Does Cocaine Use Increase Medication Noncompliance in Bipolar Disorders? A United States Nationwide Inpatient Cross-Sectional Study.

Introduction Medication noncompliance among bipolar disorder (BD) is often linked with comorbid substance use disorders. This study aims to investigate cocaine use (CU) association with medication noncompliance in hospitalized BD patients. Methods Using data on 266,303 BD hospitalizations between 2010-2014 from the US Nationwide Inpatient Sample database, we obtained medication noncompliance rates stratified by demographics and cocaine use. Logistic regression was used to evaluate factors associated with medication noncompliance. Results Overall mean age, the prevalence of CU, and medication noncompliance were 41.58 (+0.11) years, 8.34%, and 16.08%, respectively. More than half of BD patients with comorbid CU were between 40-64 years (54.4%), while more male patients with BD were in the CU group (53.9%). With univariable logistic regression, CU (odds ratio [OR]: 1.77, 95% CI: 1.66-1.88) increased the odds of medication noncompliance among BD patients, and after adjusting for other variables there was sustained increased odds (adjusted odds ratio [aOR]: 1.40, 95% CI: 1.32-1.50). Conclusion This study showed that CU is associated with medication noncompliance among hospitalized BD patients. This highlights the importance of addressing CU among BD patients. Given the possible association of CU with medication noncompliance among BD patients, collaborative work between general adult psychiatry and addiction services is imperative in improving the management outcome of BD patients with comorbid CU.

The Use of Clozapine in the Serious Mental Illness Patients Enrolled in an Assertive Community Treatment Program.

Introduction Health care cost is projected to reach 20% of the nation's gross national product (GNP) by 2016. 6.2% of this is from mental health. The National Institute of Mental Health (NIMH) estimates the prevalence of serious mental illness (SMI) at 13.1 million or 5.2% of American adults age 18 or over. Hence, mental health care cost for this patient population is significant. Patients with SMI involved in an Assertive Community Treatment (ACT) program are individuals who experience the most intractable symptoms and the greatest level of dysfunction from their mental illness. These individuals typically are institutionalized in a long-term facility such as the state hospital. Clozapine has shown superior efficacy over first- and most second-generation antipsychotics in both treating treatment-resistant and non-treatment-resistant schizophrenia which has been supported by several large trials. There is also evidence of its efficacy in suicidality, aggression and substance misuse. In fact, clozapine has been approved by the FDA for use in refractory schizophrenia and suicidality in schizoaffective disorder. Due to the risk of agranulocytosis, clozapine is underutilized. The purpose of this study is to conduct a retrospective cohort study through chart review to analyze whether the addition of clozapine to ACT treatment of SMI patients in a community hospital from 2008 to 2018 led to decreased frequency of hospitalizations and increased clinical stability. Materials and methods A retrospective study using electronic medical record (EMR) of patients ages 20 and above who were enrolled in the ACT program at a community hospital from December 1, 2008 to December 31, 2018. Variables were collected from the EMR and de-identified during data collation. Analysis was performed using SPSS software package. Results A total of 179 patients enrolled in the ACT program and their data was extracted from the EMR. Twenty-five (62.5%) of these patient enrollments were on clozapine. They were made up of 53.6% male, 81.9% White/Asian, 18.1% Black; 44.1% ages between 36 to 50 years old, 30.2% were aged 18 to 35 years old, and 25.7% greater than 50 years old. There was no difference in age, sex, race, ethnicity, and insurance type in ACT program between those using clozapine and those not on clozapine. There was a higher proportion of psychiatric hospitalizations among clozapine users compared with the non-clozapine user group (62.5% vs 41.5%, p = 0.019). However, the two groups did not differ from one another in terms of psychiatric emergency visits (p = 0.128) or frequency of ACT visits (p = 0.002). Conclusion Effective treatment that will reduce hospitalizations and the burden of chronic disability in patients with SMI would greatly reduce mental health care cost. Clozapine remains the gold standard in the treatment of refractory schizophrenia. But due to the risk of agranulocytosis, clozapine is underutilized. It was hoped that this study will support the use of clozapine in SMI patients. Disappointingly, the use of clozapine did not prevent relapses and hospitalizations in this patient population and patients on clozapine seemed to have increased hospitalizations, compared to those who were not on clozapine. Perhaps, a different outcome would have occurred if the focus was limited to the patients themselves who were on Clozapine and ascertain what the rate of hospitalization was before the start of clozapine vs after the use of clozapine.

