Telehealth Treatment of Patients in an Intensive Acute Care Psychiatric Setting During the COVID-19 Pandemic: Comparative Safety and Effectiveness to In-Person Treatment.

BACKGROUND: Most research evaluating telehealth psychiatric treatment has been conducted in outpatient settings. There is a great lack of research assessing the efficacy of telehealth treatment in more acute, intensive treatment settings such as a partial hospital. In the face of the COVID-19 pandemic, much of behavioral health treatment has transitioned to a virtual format. In the present report from the Rhode Island Methods to Improve Diagnostic Assessment and Services (MIDAS) project, we examined the effectiveness of our partial hospital program (PHP). METHOD: The sample included 207 patients who were treated virtually from May 2020 to September 2020 and a comparison group of 207 patients who were treated in the in-person partial program a year earlier. Patients completed self-administered measures of patient satisfaction, symptoms, coping ability, functioning, and general well-being. RESULTS: For both the in-person and telehealth methods of delivering partial hospital level of care, patients were highly satisfied with treatment and reported a significant reduction in symptoms and suicidality from admission to discharge. On the modified Remission from Depression Questionnaire, the primary outcome measure, both groups reported a significant (P < .01) improvement in functioning, coping ability, positive mental health, and general well-being. A large effect size of treatment (Cohen d > 0.8) was found in both treatment groups. The only significant difference in outcome between the patients treated in the different formats was a greater length of stay (mean ± SD of 13.5 ± 8.1 vs 8.5 ± 5.0 days, t = 7.61, P < .001) and greater likelihood of staying in treatment until completion (72.9% vs 62.3%, χ2 = 5.34, P < .05) in the virtually treated patients. CONCLUSIONS: Telehealth partial hospital treatment was as effective as in-person treatment in terms of patient satisfaction, symptom reduction, suicidal ideation reduction, and improved functioning and well-being. The treatment completion rate was higher in the telehealth cohort, and several patients who were treated virtually commented that they never would have presented for in-person treatment even if there was no pandemic. Telehealth PHPs should be considered a viable treatment option even after the pandemic has resolved.

Contingency plan of the Clinical Management Unit for Psychiatry and Mental Health (CMUPMH) of the Infanta Cristina University Hospital (ICUH) for the COVID-19 pandemic.

In recent decades, pandemics and health catastrophes have caused disorders in part of the population with quite diverse consequences (SARS in 2002-2003, Ebola in 2014- 2015) showing a tendency to create generalised fear in the population, stigmatisation of the sufferers and psychological effects in health-care staff themselves.

Changes in Psychiatric Emergency Room Visits Following the Boston Marathon Bombing.

OBJECTIVE: This study reviews patient encounters at a Boston-area community hospital Psychiatric Emergency Services (PES) following the Boston Marathon bombings, with the goal of describing the impact of terrorist attacks on PES encounters. METHODS: All PES encounters for 2 months preceding and 2 months following the bombing were identified in the electronic medical record. Demographics, current and past psychiatric problems, and trauma history were assessed for all records. Encounters seen post-bombing were compared with those before the bombing. RESULTS: Demographics, current and past psychiatric problems, and trauma history were not significantly different before versus after the bombing; 36 of 440 (8.2%) post-bombing encounters directly mentioned the bombings. New-onset posttraumatic stress disorder (PTSD) symptoms caused by the bombing occurred in only 4 encounters (0.9%). CONCLUSIONS: PES encounters after a terrorist event are likely to mirror those seen before a terrorist event, with only a minority of encounters presenting for new PTSD or acute stress disorder.

Changing characteristics of a Psychiatric Emergency Care Centre. An eight year follow-up study.

