Write to us at 

From the cardiac adverse effects of lithium to the road to over-the-counter naloxone, here are highlights from the week in Psychiatric Times.

The Week in Review: November 14-18

The buzz about the power of artificial intelligence (AI) to either save or doom humanity is rather deafening. A way to explain what people mean by AI is that it comprises the technologies we employ to have computers comb through large datasets using programs (“algorithms”) to find and extract patterns, help humans understand those patterns, suggest decisions regarding future choices, and predict future events or suggest outcomes not previously conceived. 

Although some expect AI to mimic human intelligence, some AI systems show performance superior to that of humans (eg, AlphaGo

). On the other hand, unlike humans, most AI systems need considerable data and training to achieve acceptable performance (eg, we only need to taste strawberries once to know if we like them or not).

One area of research that has attracted a lot of interest and funding is the AI-based design of novel drugs—small molecules, in particular.

 A simple way to classify the work being done in this area is shown in the 

 selection of a receptor or enzyme to be activated, inhibited, or modulated.

 Targets for psychiatry, for example, could be monoamine transporters (eg, SSRIs) or newer targets such as TAAR1 (eg, Ulotaront

). A receptor model implies knowing or hypothesizing its structure based on known crystalline structures.

 A ligand-based model requires a dataset containing the structure of target-selective molecules (“ligands” and “chemical probes”) and the result of their interaction with a target protein (eg, a neurotransmitter receptor) in an appropriate assay (eg, the serotonin 1A receptor

Importantly, both receptor and ligand-based approaches to 

 drug design implicitly assume that the action at this particular target is the most important action driving the therapeutic value of a drug.

The advantage ofthese modeling platforms is that existing data can be leveraged 

 to predict a new molecule’s action at a target, as well as its physical properties, before triggering costly preclinical work

As the establishment of AI expertise also comes at a considerable cost,various partnerships between AI companies and pharma have been initiated to drive development of AI-based models for 

 drug design, avoiding the need to build up internal AI expertise. 

Partnerships such as Genentech/GNS Healthcare, GSK/Insilico Medicine, Takeda/Numerate AI, Atomwise/Abbvie, CrystalGenomics/Standigm, and Cloud Pharmaceuticals/TheraMetrics use novel machine learning techniques to design or identify molecules that act on biological targets of particular interest.

 Most of these partnerships, however, do not focus on psychiatric indications or on CNS disorders in general.

Phenotypic Drug Discovery: A Holistic Approach

Drug discovery for mental health, whether traditional or AI-based, has been lagging, whereas mental health needs have continued to increase and remain a great societal burden. Although single target-based AI drug design may be adequate for some indications, the evidence from psychiatry research points to the need of polypharmacology (Figure). Indeed, action at different targets, aiming at an appropriate equilibrium, may be needed.

However, to quantify compound effects at multiple targets in a manner that encompasses downstream actions and interactions, it is necessary to explore drug activity using an 

 phenotypic drug discovery (iPDD) approach.

 An iPDD platform can be used for polypharmacology against known multi targets or in a target-agnostic manner (Figure), as the organism used for drug screening acts as an amplifier of all compound’s actions, providing a comprehensive drug profile. iPDD platforms include those high-throughput screens based on drosophila, zebrafish, and mice.

Phenotypic screening using an iPDD platform enables characterization of the complete gamut of behavioral effects of reference drugs and a data-driven, target-agnostic comparison with novel compounds. The potential of machine learning-based analysis of behavioral phenotyping data can be leveraged in many drug discovery applications, such as the mining of iPDD screened compounds libraries looking for new hits, or analysis of novel drug candidate analogs, to speed up the lengthy drug discovery process. Furthermore, using animal models of disease in iPDD platforms opens opportunities to explore phenotypic drug screening for psychiatric, neurodegenerative, and rare disorders.

iPDD drug discovery projects can progress in an agnostic manner or turn into a multi- or single-target programs as needed. Although not knowing the mechanism of action makes the road to the clinic harder, target-agnostic programs can be de-risked using “anti-target” panels, such as avoiding D2 antagonism in the development of novel antipsychotics. Biomarkers can also be used to assess target engagement in the clinic when the mechanism of action is unknown.

