Suicide Risk Assessment, Management, and Mitigation in the Emergency Setting.

Suicide is a serious public health issue and is a leading cause of death worldwide. Suicidal ideation is a common presentation in emergency department (ED) settings, with many nuanced complications. Therefore, understanding screening, assessment, and mitigation is paramount to successful encounters with individuals presenting to emergency settings in psychiatric crises. Screening helps to identify the few people at risk within a large group. Assessment seeks to decide whether a specific individual is at significant risk. Mitigation aims to reduce the risk of suicide or of a serious attempt for a person at risk. These aims cannot be achieved with perfect reliability, but some approaches are more effective than others. Suicide screening specifics are important, even to individual practitioners, because a positive screen triggers assessment. Most practitioners understand assessment well: beginning with early psychiatric training, they are taught signs and symptoms suggesting that a patient might be at risk of suicide. Mitigating suicide risk is increasingly important to reduce the misery of ED boarding for patients awaiting psychiatric admission. For many patients, hospital admission is unnecessary if support, monitoring, and contingency plans are workable. For any individual patient, there may be a complicated mix of findings, risks, and interventions. Evidence-based screening and assessment tools are inadequate for the possible complexities, making care of individual patients dependent on good clinical assessment. The authors review the available evidence and offer experienced recommendations for challenges not yet thoroughly researched.

Evergreening of Psychiatric Medications: A Systemic Literature Review of Strategies, Case Examples, and the Implications of Cost.

Evergreening consists of multiple ways that pharmaceutical companies extend patent protection and prolong profitability of brand name drugs past patent expiration. In psychotropic medications, these strategies do not necessarily make more effective drugs, and often increase drug prices, which can result in lower access and utilization. There has not been a systematic literature review of evergreening strategies for psychiatric medications. Based on such a review, 11 strategies were identified and relevant examples were provided. Four case examples of commonly used psychiatric medications indicated evergreen prices 3 to 211 times the cost of the original medication, and the evergreen costs ranging from $132.00 to $10,125.24 higher than the original cost on an annual basis. The higher cost of evergreening medications can create inefficiencies and waste in healthcare resulting in lower-quality patient care. Healthcare providers, patient advocates, health insurance companies, and policy-makers should be aware of these practices to improve healthcare systems.

A Survey of Geriatric Psychiatry Fellows and Program Directors: Specialty Choice, Program Choice, and Program Quality.

OBJECTIVE: This study explored factors influencing a physician's choice to pursue geriatric psychiatry fellowship training from fellow and program director perspectives to improve recruitment into this critical need specialty. METHODS: Questionnaires were sent to the 54 fellows and 79 fellowship program directors of programs accredited by the Accreditation Council for Graduate Medical Education (ACGME) available through the American Association for Geriatric Psychiatry (AAGP) listserv. A 5-point Likert scale (strongly disagree, disagree, neutral-undecided, somewhat agree, strongly agree) was used to score and rank these questionnaires. RESULTS: Thirty-three program directors (42%) on the AAGP listserv and 24 (44%) of all ACGME accredited fellows responded. The clinical quality of the faculty (Fellows 92%, Program Directors 92%) and the fellowship's national reputation (Fellows 75%, Program Directors 88%) were most highly ranked by both. Fellows ranked proximity to family (79%) high (2nd) in their program choice, while ranking workload, salary, and visa issues as low. CONCLUSION: This study emphasizes that family and cultural/ethnographic considerations, along with the core values of a training program, remain highly valued by trainees, and should inform structural changes to incentivize training, and enhance the inherent quality of fellowship programs.

Improving Patient Care through Collaborative Consultation Integration: a Quality Improvement Initiative.

Evidence suggests that interdisciplinary care leads to improvements in patient care and efficiency. To determine whether integrating inpatient hospital behavioral health services would result in improved perceptions of patient care and efficiency, team members (N = 23) were surveyed 1 year after integration on measures of patient care, efficiency, and personal satisfaction. A majority of respondents believed integration improved patient care and efficiency. Overall satisfaction was high. The results suggest integration of behavioral health services improves individual perceptions of patient care, efficiency, and satisfaction.

Characteristics of Patients With Constant Observers.

BACKGROUND: The use of constant observers ("sitters") has been common practice in many medical centers to maintain patient safety. RESULTS: A retrospective chart review of patients who required sitters from October 1, 2007 to September 31, 2013 at a large, private hospital serving a multiethnic community showed that the top reasons for sitters include suicide risk, agitation, fall risk, interfering with medical devices, and confusion/disorientation. Sitters were used for a mean of 3.4 days ranging from 1 to 287 days, with a mean hospital length of stay of 18.9 days. Although 42.4% of all cases with sitters had a psychiatric consultation, psychiatry was consulted on only 8.5% of those with agitation, 6.3% of those who were disoriented, and 12.7% of those with decisional capacity concerns. Psychiatry was consulted on 87.4% of patients with a constant observer for suicide risks. Sitters were most often discontinued when behaviors improved or when patients were discharged. CONCLUSION: This information will be useful for understanding the optimal way to implement a program that will increase patient safety and decrease cost.

