The Need to Adapt the Psychiatric Clinical Assessment to the Digital Age: A Practical Approach

The use of electronic devices and social media is becoming a ubiquitous part of most people's lives. Although researchers are exploring the sequelae of such use, little attention has been given to the importance of digital media use in routine psychiatric assessments of patients. The nature of technology use is relevant to understanding a patient's lifestyle and activities, the same way that it is important to evaluate the patient's occupation, functioning, and general activities. The authors propose a framework for psychiatric inquiry into digital media use, emphasizing that such inquiry should focus on quality of use, including emotional and behavioral consequences, rather than simply the amount of use.

Before and During the First COVID-19 Surge: Work Conditions, Burnout, and Mental Health Among Resident Physicians in a Department of Psychiatry in the USA

OBJECTIVE

Resident physicians are critical frontline workers during pandemics, and little is known about their health. The study examined occupational and mental health risks among US psychiatry residents before and during the first COVID-19 surge.

METHODS

Longitudinal data were collected from a cohort of US psychiatry residents at one academic medical center in October 2019, before the pandemic, and April 2020 after the initiation of a state-level stay-at-home order. Primary outcome measures were psychological work empowerment, defined as one's self-efficacy towards their work role, and occupational burnout. A secondary outcome was mental health. In May and June 2020, resident engagement sessions were conducted to disseminate study findings and consider their implications.

RESULTS

Fifty-seven out of 59 eligible residents participated in the study (97%). Half the study sample reported high burnout. From before to during the first COVID-19 surge, psychological work empowerment increased in the total sample (p = 0.03); and mental health worsened among junior residents (p = 0.004), not senior residents (p = 0.12). High emotional exhaustion and depersonalization were associated with worse mental health (p < 0.001). In engagement sessions, themes related to residents' work conditions, COVID-19, and racism emerged as potential explanations for survey findings.

CONCLUSIONS

The study is exploratory and novel. During early COVID, psychiatry residents' well-being was impacted by occupational and societal factors. Postpandemic, there is a growing psychiatrist shortage and high demand for mental health services. The findings highlight the potential importance of physician wellness interventions focused on early career psychiatrists who were first responders during COVID.

Revisiting Research Safety Protocols: The Urgency for Alternatives to Law Enforcement in Crisis Intervention

Research safety protocols are ubiquitous in mental health research involving human subjects and have the potential to harm research participants from racial-ethnic minority populations. For mental health emergencies, such protocols commonly rely on law enforcement for crisis intervention. The authors review inequities experienced by individuals with mental illness in law enforcement encounters, especially Black, Latinx, and other minoritized populations. They then describe the development of a research safety protocol that uses community-based crisis intervention programs as alternatives to law enforcement and provide a roadmap for researchers and institutional review boards to revisit and revise their human subjects safety protocols.

Long-Acting Injectable Therapy for People with HIV: Looking Ahead with Lessons from Psychiatry and Addiction Medicine

Long-acting injectable antiretroviral medications are new to HIV treatment. People with HIV may benefit from a treatment option that better aligns with their preferences, but could also face new challenges and barriers. Authors from the fields of HIV, substance use treatment, and mental health collaborated on this commentary on the issues surrounding equitable implementation and uptake of LAI ART by drawing lessons from all three fields. We employ a socio-ecological framework beginning at the policy level and moving through the community, organizational, interpersonal, and patient levels. We look at extant literature on the topic as well as draw from the direct experience of our clinician-authors.

Client Outreach in Los Angeles County's Assisted Outpatient Treatment Program: Strategies and Barriers to Engagement

Purpose

Assisted Outpatient Treatment (AOT) programs can compel treatment-refusing individuals to participate in mental health treatment via civil court order. In California's AOT programs, individuals first must be offered 30 days of outreach services and can accept services voluntarily. This study examines the use of outreach strategies in an AOT program with the potential for voluntary or involuntary enrollment.

