COVID-19

Key clinical point: Heart rate variability (HRV) is a predictor of survival and intensive care unit (ICU) admission in older adults hospitalized with COVID-19.

Major finding: After adjusting for age and chronic heart disease, HRV was a significant predictor of survival (adjusted hazard ratio [aHR] with low vs high HRV, 0.51; 95% CI, 0.27-0.97). This association was primarily driven by patients aged ≥70 years (aHR with low vs high HRV, 0.28; 95% CI, 0.12-0.66). HRV also predicted ICU admission within the first week of hospitalization (adjusted HR, 0.51; 95% CI, 0.29-0.90), independent of age and chronic heart disease.

Study details: The data come from a retrospective cohort study involving 271 consecutive adults hospitalized with COVID-19 between March 2020 and May 2020.

Disclosures: The study did not receive any specific funding. The authors declared no competing interests.

Source: Mol MBA et al. PLoS One. 2021 Oct 28. doi: 10.1371/journal.pone.0258841.

Key clinical point: Heart rate variability (HRV) is a predictor of survival and intensive care unit (ICU) admission in older adults hospitalized with COVID-19.

Major finding: After adjusting for age and chronic heart disease, HRV was a significant predictor of survival (adjusted hazard ratio [aHR] with low vs high HRV, 0.51; 95% CI, 0.27-0.97). This association was primarily driven by patients aged ≥70 years (aHR with low vs high HRV, 0.28; 95% CI, 0.12-0.66). HRV also predicted ICU admission within the first week of hospitalization (adjusted HR, 0.51; 95% CI, 0.29-0.90), independent of age and chronic heart disease.

Study details: The data come from a retrospective cohort study involving 271 consecutive adults hospitalized with COVID-19 between March 2020 and May 2020.

Disclosures: The study did not receive any specific funding. The authors declared no competing interests.

Source: Mol MBA et al. PLoS One. 2021 Oct 28. doi: 10.1371/journal.pone.0258841.

Key clinical point: Heart rate variability (HRV) is a predictor of survival and intensive care unit (ICU) admission in older adults hospitalized with COVID-19.

Major finding: After adjusting for age and chronic heart disease, HRV was a significant predictor of survival (adjusted hazard ratio [aHR] with low vs high HRV, 0.51; 95% CI, 0.27-0.97). This association was primarily driven by patients aged ≥70 years (aHR with low vs high HRV, 0.28; 95% CI, 0.12-0.66). HRV also predicted ICU admission within the first week of hospitalization (adjusted HR, 0.51; 95% CI, 0.29-0.90), independent of age and chronic heart disease.

Study details: The data come from a retrospective cohort study involving 271 consecutive adults hospitalized with COVID-19 between March 2020 and May 2020.

Disclosures: The study did not receive any specific funding. The authors declared no competing interests.

Source: Mol MBA et al. PLoS One. 2021 Oct 28. doi: 10.1371/journal.pone.0258841.

Key clinical point: Sotrovimab significantly reduced the risk for complications, hospitalization, or mortality in patients with mild-to-moderate COVID-19.

Major finding: 1% of patients in the sotrovimab group vs 7% in the placebo group experienced disease progression leading to hospitalization (relative risk reduction, 85%; P = .002). Grade 3/4 adverse events were reported in 2% of patients in the sotrovimab group vs 6% of patients in the placebo group.

Study details: The data come from a prespecified, interim analysis of the ongoing, double-blind, placebo-controlled phase 3 COMET-ICE trial assessing the efficacy and safety of sotrovimab in patients with high-risk, ambulatory, mild-to-moderate COVID-19.

Disclosures: The COMET-ICE trial was funded by Vir Biotechnology and GlaxoSmithKline. The COMET-ICE Investigators reported relationships with Vir Biotechnology and GlaxoSmithKline.

Source: Gupta A et al. N Engl J Med. 2021 Oct 27. doi: 10.1056/NEJMoa2107934.

Key clinical point: Sotrovimab significantly reduced the risk for complications, hospitalization, or mortality in patients with mild-to-moderate COVID-19.

Major finding: 1% of patients in the sotrovimab group vs 7% in the placebo group experienced disease progression leading to hospitalization (relative risk reduction, 85%; P = .002). Grade 3/4 adverse events were reported in 2% of patients in the sotrovimab group vs 6% of patients in the placebo group.

Study details: The data come from a prespecified, interim analysis of the ongoing, double-blind, placebo-controlled phase 3 COMET-ICE trial assessing the efficacy and safety of sotrovimab in patients with high-risk, ambulatory, mild-to-moderate COVID-19.

Disclosures: The COMET-ICE trial was funded by Vir Biotechnology and GlaxoSmithKline. The COMET-ICE Investigators reported relationships with Vir Biotechnology and GlaxoSmithKline.

Source: Gupta A et al. N Engl J Med. 2021 Oct 27. doi: 10.1056/NEJMoa2107934.

Key clinical point: Sotrovimab significantly reduced the risk for complications, hospitalization, or mortality in patients with mild-to-moderate COVID-19.

Major finding: 1% of patients in the sotrovimab group vs 7% in the placebo group experienced disease progression leading to hospitalization (relative risk reduction, 85%; P = .002). Grade 3/4 adverse events were reported in 2% of patients in the sotrovimab group vs 6% of patients in the placebo group.

Study details: The data come from a prespecified, interim analysis of the ongoing, double-blind, placebo-controlled phase 3 COMET-ICE trial assessing the efficacy and safety of sotrovimab in patients with high-risk, ambulatory, mild-to-moderate COVID-19.

Disclosures: The COMET-ICE trial was funded by Vir Biotechnology and GlaxoSmithKline. The COMET-ICE Investigators reported relationships with Vir Biotechnology and GlaxoSmithKline.

Source: Gupta A et al. N Engl J Med. 2021 Oct 27. doi: 10.1056/NEJMoa2107934.

Key clinical point: Individuals who had received diphtheria or tetanus vaccinations in the last 10 years were less likely to develop severe COVID-19 compared with those who had not received them.

Major finding: The study included 103,049 participants (mean age, 71.5 years; 54.2% women) with vaccination records for the past 10 years and data on COVID-19 testing.

Study details: Individuals who had been vaccinated against diphtheria (odds ratio [OR], 0.47; 95% CI, 0.33-0.68; P = .000053) and tetanus (OR, 0.52; 95% CI, 0.37-0.72; P = .00012) in the last 10 years had a lower likelihood of developing severe COVID-19 symptoms compared with those who had not received them.

Disclosures: The study was funded by the Research Council of Norway, the South-Eastern Norway Regional Health Authority, Stiftelsen Kristian Gerhard Jebsen, The European Research Council under the European Union’s Horizon 2020 research and innovation programme, and National Institutes of Health. O Andreassen and J Pinzón-Espinosa reported relationships with various pharmaceutical companies. The remaining authors declared no conflict of interests.

Source: Monereo-Sánchez J et al. Front Immunol. 2021 Oct 7. doi: 10.3389/fimmu.2021.749264.

Key clinical point: Individuals who had received diphtheria or tetanus vaccinations in the last 10 years were less likely to develop severe COVID-19 compared with those who had not received them.

Major finding: The study included 103,049 participants (mean age, 71.5 years; 54.2% women) with vaccination records for the past 10 years and data on COVID-19 testing.

Study details: Individuals who had been vaccinated against diphtheria (odds ratio [OR], 0.47; 95% CI, 0.33-0.68; P = .000053) and tetanus (OR, 0.52; 95% CI, 0.37-0.72; P = .00012) in the last 10 years had a lower likelihood of developing severe COVID-19 symptoms compared with those who had not received them.

Disclosures: The study was funded by the Research Council of Norway, the South-Eastern Norway Regional Health Authority, Stiftelsen Kristian Gerhard Jebsen, The European Research Council under the European Union’s Horizon 2020 research and innovation programme, and National Institutes of Health. O Andreassen and J Pinzón-Espinosa reported relationships with various pharmaceutical companies. The remaining authors declared no conflict of interests.