Perhaps the most convincing evidence will be at hand very soon. Ulotaront, an antipsychotic with a novel mechanism of action now being tested in Phase III, was discovered and developed in partnership between Sunovion and PsychoGenics,

 drug design approaches have promise for indications with validated hypotheses regarding needed therapeutic mechanisms of action. For complex CNS disorders, on the other hand, phenotypic screens and associated AI methods (such as iPDD platforms) are needed. The phenotypic approach in the upcoming era of AI-based drug design promises to bring new insights and accelerate drug discovery for CNS disorders.

is chief innovation officer at PsychoGenics Inc. and adjunct associate professor at Mt. Sinai School of Medicine. She is a member of the Business Advisory Board of CTF and the Scientific Advisory Board of CureVCP.

1. AlphaGo. DeepMind. Accessed October 12, 2022. 

https://www.deepmind.com/research/highlighted-research/alphago

2. Vedantam K. AI is making its way into drug discovery. What does it mean for biotech? 

. October 4, 2022. Accessed October 13, 2022. 

https://news.crunchbase.com/health-wellness-biotech/artificial-intelligence-venture-drug-discovery/

3. Mouchlis VD, Afantitis A, Serra A, et al. 

Advances in de novo drug design: from conventional to machine learning methods

4. Correll CU, Koblan KS, Hopkins SC, et al. 

Safety and effectiveness of ulotaront (SEP-363856) in schizophrenia: results of a 6-month, open-label extension study

Structural biology: a moving story of receptors

6. Czub N, Pacławski A, Szlęk J, Mendyk A. 

Do AutoML-based QSAR models fulfill OECD principles for regulatory assessment? A 5-HT1A receptor case

7. Buvailo A. How big pharma adopts AI to boost drug discovery. BioPharmaTrend.com. October 8, 2018. Accessed October 12, 2022. 

https://www.biopharmatrend.com/post/34-biopharmas-hunt-for-artificial-intelligence-who-does-what/

Multi-target approach for drug discovery against schizophrenia

9. Leahy E, Brunner D. We need a new Prozac: the demand for brain drug innovation. 

. August 15, 2022. Accessed October 12, 2022. 

https://www.thepharmaletter.com/article/we-need-a-new-prozac-the-demand-for-brain-drug-innovation

Drug screening in drosophila; why, when, and when not? 

11. McCarroll MN, Gendelev L, Keiser MJ, Kokel D. 

Leveraging large-scale behavioral profiling in zebrafish to explore neuroactive polypharmacology

12. Roberds SL, Filippov I, Alexandrov V, et al. 

Rapid, computer vision-enabled murine screening system identifies neuropharmacological potential of two new mechanisms

Mouse model systems of autism spectrum disorder: replicability and informatics signature

What is the buzz about the power of artificial intelligence?

The “cab driver test” is a convenient metric of sentiment analysis to determine when a treatment or product has reached a hype cycle. For example, when your cab driver is advising you on experimental drug infusions or supplemental enemas, the information available to the public is probably beyond the purview of the specialists. For 

, the equivalent could be that when Gwyneth Paltrow produces a 

 episode on the subject, the space has slipped out of the control of academia and science and is significantly being directed by market forces. It is no longer a “field”—it is now an “industry.”

These forces that dictate the direction in which the industry will grow and mature have shifted beyond the organicity of academic cadence. A keen eye would note the significantly disproportionate development of the industry: Of the 73 biggest companies in the psychedelic industry that have taken in $3.26 billion in capital, $2.9 billion is in drug development.

 This is unsurprising considering the valuation multiples and revenue growth of pharmaceuticals compared with the other subsectors in the psychedelic ecosystem, including clinics, therapist training, and true academia.

Although most of the industry seems intent on developing novel and patentable psychedelic substances, a key factor that appears largely overlooked by the growth wave is, as one of the most prominent researchers in this field, Robin Carhart-Harris, PhD, titled his 2018 paper, “the essential importance of context.”

Context, more commonly described in the psychedelic field as “set and setting,” refers to the careful preparation of the patient mindset before and while they go into the psychedelic session, along with the physical setting in which the dosing takes place—the structure, music, decor, and other environmental components. However, that is but the obvious, floating tip of the contextual iceberg.

Context is a multifaceted, all-encompassing construct encapsulating treatment setting, therapeutic relationship, cultural milieu, historical inclinations, and social attitudes. Although therapist proficiency is key to therapeutic sessions and drug development modulates the experiential moments of the psychedelic session, context is the only factor that works to support both the psychedelic-based and the therapist-based components. The critical role it plays in treatment is far from unique to the psychedelic field.

