The association between body mass index and physical function in adult burn survivors: A Burn Model System National Database study.

INTRODUCTION: An area of rehabilitation research in burns is the impact of co-morbidities on disease trajectory. Obesity is a comorbidity of increasing public health concern, but its role remains controversial regarding burn injury and physical recovery. Our aim was to evaluate the association between body mass index (BMI) categories as a measure of obesity at discharge and self-reported physical function (PF) during recovery of adult burn survivors. METHODS: This is a retrospective study on data collected by four major US burn centers, which contribute to the Burn Model System National Database. The data included BMI obtained at hospital discharge and self-reported PF-mobility, using the PROMIS measures assessed at 6, 12, and 24 months after burn. Subjects were classified into weight status categories based on BMI: underweight (BMI <18.5), normal weight (18.5 ≤ BMI <25), overweight (25 ≤ BMI <30), obesity class 1 (30 ≤ BMI <35), obesity class 2 (35 ≤ BMI <40), and obesity class 3 (BMI ≥40). Mixed-effects linear regression models were used to assess the association between BMI categories and PF scores over time, adjusted for patient and injury characteristics. RESULTS: A total of 496 adult burn patients aged 47 ± 16 years were included, with mean total body surface area (TBSA) burned of 18 ± 19 % and mean BMI at discharge of 28 ± 7 kg/m2. PROMIS PF scores significantly improved over time in the recovery phase after burn (time effect, p < 0.001). Compared to overweight burn patients, normal-underweights exhibited lower PF score by an average of 4.06 units (p = 0.001) but scores increased linearly by an estimated 0.17 units per month (p = 0.01) over the 24 months after discharge. Similarly, compared to overweight burn patients, class 1 obese reported lower PF score by a mean 2.67 units (p = 0.07) but PF increased linearly by 0.15 units per month (p = 0.07) over the 24 months after discharge. These findings were independent of the effects of age at discharge, sex, TBSA burned, and hand and leg burn. CONCLUSION: Being overweight was associated with improved and faster recovery of PF scores compared to normal, underweight, and obese burn patients during long-term recovery. Hence, our data suggests that long-term recovery and restoration of PF in adult burn survivors is not compromised by a small excess in body weight.

Evaluating the Prevalence of Four Recommended Practices for Suicide Prevention Following Hospital Discharge.

BACKGROUND: The Joint Commission's National Patient Safety Goal (NPSG) for suicide prevention (NPSG.15.01.01) requires that accredited hospitals maintain policies/procedures for follow-up care at discharge for patients identified as at risk for suicide. The proportion of hospitals meeting these requirements through use of recommended discharge practices is unknown. METHODS: This cross-sectional observational study explored the prevalence of suicide prevention activities among Joint Commission-accredited hospitals. A questionnaire was sent to 1,148 accredited hospitals. The authors calculated the percentage of hospitals reporting implementation of four recommended discharge practices for suicide prevention. RESULTS: Of 1,148 hospitals, 346 (30.1%) responded. The majority (n = 212 [61.3%]) of hospitals had implemented formal safety planning, but few of those (n = 41 [19.3%]) included all key components of safety planning. Approximately a third of hospitals provided a warm handoff to outpatient care (n = 128 [37.0%)] or made follow-up contact with patients (n = 105 [30.3%]), and approximately a quarter (n = 97 [28.0%]) developed a plan for lethal means safety. Very few (n = 14 [4.0%]) hospitals met full criteria for implementing recommended suicide prevention activities at time of discharge. CONCLUSION: The study revealed a significant gap in implementation of recommended practices related to prevention of suicide postdischarge. Additional research is needed to identify factors contributing to this implementation gap.

Psychological Issues.

Psychological distress is common following a burn injury, and many burn survivors have pre-morbid psychiatric illnesses including mood and trauma-related disorders, and substance and alcohol use. This article is intended to be used by all interdisciplinary health care team members to improve the identification and treatment of common psychological concerns experienced by survivors and is organized to follow the general recovery timeline.

Youth Mental Health Screening and Linkage to Care.