Source: Monereo-Sánchez J et al. Front Immunol. 2021 Oct 7. doi: 10.3389/fimmu.2021.749264.

Key clinical point: Individuals who had received diphtheria or tetanus vaccinations in the last 10 years were less likely to develop severe COVID-19 compared with those who had not received them.

Major finding: The study included 103,049 participants (mean age, 71.5 years; 54.2% women) with vaccination records for the past 10 years and data on COVID-19 testing.

Study details: Individuals who had been vaccinated against diphtheria (odds ratio [OR], 0.47; 95% CI, 0.33-0.68; P = .000053) and tetanus (OR, 0.52; 95% CI, 0.37-0.72; P = .00012) in the last 10 years had a lower likelihood of developing severe COVID-19 symptoms compared with those who had not received them.

Disclosures: The study was funded by the Research Council of Norway, the South-Eastern Norway Regional Health Authority, Stiftelsen Kristian Gerhard Jebsen, The European Research Council under the European Union’s Horizon 2020 research and innovation programme, and National Institutes of Health. O Andreassen and J Pinzón-Espinosa reported relationships with various pharmaceutical companies. The remaining authors declared no conflict of interests.

Source: Monereo-Sánchez J et al. Front Immunol. 2021 Oct 7. doi: 10.3389/fimmu.2021.749264.

Key clinical point: Addition of colchicine to standard of care (SOC) had no significant benefit in hospitalized COVID-19 patients.

Major finding: There were no significant differences between SOC alone and SOC plus colchicine groups in all-cause mortality (rate ratio [RR], 1.01; P = .77), probability of being discharged alive within 28 days (RR, 0.98; P = .44), and the risk of progressing to invasive mechanical ventilation or death (RR, 1.02; P = .47).

Study details: In the RECOVERY trial, 11,340 hospitalized COVID-19 patients were randomly assigned to receive SOC with (n=5,610) or without (n=5,730) colchicine.

Disclosures: The RECOVERY trial was funded by the UK Research and Innovation (Medical Research Council), National Institute for Health Research, and Wellcome Trust. The authors declared no competing interests.

Source: RECOVERY Collaborative Group. Lancet Respir Med. 2021 Oct 18. doi: 10.1016/ S2213-2600(21)00435-5.

Key clinical point: Addition of colchicine to standard of care (SOC) had no significant benefit in hospitalized COVID-19 patients.

Major finding: There were no significant differences between SOC alone and SOC plus colchicine groups in all-cause mortality (rate ratio [RR], 1.01; P = .77), probability of being discharged alive within 28 days (RR, 0.98; P = .44), and the risk of progressing to invasive mechanical ventilation or death (RR, 1.02; P = .47).

Study details: In the RECOVERY trial, 11,340 hospitalized COVID-19 patients were randomly assigned to receive SOC with (n=5,610) or without (n=5,730) colchicine.

Disclosures: The RECOVERY trial was funded by the UK Research and Innovation (Medical Research Council), National Institute for Health Research, and Wellcome Trust. The authors declared no competing interests.

Source: RECOVERY Collaborative Group. Lancet Respir Med. 2021 Oct 18. doi: 10.1016/ S2213-2600(21)00435-5.

Key clinical point: Addition of colchicine to standard of care (SOC) had no significant benefit in hospitalized COVID-19 patients.

Major finding: There were no significant differences between SOC alone and SOC plus colchicine groups in all-cause mortality (rate ratio [RR], 1.01; P = .77), probability of being discharged alive within 28 days (RR, 0.98; P = .44), and the risk of progressing to invasive mechanical ventilation or death (RR, 1.02; P = .47).

Study details: In the RECOVERY trial, 11,340 hospitalized COVID-19 patients were randomly assigned to receive SOC with (n=5,610) or without (n=5,730) colchicine.

Disclosures: The RECOVERY trial was funded by the UK Research and Innovation (Medical Research Council), National Institute for Health Research, and Wellcome Trust. The authors declared no competing interests.

Source: RECOVERY Collaborative Group. Lancet Respir Med. 2021 Oct 18. doi: 10.1016/ S2213-2600(21)00435-5.

Key clinical point: In patients with nonvalvular atrial fibrillation (AF), warfarin use was linked to a lower risk of SARS-CoV-2 infection and adverse COVID-19 outcomes compared with the use of direct oral anticoagulants (DOACs).

Major finding: Warfarin vs DOAC use was associated with a lower risk for testing positive for SARS-CoV-2 (adjusted hazard ratio [aHR]; 0.73; 95% CI, 0.68-0.79), COVID-19-related hospitalization (aHR, 0.75; 95% CI, 0.68-0.83), and COVID-19-related mortality (aHR, 0.74; 95% CI, 0.66-0.83).

Study details: The details come from a population-based cohort study involving 92,339 warfarin users and 280,407 DOAC users. The OpenSAFELY platform was used for data analysis.

Disclosures: The OpenSAFELY data science platform was funded by the Wellcome Trust. OpenSAFELY work was jointly funded by UKRI, NIHR, Asthma UK-BLF, and the Longitudinal Health and Wellbeing strand of the National Core Studies programme. Principal investigator B Goldacre reported relationships with various research organizations. The co-principal investigator IJ Douglas reported ties with GSK.

Source: OpenSAFELY Collaborative et al. J Hematol Oncol. 2021 Oct 19. doi: 10.1186/s13045-021-01185-0.

Key clinical point: In patients with nonvalvular atrial fibrillation (AF), warfarin use was linked to a lower risk of SARS-CoV-2 infection and adverse COVID-19 outcomes compared with the use of direct oral anticoagulants (DOACs).

Major finding: Warfarin vs DOAC use was associated with a lower risk for testing positive for SARS-CoV-2 (adjusted hazard ratio [aHR]; 0.73; 95% CI, 0.68-0.79), COVID-19-related hospitalization (aHR, 0.75; 95% CI, 0.68-0.83), and COVID-19-related mortality (aHR, 0.74; 95% CI, 0.66-0.83).

Study details: The details come from a population-based cohort study involving 92,339 warfarin users and 280,407 DOAC users. The OpenSAFELY platform was used for data analysis.

Disclosures: The OpenSAFELY data science platform was funded by the Wellcome Trust. OpenSAFELY work was jointly funded by UKRI, NIHR, Asthma UK-BLF, and the Longitudinal Health and Wellbeing strand of the National Core Studies programme. Principal investigator B Goldacre reported relationships with various research organizations. The co-principal investigator IJ Douglas reported ties with GSK.

Source: OpenSAFELY Collaborative et al. J Hematol Oncol. 2021 Oct 19. doi: 10.1186/s13045-021-01185-0.

Key clinical point: In patients with nonvalvular atrial fibrillation (AF), warfarin use was linked to a lower risk of SARS-CoV-2 infection and adverse COVID-19 outcomes compared with the use of direct oral anticoagulants (DOACs).

Major finding: Warfarin vs DOAC use was associated with a lower risk for testing positive for SARS-CoV-2 (adjusted hazard ratio [aHR]; 0.73; 95% CI, 0.68-0.79), COVID-19-related hospitalization (aHR, 0.75; 95% CI, 0.68-0.83), and COVID-19-related mortality (aHR, 0.74; 95% CI, 0.66-0.83).

Study details: The details come from a population-based cohort study involving 92,339 warfarin users and 280,407 DOAC users. The OpenSAFELY platform was used for data analysis.

Disclosures: The OpenSAFELY data science platform was funded by the Wellcome Trust. OpenSAFELY work was jointly funded by UKRI, NIHR, Asthma UK-BLF, and the Longitudinal Health and Wellbeing strand of the National Core Studies programme. Principal investigator B Goldacre reported relationships with various research organizations. The co-principal investigator IJ Douglas reported ties with GSK.

Source: OpenSAFELY Collaborative et al. J Hematol Oncol. 2021 Oct 19. doi: 10.1186/s13045-021-01185-0.

Key clinical point: There is an increased risk of neurological complications following COVID-19 vaccination; however, this risk is substantially higher following SARS-CoV-2 infection.