OBJECTIVE: The objective of this study was to report changes in characteristics of admissions to an established Psychiatric Emergency Care Centre (PECC) eight years after its opening. METHOD: Key clinical characteristics of admissions to the PECC were documented for 327 patients in 2015 and compared with the 477 patients in 2007, which is when the centre first opened. The characteristics of admission were evaluated using an audit of medical records from June to December in both 2007 and 2015. RESULTS: Statistically significant differences (p<0.05) between 2007 and 2015 were: a reduction in the numbers of patients admitted with depression; a reduction in the numbers of patients diagnosed with adjustment disorder; an increase in the numbers of patients diagnosed with borderline personality disorder; a reduction in pro re nata (prn) use, including a reduction in the need for chemical restraint with midazolam and a decrease in the length of admission in the PECC. CONCLUSIONS: The significant reduction in aggression, the use of prn medication and the number of people with longer stays within the PECC support the usefulness of PECCs in relation to patient satisfaction and adherence to admission criteria policy. These factors may be considered as indicators of the efficiency of a PECC.

Suicide risk, personality disorder and hospital admission after assessment by psychiatric emergency services.

BACKGROUND: The main objectives of the mobile Psychiatric Emergency Services (PES) in the Netherlands are to assess the presence of a mental disorder, to estimate risk to self or others, and to initiate continuity of care, including psychiatric hospital admission. The aim of this study was to assess the associations between the level of suicidality and risk of voluntary or involuntary admission in patients with and without a personality disorder who were presented to mobile PES. METHODS: Observational data were obtained in three areas of the Netherlands from 2007 to 2016. In total, we included 71,707 contacts of patients aged 18 to 65 years. The outcome variable was voluntary or involuntary psychiatric admission. Suicide risk and personality disorder were assessed by PES-clinicians. Multivariable regression analysis was used to explore associations between suicide risk, personality disorder, and voluntary or involuntary admission. RESULTS: Independently of the level of suicide risk, suicidal patients diagnosed with personality disorder were less likely to be admitted voluntarily than those without such a diagnosis (admission rate .37 versus .46 respectively). However, when the level of suicide risk was moderate or high, those with a personality disorder who were admitted involuntarily had the same probability of involuntary admission as those without such a disorder. CONCLUSIONS: While the probability of voluntary admission was lower in those diagnosed with a personality disorder, independent of the level of suicidality, the probability of involuntary admission was only lower in those whose risk of suicide was low. Future longitudinal studies should investigate the associations between (involuntary) admission and course of suicidality in personality disorder.

Elevated allostatic load in individuals presenting at psychiatric emergency services.

OBJECTIVE: Individuals requiring psychiatric emergency services are often highly distressed and intoxicated. To provide an objective and comprehensive measure of their stress-related physiological dysregulations, we indexed allostatic load with 14 biomarkers collected within 24 h of patients' admission to the largest psychiatric hospital in the Canadian province of Quebec. METHODS: This study (N = 278) combines data for emergency patients (n = 76; 65.8% women; M age = 44.97, SE = 1.6) and hospital workers who served as sex- and age-matched controls (n = 202; 70.8% women; M age = 40.10, SE = 0.83). Sex-specific allostatic load indices summarized neuroendocrine (cortisol), immune (tumor necrosis factor-α, interleukin-6, c-reactive protein), metabolic (insulin, glycosylated hemoglobin, total cholesterol, high-density lipoprotein, low-density lipoprotein, triglycerides, body mass index), and cardiovascular (heart rate, systolic and diastolic blood pressure) functioning. Well-validated questionnaires assessed substance (ab)use. RESULTS: Individuals presenting at psychiatric emergency showed elevated allostatic load, drug abuse, and tobacco use compared to controls. Elevated allostatic load in emergency patients was driven by elevated cortisol, interleukin-6, systolic blood pressure, and heart rate; however, allostatic load was not explained by substance (ab)use or demographic variables. Sub-group analyses revealed that emergency patients primarily diagnosed with bipolar, depressive, or anxiety disorders showed higher allostatic load than those diagnosed with personality disorder(s). CONCLUSIONS: This study demonstrates that individuals presenting at psychiatric emergency services show physiological dysregulations associated with chronic stress. Future research should explore the clinical utility of allostatic load in predicting comorbidities among psychiatric patients.

