Utility of in-session assessments during cognitive behavioral therapy for depression after traumatic brain injury: Results from a randomized controlled trial.

BACKGROUND: The development of depression after moderate to severe traumatic brain injury (TBI) is common. Cognitive-behavioral therapy (CBT) can be used to treat post-TBI depression, but the symptoms response is poorly described. OBJECTIVE: This secondary analysis assessed: (1) the trajectory of depression symptoms up to 12 sessions of CBT, (2) which depressive symptom clusters were responsive to in-person and phone CBT, and (3) whether interim depression thresholds predict 16-week treatment response. METHOD: This secondary analysis of the IRB-approved Life Improvement Following Traumatic Brain Injury trial included 100 adults with major depressive disorder (MDD) within ten years of moderate to severe traumatic brain injury from throughout the US. We used a combination of descriptive, graphical, and diagnostic accuracy methods. RESULTS: Cardinal and cognitive-affective symptom clusters improved most from CBT over 16 weeks. At 8 and 16 weeks, the most responsive individual symptoms were anhedonia, depressed mood, and fatigue; the least responsive were sleep and appetite. PHQ-9 thresholds with a Negative Predictive Value greater than 0.7 for sessions 6, 7, and 8 were, respectively: >15, >10, and >9. CONCLUSION: In-person and phone CBT led to similar symptom responses during treatment. Additionally, using PHQ-9 thresholds for predicting intervention response within eight sessions may help identify the need for treatment adjustments.

Psychiatry's Expanded Integration into Primary Care.

Integrated behavioral care, and in particular, the collaborative care model, has been working to improve access and treatment for people with mental health disorders. Integrated care allows for adaptable, scalable, and sustainable practice that addresses the mental health needs of the public. During the pandemic several challenges emerged to delivering integrated care. This disruption happened at a systems level, team-based care level, scope of care level, and patient access level. This article looks through the lens of those various levels to identify and some of the lessons learned to help build a more resilient and flexible integrated care program.

Development and Implementation of an Integrated Care Fellowship.

BACKGROUND: Integrated care is a common approach to leverage scarce psychiatric resources to deliver mental health care in primary care settings. OBJECTIVE: Describe a formal clinical fellowship devoted to professional development for the integrated care psychiatrist role. METHODS: The development of a formal year-long clinical fellowship in integrated care is described. The curriculum consists of an Integrated Care Didactic Series, Integrated Care Clinical Skill Experiences, and Integrated Care System-Based Leadership Experiences. Evaluation of impact was assessed with descriptive statistics. RESULTS: We successfully recruited 3 classes of fellows to the Integrated Care Fellowship, with 5 program graduates in the first 3 years. All 5 graduated fellows were hired into integrated care and/or telepsychiatry positions. Integrated Care fellows had a high participation rate in didactics (mean attendance = 80.6%; n = 5). We received a total of 582 didactic evaluations for the 151 didactic sessions. On a scale of 1 (poor) to 6 (fantastic), the mean quality of the interactive learning experience was rated as 5.33 (n = 581) and the mean quality of the talk was 5.35 (n = 582). Rotations were rated with the mean overall teaching quality of 4.98/5 (n = 76 evaluations from 5 fellows). CONCLUSIONS: The Integrated Care clinical fellowship serves as a model for training programs seeking to provide training in clinical and systems-based skills needed for practicing integrated care. Whether such training is undertaken as a standalone fellowship or incorporated into existing consultation-liaison psychiatry programs, such skills are increasingly valuable as integrated care becomes commonplace in practice.

Challenge at the Intersection of Race and Kink: Racial Discrimination, Fetishization, and Inclusivity Within the BDSM (Bondage-Discipline, Dominance-Submission, and Sadism-Masochism) Community.

The bondage-discipline, dominance-submission, and sadism-masochism (BDSM) community has achieved diversity with respect to gender identity and sexual orientation yet does so to a lesser extent with respect to race and ethnicity. A total of 398 BDSM practitioners recruited in 2018 and 2019 from BDSM conferences located within the Southern, Midwestern, and Western regions of the U.S., as well as online, completed surveys asking about racial and ethnic discrimination, fetishization, and inclusivity. People of color were 16 times more likely than non-people of color to feel discriminated against at BDSM events and 17 times more likely to feel fetishized. Qualitative results included troubling stories of overt racism and offensive racial slurs, and examples of microaggressions, feelings of isolation, and feelings of being dismissed. The results suggest that organizations can increase inclusivity by understanding the unique costs faced by people of color with an awareness that these costs might be invisible to non-people of color, diversifying positions of authority and leadership, and teaching well-meaning members what types of behaviors could create a hostile environment.