Major finding: There was an increased risk for Guillain-Barré syndrome and Bell’s palsy following vaccination with ChAdOx1nCoV-19 (incidence rate ratio [IRR], 2.90 [95% CI, 2.15-3.92] and 1.29 [95% CI, 1.08-1.56], respectively) and for hemorrhagic stroke following vaccination with BNT162b2 (IRR, 1.38; 95% CI, 1.12-1.71). The risk for all neurological complications was significantly higher within 28 days of a positive SARS-CoV-2 test, including Guillain-Barré syndrome (IRR, 5.25; 95% CI, 3.00-9.18).

Study details: The data come from an analysis of 20,417,752 individuals who received ChAdOx1nCoV-19 (AstraZeneca) COVID-19 vaccine, 12,134,782 who received BNT162b2 (Pfizer-BioNTech) COVID-19 vaccine, and 2,005,280 who tested positive for COVID-19.

Disclosures: No specific funding information was available. A Sheikh, D Hunt, K Khunti, C Robertson, and J Hippisley-Cox reported ties with various research organizations and/or advisory groups. The remaining authors declared no conflict of interests.

Source: Patone M et al. Nat Med. 2021 Oct 25. doi: 10.1038/s41591-021-01556-7.

Key clinical point: There is an increased risk of neurological complications following COVID-19 vaccination; however, this risk is substantially higher following SARS-CoV-2 infection.

Major finding: There was an increased risk for Guillain-Barré syndrome and Bell’s palsy following vaccination with ChAdOx1nCoV-19 (incidence rate ratio [IRR], 2.90 [95% CI, 2.15-3.92] and 1.29 [95% CI, 1.08-1.56], respectively) and for hemorrhagic stroke following vaccination with BNT162b2 (IRR, 1.38; 95% CI, 1.12-1.71). The risk for all neurological complications was significantly higher within 28 days of a positive SARS-CoV-2 test, including Guillain-Barré syndrome (IRR, 5.25; 95% CI, 3.00-9.18).

Study details: The data come from an analysis of 20,417,752 individuals who received ChAdOx1nCoV-19 (AstraZeneca) COVID-19 vaccine, 12,134,782 who received BNT162b2 (Pfizer-BioNTech) COVID-19 vaccine, and 2,005,280 who tested positive for COVID-19.

Disclosures: No specific funding information was available. A Sheikh, D Hunt, K Khunti, C Robertson, and J Hippisley-Cox reported ties with various research organizations and/or advisory groups. The remaining authors declared no conflict of interests.

Source: Patone M et al. Nat Med. 2021 Oct 25. doi: 10.1038/s41591-021-01556-7.

Key clinical point: There is an increased risk of neurological complications following COVID-19 vaccination; however, this risk is substantially higher following SARS-CoV-2 infection.

Major finding: There was an increased risk for Guillain-Barré syndrome and Bell’s palsy following vaccination with ChAdOx1nCoV-19 (incidence rate ratio [IRR], 2.90 [95% CI, 2.15-3.92] and 1.29 [95% CI, 1.08-1.56], respectively) and for hemorrhagic stroke following vaccination with BNT162b2 (IRR, 1.38; 95% CI, 1.12-1.71). The risk for all neurological complications was significantly higher within 28 days of a positive SARS-CoV-2 test, including Guillain-Barré syndrome (IRR, 5.25; 95% CI, 3.00-9.18).

Study details: The data come from an analysis of 20,417,752 individuals who received ChAdOx1nCoV-19 (AstraZeneca) COVID-19 vaccine, 12,134,782 who received BNT162b2 (Pfizer-BioNTech) COVID-19 vaccine, and 2,005,280 who tested positive for COVID-19.

Disclosures: No specific funding information was available. A Sheikh, D Hunt, K Khunti, C Robertson, and J Hippisley-Cox reported ties with various research organizations and/or advisory groups. The remaining authors declared no conflict of interests.

Source: Patone M et al. Nat Med. 2021 Oct 25. doi: 10.1038/s41591-021-01556-7.

Telehealth is safe and effective for the treatment of borderline personality disorder (BPD) and may even have an edge over in-person treatment, new research suggests.

Courtesy Dr. Mark Zimmerman

Investigators compared BPD outcomes with therapy delivered in person and via telemedicine and found comparable reductions in depression, anxiety, and anger symptoms as well as improved overall well-being and mental health.

The results also suggest a telehealth advantage with significantly better patient attendance vs. patients treated in-person.

“We found a large effect size of treatment in both groups, as well as comparable levels of satisfaction with treatment, symptom reduction, and improved functioning, coping ability, positive mental health, and general well-being,” study investigator Mark Zimmerman, MD, professor of psychiatry and human behavior, Brown University, Providence, R.I., said in an interview.

The study was published online Nov. 8 in the Journal of Personality Disorders.
 

‘No other option’

Most previous research investigating telehealth has occurred in outpatient, individual treatment settings and has not examined telehealth-delivered group therapy or partial hospitalization, the authors noted.

“Until the pandemic, we were delivering care in person, but when the pandemic began, because of public safety recommendations, we knew that we could no longer continue doing so,” said Dr. Zimmerman, director of the outpatient division at the partial hospital program (PHP), Rhode Island Hospital.

“In switching to a telehealth platform, we were concerned about patient safety and acceptability of delivering care in that manner, especially with patients with BPD, which is associated with impulsive behavior, self-harm, and suicidal behavior, among other problems,” he said. However “we had no other option” than to utilize a telehealth delivery mode, since the alternative was to shut down the program.

The investigators were “interested in whether or not virtual treatment in an acute intensive setting, such as a PHP, would be as safe, acceptable, and effective as in-person treatment.”

The study was part of the ongoing work of the Rhode Island Methods to Improve Diagnostic Assessment and Services.
 

Additional safety measures

Treatment, consisting of an Acceptance and Commitment Therapy (ACT) treatment model – including intake assessments, individual therapy, psychiatric visits, and group therapy – was delivered by a multidisciplinary team via Zoom.

Dr. Zimmerman noted that the team implemented additional safety precautions, including having patients check in at the beginning of each day to indicate their location, not seeing patients who were out of state, and making sure all patients had a contact person.

In addition, beyond the therapist leading the group, another therapist was always available, overseeing groups and meeting one-on-one (virtually) with participants if they had been triggered by the group process and were highly distressed.

Patients were asked to complete a number of questionnaires, including the Clinically Useful Patient Satisfaction Scale (CUPSS) at the end of their intake session. The primary outcome measure was the Remission from Depression Questionnaire (RDQ-M).

The study was conducted between May 1 and Dec. 15 of 2020 and included 64 patients with BPD who were treated for the first time in the Rhode Island Hospital PHP. They were compared to 117 patients who participated in the in-person program during the same months in 2019.

Participant characteristics were similar – for example, three-quarters of the participants in both groups were female, and the mean age was 34 years.
 

‘Sea change’

Most patients in the telehealth and in-person groups reported being “very” or “extremely” satisfied with the initial evaluation (90% vs. 85.3%, c² = 0.74) and were hopeful that they would get better (85.8% vs. 82.1%, c² = 0.45).

Upon completion of the program, 100% of the in-person and 95.4% of the telehealth group indicated that they were “very” or “extremely” satisfied (c² = 4.62), and “under both telehealth and in-person treatment conditions, the patients significantly improved from admission to discharge on each of the RDQ-M subscales, with large effect sizes found for most of the subscales,” the authors reported.

There were significant differences between the groups in the average number of days of attendance and number of days missed.

A nonsignificantly higher proportion of patients completed the telehealth program, vs. the in-person program (68.8% vs. 59%, c² = 1.69).

In both programs, transfer to inpatient care and dissatisfaction-related withdrawal from the program were low (both < 2%). Notably, no patients attempted or completed suicide during treatment.

Virtual treatment is more convenient than in-person treatment, Dr. Zimmerman noted. “Some patients – generally those with medical or transportation issues – told us they otherwise would not have been able to participate [in the program] if treatment had been in person.”

He added, “My prediction is that 5 years from now, two-thirds to three-quarters of outpatient visits will be virtual because that is what the patients prefer – and although there will certainly be individuals who prefer in-person care, I think we’ve witnessed a sea change in how behavioral health care will be delivered.”
 

