Service dogs, psychiatric hospitalization, and the ADA.

A service dog is defined as "any dog that is individually trained to do work or perform tasks for the benefit of an individual with a disability, including a physical, sensory, psychiatric, intellectual, or other mental disability." Some psychiatric patients may depend on a service dog for day-to-day functioning. The Americans with Disabilities Act (ADA) established certain rights and responsibilities for individuals with disabilities and health care providers. Psychiatric hospitalization of a patient with a service dog may pose a problem and involves balancing the requirement to provide safe and appropriate psychiatric care with the rights of individuals with disabilities. This Open Forum examines issues that arise in such circumstances, reviews the literature, and provides a foundation for the development of policies and procedures.

Psychiatric services: experience, perceptions, and needs of nursing facility multidisciplinary leaders.

OBJECTIVES: To identify the experience and perceptions of multidisciplinary nursing facility leaders regarding need for psychiatric services in residents of long-term care. DESIGN: Cross-sectional study. SETTING: Nursing facilities in Hawaii. PARTICIPANTS: Surveys were sent to 188 nursing facility administrators, medical directors, directors of nursing, and directors of social work at 47 facilities in Hawaii; 99 individual staff responses (52% response rate) were received from 42 facilities (89% response rate). MEASUREMENTS: Educational experience, psychiatric service perceptions, and needs as assessed by survey questions. RESULTS: The most commonly cited reasons for not accepting a patient with a recent history of or current psychiatric or behavioral problems were concerns of dangerousness (73.5%), the need for greater staff attention (64.3%), and difficulty accessing psychiatric support and follow-up after admission (53.1%). Easy accessibility (66.3%) was the most essential consultant quality, and pharmacological treatment interventions (88.4%) were deemed most helpful. Behavioral management of dementia (93.6%) was the most requested educational topic, followed by depression and suicide (77.7%). There were some differences noted between specialties. CONCLUSION: The findings highlight the unmet needs of nursing facility leaders, gives direction to and reinforces how psychiatrists, by virtue of their training and skills, can play a central role in meeting these needs, and offer a glimpse of the potential for collaboration to addresses the mental health and psychiatric service needs of the long-term care residents.

Alternative formulations, delivery methods, and administration options for psychotropic medications in elderly patients with behavioral and psychological symptoms of dementia.

OBJECTIVE: The purpose of this paper was to review alternative formulations, delivery methods, and administration options for psychotropic medications in elderly patients with behavioral and psychological symptoms of dementia (BPSD). METHODS: A MEDLINE search was conducted initially in December 2008 and was updated in September 2009, including the search terms pharmacologic treatment and dementia, behavioral and psychological symptoms of dementia, alternative psychotropic medication formulations, alternative dosing methods of medication, drug delivery options, antidepressants and dementia, anxiolytics and dementia, antipsychotics and dementia, mood stabilizers and dementia, cognitive enhancers and dementia, medications and enteral feeding tubes, and hiding medication. Studies were limited to English-language articles dated from 1950 to 2009. Additional relevant articles were obtained by reviewing the references in the initial articles. Drug Facts and Comparisons 4.0 Online, Lexi-Comp Online, and Lexi-Drugs Online were used to obtain additional information. Targeted patients were elderly individuals with BPSD who were considered difficult to treat because they were unable to swallow, were refusing medications, or were not able to eat or drink per physician order. RESULTS: In addition to the standard capsule or tablet given orally, a variety of formulations and delivery methods for psychotropic medications are available. Options include short- and long-acting intramuscular, intravenous, liquid, orally disintegrating, transdermal patch, sublingual, and rectal forms. Additionally, all formulations can be further altered in substance, delivery, or both. For example, tablets may be crushed and capsules opened; this changes their formulation and allows the option of mixing with food or liquids to be taken by mouth or through a tube. Caution must be used, however; in certain cases, alteration of the original form or the intended delivery method is contraindicated. In addition, many alternative administration options are not formally approved for use in the manner in which they are commonly applied and are therefore used with little or no information on tolerability and effectiveness. Ethical and legal issues include patient consent and off-label use. CONCLUSIONS: Overall, few studies have examined the use and efficacy of alternative psychotropic formulations and delivery methods in elderly patients with BPSD, and none have specifically addressed drug-alteration and alternative-administration issues. There is no evidence to compare alternative delivery forms (eg, tablet or capsule) of a given medication in terms of efficacy or tolerability. Still, alternative methods may be the only option for treatment of some patients. Practitioners must be familiar with the range of formulations and delivery options available so that they can optimize their patients' medication regimens. More data are needed on the use of alternative formulations, delivery methods, and administration options and their limitations in this population.