If we consider the standard frontline pharmacological treatments for anxiety disorders, selective serotonin reuptake inhibitors and serotonin and norepinephrine reuptake inhibitors, these drugs do not ameliorate mental illness via a single dose, nor does their continued use in isolation provide a “cure” for mental distress. Despite the many drug treatments that are available, many patients do not respond to initial treatment or even to sequential trials of differing medications.

According to an FDA meta-analysis of antidepressant effects from 15 years ago

“Drug-placebo differences in antidepressant efficacy increase as a function of baseline severity but are relatively small even for severely depressed patients. The relationship between initial severity and antidepressant efficacy is attributable to decreased responsiveness to placebo among very severely depressed patients, rather than to increased responsiveness to medication.”

In response to that, Christoph Hiemke, PhD, wrote

“Current knowledge indicates that effects of antidepressant pharmacotherapy are a sum of nonspecific effects, placebo effects, and pharmacological effects….It is proposed that 3-armed studies in which participants are assigned to either drug, placebo, or no treatment enable to measure exactly the differential effect sizes of drug and placebo. Such studies, however, do not exist so far.”

According to personal correspondence from Luke Downey, PhD, a professor and head of the Drugs and Driving Research Unit at the Centre for Human Psychopharmacology at Swinburne University of Technology in Melbourne, Australia:

“A host of reasons are implicated in the relative efficacy of these pharmaceutical treatments, and even in the cases where treatment is effective, these clinical improvements do not occur in isolation. The effects of these drugs when used in a supportive context are very important. They give patients the opportunity to benefit from other treatments and interventions including cognitive-behavioral therapy, mindfulness meditation, guided imagery with relaxation, solution-focused therapy, and coping skills and other education that address both symptoms of mental illness and triggers of distress. These nonpharmacological factors such as client-therapist relationship and the setting of any clinical intervention are considered key moderators of efficacy in psychiatry just as the developing field of psychedelic-assisted psychotherapy needs to consider modifiable components of this treatment.”

Is It Time for Psychedelic-Assisted Psychotherapy to Embrace Technology?

According to William A. Richards, “Those who have known these profoundly meaningful states of consciousness have often shared them with no one, or only with those most intimately trusted, for fear of being misunderstood, called 

 At the core of the psychedelic-based treatment is its capacity to tap into noncognitive, experiential, emotional, and embodied processes of healing, which are far more difficult to achieve with talk therapy.

In his recent thesis titled, “Integrating the Ineffable: A Social Phenomenological Analysis of the Psychedelic Experience,” Logan Neitzke-Spruill stated that, “The common understanding of the experience as ineffable may indicate a general lack of affirmative frameworks for integrating these experiences.”

In the words of Hamilton, one of the individuals who provided a narrative account of his experience with psychedelics, which were collected and published by Timothy Leary, “The experience is so fantastic in both its novelty and its power as to beggar all possibility of adequate depiction through words. The most that can be hoped for by way of description is an approximation, and only those who have had the drug can know how far removed from actuality the approximation must be.”

When we consider this in depth, the psychedelic experience appears to have more parallels with the virtual reality (VR) experience than with talk therapy. Both create an intimate, personal space for healing and introduce the patient to an alternate reality, and both experiences are characterized by ineffability. Utilizing those synergistic properties to explore and integrate the psychedelic experience allows more time for the emotional, embodied, experiential narrative to unfold, before it is analytically and logically processed. The psychedelic treatment model empowers patients to take responsibility for their own healing. The unique therapeutic process returns agency over one’s mental health to the individual.

 has always enabled distribution of power. It allows new perspectives on existing problems, often guiding our progress in ways we could not have expected. We develop tech, which, in turn, reshapes us. One of the powerful, robust tools that appears to be uniquely suited for contextual design that supports the intimate, patient-driven pathway of recovery—sometimes referred to as “the inner healing intelligence”—is VR.

At the University of Bristol, a team of computer scientists led by David R. Glowacki, PhD, concluded their study on immersive VR environments: “It is possible to design phenomenological experiences using multiperson VR, which create the conditions for mystical-type experience from which participants derive insight and meaning.”

