Search

People with serious mental illness (SMI) face a striking mortality disparity of 10 to 28 years as compared to the general population, largely attributable to chronic and preventable disease. In this article, we highlight a few practical steps that individual psychiatrists can take to implement recommended screening, monitoring, and treatment strategies for metabolic risk parameters as well as guidance for promoting tobacco cessation. We introduce several selected multicomponent behavioral interventions with demonstrated effectiveness for obesity and diabetes in this population. The article closes with a brief overview of organizational models for collaborative care and reverse integrated care, which aim to improve health outcomes for those with SMI through a team-based approach to medical and psychiatric care—such models may be considered by service providers at the institutional level. [ Psychiatr Ann . 2021;51(6):261–265.]

How to determine if your patient should continue an LAI, and how to do so safely

Diagnosing schizoaffective disorder poses unique challenges due to both its history as a “catch-all” diagnosis and recent changes to the diagnostic criteria. The Diagnostic and Statistical Manual of Mental Disorder s, fifth edition, helps to clarify the diagnosis, but issues related to validity and reliability remain. The fundamental approach to diagnosis must be done positively (as opposed to being a diagnosis of exclusion), looking at each feature of a patient's presentation and ensuring that criteria for schizoaffective disorder are met, without symptoms being better explained by a phenomenologically similar yet different psychiatric conditions (and assuming that no medical or toxic condition is responsible). This article presents a straightforward approach to generating and critically assessing a differential diagnosis when schizoaffective disorder is suspected. [ Psychiatr Ann . 2020;50(5):195–199.]

Rigorous studies of treatment efficacy in schizoaffective disorder have been limited by the diagnosis' low diagnostic validity and reliability; thus, no current consensus treatment guidelines exist. Given this limitation, the authors recommend using available data from clinical trials in the mood disorder and psychosis literature to guide clinical practice. Antipsychotic treatment remains the mainstay of pharmacotherapy for illnesses on the schizophrenia spectrum, which includes schizoaffective disorder, both the depressive and bipolar subtypes. For patients with schizoaffective disorder, depressive type, treatment with combination antipsychotic and antidepressant therapy is a reasonable therapeutic starting point. For patients with schizoaffective disorder, bipolar type, antidepressant therapy may be less helpful. Instead, mood stabilizers may be an important component of treatment for people with schizoaffective disorder, bipolar type, particularly if there is irritability or aggression; some mood stabilizers, particularly lithium, may be effective in treating the depressive subtype as well. [ Psychiatr Ann . 2020;50(5):200–204.]

Objective To examine the role of race, sex, arrest history, and psychiatric diagnoses in duration of shelter tenure and housing outcomes for patients in transitional shelters. Methods The authors performed a three-year retrospective chart review of Massachusetts Department of Mental Health (DMH) records for individuals residing in three DMH transitional homeless shelters from 2013 to 2015. Results Race was not predictive of length of stay, initial disposition, or housing status at three to five-year follow-up. Arrest history negatively predicted initial housing placement, and diagnosis of substance use disorder predicted homelessness at follow-up. There were no differences by race in arrest history or diagnosis of substance use disorder. Conclusions Race was not a factor in duration of shelter tenure, or in securing or maintaining housing following shelter stay. Arrest history and lifetime substance use disorder were associated with more negative outcomes following transitional shelter stay.

Tobacco use and resultant health complications disproportionately impact individuals with psychiatric disorders. Inpatient psychiatric hospitalizations provide an opportunity to initiate tobacco treatment. In this study, electronic medical record review identified demographic and clinical information, smoking status, and tobacco cessation treatment offered for adults hospitalized on two acute, non-smoking psychiatric units in Massachusetts from January 2016 to March 2018. We additionally conducted semi-structured interviews with 15 inpatient nursing, psychiatry, psychology and social work providers regarding their tobacco cessation treatment practices and perceived facilitators and barriers to addressing tobacco use on psychiatric inpatient units. Chart review identified 1099 of 3140 (35%) people admitted reporting daily tobacco smoking. On discharge, 5 (0.005%) of inpatient smokers received a prescription for varenicline, 43 (0.04%) for dual-nicotine replacement therapy, 211 (19.2%) for nicotine patch, and 5 (0.005%) for bupropion. Barriers to inpatient smoking cessation treatment initiation identified in qualitative interviews included: 1) smoking cessation as low priority, 2) smoking cessation as the responsibility of outpatient providers, 3) lack of education about tobacco treatment, and 4) treatment discussions framed as preventing withdrawal. Given the potential to impact a large percentage of psychiatric tobacco users, future interventions should investigate provision of tobacco cessation counseling and pharmacotherapy in inpatient settings, with interventions that take into account the barriers and opportunities presented in this study.

Background In a previous study, participation in a 16-week reverse integrated care and group behavioral and educational intervention for individuals with diabetes and serious mental illness was associated with improved glycemic control (hemoglobin A1c) and BMI. To inform future implementation efforts, more information about the effective components of the intervention is needed. Objective The goal of this study is to identify the aspects of the intervention participants reported to be helpful and to evaluate the predictors of outcomes. Methods This study involved qualitative evaluation and post hoc quantitative analysis of a previous intervention. Qualitative data were collected using semistructured interviews with 69% (24/35) of the individuals who attended 1 or more group sessions and 35% (9/26) of the individuals who consented but attended no sessions. Quantitative mixed effects modeling was performed to test whether improved diabetes knowledge, diet, and exercise or higher group attendance predicted improved hemoglobin A1c and BMI. These interview and modeling outcomes were combined using a mixed methods case study framework and integrated thematically. Results In qualitative interviews, participants identified the application of health-related knowledge gained to real-world situations, accountability for goals, positive reinforcement and group support, and increased confidence in prioritizing health goals as factors contributing to the success of the behavioral intervention. Improved knowledge of diabetes was associated with reduced BMI (β=–1.27, SD 0.40; P=.003). No quantitative variables examined were significantly associated with improved hemoglobin A1c levels. Conclusions In this mixed methods analysis of predictors of success in a behavioral diabetes management program, group participants highlighted the value of positive reinforcement and group support, accountability for goals set, and real-world application of health-related knowledge gained. Improved diabetes knowledge was associated with weight loss.

