The feasibility of a group stress management Liver SMART intervention for patients with end-stage liver disease: A pilot study.

OBJECTIVE: Structured, empirically supported psychological interventions are lacking for patients who require organ transplantation. This stage IA psychotherapy development project developed and tested the feasibility, acceptability, tolerability, and preliminary efficacy of an 8-week group cognitive behavioral stress management intervention adapted for patients with end-stage liver disease awaiting liver transplantation. METHOD: Twenty-nine English-speaking United Network for Organ Sharing-registered patients with end-stage liver disease from a single transplantation center enrolled in 8-week, group cognitive-behavioral liver stress management and relaxation training intervention adapted for patients with end-stage liver disease. Patients completed pre- and postintervention surveys that included the Beck Depression Inventory II and the Beck Anxiety Inventory. Feasibility, acceptability, tolerability, and preliminary efficacy were assessed.ResultAttendance rate was 69.40%. The intervention was rated as "good" to "excellent" by 100% of participants who completed the postintervention survey in teaching them new skills to relax and to cope with stress, and by 94.12% of participants in helping them feel supported while waiting for a liver transplant. No adverse events were recorded over the course of treatment. Attrition was 13.79%. Anxious and depressive symptoms were not statistically different after the intervention.Significance of resultsThe liver stress management and relaxation training intervention is feasible, acceptable, and tolerable to end-stage liver disease patients within a transplant clinic setting. Anxious and depressive symptoms remained stable postintervention. Randomized controlled trials are needed to study the intervention's effectiveness in this population.

Multidisciplinary Proactive Psychiatric Consultation Service: Impact on Length of Stay for Medical Inpatients.

BACKGROUND: Mental illness correlates with an increased length of stay (LOS) for patients hospitalized for medical conditions. While psychiatric consultations help manage mental illness among those hospitalized for medical conditions, consultations initiated by nonpsychiatric mental disease may lack maximum effectiveness. METHODS: In a before-and-after design, in 2 contiguous years LOS for internist-initiated, conventional consultation (CC) as usual treatment was compared to LOS of a proactive, mental health professional-initiated, multidisciplinary intervention delivered by the behavioral intervention team (BIT) on the same units. The patient populations included general medical patients with a variety of illnesses. Patients were treated in 3 different inpatient settings with a total capacity of 92 beds serving 15,858 patient visits over 3 comparison years. BIT comprised a psychiatrist, a nurse, and a social worker, each of whom performed the specific tasks of their professional discipline, while collaborating among themselves and their health-care colleagues. BIT provided timely, appropriate, and effective patient care alongside consultative advice and education to their corresponding professional peers. BIT was compared to CC on the outcome of LOS. RESULTS: There was a statistically significant reduction of LOS favoring BIT over CC for patients with an LOS of <31 days which persisted while controlling for multiple co-morbid factors. Also, a statistically significant spillover effect was suggested by the overall improvement of LOS on units implementing BIT. CONCLUSION: BIT is a promising means of lowering LOS on general medical units while providing a high level of care and staff support.

Resilience in Organ Transplantation: An Application of the Connor-Davidson Resilience Scale (CD-RISC) With Liver Transplant Candidates.

End-stage liver disease (ESLD) is a chronic and debilitating condition associated with substantial psychological stress, morbidity, and mortality. The Connor-Davidson Resilience Scale (CD-RISC; Connor & Davidson, 2003 ) is a commonly used resilience measure. This research examined the validity of the CD-RISC among ESLD patients (N = 120) using exploratory factor analysis. Results supported a single-factor solution after removing poorly loading items. The CD-RISC also was correlated with measures of depression, anxiety, quality of life, social support, age, and cognitive ability, thus providing evidence to support its construct validity. Future research should confirm this factor structure and examine its predictive validity prior to widespread use among ESLD patients. This research represents the first step in this process and proposes an alternative version of the CD-RISC for this population.

Proactive psychiatric consultation services reduce length of stay for admissions to an inpatient medical team.