The first-ever research study on combining VR with psychedelics was recently conducted by the authors in collaboration with Swinburne University of Technology and Psychedelic Society Belgium. Participants of this retreat-based study, which used psilocybin-containing truffles along with a bespoke anchoring VR designed by Enosis Therapeutics, reported that “VR brought me back to the feeling of something ineffable and a feeling of knowing,” and “VR soothed me before the talk integration process. It contributed to the sense of wonder and authenticity, and when you grab the stars, it feels beautiful.”

Those synergistic, state-altering properties can be easily taken advantage of in therapy. For example, VR expands the mode of self-expression beyond current analog means with immersive, 3-dimensional tools or personalized spatial designs of the VR model, which can be used to create representations of thoughts, insights, or emotions experienced during the psychedelic session. 

What is interesting and perhaps less obvious about this approach is that, while VR allows for a greater range of creative expression, the process of self-expression in a virtual environment also seems to challenge familiar modes of perception and activate a full-sensory engagement,

 reacquainting the patient to the experience of an altered state of consciousness. The intimate world of VR, which can be accessed without therapist interference, grants patients the unique opportunity of a space that can be used to explore and consolidate psychedelic experiences before they need to be verbally shared or discussed with another human being.

Technology leapfrogs many limitations of the analog system by offering an infinite number of levers with which to modulate the contextual design. This means that an entire range of possible solutions can be first thoroughly explored before settling on the best methodology. For example, in the current therapeutic model, patients transition from full visual range to having blindfolds on for the bulk of the psychedelic dosing session—an “all or nothing” model of stimuli exposure. 

VR allows for controlled dosing of stimuli, providing an entire spectrum of stimuli intensity, complexity, range, and duration. Just as important, it allows individual control over the stimuli that form setting design (via individualized VR environments), as well as the ability for rapid shifts in setting to correspond with volatility of the patient’s psychoemotional state.

According to Carhart-Harris, “Remarkably, despite its widespread adoption among psychedelic researchers, few controlled studies have ever been performed to test the assumed relationship between psychedelics and context.”

 Despite the apparent prioritization of “set and setting” in psychedelic research, the focus of innovation in the field is significantly skewed toward drug development while environmental and contextual factors are largely neglected.

In contrast to other medical fields, the human-technology interface is poorly explored in mental health care and almost entirely ignored in psychedelic care. A continued lack of dialog around the idea that technology could be a compatible resource rather than a competitive, counterproductive agent perpetuates the opportunity cost of the unmet potential of optimized healing environments in psychedelic treatment.

We believe that introducing technology allows an efficient and in-depth exploration of diverse contextual elements, which is of particular importance to a field that is only just beginning to take shape. This helps mitigate the risk of this paradigm-shifting approach to mental health treatment being shoehorned into incumbent psychotherapeutic models. A robust exploration and understanding of the altered-state experience should be the process driving the development of therapeutic frameworks that are designed around that experience—not the other way around.

is cofounder of Enosis Therapeutics and a PhD researcher at Swinburne University of Technology in Melbourne, Victoria, Australia. 

is cofounder of Enosis Therapeutics; founder of digital currency brokerage Caleb & Brown; and a clinical adviser to the Australian Psychedelic Society.

1. Psychedelic sector overview: opening remarks. Psychedelic Alpha. Accessed June 20, 2022. 

https://psychedelicalpha.com/psychedelic-sector-overview

2. Carhart-Harris RL, Roseman L, Haijen E, et al. 

Psychedelics and the essential importance of context

3. Kirsch I, Deacon BJ, Huedo-Medina TB, et al. 

Initial severity and antidepressant benefits: a meta-analysis of data submitted to the Food and Drug Administration

Why do antidepressant therapies have such a poor success rate?

Sacred Knowledge: Psychedelics and Religious Experiences

Integrating the Ineffable: a Social Phenomenological Analysis of the Psychedelic Experience

. Master’s thesis. University of Delaware; 2019

7. Leary T. Timothy Leary: series IV. New York Public Library Digital Collections. Accessed June 20, 2022. 

https://digitalcollections.nypl.org/collections/timothy-leary-papers#/?tab=about

8. Glowacki DR, Wonnacott MD, Freire R, et al. Isness: using multi-person VR to design peak mystical-type experiences comparable to psychedelics. Paper presented at: ACM CHI Conference on Human Factors in Computing Systems; April 25-30, 2020; Honolulu, HI. Accessed July 11, 2022. 

https://research-information.bris.ac.uk/en/publications/isness-using-multi-person-vr-to-design-peak-mystical-type-experie

Virtual reality as a moderator of psychedelic-assisted psychotherapy

10. King JL, Kaimal G, Konopka L, et al. 

Practical applications of neuroscience-informed art therapy

How can a robust understanding of the altered-state experience drive the development of therapeutic frameworks that are designed around that experience?

