RESUMO
BACKGROUND: Depression causes significant morbidity, which impacts mental health, overall general health outcomes, everyday functioning and quality of life. This study aims to contribute to knowledge in the field through enhanced understanding of factors that influence depression response and remission, with consideration for design of treatment services to optimize depression outcomes within integrated care programs. METHODS: Using routine behavioral health screening and electronic health record data, we identified a retrospective cohort consisting of 615 adult patients receiving depression treatment within an integrated care program. Cohort member Patient Health Questionnaire (PHQ-9) data was analyzed for the 6 months following initiation of treatment. Multinomial regression models were estimated to identify factors associated with depression treatment response (PHQ-9 < 10) and remission (PHQ-9 < 5). RESULTS: At 6 months, 47% of patients demonstrated treatment response and 16% demonstrated remission. Baseline trauma symptoms and suicidal ideation were significantly associated with decreased odds of achieving remission (Odds Ratio (95% CI) [OR] = 0.45 (0.23, 0.88) and OR = 0.49 (0.29, 0.82), respectively). In fully adjusted models, baseline suicidal ideation remained significant (OR = 0.53 (0.31, 0.89)) and some evidence of an association persisted for baseline trauma symptoms (OR = 0.51 (0.25, 1.01)). CONCLUSIONS: After controlling for baseline depression symptoms, the presence of suicidal ideation is associated with reduced likelihood of remission. Increased understanding of factors associated with depression treatment outcomes may be employed to help guide the delivery and design of clinical services. Alongside routine screening for co-morbid anxiety, suicidal ideation and traumatic stress should be assessed and considered when designing depression treatment services.
Assuntos
Prestação Integrada de Cuidados de Saúde , Depressão , Adulto , Depressão/epidemiologia , Depressão/terapia , Humanos , Qualidade de Vida , Estudos Retrospectivos , Ideação SuicidaRESUMO
BACKGROUND: Anti-N-methyl-d-aspartate receptor (anti-NMDAR) encephalitis was formally described in 2007 and includes a range of psychiatric and neurologic symptoms. Most patients with anti-NMDAR encephalitis initially present to psychiatrists for diagnosis and treatment. However, there is limited literature summarizing treatment strategies for psychiatric symptoms. In an effort to improve identification and treatment, this review article provides an overview of anti-NMDAR encephalitis, with a focus on psychopharmacologic treatment strategies. Two case reports provide a clinical context for the literature review. METHODS: The authors conducted a PubMed search. RESULTS: Prominent psychiatric symptoms of anti-NMDAR encephalitis include psychosis, agitation, insomnia, and catatonia. Neuroleptics may be helpful for managing psychosis and agitation, but may exacerbate movement abnormalities. Diphenhydramine and benzodiazepines are helpful for agitation and insomnia. In addition, the anticholinergic affinity of diphenhydramine can improve dystonia or rigidity attributable to anti-NMDAR encephalitis, while benzodiazepines and electroconvulsive therapy have been used for catatonia associated with this condition. CONCLUSIONS: Psychiatrists play an important role in the diagnosis and treatment of anti-NMDAR encephalitis. Recognizing the typical clinical progression and closely monitoring for accompanying neurologic symptoms will facilitate diagnosis and timely treatment. Careful selection of psychopharmacological interventions may reduce suffering.
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Encefalite Antirreceptor de N-Metil-D-Aspartato , Encefalite Antirreceptor de N-Metil-D-Aspartato/diagnóstico , Encefalite Antirreceptor de N-Metil-D-Aspartato/tratamento farmacológico , Encefalite Antirreceptor de N-Metil-D-Aspartato/fisiopatologia , HumanosRESUMO
Youth today are burdened by significant mental health challenges. In 2022, 25% of adolescents aged 12 to 17 years experienced a mental illness, with 20% experiencing a depressive episode, 12.5% reporting serious thoughts of suicide, and 17% meeting criteria for a substance use disorder.1 Close to 5% of adolescents experience posttraumatic stress disorder.2 Impairing psychiatric symptoms remain present in upwards of 40% of adolescents after receiving existing mental health services,3 so it is necessary to identify additional and more effective treatment options. We propose there is an acceptable benefit-to-risk calculation that supports trialing classic serotonergic psychedelics (eg, psilocybin) and phenethylamine compounds with empathogenic and entactogenic range of effects (eg, 3,4-methylenedioxymethamphetamine [MDMA]) in combination with psychotherapy among select adolescents aged 16 to 17 years. Specifically, we propose testing these treatments among adolescents aged 16 to 17 years who are experiencing treatment-resistant manifestations of psychiatric disorders (ie, multiple failed trials of current evidence-based treatments) or psychiatric disorders that are in line with the current evidence base for adults as determined, for example, by the breakthrough designation of the US Food and Drug Administration for a particular psychedelic medicine (eg, psilocybin for major depressive disorder, MDMA for posttraumatic stress disorder).
