A Multidisciplinary Consultation-Liaison Team Approach to Reduce Enhanced Observer Usage.

BACKGROUND: There are few evidence-informed guidelines and findings to show that the use of sitters improves patient safety; overall, it is a costly intervention to address patients with disruptive behaviors. OBJECTIVE: The purpose of this article is to demonstrate that the creation of a multidisciplinary consultation-liaison (C-L) team, integrated with a psychiatric C-L team, together can decrease sitter use and improve outcomes using nonpharmacologic interventions. METHODS: This retrospective study describes the planning, implementation, and data collection using in creating an multidisciplinary C-L team to collaborate with the psychiatric C-L team and outcomes to support the approach. The multidisciplinary C-L team was composed of advanced practice registered nurses and creative art therapists. The teams worked closely with the medical units to develop and monitor criteria for sitter use. The key outcomes of the intervention improved patient safety and reduced overall cost. RESULTS: In the first year of implementation of a multidisciplinary C-L approach, sitter use decreased by 72%. Nonpharmacologic interventions improved patient outcomes by providing education to medical staff that enhanced the assessment and implementation of enhanced observer use across all the medical units. Subsequent data also reflect a sustained reduction in cost over the next 2-year period, saving the institution nearly $70K a month. CONCLUSION: An multidisciplinary C-L and psychiatric C-L team collaborated on the need for psychiatric medications, or nonpharmacologic interventions to address behaviors and decrease the need for an enhanced observer. The teams worked together to make policy revisions and algorithms and provide education, the result of which was significant financial savings and improved patient safety.

Characteristics of Patients With Constant Observers.

BACKGROUND: The use of constant observers ("sitters") has been common practice in many medical centers to maintain patient safety. RESULTS: A retrospective chart review of patients who required sitters from October 1, 2007 to September 31, 2013 at a large, private hospital serving a multiethnic community showed that the top reasons for sitters include suicide risk, agitation, fall risk, interfering with medical devices, and confusion/disorientation. Sitters were used for a mean of 3.4 days ranging from 1 to 287 days, with a mean hospital length of stay of 18.9 days. Although 42.4% of all cases with sitters had a psychiatric consultation, psychiatry was consulted on only 8.5% of those with agitation, 6.3% of those who were disoriented, and 12.7% of those with decisional capacity concerns. Psychiatry was consulted on 87.4% of patients with a constant observer for suicide risks. Sitters were most often discontinued when behaviors improved or when patients were discharged. CONCLUSION: This information will be useful for understanding the optimal way to implement a program that will increase patient safety and decrease cost.

Promoting Optimal Native Outcomes (PONO) by Understanding Women's Stress Experiences.

A growing body of evidence links stress with mental illness and chronic disease. Existing scales of women's stress fail to capture the daily stressors of low-income, rural women. We explored the psychosocial stressors of local women residing in a rural Hawaii community with a large Native Hawaiian and Other Pacific Islander population. We recruited women, aged 18-35 years, at a community health center. We convened four focus groups to elicit information about women's stress. We identified key themes from the focus group data to generate questions that target concerns raised by participants. These were corroborated by additional focus groups. Thirty-six women participated in the study. Seven stressor themes emerged: intimate relationships-limited partner assistance, gender stereotype; family and home life-feeling like an outsider, lack of respect; childrearing-quality and affordable childcare, conflicting discipline styles; time for self-never-ending duties, being too tired to relax; neighborhood environment-safety concerns, not feeling part of the community; workplace-workload and transportation obstacles; and finances-making ends meet and arguments about money. Women in this study articulated a broad range of daily stressors. Sociocultural factors leading to feeling like an outsider within their own family, intercultural marriage conflicts, and perceptions of community discrimination are not included in other published scales. Our focus group investigations thus provided critical knowledge for developing a community-relevant scale. This is a prerequisite for developing and testing innovative intervention strategies designed to reduce stress in this population. We believe that reducing stress is necessary to mitigate the negative effects of stressors on physical and mental health among women in this rural community.

Simultaneous usage of dementia medications and anticholinergics among Asians and Pacific Islanders.