The authors appreciate the comments of Dr. Corbin and his colleagues, as well as those of our colleagues suggesting our findings are "premature conclusions." A primary concern of our colleagues pertains to the limited number of confounders adjusted in our analyses. Indeed, while we were able to adjust for two of the variables noted (substance use and mental health diagnoses), we did not have the data available in this study to analyze potential effects of infection, neurovascular or metabolic complications, or trauma.

The purpose of this study was to evaluate a 16-week, reverse-integrated care (bringing primary care interventions/services into the psychiatric setting) behavioral and educational group intervention for individuals with serious mental illness and diabetes.The primary outcome was change in glycated hemoglobin (HbA1c). Secondary outcomes included body mass index (BMI), blood pressure, lipid levels, physical activity, diabetes knowledge, and self-care.Thirty-five participants attended at least one group and were included in a modified intent-to-treat analysis. From baseline to week 16, HbA1c improved, from 7.5±1.6 to 7.1±1.4, p=0.01, and BMI improved, from 33.3±3.8 to 32.9±4.1, p0.001, as did measures of diabetes knowledge and self-care. One-year follow-up in a subset of participants showed no evidence of rebound in HbA1c.This 16-week behavioral and educational group intervention resulted in improvements in glycemic control, BMI, diabetes knowledge, and self-care. The results warrant larger-scale, controlled trial testing of this intervention to improve diabetes-related health outcomes in those with serious mental illness.

OBJECTIVE Race-based bias in health care occurs at organizational, structural, and clinical levels and impacts emergency medical care. Limited literature exists on the role of race on patient restraint in the emergency setting. This study sought to examine the role of race in physical restraint in an emergency department (ED) at a major academic medical center. METHODS Retrospective chart analysis was performed, querying all adult ED visits over a 2-year period (2016-2018) at Massachusetts General Hospital. The associations between race and restraint and selected covariates (sex, insurance, age, diagnosis, homelessness, violence) were analyzed. RESULTS Of the 195,092 unique ED visits by 120,469 individuals over the selected period, 2,658 (1.4%) involved application of a physical restraint by health care providers. There was a significant effect of race on restraint (p

Background Tobacco smoking remains the leading preventable cause of death in the US. A hospital admission provides smokers with a unique opportunity to stop smoking because it requires temporary tobacco abstinence while illness may enhance motivation to quit. Hospital interventions must continue post-discharge to increase tobacco abstinence long-term, but how best to accomplish this remains unclear. Building on two previous randomized controlled trials, each of which tested smoking cessation interventions that began in hospital and continued after discharge, this trial compares two interventions that provide sustained smoking cessation treatment after hospital discharge with the goal of improving long-term smoking cessation rates among hospitalized smokers. Methods/design Helping HAND 4 is a three-site randomized controlled trial that compares the effectiveness of two active interventions for producing validated past 7-day tobacco abstinence 6 months after hospital discharge. Smokers who are admitted to three hospitals receive a standard in-hospital smoking intervention, and those who plan to quit smoking after discharge are recruited and randomly assigned to two interventions that begin at discharge, Personalized Tobacco Care Management (PTCM) or Quitline eReferral. Each lasts 3 months. At discharge, PTCM provides 8 weeks of free nicotine replacement (NRT; a participant’s choice of patch, gum, lozenge, or a combination) and then proactive smoking cessation support using an automated communication platform and live contact with a tobacco treatment specialist who is based in the health care system. In the eReferral condition, a direct referral is made from the hospital electronic health record to a community-based resource, the state’s telephone quitline. The quitline provides up to 8 weeks of free NRT and offers behavioral support via a series of phone calls from a trained coach. Outcomes are assessed at 1, 3, and 6 months after discharge. The study hypothesis is that PTCM will produce higher quit rates than eReferral. Discussion Helping HAND 4 is a pragmatic trial that aims to evaluate interventions in real-world conditions. This project will give hospital systems critical evidence-based tools for meeting National Hospital Quality Measures for tobacco treatment and maximizing their ability to improve cessation rates and overall health for the millions of smokers hospitalized annually in the US. Trial registration Prospectively registered prior to start of enrollment at Clinicaltrials.gov, NCT03603496 (July 27, 2018). https://register.clinicaltrials.gov/prs/app/action/SelectProtocol?sid=S00084MJ&selectaction=Edit&uid=U00002G7&ts=2&cx=ff0oxn

The mortality disparity for persons with schizophrenia spectrum disorders (SSDs) due to cardiovascular disease is a devastating problem. Many risk factors are present in young adults with psychosis that may be ameliorated with lifestyle interventions. Sixteen participants with SSDs enrolled in an 11-week open trial of a novel lifestyle intervention comprised of group high intensity interval training exercise and health and wellness education. The aims were to evaluate (1) feasibility and (2) impact on sedentary behavior, physical activity, nutritional knowledge, physiological outcomes, and psychological well-being at end of intervention and 11-week follow-up. Attendance rates were 70% or higher for both intervention components and participants reported increased learning about healthy eating and exercise habits. Moderate to large effect sizes were observed for physical activity and sedentary behavior with sustained improvements in sedentary behavior at follow-up. Meaningful changes were not observed in other domains.