Report of the Academy of Consultation-Liaison Psychiatry Task Force on Lessons Learned From the COVID-19 Pandemic: Executive Summary.

BACKGROUND: The COVID-19 pandemic forced consultation-liaison psychiatrists to adapt to unprecedented circumstances. The Academy of Consultation-Liaison Psychiatry (ACLP) recognized the need and opportunity to assess its response and convened a task force in mid-2020 to review the lessons learned from the initial experience of the COVID-19 pandemic. OBJECTIVE: The aim of the study was to summarize experience and make recommendations to the ACLP Board of Directors about potential ACLP directions related to current and future pandemic response. METHODS: In August-November 2020, the task force reviewed local experiences, ACLP list-serv contributions, and the published literature and generated recommendations for ACLP actions. RESULTS: Recommendations addressed telepsychiatry, hospital staff wellness, support for consultation-liaison psychiatrists, the need for additional research on psychiatric and neuropsychiatric aspects of COVID-19, and the ACLP's role in advocacy and dissemination of information. The task force report was submitted to the ACLP Board of Directors in November 2020. CONCLUSIONS: As the preeminent organization of consultation-liaison psychiatrists, the ACLP can implement actions related to pandemic awareness and preparedness for the benefit of consultation-liaison psychiatrists, other health care workers, patients, and the general population.

Acacia Gum Is Well Tolerated While Increasing Satiety and Lowering Peak Blood Glucose Response in Healthy Human Subjects.

Acacia gum (AG) is a non-viscous soluble fiber that is easily incorporated into beverages and foods. To determine its physiological effects in healthy human subjects, we fed 0, 20, and 40 g of acacia gum in orange juice along with a bagel and cream cheese after a 12 h fast and compared satiety, glycemic response, gastrointestinal tolerance, and food intake among treatments. Subjects (n = 48) reported less hunger and greater fullness at 15 min (p = 0.019 and 0.003, respectively) and 240 min (p = 0.036 and 0.05, respectively) after breakfast with the 40 g fiber treatment. They also reported being more satisfied at 15 min (p = 0.011) and less hungry with the 40 g fiber treatment at 30 min (p = 0.012). Subjects reported more bloating, flatulence, and GI rumbling on the 40 g fiber treatment compared to control, although values for GI tolerance were all low with AG treatment. No significant differences were found in area under the curve (AUC) or change from baseline for blood glucose response, although actual blood glucose with 20 g fiber at 30 min was significantly less than control. Individuals varied greatly in their postprandial glucose response to all treatments. AG improves satiety response and may lower peak glucose response at certain timepoints, and it is well tolerated in healthy human subjects. AG can be added to beverages and foods in doses that can help meet fiber recommendations.

Health Effects and Sources of Prebiotic Dietary Fiber.

Prebiotic dietary fibers act as carbon sources for primary and secondary fermentation pathways in the colon, and support digestive health in many ways. Fructooligosaccharides, inulin, and galactooligosaccharides are universally agreed-upon prebiotics. The objective of this paper is to summarize the 8 most prominent health benefits of prebiotic dietary fibers that are due to their fermentability by colonic microbiota, as well as summarize the 8 categories of prebiotic dietary fibers that support these health benefits. Although not all categories exhibit similar effects in human studies, all of these categories promote digestive health due to their fermentability. Scientific and regulatory definitions of prebiotics differ greatly, although health benefits of these compounds are uniformly agreed upon to be due to their fermentability by gut microbiota. Scientific evidence suggests that 8 categories of compounds all exhibit health benefits related to their metabolism by colonic taxa.

Automatic address validation and health record review to identify homeless Social Security disability applicants.