Methods

Outreach staff completed a survey in which they reported and rated outreach strategies and barriers to treatment for 487 AOT-referred individuals.

Results

Outreach staff reported using a broad array of strategies to persuade and engage clients. Supportive and persuasive strategies were most common. More coercive strategies, including court order, were used when needed. More clients enrolled voluntarily (39.4%) than involuntarily (7.2%).

Conclusions

Outreach, coupled with the strategic used of potential court involvement, can lead to voluntary enrollment of treatment-refusing individuals with many, often severe, barriers to engaging in outpatient treatment.

Multi-Sector Assessment and Client-Perception of Social Need at Long-Term Follow-Up of a Group-Randomized Trial of Community-Engaged Collaborative Care for Adults with Depression

Understanding client perceptions of need for underlying social determinant support may improve services for depression care. This secondary analysis examines perceptions of "social needs" related to housing and employment, financial, and legal (EFL) concerns among individuals with depression. Data were analyzed from Community Partners in Care, a randomized comparative effectiveness trial of multi-sector collaborative care for depression among a sample of people who were predominantly racial/ethnic minorities and low-income. Adults with depression (n = 980) in both interventions were surveyed at 36-month follow-up for (1) being asked about and (2) having social needs for housing or EFL concerns. In multivariate models, life difficulty and mental health visits in non-healthcare sectors predicted being asked about housing and EFL. Lower social determinants of health-related life satisfaction increased the odds of having unmet housing and EFL needs. These findings underscore the role of non-healthcare organizations as community resources for depression care and in screening and addressing social needs.

Mental Health Conservatorship Among Homeless People With Serious Mental Illness

OBJECTIVE

The purpose of this study was to examine associations between homelessness and length of psychiatric hospitalization and to explore the role of mental health conservatorship in determining discharge location for patients who are homeless and have a grave disability from serious mental illness.

METHODS

This observational study used administrative data from a safety-net psychiatric hospital in Los Angeles. The sample included 795 adults (≥18 years) who were hospitalized on an involuntary psychiatric hold between 2016 and 2018. The outcome variables were length of stay (days) and discharge location (home, locked psychiatric facility, unlocked psychiatric facility, unhoused). The predictor variables were homelessness status and whether a mental health conservatorship was initiated during hospitalization. Multiple regression models were used to estimate associations between variables.

RESULTS

Homelessness status was associated with 27.5 additional days (SE=3.5 days) of hospitalization in adjusted models. Homeless patients for whom conservatorship was initiated comprised 6% of the sample but 41% of total inpatient days. Among people who were homeless, initiation of a conservatorship was associated with significantly longer length of inpatient stay (mean=154.8 days versus 25.6 days for the whole sample) but also with lower odds of being unhoused at the time of discharge (risk ratio=0.19, 95% confidence interval=0.09-0.34).

CONCLUSIONS

A mental health conservatorship can be a mechanism for helping homeless people with a grave disability from mental illness to transition from the streets to residential psychiatric treatment, but it requires substantial resources from facilities that initiate such conservatorships and does not guarantee resolution of long-term supportive housing needs.

We're Not Sure We Like It but We Still Want More: Trainee and Faculty Perceptions of Remote Learning During the COVID-19 Pandemic

OBJECTIVE

In this study, the authors aim to compare perceptions of remote learning versus in-person learning among faculty and trainees at a single institution during the COVID-19 pandemic and to evaluate the impact that a brief faculty training on best practices in online teaching would have on faculty attitudes towards remote learning.

METHODS

The authors conducted an attitude survey on remote learning among trainees and faculty members approximately 3 months after the transition from in-person to remote learning. The authors then conducted a faculty training on best practices in online teaching followed by an evaluation survey. Study findings were examined descriptively and by Fisher's exact testing.

