Prehospital Care of Coronary Artery Disease and Its Major Risk Factors in Geropsychiatric Inpatients.

BACKGROUND: Older adults with serious mental illness have a high prevalence of coronary artery disease and of its major risk factors, that is, arterial hypertension, dyslipidemia, and diabetes mellitus. The prevalence and clinical control of these conditions have not been compared in geropsychiatric inpatients with dementia versus those with mood or psychotic disorders. STUDY QUESTION: What is the prevalence and acuity of coronary artery disease, arterial hypertension, dyslipidemia, and diabetes mellitus among patients with dementia, mood, and psychotic disorders admitted for geropsychiatric care? STUDY DESIGN: Patients 65 years of age or older were identified in a cohort of 1000 patients consecutively admitted over a 3-year period to the geropsychiatric unit of a 200-bed mental health hospital in suburban New York. All patients had a structured clinical and laboratory evaluation within 72 hours of admission. DATA SOURCES: Primary psychiatric diagnoses, medical history, the frequency of poorly controlled cardiometabolic comorbidity requiring an immediate change in the management plan, and the Charlson Comorbidity Index (CCI). RESULTS: The 65 years and older patient sample (N = 689) had a mean age of 74.8 years, and 58.8% of the subjects were women. The 205 patients with dementia were older ( P < 0.001) than the 337 patients with mood disorders and the 147 patients with psychotic syndromes. The numbers of medical conditions and the CCI after exclusion of dementia were similar in patients with dementia versus patients without dementia. A substantial number of patients had poorly controlled arterial hypertension (51.2%), dyslipidemia (25.4%), diabetes (24.2%), and coronary artery disease (15.4%). Patients with dementia had a lower prevalence of poorly controlled dyslipidemia ( P = 0.0006), diabetes ( P = 0.0089), and coronary artery disease ( P = 0.045). CONCLUSIONS: Compared with mood or psychotic disorder, a diagnosis of dementia with behavioral disturbance seemed to be associated with better control of coronary artery disease, dyslipidemia, and diabetes mellitus in geropsychiatric inpatients.

Intentional Discontinuation of Psychostimulants Used to Treat ADHD in Youth: A Review and Analysis.

Objectives: This paper reviews the literature on intentional discontinuation of psychostimulants in ADHD to summarize what is known about clinical course of controlled discontinuation and guide practitioners who are considering stopping these medications for youth with ADHD. Methods: A systematic search was executed in Cochrane CENTRAL, EMBASE, Psychinfo, and MEDLINE databases to identify all articles that addressed the topic of deprescribing of psychotropic medications in children and adolescents. Keywords and search strings were developed using "PICO" framework, involving Population of interest (<18 y.o.), Intervention ("discontinuation," "deprescribing," and synonyms), Comparator (continuation of specific medications), and Outcomes. Ten reviewers conducted the initial screen via a single reviewer system. Articles that met a set of three inclusionary criteria were selected for full text review and identification as specific to discontinuation of stimulants in ADHD. Results: The literature review identified 35 articles specifically addressing intentional deprescribing, discontinuation, tapering, or withdrawal of stimulants for children and adolescents with ADHD. In addition to providing broad support for the efficacy of stimulants to treat ADHD and reduce negative outcomes, there is a distinct population of children and adolescents with ADHD who do not relapse or deteriorate when taken off medications for ADHD. The majority of articles addressed either the re-emergence of ADHD symptoms or side effects, both desired and adverse, following discontinuation of stimulants. While confirming the ability of stimulants to treat ADHD in youth, our results support periodic consideration of trials of stopping medications to determine continued need. Conclusions: This systematic review summarizes the literature on deprescribing stimulants for ADHD in children and adolescents. Further research is needed to determine the optimal duration of treatment, identify patients that may benefit from medication discontinuation, and inform evidence-based guidelines for discontinuation when appropriate. More research is needed to understand and define the subgroup of youth who may succeed with stimulant discontinuation.

Risks and Benefits of Using Social Media in Dermatology: Cross-sectional Questionnaire Study.