‘Game changer’

In an interview, Monica Carsky, PhD, clinical assistant professor of psychology in psychiatry and a senior fellow at the Personality Disorders Institute, Weill Cornell Medical College, New York, said the study has “a lot of valuable detail about how to set up a virtual PHP, which could guide any group wanting to try this.”

Dr. Carsky, who was not involved with the study, called it “a very important contribution to the research literature on efficacious treatment of BPD,” although it is not a randomized controlled trial.

“Adding more individual attention to the virtual group (e.g., having a co-host in the groups) seems as though it may be an important factor in dealing with the limitations of virtual treatment,” she noted.

However, she continued, “a limitation is that outcome assessment relied on self-administered questionnaires and did not include clinician rating scales, so the response may have been subject to the effects of social desirability bias.”

Courtesy Dr. Donald Black

Donald W. Black, MD, associate chief of staff for mental health at the Iowa City Veterans Administration Hospital, said in an interview that the pandemic has been a “game changer, as we have had to quickly adapt mental health programs to a virtual format.

“For the most part, they have been remarkably successful for a variety of conditions, and Zimmerman and colleagues now show this for BPD families,” said Dr. Black, who was not associated with the research.

No study funding was listed. The study authors, Dr. Carsky, and Dr. Black have disclosed no relevant financial relationships.
 

A version of this article first appeared on Medscape.com.

Telehealth is safe and effective for the treatment of borderline personality disorder (BPD) and may even have an edge over in-person treatment, new research suggests.

Courtesy Dr. Mark Zimmerman

Investigators compared BPD outcomes with therapy delivered in person and via telemedicine and found comparable reductions in depression, anxiety, and anger symptoms as well as improved overall well-being and mental health.

The results also suggest a telehealth advantage with significantly better patient attendance vs. patients treated in-person.

“We found a large effect size of treatment in both groups, as well as comparable levels of satisfaction with treatment, symptom reduction, and improved functioning, coping ability, positive mental health, and general well-being,” study investigator Mark Zimmerman, MD, professor of psychiatry and human behavior, Brown University, Providence, R.I., said in an interview.

The study was published online Nov. 8 in the Journal of Personality Disorders.
 

‘No other option’

Most previous research investigating telehealth has occurred in outpatient, individual treatment settings and has not examined telehealth-delivered group therapy or partial hospitalization, the authors noted.

“Until the pandemic, we were delivering care in person, but when the pandemic began, because of public safety recommendations, we knew that we could no longer continue doing so,” said Dr. Zimmerman, director of the outpatient division at the partial hospital program (PHP), Rhode Island Hospital.

“In switching to a telehealth platform, we were concerned about patient safety and acceptability of delivering care in that manner, especially with patients with BPD, which is associated with impulsive behavior, self-harm, and suicidal behavior, among other problems,” he said. However “we had no other option” than to utilize a telehealth delivery mode, since the alternative was to shut down the program.

The investigators were “interested in whether or not virtual treatment in an acute intensive setting, such as a PHP, would be as safe, acceptable, and effective as in-person treatment.”

The study was part of the ongoing work of the Rhode Island Methods to Improve Diagnostic Assessment and Services.
 

Additional safety measures

Treatment, consisting of an Acceptance and Commitment Therapy (ACT) treatment model – including intake assessments, individual therapy, psychiatric visits, and group therapy – was delivered by a multidisciplinary team via Zoom.

Dr. Zimmerman noted that the team implemented additional safety precautions, including having patients check in at the beginning of each day to indicate their location, not seeing patients who were out of state, and making sure all patients had a contact person.

In addition, beyond the therapist leading the group, another therapist was always available, overseeing groups and meeting one-on-one (virtually) with participants if they had been triggered by the group process and were highly distressed.

Patients were asked to complete a number of questionnaires, including the Clinically Useful Patient Satisfaction Scale (CUPSS) at the end of their intake session. The primary outcome measure was the Remission from Depression Questionnaire (RDQ-M).

The study was conducted between May 1 and Dec. 15 of 2020 and included 64 patients with BPD who were treated for the first time in the Rhode Island Hospital PHP. They were compared to 117 patients who participated in the in-person program during the same months in 2019.

Participant characteristics were similar – for example, three-quarters of the participants in both groups were female, and the mean age was 34 years.
 

‘Sea change’

Most patients in the telehealth and in-person groups reported being “very” or “extremely” satisfied with the initial evaluation (90% vs. 85.3%, c² = 0.74) and were hopeful that they would get better (85.8% vs. 82.1%, c² = 0.45).

Upon completion of the program, 100% of the in-person and 95.4% of the telehealth group indicated that they were “very” or “extremely” satisfied (c² = 4.62), and “under both telehealth and in-person treatment conditions, the patients significantly improved from admission to discharge on each of the RDQ-M subscales, with large effect sizes found for most of the subscales,” the authors reported.

There were significant differences between the groups in the average number of days of attendance and number of days missed.

A nonsignificantly higher proportion of patients completed the telehealth program, vs. the in-person program (68.8% vs. 59%, c² = 1.69).

In both programs, transfer to inpatient care and dissatisfaction-related withdrawal from the program were low (both < 2%). Notably, no patients attempted or completed suicide during treatment.

Virtual treatment is more convenient than in-person treatment, Dr. Zimmerman noted. “Some patients – generally those with medical or transportation issues – told us they otherwise would not have been able to participate [in the program] if treatment had been in person.”

He added, “My prediction is that 5 years from now, two-thirds to three-quarters of outpatient visits will be virtual because that is what the patients prefer – and although there will certainly be individuals who prefer in-person care, I think we’ve witnessed a sea change in how behavioral health care will be delivered.”
 

‘Game changer’

In an interview, Monica Carsky, PhD, clinical assistant professor of psychology in psychiatry and a senior fellow at the Personality Disorders Institute, Weill Cornell Medical College, New York, said the study has “a lot of valuable detail about how to set up a virtual PHP, which could guide any group wanting to try this.”

Dr. Carsky, who was not involved with the study, called it “a very important contribution to the research literature on efficacious treatment of BPD,” although it is not a randomized controlled trial.

“Adding more individual attention to the virtual group (e.g., having a co-host in the groups) seems as though it may be an important factor in dealing with the limitations of virtual treatment,” she noted.

However, she continued, “a limitation is that outcome assessment relied on self-administered questionnaires and did not include clinician rating scales, so the response may have been subject to the effects of social desirability bias.”

Courtesy Dr. Donald Black

Donald W. Black, MD, associate chief of staff for mental health at the Iowa City Veterans Administration Hospital, said in an interview that the pandemic has been a “game changer, as we have had to quickly adapt mental health programs to a virtual format.

“For the most part, they have been remarkably successful for a variety of conditions, and Zimmerman and colleagues now show this for BPD families,” said Dr. Black, who was not associated with the research.

No study funding was listed. The study authors, Dr. Carsky, and Dr. Black have disclosed no relevant financial relationships.
 

A version of this article first appeared on Medscape.com.

Telehealth is safe and effective for the treatment of borderline personality disorder (BPD) and may even have an edge over in-person treatment, new research suggests.

Courtesy Dr. Mark Zimmerman

Investigators compared BPD outcomes with therapy delivered in person and via telemedicine and found comparable reductions in depression, anxiety, and anger symptoms as well as improved overall well-being and mental health.

The results also suggest a telehealth advantage with significantly better patient attendance vs. patients treated in-person.

“We found a large effect size of treatment in both groups, as well as comparable levels of satisfaction with treatment, symptom reduction, and improved functioning, coping ability, positive mental health, and general well-being,” study investigator Mark Zimmerman, MD, professor of psychiatry and human behavior, Brown University, Providence, R.I., said in an interview.

The study was published online Nov. 8 in the Journal of Personality Disorders.
 

‘No other option’

Most previous research investigating telehealth has occurred in outpatient, individual treatment settings and has not examined telehealth-delivered group therapy or partial hospitalization, the authors noted.

