Care Transitions in the Psychiatric Hospital: Focus on Older Adults.

Patients undergoing a care transition are vulnerable to duplication of services, conflicting care recommendations, and errors in medication reconciliation. Older adults may be more vulnerable to care transitions given their relatively higher medical burden, cognitive impairment, and frequent polypharmacy. In this Treatment in Geriatric Mental Health: Research in Action article, we first present the results of a quality improvement study examining the frequency of care transitions to and from the medical hospital among patients admitted to a university-affiliated psychiatric hospital. Among a sample of 50 geriatric adults and 50 nongeriatric adults admitted to the psychiatric hospital, we tallied the number of care transitions to and from the medical hospital. We found that the geriatric cohort was significantly more likely to experience this type of care transition (p = 0.012, Fisher's exact test) compared to the nongeriatric cohort. In the second part of this article, we use a clinical vignette to illustrate the types of medical errors that can occur as a vulnerable and frail older adult moves between acute psychiatric and medical settings. Finally, we list provider-level and systems-level evidence-based recommendations for how care of the patient in the vignette could be improved. The quality improvement study and clinical vignette demonstrate how older adults are at greater risk for care transitions to and from the acute medical setting during psychiatric hospitalization, and that creative solutions are required to improve outcomes.

The association between mental health and cognitive screening scores in older veterans.

OBJECTIVES: : To examine overall cognitive screening results and the relationship between cognitive screen score and sociodemographic characteristics, reason for referral, and clinical outcomes of older veterans referred by primary care for a behavioral health assessment. DESIGN: : Cross-sectional, naturalistic study. SETTING: : Primary care clinics affiliated with two VA Medical Centers. PARTICIPANTS: : The sample included 4,325 older veterans referred to the Behavioral Health Laboratory who completed an initial mental health/substance abuse assessment. Veterans were categorized into the following three groups on the basis of cognitive status: within normal limits, possible cognitive impairment, and possible dementia. MEASUREMENTS: : Sociodemographic and clinical data on reason for referral, cognitive functioning (i.e., Blessed Orientation-Memory-Concentration test), and behavioral health assessment outcomes were extracted from patients' medical records. Data were analyzed using multiple linear and logistic regressions. RESULTS: : Results of cognitive screenings indicated that the majority of the sample was within normal limits (62.5%), with 25.8%, 8.1%, and 3.6% of patients evidencing possible cognitive impairment, possible dementia, and Blessed Orientation-Memory-Concentration scores of 17 or more, respectively. With regard to reason for referral, patients with greater cognitive impairment were more likely to be identified by the antidepressant case finder than patients with less impairment. Increased age, non-white ethnicity, self-perceived inadequate finances, major depressive disorder, and symptoms of psychosis were associated with greater cognitive impairment. CONCLUSIONS: : Findings highlight the importance of evaluating cognitive status in older adults who are referred for a behavioral health assessment and/or receive a new mental health/substance abuse diagnosis. Doing so has the potential to improve recognition and treatment of cognitive impairment and dementia, thereby improving quality of care for many older adults.

The Behavioral Health Laboratory: building a stronger foundation for the patient-centered medical home.

The Veterans Health Affairs is in the process of implementing a new model for the delivery of primary care: The Patient-Centered Medical Home (PCMH). One critical challenge of any PCMH model will be the integration of basic mental health treatment into primary care. Such a mental health integration program must be flexible enough to incorporate new evidence-based treatments as patient demographics and health care needs evolve over time. This paper summarizes the Behavioral Health Laboratory (BHL) care management model, a program already in place in more than 20 Veterans Affairs facilities along with private sector insurance providers, as ideally suited to fill this role in the PCMH. The BHL uses a platform of standardized, software-aided mental health assessments and clinical care managers to deliver evidence-based treatments for depression, anxiety, and substance abuse in primary care settings. The authors review this comprehensive program of screening, assessment, treatment, and referral to specialty care when needed. The BHL program is consistent with the guiding principles of the Patient-Centered Medical Home: applying chronic illness disease management principles to provide more continuous, coordinated, and efficient primary care services to patients with diverse needs. Just as importantly, the authors review how this standardized platform for delivering integrated mental health services provides the flexibility to incorporate novel interventions for a changing population.

