The Trauma Recovery Clinic: A Stepped Collaborative Care Model for Trauma Surgery Patients to Address Health Disparities.

Background: The Trauma Recovery Clinic (TRC) was developed to meet the psychiatric, psychological, and psychosocial needs of traumatically injured patients following discharge from a level-I trauma center. The objective of this study is to demonstrate the efficacy of the TRC as an application of the stepped collaborative care model in order to address health disparities.Methods: Patients with a history of inpatient treatment for a physically traumatic injury at this level-I trauma center were approached and enrolled at initial TRC outpatient appointments. Data was collected, including the PTSD Checklist-Civilian Version (PCL-C), the Patient Health Questionnaire (PHQ-9), the Attitudes towards Guns scale, and the Youth Behavior Risk Survey (questions about weapon carrying practices).Results: A total of 80 patients were included in this study. Patients expressed several social determinants of health risk factors, with 60% of the sample reporting witnessing someone being wounded or killed. Results demonstrated a significant decrease in trauma symptoms (T24 = 3.33; P = .001, d = 0.67) and depressive symptoms (T24 = 2.23, P = .02, d = 0.45) by their 6th clinic visit. Additionally, patients reported significant improvements in role limitations due to emotional problems (T25 = 1.74; P = .04; d = 0.34) and social functioning (T25 = 2.23; P = .02; d = 0.43). Interestingly, patients who reported carrying a weapon in the last 30 days reported significantly higher trauma symptoms (T64 = 3.21, P = .002) and depressive symptoms (T64 = 2.77, P = .007).Discussion: This evaluation of services at the recently implemented Trauma Recovery Clinic demonstrated that the clinic is successfully treating individuals who have experienced traumatic injuries. More specifically, the clinic services are effectively engaging a vulnerable, hard-to-reach patient population.

Alcohol Consumption and COVID-19-Related Stress Among Health Care Workers: The Need for Continued Stress-Management Interventions.

OBJECTIVES: Although a known association exists between stress and alcohol consumption among health care workers (HCWs), it is not known how the COVID-19 pandemic has affected this association. We assessed pandemic work-related stress and alcohol consumption of HCWs. METHODS: We emailed a cross-sectional, anonymous survey in June 2020 to approximately 550 HCWs at an academic hospital in New Orleans, Louisiana. HCWs from all departments were eligible to complete the survey. Questions measured work-related stress and emotional reactions to the pandemic (using the Middle East Respiratory Syndrome [MERS-CoV] Staff Questionnaire), depressive symptoms (using the Patient Health Questionnaire-9 [PHQ-9]), coping habits (using the Brief COPE scale), and pre-COVID-19 (March 2020) and current (June 2020) alcohol consumption. We measured alcohol consumption using the Alcohol Use Disorders Identification Test-Consumption (AUDIT-C), with scores >3 considered positive. We asked 4 open-ended questions for in-depth analysis. RESULTS: One-hundred two HCWs participated in the survey. The average AUDIT-C scores for current and pre-COVID-19 alcohol consumption were 3.1 and 2.8, respectively. The level of current alcohol consumption was associated with avoidant coping (r = 0.46, P < .001). Relative increases in alcohol consumption from March to June 2020 were positively associated with PHQ-9 score and greater emotional reactions to the pandemic. Availability of mental health services was ranked second to last among desired supports. Qualitative data demonstrated high levels of work-related stress from potential exposure to COVID-19 and job instability, as well as social isolation and negative effects of the pandemic on their work environment. CONCLUSIONS: Ongoing prevention-based interventions that emphasize stress management rather than mental or behavioral health conditions are needed.

Treatment of a Complex Case of Catatonia and Conversion Features With Electroconvulsive Therapy in a 14-Year-Old Male.

