ABSTRACT
Inpatient admission of unhoused patients from an emergency department is becoming more frequent. Clinicians have ethical obligations to engage early in thorough discharge planning for these vulnerable patients, as discharge to the street or even to a shelter can produce poor health outcomes. This commentary on a case considers factors that influence safe discharge planning and execution, including linkage to follow-up, patient engagement, and multidisciplinary teamwork.
Subject(s)
Continuity of Patient Care , Patient Discharge , Humans , Hospitalization , InpatientsABSTRACT
Rates of the sexually transmitted infections (STIs) Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (GC) have risen in women by 13% and 40%, respectively, since 2015. Women with Serious Mental Illness (SMI) are at disproportionate risk for STIs. A retrospective chart review was performed at a safety-net healthcare system in the Southeastern United States (US) from 2014 to 2017. CT/GC positivity rates did not differ between the general and SMI populations (6.6% vs. 6.5% for CT and 1.8% vs. 2.2% for GC, respectively). Emergency Medicine accounted for more positive STI test results in SMI patients than the general population (25.2% vs. 19.1% for CT, 47.8% vs. 35.5% for GC, respectively). SMI patients received large portions of STI care in emergency settings, where follow-up is poor. Point of Care (POC) testing could improve care in this setting, and mental healthcare providers must address sexual health with patients who otherwise may not receive this care.
ABSTRACT
Difficult patient encounters are common in clinical practice, with many arising from patient hostility owing to a breakdown in communication and the health care alliance. Patient anger may be a manifestation of fear, grief, or discontent with prior experiences in the health care system, but there may also be contributions from specific patient, physician, or situational factors. Physicians may intervene with specific actions based on these individual factors, while focusing on self-reflection to better understand their part in creating a hostile physician-patient dyad.
Subject(s)
Anger , Hostility , Communication , Grief , Humans , Physician-Patient RelationsABSTRACT
The early mortality of individuals with serious mental illness has long been documented yet persists despite calls for change. Individuals with serious mental illness have a higher rate of medical morbidity than those in the general population across all categories of disease. Cardiovascular disease is particularly prevalent in this population, and it is the leading cause of death for persons with serious mental illness. Addressing cardiovascular risk factors is essential to closing the mortality gap, yet patients with serious mental illness often receive poor continuity of medical care, and psychiatrists are often their only physicians. Thus, to have an impact on the mortality gap, psychiatrists must address the cardiovascular health of their patients with serious mental illness. Here, the author presents a framework of intervention at varying levels of intensity for psychiatrists to increase their role in addressing the cardiovascular health of patients with serious mental illness.
ABSTRACT
Individuals with severe mental illness are at a higher risk for medical illness and premature death and yet receive poorer quality healthcare. Often mental healthcare is the only care this population receives, thus models of integration are being explored. This study examined medical outcomes and care utilization patterns among patients at an outpatient behavioral health center where primary care was integrated with psychiatric and behavioral healthcare. A retrospective chart review of patients seen at the clinic both for mental and primary healthcare was performed and 147 patients were monitored over the course of one year. While medical outcome changes were not significant in the year after enrollment, primary care visits did increase, and emergency department visits decreased over the year analyzed. Decreased emergency department visits and increased attendance at primary care visits suggests this model of integration allows patients access to continuity of care and primary care services.
Subject(s)
Mental Disorders , Safety-net Providers , Humans , Mental Disorders/therapy , Outpatients , Primary Health Care , Retrospective StudiesABSTRACT
This article proposes a framework for managing the behavioral health impacts of the COVID-19 global pandemic. This framework aligns and should be integrated with an existing public health pandemic intervals model. It includes six phases of a behavioral health pandemic response strategy: preplanning, response readiness, response mobilization, intervention, continuation, and amelioration. The ways behavioral health specialists can capitalize on their competence in the leadership, prevention, education, service, research, and advocacy domains within each behavioral health pandemic response phase are articulated. Behavioral health expertise can help ensure a more comprehensive, effective pandemic response that facilitates the flattening of the curve of disease spread, along with the corresponding emotional distress curve. A case illustration, the Caring Communities (CC) initiative, is offered as an exemplar of action steps in the leadership, prevention, education, service, research, and advocacy domains that behavioral health professionals can take within each of the behavioral health pandemic response phases. Key CC action steps include providing support groups, offering virtual wellness breaks, participating in educational outreach, creating and disseminating wellness guides, launching and leading a virtual behavioral health clinic for health care staff, participating in behavioral health research and program evaluation, and engaging in advocacy initiatives aimed at improving behavioral health care and addressing and reducing health disparities. Finally, recommendations for optimizing behavioral health contributions to future pandemic responses are proffered. (PsycInfo Database Record (c) 2020 APA, all rights reserved).
