Transdiagnostic Motivational Enhancement Therapy to Reduce Treatment Attrition: Use in Emerging Adults.

Improving outcomes of youth with mental health (MH) needs as they transition into adulthood is of critical public health significance. Effective psychotherapy MH treatment is available, but can be effective only if the emerging adult (EA) attends long enough to benefit. Unfortunately, completion of psychotherapy among EAs is lower than for more mature adults (Edlund et al., 2002; Olfson, Marcus, Druss, & Pincus, 2002). To target the high attrition of EAs in MH treatment, investigators adapted a developmentally appropriate brief intervention aimed at reducing treatment attrition (TA) in psychotherapy and conducted a feasibility study of implementation. The intervention employs motivational interviewing strategies aimed at engaging and retaining EAs in outpatient MH treatment. Motivational enhancement therapy for treatment attrition, or MET-TA, takes only a few sessions at the outset of treatment as an adjunct to usual treatment. Importantly, it can be used for TA with psychotherapy for any MH condition; in other words, it is transdiagnostic. This article presents the first description of MET-TA, along with a case example that demonstrates important characteristics of the approach, and then briefly describes implementation feasibility based on a small pilot randomized controlled trial.

Instruments for Measuring Violence on Acute Inpatient Psychiatric Units: Review and Recommendations.

OBJECTIVE: Violence by patients against inpatient psychiatric unit staff is common, causing considerable suffering. Despite the Joint Commission's 2018 requirement for behavioral health organizations to use standardized instruments, no identified gold standard measures of violence and aggression exist. Therefore, accurate data are lacking on the frequency of patient-to-staff violence to guide development of safer institutional clinical policies or to assess the impact of targeted interventions to reduce violence. To inform recommendations for developing standardized scales, the authors reviewed the scoring instruments most commonly used to measure violence in recent studies. METHODS: A comprehensive literature search for violence measurement instruments in articles published in English from June 2008 to June 2018 was performed. Review criteria included use of instruments measuring patient-to-staff violence or aggression in acute, nonforensic, nongeriatric populations. Exclusion criteria included child or adolescent populations, staff-to-staff violence, and staff- or visitor-to-patient violence. RESULTS: Overall, 74 studies were identified, of which 74% used structured instruments to measure aggression and violence on inpatient psychiatric units during the past 10 years. The instruments were primarily variants of the Observed Aggression Scale (OAS); 26% of the studies used unstructured clinical notes and researcher questionnaires. Major obstacles to implementing measurement instruments included time and workflow constraints and difficulties with use. CONCLUSIONS: In the past 10 years, OAS variants with evidence of validity and reliability that define aggression and violence have been consistently used. The authors propose that adapting the Modified OAS to collect real-time clinical data could help overcome barriers to implementing standardized instruments to quantify violence against psychiatric staff.

Pushing the envelope: shared decision making in mental health.

TOPIC: This article reviews the literature on shared decision making in health and mental health and discusses tools in general health that are proposed for adaptation and use in mental health. PURPOSE: To offer findings from literature and a product development process to help inform/guide those who wish to create or implement materials for shared decision making in mental health. SOURCES USED: Published literature and research on issues related to shared decision making in health and mental health, focus groups, and product testing. CONCLUSIONS: Structured shared decision making in mental health shows promise in supporting service user involvement in critical decision making and provides a process to open all treatment and service decisions to informed and respectful dialogue.

Mobile Mindfulness Intervention on an Acute Psychiatric Unit: Feasibility and Acceptability Study.