Monoamine oxidase inhibitor usage in Hawaii.

OBJECTIVE: Previous studies involving prescriptions of monoamine oxidase inhibitors (MAOIs) have focused on predominantly Caucasian populations with little representation of Asian Americans and Pacific Islanders. The Asian American diet includes tyramine-rich fermented food items. This study describes the characteristics of MAOI prescribing patterns in Hawaii, a state with predominantly Asian Americans and Pacific Islanders. METHODS: Antidepressant usage including MAOIs were identified using a commercial insurance database from Hawaii Medical Service Association, a Blue Cross/Blue Shield subsidiary. Prescriptions from 1999 to 2003 were identified with basic information including ethnicity, age, diagnostic category, morbidity level, and 6 months adherence to MAOIs. RESULTS: Of the 28,890 patients prescribed antidepressants, seventeen individuals (0.06%, 95% confidence interval 0.03-0.09%) were prescribed MAOIs. MAOIs continue to be seldom used in treatment. There was no significant difference in prescriptions for MAOIs vs. other antidepressants based on ethnicity. CONCLUSIONS: MAOIs are vastly underutilized in all ethnic groups including Asian American and Pacific Islander groups.

Hospital psychiatric interventions and its positive effect on disposition of non-acute, long-term-care waitlisted patients: a case series.

Psychiatric interventions in hospital patients have been shown effective in reducing length of stay and costs. Its effectiveness and benefits in regard to the growing problem of disposition of non-acute, long-term-care, waitlisted hospital patients have not been characterized or described in the literature. The authors present several cases of waitlisted patients that demonstrate direct and indirect psychiatric interventions can play a significant role overcoming barriers and contributing to timely and appropriate disposition of these patients. Future prospective studies should be done to expand upon these findings to prepare for the aging of the population in Hawai'i.

A descriptive study of a unique multi-ethnic consultation-liaison psychiatry service in Honolulu, Hawaii.

OBJECTIVE: To provide a descriptive characterization of the CL Psychiatry service at a major medical center in Honolulu, Hawaii. We hypothesized differing demographic trends than seen nationally and internationally, an increasing prevalence of elderly and substance abusing patients, and increasing consultation requests related to these issues. METHODS: Retrospective data was gathered from 180 randomly selected patient records, identified as having a request for inpatient psychiatric consultation on the medical-surgical floors during identical 3-month periods in 2000 and 2005. Descriptive statistics were calculated. Chi-square and ANOVA were used to compare differences across time. RESULTS: There were no significant differences by age, reason for referral, or diagnoses between the 2 years. Patients age 65 years and older accounted for only 16.6% of the consults. Caucasians accounted for 45.6% of consultations despite low prevalence rates in the population. Hawaiian/Pacific Islander (15%), Japanese (12.5%), Filipino (5.6%), and other Asians (10.6%) accounted for the majority of remaining patients. Depression/anxiety (27.4%), alcohol/drugs (21.8%), and agitation/ psychosis (20.5%) were the most frequent reasons for consultation. Substance use (32.5%), mood (16%), and cognitive (14.1%) disorders were the top diagnoses. CONCLUSIONS: As expected, the patient demographic data reflects a unique patient population served by the QMC CL service. Much of the consultation process, diagnoses, and treatment, however, are in line with our Mainland counterparts. There were no major differences in trends over time.