A microcosting approach for planning and implementing community-based mental health prevention program: what does it cost?

BACKGROUND: Estimating program costs when planning community-based mental health programs can be burdensome. Our aim was to retrospectively document the cost for the first year of planning and implementing Healthy Minds Healthy Communities (HMHC), a mental health promotion and prevention multi-level intervention initiative. This Program is among the first to use the Community Initiated Care (CIC) model in the US and is aimed at building community resilience and the capacity for communities to provide mental health support, particularly among those disproportionately impacted by COVID-19. Our objective is to share our methods for costing a program targeting 10 zip codes that are ethnically and linguistically diverse and provide an example for estimating the cost of a mental health prevention and promotion programs consisting of multiple evidence-based interventions. METHODS: We used a semi-structured interview process to collect cost data through the first year of program planning, start-up and initial implementation from key staff. We calculated costs for each activity, grouped them by major project categories, and identified the cost drivers of each category. We further validated cost estimates through extensive literature review. The cost analysis was done from the provider's perspective, which included the implementing agency and its community partners. We delineated costs that were in-kind contributions to the program by other agency, and community partners. Sensitivity analyses were conducted to estimate uncertainty around parameters. RESULTS: For the first year of the development and implementation of the program, (funded through program and in-kind) is estimated at $1,382,669 (2022 US$). The costs for the three main activity domains for this project are: project management $135,822, community engagement $364,216 and design and execution $756,934. Overall, the cost drivers for the first year of this intervention were: hiring and onboarding staff, in-person community building/learning sessions, communications and marketing, and intervention delivery. CONCLUSION: Implementation of community-based mental health promotion and prevention programs, when utilizing a participatory approach, requires a significant amount of upfront investment in program planning and development. A large proportion of this investment tends to be human capital input. Developing partnerships is a successful strategy for defraying costs.

Pilot Implementation of a Nutrition-Focused Community-Health-Worker Intervention among Formerly Chronically Homeless Adults in Permanent Supportive Housing.

Food insecurity is a known health equity threat for formerly chronically homeless populations even after they transition into permanent housing. This project utilized a human-centered design methodology to plan and implement a nutrition-focused community-health-worker (CHW) intervention in permanent supportive housing (PSH). The project aimed to increase access to healthy foods, improve nutritional literacy, healthy cooking/eating practices, and build community/social connectedness among 140 PSH residents. Validated food-security screening conducted by CHWs identified low or very low food security among 64% of 83 residents who completed the baseline survey, which is similar to rates found in a previous study among formerly homeless populations placed in PSH. Major themes identified through an analysis of resident feedback include (1) lack of needed kitchenware/appliances for food preparation, (2) knowledge gaps on how to purchase and prepare healthier food, (3) positive perceptions of healthy food options, (4) expanded preferences for healthy, easy-to-prepare foods, (5) regaining cooking skills lost during homelessness, (6) positive experiences participating in group activities, (7) community re-entry, and (8) resident ownership. Preliminary findings suggest the use of a human-centered design methodology for planning and implementing this multi-level CHW intervention helped reduce food insecurity, engaged participants in learning and adopting healthy and safe cooking and eating practices, and fostered social connectedness and feelings of community among formerly chronically homeless PSH residents.

The Association between Potentially Traumatic Events and Cocaine, Cannabis, and Alcohol Use Differs by Race.

Background: Although exposure to potentially traumatic events (PTEs) for Black and Latinx may be comparable or lower than their White counterparts, type of trauma experiences differ such as more interpersonal trauma and violence reported by Black people, who also experience higher rates of PTSD. In this retrospective study, we examined the association between use of particular substances and various PTEs and the race/ethnicity-group differences for this association. Methods: One-hundred seventy-nine participants recruited from an outpatient substance use disorder program from February 2018 to October 2020 completed measures on lifetime trauma history and current/past cocaine, cannabis, and alcohol misuse. Bayesian generalized linear modeling with horseshoe prior was used to predict substance misuse using 17 PTEs, then PTEs were ranked and examined by racial/ethnic group. Results: No PTEs were associated with substance misuse across all four r/e groups. Transportation accident, natural disaster, war exposure, and other stressful events were associated with substance misuse across two or three r/e groups. Notably, the three PTEs involving interpersonal violence in our study (weapon assault, physical assault, and sexual assault) were only associated with substance misuse (posterior probability ≥70%) for Latinx participants. Conclusion: The relational nature of interpersonal/violent traumas may make them particularly salient for Latinx people where interpersonal relationships are prioritized. These types of traumas may also be viewed as an extension of discrimination and exclusion, two longstanding, intractable issues for people of color in the US, making them even more damaging. Furthermore, lack of resources may limit options for coping, resulting in substance use problems.