Short term risk of non-fatal and fatal suicidal behaviours: the predictive validity of the Columbia-Suicide Severity Rating Scale in a Swedish adult psychiatric population with a recent episode of self-harm.

BACKGROUND: The Columbia-Suicide Severity Rating Scale (C-SSRS) is a relatively new instrument for the assessment of suicidal ideation and behaviour that is widely used in clinical and research settings. The predictive properties of the C-SSRS have mainly been evaluated in young US populations. We wanted to examine the instrument's predictive validity in a Swedish cohort of adults seeking psychiatric emergency services after an episode of self-harm. METHODS: Prospective cohort study of patients (n = 804) presenting for psychiatric emergency assessment after an episode of self-harm with or without suicidal intent. Suicidal ideation and behaviours at baseline were rated with the C-SSRS and subsequent non-fatal and fatal suicide attempts within 6 months were identified by record review. Logistic regression was used to evaluate separate ideation items and total scores as predictors of non-fatal and fatal suicide attempts. Receiver operating characteristics (ROC) curves were constructed for the suicidal ideation (SI) intensity score and the C-SSRS total score. RESULTS: In this cohort, the median age at baseline was 33 years, 67% were women and 68% had made at least one suicide attempt prior to the index attempt. At least one non-fatal or fatal suicide attempt was recorded during follow-up for 165 persons (20.5%). The single C-SSRS items frequency, duration and deterrents were associated with this composite outcome; controllability and reasons were not. In a logistic regression model adjusted for previous history of suicide attempt, SI intensity score was a significant predictor of a non-fatal or fatal suicide attempt (OR 1.08; 95% CI 1.03-1.12). ROC analysis showed that the SI intensity score was somewhat better than chance in correctly classifying the outcome (AUC 0.62, 95% CI 0.57-0.66). The corresponding figures for the C-SSRS total score were 0.65, 95% CI 0.60-0.69. CONCLUSIONS: The C-SSRS items frequency, duration and deterrents were associated with elevated short term risk in this adult psychiatric cohort, as were both the SI intensity score and the C-SSRS total score. However, the ability to correctly predict future suicidal behaviour was limited for both scores.

Violence, research, and non-identity in the psychiatric clinic.

Violence in psychiatric clinics has been a consistent problem since the birth of modern psychiatry. In this paper, I examine current efforts to understand and reduce both violence and coercive responses to violence in psychiatry, arguing that these efforts are destined to fall short. By and large, scholarship on psychiatric violence reduction has focused on identifying discrete factors that are statistically associated with violence, such as patient demographics and clinical qualities, in an effort to quantify risk and predict violent acts before they happen. Using the work of Horkheimer and Adorno, I characterize the theoretical orientation of such efforts as identity thinking. I then argue that these approaches lead to epistemic imperceptiveness and a subtle form of conceptual restraint on patients. I suggest a reorientation in psychiatric research, away from identity thinking and toward a more productive and just approach to the problem of violence in psychiatric clinics.

Exploring the relationship between vitamin D and mania: correlations between serum vitamin D levels and disease activity.