BACKGROUND: Some studies suggest intensive psychiatric consultation services facilitate medical care and reduce length of stay (LOS) in general hospitals. OBJECTIVE: To compare LOS between a consultation-as-usual model and a proactive consultation model involving review of all admissions, rapid consultation, and close follow-up. METHODS: LOS was compared in an ABA design between a 33-day intervention period and 10 similar control periods, 5 before and 5 after the intervention, on an internal medical unit. During the intervention period, a staff psychiatrist met with the medical team each weekday, reviewed all admissions, provided immediate consultation as needed, and followed all cases throughout their hospital stay. RESULTS: Time required for initial case review was brief, 2.9 ± 2.2 minutes per patient (mean ± S.D.). Over 50% of admissions had mental health needs: 20.3% were estimated to require specialist consultation to avoid potential delay of discharge. The consultation rate for the intervention sample was 22.6%, significantly greater than in the control sample, 10.7%. Mean LOS was significantly shorter in the intervention sample, 2.90 ± 2.12 versus 3.82 ± 3.30 days, and the fraction of cases with LOS > 4 days was significantly lower, 14.5% versus 27.9%. A rough cost benefit analysis was favorable with at least a 4.2 ratio of financial benefit to cost. CONCLUSIONS: Psychiatric review of all admissions is feasible, indicates a high incidence of mental health barriers to discharge, identifies more necessary consultations than typically requested, and results in earlier consultation. A proactive consultation model can reduce hospital LOS.

Predicting time to readmission in patients with recent histories of recurrent psychiatric hospitalization: a matched-control survival analysis.

The most robust predictor of future psychiatric hospitalization is the number of previous admissions. About half of psychiatric inpatients with histories of repeated hospitalizations are readmitted within 12 months. This study sought to determine which patient characteristics predicted time-to-readmission within 12 months after controlling for the number of previous hospitalizations in 75 adults with recent histories of recurrent admissions and 75 matched controls. Results revealed multiple clinical and demographic between-group differences at index hospitalization. However, the only predictors of shorter time-to-readmission in multivariate Cox proportional hazards were unemployment (hazards ratio = 9.26) and residential living status (hazards ratio = 2.05) after controlling for prior hospitalizations (hazard ratio = 1.24). Unemployment and residential living status were not proxies of psychosis or moderated by illness severity or comorbid substance use. Results suggest that early psychiatric readmission may be more influenced by residential and employment status than by severe mental illness.

Outcomes of a Peer Mentor Intervention for Persons With Recurrent Psychiatric Hospitalization.

OBJECTIVE: This article presents findings from a randomized controlled trial of a peer support mentorship intervention designed for individuals with serious mental illness and frequent, recurrent psychiatric hospitalizations. METHODS: Seventy-six individuals who were diagnosed as having a major psychotic or mood disorder and who had at least two psychiatric hospitalizations or more than three emergency department visits within the 18 months prior to the index hospitalization participated in this trial. Participants were randomly assigned to one of two conditions: standard care or a peer mentor plus standard care. Substance use, psychiatric symptoms, psychosocial functioning, and hope were assessed at baseline and at three and nine months after hospital discharge. RESULTS: Participants assigned to the peer mentor condition reported significantly greater reductions in substance use and psychiatric symptoms and greater improvements in functioning compared with participants assigned to standard care. Moreover, participants in the peer mentor program remained out of the hospital for significantly longer periods of time compared with those assigned to standard care. CONCLUSIONS: Peer services for those who are hospitalized recurrently hold promise as an effective component of behavioral health care for persons with serious mental illnesses.

Psychiatric Comorbidity, Health-Related Quality of Life, and Mental Health Service Utilization Among Patients Awaiting Liver Transplant.

