Sex Differences in Delirium after Coronary Artery Bypass Graft Surgery and Perioperative Neuropsychiatric Conditions: A Secondary Analysis of a Cohort Study.

BACKGROUND: Biological sex influences the risk of depression and cognitive impairment, but its role in relation to postoperative delirium is unclear. This analysis investigates sex differences in delirium risk after coronary artery bypass graft (CABG) surgery and sex-related differences in relation to affective and cognitive symptoms. METHODS: This is a secondary analysis of the Neuropsychiatric Outcomes After Heart Surgery (NOAHS) study, a single-site, observational study of a CABG surgery cohort (n = 149). Preoperative characteristics are stratified by sex, and baseline variables that differ by sex are evaluated to understand whether sex modifies their relationships with delirium. We also evaluate sex differences in one-month depression and cognition. RESULTS: Female sex is associated with several delirium risk factors, including higher risk of preoperative depression and middle cerebral artery (MCA) stenosis. MCA stenosis was statistically associated with delirium only among women (OR 15.6, 95% CI 1.5, 164.4); mild cognitive impairment (MCI) was associated with delirium only in men (OR 4.6, 95% CI 1.2, 17.9). Other sex-based differences failed to reach statistical significance. Depression remained commoner among women 1 month post-CABG. CONCLUSIONS: Women in this CABG cohort were more likely to have depression at baseline and 1 month postoperatively, as well as MCA stenosis and postoperative delirium. Sex might modify the relationship between post-CABG delirium and its risk factors including MCA stenosis and MCI. Cerebrovascular disease deserves study as a potential explanation linking female sex and a range of poor outcomes among women with coronary heart disease.

Primary Care Behavioral Health Integration and Care Utilization: Implications for Patient Outcome and Healthcare Resource Use.

BACKGROUND: Behavioral health (BH) integration in primary care (PC) can potentially improve outcomes and reduce cost of care. While different models of integration exist, evidence from real-world examples is needed to demonstrate the effectiveness and value of integration. This study aimed to evaluate the outcomes of six PC practice sites located in Western New York that implemented a primary care behavioral health (PCBH) integration model. OBJECTIVE: To assess the impact of PCBH on all-cause healthcare utilization rates. DESIGN: A retrospective observational study based on historical multi-payer health insurance claims data. Claims data were aggregated on a per-member-per-month basis to compare utilization rates among the patients in the PC practice sites that had implemented PCBH to those in the sites that had not yet done so. PARTICIPANTS: The sample included 6768 unique adult health plan members between October 2015 and June 2017 with at least one BH diagnosis code who were attributed to one of the six newly integrated PC practice sites. INTERVENTIONS: Under the PCBH integration model, BH specialists were embedded in PC practice sites to treat a wide range of BH conditions. MAIN MEASURES: Rates of all-cause ED visits and hospital admissions, along with rates of PC provider and BH provider visits. KEY RESULTS: PCBH implementation was associated with reductions in the rates of outpatient ED visits (14.2%; p < 0.001) and PC provider visits (12.0%; p < 0.001), as well as with an increased rate of BH provider visits (7.5%; p = 0.018). CONCLUSIONS: PCBH integration appears to alter the treatment patterns among patients with BH conditions by shifting patient visits away from ED and PC providers toward BH providers who specialize in treatment of such patients.

Depression predicts cognitive and functional decline one month after coronary artery bypass graft surgery (Neuropsychiatric Outcomes After Heart Surgery study).

BACKGROUND: Prior research on cognitive and functional outcomes after coronary artery bypass graft (CABG) surgery has largely explored these two domains in isolation. In this study, we assess baseline depression and cognition as risk factors for decline in the Clinical Dementia Rating Sum-of-Boxes (CDR-SB) 1 month post-CABG surgery, which a combined measure of cognition and function. DESIGN: The Neuropsychiatric Outcomes After Heart Surgery study is a prospective observational cohort study. SETTING: A tertiary care, academic center. PARTICIPANTS: Of a total study sample of 148 patients undergoing CABG surgery, 124 (83.8%) completed 1-month follow-up assessment. Mean age was 66.3, 32 (25.8%) female and 112 (90.3%) White. MEASUREMENTS: Cognition, function, and depression were assessed on semi-structured clinical interviews. Cognitive and functional status were defined using CDR-SB; mild or major depression was defined by the Hamilton Depression Rating Scale. Additionally, neuropsychological battery was performed at baseline. RESULTS: CDR-SB decline occurred in 18 (14.5%) subjects. Older age, depression, baseline CDR-SB, and postoperative delirium were associated with 1-month decline on univariate analysis. Older age (OR 1.1 [1.0-1.2]) and depression (OR 6.2 [1.1-35.0]) remained significant on multivariate regression. In separate models, baseline performance on visual Wechsler memory scale (delayed), Hopkins verbal learning test (immediate and delayed), controlled oral word fluency test, and Trails B predicted CDR-SB decline. CONCLUSION: Roughly one in seven patients experienced CDR-SB decline 1 month after CABG surgery. Also, preoperative depression deserves recognition for being a predictor of CDR-SB decline one month post-CABG.

