Boarding of Mentally Ill Patients in Emergency Departments: American Psychiatric Association Resource Document.

The treatment of severe mental illness has undergone a paradigm shift over the last fifty years, away from a primary emphasis on hospital-based care and toward community-based care. Some of the forces driving this deinstitutionalization have been scientific and patient-centered, such as better differentiation between acute and subacute risk, innovations in outpatient and crisis care (assertive community treatment programs, dialectical behavioral therapy, treatment-oriented psychiatric emergency services), gradually improving psychopharmacology, and an increased appreciation of the negative effect of coercive hospitalization, except when risk is very high. On the other hand, some of the forces have been less focused on patient needs: budget-driven cuts in public hospital beds divorced from population-based need; managed care's profit-driven impact on private psychiatric hospitals and outpatient services; and purported patient-centered approaches promoting non-hospital care that may under-recognize that some extremely ill patients need years of painstaking effort to make a community transition. The result has been a reconfiguration of the country's mental health system that, at times, leaves large numbers of people without adequate mental health and substance abuse services. Often their only option is to seek care in medical emergency department's (ED's) that are not designed for their needs. Increasingly, many of those individuals end up waiting in ED's for appropriate care and disposition for hours or days. This overflow phenomenon has become so prevalent in ED's that it has been given a name: "boarding". This practice is almost certainly detrimental to patients and staff, and it has spawned efforts on multiple fronts to understand and resolve it. When considering solutions, both ED-focused and system-wide considerations must be explored. This resource document provides an overview and recommendations regarding this complex topic. Reprinted with permission from American Psychiatric Association. Copyright © 2019.

Trauma-Informed Care for Obstetric and Gynecologic Settings.

PURPOSE: Trauma is common among those seeking Ob-Gyn care and may have pervasive impact on obstetrical and gynecological health, social functioning, and healthcare engagement. While guidelines exist on the detection and treatment of perinatal mood and anxiety disorders within Ob-Gyn care, the role of Ob-gyn clinicians in identifying and addressing patients' traumatic experiences and related symptoms is less clearly delineated. This manuscript provides an overview of trauma-related symptoms in the context of Ob-Gyn care and practical guidance of clinicians aiming to improve their detection and response to trauma in their clinical practice. DESCRIPTION: Posttraumatic stress disorder (PTSD) describes a psychiatric illness which develops as a response to a traumatic event. Women who have experienced trauma are also at increased risk for borderline personality disorder and other psychiatric comorbidities. Postpartum PTSD has particular relevance to obstetrical care. ASSESSMENT: Screening for trauma in Ob-Gyn care can provide an opportunity to address risk and offer targeted intervention. Several brief evidence-based screening tools are available. Individuals who screen positive require assessment of immediate safety and targeted referrals. Trauma informed care describes an approach to healthcare aimed to enhance physical and emotional safety for patients and clinicians. CONCLUSION: Given the prevalence and the potentially devastating and enduring impact of trauma and trauma-related symptoms, there is a critical need to address trauma within Ob-Gyn care. By recognizing the signs of trauma and initiating or referring to appropriate treatments, Ob-Gyn clinicians have a unique opportunity to better understand their patients and to improve their care.

Trauma Informed Care in the Obstetric Setting and Role of the Perinatal Psychiatrist: A Comprehensive Review of the Literature.