Background: Pediatric catatonia is a rare and poorly understood phenomenon. The majority of reported cases have a psychiatric etiology. Because of the heterogeneous presentation and treatment issues unique to the pediatric population, identification and management can be challenging. Additionally, few definitive guidelines or practice parameters are available for pediatric patients. The first-line treatment for catatonia is pharmacologic, and when treatment fails or is inadequate, electroconvulsive therapy (ECT) has been shown to be safe and effective. Case Report: A previously healthy, 14-year-old male presented with acute onset of catatonia that resolved at 4 weeks after a short course of ECT with adjunctive lorazepam and risperidone. An interesting feature of this case was the resolution of autonomic symptoms and the emergence of conversion features. The resolution of the catatonia (negativism, mutism, and withdrawal) made it possible for the team to identify a thought disorder and initiate appropriate pharmacologic treatment for the precipitating etiology. Conclusion: ECT was a safe and effective treatment for the resolution of catatonia symptoms in this patient. Conversion and catatonia features may exist on a continuum.

Motivational Interviewing for Victims of Armed Community Violence: A Nonexperimental Pilot Feasibility Study.

OBJECTIVE: The present study aimed to develop a novel, hospital-based motivational interviewing (MI) intervention for victims of armed community violence (MI-VoV) targeting patient-specific risk factors for future violence or violent victimization. METHOD: This uncontrolled pilot feasibility study examined a sample of patients (n = 71) hospitalized due to violent injury at a Level 1 Trauma Center in [Location Redacted for Masked Review] between January 2013 and May 2014. Patients first participated in a brief assessment to identify risk factors for violence/violent injury. A single MI session then targeted risk behaviors identified for each patient. Proximal outcomes, including motivation for change and behaviors to reduce risk, were examined at 2 weeks and 6-12 weeks post-discharge. Distal outcomes, including fighting, weapon-carrying, and gun-carrying, and other violence risk factors were examined at 6-12 week follow-up. RESULTS: Ninety-five patients were offered participation, 79 (83.2%) agreed to participate, and 73 (76.8%) completed the risk assessment. Of these, 71 had at least one violence/violent injury risk factor. Behaviors to reduce risk were significantly greater at two-week and 6-12 week follow-up (ps < .05). Fighting, weapon-carrying, gun-carrying were significantly reduced at 6-12 week follow-up (p < .05). CONCLUSIONS: This intervention appears to be feasible to implement and acceptable to patients. A randomized controlled trial evaluating efficacy appears warranted.

Combined Oral Contraceptive Pill Initiation in a Patient With Major Depressive Disorder, Premenstrual Dysphoric Disorder, Social Anxiety, Panic Disorder, and Histrionic Personality Disorder.

BACKGROUND: Comorbid psychiatric conditions present an added layer of challenge in managing patients, as each condition and associated set of symptoms exacerbate the complexity of the overall presentation. Premenopausal women may be at particular risk for inadequate care, as their comorbid conditions may present overlapping symptoms and mask independent premenstrual symptoms. The prevalence of premenstrual dysphoric disorder and associated conditions can be as high as 8% in women of reproductive age. Recognizing and assessing premenstrual symptoms that are comorbid with other psychiatric conditions can help contribute to a comprehensive treatment strategy and potentially improve the treatment response for the comorbid conditions. Combined oral contraceptive pills (COCPs) have been approved for premenstrual conditions and should be considered by the psychiatrist as an available treatment option. CASE REPORT: A 34-year-old Caucasian female patient with comorbid major depressive disorder, premenstrual dysphoric disorder, social anxiety, panic disorder, and histrionic personality disorder, with persistent suicidal ideation and distress intolerance, was treated with norgestimate-ethinyl estradiol with improvement in mood, anxiety, and menstrual cramping and with associated diminished suicidal ideation and improved distress tolerance. CONCLUSION: In this case, Beck Depression Inventory and Beck Anxiety Inventory scores, as well as self- and peer-reported functionality, all suggested improvement in symptoms following the introduction of COCPs. The neurohormonal contribution to psychiatric conditions continues to be studied and is becoming increasingly important. An understanding of the presence and etiology of premenstrual symptoms should be part of a comprehensive psychiatric assessment of female patients, and consideration of COCPs in the treatment plan adds a potentially potent option for symptom mitigation and remission.