Cognitive, Psychiatric, and Quality of Life Outcomes in Adult Survivors of Extracorporeal Membrane Oxygenation Therapy: A Scoping Review of the Literature.

OBJECTIVES: To perform a scoping literature review of cognitive, psychiatric, and quality of life outcomes in adults undergoing extracorporeal membrane oxygenation for any indication. DATA SOURCES: We searched PubMed, EMBASE, Cochrane Library, Web of Science, CINAHL, and PsycINFO from inception to June 2019. STUDY SELECTION: Observational studies, clinical trials, qualitative studies, and case series with at least 10 adult subjects were included for analysis. Outcomes of interest consisted of general or domain-specific cognition, psychiatric illness, and quality of life measures that included both mental and physical health. DATA EXTRACTION: Study selection, data quality assessment, and interpretation of results were performed by two independent investigators in accordance with the PRISMA statement. DATA SYNTHESIS: Twenty-two articles were included in this review. Six described cognitive outcomes, 12 described psychiatric outcomes of which two were qualitative studies, and 16 described quality of life outcomes. Cognitive impairment was detected in varying degrees in every study that measured it. Three studies examined neuroimaging results and found neurologic injury to be more frequent in venoarterial versus venovenous extracorporeal membrane oxygenation, but described a variable correlation with cognitive impairment. Rates of depression, anxiety, and post-traumatic stress disorder were similar to other critically ill populations and were related to physical disability after extracorporeal membrane oxygenation. Extracorporeal membrane oxygenation survivors' physical quality of life was worse than population norms but tended to improve with time, while mental quality of life did not differ significantly from the general population. Most studies did not include matched controls and instead compared outcomes to previously published values. CONCLUSIONS: Extracorporeal membrane oxygenation survivors experience cognitive impairment, psychiatric morbidity, and worse quality of life compared with the general population and similar to other survivors of critical illness. Physical disability in extracorporeal membrane oxygenation patients plays a significant role in psychiatric morbidity. However, it remains unclear if structural brain injury plays a role in these outcomes and whether extracorporeal membrane oxygenation causes secondary brain injury.

Depression Predicts Delirium After Coronary Artery Bypass Graft Surgery Independent of Cognitive Impairment and Cerebrovascular Disease: An Analysis of the Neuropsychiatric Outcomes After Heart Surgery Study.

OBJECTIVE: Although depression is a known risk factor for delirium after coronary artery bypass graft (CABG) surgery, it is unclear whether this risk is independent of delirium risk attributable to cognitive impairment or cerebrovascular disease. This study examines depression, mild cognitive impairment (MCI), and cerebrovascular disease as post-CABG delirium risk factors. METHODS: This prospective observational cohort study was performed in a tertiary-care academic hospital. Subjects were without dementia and undergoing CABG surgery. Preoperative cognitive assessment included Clinical Dementia Rating and neuropsychological battery; depression was assessed using Depression Interview and Structured Hamilton. Baseline intracranial stenosis was evaluated by transcranial Doppler of bilateral middle cerebral arteries (MCAs). Study psychiatrists assessed delirium on postoperative days 2-5 using the Confusion Assessment Method. RESULTS: Our analytic sample comprised 131 subjects (average age: 65.8 ± 9.2years, 27% women). MCI prevalence was 24%, preoperative depression 10%, lifetime depression 35%, and MCA stenosis (≥50%) 28%. Sixteen percent developed delirium. Multivariate analysis revealed that age, MCI (odds ratio [OR]: 5.1; 95% confidence interval [CI]: 1.3-20.1), and preoperative depression (OR: 9.9; 95% CI: 1.3-77.9)-but not lifetime depression-predicted delirium. MCA stenosis and severity predicted delirium in univariate but not multivariate analysis. Right MCA stenosis severity predicted delirium severity, but left-sided stenosis severity did not. CONCLUSION: We established that the risk of delirium attributable to depression extends beyond the potential moderating influence of cognitive impairment and cerebrovascular disease alone. Even mild depression and cognitive impairment before CABG deserve recognition for their effect on post-CABG cognitive health.

