Patient Engagement in and Adaptations to Delivery of Outpatient Care for Opioid Use Disorder During the COVID-19 Pandemic

OBJECTIVE

The authors investigated adaptations to outpatient care delivery and changes in treatment demand and engagement among patients receiving medications for opioid use disorder (MOUD) in the months after the declaration of the COVID-19 public health emergency in 2020.

METHODS

Data were collected through an online survey (June-November 2020) of outpatient MOUD prescribers. The survey obtained information on outpatient practices' adaptations to MOUD treatment and urine drug screening (UDS) and elicited provider views on the effects of the COVID-19 pandemic on patient demand for, and engagement in, treatment. Multivariable regression analyses were used to examine associations among practice characteristics, patient engagement, and service adaptations.

RESULTS

Of 516 respondents, 74% reported adaptations to MOUD delivery during the pandemic. Most respondents implemented virtual visits for initial (67%) and follow-up (77%) contacts. Prescribers of buprenorphine were more likely than those who did not prescribe the medication to report MOUD adaptations. Among respondents reporting any MOUD adaptation, 77% made adaptations to their UDS practices. Among 513 respondents who answered COVID-19-related questions, 89% reported that the pandemic had affected the treatment and engagement of their patients. Of these respondents, 30% reported increased difficulty with patient engagement, and 45% reported that their patients preferred virtual visits during this period, whereas 18% endorsed patient preference for in-person visits.

CONCLUSIONS

Telehealth and federal regulatory easements in response to the COVID-19 pandemic enabled providers to continue treating patients for opioid use disorder in 2020. The results suggest that care adaptations and changes in patient demand and engagement were common in the practices surveyed.

DSM-5-TR: Rationale, Process, and Overview of Changes

The DSM-5 text revision (DSM-5-TR) is the first published revision of the DSM-5 since its publication in 2013. Like the previous text revision (DSM-IV-TR), the main goal of the DSM-5-TR is to comprehensively update the descriptive text accompanying each DSM disorder on the basis of reviews of the literature over the past 10 years. In contrast to the DSM-IV-TR, in which updates were confined almost exclusively to the text, the DSM-5-TR includes many other changes and enhancements of interest to practicing clinicians, such as the addition of diagnostic categories (prolonged grief disorder, stimulant-induced mild neurocognitive disorder, unspecified mood disorder, and a category to indicate the absence of a diagnosis); the provision of ICD-10-CM symptom codes for reporting suicidal and nonsuicidal self-injurious behavior; modifications, mostly for clarity, of the diagnostic criteria for more than 70 disorders; and updates in terminology (e.g., replacing "neuroleptic medications" with "antipsychotic medications or other dopamine receptor blocking agents" throughout the text and replacing "desired gender" with "experienced gender" in the text for gender dysphoria). Finally, the entire text was reviewed by an Ethnoracial Equity and Inclusion Work Group to ensure appropriate attention to risk factors such as the experience of racism and discrimination, as well as the use of nonstigmatizing language.

Strategies to aid self-isolation and quarantine for individuals with severe and persistent mental illness during the COVID-19 pandemic: A systematic review

Background

Individuals with severe and persistent mental illness (SPMI) have a higher risk of contracting COVID‐19 than individuals without SPMI. In combination with physical distancing, hygiene protocols, and vaccines, quarantine and self‐isolation are primary means of viral containment. However, individuals with SPMI may experience more difficulties with mandated quarantine or self‐isolation because of their illness(es), stigma, and marginalization. To date, there is a lack of consensus on strategies that could aid such individuals in completing isolation.

Aim

This review aimed to synthesize evidence for interventions to support self‐isolation and mandated quarantine for COVID‐19 among individuals with SPMIs.

Methods

We followed the PRISMA guidelines, searching 19 electronic databases (9 published literature registries and 10 gray literature sources). We looked for relevant randomized controlled trials, quasi‐experimental studies, and program evaluations of the effectiveness of relevant psychosocial, pharmacological, harm reduction, and addiction management strategies to support isolation settings or quarantine requirements for individuals with any SPMI (e.g., any mental disorder, substance use disorder, or their combination).

Findings

Of 10,298 total records that were located, 5582 were duplicate citations. Upon screening the remaining 4716 unique records by title and abstract, we excluded a further 3562 records. Only one original article met our inclusion criteria after reviewing the full texts of the remaining 1154 citations. To support individuals experiencing homelessness during the COVID‐19 pandemic, San Francisco developed an isolation hotel that reduced COVID‐19 hospital strain for 1009 participants (25% had a mental health disorder and 26% had a substance use disorder). While 81% completed their hotel stay, 48 patients had behavioral health needs that exceeded the hotel's capabilities. No other studies met our review's eligibility criteria. Most articles located by the search simply proposed solutions or discussed the challenges brought by COVID‐19 for people with SPMIs. While some documents went a step further (e.g., shelter guidance documents to support individuals experiencing homelessness), these rarely addressed individuals with SPMIs directly.

Conclusions

This systematic review evaluated evidence from published and gray literature on interventions to support self‐isolation and mandated COVID‐19 quarantine for individuals with SPMIs. Only one study met our inclusion criteria. This study found a beneficial effect of a dedicated isolation hotel for individuals experiencing homelessness and COVID‐19—where approximately 25%–50% of the study sample had a mental or substance use disorder. While there has been an abundance of COVID‐19 protocols in general, information for SPMIs is lacking. As the pandemic continues and we better prepare for future pandemics, developing protocols for supporting SPMIs in this context is imperative.

Individuals with severe and persistent mental illness (SPMI) have a higher risk of contracting COVID‐19 than individuals without SPMI.

This review aimed to synthesize evidence for interventions to support self‐isolation and mandated quarantine for COVID‐19 among individuals with SPMIs.

Only one study met our inclusion criteria. This study found a beneficial effect of a dedicated isolation hotel for individuals experiencing homelessness and COVID‐19—where approximately 25%–50% of the study sample had a mental or substance use disorder.

While there has been an abundance of COVID‐19 protocols in general, information for SPMIs is lacking.

As the pandemic continues and we better prepare for future pandemics, developing protocols for supporting SPMIs in this context is imperative.