Patient and Provider Perspectives on Medication Non-adherence Among Patients with Depression and/or Diabetes in Diverse Community Settings - A Qualitative Analysis.

Background: Diabetes and depression affect a significant percentage of the world's total population, and the management of these conditions is critical for reducing the global burden of disease. Medication adherence is crucial for improving diabetes and depression outcomes, and research is needed to elucidate barriers to medication adherence, including the intentionality of non-adherence, to intervene effectively. The purpose of this study was to explore the perspectives of patients and health care providers on intentional and unintentional medication adherence among patients with depression and diabetes through a series of focus groups conducted across clinical settings in a large urban area. Methods: This qualitative study utilized a grounded theory approach to thematically analyze qualitative data using the framework method. Four focus groups in total were conducted, two with patients and two with providers, over a one-year period using a semi-structured facilitation instrument containing open-ended questions about experiences, perceptions and beliefs about medication adherence. Results: Across the focus groups, communication difficulties between patients and providers resulting in medication non-adherence was a primary theme that emerged. Concerns about medication side effects and beliefs about medication effectiveness were identified as perceptual barriers related to intentional medication non-adherence. Practical barriers to medication adherence, including medication costs, forgetting to take medications and polypharmacy, emerged as themes related to unintentional medication non-adherence. Conclusion: The study findings contribute to a growing body of research suggesting health system changes are needed to improve provider education and implement multicomponent interventions to improve medication adherence among patients with depression and/or diabetes, both chronic illnesses accounting for significant disease burden globally.

Inpatient Early Intervention for Serious Mental Illnesses Is Associated With Fewer Rehospitalizations Compared With Treatment as Usual in a High-volume Public Psychiatric Hospital Setting.

OBJECTIVE: High-acuity publicly funded inpatient psychiatric settings usually feature short lengths of stay and high readmission rates. This study examined the influence of an early intervention program for serious mental illnesses (SMI) on readmissions at 6 and 12 months postdischarge at a high-volume, urban public inpatient psychiatric hospital. METHODS: The Early Onset Treatment Program (EOTP) is a cost-free, 90-day inpatient multidisciplinary service intervention program for uninsured patients who are within 5 years of SMI onset, funded as a pilot program by the Texas state legislature. Rehospitalization rates at 6 and 12 months were extracted from electronic medical records for EOTP participants (n=165) and comparison patients matched on demographics and diagnosis (n=155). The comparison group received treatment as usual at the same psychiatric hospital. Group re-admission rates were compared using logistic and Poisson regression analyses. RESULTS: Group membership was a significant predictor of rehospitalization (P<0.0001) at both 6 and 12 months. Expressed as 1/odds ratio (OR), the EOTP group was less likely to readmit once and more than once at 6 months postdischarge (1/OR=3.82 and 4.74, respectively) compared with the non-EOTP group. The EOTP group was also less likely to readmit once and more than once at 12 months postdischarge (1/OR=2.96 and 3.51, respectively). CONCLUSIONS: The results suggest that participation in the EOTP service in this high-acuity setting was significantly related to reduced likelihood of rehospitalization at 6 and 12 months. Several variables may account for this observation, including length of stay, longer medication adherence, environmental stability, and more individualized and extensive psychotherapy treatment.

Customizing Early Intervention Treatment for Psychosis in the UTHealth - Harris County Psychiatric Center.

