Respiratory-gated auricular vagal afferent nerve stimulation (RAVANS) modulates brain response to stress in major depression.

BACKGROUND: Negative stress significantly impacts major depressive disorder (MDD), given the shared brain circuitry between the stress response and mood. Thus, interventions that target this circuitry will have an important impact on MDD. The aim of this study was to evaluate the acute effects of a novel respiratory-gated auricular vagal afferent nerve stimulation (RAVANS) technique in the modulation of brain activity and connectivity in women with MDD in response to negative stressful stimuli. METHODS: Twenty premenopausal women with recurrent MDD in an active episode were included in a cross-over experimental study that included two functional MRI visits within one week, randomized to receive exhalatory- (e-RAVANS) or inhalatory-gated (i-RAVANS) at each visit. Subjects were exposed to a visual stress challenge that preceded and followed RAVANS. A Factorial analysis was used to evaluate the effects of RAVANS on brain activity and connectivity and changes in depressive and anxiety symptomatology post-stress. RESULTS: Compared with i-RAVANS, e-RAVANS was significantly associated with increased activation of subgenual anterior cingulate, orbitofrontal and ventromedial prefrontal cortices and increased connectivity between hypothalamus and dorsolateral prefrontal cortex, and from nucleus tractus solitarii to locus coeruleus and ventromedial prefrontal cortex. Changes in brain activity and connectivity after e-RAVANS were significantly associated with a reduction in depressive and anxiety symptoms. CONCLUSIONS: Our study suggests exhalatory-gated RAVANS effectively modulates brain circuitries regulating response to negative stress and is associated with significant acute reduction of depressive and anxiety symptomatology in women with recurrent MDD. Findings suggest a potential non-pharmacologic intervention for acute relief of depressive symptomatology in MDD.

Impact of a Rapid-Access Ambulatory Psychiatry Encounter on Subsequent Emergency Department Utilization.

The authors sought to determine whether providing a rapid-access ambulatory psychiatry encounter correlated with emergency department utilization during a 6-month follow-up period. Electronic medical records of patients who accessed ambulatory psychiatric care through an urgent care psychiatry clinic that offers treatment exclusively on a walk-in basis over a 1-year period (N = 157) were reviewed retrospectively to track emergency department encounters with and without a psychiatric chief complaint in the 6 months before and after the initial psychiatry evaluation. Among patients who had not previously received ambulatory psychiatric care (N = 88), emergency department utilization decreased from 0.68 visits per patient to 0.36, and this difference was statistically significant (p = 0.0147). No statistically significant differences were found between the average number of emergency department encounters in the 6 months before and after the rapid-access ambulatory psychiatry encounter, regardless of chief complaint, when all patients were included in the analysis. Providing a rapid-access ambulatory psychiatry encounter may reduce subsequent emergency department utilization among patients who have not previously received ambulatory psychiatric care.

Virtual monitoring of suicide risk in the general hospital and emergency department.

OBJECTIVE: To determine whether continuous virtual monitoring, an intervention that facilitates patient observation through video technology, can be used to monitor suicide risk in the general hospital and emergency department (ED). METHOD: This was a retrospective analysis of a protocol in which select patients on suicide precautions in the general hospital and ED received virtual monitoring between June 2017 and March 2018. The primary outcome was the number of adverse events among patients who received virtual monitoring for suicide risk. Secondary outcomes were the percentage of patients for whom virtual monitoring was discontinued for behavioral reasons and the preference for observation type among nurses. RESULTS: 39 patients on suicide precautions received virtual monitoring. There were 0 adverse events (95% confidence interval (CI) = 0.000-0.090). Virtual monitoring was discontinued for behavioral reasons in 4/38 cases for which the reason for terminating was recorded (0.105, 95%CI = 0.029-0.248). We were unable to draw conclusions regarding preference for observation type among nurses due to a low response rate to our survey. CONCLUSIONS: Suicide risk can feasibly be monitored virtually in the general hospital or ED when their providers carefully select patients for low impulsivity risk.

A Successful Walk-In Psychiatric Model for Integrated Care.