Addiction Medicine Practice-Based Research Network (AMNet): Building Partnerships

This column describes the collaboration among the American Psychiatric Association (APA), American Society of Addiction Medicine, Friends Research Institute, and the National Institute on Drug Abuse to create the Addiction Medicine Practice-Based Research Network (AMNet). The collaboration, which aims to address the opioid overdose epidemic in the United States, leverages the APA's clinical data registry (PsychPRO) and is recruiting office-based addiction medicine and addiction psychiatry practices for AMNet. AMNet aims to address knowledge gaps regarding patient care in such practices, facilitate performance improvement efforts, and serve as a research platform.

Addiction Medicine Practice-Based Research Network (AMNet): Assessment Tools and Quality Measures

INTRODUCTION

The need for innovative approaches to address the opioid epidemic in the United States is widely recognized. Many challenges exist to addressing this epidemic, including the obstacles outpatient substance use treatment practices face in implementing measurement-based care (MBC), quality measurement systems, and evidence-based treatments. Also, there are insufficient opportunities for clinicians in these settings to participate in research, resulting in diminished translation of research findings into community-based practice. To address these challenges, the Addiction Medicine Practice-Based Research Network (AMNet) was developed to facilitate the uptake of MBC in outpatient practices via implementation of patient-reported assessments and quality of care performance measures to improve patient outcomes. This network will offer clinicians in outpatient settings (not incuding opioid treatment programs [OTPs]) the opportunity to participate in future substance use disorder treatment research studies.

METHODS

A key step in the development of AMNet was the selection of substance use-specific assessment tools and quality of care performance measures for incorporation into the American Psychiatric Association's mental health patient registry, PsychPRO. A scoping review and multi-step consensus-based process were used to identify, review and select candidate assessment tools and quality of care performance measures for opioid use disorders (OUD) and substance use disorders (SUD).

RESULTS

Following a consensus-based methodology, 12 standardized assessment tools and 3 quality of care performance measures for OUD and SUD were selected to help facilitate the implementation of MBC and quality improvement for AMNet participants. These tools were further categorized as core and optional.

CONCLUSION

By offering a collection of carefully vetted assessment tools and quality measures through PsychPRO, AMNet will help participating clinicians with the systematic uptake of MBC and delivery of evidence-based treatment for patients with SUD. Also, AMNet will act as a centralized repository of data collected from patients and clinicians in non-OTP outpatient addiction medicine practices and serve as a platform for opioid treatment research.

An Ecological Study of a Universal Employee Depression Awareness and Stigma Reduction Intervention: "Right Direction"

Objective: Right Direction (RD) was a component of a universal employee wellness program implemented in 2014 at Kent State University (KSU) to increase employees' awareness of depression, reduce mental health stigma, and encourage help-seeking behaviors to promote mental health. We explored changes in mental health care utilization before and after implementation of RD. Methods: KSU Human Resources census and service use data were used to identify the study cohort and examine the study objectives. A pre-post design was used to explore changes in mental health utilization among KSU employees before and after RD. Three post-intervention periods were examined. A generalized linear mixed model approach was used for logistic regression analysis between each outcome of interest and intervention period, adjusted by age and sex. Logit differences were calculated for post-intervention periods compared to the pre-intervention period. Results: Compared to the pre-intervention period, the predicted proportion of employees seeking treatment for depression and anxiety increased in the first post-intervention period (OR = 2.14, 95% Confidence Interval [CI] = 1.37-3.34), then declined. Outpatient psychiatric treatment utilization increased significantly in the first two post-intervention periods (OR =1.89, 95% CI = 1.23-2.89; OR = 1.75, 95% CI = 1.11-2.76). No difference was noted in inpatient psychiatric treatment utilization across post-intervention periods. Unlike prescription for anxiolytic prescriptions, receipt of antidepressant prescriptions increased in the second (OR = 2.25, 95% CI = 1.56-3.27) and third (OR = 2.16, 95% CI = 1.46-3.20) post-intervention periods. Conclusions: Effects of RD may be realized over the long-term with follow-up enhancements such as workshops/informational sessions on mindfulness, stress management, resiliency training, and self-acceptance.

Suicide in the Time of COVID-19: Review and Recommendations

The coronavirus (COVID-19) pandemic presents us with unusual challenges to the global health system and economics. The pandemic may not have an immediate impact on suicide rates, however, given that it is likely to result in a confluence of risk factors for suicide and economic crisis, it is highly possibly that it will lead to increases in suicide rates in the long-run. Elderly persons are more likely to live alone, be socially isolated during COVID-19 and have physical health problems, which are risk factors for suicide. Young children and health professionals may also be population at risk. Isolation, quarantine and the economic crisis that follows may impact mental health significantly. The International Academy of Suicide Research (IASR) is an organization dedicated to promote high standards of research and scholarship in the field of suicidal behaviour to support efforts to prevent suicide globally. This IASR's board position paper gives recommendations for suicide research during the COVID-10 pandemic. Clinical research has to be modified due to COVID-19 shutdown.

Proxy WHO Disability Assessment Schedule 2.0 Is Clinically Useful for Assessing Psychosocial Functioning in Severe Mental Illness

AIMS

This study explores how well the World Health Organization Disability Assessment Schedule (WHODAS 2.0) assesses problems with psychosocial functioning in patients with severe mental illness (SMI). Further, we assessed the relationships between psychosocial functioning and psychopathology, medication side effects, treatment setting, and quality of life.

METHODS

We performed an observational, cross-sectional study on the island of Curaçao to assess psychosocial functioning in 77 patients with SMI; they mainly had psychotic disorders. We interviewed their healthcare providers using the proxy version of the WHODAS 2.0. In addition, patients were examined for psychiatric symptoms, medication side effects (including drug-induced movement disorders), and quality of life. Associations were examined with Spearman's rank correlation (ρ).

RESULTS

Difficulties in psychosocial functioning were reported by patients with SMI in the WHODAS 2.0 domains of understanding and communicating [mean (M)=34.5, standard deviation (SD)=18.6), participation in society (M=25.5, SD=15.6), and getting along with people (M=24.1, SD=16.1)]. Notably, outpatients had more problems participating in society than inpatients (M=33.6, SD=18.5 versus M=23.2, SD=14.1, p=0.03). A positive correlation was observed between drug-induced parkinsonism and the WHODAS 2.0 total score (ρ =0.30; p=0.02), as well as with various subscales, getting around, and household activities.

