An Observational Study of Proactive and On-Request Psychiatry Consultation Services: Evidence for Differing Roles and Outcomes.

BACKGROUND: Proactive psychiatric consultation services rapidly identify and assess medical inpatients in need of psychiatric care. In addition to more rapid contact, proactive services may reduce the length of stay and improve staff satisfaction. However, in some settings, it is impractical to integrate a proactive consultation service into every hospital unit; on-request and proactive services are likely to coexist in the future. Prior research has focused on changes in outcomes with the implementation of proactive services. OBJECTIVE AND METHODS: This report describes differences between contemporary proactive and on-request services within the same academic medical center, comparing demographic and clinical data collected retrospectively from a 4-year period from the electronic medical record. RESULTS: The proactive service saw patients over four times as many initial admissions (7592 vs. 1762), but transitions and handoffs between services were common, with 434 admissions involving both services, comprising nearly 20% of the on-request service's total contacts. The proactive service admissions had a shorter length of stay and a faster time to first psychiatric contact, and the patients seen were more likely to be female, of Black race, and to be publicly insured. There were over three times as many admissions to psychiatry from the proactive service. The on-request service's admissions had a longer length of stay, were much more likely to involve intensive care unit services, surgical services, and transfers among units, and the patients seen were more likely to die in the hospital or to be discharged to subacute rehabilitation. CONCLUSIONS: Overall, the results suggest that the two services fulfill complementary roles, with the proactive service's rapid screening and contact providing care to a high volume of patients who might otherwise be unidentified and underserved. Simultaneously, the on-request service's ability to manage patients in response to consult requests over a much larger area of the hospital provided important support and continuity for patients with complex health needs. Institutions revising their consultation services will likely need to consider the best balance of these differing functions to address perceived demand for services.

Role Distinctions and Role Overlap Among Behavioral Health Providers.

Integrated behavioral health care (IBHC) models are a growing trend for health care delivery, particularly in the primary setting. Clinicians working within IBHC contexts provide a spectrum of behavioral health services, including screening, prevention and health promotion, assessment, and treatment services. Integration of behavioral health providers into primary and specialty medical settings addresses the significant need for behavioral health services, improves care quality, improves patient experience, and reduces costs of care, access issues, and delays in service provision. While benefits are clear, what type of model to implement and which behavioral health care providers to include in that model remain elusive. This is partly due to the failure of IBHC models to include all behavioral health providers in their design, a lack of clarity of the expertise of each provider, and how providers work together. IBHC models are also complicated by contextual issues such as the relative availability of each profession, population health needs in different clinic populations, and financial factors. The purpose of this manuscript is to the clarify roles and responsibilities of different behavioral health professions including similarities and differences in their training, areas of unique expertise (role distinctions), shared responsibilities (role overlap), and relative cost and availability in the United States.

Differences in Demographic and Clinical Characteristics of Patients With Depressive vs. Manic First Episode of Bipolar Disorder.

Background: Bipolar disorder is a serious mental disease marked by episodes of depression, mania, hypomania, or mixed states. Patients with bipolar disorder may present with different symptoms at first onset. The aim of this study is to compare demographic and clinical variables based on a patient's first episode of bipolar disorder, including risk of recurrence over a 2-year period. Methods: A large cohort (N = 742) of patients with bipolar disorder in China was analyzed. Patients were divided into two groups according to their first episode of bipolar disorder, either depression or mania. Patients in mixed state first episode were classified based on predominant symptoms. Three hundred eighteen patients of the cohort had a first episode of mania and 424 patients had initial symptoms of depression. Demographic and clinical data were collected. All patients were followed up for 24 months. Data on compliance with follow-up appointments and recurrence of symptoms after 6, 12, 18, and 24 months were collected. Clinical characteristics (course of disease, age of onset, psychiatric family history, etc.) were compared between the mania group and depression groups. Results: More patients with bipolar disorder had a first episode of depression than mania (57.14 vs. 42.86%). Compared with the depression group, the mania group had later age of diagnosis of bipolar disorder [(38.64 ± 13.50) vs. (36.34 ± 14.94), P = 0.028], lower education level [(9.37 ± 4.34) vs. (10.17 ± 4.81), P = 0.017] and longer latency between an initial episode of psychiatric symptoms and formal bipolar diagnosis [(10.80 ± 10.76) vs. (8.85 ± 9.90), P = 0.012]. More patients in the mania group were male and without psychotic symptoms (all P < 0.05). In comparison with the mania group, more patients in the depression group were female, with higher frequency of a reported precipitating event before first mood episode (all P < 0.05). Compared with the depression group, the mania group had more recurrences of illness at the end of 12 months (Z =-2.156, P = 0.031), 18 months (Z =-2.192, P = 0.028), and 24 months (Z = -2.364, P = 0.018). Conclusions: In our study, there are a number of differences in demographic and clinical characteristics of patients with different onset syndromes of bipolar disorder. These differences include gender, education level, diagnosis age, the rate of recurrences, and others. These data of a cohort of Chinese patients add to the growing international literature on the relationship between index episode of bipolar disorder and clinical variables and outcomes. These results and further study may allow clinicians to offer patients and families more reliable prognostic information at the onset of disease.

