Psychiatric Hospital Outcomes of Dual Diagnosis Patients Under Managed Care

The authors compared patterns of psychiatric hospitalization utilization and outcomes between persons with and without co-existing substance-related disorders in a managed care environment by means of a prospective follow-along study of persons hospitalized for psychiatric reasons under the auspices of a large regional managed care firm. Forty-two psychiatric inpatients with comorbid substance disorders and 121 inpatients without coexisting substance disorders were compared across measures of service use and psychiatric acuity. Readmission to the hospital was assessed at 30 days and after 6 months. Patients with coexisting substance disorders spent fewer days in the hospital, but were rehospitalized at a higher rate both within 30 days and (significantly) after 6 months. These results suggest that the revolving-door pattern of service utilization is also present in managed care environments.     

Drug Dependence in Psychiatric Admissions

A full drug history was taken from 378 patients admitted to a Psychiatric Service. Individuals who had received continuous psychotropic medication for 4 weeks were assessed for evidence of drug dependence as manifested by emotioned distress an withdrawal or threat of withdrawal of the drug. 104 patients (27.5 per cent) were regarded as being drug dependent. Further characteristics of the patients and drugs are reviewed.     

The Processes of Referral and Disposal within a London Drug Dependence Clinic

This study looks at the processes whereby individuals with drug problems were referred to a London drug dependence clinic during a seven month period, and at the responses of the clinic to such referrals. One hundred and ninety four cases were referred, mainly from G.P.s. Of the referrals, almost half (44%) failed to attend the clinic. Most of the people who did attend were opiate addicts. The movement of these people through the various procedures of the clinic is described. There were substantial waiting periods between each stage of treatment, though this was not found to be related to attendance or failure to attend. The results are discussed in terms of problems associated with the referral process and the issue of access to treatment facilities. The results provide basic information about the operation of one clinic but raises several important issues that deserve further empirical investigation.     

The Presentation of Dual Diagnosis in an Adolescent Chemical Dependence Unit

Clinical observation of several hundred admissions to a short-term, residential, adolescent chemical dependency unit reveal a number of dual diagnoses cases. This paper discusses the most often occurring dual diagnoses cases, i.e., chemical dependency coexistent with Attention Deficit Disorder, Affective Disorder, Physical Abuse and Sexual Abuse. Diagnostic and treatment issues are presented and discussed.     

Misleading T3-test Values in Psychiatric Patients Treated with Orphenadrine

ABSTRACT Thyroid laboratory tests were assessed in 74 psychiatric patients without clinical evidence of overt thyroid disorder. In a first screening of 42 patients, 13 were found to have elevated levels of triiodothyronine uptake test (T₃-test) by a Sephadex method. Ten of these patients also had an elevated free thyroxine index (fT₄-index). Of the 13 patients with increased T₃-test values, 10 were on orphenadrine (Disipal®) treatment or had recently stopped taking the drug. In a second study, thyroid function tests were compared in 15 pairs of matched psychiatric patients treated with orphenadrine or other anticholinergic drugs. Values of T₃-test and free thyroxine index were significantly higher among patients treated with orphenadrine. Finally, orphenadrine was instituted in four patients and withdrawn in six patients. T₃-test values and free thyroxine indices increased gradually after orphenadrine treatment had been initiated and decreased gradually when it was withdrawn.     

Dual Diagnosis in a State Psychiatric Facility: Risk Factors,Correlates, and Phenomenology of Use

Patients admitted to a state psychiatric facility were interviewed to ascertain the co-occurrence of mental illness and chemical abuse (MI/CA), lifetime substance use, childhood experiences, current living conditions, and use of mental health services. Of the sample, 49% currently had MI/CA, and 20% more had used multiple substances. MI/CA patients were more likely to have been exposed to multiple early risk factors for substance use, including familial substance abuse, mental illness, and physical abuse. They were also younger, male, and experienced more adult homelessness, legal trouble, and family conflict. These results demonstrate the continuing need to develop MI/CA programs.     

Diagnosis and Management of Chronic Obstructive Pulmonary Disease (COPD) in a Primary Care Clinic

ABSTRACT

Chronic Obstructive pulmonary disease (COPD) is an important cause of morbidity and mortality in the United States and internationally. The purpose of this study was to describe spirometry use in the diagnosis of COPD and to evaluate the management of COPD occurring in a primary care clinic. Methods: Two hundred patients with a diagnosis of COPD attending a university-based family medicine clinic were randomly chosen for a retrospective medical record review. Pulmonary function testing, provision of smoking cessation advice and pharmacological management were compared to the recommendations of the Global Initiative for Chronic Obstructive Lung Disease. Results: Mean age was 65.4 years, 48% were male and 72% were Caucasian. Overall, 58.5% (n = 117) of patients had pulmonary function testing, with 60.7% acknowledged in the outpatient record; 55% (n = 110) were receiving medications in combinations that are recommended; and 40% of patients were receiving stage appropriate medications. 67.8% of current smokers were offered smoking cessation advice or treatment. Conclusions: Overall there was low use of recommended medication combinations and stage appropriate treatment, with better observance of diagnostic and risk factor reduction guidelines. In order to improve COPD care for patients, physicians need education about the recommended stepwise treatment options and office systems that promote integration of pulmonary function testing findings into care.     