High-need, high-cost patients include those with diagnosed serious mental illnesses (e.g., schizophrenia; SMI). They often delay or fail to seek treatment. If they receive treatment, care is often sought from generalist settings (e.g., primary care or emergency medicine) or is suboptimal due to the provision of limited, non-evidence-based intervention and lack of communication, integration, and coordination among providers. This results in high aggregate costs and poor outcomes. Value-based health care requires care coordination to address the medical and social needs of this population. We describe a unique early intervention program for SMI that emanates from an inpatient setting: The Early Onset Treatment Program (EOTP) at the University of Texas Health Science Center at Houston-Harris County Psychiatric Center. The EOTP offers free, phase-specific, multidisciplinary treatment to young adults without health insurance with the aim of improving their long-term outcomes and reducing the rate of rehospitalization. An evaluation of the EOTP indicates program participants were significantly less likely to be rehospitalized at six months (4.73 times less likely) and at 12 months (3.5 times less likely) than a comparison group (p <.001), and participants' scores of symptomatology and disability significantly decreased following treatment.

Determinants of High Psychiatric Utilization at a Large Urban Safety-Net Hospital.

Research indicates that high utilizers of the health care system are more likely to have mental illness, to be from socially disadvantaged groups, and to have limited access to community-based services. In this retrospective study, three definitions of high utilization were examined: (1) across time: non-high utilization versus high-utilization, (2) single year versus multi-year, and (3) year-to-year. Univariate logistic regression models were fit to a set of 20 theory-selected predictors of high utilization. An optimal multiple predictor model was then derived via penalized multiple logistic regression (via elastic net, a machine learning algorithm). Three factors were identified in the optimized model as increasing the likelihood of high utilization: having a diagnosis of schizophrenia, having a co-occurring personality disorder diagnosis, and having less than a high school education. Given the complex needs of psychiatric high utilizers, innovative approaches should be considered to improve patient outcomes and reduce costly psychiatric hospitalizations.

Race, History of Abuse, and Homelessness Are Associated With Forced Medication Administration During Psychiatric Inpatient Care.

OBJECTIVE: Although previous research has suggested that racial disparities exist in the administration of forced medication (FM) in psychiatric inpatients, data remain scarce regarding other contributing variables. Therefore, this study examined sociodemographic and clinical variables associated with FM administration in psychiatric inpatients. METHODS: Electronic medical records from 57,615 patients admitted to an academic psychiatric hospital between 2010 and 2018 were reviewed to identify patients who received FM. These records indicated that FM petitions were requested and approved for ∼6200 patients. Patients were excluded from the analysis if they met the following exclusion criteria: under 18 years of age, presence of intellectual/developmental disability, dementia, or other neurological condition, or primary diagnosis of a nonpsychiatric medical condition or a substance-induced mood or psychotic disorder. After data on those patients were excluded, the final sample included records from 2569 patients (4.5% of the total records) in which the administration of FM was petitioned for and approved. The FM group was compared with a control group of 2569 patients matched in terms of age, sex, and admission date (no-forced medication group; NFM) via propensity scoring matching. Group comparisons (FM vs. NFM group) examined sociodemographic factors (race, age, sex, living situation), clinical features (diagnosis, substance abuse, history of abuse), and outcomes (length of stay, readmission rate). Regression analyses examined the association between FM and sociodemographic, clinical, and outcome variables. RESULTS: Compared with the NFM group, the FM group contained significantly more African Americans (P<0.001), homeless individuals (P<0.001), and individuals with histories of abuse (P<0.001). Having received FM was a significant predictor of a longer length of stay (P<0.001) and higher readmission rates (P<0.001). DISCUSSION: These results suggest that FM is more likely to be instituted in psychiatric inpatients who are of a minority race (African American), are in a homeless living situation, and/or have a history of abuse. Moreover, FM may be associated with poorer clinical outcomes at least as measured by the length of stay and higher readmission rates. We discuss possible reasons for these results and the importance of culturally competent and trauma-focused care.

Cannabis use: A co-existing condition in first-episode bipolar mania patients.