Subject(s)
Coronavirus Infections , Health Planning/organization & administration , Mental Disorders/therapy , Mental Health Services/organization & administration , Pandemics , Pneumonia, Viral , Psychological Distress , Public Health , COVID-19 , Coronavirus Infections/prevention & control , Humans , Pandemics/prevention & control , Pneumonia, Viral/prevention & controlABSTRACT
OBJECTIVE: This study's purpose was to examine attitudes and perceptions of resident psychiatrists regarding the sexual and reproductive health needs of their female patients with severe mental illness. The three aims were to investigate resident psychiatrists' (1) perceptions regarding the importance of providing sexual and reproductive health services to female patients in the outpatient behavioral health setting, (2) current engagement in providing sexual and reproductive health services to their female patients, and (3) perceived barriers and facilitators to addressing sexual and reproductive health in this vulnerable patient population. METHODS: Fifteen resident psychiatrists were recruited from the behavioral health clinic at a safety-net public sector hospital for a structured interview. Interviews were recorded, transcribed, and then coded using MAXQDA© software. RESULTS: Resident psychiatrists recognized the importance of addressing sexual and reproductive health with their female patients and recognized their hypothetical ability to provide sexual and reproductive health counseling and services based on their training and resources. However, residents reported rarely providing these services, mostly addressing sexual and reproductive health only when necessitated by medication changes. Perceived barriers included lack of training or knowledge, discomfort, and limited appointment time. CONCLUSIONS: Resident psychiatrists perceive a need to address sexual and reproductive health with their female patients with serious mental illness but lack the confidence and resources to do so. Directed education and clear institutional guidelines are necessary to equip the next generation of psychiatrists with the tools needed to address the sexual and reproductive health needs of women with serious mental illness.
Subject(s)
Internship and Residency , Mental Disorders , Perception , Psychiatry/education , Reproductive Health , Sexual Health , Adult , Humans , Qualitative Research , Severity of Illness IndexSubject(s)
Confidentiality , Feedback , Internet , Internship and Residency , Psychiatry/education , Education, Medical, Graduate , HumansSubject(s)
Counseling , Mental Disorders/therapy , Mental Health , Caregivers , Health Status , Humans , Mental Disorders/psychologySubject(s)
Internship and Residency , Psychiatry/education , Students, Medical , Teaching , Education, Medical , Humans , Models, EducationalABSTRACT
The American Psychiatric Association Integrated Care Workgroup recently convened an expert panel charged with addressing the role of psychiatry in improving the physical health of persons with serious mental illness. The group reviewed the peer-reviewed and gray literature and developed a set of recommendations grounded in this review. This column summarizes the panel's primary findings and recommendations to key stakeholders, including clinicians, health care organizations, researchers, and policy makers.
Subject(s)
Guidelines as Topic , Health Status , Mental Disorders , Psychiatry , Societies, Medical , Guidelines as Topic/standards , Humans , Mental Disorders/therapy , Psychiatry/methods , Psychiatry/standards , Societies, Medical/standardsABSTRACT
Medicaid is an important funder of care for individuals with behavioral (psychiatric and/or substance use) diagnoses, and expenditures will likely increase with expansion of services under the Affordable Care Act. This study provides national estimates of Medicaid expenditures using a comprehensive sample of fee-for-service Medicaid enrollees with behavioral diagnoses. Data for analysis came from 2003 to 2004 Medicaid Analytic eXtract (MAX) files for 50 states and the District of Columbia. Individuals with behavioral diagnoses had high rates of chronic medical comorbidities, and expenditures for medical (non-behavioral) diagnoses accounted for 74 % of their health care expenditures. Total Medicaid expenditure was approximately 15 billion dollars (equivalent to 18.91 billion in 2016 dollars) for individuals with any behavioral diagnosis. Medicaid fee-for-service beneficiaries with behavioral diagnoses have a high treated prevalence of individual medical comorbid conditions, and the majority of health care expenditures in these individuals are for medical, rather than behavioral health, services.
