Areas of Improvement in Suicide Risk Identification, Assessment, and Risk Mitigation Documentation by Mental Health Prescribers at a Veterans Affairs Health Care System.

PURPOSE: Veterans have a suicide rate 1.5 times higher than the non-veteran population. The Department of Veterans Affairs (VA) implemented suicide risk screening recommendations in 2018. This project assessed the impact of mental health (MH) prescribers on these recommendations and identified areas of improvement. METHODS: Seventy MH Clinical Pharmacy Specialists (CPS) and 52 other MH prescribers were included. Patients with a positive question nine (from the Patient Health Questionnaire-9) and a same-day Columbia Suicide Severity Rating Scale (C-SSRS) between 11/01/18 and 11/01/19 at a VA system were reviewed. Completion of same-day Comprehensive Suicide Risk Evaluation (CSRE), same-day Suicide Prevention Safety Plan (SPSP), number of patients who were not offered naloxone despite access to opioids, and number of patients who were not offered a gunlock despite access to firearms were compared between groups. Time from C-SSRS to suicidal behavior was compared between those who did and did not receive a same-day CSRE. RESULTS: MH CPS were significantly more likely to complete a same-day CSRE (p = 0.0201) and SPSP (p < 0.001) when recommended. Naloxone outcomes were not assessed due to availability of only one data point. Rates of gunlock offers did not differ significantly between groups (Fisher's exact test, p = 0.3189) however there was no documentation stating why they were not offered when appropriate 40% of the time. Time to suicidal behavior did not vary across patients based on CSRE completion (p = 0.16). CONCLUSION: MH CPS play an important role in suicide risk screening for veterans. There is a need for improvement regarding the offering and documentation of firearm risk mitigation strategies.

Evaluating psychiatric outcomes associated with direct-acting antiviral treatment in veterans with hepatitis C infection.

INTRODUCTION: Approximately 70% of veterans with hepatitis C virus infection have at least one psychiatric illness. The advent of direct-acting antiviral (DAA) therapy provided an alternative to interferon-alpha regimens and revolutionized treatment, however, the extent of psychiatric effects attributed to these agents are unclear. The primary objective of this pilot study was to prospectively analyze psychiatric outcomes, specifically depression, in veterans with hepatitis C virus infection who are initiated on DAA therapy. METHODS: In this single center, prospective cohort study, psychiatric outcomes were analyzed using Patient Health Questionnaire assessments at baseline and weeks 4, 8, and 12 of complete DAA treatment. Outcome analysis were stratified based on specific DAA therapy and preexisting mental illness (mental health [MH] subjects and non-MH subjects), with a sub-analysis of major depressive disorder patients. RESULTS: Analysis included 48 patients, majority males (96%), with a mean age of 59.4 years (±8.0). Twenty-four (50%) patients had a preexisting MH diagnosis, with major depressive disorder being the most common MH diagnosis (50%, n = 12). Despite a trend toward improvement, no significant changes in questionnaire scores after 12 weeks of DAA therapy were observed for all patient groups (P > .05). Neither MH subjects nor non-MH subjects displayed a significant change in questionnaire scores from baseline to end of treatment (P > .05). No patients required acute psychiatric interventions during DAA treatment. DISCUSSION: Treatment with DAA therapy was not associated with psychiatric decompensation. Data from this pilot study supports the safe utilization of DAA therapy in hepatitis C virus patients with preexisting MH illness as it appears to be devoid of depressive and psychiatric side effects.

Safe lithium use in a non-psychiatric versus a psychiatric inpatient veterans affairs hospital setting: a retrospective assessment.

OBJECTIVE: This study examined practices for monitoring lithium in a non-psychiatric versus psychiatric inpatient setting at a Veterans Affairs facility. METHODOLOGY: This retrospective chart review included veterans who had an active order of lithium during their non-psychiatric or psychiatric inpatient stay over the time period of January 2000 to September 2011. Chi-square tests were used for data analysis. Frequency of appropriate lithium monitoring was assessed using standards set by the National Institute for Clinical Excellence and British Association for Psychopharmacology guidelines for bipolar disorder. RESULTS: A total of 200 patients (100 for each group) were included in the final analysis. Psychiatric inpatients had more frequent serum lithium levels measured during inpatient stay (p = 0.0002), whereas nonpsychiatric patients had more frequent renal monitoring (p = 0.0001). Non-psychiatric patients were significantly more likely to have action taken upon abnormal safety assessments (p = 0.0075). CONCLUSIONS: Our results demonstrate significant differences between the non-psychiatric and psychiatric inpatient settings in respect to monitoring lithium. The frequency of serum lithium level monitoring in both groups was below the level set by both the National Institute for Clinical Excellence and British Association for Psychopharmacology guidelines. Additionally, frequency of corrective measures in both settings was low, indicating a need for improvement in this area.