Challenging the Status Quo of the Challenge to the Status Quo

COVID-19 has become a global pandemic affecting the lives of millions worldwide.

 Widespread outbreaks like COVID-19 have been found to be closely associated with symptoms of mental illness such as anxiousness, increased stress, feelings of hopelessness, and depressed mood.

In the elderly population, living under quarantine during previous disease outbreaks has led to increased incidences of depression, irritability, insomnia, and suicidal behavior.

 Adverse psychological sequelae of social isolation, which will be discussed in greater detail, have been shown to be correlated with female gender, toddler- and adolescent-aged children, higher-educational status, student status, and having symptoms resembling a COVID-19 infection.

 In elderly individuals, additional risk factors include having a negative perception of aging, health care-related occupations, abundant exposure to COVID-19-related information, knowing someone infected with COVID-19, and having a history of medical concerns.

Any given population under quarantine is more likely to experience heightened anxiety. Unwavering and occasionally sensationalized media coverage, sometimes perpetuating misinformation, may precipitate mass hysteria, stockpiling of supplies, xenophobia, and social unrest.

 Families unable to see loved ones in the hospital before their deaths are vulnerable to anger, resentment, and trauma.

 Rates of domestic violence have risen as more time is spent with those living in the same home.

Individuals who are predisposed to anxious tendencies may find that their anxiety manifests in the form of obsessive behaviors, such as increased temperature checks and more frequent sterilization.

 Patients previously treated for underlying psychiatric illness(es) may discontinue therapy and/or medications due to strict policies placed on health care access.

 In infected individuals, posttraumatic symptoms have been noted to develop during isolation, the severity of which correlated with the length of quarantine.

 It appears that virtually no demographic can escape the psychological pressure that quarantine imposes, resulting in various expressions of mental illness among the population as a whole.

In the setting of this public health crisis and subsequent mass psychological distress, society relies on health care professionals to support mental health. Abruptly increased patient volume can present new challenges for clinicians regarding their ability to meet these demands in a timely and effective manner. Because of the pandemic, telemedicine is being utilized more frequently to help provide better access to care.

 New technological advances have made it possible to provide a virtual platform for medical care that minimizes physical exposure.

To illustrate the challenges and opportunities for improvement in access to COVID-19-related mental health care, we present a case of a 58-year-old female who tested positive for COVID-19. Shortly thereafter, the patient developed symptoms of psychological and emotional distress, which necessitated mental health services.

History (Obtained During the Initial Psychiatry Assessment)

“Ms Harris” is a 58-year-old, single, Black-American woman with no significant psychiatric history. Ms Harris had been employed fulltime as a primary caregiver. She was referred to psychiatry for anxiety and concerns for possible depression. Ms Harris reported limited social support and no close relationships with family members.

Prior to her first appointment with psychiatry, the patient self-isolated at home for 3 weeks after testing positive for COVID-19. The patient agreed to a telephone visit, given the circumstances of an ongoing outbreak. During her initial psychiatric consult, Ms Harris endorsed feeling extremely “down and depressed,” noticing changes in her mood and behavior after learning of her positive test result. She said that she received no follow-up care from any health care provider since being in quarantine and isolation, and she described feeling as though she has been “abandoned and left alone.” Ms Harris speculated that “Maybe there is nothing they can do for me,” and disclosed severe feelings of anxiety regarding her health. Due to in-house quarantine measures, Ms Harris had not been working and was worried about being able to support herself financially. She stated that she had been living in fear, unsure if or when she would recover.

Ms Harris was diagnosed with adjustment disorder with anxiety and depression after a clinical psychiatric telephone interview. The patient was counseled regarding coping strategies and skills and provided with both online and telephone resources related to COVID-19. Ms Harris was scheduled for a follow-up telephone appointment with psychiatry 3 weeks after her initial consult, at which time she reported that her mood had improved and that she was less anxious about her health. Given her improvement, no medications were prescribed. Afterward, Ms Harris attended 2 subsequent appointments in which she demonstrated gradual improvement in her mental health. Ms Harris missed her fourth appointment and did not return the clinic’s calls thereafter.