CONCLUSION

The proxy version of the WHODAS 2.0 is clinically useful for patients with severe mental illness. The highest scores on the WHODAS 2.0 were found in domains related to interactions with other people and to participation in society. Inpatient status appeared to aid participation in society; this might be due to living in the sheltered clinic environment and its associated daily activities. We further found that drug-induced parkinsonism was associated with a broad spectrum of psychosocial disabilities.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov, identifier: NCT02713672; retrospectively registered in February 2016.

The impact of educational interventions on attitudes of emergency department staff towards patients with substance-related presentations: a quantitative systematic review

BACKGROUND

Visits to emergency departments for substance use/abuse are common worldwide. However, emergency department health care providers perceive substance-using patients as a challenging group to manage which can lead to negative attitudes. Providing education or experience-based exercises may impact positively on behaviors towards this patient population. Whether staff attitudes are similarly impacted by knowledge acquired through educational interventions remains unknown.

OBJECTIVES

To synthesize available evidence on the relationship between new knowledge gained through substance use educational interventions and emergency department health care providers' attitudes towards patients with substance-related presentations.

INCLUSION CRITERIA TYPES OF PARTICIPANTS

Health care providers working in urban and rural emergency departments of healthcare facilities worldwide providing care to adult patients with substance-related presentations.

TYPE OF INTERVENTION

Quantitative papers examining the impact of substance use educational interventions on health care providers' attitudes towards substance using patients.

TYPES OF STUDIES

Experimental and non-experimental study designs.

OUTCOMES

Emergency department staff attitudes towards patients presenting with substance use/abuse.

SEARCH STRATEGY

A three-step search strategy was conducted in August 2015 with a search update in March 2017. Studies published since 1995 in English, French or Spanish were considered for inclusion.

METHODOLOGICAL QUALITY

Two reviewers assessed studies for methodological quality using critical appraisal checklists from the Joanna Briggs Institute Meta-Analysis of Statistics Assessment and Review Instrument (JBI-MAStARI). Reviewers agreed on JBI-MAStARI methodological criteria a study must meet in order to be included in the review (e.g. appropriate use of statistical analysis).

DATA EXTRACTION AND SYNTHESIS

The data extraction instrument from JBI-MAStARI was used. As statistical pooling of the data was not possible, the findings are presented in narrative form.

RESULTS

A total of 900 articles were identified as relevant for this review. Following abstract and full text screening, four articles were selected and assessed for methodological quality. One article met methodological criteria for inclusion in the review: use of random assignment and comparable study groups and measurement outcomes in a reliable and consistent manner. The included study was a cluster randomized controlled trial. Participants were emergency medicine residents with a mean age of 30 years. The study assessed the impact of a skills-based educational intervention on residents' attitudes, knowledge and practice towards patients with alcohol problems. While knowledge and practice behaviors improved one year following the intervention, there were no significant differences between groups on attitudinal measures.

CONCLUSIONS

Employing educational interventions to improve the attitudes of emergency department staff towards individuals with drug and alcohol related presentations is not supported by evidence.

Young women's experiences of psychotic illness: a systematic review of qualitative research

BACKGROUND

The relationship between young adulthood, women and psychosis was the focus for this systematic review. Age and gender are factors that can influence responses to illness. Research indicates that there are differences in how young men and women are affected biologically and psychosocially, including the presentation of a constellation of symptoms, response to anti-psychotic medications and how they assess their life circumstances. Yet in literature that examines experiences of young people with psychosis, the specific needs of young women are usually not presented separately. To better understand and address young adult women's healthcare and social service needs, a synthesis of evidence addressing the relationship between young adulthood, women and psychosis is needed.

OBJECTIVES

The aim of this systematic review was to synthesize the best available evidence on the experiences of young adult women (aged 18-35 years) living with a psychotic illness in the community. Specifically, the review question was:What are the experiences of young adult women living with a psychotic illness?

INCLUSION CRITERIA TYPES OF PARTICIPANTS

Participants were young women between 18 and 35 years of age who were living with a psychotic illness in the community.

PHENOMENA OF INTEREST

The phenomenon of interest was the experiences of living with a psychotic illness of women aged 18-35 years in the community. Experiences were defined broadly as and inclusive of perceptions and experiences with health and social systems.

CONTEXT

The context for this review was the community setting.

TYPES OF STUDIES

The current review included studies that focused on qualitative data including, but not limited to, designs such as phenomenology, grounded theory, ethnography, action research, feminist research and the qualitative component of mixed methods studies.

SEARCH STRATEGY

A three-step search strategy was used to locate both published and unpublished studies. The search was limited to studies published from 1995 to the search date of May 13, 2015.

METHODOLOGICAL QUALITY

Two reviewers independently appraised the nine included studies using the Joanna Briggs Institute Qualitative Assessment and Review Instrument (JBI-QARI) assessment tool.

DATA EXTRACTION

Data were extracted from included papers using the standardized data extraction tool from JBI-QARI.

DATA SYNTHESIS

Two reviewers independently reviewed the extracted findings to identify potential categories to pool similar findings. A third member of the team met with the reviewers to collaboratively review these derived categories to create a meta-synthesis that reflected a comprehensive set of synthesized findings.

RESULTS

Based on the thematic findings from nine qualitative studies, two synthesized findings were identified: (1) the complexity of living with psychosis and finding health, and (2) the presence of harming and healing relationships in young women's lives. The included studies explored a range of experiences relevant for women within the broader phenomenon of experiences of living with a psychotic illness, including experiences within healthcare and social systems.

CONCLUSION

The systematic exploration of the literature resulted in identification of nine studies of moderate-to-high methodological quality that met the inclusion criteria. The ConQual evaluation of the level of evidence resulted in synthesized finding 1 (the complexity of living with psychosis and finding health) rated as moderate and synthesized finding 2 (the presence of harming and healing relationships in young women's lives) rated as low. Practitioners can use these findings to guide practice. Further research exploring other experiences relevant for this population is needed.

Are Psychiatrists Ready for Health Care Reform? Findings From the Study of Psychiatric Practice Under Health Care Reform

OBJECTIVE

This study sought to describe the extent to which psychiatrists, prior to insurance expansions under the Affordable Care Act (ACA), reported currently participating or being likely to participate in integrated services delivery models, to assume new roles, to accept new reimbursement structures, and to use electronic health records (EHRs).