OBJECTIVE: Homeless patients face a variety of obstacles in pursuit of basic social services. Acknowledging this, the Social Security Administration directs employees to prioritize homeless patients and handle their disability claims with special care. However, under existing manual processes for identification of homelessness, many homeless patients never receive the special service to which they are entitled. In this paper, we explore address validation and automatic annotation of electronic health records to improve identification of homeless patients. MATERIALS AND METHODS: We developed a sample of claims containing medical records at the moment of arrival in a single office. Using address validation software, we reconciled patient addresses with public directories of homeless shelters, veterans' hospitals and clinics, and correctional facilities. Other tools annotated electronic health records. We trained random forests to identify homeless patients and validated each model with 10-fold cross validation. RESULTS: For our finished model, the area under the receiver operating characteristic curve was 0.942. The random forest improved sensitivity from 0.067 to 0.879 but decreased positive predictive value to 0.382. DISCUSSION: Presumed false positive classifications bore many characteristics of homelessness. Organizations could use these methods to prompt early collection of information necessary to avoid labor-intensive attempts to reestablish contact with homeless individuals. Annually, such methods could benefit tens of thousands of patients who are homeless, destitute, and in urgent need of assistance. CONCLUSION: We were able to identify many more homeless patients through a combination of automatic address validation and natural language processing of unstructured electronic health records.

Fermentability of Novel Type-4 Resistant Starches in In Vitro System.

Resistant starches are non-digestible starches that are fermented in the colon by microbiota. These carbohydrates are prebiotic and can be beneficial to consumer health. Many types of resistant starch exist with varying physical properties that may result in differences in fermentability. The objective of this research project was to compare potential prebiotic effects and fermentability of four novel resistant starches using an in vitro fermentation system and measuring changes in total gas production, pH, and formation of SCFAs (short chain fatty acids). Fecal donations were collected from seven healthy volunteers. Four novel resistant starches, modified potato starch (MPS), modified tapioca starch (MTS), and modified maize starches (MMS-1 and MMS-2), were analyzed and compared to polydextrose and short chain fructooligosaccharides (FOS) as controls. After twenty-four hours of fermentation, MPS and MTS responded similarly in gas production (74 mL; 70.6 mL respectively), pH (5.93; 5.93 respectively), and SCFA production (Acetate: 115; 124, Propionate: 21; 26, Butyrate: 29; 31 µmol/mL respectively). While MMS-1 had similar gas production and individual SCFA production, the pH was significantly higher (6.06). The fermentation of MMS-2 produced the least amount of gas (22 mL), with a higher pH (6.34), and lower acetate production (78.4 µmol/mL). All analyzed compounds were fermentable and promoted the formation of beneficial SCFAs.

Prebiotic Dietary Fiber and Gut Health: Comparing the in Vitro Fermentations of Beta-Glucan, Inulin and Xylooligosaccharide.

Prebiotic dietary fiber supplements are commonly consumed to help meet fiber recommendations and improve gastrointestinal health by stimulating beneficial bacteria and the production of short-chain fatty acids (SCFAs), molecules beneficial to host health. The objective of this research project was to compare potential prebiotic effects and fermentability of five commonly consumed fibers using an in vitro fermentation system measuring changes in fecal microbiota, total gas production and formation of common SCFAs. Fecal donations were collected from three healthy volunteers. Materials analyzed included: pure beta-glucan, Oatwell (commercially available oat-bran containing 22% oat ß-glucan), xylooligosaccharides (XOS), WholeFiber (dried chicory root containing inulin, pectin, and hemi/celluloses), and pure inulin. Oatwell had the highest production of propionate at 12 h (4.76 µmol/mL) compared to inulin, WholeFiber and XOS samples (p < 0.03). Oatwell's effect was similar to those of the pure beta-glucan samples, both samples promoted the highest mean propionate production at 24 h. XOS resulted in a significant increase in the genus Bifidobacterium after 24 h of fermentation (0 h:0.67 OTUs (operational taxonomic unit); 24 h:5.22 OTUs; p = 0.038). Inulin and WholeFiber increased the beneficial genus Collinsella, consistent with findings in clinical studies. All analyzed compounds were fermentable and promoted the formation of beneficial SCFAs.

Decisional and Dispositional Capacity Determinations: Neuropsychiatric Illness and an Integrated Clinical Paradigm.

