Suicide Prevention in the U.S. Department of Veterans Affairs: Using the Evidence Without Losing the Narrative.

The rate of suicide among veterans continues to be highly problematic. The widespread adoption and mandated implementation of thinly validated and scripted assessment tools have the potential to increase clinician burnout and erode clinician-patient relationships without reaching the goal of reducing veteran suicides. While further development and widespread use of validated suicide prevention interventions are necessary, the need remains to guard against a reductionistic approach that may marginalize valuable patient narratives in the process.

Electroconvulsive Therapy for Depression Comorbid With Myasthenia Gravis: A Case Report and Review of the Literature.

OBJECTIVES: Myasthenia gravis (MG) is a rare but well-described autoimmune disease, which is sometimes comorbid with psychiatric illness. There have been several case reports describing the use of electroconvulsive therapy (ECT) for the treatment of core psychopathology in the context of MG. We sought to review the available published data on ECT in MG and add another case example to the literature. METHODS: We performed a PubMed search for relevant articles or case reports in English describing ECT in MG and summarized findings. RESULTS: We identified 7 published cases meeting our inclusion criteria in varying detail with different psychiatric presentations and different anesthetic and ECT technique approaches. In addition, we add our own case. CONCLUSIONS: Based on the literature and our own clinical experience, ECT seems to be a safe option for the treatment of core psychopathology with comorbid MG as long as appropriate precautions are in place, particularly when choosing an anesthetic approach.

Residents Teaching Residents: Results of an Interdisciplinary Educational Endeavor.

OBJECTIVES: Resident physicians across disciplines are engaged in teaching at multiple levels. Available literature focuses on medical student education and intra-disciplinary teaching. The national shortage of psychiatrists coupled with an increasing mental illness burden necessitates development of creative interdisciplinary collaboration. The authors report on an interdisciplinary, resident-to-resident didactic series assessing whether such a model could improve internal medicine resident comfort with managing psychiatric illness on inpatient medical wards. METHODS: Internal medicine residents were assessed regarding their comfort level with managing certain common inpatient psychiatric presentations before and after the delivery of a teaching curriculum designed and delivered by psychiatry residents. RESULTS: Internal medicine residents' overall confidence with identifying and managing common psychiatric problems on inpatient medical wards improved. Comfort level with managing depression and demoralization and determining decisional capacity both improved to a statistically significant degree. CONCLUSIONS: Collaborative, interdisciplinary care is complex and its benefits can be difficult to assess. Data from this study showed that interdisciplinary teaching at the resident level has the potential to be an effective means for building collaboration and can lead to a subjective improvement in comfort managing common inpatient psychiatric presentations on medical wards. Additionally, qualitative observations suggest that such an intervention can improve interdisciplinary collaboration.

Disclosing Huntington's Genetic Testing Results in the Context of Intellectual Disability and Guardianship: Using the Family Illness Narrative to Guide the Flow of Information.

A diagnosis of Huntington's disease has broad social, vocational, reproductive and psychological implications. The ability to accurately diagnose the illness via genetic testing is not new. However, given a persistent lack of robustly effective interventions, it remains an area of ethical concern. The difficulty is compounded in cases of intellectual disability. This paper presents a case of genetic testing for Huntington's disease conducted on a patient with intellectual disability with guardian consent, but without the patient's direct knowledge and how the family illness narrative and psychiatric care were employed in the eventual disclosure of the patient's diagnosis and subsequent management.

Intravenous melatonin abuse leading to recurrent aortic valve endocarditis: a case report and discussion.

BACKGROUND: Reports of inappropriate medication use are widespread. There is a growing literature detailing abuse of drugs not typically thought to have high abuse liability. Melatonin is considered to be generally safe and is categorized by the Food and Drug Administration as a nutritional supplement. There are no known reports of intravenous melatonin abuse in the medical literature. CASE PRESENTATION: The authors report a case of a patient injecting melatonin with euphoric and then sedative effects leading to two episodes of infective endocarditis culminating in aortic valve replacement. CONCLUSION: Infective endocarditis continues to be a major potential complication of intravenous drug abuse. The proliferation of novel street drugs, resurgence in the use of older drugs and ongoing abuse of medications warrant continued research and vigilance in treating substance use disorders and attendant medical complications.

Laboring in the Shadow of the Media: Care and Perceptions of Care in the VA.

Unbalanced criticism of the VA risks marginalizing the superlative care that many veterans receive and the important research, training, and innovative care that the VA provides.

Prolonged length of stay in ED psychiatric patients: a multivariable predictive model.