BACKGROUND: Several studies suggest an association between hypovitaminosis D and mood disorders including major depressive disorder, seasonal affective disorder and premenstrual dysphoric disorder. On the other hand, there is not enough study about acute manic episode and hypovitaminosis D. This data insufficient zone led us to study on whether vitamin D deficiency is associated with acute manic episode and has an impact on disease activity Methods: Thirty-one patients with bipolar disorder in remission, 26 patients with acute manic episode and 40 healthy controls with no major psychopathology were recruited in this study. Hamilton Depression Rating Scale (HAM-D), Young Mania Rating Scale (YMRS) and the Clinical Global Impression - Severety scale (CGI-S) were used to evaluate disease activity. Total vitamin D (D2 + D3) values were measured. RESULTS: Patients in acute manic episode had significantly lower (p = .002) vitamin D serum concentrations than healthy controls (respectively 15.16 ± 7.48 and 22.31 ± 8.8) but remission group's serum concentrations (18.40 ± 7.30) did not differ significantly from healthy controls or acute manic episode patients (p > .05). We observed negative and moderate correlations between vitamin D levels and YMRS scores (r: -0.641, p < .001), vitamin D levels and CGI scores (r: -0.559, p= .003). CONCLUSIONS: Our results contribute to the idea that vitamin D deficiency and acute manic episode may have interactions with many pathways. Future trials may investigate this association with longer follow up. We recommend that serum vitamin D levels should be measured in patients with bipolar disorder especially in long term care.

Clinical profiles and temporal patterns of psychiatric emergency room visitors in Sweden.

AIMS: To describe persons visiting the psychiatric emergency room (PER) in Sweden and to compare persons who frequently (PFV) and infrequently (PIFV) visit PERs in terms of group size, age, gender, PER location inside versus outside the home municipality, diagnosis (ICD 10), temporal patterns of visits and hospital admissions. METHODS: This register study included all visits to PERs in one Swedish county over 3 years, 2013-2015 (N = 67,031 visits). The study employed descriptive statistics as well as Chi-square tests combined with Bonferroni correction to compare PFV with PIFV. RESULTS: Of the total of 27,282 visitors, 2201 (8.1%) were identified as PFV (five or more visits within 12 months) and they accounted for 38.1% of the total visits. The study found differences between PFV and PIFV in gender, diagnostic profile, hospital admissions and temporal patterns. Differences were also detected with regard to distance between PERs and home municipalities. However, no age-related differences were found between the two groups. CONCLUSIONS: PFV and PIFV have different clinical profiles and temporal patterns. These results may be important when planning, developing and evaluating interventions targeting the needs of each group, which is in accordance with a person-centred approach. Such an approach might eventually result in fewer visits to PERs.

Development of Collaborative Drug Therapy Management and Clinical Pharmacy Services in an Outpatient Psychiatric Clinic.

Collaborative drug therapy management (CDTM) is a written agreement that allows a pharmacist to initiate, modify, or continue pharmacotherapies under a physician's scope of practice. While available literature pertaining to cardiometabolic and respiratory CDTM services is growing, publications are sparse in psychiatry, particularly outside Veterans Health Administration medical centers. A descriptive study was undertaken to demonstrate how a board-certified psychiatric pharmacist would begin organizing a protocol for clinical pharmacy services at an outpatient, community treatment center for mental health and substance abuse disorders. The primary CDTM service proposed was metabolic monitoring for atypical antipsychotics, though profile reviews for medication reconciliation, drug level monitoring, and insurance coverage were also considered. Potential obstacles identified and worked through during the project included pharmacist-prescriber relationships, federal and state law requirements, pharmacy informatics development, and pharmacy services billing. Discussions with both administrative and medical stakeholders across the health system were essential in helping a pharmacist detail professional qualifications, justify positive impacts on patient outcomes, and navigate these legal and financial issues. The systematic approach arrived at through the study addresses current literature gaps concerning how pharmacists can evolve their practices from ancillary to collaborative design by nature within psychiatric settings.

Tendencias futuras en urgencias psiquiátricas / Future trends in psychiatric emergencies

Es importante describir algunas de las proyecciones futuras que la Urgencia psiquiátrica podría desarrollar e implementar para mejorar su entrega. Entre ellas, nos parecen ahora necesarias para una efectiva acción clínica: la seguridad del personal de salud y el paciente, implementación de un triage, hospitalización domiciliaria, disponer de fármacos de última generación, mejorar la capacidad resolutiva en pacientes con comorbilidad médica, protocolos de acción, auditoría de fichas, atención telefónica a pacientes en crisis y difusión de estos temas en distintas áreas. Palabras claves: urgencias psiquiátricas, seguridad, triage, hospitalización domiciliaria, patología médica, protocolos, atención telefónica, enseñanza, auditoría de fichas.