BACKGROUND: Aggression and violence on acute psychiatric inpatient units is extensive and leads to negative sequelae for staff and patients. With increasingly acute inpatient milieus due to shorter lengths of stay, inpatient staff is limited in training and time to be able to provide treatments. Mobile technology provides a new platform for offering treatment on such units, but it has not been tested for feasibility or usability in this particular setting. OBJECTIVE: The aim of this study was to examine the feasibility, usability, and acceptability of a brief mindfulness meditation mobile phone app intended to reduce anger and aggression in acute psychiatric inpatients with schizophrenia, schizoaffective disorder, or bipolar disorder, and a history of violence. METHODS: Participants were recruited between November 1, 2015 and June 1, 2016. A total of 13 inpatients at an acute care state hospital carried mobile phones for 1 week and were asked to try a commercially available mindfulness app called Headspace. The participants completed a usability questionnaire and engaged in a qualitative interview upon completion of the 7 days. In addition, measures of mindfulness, state and trait anger, and cognitive ability were administered before and after the intervention. RESULTS: Of the 13 enrolled participants, 10 used the app for the 7 days of the study and completed all measures. Two additional participants used the app for fewer than 7 days and completed all measures. All participants found the app to be engaging and easy to use. Most (10/12, 83%) felt comfortable using Headspace and 83% (10/12) would recommend it to others. All participants made some effort to try the app, with 6 participants (6/12, 50%) completing the first 10 10-minute "foundation" guided meditations. CONCLUSIONS: This is the first known study of the use of a commercially available app as an intervention on acute psychiatric inpatient units. Acutely ill psychiatric inpatients at a state hospital found the Headspace app easy to use, were able to complete a series of meditations, and felt the app helped with anxiety, sleep, and boredom on the unit. There were no instances of an increase in psychotic symptoms reported and there were no episodes of aggression or violence noted in the record.

Use of Multimodal Technology to Identify Digital Correlates of Violence Among Inpatients With Serious Mental Illness: A Pilot Study.

OBJECTIVE: The study examined multimodal technologies to identify correlates of violence among inpatients with serious mental illness. METHODS: Twenty-eight high-risk inpatients were provided with smartphones adapted for data collection. Participants recorded their thoughts and behaviors by using self-report software. Sensors embedded in each device (microphone and accelerometers) and throughout the inpatient unit (Bluetooth beacons) captured patients' activity and location. RESULTS: Self-reported delusions were associated with violent ideation (odds ratio [OR]=3.08), damaging property (OR=8.24), and physical aggression (OR=12.39). Alcohol and cigarette cravings were associated with violent ideation (OR=5.20 and OR=6.08, respectively), damaging property (OR=3.71 and OR=4.26, respectively), threatening others (OR=3.62 and OR=3.04, respectively), and physical aggression (OR=6.26, and OR=8.02, respectively). Drug cravings were associated with violent ideation (OR=2.76) and damaging property (OR=5.09). Decreased variability in physical activity and noisy ward conditions were associated with violent ideation (OR=.71 and OR=2.82, respectively). CONCLUSIONS: Identifiable digital correlates may serve as indicators of increased risk of violence.

Working therapeutically with deaf people recovering from trauma and addiction.

OBJECTIVE: This article reviews what is known about behavioral health treatment of deaf persons with comorbid trauma and addiction. METHOD: We discuss how to work therapeutically with deaf people with comorbid trauma and addiction, both through a review of the literature and through clinical observations of the authors. The article also includes the personal stories of two people-a Deaf peer specialist and a hearing psychiatrist-who share their humbling stories about the recovery process for deaf people and the challenges of learning to become an effective Deaf mental health care provider. FINDINGS: Deaf people report higher rates of mental health problems than the general population. Although initial empirical work with the deaf population suggests high rates of posttraumatic stress disorder (PTSD) and substance use disorder (SUD), little is known about the rates of comorbid PTSD/SUD or how to effectively address this comorbidity in treatment. CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: Substantial work is needed to raise awareness of comorbid PTSD/SUD and provide treatment tools to agencies and providers who work with deaf clients, infusing trauma-informed care into deaf SUD services and SUD treatment into deaf mental health care. Fortunately, several endeavors are on the horizon to disseminate assessment and treatment tools to work with deaf people recovering from trauma and addiction.

