Telepsychiatry Revolution Amid COVID-19 Outbreak

If you are a psychiatrist or patient, chances are there has been a transition to telemedicine for outpatient services. With the COVID-19 pandemic creating chaos for patients and psychiatrists alike, many systems worked frantically to implement telemedicine platforms. As the world of technology moves at ever increasing speeds, we as physicians must keep up. There is a saying barrowed from motivational interviewing that goes “meet the patient where they are at.” Of course, I’m not talking about where they are in the process of change, but rather we can meet the patients literally where they are at. This provides convenient access to psychiatric care for patients who cannot make it to the office. 

The current situation is terrible, but it provides us new opportunities to learn and grow. If there is one thing I learned in my residency training, it’s how to be flexible and role with the punches. I have learned over the last several years that resistance to the reality of a situation will lead to unhappiness. While I miss the deep personal connections with my patients during in person visits, I have learned that most of that experience can be maintained through telepsychiatry. 

Telepsychiatry is becoming more common, and many younger psychiatrists are making a career out of it. In the past, telepsychiatry required patients be seen in places such as the primary care clinic, now we are able to see patients in their homes. With most patients having access to a smart phone, they are able to complete the consultation in their car, or while on break at work. For busy people such as physicians who need a psychiatric consultation, the convenience of telepsychiatry is unparalleled.   

Here are some of the questions I had after I found out I would be doing telemedicine visits. 

Are We Compromising Patient care?

One of my biggest concerns moving to a telemedicine platform is the quality of patient care. It’s important to consider, since one of the most therapeutic aspects of a psychiatric consult is the physician patient relationship. Countless articles have detailed the importance of physician patient relationship in treatment outcomes. I believe it influences treatment outcomes even more in psychiatry than other specialties. Multiple studies in the literature have shown that telepsychiatry is just as good as in person visits for many psychiatric disorders including depression, anxiety, and PTSD. If you work with children, it may even be a clinical advantage to use telepsychiatry. Most child and adolescent patients actually prefer using technology to interact, and doctors’ appointments are no different. 

Is telepsychiatry HIPAA Compliant? 

It’s important to remember that not all video-based systems are HIPAA compliant. The ones we are most familiar with (Facetime, google hangouts) are not HIPAA compliant. There are a number of companies that offer telemedicine platforms that do comply with HIPAA regulations. Skype for business is a HIPPA compliant product but the free version is not for example. The companies that offer HIPAA compliant services will provide you with a Business Associate Agreement (BAA). It’s basically a document that indicates the data transmitted over the service is confidential. The company agrees to provide the service and cannot look at any of that data transmitted over the platform. Ensuring you have the BAA in place will confirm HIPAA compliance. 

How does State Licensing Work?

In order to use telepsychiatry you have to be licensed within the state that the patient is located in. For example, if you are licensed in Florida and the patient is located in South Carolina you would need a license in the state of South Carolina. However, the physician is allowed to be located anywhere in the world.  

Are There Limitations to Medication Prescribing?

For routine psychiatric medications, these can be electronically sent to the pharmacy like an outpatient visit. The one caveat to be aware of is prescribing controlled substances such as stimulants and benzodiazepines should not be done via telepsychiatry. Careful monitoring of patients on these medications necessitates the need for in person follow up. The legal guidelines are not clear at this point, so it’s best to avoid prescribing controlled substances. 

What About High risk situations?

Another area of concern is what to do in the event that a person is suicidal or needs emergency care. These situations are rare, but they can happen, and you need to be prepared. It’s a misconception that someone has to be in the room with the patient during the consult. This is not true, however it’s prudent to have a person you can contact in the event of an emergency. This can be a friend or family member who lives close to the patient and can reach out quickly. You should also get a list of the local police departments in the area where your patients are residing. This is a last resort but may be required in some situations. To summarize you should have the patient’s address, phone number, a friend or family member’s contact information, and the local police departments number. This should be enough information in the event you need to alert emergency services. 

What Is The Out of Pocket Cost to Physicians?

One issue that may be more important to the private practice psychiatrist is the equipment required to start telepsychiatry. In many cases the equipment required is already possessed, a laptop computer with built in speakers, camera, and microphone will likely be enough for most practitioners to get started. You can purchase higher end microphones and cameras which may be important to psychiatrists who plan to continue using telepsychiatry after COVID-19 however, it’s not required. The take home point is a basic laptop computer will cover most physician and patient needs. 

How Do I Get Vital Signs?

Blood pressure, pulse, height and weight are usually recorded on every patient, at every visit. A simple way to get around this issue is having the patient purchase a blood pressure cuff from the store, which is relatively inexpensive. Have the patient perform the blood pressure check while in the session and show you the monitor. This will allow you to record pulse and blood pressure easily. Many patients will have a scale in the house, and if not one can be purchased. 

What about Urine Drug Screen and Routine Labs?

This is a simple situation to handle and much like regular outpatient visits the patient can be sent to LabCorp or Quest diagnostics for these tests. Other examinations like the Abnormal Involuntary Movement Scale (AIMS) test for patient’s taking antipsychotics can be easily completed with telepsychiatry. 

