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Comorbidity of psychiatric and medical illnesses among older adult populations is highly prevalent and associated with adverse outcomes. Care management is a common form of outpatient support for both psychiatric and medical conditions in which assessment, care planning, and care coordination are provided. Although care management is often remote and delivered by telephone, the evidence supporting this model of care is uncertain.To perform a systematic review of the literature on remote care management programs for older adult populations with elevated prevalence of depression or anxiety and comorbid chronic medical illness.A systematic review was performed in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. A multidatabase search was performed. Articles were included for review if they studied fully remote care management for older adult populations with elevated prevalence of depression or anxiety and chronic medical illness or poor physical health. A narrative synthesis was performed.A total of 6 articles representing 6 unique studies met inclusion criteria. The 6 studies included 4 randomized controlled trials, 1 case-matched retrospective cohort study, and 1 pre-post analysis. Two studies focused on specific medical conditions. All interventions were entirely telephonic. Five of 6 studies involved an intervention that was 3 to 6 months in duration. Across the 6 studies, care management demonstrated mixed results in terms of impact on psychiatric outcomes and limited impact on medical outcomes. No studies demonstrated a statistically significant impact on health care utilization or cost.Among older adult populations with elevated prevalence of depression or anxiety and comorbid chronic medical illness, remote care management may have favorable impact on psychiatric symptoms, but impact on physical health and health care utilization is uncertain. Future research should focus on identifying effective models and elements of remote care management for this population, with a particular focus on optimizing medical outcomes.

This article summarizes the existing literature on psychiatric electronic consultation (e-consultation or e-consult) to provide guidance on psychiatric e-consult practice and suggest next steps in research on psychiatric e-consults.A narrative review was conducted using relevant search terms in PubMed and Google Scholar.The psychiatric e-consult is a method of asynchronous consultation between primary care providers and psychiatric specialists that is associated with primary care provider satisfaction and promotes access to specialist guidance in mental health care. Major themes in the literature include contextual factors that affect implementation of psychiatric e-consult services, outcomes associated with psychiatric e-consults, and specific practical considerations that may affect psychiatric e-consult technique.Psychiatric e-consults may help address the widespread lack of access to specialty psychiatric care. Further studies are needed to examine clinical outcomes based on psychiatry e-consults.

Persons with serious mental illness face adverse psychiatric and medical outcomes, and their care is associated with a large burden of health care costs. Care management, in which assessment, care planning, and care coordination are provided, is a common model of support, yet the evidence supporting its use among psychiatric populations is mixed. A systematic review and a meta-analysis were undertaken to determine the impact of care management on clinical outcomes, acute care utilization, cost, and satisfaction among adults with serious mental illness.A multidatabase literature search was performed. Articles were included if they compared standard outpatient care plus care management with standard outpatient care alone for adults with serious mental illness and reported on one or more predefined outcomes. Randomized controlled trials (RCTs) and other study designs were permitted for inclusion in the systematic review. The meta-analysis included only RCTs.For the systematic review, 34 articles representing 28 unique studies were included. Fifteen of these articles, representing 12 unique studies, were included in the meta-analysis, which indicated that care management was associated with small, statistically significant improvements in psychiatric symptoms, overall quality of life (QOL), and mental QOL (Hedges' g range 0.13-0.26). In addition, care management was associated with a small, statistically significant reduction in inpatient psychiatric hospital days (Hedges' g=0.16, p=0.02).Care management is associated with fewer psychiatric symptoms and greater QOL for persons with serious mental illness. Further work is needed to determine which components of the intervention are associated with effectiveness.