BACKGROUND: An association between first-episode presentation of bipolar mania and concurrent cannabis use disorder has been well established in the current literature (Bally et al., 2014, Baethge et al., 2008). Previous studies have shown that 30-70% of patients admitted for a first manic episode had concurrent cannabis use (Bally et al., 2014). The exact mechanism of this association has yet to be confirmed. AIMS: We aim to evaluate the prevalence of cannabis use in patients with bipolar disorder (BD) admitted to UTHealth Harris County Psychiatric Center (HCPC) for a first manic episode. METHODS: In this retrospective cohort study, 15,969 inpatient records of patients admitted to HCPC between 2012-2013 were examined to identify patients admitted with a first manic episode according to ICD-9 criteria (single episode mania). The prevalence of multiple sociodemographic and clinical variables including cannabis positivity in urine drug screening (UDS) were examined. RESULTS: Twenty patients were admitted for a first manic episode. Half of the patients were females; mean age was 28.65 ± 10.56 years and mean length of stay (LOS) was 7.15 ± 3.72 days. Fifteen patients received a UDS. Of these fifteen, seven were positive for cannabinoids (47%). One patient was positive for phencyclidine (in addition to cannabis) and one patient was positive for amphetamine (but not cannabis). CONCLUSIONS: The prevalence of cannabis use was higher in first-episode mania patients compared to the general population. The influence of cannabis on the first episode of mania requires additional study.

Treatment Retention Among Patients Participating in Coordinated Specialty Care for First-Episode Psychosis: a Mixed-Methods Analysis.

Young adults experiencing first-episode psychosis have historically been difficult to retain in mental health treatment. Communities across the United States are implementing Coordinated Specialty Care to improve outcomes for individuals experiencing first-episode psychosis. This mixed-methods research study examined the relationship between program services and treatment retention, operationalized as the likelihood of remaining in the program for 9 months or more. In the adjusted analysis, male gender and participation in home-based cognitive behavioral therapy were associated with an increased likelihood of remaining in treatment. The key informant interview findings suggest the shared decision-making process and the breadth, flexibility, and focus on functional recovery of the home-based cognitive behavioral therapy intervention may have positively influenced treatment retention. These findings suggest the use of shared decision-making and improved access to home-based cognitive behavioral therapy for first-episode psychosis patients may improve outcomes for this vulnerable population.

A qualitative study investigating bipolar patients' expectations of a lifestyle intervention: A self-management program.

BACKGROUND: There is some evidence supporting the efficacy of lifestyle interventions in changing unhealthy habits and reduce the risk of developing comorbid conditions in Bipolar Disorder (BD). AIMS: This qualitative study aimed to identify what an optimal lifestyle intervention would look like for individuals with BD. METHODS: The current findings are based on one focus group and two paired interviews including a total of 10 individuals with BD (44.20 ±â€¯11.11 years; 6 females). Groups' transcripts were analyzed using a narrative approach. Primary themes included facilitating factors and barriers, general content, outcomes, format of the intervention, and background factors. RESULTS: Participants were in favor of a group-based lifestyle intervention as part of their usual treatment. The optimal group format would include 4 to 10 individuals, and comprise of 12 to 18 sessions lasting 1 to 1.5 h each. Accountability, motivation, interaction, and group activities were identified as contributing to the success of a lifestyle intervention. CONCLUSIONS: This qualitative study provides important information regarding aspects of lifestyle intervention format and delivery for individuals with BD. We identified barriers and facilitating factors that should be addressed in health promotion interventions delivered within community mental health settings.

Ethnic differences in the diagnosis of schizophrenia and mood disorders during admission to an academic safety-net psychiatric hospital.

