Perinatal psychiatric practitioner consultation program delivers rapid response to OB/GYN practitioners.

INTRODUCTION: Screening and treatment initiation for perinatal psychiatric conditions is a recommended competency in OB/GYN practitioners, yet perinatal psychiatry is rapidly evolving. Practitioner-to-psychiatrist consultation programs have the potential to improve the management of psychiatric conditions in perinatal women. This study describes utilization of a statewide perinatal psychiatric consultation service by OB/GYN practitioners through examination of the volume, responsivity, content and outcomes of clinical inquiries, and satisfaction. METHODS: This quality improvement study describes the 460 telephone or e-mail consultations requested by OB/GYN practitioners over 2 years and housed within a REDCap database. Data include the characteristics of consult users, month-over-month and total utilization, the patient's perinatal status, the reason for contact, current symptoms and medications, and the consulting psychiatrist recommendations. Practitioner satisfaction with consultation is also described. RESULTS: After completion of triage, the psychiatrist returned the practitioner's call ≤5 min in 59% of consultations. The most common inquiries were for pregnant (64%) women for depressive (51%) or anxiety (46%) symptoms with 47% of inquiries reporting the patient was currently taking a psychiatric medication. Had consultation not been available, referral to mental health (41%) or starting a medication (15%) were most often reported. CONCLUSIONS: This perinatal psychiatric consultation service rapidly and effectively met the needs of practitioners practicing in OB/GYN settings across a state having a critical psychiatry shortage and varying urban and rural geography. Future recommendations include the assessment of direct patient outcomes, practitioner skill attainment, and long-term cost savings of this perinatal psychiatric consultation model.

Differences in Utilization of Perinatal Psychiatric Teleconsultation Line Between Primary Care and Mental Health Providers.

PURPOSE: Teleconsultation has been a newly recognized avenue by which to provide psychiatric services to perinatal populations being treated either by psychiatric or primary care providers. The Periscope Project (TPP) is a business-hours teleconsultation line providing enrolled clinicians with access to a subspecialty-trained psychiatrist, as well as community resources and provider education. This study examines the differences in consultation between enrolled providers. METHODS: Encounter data was entered into REDCap by TPP's team members. Data was analyzed using summary statistics. Satisfaction information was attained by follow-up survey. RESULTS: During the first 24 months of program activity, TPP had a total of 737 referred encounters, 70.4% from primary care and 20.5% from psychiatry. There were statistically significant differences between psychiatric and primary care providers in terms of recommendations for use of certain types of medications and use of diagnostic screenings, as well as differences in what providers would have recommended in absence of TPP's involvement. CONCLUSIONS: Differences in enrollee's rationale for consultation allows for better understanding of the needs of front-line providers. Tailoring educational information and even teleconsultation information based on provider group can allow for more efficient patient care and resource utilization. Providers across the spectrum found TPP beneficial, indicating that continued availability to all providers caring for women of reproductive age is important.

Feasibility of model adaptations and implementation of a perinatal psychiatric teleconsultation program.

OBJECTIVE: Given the critical shortage of perinatal psychiatrists, combined with the prevalence of psychiatric conditions in the perinatal period, teleconsultation may help to maximize the efficiency of psychiatrists to reach this population. The Periscope Project (TPP) is a Wisconsin-based program offering real-time provider-to-provider teleconsultation, community resource information, and provider education. This paper describes model adaptations and implementation of TPP and the first 18 months of program data. METHOD: Enrollment and satisfaction data was collected via self-reported online surveys. Encounter data was entered by TPP team members through communication with providers. All data was housed in REDCap. RESULTS: Four hundred eight-five providers enrolled and 268 unique providers accessed services at least once. There were 594 encounters with 85% of encounters resulting in a teleconsultation. Mean call-back time from the psychiatrist was 6.8 min. Over half of utilizing providers practiced in obstetrical settings and 23% practiced in mental health settings. Provider satisfaction with the service was 100%. CONCLUSIONS: Utilization and satisfaction with TPP suggest that perinatal psychiatry access program models can vary in structure and process and experience similar utilization rates. Model adaptations are feasible and demonstrate the teleconsultation service is accepted by providers and may improve the population's health over time.

