Medical Student Education in State Psychiatric Hospitals: A Survey of US State Hospitals.

OBJECTIVE: State hospitals may be underutilized in medical education. US state psychiatric hospitals were surveyed on current and potential psychiatry medical student education. METHODS: A 10-item questionnaire, with multiple response formats, was sent to identified hospitals in late 2012. RESULTS: Ninety-seven of 221 hospitals contacted responded. Fifty-three (55%) reported current medical student education programs, including 27 clinical clerkship rotations. Education and training in other disciplines was prevalent in hospitals both with and without medical students. The large majority of responders expressed enthusiasm about medical education. The most frequent reported barrier to new programs was geographic distance from the school. Limited resources were limiting factors for hospitals with and without current programs. CONCLUSIONS: Only a minority of US state hospitals may be involved in medical student education. While barriers such as geographic distance may be difficult to overcome, responses suggest opportunities for expanding medical education in the state psychiatric hospitals.

Best practices: An initiative to curtail the use of antipsychotic polypharmacy in a state psychiatric hospital.

A performance improvement initiative was undertaken at a state psychiatric hospital to reduce antipsychotic polypharmacy. Data from physicians' order forms were used to document the prescribing practices of 14 psychiatrists in November 2001 and in August 2002. After baseline data were collected, the chief of psychiatry met with each psychiatrist to compare his or her prescribing data with data of anonymous peers. The chief also asked all psychiatrists to decrease antipsychotic polypharmacy by at least 10 percent. Antipsychotic polypharmacy fell significantly--from 42 percent of patients treated with antipsychotics in November 2001 to 31 percent in August 2002. Higher utilizers of polypharmacy at baseline continued to be high utilizers at follow-up. Less antipsychotic polypharmacy was not associated with more use of other psychotropic medications. The findings suggest that initiatives that involve the focused attention of leadership and only a modest investment of effort can result in significant change in prescribing practices in a state hospital.

Facilitating discharge in state psychiatric institutions: a group intervention strategy.

Despite more than 30 years of deinstitutionalization, a significant number of individuals continue to experience prolonged stays in state psychiatric hospitals. Many of these individuals appear to develop an ambivalence or resistance to discharge. This can itself contribute to further delay in discharge planning and implementation. We will describe a group intervention for persons with long stays labeled as "resistant." This effort was guided by the premise that each individual could benefit from personally exploring those aspects of his or her experience that may be contributing to continued hospitalization. The group utilized standard methods of rehabilitation and training with strong emphasis on validating individual needs and feelings, peer support and practical results. After 1 1/2 years of group intervention, 5 of the 7 group members had achieved discharge and initial community success.

Animal-assisted therapy with chronic psychiatric inpatients: equine-assisted psychotherapy and aggressive behavior.

OBJECTIVE: Animal-assisted therapy (AAT), most frequently used with dogs, is being used increasingly as an adjunctive alternative treatment for psychiatric patients. AAT with larger animals, such as horses, may have unique benefits. In this randomized controlled study, equine and canine forms of AAT were compared with standard treatments for hospitalized psychiatric patients to determine AAT effects on violent behavior and related measures. METHODS: The study included 90 patients with recent in-hospital violent behavior or highly regressed behavior. Hospitalization at the 500-bed state psychiatric hospital was two months or longer (mean 5.4 years). Participants were randomly selected to receive ten weekly group therapy sessions of standardized equine-assisted psychotherapy (EAP), canine-assisted psychotherapy (CAP), enhanced social skills psychotherapy, or regular hospital care. Participants' mean age was 44, 37% were female, 76% had diagnoses of schizophrenia or schizoaffective disorder, and 56% had been committed involuntarily for civil or forensic reasons. Violence-related incident reports filed by staff in the three months after study intake were compared with reports two months preintake. RESULTS: Interventions were well tolerated. Analyses revealed an intervention group effect (F=3.00, df=3 and 86, p=.035); post hoc tests showed specific benefits of EAP (p<.05). Similar AAT effects were found for the incidence of 1:1 clinical observation (F=2.70, df=3 and 86, p=.051); post hoc tests suggested benefits of CAP (p=.058) as well as EAP (p=.082). Covariance analyses indicated that staff can predict which patients are likely to benefit from EAP (p=.01). CONCLUSIONS: AAT, and perhaps EAP uniquely, may be an effective therapeutic modality for long-term psychiatric patients at risk of violence.

