Faculty Bibliography

OBJECTIVE:During the COVID-19 pandemic, telemental health (TMH) use rapidly increased. Though patients report satisfaction with TMH, acceptability among different psychiatric providers (inpatient, outpatient, nurses) and for various diagnoses is less understood. This study aimed to expand understanding by examining TMH acceptability, benefits, and barriers for providers and patients during the early transition to TMH in the COVID-19 pandemic. METHODS:Online anonymous surveys evaluated patient (n = 64) and provider (n = 39) satisfaction with and perceived benefits and challenges to TMH from October-December 2020 on 5-point Likert scales. Qualitative data was collected and themes identified. RESULTS:Outpatient (3.97 ± 1.05) and inpatient (3.11 ± 1.6) providers, including nurses, reported high satisfaction with TMH, despite over 50% never having used TMH prior to the pandemic. TMH was viewed as acceptable across diagnoses, including serious mental illness and substance use. Provider-rated benefits of outpatient TMH versus in-person visits included COVID safety (mean difference[MD] = 3.05), travel (MD = 2.95), and reduced cancellations (MD = 1.81). Inpatient TMH similarly included COVID safety benefits (MD = 3.31), but also challenges related to team-based service provision (MD = 1.68) and working with trainees (MD = 1.19). Qualitative themes identified TMH challenges (e.g., technological: 56.7% patients, 66.7% providers) and benefits (e.g., convenience/flexibility: 80% patients, 81.5% providers). CONCLUSIONS:TMH was associated with high satisfaction for patients and across provider types and patient diagnoses. This study provides further support that TMH across clinical settings allows for greater flexibility and accessibility to evidence-based care, and ongoing benefits even outside the context of the COVID-19 pandemic. It suggests the benefits of ongoing training of staff and trainees in TMH.

Numerous relationship process variables are positively associated with psychotherapy outcomes, but less is known about the therapeutic relationship in mind-body interventions (e.g., yoga). This study examined components of the therapeutic relationship (alliance, credibility/expectations) for patients with generalized anxiety disorder randomized to 12-weeks of group Kundalini Yoga (yoga), cognitive behavior therapy (CBT), or stress education (SE) in groups of 3-6. 147 participants (71% women, M age=33.2±13.3) completed the Working Alliance Inventory (WAI) and Credibility and Expectancy Questionnaire (CEQ) (yoga: n=56, CBT: n=65, SE: n=26) and outcome measures of worry, anxiety, and depression. WAI included subscales of goal, task, and bond. ANOVA assessed differences in WAI and CEQ scores by treatment at midpoint (Week 6) and endpoint (Week 12). Longitudinal linear mixed effects models assessed effects of midpoint WAI by treatment on self-report outcomes. Mean WAI and CEQ scores were significantly higher for CBT than SE by midpoint. The largest differences in WAI subscale scores compared to SE were in task for both CBT and yoga. No significant differences emerged between CBT and yoga. WAI at midpoint was not a significant predictor of midpoint to posttreatment change in worry, anxiety, or depression, nor was the effect of WAI on change in these outcomes different between treatment groups. Results suggest patient ratings of relationship process variables were similar between yoga and CBT, but different from SE in group treatment for anxiety, and that components of the relationship may be optimized within yoga by augmenting goal and task, perhaps by borrowing elements from CBT-based treatments.

Homework is a potential contributor to treatment response in cognitive-behavioral therapy (CBT) for anxiety, but less is known regarding the importance of yoga homework for generalized anxiety disorder (GAD). This study examined the impact of homework engagement on treatment response within a randomized controlled trial (RCT) of 12 weeks of group CBT, Kundalini Yoga (KY), or stress education (SE) in a subsample of 190 adults with GAD (71% female, Mean age = 33 ± 13) who attended ≥2 sessions and submitted ≥1 homework log. Participants in CBT and KY showed greater overall homework engagement than those in SE (ps < .05). Across treatment arms, staff-rated homework compliance (p = .002, OR = 1.74), but not participant-reported days per week engaged in homework (p = .108), predicted clinical response at post-treatment ("response"). Greater staff-rated homework compliance was related to a greater response for those in CBT (p = .005, OR = 2.49) and KY (p = .049, OR = 1.66), but not SE. Greater participant-reported homework days per week was only marginally related to response to CBT (p = .054, OR = 1.71), and was not related to response to KY or SE. These findings highlight the importance of homework engagement in CBT for GAD. More research is needed to further elucidate the role of homework engagement in yoga for GAD.TRIAL REGISTRATION: clinicaltrials.gov: NCT01912287; https://clinicaltrials.gov/ct2/show/NCT01912287.