Criminal Behavior and Repeat Violent Trauma: A Case-Control Study.

INTRODUCTION: Repeat violent injury is common among young urban men and is increasingly a focus of trauma center-based injury prevention efforts. Though understanding risk factors for repeat violent injury may be critical in designing such interventions, this knowledge is limited. This study aims to determine which criminal behaviors, both before and after the initial trauma, predict repeat violent trauma. Gun, violent, and drug crimes are expected to increase risk of subsequent violent injury among victims of violence. METHODS: A case-control design examined trauma registry and publicly available criminal data for all male patients aged <40 years presenting for violent trauma between April 2006 and December 2011 (N=1,142) to the sole Level 1 trauma center in a city with high rates of violence. Logistic regression was used to determine criminal behaviors predictive of repeat violent injury. Data were obtained and analyzed between January 2013 and June 2014. RESULTS: Regarding crimes committed before the first injury, only drug crime (OR=5.32) predicted repeat violent trauma. With respect to crimes committed after the initial injury, illegal gun possession (OR=2.70) predicted repeat victimization. Initiating gun (OR=3.53) or drug crime (OR=5.12) was associated with increased risk. CONCLUSIONS: Prior drug involvement may identify young male victims of violence as at high risk of repeat violent injury. Gun carrying and initiating drug involvement after the initial injury may increase risk of repeat injury and may be important targets for interventions aimed at preventing repeat violent trauma.

Clinical Case of the Month: A 48-Year-Old Man With Fever and Abdominal Pain of One Day Duration.

A 48-year-old man residing in a mental health department inpatient program with a history of schizoaffective disorder presented to the emergency department with a chief complaint of fever and intense abdominal pain for one day. The patient stated he initially fell in the shower and afterwards experienced back pain. He was transferred to an acute care unit within the facility for further evaluation. The facility physician noted that the patient had a mild temperature elevation and abdominal rigidity on exam. At that time, he was given two doses of benztropine intramuscularly, and transferred to our hospital for further evaluation. The patient exhibited fever, diffuse abdominal pain and a nonproductive cough, but denied chills, dysuria, urinary frequency, hematuria, weakness, diarrhea, melena or hematochezia. He did have a one-week history of constipation for which he was given sodium phosphate enemas, magnesium citrate and docusate sodium, eventually resulting in a bowel movement. He also complained of new onset dysphagia. There were no recent changes to his medications, which included clonazepam, divalproex sodium extended release, olanzapine and risperidone. He denied use of tobacco, alcohol or illicit drugs.

Patient Smartphone Ownership and Interest in Mobile Apps to Monitor Symptoms of Mental Health Conditions: A Survey in Four Geographically Distinct Psychiatric Clinics.

BACKGROUND: Despite growing interest in mobile mental health and utilization of smartphone technology to monitor psychiatric symptoms, there remains a lack of knowledge both regarding patient ownership of smartphones and their interest in using such to monitor their mental health. OBJECTIVE: To provide data on psychiatric outpatients' prevalence of smartphone ownership and interest in using their smartphones to run applications to monitor their mental health. METHODS: We surveyed 320 psychiatric outpatients from four clinics around the United States in order to capture a geographically and socioeconomically diverse patient population. These comprised a state clinic in Massachusetts (n=108), a county clinic in California (n=56), a hybrid public and private clinic in Louisiana (n=50), and a private/university clinic in Wisconsin (n=106). RESULTS: Smartphone ownership and interest in utilizing such to monitor mental health varied by both clinic type and age with overall ownership of 62.5% (200/320), which is slightly higher than the average United States' rate of ownership of 58% in January 2014. Overall patient interest in utilizing smartphones to monitor symptoms was 70.6% (226/320). CONCLUSIONS: These results suggest that psychiatric outpatients are interested in using their smartphones to monitor their mental health and own the smartphones capable of running mental healthcare related mobile applications.