One Mind, in partnership with Meadows Mental Health Policy Institute, convened several virtual meetings of mental health researchers, clinicians, and other stakeholders in 2020 to identify first steps toward creating an initiative for early screening and linkage to care for youths (individuals in early adolescence through early adulthood, ages 10-24 years) with mental health difficulties, including serious mental illness, in the United States. This article synthesizes and builds on discussions from those meetings by outlining and recommending potential steps and considerations for the development and integration of a novel measurement-based screening process in youth-facing school and medical settings to increase early identification of mental health needs and linkage to evidence-based care. Meeting attendees agreed on an initiative incorporating a staged assessment process that includes a first-stage brief screener for several domains of psychopathology. Individuals who meet threshold criteria on the first-stage screener would then complete an interview, a second-stage in-depth screening, or both. Screening must be followed by recommendations and linkage to an appropriate level of evidence-based care based on acuity of symptoms endorsed during the staged assessment. Meeting attendees proposed steps and discussed additional considerations for creating the first nationwide initiative for screening and linkage to care, an initiative that could transform access of youths to mental health screening and care.

A Longitudinal Study of Suicidality in a Homeless Population Sample.

OBJECTIVE: Little research has been conducted on the timing of the onset and course of suicidality relative to the timing of the onset and temporal status of homelessness. Therefore, this longitudinal study investigated suicidal ideation and plans and suicide attempts in a homeless population in relation to housing attainment, psychiatric disorders, and substance use/disorders. METHOD: Prospective longitudinal follow-up data were collected from a representative sample of literally homeless adults in St. Louis (N = 255) using the Diagnostic Interview Schedule/Homeless Supplement, the Composite International Diagnostic Interview-Substance Abuse Module, and urine drug screens. Associations among suicidal symptom variables, housing status, psychiatric/substance use disorders, and substance use were examined at baseline and longitudinally. RESULTS: Lifetime prevalence of suicidal ideation/plan and suicide attempts in this homeless population were much higher than in the general population. Onset of suicidal symptoms had typically preceded onset of homelessness. Few individuals experienced suicidal ideation/plans or attempted suicide during this study, and even fewer experienced new suicidal symptoms after baseline. Securing stable housing during the study follow-up was associated with lower rates of suicidal ideation/plans. CONCLUSIONS: This study's findings contradict assumptions that the high prevalence of suicidal symptoms in homeless populations can be explained by the difficulties and miseries of homelessness. Psychiatric illness, substance abuse, and psychosocial factors associated with homelessness may be direct contributors to suicidal symptoms and thus represent strategic intervention targets.HIGHLIGHTSMost suicidality reported at baseline first emerged long before first homelessnessAfter baseline, few reported new suicidal symptoms or had active suicidal symptomsSignificantly fewer reports of suicidal ideation/plans over time were found in those with the most stable housing outcome.

Posttraumatic Stress Disorder Symptom Clusters as Predictors of Pain Interference in Burn Survivors: A Burn Model System National Database Study.

Individuals who experience burns are at higher risk of developing posttraumatic stress disorder and chronic pain. A synergistic relationship exists between posttraumatic stress disorder and chronic pain. We sought to evaluate the role of individual posttraumatic stress disorder symptom clusters as predictors of pain interference. We hypothesized that the hyperarousal and emotional numbing symptom clusters would be predictive of pain interference, even when accounting for the other two posttraumatic stress disorder symptom clusters, pain intensity, and other covariates. Multivariate linear regression analyses were completed using data from the Burn Model System National Database. A total of 439 adult participants had complete responses on self-report measures assessing posttraumatic stress disorder symptoms, pain intensity, and pain interference at 6-month after discharge and were included in analyses. Results indicate hyperarousal (B = .10, p = .03) and emotional numbing (B = .13, p = .01) posttraumatic stress disorder symptom clusters were each significantly associated with pain interference, even when accounting for pain intensity (B = .64, p < .001). Results highlight the importance of the emotional numbing and hyperarousal posttraumatic stress disorder symptom clusters in explaining pain interference. Findings suggest that when posttraumatic stress disorder symptoms or chronic pain are present, screening for and treating either condition may be warranted to reduce pain interference. Further, psychological interventions that target emotional numbing and hyperarousal posttraumatic stress disorder symptoms may be fruitful for promoting better coping with chronic pain and reducing pain interference.

Comparison of violence risk screening experiences of emergency department clinicians.