Text Messaging to Reduce Alcohol Relapse in Prelisting Liver Transplant Candidates: A Pilot Feasibility Study.

BACKGROUND: Many liver transplantation programs require documented alcohol sobriety prior to United Network for Organ Sharing (UNOS) listing. This pilot study examined the feasibility of the first mobile, alcohol relapse prevention intervention for liver transplant patients with alcoholic liver disease (ALD). METHODS: This was a randomized 8-week pilot feasibility trial of a text message-based alcohol intervention. In-treatment assessment was conducted at 4 weeks (4W), and immediate posttreatment assessment was conducted at 8W. Participants were liver transplant candidates (N = 15) diagnosed with ALD who reported at least 1 drinking episode in the past year. Primary feasibility outcomes were percent of messages responded to and posttreatment intervention satisfaction ratings. Preliminary clinical efficacy outcomes were any biologically confirmed alcohol consumption, stress, abstinence self-efficacy, and alcohol craving. RESULTS: On feasibility outcomes, participants responded to 81% of messages received and reported high rates of intervention satisfaction, looked forward to receiving the messages, and found it easy to complete the intervention. On preliminary efficacy outcomes, zero participants in the text message (TM) had positive urine alcohol tests at 8W. Two of the 6 participants in standard care (SC) tested positive at 8W. No effects were seen on craving. For stress, a condition × time interaction emerged. TM participants had less stress at 4W and 8W compared with SC at baseline. They maintained their stress level during the intervention. For self-efficacy, a trend for condition effect emerged. TM participants had higher self-efficacy than SC participants. CONCLUSIONS: Participants reported high satisfaction with the intervention, looked forward to the messages, and found it easy to complete. Participants who received the intervention had better treatment outcomes than those who received standard care. They maintained higher levels of self-efficacy and lower stress. Mobile alcohol interventions may hold significant promise to help ALD liver transplant patients maintain sobriety.

Impact of Delirium After Hip Fracture Surgery on One-Year Mortality in Patients With or Without Dementia: A Case of Effect Modification.

OBJECTIVES: We evaluated whether delirium after hip fracture repair modifies the relationship between baseline dementia and one-year mortality after surgery. METHODS: Patients age 65 years and older undergoing hip fracture repair surgery at John Hopkins Bayview Medical Center between 1999 and 2009 were eligible for this prospective cohort study. Baseline probable dementia was defined as either preoperatively diagnosed dementia per geriatrician or score less than 24 on the Mini-Mental State Examination. Delirium was assessed using the Confusion Assessment Method. Four cognitive groups were defined: 1) neither probable dementia nor delirium (NDD), 2) probable dementia only, 3) delirium only, or 4) delirium superimposed on dementia (DSD). Primary outcome of mortality was obtained through hospital records, obituaries, the National Death Index, and Social Security Death Index. RESULTS: The current sample comprises 466 subjects (average age: 80.8 ± 7.0 years; 73.6% female). Of these, 77 (17%) were categorized as DSD, 68 (15%) probable dementia only, 73 (16%) delirium only, and 248 (53%) NDD. Cox regression revealed that DSD subjects had a significantly higher hazard of one-year mortality than NDD subjects (hazard ratio [HR]: 1.71, 95% CI: 1.06, 2.77) after adjusting for age, sex, medical comorbidity, and surgery duration. Trends toward greater mortality for probable-dementia and delirium only subjects were not significant (HR: 1.42 [95% CI: 0.80, 2.52] and 1.12 [95% CI: 0.64, 1.95], respectively). CONCLUSIONS: Delirium after hip fracture repair surgery in patients with preoperative dementia modifies the risk of mortality over the first postoperative year. Patients with DSD have a nearly two-fold greater odds of one-year mortality than those without dementia or delirium.

Mood Symptoms and Restless Legs Syndrome Without Periodic Limb Movements During Sleep: Is it a Clinical Subtype?

