Acceptability and Feasibility of an Ecological Momentary Intervention for Managing Emotional Distress Among Psychiatric Inpatients at Risk for Suicide.

The weeks following an inpatient psychiatric hospitalization are known to be the highest-risk time for suicide. Interventions are needed that are well-matched to the dynamic nature of suicidal thoughts and easily implementable during this high-risk time. We sought to determine the feasibility and acceptability of a novel registered clinical trial that combined three brief in-person sessions to teach core cognitive-behavioral therapy (CBT) skills during hospitalization followed by smartphone-based ecological momentary intervention (EMI) to facilitate real-time practice of the emotion management skills during the 28 days after hospital discharge. Results from this pilot study (N = 26) supported some aspects of feasibility and acceptability. Regarding feasibility, 14.7% of all screened inpatients met study eligibility criteria. Half (50.3%) of those who were ineligible were ineligible because they were not part of the population for whom this treatment was designed (e.g., symptoms such as psychosis rendered them ineligible for the current study). Those who were otherwise eligible based on symptoms were primarily ineligible due to inpatient stays that were too short. Nearly half (48%) of study participants did not receive all three in-person sessions during their hospitalization. Among enrolled participants, rates of engagement with the smartphone-based assessment and EMI prompts were 51.47%. Regarding acceptability, quantitative and qualitative data supported the perceived acceptability of the intervention, and provided recommendations for future iterations. Well-powered effectiveness (and effectiveness-implementation) studies are needed to determine the effects of this promising and highly scalable intervention approach.

Real-time digital monitoring of a suicide attempt by a hospital patient.

Suicide is among the most devastating problems facing clinicians, who currently have limited tools to predict and prevent suicidal behavior. Here we report on real-time, continuous smartphone and sensor data collected before, during, and after a suicide attempt made by a patient during a psychiatric inpatient hospitalization. We observed elevated and persistent sympathetic nervous system arousal and suicidal thinking leading up to the suicide attempt. This case provides the highest resolution data to date on the psychological, psychophysiological, and behavioral markers of imminent suicidal behavior and highlights new directions for prediction and prevention efforts.

Psychology Internship Training Amidst COVID-19: Balancing Training Opportunities, Patient Care, and Risk of Exposure.

The emergence of the 2019 novel coronavirus (COVID-19) has dramatically altered how psychologists deliver its training. At least for the time being, virtual care has become the primary method for delivering mental health services. This has allowed patients and clinicians to continue to access and provide services in a way that would have been impossible years ago. Not only has this shift impacted patients, but it has also impacted supervision and training. The impact has been especially profound on inpatient units where the psychiatric and medical acuity is high of patients and the therapeutic milieu is an important aspect of treatment. The purpose of this paper is to review the impact of COVID-19 on pre-doctoral psychology interns during their rotation on an inpatient psychiatry unit at the start of the pandemic (January to June of 2020) and use these experiences to onboard the next class of interns in the new academic year (July 2020 to June 2021) using a hybrid model of in-person and virtual training experiences. At the end of 2020/2021 rotation, we voluntarily asked interns to complete a questionnaire that was developed based on the qualitative experiences of the previous class to assess the effectiveness of this hybrid model. We also surveyed multi-disciplinary staff members who were essential personnel and required to work in person during this time about their experiences of safety and support. With this information, we explore and offer guidance to other inpatient training sites who are likely to encounter similar challenges during this time. In particular, we discuss the integration of virtual technology into this training experience, as well as the restructuring of clinical and supervisory experiences. We highlighted several short-term strategies that we have flexibly adapted to our inpatient unit. The lessons learned herein seek to guide supervisors and trainees alike in adapting their psychology training programs to meet the evolving demands of COVID-19.

Racial and Ethnic Inequities in Inpatient Psychiatric Civil Commitment.