Heather Huang,1 Nicholas Nissen,2 Christopher T Lim,3 Jessica L Gören,2,4 Margaret Spottswood,5,6 Hsiang Huang2 1Department of Psychiatry, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA; 2Department of Psychiatry, Cambridge Health Alliance, Harvard Medical School, Cambridge, MA, USA; 3Department of Psychiatry, Boston Medical Center, Boston University School of Medicine, Boston, MA, USA; 4Department of Pharmacy, Cambridge Health Alliance, Cambridge, MA, USA; 5Community Health Centers of Burlington, Burlington, VT, USA; 6Department of Psychiatry, University of Vermont College of Medicine, Burlington, VT, USACorrespondence: Hsiang Huang, Department of Psychiatry, Cambridge Health Alliance, 1493 Cambridge St, Cambridge, MA, 02139, USA, Tel +1-206-414-8198, Email hhuang@cha.harvard.eduAbstract: Bipolar disorder is a chronic mental illness associated with early mortality, elevated risk of comorbid cardiovascular disease, enormous burden of disability, and large societal costs. Patients often seek treatment for symptoms of bipolar disorder in the primary care setting but are frequently misdiagnosed. This article provides primary care providers with an evidence-based approach to the screening, diagnosis, and pharmacological management of bipolar disorder. Guidance is also provided for helping patients connect with higher levels of specialty psychiatric care when clinically indicated.Keywords: bipolar disorder, mood disorders, integrated behavioral care, primary care mental health

In 2018, the Massachusetts General Hospital Center for Cross-Cultural Student Emotional Wellness (CCCSEW) developed the CCCSEW Consortium, a year-long virtual program for secondary schools, colleges, and universities, to support campus staff in promoting the mental health of Asian American and Asian international students. The program shares similarities with the Extension for Community Healthcare Outcomes model, including the hub-and-spoke virtual learning environment, development of self-efficacy, and peer learning. The program is in its second year of operation and has been well received by participants. The Consortium, a nonprofit entity, has achieved financial sustainability through support of annual membership fees.

Technology can expand access to specialty health services for disadvantaged and underserved populations. A novel psychiatric consultation service involving both electronic consultations (e-consultations) and telephonic consultations (tele-consultations) was implemented by hospital-based staff and trainee psychiatrists in 12 primary care sites within a public safety-net health system. Utilization data were collected over a three-year period. A brief provider satisfaction survey was distributed to primary care providers. Over the three-year study period, 490 technology-enabled consultations were provided, of which three-fifths were e-consultations and two-fifths were tele-consultations. Most addressed medication questions (81%). Average time spent by the consulting psychiatrist was 30 minutes. Four-fifths (80%) of primary care providers reported being extremely or moderately satisfied with the service. The model represents multimodal support for primary care providers in providing community-level mental health care, including the provision of same-day consultation. This report demonstrates the feasibility of such a service in lowresource settings.

Coronavirus disease 2019 (COVID-19) is currently ravaging health systems across the world. Psychiatric trainees are at risk of exposure to patients with COVID-19 given their clinical roles in emergency and inpatient psychiatric settings. This article represents a case study of group dynamics in which we reflect on our own experience as psychiatric residents at a Boston-area hospital system in the era of COVID-19 and apply Wilfred Bion's concepts of the “work group” and the “basic assumption group” processes of group operation. We assess dynamics between trainees and administrative leadership both at baseline and in the current pandemic. Since navigation through crises is more effective if group leadership recognizes and responds to basic assumption behaviors, we propose suggestions to enable health system administration to successfully lead health care organizations through periods of societal turmoil. We posit that these principles apply across settings, specialties, and provider types. In addition, we use our observations to indicate future directions for expanding Bion's theories in the contemporary context.

Legacy may play an important role in how children integrate the loss of a parent. Sixteen adults (19-40 years old, 69% women) who experienced the death of a parent from an illness before age 12 were interviewed, exploring legacies from their deceased parent. Transcribed interviews were iteratively analyzed by three independent coders. Extracted themes described their experiences and wish for remembrances and specific communication left for them, information about the parent's values and feelings about them, and personal possessions. This study provides novel data about legacies that bereaved children wish for in adulthood.

The COVID-19 pandemic has been expected to lead to substantial increases in need for behavioral health care. A population health framework can facilitate the development of interventions and policies to promote the equitable distribution of care across the population. This column describes the application of population behavioral health principles in a safety-net health system during the pandemic. The approach includes stepped models of care, interventions to target individuals at high behavioral health risk, and measurement-based care. Early data suggest that these strategies have resulted in expanded behavioral health care capacity.