BACKGROUND: The simultaneous use of dementia medications and anticholinergic medications occurs frequently. Cholinesterase inhibitors and anticholinergic medications likely counteract one another, potentially exposing patients to medications with decreased benefit, more adverse effects, and higher cost of care. We identified the rate of concurrent prescriptions of cholinesterase inhibitors/memantine with anticholinergics in an urban hospital setting with a large Asian and Pacific Islander population. METHODS: This study is a retrospective review of patients hospitalized from 1 January 2006 to 31 December 2010 at a general hospital who simultaneously received US Food and Drug Administration-approved dementia medications (galantamine, rivastigmine, donepezil, and/or memantine) and anticholinergics. RESULTS: Overall, 304 patients receiving cholinesterase inhibitors/memantine also received anticholinergics. Of these patients, 64.1% were given high-potency anticholinergic medications, and 35.9% received medium-potency medications. Indications for the use of anticholinergic medication were urological (17.8%), gastrointestinal excluding nausea (32.6%), nausea (10.2%), psychiatric (7.9%), and other (31.6%). Asian patients received the combination of cholinesterase inhibitors/memantine and anticholinergics less frequently than Native Hawaiian or Caucasian patients (8.4% vs 12.2% and 13.3%, respectively; χ2 = 16.04, degrees of freedom = 2, P < 0.0003). CONCLUSIONS: Simultaneous prescribing of cholinesterase inhibitors, memantine, and anticholinergic medications was significantly less common than in previous studies, with some ethnic variability. The less frequent occurrence of concurrent medications in the Asian population may be because of variations in the rate of indications or in tolerability for anticholinergic medications among the population.

Folk and biological perceptions of dementia among Asian ethnic minorities in Hawaii.

OBJECTIVE: To study if Asian ethnic groups in Hawaii today maintain folk-based beliefs about dementia, have inadequate biomedical understanding of dementia, and differ among each other regarding perceptions of dementia. DESIGN: The study adapts and expands a 2004 survey of ethnic groups on perceptions of Alzheimer disease demonstrating that ethnic minority groups hold more folk perceptions and less biomedical perceptions of dementia than Caucasians. This study surveys particular ethnic minority family members of elders admitted to four long-term care and inpatient facilities in Hawaii. Seventy-one family members completed surveys, including 23 Chinese, 18 Filipino, and 30 Japanese participants. Elders may or may not have had the diagnosis of dementia, though an estimated half of elders in all four facilities already held the diagnosis of dementia. RESULTS: Findings indicated that Japanese and Chinese respondents in this study held perceptions about dementia that were more consistent with current biomedical understanding compared with their Filipino counterparts (mean differences/percent correct for Japanese: 57%, Chinese: 56% versus Filipino: 38%; F = 6.39, df = 2,55, p = 0.003). Filipino respondents were less likely than Japanese and Chinese respondents to report that persons with dementia can develop physical and mental problems-97% of Japanese participants and 82% of Chinese participants responded correctly compared with 63% of Filipino participants (Fisher's Exact test p = 0.009). With regard to folk beliefs about dementia, variation occurred with no consistent trend among the groups. CONCLUSION: Low levels of biomedical understanding of dementia were reflected by all three subgroups of Asians living in Hawaii with less prominence of folk beliefs compared with prior studies of ethnic minority perceptions. Education did not predict variability in dementia perceptions among the groups. Lower levels of acculturation, suggested by primary home language other than English, may correlate with a perception of dementia that is less consistent with current biomedical understanding of dementia. Persisting folk beliefs about dementia and the evident lack of biomedical understanding, particularly the belief that dementia is a normal part of aging, emphasizes the need for more culturally tailored strategies in patient education about dementia and the importance of early intervention.

An observational study of buprenorphine treatment of the prescription opioid dependent pain patient.

BACKGROUND AND OBJECTIVES: In some countries, particularly the United States and Canada, there has been a growing problem of opioid dependence associated with the treatment of chronic pain. Controversy exists regarding the efficacy and safety of opioid therapy, particularly in high doses for extended periods of time. This study reports on the outcome of chronic pain patients treated with buprenorphine in an outpatient psychiatric consultation clinic. METHODS: Forty three consecutive outpatient clinic chronic pain patients with a DSM-IV diagnosis of opioid dependence and treated with buprenorphine during a 3-year period were monitored for follow-up periods of up to 5 years. All subjects were dependent on drugs prescribed for pain and were divided into two groups: those who had a history of abuse of alcohol or drugs and those who did not Historical, physical, demographic, and outcome data were collected. RESULTS: The majority of patients were male, not working, and between the ages of 45-60. Follow-up revealed that treatment with buprenorphine was effective. Most patients had improved pain with treatment of the opioid dependence. There were no differences between those with or without a history of substance abuse. DISCUSSION AND CONCLUSIONS: Patients often improved with much less preoccupation with pain, expressing great satisfaction with buprenorphine treatment. SCIENTIFIC SIGNIFICANCE: Buprenorphine is an effective tool when treating the opioid-dependent chronic pain patient.

One Model of Residency Journal Clubs With Multifaceted Support.