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Contratos , Emprego , Negociação , Psiquiatria/educação , Humanos , Gestão de Recursos Humanos , Salários e BenefíciosRESUMO
Barriers to conducting standardized behavioral health screening within pediatric primary care settings include engaging youth and families, limited time available for this activity, and difficulties related to obtaining behavioral health consultation and treatment from specialists. Child and adolescent psychiatrists may assist pediatric primary care practices with engaging youth and families around screening by assisting with identifying rating scales that have good psychometric characteristics across multiple languages and are validated in diverse samples and available within the public domain. Additionally, they may partner with pediatric primary care professionals to assist with optimizing screening workflows and linkage to specialized services.
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Atenção Primária à Saúde , Psiquiatria , Adolescente , Criança , Humanos , Programas de Rastreamento , Encaminhamento e ConsultaRESUMO
Access to mental health care is a long-standing challenge. The high, rising prevalence of mental health disorders and a shortage of mental health professionals has further strained an already fragile system. The clinical pharmacy is underutilized within the mental health space. Interdisciplinary collaboration between child psychiatrists and mental health pharmacists gives the psychiatrist more time for patient evaluation and treatment, while the psychiatric pharmacist provides drug monitoring, medication coordination, and education for providers. This collaborative approach improves outcomes, prevents adverse drug events, reduces hospital stays, lessens emergency department visits, and improves engagement and adherence.
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Efeitos Colaterais e Reações Adversas Relacionados a Medicamentos , Psiquiatria , Adolescente , Criança , Humanos , Saúde Mental , Farmacêuticos , Resultado do TratamentoRESUMO
The unmet behavioral health treatment needs of children and adolescents have become a public health crisis in the United States, with only 20% of youths obtaining assessment and intervention when indicated. Workforce shortages, including mental health professionals who can provide pharmacologic intervention within an appropriate biopsychosocial context, directly impede our ability to address this crisis. The authors examine the history, education, regulation, and practice of advanced practice psychiatric nurses and consider models of collaborative practice that can be beneficial across treatment settings in order to provide better care of vulnerable youth in ways that foster partnership rather than competition.
Assuntos
Prática Avançada de Enfermagem , Enfermeiras e Enfermeiros , Enfermagem Psiquiátrica , Psiquiatria , Adolescente , Criança , Humanos , Estados UnidosRESUMO
BACKGROUND: Given the high rates at which patients present with behavioural health (BH) concerns in primary care (PC), this setting has become the de facto mental health system. As a result, screening for depression and other BH conditions in PC has become a critical target for improving patient outcomes. However, integration of screening into busy PC workflows can be challenging due to barriers such as limited time and resources. METHODOLOGY: A digital, cloud-based BH assessment tool, which included electronic health record enhancements, was developed and implemented in two urban PC practices as a prelude to a planned larger-scale implementation. The implementation strategies included a reorganisation of workflows within the PC setting, comprehensive training for staff and PC physicians, and institution of an incentive programme for PC clinic managers. To examine whether the introduction of the cloud-based BH assessment tool and associated implementation strategies was associated with increased screening rates, we compared rates of screening from January through June 2017 to rates of screening from January through June 2018 (subsequent to implementation). We also examined BH symptomatology reported by patients in PC. RESULTS: Following the implementation process, rate of BH screening with Patient Health Questionnaire-2 (PHQ-2) increased from 50.5% to 57% (p<0.00000000000000022) and rates of subsequent screening with PHQ-9, for those scoring at risk, defined as a score of ≥1, on PHQ-2, increased from 34.5% to 91.4% (p<0.00000000000000022). Additionally, high rates of 'moderate' and 'severe' symptoms of depression (40.3%), anxiety (42.6%) and substance use (26.7% alcohol; 31.2% other substance use) were observed among PC patients. CONCLUSIONS: Results suggest that a comprehensive implementation plan, including digitisation of BH assessment, reduced the burden of systematic screening. High rates of BH symptomatology underscore the need for comprehensive BH assessment and systems planning to address the high need for BH services among PC patients.