Co-located perinatal psychiatry clinic: impact of adding a psychologist on clinical quality improvement metrics.

Purpose: To describe the impact of adding a psychologist (the intervention) to a co-located perinatal psychiatry clinic (PPC) in terms of effects on clinical quality improvement (QI) metrics. Methods: Six-month pre- and postintervention study design with measurement of QI metrics: number of unique patients treated; number of new and established visits; percent no-shows for new and established visits; and mean wait time to new visit. Results: Number of unique patients treated by the psychiatrist increased by 30%, from 90 preintervention to 118 postintervention (p = .06). Total number of visits completed by the psychiatrist increased by 20% from 174 preintervention to 208 postintervention. Mean wait time for new visits for a physician decreased from 20 days preintervention to 14 days postintervention, with a mean difference of 6.4 days (p = .0015). Percentage of no-shows for new visits increased slightly from 23% preintervention to 26% postintervention (p = .72). The percentage of no-shows for established visits decreased significantly from 22% preintervention to 10% postintervention (p < .005). Conclusions: By adding a psychologist to the co-located PPC, we improved quality of perinatal mental health care by improving efficiency, timeliness and patient-centered care. The psychiatrist saw a greater number of unique patients, decreased wait time to new visits and decreased no-show rates for established visits, likely by better matching patient needs with provider services. A psychologist could be a valuable addition to a PPC, given the shortage of psychiatrists in the United States.

NEEDS AND CHALLENGES OF HOME VISITORS CONDUCTING PERINATAL DEPRESSION SCREENING.

This article describes the needs and challenges faced by home visitors, supervisors, and clients when conducting perinatal depression screening. Home visitors (n = 11), supervisors (n = 5), and clients (n = 9) representing rural and urban practice settings in Wisconsin were recruited into three separate focus groups. Themes were identified from the transcribed audio-recorded interviews using content analysis. Results indicate that a trusting relationship was leveraged to facilitate depression screening and referral. Home visitors personalized care to a client's context and to protect confidentiality. Home-visiting practice demanded flexibility and negotiation in decision-making with clients and families. Coordinating access to mental health evaluation in areas of limited access was a common challenge. Participants reported a need for further training on safety management. With adequate training and support, home visitors are well-positioned to promote access to mental health services in vulnerable families to support infant mental health.

Managing Your Own Mood Lability: Use of Mood Stabilizers and Antipsychotics in Pregnancy.

The management of psychiatric disorders during the perinatal period can be difficult; psychiatric decompensation during pregnancy can affect not only the mother but also the fetus and neonate. It is imperative that psychiatric providers proactively discuss pregnancy planning, and be able to thoughtfully weigh the risks of untreated psychiatric illness and psychotropic medications in pregnancy and breast-feeding. With the exception of valproate and carbamazepine, several mood stabilizers and antipsychotics can be utilized during pregnancy with minimal risk to the fetus and neonate in terms of major malformations; there is a growing body of evidence regarding the risk profile of use of these medications in pregnancy. Key Points Preconception planning is very helpful when it can be done; consider discussion and documentation of risks at time of administration of psychotropic medications for any reproductive-aged women, regardless of plans for conception. Continued psychiatric stability through the perinatal period is imperative; the risks of an untreated psychiatric disorder are just as important, if not more so important, than the risks of psychotropic medication exposure. Exposure to one psychotropic medication is safer than exposure to multiple medications. Utilize lowest effective dose of medication; most risks are not dose dependent, therefore would typically prefer higher dose of medication, rather than emergence of psychiatric symptoms, in order to avoid exposure of the fetus to both psychotropic medications and psychiatric symptoms. General recommendations are to avoid valproate and carbamazepine in reproductive-aged women. With close monitoring, lithium can be safely utilized in pregnancy. Preliminary data regarding use of atypical antipsychotics is reassuring in regards to major malformations; however, larger numbers of participants are needed to provide more complete reproductive safety data with this class. Clearly document risks of an untreated psychiatric illness as well as risks of psychotropic medication management to the mother and developing fetus/neonate.