BACKGROUND:Although evidence-based Prolonged Grief Disorder treatments (PGDT) exist, pretreatment characteristics associated with differential improvement remain unidentified. To identify clinical factors relevant to optimizing PGDT outcomes, we used unsupervised and supervised machine learning to study treatment effects from a double-blinded, placebo-controlled, randomized clinical trial. METHODS:Patients were randomized into four treatment groups for 20 weeks: citalopram with grief-informed clinical management, citalopram with PGDT, pill placebo with PGDT, or pill placebo with clinical management. The trial included 333 PGD patients aged 18-95 years (M = 53.9; SD = 14.4). Symptom trajectories were assessed using latent growth mixture modeling based on Inventory for Complicated Grief scores collected every 4 weeks. The relationship between patient-level characteristics and assigned trajectories was examined using logistic regression with elastic net regularization based on the administration of citalopram, PGDT, and risk factors for developing PGD. RESULTS:Three response trajectories were identified: lesser severity responders (60 %, n = 200), greater severity responders (18.02 %, n = 60), and non-responders (21.92 %, n = 73). Significant differences between greater severity responders and non-responders emerged by Week 8, persisting through the 6-month follow-up assessment. The elastic net model (AUC = 0.702; F1 = 0.777) indicated that higher baseline depression severity, grief-related functional impairment, and not receiving PGDT were associated with a decreased probability of response. LIMITATIONS/CONCLUSIONS:An independent validation cohort of PGDT patients is needed to further study generalizability of findings. CONCLUSIONS:Differential PGDT courses and the role of depression severity and grief-related functional impairment in treatment non-response were identified. These findings underscore the importance of determining clinical factors relevant to optimizing individual treatment strategies.

BACKGROUND:During the pandemic, a randomized controlled trial (RCT) of Mindfulness-Based Stress Reduction (MBSR) versus the antidepressant, escitalopram (ESC) added a second phase using a synchronous, videoconference (VC) format for both interventions, enabling randomized and naturalistic comparisons. The original in-person RCT demonstrated non-inferiority of MBSR to ESC. In the second phase, we hypothesized that MBSR-VC would be non-inferior to ESC-VC, and that MBSR-VC would be non-inferior to in-person MBSR (MBSR-IN). METHODS:Adults with anxiety disorders were recruited for a 3-center RCT. Primary (Clinical Global Impression of Severity: CGIS) and secondary outcomes (satisfaction, other measures for anxiety subtypes) were compared between MBSR-IN vs MBSR-VC, ESC-IN vs ESC-VC and MBSR-VC vs ESC-VC. RESULTS:MBSR-VC (n = 100) and ESC-VC (n = 102) did not significantly differ in mean CGI-S change at endpoint (1.39 vs 1.51, p = 0.17) but non-inferiority of MBSR-VC was not supported. MBSR did not vary by delivery format (VC: 1.3 vs. IN: 1.3, p = 0.77) and MBSR-VC's non-inferiority to MBSR-IN was demonstrated within the pre-specified margin of -0.40 (95 % CI: -0.34 to 0.25). ESC-IN and ESC-VC were not significantly different in CGI-S change in unadjusted comparisons (1.4 vs 1.5, p = 0.53), but the average CGI-S at endpoint was significantly lower in the ESC-VC group in a multivariable longitudinal model. Other findings included in-person treatments having a greater impact on social anxiety compared to their VC version, ESC-VC having higher satisfaction ratings and a greater impact on panic symptoms than MBSR-VC. CONCLUSIONS:Remotely delivered MBSR demonstrated comparable effectiveness to in-person MBSR for anxiety disorders, providing support for this delivery approach. Social anxiety symptoms improved more with in-person care. TRIAL REGISTRATION/BACKGROUND:Clinicaltrials.gov: NCT03522844.

