Measurement-based care training curriculum in psychiatry residency programs: I: Description of the curriculum and demonstration of implementation.

BACKGROUND: Recent literature shows that most practicing psychiatrists do not receive training in measurement-based care (MBC). Among the primary barriers to MBC implementation are the lack of formal training and curriculums. We present the first comprehensive MBC curriculum for use in adult psychiatric practice, and describe how the curriculum is adapted and implemented in psychiatry residency training programs. METHODS: The Standard for Clinicians' Interview in Psychiatry (SCIP) was developed as a measurement-based care tool for clinicians' use. The SCIP is the only instrument that includes 18 reliable and validated clinician-rated scales covering most adult psychiatric disorders. The SCIP has simple, unified rules of measurement that apply to the 18 scales. The MBC curriculum includes 2 instruction manuals, 4 didactic lectures, and 12 videotaped interviews. We describe the annual learning and implementation of MBC curriculum in residency programs. RESULTS: The curriculum implementation at West Virginia University and Delaware Psychiatric Center began in 2019 and is ongoing. We present 3 case demonstrations of the implementation of MBC in clinical settings. CONCLUSIONS: Comprehensive implementation of MBC curriculum in residency programs has the potential to facilitate research and create a "culture" of MBC in future generations of psychiatrists.

COVID-19 Pandemic-Delayed Diagnosis and Treatment of Atypical Neuroleptic Malignant Syndrome in a Violent Forensics Patient With Intellectual Disability and Treatment-Resistant Schizophrenia.

This case report highlights an episode of neuroleptic malignant syndrome (NMS) in a forensic psychiatry inpatient unit and how the coronavirus disease (COVID) pandemic, as well as, an atypical presentation of NMS delayed diagnosis and treatment of a patient, which could have been fatal. NMS and atypical NMS manifest typically after the use of anti-psychotics during the first two weeks of initiation of treatment. COVID can mimic many of the initial symptoms of NMS such as changes in mental status, fever, and, at times, dysautonomia. This case will try and highlight why this crossover of symptoms and the forensic environment made diagnosis and treatment in this particular case more difficult.

Bath salts: an emerging danger.

We report a case of psychosis in an individual who has ingested a new compound known as "bath salts." Bath salts represent an emerging public health threat due to serious neuropsychiatric and behavioral symptoms associated with their use.

Neurosyphilis and organic psychosis.

Neurosyphilis is a Central Nervous System infection that can manifest as a psychiatric condition. Although neurosyphilis is not widely considered in the differential when patients present with psychiatric symptoms, routine Rapid Plasma Reagin (RPR) screening is indicated when assessing new-onset psychiatric illness. This case report will illustrate the usefulness of RPR testing for patients admitted to inpatient or outpatient psychiatric treatment.

Impact of the wait for an initial appointment on the rate of kept appointments at a mental health center.

Failure to keep initial appointments at a community mental health center results in a burden on the staff and the center's financial resources. The authors studied referrals to an outpatient program and found that delay in scheduling appointments had a significant impact on rate of kept appointments. The impact was significant during the first week of delay and appeared to stabilize after day seven. Age influenced the rate but differed in influence between the adult and child programs. Changes aimed at reducing wait time for initial appointments may favorably affect rate of kept appointments and ultimately preserve staff and financial resources.

Cost-sharing requirements and access to mental health care among medicare enrollees with schizophrenia.

OBJECTIVE: This study explored the association between Medicare cost-sharing requirements and the probability of use of various mental health outpatient services among Medicare enrollees with schizophrenia. METHODS: Multivariate logistic regression was used to estimate the probability of use of each of seven types of services over six months. Patients were recruited from public and private mental health treatment provider organizations in six states. The analyses included 1,088 Medicare enrollees, of whom approximately 55 percent were also enrolled in Medicaid. RESULTS: Medicare-only patients (with greater cost-sharing) were 25 to 45 percent less likely to have used rehabilitation services, individual therapy with nonpsychiatrist mental health providers, and case management. No association was found between Medicaid enrollment and probability of service use for medical clinic visits, group therapy, individual contact with a psychiatrist, or receipt of second-generation antipsychotics. CONCLUSIONS: Among Medicare enrollees with schizophrenia, gaps in Medicare coverage may be more problematic for rehabilitation, case management, and contact with nonpsychiatrist providers. Local public and private subsidies for mental health treatment may compensate for some of the gaps in coverage. However, such subsidies are not universally or uniformly provided.

A web-based program to empower patients who have schizophrenia to discuss quality of care with mental health providers.