An evaluation of proactive psychiatric consults on general medical units.

OBJECTIVE: Recent studies have shown an association between proactive psychiatric consultation on medical units and shorter length of stay. The aim of this study was to assess the impact of implementing a proactive psychiatric consult service on general medical units in an urban teaching hospital on length of stay and qualitative measurement of satisfaction of adequacy of psychiatric services. METHODS: Bivariate and multivariate analyses of demographic, clinical and outcome data were performed comparing patients seen by the proactive psychiatric consult team, patients seen contemporaneously on other general medical units by a traditional, reactive consult team and patients seen the prior year on the proactive intervention units by the reactive consult team. Length of stay was the primary outcome examined. Regression modeling was performed to assess further the relationship of length of stay with the three groups. Nursing and physician staff were queried before and after intervention regarding satisfaction with psychiatric resources on the intervention units. RESULTS: Patients seen by the proactive team had shorter length of stay than those seen by contemporaneous reactive consult team (p = 0.005) or the prior year by the reactive team on the intervention units (p = 0.005). There was no significant difference between the latter two groups. Time to consult was also shorter for patients seen through the proactive model than the reactive model on other units at the same time (0.01) or the preceding year (<0.001). Nursing and physician satisfaction with psychiatric help increased significantly in three of four measures. CONCLUSIONS: Proactive psychiatric consultation in our study correlated with shorter time to consult, shorter length of stay, and improved staff satisfaction compared to a reactive consult model.

Lung cancer incidence in patients with schizophrenia: meta-analysis.

BACKGROUND: Lung cancer risk factors, like tobacco smoking, are highly prevalent in patients with schizophrenia. Whether these patients have a higher risk of lung cancer remains unknown. AIMS: We aimed to investigate whether patients with schizophrenia have a higher incidence of lung cancer compared with general population, in a meta-analysis. METHOD: Eligible studies were searched from PubMed and EMBASE databases to identify cases of lung cancer in patients with schizophrenia and the general population. This meta-analysis utilised the random-effects model and prediction interval was used to calculate the heterogeneity of these eligible studies. We assessed the quality of evidence with the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. RESULTS: There were 12 studies, totalling 496 265 patients, included in this meta-analysis. The data showed that the baseline schizophrenia diagnosis was not associated with any changes in lung cancer incidence in the overall population, with a standardised incidence ratio of 1.11 (95% CI 0.90-1.37; P = 0.31), although there was a significant heterogeneity among these studies (I2 = 94%). Moreover, there was also a substantial between-study variance with wide prediction interval values (0.47-2.64). The data were consistent for both males and females. CONCLUSIONS: Up-to-date evidence from epidemiological studies indicates the lack of certainty about the association between schizophrenia diagnosis and lung cancer incidence.

Association of Schizophrenia With the Risk of Breast Cancer Incidence: A Meta-analysis.

Importance: Patients with schizophrenia are considered to have many risk factors for the development of cancer. However, the incidence of breast cancer in women with schizophrenia compared with the general population remains uncertain. Objective: To perform an updated meta-analysis to evaluate the association between schizophrenia and the risk of breast cancer. Data Sources: A systematic search of the PubMed and EMBASE databases was conducted using the search terms schizophrenia, schizophrenic, psychosis, combined with breast and cancer, tumor, neoplasm, or carcinoma. The final literature search was performed on August 15, 2017. Study Selection: Cohort studies reporting the standardized incidence ratio (SIR) for the risk of breast cancer in women with schizophrenia compared with the general population. Data Extraction and Synthesis: The meta-analysis adhered to Meta-analysis of Observational Studies in Epidemiology and the Cochrane Handbook for Systematic Reviews of Interventions. Data extraction was performed independently. A random-effects model was used to pool the results, and a recently proposed prediction interval was calculated to describe the heterogeneity. Main Outcomes and Measures: The SIR for the risk of breast cancer in women with schizophrenia compared with the general population or those without schizophrenia. Results: Twelve cohorts including 125 760 women were included in this meta-analysis. The results of the meta-analysis showed that schizophrenia was associated with a significantly increased risk of breast cancer incidence in women (SIR, 1.31; 95% CI, 1.14-1.50; P < .001), with significant heterogeneity (P < .001; I2 = 89%). Substantial between-study variance was also suggested by the wide prediction interval (0.81-2.10), which indicated that it is possible that a future study will show a decreased breast cancer risk in women with schizophrenia compared with the general population. The subgroup analysis results showed that the association was not significantly affected by whether breast cancer cases were excluded at baseline or the sample size of the included studies. Conclusions and Relevance: The incidence of breast cancer in women with schizophrenia is higher than that of the general female population. However, significant heterogeneity exists among the included studies. Women with schizophrenia deserve intensive prevention and treatment of breast cancer.

Urban-Rural Differences in Suicide in the State of Maryland: The Role of Firearms.