PROBLEM: The field of medical education is represented by a fairly wide variety of models for utilizing journal clubs as an effective teaching tool, each with varying levels of empirical support. Our own prior attempts at developing and implementing an effective journal club required improvements. INTERVENTION: Our intervention consisted of an innovative, effective journal club model that has more well-defined elements that are readily adaptable for other residency programs. The collective strategies were based on the previous literature and our own experiences. CONTEXT: Our intervention was implemented in a department of psychiatry within a university-based medical school. Study participants came from a psychiatry department's residency programs (N = 36) during academic year 2011-2012 with senior residents having the option to attend journal club. Using a multifaceted approach, measures included attendance, presession quizzes, postsession evaluations, and a final postcourse evaluation of 11 dimensions (e.g., goals, objectives). OUTCOME: Thirty-one (86%) trainees attended journal club-a substantial increase from previous years. The presession-quiz median was 4.4 total correct out of 6 questions (range = 3.3-5.3), indicating that the articles were generally read before the session. The postsession-evaluation median was 4.6 (1-5 scale, 5 the highest; range = 4.1-4.8), indicating sessions were well received. The final postcourse-evaluation overall mean was 3.9 (1-5 scale, 5 the highest; subscale M range = 3.4-4.5). Qualitative and quantitative analyses of the postcourse evaluation indicated the following positive aspects: educational objectives generally met, overall structured format, quality of discussions, individuals involved (e.g., course directors, trainees, faculty facilitators), and availability of food. Areas of possible improvement included time management within the sessions, more contemporary and clinically relevant articles, consistency in faculty moderators, and evaluation process. Engagement in learning appeared to have been dramatically increased through five strategies: (a) meaningful incentives; (b) assigned, engaged consistently prepared faculty; (c) meaningful evaluation; (d) prejournal club preparations that helped residents assimilate critical appraisal with time-and-task-management skills; and (e) a planning group that developed and improved curricula and instruction to meet the objectives of the course. LESSONS LEARNED: Overall, effective, and successful journal clubs require systematic planning, implementation, modification, and refinement.

Interpersonal youth violence perpetration and victimization in a diverse Asian American and Pacific Islander adolescent sample.

This study was the first to examine ethnic, sex, and ethnicity-by-sex differences for under-researched, Asian American and Pacific Islander, adolescent groups on youth violence outcomes other than cyberbullying. This effort included the less researched, emotional violence, and included socioeconomic status (SES) measures as covariates. The sample size from 2 high schools in spring 2007 was 881, using an epidemiologic survey design. The pattern of results was higher rates of violence victimization for ethnic groups, with lower representation in the 2 schools' population, and ethnic groups that more recently moved or immigrated to Hawai'i. For emotional victimization, girls of European American and "other", ethnicities self-reported higher rates than boys. Several implications (e.g., need for ethnically and gender-based approaches) and further research (e.g., ethnocultural identity) are discussed.

Sociodemographic characterization of ECT utilization in Hawaii.

OBJECTIVES: Minimal research has been done on sociodemographic differences in utilization of electroconvulsive therapy (ECT) for refractory depression, especially among Asian Americans and Pacific Islanders. METHODS: This study examined sociodemographic and diagnostic variables using retrospective data from Hawaii, an island state with predominantly Asian Americans and Pacific Islanders. Retrospective data were obtained from an inpatient and outpatient database of ECT patients from 2008 to 2010 at a tertiary care community hospital on O'ahu, Hawaii. RESULTS: There was a significant increase in overall ECT utilization from 2008 to 2009, with utilization remaining stable from 2009 to 2010. European Americans (41%) and Japanese Americans (29%) have relatively higher rates of receiving ECT, and Filipino Americans and Native Hawaiians have relatively lower rates in comparison with their population demographics. Japanese Americans received significantly more ECT procedures than European Americans. CONCLUSIONS: Electroconvulsive therapy is underutilized by certain sociodemographic groups that may benefit most from the treatment. There are significant differences in ECT usage based on ethnicity. Such differences may be related to help-seeking behavior, economic differences, and/or attitudes regarding mental illness. Further research is needed to elucidate the reasons for differences in utilization.

A Mixed-Methods Evaluation to Inform the Hawai'i Suicide Prevention Strategic Plan.