BACKGROUND: Dermatological information on social media is often presented by nondermatologists. Increasing the online engagement of trained dermatologists may improve information quality, patient education, and care. OBJECTIVE: Our study assesses dermatologists' perceptions of social media and patterns of use to identify barriers limiting engagement. METHODS: In our cohort study, a 36-item online survey was distributed to dermatologists in the United States; responses were captured on a 1-100 sliding scale. RESULTS: Of 166 initiated surveys, 128 valid responses were submitted. Dermatologists showed greater concern for social media risk-related issues (mean 77.9, SD 15.1) than potential benefits (mean 61.8, SD 16.4; P<.001). Leading concerns were poor patient care, nonevidence-based information, and breaching patient privacy. Benefits included interphysician collaboration, patient education, and public health awareness. The most avid and enthusiastic social media users were millennials (mean total optimism score 67.5, SD 14.9) and baby boomers (mean total optimism score 63.1, SD 11.2) compared with Generation X dermatologists (mean total optimism score 52.2, SD 16.3, P<.001). Of 128 dermatologists, 103 (82.4%) plan on increasing their social media use (P=.003). Predictors showing an intent to increase future social media use were younger age, integration into professional use, and an optimistic view (r2=.39; P<.001). CONCLUSIONS: Dermatologists perceive the risk of social media to be considerable but still intend to increase its use, likely recognizing the value and importance of social media to the field.

Measurement-Based Care in the Treatment of Adolescent Depression.

Measurement-based care is a helpful adjunct to clinical assessment in improving outcomes in depression in adults and adolescents. Measurement-based care principles are incorporated in current regulatory requirements for use of standardized instruments in efforts to improve care and prevent suicide. Challenges for child and adolescent psychiatrists and other clinicians in implementing measurement-based care include concerns about time and expense involved in administration and interpretation of results from rating scales and other instruments. Implementation can be facilitated by selection of instruments that are brief, easy to administer and score, compatible with electronic health record systems, and available in the public domain.

Correlates of psychiatric inpatient readmissions of children and adolescents with mental disorders.

To identify correlates of psychiatric readmission of youth, we conducted a consecutive, retrospective 1-year cohort study (07.01.2014-06.30.2015) of youth (age = 5-17.9) admitted to psychiatric inpatient facility. Stepwise elimination, multivariable logistic regression analyses were conducted to identify independent correlates of 1-year and 30-day psychiatric readmissions. The Family/Caregiver Interview Tool (FCIT) was given to caregivers of 30-day readmitted youth and analyzed using generalized linear model to predict time to readmission. Altogether, 1231 youth experienced 1534 hospitalizations. The 1-year readmission rate was 32.4%; 30-day readmission rate was 10.2%. Significant independent correlates of readmissions were longer length of stay, higher antipsychotic treatment rates, living closer to the hospital, and comorbid obesity, all accounting for 12.2% of variance. FCIT revealed that caregiver's ability to fill prescription after discharge delayed readmission, while shorter time to follow-up appointment hastened it. Illness exacerbation was responsible for 73% of 30-day readmissions; system of care factors accounted for 13%. Compared to clinicians, caregivers significantly underestimated environment of care factors (including caregiver's mental health) as the primary cause for readmission. Readmissions are common and correlate with illness severity and systems of care factors. Family support services may help reduce readmissions. Hospital-specific qualitative investigation may help identify intervention targets to reduce readmissions.

Infliximab-induced Depression and Suicidal Behavior in Adolescent with Crohn's Disease: Case Report and Review of Literature.

Infliximab, an anti-inflammatory agent, is used to treat various autoimmune disorders. There are at least 3 reports of severe psychiatric adverse effects of the drug, including suicidal behaviors in adults and psychosis in adult and adolescent patients. We report a case of an adolescent who developed depression and suicidal behaviors shortly after beginning infliximab. Although there have been reports of adolescents developing acute psychosis shortly after starting infliximab, this is, to our knowledge, the first report of adolescent suicidal behavior in the setting of infliximab treatment. METHODS: We describe a patient's presentation and clinical course, as well as existing reports of adverse psychiatric effects of infliximab. RESULTS: A 16-year-old male with a 2-year history of disabling symptoms and complications of Crohn's disease was initiated on a trial of infliximab. Within days of the first infliximab infusion, he experienced symptoms of depression, which intensified over weeks and resulted in a serious suicide attempt. The patient was treated with fluoxetine, melatonin, and psychotherapy, which effectively managed his infliximab-induced depressive disorder with suicidal thoughts and behaviors. Posttreatment, he tolerated additional infliximab infusions without the recurrence of psychiatric symptoms. CONCLUSIONS: Treatment with infliximab may rarely and suddenly cause severe and potentially life-threatening psychiatric symptoms. Therefore, youth with chronic illnesses considered for infliximab treatment should be screened for preexisting, as well as for a family history of, psychiatric disorders and suicidal behavior.