Communicating suicide risk to families of chronically suicidal borderline personality disorder patients to mitigate malpractice risk.

OBJECTIVE: The distinction between acute and chronic suicidality is important, because interventions designed to address acute suicidality can worsen chronic suicidality, resulting in an escalating cycle of suicide threats, suicide attempts, and futile hospitalizations. Though most chronically suicidal borderline personality disorder patients improve and do not complete suicide, the potential for suicide contributes to these hospitalizations and a paucity of outpatient services due to treaters' concern over malpractice lawsuits in case of suicide. Communicating with patients' families about the suicide risk has been suggested as a means to mitigate this malpractice risk, but the approach to such communication has not been described. METHOD: Once chronic suicidality is identified, a stepwise approach to communicating with the patient's family is described. RESULTS: The potential benefits of this risk communication are described, for patients, families, treaters, healthcare systems, and health and malpractice insurers. CONCLUSION: It helps to develop an alliance with families and patients around a shared understanding of outcomes in chronic suicidality - most eventually do better, but the risk of completed suicide is real. This enables patients and families to make a more fully informed choice about treatment, which in turn can reduce litigation risk in the minority of cases where the patient completes suicide.

Post-hospitalization transitional care needs of depressed elderly patients: models for improvement.

PURPOSE OF REVIEW: In the weeks immediately following psychiatric hospital discharge, severely depressed elderly patients are at risk of 'falling through the cracks' in a complex health care system: becoming lost to follow-up, receiving inadequate care, or requiring prompt readmission. The purpose of this review is to highlight recent literature on the comorbid physical health problems and complex care needs of elderly patients hospitalized for depression. This paper will also review recent initiatives to improve the quality of care transitions for elderly patients discharged from medical hospitals that may be adaptable to a severely depressed population. RECENT FINDINGS: Due to shorter hospital stays, comorbid physical health problems, and limitations in functional capacity, severely depressed elderly patients discharged from psychiatric hospitals have complex service needs, and numerous barriers to care, immediately following hospital discharge. There is a lack of research specifically addressing the transitional care needs of this population. Improvement interventions assigning transitional care providers to chronically medically ill elderly patients immediately after medical hospital discharge have shown decreased rates of rehospitalization and emergency services utilization, and appear to be cost-effective. SUMMARY: Further research is needed to adapt successful transitional care interventions targeting chronically ill elderly patients in medical hospitals to severely depressed elderly patients being discharged from psychiatric hospitals.

A randomized comparison of high-charge right unilateral electroconvulsive therapy and bilateral electroconvulsive therapy in older depressed patients who failed to respond to 5 to 8 moderate-charge right unilateral treatments.

BACKGROUND: Electroconvulsive therapy (ECT) is the treatment of choice in some older patients with severe depression. When compared with younger depressed patients, older patients have been shown to be as likely to respond to ECT but more likely to develop cognitive impairment. This study addresses whether adults aged 50 years and over who have already failed to respond to at least 5 moderate-charge right unilateral (RUL) ECT treatments (150% above seizure threshold) are more likely to benefit from a switch to high-charge RUL ECT (450% above threshold) or to bilateral (BL) ECT. METHOD: Twenty-four patients who were treated with 5 to 8 moderate-charge RUL ECT treatments and who failed to improve sufficiently were randomly assigned to receive either BL ECT (N = 11) or high-charge RUL ECT (N = 13). Depressive (24-item Hamilton Rating Scale for Depression) and cognitive scores (Mini-Mental State Examination [MMSE]) were compared under double-blind conditions at 3 phases of treatment. RESULTS: Patients in the BL ECT group exhibited significantly greater cognitive impairment (mean MMSE score decrease of 1.13) than those receiving high-charge RUL ECT (mean MMSE increase of 1.71). There were no statistically significant differences in clinical response to BL or high-charge RUL ECT (63.6% and 61.5%, respectively) or in depressive symptom remission (18.1% and 46.2%). CONCLUSION: These results suggest that older patients who fail to respond to moderate-charge RUL ECT may benefit from a switch to high-charge RUL ECT rather than BL ECT. Larger future studies will be needed to compare clinical response in patients switched from moderate-dose RUL ECT to higher-dose RUL or to BL ECT.