OBJECTIVE: Involuntary psychiatric treatment may parallel ethnoracial inequities present in the larger society. Prior studies have focused on restraint and seclusion, but less attention has been paid to the civil commitment system because of its diversity across jurisdictions. Using a generalizable framework, this study investigated inequities in psychiatric commitment. METHODS: A prospective cohort was assembled of all patients admitted to an inpatient psychiatric unit over 6 years (2012-2018). Patients were followed longitudinally throughout their admission; raters recorded legal status each day. Sociodemographic and clinical data were collected to adjust for confounding variables by using multivariate logistic regression. RESULTS: Of the 4,393 patients with an initial admission during the study period, 73% self-identified as White, 11% as Black, 10% as primarily Hispanic or Latinx, 4% as Asian, and 3% as another race or multiracial. In the sample, 28% were involuntarily admitted, and court commitment petitions were filed for 7%. Compared with White patients, all non-White groups were more likely to be involuntarily admitted, and Black and Asian patients were more likely to have court commitment petitions filed. After adjustment for confounding variables, Black patients remained more likely than White patients to be admitted involuntarily (adjusted odds ratio [aOR]=1.57, 95% confidence interval [CI]=1.26-1.95), as were patients who identified as other race or multiracial (aOR=2.12, 95% CI=1.44-3.11). CONCLUSIONS: Patients of color were significantly more likely than White patients to be subjected to involuntary psychiatric hospitalization, and Black patients and patients who identified as other race or multiracial were particularly vulnerable, even after adjustment for confounding variables.

An Ecological Momentary Intervention Study of Emotional Responses to Smartphone-Prompted CBT Skills Practice and the Relationship to Clinical Outcomes.

The practice of therapeutic skills outside of sessions in which they are learned is one presumed key component of cognitive behavioral therapy (CBT). Yet, our understanding of how skills practice relates to clinical outcomes remains limited. Here, we explored patients' emotional responses to CBT skills practice in a pilot study pairing smartphone-app-delivered skills reminders and guided practice (ecological momentary intervention [EMI]) using ecological momentary assessment (EMA). Participants (n = 25) were adults recently hospitalized for a suicide attempt or severe suicidal thinking. They received brief inpatient CBT (1 to 3 sessions covering core CBT skills from the Unified Protocol), followed by 1 month of EMI and EMA after discharge. On average, participants reported modest reductions in negative affect after skills use (i.e., immediate responses; median time elapsed = 4.30 minutes). Additionally, participants tended to report less negative affect when the timepoint preceding the current assessment included EMI skills practice, rather than EMA alone (i.e., delayed responses; median time elapsed between prompts = 2.17 hours). Immediate effects were unrelated to longer-term clinical outcomes, whereas greater delayed effects were associated with lower symptom severity at follow-up. Future studies should further examine how CBT skills use in daily life may alleviate symptoms.

Do Patterns and Types of Negative Affect During Hospitalization Predict Short-Term Post-Discharge Suicidal Thoughts and Behaviors?

We still have little understanding of short-term predictors of suicidal thoughts and behaviors (STBs). Prior research links increased negative affect to STBs, but the vast majority of earlier work is limited by measuring negative affect at one time point and aiming to predict STBs months or years in the future. Recently, intensive longitudinal studies have shown that negative affect is associated with suicidal thoughts over relatively short, clinically useful time periods; however, the specific patterns and types of negative affect that predict STBs remain unclear. Using ecological momentary assessment (EMA) data from psychiatric inpatients hospitalized for suicide risk (N = 83), this study sought to test whether the patterns (means and variability) of two types of negative affect (anxiety/agitation and shame/self-hatred, which were derived from a larger EMA battery) during hospitalization predict STBs in the four weeks after discharge: an extremely high-risk time for suicidal behavior. The mean - but not the variability - of both anxiety/agitation and shame/self-hatred during hospitalization predicted the number of days with suicidal thoughts after discharge. The mean and the variability of shame/self-hatred - but not anxiety/agitation - predicted post-discharge suicide attempt. We discuss implications for assessment and treatment of suicidal individuals and propose key directions for future research.

Negative affect is more strongly associated with suicidal thinking among suicidal patients with borderline personality disorder than those without.