“Until the pandemic, we were delivering care in person, but when the pandemic began, because of public safety recommendations, we knew that we could no longer continue doing so,” said Dr. Zimmerman, director of the outpatient division at the partial hospital program (PHP), Rhode Island Hospital.

“In switching to a telehealth platform, we were concerned about patient safety and acceptability of delivering care in that manner, especially with patients with BPD, which is associated with impulsive behavior, self-harm, and suicidal behavior, among other problems,” he said. However “we had no other option” than to utilize a telehealth delivery mode, since the alternative was to shut down the program.

The investigators were “interested in whether or not virtual treatment in an acute intensive setting, such as a PHP, would be as safe, acceptable, and effective as in-person treatment.”

The study was part of the ongoing work of the Rhode Island Methods to Improve Diagnostic Assessment and Services.
 

Additional safety measures

Treatment, consisting of an Acceptance and Commitment Therapy (ACT) treatment model – including intake assessments, individual therapy, psychiatric visits, and group therapy – was delivered by a multidisciplinary team via Zoom.

Dr. Zimmerman noted that the team implemented additional safety precautions, including having patients check in at the beginning of each day to indicate their location, not seeing patients who were out of state, and making sure all patients had a contact person.

In addition, beyond the therapist leading the group, another therapist was always available, overseeing groups and meeting one-on-one (virtually) with participants if they had been triggered by the group process and were highly distressed.

Patients were asked to complete a number of questionnaires, including the Clinically Useful Patient Satisfaction Scale (CUPSS) at the end of their intake session. The primary outcome measure was the Remission from Depression Questionnaire (RDQ-M).

The study was conducted between May 1 and Dec. 15 of 2020 and included 64 patients with BPD who were treated for the first time in the Rhode Island Hospital PHP. They were compared to 117 patients who participated in the in-person program during the same months in 2019.

Participant characteristics were similar – for example, three-quarters of the participants in both groups were female, and the mean age was 34 years.
 

‘Sea change’

Most patients in the telehealth and in-person groups reported being “very” or “extremely” satisfied with the initial evaluation (90% vs. 85.3%, c² = 0.74) and were hopeful that they would get better (85.8% vs. 82.1%, c² = 0.45).

Upon completion of the program, 100% of the in-person and 95.4% of the telehealth group indicated that they were “very” or “extremely” satisfied (c² = 4.62), and “under both telehealth and in-person treatment conditions, the patients significantly improved from admission to discharge on each of the RDQ-M subscales, with large effect sizes found for most of the subscales,” the authors reported.

There were significant differences between the groups in the average number of days of attendance and number of days missed.

A nonsignificantly higher proportion of patients completed the telehealth program, vs. the in-person program (68.8% vs. 59%, c² = 1.69).

In both programs, transfer to inpatient care and dissatisfaction-related withdrawal from the program were low (both < 2%). Notably, no patients attempted or completed suicide during treatment.

Virtual treatment is more convenient than in-person treatment, Dr. Zimmerman noted. “Some patients – generally those with medical or transportation issues – told us they otherwise would not have been able to participate [in the program] if treatment had been in person.”

He added, “My prediction is that 5 years from now, two-thirds to three-quarters of outpatient visits will be virtual because that is what the patients prefer – and although there will certainly be individuals who prefer in-person care, I think we’ve witnessed a sea change in how behavioral health care will be delivered.”
 

‘Game changer’

In an interview, Monica Carsky, PhD, clinical assistant professor of psychology in psychiatry and a senior fellow at the Personality Disorders Institute, Weill Cornell Medical College, New York, said the study has “a lot of valuable detail about how to set up a virtual PHP, which could guide any group wanting to try this.”

Dr. Carsky, who was not involved with the study, called it “a very important contribution to the research literature on efficacious treatment of BPD,” although it is not a randomized controlled trial.

“Adding more individual attention to the virtual group (e.g., having a co-host in the groups) seems as though it may be an important factor in dealing with the limitations of virtual treatment,” she noted.

However, she continued, “a limitation is that outcome assessment relied on self-administered questionnaires and did not include clinician rating scales, so the response may have been subject to the effects of social desirability bias.”

Courtesy Dr. Donald Black

Donald W. Black, MD, associate chief of staff for mental health at the Iowa City Veterans Administration Hospital, said in an interview that the pandemic has been a “game changer, as we have had to quickly adapt mental health programs to a virtual format.

“For the most part, they have been remarkably successful for a variety of conditions, and Zimmerman and colleagues now show this for BPD families,” said Dr. Black, who was not associated with the research.

No study funding was listed. The study authors, Dr. Carsky, and Dr. Black have disclosed no relevant financial relationships.
 

A version of this article first appeared on Medscape.com.

The anticipated biennial peak in acute flaccid myelitis cases did not occur in 2020, possibly because of “nonpharmaceutical interventions implemented during the COVID-19 pandemic,” suggested researchers at the Centers for Disease Control and Prevention.

Acute flaccid myelitis (AFM) is an uncommon but serious complication of some viral infections, including West Nile virus and nonpolio enteroviruses. It is “characterized by sudden onset of limb weakness and lesions in the gray matter of the spinal cord,” they said, and more than 90% of cases occur in young children.

Cases of AFM, which can lead to respiratory insufficiency and permanent paralysis, spiked during the late summer and early fall in 2014, 2016, and 2018 and were expected to do so again in 2020, Sarah Kidd, MD, and associates at the division of viral diseases at the CDC’s National Center for Immunization and Respiratory Diseases, Atlanta, said in the Morbidity and Mortality Weekly Report.

Monthly peaks in those previous years – each occurring in September – reached 51 cases in 2014, 43 cases in 2016, and 88 cases in 2018, but in 2020 there was only 1 case reported in September, with a high of 4 coming in May, CDC data show. The total number of cases for 2020 (32) was, in fact, lower than in 2019, when 47 were reported.

The investigators’ main objective was to see if there were any differences between the 2018 and 2019-2020 cases. Reports from state health departments to the CDC showed that, in 2019-2020, “patients were older; more likely to have lower limb involvement; and less likely to have upper limb involvement, prodromal illness, [cerebrospinal fluid] pleocytosis, or specimens that tested positive for EV [enterovirus]-D68” than patients from 2018, Dr. Kidd and associates said.

Mask wearing and reduced in-school attendance may have decreased circulation of EV-D68 – the enterovirus type most often detected in the stool and respiratory specimens of AFM patients – as was seen with other respiratory viruses, such as influenza and respiratory syncytial virus, in 2020. Previous studies have suggested that EV-D68 drives the increases in cases during peak years, the researchers noted.

The absence of such an increase “in 2020 reflects a deviation from the previously observed biennial pattern, and it is unclear when the next increase in AFM should be expected. Clinicians should continue to maintain vigilance and suspect AFM in any child with acute flaccid limb weakness, particularly in the setting of recent febrile or respiratory illness,” they wrote.
 

[email protected]

The anticipated biennial peak in acute flaccid myelitis cases did not occur in 2020, possibly because of “nonpharmaceutical interventions implemented during the COVID-19 pandemic,” suggested researchers at the Centers for Disease Control and Prevention.

Acute flaccid myelitis (AFM) is an uncommon but serious complication of some viral infections, including West Nile virus and nonpolio enteroviruses. It is “characterized by sudden onset of limb weakness and lesions in the gray matter of the spinal cord,” they said, and more than 90% of cases occur in young children.

Cases of AFM, which can lead to respiratory insufficiency and permanent paralysis, spiked during the late summer and early fall in 2014, 2016, and 2018 and were expected to do so again in 2020, Sarah Kidd, MD, and associates at the division of viral diseases at the CDC’s National Center for Immunization and Respiratory Diseases, Atlanta, said in the Morbidity and Mortality Weekly Report.

Monthly peaks in those previous years – each occurring in September – reached 51 cases in 2014, 43 cases in 2016, and 88 cases in 2018, but in 2020 there was only 1 case reported in September, with a high of 4 coming in May, CDC data show. The total number of cases for 2020 (32) was, in fact, lower than in 2019, when 47 were reported.