BACKGROUND: Trauma is highly prevalent, and women are twice as likely as men to develop posttraumatic stress disorder following a traumatic exposure. Consequently, many women entering the perinatal period have trauma histories. In the perinatal period, a trauma history can negatively impact treatment engagement and adversely affect the experience of pregnancy, postpartum, and parenting. A trauma-informed care approach can mitigate these effects. OBJECTIVE: This review aims to summarize literature that can aid psychiatrists in (1) identifying signs and symptoms of trauma in perinatal women, (2) integrating elements of trauma-informed care into perinatal mental health care, and (3) offering interventions that can minimize adverse outcomes for perinatal women and their children. METHODS: A PubMed search was conducted with keywords including trauma, pregnancy, perinatal, posttraumatic stress disorder, postpartum posttraumatic stress disorder, and trauma informed care. RESULTS: Perinatal care, given its somewhat invasive nature, has the potential to traumatize or cause retraumatization. Trauma-related disorders are common and can present or worsen in the perinatal period. Trauma can manifest in multiple forms in this population, including exacerbation of preexisting posttraumatic stress disorder, new onset acute stress disorder in the perinatal period, or postpartum posttraumatic stress disorder secondary to traumatic childbirth. Unaddressed trauma can adversely affect the experience of pregnancy, postpartum, and parenting. Psychiatrists caring for women in the perinatal period are in an ideal position to screen for trauma and offer appropriate intervention. A trauma-informed approach to obstetric care can help clinical teams respond to the unique trauma-related challenges that can arise during obstetric care. Trauma-informed care, with its emphasis on establishing a culture of safety, transparency, trustworthiness, collaboration, and mutuality, can empower health care providers and systems with powerful tools to respond to trauma and its myriad effects in a strengths-based manner. By applying a trauma-informed lens, psychiatrists can help their obstetric colleagues provide patient-centered compassionate care and treatment. CONCLUSIONS: Applying a trauma-informed approach to evaluation and treatment of perinatal populations could decrease the toll trauma has on affected women and their children.

Telepsychiatry in Obstetrics.

Each year in the United States, approximately half a million reproductive-aged women are afflicted with major depression. Pregnant and postpartum women can be reluctant to openly disclose their suffering related to depression and other stigmatizing illnesses (eg, mood and anxiety disorders, posttraumatic stress disorder, and substance use disorders) and subsequently remain symptomatic with no relief. Maternal mortality related to these conditions is significant, with maternal suicide and overdose-related death peaking between 7 and 12 months postpartum. Geographic challenges in accessing perinatal mental health experts can be overcome through the use of telepsychiatry services using a secure video platform (telemedicine).

A Professional Development Course Improves Unprofessional Physician Behavior.

BACKGROUND: In 2008 The Joint Commission issued a Sentinel Event Alert that further defined "behaviors that undermine a culture of safety," stating that "intimidating and disruptive behaviors" can result in medical errors that affect patient care and safety. The American College of Physician Executives found that more than 95% of respondents encountered "disturbing . . . and potentially dangerous" behaviors on a regular basis. The purpose of this study is to evaluate the effectiveness of a professional development program on unprofessional physician behaviors using the B29™, a reliable and valid tool to assess workplace behaviors. METHODS: A pre-post study design was used to measure changes in physicians' unprofessional behaviors using the B29, a 35-item, Web-based survey. The survey is completed as a 360° assessment by peers, colleagues, administrators, and staff, and the physician completes a self-assessment. In most cases, the survey is voluntary. Those who completed both a precourse and a postcourse survey made up a convenience sample or subset of the larger number of physicians who completed the course. RESULTS: Twenty-four of 28 physicians in the study experienced an improvement in professional behavior, demonstrated as a decrease in the number of lowest-rated items. The mean decrease for all 28 physicians was 51.1%. Lowest-rated items improved an average of 53.5% overall. T-scores increased (also improved) for 24 of 28 physicians over the six-month period. CONCLUSION: Unprofessional behavior by physicians, as observed and reported by their peers and colleagues, can be positively modified by a relatively brief education program focused on teaching professionalism.

Boarding of Mentally Ill Patients in Emergency Departments: American Psychiatric Association Resource Document.

The treatment of severe mental illness has undergone a paradigm shift over the last 50 years, away from a primary emphasis on hospital-based care and toward community-based care. Some of the forces driving this deinstitutionalization have been scientific and patient-centered, such as better differentiation between acute and subacute risk, innovations in outpatient and crisis care (assertive community treatment programs, dialectical behavioral therapy, treatment-oriented psychiatric emergency services), gradually improving psychopharmacology, and an increased appreciation of the negative effect of coercive hospitalization, except when risk is very high. On the other hand, some of the forces have been less focused on patient needs: budget-driven cuts in public hospital beds divorced from population-based need; managed care's profit-driven impact on private psychiatric hospitals and outpatient services; and purported patient-centered approaches promoting non-hospital care that may under-recognize that some extremely ill patients need years of painstaking effort to make a community transition.The result has been a reconfiguration of the country's mental health system that, at times, leaves large numbers of people without adequate mental health and substance abuse services. Often their only option is to seek care in medical emergency departments (ED) that have not been designed for the needs of mentally ill patients. Increasingly, many of those individuals end up waiting in EDs for appropriate care and disposition for hours or days. This overflow phenomenon has become so prevalent that it has been given a name: "boarding." This practice is almost certainly detrimental to patients and staff, and it has spawned efforts on multiple fronts to understand and resolve it. When considering solutions, both ED-focused and systemwide considerations must be explored. This resource document provides an overview and recommendations regarding this complex topic.