Wind tunnel studies on spray deposition on leaves of tree species used for windbreaks and exposure of honey bees.

A wind tunnel study was conducted to determine pesticide deposition on commonly used windbreak tree species used as spray drift barriers and associated exposure of honey bees. Although it has been known that windbreaks are effective in reducing chemical drift from agricultural applications, there is still an enormous information and data gap on details of the dependence of the mechanism on the biological materials of the barriers and on standardization of relevant assessment methods. Beneficial arthropods like honey bees are adversely affected by airborne drift of pesticides. A study was initiated by first establishing a wind tunnel to create a controlled environment for capture efficiency work. Suitable spray parameters were determined after a preliminary study to construct and develop a wind tunnel protocol. A tracer dye solution was sprayed onto the windbreak samples and honey bees located in the wind tunnel at various simulated wind speeds. Analysis of data from this work has shown that needle-like foliage of windbreak trees captures two to four times more spray than broad-leaves. In addition, it was determined that, at lower wind speeds, flying bees tend to capture slightly more spray than bees at rest.

Psychiatric status and work performance of veterans of Operations Enduring Freedom and Iraqi Freedom.

OBJECTIVE: This cross-sectional study investigated the relationship between psychiatric diagnosis and impaired work functioning among American service members returning from Operation Iraqi Freedom-Operation Enduring Freedom (OEF-OIF). METHODS: Participants were 797 OEF-OIF veterans, of whom 473 were employed. They were referred for further psychiatric assessment by primary care providers at six Veterans Affairs medical centers and underwent a behavioral health interview that assessed psychiatric and health status and work impairment as measured by the Work Limitations Questionnaire (WLQ). The four WLQ subscales (mental-interpersonal demands, time management, output, and physical demands) and an aggregated measure of productivity loss were considered in the analysis. Associations between patient characteristics, psychiatric status, and work impairments were investigated with regression models. RESULTS: Major depressive disorder, posttraumatic stress disorder, and generalized anxiety or panic disorder were significantly associated with impairments in mental-interpersonal demands, time management, and output. Alcohol dependence and illicit drug use were associated with impairments in output and physical demands. On average these productivity losses were four times those found in a previous study of nonveteran employees with no psychiatric disorders. CONCLUSIONS: Veterans' ability to maintain gainful employment is a major component of successful reintegration into civilian life, and psychiatric disorders have a negative impact on work performance. This study demonstrated that multiple dimensions of job performance are impaired by psychiatric illness among OEF-OIF veterans. Delivery of empirically supported interventions to treat psychiatric disorders and development of care models that focus on work-specific interventions are needed to help veterans return to civilian life.

Differences in treatment attitudes between depressed African-American and Caucasian veterans in primary care.

OBJECTIVES: Depressive disorders are common, and it is important to understand the factors that contribute to racial disparities in depression treatment. This primary care study of veterans with subsyndromal depression examined two hypotheses: that African Americans would be less likely than Caucasians to believe that medication is beneficial in depression treatment and would be more likely to believe that counseling or psychotherapy is beneficial. METHODS: Primary care patients with subsyndromal depression were referred to the Philadelphia Department of Veterans Affairs Behavioral Health Laboratory and asked about past experiences and attitudes toward depression treatment. RESULTS: Among 111 African-American and 95 Caucasian participants, logistic regression analyses determined that African Americans were less likely to view medication as beneficial (odds ratio=.44). No racial differences were found in participants' attitude toward counseling or psychotherapy. CONCLUSIONS: The findings support the premise that clinicians treating patients with subsyndromal depressive syndromes should take into account racial differences in attitudes toward treatment.

Relapse during continuation pharmacotherapy after acute response to ECT: a comparison of usual care versus protocolized treatment.

