As the demand for telepsychiatry increases during the COVID-19 pandemic, the strengths and challenges of telepsychiatry implementation must be articulated to improve clinical practices in the long term. Currently, observations within US contexts are lacking; therefore, we report on the rapid implementation of telepsychiatry and workflow experiences in a psychiatric practice based within a large health care system in southeast Texas with a national catchment area. We discuss the logistics of the implementation, including modes of communication, scheduling, coordination, and capacity; the psychological effects of web-based services, including both the loss of the physical therapeutic environment and the unique interpersonal dynamics experienced in the virtual environment; and postadoption patterns of engagement with our services and with other clinical functions affected by the rapid adaptation to telemedicine. Our art therapy group programming serves as an applied case study, demonstrating the value of a well-managed web-based program (eg, patients were receptive and well-engaged, and they appreciated the continuity of accessible service) as well as the challenges (eg, the need for backup plans and technological fallbacks, managing interruptions and telecommunication learning curves, and working around the difference in resources for art and music therapy between a well-stocked clinical setting versus clients’ home spaces). We conclude from our experience that the overall strengths of telepsychiatry include receptive and well-engaged responses from patients as well as the expansion of boundaries, which provides a directly contextualized view into patients’ home lives. Challenges and corresponding recommendations include the need for more careful safety planning for high-risk patients; maintaining professional boundaries in the newly informal virtual setting; designing the physical space to both frame the patient encounter and maintain work-life balance for the therapist; allowing for delays and interruptions (including an initial acclimation session); and preserving interprofessional care team collaboration when the physical locations that normally facilitate such encounters are not accessible. We believe that careful observations of the strengths and challenges of telepsychiatry during this pandemic will better inform practices that are considering telepsychiatry adoption both within pandemic contexts and more broadly thereafter.

Objective: This article describes the development, factor structure, concurrent validity, and predictive validity of the Safe At Home instrument, a 35-item self-report measure designed for social work assessment of individuals' readiness to change their intimate partner violence behaviors. Method: Multisite data (five sites, a total of 1,359 men at intake) addressed questions concerning instrument properties. Results: Initial exploratory factor analysis identified three scales that are consistent with the early stages outlined in the Transtheoretical Model of Behavior Change (Precontemplation, Contemplation, and Preparation/Action). Confirmatory factor analysis further supported the three-factor solution. Concurrent and predictive validity were examined on a subset of cases. Conclusions: The Safe At Home instrument has applicability for social work evaluation of batterer's treatment intervention; additional study is needed for reliable use as an individual clinical assessment tool.

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This article describes the development and factor structure of the Revised Safe At Home instrument, a 35-item self-report measure designed to assess individuals' readiness to change their intimate partner violence behaviors. Seven new items have been added, representing content specific to the Maintenance stage, and other items have been revised to strengthen the assessment of earlier stages and address gender concerns. Confirmatory factor analysis using multisite data (two sites, a total of 281 men at intake) supported the conclusion that a four-factor model (Precontemplation, Contemplation, Preparation/Action, and Maintenance stages) was consistent with the observed covariances. A high degree of correlation between the Preparation/Action and Maintenance scales was observed, but subsequent testing indicated a need to treat the two as distinct factors in the model. It is recommended that scoring include only 31 items that perform well.

Objective U.S. military special operation forces represent the most elite units of the U.S. Armed Forces. Their selection is highly competitive, and over the course of their service careers, they experience intensive operational training and combat deployment cycles. Yet, little is known about the health-care needs of this unique population. Method Professional consultations with over 50 special operation forces operators (and many spouses or girlfriends) over the past 6 years created a naturalistic, observational base of knowledge that allowed our team to identify a unique pattern of interrelated medical and behavioral health-care needs. Results We identified a consistent pattern of health-care difficulties within the special operation forces community that we and other special operation forces health-care providers have termed “Operator Syndrome.” This includes interrelated health and functional impairments including traumatic brain injury effects; endocrine dysfunction; sleep disturbance; obstructive sleep apnea; chronic joint/back pain, orthopedic problems, and headaches; substance abuse; depression and suicide; anger; worry, rumination, and stress reactivity; marital, family, and community dysfunction; problems with sexual health and intimacy; being “on guard” or hypervigilant; memory, concentration, and cognitive impairments; vestibular and vision impairments; challenges of the transition from military to civilian life; and common existential issues. Conclusions “Operator Syndrome” may be understood as the natural consequences of an extraordinarily high allostatic load; the accumulation of physiological, neural, and neuroendocrine responses resulting from the prolonged chronic stress; and physical demands of a career with the military special forces. Clinical research and comprehensive, intensive immersion programs are needed to meet the unique needs of this community.