Immunity in adolescents with major depression.

OBJECTIVE: The association between major depression (MD) and altered immunity appears to be age-related, with differing immune changes found in prepubertal children, young adults, and older adults. There is limited information concerning immunity in adolescents with MD. METHOD: Thirty-six otherwise healthy medication-free adolescents (aged 14-20; 23 female) from a community sample, meeting Diagnostic Interview Schedule for Children DSM-III-R criteria for unipolar MD, were compared with 36 nondepressed adolescents matched by gender, age, and racial background. A battery of quantitative and functional immune measures was obtained. RESULTS: MD adolescents had increased (p < .05) circulating lymphocytes and lymphocyte subsets; however, altered distribution of lymphocyte subsets was found only for activated T (HLA-DR+) cells (p < .004) and, possibly, natural killer (NK) (CD56+) cells (p < .06), each showing lower percentages in the MD adolescents. Concanavalin A (but not phytohemagglutinin or pokeweed mitogen) mitogen response was lower in the MD adolescents (p < .02). NK cell activity was elevated at higher effector-target ratios (p < .001), an effect not associated with the number of circulating CD56+ (NK) cells. CONCLUSIONS: Depressed adolescents showed changes in immune measures that have been found to be altered in other MD groups, although the pattern of effects differs.

Immune measures in alcohol-dependent persons with minor health abnormalities.

Altered immunity is commonly associated with alcoholism. However, few studies have contrasted alcoholism per se with effects of the medical sequelae or comorbidities of alcoholism on the immune system. We previously found few differences in lymphocyte subsets, mitogen response, granulocytic phagocytosis, or natural killer cell activity when we compared healthy urban alcohol-dependent individuals with community control subjects. To begin to explore the role of medical factors, 11 alcohol-dependent persons derived from the same clinical population but showing mild medical abnormalities (AMMAs), primarily abnormal liver function test results, were compared with the previously described 44 alcohol-dependent persons without medical dysfunctions and 34 nonabusing community persons. The AMMAs had lower numbers of CD45RA + inducer-suppressor/naive cells (P <.02) and HLA-DR+-activated T cells (P <.04) compared with findings for nonabusers and higher percentages of circulating CD56 + natural killer cells (P <.03). Mitogen responses to concanavalin A, phytohemagglutinin, and pokeweed mitogen; natural killer cell activity; and granulocyte functions did not differ across groups. The AMMAs reported higher alcohol consumption than that reported by the other groups. The findings seem to indicate that mild medical conditions, or conditions linked to abnormal liver function test results, are associated with some of the immune alterations reported in alcohol-dependent persons. Immune changes, even among chronically alcohol-dependent persons, may occur along a continuum associated with total alcohol exposure and intercurrent physiologic abnormalities. Clinical studies may need to control for such mild abnormalities when investigating alcohol-immune relationships, and clinical interventions may be especially important for alcohol-dependent individuals who show early signs of compromised health.

Medical versus nonmedical mental health referral: clinical decision-making by telephone access center staff.

A database review investigated decisions of clinicians staffing a university-based telephone access center in referring new adult patients to nonpsychiatrists versus psychiatrists for initial ambulatory behavioral health care appointments. Systematically collected demographic and clinical data in a computer log of calls to highly trained care managers at the access center had limited predictive value with respect to their referral decisions. Furthermore, while 28% of the 610 study patients were initially referred to psychiatrists, billing data revealed that in-person therapists soon cross-referred at least 20% more to a psychiatrist. Care managers sent 56% of callers already taking psychotropic medications to nonpsychiatrists, 51% of whom were then cross-referred to psychiatrists. Predictive algorithms showed no potential to enhance efficiency of decisions about referral to a psychiatrist versus a nonpsychiatrist. Efforts to enhance such efficiency may not be cost-effective. It may be more fiscally efficient to assign less-experienced personnel as telephone care managers.

Using structured clinical feedback to encourage alternatives to use of "P.R.N." medication in a state psychiatric hospital.