OBJECTIVE: This study evaluated a Web-based tool to help patients with schizophrenia communicate with clinicians about evidence-based treatments. METHODS: Fifty patients used an interactive Web-based intervention featuring actors simulating a patient discussing treatment concerns (intervention group; N=24) or were shown an educational video about schizophrenia treatment before an appointment for routine follow-up care (control group; N=26). The visits were recorded and analyzed by using the Roter Interaction Analysis System. RESULTS: Visits by patients in the intervention group were longer (24 versus 19 minutes, p<.05) and had a proportionately greater patient contribution to the dialogue (288 versus 229 statements, p<.05) and a smaller ratio of clinician to patient talk (1.1 versus 1.4, p<.05) compared with visits by the control group. Patients in the intervention group asked more questions about treatment (2 versus .9, p<.05), disclosed more lifestyle information (76 versus 53 statements, p<.005), and more often checked that they understood information (3.6 versus 2.1 checks, p<.05). Clinicians asked more questions about treatment (7.5 versus 5.1, p<.05) and the medical condition (7.8 versus 4.7, p<.05) to control group patients but made more statements of empathy (1.3 versus .4, p<.03) and cues of interest (48 versus 22, p<.05) with the intervention group. The patient-centeredness ratio was greater for visits by patients in the intervention group than by the control group (8.5 versus 3.2, p<.05). Patients' tone was more dominant and respectful (p<.05) and clinicians' tone was more sympathetic (p<.05) during visits by patients in the intervention. CONCLUSIONS: The Web-based tool empowered persons with schizophrenia to engage more fully in a patient-centered dialogue about their treatment.

SCREENING FOR AND PREVALENCE OF HIV AND HEPATITIS C AMONG AN OUTPATIENT URBAN SAMPLE OF PEOPLE WITH SERIOUS MENTAL ILLNESS AND CO-OCCURRING SUBSTANCE ABUSE.

BACKGROUND: To assess rates of screening and testing of HIV and HCV among those with serious mental illness and co-occurring substance use disorders. METHODS: One hundred fifty-three people with serious mental illness and cooccurring substance use disorders completed measures and were screened for HIV and HCV. RESULTS: Six percent were HIV positive and 25% were HCV positive. Almost a quarter reported a history of injection drug use and 86% reported a history of unprotected sexual encounters. Compared to those without a diagnosis of Hepatitis C, those diagnosed with Hepatitis C were significantly more likely to have a sexually transmitted infection, (p = 0.01), have a lifetime history of injection drug use, (p < 0.001), and a lifetime history of sniffing drugs, (p = 0.01). CONCLUSIONS: Given the high levels of infection of HIV and HCV and high levels of transmission risk factors efforts to improve screening and provide risk reduction counseling are warranted.

Assessing the STIRR model of best practices for blood-borne infections of clients with severe mental illness.

OBJECTIVES: People with co-occurring severe mental illness and a substance use disorder are at markedly elevated risk of infection from HIV, hepatitis B virus (HBV), and hepatitis C virus (HCV), but they generally do not receive basic recommended screening or preventive and treatment services. Barriers to services include lack of programs offered by mental health providers and client refusal of available services. Clients from racial-ethnic minority groups are even less likely to accept recommended services. The intervention tested was designed to facilitate integrated infectious disease programming in mental health settings and to increase acceptance of such services among clients. METHODS: A randomized controlled trial (N=236) compared enhanced treatment as usual (control) with a brief intervention to deliver best-practice services for blood-borne diseases in an urban sample of clients with co-occurring disorders who were largely from racial-ethnic minority groups. The "STIRR" intervention included Screening for HIV and HCV risk factors, Testing for HIV and hepatitis, Immunization against hepatitis A and B, Risk reduction counseling, and medical treatment Referral and support at the site of mental health care. RESULTS: Clients randomly assigned to the STIRR intervention had high levels (over 80%) of participation and acceptance of core services. They were more likely to be tested for HBV and HCV, to be immunized against hepatitis A virus and HBV, and to increase their knowledge about hepatitis and reduce their substance abuse. However, they showed no reduction in risk behavior, were no more likely to be referred to care, and showed no increase in HIV knowledge. Intervention costs were $541 per client (including $234 for blood tests). CONCLUSIONS: STIRR appears to be efficacious in providing a basic, best-practice package of interventions for clients with co-occurring disorders.

Developing a model psychiatric treatment program for patients with intellectual disability in a community mental health center.

The Special Needs Clinic of the Johns Hopkins Bayview Medical Center in Baltimore, Maryland provides comprehensive treatment for patients with developmental or intellectual disability and psychiatric illness. This report describes the clinical characteristics and service utilization of patients attending this clinic. Factors that support quality mental health services that are both cost-effective and accessible are identified.