Assessment of psychiatric symptoms at a level I trauma center surgery follow-up clinic: a preliminary report.

At Level I trauma centers, psychiatric consultation is readily available to inpatient surgical services. This study sought to characterize the psychiatric symptoms present in the surgical follow-up clinic. Patients aged 18 years and older were assessed over one month for symptoms of posttraumatic stress disorder (PTSD) with the Short PTSD Rating Interview (SPRINT), depression with the Patient Health Questionnaire (PHQ-9), alcohol abuse with the Alcohol Use Disorder Identification Test (AUDIT), and the presence of violence using the MacArthur Community Violence Instrument (MCVIa [victimization] MCVIb [perpetration]). Twenty-five individuals participated. Using the SPRINT, 13 (52.0%) met the cutoff for PTSD. For PHQ-9 depression, 11 (44%) were in the moderate to severe range. For AUDIT, five (20.0%) likely had an alcohol problem. Using the MCVI, 15 (60.0%) reported victimization and 12 (48.0%) reported perpetration. Elevated levels of psychiatric symptoms were found in the trauma surgery follow-up clinic. Psychiatric care embedded in this setting may be warranted.

Psychiatry consultation during disaster preparedness: Hurricane Gustav.

OBJECTIVES: Little is known about patient populations that remain during or after the mandatory evacuation of a city and use hospital services. This study sought to characterize the population that presented to an emergency department during Hurricane Gustav in 2008. METHODS: This was a retrospective chart review of patients who presented to the Interim Louisiana State University Hospital emergency department in New Orleans during the 72-hour activation phase of Hurricane Gustav. RESULTS: Of the 104 patients, 51 (49%) had a psychiatric diagnosis. Among the psychiatric patients, 34 (67%) had a substance use disorder diagnosis, 16 (31%) had a mood disorder, 13 (25%) had a psychotic disorder, and 4 (8%) had an anxiety disorder. The psychiatry service was the most used consultation service. CONCLUSIONS: To our knowledge, this is the first report to characterize the patient population presenting to an emergency department during a hurricane evacuation. Data suggest that disaster preparedness should include psychiatric consultation services. The consultation psychiatrist may anticipate patients with high levels of substance use disorders and the need for ongoing psychiatric management until the event ends.

A double-blind placebo-controlled trial of lamotrigine as an antidepressant augmentation agent in treatment-refractory unipolar depression.

BACKGROUND: Previous reports have suggested that lamotrigine is effective as an antidepressant augmentation agent in patients with treatment-resistant unipolar depression. This study is the largest double-blind placebo-controlled study conducted to date of lamotrigine in this role. METHOD: In this multicenter trial, conducted at 19 sites, patients aged 18-65 years with a DSM-IV/ICD-10 diagnosis of unipolar, nonpsychotic major depressive disorder (confirmed by the Mini-International Neuropsychiatric Interview) who had failed at least 1 adequate trial of an antidepressant (N = 183) were first treated for 8 weeks with open-label paroxetine or paroxetine controlled-release in dosages up to 50 mg/d or 62.5 mg/d, respectively. Individuals with a 17-item Hamilton Depression Rating Scale (HDRS-17) score ≥ 15 (n = 96) were then randomized on a double-blind basis to receive either placebo or lamotrigine in dosages titrated upward to a maximum of 400 mg/d for 10 weeks. Sixty-five patients completed the study. The primary outcome measure was the Montgomery-Asberg Depression Rating Scale (MADRS), and the main secondary outcome measures were the HDRS-17 and Clinical Global Impressions-Severity of Illness (CGI-S) and Clinical Global Impressions-Improvement (CGI-I) ratings. Data were collected from 2003 to 2006. RESULTS: Results of the primary efficacy analysis of the randomized patients using the MADRS, HDRS-17, CGI-S, and CGI-I did not demonstrate a statistically significant difference between lamotrigine and placebo groups, although some secondary analyses were suggestive of efficacy, particularly in those patients who completed the study (completer analysis) and in more severely ill patients (HDRS-17 ≥ 25). CONCLUSIONS: This add-on study of patients with treatment-resistant depression failed to detect a statistically significant difference between lamotrigine and placebo given for 10 weeks. However, post hoc analyses suggest that future studies of lamotrigine's efficacy might focus on specific subgroups with depression. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT00901407.