CONTEXT: The prevalence of psychiatric disorders and mental health service utilization among patients with end-stage liver disease awaiting transplant remains understudied. OBJECTIVES: This study assessed the prevalence of psychological disorders and symptoms with the use of a structured diagnostic interview and self-report measures, and examined patient-reported mental health service utilization and barriers to care. METHODS: Waitlisted liver transplant candidates (N = 120) completed assessments during routine clinic appointments at a single time point. RESULTS: Participants endorsed moderate-to-severe levels of depression (19.2%), anxiety (26.7%), and Post Traumatic Stress Disorder (PTSD) (23.3%). Forty-three percent had received some form of mental health treatment in the recent past, and a range of barriers to accessing mental health services were endorsed. In a subset of 39 participants who received a structure diagnostic assessment, there was a high prevalence of current (51.3%) and past (82.1%) psychiatric disorders. Elevated scores on depression, anxiety, and PTSD measures were associated with significant decrements in health-related quality of life, but were not differentially associated with mental health service utilization. CONCLUSION: There are a significant number of end-stage liver disease patients who could benefit from intervention who are not currently connected to treatment. Many patients do not see the need for accessing services, perhaps because of a lack of insight or knowledge about the benefits of mental health treatment. Future research should determine optimal treatment and service delivery methods for this vulnerable population.

A randomized trial of primary intensive care to reduce hospital admissions in patients with high utilization of inpatient services.

Randomized controlled trials of case management in primary care have been infrequent and contradictory. The aim of this study was to determine if a clinic-based ambulatory case management intervention, Primary Intensive Care (PIC), would reduce hospital utilization and total cost and/or improve health outcomes among primary care patients with a recent history of high use of inpatient services. Current patients with > or =2 hospital admissions per year in the 12-18 months prior to recruitment in an urban primary care clinic were enrolled in a randomized clinical trial. Patients were randomized to the PIC intervention or usual care. PIC patients underwent a comprehensive multidisciplinary assessment with the result being a team-generated plan. The PIC team nurse practitioner served as case manager for the 12 months of follow-up and provided services designed to implement the care plan for those in the experimental group. Health care use, function, and a medication adherence scale were measured at baseline and at 12 months. There were no significant differences when either comparing the number of admissions pre and post enrollment within groups or the followup results post intervention between groups. A similar result was noted for the number of emergency department visits. The number of clinic visits increased in the intervention group by 1.5 visits per year which was statistically significant when compared to the control group. Overall functional status, health outcomes, and the Mental Health Functional Status subscore did not change significantly in either group during the study. We were unable to detect a difference in hospital use or functional status, mental health function, or medication adherence among patients who require frequent hospital admissions using our intervention.

Family caregiving for adults with sickle cell disease and extremely high hospital use.

This study investigated coping with chronic illness in the adult patient-caregiver relationship for sickle cell disease, marked by debilitating acute and chronic pain. One-on-one interviews (N = 16) were conducted with eight primary caregivers of eight adults with extremely high hospital use, severe sickle cell disease with hospital admissions several times monthly over successive years. Caregivers were predominantly parents; two were romantic partners. Caregivers attributed disruptions to the disease's variability, tensions in how much support to give, and adults' inability to fulfill parental obligations. Both groups expressed fears of patients' increasing age, declining health, and early death. Targeted counseling and resilience training is recommended.

Primary intensive care: pilot study of a primary care-based intervention for high-utilizing patients.

This pilot study was conducted to determine whether primary care patients with perceived inappropriate high healthcare utilization would require fewer emergency or inpatient services while enrolled in a weekly multidisciplinary clinic. Seventeen high-utilizing or difficult management patients of a primary care center were referred for the special intervention, Primary Intensive Care (PIC). Although not selected for the presence of psychopathology, 16 patients had comorbid psychiatric diagnoses. Patients followed in the PIC Clinic had significantly lower inpatient and emergency department use during their enrollment in the intervention when compared to the matched pre-enrollment time period, although the total hospital cost differences did not reach statistical significance. Patient and staff satisfaction was high, although the intervention was very difficult for the providers.

Sickle cell disease patients with and without extremely high hospital use: pain, opioids, and coping.