OBJECTIVE: The study examined whether reductions in the use of pro re nata (p.r.n.) psychotropic medications could be achieved in a large public-sector psychiatric hospital, without adverse behavioral consequences, by disseminating a database that tracks p.r.n. use to clinical teams. METHODS: A performance improvement project was implemented over 28 months, involving all 166 patients in one section of a state psychiatric hospital. A spread- sheet tracking p.r.n. administration for each patient was provided weekly to unit treatment teams. Clinical outcome monitoring focused on the number of p.r.n. administrations and on p.r.n. "events," defined as ≥ 3 multiple administrations per week and ≥ 10 per month. Episodes of patient seclusion, restraint, and violent incidents were also monitored. RESULTS: From September 2008 to December 2010, with a stable patient population census, total monthly administrations of psychotropic p.r.n. medications decreased from 642 to 240; administrations of non-psychotropic "medical" p.r.n. agents also decreased, from 279 to 72. In year-by-year comparisons, significant decreases (P < 0.05) were observed in the total number of psychotropic and medical p.r.n. administrations, in weekly as well as monthly p.r.n. events, and in the number of patients receiving any p.r.n. administrations. There was no change from 2008 to 2010 in the number of violent incidents; the use of both seclusion and restraint decreased (P < 0.05). CONCLUSION: The findings suggest that p.r.n. use can be reduced safely through timely feedback of relevant clinical data.

Reported allergies to antipsychotic agents in a long-term psychiatric hospital.

The incidence of allergic reactions to antipsychotic agents is not well known but would be expected to be low. However, pharmacy records at a large state psychiatric hospital indicated surprisingly high rates of such allergies. We hypothesized that these high rates of reported allergies in the pharmacy database would not be supported by clinical history, but rather that they represented other side effects or past uncritical acceptance of casual patient reports. Method. Patients listed as having experienced allergies to antipsychotic medications were interviewed by two psychiatrists and any clinical evidence that suggested an allergy was noted. Results. Of 585 patients who were hospitalized on the day the data were reviewed, 138 patients (23.6%) were identified by the pharmacy as allergic to an antipsychotic medication, 79 of whom were available and consented to be interviewed. Of these 79 patients, 7 (8.9%) provided evidence of a true allergy and 12 (15.2%) provided evidence that suggested a remote possibility of an allergy. Of the 60 "allergic" patients who provided no evidence of an allergy, 57% reported a non-allergic adverse drug reaction (ADR) that may have accounted for the allergy assignment and 32% reported possible symptoms that might have done so. Length of stay was possibly associated with an unsupported allergy designation (p <0.07). Reported allergies to other psychotropic agents (p <0.02) or to nonpsychotropic agents (p <0.07) were associated with evidence of a "true" allergy to an antipsychotic agent. Conclusions. Allergies to antipsychotic medications may be much less common than suggested by clinical records. The examination of focused clinical histories from patients who have been reported to experience such "allergies" would likely expand the pool of available medications for many patients.

Dental care and oral disease in alcohol-dependent persons.

Dental/Oral health of alcohol-dependent persons and substance abusers is often neglected. It is not clear that alcohol dependence has effects on oral health beyond those expected in nonalcoholic persons of similar socioeconomic status (SES). Study objectives were to examine the personal dental care habits, ability to access professional dental care, and the types of services received and to examine their effect on the oral health of alcohol-dependent persons and substance abusers. Forty Diagnostic and Statistical Manual of Mental Disorders, Third Edition Revised-diagnosed alcohol-dependent persons and a comparison group of 25 non-alcohol-dependent subjects matched for race, age, gender, and SES were recruited. Subjects were medically healthy. Each subject received a comprehensive oral/dental examination, and an interview was conducted to record personal dental hygiene habits, ability to access professional dental care, and types of dental services provided. No statistical differences were found between the oral care habits of the groups. Forty-four percent of all subjects had access to charity professional dental care. Tooth extraction was the main dental service they received. Seventy-five percent of subjects brushed their teeth once or more per day. In the non-alcohol-dependent group, brushing frequency was inversely associated with plaque levels (p < .05); in the alcohol-dependent group, brushing frequency showed no statistical effect on plaque levels. Access to professional dental care was inversely associated with periodontitis in the alcohol-dependent group (p < .05). Alcohol dependence may increase plaque levels above that seen in race, gender, age, and SES-matched controls, but professional dental care can limit the subsequent development of periodontal disease in these people.