OBJECTIVE: Individuals commonly present to the emergency department (ED) for care after violence and many are also at risk for subsequent self or other-directed violence. Screening for violence risk represents an important part of ED care, but is challenging to implement effectively. Feedback from ED providers is needed to characterize differences across provider types in order to facilitate implementation of enhanced screening practices. METHODS: This qualitative focus group study examined the experiences of 6 psychiatric social workers, 16 emergency medicine physicians, and 15 psychiatric providers in conducting violence risk screening to elicit ideas about solutions and barriers. RESULTS: Eight themes emerged: Approach to Patient Assessment, High-Yield Clinical Data in Risk Assessment, Suicide Risk Screen, ED Clinician Resources, Analysis of Professional Risk, Affective Response of Clinician, ED Role and Scope, and Clinical Management. All clinician types discussed the themes from their professional perspectives and generated important knowledge of violence risk screening practices. CONCLUSIONS: The findings affirm the importance of interdisciplinary cooperation in addressing violence risk in the ED and emphasize the need for ongoing clinical education and feedback as well as the importance of optimizing efficiency.

A study of suicidal thoughts and behaviour in a sample of adults affected by the 9/11 attacks on New York City's World Trade Center.

Previous research on suicide risk in relation to disasters has yielded varying findings, likely resulting at least in part from inconsistencies in definitions of disaster exposure and assessment of psychiatric disorders. This study examined suicidal thoughts and behaviour in a sample of 379 adults affected by the 9/11 attacks on New York City, using carefully-defined disaster exposure variables and assessing psychopathology with full diagnostic criteria, nearly 3 years after the disaster. Only 7% of the sample reported any postdisaster suicidal thoughts or behaviour, only 1% of which were new (incident) after the disaster, amounting to very little evidence of incident suicidal risk. The occurrence of a postdisaster psychiatric disorder in nearly one-half of the sample (45%) was significantly associated with postdisaster suicide risk (15% vs 1%). Disaster trauma exposure was not associated with postdisaster suicide risk. The findings of this study are not consistent with the disaster experience itself giving rise to suicide risk. Nonetheless, the postdisaster setting provides opportunities for education about and surveillance for suicide risk and other mental health concerns.

Association between headache and suicidality: An analysis of universal suicide screening data at a large urban county hospital.

BACKGROUND: Identifying individuals at increased risk of suicide is important, particularly those who present for treatment for nonpsychiatric chief complaints who may go undetected. It has been found that pain symptoms, such as headache, are associated with suicide, although this association requires further characterization. This study examined specific components of suicidality in relation to headache subtypes. METHODS: This study retrospectively reviewed 2,832,835 nonpsychiatric adult clinical encounters at a large county hospital, where a standardized suicide risk screening tool, the Columbia-Suicide Severity Rating Scale (C-SSRS), was universally implemented. The C-SSRS assesses specific components of suicidality: wish to be dead and suicidal ideation, method, intent, plan, and action. Multivariate logistic regressions were performed to assess the association between headache, as well as headache subtype (migraine, tension, or cluster), and each component of suicidality. RESULTS: There were significant positive associations between presenting with a headache and 2 specific components of suicidality: wish to be dead and suicidal action. Individuals with tension headache may have a lower risk of wishing to be dead compared to those with migraine and cluster headaches. CONCLUSIONS: The association of headaches with specific elements of sui-cidality demonstrates the potential yield of identification of suicide risk among individuals with nonpsychiatric presentations.

Are burns a chronic condition? Examining patient reported outcomes up to 20 years after burn injury-A Burn Model System National Database investigation.

BACKGROUND: People living with burn injury often face long-term physical and psychological sequelae associated with their injuries. Few studies have examined the impacts of burn injuries on long-term health and function, life satisfaction, and community integration beyond 5 years postinjury. The purpose of this study was to examine these outcomes up to 20 years after burn injury. METHODS: Data from the Burn Model System National Longitudinal Database (1993-2020) were analyzed. Patient-reported outcome measures were collected at discharge (preinjury status recall) and 5 years, 10 years, 15 years, and 20 years after injury. Outcomes examined were the SF-12/VR-12 Physical Component Summary and Mental Component Summary, Satisfaction with Life Scale, and Community Integration Questionnaire. Trajectories were developed using linear mixed models with repeated measures of outcome scores over time, controlling for demographic and clinical variables. RESULTS: The study population included 421 adult burn survivors with a mean age of 42.4 years. Lower Physical Component Summary scores (worse health) were associated with longer length of hospital stay, older age at injury and greater time since injury. Similarly, lower Mental Component Summary scores were associated with longer length of hospital stay, female sex, and greater time since injury. Satisfaction with Life Scale scores decrease negatively over time. Lower Community Integration Questionnaire scores were associated with burn size and Hispanic/Latino ethnicity. CONCLUSION: Burn survivors' physical and mental health and satisfaction with life worsened over time up to 20 years after injury. Results strongly suggest that future studies should focus on long-term follow-up where clinical interventions may be necessary. LEVEL OF EVIDENCE: Prognostic and Epidemiologic; Level III.