In order to limit the spread of disease, quarantine and isolation procedures have been implemented during the COVID-19 pandemic. Quarantine was recently implemented during the 2003 SARS epidemic and the 2009 H1N1 epidemic.

 Studies of psychological symptoms during those periods found that being quarantined may be associated with a wide range of negative responses, including symptoms such as depressed mood, increased stress, irritability, insomnia, anger, fear, and emotional exhaustion.

 Other studies concerned with the long-term psychological sequelae of quarantine demonstrate that quarantined individuals may be at higher risk of posttraumatic stress disorder (PTSD) and depressive symptoms up to 3 years later.

 Literature on the current and prior quarantines have uncovered a plethora of risk factors for developing or exacerbating depression and anxiety, of which Ms Harris had several: female gender, advanced age, Black-American race, unemployment, recent health care occupation, single status, and lack of offspring.

Black Americans have been found to have higher rates of infections, unemployment, death, and anxiety related to the financial recession during the pandemic.19 Despite these experiences, in the same study, it was found that Black Americans had lower rates of anxiety and depression overall compared to non-Black Americans.

 Conversely, another study found that Black Americans experienced higher rates of anxiety and depression.

 Given the discrepancy between these 2 studies, it may be worthwhile to further investigate the psychological effect of the COVID-19 pandemic on Black Americans.

As previously discussed, health care workers are also at increased risk for adverse psychological outcomes during and after quarantine. Health care staff forced to isolate themselves at home may experience feelings of worthlessness.

 As a result of unrelenting exposure to acutely ill patients, those who continue as clinicians may experience apathy and withdrawal.

Relationship status is another notable demographic. Isolation for married couples can lead to increased anxiety due to a perceived imbalance in support, while nonmarried couples may struggle with increased jealousy.

 Moreover, single individuals have been shown to experience feelings of loneliness and depression.

Given the inordinate list of stressors that a population faces under quarantine, it is imperative that measures are taken to mitigate adverse mental health outcomes. Firstly, sleep difficulties are associated with suicidal behavior, so anyone with such a history should be evaluated for suicidal ideation.

 Furthermore, engagement in group activities and psychological interventions aimed at addressing maladaptive thought processes related to loneliness have demonstrated efficacy.

 In addition, elderly individuals may ameliorate the burden of the pandemic by strengthening social connections via virtual means (eg, group chat rooms, video chats), practicing good sleep hygiene, and engaging in cognitive stimulation.

An additional hurdle that individuals face during a pandemic is seeing a health care clinician in person, which causes many patients to participate in telemedicine. Telemedicine provided access to mental health services for Ms Harris while she quarantined and involved a phone interview with 2-way, real-time communication via audio only.

However, other telemedicine modalities are now being implemented as well. We are accustomed to some of these mediums (eg, electronic medical records, mobile phones, email, SMS text messaging, videoconferencing), while others have not yet been as widely incorporated (eg, patient portals, smartphone applications, social media). Clinicians seeking to utilize these modalities must be deliberate in determining the clinical function they serve while assessing the clinical impact that the modality may have on a particular patient.

The primary consideration should be that disinhibition between the patient and clinician can occur using any of these virtual platforms, the degree of which varies with the modality.

 As Jay Shore, MD, MPH, outlines in his evaluation of digital health care, virtual disinhibition may actually lead to the patient being more genuine about their experiences, although the modality itself may lead to more miscommunication.

Other constraints must be considered as well. Without video, clinicians are limited in their ability to observe nonverbal cues and perform physical exams.

 A sense of mutual connectedness and understanding between the patient and clinician may also be limited, as well as between physicians and their team.

 Studies have shown that phone-centered (as opposed to video-centered) telemedicine further decreases the ability to maintain positive therapeutic relationships, as facial expressions are perceived to facilitate communication.

 Even with video accessibility, it is a challenge to assess suicide risk, interpret body language, and provide appropriate therapy.

Some studies show that, with telemedicine, patients expect more frequent consultations, while others become less engaged.