The Prevent Suicide Hawai'i Taskforce is a state, public, and private partnership of individuals, organizations, and community groups that leads statewide suicide prevention efforts in Hawai'i. The purpose of this evaluation was to identify the progress and barriers of the Taskforce to inform the upcoming 2025 Hawai'i Suicide Prevention Strategic Plan in the following areas: Hope, Help, Heal, Research and Evaluation, and Policy and Advocacy. Utilizing a sequential exploratory mixed-methods approach, 18 key informants were interviewed, followed by a 13-question survey sent to the Taskforce member listserv. Results were analyzed using qualitative coding techniques and descriptive statistics. Interview findings contained six themes: importance of community relationships, interconnection of suicide prevention efforts, progress in diversifying training, organizational challenges, adaptations to the COVID-19 pandemic, and funding challenges. Of the 34 survey respondents, most were involved in the area of Hope (91%). The respondents reported the area with most progress was Hope (87%), and the most important area to address was Help (41%). The majority (82%) of the respondents characterized the level of Taskforce communication as Excellent or Good. Interview and survey data corroborated each other and revealed new insights about the successes and barriers of the Taskforce and their progress in implementing the Strategic Plan. Recommendations included advocating for long-term funding for suicide prevention and building community relationships.

Disparities in psychiatric emergency department visits among youth in Hawai'i, 2000-2010.

OBJECTIVE: To describe the frequency and patient characteristics of emergency department encounters for mental health among youth, and to examine differences in utilization and treatment patterns. STUDY DESIGN: Data were obtained from the Hawai'i Health Information Corporation database of emergency department records between January 1, 2000, and December 31, 2010. Analyses were limited to records of visits by patients aged <18 years with a diagnosis of mental disorder or a suicide attempt. RESULTS: The annual average rate was 49.7 emergency department visits related to mental health issues per 10 000 youth, accounting for 2.1% of all emergency department visits among youth. Rates of mental health-related visits significantly and steadily increased, from a low of 25.8 in 2000 to a high of 67.4 in 2010. Rural areas consistently exhibited higher rates and acceleration at a steeper incline across time. Rural youth were more likely to be discharged or transferred for inpatient care or outpatient services compared with urban youth (6.3% vs 12.4%; χ(2) = 61.42; df = 3; P < .001). CONCLUSION: The trend in emergency department utilization for mental health-related issues in adolescents is apparently increasing, with significantly higher rate and morbidity for youth in rural areas. Several recommendations are described for creating a responsive and integrated system of mental health care for youth, covering training, consultation, screening, and brief interventions.

Changes in PTSD symptomatology and mental health during pregnancy and postpartum.

Changes in mental health symptoms throughout pregnancy and postpartum may impact a woman's experience and adjustment during an important time. However, few studies have investigated these changes throughout the perinatal period, particularly changes in posttraumatic stress disorder (PTSD) symptoms. The purpose of this study was to examine longitudinal changes in PTSD, depression, and anxiety symptomatology during pregnancy and postpartum. Pregnant women of ethnically diverse backgrounds receiving services for prenatal care at an outpatient obstetric-gynecology clinic or private physicians' office were assessed by interview on symptoms of PTSD, depression, anxiety, and general stress up to four times, including their first, second, and third trimester, and postpartum visits. Overall, during pregnancy there was a declining trend of PTSD symptoms. For anxiety, there was no overall significant change over time; however, anxiety symptoms were individually variable in the rate of change. For both depression and general stress symptoms, there was a declining trend, which was also variable in the individual rate of change among women during their pregnancy. Visual and post hoc analyses also suggest a possible peak in PTSD symptoms in the weeks prior to delivery. While most mental health symptoms may generally decrease during pregnancy, given the individual variability among women in the rate of change in symptoms, screening and monitoring of symptom fluctuations throughout the course of pregnancy may be needed. Further studies are needed to examine potential spiking of symptoms in the perinatal period.

The risk of adolescent suicide across patterns of drug use: a nationally representative study of high school students in the United States from 1999 to 2009.

OBJECTIVE: Substance use is associated with suicidal ideation, planning and attempts among adolescents, but it is unclear how this association varies across different types and number of substances. This study examined the association between patterns of substance use and suicidality among a nationally representative sample of high school students in the United States during the last decade. METHOD: Data from the 2001 to 2009 Youth Risk Behavior Survey including 73,183 high school students were analyzed. Logistic regression analyses examined the association between lifetime use of ten common substances of abuse (alcohol, cocaine, ecstasy, hallucinogens, heroin, inhalants, marijuana, methamphetamines, steroids, and tobacco) and four measures of suicidality over the last year (suicidal ideation, suicide plan, suicide attempt, and severe suicide attempt requiring medical attention), controlling for potential confounders (socio-demographic variables, interpersonal violence, sexual intercourse, and symptoms of depression and eating disorder). RESULTS: Among the ten substances, univariate analysis demonstrates that adolescents reporting a history of heroin use have the strongest association with suicidal ideation, suicide plan, suicide attempts and severe suicide attempts in the last year (odds ratio = 5.0, 5.9, 12.0, and 23.6 compared to non-users), followed by users of methamphetamines (OR = 4.3-13.1) and steroids (OR = 3.7-11.8). Cocaine, ecstasy, hallucinogens and inhalants had a moderate association with suicidality (OR = 3.1-10.8). Users of marijuana, alcohol and tobacco also had an increased odds ratio of suicidality (OR = 1.9-5.2). The association between each of ten substances and the four measures of suicidality remained significant with multivariate analysis controlling for multiple confounders (p < 0.05), except for the association between alcohol use and severe suicide attempts. The seven illicit substances had a stronger association with severe suicide attempts as compared to all other confounding risk factors except depression. The number of substances used had a graded relationship to suicidality. CONCLUSIONS: Substance abuse is a strong risk factor for suicidal thoughts and behaviors among American high school students, with the strength of this relationship dramatically increasing with particular illicit drugs and a higher number of substances. The findings reinforce the importance of routine screening for substance abuse in the assessment of adolescent suicide risk.

