Embedded Psychiatric Services in a Multidisciplinary Amyotrophic Lateral Sclerosis Clinic: An Assessment of Patient Needs and Perceptions.

OBJECTIVE: Amyotrophic lateral sclerosis (ALS) is often associated with a range of difficult neuropsychiatric symptoms and conditions, including depression, apathy, pseudobulbar affect, and frontotemporal dementia (FTD). Despite the potential role for psychiatrists in the treatment of ALS, they are not typically involved in the ALS clinical team. The investigators describe a quality improvement intervention providing embedded psychiatric services within a multidisciplinary clinic (MDC). METHODS: A psychiatrist working within an ALS MDC evaluated patients (N=116) over a 1-year period. The clinic assessed the prevalence of neuropsychiatric symptoms and conditions in patients with ALS (depression, anxiety, pseudobulbar affect, and cognitive impairment, including FTD) using standardized screening methods. Fifty-five patients and 47 family members completed surveys about perceptions of their need for psychiatric care, their experience of meeting with a psychiatrist, and their desire for future access to psychiatric care. RESULTS: Prevalence rates for neuropsychiatric symptoms were 14.9% for depression, 11.3% for anxiety, 19% for cognitive impairment (including FTD, 8.6%), and 36.2% for pseudobulbar affect; 62.0% of patients were being prescribed at least one psychotropic medication. Both patients and family members reported that meeting with a psychiatrist was helpful, that the treatment provided was helpful, and that they would prefer continued availability of psychiatric services in the future. The presence of cognitive impairment and use of antidepressants increased the likelihood of patients reporting a benefit from psychiatric care. CONCLUSIONS: Patients with ALS report a benefit from increased access to psychiatric services. The inclusion of a psychiatrist within the ALS MDC model should be considered to improve quality of care for this patient population.

The market-reach of pandemics: Evidence from female workers in Ethiopia's ready-made garment industry.

In a globalized world, pandemics transmit impacts through markets. We document employment changes, coping strategies, and welfare of garment factory workers in Ethiopia's largest industrial park during the early stages of the Coronavirus Disease 2019 pandemic. We field a phone survey of female workers during a two month period in which cases are rapidly rising globally, but not locally. Our data suggest significant changes in employment, high levels of migration away from urban areas to rural areas if women are no longer working, and high levels of food insecurity. These findings compel a research and policy focus on documenting and mitigating the market-reach of pandemics on low-income workers at the margins.

Patient Attribution of Posttraumatic Symptoms to Brain Injury Versus PTSD in Military-Related Mild TBI.

OBJECTIVE: Persistent cognitive, somatic, and neuropsychiatric symptoms following mild traumatic brain injury (TBI) are influenced by posttraumatic stress disorder (PTSD), particularly in military patients. The authors evaluated the degree to which military service members with a history of mild TBI attributed posttraumatic symptoms to TBI versus PTSD. METHODS: Service members (N=372) with mild TBI were surveyed about the severity of posttraumatic symptoms across four symptom clusters (cognitive, affective, somatosensory, and vestibular) with the Neurobehavioral Symptom Inventory (NSI). Participants rated the degree to which they believed TBI, PTSD, or other conditions contributed to their symptoms. Differences in cognitive, affective, somatosensory, and vestibular symptom severity were evaluated across participants with TBI, PTSD, or combined TBI-PTSD attribution. Logistic regression was used to evaluate the association between symptom profiles and attribution. RESULTS: Participants attributed symptoms mostly to TBI, followed by insufficient sleep, PTSD, chronic pain, depression, and deployment-readjustment stress. PTSD and combined TBI-PTSD attribution were associated with higher total NSI scores (39.5 and 51.6, respectively), compared with TBI attribution only (31.4) (F=29.08, df=3, 358, p<0.01), as well as higher scores in every symptom category. More severe affective symptoms were associated with decreased odds of TBI attribution (odds ratio=0.90, 95% CI=0.83-0.97) and increased odds of PTSD attribution (odds ratio=1.14, 95% CI=1.03-1.26). A PTSD diagnosis was highly associated with PTSD attribution (odds ratio=2.44, 95% CI=1.07-5.58). CONCLUSIONS: The nature and severity of posttraumatic symptoms appear to play a role in patient beliefs about the causes of symptoms, whether from TBI or PTSD.