BACKGROUND: Assessment of decisional capacity requires thorough clinical review of a patient's current psychiatric symptoms and cognitive processes. The assessment to determine the patient's capacity for self-management postdischarge is a different clinical concept from decisional capacity. OBJECTIVES: Standardized guidelines for capacity determinations (both for informed consent and for disposition) would be helpful to clinicians, patients, and their caregivers. METHOD: The authors reviewed the recent clinical literature on neuropsychiatric illnesses associated with impaired decisional capacity, as well as for the term "dispositional capacity." RESULTS: Neurocognitive disorders and neurologic disorders are commonly associated with impaired decisional capacity; other psychiatric illnesses are less commonly associated. There were no articles identified that used the term "dispositional capacity" to describe a subtype of decisional capacity determination. No definition or guidelines for determination of dispositional capacity were found. CONCLUSIONS: Routine evaluation for neurocognitive disorders including standardized cognitive assessment should be included in decisional capacity determinations. There is a need for a new subtype of decisional capacity determination, for which we propose the term "dispositional capacity." This concept is introduced and defined. For dispositional capacity determinations, supplementation of the usual decisional capacity evaluation with in vivo demonstration of self-management skills is recommended. Decisional and dispositional capacity determination is conceptualized with a biopsychosociocultural approach and guidelines for standardized assessment are presented.

Gastrointestinal tolerance of low FODMAP oral nutrition supplements in healthy human subjects: a randomized controlled trial.

BACKGROUND: There has been increasing interest in utilizing a diet low in fermentable oligosaccharides, disaccharides, monosaccharides and polyols (FODMAPs) for the treatment of irritable bowel syndrome (IBS), a functional gastrointestinal disease. While studies have indicated that this diet can be effective at symptom reduction, it is a restrictive diet and patients may find it challenging to find low FODMAP products to meet their nutrient needs. The primary objective of this study was to assess the gastrointestinal (GI) tolerance of three low FODMAP oral nutrition supplements (ONS) in healthy adults. METHODS: A double-blind randomized controlled crossover study was conducted in 21 healthy adults (19-32 years). Fasted subjects consumed one of four treatments at each visit, with a one week wash out period between visits. Each participant received all treatments. Treatments included three low FODMAP ONS formulas (A, B, and C) as well as a positive control consisting of 5 g fructooligosaccharides (FOS) mixed in lactose-free milk. Breath hydrogen was measured at baseline, 1, 2, 3, and 4 h post treatment consumption. Subjective GI symptom questionnaires were completed at baseline, 0.5, 1, 1.5, 2, 3, 4, 12, 24 and 48 h following treatment consumption. Mean breath hydrogen concentrations and baseline corrected area under the curve for both breath hydrogen and GI symptoms were analyzed and compared between treatments. Significance was determined at P < 0.05. RESULTS: The positive control resulted in higher breath hydrogen response compared to all three of the low FODMAP ONS beverages at 3 and 4 h after consumption. There were no differences in GI symptom response between treatments. CONCLUSIONS: All treatments were well tolerated in healthy participants. The low FODMAP formulas resulted in a lower breath hydrogen response compared to the positive control, and may be better tolerated in individuals with IBS. More research should be conducted to better understand the GI tolerance of low FODMAP ONS in individuals with IBS. TRIAL REGISTRATION: The protocol for this study was registered on ClinicalTrials.gov in January 2016 (Clinical Trials ID: NCT02667184 ).

White Grape Juice Elicits a Lower Breath Hydrogen Response Compared with Apple Juice in Healthy Human Subjects: A Randomized Controlled Trial.

