Changes in voluntary admission and restraint use after a comprehensive tobacco-free policy in inpatient psychiatric health facilities.

Background: Cardiovascular and respiratory diseases, predominantly due to tobacco use, are the leading causes of death among individuals with serious and persistent mental illness. However, many psychiatric health facilities do not routinely treat tobacco use disorder. The purpose of the current study was to examine the impact of implementing a tobacco-free policy in inpatient psychiatric health facilities in a large, urban setting on behavioral problems, treatment access, and tobacco treatment. Methods: Data on seclusion and restraint incidents, voluntary commitment at admission for each hospitalization episode, and nicotine replacement therapy (NRT) prescriptions were collected through secondary analysis of Medicaid administrative records from baseline in January 2015 (n = 8983) to follow-up in December 2016 (n = 9685) at 14 inpatient psychiatric health facilities. Results: There were no significant changes from baseline to follow-up in odds of seclusion and restraint incidents or voluntary admission status. There was a significant increase in the odds of NRT prescriptions at both 30 and 180 days post discharge (odds ratio [OR] range = 1.58-2.09, P < .01). Conclusions: In a large, urban setting among Medicaid enrollees, implementation of a tobacco-free policy in inpatient psychiatric health facilities had no negative impact on behavioral problems or treatment access and improved access to NRT, although overall NRT use remained low. This study challenges perceptions among some providers that addressing tobacco use disorder will negatively impact treatment outcomes in individuals with serious mental illness. These findings support tobacco-free policies in psychiatric health facilities and the role of psychiatric health providers in treating tobacco use in this population, which is at high risk for tobacco-related mortality.

Assessment of ADHD documentation from candidates requesting Americans With Disabilities Act (ADA) accommodations for the National Board of Osteopathic Medical Examiners COMLEX exam.

PURPOSE: Every year increasing numbers of candidates request special accommodations for high-stakes medical licensing examinations, due to ADHD, on the basis of the Americans with Disabilities Act (ADA). This poses significant challenges for both the applicant and the medical boards and has significant financial, legal, and ethical implications. The purpose of this survey is to review all applications requesting ADA accommodations, on the basis of ADHD, submitted to the National Board of Osteopathic Medical Examiners (NBOME) COMLEX exam. METHOD: The authors review all 50 requests for special accommodations, on the basis of ADHD, submitted to the NBOME between 2005 and 2007. All requests are reviewed by the investigators independently and then cross-checked to determine interrater reliability. RESULTS: Of all applicants, only 14% (7/50) provide sufficient documentation to support a diagnosis of ADHD. Interrater reliability is high. CONCLUSIONS: The majority of applicants who request special testing accommodations on the basis of ADHD do not provide adequate documentation to the medical boards to support the diagnosis.

Medication adherence: a review of the literature and implications for clinical practice.

Adherence is defined as the extent to which a patient's behavior coincides with medical or prescribed health advice. Adherence is considered non-judgmental and is preferred over the term "compliance," which carries negative connotations and suggests blame for the patient. A major challenge in the field of psychiatry has been to understand why patients may or may not adhere to medication and other treatment recommendations. A comprehensive review of the literature on medication adherence among patients with psychiatric illnesses was conducted with the following objectives: (1) to better understand the impact of medication nonadherence, (2) to identify risk factors for medication nonadherence, and (3) to study interventions designed to improve patient adherence. The authors initially searched the Ovid Medline electronic database using the key words "medication adherence" and "compliance" to identify all articles written in the English language published through early 2008. This produced over 2000 references. The search was then narrowed to publications specific to psychotropic medication. The ultimate goal of the review was to increase awareness of this critical issue and to discuss strategies that the psychiatric clinician can implement to address patient adherence to prescribed medications. The authors chose to include articles that were deemed to be clinically useful to the practicing clinician.Studies that have specifically investigated adherence to psychiatric medications vary in the definitions of adherence and methodology that were used, making interpretation of results across studies difficult. Psychoeducational interventions have long been the mainstay of treatment for adherence problems. However, there is growing evidence that other approaches such as cognitive-behavioral strategies and motivational interviewing may be effective. Based on a comprehensive literature review, the authors recommend the following strategies for addressing adherence problems: focus on strengthening the therapeutic alliance; devote time in treatment specifically to address medication adherence; assess patients' motivation to take prescribed medications; and identify and address potential barriers to treatment adherence.