In today's world of smart-device monitoring systems, clinicians may be lulled into the assumption that we can download software to monitor our patients' psychological and behavioral functioning with little or no effort or follow-up. This belief is as erroneous as it is tempting; in fact, implementing effective and efficient systems for utilizing patient-reported outcomes (PROs) in daily practice and research takes a virtual village of stakeholders, clinicians, developers, analysts, and clinical researchers. Here, we describe the iterative processes required for designing, implementing, and updating a large-scale inpatient psychiatric quality improvement/research platform that provides real-time feedback to clinicians and patients. During the past 10 years, many surprises and counterintuitive discoveries have emerged from this project, not the least of which is how difficult it is to establish and maintain "buy-in" and the utilization of PROs with busy clinicians and administrators. Methods for prioritizing and structuring data for different uses, including examining the effectiveness of treatment programs, identifying moderators of change, and improving treatment planning by developing algorithms to alert clinicians to adverse outcomes, are highlighted. The authors conclude by describing a new venture to integrate biological data and between-visit PROs monitoring to enhance well-being and reduce emergency department and hospital admissions for high-risk patients. Clinical Impact StatementQuestion: This article describes the process, challenges, and pitfalls of making patient-reported outcomes (PROs) in daily practice and research a high-value proposition. Findings: Lessons learned from this 10-year project provide broad guidelines to clinical researchers planning to implement PROs in practice. Meaning: Although PRO platforms are driving toward fully automated systems, clinical systems will be best served by a counterbalance of human engagement in the feedback process. Next Steps: Future directions for integrated PROs platforms will include physiological data and ecological momentary assessments between office visits to optimize patient care.

The alpha subunit of the heterotrimeric G protein Gs (Gsalpha) is involved in numerous physiological processes and is a primary determinant of cellular responses to extracellular signals. Genetic variations in the Gsalpha gene may play an important role in complex diseases and drug responses. To characterize the genetic diversity in this locus, we resequenced exons and flanking introns of the gene in 44 genomic samples and analysed the haplotype structure of the gene in an additional 50 African-Americans and 50 Caucasians. Significant differences in allele frequency for nearly all the genotyped single nucleotide polymorphism (SNPs) were detected between the two ethnic groups. Linkage disequilibrium (LD) analysis of this locus revealed two haplotype blocks characterized by strong LD and reduced haplotype diversity, especially in Caucasians. Between the two blocks is a narrow (approximately 3 kb) recombination hotspot centred on exons 4 and 5, and a widely used genetic marker in association studies in this region (rs7121) was in linkage equilibrium with the rest of the gene. The haplotype structure of the GNAS locus warrants reevaluation of previous association studies that used marker rs7121 and affects choice of SNP markers to be used in future studies of this locus.

Outcomes assessment has become an important tool in assessing the quality of health care. To date, most quality initiatives have focused on adverse events, clinical processes, and/or cost variables. Considerably less attention has been paid to indices of clinical improvement, especially from a patient's perspective and in behavioral health settings. The relative inattention given to clinical improvement is attributable to a number of reasons, including (but not limited to) a lack of consensus regarding measures of improvement, few simple methods for data collection and analysis, and an inability to provide timely feedback. In this article, the authors describe a Web-based system designed to routinely collect quality-of-life ratings from patients in outpatient behavioral health clinics, allowing for real-time feedback at the patient levels regarding clinical improvement. The system also allows for administrative evaluation of overall clinic performance. The costs and benefits of this system are discussed.