Guidelines for the Management of Pregnant Women With Substance Use Disorders.

BACKGROUND: Women of reproductive potential with substance use disorders, especially those who are pregnant, present many clinical challenges to healthcare providers, including comorbid psychiatric disorders, a history of trauma and abuse, avoidance of or poor access to prenatal care, fear of legal consequences, and countertransference reactions. METHODS: In November 2013, members of the Women's Mental Health Special Interest Group of the Academy of Psychosomatic Medicine presented a Workshop reviewing substance abuse in pregnancy, highlighting the specific contributions that psychosomatic medicine specialists can make in the care of these patients. The discussion focused on epidemiology; maternal and fetal risks; and screening and treatment considerations for tobacco, alcohol, cannabis, opioids, benzodiazepines, stimulants, and several other substances. OBJECTIVE: Our purpose in publishing this review is to provide clinicians and educators with the most up-to-date summary in this field to better engage these patients in care and break the intergenerational cycle of abuse and addiction.

Transformative learning in a professional development course aimed at addressing disruptive physician behavior: a composite case study.

Disruptive physician behavior presents a challenge to the academic medical center. Such behaviors threaten the learning environment through increasing staff conflict, role modeling poor behaviors to trainees, and, ultimately, posing a risk to patient safety. Given that these physicians are often respected and valued for their clinical skills, many institutions struggle with how to best manage their behaviors. The authors present a composite case study of an academic physician referred to a professional development program for his disruptive behavior. They outline how transformative learning was applied to the development of concrete learning objectives, activities, and assessments for a curriculum aimed at promoting behavior change. Important themes include a safe group process in which the physician's assumptions are critically examined so that through experiential exercises and reflection, new roles, skills, and behaviors are learned, explored, and practiced. Timely feedback to the physician from the institution, colleagues, and administrators is critical to the physician's understanding of the impact of his or her behavior. Ultimately, the physician returns to practice demonstrating more professional behavior. Implications for medical education, prevention, and other professional development programs are discussed.

Psychiatrists for medically complex patients: bringing value at the physical health and mental health/substance-use disorder interface.

BACKGROUND: In their current configuration, traditional reactive consultation-liaison services see a small percentage of the general-hospital patients who could benefit from their care. These services are poorly reimbursed and bring limited value in terms of clinical improvement and reduction in health-service use. METHOD: The authors examine models of cross-disciplinary, integrated health services that have been shown to promote health and lower cost in medically-complex patients, those with complicated admixtures of physical, mental, social, and health-system difficulties. CONCLUSION: Psychiatrists who specialize in the treatment of medically-complex patients must now consider a transition from traditional consultation to proactive, value-added programs and bill for services from medical, rather than behavioral, insurance dollars, since the majority of health-enhancement and cost-savings from these programs occur in the medical sector. The authors provide the clinical and financial arguments for such program-creation and the steps that can be taken as psychiatrists for medically-complex patients move to the next generation of interdisciplinary service.

Our fallen peers: a mandate for change.

OBJECTIVE: The author identifies and seeks to remove barriers contributing to physician/medical students' decisions NOT to seek mental health care. METHODS: Following a cluster of medical student and physician suicides in one medical community, medical trainees anonymously shared their views regarding seeking mental health treatment in light of the current disclosure requirements for medical licensure. In an effort to identify medical licensure questions that more accurately assess for potential impairment--replacing the stigmatizing global inquiry about past mental health treatment--47 states' medical licensure questions available on the web were examined. Representatives from the state's psychiatric and medical societies joined efforts to formally request the State Medical Board to revise the licensure questions. RESULTS: The State Medical Board unanimously approved the recommended changes. CONCLUSION: Overcoming stigma within the medical profession regarding seeking psychiatric care is a difficult process requiring ongoing education of our colleagues. Physicians must have the opportunity to seek confidential mental health treatment at their earliest signs of distress in order to maximize their optimal functioning in an effort to prevent impairment.