Haloperidol and sudden cardiac death in dementia: autopsy findings in psychiatric inpatients.

OBJECTIVE: Treatment with haloperidol has been shown, in studies using death certificates and prescription files, to be associated with an excess of sudden cardiac deaths, and regulatory warnings highlight this risk in patients with dementia. We used autopsy findings to determine whether the rate of sudden cardiac death is greater in cases of unexpected deaths of patients with dementia treated with haloperidol. METHODS: From 1989 through 2013, 1219 patients with a primary diagnosis of dementia with behavioral disturbance were admitted to a psychiatric hospital, and 65 (5.3%) died suddenly. Sixty-five patients (5.3%) died unexpectedly. Complete post-mortem examinations after the sudden death were performed in 55 (84.6%) patients. Twenty-seven of the autopsied cases (49.1%) had been treated with haloperidol orally (2.2 mg ± 2.1 mg/day), the only antipsychotic used in this cohort. Univariable comparisons and multivariable regression analyses compared the groups of patients with or without sudden cardiac death. RESULTS: The leading causes of death were sudden cardiac death (32.7%), myocardial infarction (25.5% of patients), pneumonia (23.6%), and stroke (10.9%). Patients with sudden cardiac death and those with anatomically established cause of death were similar regarding the use of haloperidol (p = 0.5). Sudden cardiac death patients were more likely to suffer from Alzheimer's dementia (p = 0.027) and to have a past history of heart disease (p = 0.0094), and less likely to have been treated with a mood stabilizer (p = 0.024), but none of these variables were independent predictors of sudden cardiac death. CONCLUSION: Autopsy data suggest that oral haloperidol is not associated with increased risk of sudden cardiac death in psychiatric inpatients with dementia.

Characteristics and disposition of youth referred from schools for emergency psychiatric evaluation.

We aimed to describe the characteristics and disposition of youth referred from schools to the emergency department (ED) for psychiatric evaluations. Consecutive 12-month records of ED psychiatric consultations at a large urban hospital from 07.01.2009 to 06.30.2010 were retrospectively analyzed. School-initiated referrals were deemed inappropriate if youth were discharged from the ED without any recommended mental health follow-up. Of the 551 psychiatric ED evaluations, 243 (44.1%) were initiated by schools. Of all school referrals, only 19 (7.8%) children were psychiatrically hospitalized, 108 (44.4%) were discharged from the ED with a follow-up appointment; and 116 (47.7%) were discharged without arranged follow-up. Those with a chief complaint of "suicidality" (n = 109, 44.9%) were more likely to be discharged without arranged follow-up than youth with other presenting complaints (56.0 vs. 41.0%, p = 0.021). Altogether, only 37 (18.5%) of 200 school-referred youth with information were evaluated by a school nurse, social worker, or other professional before being sent to the ED. Students without in-school screening were significantly more frequently discharged without follow-up than students with in-school evaluations prior to the ED referral (51.5 vs. 27.0%, p = 0.0070; odds ratio = 2.87 (95% CI 1.30-6.31). Multivariate predictors of inappropriate school referrals of youth discharged without any outpatient follow-up were higher Children's Global Assessment Scale score (p < 0.0001), absent in-school evaluation (p = 0.0069), absent prior psychiatric history (p = 0.011) and absent current psychotropic medication treatment (p = 0.012) (r(2) = 0.264%, p < 0.0001). Altogether 44.1% of ED consultations were school referred, of which 47.7% were potentially inappropriate for the emergency setting. In-school screening, which occurred infrequently, reduced unnecessary evaluations by 52%.

Suicidality and hospitalization as cause and outcome of pediatric psychiatric emergency room visits.