U.S. Hispanics, now the single largest minority group in the country, face unique mental health disparities. The current study utilizes Andersen's Behavioral Model of Health Service Use to examine ethnic disparities in receiving a schizophrenia or mood disorder diagnosis at psychiatric hospital admission. Our retrospective cohort study examined electronic health record data at an academic safety-net psychiatric hospital for adult patients (n = 5571) admitted between 2010 and 2013. Logistic regression with block-wise entry of predisposing, enabling and need variables was used to examine ethnic disparities in receiving a schizophrenia diagnosis at admission. The block of need factors was the strongest predictor of receiving a schizophrenia diagnosis compared to predisposing and enabling factors. Compared to non-Hispanic whites, Hispanics and African Americans had a greater likelihood of receiving a schizophrenia diagnosis at admission. Additionally, patients diagnosed with schizophrenia had elevated positive and negative symptoms and were more likely to be male, single/unmarried, homeless, high inpatient service utilizers, involuntarily hospitalized, and to exhibit functional impairment at psychiatric hospital admission. To address elevated positive and negative symptoms of schizophrenia, functional impairment, social withdrawal, and high inpatient service utilization, promising psychosocial interventions should be adapted for racial and ethnic minority populations and utilized as an adjuvant to antipsychotic medication.

Factors Associated With the Likelihood of Hospitalization Following Emergency Department Visits for Behavioral Health Conditions.

OBJECTIVES: Behavioral health-related emergency department (ED) visits have been linked with ED overcrowding, an increased demand on limited resources, and a longer length of stay (LOS) due in part to patients being admitted to the hospital but waiting for an inpatient bed. This study examines factors associated with the likelihood of hospital admission for ED patients with behavioral health conditions at 16 hospital-based EDs in a large urban area in the southern United States. METHODS: Using Andersen's Behavioral Model of Health Service Use for guidance, the study examined the relationship between predisposing (characteristics of the individual, i.e., age, sex, race/ethnicity), enabling (system or structural factors affecting healthcare access), and need (clinical) factors and the likelihood of hospitalization following ED visits for behavioral health conditions (n = 28,716 ED visits). In the adjusted analysis, a logistic fixed-effects model with blockwise entry was used to estimate the relative importance of predisposing, enabling, and need variables added separately as blocks while controlling for variation in unobserved hospital-specific practices across hospitals and time in years. RESULTS: Significant predisposing factors associated with an increased likelihood of hospitalization following an ED visit included increasing age, while African American race was associated with a lower likelihood of hospitalization. Among enabling factors, arrival by emergency transport and a longer ED LOS were associated with a greater likelihood of hospitalization while being uninsured and the availability of community-based behavioral health services within 5 miles of the ED were associated with lower odds. Among need factors, having a discharge diagnosis of schizophrenia/psychotic spectrum disorder, an affective disorder, a personality disorder, dementia, or an impulse control disorder as well as secondary diagnoses of suicidal ideation and/or suicidal behavior increased the likelihood of hospitalization following an ED visit. CONCLUSION: The block of enabling factors was the strongest predictor of hospitalization following an ED visit compared to predisposing and need factors. Our findings also provide evidence of disparities in hospitalization of the uninsured and racial and ethnic minority patients with ED visits for behavioral health conditions. Thus, improved access to community-based behavioral health services and an increased capacity for inpatient psychiatric hospitals for treating indigent patients may be needed to improve the efficiency of ED services in our region for patients with behavioral health conditions. Among need factors, a discharge diagnosis of schizophrenia/psychotic spectrum disorder, an affective disorder, a personality disorder, an impulse control disorder, or dementia as well as secondary diagnoses of suicidal ideation and/or suicidal behavior increased the likelihood of hospitalization following an ED visit, also suggesting an opportunity for improving the efficiency of ED care through the provision of psychiatric services to stabilize and treat patients with serious mental illness.

Identifying a clinical signature of suicidality among patients with mood disorders: A pilot study using a machine learning approach.

OBJECTIVE: A growing body of evidence has put forward clinical risk factors associated with patients with mood disorders that attempt suicide. However, what is not known is how to integrate clinical variables into a clinically useful tool in order to estimate the probability of an individual patient attempting suicide. METHOD: A total of 144 patients with mood disorders were included. Clinical variables associated with suicide attempts among patients with mood disorders and demographic variables were used to 'train' a machine learning algorithm. The resulting algorithm was utilized in identifying novel or 'unseen' individual subjects as either suicide attempters or non-attempters. Three machine learning algorithms were implemented and evaluated. RESULTS: All algorithms distinguished individual suicide attempters from non-attempters with prediction accuracy ranging between 65% and 72% (p<0.05). In particular, the relevance vector machine (RVM) algorithm correctly predicted 103 out of 144 subjects translating into 72% accuracy (72.1% sensitivity and 71.3% specificity) and an area under the curve of 0.77 (p<0.0001). The most relevant predictor variables in distinguishing attempters from non-attempters included previous hospitalizations for depression, a history of psychosis, cocaine dependence and post-traumatic stress disorder (PTSD) comorbidity. CONCLUSION: Risk for suicide attempt among patients with mood disorders can be estimated at an individual subject level by incorporating both demographic and clinical variables. Future studies should examine the performance of this model in other populations and its subsequent utility in facilitating selection of interventions to prevent suicide.