Frequently co-occurring restless legs syndrome (RLS) and periodic limb movements during sleep (PLMS) are postulated to share common pathophysiology. The authors compared clinical characteristics and polysomnography (PSG) parameters among 155 idiopathic, untreated RLS patients who were stratified into three groups based on periodic limb movement index (PLMI). The authors found that RLS patients without PLMS (PLMI <5) had higher depression and anxiety scores, a lower total arousal index, longer latency to REM, and a higher spontaneous arousal frequency on PSG than RLS patients with PLMS. RLS severity was associated with PLMI in RLS patients with PLMS but not without PLMS. RLS without PLMS seems to be a phenotypically distinct clinical subtype of RLS. Future study should examine whether RLS without PLMS has a different clinical course, treatment response, and pathophysiology than RLS with PLMS.

Cystic Fibrosis Transmembrane Regulator Modulators: Implications for the Management of Depression and Anxiety in Cystic Fibrosis.

BACKGROUND: Individuals with cystic fibrosis (CF) are at high risk for depression and anxiety, which are associated with worse medical outcomes. Novel therapies for CF hold great promise for improving physical health, but the effects of these therapies on mental health remain poorly understood. OBJECTIVE: This review aims to familiarize psychiatrists with the potential effect of novel CF therapies on depression and anxiety. METHODS: We discuss novel therapies that directly target the mutant CF protein, the CF transmembrane regulator (CFTR), which are called CFTR modulators. We summarize depression and anxiety screening and treatment guidelines under implementation in accredited CF centers. Case vignettes highlight the complexities of caring for individuals with CF with comorbid depression and anxiety, including patients experiencing worsening depression and anxiety proximate to initiation of CFTR modulator therapy, and management of drug-drug interactions. CONCLUSIONS: Although CFTR modulator therapies provide hope for improving clinical outcomes, worsening depression and anxiety occurs in some patients when starting these novel agents. This phenomenon may be multifactorial, with hypothesized contributions from CFTR modulator-psychotropic medication interactions, direct effects of CFTR modulators on central nervous system function, the psychologic effect of starting a potentially life-altering drug, and typical triggers of depression and anxiety such as stress, pain, and inflammation. The medical and psychiatric complexity of many individuals with CF warrants more direct involvement of mental health specialists on the multidisciplinary CF team. Inclusion of mental health variables in patients with CF registries will facilitate further examination at an epidemiologic level.

Predictors of suicidal ideation in Korean American older adults: analysis of the Memory and Aging Study of Koreans (MASK).

OBJECTIVE: Our aim is to investigate the prevalence and predictors of suicidal ideation among Korean American older adults and assess the self-rated mental health of Korean American older adults with suicidal ideation with or without depressive syndrome. METHODS: The Memory and Aging Study of Koreans is a cross-sectional, epidemiologic study of a community-representative sample of Korean American older adults (N = 1116) residing in the Baltimore-Washington area. Participants were interviewed using the Korean version of the Patient Health Questionnaire (PHQ-9K). In addition, demographic information, self-rated mental health, and self-rated physical health status were obtained. RESULTS: In this study, 14.7% of Korean American older adults reported suicidal ideation. Predictors of suicidal ideation included living alone, major or minor depressive syndrome (diagnosed by the PHQ-9K), shorter duration of residency in the USA, and poorer self-rated mental health status. Of those who reported suicidal ideation, 64% did not have minor or major depressive syndrome. However, their self-rated mental health was as poor as that of those with major or minor depressive syndrome but without suicidal ideation. CONCLUSION: Suicidal ideation without depressive syndromes was common among Korean American older adults. For this group of elders with poor self-rated mental health, future studies should look to improving early detection of suicide risks and developing feasible suicide prevention interventions. Copyright © 2016 John Wiley & Sons, Ltd.

Circadian Rhythm Disruption in the Critically Ill: An Opportunity for Improving Outcomes.