METHODS

A cross-sectional probability survey of U.S. psychiatrists was fielded from September to December 2013. In total, 2,800 psychiatrists were randomly selected from the AMA Physician Masterfile, and 45% responded. Of these, 93% (N=1,099) reported treating patients, forming the sample.

RESULTS

Overall, 29% reported practicing in new ACA or integrated models, and 64% reported assuming at least one new role. Forty-two percent reported currently receiving a salary; other capitated and risk-based reimbursement was rarely used. Half (53%) reported current use of EHRs for clinical functions not limited to billing or practice management; only 21% reported participating in the Medicare or Medicaid EHR Incentive Program. Those who reported currently practicing or being very likely to practice in primary care or integrated treatment settings, to assume at least one ACA role, to receive a salary, or to use an EHR were younger and more racially-ethnically diverse and more likely to see Medicaid and public outpatient clinic patients Conclusions: Although substantial proportions of psychiatrists reported current practice in ACA services delivery models and ACA roles, the findings highlight opportunities for workforce development, training, and technical assistance to strengthen participation in these activities. The findings also underscore the need to prepare psychiatrists for merit-based payment reforms and use of EHRs.

Psychiatrists' Comfort Using Computers and Other Electronic Devices in Clinical Practice

This report highlights findings from the Study of Psychiatrists' Use of Informational Resources in Clinical Practice, a cross-sectional Web- and paper-based survey that examined psychiatrists' comfort using computers and other electronic devices in clinical practice. One-thousand psychiatrists were randomly selected from the American Medical Association Physician Masterfile and asked to complete the survey between May and August, 2012. A total of 152 eligible psychiatrists completed the questionnaire (response rate 22.2 %). The majority of psychiatrists reported comfort using computers for educational and personal purposes. However, 26 % of psychiatrists reported not using or not being comfortable using computers for clinical functions. Psychiatrists under age 50 were more likely to report comfort using computers for all purposes than their older counterparts. Clinical tasks for which computers were reportedly used comfortably, specifically by psychiatrists younger than 50, included documenting clinical encounters, prescribing, ordering laboratory tests, accessing read-only patient information (e.g., test results), conducting internet searches for general clinical information, accessing online patient educational materials, and communicating with patients or other clinicians. Psychiatrists generally reported comfort using computers for personal and educational purposes. However, use of computers in clinical care was less common, particularly among psychiatrists 50 and older. Information and educational resources need to be available in a variety of accessible, user-friendly, computer and non-computer-based formats, to support use across all ages. Moreover, ongoing training and technical assistance with use of electronic and mobile device technologies in clinical practice is needed. Research on barriers to clinical use of computers is warranted.

Availability of Mental Health Services Prior to Health Care Reform Insurance Expansions

OBJECTIVES

This study sought to examine psychiatrists' perceptions of gaps in the availability of mental health and substance use services and their ability to spend sufficient time and provide enough visits to meet patients' clinical needs.

METHODS

A cross-sectional probability survey of U.S. psychiatrists was fielded during September through December 2013 by using practice-based research methods, including distribution by priority mail. Psychiatrists (N=2,800) were randomly selected from the American Medical Association Physician Masterfile, and 1,188 of the 2,615 (45%) with deliverable addresses responded. Of those, 93% (N=1,099) reported currently treating psychiatric patients, forming the sample for this study.

RESULTS

Thirty percent or more of psychiatrists reported being unable to provide or find a source for each of the following services in the past 30 days: psychotherapy, housing, supported employment, case management or assertive community treatment, and substance use treatment. Approximately 20% reported being unable to provide or find a source for inpatient treatment, psychosocial rehabilitation, general medical care, pharmacologic treatment, and child and adolescent treatment. Approximately half (52%) of psychiatrists reported not having enough time during patient visits, affecting 28% of patients. More than one-third (37%) reported being unable to provide enough visits to meet patients' clinical needs, affecting 24% of patients.

CONCLUSIONS

Psychiatrists reported constrained availability of a range of mental health, substance use, and general medical services. In order for the Affordable Care Act to realize the promise of increased access to care, the infrastructure for mental health and substance use treatment, workforce, and services delivery may require significant enhancement.

Canadian Triage and Acuity Scale: testing the mental health categories

PURPOSE

The study tested the inter-rater reliability and accuracy of triage nurses' assignment of urgency ratings for mental health patient scenarios based on the 2008 Canadian Triage and Acuity Scale (CTAS) guidelines, using a standardized triage tool. The influence of triage experience, educational preparation, and comfort level with mental health presentations on the accuracy of urgency ratings was also explored.

METHODS

Study participants assigned urgency ratings to 20 mental health patient scenarios in randomized order using the CTAS. The scenarios were developed using actual triage notes and were reviewed by an expert panel of emergency and mental health clinicians for face and content validity.

RESULTS

The overall Fleiss' kappa, the measure of inter-rater reliability for this sample of triage nurses (n=18), was 0.312, representing only fair albeit statistically significant (P<0.0001) agreement. Kendall's coefficient of concordance for the sample was calculated to be 0.680 (P<0.0001), which signifies moderate agreement. Although the sample reported high levels of education, comfort with mental health presentations, and experience, accuracy in urgency ratings measured by the percentage of correct responses ranged from 0.05% to 94% (mean: 54%). Greater accuracy in urgency ratings was recorded for triage nurses who used second-order modifiers and avoided the use of override.

CONCLUSION

Specific focus on the use of second-order modifiers in orientation and ongoing education of triage nurses may improve the reliability and validity of the CTAS when used to assign urgency ratings to mental health presentations.

Feasibility and acceptability of the DSM-5 Field Trial procedures in the Johns Hopkins Community Psychiatry Programs

The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) contains criteria for psychiatric diagnoses that reflect advances in the science and conceptualization of mental disorders and address the needs of clinicians. DSM-5 also recommends research on dimensional measures of cross-cutting symptoms and diagnostic severity, which are expected to better capture patients' experiences with mental disorders. Prior to its May 2013 release, the American Psychiatric Association (APA) conducted field trials to examine the feasibility, clinical utility, reliability, and where possible, the validity of proposed DSM-5 diagnostic criteria and dimensional measures. The methods and measures proposed for the DSM-5 field trials were pilot tested in adult and child/adolescent clinical samples, with the goal to identify and correct design and procedural problems with the proposed methods before resources were expended for the larger DSM-5 Field Trials. Results allowed for the refinement of the protocols, procedures, and measures, which facilitated recruitment, implementation, and completion of the DSM-5 Field Trials. These results highlight the benefits of pilot studies in planning large multisite studies.