RESULTS

The response rates for the attitudes survey were 68% among trainees and 61% among faculty. Trainees and faculty perceived in-person learning more favorably than remote learning across a variety of domains, including overall enjoyment, interpersonal connection, ability to communicate, and concentration. Despite these trends, only 10% of trainees and 14% of faculty felt that all lectures would be most effectively delivered in-person when this becomes possible again. The response rate for the faculty training evaluation survey was 16%. Compared to non-attendees, faculty attendees reported more confidence in their ability to teach remotely (89% vs 56%, p=0.02) but not increased optimism (89% vs 63%, p=0.06).

CONCLUSIONS

The study findings suggest that both trainees and faculty perceive remote learning negatively compared to in-person learning but still feel that some lectures should be delivered remotely even after a return to in-person learning is possible.

Directing Research Toward Health Equity: a Health Equity Research Impact Assessment

Despite medical research advancements, inequities persist, as research has enhanced the health of some while leaving many communities untouched. Reforms are needed to direct research toward health equity, both during this pandemic and beyond. All research must currently pass scientific and ethical review processes, but neither may adequately examine a project's potential impact on inequities and local communities. Research stakeholders need practical tools to help review and examine any given study's impact on health equity. We articulate a health equity research impact assessment, which draws from existing research impact assessments and health disparities research measures and frameworks. We describe how this tool was developed and how it may be used by research reviewers, researchers, academic institutions, and funding agencies to elevate health equity in medical science.

How Pharmaceuticals Mask Health and Social Inequity

Medications, like all interventions, shape the ways in which physicians see disease, provide care, define successful outcomes, and organize health care systems. Pharmaceuticals make symptoms and biological drug targets more visible while rendering individuals and their social suffering invisible, thereby focusing our profession on the intracellular effects of an unequal society. This article uses psychopharmacology as a probe to trace a more general problem within contemporary medicine: the pervasive influence of biomedical narratives and therapeutic rationales extending from clinical practice, to medical education, to health care finance.

Recovery in Context: Thirty Years of Mental Health Policy in California

Over the past quarter century, Recovery has become the hegemonic model guiding mental health policy. Advocates presented Recovery as a radical departure from the past, with the promise of dramatically improved outcomes for those with serious mental illness. This article looks at the implementation of Recovery-based policies in California from the 1990s to the present and interrogates the ways these policies emerged out of and reinforced many of the problems they were intended to solve. Against the backdrop of welfare reform, managed care, and a growing belief in market forces and individual responsibility, California policymakers pivoted from rigorously studied pilot programs that were intended to provide intensive, long-term treatment to Recovery-oriented programs that, while initially intensive, promised to "flow" increasingly independent and self-sufficient patients to less-intensive services. Moreover, these new programs promised to produce cost savings by reducing homelessness, hospitalization, and incarceration. Reported outcomes from these programs have been overwhelmingly positive but are based on flawed evaluations that lean more heavily on belief than on evidence. While proclaiming a comprehensive, patient-centered approach, Recovery's embrace of independence over long-term care and social supports has justified a system of care that systematically fails the sickest patients by abandoning them to the streets and jails.

Reconsidering Systems-Based Practice: Advancing Structural Competency, Health Equity, and Social Responsibility in Graduate Medical Education

Health inequities stem from systematic, pervasive social and structural forces. These forces marginalize populations and create the circumstances that disadvantage these groups, as reflected in differences in outcomes like life expectancy and infant mortality and in inequitable access to and delivery of health care resources. To help eradicate these inequities, physicians must understand racism, sexism, oppression, historical marginalization, power, privilege, and other sociopolitical and economic forces that sustain and create inequities. A new educational paradigm emphasizing the knowledge, skills, and attitudes to achieve health equity is needed.Systems-based practice is the graduate medical education core competency that focuses on complex systems and physicians' roles within them; it includes topics like multidisciplinary team-based care, patient safety, cost containment, end-of-life goals, and quality improvement. This competency, however, is largely health care centric and does not train physicians to engage with the complexities of the social and structural determinants of health or to partner with systems and communities that are outside health care.The authors propose a new core competency centered on health equity, social responsibility, and structural competency to address this gap in graduate medical education. For the development of this new competency, the authors draw on existing, innovative undergraduate and graduate medical pedagogy and public health, health services research, and social medicine frameworks. They describe how this new competency would inform graduate medical education and clinical care and encourage future physicians to engage in the work of health equity.