OBJECTIVES: Circadian rhythms are severely disrupted among the critically ill. These circadian arrhythmias impair mentation, immunity, autonomic function, endocrine activity, hormonal signaling, and ultimately healing. In this review, we present a modern model of circadian disruption among the critically ill, discuss causes of these circadian arrhythmias, review observational and intervention studies of the effects of circadian-rhythm-restoring factors on medical outcomes, and identify needed key trials of circadian interventions in the critically ill. DATA SOURCES: MEDLINE, EMBASE, PsychINFO, Google Scholar through December 2014. STUDY SELECTION: Articles relevant to circadian rhythms, melatonin, and light in the critically ill were selected. DATA EXTRACTION AND DATA SYNTHESIS: Articles were synthesized for this review of circadian arrhythmia and the use of circadian-rhythm-restoring interventions among the critically ill. CONCLUSIONS: Circadian disruption often demonstrates serial degradation: initially, the amplitude attenuates along with delayed circadian phase. With increasing acuity of illness, circadian rhythmicity may be lost entirely. Causes of chronodisruption may be environmental or internal to the patient. In particular, inadequate daytime illumination and nocturnal light pollution disrupt healthy circadian periodicity. Internal causes of circadian arrhythmia include critical illness itself and subjective experience of distress and pain. Observational studies of windowed rooms and real-time ambient lighting have found that physiologic light-dark patterns may support recovery from critical illness. Studies of early morning bright light or evening melatonin agonists have found improved rates of delirium, enhanced sleep, and lower arrhythmia prevalence. The current evidence base emphasizes that lighting and melatoninergic interventions deserve to be tested in full-scale trials.

Community Health Workers Versus Nurses as Counselors or Case Managers in a Self-Help Diabetes Management Program.

OBJECTIVES: To confirm the effectiveness of community health workers' involvement as counselors or case managers in a self-help diabetes management program in 2009 to 2014. METHODS: Our open-label, randomized controlled trial determined the effectiveness of a self-help intervention among Korean Americans aged 35 to 80 years in the Baltimore-Washington metropolitan area with uncontrolled type 2 diabetes. We measured and analyzed physiological and psychobehavioral health outcomes of the community health worker-counseled (n = 54) and registered nurse (RN)-counseled (n = 51) intervention groups in comparison with the control group (n = 104). RESULTS: The community health workers' performance was comparable to that of the RNs for both psychobehavioral outcomes (e.g., self-efficacy, quality of life) and physiological outcomes. The community health worker-counseled group showed hemoglobin A1C reductions from baseline (-1.2%, -1.5%, -1.3%, and -1.6%, at months 3, 6, 9, and 12, respectively), all of which were greater than reductions in the RN-counseled (-0.7%, -0.9%, -0.9%, and -1.0%) or the control (-0.5%, -0.5%, -0.6%, and -0.7%) groups. CONCLUSIONS: Community health workers performed as well as or better than nurses as counselors or case managers in a self-help diabetes management program in a Korean American community.

Restless Legs Syndrome and Depression: Effect Mediation by Disturbed Sleep and Periodic Limb Movements.

OBJECTIVE: To investigate an association between restless legs syndrome (RLS) and depression and to what extent sleep disturbance, periodic limb movements during sleep (PLMS), and antidepressant medication mediate this relationship. METHODS: A cross-sectional analysis was conducted of the Osteoporotic Fractures in Older Men Study data in 982 men assessed for RLS (International RLS Study Group scale [IRLSS]) and depression (Geriatric Depression Scale [GDS]), who underwent actigraphy (for sleep latency/efficiency) and polysomnography (for PLMS). Men were split into three groups: no RLS (N = 815), mild RLS (IRLSS ≤ 12, N = 85), moderate-to-severe RLS (IRLSS > 12, N = 82). Depression was defined as GDS score ≥ 6. Logistic and linear regression assessed associations of RLS and depression or number depressive symptoms, respectively. Models were adjusted for age, site, race, education, body mass index, personal habits, benzodiazepine/dopaminergic medication, physical activity, cardiovascular risk factors, and apnea-hypopnea index. RESULTS: Of 982 men, 167 (17.0%) had RLS. Depression was significantly associated with moderate-to-severe RLS after adjustment (versus no RLS: OR [95% CI] 2.85 [1.23, 6.64]). Further adjustment for potential mediators attenuated effect size modestly, most for sleep efficiency (OR: 2.85-2.55). Compared with no RLS, moderate-to-severe RLS was associated with the number of depressive symptoms after adjustment (adjusted means [95% CI]; no RLS: 1.14 [1.05, 1.24] versus IRLSS > 12: 1.69 [1.32, 2.11]). Further adjustment for potential mediators did not alter effect size. For men with PLMS index at least median, number of depressive symptoms significantly increased as RLS category became more severe. CONCLUSION: Depression is more common as RLS severity worsens. The RLS-depression relationship is modestly explained by sleep disturbance and PLMS.