CONTEXT: Patients with sickle cell disease (SCD) and extremely high hospital use (EHHU) encounter significant challenges in pain management because of opioid medication use for pain and providers' concerns about addiction. OBJECTIVES: To characterize engagement with the health care system surrounding opioid pain management among SCD patients with EHHU by comparing their experiences with low-hospital-using (LHU) patients and their medical providers' perspectives. METHODS: One-on-one, semistructured qualitative interviews with patients and medical providers were audiotaped and transcribed. Participants were eight SCD patients with EHHU; matched by age, gender, and hemoglobinopathy type with eight SCD patients with low hospital use; and five providers identified by patients with EHHU as important to their care. A multidisciplinary team conducted chart review, created narrative summaries from the interviews, and used qualitative software to code transcripts based on themes. RESULTS: High-hospital-using patients and LHU patients had similar descriptions of their experience of pain and pain management with opioids. Patients and medical providers shared concerns about addiction. LHU patients described themselves as allies using specific interpersonal and symptom-related strategies, whereas high-hospital-using patients took a defensive and reactive stance toward their providers, who were similarly defensive about their care. CONCLUSION: The prescription of opioid medications for SCD pain management exacerbates issues of distrust in the patient-provider relationship. Such issues dominate patient care in patients with EHHU. Patients with EHHU and providers may learn from the proactive nature of LHU patients' engagement with the health care system as further research and interventions are designed for EHHU.

Workplace effectiveness and psychotherapy for mental, substance abuse, and subsyndromal conditions.

While it is known that psychiatric illness and subclinical psychiatric illness can be very disabling, their impact on workers' productivity has been little appreciated or appropriately addressed. Complex variables are involved in fashioning an appropriate policy to ameliorate the impact of mental illness on productivity including the identification of effective treatments and potential negative effects of controlling patients' access to them. The cost-effectiveness of such treatments is considered from the differing perspectives and goals of the various stakeholders involved, including employers, insurers, and workers with psychiatric illness. Depression in workers leads to significant absenteeism, "presenteeism" (diminished capacity due to illness while still present at work), and significantly increased medical expenses in addition to the costs of psychiatric care. In addition to the specific usefulness of psychotropic medication, there are a variety of studies on the cost-effectiveness of different psychotherapeutic treatments that improve health and productivity in psychiatrically ill workers. Research indicates the usefulness of approaches including employee assistance programs, specialized cognitive-behavioral treatments, and brief and longer term psychodynamic interventions. It is clear that substance abuse disorders and especially depression and subsyndromal depression have a profound negative effect on work productivity and increases in medical visits and expenses. The current system of mental health care suffers from ignorance of the negative effects of psychiatric illness in workers, from a lack of subtle awareness of which treatments are most appropriate for which diagnoses and from the reluctance by payers to invest in them. Access to evidence-based appropriate treatment can improve the negative impact on productivity as well as workers' health. This article considers these issues and argues for a role of psychotherapy in the treatment of mental illness and substance abuse from the perspective of worker productivity.

Important medical decisions: Using brief motivational interviewing to enhance patients' autonomous decision-making.

GOALS: The use of motivational interviewing (MI) when the goals of patient and physician are not aligned is examined. A clinical example is presented of a patient who, partly due to anxiety and fear, wants to opt out of further evaluation of his hematuria while the physician believes that the patient must follow up on the finding of hematuria. BACKGROUND: As patients struggle in making decisions about their medical care, physician interactions can become strained and medical care may become compromised. Physicians sometimes rely on their authority within the doctor-patient relationship to assist patients in making decisions. These methods may be ineffective when there is a conflict in motivations or goals, such as with patient ambivalence and resistance. Furthermore, the values of patient autonomy may conflict with the values of beneficence. METHOD: A patient simulation exercise is used to demonstrate the value of MI in addressing the motivations of a medical patient when autonomy is difficult to realize because of a high level of resistance to change due to fear. DISCUSSION: The salience of MI in supporting the value of patient autonomy without giving up the value of beneficence is discussed by providing a method of evaluating the patient's best interests by psychotherapeutically addressing his anxious, fear-based ambivalence.

Qualitative study of high-cost patients in an urban primary care centre.

