Taking the Long View in an Inpatient Medical Unit: A Person-Centered, Integrated Team Approach for Patients With Severe Mental Illnesses.

OBJECTIVE: Patients with severe mental illnesses and related conditions, such as substance misuse and suicide attempts, are among the highest utilizers of acute inpatient medical services. The objective of this study was to assess the impact of a specialized medical unit that uses a comprehensive biopsychosocial model to care for patients with severe mental illnesses. METHODS: The study used administrative data to compare patients with severe mental illnesses admitted to a specialized unit with patients admitted to medically similar acute (non-intensive care) medical units in a tertiary academic medical center. With controls for sociodemographic variables, illness severity, and medical complexity, multivariate regression analyses compared utilization outcomes for patients from the specialized unit with outcomes from comparison units. RESULTS: Patients on the specialized unit (N=2,077) were younger, had more mental disorder diagnoses, and were more likely to have less severe general medical illness and less medical complexity than patients from comparison units (N=12,824). Analyses of a subsample of patients with complex behavioral health diagnoses indicated that those on the specialized unit had a shorter average stay, higher odds of discharge to home, and lower odds of 30-day readmission, compared with those on comparison units. CONCLUSIONS: Specialized units targeted to the needs of patients with serious mental illnesses can provide a moment of engagement when vulnerable patients are likely to benefit from more coordinated care. Findings suggest that a specialized unit that capitalizes on this moment of engagement and uses a biopsychosocial model of care can improve utilization outcomes.

Immigration generation status and its association with suicide attempts, substance use, and depressive symptoms among latino adolescents in the USA.

This study investigated the relation between suicide attempts and immigrant generation status using the Latino subset of the National Longitudinal Study of Adolescent Health, a school-based, nationally representative sample. This study also examined whether generation status predicted risk factors associated with elevated suicide behaviors, namely illicit substance use, problematic alcohol use, and depressive symptoms. Finally, hypothesizing that elevated depressive symptoms and substance use mediate the relation between immigrant generation status and suicide attempts among Latino adolescents, a path model was tested. Our findings revealed immigrant generation status was a determinant for suicide attempts, problematic alcohol use, repeated marijuana use, and repeated other drug use for Latino adolescents. US-born Latinos with immigrant parents (i.e., second-generation youth) were 2.87 (95% CI, 1.34, 6.14) times more likely to attempt suicide, 2.27 (95% CI, 1.53, 3.35) times more likely to engage in problematic alcohol use, 2.56 (95% CI, 1.62, 4.05) times more likely to engage in repeated marijuana use, and 2.28 (95% CI, 1.25, 4.17) times more likely to engage in repeated other drug use than were foreign-born youth (i.e., first-generation youth). Later-generations of US-born Latino youth with US-born parents were 3.57 (95% CI, 1.53-8.34) times more likely to attempt suicide, 3.34 (95% CI, 2.18-5.11) times more likely to engage in problematic alcohol use, 3.90 (95% CI, 2.46, 6.20) times more likely to engage in repeated marijuana use, and 2.80 (95% CI, 1.46, 5.34) times more likely to engage in repeated other drug use than were first-generation youth. Results from the path analysis indicated that repeated other drug use may mediate the effect of generation status on suicide attempts.

Diabetic ketoacidosis among patients receiving clozapine: a case series and review of socio-demographic risk factors.

BACKGROUND: Diabetic ketoacidosis (DKA) has been associated with clozapine. The purpose of this study is to examine the clinical-demographic correlates of DKA among outpatients receiving clozapine. METHODS: A literature search was conducted from 1966 to present using Medline to identify 23 case reports of clozapine-associated DKA. In addition, a cohort of twenty-six patients with clozapine-associated diabetes at the University of Rochester Medical Center Department of Psychiatry were examined for histories of DKA through review of medical records. Based on a total sample of 26 case reports including three unpublished cases at University of Rochester, associations between clinical and demographic variables and DKA were examined. RESULTS: African American patients were significantly more likely than other patients to have DKA (p < 0.0001). Clozapine treatment duration was significantly shorter among patients with DKA than those without DKA (p < 0.0001), with 61.5% of patients developing DKA within three months of clozapine initiation. Also, presence of antidiabetic medications was negatively correlated with DKA (p < 0.0001). Trends were noted toward an association between low doses of clozapine (p < 0.0583) and toward a negative association between family history of diabetes (p < 0.0696). CONCLUSION: Clozapine is associated with DKA that usually presents in patients who have not previously been diagnosed with diabetes. DKA typically occurs early in the course of treatment, when clozapine treatment duration is short and doses are low.

