Background ‘Tele-Mental Health (MH) services,’ are an increasingly important way to expand care to underserved groups in low-resource settings. In order to continue providing psychiatric, psychotherapeutic and counselling care during COVID-19-related movement restrictions, Médecins Sans Frontières (MSF), a humanitarian medical organization, abruptly transitioned part of its MH activities across humanitarian and resource-constrained settings to remote format. Methods From June–July of 2020, investigators used a mixed method, sequential explanatory study design to assess MSF staff perceptions of tele-MH services. Preliminary quantitative results influenced qualitative question guide design. Eighty-one quantitative online questionnaires were collected and a subset of 13 qualitative follow-up in-depth interviews occurred. Results Respondents in 44 countries (6 geographic regions), mostly from Sub-Saharan Africa (39.5%), the Middle East and North Africa (18.5%) and Asia (13.6%) participated. Most tele-MH interventions depended on audio-only platforms (80%). 30% of respondents reported that more than half of their patients were unreachable using these interventions, usually because of poor network coverage (73.8%), a lack of communication devices (72.1%), or a lack of a private space at home (67.2%). Nearly half (47.5%) of respondents felt their staff had a decreased ability to provide comprehensive MH care using telecommunication platforms. Most respondents thought MH staff had a negative (46%) or mixed (42%) impression of remote care. Nevertheless, almost all respondents (96.7%) thought tele-MH services had some degree of usefulness, notably improved access to care (37.7%) and time efficiency (32.8%). Qualitative results outlined a myriad of challenges, notably in establishing therapeutic alliance, providing care for vulnerable populations and those inherent to the communications infrastructure. Conclusion Tele-MH services were perceived to be a feasible alternative solution to in-person therapeutic interventions in humanitarian settings during the COVID-19 pandemic. However, they were not considered suitable for all patients in the contexts studied, especially survivors of sexual or interpersonal violence, pediatric and geriatric cases, and patients with severe MH conditions. Audio-only technologies that lacked non-verbal cues were particularly challenging and made risk assessment and emergency care more difficult. Prior to considering tele-MH services, communications infrastructure should be assessed, and comprehensive, context-specific protocols should be developed.

Introduction. Mixed states represent a frequent presentation of bipolar disorder, associated with higher resistance to psychopharmacology. Limited evidence supports the use of ECT in these patients. We aim to report our experience on treating bipolar mixed states with ECT. Methods. Retrospective data were collected from all bipolar patients submitted to acute ECT treatment, between June 2006 and June 2011. Three groups were created in terms of affective polarity of the episode. CGI rating was used to establish clinical remission and demographic and clinical variables were compared among groups. Long-term outcome was assessed through readmission measures, considering the use of continuation or maintenance ECT. Results. During the study time frame, a total of 50 ECT course treatments were performed on 41 bipolar patients. All affective episodes, except one mixed state, showed a positive clinical response. Patients with mixed state presentation tended to be younger and have an earlier first hospitalization than depressed patients. No differences were found in terms of ECT sessions performed, length of hospital admission, referral to continuation ECT treatment, number of readmissions, and time until next readmission. Conclusions. Our results support the effectiveness of ECT in patients experiencing a mixed affective state.

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Introduction: The co-occurrence of mania and delirium, named "delirious mania", is an under-recognized entity not listed in major diagnostic classifications. Literature about this syndrome is still scarce and lacking evidence. Usually, reports of affective syndromes with delirium tend to be subdued in the manic descriptor. Objectives: We report the case of a 44 year old female patient with a simultaneous affective episode and delirium. Aims: To demonstrate the co-occurrence of depressive/mixed symptoms and delirium Methods: Review of clinical records and complementary exams. Results: The patient was admitted after a three week long depressive syndrome with psychomotor agitation, followed by a week-long fluctuating pattern of delirious and mixed affective features. Shortly after admission the patient exhibited a stuporous state, with nocturnal agitation. A fluctuating pattern of symptoms ensued, with disorientation, disorganized behavior, cognitive impairment, anxiety and depressive features. The patient was put on mood stabilizers, antipsychotics and benzodiazepines. She was discharged symptom-free two months later and re-admitted 4 weeks later due to recurrence of symptoms. Electroconvulsive treatment was applied,with quick remission of affective symptoms. Yet, it took another two months until discharge, due to persistent cognitive symptoms. Medical conditions were excluded. Conclusions: This case shows the simultaneous occurrence of an affective syndrome alongside delirium. The strongest treatment response occurred with ECT. The presence of depressed mood highlights the fact that this syndrome can begin without clear-cut manic symptoms. We suggest that its name should be changed to Delirious Affective Disorder, which might help to avoid misdiagnosis. Persistent cognitive deficits raise some questions in this case.

Background‘Digital Mental Health services,’ or mental health care delivered via internet, computers, mobile phones, tablets, or text messaging services, are an increasingly important way to expand care to underserved groups in low-resource settings. In order to continue providing psychiatric, psychotherapeutic and counselling care during COVID-19-related movement restrictions, Médecins Sans Frontières (MSF), a humanitarian medical organization, abruptly transitioned part of its mental health (MH) activities to digitally supported remote services in 2020 across humanitarian and resource-constrained settings. MethodsFrom June-July of 2020, investigators used a mixed method, sequential explanatory study design to assess MSF staff perceptions of digital MH services provided during the COVID-19 crisis. Preliminary quantitative results influenced qualitative question guide design. Eighty-one quantitative online questionnaires were collected and a subset of 13 qualitative follow-up in-depth interviews (IDI) occurred.ResultsRespondents in 44 countries (6 world regions), mostly from Sub-Saharan Africa (39.5%), the Middle East (18.5%) and Asia (13.6%) participated. Most digital MH interventions depended on audio-only platforms (80%). 30% of respondents reported that more than half of their patients were unreachable using digital interventions, usually because of poor network coverage (73.8%), a lack of communication devices (72.1%), or a lack of a private space at home (67.2%). Nearly half (47.5%) of respondents felt their staff had a decreased ability to provide comprehensive MH care using digital platforms. Most respondents thought MH staff had a negative (46%) or mixed (42%) impression of remote care. Nevertheless, almost all respondents (96.7%) thought digital MH services had some degree of utility, most commonly citing improved access to care (37.7%) and greater time efficiency (32.8%) as reasons for its continued use.ConclusionDigital MH activities were seen as an acceptable alternative to in-person therapeutic interventions in humanitarian settings during the COVID-19 pandemic. However, they were not considered suitable for all patients in the humanitarian contexts studied, especially survivors of sexual or interpersonal violence, pediatric and geriatric cases, and patients with severe MH conditions. Audio-only technologies that lacked non-verbal cues were particularly challenging and made risk assessment and emergency care more difficult. Prior to considering digital MH services, communications infrastructure should be assessed, and comprehensive, context-specific protocols should be developed.