The aim of this study was to identify predictors of suicidality in youth presenting to a pediatric psychiatric emergency room service (PPERS). To this end, we conducted a retrospective cohort study of youth aged <18 years consecutively assessed by a PPERS 01.01.2002-12.31.2002, using a 12-page semi-structured institutional evaluation form and the Columbia Classification Algorithm for Suicide Assessment. Multivariate regression analyses were conducted to identify correlates of suicidal thoughts and attempts/preparation and their relationship to outpatient/inpatient disposition. Of 1,062 youth, 265 (25.0%) presented with suicidal ideation (16.2%) or attempt/preparation (8.8%). Suicidal ideation was associated with female sex, depression, adjustment disorder, absent referral by family/friend/self, school referral, precipitant of peer conflict, and no antipsychotic treatment (p < 0.0001). Suicidal attempt/preparation was associated with female sex, depression, lower GAF score, past suicide attempt, precipitant of peer conflict, and no stimulant treatment (p < 0.0001). Compared to suicidal attempt/preparation, suicidal ideation was associated with school referral, and higher GAF score (p < 0.0001). Of the 265 patients with suicidality, 58.5% were discharged home (ideation = 72.1% vs. attempt/preparation = 33.7%, p < 0.0001). In patients with suicidal ideation, outpatient disposition was associated with higher GAF score, school referral, and adjustment disorder (p < 0.0001). In patients with suicidal attempt/preparation, outpatient disposition was associated with higher GAF score, lower acuity rating, and school referral (p < 0.0001). Suicidality is common among PPERS evaluations. Higher GAF score and school referral distinguished suicidal ideation from suicidal attempt/preparation and was associated with outpatient disposition in both presentations. Increased education of referral sources and establishment of different non-PPERS evaluation systems may improve identification of non-emergent suicidal presentations and encourage more appropriate outpatient referrals.

Antidepressants for cognitive impairment in schizophrenia--a systematic review and meta-analysis.

BACKGROUND: Cognitive impairment in schizophrenia is disabling, but current treatment options remain limited. OBJECTIVE: To meta-analyze the efficacy and safety of adjunctive antidepressants for cognitive impairment in schizophrenia. DATA SOURCES AND STUDY SELECTION: PubMed, MEDLINE, PsycINFO, and Cochrane Library databases were searched until 12/2013 for randomized controlled trials comparing antidepressant augmentation of antipsychotics with placebo regarding effects on cognitive functioning in schizophrenia. DATA EXTRACTION: Two authors independently extracted data. Standardized mean differences (SMDs) were calculated for continuous outcomes and risk ratios for categorical outcomes. SMDs of individual cognitive tests were pooled on a study level within domains (primary outcome) and across domains. When results were heterogeneous, random instead of fixed effects models were used. RESULTS: We meta-analyzed 11 studies (duration = 8.7 ± 3.7 weeks) including 568 patients (mean age = 39.5 ± 6.9 years, males = 67.2%, illness duration = 12.5 ± 8.0 years). Antidepressants included mirtazapine (4 studies; n = 126), citalopram (2 studies; n = 231), fluvoxamine (1 study; n = 47), duloxetine (1 study; n = 40), mianserin (1 study; n = 30), bupropion (1 study; n = 61), and reboxetine (1 study; n = 33). Statistically significant, but clinically negligible, advantages were found for pooled antidepressants compared to placebo in executive function (Hedges' g = 0.17, p = 0.02) and a composite cognition score (Hedges' g = 0.095, p = 0.012). Depression improved with serotonergic antidepressants (p = 0.0009) and selective serotonin reuptake inhibitors (p = 0.009), but not with pooled antidepressants (p = 0.39). Sedation was more common with pooled antidepressants (p = 0.04). CONCLUSION: Adjunctive antidepressants do not demonstrate clinically significant effects on cognition in schizophrenia patients, however, larger studies, preferably in euthymic schizophrenia patients and using full neurocognitive batteries, are needed to confirm this finding.

Nocturnal Anxiety in a Youth with Rapid-onset Obesity, Hypothalamic Dysfunction, Hypoventilation, and Autonomic Dysregulation (ROHHAD).