Testing DSM-5 in routine clinical practice settings: feasibility and clinical utility

OBJECTIVE

This article describes the clinical utility and feasibility of proposed DSM-5 criteria and measures as tested in the DSM-5 Field Trials in Routine Clinical Practice Settings (RCP). METHODS RCP data were collected online for six months (October 2011 to March 2012). Participants included psychiatrists, licensed clinical psychologists, clinical social workers, advanced practice psychiatric-mental health nurses, licensed counselors, and licensed marriage and family therapists. Clinicians received staged, online training and enrolled at least one patient. Patients completed self-assessments of cross-cutting symptom domains, disability measures, and an evaluation of these measures. Clinicians conducted diagnostic interviews and completed DSM-5 and related assessments and a clinical utility questionnaire.

RESULTS

A total of 621 clinicians provided data for 1,269 patients. Large proportions of clinicians reported that the DSM-5 approach was generally very or extremely easy for assessment of both pediatric (51%) and adult (46%) patients and very or extremely useful in routine clinical practice for pediatric (48%) and adult (46%) patients. Clinicians considered the DSM-5 approach to be better (57%) or much better (18%) than that of DSM-IV. Patients, including children age 11 to 17 (47%), parents of children age six to ten (64%), parents of adolescents age 11 to 17 (72%), and adult patients (52%), reported that the cross-cutting measures would help their clinicians better understand their symptoms. Similar patterns in evaluations of feasibility and clinical utility were observed among clinicians from various disciplines.

CONCLUSIONS

The DSM-5 approach was feasible and clinically useful in a wide range of routine practice settings and favorably received by both clinicians and patients.

DSM-5 field trials in the United States and Canada, Part I: study design, sampling strategy, implementation, and analytic approaches

OBJECTIVE

This article discusses the design,sampling strategy, implementation,and data analytic processes of the DSM-5 Field Trials.

METHOD

The DSM-5 Field Trials were conducted by using a test-retest reliability design with a stratified sampling approach across six adult and four pediatric sites in the United States and one adult site in Canada. A stratified random sampling approach was used to enhance precision in the estimation of the reliability coefficients. A web-based research electronic data capture system was used for simultaneous data collection from patients and clinicians across sites and for centralized data management.Weighted descriptive analyses, intraclass kappa and intraclass correlation coefficients for stratified samples, and receiver operating curves were computed. The DSM-5 Field Trials capitalized on advances since DSM-III and DSM-IV in statistical measures of reliability (i.e., intraclass kappa for stratified samples) and other recently developed measures to determine confidence intervals around kappa estimates.

RESULTS

Diagnostic interviews using DSM-5 criteria were conducted by 279 clinicians of varied disciplines who received training comparable to what would be available to any clinician after publication of DSM-5.Overall, 2,246 patients with various diagnoses and levels of comorbidity were enrolled,of which over 86% were seen for two diagnostic interviews. A range of reliability coefficients were observed for the categorical diagnoses and dimensional measures.

CONCLUSIONS

Multisite field trials and training comparable to what would be available to any clinician after publication of DSM-5 provided “real-world” testing of DSM-5 proposed diagnoses.

DSM-5 field trials in the United States and Canada, Part II: test-retest reliability of selected categorical diagnoses

OBJECTIVE

The DSM-5 Field Trials were designed to obtain precise (standard error,0.1) estimates of the intraclass kappa asa measure of the degree to which two clinicians could independently agree on the presence or absence of selected DSM-5 diagnoses when the same patient was interviewed on separate occasions, in clinical settings, and evaluated with usual clinical interview methods.

METHOD

Eleven academic centers in the United States and Canada were selected,and each was assigned several target diagnoses frequently treated in that setting.Consecutive patients visiting a site during the study were screened and stratified on the basis of DSM-IV diagnoses or symptomatic presentations. Patients were randomly assigned to two clinicians for a diagnostic interview; clinicians were blind to any previous diagnosis. All data were entered directly via an Internet-based software system to a secure central server. Detailed research design and statistical methods are presented in an accompanying article.

RESULTS

There were a total of 15 adult and eight child/adolescent diagnoses for which adequate sample sizes were obtained to report adequately precise estimates of the intraclass kappa. Overall, five diagnoses were in the very good range(kappa=0.60–0.79), nine in the good range(kappa=0.40–0.59), six in the questionable range (kappa = 0.20–0.39), and three in the unacceptable range (kappa values,0.20). Eight diagnoses had insufficient sample sizes to generate precise kappa estimates at any site.

CONCLUSIONS

Most diagnoses adequately tested had good to very good reliability with these representative clinical populations assessed with usual clinical interview methods. Some diagnoses that were revised to encompass a broader spectrum of symptom expression or had a more dimensional approach tested in the good to very good range.

DSM-5 field trials in the United States and Canada, Part III: development and reliability testing of a cross-cutting symptom assessment for DSM-5

OBJECTIVE

The authors sought to document, in adult and pediatric patient populations, the development, descriptive statistics,and test-retest reliability of cross-cutting symptom measures proposed for inclusion in DSM-5.

METHOD

Data were collected as part of the multisite DSM-5 Field Trials in large academic settings. There were seven sites focusing on adult patients and four sites focusing on child and adolescent patients.Cross-cutting symptom measures were self-completed by the patient or an informant before the test and the retest interviews, which were conducted from 4 hours to 2 weeks apart. Clinician-report measures were completed during or after the clinical diagnostic interviews. Informants included adult patients, child patients age 11 and older, parents of all child patients age 6 and older, and legal guardians for adult patients unable to self-complete the measures. Study patients were sampled in a stratified design,and sampling weights were used in data analyses. The mean scores and standard deviations were computed and pooled across adult and child sites. Reliabilities were reported as pooled intraclass correlation coefficients (ICCs) with 95% confidence intervals.

RESULTS

In adults, test-retest reliabilities of the cross-cutting symptom items generally were good to excellent. At the child and adolescent sites, parents were also reliablereporters of their children’s symptoms,with few exceptions. Reliabilities were not as uniformly good for child respondents, and ICCs for several items fell into the questionable range in this age group. Clinicians rated psychosis with good reliability in adult patients but were less reliable in assessing clinical domains related to psychosis in children and to suicide in all age groups.

