Medical Student Education in State Psychiatric Hospitals: A Survey of US State Hospitals.

OBJECTIVE: State hospitals may be underutilized in medical education. US state psychiatric hospitals were surveyed on current and potential psychiatry medical student education. METHODS: A 10-item questionnaire, with multiple response formats, was sent to identified hospitals in late 2012. RESULTS: Ninety-seven of 221 hospitals contacted responded. Fifty-three (55%) reported current medical student education programs, including 27 clinical clerkship rotations. Education and training in other disciplines was prevalent in hospitals both with and without medical students. The large majority of responders expressed enthusiasm about medical education. The most frequent reported barrier to new programs was geographic distance from the school. Limited resources were limiting factors for hospitals with and without current programs. CONCLUSIONS: Only a minority of US state hospitals may be involved in medical student education. While barriers such as geographic distance may be difficult to overcome, responses suggest opportunities for expanding medical education in the state psychiatric hospitals.

Animal-assisted therapy with chronic psychiatric inpatients: equine-assisted psychotherapy and aggressive behavior.

OBJECTIVE: Animal-assisted therapy (AAT), most frequently used with dogs, is being used increasingly as an adjunctive alternative treatment for psychiatric patients. AAT with larger animals, such as horses, may have unique benefits. In this randomized controlled study, equine and canine forms of AAT were compared with standard treatments for hospitalized psychiatric patients to determine AAT effects on violent behavior and related measures. METHODS: The study included 90 patients with recent in-hospital violent behavior or highly regressed behavior. Hospitalization at the 500-bed state psychiatric hospital was two months or longer (mean 5.4 years). Participants were randomly selected to receive ten weekly group therapy sessions of standardized equine-assisted psychotherapy (EAP), canine-assisted psychotherapy (CAP), enhanced social skills psychotherapy, or regular hospital care. Participants' mean age was 44, 37% were female, 76% had diagnoses of schizophrenia or schizoaffective disorder, and 56% had been committed involuntarily for civil or forensic reasons. Violence-related incident reports filed by staff in the three months after study intake were compared with reports two months preintake. RESULTS: Interventions were well tolerated. Analyses revealed an intervention group effect (F=3.00, df=3 and 86, p=.035); post hoc tests showed specific benefits of EAP (p<.05). Similar AAT effects were found for the incidence of 1:1 clinical observation (F=2.70, df=3 and 86, p=.051); post hoc tests suggested benefits of CAP (p=.058) as well as EAP (p=.082). Covariance analyses indicated that staff can predict which patients are likely to benefit from EAP (p=.01). CONCLUSIONS: AAT, and perhaps EAP uniquely, may be an effective therapeutic modality for long-term psychiatric patients at risk of violence.

Neutrophil function and periodontitis in alcohol-dependent males without medical disorders.

BACKGROUND: Periodontitis and immune dysfunction are often reported in alcohol-dependent patients. Our objectives were to investigate the effects of alcohol exposure on neutrophil function and the associated consequential effects on the periodontium in a group of African American (AA) males with documented history of alcohol use without medical complications. METHODS: Thirty-three AA males with documented history of alcohol use were included in this analysis. All subjects were free from systemic illness. Blood levels of gamma-glutamyl transpeptidase (GGTP) were determined and used as a measure of alcohol consumption. Periodontal evaluations including attachment levels (AL) were recorded on 6 sites per tooth. Enumerative and functional neutrophil measures were obtained. RESULTS: GGTP blood levels inversely associated with neutrophil bacterial killing (NBK) (p = 0.04). Regression analysis, adjusting for risk factors associated with periodontitis, showed an inverse association between NBK and percent of sites with AL > or = 5 mm (p <0.05) and a direct significant interaction between GGTP (> 51 international units) and increasing NBK activity on percent of sites with AL > or = 5 mm (p < 0.05). CONCLUSIONS: In AA males with excessive alcohol use, neutrophils show depressed NBK. Depressed NBK was not associated with loss of periodontal attachment in this population. Furthermore, AA males with excessive alcohol use and uncompromised neutrophil function are at greater risk of periodontal tissue damage.

Using structured clinical feedback to encourage alternatives to use of "P.R.N." medication in a state psychiatric hospital.