PURPOSE: Accommodating walk-in psychiatry visits in primary care can improve access to psychiatric care for patients from historically underserved groups. We sought to determine whether a walk-in psychiatry model embedded within an integrated care practice could be sustained over time, and to characterize the patients who accessed care through it. METHODS: We reviewed electronic health records linked to 811 psychiatry encounters in an integrated care practice between October 1, 2015 and September 30, 2017. Primary outcomes were the initial and return psychiatry encounters per month. Secondary outcomes were the demographics and diagnoses of patients who accessed their initial visits through walk-in sessions and scheduled appointments. RESULTS: 490 initial psychiatry evaluations and 321 return encounters took place over the 2-year study period. The volume of initial psychiatry evaluations per month did not significantly change, but the volume of psychiatry follow-up encounters significantly increased after the walk-in session expanded. Medicaid recipients (OR, 1.9; 95% CI, 1.2 to 3.0); individuals without a college degree (OR, 1.7; 95% CI, 1.1 to 2.5); individuals who were single, divorced, or separated (OR, 1.7; 95% CI, 1.1 to 2.5); and individuals who identified as Black or Hispanic (OR, 2.5; 95% CI, 1.7 to 3.6) were more likely to access an initial psychiatry evaluation through a walk-in session as opposed to a scheduled appointment. CONCLUSIONS: Providing psychiatric care on a walk-in basis in integrated care is sustainable. Patients from historically underserved groups may access psychiatric care disproportionately through a walk-in option when it is available.

Longitudinal Urgent Care Psychiatry as a Unique Access Point for Underserved Patients.

OBJECTIVE: The authors sought to determine whether a walk-in psychiatry model with longitudinal follow-up capability could improve access for patients who traditionally miss appointments. METHODS: An urgent care clinic that offers treatment exclusively on a walk-in basis was opened within an adult psychiatry practice to accommodate patients who missed prior scheduled appointments. Electronic health records for patients who received an initial psychiatry evaluation at the practice during a 6-month period (N=355) were reviewed retrospectively to track the clinic's productivity and patient demographic characteristics. RESULTS: Eighty patients (23%) accessed their initial psychiatry encounters through the walk-in clinic. Medicaid recipients (odds ratio [OR]=1.89, 95% confidence interval [CI]=1.10-3.24) and individuals without a college degree (OR=1.86, 95% CI=1.04-3.32) were more likely than patients with other insurance carriers and those with a college degree, respectively, to access care through a walk-in encounter versus a scheduled appointment. CONCLUSIONS: Longitudinal walk-in psychiatry services can feasibly be offered through the longitudinal urgent care psychiatry model. This model may serve as a unique access point for patients from historically underserved groups.

Hospital Length of Stay With a Proactive Psychiatric Consultation Model in the Medical Intensive Care Unit: A Prospective Cohort Analysis.

BACKGROUND: Previous studies have demonstrated that proactive psychiatric consultation reduces hospital length of stay (LOS) in the general medical setting; however this model has not been studied in the intensive care unit (ICU). OBJECTIVE: To compare outcomes between a conventional consultation model and a proactive psychiatric consultation model. METHODS: Two medical ICUs (MICUs) were randomized to proactive psychiatric consultation vs conventional consultation psychiatric models. Proactive consultation included embedding a psychiatrist into daily MICU team rounds on all patients. In the conventional consultation MICU, psychiatric consultations were activated when deemed necessary. Primary outcomes were hospital LOS and MICU LOS. Secondary outcomes included delirium-coma-free hours and ventilator-free hours. RESULTS: A total of 429 patients were admitted to the proactive consultation MICU; 393 patients were admitted to the conventional consultation MICU. The consultation rate for the intervention group was 24.2% vs 6.1% in the control group (p < 0.001). Time to psychiatric consultation was shorter in the intervention group. Median hospital LOS was 6.92 days, interquartile range 3.70-14.31 in the intervention group vs 7.69 days, interquartile range 3.95-16.21 in the control group (p = 0.113). MICU LOS, delirium-coma-free hours, and ventilator-free hours were not significantly different between the 2 groups. Among the respiratory failure subgroup, hospital LOS was shorter in the intervention vs control group (median 9.46 days, interquartile range 4.95-17.56 vs 12.29 days, interquartile range 6.58-21.10, p = 0.011). CONCLUSIONS: Proactive psychiatric consultation in a MICU was associated with decreased time to consultation among all patients and shorter hospital LOS among patients with respiratory failure.

The Psychiatry Morbidity and Mortality Incident Reporting Tool Increases Psychiatrist Participation in Reporting Adverse Events.