Outcomes of two quality improvement implementation interventions for depression services in adults with substance use problems

Background: Comorbid depression and substance use disorders (SUDs) are associated with poor health and social outcomes disproportionately affecting under-resourced communities.Objectives: To test the hypothesis that a coalition approach to collaborative care (CC) for depression would improve outcomes of hazardous drinking and behavioral health hospitalizations, relative to technical assistance, for individuals with comorbid substance use problems. Substance use problems were defined by meeting criteria for DSM-IV substance abuse or dependence, hazardous drinking by AUDIT-C, or treatment in a SUD program within the prior 6 months.Methods: Two depression CC implementation approaches were compared: Resources for Services (RS) provided expert technical support for CC toolkits to individual programs. Community engagement and planning (CEP) supported multi-sector coalitions in collaborating in planning, adapting, implementing and monitoring CC toolkits. One thousand eighteen individuals with depression (PHQ-8 ≥10) enrolled. Regression analyses estimated intervention effects in participants with comorbid substance use problems (n = 588, 281 females, 307 males). Substance use problems were defined by meeting criteria for DSM-IV substance abuse or dependence, hazardous drinking by AUDIT-C, or treatment in a SUD program within the prior 6 months.Results: There were no significant baseline differences by intervention status among participants with depression and substance use problems. Intervention effects on primary outcomes including depression were not significant at 6 months. Compared to RS, CEP significantly reduced alcohol consumption (CEP = 1.6, RS = 2.1, p = .038), probability of behavioral health hospitalizations (OR = 0.50, p = .036), and use of specialty mental health visits (IRR = 0.52, p = .027), while increasing use of faith-based depression services (IRR = 3.4, p = .001).Conclusions: Given feasibility and possible benefits, CEP should be considered a promising approach to implementing depression CC with potential benefits to adults with comorbid substance use problems.

Community Interventions to Promote Mental Health and Social Equity

(Reprinted with permission from Current Psychiatry Reports (2020) 21: 35).

Community Interventions to Promote Mental Health and Social Equity

PURPOSE OF REVIEW

We review recent community interventions to promote mental health and social equity. We define community interventions as those that involve multi-sector partnerships, emphasize community members as integral to the intervention, and/or deliver services in community settings. We examine literature in seven topic areas: collaborative care, early psychosis, school-based interventions, homelessness, criminal justice, global mental health, and mental health promotion/prevention. We adapt the social-ecological model for health promotion and provide a framework for understanding the actions of community interventions.

RECENT FINDINGS

There are recent examples of effective interventions in each topic area. The majority of interventions focus on individual, family/interpersonal, and program/institutional social-ecological levels, with few intervening on whole communities or involving multiple non-healthcare sectors. Findings from many studies reinforce the interplay among mental health, interpersonal relationships, and social determinants of health. There is evidence for the effectiveness of community interventions for improving mental health and some social outcomes across social-ecological levels. Studies indicate the importance of ongoing resources and training to maintain long-term outcomes, explicit attention to ethics and processes to foster equitable partnerships, and policy reform to support sustainable healthcare-community collaborations.

Community, Public Policy, and Recovery from Mental Illness: Emerging Research and Initiatives

This commentary examines the roles that communities and public policies play in the definition and processes of recovery for adults with mental illness. Policy, clinical, and consumer definitions of recovery are reviewed, which highlight the importance of communities and policies for recovery. This commentary then presents a framework for the relationships between community-level factors, policies, and downstream mental health outcomes, focusing on macroeconomic, housing, and health care policies; adverse exposures such as crime victimization; and neighborhood characteristics such as social capital. Initiatives that address community contexts to improve mental health outcomes are currently under way. Common characteristics of such initiatives and select examples are discussed. This commentary concludes with a discussion of providers', consumers', and other stakeholders' roles in shaping policy reform and community change to facilitate recovery.