OBJECTIVE: The study examined whether reductions in the use of pro re nata (p.r.n.) psychotropic medications could be achieved in a large public-sector psychiatric hospital, without adverse behavioral consequences, by disseminating a database that tracks p.r.n. use to clinical teams. METHODS: A performance improvement project was implemented over 28 months, involving all 166 patients in one section of a state psychiatric hospital. A spread- sheet tracking p.r.n. administration for each patient was provided weekly to unit treatment teams. Clinical outcome monitoring focused on the number of p.r.n. administrations and on p.r.n. "events," defined as ≥ 3 multiple administrations per week and ≥ 10 per month. Episodes of patient seclusion, restraint, and violent incidents were also monitored. RESULTS: From September 2008 to December 2010, with a stable patient population census, total monthly administrations of psychotropic p.r.n. medications decreased from 642 to 240; administrations of non-psychotropic "medical" p.r.n. agents also decreased, from 279 to 72. In year-by-year comparisons, significant decreases (P < 0.05) were observed in the total number of psychotropic and medical p.r.n. administrations, in weekly as well as monthly p.r.n. events, and in the number of patients receiving any p.r.n. administrations. There was no change from 2008 to 2010 in the number of violent incidents; the use of both seclusion and restraint decreased (P < 0.05). CONCLUSION: The findings suggest that p.r.n. use can be reduced safely through timely feedback of relevant clinical data.

Reported allergies to antipsychotic agents in a long-term psychiatric hospital.

The incidence of allergic reactions to antipsychotic agents is not well known but would be expected to be low. However, pharmacy records at a large state psychiatric hospital indicated surprisingly high rates of such allergies. We hypothesized that these high rates of reported allergies in the pharmacy database would not be supported by clinical history, but rather that they represented other side effects or past uncritical acceptance of casual patient reports. Method. Patients listed as having experienced allergies to antipsychotic medications were interviewed by two psychiatrists and any clinical evidence that suggested an allergy was noted. Results. Of 585 patients who were hospitalized on the day the data were reviewed, 138 patients (23.6%) were identified by the pharmacy as allergic to an antipsychotic medication, 79 of whom were available and consented to be interviewed. Of these 79 patients, 7 (8.9%) provided evidence of a true allergy and 12 (15.2%) provided evidence that suggested a remote possibility of an allergy. Of the 60 "allergic" patients who provided no evidence of an allergy, 57% reported a non-allergic adverse drug reaction (ADR) that may have accounted for the allergy assignment and 32% reported possible symptoms that might have done so. Length of stay was possibly associated with an unsupported allergy designation (p <0.07). Reported allergies to other psychotropic agents (p <0.02) or to nonpsychotropic agents (p <0.07) were associated with evidence of a "true" allergy to an antipsychotic agent. Conclusions. Allergies to antipsychotic medications may be much less common than suggested by clinical records. The examination of focused clinical histories from patients who have been reported to experience such "allergies" would likely expand the pool of available medications for many patients.

Dental care and oral disease in alcohol-dependent persons.

Dental/Oral health of alcohol-dependent persons and substance abusers is often neglected. It is not clear that alcohol dependence has effects on oral health beyond those expected in nonalcoholic persons of similar socioeconomic status (SES). Study objectives were to examine the personal dental care habits, ability to access professional dental care, and the types of services received and to examine their effect on the oral health of alcohol-dependent persons and substance abusers. Forty Diagnostic and Statistical Manual of Mental Disorders, Third Edition Revised-diagnosed alcohol-dependent persons and a comparison group of 25 non-alcohol-dependent subjects matched for race, age, gender, and SES were recruited. Subjects were medically healthy. Each subject received a comprehensive oral/dental examination, and an interview was conducted to record personal dental hygiene habits, ability to access professional dental care, and types of dental services provided. No statistical differences were found between the oral care habits of the groups. Forty-four percent of all subjects had access to charity professional dental care. Tooth extraction was the main dental service they received. Seventy-five percent of subjects brushed their teeth once or more per day. In the non-alcohol-dependent group, brushing frequency was inversely associated with plaque levels (p < .05); in the alcohol-dependent group, brushing frequency showed no statistical effect on plaque levels. Access to professional dental care was inversely associated with periodontitis in the alcohol-dependent group (p < .05). Alcohol dependence may increase plaque levels above that seen in race, gender, age, and SES-matched controls, but professional dental care can limit the subsequent development of periodontal disease in these people.

