Ketamine for major depressive disorder during an inpatient psychiatric admission: Effectiveness, adverse events, and lessons learned.

OBJECTIVE: Most studies examining the efficacy of ketamine for Major Depressive Disorder (MDD) have been conducted in outpatient or mixed inpatient/outpatient settings. Less is known about effectiveness and tolerability of ketamine for psychiatrically hospitalized patients. Efficacy and tolerability data from a naturalistic sample of acute inpatients may help inform institutions considering ketamine therapy for inpatient services. METHODS: We performed a retrospective chart review of inpatients with non-psychotic MDD treated during the initial 3 years of a ketamine infusion program. Treatment effectiveness was defined using change in Montgomery Asberg Depression Rating Scale (MADRS) scores over five infusions. MDD treatment response was defined by a 50 % reduction of MADRS score, and remission was defined as MADRS score ≤ 10 at any point during the treatment. We also report the frequency of adverse events. RESULTS: 41 patients with MDD were treated and had outcome data. 19 patients (46.5 %) met criteria for response and 15 patients (26.5 %) met criteria for remission during treatment. Four patients (10 %) had adverse psychological or behavioral outcomes. LIMITATIONS: MADRS scales were administered by psychiatrists, psychologists, and trainees in each discipline who did not undergo standardized training in scale administration. Consistent data regarding the race/ethnicity of the patients was not available. CONCLUSION: Twice weekly racemic ketamine infusion is an effective treatment option for patients hospitalized with MDD. Unmonitored or at home ketamine therapy may pose substantial risks.

Low COVID-19 Vaccination Rates Among Psychiatric Inpatients: Implications for Institutional Settings and Outreach Efforts.

OBJECTIVE: This study sought to determine COVID-19 vaccination rates for individuals with serious mental illness admitted to a large health system in New York State. METHODS: Vaccination rates among 12,714 patients admitted to psychiatric units and to medical and surgical units were compared between April 6, 2021, and September 30, 2021. RESULTS: Only 40% (N=416 of 1,029) of patients admitted to psychiatric services had at least one COVID-19 vaccination, whereas 64.4% (7,523 of 11,685) of patients admitted to medical and surgical services had at least one vaccination. After adjustment for differences in key demographic and clinical characteristics, patients admitted to psychiatric services had a significantly lower likelihood of vaccination during the study period (risk ratio=0.78, 95% confidence interval=0.73-0.85, p<0.001). Black psychiatric patients had the lowest vaccination rate (28%). CONCLUSIONS: Psychiatric patients with acute illness had low COVID-19 vaccination rates. Targeted outreach for COVID-19 vaccination is necessary to reach this population.

Inpatient psychiatry response to the SARS-CoV-2 Omicron variant surge.

The increased transmissibility of the omicron variant of the SARS-CoV-2 virus resulted in a rapid increase in infection among many psychiatric inpatients in our hospital between December 2021 and February 2022. This required our institution to close affected units to new admissions. In response, we implemented a model utilizing universal SARS-CoV-2 polymerase chain reaction (PCR) testing at the time of admission, the development of "admitting units" where all patients were quarantined for four days followed by repeat PCR testing, and subsequent transition to COVID-19 negative and COVID-19 positive "receiving units" based on the results of the second test. No unit closures occurred following full implementation of the model.

Universal COVID-19 testing and a three-space triage protocol is associated with a nine-fold decrease in possible nosocomial infections in an inpatient psychiatric facility.

In May of 2020, the Substance Abuse and Mental Health Service Administration (SAMSA) issued guidelines for state psychiatric hospitals, recommending that these facilities adopt universal testing for COVID-19 and "three-space" triage protocols for dedicated COVID-19 positive, negative, and quarantine spaces to mitigate the risk of nosocomial infection. The Westchester Behavioral Health Center of New York Presbyterian Hospital (WBHC-NYP) adopted a comprehensive infection control protocol consistent with these recommendations in April, 2020. We reviewed the records of 1,139 patients treated on the inpatient service at WBHC-NYP between March 14th and June 10th, 2020, dates corresponding to the first COVID-19 surge in the New York City metropolitan region. The incidence of detected nosocomial or possible nosocomial infections before and during the implementation of the protocol was 0.096 (16/167), or 0.96 infections per 10 at-risk patients. The incidence of nosocomial or possible nosocomial infections after complete implementation was 0.0110 (2/182), or 1.1 infections per 100 at-risk patients. The difference in incidence between the two time points was statistically significant (p<.0003) and represents a 9-fold decrease.  Our findings support the institutional use of a combined testing and space allocation protocol to mitigate risk of outbreaks in confined settings.