Differences in Posttraumatic Stress Disorder, Depression, and Attribution of Symptoms in Service Members With Combat Versus Noncombat Mild Traumatic Brain Injury.

OBJECTIVE: This study compares combat-related mild traumatic brain injury (mTBI) to non-combat-related mTBI in rates of posttraumatic stress disorder (PTSD) and depression after injury, severity of postconcussive symptoms (PCSs), and attribution of those symptoms to mTBI versus PTSD. PARTICIPANTS: A total of 371 active duty service members (SMs) with documented history of mTBI, divided into combat and non-combat-related cohorts. DESIGN: Retrospective cohort study. MAIN MEASURES: Diagnoses of PTSD and depression based on medical record review and self-report. PCSs measured using Neurobehavioral Symptom Index. Attribution of symptoms based on a rating scale asking how much mTBI, PTSD, depression, deployment, or readjustment stress contributed to current symptoms. RESULTS: Prevalence of PTSD was significantly higher after a combat-related mTBI, compared with a noncombat mTBI (P = .001). Prevalence of depression did not differ between the 2 groups. PCSs were high in both combat and noncombat mTBIs, with no statistical difference between groups. SMs with PTSD reported higher PCS, regardless of combat status. SMs without PTSD attributed symptoms mainly to mTBI, whereas SMs with PTSD, regardless of combat status, were much more likely to attribute symptoms to PTSD, depression, and deployment/readjustment stress. CONCLUSIONS: This research contributes to our understanding of the complex interplay between mTBI and PTSD in both combat and noncombat injuries within the military population and the importance of addressing both simultaneously.

Antipsychotic adherence and emergency department utilization among patients with schizophrenia.

This retrospective cohort study evaluated the relationship between antipsychotic medication adherence and emergency department (ED) utilization for 7851 Medicaid patients with schizophrenia enrolled in Community Care of North Carolina (CCNC). Claims and pharmacy data from January to December 2015 were collected. Medication adherence was approximated using the medication possession ratio (MPR). Negative binomial regressions estimated the effect of antipsychotic adherence on rates of medical and psychiatric ED visits. The results demonstrated a statistically significant negative relationship between antipsychotic adherence and medical ED utilization. Non- and partially adherent patients (MPR < 0.80) had 1.61 times the rate of medical ED visits as fully adherent patients (MPR ≥ 0.80) (95% CI: 1.50-1.74, p-value < 0.001). The relationship between adherence and psychiatric utilization was small and not statistically significant. The most common diagnostic categories of ED visits were injuries and poisonings (16%), ill-defined symptoms (14%), and musculoskeletal conditions (12%). This study demonstrates a clear association between antipsychotic adherence and medical ED utilization, suggesting an important link between psychiatric management and medical utilization in patients with schizophrenia.

Understanding Frequent Emergency Department Use Among Primary Care Patients.

Patients with high emergency department (ED) utilization are an important focus in population health management. This retrospective cohort study analyzed patterns of frequent ED use for 4087 patients enrolled at an academically-affiliated primary care clinic. For all ED visits (n = 4776), the chief complaints, admission rates, number of complaints per patient, and median time between return visits were assessed. Chart reviews were conducted for the 10 highest utilizers from each of the 3 leading complaints to help explain repeated ED use for the same complaints. Results showed that chief complaints for high utilizers were statistically similar to other patients. Nearly half (49.8%) of all ED visits among high utilizers were repeat visits for the same complaint. However, most high utilizers (85%) had 4 or more separate complaints. Their visits clustered temporally, with 55% occurring less than 30 days apart. Visits for psychiatric symptoms demonstrated the shortest time to repeat visit (median 17.5 days, interquartile range: 39.5). Abdominal pain, chest pain, and shortness of breath were the leading complaints and the leading sources of hospital admissions and repeat visits. Chart review revealed that these 3 chief complaints often were associated with a wide range of ongoing chronic conditions, confounded by substance abuse, anxiety, and treatment nonadherence. This study demonstrates an integrative method for examining patterns of ED use among high utilizers. It also highlights the complex nature of high utilization and the inherent difficulty in predicting and addressing the needs of high-utilizer patients.