Simultaneous usage of dementia medications and anticholinergics among Asians and Pacific Islanders.

BACKGROUND: The simultaneous use of dementia medications and anticholinergic medications occurs frequently. Cholinesterase inhibitors and anticholinergic medications likely counteract one another, potentially exposing patients to medications with decreased benefit, more adverse effects, and higher cost of care. We identified the rate of concurrent prescriptions of cholinesterase inhibitors/memantine with anticholinergics in an urban hospital setting with a large Asian and Pacific Islander population. METHODS: This study is a retrospective review of patients hospitalized from 1 January 2006 to 31 December 2010 at a general hospital who simultaneously received US Food and Drug Administration-approved dementia medications (galantamine, rivastigmine, donepezil, and/or memantine) and anticholinergics. RESULTS: Overall, 304 patients receiving cholinesterase inhibitors/memantine also received anticholinergics. Of these patients, 64.1% were given high-potency anticholinergic medications, and 35.9% received medium-potency medications. Indications for the use of anticholinergic medication were urological (17.8%), gastrointestinal excluding nausea (32.6%), nausea (10.2%), psychiatric (7.9%), and other (31.6%). Asian patients received the combination of cholinesterase inhibitors/memantine and anticholinergics less frequently than Native Hawaiian or Caucasian patients (8.4% vs 12.2% and 13.3%, respectively; χ2 = 16.04, degrees of freedom = 2, P < 0.0003). CONCLUSIONS: Simultaneous prescribing of cholinesterase inhibitors, memantine, and anticholinergic medications was significantly less common than in previous studies, with some ethnic variability. The less frequent occurrence of concurrent medications in the Asian population may be because of variations in the rate of indications or in tolerability for anticholinergic medications among the population.

Atypical antipsychotic usage among Asian Americans and Pacific Islanders.

Previous studies have shown significant ethnic differences in prescribing patterns of two or more antipsychotics. This study examined changes in atypical and typical antipsychotic prescriptions among Asian Americans and Pacific Islanders. Five hundred consecutive charts were reviewed for antipsychotics at the time of admission and discharge from each of two inpatient psychiatric facilities in Hawai'i. Multiple antipsychotic prescription rates were 9% at intake and 6% at discharge. For the ethnic groups studied, there were no statistically significant differences by patient ethnicity regarding antipsychotics at intake (χ(2) = 29.2, df = 21, P = .110) or discharge (χ(2) = 20.5, df = 24, P = .667). There were no significant differences in prescription and polypharmacy patterns among Asian Americans and Pacific Islanders ethnic groups in this study.

Cohort profile: the Hawai'i Family Study of Cognition.

Intergenerational longitudinal studies over the lifespan provide valuable information for understanding the contexts and dynamic relations among cognition, family and health in adults and the elderly. The Hawai'i Family Study of Cognition (HFSC), initiated in the early 1970s, included a cohort of over 6500 individuals representing over 1800 families of parents and their offspring. The HFSC gathered data on cognitive, personality, biological and other psychosocial variables, and provided novel information on the nature of cognitive abilities, especially on family issues. Some families were reassessed with short-term retesting in the 1970s. A select sample of offspring and their siblings and spouses were re-measured in the 1980s. Decades later, a 40-year follow-up of the original HFSC cohort was facilitated by the availability of contemporary tracking and tracing methods and internet-based testing. A subgroup of the original HFSC participants was re-contacted and retested on contemporary cognitive as well as socio-demographic and health measures. In this paper, we describe the original HFSC cohort and the design and methodology of the re-contact and retest studies of the HFSC, plans for expanding the re-contact and retesting, as well as directions for future research and collaborations. The Principal Investigator may be contacted for more information regarding the application, review and approval process for data access requests from qualified individuals outside the project.

Sociodemographic characterization of ECT utilization in Hawaii.

OBJECTIVES: Minimal research has been done on sociodemographic differences in utilization of electroconvulsive therapy (ECT) for refractory depression, especially among Asian Americans and Pacific Islanders. METHODS: This study examined sociodemographic and diagnostic variables using retrospective data from Hawaii, an island state with predominantly Asian Americans and Pacific Islanders. Retrospective data were obtained from an inpatient and outpatient database of ECT patients from 2008 to 2010 at a tertiary care community hospital on O'ahu, Hawaii. RESULTS: There was a significant increase in overall ECT utilization from 2008 to 2009, with utilization remaining stable from 2009 to 2010. European Americans (41%) and Japanese Americans (29%) have relatively higher rates of receiving ECT, and Filipino Americans and Native Hawaiians have relatively lower rates in comparison with their population demographics. Japanese Americans received significantly more ECT procedures than European Americans. CONCLUSIONS: Electroconvulsive therapy is underutilized by certain sociodemographic groups that may benefit most from the treatment. There are significant differences in ECT usage based on ethnicity. Such differences may be related to help-seeking behavior, economic differences, and/or attitudes regarding mental illness. Further research is needed to elucidate the reasons for differences in utilization.