 Patients often do not answer the phone when called, or they may conduct visits while they are at the grocery store, driving, at work, or otherwise distracted, which might greatly alter a psychiatric interview. During interactions, misunderstandings may arise from the use of abbreviations and emojis, or the possibility of a household member eavesdropping and/or otherwise influencing the patient’s report. The clinician should compensate for miscommunication by regularly asking if the patient’s message is being understood correctly. Ms Harris did not return for additional follow-ups after only a few telemedicine appointments, underscoring one of the major pitfalls of telemedicine: difficulty in building a therapeutic alliance

The preferred medium for telemedicine can vary according to the age of the patient and/or clinician. In a recent study, 75% of adults over 18 years old used phone-to-phone communication while individuals under 18 used video conferencing 50% of the time.

 Reductions in treatment success can occur when patients and/or clinicians use a telehealth format that they are not skilled with. However, in their study, Landes et al concluded that 48% of telemedicine challenges reported by clinicians were resolved over time after the clinicians became accustomed to the system.

 Early education on how to incorporate telemedicine into patient care could mitigate these challenges before they arise.

Although we are headed in the right direction in adapting to these difficult times, there are still concerns to be addressed and further investigated. Continued research should be conducted on the disparities in mental health, specifically related to the use of telemedicine, which relies heavily on digital devices and electronic tools. The best strategy to mitigate risks associated with digital care might be to have a combination of face-to-face appointments interspersed with telemedicine visits. In their study, Tse et al determined that 83% of patients would prefer a mix of the 2 services.

One possibility could be to mandate initial consultations as face-to-face, while additional follow-up visits could be performed either virtually or in person. Alternatively, physicians could implement a system in which a patient must have a certain number of in-person visits each year. Further research needs to be performed to assess which strategies would work best for patients. Discussion of the telehealth channel should occur with the patient prior to its use and continue after as the clinician and patient adapt to its impact.

The psychological consequences of living through a pandemic and being in quarantine are significant and should promote a sense of urgency to find ways to support the expansion of access to mental health care. Striving for improvement in the population’s access to care will not only help during this crisis, but also cause permanent changes in future health care delivery. As we continue to make innovative advancements in medicine, physicians must strive to be informed regarding the strengths and limitations of current practices and take into consideration the population being served to provide the best patient care.

 is a clinical assistant professor in the Department of Psychiatry at the University of Illinois College of Medicine in Chicago, Illinois. 

 is a member of the psychiatry residency faculty at Advocate Lutheran General Hospital in Park Ridge, Illinois. 

 is a fourth-year medical student at Rosalind Franklin University of Medicine and Science in North Chicago, Illinois.

Note: The views expressed in this paper are those of the authors and do not necessarily represent the official position or policy of institutions represented by the authors.

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System effectiveness of detection, brief intervention and refer to treatment for the people with post-traumatic emotional distress by MERS: a case report of community-based proactive intervention in South Korea

6. Sepúlveda-Loyola W, Rodríguez-Sánchez I, Pérez-Rodríguez P, et al. 

Impact of social isolation due to COVID-19 on health in older people: mental and physical effects and recommendations

8. Kannarkat JT, Smith NN, McLeod-Bryant SA. 

Mobilization of telepsychiatry in response to COVID-19-moving toward 21st century access to care

9. DiGiovanni C, Conley J, Chiu D, Zaborski J. 

Factors influencing compliance with quarantine in Toronto during the 2003 SARS outbreak

Is quarantine related to immediate negative psychological consequences during the 2009 H1N1 epidemic? 

11. Caleo G, Duncombe J, Jephcott F, et al. 

The factors affecting household transmission dynamics and community compliance with Ebola control measures: a mixed-methods study in a rural village in Sierra Leone

The experience of SARS-related stigma at Amoy Gardens

13. Marjanovic Z, Greenglass ER, Coffey S. 

The relevance of psychosocial variables and working conditions in predicting nurses' coping strategies during the SARS crisis: an online questionnaire survey

What are the challenges and opportunities for improvement in COVID-19-related mental health care?

Digital Psychiatry

The Week in Review: November 14-18

Harnessing the Power of AI Technology for Drug Discovery Treatments

Challenging the Status Quo of the Challenge to the Status Quo

Telepsychiatry in the Setting of COVID-19 and Beyond

Virtual Psychiatry is Here to Stay

Mental Health App Collaborates With the American Foundation for Suicide Prevention

Challenges with mHealth Apps for Depression and Suicide Prevention

Treating Depression and Preventing Suicide: The Impact of mHealth Apps

mHealth Apps for Depression: Overcoming Challenges

Suicide in Older Adults: Advances and the Role of Technology in Treatment