OBJECTIVES: We examined patient accounts of illness and care among primary care patients whose medical services costs were high in order to illuminate factors associated with high cost. METHODS: Thirty-three primary care patients with multiple chronic illnesses in an urban clinic serving a resource poor neighbourhood were selected from a range of high medical cost patients. Participants were interviewed with open-ended questions to investigate experiences of illnesses and care; their responses were examined for prominent themes using qualitative analysis methodology. RESULTS: Patients sorted themselves into two categories based on the dominant focus of the roles of the care givers: one termed 'professional', in which the focus was on the competence and effectiveness of the care giver; and the second, 'personal', in which the focus was on the interpersonal relationship. DISCUSSION: We examine similarities with other recent studies, suggest factors influencing these two different types of relationships such as intensity of involvement in the healthcare system as well as personality characteristics, and explore the challenge for healthcare programme development. We also noted that these two ways of conceptualizing the doctor-patient relationship may have adaptive or maladaptive consequences depending on the match between physician and patient.

Effectiveness of peer support in reducing readmissions of persons with multiple psychiatric hospitalizations.

OBJECTIVE: The study examined the feasibility and effectiveness of using peer support to reduce recurrent psychiatric hospitalizations. METHODS: A randomized controlled design was used, with follow-up at nine months after an index discharge from an academically affiliated psychiatric hospital. Patients were 18 years or older with major mental illness and had been hospitalized three or more times in the prior 18 months. Seventy-four patients were recruited, randomly assigned to usual care (N=36) or to a peer mentor plus usual care (N=38), and assessed at nine months. RESULTS: Participants who were assigned a peer mentor had significantly fewer rehospitalizations (.89 ± 1.35 versus 1.53 ± 1.54; p=.042 [one-tailed]) and fewer hospital days (10.08 ± 17.31 versus 19.08 ± 21.63 days; p<.03, [one tailed]). CONCLUSIONS: Despite the study's limitations, findings suggest that use of peer mentors is a promising intervention for reducing recurrent psychiatric hospitalizations for patients at risk of readmission.

Cascading crises, resilience and social support within the onset and development of multiple chronic conditions.

OBJECTIVE: To describe and better understand adults' responses to the onset, accrual and influence of multiple chronic conditions and to social support in adapting to consequent difficulties. METHODS: Qualitative study of 33 adults with multiple chronic illnesses randomly sampled from an urban primary care clinic. Semi-structured interviews targeted retrospective accounts of illness onset, consequent loss, as well as current accounts of social support and adaptation. All interviews were audio-recorded, professionally transcribed and analysed according to established phenomenological procedures. RESULTS: Participants' responses revealed illness onset as a virtual cascade of medical, emotional and social hardships, leading to loss and subsequent adaptation through personal resilience and particularly, available social support. Participants also described patterns of adaptation punctuated by the felt need and rewards of providing care to others. DISCUSSION: The experience of multiple chronic illnesses has a distinct pattern of development and consequence, involving challenges to personal identity and the benefits of social support from and to others. Our results suggest that programmes addressing the needs of persons with multiple chronic conditions might tailor interventions in ways that maximally address their unique challenges.

Major depression and recent physical or sexual abuse increase readmissions among high-utilising primary care patients.

Objective To investigate whether current major depression and past physical/sexual victimisation is associated with recurrent general hospital admissions.Method Ninety-six inner-city primary care patients with a history of high medical service utilisation completed the PRIME-MD and the Abuse Assessment Screen; medical records were reviewed to assess reasons for re-hospitalisations. We compared hospitalisation rates over the preceding 12 months between those subjects with and without major depression and those with and without histories of abuse.Results Compared to non-abused subjects, patients with past-year abuse showed significantly increased past-year hospitalisations (3.2 versus 1.8, P = 0.007). Re-admissions were related to chronic disease management and were not because of acute physical effects of trauma. Analysis of variance revealed that major depressive disorder and past-year abuse history interacted to increase an association with re-admissions.Conclusions Past-year abuse was independently associated with increased hospital admissions. Psychological effects of recent abuse combined with depression may particularly increase rates of medical/surgical hospitalisations.