Prevalence and Predictors of Depression in Korean American Elderly: Findings from the Memory and Aging Study of Koreans (MASK).

OBJECTIVES: To estimate the prevalence and identify the predictors of depression among community-dwelling Korean American elderly (KAE). DESIGN: A cross-sectional descriptive epidemiological survey using a two-step sampling strategy to obtain a representative community sample. SETTING: The authors recruited study participants at religious, service, and business establishments in the KA community (26 churches, 6 senior centers, 2 medical daycare centers, 1 supermarket). PARTICIPANTS: Community-dwelling first-generation KAE (N = 1,118; mean age ± SD: 70.5 ± 7.0 years; female: 67.2%). MEASUREMENTS: Trained bilingual nurses and community health workers interviewed participants face-to-face for demographic information, chronic conditions, and depression using the Korean versions of the Patient Health Questionnaire (PHQ-9K). RESULTS: 30.3% of KAEs were classified as having either mild (PHQ-9K score 5-9; N = 218, 19.5%) or clinical depression (PHQ-9K score ≥10; N = 120, 10.8%), respectively. One of seven KAE (N = 164, 14.7%) endorsed thoughts of death or self-injury, but only 63 (5.7%) reported utilizing mental health services. The authors also identified several predictors of depression, including living arrangement (living alone versus living with family/spouse); having chronic conditions such as diabetes, arthritis, digestive disorders, or chronic bronchitis; years of education; and cognitive impairment. CONCLUSIONS: The authors' findings reveal a high prevalence of depression among KAE and a low level of mental health service utilization. Because there are urgent needs for culturally and contextually relevant interventions, the authors also discuss the feasibility of community-based interventions to reduce the burden of depression, which should be incorporated into a management system for multiple chronic conditions.

Cognitive and functional status predictors of delirium and delirium severity after coronary artery bypass graft surgery: an interim analysis of the Neuropsychiatric Outcomes After Heart Surgery study.

BACKGROUND: Cognitive and functional impairment increase risk for post-coronary artery bypass graft (CABG) surgery delirium (PCD), but how much impairment is necessary to increase PCD risk remains unclear. METHODS: The Neuropsychiatric Outcomes After Heart Surgery (NOAHS) study is a prospective, observational cohort study of participants undergoing elective CABG surgery. Pre-operative cognitive and functional status based on Clinical Dementia Rating (CDR) scale and neuropsychological battery are assessed. We defined mild cognitive impairment (MCI) based on either (1) CDR global score 0.5 (CDR-MCI) or (2) performance 1.5 SD below population means on any cognitive domain on neurocognitive battery (MCI-NC). Delirium was assessed daily post-operative day 2 through discharge using the confusion assessment method (CAM) and delirium index (DI). We investigate whether MCI - either definition - predicts delirium or delirium severity. RESULTS: So far we have assessed 102 participants (mean age 65.1 ± 9; male: 75%) for PCD. Twenty six participants (25%) have MCI-CDR; 38 (62% of those completing neurocognitive testing) met MCI-NC criteria. Fourteen participants (14%) developed PCD. After adjusting for age, sex, comorbidity, and education, MCI-CDR, MMSE, and Lawton IADL score predicted PCD on logistic regression (OR: 5.6, 0.6, and 1.5, respectively); MCI-NC did not (OR [95% CI]: 11.8 [0.9, 151.4]). Using similarly adjusted linear regression, MCI-CDR, MCI-NC, CDR sum of boxes, MMSE, and Lawton IADL score predicted delirium severity (adjusted R(2): 0.26, 0.13, 0.21, 0.18, and 0.32, respectively). CONCLUSIONS: MCI predicts post-operative delirium and delirium severity, but MCI definition alters these relationships. Cognitive and functional impairment independently predict post-operative delirium and delirium severity.

Augmentation in restless legs syndrome patients in Korea.