The Use of Long-Acting Injectable Antipsychotics (LAI) in the Serious Mental Illness (SMI) Patients Enrolled in an Assertive Community Treatment (ACT) Program.

Introduction Patients with serious mental illness (SMI) experience highly intractable symptoms and great levels of dysfunction from their mental illness. Relapse prevention is critical as psychopathology, social and occupational functioning worsen with repeated psychotic episodes. Poor medication adherence is a strong predictor of relapse. Use of long-acting injectable antipsychotics (LAI) is among the most effective treatment specially in the context of non-adherence and yet remains underutilized. This single center retrospective study conducted using the electronic medical record (EMR) of patients enrolled in an Assertive Community Treatment (ACT) program at a community hospital was analyzed as to whether use of LAI among these patients reduce the frequency of emergency room visits and hospitalizations. Materials and methods Single center retrospective study using EMR of patients ages 20 and above who were enrolled at the ACT program at a community hospital from December 1, 2008 to December 31, 2018. Variables were collected from the EMR and de-identified into an Excel spreadsheet for data collation. Analysis was performed using SPSS software package. Results A total of 179 patients enrolled in the ACT program and their hospitalizations were extracted from the EMR. Seventy-six (42.5%) of these hospitalizations had patients on LAI. The hospitalizations were made up of 53.6% male, 81.9% White/Asian, 18.1% Black; 44.1% ages between 36 and 50 years old, 30.2% ages between 18 and 35 years old, and 25.7% greater than 50 years old. There was no difference in age, sex, race, ethnicity, insurance type and time spent in ACT program between those using LAI and those not on LAI. There was a higher proportion of psychiatric hospitalizations among LAI users compared with the non-LAI user group (57.9% vs 37.4%, p = 0.007). However, the two groups did not differ from one another in terms of psychiatric emergency visits (p = 0.266) or frequency of ACT visits (p = 0.062). Conclusion To date, all of the new-generation antipsychotic LAI have demonstrated a statistically and clinically significant decrease of relapse rates over placebo. Despite this, LAIs are not widely prescribed for a variety of reasons, including the reservations of patients, clinicians and payers. It would seem, though, that our patient population at the ACT program do not seem to benefit from use of LAI in relapse prevention. These results are counterintuitive in that one would expect that patients with serious mental illness would benefit from use of LAI. Perhaps, individuals with SMI are a different subset of population and they do not respond as well to LAI.

A Retrospective Review of the Clinical Significance of the Outcome Questionnaire (OQ) Measure in Patients at a Psychiatric Adult Partial Hospital Program.

Introduction Outcome Questionnaire (OQ) measure is becoming a more popular assessment tool for monitoring treatment progress in psychiatry at different settings including inpatient and outpatient settings. It can also be used in non-clinical populations. However, little is known about the evaluation of this tool in the Adult Partial Hospital Program (PHP). Methods We conducted a study among patients in an Adult PHP where we extracted data from the OQ analysis program recorded for patients from January 1, 2015 to July 31st, 2020. Results We studied a total of 742 patients among which 509 (68.4%) were males. The mean age was 38.58 ± 14.86 years. Most of the patients had depressive disorder (56.9%). The mean numbers of days on admission were 17.37 ± 25.29 days. There is a consistent decrease in the total score average OQ score from initial to final measure with the year 2019 being 31.99 followed by 2017 (30.05) then 2020 (29.56) then 2015/2016 (28.38) and 2018 (27.27) p < 0.001. Also, for treatment progress it was observed that in years 2015/2016, there was significant improvement in 71.67% of the patients; in 2017, there was significant improvement in 78.53% of the patients; in 2018, there was significant improvement in 77.71% of the patients; while in 2019, there was significant improvement in 76.05% of the patients, and in 2020, there was significant improvement in 70.18% of the patients. Conclusion The direct benefit of the OQ measure to patients is to provide objective measurements of assessing clinical improvement or deterioration in the treatment progress of their clinical condition. Our study has proved that this is a useful tool to assess such in the Adult PHP.