The therapeutic potential of escitalopram in the treatment of panic disorder.

Panic disorder is a chronic and disabling condition that is often accompanied by other psychiatric and medical conditions. The serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs) have been used effectively with panic disorder (PD) and conditions in which panic attacks frequently occur. Escitalopram is the most selective SSRI and a variety of evidence suggests it is of great value in the treatment of panic disorder. In this paper, we review the theoretical and practical implications of its use.

The effectiveness of olanzapine, risperidone, quetiapine, and ziprasidone as augmentation agents in treatment-resistant major depressive disorder.

BACKGROUND: Many questions remain regarding the use of atypical neuroleptics as antidepressant augmentation agents. To date, there have been no reports in the literature regarding the effectiveness of these drugs when trials of one or more of them have failed previously as antidepressant augmentation. METHOD: This retrospective chart review was conducted to determine the effectiveness of olanzapine, risperidone, quetiapine, and ziprasidone when given in a fee-for-service setting as anti-depressant augmentation agents to patients with treatment-resistant, nonpsychotic major depressive disorder (DSM-IV). Prospective (Global Assessment of Functioning [GAF]) along with retrospective (Clinical Global Impressions-Improvement [CGI-I] and -Severity of Illness scales) ratings were completed for each patient. Analyses were conducted in an attempt to identify factors that appeared to correlate with response, including order of administration and Thase-Rush staging of treatment resistance. RESULTS: In this study of 76 medication trials in 49 patients, the overall response rate based on the CGI-I ratings was 65% (32/49). Individual rates of response were 57% (21/37) for olanzapine, 50% (7/14) for risperidone, 33% (6/18) for quetiapine, and 10% (1/10) for ziprasidone. None of the differences between neuroleptics in rates of response were significant. The difference between baseline and final GAF scores was statistically significant only in the olanzapine (p <.001) and risperidone (p =.047) groups. Rates of discontinuation did not vary significantly between agents, though trends were present. Crossover trials from one atypical neuroleptic to another in the event of nonresponse appeared to be effective. CONCLUSIONS: Although limited by its design, this study suggests atypical neuroleptic augmentation of antidepressants may be a viable option in treatment-resistant major depressive disorder.

Aripiprazole augmentation in treatment-resistant depression.

BACKGROUND: Evidence is accumulating to support the use of atypical neuroleptics as adjunctive treatment for refractory mood disorders, although there are currently no published data on the efficacy of an atypical neuroleptic in treatment-resistant depression when a previous trial of drug from the same class has failed. The authors hypothesized that aripiprazole would be efficacious in augmenting antidepressant treatment in resistant patients with non-psychotic unipolar depression who had previously failed a trial of another atypical neuroleptic. METHODS: This study was a retrospective chart review of the efficacy of aripiprazole augmentation in 30 treatment-resistant unipolar depression patients who had failed multiple previous antidepressant trials and had also failed augmentation with at least one other atypical neuroleptic. Prospective Global Assessment of Functioning and Clinical Global Impressions-Improvement scores were completed on each patient throughout treatment. RESULTS: Utilizing an intent-to-treat analysis (including 9 patients who dropped out prior to completion of 6 weeks), 46.7% (14/30) patients were rated much improved or very much improved with treatment. This improvement negatively correlated with Thase-Rush staging of treatment resistance. GAF scores also showed a significant improvement. Six of the 14 patients who initially improved subsequently relapsed (yielding a long-term net response rate of 26.7%). CONCLUSION: Aripiprazole may be effective as an antidepressant augmentation agent in highly treatment resistant patients who had failed a prior trial of another atypical neuroleptic.