OBJECTIVES: Although the reporting of adverse events (AEs) is widely thought to be a key first step to improving patient safety in hospital systems, underreporting remains a common problem, particularly among physicians. We aimed to increase the number of safety reports filed by psychiatrists in our hospital system. METHODS: We piloted an online survey for psychiatry-specific AE reporting, the Psychiatry Morbidity and Mortality Incident Reporting Tool (PMIRT) for a 1-year period. An e-mail prompt containing a link to the survey was sent on a weekly basis to all psychiatry department clinical staff. The primary outcome was the total number of events reported by psychiatrists through PMIRT; secondary outcomes were the total number of AEs and the number of serious harm events filed by psychiatrists in our hospital's formal event reporting system before and after implementation of the new protocol. RESULTS: Psychiatrists filed 65 reports in PMIRT during the study period. The average number of AEs reported by psychiatrists in the hospital's formal event reporting system significantly increased after the intervention (P = 0.0251), and the average number of serious harm events reported by psychiatrists increased nonsignificantly (P = 0.1394). CONCLUSIONS: The combination of an increase in awareness of event reporting with a psychiatry-specific AE reporting tool resulted in a significant improvement in the number of reports by psychiatrists.

Quality of Life and Psychosocial Functioning 2 Years Following Facial Transplantation.

BACKGROUND: Face transplantation is a novel option for patients with severe facial disfigurement. Quality of life (QoL) outcomes of face transplantation remain poorly understood. OBJECTIVES: We sought to evaluate psychosocial functioning among 6 patients undergoing facial transplantation. METHODS: We prospectively assessed depressive symptoms, health status, mental and physical QoL, and self-esteem at 3-month intervals for 2 years. Social desirability was assessed pretransplant. RESULTS: On average, before transplantation, patients generally reported minimal to subthreshold depressive symptoms, normal to high health status, normal mental-health QoL, slightly below normal physical-health QoL, and normal to high self-esteem. Most endorsed high social desirability. As patients recovered from surgery, hospitalization, and immunosuppression induction, physical-health QoL generally deteriorated 3 months posttransplantation. Posttransplant trajectories show that perceived health state improved; health status and mental and physical health-related QoL slightly improved; self-esteem remained stable and high; and overall depressive symptoms remained stable but 3 patients experienced a depressive episode. CONCLUSIONS: Pretransplant ceiling effects may render improvements difficult to quantify. Future research should use mixed methods including population-specific measures with demonstrated sensitivity to change.

Clinical Severity Alone Does Not Determine Disposition Decisions for Patients in the Emergency Department with Suicide Risk.

BACKGROUND: Boarding of patients with suicide risk in emergency departments (EDs) negatively affects both patients and society. Factors other than clinical severity may frequently preclude safe outpatient dispositions among suicidal patients boarding for psychiatric admission in the ED. OBJECTIVE: To determine the extent to which nonclinical factors preclude safe outpatient discharge from the ED among patients boarding for psychiatric admission based on suicide risk. METHODS: A survey regarding the importance of 13 clinical and 19 nonclinical barriers to safe outpatient disposition was administered in the ED to 40 adults who were determined by psychiatrists to require inpatient level of psychiatric care due to suicide risk. A second survey regarding whether addressing the nonclinical factors would have enabled a safe outpatient disposition in each case was administered to the psychiatrists who evaluated each patient participant. RESULTS: Out of 40 patient participants, 39 cited at least one nonclinical factor that could have enabled a safe outpatient disposition had it been correctable in the ED. According to the psychiatrists who made the decision to hospitalize, 10 (25%) of the patient participants could have been discharged had social support become available. CONCLUSION: Both clinical and nonclinical factors affect disposition from the ED after an evaluation for suicide risk. Attention to nonclinical factors should be considered in programmatic efforts to reduce ED boarding of patients with suicide risk.

Consultation-Liaison Psychiatry vs Psychosomatic Medicine: What's in a name?

BACKGROUND: In November of 2017, The Academy of the Psychosomatic Medicine voted to change its name to the Academy of Consultation-Liaison Psychiatry. It followed a similar change in which the American Board of Medical Specialties voted to change the name of the field to Consultation-Liaison Psychiatry. OBJECTIVE: The authors, all instrumental in bringing about this change, discuss the history and rationale for this name change.

The role of face transplantation in the self-inflicted gunshot wound.