OBJECTIVE: Behavioral and psychiatric disorders are common in youth with rapid-onset obesity with hypothalamic dysfunction, hypoventilation, and autonomic dysregulation (ROHHAD). We outline a rational approach to psychiatric treatment of a patient with a complex medical condition. METHODS: We report the course of symptoms in a teen with ROHHAD, the inpatient treatment, and review current evidence for use of psychopharmacologic agents in youth with sleep and anxiety disturbances. RESULTS: A 14-year-old female began rapidly gaining weight as a preschooler, developed hormonal imbalance, and mixed sleep apnea. Consultation was requested after a month of ROHHAD exacerbation, with severe anxiety, insomnia, and auditory hallucinations. Olanzapine and citalopram were helpful in controlling the symptoms. Following discharge, the patient gained weight and olanzapine was discontinued. Lorazepam was started in coordination with pulmonary service. Relevant pharmacologic considerations included risk of respiratory suppression, history of paradoxical reaction to hypnotics, hepatic isoenzyme interactions and side effects of antipsychotics. CONCLUSIONS: Core symptoms of ROHHAD may precipitate psychiatric disorders. A systematic evidence-based approach to psychopharmacology is necessary in the setting of psychiatric consultation.

OBJECTIF: Les troubles comportementaux et psychiatriques sont fréquents chez les adolescents souffrant du syndrome d'obésité infantile d'installation rapide-dysfonctionnement hypothalamique-hypoventilation-dysautonomie (ROHHAD). Nous présentons une approche rationnelle de traitement psychiatrique d'une patiente souffrant d'une affection médicale complexe. MÉTHODES: Nous rendons compte de l'évolution des symptômes chez une adolescente souffrant du syndrome ROHHAD et du traitement de la patiente hospitalisée, et nous examinons les données probantes actuelles sur l'utilisation d'agents psychopharmacologiques chez les adolescents souffrant de perturbations du sommeil et d'anxiété. RÉSULTATS: Une adolescente de 14 ans s'est mise à prendre rapidement du poids en âge préscolaire, a développé un déséquilibre hormonal, et une apnée du sommeil mixte. Une consultation a été demandée après un mois d'exacerbation du ROHHAD, avec grave anxiété, insomnie, et hallucinations auditives. L'olanzapine et le citalopram ont aidé à contrôler les symptômes. Après son congé, la patiente a pris du poids et cessé l'olanzapine. Le lorazépam a été initié en coordination avec un service de pneumologie. Les considérations pharmacologiques pertinentes étaient notamment le risque de suppression respiratoire, les antécédents de réaction paradoxale aux hypnotiques, les interactions de l'isoenzyme hépatique, et les effets secondaires des antipsychotiques. CONCLUSIONS: Les symptômes de base du syndrome ROHHAD peuvent précipiter les troubles psychiatriques. Une approche systématique de la psychopharmacologie fondée sur les données probantes est nécessaire dans le contexte de la consultation psychiatrique.

Medical outcome of patients with dementia in a free-standing psychiatric hospital.

BACKGROUND: The hospital outcome of patients with dementia is significantly worse than that of cognitively intact persons of the same age admitted to medical or surgical units but has not been investigated in psychiatric settings. AIM OF STUDY: To determine the medical outcome of patients with dementia admitted for behavioral disturbance to a free-standing psychiatric hospital. METHODS: Emergency transfers from the psychiatric setting to a general hospital were used as proxies for medical deteriorations occurring among the 71 patients with dementia (age 78.4 ± 10.4 years; 40.1% males) and 71 age- and gender-matched nondementia control patients. The patients were identified in a cohort of 1000 patients consecutively admitted to a free-standing mental health institution. Logistic regression was used to determine the clinical and laboratory variables independently associated with medical deteriorations. RESULTS: A total of 30 patients with dementia and 25 nondementia patients were transferred to a general hospital after an acute medical deterioration (42.3% vs 35.2%, P = .38). Febrile illnesses and falls with head trauma were the most common reasons for transfers in the dementia group, in which they constituted more than half of medical deteriorations, a proportion significantly higher than in the control group (P = .011). Admission hemoglobin levels were the only independent predictor of medical deterioration in this geriatric sample. CONCLUSIONS: Although nearly 50% of patients with dementia admitted for behavioral disturbance to a free-standing psychiatric institution required transfer to a general hospital, their rate of medical deteriorations was similar to age-matched nondementia control patients.