The Interface of COVID-19 and Inpatient Psychiatry: Our Experience and Lessons Learned.

The coronavirus disease 2019 (COVID-19) pandemic presented unprecedented challenges to the provision of inpatient psychiatric care. The nature of the physical plant, programmatic constraints, and the patient population required a rapid and agile approach to problem-solving under conditions of uncertainty and stress. Flexibility in decision-making, excellent communication, an effective working relationship with infection prevention and control experts, and attention to staff morale and support were important elements of successful provision of care to our inpatients. We present our experience, lessons learned, and recommendations should a resurgence of the pandemic or a similar crisis occur.

The Psychiatric Inpatient Multidisciplinary Team Meeting: A Model for Current Practice.

The multidisciplinary treatment team meeting (MTTM) has been the central forum for treatment planning and clinical decision-making on many psychiatric inpatient units for decades. While the principles underlying MTTMs were described in the distant past, a detailed model for how these meetings are structured and how they function has not been well presented. In an era of very brief hospital lengths of stay, collaborative, thoughtful, comprehensive, and efficient team meetings have become increasingly important. The goal of this article is to describe a highly structured, successful MTTM model that borrows heavily from an invaluable knowledge base and tradition and is well suited for the modern era.

When patients refuse COVID-19 testing, quarantine, and social distancing in inpatient psychiatry: clinical and ethical challenges.

The COVID-19 pandemic has introduced new ethical challenges in the care of patients with serious psychiatric illness who require inpatient treatment and who may have beeen exposed to COVID-19 or have mild to moderate COVID-19 but refuse testing and adherence to infection prevention protocols. Such situations increase the risk of infection to other patients and staff on psychiatric inpatient units. We discuss medical and ethical considerations for navigating this dilemma and offer a set of policy recommendations.

A COVID-19 testing and triage algorithm for psychiatric units: One hospital's response to the New York region's pandemic.

Psychiatric patients are at high risk for contracting COVID-19, and inpatient psychiatric units face substantial risks of institutional outbreaks. Here, the authors describe an algorithm for testing and triage in a large psychiatric facility designed to prevent local COVID-19 transmission. The algorithm is based on expert opinion and clinical experience between March and April of 2020, during which the institution cared for 47 COVID-19 positive psychiatric inpatients. The implementation of the algorithm is designed to mitigate COVID-19 transmission, preserve the safest and least restrictive treatment environment for psychiatric inpatients, and provide a model adaptable to other institutional settings.

Characteristics of Patients Involved in Physical Assault in an Acute Inpatient Psychiatric Setting.

BACKGROUND: Although aggressive behavior in psychiatric settings is a major concern, very few studies have focused exclusively on physical assault in a general inpatient psychiatric population. OBJECTIVES: This study had 3 main goals: (1) to evaluate the prevalence of assaultive behavior in an acute psychiatric hospital; (2) to identify the clinical and socio-demographic factors associated with assaultive behavior during hospitalization; and (3) to explore whether a diagnosis of schizophrenia spectrum disorder increases the risk of assaultive behavior. METHODS: We conducted a retrospective chart review of patients admitted to acute units in a psychiatric hospital between 2009 and 2012. A subset of occurrence reports identified by a multidisciplinary team as "physical assault" was included in the analysis. Using logistic multivariate regression analysis, these patients were compared with a randomly selected nonassaultive control group, matched for length of stay to identify factors associated with assaultive behavior. RESULTS: Of 757 occurrence reports, 613 met criteria for significant assault committed by 356 patients over 309,552 patient days. The assault incident density was 1.98 per 1000 patient days. In the logistic regression model of best fit, the factors significantly associated with assaultive behavior were age, legal status, and substance use. A diagnosis of schizophrenia spectrum disorder was not significantly associated with assaultive behavior. CONCLUSIONS: Clinicians should take extra precautions for involuntarily admitted young patients with a history of substance use, as they are more likely to exhibit assaultive behavior. A diagnosis of schizophrenia spectrum disorder in itself is not significantly associated with assaultive behavior. Screening instruments such as the Dynamic Appraisal of Situational Aggression may be useful in assessing risk of assault.