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Depressão , Atenção Primária à Saúde , Depressão/diagnóstico , Depressão/epidemiologia , Humanos , Internet , Programas de Rastreamento , TecnologiaRESUMO
INTRODUCTION: Disorders of orgasm in women, defined as the persistent or recurrent delay in or absence of orgasm, affect up to a quarter of the female population. AIM: To review existing research findings on the etiology and treatments of disorders of orgasm in women to provide a useful reference tool for clinicians who evaluate and treat patients with these conditions. METHODS: PubMed and PsycINFO search for articles published between 1980 and 2009 using the keywords "orgasm*,""anorgasmia," and "female*,""woman," or "women," in addition to "female orgasmic disorder" and "disorders of orgasm in women." MAIN OUTCOME MEASURES: Findings on the etiological factors and effects of a variety of treatment interventions on improving disorders of orgasm in women. Results. Literature on prevalence and causes of disorders of orgasm in women is abundant, yet more reports of successful treatments are needed. Nevertheless, many promising approaches have been suggested, and data support several potential treatments such as bupropion, sildenafil, estrogen, and testosterone among others. CONCLUSIONS: Although more research is needed to better understand and manage disorders of orgasm in women, significant progress is being made.
Assuntos
Orgasmo , Disfunções Sexuais Fisiológicas/etiologia , Disfunções Sexuais Psicogênicas/etiologia , Feminino , Humanos , Menopausa/fisiologia , Menopausa/psicologia , Orgasmo/fisiologia , Prevalência , Psicologia , Disfunções Sexuais Fisiológicas/tratamento farmacológico , Disfunções Sexuais Fisiológicas/epidemiologia , Disfunções Sexuais Fisiológicas/terapia , Disfunções Sexuais Psicogênicas/tratamento farmacológico , Disfunções Sexuais Psicogênicas/epidemiologia , Disfunções Sexuais Psicogênicas/terapia , Estados Unidos/epidemiologiaRESUMO
Measurement-based care (MBC) is recognized as a valuable component to maximize quality in psychiatric care; however, actual use of MBC by practitioners is poor. A host of implementation barriers have been noted, and are likely significant contributors to this poor adoption. Many of these barriers are related to work-flow issues that can be managed or mitigated by appropriate infrastructure considerations. This article offers an overview of the continuum of infrastructures to support MBC in clinical practice, delineating the tradeoffs between these infrastructures, and then identifying specific experience-based strategies for addressing several major patient-, provider-, and organization-level barriers to MBC implementation.
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Implementação de Plano de Saúde , Serviços de Saúde Mental/normas , Medidas de Resultados Relatados pelo Paciente , Humanos , Fluxo de TrabalhoRESUMO
Measurement-based care involves the practice of systematically administrating rating scales to patients in order to use the collected information to enhance clinical evaluation, monitor treatment progress, and directly inform decisions relating to each patient's treatment. Rating scales must be psychometrically validated and efficiently administered within the practice setting. Brief rating scales that are available within the public domain may help to optimize workflows and prevent response fatigue. Clinicians should also have a sufficient understanding of the underlying psychometric properties of rating scales to accurately interpret changes in scores over time and use these results to appropriately direct care.