Stress, NK cells, and cancer: Still a promissory note.

Although the last decades have provided ample evidence for deleterious effects of stress on immunity and on cancer development and suggested mediating mechanisms, no psychoneuroimmunology (PNI)-related intervention has become a standard of care in conventional cancer treatment. We believe the reasons for this include the unique nature of cancer evolvement and interactions with the immune system, and the many conceptual and technical obstacles to studying stress effects on immune activity and their implications for human resistance to malignancy. However, the numerous and diverse interactions between malignant tissue and immunocytes are now better understood, and suggestions can be made with respect to certain critical periods to be investigated in cancer-PNI research. Animal models of cancer progression are instrumental in suggesting neuroendocrine and immunological mediators of stress effects on specific aspects of cancer progression, especially with respect to the role of NK cell activity. The ultimate clinical relevance, however, must be tested in cancer patients. Recent animal studies suggest a role for the sympathetic nervous system in mediating biologically relevant stress effects on immunity and on tumor progression. Related interventions can now be tested in patients to support or refute the promise of such studies.

Facilitating discharge in state psychiatric institutions: a group intervention strategy.

Despite more than 30 years of deinstitutionalization, a significant number of individuals continue to experience prolonged stays in state psychiatric hospitals. Many of these individuals appear to develop an ambivalence or resistance to discharge. This can itself contribute to further delay in discharge planning and implementation. We will describe a group intervention for persons with long stays labeled as "resistant." This effort was guided by the premise that each individual could benefit from personally exploring those aspects of his or her experience that may be contributing to continued hospitalization. The group utilized standard methods of rehabilitation and training with strong emphasis on validating individual needs and feelings, peer support and practical results. After 1 1/2 years of group intervention, 5 of the 7 group members had achieved discharge and initial community success.

Best practices: An initiative to curtail the use of antipsychotic polypharmacy in a state psychiatric hospital.

A performance improvement initiative was undertaken at a state psychiatric hospital to reduce antipsychotic polypharmacy. Data from physicians' order forms were used to document the prescribing practices of 14 psychiatrists in November 2001 and in August 2002. After baseline data were collected, the chief of psychiatry met with each psychiatrist to compare his or her prescribing data with data of anonymous peers. The chief also asked all psychiatrists to decrease antipsychotic polypharmacy by at least 10 percent. Antipsychotic polypharmacy fell significantly--from 42 percent of patients treated with antipsychotics in November 2001 to 31 percent in August 2002. Higher utilizers of polypharmacy at baseline continued to be high utilizers at follow-up. Less antipsychotic polypharmacy was not associated with more use of other psychotropic medications. The findings suggest that initiatives that involve the focused attention of leadership and only a modest investment of effort can result in significant change in prescribing practices in a state hospital.

Major depression and immunity in alcohol-dependent persons.

UNLABELLED: Altered immunity has been associated with both alcoholism and major depression (MD). We investigated the contribution of MD, as well as alcoholism, to in vitro measures of immunity in inner-city alcohol-dependent (SCID-DSM-III-R) persons and community nonabusers, all otherwise in good health. METHODS: Alcohol-dependent persons at an ambulatory alcohol treatment center who did not abuse other substances were studied along with the comparison sample (total n=122). Enumerative and functional immune measures included leukocyte and lymphocyte subsets, mitogen response, natural killer cell activity (NKCA), and granulocytic phagocytosis. RESULTS: Controlling for alcohol dependence, age, gender, racial background, and medical status, MD was associated with decreased phytohemagglutinin (PHA) responses (p<.03), possibly decreased NKCA (p<.08), and increased circulating monocytes (p<.04). Controlling for MD, age, gender, racial background, and medical status, alcohol dependence was associated with decreased circulating B lymphocytes (p<.02), possibly decreased CD56+ (NK) cells (p<.06), and increased monocytes (p<.04). Responses to concanavalin A and pokeweed mitogen, granulocyte functions, and the composition of other leukocyte and lymphocyte subsets showed no evidence of being associated with MD or with alcoholism (p>.1). Secondary analyses exploring factors such as recent alcohol use, cigarette use, and nutrition suggested that these factors accounted for the altered lymphocyte subsets associated with alcoholism and the possibly decreased NKCA with MD. They did not account for the association of MD with increased monocytes and decreased PHA. DISCUSSION: MD-associated immune changes in alcoholics are modest and consistent with those seen in MD without alcoholism. Some MD- and many alcoholism-associated immune effects appear related to factors such as cigarette use and recent alcohol exposure.