Predicting Depression and Posttraumatic Stress Symptoms Following Burn Injury: A Risk Scoring System.

Depression and posttraumatic stress (DPTS) are common psychiatric comorbidities following burn injury. The purpose of this study was to develop an admission scoring system that assesses the risk of development of depression or posttraumatic symptoms in the burn population. This study is a retrospective review of the prospectively collected Burn Model System National Database. Adult burn survivors enrolled from 2014 to 2018 (n = 486) were included. The primary outcome was the presence of DPTS symptoms at 6, 12, or 24 months postinjury. Logistic regression analysis was used to identify demographic and clinical predictors of DPTS symptoms. A risk scoring system was then created based on assigning point values to relevant predictor factors. The study population had a mean age of 46.5 ± 15.8 years, mean burn size of 18.3 ± 19.7%, and was 68.3% male. Prior to injury, 71.3% of the population was working, 47.9% were married, and 50.8% had completed more than a high school education. An 8-point risk scoring system was developed using the following predictors of DPTS symptom development: gender, psychiatric treatment in the past year, graft size, head/neck graft, etiology of injury, and education level. This study is the first to develop a DPTS symptom risk scoring system for burn injury. This scoring system will aid in identifying burn survivors at high risk of long-term psychiatric symptoms that may be used to improve screening, monitoring, timely diagnosis, and interventions.

The relation between satisfaction with appearance and race and ethnicity: A National Institute on Disability, Independent Living, and Rehabilitation Research burn model system study.

Research supports that people of color in the U.S. have poorer outcomes after burn injury compared to White individuals. The current study sought to explore burn health disparities by testing the relationship between racial and ethnic minority status, a proxy for systemic discrimination due to race and ethnicity, with two key constructs linked to functional outcomes, satisfaction with appearance and social community integration. Participants included 1318 burn survivors from the Burn Model System National Database (mean age = 40.2, SD = 12.7). Participants completed measures of satisfaction with appearance and social community integration at baseline, 6-, 12-, and 24-months after burn injury. Linear regressions revealed that racial and ethnic minority status significantly related to lower satisfaction with appearance and social community integration compared to White individuals at all time points. In addition, satisfaction with appearance continued to significantly relate to greater social community integration even while accounting for race and ethnicity, age, sex, burn size, and physical disability at 6-, 12-, and 24-month time points. Overall, the study supports that racial and ethnic minority burn survivors report greater dissatisfaction with their appearance and lower social community reintegration after burn injury.

Universal Pediatric Suicide Risk Screening in a Health Care System: 90,000 Patient Encounters.

BACKGROUND: Suicidal behavior is increasing among US youths. Contact with the health care system is common in the months before suicide. OBJECTIVE: To assess the characteristics of suicide risk among youths presenting for health care, universal screening results from a large hospital system were analyzed. METHODS: A retrospective analysis of the Ask Suicide-Screening Questions tool administered to patients aged 10-17 years in a hospital system including an emergency department, inpatient medical units, and primary care clinics was conducted. Demographic and clinical data from 3 years of encounters were analyzed. RESULTS: The sample consisted of 91,580 pediatric encounters, predominantly white Hispanic and women, with one third speaking Spanish. Across health care settings, 2.9% of encounters produced positive suicide risk screens, with the highest rate in the emergency department (8.5%). Acute positive screens, indicating imminent risk for suicidal behavior, accounted for 0.3% of all encounters. Approximately one-fourth (27.6%) of encounters for psychiatric presenting problems screened positive compared with 2.3% for nonpsychiatric encounters. Higher rates of positive screens were present among encounters for psychiatric presenting problems across all settings. Positive screens were less common among preteen (1.8%) than adolescent (3.1%) encounters (χ2 = 65.50, P < 0.001). CONCLUSIONS: Universal screening detected suicide risk in approximately 3% of pediatric health care encounters. Screening identified risk in encounters among preteen and adolescent patients, with a higher prevalence of positive screens in encounters for youths presenting with psychiatric problems and for emergency department visits. Acute positive screens were rare, occurring in less than half of 1 percent of encounters.