Updates in Psychosomatic Medicine: 2014.

BACKGROUND: The amount of literature published annually related to psychosomatic medicine is vast; this poses a challenge for practitioners to keep up-to-date in all but a small area of expertise. OBJECTIVES: To introduce how a group process using volunteer experts can be harnessed to provide clinicians with a manageable selection of important publications in psychosomatic medicine, organized by specialty area, for 2014. METHODS: We used quarterly annotated abstracts selected by experts from the Academy of Psychosomatic Medicine and the European Association of Psychosomatic Medicine in 15 subspecialties to create a list of important articles. RESULTS: In 2014, subspecialty experts selected 88 articles of interest for practitioners of psychosomatic medicine. For this review, 14 articles were chosen. CONCLUSIONS: A group process can be used to whittle down the vast literature in psychosomatic medicine and compile a list of important articles for individual practitioners. Such an approach is consistent with the idea of physicians as lifelong learners and educators.

Comparison of multiple psychological distress measures between men and women preparing for in vitro fertilization.

OBJECTIVE: To compare multiple measures of psychological distress between men and women preparing for IVF. DESIGN: Retrospective cohort study. SETTING: Outpatient, academic infertility clinic. PATIENT(S): One hundred sixty-two consecutive couples presenting for infertility treatment with IVF. INTERVENTION(S): Measures were completed as part of a routine, infertility-focused psychological evaluation, including the Beck Depression Inventory, State-Trait Anxiety Inventory, State-Trait Anger Inventory, and Impact of Events Scale. MAIN OUTCOME MEASURE(S): Scores of above psychological questionnaires. RESULT(S): Psychological distress scores were statistically significantly higher among women than men for symptoms of depression, state anxiety, infertility specific distress, and general perceived stress. However, aside from infertility-specific distress (d = .43), effect sizes for the paired differences between females and males ranged from d = .18 to .23. CONCLUSION(S): Women consistently scored higher on multiple measures of psychological distress than their male partners in the context of preparing for IVF. Comparison of infertility-specific distress scores yielded the largest statistically and clinically significant difference compared with traditional measures of general depression and anxiety symptoms.

Takotsubo cardiomyopathy after electroconvulsive therapy.

BACKGROUND: Takotsubo cardiomyopathy is a novel acute cardiac syndrome characterized by transient regional systolic dysfunction of the left-ventricular apex and mid-ventricle, with hyperkinesis of the basal left ventricular segments, which has been associated with severe emotional or physical stress. METHOD: This is the second published case report of takotsubo cardiomyopathy occurring in the setting of electroconvulsive therapy (ECT). RESULTS: The patient, a 52-year-old woman, experienced chest pain and discomfort shortly after ECT treatment. She was shown to have moderate left-ventricular dysfunction, with mid-cavity left-ventricular hypo- to akinesis, and hyperkinesis in the basilar region, consistent with a diagnosis of takotsubo cardiomyopathy. There was full resolution of her symptoms within 48 hours of the initial event. DISCUSSION: This report highlights a previously undocumented complication of ECT and adds to the growing list of stressors responsible for cases of takotsubo cardiomyopathy. The prognosis is favorable, and recovery is generally complete, especially with early recognition of the syndrome and proper supportive treatment.

Postpartum depression screening: initial implementation in a multispecialty practice with collaborative care managers.

