Psychiatric services最新文献

Objective: Clozapine is the drug of choice for treatment-resistant schizophrenia. Routine monitoring of an absolute neutrophil count (ANC) is required to detect severe neutropenia, which is a black box warning for clozapine. However, during the COVID-19 pandemic, laboratory monitoring became less frequent because of decreased access to health care services and concern about increased viral exposure. The purpose of this study was to evaluate the discontinuation rate of clozapine due to severe neutropenia during the COVID-19 pandemic.

Methods: This 16-month retrospective study included all adult patients within the Veterans Health Administration who had a clozapine prescription at least 12 months before March 2020. Demographic data included indication for use, concomitant antipsychotic prescriptions, age, and race-ethnicity. Descriptive statistics were performed to analyze study objectives and demographic data.

Results: In total, 2,106 patients were included in this study. No patients discontinued clozapine because of severe neutropenia, and only one patient had severe neutropenia during the study period. All-cause clozapine discontinuation occurred for 96 patients (5%). Significant differences were found between individuals who discontinued clozapine and those who did not for the longest ANC gap category (p<0.001), neutropenia category (p=0.042), and duration of clozapine use (p=0.001).

Conclusions: Less frequent ANC monitoring as a consequence of the COVID-19 pandemic did not lead to increased incidence of clozapine discontinuation due to severe neutropenia. These results demonstrate the feasibility and safety of extended-interval laboratory monitoring (i.e., every 90 days) for patients receiving clozapine treatment for at least 1 year.

Objective: Cognitive health should be addressed as part of routine clinical care for people with schizophrenia spectrum disorder, including those with early psychosis. Providers need an efficient workflow that includes screening tools with adequate sensitivity and specificity to facilitate appropriate cognitive symptom management. This study aimed to examine the utility of a cognitive health screening protocol by analyzing data from 102 participants in OnTrackNY, a specialized network of programs for people experiencing early psychosis.

Methods: Screening elicited participants' perceptions of the usefulness of better memory, attention, and critical thinking skills and aimed to detect the presence of cognitive difficulties via participant and clinician reports. The screening protocol's sensitivity and specificity for detecting cognitive impairment, as defined by scores on a brief cognitive assessment, were evaluated.

Results: About half the sample had global cognitive impairment, whereas more than 90% demonstrated impairment in at least one cognitive domain. Screening items demonstrated high sensitivity to detect global (≥0.80) and specific cognitive impairment (≥0.74), such that individuals with objectively measured cognitive impairment were likely to be correctly identified, although specificity remained low (≤0.34).

Conclusions: The screening protocol may best be considered as a means to initiate shared decision making for next steps, which may include brief cognitive assessment or more resource-intensive evaluation, and to inform appropriate treatment recommendations.

Objective: Prior research has shown that Medicaid expansion is linked with slightly reduced suicide rates at the state level. This study aimed to investigate the association between Medicaid expansion and suicide rates at the county level, as well as disparities based on rurality and areas with a shortage of mental health professionals.

Methods: In this cross-sectional study, the authors conducted a difference-in-differences analysis, with regression-adjusted ordinary least squares and fixed effects of county and year, to compare changes in county-level suicide mortality rates among nonelderly adults before and after Medicaid expansion. Whether these changes differed by rurality and by mental health professional availability was also examined.

Results: Among 3,068 unique counties included in the analysis, on average, 50.0% of residents were male, 17.1% ages ≥65 years, 34.8% high school graduates, and 76.8% non-Hispanic White. The estimated suicide incidence rate per 100,000 population was 17.2 across all counties from 2007 to 2021. Medicaid expansion was not significantly associated with suicide rates. However, the three-way interaction term indicated a significant decrease in suicide rates after Medicaid expansion in metropolitan counties without mental health professional shortages (adjusted coefficient=-1.32, 95% CI=-2.37 to -0.28, p=0.014).

Conclusions: These findings suggest that Medicaid expansion may have a greater impact in areas with more resources and infrastructure to provide mental health care. Further investigation is needed into the mechanisms that drive these differences.

In 2024, the American Law Institute revised its influential Restatement of the Law for medical malpractice. The most important change is an updated standard for determining when a clinician is negligent, which emphasizes the failure to provide reasonable care, replacing the traditional standard of customary care. Determinations of reasonable care can consider evidence from the medical literature and practice guidelines, even if they have not yet generally been adopted in ordinary practice, as well as contextual factors. Although not yet incorporated into law, the new standard underscores the importance of clinicians staying current with changes in evidence-based practice.

Increasingly, mental health is regarded as fundamental to a person's overall health. As communities mobilize to improve mental health outcomes, activities designed to improve well-being can be integrated into these approaches. Although well-being is generally perceived as being associated with mental health, it has not been culturally operationalized for marginalized and oppressed groups. The authors participated in the coproduction of a well-being model for young Black adults and a workbook, filling a gap by translating research into practice. Researchers are encouraged to engage in strategies to jointly create well-being tools to support the mental health of individuals who have been underserved, understudied, and underrepresented.

Objective: This study aimed to describe the goals of service users with first-episode psychosis who enrolled in coordinated specialty care (CSC), along with the goals their family members have for them, and to understand service users' and family members' perceived needs for recovery after discharge from the program.

Methods: The authors conducted 32 in-depth interviews in English or Spanish with service users and their family members recruited between September 2021 and December 2022. Transcripts were analyzed to determine the common concerns and expectations of service users and family members.

Results: Most service users described wanting financial and social independence from their families of origin, including an education that would allow them to obtain well-paid, stable employment; transportation; and an independent residence. Service users described hoping to replace some of the support they received from CSC with friends they would make in the future; some family members hoped their loved one would be able to develop and sustain romantic relationships. Most family members described not feeling ready to leave CSC at the 2-year mark, whereas service users expressed mixed opinions about their readiness to exit the program.

Conclusions: Although service users were excited about the prospect of discharge, they, along with their family members, agreed that ongoing support was needed after CSC. On the basis of the findings, the authors delineate supports that service users and family members believe are necessary for a successful step-down.

This column explores the use of a wellness model developed by and for individuals with lived experience of mental health or substance use conditions. An overview of the model, including its development and rationale, is provided along with examples of the effective use of tools based on the wellness model. The use of this approach among members of a community wellness center is described. Firsthand experiences of the authors are used to illustrate their personal journeys in using the model for their own recovery and in peer support work.

Gaps exist in the delivery of effective, culturally mindful treatment for trauma-related mental health problems, and providers who treat those problems in underresourced communities need more support. Adapting Project ECHO (Extension for Community Healthcare Outcomes), the authors developed a virtual learning community to link mental health providers in Washington State with specialists in trauma recovery. Goals were to evaluate provider demand for trauma-specific training and the project's feasibility, acceptability, and initial impacts on providers' practice and well-being. The 26 participating providers showed demand for and engagement in the learning community and reported high satisfaction. Findings were mixed with respect to impact. Potential changes to increase future impact are discussed.