Early Health Impacts of a Primary Care Consultation Model for People Served by Assertive Community Treatment teams.

The cardiometabolic health outcomes and life expectancy of people living with serious mental illness (SMI) continue to significantly flag behind that of the general population. This study explores the possibility of using the evidence-based Assertive Community Treatment (ACT) model and infrastructure to increase access to primary care and improve cardiometabolic outcomes of people with SMI. Four ACT teams in a large urban area received the services of a primary care consultant who was co-located at a Federally Qualified Health Center (FQHC), met regularly with ACT team clinicians to review a cardiometabolic registry of participants, and engaged participants in primary care services. Health screening rates, primary care utilization, and cardiometabolic outcomes-body mass index, blood pressure, hemoglobin A1c, cholesterol, and tobacco smoking status-were monitored over the course of a year. The efficacy of this integrated care model was also explored through focus groups with ACT team staff and participants. Significant improvements in screening rates were found for the ACT teams that received this integrated care intervention; however, only modest improvements in cardiometabolic outcomes were found. Future longitudinal, multi-site studies are needed to fully determine the impact of integrated care models on the physical health outcomes of this vulnerable population.

Sharing perspectives on feedback: a combined resident-faculty workshop.

BACKGROUND: Feedback is essential to medical education. Although the need for effective feedback delivery is well known, more recent focus is on understanding and strengthening the faculty-trainee relationship within which the feedback process is carried out. The authors developed and implemented a combined resident-faculty feedback workshop within a psychiatry residency training program to enhance participants' understanding of challenges residents and faculty experience with the feedback process. METHODS: The one-hour workshop consisted of small group activities and large group discussions, focused on (i) feedback challenges for both residents and faculty and (ii) potential ways to address identified challenges. Participants completed pre-and post-workshop questionnaires to rate their level of understanding of, and answer open-ended questions regarding, feedback challenges. Mixed-methods assessment of questionnaire responses examined quantitative rating changes from pre- to post-workshop, as well as emergent qualitative themes from the open-ended responses. RESULTS: From a pool of 30 workshop participants, 26 completed each of the pre- and post-workshop questionnaires. Overall, participants were satisfied with the programming. Important considerations for the feedback process were (i) specific/constructive/timely feedback, (ii) meeting logistical/administrative feedback requirements, (iii) setting norms/expectations of effective/routine feedback, and (iv) relational/emotional considerations surrounding feedback. It appeared both faculty and residents were able to increase perspective taking about how the other group perceived the feedback process. CONCLUSIONS: This pilot project is one of the first to examine a joint resident-faculty workshop focused on understanding how faculty and residents can interact to better understand each other's perspective on the feedback process. Further work in this area is needed to identify common misperceptions and design programming to help correct them. Further research is also needed to examine the impact of such programming on the feedback process.

Integrating Primary Care Into Assertive Community Treatment.

OBJECTIVE: This program evaluation examined integration of primary care nurse practitioners into assertive community treatment (ACT). METHODS: From January to June 2019, primary care nurse practitioners in a postgraduate fellowship program were assigned to five ACT teams (N=305 participants). Focus groups explored staff members' and participants' experiences. Screening rates for hemoglobin A1c and cholesterol for ACT participants were compared over time. RESULTS: Staff and participants in ACT described improved engagement in primary care, citing benefit from colocation and consultation. Field visits were not found to be an efficient use of the primary care nurse practitioners' time to serve most ACT participants. A significant increase in screening was observed after 6 months for the ACT teams with integrated primary care. CONCLUSIONS: An integrated primary care nurse practitioner readily available for participant engagement and consultation with the ACT team, using a cardiometabolic registry to guide care, may offer a sustainable model of integration.

The psychopharmacology algorithm project at the Harvard South Shore Program: An algorithm for adults with obsessive-compulsive disorder.

A previous algorithm for the pharmacological treatment of obsessive-compulsive disorder was published in 2012. Developments over the past 7 years suggest an update is needed. The authors conducted searches in PubMed, focusing on new studies and reviews since 2012 that would support or change previous recommendations. We identified exceptions to the main algorithm, including pregnant women and women of child-bearing potential, the elderly, and patients with common medical and psychiatric co-morbidities. Selective serotonin reuptake inhibitors (SSRIs) are still first-line. An adequate trial requires a period at typical antidepressant doses and dose adjustments guided by a plasma level to evaluate for poor adherence or ultra-rapid metabolism. If the response is inadequate, consider a trial of another SSRI this time possibly taken to a very high dose. Clomipramine could be an alternative. If the response to the second trial remains inadequate, the next recommendation is to augment with aripiprazole or risperidone. Alternatively, augmentation with novel agents could be selected, including glutamatergic (memantine, riluzole, topiramate, n-acetylcysteine, lamotrigine), serotonergic (ondansetron), and anti-inflammatory (minocycline, celecoxib) agents. A third option could be transcranial magnetic stimulation. Lastly, after several of these trials, deep brain stimulation and cingulotomy have evidence for a role in the most treatment-refractory patients.

Mapping Movement: Applying Motion Measurement Technologies to the Psychiatric Care of Older Adults.

PURPOSE OF REVIEW: Recent advances in technology have changed the landscape of treatment for adults with mental illness. This review highlights technological innovations that may improve care for older adults with mental illness and neurocognitive disorders through the measurement and assessment of physical motion. These technologies include wearable sensors (such as smart watches and Fitbits), passive motion sensors, and smart home models that incorporate both active and passive motion technologies. RECENT FINDINGS: Clinicians have evaluated motion measurement technologies in older adults with depression, dementia, anxiety, and schizophrenia. Results from studies in dementia populations suggest that motion measurement technologies can assist clinicians in diagnosing dementia earlier through the evaluation of gait, balance, and postural kinematics. Motion detection technologies can also be used to identify mood episodes at an earlier stage by detecting subtle behavioral changes. Clinicians may use the objective data provided by technologies such as accelerometers to identify illnesses earlier, which may inform treatment decisions. The data may be used as a suitable surrogate marker for detecting depression in older adults, predicting the likelihood of falls, or quantifying physical activity in older adults with chronic mental illnesses or anxiety. Motion-based technologies also have the potential to detect physical activity for older adults residing in nursing homes. Wearable technologies are generally well tolerated in older adults, although the use of new technology and electronic health data could involve privacy and security concerns among this vulnerable population.