Underage drinking among Asian American and Pacific Islander adolescents.

This study assessed the prevalence of alcohol abuse and dependence rates among four major ethnic groups of Hawai'i and examined the relationship among risk factors, protective factors, and demographic variables related to underage drinking. A total of 196 students were administered the Diagnostic Interview Schedule for Children, the American Drug and Alcohol Survey, and the Prevention Planning Survey. Drinking rates for Native Hawaiian students were significantly higher than those for Japanese and Caucasian students. Multiple logistic regression models accounted for 49% of the variance for any alcohol use. Ethnic group differences were found when data were disaggregated for Asian and Pacific Islander students.

A confirmatory model for substance use among Japanese American and part-Japanese American adolescents.

Few studies have examined the effect of ethnicity and cultural identity on substance use among Asian and Pacific Islander adolescents. A cross-sequential study conducted in Hawai'i with 144 Japanese and part-Japanese American adolescents assessed a model integrating Japanese ethnicity, cultural identity, substance use, major life events, and social support. Japanese American adolescents scored higher on the Japanese Culture Scale and on the Peers' Social Support than the part-Japanese American adolescents. Significant associations for substance use and impairment included culturally intensified events and Japanese cultural identity-behavior subset. Models had good overall fits and suggested that conflict surrounding cultural identity may contribute to substance use.

Suicide Risk Assessment, Management, and Mitigation in the Emergency Setting.

Suicide is a serious public health issue and is a leading cause of death worldwide. Suicidal ideation is a common presentation in emergency department (ED) settings, with many nuanced complications. Therefore, understanding screening, assessment, and mitigation is paramount to successful encounters with individuals presenting to emergency settings in psychiatric crises. Screening helps to identify the few people at risk within a large group. Assessment seeks to decide whether a specific individual is at significant risk. Mitigation aims to reduce the risk of suicide or of a serious attempt for a person at risk. These aims cannot be achieved with perfect reliability, but some approaches are more effective than others. Suicide screening specifics are important, even to individual practitioners, because a positive screen triggers assessment. Most practitioners understand assessment well: beginning with early psychiatric training, they are taught signs and symptoms suggesting that a patient might be at risk of suicide. Mitigating suicide risk is increasingly important to reduce the misery of ED boarding for patients awaiting psychiatric admission. For many patients, hospital admission is unnecessary if support, monitoring, and contingency plans are workable. For any individual patient, there may be a complicated mix of findings, risks, and interventions. Evidence-based screening and assessment tools are inadequate for the possible complexities, making care of individual patients dependent on good clinical assessment. The authors review the available evidence and offer experienced recommendations for challenges not yet thoroughly researched.

Utilization of Nurse-Administered Screening, Brief Intervention, and Referral to Treatment in a Brief Psychiatric Inpatient Unit.

BACKGROUND: Screening, Brief Intervention, and Referral to Treatment (SBIRT) has been established as an effective screening tool for providing interventions for patients with risky substance use. OBJECTIVES: The objectives of this project were to train and coach staff nurses in the use of SBIRT, offer SBIRT to all admissions of a brief psychiatric inpatient unit, and decrease readmission rates. DESIGN: Using the Iowa Model for Implementing Evidence-Based Practices, SBIRT was implemented on the unit. Data were collected on the frequency of patients offered SBIRT and readmission rates. RESULTS: Fifty-nine percent of all admissions were offered SBIRT. The average readmission rates decreased by 18.3% for the first 2 months of implementation and by 67.5% for Days 16-31 postdischarge. CONCLUSIONS: SBIRT is an effective tool for nurses on psychiatric units to address substance use and to decrease readmission rates.