The New Hampshire Hospital Screening and Referral Algorithm (NHHSRA) for Substance Use in People With Serious Mental Illness.

Objective: Substance use is a common co-occurrence among psychiatrically hospitalized adults, yet it is especially difficult to identify in those with serious mental illness. Existing screening instruments are not feasible for individuals with serious mental illness, as they rely heavily on subjective self-report. This study aimed to develop and validate an objective substance use screening instrument for use in seriously mentally ill patient populations.Methods: Objective elements were extracted from existing substance use screening instruments and used to develop a new, data-driven referral tool, the New Hampshire Hospital screening and referral algorithm (NHHSRA). Descriptive statistics were employed to compare NHHSRA summed score and individual patient data elements in a convenience sample of patients who were referred to the Addiction Services by expert addiction psychiatrist evaluation to those who were not referred. Pearson correlation coefficients and logistic regression models assessed the association between patient referral and the overall NHHSRA score and individual items. The NHHSRA was then piloted in a smaller convenience sample of patients against the standard clinical-based identification for substance use treatment needs.Results: The instrument consists of 5 objective items. These were tested in a sample of 302 sequentially admitted adults with serious mental illness. Three of the items were significantly associated with likelihood of benefitting from referral for substance use interventions (maximum likelihood estimate and standard deviation [SD] for positive non-tetrahydrocannabinol [non-THC] toxicology screen or > 0% blood alcohol level = 3.61 [0.6]; diagnosis of a substance use disorder = 4.89 [0.73]; and medication-assisted treatment or relapse prevention = 2.78 [0.67]), and these were prioritized in building a decision tree algorithm. The area under the receiver operating characteristic (ROC) curve for the NHHSRA was 0.96, indicating that the NHHSRA has high overall sensitivity and the algorithm was capable of distinguishing between patients needing substance use intervention versus those who do not with 96% accuracy. In the pilot implementation study of another 20 patient admissions, the NHHSRA accurately identified 100% (n = 6) of patients deemed to benefit from substance use interventions by expert addiction psychiatric evaluation. The standard clinical-based referral process identified only 33% (n = 2) and erroneously identified another 4 for referral to substance use intervention that would not have been warranted.Conclusions: The NHHSRA holds promise in its ability to improve objective and timely identification of substance use in a seriously mentally ill inpatient population, helping to facilitate treatment.

Psychiatric Boarding in Emergency Departments and the COVID-19 First Wave: The New Hampshire Response.

The COVID-19 pandemic forced unprecedented challenges for emergency department operations during the spring of 2020. Before the COVID-19 pandemic, psychiatric boarding in emergency departments required a substantial amount of staffing and administrative resources. This case study describes one state's efforts to rapidly decrease psychiatric boarding by 93% in 2 weeks with a multipronged approach, and simultaneously minimal effects observed on outcome measures of psychiatric hospital readmissions and suicide rates. Lessons learned are discussed regarding workflow adaptations and leadership implications.

Renewed call for lifestyle interventions to address obesity among individuals with serious mental illness in the COVID-19 era and beyond.

Behavioral health has the opportunity to lead the way in using lifestyle interventions to address obesity and health disparities in people with serious mental illness (SMI) in the COVID-19 era. Evidence-based interventions for weight loss in individuals with SMI exist, and the field has developed strategies for implementing these interventions in real-world mental health care settings. In addition to promoting weight loss, lifestyle interventions have the potential to address social isolation and loneliness and other patient-centered outcomes among individuals with SMI, which will be especially valuable for mitigating the growing concerns about loneliness attributed to the COVID-19 pandemic restrictions on in-person encounters. In this commentary, we discuss practice, policy, and research implications related to using evidence-based lifestyle interventions for individuals with SMI during the COVID-19 pandemic and sustaining these programs in the long-term.

A Framework for the Community Psychiatrist's Role in the COVID-19 Response.

The COVID-19 pandemic has disrupted community mental health center (CMHC) operations by limiting in-person access to patients and contributing to staff absenteeism. States adjust social distancing levels over time in response to changes in economic needs, healthcare system utilization, and COVID-19 virus transmission levels. Community mental health centers also need to balance service needs with infection risk, which requires adjusting social distancing levels in response to changes in the local conditions. This article will: (1) briefly describe epidemiological indicators most useful for judging the local infection trends, (2) describe a strategy for organizing specific agency clinical functions on a social distancing level scale, (3) propose a set of agency phases to inform administrative responses to changes in the risk to operations, and (4) discuss the role of psychiatrists as physicians in a mental health agency during a pandemic.

Diagnosing and managing violence.

Available categorization systems for violence encountered in medical practice do not constitute optimal tools to guide management. In this article, 4 common patterns of violence across psychiatric diagnoses are described (defensive, dominance-defining, impulsive, and calculated) and management implications are considered. The phenomenologic and neurobiological rationale for a clinical classification system of violence is also presented.

Psychosocial Response to Mass Casualty Terrorism: Guidelines for Physicians.

Background: All physicians would need to address the psychosocial consequences of a mass casualty terrorist attack should it occur.Method: A review of evidence and expert opinion regarding psychosocial response to mass casualty incidents was performed. Data were obtained via the PubMed database in an English-language search using the terms PTSD secondary prevention, psychological first aid, and disaster psychiatry and the dates 1995 through 2004.Results: There is a National Institute of Mental Health consensus statement on the psychiatric response to mass violence, but sparse psychopharmacologic literature. Psychotherapeutic interventions are well studied in posttraumatic settings.Conclusions: The physician's response to mass casualty terrorism must address the high volume of patients with anxiety reactions and somatic symptoms likely to present for care. Supportive interventions include fostering a sense of safety and efficacy, connecting patients with communities and services, and helping parents talk about the trauma with their children. In the future, early pharmacologic interventions may be proven effective.