The investigators’ main objective was to see if there were any differences between the 2018 and 2019-2020 cases. Reports from state health departments to the CDC showed that, in 2019-2020, “patients were older; more likely to have lower limb involvement; and less likely to have upper limb involvement, prodromal illness, [cerebrospinal fluid] pleocytosis, or specimens that tested positive for EV [enterovirus]-D68” than patients from 2018, Dr. Kidd and associates said.

Mask wearing and reduced in-school attendance may have decreased circulation of EV-D68 – the enterovirus type most often detected in the stool and respiratory specimens of AFM patients – as was seen with other respiratory viruses, such as influenza and respiratory syncytial virus, in 2020. Previous studies have suggested that EV-D68 drives the increases in cases during peak years, the researchers noted.

The absence of such an increase “in 2020 reflects a deviation from the previously observed biennial pattern, and it is unclear when the next increase in AFM should be expected. Clinicians should continue to maintain vigilance and suspect AFM in any child with acute flaccid limb weakness, particularly in the setting of recent febrile or respiratory illness,” they wrote.
 

[email protected]

The anticipated biennial peak in acute flaccid myelitis cases did not occur in 2020, possibly because of “nonpharmaceutical interventions implemented during the COVID-19 pandemic,” suggested researchers at the Centers for Disease Control and Prevention.

Acute flaccid myelitis (AFM) is an uncommon but serious complication of some viral infections, including West Nile virus and nonpolio enteroviruses. It is “characterized by sudden onset of limb weakness and lesions in the gray matter of the spinal cord,” they said, and more than 90% of cases occur in young children.

Cases of AFM, which can lead to respiratory insufficiency and permanent paralysis, spiked during the late summer and early fall in 2014, 2016, and 2018 and were expected to do so again in 2020, Sarah Kidd, MD, and associates at the division of viral diseases at the CDC’s National Center for Immunization and Respiratory Diseases, Atlanta, said in the Morbidity and Mortality Weekly Report.

Monthly peaks in those previous years – each occurring in September – reached 51 cases in 2014, 43 cases in 2016, and 88 cases in 2018, but in 2020 there was only 1 case reported in September, with a high of 4 coming in May, CDC data show. The total number of cases for 2020 (32) was, in fact, lower than in 2019, when 47 were reported.

The investigators’ main objective was to see if there were any differences between the 2018 and 2019-2020 cases. Reports from state health departments to the CDC showed that, in 2019-2020, “patients were older; more likely to have lower limb involvement; and less likely to have upper limb involvement, prodromal illness, [cerebrospinal fluid] pleocytosis, or specimens that tested positive for EV [enterovirus]-D68” than patients from 2018, Dr. Kidd and associates said.

Mask wearing and reduced in-school attendance may have decreased circulation of EV-D68 – the enterovirus type most often detected in the stool and respiratory specimens of AFM patients – as was seen with other respiratory viruses, such as influenza and respiratory syncytial virus, in 2020. Previous studies have suggested that EV-D68 drives the increases in cases during peak years, the researchers noted.

The absence of such an increase “in 2020 reflects a deviation from the previously observed biennial pattern, and it is unclear when the next increase in AFM should be expected. Clinicians should continue to maintain vigilance and suspect AFM in any child with acute flaccid limb weakness, particularly in the setting of recent febrile or respiratory illness,” they wrote.
 

[email protected]

Similarly, Lin et al report the results of an international study of adults from 99 countries, which utilized longitudinal mobile based surveys to examine risk factors associated with SARS-CoV-2 infection. The mobile surveys captured baseline characteristics and behaviors of participants, and data was reported out for the study period of March to October 2020 (before vaccines were available). Adjusting for demographics, education level, a proxy for occupational risk, as well as medical comorbidities, authors found that greater number of non-household contacts, attending events with 10 or more individuals and restaurant visits predicted higher risk of SARS-CoV-2. Alternatively, older age was associated with lower risk, likely because of the protective behaviors undertaken by many in the older age group.

Lastly, the RECoVERED Study (Wynberg, at al), based in Netherlands, followed recently diagnosed laboratory confirmed SARS-CoV-2 patients for a year, initially with three in person visits (where disease severity was determined based on vital signs and level of care needed) within the first month of illness and then monthly online surveys. Authors utilized a survey examining severity of 18 symptoms based on the World Health Organization Case Report Form. Authors found 86.7% of those with initial severe disease [95% confidence interval {CI} = 76.5–92.7%]), 63.8%  of those moderate disease 63.8% [95% CI = 54.8–71.5%], and 30.7% of those with mild disease [95% CI = 21.1–40.9%] had at least one persistent symptom at 12 weeks.  Fatigue was the most common symptom reported at 12 weeks overall, but among those with moderate and severe disease, dyspnea and myalgia also persisted frequently. After one years of follow up, about one-fifth still had one persistent symptom. Over half of those with initial severe disease reported symptom persistence (52.5% [95% CI = 38.0–65.1%]). In a multivariable Cox proportional hazard model, female sex and higher BMI were associated with slower recovery. One limitation of the study was that was no control group recruited.

Similarly, Lin et al report the results of an international study of adults from 99 countries, which utilized longitudinal mobile based surveys to examine risk factors associated with SARS-CoV-2 infection. The mobile surveys captured baseline characteristics and behaviors of participants, and data was reported out for the study period of March to October 2020 (before vaccines were available). Adjusting for demographics, education level, a proxy for occupational risk, as well as medical comorbidities, authors found that greater number of non-household contacts, attending events with 10 or more individuals and restaurant visits predicted higher risk of SARS-CoV-2. Alternatively, older age was associated with lower risk, likely because of the protective behaviors undertaken by many in the older age group.

Lastly, the RECoVERED Study (Wynberg, at al), based in Netherlands, followed recently diagnosed laboratory confirmed SARS-CoV-2 patients for a year, initially with three in person visits (where disease severity was determined based on vital signs and level of care needed) within the first month of illness and then monthly online surveys. Authors utilized a survey examining severity of 18 symptoms based on the World Health Organization Case Report Form. Authors found 86.7% of those with initial severe disease [95% confidence interval {CI} = 76.5–92.7%]), 63.8%  of those moderate disease 63.8% [95% CI = 54.8–71.5%], and 30.7% of those with mild disease [95% CI = 21.1–40.9%] had at least one persistent symptom at 12 weeks.  Fatigue was the most common symptom reported at 12 weeks overall, but among those with moderate and severe disease, dyspnea and myalgia also persisted frequently. After one years of follow up, about one-fifth still had one persistent symptom. Over half of those with initial severe disease reported symptom persistence (52.5% [95% CI = 38.0–65.1%]). In a multivariable Cox proportional hazard model, female sex and higher BMI were associated with slower recovery. One limitation of the study was that was no control group recruited.

Similarly, Lin et al report the results of an international study of adults from 99 countries, which utilized longitudinal mobile based surveys to examine risk factors associated with SARS-CoV-2 infection. The mobile surveys captured baseline characteristics and behaviors of participants, and data was reported out for the study period of March to October 2020 (before vaccines were available). Adjusting for demographics, education level, a proxy for occupational risk, as well as medical comorbidities, authors found that greater number of non-household contacts, attending events with 10 or more individuals and restaurant visits predicted higher risk of SARS-CoV-2. Alternatively, older age was associated with lower risk, likely because of the protective behaviors undertaken by many in the older age group.

Lastly, the RECoVERED Study (Wynberg, at al), based in Netherlands, followed recently diagnosed laboratory confirmed SARS-CoV-2 patients for a year, initially with three in person visits (where disease severity was determined based on vital signs and level of care needed) within the first month of illness and then monthly online surveys. Authors utilized a survey examining severity of 18 symptoms based on the World Health Organization Case Report Form. Authors found 86.7% of those with initial severe disease [95% confidence interval {CI} = 76.5–92.7%]), 63.8%  of those moderate disease 63.8% [95% CI = 54.8–71.5%], and 30.7% of those with mild disease [95% CI = 21.1–40.9%] had at least one persistent symptom at 12 weeks.  Fatigue was the most common symptom reported at 12 weeks overall, but among those with moderate and severe disease, dyspnea and myalgia also persisted frequently. After one years of follow up, about one-fifth still had one persistent symptom. Over half of those with initial severe disease reported symptom persistence (52.5% [95% CI = 38.0–65.1%]). In a multivariable Cox proportional hazard model, female sex and higher BMI were associated with slower recovery. One limitation of the study was that was no control group recruited.