PURPOSE/OBJECTIVE:To evaluate the feasibility and acceptability of Capnography-Assisted Learned Monitored (CALM) Breathing, a carbon dioxide (CO 2 ) biofeedback, and motivational interviewing intervention, to treat dyspnea and anxiety together. METHODS:We randomized adults (n = 42) with chronic obstructive pulmonary disease (COPD) to a 4-week, 8-session intervention (CALM Breathing, n = 20) or usual care (n = 22). The CALM Breathing intervention consisted of tailored, slow nasal breathing exercises, capnography biofeedback, motivational interviewing, and a home breathing exercise program. The intervention targeted unlearning dysfunctional breathing behaviors. All participants were offered outpatient pulmonary rehabilitation (PR) in the second phase of the study. The primary outcomes were feasibility and acceptability of CALM Breathing. Exploratory secondary outcomes included respiratory and mood symptoms, physiological and exercise tolerance measures, quality of life, and PR uptake. RESULTS:Attendance at CALM Breathing sessions was 84%, dropout was 5%, and home exercise completion was 90% and 73% based on paper and device logs, respectively. Satisfaction with CALM Breathing therapy was rated as "good" to "excellent" by 92% of participants. Significantly greater between-group improvements in secondary outcomes-respiratory symptoms, activity avoidance, oxygen saturation (SpO 2 ), end-tidal CO 2 , and breathing self-regulation (interoception)-were found post-intervention at 6 weeks in support of CALM Breathing compared with usual care. At 3 months (after PR initiation), statistically significant between-group differences in Borg dyspnea and SpO 2 post-6-minute walk test were identified also supporting CALM Breathing. CONCLUSIONS:Patient-centered CALM Breathing was feasible and acceptable in adults with COPD and dyspnea anxiety. A CALM Breathing intervention may optimize dyspnea treatment and complement PR.

Prolonged grief disorder (PGD) is a condition of persistent, intense grief and PGD-targeted psychotherapy (PGDT) is an efficacious treatment. This study aimed to compare participants with PGD who self-identified as Black versus White, with respect to baseline features and response to PGDT. We performed a secondary data analysis of 55 Black and 455 White adults from two randomized clinical trials. Racial differences in baseline features were examined using Chi-squared and T-tests. We compared assessment completion and treatment response rates (PGDT vs. no PGDT) by race and evaluated posttreatment self-reported measures using linear models. There were racial differences in the cause of death, relation to the deceased, and taking comfort in religion. Black participants had similar ratings to their counterparts on impairment and grief severity at baseline. However, they had higher scores on a baseline measure of typical grief-related beliefs. Both racial groups had significantly greater response rates to PGDT than the comparison treatment. Similarly, PGDT resulted in lower posttreatment impairment than the comparison treatment for both racial groups. However, only the White participants had a difference in posttreatment grief severity between the treatment groups. This study supports the idea that PGD characteristics are similar in Black and White treatment seeking individuals, and that Black and White participants display improvement in response to PGDT.

BACKGROUND:COVID infection has been associated with long term sequalae (Long COVID) which include neurological and behavioral effects in thousands of patients, but the etiology and scope of symptoms is not well understood. This paper reviews long term sequelae of COVID on brain and mental health in patients with the Long COVID syndrome. METHODS:This was a literature review which queried databases for Pubmed, Psychinfo, and Medline for the following topics for January 1, 2020-July 15, 2023: Long COVID, PASC, brain, brain imaging, neurological, neurobiology, mental health, anxiety, depression. RESULTS:Tens of thousands of patients have developed Long COVID, with the most common neurobehavioral symptoms anosmia (loss of smell) and fatigue. Anxiety and mood disorders are elevated and seen in about 25% of Long COVID patients. Neuropsychological testing studies show a correlation between symptom severity and cognitive dysfunction, while brain imaging studies show global decreases in gray matter and alterations in olfactory and other brain areas. CONCLUSIONS:Studies to date show an increase in neurobehavioral disturbances in patients with Long COVID. Future research is needed to determine mechanisms.

UNLABELLED: TRIAL REGISTRATION/UNASSIGNED:clinicaltrials.gov Identifier: NCT01179568.

Ecological momentary assessment (EMA) is a method of data collection that entails prompting individuals to report their experiences (e.g., thoughts, feelings, and behaviors) in real time over the course of their day-to-day lives. By providing rich information about how these experiences unfold over time within an individual, EMA has the potential to substantially advance our understanding of grief. However, there is uncertainty about how bereaved adults will respond to EMA, especially among those with high prolonged grief symptom severity. Accordingly, we evaluated the feasibility and acceptability of an EMA protocol in bereaved adults with low and high prolonged grief severity. Participants completed six 12-item EMA surveys per day on their smartphones for 17 days. Adherence was high (mean survey completion = 90%, median = 96%), and only 6% of participants withdrew. Adherence remained high in those with high prolonged grief symptom severity (mean = 86%; median = 96%). On average, participants reported agreement that survey frequency and length were acceptable. There was no evidence for systematic worsening of symptoms during EMA data collection. Together, these findings suggest that EMA is feasible, acceptable, and safe for bereaved adults, including those with high prolonged grief symptom severity.