BACKGROUND: ECT, an effective treatment for major depression, is associated with a high relapse rate. Roughly half of all responders during the acute treatment phase relapse during continuation treatment. Recent literature has pointed out an "efficacy-effectiveness gap" in outcomes of patients enrolled in study protocols when compared to "care as usual." This study compares the effectiveness of usual care versus protocolized pharmacotherapy in preventing relapse following ECT. METHODS: One hundred twenty-six depressed patients responded to acute ECT. Seventy-three were randomized to continuation pharmacotherapy consisting of nortriptyline, nortriptyline-plus-lithium, or placebo. The 53 patients that refused to participate in the randomized trial were followed naturalistically for 6 months or until depression relapse in usual care settings. RESULTS: All but one "usual care" patient received pharmacotherapy following ECT; 27 (51%) relapsed within 6 months. Only one usual care patient received continuation ECT as a first-line treatment. The "usual care" relapse rate was intermediate to the relapse rates of the patients receiving protocolized nortriptyline (60%) and nortriptyline-plus-lithium (39%), but superior to placebo (84%). CONCLUSIONS: The relapse rate associated with usual care following ECT was comparable to that of protocolized pharmacotherapy. This suggests that high relapse rates following ECT are not due solely to an "efficacy-effectiveness gap."

A developmental model for enhancing research training during psychiatry residency.

OBJECTIVE: The authors describe a developmental model for enhancing residency research training for careers in academic psychiatry. Over the past 10 years, the University of Pittsburgh Department of Psychiatry has developed a research track (RT) for its residents. While the Department's plan has been to address the critical need of training physician-scientists in psychiatry, the RT continues to evolve as a structured extension of the University's residency-training program. Recently, the University's departmental leadership has taken several steps that address regulatory, institutional, and personal barriers to residency research training put forth by the 2003 Institute of Medicine (IOM) report. METHODS: The authors outline a model of residency research training, elements of which should be exportable to the majority of U.S. psychiatry residency programs. RESULTS: For residents in the RT, up to 50% of time in PGY-3 and up to 75% of time in PGY-4 can be devoted to research-related activities. The authors currently have 13 residents and fellows in their track. Over the past 10 years, 15 of 33 RT residents have become research postdocs or full-time grant-funded researchers in academic positions. CONCLUSION: The authors' experience suggests that it is possible to organize and implement an RT during psychiatry residency within the parameters presented by the Psychiatry Residency Review Committee (RRC).

Impact of prior treatment exposure on response to antidepressant treatment in late life.

OBJECTIVE: The objective of this study was to describe the correlates of prior antidepressant exposure and its association with response to protocolized treatment in older patients with major depression. METHODS: Based on their prior antidepressant treatment exposure, 193 elderly patients with a major depressive episode were divided into three groups: those with no prior treatment for their current episode (not treated [TN]), those with antidepressant trials of inadequate dose or duration ("treatment-inadequate" [TI]), and those with at least one adequate trial but persisting depression ("treatment-resistant" [TR]). All patients then received protocolized treatment with interpersonal psychotherapy (IPT) and paroxetine plus pharmacologic augmentation if needed. The demographic, clinical, and outcome information were compared among these three groups. RESULTS: Approximately one-third of the patients referred to the study had been adequately treated (TR), one-third had been inadequately treated (TI), and one-third were not treated for the current episode (TN). Treatment completion rates and reasons for dropping out did not differ statistically among TR, TI, and TN patients. TR patients took longer to respond (13.0 weeks) than either TI or TN patients (7.6 and 8.0 weeks, respectively). TR and TI patients had lower response rates (67% and 71%) than TN patients (86%). CONCLUSIONS: Prior treatment exposure is an important correlate of course and outcome in late-life depression. Most TR and TI patients eventually respond, but TR patients may require more intensive and longer courses of treatment than TI and TN patients.

Psychiatric comorbidity: is more less?

With each successive revision of the DSM and ICD, psychiatric comorbidity has become more prevalent. The 'atheoretical' approaches of the DSM and ICD explicitly encourage multiple diagnoses with few exclusionary hierarchies, in the hope that all clinically relevant information will be captured. However, the current strategy of diagnosing 'maximal' comorbidity may not reflect 'optimal' comorbidity. Many clinicians and health information systems, particularly those in developing countries, have a limited capacity for capturing this diagnostic information, and fail to characterize additional diagnoses that are present. This article will address the evolution of our current diagnostic system as a way of understanding the emergence of comorbid psychiatric diagnoses. Alternative diagnostic approaches (a dimensional system, diagnostic hierarchies, and mixed diagnostic categories) that could be used to address the emergence of comorbid psychiatric diagnoses are considered. Future challenges for the next evolution of DSM and ICD are presented.