Subject(s)
Fee-for-Service Plans/economics , Health Expenditures/trends , Medicaid/economics , Adult , Databases, Factual , Female , Humans , Male , Mental Health Services/statistics & numerical data , Middle Aged , Patient Protection and Affordable Care Act , United States , Young AdultABSTRACT
OBJECTIVE: Behavioral health homes provide primary care health services to patients with serious mental illness treated in community mental health settings. The objective of this study was to compare quality and outcomes of care between an integrated behavioral health home and usual care. METHOD: The study was a randomized trial of a behavioral health home developed as a partnership between a community mental health center and a Federally Qualified Health Center. A total of 447 patients with a serious mental illness and one or more cardiometabolic risk factors were randomly assigned to either the behavioral health home or usual care for 12 months. Participants in the behavioral health home received integrated medical care on-site from a nurse practitioner and a full-time nurse care manager subcontracted through the health center. RESULTS: Compared with usual care, the behavioral health home was associated with significant improvements in quality of cardiometabolic care, concordance of treatment with the chronic care model, and use of preventive services. For most cardiometabolic and general medical outcomes, both groups demonstrated improvement, although there were no statistically significant differences between the two groups over time. CONCLUSIONS: The results suggest that it is possible, even under challenging real-world conditions, to improve quality of care for patients with serious mental illness and cardiovascular risk factors. Improving quality of medical care may be necessary, but not sufficient, to improve the full range of medical outcomes in this vulnerable population.
Subject(s)
Behavioral Medicine/organization & administration , Cardiovascular Diseases/therapy , Delivery of Health Care, Integrated/organization & administration , Mental Disorders/therapy , Outcome Assessment, Health Care/organization & administration , Patient-Centered Care/organization & administration , Primary Health Care/organization & administration , Adult , Community Mental Health Centers , Comorbidity , Female , Georgia , Humans , Male , Middle Aged , Quality Improvement/organization & administration , Single-Blind MethodABSTRACT
Medical progress has greatly extended the life span of individuals living in the United States, yet certain groups have lagged behind in achieving wellness and longevity. Prominent among these are individuals with serious mental illness. Because of this, various initiatives have been launched at the community, state, and national level to improve the medical care of those with serious mental illness. Many of these initiatives promote "reverse integration," or the provision of collaborative care services in behavioral health locations. Despite significant barriers to implementation, these initiatives have shown moderate success in improving medical outcomes for those with serious mental illness, in both research and "real-life" settings. Additionally, the role of psychiatrists in addressing physical health has been explored, and there is a need for educational opportunities to optimize competency in this area. Overall, work still needs to be done before the mortality gap for those with serious mental illness dissipates.
ABSTRACT
Diabetes is highly prevalent in people with psychotic disorders, including schizophrenia and schizoaffective disorders. Exact prevalence is difficult to estimate, since diabetes is often underdiagnosed in people with psychosis. Results of several studies show that the prevalence of diabetes exceeds that in the general population, with documented prevalence in those with psychosis ranging from 1·26% to 50% across studies (median 13%). The association between diabetes and psychosis is complex and multifactorial. Many of the traditional risk factors for disease have increased prevalence in patients with psychotic disorders. In addition to these traditional risk factors, people with psychosis have unique risks that might have additive or even synergistic effects. These risks include the use of antipsychotic medication, the effects of adverse social determinants of health, and genetic loading. Despite evidence that rates of diabetes are increased in individuals with psychosis, many of these patients are not diagnosed or treated, resulting in increased diabetes-associated morbidity and mortality. Specific patient factors, provider issues, and systems-level factors contribute to the treatment gap. Interventions at both the clinical and public health levels are needed to successfully address this problem.