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Psiquiatria do Adolescente , Psiquiatria Infantil , Escalas de Graduação Psiquiátrica , Psicometria/normas , Adolescente , Criança , Humanos , AutorrelatoRESUMO
Quality of life (QOL) is greatly diminished in patients with major depressive disorder (MDD) before treatment. This deficit persists even when patients are in remission; thus, interventions are needed to improve QOL. This article reviews QOL impairment in MDD and the cost of impairment, then summarizes the empiric literature on the effects of dopaminergic agents on QOL in patients with MDD. Studies were identified through a MEDLINE search from the past 35 years (1974-2009) using key terms "quality of life," "major depression," and "major depressive disorder," and "dopaminergic," "bupropion," or "modafinil." A total of 47 studies were included in this review. A brief overview of the relationship between QOL and MDD is presented, followed by a review of dopaminergic agent chemistry, mechanism of action, use, and trials conducted to investigate agents' effects on QOL. Preliminary evidence suggests dopaminergic agents may have a positive effect on QOL for patients with MDD. Prospective, randomized, double-blind, placebo-controlled studies are needed to extend these findings.
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Compostos Benzidrílicos/uso terapêutico , Bupropiona/uso terapêutico , Transtorno Depressivo Maior/tratamento farmacológico , Qualidade de Vida/psicologia , Estimulantes do Sistema Nervoso Central/uso terapêutico , Transtorno Depressivo Maior/psicologia , Inibidores da Captação de Dopamina/uso terapêutico , Humanos , Modafinila , Ensaios Clínicos Controlados Aleatórios como Assunto , Recidiva , AutoimagemRESUMO
OBJECTIVE: To assess the benefits of adenotonsillectomy in the treatment of pediatric patients with PFAPA (periodic fever, aphthous ulcers, pharyngitis, and adenitis) syndrome. DESIGN: Prospective case series. SETTING: Tertiary care pediatric hospital. PATIENTS: Pediatric patients meeting criteria for PFAPA syndrome. INTERVENTION: Tonsillectomy with or without adenoidectomy. MAIN OUTCOME MEASURE: Resolution of PFAPA symptoms. RESULTS: Twenty-seven (14 female, 13 male) children with PFAPA syndrome underwent tonsillectomy with or without adenoidectomy from 2004 through 2006. The length of follow-up for all patients ranged from 8 to 41 months. A total of 26 patients experienced a complete resolution of their symptoms. The 1 child who continued to have febrile episodes had fever cycles that were not regular in duration or interval and in hindsight was not likely a patient with PFAPA syndrome. CONCLUSIONS: Our findings showed complete resolution of symptoms in 26 of 27 patients with PFAPA syndrome treated surgically. Patients who meet clinical criteria for PFAPA syndrome should be considered for tonsillectomy and adenoidectomy if they do not respond to medical management.
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Tonsila Faríngea/cirurgia , Linfadenite/cirurgia , Faringite/cirurgia , Estomatite Aftosa/cirurgia , Tonsilectomia , Adolescente , Criança , Pré-Escolar , Feminino , Humanos , Lactente , Masculino , Periodicidade , SíndromeRESUMO
Efficient response to health care needs when clinical resources are limited is a critical issue in health care delivery. Technologies such as telemedicine hold promise to support adaptive service delivery models to address these issues. The authors explore how a simple, low-tech approach to telemedicine paired with an on-demand staffing model to create a virtual pool of consultants may improve capacity and flexibility for providing inpatient consultation-liaison psychiatric services.
Assuntos
Pacientes Internados , Transtornos Mentais/terapia , Recursos Humanos de Enfermagem Hospitalar/organização & administração , Psiquiatria/organização & administração , Centros de Cuidados de Saúde Secundários , Telemedicina/organização & administração , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Pacientes Internados/estatística & dados numéricos , Los Angeles , Masculino , Pessoa de Meia-Idade , Recursos Humanos de Enfermagem Hospitalar/estatística & dados numéricos , Psiquiatria/estatística & dados numéricos , Consulta Remota/organização & administração , Consulta Remota/estatística & dados numéricos , Centros de Cuidados de Saúde Secundários/estatística & dados numéricos , Telemedicina/estatística & dados numéricos , Adulto JovemRESUMO
OBJECTIVE: This study's objective is to determine if there is an association between rates of violence and rates of childhood asthma in Los Angeles County communities. METHODS: Rates of hospitalization for assault and for asthma were calculated for each ZIP Code and city in Los Angeles County. Linear regression was used to determine the effect of assault rates on asthma rates while controlling for potential confounders such as poverty and racial/ethnic distribution. At the city level, crime rates were included in the model as additional measures of community violence. RESULTS: Hospitalization rates for childhood asthma and assaults were significantly correlated at both the city (r = 0.80) and the ZIP Code (r = 0.54) levels. The association remained significant when controlling for poverty and racial/ethnic distribution with linear regression (p < 0.0001). At the city level, the variables measuring the crime rate were not significant predictors of asthma hospitalizations. CONCLUSIONS: Community violence as measured by the rate of assault hospi; talizations is associated with childhood asthma in Los Angeles County. Health care providers should consider their asthmatic patients' social environments when devising treatment plans.