Underdiagnosis of Alcohol Dependence in Psychiatric Inpatients

Abstract

Alcoholism is prevalent among psychiatric inpatients, and accurately diagnosing alcohol prob lems is a critical step in treatment planning. The authors diagnosed alcohol dependence in 35 psychiatric inpatients by blind review of interview protocols and hospital records. They then examined the frequency with which admitting and attending clinicians diagnosed alcohol abuse and dependence in these patients. Alcoholism was underdiagnosed; 24% of the clinicians' diagnoses included no alcoholism diagnosis, 39% were alcohol abuse, and only 37% were alcohol dependence. Underdiagnosis was strongly associated with the presence of a comorbid psychosis, as well as with patients' denial of alcoholism and with less severe alcoholism. The authors discuss the patient and clinician variables which may contribute to underdiagnosing alcoholism and recommend educational and administrative measures to improve clinicians' diagnostic sensitivity.     

Evidence for a Drug Dependence Syndrome Among Narcotic Users

Recent developments in international classifications of alcohol and drug-related problems have stressed the distinction between a dependence syndrome and various drug-related disabilities. Although considerable research has supported the concept of an alcohol dependence syndrome, little empirical work has been conducted to date with other psychoactive substances. The present study evaluated whether a dependence syndrome could be identified among a clinical sample of 105 narcotic users who had completed the drug Abuse Screening Test (DAST). A factor analysis of the 20 DAST items revealed a dependence factor characterized by an inability to slop drug use, problems in getting through the week without drugs, and withdrawal symptoms when drug use stopped. In addition, four other factors were identified reflecting social problems, medical problems, polydrug abuse and previous treatment. The dependence factor was most strongly correlated with recent use (past 60 days) of narcotics, and was not correlated with age, sex or social status.     

Co-occurrence of Psychiatric Disorders and Alcoholism in Untreated Alcoholic Patients in a VA Medical Walk-in (Triage) Clinic Population

The authors identified 1,836 male veterans who were seeking treatment for various medical disorders at a walk-in (triage) clinic and screened these patients for the presence of alcohol problems by administering a brief interview and the CAGE questionnaire. Patients who screened positive for alcohol problems and who had little or no prior treatment for these problems were then interviewed using a structured psychiatric interview to establish the presence of alcohol dependence and co-occurring psychiatric disorders. The rate of alcohol dependence and co-occurring disorders was substantial, and the pattern was consistent with studies of veteran patients surveyed in other clinical settings.     

Young Drug and Alcohol Casualties Compared: Review of 100 Patients at a Scottish Psychiatric Hospital

The case notes of 100 young drug and alcohol abusers attending a psychiatric hospital were reviewed. Only two of the study group were recorded by the hospital as dependent upon both drugs and alcohol. Case notes revealed that an additional 32 individuals abused both drugs and alcohol, often taking these in conjunction. It was concluded that many of the study group were multi-problem patients whose general lifestyles were more problematic than the varied substances they abused.     

Clinical Predictors of Engagement in Teleintegrated Care and Telereferral Care for Complex Psychiatric Disorders in Primary Care: a Randomized Trial

BackgroundTelepsychiatry Collaborative Care (TCC) and Telepsychiatry/Telepsychology Enhanced Referral (TER) expand the reach of specialty mental health services to underserved populations.ObjectiveAssess clinical predictors of treatment engagement for complex psychiatric conditions in TCC—in which remote specialists consult with primary care teams via an onsite care manager who also provides brief psychotherapy—and TER, in which remote specialists provide direct telehealth treatment.DesignA randomized pragmatic trial from twenty-four primary care clinics without onsite psychiatrists or psychologists.ParticipantsA total of 1,004 adult patients screened positive for posttraumatic stress disorder (PTSD)and/or bipolar disorder were randomized to receive TCC or TER for 1 year.Main MeasuresPsychotherapy engagement was measured by the number of sessions completed, and pharmacotherapy engagement by the medication adherence item from the Schizophrenia Care and Assessment Program Health Questionnaire (SCAP-HQ).Key ResultsEngagement in TCC psychotherapy visits was greater compared to TER. There was no association between the PTSD symptom severity and treatment engagement. The internal state scale (ISS) activation subscale, an indicator of mania, was associated with reduced odds of initiating psychotherapy (odds ratio [OR] = 0.70; 95% CI, 0.59 to 0.84) but not the number of sessions attended once psychotherapy started. The Drug Abuse Screening Test-10(DAST-10) score was associated with receipt of fewer psychotherapy sessions (incidence ratio rate [IRR] = 0.88; 95% CI, 0.81 to 0.95). The number of physical health comorbidities was associated with greater engagement in psychotherapy (IRR = 1.11, 95% CI, 1.03 to 1.19) and pharmacotherapy (OR = 1.54; 95% CI, 1.27 to 1.87). None of the findings varied by intervention group.ConclusionsBoth teleintegrated and telereferral care offer an opportunity to treat patients with complex psychiatric conditions. While there was no difference in clinical characteristics predicting engagement, onsite care managers engaged patients in more psychotherapy sessions than remote therapists.Trial RegistrationClinicalTrials.gov Identifier: {"type":"clinical-trial","attrs":{"text":"NCT02738944","term_id":"NCT02738944"}}NCT02738944Supplementary InformationThe online version contains supplementary material available at 10.1007/s11606-021-07343-x.KEY WORDS: telehealth, collaborative care, treatment engagement, psychiatric disorders, PTSD, bipolar disorder, primary care, federally qualified, health centers