Community Partnering for Behavioral Health Equity: Public Agency and Community Leaders' Views of its Promise and Challenge

Objective

To understand potential for multi-sector partnerships among community-based organizations and publicly funded health systems to implement health improvement strategies that advance health equity.

Design

Key stakeholder interviewing during HNI planning and early implementation to elicit perceptions of multi-sector partnerships and innovations required for partnerships to achieve system transformation and health equity.

Setting

In 2014, the Los Angeles County (LAC) Board of Supervisors approved the Health Neighborhood Initiative (HNI) that aims to: 1) improve coordination of health services for behavioral health clients across safety-net providers within neighborhoods; and 2) address social determinants of health through community-driven, public agency sponsored partnerships with community-based organizations.

Participants

Twenty-five semi-structured interviews with 49 leaders from LAC health systems, community-based organizations; and payers.

Results

Leaders perceived partnerships within and beyond health systems as transformative in their potential to: improve access, value, and efficiency; align priorities of safety-net systems and communities; and harness the power of communities to impact health. Leaders identified trust as critical to success in partnerships but named lack of time for relationship-building, limitations in service capacity, and questions about sustainability as barriers to trust-building. Leaders described the need for procedural innovations within health systems that would support equitable partnerships including innovations that would increase transparency and normalize information exchange, share agenda-setting and decision-making power with partners, and institutionalize partnering through training and accountability.

Conclusions

Leaders described improving procedural justice in public agencies' relationships with communities as key to effective partnering for health equity.

The Community and Patient Partnered Research Network (CPPRN): Application of Patient-Centered Outcomes Research to Promote Behavioral Health Equity

Objective

We describe the rationale, development, and progress on the Community and Patient Partnered Research Network (CPPRN). The CPPRN builds on more than a decade of partnered work and is designed to promote health equity by developing partnered research on behavioral health and social risk factors in Los Angeles and New Orleans.

Setting

A community-academic partnership across Los Angeles County and New Orleans.

Methods

Review of rationale, history, structure, activities and progress in applying community partnered participatory research (CPPR) to CPPRN.

Findings

Patient and community stakeholders participated in all phases of development, including local and national activities. Key developments include partnered planning efforts, progress on aggregating a large, de-identified dataset across county agencies, and development of an information technology-supported screening approach for behavioral and social determinants in health care, social, and community-based settings.

Conclusion

The CPPRN represents a promising approach for research data networks, balancing the potential benefit of information technology and data analytic approaches while addressing potential risks and priorities of relevant stakeholders.

Stakeholder Perspectives on the Social Determinants of Mental Health in Community Coalitions

Objective

Although evidence supports the potential for community coalitions to positively address social determinants of mental health, little is known about the views of stakeholders involved in such efforts. This study sought to understand county leaders' perspectives about social determinants related to the Health Neighborhood Initiative (HNI), a new county effort to support community coalitions.

Design

Descriptive, qualitative study, 2014.

Setting

Community coalitions, located in a large urban city, across eight service planning areas, that serve under-resourced, ethnic minority populations.

Procedures

We conducted key informant interviews with 49 health care and community leaders to understand their perspectives about the HNI. As part of a larger project, this study focused on leaders' views about social determinants of health related to the HNI. All interviews were audio-recorded and transcribed. An inductive approach to coding was used, with text segments grouped by social determinant categories.

Results

County leaders described multiple social determinants of mental health that were relevant to the HNI community coalitions: housing and safety, community violence, and employment and education. Leaders discussed how social determinants were interconnected with each other and the need for efforts to address multiple social determinants simultaneously to effectively improve mental health.

Conclusions

Community coalitions have an opportunity to address multiple social determinants of health to meet social and mental health needs of low-resourced communities. Future research should examine how community coalitions, like those in the HNI, can actively engage with community members to identify needs and then deliver evidence-based care.