A Model for Incident Review Committees in Behavioral Health Settings.

Despite the fact that incident review committees have been a key component of quality improvement in behavioral health settings for decades, specific models of how these committees are structured and operate are not well described. We present a model for an incident review committee that has been implemented in 2 large, academic acute care psychiatric hospitals. We believe the model not only permitted us to efficiently and effectively review untoward incidents, but that it also provided an approach to calibrating standards of care for the institution, engaging physicians in an interdisciplinary effort, promulgating a culture of quality review and improvement throughout the organization, promoting continuity and sustainability of the incident review process, and, most importantly, driving beneficial change in clinical practice. Demonstration of the effectiveness of this model requires formal investigation.

Correlates of the Third Victim Phenomenon.

The third victim phenomenon refers to a system-wide organizational response to a serious untoward event in health care settings. The objective of this report is to describe possible measurable correlates of this phenomenon. A serious incident on one unit in the hospital is described. Utilization of constant observation and rate of discharge in the aftermath throughout the hospital were assessed. There was a hospital-wide uptick in conservative decision making following the serious incident, exemplified by an increase in the utilization of constant observation and decreased rate of discharges. These findings lend support to the validity of the concept of the third victim phenomenon and underscore the imperative for a coherent leadership response to prevent damage to institutional core values, morale, and reputation. Systematic investigation of this phenomenon and its potential effects on clinical practice in the aftermath of serious incidents is warranted.

Indications for and use of long-acting injectable antipsychotics: consideration from an inpatient setting.

Studies have examined the differences in sociodemographic/clinical characteristics between patients on long-acting injectable (LAI) versus oral medications. However, most studies did not focus specifically on patients for whom LAIs would clearly be indicated. We performed a chart review of patients with schizophrenia or schizoaffective disorder. Patients were categorized as having an 'indication for an LAI' or not on the basis of their adherence history. Patients for whom an LAI was indicated and prescribed on discharge were then compared with similar patients for whom an LAI was not prescribed. Of 305 charts reviewed, consisting of 279 unique patients, 27.2% were judged to have an indication for an LAI (n=76), but only 32.9% of these (n=25) were discharged on an LAI. In the multiregression model, being African American, residing in a psychiatric residence, having a previous history of an LAI trial, and being treated with a higher antipsychotic dose were predictive of LAI prescription. It is important to focus on the population who are not likely to receive an LAI, but who have such indications for treatment.

Constant Observation of Suicidal Patients: The Intervention We Love to Hate.

Constant observation (CO) of psychiatric inpatients at risk for suicidal behavior has been criticized in the literature because of the absence of demonstrable effectiveness, associated costs, staff and patient acceptance, and related issues. Our inability to demonstrate effectiveness, however, is an ethical conundrum that cannot readily be solved. Frequent and often vociferous references in the literature to the absence of an evidence base for this intervention carries the risk that CO may be underutilized in particular clinical circumstances with untoward results. A case is made for shifting focus from the lack of evidence supporting CO to agreement on an observation protocol that achieves the desired goal of maximizing patient safety. A sample protocol is presented.

Discontinuing the Use of PRN Intramuscular Medication for Agitation in an Acute Psychiatric Hospital.

This study examined the impact of eliminating intramuscular PRN medication for agitation on patient and staff safety in an acute psychiatric inpatient setting. The current retrospective chart review investigated the use of PRN medications (oral and intramuscular) to treat acute agitation, including aggression, and related outcomes before and after a mandated change in PRN practice that required real time physician input before administration of intramuscular medications. The use of both oral and intramuscular PRN medications dramatically decreased following implementation of the mandated change in practice. In particular, the use of intramuscular PRNs for agitation decreased by about half. Despite this decrease, the assault rate in the hospital was unchanged, and the utilization of restraint and seclusion continued to decrease. It is possible to reduce the utilization of PRN medications for agitation without broadly compromising safety on acute care psychiatric inpatient units.

Body mass index identified as an independent predictor of psychiatric readmission.