It is important to describe some of the future projections that psychiatric Urgency could develop and implement to improve delivery. Among them, we now seem necessary for effective clinical action: security of health personnel and patients, implementing a triage, home care, to have last generation drugs, improve treatment capacity in patients with medical comorbidity, action protocols, records audit, calling patients in crisis and dissemination of these issues in different areas.

[Psychiatric Emergencies in the Preclinical Emergency Medicine Service in Ulm, Germany in 2000 and 2010, and Practical Consequences]. / Psychiatrische Notfälle im Notarzt- und Rettungsdienst in Ulm in den Jahren 2000 und 2010 und Konsequenzen für die Praxis.

Background Psychiatric emergencies (PE) in preclinical emergency medical services are about 5 - 10 % of all emergencies and represent often a source of difficulties in handling for the non-psychiatric professional helpers that deal with them. Studies informing about quantitative and qualitative changes of PEs in preclinical emergency medicine in Germany are scarce. Methods Therefore, we conducted a retrospective cross-sectional study of PE in a preclinical emergency medical service based on the protocols of the emergency ambulance of the Section for Emergency Medicine at the University Hospital Ulm comparing the years 2000 and 2010. Results We observed a significant increase of PEs from 8.8 % in the year 2000 (n = 285, from a total of n = 3227) to 10.3 % in 2010 (n = 454, from a total of n = 4425). In both years intoxications were the most common PE [2000: n = 116 (44.4 %); 2010: n = 171 (37.7 %)], followed by suicide-related behavior [2000: n = 59 (22.6 %); 2010: n = 78 (17.2 %)] and acute anxiety disorders [2000: n = 37 (13 %); 2010: n = 105 (23.1 %)]. The mentioned three conditions accounted for about 80 % of all PE. Most frequently PE occurred at the weekend and with the highest density in the evening and at night (18 - 24 h) in both years. Patients with PE were predominantly men, but the rate of women causing PE increased between 2000 and 2010. Discussion/Conclusion This study provides preliminary data on current trends in PEs in preclinical emergency medicine in Germany and has implications for improving the medical care provided.

The Changing Health Policy Environment and Behavioral Health Services Delivery.

Deinstitutionalization has left an inadequate supply of inpatient psychiatric beds. Simultaneous cuts to public funding and insurance coverage for outpatient mental health treatment have increased the frequency of acute psychiatric crises. The resulting lack of available options has shifted the burden of treatment to emergency departments and the criminal justice system. Recent legislation has improved insurance access, but rules are not always enforced and there are still few options for care. Discussion of mental health care delivery must acknowledge that many emergent behavioral health crises arise in the context of acute substance intoxication, withdrawal, or dependence.

Emergency psychiatry: a product of circumstance or a growing sub-speciality field?

OBJECTIVES: This article reviews recent trends in the provision of psychiatric services to the emergency departments of tertiary hospitals in Australia, involving the establishment of specialised in-reach or liaison services as well as various forms of short stay unit attached to emergency departments. The Emergency Psychiatry Service at Flinders Medical Centre, South Australia, is described as a case example. Its specialised models of assessment and clinical care are described, highlighting how these are differentiated from more traditional models in inpatient, community and general hospital consultation-liaison psychiatry. CONCLUSIONS: Emergency psychiatry, and in particular the application of specialised psychiatric models of in-reach service and short stay units, is an increasingly important and growing field of psychiatry that warrants further exploration in research. The Emergency Psychiatry Service at Flinders Medical Centre has developed a distinct group of assessment and treatment approaches that exemplifies this growing field.