Diagnosis of methamphetamine-induced psychotic disorder: Findings of an expert consensus panel.

AIM: We define criteria for methamphetamine-induced psychotic disorder (MIPD) to aid in accurate and reliable diagnosis. METHOD: An expert panel was recruited and engaged in an iterative consensus process. A literature search supported this work. The a priori level for consensus was considered ≥80% of voting panellists. RESULTS: The final expert panel included 22 physicians from different backgrounds and practice environments. The panel produced two consensus diagnoses: (1) acute MIPD and (2) persisting MIPD, which is further separated into subacute and chronic timeframes. Although certain characteristics differentiate methamphetamine-induced psychosis shortly after use, identification of persisting MIPD depends largely on a history of symptom onset. All respondents voted in the final round, and both criteria were fully endorsed by 91% (20/22) of respondents. Panellists further recommended next steps in validation and research on this topic. CONCLUSION: These diagnostic criteria aid clinicians in differentiating methamphetamine-induced psychotic symptoms from psychosis because of other psychiatric disorders and can guide future studies. Future research might examine these criteria's prognostic significance, interrater reliability and acceptability including among persons in recovery. This work is a necessary and vital step in advancing the science of methamphetamine addiction treatment.

Program Evaluation to Aid Choice of Aripiprazole or Risperidone for Hospitalized Adolescents with Cannabis Use Disorder and Psychosis.

Introduction: Co-occurring cannabis use and psychosis is an increasing problem. No single behavioral or pharmacologic treatment has emerged as clearly superior. To address the gap, this nonrandomized, quality improvement project compares outcomes for adolescents with co-occurring cannabis use disorder and psychosis prescribed risperidone or aripiprazole. Materials and Methods: This project is a retrospective chart review of 110 adolescents (ages 13-21 years) hospitalized for psychosis and co-occurring cannabis use disorder. The primary outcomes are length of stay and length of stay index. Results: Adolescents prescribed risperidone compared with aripiprazole had a significantly greater length of stay (9.7 days vs. 5.8 days, p = 0.002) and length of stay index (1.4 vs. 0.79, p = 0.004). Conclusions: Adolescents hospitalized for co-occurring psychosis and cannabis use disorder had a significantly longer length of stay and length of stay index. These data are consistent with a more rapid reduction in acute psychotic symptoms for aripiprazole compared with risperidone in the context of co-occurring cannabis use disorder.

Evaluation of the BEAT Meth Intervention for Emergency Department Patients with Methamphetamine Psychosis.

OBJECTIVES: Methamphetamine is the second leading cause of overdose death in America and a leading cause of emergency department (ED) visits. Methamphetamine-induced psychosis is a dangerous and difficult-to-treat consequence of methamphetamine use. We describe the pilot implementation and outcomes of a multimodal treatment intervention for ED patients with methamphetamine psychosis, Beginning Early and Assertive Treatment for Methamphetamine Psychosis (BEAT Meth). METHODS: BEAT Meth was implemented in an urban safety net health system. The protocol includes early identification and treatment of methamphetamine psychosis, a protocolized hospitalization, and support for transitioning patients to specialty addiction treatment. Patients receiving BEAT Meth were compared with ED patients with methamphetamine psychosis who were discharged. Implementation fidelity was measured to assess feasibility. RESULTS: BEAT Meth patients were nearly 3 times more likely to attend an outpatient specialty addiction appointment in the 30 days after discharge than comparison patients (32% vs 11%, P < 0.01). Subsequent ED utilization was common among all patients, and there was no significant difference in 30-day ED return rates between BEAT Meth and comparison patients (28% vs 37%, P = 0.10). Exploratory analyses suggested that increased attendance at outpatient treatment reduced ED utilization. CONCLUSIONS: BEAT Meth is an intervention framework to support identification, management, and treatment engagement of ED patients with methamphetamine psychosis. Treatment strategies like BEAT Meth are necessary to manage the unique challenges of methamphetamine addiction. These findings will guide clinical care, program development, and research.

Improving Patient Flow and Access to Care at an Academically Affiliated Urban Safety-Net Hospital.

Access to inpatient psychiatric beds remains a significant barrier to care for patients having a mental health crisis. A quality improvement initiative described here was designed to increase access to care by increasing efficiency of health care delivery on an adult and adolescent inpatient psychiatric unit. Design and implementation centered on collaborative relationships among hospital administration, physician leadership, frontline physicians, and members of the multidisciplinary treatment team. Initial 5 months of data indicated significant improvements in care access as measured by number of encounters on both units. Reductions in length of stay were made possible by optimizing internal work flows and standardizing goals of hospitalization.

Agreement between a single, self-defined burnout item and the ProQOL burnout subscale for behavioural health staff.

Burnout in the field of behavioural health care is widespread. Occupational burnout can negatively impact providers' well-being and patient care, as well as lead to substantial fiscal cost to healthcare institutions. The objective of this quality improvement project was to develop a single-item survey to rapidly assess individual burnout and workforce well-being among behavioural health staff in our urban, safety-net hospital. We examined the degree of agreement between a single, self-defined burnout item from the Mini-Z and the ProQOL burnout subscale among one hundred and thirty-five nurses, behavioural technicians and administrative staff. Our findings indicate that ProQOL and Mini-Z have a low-to-moderate correlation at a baseline (k = 0.52, 95% CI 0.26, 0.69). However, using a modified ProQOL cut-off score with a binary classification of both surveys yields a moderate-to-high agreement (K = 0.67, 95% CI 0.54, 0.80). To our knowledge, this is the first published comparison of the Mini-Z with the ProQOL instrument. The project adheres to the Standards for Quality Improvement Reporting Excellence (SQUIRE) 2.0 reporting guidelines for quality improvement (Ogrinc et al., 2016). A single, validated question measuring burnout allows for more rapid assessment and the maximization of response rates, both of which are important steps in evaluating the level of burnout of the collective whole.

Management of Alcohol Withdrawal in the Emergency Department: Current Perspectives.

Alcohol withdrawal syndrome (AWS) is a common, heterogenous, and life-threatening complication of alcohol use disorder (AUD). AUD is a leading cause of worldwide mortality, and many patients with AUD will develop AWS during their ED course. This review summarizes the epidemiology, pathology, and management of AWS and AUD in the emergency setting. The time course of AWS and its impact on ED treatment is emphasized. Once AWS is diagnosed, symptom-triggered benzodiazepine administration remains the most commonly provided treatment but may not be appropriate for patients with significant medical or psychiatric comorbidity or pending discharge. In these cases, ED clinicians may consider short courses of barbiturates or alternative regimens based on novel anticonvulsants. Specific treatment protocols are enumerated for clinical practice. Finally, emergency providers must not only manage acute patients' AWS but also lay the foundation for successful treatment of AUD. An approach to the disposition of the patient with AUD is presented. The authors examine shortcomings in the extant literature and suggest opportunities for further study.