BACKGROUND: Psychiatric hospital readmissions correlate with illness severity, drug selection, and compliance with treatment in the outpatient setting. The risk factors for psychiatric rehospitalization have been mainly assessed in databases lacking information regarding somatic comorbidity and anthropometric variables, such as body mass index (BMI), which are known to predict readmissions in nonpsychiatric settings. OBJECTIVE: To determine independent predictors of 1-year readmission occurring among unselected adults consecutively admitted for treatment of severe mental illness to an academic, freestanding psychiatric hospital in New York City from August 2010 through January 2011. METHOD: After identifying univariate correlates of readmission, we used logistic regression with backward elimination to identify independent predictors of readmissions within 1 year after the index psychiatric hospitalization. RESULTS: Among 224 (23.7%) of 945 readmitted patients, psychiatric readmission was significantly associated with age (P = .0029), length of stay (P = .036), schizophrenia/schizoaffective disorder (P < . 0001), dementia (P = .027), major depressive disorder (P = .0006), treatment with atypical antipsychotic drugs (P = .0054), electroconvulsive therapy (P < .0001), and BMI (P = .0079), but not with physical comorbidities and routine laboratory data.The independent predictors of readmission were higher BMI (median = 28.5 kg/ m2; odds ratio [OR] = 3.6; Cl, 1.2-10.6), a diagnosis of schizophrenia/schizoaffective disorder (OR = 2.2; Cl, 1.5-3.4), clozapine treatment (OR = 2.8; CI, 1.1-6.9), no electroconvulsive therapy (OR = 0.13; Cl, 0.02-0.45), and shorter length of stay (median = 18 days; OR = 0.08; Cl, 0.01-0.42). CONCLUSIONS: Body mass index was identified, for the first time, as an independent predictor of psychiatric rehospitalization. Enhanced outpatient treatment programs for overweight and obese psychiatric patients might influence readmission rates and should be explored in prospective studies.

Outcomes associated with court-ordered treatment over objection in an acute psychiatric hospital.

The postdischarge outcomes of court-ordered treatment of acute psychiatric inpatients have not been adequately investigated. We reviewed the medical records of all patients who refused medication for whom a court order was sought during a recent three-year period, and compared this group to control patients who agreed to treatment and a group of patients who transiently refused medication. The principal outcome measures were successful linkage after discharge, readmission within six months of discharge, and transfer to a state hospital. The study group was less likely to link to an aftercare provider, and more likely to be transferred to a state hospital, had poorer insight on admission, had a longer average stay, and was more likely to utilize mandatory outpatient treatment and long-acting injectable medications after discharge. Patients who require court-ordered medication over objection constitute a group that is high risk for nonadherence after discharge and being refractive to treatment.

Plasma free polyunsaturated fatty acid levels are associated with symptom severity in acute mania.

OBJECTIVES: Nutritionally essential polyunsaturated fatty acids (PUFAs) have been implicated as potentially important factors in mood disorders. For instance, n-3 PUFA supplementation is reported to improve outcomes in major depressive disorder and bipolar disorder. However, the role of PUFAs in acute mania has been minimally investigated. We performed a pilot study to compare plasma levels of free (non-esterified) and esterified PUFAs between patients in an acute manic episode and healthy volunteers, and to explore associations between symptom severity and levels of fatty acids and of the arachidonic acid metabolite, prostaglandin E2 (PGE2). METHODS: Patients (n=10) who were medication-free for at least two weeks and seeking inpatient admission for an acute manic episode were compared with healthy volunteers (n=10). Symptom severity was assessed at admission and after six weeks of naturalistic treatment. Fasting baseline free and esterified plasma levels of docosahexaneoic acid (DHA, 22:6n-3), eicosapentaenoic acid (EPA, 20:5n-3), arachidonic acid (AA,20:4n-6) and the AA metabolite PGE2 were determined, and PGE2 levels were tested again at six weeks. RESULTS: No between-group differences were found in levels of individual or total fatty acids, or of PGE2. Among subjects, manic symptom severity correlated negatively with levels of free AA and free EPA, and positively with the free AA:EPA ratio. PGE2 levels did not differ between groups or in subjects pre- and post-treatment. CONCLUSIONS: Our preliminary results suggest that, in susceptible persons, low plasma levels of free EPA compared with AA are related to the severity of mania.