Objective and Subjective Perspectives on Implementation of a Violence Risk Screening Program in an Emergency Department.

OBJECTIVE: The objective of this study was to use quantitative and qualitative data to gather information about emergency medicine and psychiatric provider perspectives regarding the evolution of a violence risk screening process including the simultaneous implementation of a universal suicide screening program. METHODS: A retrospective review of violence risk screening data for 496 patient encounters over a 2-year period and across 4 phases of implementation and improvement was completed. Four focus groups were conducted with emergency medicine and psychiatric providers using nondirective facilitation methods to gather data regarding provider perspectives about violence and suicide risk screening. The focus groups were recorded, transcribed, and analyzed for thematic content. RESULTS: Four of the 6 violence risk screening items were most strongly associated with high-risk stratification across all phases. There were no changes in proportions of positive responses for 3 of the items. The proportion of positive responses for the other items changed significantly after expert feedback and clarification of item wording. Only 3% of the focus group passages included discussion of the universal suicide screening program. CONCLUSIONS: The providers indicated that they believed the violence risk screening and suicide screening procedures helped improve clinical thoroughness and documentation. Ongoing feedback between providers and program developers was beneficial. The implementation of the universal suicide screening process was relatively seamless for these providers.

Suicidal Ideation and Depression Among Adolescent and Young Adult Cancer Patients.

Purpose: Adolescent and young adult (AYA) cancer patients (aged 18-39 years) represent a unique population within oncology. The developmental and mental health challenges that can co-occur with a diagnosis of cancer during this age range make AYAs a high-risk group for mental health problems, including depression and suicidal ideation. Therefore, the objective of this study was to assess the differences in rates of suicidal ideation and depression between AYAs and older adults (OAs; aged 40+ years) within an outpatient cancer support clinic. Methods: Depression screening data from routine clinical care were gathered and analyzed for adult patients receiving support services at an outpatient academic cancer clinic. The general mental health screening protocol included the Patient Health Questionnaire (PHQ)-9, which was used as a measure of depression symptoms, including suicidal ideation. Results: Five hundred cancer survivors were included in the initial data analysis, with 21 (40.38%) of the AYAs and 143 (31.92%) of the OAs scoring ≥5 on the PHQ-9. Statistical analysis of groups at this cutoff score reflected no significant difference in depression between AYA and OA groups. However, a chi-square analysis revealed significantly higher suicidal ideation endorsement by AYAs versus OAs in this sample (χ2 [1, N = 500] = 3.98, p = 0.046). Conclusion: Results from routinely collected clinical data reveal a higher rate of suicidal ideation in AYAs compared with OA cancer patients, which supports the need for additional research on AYA cancer patient suicidal ideation in different settings and the implementation of mental health programs specifically for AYA patients.

Exploratory analysis of long-term physical and mental health morbidity and mortality: A comparison of individuals with self-inflicted versus non-self-inflicted burn injuries.

INTRODUCTION: Self-inflicted burn (SIB) injuries are relatively rare, but patients may experience complex biopsychosocial challenges. This study aimed to compare long-term physical and psychological outcomes for individuals with SIB and non-SIB injuries. METHODS: Records of adult SIB (n = 125) and non-SIB (n = 3604) injuries were collected from U.S. burn centers within the Burn Model System between 1993 and 2018. Assessments were administered at discharge, 6 months, 24 months, 5 years, and 10 years. RESULTS: SIB patients were more often younger, unmarried, unemployed, male, struggling with pre-morbid psychiatric issues, and injured by fire/flame (all p < 0.001). SIB injury predicted prolonged mechanical ventilation, hospitalization, and rehabilitation (all p < 0.001). After injury, SIB patients had increased anxiety at 24 months (p = 0.0294), increased suicidal ideation at 5 years (p = 0.004), and clinically worse depression at 10 years (p = 0.0695). SIB patients had increased mortality across 24 months compared to non-SIB patients (OR = 4.706, p = 0.010). CONCLUSION: SIB injuries are associated with worse physical and psychological outcomes compared to non-SIB injuries including complicated hospitalizations and chronic problems with anxiety, depression, suicidality, and mortality, even when controlling for common indicators of severity such as burn size. This underscores the importance of multidisciplinary treatment, including mental healthcare, and long-term follow-up for SIB patients. Identified pre-morbid risk factors indicate the need for targeted injury prevention.