Deep Venous Thrombosis in a 62-Year-Old Female With Schizoaffective Disorder Who Developed COVID-19.

COVID-19 pandemic cases first started in November 2019 in Wuhan, China. However, the origins of the virus remain uncertain. Information and clinical complications of the disease, as well as treatment, continue to evolve in real-time. The latest complication of thrombolytic events of COVID-19 was thrust into the spotlight following the Associated Press report of Broadway star Nick Cordero having to undergo leg amputation for deep venous thrombosis (DVT) in April 2020 and eventually succumbing to the infection. DVT is a subset of venous thromboembolism and is a preventable cause of morbidity and mortality. Here, we describe a woman with serious mental illness developing COVID-19 and DVT complications.

Seasonal Trends in Hospitalization of Attempted Suicide and Self-Inflicted Injury in United States Adults.

Introduction  Suicide is the 10th leading cause of death in the United States (US) and the prevalence continues to increase. It is estimated that there is an average of 25 attempted suicides for every suicide death in the US, and the economic burden of suicide and attempted suicide is high. Identification of those at risk for suicide and attempted suicide can help with early and prompt intervention. Studies in Europe and Asia have shown that there is a relationship between seasonal patterns and suicidal risk. However, little is known about seasonal patterns of suicidal attempts in the US. Therefore, our study aimed to assess seasonal patterns by days of the week and months of the year in the US. Methods Hospitalized adult patients with suicide attempts and self-inflicted injury were identified using the discharge data from the National Inpatient Sample (NIS) from January 1, 2010 to December 31, 2014. We looked at the seasonal trends of patients with attempted suicide and self-inflicted injury by weekday vs weekend and month of the year over the five-year study period. We also assessed two groups, male and female with attempted suicide and compared trends and contributing risk factors over the study period using Student's t-test and chi-square test. Results A total of 249,845 patients with attempted suicide and self-inflicted injury were reported during the study period with a prevalence rate increase of 15%, among which 70% were males, 65.5% white and 38.8% were age 40-64 years. An overall prevalence rate of about 168-200 per 100,000 hospitalizations was reported. There was a higher admission rate on weekends as compared to weekdays (190-300 vs 150-178 per 100,000 hospitalizations). Attempted suicide and self-inflicted injury admissions peaked during the months of July and August with a peak period range of 200-230 per 100,000 hospitalizations in a year. Conclusion The prevalence of attempted suicide is steadily rising. Awareness of the seasonal and epidemiological trends of attempted suicide and self-inflicted injury is a very important step towards developing effective strategies to prevent suicide and attempted suicide.

Trends of Opioid Use Disorder and Associated Factors in Hospitalized Patients With Arthritis.