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Asma/epidemiologia , Violência/tendências , Adolescente , Adulto , Idoso , Criança , Hospitalização , Humanos , Los Angeles/epidemiologia , Pessoa de Meia-IdadeRESUMO
Patients with behavioral health disorders often have worse health outcomes and have higher health care utilization than patients with medical diseases alone. As such, people with behavioral health conditions are important populations for accountable care organizations (ACOs) seeking to improve the efficiency of their delivery systems. However, ACOs have historically faced numerous barriers in implementing behavioral health population-based programs, including acquiring reimbursement, recruiting providers, and integrating new services. We developed an evidence-based, all-payer collaborative care program called Behavioral Health Associates (BHA), operated as part of UCLA Health, an integrated academic medical center. Building BHA required several innovations, which included using our enterprise electronic medical record for behavioral health referrals and documentation; registering BHA providers with insurance plans' mental health carve-out products; and embedding BHA providers in primary care practices throughout the UCLA Health system. Since 2012 BHA has more than tripled the number of patients receiving behavioral health services through UCLA Health. After receiving BHA treatment, patients had a 13 percent reduction in emergency department use. Our efforts can serve as a model for other ACOs seeking to integrate behavioral health care into routine practice.
Assuntos
Organizações de Assistência Responsáveis/organização & administração , Serviço Hospitalar de Emergência/estatística & dados numéricos , Acessibilidade aos Serviços de Saúde/organização & administração , Transtornos Mentais/terapia , Avaliação de Resultados em Cuidados de Saúde , Centros Médicos Acadêmicos , Adulto , Idoso , Bases de Dados Factuais , Feminino , Humanos , Masculino , Transtornos Mentais/diagnóstico , Transtornos Mentais/economia , Serviços de Saúde Mental/organização & administração , Pessoa de Meia-Idade , Desenvolvimento de Programas , Avaliação de Programas e Projetos de Saúde , Estudos Retrospectivos , Estados UnidosRESUMO
This resident physician-led quality improvement project was conducted with aims to improve the health of youth prescribed atypical antipsychotic medications by increasing physician monitoring for metabolic side effects, while simultaneously educating trainees in quality improvement methodology. The plan, do, study, act quality improvement framework was utilized. Baseline metabolic monitoring rates of patients prescribed atypical antipsychotic medications in the two psychiatry resident outpatient clinics were obtained. Rates were stratified based on time on medication (<1 year, ≥1 year) and parameter monitored. Metabolic monitoring rates subsequent to targeted changes were obtained. Problem solving with residents revealed barriers to monitoring, such as limited awareness of specific guideline recommendations and lack of convenient access to medical equipment (calibrated scales). Residents received education about atypical antipsychotic monitoring guidelines and side effect treatment. Residents were provided with calibrated scales. Atypical antipsychotic monitoring templates were introduced. Online surveys using were conducted to determine self-reported baseline-monitoring rates and comfort with guidelines following targeted change. The baseline metabolic monitoring rates of patients prescribed atypical antipsychotic medications was 9% (range: 0 to 17.6%) for youth in their first year taking an atypical antipsychotic medication and 58.9% (range: 29% to 100%) in subsequent years on medication. The results of relatively easy changes resulted in modest improvement in monitoring rates. The metabolic monitoring rate of a patient initiated on an atypical antipsychotic medication was 29% after targeted quality improvement measures were employed. Following quality improvement changes, residents reported increased knowledge about guidelines and increased monitoring for side effects. Use of a standardized data collection instrument to track monitoring of patients increased from 0% to 70% (range: 30% to 90%). Quality improvement projects provide an avenue with which to improve atypical antipsychotic monitoring rates. Through active participation in quality improvement projects, psychiatry residents may be taught to employ quality improvement methodology.