A Window of Opportunity: Visions and Strategies for Behavioral Health Policy Innovation

Objective

The New York City's Thrive (ThriveNYC) and the Los Angeles County Health Neighborhood Initiative (HNI) are two local policies focused on addressing the social determinants of behavioral health as a preventive strategy for improving health service delivery. On January 29, 2016, leaders from both initiatives came together with a range of federal agencies in health care, public health, and policy research at the RAND Corporation in Arlington, Virginia. The goal of this advisory meeting was to share lessons learned, consider research and evaluation strategies, and create a dialogue between stakeholders and federal funders - all with the purpose to build momentum for policy innovation in behavioral health equity.

Methods

This article analyzes ethnographic notes taken during the meeting and in-depth interviews of 14 meeting participants through Kingdon's multiple streams theory of policy change.

Results

Results demonstrated that stakeholders shared a vision for behavioral health policy innovation focused on community engagement and social determinants of health. In addition, Kingdon's model highlighted that the problem, policy and politics streams needed to form a window of opportunity for policy change were coupled, enabling the possibility for behavioral health policy innovation.

Conclusions

The advisory meeting suggested that local policy makers, academics, and community members, together with federal agents, are working to implement behavioral health policy innovation.

Emotional Well-Being and Public Health: Proposal for a Model National Initiative

In 2011, the National Prevention, Health Promotion, and Public Health Council named mental and emotional well-being as 1 of 7 priority areas for the National Prevention Strategy. In this article, we discuss emotional well-being as a scientific concept and its relevance to public health. We review evidence that supports the association between emotional well-being and health. We propose a national emotional well-being initiative and describe its 6 components: systematic measurement of emotional well-being, identification of the drivers of emotional well-being, formation of partnerships with diverse stakeholders, implementation and dissemination of evidence-based interventions to promote emotional well-being and its drivers, development of public health messaging, and identification of and strategies to address disparities in emotional well-being and its drivers. Finally, we discuss ways in which a national emotional well-being initiative would complement current public health efforts and the potential challenges to such an initiative.

Improving Depression Care for Adults With Serious Mental Illness in Underresourced Areas: Community Coalitions Versus Technical Support

OBJECTIVE

Community Partners in Care (CPIC) was a group-randomized study of two approaches to implementing expanded collaborative depression care: Community Engagement and Planning (CEP), a coalition approach, and Resources for Services (RS), a technical assistance approach. Collaborative care networks in both arms involved health care and other agencies in five service sectors. This study examined six- and 12-month outcomes for CPIC participants with serious mental illness.

METHODS

This secondary analysis focused on low-income CPIC participants from racial-ethnic minority groups with serious mental illness in underresourced Los Angeles communities (N=504). Serious mental illness was defined as self-reported severe depression (≥20 on the Patient Health Questionnaire-8) at baseline or a lifetime history of bipolar disorder or psychosis. Logistic and Poisson regression with multiple imputation and response weights, controlling for covariates, was used to model intervention effects.

RESULTS

Among CPIC participants, 50% had serious mental illness. Among those with serious mental illness, CEP relative to RS reduced the likelihood of poor mental health-related quality of life (OR=.62, 95% CI=.41-.95) but not depression (primary outcomes); reduced the likelihood of having homelessness risk factors and behavioral health hospitalizations; increased the likelihood of mental wellness; reduced specialty mental health medication and counseling visits; and increased faith-based depression visits (each p<.05) at six months. There were no statistically significant 12-month effects.

CONCLUSIONS

Findings suggest that a coalition approach to implementing expanded collaborative depression care, compared with technical assistance to individual programs, may reduce short-term behavioral health hospitalizations and improve mental health-related quality of life and some social outcomes for adults with serious mental illness, although no evidence was found for long-term effects in this subsample.