CONCLUSIONS

These results show promising test-retest reliability results for this group of assessments, many of which are newly developed or have not been previously tested in psychiatric populations

Effectiveness of a vegetable dental chew on periodontal disease parameters in toy breed dogs

Sixteen toy breed dogs completed a parallel, 70-day two-period, cross-over design clinical study to determine the effect of a vegetable dental chew on gingivitis, halitosis, plaque, and calculus accumulations. The dogs were randomly assigned into two groups. During one study period the dogs were fed a non-dental dry diet only and during the second study period were fed the same dry diet supplemented by the daily addition of a vegetable dental chew. Daily administration of the dental chew was shown to reduce halitosis, as well as, significantly reduce gingivitis, plaque and calculus accumulation and therefore may play a significant role in the improvement of canine oral health over the long-term.

Are the available apathy measures reliable and valid? A review of the psychometric evidence

OBJECTIVE

Apathy is highly prevalent among neuropsychiatric populations and is associated with greater morbidity and worse functional outcomes. Despite this, it remains understudied and poorly understood, primarily due to lack of consensus definition and clear diagnostic criteria for apathy. Without a gold standard for defining and measuring apathy, the availability of empirically sound measures is imperative. This paper provides a psychometric review of the most commonly used apathy measures and provides recommendations for use and further research.

METHODS

Pertinent literature databases were searched to identify all available assessment tools for apathy in adults aged 18 and older. Evidence of the reliability and validity of the scales were examined. Alternate variations of scales (e.g., non-English versions) were also evaluated if the validating articles were written in English.

RESULTS

Fifteen apathy scales or subscales were examined. The most psychometrically robust measures for assessing apathy across any disease population appear to be the Apathy Evaluation Scale and the apathy subscale of the Neuropsychiatric Inventory based on the criteria set in this review. For assessment in specific populations, the Dementia Apathy Interview and Rating for patients with Alzheimer's dementia, the Positive and Negative Symptom Scale for schizophrenia populations, and the Frontal System Behavior Scale for patients with frontotemporal deficits are reliable and valid measures.

CONCLUSION

Clinicians and researchers have numerous apathy scales for use in broad and disease-specific neuropsychiatric populations. Our understanding of apathy would be advanced by research that helps build a consensus as to the definition and diagnosis of apathy and further refine the psychometric properties of all apathy assessment tools.

The Brøset Violence Checklist: clinical utility in a secure psychiatric intensive care setting

Violence towards health-care workers, especially in areas such as mental health/psychiatry, has become increasingly common, with nursing staff suggesting that a fear of violence from their patients may affect the quality of care they provide. Structured clinical tools have the potential to assist health-care providers in identifying patients who have the potential to become violent or aggressive. The Brøset Violence Checklist (BVC), a six-item instrument that uses the presence or absence of three patient characteristics and three patient behaviours to predict the potential for violence within a subsequent 24-h period, was trialled for 3 months on an 11-bed secure psychiatric intensive care unit. Despite the belief on the part of some nurses that decisions related to risk for violence and aggression rely heavily on intuition, there was widespread acceptance of the tool. During the trial, use of seclusion decreased suggesting that staff were able to intervene before seclusion was necessary. The tool has since been implemented as a routine part of patient care on two units in a 92-bed psychiatric centre. Five-year follow-up data and implications for practice are presented.

Seasonal allergies and suicidality: results from the National Comorbidity Survey Replication

OBJECTIVE

Studies have shown an association between allergies and suicidality, and a seasonality of suicide has also been described. We hypothesize an association between history of seasonal allergies and suicide ideation and attempt.

METHOD

Data came from the National Comorbidity Survey Replication, a nationally representative sample (n = 5692) of adults living in the US. Logistic regression models were used to calculate adjusted odds ratios (OR) controlling for the following: age, sex, race, smoking, asthma and depression.

RESULTS

After weighting and adjustment, a positive and statistically significant association was found between history of seasonal allergies and history of suicidal ideation [adjusted OR = 1.27 (1.01-1.58)]. We found no association between history of seasonal allergies and history of suicide attempts [adjusted OR = 1.17 (0.89-1.52)].

CONCLUSION

Findings from a population-based sample support the hypothesized relationship between allergies and suicidal ideation.

Increased risk of suicidal ideation in smokers and former smokers compared to never smokers: evidence from the Baltimore ECA follow-up study

The incidence rate of suicidal ideation among current and former smokers versus never smokers is not known. In this study, the age-adjusted incidence of suicidal ideation was highest among current smokers, followed by former, then never smokers. The adjusted hazard for suicide ideation was 2.22 (95%CI = 1.48, 3.33) and 1.19 (95%CI = 0.78, 1.82) for current and former smokers, respectively, compared to never smokers. Results indicate that current smokers have increased risks of suicidal ideation above and beyond the risk for never and former smokers regardless of age, gender, history of depressive disorder or anxiety symptoms, and alcohol abuse/dependence. Smoking cessation might be beneficial for some suicide prevention efforts.

Effect of Kibble Size, Shape, and Additives on Plaque in Cats

Forty mixed-breed cats completed a parallel-group, clinical study to compare supragingival plaque accumulation using a triangular or rectangular shaped dry-expanded diet, with or without an anti-calculus agent (sodium tripolyphosphate) or an anti-plaque agent (plaque-reducing nutrient). The cats were divided into 4 equal groups based on plaque scores. Results showed that coating the kibble with sodium tripolyphosphate had no effect on plaque accumulation. Increasing the surface area and volume and changing the shape of the kibble was associated with a reduction in plaque accumulation, and coating the kibble with a plaque-reducing nutrient further reduced plaque accumulation. The importance of a combination of both mechanical abrasion (chewing) and chemical interference (plaque-reducing nutrient) was demonstrated in this study.

Apathy in dementia: clinical and sociodemographic correlates

The authors examine prevalence and the sociodemographic and clinical correlates of apathy in dementia. Apathy was assessed in 121 outpatients in a behavioral neurology clinic using the Informant and Clinician versions of the Apathy Evaluation Scale (AES-I, AES-C). Apathy was found to be very prevalent across the dementias. Functional impairment, aberrant motor behavior, and irritability were associated with a greater likelihood of being apathetic upon evaluation with the AES-I. Additionally, with the AES-C, persons with dementia who lived with individuals other than their spouses were more likely to suffer apathy compared to those who lived with their spouses. These findings have clinical and research implications.