Final Points:

In conclusion, I do not think telepsychiatry will replace all in person psychiatric evaluations and follow ups. However, it does provide a convenient option for busy patients with time constraints, and those who are more comfortable communicating electronically. I have embraced the change and I really have enjoyed the process of transitioning to telemedicine. 

I would love to hear any thoughts on telemedicine from the patient or physician perspective. Please, like comment, and subscribe to the blog. 

Diagnosis Depression: Major Depressive Disorder (MDD)

This is the beginning of a series on depressive disorders starting with MDD. I want to keep the posts short and to the point, less than 500 words each. 

Major depressive disorder (MDD) is very common. The lifetime and 12-month prevalence are 13-17% and 6-7% in American adults over the age of 18. For adults under the age of 50, it’s twice as likely to affect females when compared to males. MDD is associated with high rates of psychiatric and medical morbidity, impaired work function, and disability. 

DSM-5 Criteria for Diagnosis

To diagnose MDD you must have at least 5 of the following symptoms over the same two-week period. At least one of the symptoms must be depressed mood or loss of interest. 

The symptoms are as follows, depressed mood; diminished interest in pleasurable activities; changes in appetite either increased or decreased; insomnia or hypersomnia (increased sleep); psychomotor agitation (restlessness) or retardation (slow movement); decreased energy; guilt or feelings of worthlessness; diminished ability to concentrate; and recurrent thoughts of suicide. These symptoms must occur every day or nearly every day and last all day over that same two-week period. The symptoms can be either a subjective account, observed by others, or some combination of both.

It must cause significant disruption in social, occupational, and other important areas of function. It cannot be caused by a medical condition or substance use. 

Specifiers for MDD

Mild; Moderate; Severe; without psychotic features; Severe with psychotic features; in partial remission; in full remission; chronic; with catatonic featureswith melancholic features; with atypical featureswith post-partum onset; with or without full inter-episode recovery; and with seasonal pattern. 

In the next post we will cover the highlighted specifiers and what specific symptoms separate them from each other. Please like, share, and comment we want to hear from you. 

Chronic Inflammation And Depression

Processed with VSCO with kp1 preset

Introduction:

Inflammation is the body’s natural response to infection or injury. It’s an important response in the acute setting but chronic inflammation can contribute to the development of diseases such as heart disease and even depression. Most psychiatrists now recognize that inflammation plays a role in depressive disorders, although it’s not an inflammatory disease. Much of the research on inflammation and depression is ongoing and will develop over time. 

Risk Factors for Inflammation

·         Childhood trauma

·         High stress levels (work, school)

·         Depression that is resistant to treatment

·         Severe anxiety

·         Obesity BMI> 30

·         Medical illness

·         Recent injury or surgery

What are some nonpharmacological things we can do to reduce inflammation and thus the risk of disease?

Complementary and alternative therapies

Lifestyle: Exercise, Healthy diet, Mindfulness practice, CBT all have anti-inflammatory effects.

N-acetylcysteine studies with 2000 mg/day improved anxiety and depressive symptoms

L-methyl folate: L-methyl folate 15 mg/day as augmentation to antidepressants

Omega-3: 1000 mg/day of omega-3 fatty acids with DHA to EPA ratio > 60% improved depressive symptoms

When Should Hospitalization be Considered for Depression?

Introduction 

This post is significant to me because one area I really enjoy working is the inpatient psychiatric unit. This might seem strange, but it’s a place I just gravitate towards and fell like I’m having a meaningful impact. You can think of it as the equivalent to the medical intensive care unit (ICU). It’s a place to learn about the most severe psychiatric pathologies and medication management.

In this post I will cover some of the signs and symptoms that may indicate inpatient hospitalization could help and possibly be lifesaving. 

Signs and Symptoms

Suicidal Ideation:

If your depression has become so profound that you have thoughts about “killing yourself,” then it might be time for inpatient treatment. Many clinicians, especially those not working in mental health, feel uncomfortable asking direct questions about suicide. Contrary to a common belief, asking about suicide does not increase the risk of suicide. I like to use the term “kill yourself” when doing a suicide assesment. It’s very definitive and clear to the patient what I’m talking about. The concern increases if there is a plan in place for the person to kill themselves, the plan is logical, feasible, and the person intends to carry out the plan. All of these are warnings that the person is at high risk. If these thoughts are persistent that’s another indicator that the problem is more serious. 

There is a significant difference between the above situation and the person who has “passive suicidal thoughts.” Passive suicidal thoughts are statements like “If I didn’t wake up tomorrow, I would be okay with it.” It’s not that the person is actively trying to prematurely end their life, rather they would not mind if something happened that hastened the path towards death. 

Hopelessness:

Another validated risk factor for suicide is severe, unremitting hopelessness. Hopelessness consists of feeling that nothing is getting better, nothing will ever get better, and there’s nothing I can do about it. This, independent of other risk factors, puts the person at high risk for suicide.

Loss of Interest:

Severe anhedonia (loss of interest) in previously pleasurable activities is part of the diagnostic criteria for depression, it’s also something that can increase suicide risk. If a person previously went to the gym five days a week or watched every new episode of The Bachelor and suddenly no longer cares about these things, it may be cause for concern.