Antipsychotic polypharmacy: is there evidence for its use?

Antipsychotic polypharmacy occurs frequently in clinical practice; however, there is a lack of controlled clinical studies testing the efficacy of the combinations used. The purpose of this literature review was to examine studies and other reports that have assessed the incremental benefits and deficits of combination antipsychotic therapy versus monotherapy. A PUBMED search covering a 26-year period from 1976 to 2002 was conducted. The search was limited to clinical trials, case series, and reports. Fifty-two reports were identified that systematically assessed the efficacy of combination therapy as opposed to monotherapy: 4 double-blind studies, 13 open-label clinical trials, and 35 case reports. Only one open-label trial and 2 case reports met the design criteria of having trials of each medication and the combination in the same patients and using some type of standardized assessment to evaluate outcome. The most frequent combination was clozapine-risperidone. Of the clinical trials, 75% (3/4) of the double-blind studies and 69% (9/13) of the open-label trials found that combination therapy was effective in reducing symptoms, while 37% (13/35) of case reports documented an overall positive outcome. Currently, the clinical practice of antipsychotic polypharmacy is not evidence-based; however, there is also no evidence against its use. Expanded systematic research to assess this clinical practice is needed.

Medical versus nonmedical mental health referral: clinical decision-making by telephone access center staff.

A database review investigated decisions of clinicians staffing a university-based telephone access center in referring new adult patients to nonpsychiatrists versus psychiatrists for initial ambulatory behavioral health care appointments. Systematically collected demographic and clinical data in a computer log of calls to highly trained care managers at the access center had limited predictive value with respect to their referral decisions. Furthermore, while 28% of the 610 study patients were initially referred to psychiatrists, billing data revealed that in-person therapists soon cross-referred at least 20% more to a psychiatrist. Care managers sent 56% of callers already taking psychotropic medications to nonpsychiatrists, 51% of whom were then cross-referred to psychiatrists. Predictive algorithms showed no potential to enhance efficiency of decisions about referral to a psychiatrist versus a nonpsychiatrist. Efforts to enhance such efficiency may not be cost-effective. It may be more fiscally efficient to assign less-experienced personnel as telephone care managers.

The influence of gingival margin recession on loss of clinical attachment in alcohol-dependent patients without medical disorders.

BACKGROUND: The objective of this study was to examine the effects of alcohol and cocaine misuse on periodontal status in a group of alcohol-dependent patients. METHODS: Forty verified alcoholics, either exclusively (n = 10) or with cocaine abuse (n = 30), and a matched comparison group of 25 non-alcoholic subjects, 14 of whom abused cocaine, were entered in the study. All subjects were free from systemic illnesses. Blood levels of gamma glutamyl transpeptidase (GGTP), a liver enzyme indicator of alcohol drinking, were determined. A comprehensive periodontal examination was performed on 6 sites per tooth. The gingival index (GI) and plaque index (PI) were recorded. Attachment levels (AL) were computed as probing depth (PD) plus gingival margin level (GM). RESULTS: No statistically significant differences were noted between the groups for average AL, PD, GM, GI, and PI. In alcoholics, Pearson correlation showed a positive association between GGTP levels and loss of periodontal attachment (P<0.05). A series of regression analyses predicting AL from selected periodontal and demographic factors showed that alcoholics manifest AL by greater increases in GM than non-alcoholics (P<0.07). Severe alcohol use as measured by GGTP >51 iu/l worsens PI (P<0.07), which adversely impacts GM, GI, PD, and ultimately AL. No significant associations were found between cocaine use and AL. CONCLUSIONS: The results suggest that persistent alcohol abuse increases periodontitis development by heightening the loss of attachment through recession of gingival margins.