Patients suffering from borderline personality disorder (BPD) are at elevated risk for suicidal thoughts and behaviors (STBs), but this well-described and clinically important association is not well-understood. Prior research suggests that STBs often function as an attempt to escape aversive affect, and that people with BPD experience stronger emotion reactivity and greater discomfort with emotion than those without BPD. Here, we tested whether negative affective states are more likely to predict suicidal thoughts among those with BPD than those without this disorder. Data on affective states and suicidal thoughts were collected several times per day from 35 psychiatric inpatients using their smartphones to capture real-time associations between negative affect and suicidal thoughts. Results revealed that the association between negative affective states (e.g., abandonment, desperation, guilt, hopelessness, loneliness, rage, self-hatred, and upset), and severity of suicidal thinking was stronger among those with BPD than among those without BPD. This finding has implications for risk assessment and intervention in the clinical setting: for a given degree of reported negative affect, patients with BPD experience more suicidal ideation than those without. Further research needs to be done to elucidate the mechanism of this effect.

Development and delivery of a quality improvement program to reduce antipsychotic polytherapy.

BACKGROUND: Although antipsychotic polytherapy is considered appropriate in limited circumstances (e.g., during a brief "cross-titration" period when switching medications), its increasing prevalence indicates use beyond this limited scope. Despite absence of support in the medical literature and higher costs, antipsychotic polytherapy is common in the treatment of schizophrenia and related disorders. The highest utilization of antipsychotic polytherapy occurs on psychiatric inpatient units, and in 2008, the Joint Commission released the first set of 7 hospital-based inpatient psychiatric services (HBIPS) core measures, 2 of which assess antipsychotic polytherapy at time of discharge. OBJECTIVE: To describe the effect on antipsychotic polytherapy at time of discharge of a 2-part quality improvement program composed of educational seminars and prescriber-specific feedback provided to 11 psychiatrists in 4 acute inpatient psychiatric units in 2 hospitals. METHODS: In a regional academic health care system, we determined the prevalence of antipsychotic monotherapy and polytherapy at time of discharge for all patients discharged on standing antipsychotic medications during 3 periods: (a) a 3-month baseline period (August 2006 through October 2006); (b) in July 2007, after delivery of 4 educational luncheon seminars to 11 psychiatrists from November 2006 through June 2007; and (c) in June 2008, following the provision of monthly prescriber-specific audit feedback from August 2007 through June 2008. To prepare nurses for the change and address possible safety concerns, an educational module was delivered to the psychiatric nursing staff at "best practice" day lectures held in the first quarter of 2007. General themes in the educational presentations included literature-based reviews of (a) safety and efficacy of antipsychotic polytherapy, (b) medical risks of antipsychotic medications, (c) specific versus nonspecific effects of these medications, and (d) effectiveness of first- versus second-generation antipsychotic medications. The prescriber-specific audit feedback was provided in paper form and masked the identity of the other prescribers. The chief of service reviewed audit feedback individually with each psychiatrist on a quarterly basis. The primary outcome measure was the percentage of patients prescribed 2 or more antipsychotics at discharge. A secondary outcome measure was the percentage of patients prescribed 3 or more antipsychotics at discharge. Differences in the primary outcome measure, comparing (a) July 2007 with the baseline period and (b) June 2008 with July 2007, were analyzed using Fisher's Exact tests. The Cochran-Armitage test for trend was used to assess the relationship between the primary outcome measure and the extent of the intervention, measured as the 3 time periods. For the secondary outcome measure, the Goodman-Kruskal gamma test for ordered categorical data was calculated to examine the association between the the proportion of patients receiving 1, 2, or 3 or more antipsychotics at discharge and the 3 time periods. RESULTS: The percentage of patients prescribed 2 or more antipsychotics at discharge declined from 33.9% at baseline (132 of 389 patients), to 21.8% after delivery of the educational modules (44 of 202 patients, P = 0.002), and to 12.2% after audit feedback (18 of 147 patients, P = 0.023; Cochran-Armitage test for trend P < 0.001). When antipsychotic use was classified as 1, 2, or 3 or more antipsychotic medications, more extensive intervention was associated with decreased combination use (Goodman- Kruskal gamma = 0.39, P < 0.001). In the baseline period, 5.9% of patients were prescribed 3 or more antipsychotics at discharge. Following completion of the educational and audit components, respectively, the proportion of patients prescribed 3 or more antipsychotics declined to 2.5% and then to 0.0%. CONCLUSION: Educational modules presented to psychiatrists and nurses in group settings were associated with a decrease in the rate of prescribing 2 or more antipsychotics at discharge from acute psychiatric inpatient units. Addition of monthly audit feedback provided to psychiatrists was associated with further decreases.