Prevalence of the metabolic syndrome among patients receiving clozapine.

OBJECTIVE: This study compared the prevalence of the metabolic syndrome among outpatients with schizophrenia and schizoaffective disorder receiving clozapine with a matched comparison group from the National Health and Nutrition Examination Survey. METHOD: Ninety-three outpatients and a matched group of 2,701 comparison subjects were compared according to National Cholesterol Education Program criteria. Outpatient data were obtained through physical assessments, laboratory testing, and reviews of medical records. RESULTS: The prevalence of the metabolic syndrome was significantly higher among clozapine patients (53.8%) than among the comparison group (20.7%). For clozapine patients, logistic regression analysis revealed significant associations with age, body mass index, and duration of clozapine treatment. Only age and body mass index were associated with the prevalence of metabolic syndrome in both groups. CONCLUSIONS: Patients receiving clozapine are at significantly increased risk for developing the metabolic syndrome. Psychiatrists and other providers should consider performing regular physical health monitoring to prevent long-term adverse health consequences.

Diabetes mellitus among outpatients receiving clozapine: prevalence and clinical-demographic correlates.

BACKGROUND: Treatment with antipsychotic drugs has been associated with increased risk for developing diabetes mellitus. Recent consensus statements suggest that clozapine may pose an especially high risk. The purpose of this study is to examine the prevalence and clinical-demographic correlates of diabetes among outpatients with DSM-IV-diagnosed schizophrenia or schizoaffective disorder receiving clozapine. METHOD: One hundred one outpatients receiving clozapine at the University of Rochester Department of Psychiatry, Rochester, N.Y., were evaluated between September 2002 and September 2003. Demographic data were collected from medical records, and body mass index (BMI) and body fat measurements were conducted. Diagnosis of diabetes was established through review of medical records and fasting blood glucose testing. Associations between clinical and demographic variables and diabetes were examined using t tests, Fisher exact tests, and logistic regression. RESULTS: Mean (SD) age of patients was 40.4 (9.5) years, and 79% were white. Mean (SD) dose and duration of clozapine treatment were 426 (164) mg/day and 5.7 (3.6) years, respectively. Point prevalence of diabetes was 25.7%. Mean (SD) BMI was 32.6 (8.0) kg/m(2), and mean (SD) body fat was 34.0% (11.0%). Logistic regression revealed significant associations between diabetes and nonwhite race/ethnicity and family history of diabetes (p = .02 and .002, respectively). No significant associations were found between diabetes prevalence and BMI or body fat. CONCLUSION: Patients receiving clozapine are at substantial risk for developing diabetes, although the level of risk relative to other antipsychotic medications has not been fully determined. Clinicians should monitor all severely mentally ill patients receiving antipsychotic drugs for diabetes, with closer monitoring of patients with established demographic risk factors.

Residents' Morning Report in Psychiatry Training: Description of a Model and a Survey of Resident Attitudes.

A residents' morning report, adapted from the traditional internal medicine model, was introduced into a psychiatry residency curriculum to supplement bedside teaching for junior residents during inpatient service rotations by focusing on case presentations, clinical reasoning, and evidence-based decision-making skills. This paper describes the design of the report and findings from surveys of residents who participated in the report over a 3-year period. The surveys demonstrate high levels of satisfaction with the exercise and offer insight into factors that may optimize or impede learning in the morning report setting in psychiatry.