In this modern age of health care where telemedicine rules, conversational agents (CAs) that use text messaging systems are becoming a major mode of communication.

Many people are familiar with voice-enabled agents, such as Apple’s Siri, Google Now, and Microsoft’s Cortana. However, CAs come in different forms of complexity, ranging from a short message service–based texting platform to an embodied conversational agent (ECA).

ECAs allow participants to interact with a physical or graphical figure that simulates a person in appearance, behavior, and dialect. These are essentially virtual humans, or avatars, who talk with participants. By taking greater advantage of these automated agents, some have projected there may be $11 billion in combined cost savings across a variety of business sectors by 2023.¹ The health care field is one sector in which CAs can play an important role. Because of their accessibility, CAs have the potential to improve mental health by combating health care inequities and stigma, encouraging disclosure from participants, and serving as companions during the COVID-19 pandemic.

CAs provide accessible health care for rural, low socioeconomic status (SES), and minority communities in a variety of advantageous ways. For example, one study found that long-term use of a text-based agent that combines motivational interviewing and cognitive-behavioral therapy (CBT) can support smoking cessation in adolescents of low SES.²

CAs can help vulnerable participants advocate for themselves and proactively maintain their mental health through access to health care resources. In specific cases, these agents equalize health care treatment for different populations. Even though some participants live in secluded areas or are blocked by barriers, these text-based agents can still provide self-help intervention for them at any time on an individual basis, regardless of their location or socioeconomic status. Furthermore, they serve as highly cost-effective mental health promotion tools for large populations, some of which might not otherwise be reached by mental health care.

In combating mental illnesses such as depression and anxiety, studies have found that CAs are great treatment tools. For example, participants in an experimental group who received a self-help program based on CBT from a text-based CA named Woebot experienced significantly reduced depression symptoms when compared to the control group of participants, who received only information from a self-help electronic book.³ As a result, CAs might prove successful in treating younger populations who find online tools more feasible and accessible. Often, this population self-identifies depressive and anxiety symptoms without consulting a health care professional. Thus, this tool would prove useful to those who are bothered by the stigma of seeing a mental health professional.

Virtual human–based CAs also encourage participants to disclose more information in a nonjudgmental manner, especially among people with diseases with stigma. CAs use neutral languages, which may be helpful when dealing with stigmatized issues such as HIV, family planning, and abortion care because this heightens confidentiality and privacy. When participants believe that the agent does not “judge” or evaluate their capabilities, this elicits more sensitive information from them. For example, one study found that military service members who believed that they were interacting with a computer rather than a human operator reported lower fear of self-disclosure, displayed more sadness, and were rated by observers as more willing to disclose posttraumatic stress disorder symptoms.⁴ Additional findings show that participants prefer CAs when topics are highly sensitive and more likely to evoke negative self-admissions.

In what we hope will soon be a post–COVID-19 landscape of medicine, CAs are fast being used on the front lines of health care technology. Empathetic CAs can combat adverse effects of social exclusion during these pressing times. Etsuko Ishii, a researcher affiliated with the Hong Kong University of Science and Technology, and associates demonstrated that a virtual CA was as effective as a COVID-19 companion because it uses natural language processing (NLP) and nonverbal facial expressions to give users the feeling that they are being treated with empathy.⁵ While minimizing the number of in-person interactions that could potentially spread COVID-19, these agents promote virtual companionship that mirrors natural conversations and provide emotional support with psychological safety as participants express their pent-up thoughts. Not only do these agents help recover mood quickly, but they also have the power to overcome geographic barriers, be constantly available, and alleviate the high demand for mental health care. As a result, CAs have the potential to facilitate better communication and sustain social interactions within the isolated environment the pandemic has created.

CAs can predict, detect, and determine treatment solutions for mental health conditions based on behavioral insights. These agents’ natural language processing also allows them to be powerful therapeutic agents that can serve different communities, particularly for populations with limited access to medical resources. As the use of CAs becomes more integrated into telemedicine, their utility will continue to grow as their proven versatility in many situations expands the boundaries of health care technology.
 

Ms. Wong, a medical student at New York Institute of Technology College of Osteopathic Medicine in Old Westbury, conducts research related to mental health care services. She disclosed writing a telemental health software platform called Orchid. Dr. Vo, a board-certified psychiatrist, is the medical director of telehealth for the department of child and adolescent psychiatry and behavioral sciences at Children’s Hospital of Philadelphia. She is a faculty member of the University of Pennsylvania, also in Philadelphia. Dr. Vo conducts digital health research focused on using automation and artificial intelligence for suicide risk screening and connecting patients to mental health care services. She disclosed serving as cofounder of Orchid.

References

1. Chatbots: Vendor opportunities & market forecasts 2020-2024. Juniper Research, 2020.

2. Simon P et al. On using chatbots to promote smoking cessation among adolescents of low socioeconomic status, Artificial Intelligence and Work: Association for the Advancement of Artificial Intelligence (AAAI) 2019 Fall Symposium, 2019.

3. Fitzpatrick KK et al. JMIR Mental Health. 2017;4(2):e19.

4. Lucas GM et al. Front Robot AI. 2017 Oct 12. doi: 10.3389/frobt.2017.00051.

5. Ishii E et al. ERICA: An empathetic android companion for COVID-19 quarantine. arXiv preprint arXiv:2106.02325.

In this modern age of health care where telemedicine rules, conversational agents (CAs) that use text messaging systems are becoming a major mode of communication.

Many people are familiar with voice-enabled agents, such as Apple’s Siri, Google Now, and Microsoft’s Cortana. However, CAs come in different forms of complexity, ranging from a short message service–based texting platform to an embodied conversational agent (ECA).

ECAs allow participants to interact with a physical or graphical figure that simulates a person in appearance, behavior, and dialect. These are essentially virtual humans, or avatars, who talk with participants. By taking greater advantage of these automated agents, some have projected there may be $11 billion in combined cost savings across a variety of business sectors by 2023.¹ The health care field is one sector in which CAs can play an important role. Because of their accessibility, CAs have the potential to improve mental health by combating health care inequities and stigma, encouraging disclosure from participants, and serving as companions during the COVID-19 pandemic.

CAs provide accessible health care for rural, low socioeconomic status (SES), and minority communities in a variety of advantageous ways. For example, one study found that long-term use of a text-based agent that combines motivational interviewing and cognitive-behavioral therapy (CBT) can support smoking cessation in adolescents of low SES.²

CAs can help vulnerable participants advocate for themselves and proactively maintain their mental health through access to health care resources. In specific cases, these agents equalize health care treatment for different populations. Even though some participants live in secluded areas or are blocked by barriers, these text-based agents can still provide self-help intervention for them at any time on an individual basis, regardless of their location or socioeconomic status. Furthermore, they serve as highly cost-effective mental health promotion tools for large populations, some of which might not otherwise be reached by mental health care.

In combating mental illnesses such as depression and anxiety, studies have found that CAs are great treatment tools. For example, participants in an experimental group who received a self-help program based on CBT from a text-based CA named Woebot experienced significantly reduced depression symptoms when compared to the control group of participants, who received only information from a self-help electronic book.³ As a result, CAs might prove successful in treating younger populations who find online tools more feasible and accessible. Often, this population self-identifies depressive and anxiety symptoms without consulting a health care professional. Thus, this tool would prove useful to those who are bothered by the stigma of seeing a mental health professional.

Virtual human–based CAs also encourage participants to disclose more information in a nonjudgmental manner, especially among people with diseases with stigma. CAs use neutral languages, which may be helpful when dealing with stigmatized issues such as HIV, family planning, and abortion care because this heightens confidentiality and privacy. When participants believe that the agent does not “judge” or evaluate their capabilities, this elicits more sensitive information from them. For example, one study found that military service members who believed that they were interacting with a computer rather than a human operator reported lower fear of self-disclosure, displayed more sadness, and were rated by observers as more willing to disclose posttraumatic stress disorder symptoms.⁴ Additional findings show that participants prefer CAs when topics are highly sensitive and more likely to evoke negative self-admissions.