Asthma and suicidal ideation with and without suicide attempts among adults in the United States: what is the role of cigarette smoking and mental disorders?

BACKGROUND

Evidence of a respiratory diseases and suicidal ideation and suicide attempts link exists. To improve our understanding of the mechanism underlying these links, there is a need for examination of the relationship between specific respiratory disease, such as asthma, and suicidal ideation and behavior. In addition, studies need to examine many common risk factors that may play a role in the association between asthma and suicidal ideation and suicide behavior.

OBJECTIVE

To examine the association between asthma and suicidal ideation with and without attempts among adults in the United States, specifically investigating the role of cigarette smoking, nicotine dependence, depression, anxiety, and alcohol abuse.

METHODS

Data on 5,692 individuals 18 years and older were drawn from the US National Comorbidity Survey Replication. Descriptive and multivariate logistic regression analyses were conducted to examine the study objectives.

RESULTS

The estimates of lifetime prevalence for suicidal ideation without and with attempts and asthma were 8.7%, 4.2%, and 12.0%, respectively. Being a woman, a current smoker, depressed, anxious, an alcohol abuser, or nicotine dependent increased the likelihood of suicidal ideation with attempts and asthma. Asthma was significantly (P < .001) associated with suicidal ideation with but not without attempts. Adjustment for smoking, nicotine dependence, age, sex, and race/ethnicity decreased the association between asthma and suicidal ideation with attempts by 16%. Similarly, adjustment for depression, panic disorder, and alcohol abuse led to a 12.4% decrease in this relationship. Despite these adjustments, independently or combined, a statistically significant (P = .02) association remained between asthma and suicidal ideation with attempts.

CONCLUSIONS

Cigarette smoking and concurrent mental health conditions may independently account for significant proportions of the association between asthma and suicidal ideation with attempts. More research is needed to further elucidate the mechanism of the remaining association between asthma and suicide attempts. Modification of smoking behaviors and effective treatment of depression, anxiety, alcohol abuse, and possibly asthma are important suicide prevention strategies.

Relationship-based support for women living with serious mental illness

Relationships are critical to a woman's growth and development, yet when living with serious mental illness, developing and nurturing connections can be challenging. This qualitative study explored the nature and quality of support provided within relationships for 14 women with schizophrenia. Families were key supporters. Female friends with mental illness often provided a meaningful source of connection for participants. Problematic relationships, losses over time, and living in poverty were among the barriers to receiving needed support. Participants conveyed a sense of wanting relational reciprocity as they talked about their relationships and place within the community.

Pathways to suicidality across ethnic groups in Canadian adults: the possible role of social stress

BACKGROUND

Ethnicity is an important determinant of mental health outcomes including suicidality (i.e. suicidal ideation and suicide attempt). Understanding ethnic differences in the pathways to suicidality is important for suicide prevention efforts in ethnically diverse populations. These pathways can be conceptualized within a social stress framework.

METHOD

The study examines ethnic differences in the pathways to suicidality in Canada within a social stress framework. Using data from the Canadian Community Health Survey Cycle 1.1 (CCHS 1.1) and path analysis, we examined the hypotheses that variations in (1) socio-economic status (SES), (2) sense of community belonging (SCB), (3) SES and SCB combined, and (4) SES, SCB and clinical factors combined can explain ethnic differences in suicidality.

RESULTS

Francophone whites and Aboriginals were more likely to report suicidality compared to Anglophone whites whereas visible minorities and Foreign-born whites were least likely. Disadvantages in income, income and education, income and its combined effect with depression and alcohol dependence/abuse led to high rates even among the low-risk visible minority group. Indirect pathways for Asians differed from that of Blacks and South Asians, specifically through SCB. With the exception of SCB, Aboriginals were most disadvantaged, which exacerbated their risk for suicidality. However, their strong SCB buffered the risk for suicidality across pathways. Disadvantages in education, income and SCB were associated with the high risk for suicidality in Francophone whites.

CONCLUSIONS

Francophone whites and Aboriginals had higher odds of suicidality compared to Anglophone whites; however, some pathways differed, indicating the need for targeted program planning and prevention efforts.

Ethnicity and mental health: conceptualization, definition and operationalization of ethnicity from a Canadian context

The current study provides a critical review of Canadian studies on ethnicity and mental health with respect to the definition, conceptualization and operationalization of ethnicity. It provides a discussion on the methodological issues related to these factors and their implications to guide future research and enable comparability of results across studies. Sociological Abstracts, PsycINFO, MEDLINE and CINAHL were used to identify relevant Canadian articles published between January 1980 and December 2004. The review highlights a number of key issues for future researchers to consider such as the need for: 1) clear rationales as to why ethnicity is important to their outcome of interest; 2) clarity on the definition of ethnicity, which affects its conceptualization and operationalization; 3) a theoretically driven conceptualization of ethnicity, which should be related to the research question of interest; and 4) clear rationales for the decisions made regarding the data source used, the operationalization of ethnicity, and the ethnic categories included in their studies.

Emergency department from the mental health client's perspective

General hospital emergency departments (EDs) are obvious places for individuals in psychiatric distress or a mental health crisis to seek assistance. However, the typical mental health presentation does not fit with the treatment norm of most EDs creating a tension around the care of individuals with mental illnesses. Eight focus groups were held with mental health patients and their families to determine their satisfaction with care received in regional EDs with particular emphasis on their evaluation of the role of the psychiatric emergency nurse. Themes identified were: waiting in the ED, attitudes of treatment staff, diagnostic overshadowing, 'no where else to go', family needs, and a wish list for ideal services. These issues are described in this paper along with clinical and systemic implications.

Apathy in dementia: an examination of the psychometric properties of the apathy evaluation scale

The psychometric properties of the clinician, informant, and self-rated versions of the Apathy Evaluation Scale (AES-C/I/S) were examined using data on 121 outpatients seen in a behavioral neurology clinic for the assessment of dementia and associated neuropsychiatric disorders. Two factors, apathy and interest, were identified for the AES-C and the AES-I. The AES-S had only an apathy factor. The AES-C was found to have fairly good psychometric properties. However, from a diagnostic point of view, the AES-I provided the greatest sensitivity and the strongest positive and negative predictive values. Generally, the AES-S performed poorly compared with the AES-C and AES-I.