BACKGROUND: Diets low in fermentable oligosaccharides, disaccharides, monosaccharides, and polyols (FODMAPS) are used to manage symptoms in individuals with irritable bowel syndrome. Although effective at reducing symptoms, the diet can be complex and restrictive. In addition, there are still large gaps in the literature and many foods with unclear effects in the gastrointestinal (GI) tract, like fruit juice. Although many fruits are allowable on a low-FODMAP diet, consumption of all fruit juice is generally cautioned due to the large fructose load contained in juice, regardless of the glucose concentration. Very little research exists regarding the importance of limiting fructose load during a low-FODMAP diet; therefore, individuals following a low-FODMAP diet may be unnecessarily restricting their diets. OBJECTIVE: To determine whether there is a difference in GI tolerance between juice from a high-FODMAP fruit (apple juice) and juice from a low-FODMAP fruit (white grape juice) in healthy human subjects. The goal is to provide insight into the role of juice in a low-FODMAP diet. METHODS: A double-blind, randomized, controlled crossover study was conducted with 40 healthy adults. Fasted subjects consumed 12 oz of either apple juice or white grape juice. Breath hydrogen measures were taken at baseline, 1, 2, and 3 hours. Subjective GI tolerance surveys were completed at the same time intervals and at 12 and 24 hours. Breath hydrogen and GI symptoms were assessed with area under the curve analysis. Significance was determined with a two-sided t test with a P value <0.05. RESULTS: Consumption of apple juice resulted in a greater mean breath hydrogen area under the curve at 23.3 ppm/hour (95% CI 13.0 to 33.6) compared with white grape juice at 5.8 ppm/hour (95% CI -4.6 to 16.1) (P<0.001). No differences in reported GI symptoms were seen between treatments. CONCLUSIONS: Both juices were well tolerated and neither produced any severe symptoms in healthy adults. White grape juice consumption resulted in only a small rise in breath hydrogen, which may suggest excluding foods only because of the high fructose load could be unnecessarily restrictive. The results of this study suggest that the fructose-to-glucose ratio is likely more important than the total fructose load of the food when considering the acceptability of a food on a low-FODMAP diet. More research is needed in individuals with irritable bowel syndrome to determine whether white grape juice and other juices from low-FODMAP fruits could be additional beverage options for individuals following a low-FODMAP diet.

Dietary guidance for pulses: the challenge and opportunity to be part of both the vegetable and protein food groups.

Pulses are a dry, edible variety of beans, peas, and lentils that have been consumed for 10,000 years. Pulses are rich in plant-based protein and fiber, as well as micronutrients such as iron and potassium. The satiating effect of both fiber and protein assists in managing weight and combating obesity. The high fiber content and low glycemic index of pulses aid people with diabetes in maintaining blood glucose and insulin levels. Pulse consumption may improve serum lipid levels to reduce the risk of cardiovascular disease. Pulses developed as a member of both the protein and vegetable food groups as a result of its high content of plant-based protein and dietary fiber. The last two revisions of the Dietary Guidelines saw the transformation from the MyPyramid "meat and beans group" to the MyPlate "protein foods group," a nutrient name rather than a food source. Research suggests that consumers better identify with food source examples rather than nutrient names. The 2015 Dietary Guidelines also came with a new area: sustainable diets. Encouraging the consumption of sustainable food sources, like pulses, is imperative to ensuring a secure, healthy food supply for the U.S. population over time and for future generations.

Automatic health record review to help prioritize gravely ill Social Security disability applicants.

OBJECTIVE: Every year, thousands of patients die waiting for disability benefits from the Social Security Administration. Some qualify for expedited service under the Compassionate Allowance (CAL) initiative, but CAL software focuses exclusively on information from a single form field. This paper describes the development of a supplemental process for identifying some overlooked but gravely ill applicants, through automatic annotation of health records accompanying new claims. We explore improved prioritization instead of fully autonomous claims approval. MATERIALS AND METHODS: We developed a sample of claims containing medical records at the moment of arrival in a single office. A series of tools annotated both patient records and public Web page descriptions of CAL medical conditions. We trained random forests to identify CAL patients and validated each model with 10-fold cross validation. RESULTS: Our main model, a general CAL classifier, had an area under the receiver operating characteristic curve of 0.915. Combining this classifier with existing software improved sensitivity from 0.960 to 0.994, detecting every deceased patient, but reducing positive predictive value to 0.216. DISCUSSION: True positive CAL identification is a priority, given CAL patient mortality. Mere prioritization of the false positives would not create a meaningful burden in terms of manual review. Death certificate data suggest the presence of truly ill patients among putative false positives. CONCLUSION: To a limited extent, it is possible to identify gravely ill Social Security disability applicants by analyzing annotations of unstructured electronic health records, and the level of identification is sufficient to be useful in prioritizing case reviews.