Lifestyle interventions targeting dietary habits and exercise in bipolar disorder: A systematic review.

BACKGROUND: Bipolar disorder (BD) is a serious mental illness associated with a high risk of medical comorbidities, long-term disability and premature death. This systematic review examined the current literature on therapeutic interventions targeting nutrition, physical activity and wellness in BD and collecting health-related measures such as mood and course of illness. METHODS: Scopus (all databases), Pubmed and Ovid Medline were systematically searched with no language or year restrictions, up to June 2015, for studies focusing on lifestyle interventions in BD. Search terms were related to bipolar disorder, nutrition, physical activity, wellbeing, psychosocial interventions and course of illness. We hand searched content pages of Bipolar Disorders and Journal of Affective Disorders and checked references of relevant reviews and dissertations to identify additional papers. RESULTS: After applying inclusion and exclusion criteria to identified hits, this literature search retrieved six papers. Overall findings point towards a beneficial role of lifestyle interventions on mood, weight, blood pressure, lipid profile, physical activity and overall wellbeing. Methodological limitations include small sample size, gender ratio imbalance, inconsistencies in terms of laboratory measures, and lack of randomized controlled trials and absence of follow-up and longitudinal studies to determine the benefits of these factors on clinical and functional outcomes over time CONCLUSIONS: Lifestyle interventions in BD targeting nutrition, exercise, wellbeing alongside beliefs, coping strategies and attitudes towards health show promise in reducing the risk of comorbid ailments in BD. There is still a strong need for studies a) developing interventions which are informed by the patient's input and b) examining the effectiveness of such interventions targeting general wellness using well-controlled trials.

Predictors of psychiatric readmission among patients with bipolar disorder at an academic safety-net hospital.

OBJECTIVE: Even with treatment, approximately one-third of patients with bipolar disorder relapse into depression or mania within 1 year. Unfavorable clinical outcomes for patients with bipolar disorder include increased rates of psychiatric hospitalization and functional impairment. However, only a few studies have examined predictors of psychiatric hospital readmission in a sample of patients with bipolar disorder. The purpose of this study was to examine predictors of psychiatric readmission within 30 days, 90 days and 1 year of discharge among patients with bipolar disorder using a conceptual model adapted from Andersen's Behavioral Model of Health Service Use. METHODS: In this retrospective study, univariate and multivariate logistic regression analyses were conducted in a sample of 2443 adult patients with bipolar disorder who were consecutively admitted to a public psychiatric hospital in the United States from 1 January to 31 December 2013. RESULTS: In the multivariate models, several enabling and need factors were significantly associated with an increased risk of readmission across all time periods examined, including being uninsured, having ⩾3 psychiatric hospitalizations and having a lower Global Assessment of Functioning score. Additional factors associated with psychiatric readmission within 30 and 90 days of discharge included patient homelessness. Patient race/ethnicity, bipolar disorder type or a current manic episode did not significantly predict readmission across all time periods examined; however, patients who were male were more likely to readmit within 1 year. The 30-day and 1-year multivariate models showed the best model fit. CONCLUSION: Our study found enabling and need factors to be the strongest predictors of psychiatric readmission, suggesting that the prevention of psychiatric readmission for patients with bipolar disorder at safety-net hospitals may be best achieved by developing and implementing innovative transitional care initiatives that address the issues of multiple psychiatric hospitalizations, housing instability, insurance coverage and functional impairment.

Racial disparities during admission to an academic psychiatric hospital in a large urban area.