Proportional differences in emergency room adult patients with PTSD, mood disorders, and anxiety for a large ethnically diverse geographic sample.

Underserved populations often utilize the emergency room in place of primary care, particularly for short term behavioral health services. This study examined emergency department (ED) utilization rates for rurality, insurance, sex, and ethnicity in a large sample of adult patients in Hawai'i hospitals from 2000-2010 with a diagnosis of post-traumatic stress disorder (PTSD), mood disorder, or other anxiety disorder. Findings showed a higher rate of use by rural and suburban residents with a diagnosis of PTSD or other anxiety than by urban residents. Utilization of EDs by African Americans and Other Pacific Islanders with PTSD was proportionally higher than for those with mood disorders or other anxiety disorders. Military ED visits were also proportionally higher for individuals with PTSD than for those with mood or other anxiety disorders. Limited economic resources and increasingly costly mental health disorders such as PTSD highlight the importance of better understanding the needs for behavioral health services for underserved populations.

Does cultural assimilation influence prevalence and presentation of depressive symptoms in older Japanese American men? The Honolulu-Asia aging study.

OBJECTIVE: : Sociocultural factors have been implicated in affecting prevalence, incidence, and diagnosis of depression but previous studies have included heterogeneous ethnic populations. We studied the influence of cultural assimilation on the prevalence and presentation of depressive symptoms in elderly Japanese American men. METHOD: : This analysis was based on 3,139 Japanese American men aged 71-93 years who were participants in the Honolulu-Asia Aging Study between 1991 and 1993. We created a Cultural Assimilation Scale (CAS) using 8 questions assessing the degree of Japanese identity and lifestyle compared to a Western one. Subjects were divided into tertiles of CAS score for analysis. Prevalence of depressive symptoms was measured using an 11-question version of the Centers for Epidemiologic Studies Depression Scale questionnaire, and presence of depressive symptoms was defined as score 9 or more. RESULTS: : Prevalent depressive symptoms did not reach a statistically significant association with CAS tertiles (Western, 10.8%; Mixed, 9.6%; and Japanese, 8.5%). However after adjusting for demographic, functional, and disease factors, the most culturally Japanese group had significantly lower odds for prevalent depressive symptoms, compared to the most Western group. Among the subset of subjects with a high-Centers for Epidemiologic Studies Depression Scale-11 score, there were no significant differences in both mean psychological scores and mean somatic scores between the three CAS groups. CONCLUSIONS: : Prevalent depressive symptoms were significantly lower among elderly Japanese American men who were most culturally Japanese, compared to more westernized men. Improving knowledge and understanding about the pathogenesis of depression will have important public health implications.

Treatment of generalized anxiety disorder: a comprehensive review of the literature for psychopharmacologic alternatives to newer antidepressants and benzodiazepines.

OBJECTIVE: Generalized anxiety disorder (GAD) is common, chronic, and debilitating. Treatment with benzodiazepines and newer antidepressants is often inadequate. This article reviews the effectiveness of alternative and augmenting medications, such as older antidepressants, antipsychotics, anticonvulsants, and ß-blockers. DATA SOURCES: A search using MEDLINE (1980 to week 4 of May 2010) with the key words generalized anxiety disorder or GAD and therapeutics or treatment was conducted. Articles included adult patients with a GAD diagnosis that established chronicity of illness. These included a small number of studies that used DSM-III criteria but added a chronicity of symptoms and included all studies that used DSM-III-R and DSM-IV criteria. Articles that did not include medications or that exclusively focused on newer antidepressants (selective serotonin reuptake inhibitors, serotonin-norepinephrine reuptake inhibitors, bupropion, and mirtazapine), buspirone, benzodiazepines, or herbal or investigational medications were excluded. Review articles and non-English-language articles were also excluded. RESULTS: Thirty-six studies were reviewed. All of the references were then analyzed, and key portions were extracted. Many studies were open trials. Double-blind, placebo-controlled studies with imipramine, risperidone, olanzapine, hydroxyzine, ondansetron, tiagabine, valproate, and pregabalin had been conducted. Imipramine, hydroxyzine, valproate, and pregabalin were the most effective, although risperidone, olanzapine, ziprasidone, and aripiprazole may also reduce symptoms. CONCLUSIONS: Several medication strategies can be considered as promising alternatives or augmenting to antidepressant or benzodiazepine therapy in GAD.