BACKGROUND: Facial self-inflicted gunshot wounds (SIGSWs) cause a devastating midfacial defect and pose a challenging problem to the reconstructive surgeon. Face transplantation (FT) has the potential for near-normal restoration in otherwise non-reconstructible defects. Two out of 7 FT recipients at Brigham and Women's Hospital (BWH) sustained SIGSWs. In this study, we illustrate the role of FT in the management of SIGSWs through an aesthetic, functional, and psychosocial examination of outcomes. METHODS: We performed a retrospective analysis of individuals with SIGSWs who were screened at BWH between 2008 and 2015. We then collected data of the injuries, modes of conventional reconstruction (CR), and deficits. For the FT recipients, we critically reviewed the psychosocial screening process and post-transplantation aesthetic, functional, and psychosocial outcomes. RESULTS: A total of six individuals post-SIGSWs were screened for FT. All of them had undergone CR, with five receiving loco-regional flaps and free tissue transfers, and one undergoing serial debridement and primary soft-tissue repair. Following CR, all suffered from residual functional and aesthetic deficits. Two underwent partial FT and one is currently undergoing FT screening. We describe the pre-transplant psychosocial screening process and the aesthetic, functional, and psychosocial outcomes of the SIGSW FT recipients. CONCLUSIONS: We examined the facial SIGSW injury, outcomes of CR, and the mechanism of FT to offer a potential solution to the shortcomings of CR. More importantly, we highlight the critical nature of the psychosocial component of the multidisciplinary evaluation given the history of mental illness and suicidal behavior in this subset of patients.

The walk-in clinic model improves access to psychiatry in primary care.

OBJECTIVE: Missed appointments decrease clinic capacity and negatively affect health outcomes. The objective of this study was to increase the proportion of filled initial psychiatry appointments in an urban, hospital-based primary care practice. METHODS: Patients were identified as having a high or low risk of missing their initial psychiatry appointments based on prior missed medical appointments. High-risk patients were referred to a walk-in clinic instead of a scheduled appointment. The primary outcome was ratio of filled appointments to booked appointments. We used a statistical process control chart (p chart) to measure improvement. Secondary outcomes were percentages of patients from historically underserved groups who received an initial psychiatry evaluation before and after the intervention. RESULTS: The average ratio of filled to booked initial appointments increased from 59% to 77% after the intervention, and the p chart confirmed that this change represented special cause variation. No statistically significant demographic differences between the patients who received psychiatric evaluations before and after the intervention were found. CONCLUSIONS: Missed initial psychiatry appointments can be accurately predicted by prior missed medical appointments. A referral-based walk-in clinic is feasible and does not reduce access to care for historically underserved patient groups.

Do Consultation Psychiatrists, Forensic Psychiatrists, Psychiatry Trainees, and Health Care Lawyers Differ in Opinion on Gray Area Decision-Making Capacity Cases? A Vignette-Based Survey.

BACKGROUND: Previous research in the area of medical decision-making capacity has demonstrated relatively poor agreement between experienced evaluators in "gray area" cases. We performed a survey to determine the level of agreement about gray area decision-making capacity case scenarios within and between individuals of different professional backgrounds. METHOD: Participants received a survey consisting of 3 complicated decision-making capacity vignettes with an accompanying "yes/no" question regarding capacity and a certainty scale for each vignette. Participants were identified from mailing lists of professional organizations and local hospitals. We received responses from psychiatry trainees, consultation-liaison psychiatrists, forensic psychiatrists, and lawyers with experience in health care law. Results were analyzed using SPSS. RESULTS: Across the 3 vignettes, the percentage agreeing that the individual described had capacity to refuse medical treatment ranged between 35% and 40% for trainees, 33% and 67% for consult psychiatrists, 41% and 76% for forensic psychiatrists, and 40% and 83% for health care lawyers. Only question 2 reached significance between-group differences (Pearson χ(2) = 11.473, p < 0.01). Across vignettes, trainees were less likely to consider patients to have capacity for decision-making than were forensic psychiatrists and lawyers. CONCLUSIONS: As found in previous research, agreement among experienced evaluators appears generally low in gray area capacity cases. It is noteworthy that individuals of different professional backgrounds at times offer divergent between-group opinions on capacity.

Tissue Expansion Technique for Desyndactylization of Toes Using an External Fixator.