Multiple studies confirm that African Americans are less likely than non-Hispanic whites to receive needed mental health services. Research has consistently shown that African Americans are under-represented in outpatient mental health treatment settings and are over-represented in inpatient psychiatric settings. Further, African Americans are more likely to receive a diagnosis of schizophrenia and are less likely receive an affective disorder diagnosis during inpatient psychiatric hospitalization compared to non-Hispanic white patients, pointing to a need for examining factors contributing to mental health disparities. Using Andersen's Behavioral Model of Health Service Use, this study examined predisposing, enabling and need factors differentially associated with health service utilization among African American and non-Hispanic white patients (n=5183) during psychiatric admission. We conducted univariate and multivariate logistic regression analyses to examine both main effects and interactions. In the multivariate model, African American race at admission was predicted by multiple factors including younger age, female gender, multiple psychiatric hospitalizations, elevated positive and negative symptoms of psychosis, a diagnosis of schizophrenia and substance use, as well as having housing and commercial insurance. Additionally, screening positive for cannabis use at intake was found to moderate the relationship between being female and African American. Our study findings highlight the importance of examining mental health disparities using a conceptual framework developed for vulnerable populations (such as racial minorities and patients with co-occurring substance use).

Factors differentially associated with early readmission at a university teaching psychiatric hospital.

RATIONALE, AIMS AND OBJECTIVES: The rate of psychiatric readmissions within 30 days of discharge is a well-established behavioural health system performance measure linked to the quality of inpatient hospital care as well as to access to community-based aftercare services. The purpose of this study was to examine the factors differentially associated with earlier readmission among a sample of patients (n = 588) readmitted within 30 days of discharge to a university teaching psychiatric hospital from 2001 to 2010. METHODS: Quality assurance interviews were conducted with patients readmitted within 30 days of discharge. The interview data were merged with clinical symptom and electronic medical record data. Multinomial logistic regression analysis was used to examine readmission within 7 days and from 8 to 14 days compared with 15-30 days after discharge while controlling for socio-demographic and treatment variables previously associated with psychiatric readmission. RESULTS: Multiple clinical, treatment and patient-reported factors were differentially associated with earlier readmission. In particular, lack of engagement in post-discharge aftercare services was a strong predictor of earlier readmission. CONCLUSIONS: Strategies are needed to improve patients' transition from inpatient psychiatric hospitalization to aftercare services. Psychiatric hospitals attempting to reduce very early readmissions should seek to implement innovative transitional care initiatives targeting both patient and treatment factors.

Shared clinical associations between obesity and impulsivity in rapid cycling bipolar disorder: a systematic review.

BACKGROUND: Obesity seems to show a two-way relationship with bipolar disorder (BD), representing not only a possible vulnerability factor but also a consequence of chronic mood dysregulation associated with an overall poor prognosis. Increased impulsivity has been described across all stages and phases of BD as being also associated with a worse prognosis. Although obesity and impulsivity are common features among rapid cycling bipolar disorder (RC-BD) patients, there is a lack of understanding about the clinical implications of these conditions combined in BD. METHODS: To explore and integrate available evidence on shared clinical associations between obesity and impulsivity in RC-BD a systematic search of the literature in the electronic database of the National Library of Medicine (PubMed) has been conducted. RESULTS: One hundred and fourteen articles were included in our systematic review. Among RC-BD patients, substance abuse disorders (SUDs), anxiety disorders (ADs), predominantly depressive polarity, chronic exposure to antidepressants, psychotic symptoms, suicidality, and comorbid medical conditions are strongly associated with both obesity and impulsivity. LIMITATIONS: Heterogeneity of published data, inconsistent measurements of both obesity and impulsivity in RC-BD and an absence of control for RC-BD in epidemiological surveys. Consequently, their combined impact on the severity of RC-BD is yet to be recognized and remains to be poorly understood. CONCLUSION: In RC-BD patients the co-occurrence of obesity and impulsivity is associated with an unfavorable course of illness, specific shared clinical correlates, negative psychosocial impact, and overall worse prognosis. There is a need to examine obesity and impulsivity as modulating factors and markers of severity in RC-BD.