BACKGROUND: We aimed to evaluate factors associated with prolonged emergency department (ED) length of stay (LOS) among psychiatric patients and to develop a multivariable predictive model to guide future interventions to reduce ED LOS. METHODS: Electronic health records of ED patients receiving a psychiatric consultation and providing research authorization were reviewed from September 14, 2010, through September 13, 2013, at an academic hospital with approximately 73000 visits annually. Prolonged LOS was defined as ≥8 hours. RESULTS: We identified 9247 visits among 6335 patients; median LOS was 4.1 hours, with 1424 visits (15%) with prolonged LOS. In the multivariable model, characteristics associated with an increased risk of a prolonged LOS included patient age 12 to 17 years (odds ratio [OR], 2.43; P<.001) or ≥65 years (OR, 1.46; P=.007); male gender (OR, 1.24; P=.002); Medicare insurance coverage (OR, 1.34; P=.008); use of restraints (OR, 2.25; P=.006); diagnoses of cognitive disorder (OR, 4.62; P<.001) or personality disorder (OR, 3.45; P<.001); transfer to an unaffiliated psychiatric hospital (OR, 22.82; P<.001); ED arrival from 11 pm through 6:59 am (OR, 1.53; P<.001) or on a Sunday (OR, 1.76; P<.001); or ED evaluation in February (OR, 1.59; P=.006), April (OR, 1.66; P=.002), and May (OR, 1.54; P=.007). CONCLUSIONS: Many psychiatric patients had a prolonged ED LOS. Understanding the multiple, patient-specific, ED operational, and seasonal factors that predict an increased LOS will help guide allocation of resources to improve overall ED processes and patient care.

Code status discussions in psychiatric and medical inpatients.

BACKGROUND: The Patient Self-Determination Act along with regulatory standards and institutional standards of care highlight the need for collaboration between care providers and patients with respect to goals of care and, in emergency situations, code status and measures to be taken in keeping with patients' wishes. Addressing code status may be lacking in patients who require psychiatric hospitalization due to the nature of psychiatric illness, relative medical stability, and a general expectation of survival. We sought to compare code status documentation and discussion between psychiatric and medical inpatients, as this knowledge will help shape future interventions for process improvement. METHOD: We conducted a retrospective chart review of hospitalized patients in psychiatric and medical units during a 12-month period in 2008. For those with multiple admissions, we reviewed only the index (or first) hospitalization. Data collected included demographic information, clinical information regarding cancer as a primary diagnosis or a diagnosis that met National Hospice and Palliative Care Organization (NHPCO) guidelines, code status order and discussion documentation, the presence of an advance directive, length of stay, and 1-year mortality. Data were summarized using mean values, percentages, and frequencies. The 2 groups (psychiatric and medical groups) were compared. RESULTS: The charts of 276 psychiatric patients and 317 general medical patients were reviewed. More psychiatric patients had dementia (P < .001). Medical inpatients had a higher rate of code status order documented on admission (96% vs 65%, P < .001) and "full-code, discussed" order (67% vs 33%, P < .001). Psychiatric inpatients had more "do not resuscitate/do not intubate" orders (20% vs 13%, P = .037), more frequent changes in code status order (18% vs 7%, P < .001), and a higher percentage of advance directives (46% vs 25%, P < .001). CONCLUSIONS: A code status discussion with hospitalized patients needs to occur at admission regardless of reason for admission. Strategies are needed to improve this process for psychiatric inpatients.

Munchausen syndrome by adult proxy: a review of the literature.

BACKGROUND: Munchausen syndrome by proxy (MSBP), more formally known as factitious disorder imposed on another, is a form of abuse in which a caregiver deliberately produces or feigns illness in a person under his or her care so that the proxy will receive medical care that gratifies the caregiver. Although well documented in the pediatric literature, few cases of MSBP with adult proxies (MSB-AP) have been reported. This study reviews existing literature on MSB-AP to provide a framework for clinicians to recognize this disorder. METHODS: We searched Ovid MEDLINE, Ovid EMBASE, PubMed, Web of Knowledge, and PsychINFO, supplemented by bibliographic examination. RESULTS: We identified 13 cases of MSB-AP. Perpetrators were caregivers, most (62%) were women, and many worked in healthcare. The age range of the victims was 21 to 82 years. Most were unaware of the abuse, although in 2 cases the victim may have colluded with the perpetrator. Disease fabrication most often resulted from poisoning. CONCLUSIONS: MSB-AP should be included in the differential diagnosis of patients presenting with a complex constellation of symptoms without a unifying etiology and an overly involved caregiver with suspected psychological gain. Early identification is necessary so that healthcare providers do not unknowingly perpetuate harm through treatments that satisfy the perpetrator's psychological needs at the proxy's expense.