Postpartum depression (PPD) has emerged as an important issue for pediatricians and family practitioners because of detrimental effects on children. PPD occurs in 10% to 22% of women who have recently given birth, but fewer than half of cases are recognized. Despite the impact of PPD, many primary care clinicians do not have systemic screening approaches implemented. This paper will review the development of a screening protocol for PPD in a multispecialty clinic, with the implementation utilizing depression care managers and the preliminary results of our process. Of the 333 screened examinations during the 4-month study, 38.1% (n = 127) were performed for the 2-month well child examination; 33.6% (n = 112) were for the 4-month examination, with 28.2% (n = 94) being performed for the 6-month well child examination. Only 15 (4.5%) were positive for possible depression with a screening compliance rate of 47.9%. No significant difference was noted in the timing of the well child visit with a positive screening test result, nor was there any difference in family medicine versus pediatric colleagues in the utilization of the screening or diagnosis of PPD. Implementation of PPD screening in a multispecialty clinic can be effective, given utilization of depression care managers.

Preparing psychiatric residents for the "real world": a practice management curriculum.

OBJECTIVE: The authors describe a course designed for residents to develop the knowledge and skills necessary to collaborate and successfully compete in today's complex health care environment and to achieve competency in systems-based practice. METHODS: Postgraduation surveys demonstrated a need for improvement in preparing residents for practice management issues. The authors outline a 32-week practice management curriculum for postgraduate-year 3 (PGY 3) psychiatric residents. RESULTS: The course was rated highly by residents in terms of topics covered, faculty involvement, and overall expectations. The project assignments completed by the residents were effective in creating objective change in the resident outpatient practice. CONCLUSION: Practice management is an essential part of residency training and can be successfully integrated into the residents' clinical practice experience. Future steps include assessment of the graduates at 1 and 5 years postgraduation to evaluate the long-term efficacy of the course.

Atypical antipsychotic use in pregnancy: a retrospective review.

To determine the prevalence of use of atypical antipsychotics in pregnancy and describe infant outcomes associated with these exposures. A retrospective chart review of all pregnant women presenting at our medical center, from the years 1993 to 2007, was conducted. 30,092 total deliveries during that time period were identified. 16 mothers were treated with atypical antipsychotics during their pregnancy. The medical charts of the infants exposed to atypical antipsychotics during pregnancy were reviewed to determine their outcomes, including gestational age, birth weight, and malformations. Only 16 (0.053%) of the women took an atypical antipsychotic at some point during the antenatal period. Average gestational age was 37 5/7 weeks with a standard deviation of 2.54 days. Average birth weight was 3,188 g with a standard deviation of 615 g, which is appropriate for early gestational age. One (6.25%) major malformation was noted. Additional studies need to be completed regarding the effect of atypical antipsychotic use in pregnancy and outcomes related to gestational age, birth weight and malformations.

Congenital heart disease associated with selective serotonin reuptake inhibitor use during pregnancy.

OBJECTIVE: To determine the risk of congenital cardiac abnormalities associated with use of selective serotonin reuptake inhibitors (SSRIs) during pregnancy. PATIENTS AND METHODS: We conducted a retrospective review of the medical records of all pregnant women presenting at Mayo Clinic's site in Rochester, MN, from January 1, 1993, to July 15, 2005, and identified 25,214 deliveries. A total of 808 mothers were treated with SSRIs at some point during their pregnancy. We reviewed the medical records of the newborns exposed to SSRIs during pregnancy to analyze their outcomes, specifically for congenital heart disease and persistent pulmonary hypertension of the newborn. RESULTS: Of the study patients, 808 (3.2%) took an SSRI at some point during the antenatal period. Of the 25,214 deliveries, 208 newborns (0.8%) were diagnosed as having congenital heart disease. Of the 808 women exposed to SSRI during pregnancy, 3 (0.4%) had congenital heart disease compared with 205 (0.8%) of the 24,406 women not exposed to an SSRI (P=.23). Of the total number of deliveries, 16 newborns were diagnosed as having persistent pulmonary hypertension of the newborn, none of whom had exposure to SSRIs (P>.99). CONCLUSION: Our data are reassuring regarding the safety of using SSRIs during pregnancy.