OBJECTIVES: To assess whether the use of firearms explains rural-urban differences in suicide rates. METHODS: We performed a retrospective analysis on all 6196 well-characterized adult suicides in Maryland from 2003 through 2015. We computed rate ratios by using census data and then stratified by sex, with adjustment for age and race. RESULTS: Suicide rates were higher in rural compared with urban counties. However, the higher rural suicide rates were limited to firearm suicides (incident rate ratio [IRR] = 1.66; 95% confidence interval [CI] = 1.20, 2.31). Nonfirearm suicide rates were not significantly higher in rural settings. Furthermore, 89% of firearm suicides occurred in men and the higher rural firearm suicide rate was limited to men (IRR = 1.36; 95% CI = 1.09, 1.69). Women were significantly less likely to complete suicide in rural areas (IRR = 0.63; 95% CI = 0.43, 0.94), regardless of method. CONCLUSIONS: Male firearm use drives the increased rate of suicide in rural areas. The opposite associations between urbanicity and suicide in men and women may be driven by the male preference for firearms as a method for committing suicide.

The Milieu Manager: A Nursing Staffing Strategy to Reduce Observer Use in the Acute Psychiatric Inpatient Setting.

BACKGROUND: Rising acuity levels in inpatient settings have led to growing reliance on observers and increased the cost of care. OBJECTIVES: Minimizing use of observers, maintaining quality and safety of care, and improving bed access, without increasing cost. DESIGN: Nursing staff on two inpatient psychiatric units at an academic medical center pilot-tested the use of a "milieu manager" to address rising patient acuity and growing reliance on observers. Nursing cost, occupancy, discharge volume, unit closures, observer expense, and incremental nursing costs were tracked. Staff satisfaction and reported patient behavioral/safety events were assessed. RESULTS: The pilot initiatives ran for 8 months. Unit/bed closures fell to zero on both units. Occupancy, patient days, and discharges increased. Incremental nursing cost was offset by reduction in observer expense and by revenue from increases in occupancy and patient days. Staff work satisfaction improved and measures of patient safety were unchanged. CONCLUSIONS: The intervention was effective in reducing observation expense and improved occupancy and patient days while maintaining patient safety, representing a cost-effective and safe approach for management of acuity on inpatient psychiatric units.

Psychiatry and the meaningful use of electronic health records.

Use of electronic health records (EHRs) for psychiatric care is on the rise, although the software and the workflow patterns on which the software has been built are often based on non-psychiatric practices. For providers, the transition from paper psychiatric records to electronic ones requires the development of a new set of skills that includes accommodating the physical presence of the computer and performing various forms of data entry, while still managing to carry out the tasks required for psychiatric practice. These changes alter the dynamic of communication, including elements of assessment and treatment that occur between the psychiatrist and patient. EHRs also raise issues of security of records and greater access by patients to providers and their records. Although EHRs promise an abundance of useful data for research and potentially helpful innovations, they also impose a practice pattern on psychiatry that is made to work largely through the efforts of the physician. EHRs do not enhance interactions in the psychiatric examination room, but instead alter the traditional pattern on which the doctor-patient relationship is founded in psychiatry and through which care is delivered.

The Intensive Treatment Unit: A brief inpatient detoxification facility demonstrating good postdetoxification treatment entry.

Inpatient detoxification is frequently used to treat substance use disorders, despite consistent findings that drug use soon after detoxification is the norm. A number of lines of evidence suggest the most rational means of improving outcomes after detoxification is to improve postdetoxification treatment entry. This report presents outcomes from the Intensive Treatment Unit (ITU), a brief inpatient detoxification unit in Baltimore, MD, found to have good postdischarge treatment entry outcomes. The patients followed were predominantly male African Americans in early middle age who were sequentially admitted to the unit (N = 134) and demonstrated severe social disruption and psychiatric comorbidity. More than 80% of the patients discharged from the ITU were admitted to treatment postdetoxification, with most going to long-term residential settings or recovery houses. Success was associated with seeking residential treatment, and failure was concentrated among the minority discharged with no plan for aftercare and those seeking outpatient treatments. The report explores patient and process factors associated with these outcomes and discusses the possibility that the ITU may be a model system for improving outcomes postdetoxification.

Content of advance directives for individuals with advanced dementia.

OBJECTIVE: To examine how people with end-stage dementia have conveyed their wishes for end-of-life care in advance directives. METHOD: The documents of 123 residents of three Maryland nursing homes, all with end-stage dementia, were reviewed. RESULTS: More years of education and White race were significantly associated with having an advance directive. With the exceptions of comfort care and pain treatment, advance directives were used primarily to restrict, not request, many forms of care at the end of life. Decisions about care for end-stage conditions such as Alzheimer's dementia are less often addressed in these documents than for terminal conditions and persistent vegetative state. DISCUSSION: For advance directives to better reflect a person's wishes, discussions with individuals and families about advance directives should include a range of care issues in the settings of terminal illness, persistent vegetative state or end-stage illness. These documents should be reviewed periodically to make certain that they convey accurately the person's treatment preferences.