Developing effective collaboration between primary care and mental health providers.

OBJECTIVE: Improving care for depressed primary care (PC) patients requires system-level interventions based on chronic illness management with collaboration among primary care providers (PCPs) and mental health providers (MHPs). We describe the development of an effective collaboration system for an ongoing multisite Department of Veterans Affairs (VA) study evaluating a multifaceted program to improve management of major depression in PC practices. METHOD: Translating Initiatives for Depression into Effective Solutions (TIDES) is a research project that helps VA facilities adopt depression care improvements for PC patients with depression. A regional telephone-based depression care management program used Depression Case Managers (DCMs) supervised by MHPs to assist PCPs with patient management. The Collaborative Care Workgroup (CWG) was created to facilitate collaboration between PCPs, MHPs, and DCMs. The CWG used a 3-phase process: (1) identify barriers to better depression treatment, (2) identify target problems and solutions, and (3) institutionalize ongoing problem detection and solution through new policies and procedures. RESULTS: The CWG overcame barriers that exist between PCPs and MHPs, leading to high rates of the following: patients with depression being followed by PCPs (82%), referred PC patients with depression keeping their appointments with MHPs (88%), and PC patients with depression receiving antidepressants (76%). The CWG helped sites implement site-specific protocols for addressing patients with suicidal ideation. CONCLUSION: By applying these steps in PC practices, collaboration between PCPs and MHPs has been improved and maintained. These steps offer a guide to improving collaborative care to manage depression or other chronic disorders within PC clinics.

Using relationship styles based on attachment theory to improve understanding of specialty choice in medicine.

BACKGROUND: Patient-provider relationships in primary care are characterized by greater continuity and depth than in non-primary care specialties. We hypothesized that relationship styles of medical students based on attachment theory are associated with specialty choice factors and that such factors will mediate the association between relationship style and ultimately matching in a primary care specialty. METHODS: We determined the relationship styles, demographic characteristics and resident specialty match of 106 fourth-year medical students. We assessed the associations between 1) relationship style and specialty choice factors; 2) specialty choice factors and specialty match, and 3) relationship style and specialty match. We also conducted mediation analyses to determine if factors examined in a specialty choice questionnaire mediate the association between relationship style and ultimately matching in a primary care specialty. RESULTS: Prevalence of attachment styles was similar to that found in the general population and other medical school settings with 59% of students rating themselves as having a secure relationship style. Patient centeredness was directly associated, and career rewards inversely associated with matching in a primary care specialty. Students with a self-reliant relationship style were significantly more likely to match in a non-primary care specialty as compared to students with secure relationship style (OR = 5.3, 95% CI 1.8, 15.6). There was full mediation of the association between relationship style and specialty match by the specialty choice factor characterized by patient centeredness. CONCLUSION: Assessing relationship styles based on attachment theory may be a potentially useful way to improve understanding and counsel medical students about specialty choice.

Voucher-based incentives for cigarette smoking reduction in a women's residential treatment program.

Participants were women (N = 16) living with their children in a residential substance abuse treatment facility. In this within-subjects repeated measures study, a 1-week baseline was followed by a 4-week intervention and a 2-week follow-up (same as the baseline). The intervention consisted of exposure to an educational video and a smoking cessation workbook, brief individual support meetings, and an escalating schedule of voucher-based reinforcement of abstinence. Throughout the study, three daily breath samples (8 a.m., noon, and 4 p.m.) were collected Monday through Friday to determine carbon monoxide (CO) concentration. In addition, urine cotinine (COT) was assessed on Monday mornings to monitor weekend tobacco use. Participants received vouchers of escalating value for CO-negative breath and COT-negative urine samples. Positive samples reset the voucher value. Significantly more negative tests were submitted during the intervention than during baseline and follow-up. The intensive behavioral intervention evaluated in this study produced a substantial reduction in cigarette smoking, and 25% of participants remained abstinent 2 weeks after the intervention was suspended. Nevertheless, the percentage of CO-negative samples submitted during the follow-up returned to baseline levels. While retaining many real-world characteristics, residential treatment facilities provide important opportunities for smoking cessation treatment and research.