Introduction Opioid use was primarily limited to acute pain, postsurgical care, and end of life care setting but now is the most prescribed medication for chronic pain. Arthritis is a chronic disease associated with chronic pain. Given limited options for pain relief in the patient population, these patients are often prescribed opioids and are at increased risk of opioid use disorder (OUD). Therefore, our study aimed to identify factors associated with OUD in patients with arthritis. Methods We analyzed hospitalized adult patients with arthritis with and without OUD using discharge data from National Inpatient Sample (NIS) over five years from January 1, 2010, to December 31, 2014. We looked at trends of OUD in hospitalized patients with arthritis and compared demographic and clinical characteristics of patients with and without OUD using Student's t-test and chi-square test. Multivariate analysis was also used to adjust for variables. Results A total of 21,396,252 arthritis hospitalizations were identified during the five-year study period among which 227,608 had OUD. The prevalence of OUD in arthritis hospitalization increased over the five-year period by 43%. After adjusting for other variables, mental health (OR 2.50 (2.43-2.58)), and substance use (OR 6.39 (6.14-6.66)) disorders were associated with increased odds of OUD. Conclusion The prevalence of OUD among patients with arthritis increased over the five-year study period. Mental health and substance use disorders were associated with increased odds of OUD. More studies are needed to explore alternative pain management options for arthritis patients particularly in those with mental health and substance use disorders.

Predictors and Outcomes of Invasive Mechanical Ventilation in Opioid Overdose Hospitalization in the United States.

Introduction  Opioid overdose is increasingly becoming common and so is the need for invasive mechanical ventilation (IMV) for opioid overdose admissions in hospitalized patients. Respiratory failure requiring invasive mechanical ventilation is the most common reason for the admission of opioid-associated overdose patients. The aim of our study was to assess the demographic and clinical characteristics associated with the increased need for IMV in hospitalized opioid overdose patients. Methods  We analyzed all adult admissions (18 years and above) using the National Inpatient Sample (NIS) database for five years from January 1, 2010-December 31, 2014 to identify opioid overdose patients requiring invasive mechanical ventilation. We compared the demographic and clinical characteristics of opioid overdose patients requiring and not requiring mechanical ventilator support and performed univariate and multivariate analyses to determine the odds ratio (OR) of association. Results A total of 2,528,751 opioid overdose patients were identified among which 6.4% required IMV during hospitalization. The prevalence of opioid overdose and the need for IMV increased by 31% and 38%, respectively, over the study period. Multivariate logistic regression (OR (95% CI), p<0.001) determined the following to be associated with increased odds of mechanical ventilator use: (OR 1.12 (1.06-1.19)) among patients aged 25-39 years vs (1.36 (1.28-1.44)) for the age group 40-64 years when compared to 18-24 years; hospital locations in the south US region (OR 1.62 (1.49-1.75)) when compared to the northeast US region; the presence of aspiration pneumonia (OR 14.30 (13.63-15.0)), rhabdomyolysis (3.22 (3.04-3.42)), septic shock (9.15 (8.41-9.97)), and anoxic brain injury (15.5 (13.70-17.50)). Other factors associated with decreased odds of IMV include hepatitis C virus infection (OR 0.75 (0.72-0.79)) and black race (OR 0.68 (0.63-0.74)]. Opioid overdose patients requiring IMV had a higher length of stay by 8.9 ± 0.1 days, higher hospitalization cost by US$ 28,117.81 ± 373.53, and higher in-hospital mortality rate (13.4% vs 0.3%). Conclusion The prevalence of opioid overdose and the need for IMV increased over the five-year study period, reflecting an increase in the relatively high in-hospital mortality of opioid overdose patients on IMV. Patient's age, geographic location, race, and several comorbidities affect the need for invasive mechanical ventilation in hospitalized opioid overdose patients. These findings emphasize the need for a better understanding of these risk factors in creating a strategic approach for hospital care of opioid overdose patients.

Use of Valbenazine in a 54-Year-Old Female with Severe Tardive Dyskinesia.

Tardive dyskinesia (TD) is a serious and often irreversible involuntary muscle movement that involves the face, lips, tongue, trunk, and extremities. TD is a risk in the use of antipsychotic medications, whether it is typical or first generation or atypical or second-generation antipsychotic. The risk is highest in patients receiving long-term antipsychotic treatment. Before the availability of valbenazine, clozapine was used to reverse or at least ameliorate TD. We report a case of a patient on long-term antipsychotic treatment whose TD was initially reversed by clozapine but was completely reversed by valbenazine.