PURPOSE: Augmentation has been known as the major complication of long-term dopaminergic treatment of restless legs syndrome (RLS). However, there have been no reports on the prevalence of augmentation in Korea. Thus, we aimed to assess the rate of augmentation and evaluate related factors in Korean RLS patients. METHODS: Ninety-four idiopathic RLS patients who have been treated over a period of at least 6 months were enrolled. Thirty subjects were treated with a dopamine agonist only, and 64 were treated with a dopamine agonist and alpha two delta ligands. We assessed the clinical characteristics of those RLS subjects and evaluated the rate of augmentation. Augmentation was assessed using the NIH criteria for augmentation by two RLS experts independently. RESULTS: Eleven subjects (11.7%) were classified as having definitive or highly suggestive clinical indication of augmentation. In comparing the augmentation group with the non-augmentation group, there were no significant differences of baseline clinical characteristics. Four (13.3%) of the dopamine agonists monotherapy group and seven (10.9%) of the combination therapy group were categorized as augmentation. There was no significant difference in the augmentation rate between these two groups. CONCLUSIONS: We found an 11.7% augmentation rate in Korean RLS subjects. There was no difference in the rate of RLS augmentation between the dopaminergic monotherapy group and the combined treatment group. It may be related with using a similar dosage of dopaminergic drugs.

Mental disorders and mental health service use across Asian American subethnic groups in the United States.

This study analyzed the National Epidemiological Survey on Alcohol and Related Conditions data, 2001-2002, to compare the prevalence and odds of DSM-IV mood, anxiety, and substance use disorders and mental health service use across Asian American subethnic groups (648 East Asians, 485 Southeast Asians, 298 South Asians). Asian American subethnic groups varied in lifetime prevalence of psychiatric disorders (p=0.004), mainly due to differences in the presence of any substance use disorder (p=0.06), and specifically, drug use disorders (p=0.02). While Southeast Asians had the highest prevalence of substance use disorders (16.7%), fewer Southeast Asians with substance use disorders used mental health services (11.1%) compared to South Asians with substance use disorders (24.2%). East Asians compared to South Asians had significantly lower odds of mental health service use for substance use disorders (confidence interval=0.08-0.84). Asian American subethnic groups vary in the prevalence of mental disorders and in mental health service use, especially for substance use disorders.

Certified Community Behavioral Health Clinic Demonstration Impact on Health Care Utilization Among Non-Medicaid Patients with Severe Mental Illnesses.

In 2017, the Certified Community Behavioral Health Clinic (CCBHC) demonstration was implemented in New York State to redesign care delivery and financing for behavioral health services. Although CCBHC primarily targeted Medicaid patients, it was hypothesized that the clinic-level benefits of CCBHC were expected to impact even non-Medicaid patients treated in CCBHCs. To test this hypothesis, this study conducted a health insurance claims data analysis of non-Medicaid (ie, commercial and Medicare) patients with severe mental illnesses, comparing a cohort of CCBHC-treated patients with a propensity score-matched comparison cohort of patients treated by non-CCBHC clinics on rates of mental health service utilization, hospitalization, and emergency department (ED) visits. The data suggested CCBHC was associated with more than 10% increase in outpatient mental health service utilization by the patients' second year of CCBHC exposure, accompanied by similarly significant reductions in the rates of all-cause ED visits and non-psychiatric hospitalization. These findings suggest that for behavioral health clinics that serve a sufficiently large population of Medicaid, the impact of innovative clinical redesign attributable to CCBHC is likely to extend to all patients treated by them.

Using Discrete Form Data in the Electronic Medical Record to Predict the Likelihood of Psychiatric Consultation.

BACKGROUND: Manually screening for mental health needs in acute medical-surgical settings is thorough but time-intensive. Automated approaches to screening can enhance efficiency and reliability, but the predictive accuracy of automated screening remains largely unknown. OBJECTIVE: The aims of this project are to develop an automated screening list using discrete form data in the electronic medical record that identify medical inpatients with psychiatric needs and to evaluate its ability to predict the likelihood of psychiatric consultation. METHODS: An automated screening list was incorporated into an existing manual screening process for 1 year. Screening items were applied to the year's implementation data to determine whether they predicted consultation likelihood. Consultation likelihood was designated high, medium, or low. This prediction model was applied hospital-wide to characterize mental health needs. RESULTS: The screening items were derived from nursing screens, orders, and medication and diagnosis groupers. We excluded safety or suicide sitters from the model because all patients with sitters received psychiatric consultation. Area under the receiver operating characteristic curve for the regression model was 84%. The two most predictive items in the model were "3 or more psychiatric diagnoses" (odds ratio 15.7) and "prior suicide attempt" (odds ratio 4.7). The low likelihood category had a negative predictive value of 97.2%; the high likelihood category had a positive predictive value of 46.7%. CONCLUSIONS: Electronic medical record discrete data elements predict the likelihood of psychiatric consultation. Automated approaches to screening deserve further investigation.