An appraisal of the psychometric properties of the Clinician version of the Apathy Evaluation Scale (AES-C)

This article examines the psychometric properties of the clinician version of the Apathy Evaluation Scale (AES-C) to determine its ability to characterize, quantify and differentiate apathy. Critical appraisals of the item-reduction processes, effectiveness of the administration, coding and scoring procedures, and the reliability and validity of the scale were carried out. For training, administration and rating of the AES-C, clearer guidelines, including a more standardized list of verbal and non-verbal apathetic cues, are needed. There is evidence of high internal consistency for the scale across studies. In addition, the original study reported good test-retest and inter-rater reliability coefficients. However, there is a lack of replication on these more stable and informative measures of reliability and as such they warrant further investigation. The research evidence confirms that the AES-C shows good discriminant, convergent and criterion validity. However, evidence of its predictive validity is limited. As this aspect of validity refers to the scale's ability to predict future outcomes, which is important for treatment and rehabilitation planning, further assessment of the predictive validity of the AES-C is needed. In conclusion, the AES-C is a reliable and valid measure for the characterization and quantification of apathy.

Education to improve the triage of mental health patients in general hospital emergency departments

General hospital emergency departments (EDs) are obvious places for individuals in distress or in a mental health crisis to seek assistance. However, triage nurses admit to a lack of expertise and confidence in psychiatric assessment which can result in less accurate assessments than for medical or trauma presentations. The objectives of a collaborative project between an Adult Mental Health Program and an Adult Emergency Program in a Canadian regional health authority were to: provide education and training to triage nurses regarding mental health and illness; monitor the transit of mental health patients through the ED; monitor wait times; and determine the adequacy of the Canadian Triage Acuity and Assessment Scale in the triage of psychiatric presentations. Although the percentages of patients triaged as "emergent" did not change as a result of the education, the percentage of patients who were triaged as "not urgent" but required hospitalization was significantly reduced. Although average lengths of stay in the ED were also reduced after the education, this may or may not have been related to the educational sessions. The project was successful in increasing collaboration between the two departments and has resulted in enhanced, on-going mental health education for ED nurses.

Differential experiences during the holocaust and suicidal ideation in older adults in treatment for depression

Data were used on 275 Jewish individuals aged 50 and older in outpatient treatment for depression in this retrospective cross-sectional study. Holocaust survivors who were in work camps, in ghettos, or in hiding (HS-WGH) and holocaust survivors who were in concentration camps (HS-CC) were more likely to suffer posttraumatic stress disorder compared to other survivors (HS-OT) and controls. The HS-WGH and HS-CC groups had at least a threefold greater odds of suicidal ideation compared to controls. Suicidal ideation rates did not differ significantly between HS-OT group and controls. Among survivors, HS-WGH had a threefold greater odds of suicidal ideation compared to HS-OT. The results are applicable to survivors of similar atrocities and show that differing types and severities of traumatic experiences have important implications for treatment planning.

Smoking reduction & cessation: a hospital based survey of outpatients' attitudes

1. Most people with mental illnesses have made at least one attempt to quit smoking on their own. 2. Psychiatric diagnosis and degree of nicotine dependence do not appear to be predictive of ability to quit. 3. People with mental illnesses are aware of nicotine replacement therapy (NRT), but do not combine it with a behavioral program, possibly contributing to the higher rates of recidivism in this population. 4. The lack of participation of mental health care providers in promoting smoking cessation is a complex issue.

Differential cognitive impairment in subjects with geriatric depression who will develop Alzheimer's disease and other dementias: a retrospective study

OBJECTIVE

The aim of this study was to retrospectively differentiate the cognitive profile of subjects with geriatric depression who will later be diagnosed with Alzheimer's disease (AD) from those who will be diagnosed with other dementias, and subjects who will remain with no dementia.

METHODS

Forty-four depressed patients admitted to a day hospital program for depression who participated in a historical cohort study were assessed after 7.5 years of follow-up. Fourteen of these subjects subsequently developed dementia: seven met the criteria for probable AD and seven met the criteria for dementias other than AD (Dementia-No-AD; D-NAD, such as dementia with Lewy bodies (DLB), vascular and mixed dementia). Thirty subjects remained without dementia (No Dementia, ND) at follow-up. The three groups were thus compared on their baseline cognitive performances on the six sections of the Mini-mental State Examination (MMSE) and on the five subscales of the Dementia Rating Scale (DRS).

RESULTS

An analysis of variance (ANOVA) and post-hoc Student-Newman-Keuls analyses with an alpha of p < 0.05 revealed that the subjects who received a diagnosis of dementia at follow-up had previously had more impairment on tasks measuring attention and memory (DRS-MMSE) than those who did not develop dementia (AD = D-NAD < ND). Moreover, the future AD subjects could be differentiated on the basis of their difficulties on the MMSE-orientation subtest (AD < ND = D-NAD), whereas the future D-NAD subjects initially had more problems with executive functions (DRS) and MMSE-visuospatial abilities (D-NAD < AD = ND).

CONCLUSION

The identification of early neuropsychological markers in elderly depressed patients highlights the need to evaluate this population broadly as soon as possible in the depression/dementia process in order to improve the prognosis.

Holocaust experience and suicidal ideation in high-risk older adults

OBJECTIVE

Depression is an identified risk factor for suicidal ideation, a precursor for more serious suicidal behaviors. This risk might be further compounded in individuals who experience negative life events, including traumatic experiences, and those who might have comorbid illnesses. The authors examined the impact of past exposure to the Nazi Holocaust on the development of suicidal ideation in a sample of depressed older adults.

METHODS

Authors conducted a retrospective cross-sectional study. The study sample comprised data on 530 consecutive eligible first admissions of Jewish patients who were referred and admitted to a geriatric psychiatry day hospital program between September 1986 and December 2000.

RESULTS

Multiple logistic-regression analyses, controlling for social support, history of suicide attempts, and other negative life events, showed that severity of depression and exposure to the Holocaust were independently associated with suicidal ideation. Those not showing suicidal ideation were slightly more likely to have reported having a confidant.

CONCLUSIONS

This is the first empirical study to demonstrate an increased likelihood for suicidal ideation in survivors of the Nazi Holocaust. The chronic stress produced by these traumatic events may have predisposed survivors to cope ineffectively as they age, thus resulting in suicidal ideation. Authors highlight the importance of a multifaceted approach when assessing suicidal behaviors in high-risk groups.