"My Patient Can't Sleep": Resident-Led Curriculum Development for Insomnia Management.

OBJECTIVE: Insomnia is a prevalent complaint on acute psychiatric units. When not addressed by primary treating teams, patients request sleep aids "as needed," leading to increased burden on on-call residents and decreased individualized treatment. The authors implemented a new educational curriculum and computer order set for inpatient insomnia management, and examined changes in residents' comfort level in its management and in inpatient sleep medication ordering patterns. METHODS: In this IRB-approved quality improvement project, the authors identified best practices for insomnia management, developed a new curriculum for psychiatry residents, and created a "Sleep Order set" in the electronic medical record (EMR). Residents were surveyed and EMR queried for sleep medication orders for 6 months pre- and post-intervention. RESULTS: The level of comfort of the residents in ordering a variety of sleep medications increased significantly. Sleep medication orders placed by primary teams surged from 938 during the pre-intervention period to 1801 post-intervention (p < 0.001), while those placed by on-call teams fell considerably. CONCLUSION: Education on insomnia management boosted residents' confidence in handling inpatient sleep disorders. Implementation of the new resident-developed "Sleep Order set" greatly reduced the work load of on-call residents, in terms of "as needed" sleep medication orders.

Psychiatric Emergency Services - Can Duty-Hour Changes Help Residents and Patients?

Limitations on resident duty hours have been widely introduced with the intention of decreasing resident fatigue and improving patient outcomes. While there is evidence of improvement in resident well-being and education following such initiatives, they have inadvertently resulted in increased number of hand-offs between clinicians leading to potential errors in patient care. Current literature emphasizes need for more specialty/setting-specific scheduling, while considering residents' opinions when implementing duty-hour reforms. There are no reports examining the impact of duty-hour changes on residents or patients in psychiatric emergency service (PES) settings. Our purpose was to assess the impact of a recent scheduling change and decrease in overall duty hours, on resident well-being and sense of burnout, while also evaluating changes to patient wait-time and length of stay (LOS) in PES. Residents completed Maslach Burnout Inventory and anonymous surveys focusing on: fatigue, sleep, life outside work for shifts - regular (8 am-8 pm) and swing shifts (12 pm-10 pm). Data from the electronic medical records were collected for 6 months pre- and post-schedule change (January 2016-February 2017), for LOS and patient wait-time. Residents' preference for shifts was split. However, 86% reported getting enough sleep during swing shifts, while 83% reported lack of sleep during regular shifts. The average patient wait-time and LOS significantly decreased from 169 to 147 and 690 to 515 min, respectively. The change to swing shifts significantly impacts LOS and patient wait-time. The short shifts demonstrated an improvement in well-being for residents, but were not the singular factor for overall resident satisfaction.

Scaling the great wall: The impact of communication barriers on quality of psychiatric care in Chinese patients.

BACKGROUND: Racial and ethnic minorities (such as Chinese-speaking (CS)) are known to have less equitable access to mental health services than Caucasians. These disparities have a powerful influence on minority groups that already endure a greater burden from mental health needs. AIM: The aim was to identify perceived provider barriers to care for CS patients. METHODS: The study involved an 11-item web-based survey to multidisciplinary health professionals in the department of psychiatry at a 75-bed teaching community mental health center. RESULTS: More than half the respondents agreed that there are disparities in the management of CS versus non-CS patients primarily due to the language barrier (46%). However, older participants and participants who worked fewer hours per week in patient care were less likely to agree (rho = -.27, p = .05 and rho = .33, p = .015, respectively) that these perceived difficulties prevented them from caring for these patients. CONCLUSION: The study revealed that certain modifiable factors like the limited availability of interpreters and culturally appropriate services, rendering psychoeducation and forming therapeutic alliances with CS patients, posed the greatest challenges on inpatient units. In light of these findings, we aim to make recommendations to remediate concerns of limited provider availability by proposing ways to efficiently utilize current resources and advocate for better staffing to improve the overall well-being of this challenging patient subset.

Is the Concept of Pseudoneurotic Schizophrenia Still Valid? A Case Series and Revisiting the Topic.