Subject(s)
Diabetes Mellitus/epidemiology , Psychotic Disorders/epidemiology , Humans , Prevalence , Risk FactorsABSTRACT
OBJECTIVE: Individuals with serious mental illness die years younger than members of the general population, with cardiovascular disease and related risk factors accounting for the majority of deaths. Lifestyle interventions targeting these risk factors have begun to be developed for those with serious mental illness, but they have largely been created de novo rather than with information from work already done in the general population. This review aims to synthesize for a mental health audience the common factors for success in nonpharmacologic lifestyle interventions and identify specific considerations in adapting these models for those with serious mental illness. DATA SOURCES: We searched the PubMed and Cochrane databases for English-language reviews from 2003 to 2013. The search employed combinations of the following terms: diabetes, diabetes mellitus, hypertension, hyperlipidemia, dyslipidemia, obesity, mental illness, schizophrenia, psychosis, bipolar disorder, lifestyle intervention, non-pharmacologic intervention, lifestyle modification, and weight gain. STUDY SELECTION: We identified 8,147 review articles from the PubMed and Cochrane databases. 123 articles were selected. The selected articles were reviews of dietary, behavioral, or exercise interventions that focused on obesity and related cardiometabolic risk factors. DATA EXTRACTION: We undertook a qualitative "review of reviews" focusing on nonpharmacologic interventions for obesity and related cardiometabolic risk factors. RESULTS: Effects of interventions in the general population were meaningful but generally modest. Specific elements of diet, exercise, and behavioral therapy produced larger effects. Additionally, successful programs employed multiple components, personalization, longer duration, more frequent contact, and trained treatment providers. Interventions addressing these risk factors in people with serious mental illness typically incorporated some, but not all, of the elements demonstrated to be effective in general medical populations. CONCLUSIONS: Studies from the general medical literature demonstrate considerable promise in addressing lifestyle risk factors. Existing programs will require tailoring to address the needs of those with serious mental illness and may be harder to implement given the challenges faced by this population. However, successful lifestyle interventions for those with serious mental illness can make a significant impact on the health and well-being of this vulnerable population and may inform future strategies for other underserved groups.
Subject(s)
Behavior Therapy , Cardiovascular Diseases/prevention & control , Cardiovascular Diseases/psychology , Health Behavior , Life Style , Mentally Ill Persons/psychology , Cardiovascular Diseases/epidemiology , Cardiovascular Diseases/etiology , Comorbidity , Cross-Sectional Studies , Exercise/psychology , Feeding Behavior , Humans , Mental Disorders/complications , Mental Disorders/epidemiology , Mental Disorders/psychology , Mentally Ill Persons/statistics & numerical data , Risk FactorsABSTRACT
BACKGROUND: In line with hopelessness theory, both increased negative expectancies and reduced positive expectancies for the future have been associated with suicidal ideation. This study evaluated two depression symptom clusters as mediators of the relationship between future disposition and suicide: subjective feelings of depression and self-blame. METHODS: Data from 140 undergraduate students with moderate to severe depression symptoms are presented who completed the Beck Scale for Suicidal Ideation, Beck Depression Inventory, and the Future Disposition Inventory. RESULTS: On mediation analysis, subjective depression mediated the relationship between positive disposition and suicidal ideation. In contrast, the relationship between negative disposition and suicidal ideation was mediated by self-blame. The reverse of these relationships was not significant. LIMITATIONS: This is a cross-sectional study of an undergraduate sample and results warrant replication in clinical samples with clinician-administered assessments. CONCLUSIONS: Findings suggest two potential pathways to suicidal thoughts with implications for assessment and treatment. Depressed individuals with few positive expectations of the future may benefit from interventions focusing on subjective depression symptoms, such as sadness or anhedonia. For depressed individuals with negative expectations for the future, a clinical focus on negative attributions or self-blame may be warranted.
Subject(s)
Depression/psychology , Suicidal Ideation , Adolescent , Adult , Cross-Sectional Studies , Depression/diagnosis , Female , Hope , Humans , Male , Psychiatric Status Rating Scales , Self-Assessment , Young AdultABSTRACT
Urachal adenocarcinoma (UAC) is a rare tumor of the urinary bladder, which can show intestinal, mucinous, and signet ring cell histology. The morphology is similar to that of colorectal adenocarcinoma (CAC). Microsatellite instability (MSI), KRAS, and BRAF have been more extensively studied in CAC. What is not known is whether UAC in its morphologic similarity to CAC could show immunohistochemical features of MSI along with KRAS- and BRAF-activating mutations. A retrospective review of institutional archives for UAC cases found 7 cases, all of which were high stage. Most (6/7) of our UAC cases showed evidence of MSI or mutations of KRAS. No cases showed a BRAF mutation at codon 600. Of the cases that demonstrated MSI, 1 showed mutS homolog 2 and mutS homolog 6 loss, and 2 showed PMS2 (postmeiotic segregation increased 2) loss. Of the remaining 4 cases, 3 showed KRAS mutations at codon 12. Our UAC series showed mutual exclusivity of MSI and KRAS mutations. Furthermore, our UAC cases with KRAS mutations showed markedly better overall survival (mean, 101.7 versus 6.5 months; P = .035). Thus, our study justifies ancillary testing for MSI and KRAS in UAC, particularly when there is high-stage and mucinous histology, but a larger multi-institutional accruement of UAC cases is necessary to further validate our novel findings.