Stress, NK cells, and cancer: Still a promissory note.

Although the last decades have provided ample evidence for deleterious effects of stress on immunity and on cancer development and suggested mediating mechanisms, no psychoneuroimmunology (PNI)-related intervention has become a standard of care in conventional cancer treatment. We believe the reasons for this include the unique nature of cancer evolvement and interactions with the immune system, and the many conceptual and technical obstacles to studying stress effects on immune activity and their implications for human resistance to malignancy. However, the numerous and diverse interactions between malignant tissue and immunocytes are now better understood, and suggestions can be made with respect to certain critical periods to be investigated in cancer-PNI research. Animal models of cancer progression are instrumental in suggesting neuroendocrine and immunological mediators of stress effects on specific aspects of cancer progression, especially with respect to the role of NK cell activity. The ultimate clinical relevance, however, must be tested in cancer patients. Recent animal studies suggest a role for the sympathetic nervous system in mediating biologically relevant stress effects on immunity and on tumor progression. Related interventions can now be tested in patients to support or refute the promise of such studies.

Major depression and immunity in alcohol-dependent persons.

UNLABELLED: Altered immunity has been associated with both alcoholism and major depression (MD). We investigated the contribution of MD, as well as alcoholism, to in vitro measures of immunity in inner-city alcohol-dependent (SCID-DSM-III-R) persons and community nonabusers, all otherwise in good health. METHODS: Alcohol-dependent persons at an ambulatory alcohol treatment center who did not abuse other substances were studied along with the comparison sample (total n=122). Enumerative and functional immune measures included leukocyte and lymphocyte subsets, mitogen response, natural killer cell activity (NKCA), and granulocytic phagocytosis. RESULTS: Controlling for alcohol dependence, age, gender, racial background, and medical status, MD was associated with decreased phytohemagglutinin (PHA) responses (p<.03), possibly decreased NKCA (p<.08), and increased circulating monocytes (p<.04). Controlling for MD, age, gender, racial background, and medical status, alcohol dependence was associated with decreased circulating B lymphocytes (p<.02), possibly decreased CD56+ (NK) cells (p<.06), and increased monocytes (p<.04). Responses to concanavalin A and pokeweed mitogen, granulocyte functions, and the composition of other leukocyte and lymphocyte subsets showed no evidence of being associated with MD or with alcoholism (p>.1). Secondary analyses exploring factors such as recent alcohol use, cigarette use, and nutrition suggested that these factors accounted for the altered lymphocyte subsets associated with alcoholism and the possibly decreased NKCA with MD. They did not account for the association of MD with increased monocytes and decreased PHA. DISCUSSION: MD-associated immune changes in alcoholics are modest and consistent with those seen in MD without alcoholism. Some MD- and many alcoholism-associated immune effects appear related to factors such as cigarette use and recent alcohol exposure.

Panic disorder and immunity: few effects on circulating lymphocytes, mitogen response, and NK cell activity.

Altered immune measures are commonly found in major depression (MD), however, less is known about the immune system in anxiety disorders. We examined quantitative and functional in vitro immune measures in patients with panic disorder (PD), which is often comorbid with MD. Fourteen otherwise healthy medication-free adults (ages 23-49; 11 female) meeting SCID-UP DSM-IIIR criteria for PD with agoraphobia and without current MD, were compared with 14 subjects free of PD, MD, or other major psychiatric disorders, matched by gender, age, and racial background. PD was associated with decreased percentage (p<.03) and total (p<.03) circulating CD19+ B lymphocytes, but no differences in other enumerative lymphocyte measures. Mitogen responses (Con A, PHA, PWM) did not differ except for possibly decreased PHA in PD (p<.06). NK cell activity did not differ between PD and control subjects. The few immune measure changes in PD contrast with those found in MD, providing further evidence for the specificity of immune changes in psychiatric disorders.