Introduction Catatonia has been associated with many medical conditions, including systemic infections. Several neuropsychiatric sequelae of coronavirus disease 2019 (COVID-19) have been identified to date. Case We describe a case of catatonia in a patient with COVID-19. He had no prior medical, substance use, or psychiatric history. His condition improved with administration of lorazepam. Discussion Potential etiologies of this patient’s catatonia are explored, including COVID-19 itself, medications, and an acute presentation of a psychiatric disorder. The limitations posed by infection risk on psychiatric evaluations are discussed. Conclusion We highlight the importance of considering catatonia in the diagnosis of altered mental status. We also identify catatonia as a potential neuropsychiatric consequence of COVID-19

Background: Low enrollment rates are a threat to the external validity of clinical trials. The purpose of this study was to identify factors associated with lower enrollment rates in randomized controlled trials (RCTs) involving orthopedic procedures. Methods: We performed a search in PubMed/MEDLINE for RCTs that involved any orthopedic surgical procedure, compared different intraoperative interventions, were published in English in a peer-reviewed journal between 2003 and 2014, and reported the numbers of both enrolled and eligible subjects. The primary outcome was the enrollment rate, defined as the number of enrolled subjects divided by the number of eligible subjects. We used a meta-regression to identify factors associated with lower enrollment rates. Results: The combined estimate of enrollment rate across all 393 studies meeting inclusion criteria was 90% (95% CI: 89–92%). Trials in North America had significantly lower enrollment rates compared to trials in the rest of the world (80% vs. 92%, p

While vast opportunities for using qualitative methods exist within palliative care research, few studies provide practical advice for researchers and clinicians as a roadmap to identify and utilize such opportunities.To provide palliative care clinicians and researchers descriptions of qualitative methodology applied to innovative research questions relative to palliative care research and define basic concepts in qualitative research. Body: We describe three qualitative projects as exemplars to describe major concepts in qualitative analysis of early palliative care: (1) a descriptive analysis of clinician documentation in the electronic health record, (2) a thematic content analysis of palliative care clinician focus groups, and (3) a framework analysis of audio-recorded encounters between patients and clinicians as part of a clinical trial.This study provides a foundation for undertaking qualitative research within palliative care and serves as a framework for use by other palliative care researchers interested in qualitative methodologies.

There is a large misalignment between unmet need and both private and public investment activity in cardiovascular disease. In this paper, we quantify the magnitude of the gap, analyze a range of potential root causes in two main categories (issues of feasibility and valuation), and propose steps toward solutions to close the gap.

2 Background: Studies have shown that palliative care (PC) integrated early in the course of metastatic cancer, shortly after diagnosis, leads to improved patient outcomes. Unlike PC in the inpatient setting, PC initiated early, in the ambulatory setting, had not been well studied. Our aim was to elucidate the practice of early PC through analysis of PC clinic visit transcripts. Methods: As part of an ongoing study of early PC in patients with advanced lung and gastrointestinal cancers at the Massachusetts General Hospital, we are audio-recording patients’ outpatient PC clinic visits. To capture the range of PC content, we randomly selected five patients and analyzed three clinic transcripts per patient: early, midway, and late in each patient’s clinical course. We performed thematic analysis on these clinic transcripts using NVivo 10. Results: Our analysis suggests that the elements of early PC that occur most frequently across the disease course are managing symptoms, facilitating coping, and developing the relationship with patients and their family caregivers. Elements that tend to occur during clinical transitions include advising treatment decision-making, facilitating medical understanding, and advance care planning. Our analysis also identifies four broad approaches to PC that are applied longitudinally, over the course of the patient-clinician relationship: 1) eliciting versus commenting on patients’ perspectives, 2) alluding to and preparing for the future, 3) transitioning between managing symptoms and facilitating coping, and 4) transitioning between developing the relationship and facilitating coping. Lastly, we observe three specific techniques applied by PC clinicians: 1) coordinating with oncologists, 2) providing referrals, and 3) addressing family dynamics. Conclusions: Our study identifies the predominant elements, four longitudinal approaches, and three specific techniques of early PC. These novel insights can be applied to care delivered by both PC and non-PC clinicians, well before patients approach the end of life. The longitudinal approaches in particular may help explain the significance of early integration of PC into cancer care.