Engagement-focused care during transitions from inpatient and emergency psychiatric facilities.

OBJECTIVES: As many as 40% of those with serious mental illness (SMI) do not attend any outpatient visits in the 30 days following discharge. We examined engagement-focused care (EFC) versus treatment as usual in a university-based transitional care clinic (TCC) with a 90-day program serving individuals with SMI discharged from hospitals and emergency rooms. EFC included a unique group intake process (access group) designed to get individuals into care rapidly and a shared decision-making coach. METHODS: Assessments of quality of life, symptomatology, and shared decision-making preferences were conducted at baseline, at 3 months corresponding to the end of TCC treatment and 6 months after TCC discharge. Communication among the patients and providers was assessed at each visit as was service utilization during and after TCC. RESULTS: Subjective quality of life improved in EFC. Prescribers and patients saw communication more similarly as time went on. Ninety-one percent of patients wanted at least some say in decisions about their treatment. CONCLUSIONS: SDM coaching and improved access improve quality of life. Most people want a say in treatment decisions.

Following AACP Guidelines for Transitions in Care: The Transitional Care Clinic.

The period of transition from hospital to community services is critical for individuals with serious mental illness. The American Association of Community Psychiatry developed guidelines for transitional services in behavioral health care. This column describes ways in which the Transitional Care Clinic (TCC) at the University of Texas Health Science Center at San Antonio has implemented these guidelines. The TCC includes active outreach to hospitals and a Web-based referral system that allows hospital staff to make TCC appointments for patients for as soon as the day after discharge. The program includes a unique group intake process that allows rapid development of individualized plans while maximizing access to services and use of provider time.

Conceptualization and treatment of negative symptoms in schizophrenia.

Negative symptoms of schizophrenia including social withdrawal, diminished affective response, lack of interest, poor social drive, and decreased sense of purpose or goal directed activity predict poor functional outcomes for patients with schizophrenia. They may develop and be maintained as a result of structural and functional brain abnormalities, particularly associated with dopamine reward pathways and by environmental and psychosocial factors such as self-defeating cognitions and the relief from overstimulation that accompanies withdrawal from social and role functioning. Negative symptoms are more difficult to treat than the positive symptoms of schizophrenia and represent an unmet therapeutic need for large numbers of patients with schizophrenia. While antipsychotic medications to treat the symptoms of schizophrenia have been around for decades, they have done little to address the significant functional impairments in the disorder that are associated with negative symptoms. Negative symptoms and the resulting loss in productivity are responsible for much of the world-wide personal and economic burden of schizophrenia. Pharmacologic treatments may be somewhat successful in treating secondary causes of negative symptoms, such as antipsychotic side effects and depression. However, in the United States there are no currently approved treatments for severe and persistent negative symptoms (PNS) that are not responsive to treatments for secondary causes. Pharmacotherapy and psychosocial treatments are currently being developed and tested with severe and PNS as their primary targets. Academia, clinicians, the pharmaceutical industry, research funders, payers and regulators will need to work together to pursue novel treatments to address this major public health issue.