We present an alternative technique for desyndactylization of toes using soft tissue traction with an external fixator. This method allows for tissue expansion for subsequent skin plasty, thereby avoiding the need for a graft or complicated local skin rearrangement. The use of the conventional acute correction technique can create more scarring and might increase the potential for complications, especially if the graft is obtained from a remote site. We believe that this technique provides a satisfactory functional and cosmetic outcome. This method has the potential to minimize postoperative complications, provide functional digits, and allow for good cosmetic results.

A Population-Based Care Improvement Initiative for Patients at Risk for Delirium, Alcohol Withdrawal, and Suicide Harm.

BACKGROUND: In a population-based approach, a hospital-wide interprofessional care redesign at Brigham and Women's Hospital (BWH; Boston), was conducted to provide optimal evidence-informed care for patients at risk for delirium, alcohol abuse, and suicide harm (DASH). The initiative involved enhanced screening and the introduction of new care management guidelines and order sets pertaining to the DASH diagnoses. METHODS: An interprofessional group from medicine, nursing, and psychiatry jointly led a hospitalwide effort for the improvement of care and outcomes of patients presenting with a DASH diagnosis (delirium, alcohol withdrawal, and suicide harm). The care improvement process consisted of four phases: (1) development of guidelines, (2) imple mentation/rollout, (3) integration into practice, and (4) sustainability, including ongoing practice development and evaluation. RESULTS: Implementation outcomes were evaluated using eight parameters-acceptability, adoption, appropriateness, feasibility, fidelity, implementation cost, penetration, and sustainability. Internal billing data and ICD-9-CM [International Classification of Diseases, Ninth Revision, Clinical Modification] diagnostic codes were used to identify the DASH population. Patients were compared pre- and postprogram implementation for fiscal years 2010 through 2013. The average length of stay, reported as the number of midnights in the hospital, remained consistent for DASH patients-9.3-10.0 days (versus 5.3-6.0 days for BWH over all). The DASH readmission rate decreased by 9%-from 15.1% to 13.7%, approaching the overall BWH rate of 13.3%. CONCLUSION: Close nurse-physician collaboration, including joint leadership and simultaneous rollout for nurses and physicians, contributed to the initiative's effective implementation.

Psychiatry department response to the Boston Marathon bombings within a level-1 trauma center.

In this article we present how the consultation-liaison and psychology divisions of an academic medical center's Department of Psychiatry responded in the first week after the Boston Marathon bombings, specifically in the context of disaster response guidelines and evidence-based approaches to acute trauma. Since the department had to address several complicated matters at multiple levels within the hospital system, we highlight unexpected issues unique to this particular event as they arose within the primary domains of our involvement. This article aims to (1) provide a descriptive analysis of how we enacted disaster and trauma guidelines and evidence-based care within a hospital setting, (2) shed light on the unique and unexpected administrative and systemic issues encountered in our response, and (3) discuss lessons learned, including opportunities to improve trauma-related care.

Readings on psychosomatic medicine: survey of resources for trainees.

BACKGROUND: As systems of care become more complex and comorbid medical and psychiatric illness becomes more evident, it is essential to prepare psychiatric trainees for practice in more integrated models of care. OBJECTIVE: We sought to identify readings available for residency training in consultation-liaison (C-L) psychiatry/psychosomatic medicine with the intent to help educators and trainees identify appropriate and essential learning resources within the field. METHODS: We reviewed readings available to the residents (including commonly used textbooks in C-L psychiatry and C-L training programs' required reading lists) and identified areas of consensus regarding the topics germane to the care of patients with comorbid medical and psychiatric illness (namely depression, dementia, and delirium) and the education of trainees. RESULTS: There was considerable variation in the references cited by well-regarded textbooks and by reading lists created for trainees in C-L psychiatry. In the 4 textbooks reviewed, there were 83 shared citations on delirium (including 10 citations that were common to all 4 textbooks and 17 citations shared by 3 textbooks). Markedly less overlap was noted in the chapters on depression (only 2 references cited in all of the textbooks with relevant content) and dementia (only 7 shared references). CONCLUSION: Given the paucity of overlap of citations in commonly used textbooks, we recommend that practical topical reviews or textbook chapters be used as core (required) or recommended readings for residents on C-L psychiatry rotations, supplemented by a small number of studies or case series that illustrate key teaching points on each essential topic.