Assessing recent suicidal ideation and behavior in the adult epilepsy monitoring unit.

OBJECTIVES: The objective of the study was to describe the prevalence of recent suicidal ideation and behavior in adult patients admitted to a tertiary epilepsy monitoring unit (EMU) and to assess the difference between patients with epileptic seizures, psychogenic nonepileptic spells (PNES), and other inpatient populations. RESULTS: Over the 14-month period, 316 patients were included in the study. One hundred and seventy-nine (57%) were classified as having epilepsy (ES), 116 (37%) with PNES, and 21 (7%) with comorbid ES and PNES (ES/PNES). Overall, 25 patients (8%) were screened positive for suicide risk factors (recent suicidal ideation and/or suicidal behavior). Patients admitted to the EMU had double the risk of suicide ideation and behavior when compared with other inpatient populations. There was no significant difference in the risk of suicidal ideation and behavior among patients with ES, PNES, and comorbid ES/PNES. Patients with comorbid ES/PNES had the highest risk (14%), although this did not reach statistical significance. Across all groups, patients with any comorbid psychiatric disorder had increased rates of suicidal ideation and behavior (11% vs 5%, p = 0.04). CONCLUSIONS: The rate of suicidal ideation and behavior in this sample of EMU patients was higher compared with other inpatient populations. The presence of a psychiatric disorder was independently associated with a higher risk. There was no statistically significant difference in the risk between those with ES and PNES. Screening for suicide risk, suicidal ideation, and behavior is recommended for all patients admitted to the EMU.

An inflammatory profile linked to increased suicide risk.

BACKGROUND: Suicide risk assessments are often challenging for clinicians, and therefore, biological markers are warranted as guiding tools in these assessments. Suicidal patients display increased cytokine levels in peripheral blood, although the composite inflammatory profile in the subjects is still unknown. It is also not yet established whether certain inflammatory changes are specific to suicidal subjects. To address this, we measured 45 immunobiological factors in peripheral blood and identified the biological profiles associated with cross-diagnostic suicide risk and depression, respectively. METHODS: Sixty-six women with mood and anxiety disorders underwent computerized adaptive testing for mental health, assessing depression and suicide risk. Weighted correlation network analysis was used to uncover system level associations between suicide risk, depression, and the immunobiological factors in plasma. Secondary regression models were used to establish the sensitivity of the results to potential confounders, including age, body mass index (BMI), treatment and symptoms of depression and anxiety. RESULTS: The biological profile of patients assessed to be at increased suicide risk differed from that associated with depression. At the system level, a biological cluster containing increased levels of interleukin-6, lymphocytes, monocytes, white blood cell count and polymorphonuclear leukocyte count significantly impacted suicide risk, with the latter two inferring the strongest influence. The cytokine interleukin-8 was independently and negatively associated with increased suicide risk. The results remained after adjusting for confounders. LIMITATIONS: This study is cross-sectional and not designed to prove causality. DISCUSSION: A unique immunobiological profile was linked to increased suicide risk. The profile was different from that observed in patients with depressive symptoms, and indicates that granulocyte mediated biological mechanisms could be activated in patients at risk for suicide.

Suicide Risk Assessment and Management in the Psychiatry Emergency Service: Psychiatric Provider Experience and Perceptions.

The objective of this study was to explore suicide risk identification and flow of patients with differing suicide risk through the Psychiatric Emergency Service (PES) to their clinical dispositions. 3 focus groups (N = 15 psychiatric providers working in the PES of a large urban teaching hospital) discussing suicide risk assessment in the PES were conducted, followed by thematic analysis. A total of 7 themes were identified in 624 coded passages. In focus groups conducted to explore suicide risk assessment, discussions shifted to broader matters, e.g., frustrations with the system in which the providers worked. 4 main messages emerged: screening tools cannot replace clinical judgment; the existing electronic health record is not efficient and sufficiently informative; competing demands challenge PES psychiatrists; and post-discharge patient outcome data are needed. These concerns suggest directions for improving patient care.