Mobile Behavioral Sensing for Outpatients and Inpatients With Schizophrenia.

OBJECTIVE: This study examined the feasibility, acceptability, and utility of behavioral sensing among individuals with schizophrenia. METHODS: Nine outpatients and 11 inpatients carried smartphones for two- or one-week periods, respectively. Device-embedded sensors (accelerometers, microphone, global positioning system, WiFi, and Bluetooth) collected behavioral data and ascertained the patients' location, activity, and exposure to human speech as they went about their day. Participants rated this approach by completing usability and acceptability measures. RESULTS: Sensing successfully captured individuals' activity, time spent proximal to human speech, and time spent in various locations. Participants felt comfortable using the sensing system (95%), and most were interested in receiving feedback (65%) and suggestions (65%). Approximately 20% reported that sensing made them upset. One-third of inpatients were concerned about their privacy, but no outpatients expressed this concern. CONCLUSIONS: Mobile behavioral sensing was a feasible, acceptable, and informative approach for data collection among outpatients and inpatients with schizophrenia.

Health care for patients with serious mental illness: family medicine's role.

Numerous studies document disproportionate physical morbidity and premature death among people with serious mental illness. Although suicide remains an important cause of mortality for this population, cardiovascular disease is the leading cause of death. Cardiovascular death among those with serious mental illness is 2 to 3 times that of the general population. This vulnerability is commonly attributed to underlying mental illness and behavior. Some excess disease and deaths result from poor access to and use of quality health care. Negative cardiometabolic effects of newer psychotropic medications augment these trends by increasing rates of obesity, diabetes, and hyperlipidemia among those treated. Researchers have developed innovative care models aimed at minimizing the disparate health outcomes of patients with serious mental illness. Most strive to enhance access to primary care, but publications on this topic appear almost exclusively in the psychiatric literature. A focus on primary care for the prevention of excess cardiometabolic morbidity and mortality in this population is appropriate, but depends on primary care physicians' understanding of the problem, involvement in the solutions, and collaboration with psychiatrists. We review health outcomes of the seriously mentally ill and models designed to improve these outcomes. We propose specific strategies for Family Medicine clinicians and researchers to address this problem.

Shared decision making in antipsychotic management.

The similar efficacies of currently available antipsychotic medications (other than clozapine) make them appropriate for preference-sensitive care; therefore, prescribing these medications is amenable to shared decision-making. In this conceptual article, we describe the current state of antipsychotic prescribing based on a review of the literature from recent landmark studies and updated prescribing guidelines. Recent literature and guidelines on schizophrenia treatment in the United States do not reveal strong endorsement of the idea of shared decision-making. We suggest methods for incorporating shared decision-making into antipsychotic prescribing in the future, with an emphasis on the use of information technology.

Case report of 3 patients with severe mental illness and chronic hepatitis C virus infection treated with interferon-alpha.

We report on three patients with hepatitis C virus infection, severe mental illness, and substance use disorders that we treated successfully with interferon and ribavirin. This population has historically been refused such treatment on the grounds that they were unlikely to be adherent to treatment or would experience untoward psychiatric side effects. These case reports add support to the growing body of evidence that persons with severe mental illness and substance use disorders can be successfully treated for hepatitis C with careful monitoring and psychiatric oversight.

Hepatitis C treatment for people with severe mental illness.

Over 4 million people in the United States are chronically infected with hepatitis C virus (HCV), and, if untreated, over 20% of these will progress to more serious disease. Persons with severe mental illness (SMI) have markedly elevated rates of HCV infection, but treatment of persons with SMI and HCV has been controversial. Effective antiviral treatment is available, but side effects include depression and other neuropsychiatric symptoms. This article reviews the available data on neuropsychiatric side effects of interferon (IFN) treatment, discusses the limitations of the current research, and makes recommendations regarding HCV treatment in persons with SMI.