We describe two cases to emphasize the importance of recognizing symptoms of psychosis underlying a constellation of neurotic symptoms, and to highlight the overlap and potential for misdiagnosis with personality and anxiety disorders. We also provide an overview of pseudoneurotic schizophrenia and familiarize readers about the challenges in making accurate diagnoses in light of this term used in the past. We refer to cases in the literature and point out the implications of this concept on diagnosis, management, and prognosis. Based on the management strategies deployed for the two cases described, we finally recommend that it is imperative to perform accurate and detailed assessments and take into consideration the evolution of the concept of pseudoneurotic schizophrenia to currently accepted DSM-V disorders, in order to effectively treat patients.

Violence Associated with Somatic Delusions.

The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) characterizes delusional disorder (DD) by the presence of delusions for longer than one month, without bizarre behavior or functional impairment. According to Kaplan and Saddock, the lifetime prevalence of DD (all subtypes) is about 0.2%. The persecutory subtype of delusional disorder (DD-PS) is the most common and the somatic subtype (DD-SS) is exceedingly rare. We aim to describe two cases of patients with somatic delusions, both presenting as imminently dangerous and threatening. We also discuss one case that resulted from our extensive literature review where somatic delusions were implicated in elevating a mass shooter's violence risk. Both patients whose cases are presented were involuntarily hospitalized after their doctors called 911 to report that they were being threatened by a weapon. These patients had no established psychiatric diagnoses and were evaluated thoroughly and diagnosed with DD-SS. Both perceived that their physicians were indifferent to their needs and cited their frustration as the trigger for planning attacks on the doctors. Unlike PS, SS is not traditionally described as increasing danger or risk of violence, and thorough risk assessments are not usually performed in DD-SS. We demonstrate that formal psychiatric violence risk assessments remain a useful tool to methodically stratify and effectively address risk, even in patients we do not typically expect to demonstrate premeditated violence.

Persistent Psychosis due to Single Dose of Ecstasy.

Ecstasy, a popular drug among the younger generation, the primary psychoactive component of which is 3,4-Methylenedioxymethamphetamine (MDMA), is rarely known to have acute psychiatric effects and when it does, it is usually short term. We describe a patient who presented to the emergency room in a psychotic state after using ecstasy recreationally. Given his aggressive behavior in the community and risk for self-harm, he was emergently hospitalized to ensure safety. He developed persistent psychotic symptoms (delusions) after one dose of recreational MDMA and the team had the opportunity to observe, monitor, and treat his psychosis. This case along with few other documented cases highlights the gaps in research about the chronic, persistent effects and long-term consequences of MDMA. It also suggests that neuropsychiatric symptoms may not be readily reversible after cessation of use. There is an emphasis on the need for physicians to inquire about MDMA use and include it in toxicology screenings and as a potential differential diagnosis.

Adding Psychotherapy to the Naltrexone Treatment of Alcohol Use Disorder: Meta-analytic Review.

Background It remains unclear if naltrexone combined with psychotherapy is superior to naltrexone alone in treating alcohol use disorders (AUD). The current meta-analysis examined the hypothesis that psychotherapy is a significant moderator that influences AUD-related outcomes and that naltrexone combined with psychotherapy is associated with significantly better AUD-related outcomes than naltrexone alone. Methods A total of 30 studies (Nnaltrexone = 2317; Nplacebo = 2056) were included. Random effects model meta-analyses were carried out for each of the studied outcomes. Subsequently, the random effects model pooled estimates from studies with and without psychotherapy were compared using a Wald test. A mixed-effect model, incorporating psychotherapy as a moderator, was used to examine the impact of psychotherapy on treatment outcomes. Results Naltrexone had a significant treatment effect on abstinence relapse and Gamma-Glutamyl Transferase levels, but not cravings. The pooled estimates for studies with and without psychotherapy were not significantly different for any of the studied outcomes. Psychotherapy was not a significant moderator in the mixed effects models for any of the studied outcomes. Conclusions Naltrexone treatment is efficacious in reducing alcohol consumption, but not reducing cravings. Adding psychotherapy on top naltrexone did not result in any significant additional benefit for AUD patients.

Decoding New York State's Prescription Monitoring Program.

This column describes the Internet System for Tracking Over-Prescribing (I-STOP), New York State's prescription monitoring program, and its compatibility with HIPAA and Part 2 of Volume 42 of the Code of Federal Regulations (CFR). The authors review use of information that is permitted by I-STOP and CFR for health care operations, including disclosure, and present information from the state Bureau of Narcotics Enforcement about appropriate use of the program. Physicians are permitted, for example, to contact other prescribers in I-STOP, even without explicit permission from the patient, an area in which physicians need more training. Common clinical scenarios encountered while navigating I-STOP are described.