Due to limited availability of mental health specialists in underserved areas, primary care practices often treat patients with complex psychiatric conditions^1–3, including posttraumatic stress disorder (PTSD) and bipolar disorder (BD) which respectively affects up to 20%^4,5 and 4%³ of their population. Bipolar disorder and PTSD frequently co-occur⁶ and have a high likelihood of psychiatric comorbidities^7–9, including substance use disorders^10,11, resulting in greater symptom burden and lower quality of life^6,8, premature mortality^9,12, and higher disengagement from care^10,13–15. A review of empirically supported treatments for PTSD yielded attrition rates as high as 60% for veterans¹⁶ and 57% for the general population¹⁷. Premature dropout rates for pharmacotherapy for BD range between 30 and 40%^13,18.Telepsychiatry Collaborative Care (TCC) and Telepsychiatry/Telepsychology Enhanced Referral (TER) expand the reach of specialty mental health services to underserved populations^19–22. TCC uses a team-based approach with a lead primary care provider, support from a care manager and consultation from a telepsychiatrist for treatment recommendations^21,22. TER allows for live synchronous audio-visual interactions between patients and mental health clinicians for delivery of care^20,21. Telepsychiatrists prescribed medications directly to the patient and telepsychologists deliver psychotherapy. Both models are evidence-based practices for depressive and anxiety disorders^20,21 but little is known regarding the engagement of patients with complex psychiatric conditions. Prior studies showed PTSD severity and the symptom cluster of avoidance to be associated with patient dropout in specialty mental health care ^23–25. Studies of patients with BD demonstrated a switch to hypomania negatively impacts treatment engagement, particularly when associated with substance use^8,18. Whether PTSD and BD symptomatology and comorbidities are associated with engagement in TCC or TER, or differences in engagement between models, could inform individual patient care decisions, treatment guidelines, and service implementation for millions of Americans increasingly relying on telehealth services²⁶.We assessed clinical predictors of psychotherapy and pharmacotherapy engagement using data from the Study to Promote Innovation in Rural Integrated Telepsychiatry (SPIRIT), a large comparative effectiveness trial of TCC (an integrated care model), and TER (a virtually co-located, but not integrated, model), for the management of PTSD and BD in underserved primary care settings²⁷. Improved outcomes were observed in both intervention groups, and there was overall greater engagement in psychotherapy in the TCC arm²⁸. This secondary analysis focuses on potential differences in clinical predictors of engagement in treatment across and between arms to inform patient-level clinical decision-making. We hypothesized that PTSD avoidance symptoms would be associated with decreased engagement across both arms. We also conducted exploratory analyses to assess whether overall PTSD symptoms, mania, and clinical covariates were associated with treatment engagement and whether the effects differed by care model. We hypothesized that negative predictors of engagement would have stronger effects in the TER arm compared to the TCC arm, as the latter offers more proactive efforts to engage and activate patients through the primary care-based care manager.     

Treatment of Alcoholic Patients in a Psychiatric Hospital

This study was undertaken on 50 male patients chosen at random among the 188 who came in the last 6 months.     

Disulfiram Treatment of Patients with Both Alcohol Dependence and Other Psychiatric Disorders: A Review

In treatment of alcohol dependence, disulfiram is most useful in conjunction with a structured, supervised, aftercare program. However, it has been reported to cause psychiatric side effects and to interact with various psychiatric medications. Many patients with alcohol dependence suffer from other psychiatric disorders and are treated with such psychiatric medications. This paper reviews the pertinent clinical pharmacology of disulfiram and the literature on potential psychiatric complications and drug interactions of disulfiram. At the usual dosage, about 250 mg/day, disulfiram does not appear to increase significantly the risk of psychiatric complications or of psychiatric drug interactions. Therefore, it can be considered a treatment option for patients with alcohol dependence and other psychiatric disorders.