In what we hope will soon be a post–COVID-19 landscape of medicine, CAs are fast being used on the front lines of health care technology. Empathetic CAs can combat adverse effects of social exclusion during these pressing times. Etsuko Ishii, a researcher affiliated with the Hong Kong University of Science and Technology, and associates demonstrated that a virtual CA was as effective as a COVID-19 companion because it uses natural language processing (NLP) and nonverbal facial expressions to give users the feeling that they are being treated with empathy.⁵ While minimizing the number of in-person interactions that could potentially spread COVID-19, these agents promote virtual companionship that mirrors natural conversations and provide emotional support with psychological safety as participants express their pent-up thoughts. Not only do these agents help recover mood quickly, but they also have the power to overcome geographic barriers, be constantly available, and alleviate the high demand for mental health care. As a result, CAs have the potential to facilitate better communication and sustain social interactions within the isolated environment the pandemic has created.

CAs can predict, detect, and determine treatment solutions for mental health conditions based on behavioral insights. These agents’ natural language processing also allows them to be powerful therapeutic agents that can serve different communities, particularly for populations with limited access to medical resources. As the use of CAs becomes more integrated into telemedicine, their utility will continue to grow as their proven versatility in many situations expands the boundaries of health care technology.
 

Ms. Wong, a medical student at New York Institute of Technology College of Osteopathic Medicine in Old Westbury, conducts research related to mental health care services. She disclosed writing a telemental health software platform called Orchid. Dr. Vo, a board-certified psychiatrist, is the medical director of telehealth for the department of child and adolescent psychiatry and behavioral sciences at Children’s Hospital of Philadelphia. She is a faculty member of the University of Pennsylvania, also in Philadelphia. Dr. Vo conducts digital health research focused on using automation and artificial intelligence for suicide risk screening and connecting patients to mental health care services. She disclosed serving as cofounder of Orchid.

References

1. Chatbots: Vendor opportunities & market forecasts 2020-2024. Juniper Research, 2020.

2. Simon P et al. On using chatbots to promote smoking cessation among adolescents of low socioeconomic status, Artificial Intelligence and Work: Association for the Advancement of Artificial Intelligence (AAAI) 2019 Fall Symposium, 2019.

3. Fitzpatrick KK et al. JMIR Mental Health. 2017;4(2):e19.

4. Lucas GM et al. Front Robot AI. 2017 Oct 12. doi: 10.3389/frobt.2017.00051.

5. Ishii E et al. ERICA: An empathetic android companion for COVID-19 quarantine. arXiv preprint arXiv:2106.02325.

In this modern age of health care where telemedicine rules, conversational agents (CAs) that use text messaging systems are becoming a major mode of communication.

Many people are familiar with voice-enabled agents, such as Apple’s Siri, Google Now, and Microsoft’s Cortana. However, CAs come in different forms of complexity, ranging from a short message service–based texting platform to an embodied conversational agent (ECA).

ECAs allow participants to interact with a physical or graphical figure that simulates a person in appearance, behavior, and dialect. These are essentially virtual humans, or avatars, who talk with participants. By taking greater advantage of these automated agents, some have projected there may be $11 billion in combined cost savings across a variety of business sectors by 2023.¹ The health care field is one sector in which CAs can play an important role. Because of their accessibility, CAs have the potential to improve mental health by combating health care inequities and stigma, encouraging disclosure from participants, and serving as companions during the COVID-19 pandemic.

CAs provide accessible health care for rural, low socioeconomic status (SES), and minority communities in a variety of advantageous ways. For example, one study found that long-term use of a text-based agent that combines motivational interviewing and cognitive-behavioral therapy (CBT) can support smoking cessation in adolescents of low SES.²

CAs can help vulnerable participants advocate for themselves and proactively maintain their mental health through access to health care resources. In specific cases, these agents equalize health care treatment for different populations. Even though some participants live in secluded areas or are blocked by barriers, these text-based agents can still provide self-help intervention for them at any time on an individual basis, regardless of their location or socioeconomic status. Furthermore, they serve as highly cost-effective mental health promotion tools for large populations, some of which might not otherwise be reached by mental health care.

In combating mental illnesses such as depression and anxiety, studies have found that CAs are great treatment tools. For example, participants in an experimental group who received a self-help program based on CBT from a text-based CA named Woebot experienced significantly reduced depression symptoms when compared to the control group of participants, who received only information from a self-help electronic book.³ As a result, CAs might prove successful in treating younger populations who find online tools more feasible and accessible. Often, this population self-identifies depressive and anxiety symptoms without consulting a health care professional. Thus, this tool would prove useful to those who are bothered by the stigma of seeing a mental health professional.

Virtual human–based CAs also encourage participants to disclose more information in a nonjudgmental manner, especially among people with diseases with stigma. CAs use neutral languages, which may be helpful when dealing with stigmatized issues such as HIV, family planning, and abortion care because this heightens confidentiality and privacy. When participants believe that the agent does not “judge” or evaluate their capabilities, this elicits more sensitive information from them. For example, one study found that military service members who believed that they were interacting with a computer rather than a human operator reported lower fear of self-disclosure, displayed more sadness, and were rated by observers as more willing to disclose posttraumatic stress disorder symptoms.⁴ Additional findings show that participants prefer CAs when topics are highly sensitive and more likely to evoke negative self-admissions.

In what we hope will soon be a post–COVID-19 landscape of medicine, CAs are fast being used on the front lines of health care technology. Empathetic CAs can combat adverse effects of social exclusion during these pressing times. Etsuko Ishii, a researcher affiliated with the Hong Kong University of Science and Technology, and associates demonstrated that a virtual CA was as effective as a COVID-19 companion because it uses natural language processing (NLP) and nonverbal facial expressions to give users the feeling that they are being treated with empathy.⁵ While minimizing the number of in-person interactions that could potentially spread COVID-19, these agents promote virtual companionship that mirrors natural conversations and provide emotional support with psychological safety as participants express their pent-up thoughts. Not only do these agents help recover mood quickly, but they also have the power to overcome geographic barriers, be constantly available, and alleviate the high demand for mental health care. As a result, CAs have the potential to facilitate better communication and sustain social interactions within the isolated environment the pandemic has created.

CAs can predict, detect, and determine treatment solutions for mental health conditions based on behavioral insights. These agents’ natural language processing also allows them to be powerful therapeutic agents that can serve different communities, particularly for populations with limited access to medical resources. As the use of CAs becomes more integrated into telemedicine, their utility will continue to grow as their proven versatility in many situations expands the boundaries of health care technology.
 

Ms. Wong, a medical student at New York Institute of Technology College of Osteopathic Medicine in Old Westbury, conducts research related to mental health care services. She disclosed writing a telemental health software platform called Orchid. Dr. Vo, a board-certified psychiatrist, is the medical director of telehealth for the department of child and adolescent psychiatry and behavioral sciences at Children’s Hospital of Philadelphia. She is a faculty member of the University of Pennsylvania, also in Philadelphia. Dr. Vo conducts digital health research focused on using automation and artificial intelligence for suicide risk screening and connecting patients to mental health care services. She disclosed serving as cofounder of Orchid.

References

1. Chatbots: Vendor opportunities & market forecasts 2020-2024. Juniper Research, 2020.

2. Simon P et al. On using chatbots to promote smoking cessation among adolescents of low socioeconomic status, Artificial Intelligence and Work: Association for the Advancement of Artificial Intelligence (AAAI) 2019 Fall Symposium, 2019.

3. Fitzpatrick KK et al. JMIR Mental Health. 2017;4(2):e19.

4. Lucas GM et al. Front Robot AI. 2017 Oct 12. doi: 10.3389/frobt.2017.00051.

5. Ishii E et al. ERICA: An empathetic android companion for COVID-19 quarantine. arXiv preprint arXiv:2106.02325.