Poor Response to Outpatient Treatment:

If you have been in traditional outpatient therapy and medication management for many years with minimal or no improvement, and you have never been hospitalized for psychiatric purposes before, then inpatient hospitalization may help. Sometimes the break from the daily life stressors for 3-5 days allows the mind and body to rest. If you tried everything else, then who knows? This could be the intervention that changes your life.

Seeking inpatient psychiatric care is nothing to be ashamed of, and many mental health professionals are working hard to destigmatize psychiatric care. I like to think about inpatient psychiatric care as a mental wellness camp, and not as a punishment for mental illness.

If this information is useful please like, share, and subscribe to the blog and other social media sites. Drop us a comment about what topics you are interested in, and we will try to cover them. 

If you or someone you love is at risk for suicide, the following resources are available. 

National Suicide Prevention Lifeline: https://suicidepreventionlifeline.org

National Suicide Prevention Hotline: 1-800-273-8255

SAMHSA: https://www.samhsa.gov/grants/grant-announcements/sm-20-011

How to Tell if You Have Depression

Images that show what it feels like to suffer from mental illness. Bringing the inside to the outside.

Depression is not always easy to spot, and in a world filled with social media it always seems like everyone is living their best life. 

In the most severe states people can have suicidal thoughts and profound hopelessness. The symptoms can be mild, moderate, or severe. Depression can affect anyone. 

Depression is an illness like any other disease (diabetes, hypertension, heart disease) that affects thoughts, feelings, physical health, and behaviors. 

People with major depressive disorder have several of these symptoms every day or nearly every day for 2 weeks or more. 

Here are some signs that you may have depression 

At least one of the following, loss of interest in things you previously enjoyed or depressed mood  

At least 3 of the following 

  • Feeling slow or restless 
  • Feeling guilty or worthless
  • Increased or decreased appetite
  • Suicidal thoughts 
  • Problems concentrating, making choices, or remembering things 
  • Difficulty sleeping or sleeping too much 
  • Having low energy 

Potential physical signs of depression include 

  • Headaches
  • Muscle tension 
  • Digestive symptoms 
  • Sexual problems 
  • Feeling “keyed up”

This can be summed up in the mnemonic SIGECAPS taught to medical students everywhere. The mnemonic comes from the prescription a doctor might write for a depressed patient

 SIG:  1 energy capsules per day 

Please like, comment, and share the post if it was helpful. Let us know what else you would like to see. 

Ketamine: What You Need to Know

Anyone following psychiatry in the media will have heard about ketamine. Ketamine as a medicine was primarily used for starting and maintaining anesthesia. It’s also a well-known recreational drug (special K) for its hallucinogenic and dissociative effects. Ketamine nasal spray was approved by the Food and Drug Administration (FDA) in March of 2019 for treatment resistant depression (TRD). Ketamine intravenous infusions were being offered for several years prior to FDA approval as an off-label treatment for TRD. esketamine is the S-isomer of ketamine (usually a mixture of both s-ketamine and r-ketamine). The nasal spray device contains 28 mg of esketamine and is administered as a single spray in each nostril.

The guidelines for dosing the medication include an induction phase (weeks 1-4) of 56 mg on day one followed by 56 mg or 84 mg twice per week. From week five on 56 mg or 84 mg will be given every 1-2 weeks depending on patient response. Patients are required to remain in the office to be observed by a healthcare provider for at least two hours after receiving the medication. The device cannot be taken home, and the patient must come to the office for each dose. The clinic must be a certified Spravato treatment center to use the medication. Patients should be remined to avoid food 2 hours prior to treatment, and liquids 30 minutes prior to treatment. Blood pressure should be monitored 40 minutes after the dose. 

Some of the limitations associated with this medication include high cost to the patient. Insurance will cover some of the cost and Johnson & Johnson set a list price of $590 to $885 per treatment. The major side effects include sedation, dissociation, increased blood pressure which is transient, cognitive impairment and inability to drive. One of the major arguments against the use of ketamine products is the potential for abuse/misuse. Some of this is mitigated by only allowing the medication to be administered at certified centers, and not allowing take home doses. Still patients with a history of substance use disorder may be at risk, and each case should be evaluated carefully. 

What makes esketamine so exciting is this is the first medication that works through a different mechanism of action (MOA) to treat depression. The focus of depression treatment to this point has been on monoamines such as serotonin. Esketamine acts as N-methyl-D-aspartate receptor antagonist (NMDAR). The other exciting finding is the rapid relief of depressive symptoms this medication provides. Efficacy can be seen as early as 24 hours after the first dose. There is no other antidepressant medication on the market that can produce improvements in depressive symptoms so rapidly.  

Esketamine’s use remains limitted to patients with treatment resistant depression. Research indicates it’s moderately effective and should be offered as an alternative for those who prefer medication over electroconvulsive therapy (ECT). The barriers to use include high cost, frequent clinic visits, and lots or regulation and monitoring requirements on the part of clinics offering the treatment.

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