How Do Clinicians Prefer Cultural Competence Training? Findings from the DSM-5 Cultural Formulation Interview Field Trial

OBJECTIVE

This study's objective is to analyze training methods clinicians reported as most and least helpful during the DSM-5 Cultural Formulation Interview field trial, reasons why, and associations between demographic characteristics and method preferences.

METHOD

The authors used mixed methods to analyze interviews from 75 clinicians in five continents on their training preferences after a standardized training session and clinicians' first administration of the Cultural Formulation Interview. Content analysis identified most and least helpful educational methods by reason. Bivariate and logistic regression analysis compared clinician characteristics to method preferences.

RESULTS

Most frequently, clinicians named case-based behavioral simulations as "most helpful" and video as "least helpful" training methods. Bivariate and logistic regression models, first unadjusted and then clustered by country, found that each additional year of a clinician's age was associated with a preference for behavioral simulations: OR = 1.05 (95 % CI: 1.01-1.10; p = 0.025).

CONCLUSIONS

Most clinicians preferred active behavioral simulations in cultural competence training, and this effect was most pronounced among older clinicians. Effective training may be best accomplished through a combination of reviewing written guidelines, video demonstration, and behavioral simulations. Future work can examine the impact of clinician training satisfaction on patient symptoms and quality of life.

An Initiative to Improve Clozapine Prescribing in New York State

Clozapine remains the only medication approved for treatment-resistant schizophrenia. But underuse is the norm. In 2010, the New York State Office of Mental Health began a multifaceted initiative to promote the evidence-based use of clozapine. From 2009 to 2013, in the absence of a well-funded pharmaceutical marketing campaign, the proportion of new clozapine trials among all new outpatient antipsychotic trials increased 40% among adult New York Medicaid recipients with a diagnosis of schizophrenia. The largest gains occurred in state-operated clinics. New York's experience demonstrates the feasibility of making clozapine more accessible to patients who stand to benefit most.

Metabolic Syndrome Screening and Assertive Community Treatment: A Quality Improvement Study

Metabolic syndrome defines a collection of cardiometabolic illnesses that predict risk for poor physical health and early death and is highly prevalent among those with serious mental illness. Despite recommendations for routine monitoring, those with serious mental illness frequently do not receive physical health screenings. We conducted a quality improvement (QI) project to increase rates of metabolic syndrome screening in three New York City Assertive Community Treatment (ACT) teams. The project, conducted from December 2010 to May 2011, involved educational sessions for staff and consumers and a systematic screening protocol. We collected complete metabolic syndrome screening measurements for 71% of participating ACT consumers. We found metabolic risk to be nearly universal among participants, with over half diagnosed with metabolic syndrome. We also found high rates of previously undiagnosed hypertension, diabetes, and dyslipidemia. We describe the resources and obstacles we encountered in our QI project to make systematic metabolic screening a routine part of ACT care. This QI project suggests that ACT teams can take a leadership role in screening their consumers for physical health issues, aligning with recent policy trends to better integrate behavioral health and primary care services.

Electronic health records in mental health research: a framework for developing valid research methods

This Open Forum describes research methods to ensure high-quality health services research using electronic health records (EHRs) as a data source. The authors describe unique characteristics of EHRs that could introduce data inaccuracies into research, and they outline a framework for methods to evaluate the validity of EHR-derived data, including the development of data extraction rules and ways to validate those rules. The authors argue that the use of such methods will help ensure the validity of research using EHRs as a data source.

Communication profiles of psychiatric residents and attending physicians in medication-management appointments: a quantitative pilot study

OBJECTIVE

The authors quantitatively examined differences in psychiatric residents' and attending physicians' communication profiles and voice tones.

METHODS

Audiotaped recordings of 49 resident-patient and 35 attending-patient medication-management appointments at four ambulatory sites were analyzed with the Roter Interaction Analysis System (RIAS). Nonparametric tests were used to compare differences in proportions of speech devoted to relationship-building, activating, and partnering in decision-making processes, and data-gathering/counseling/patient education. Differences in affect expressed by psychiatrists' voice tones were also examined.

RESULTS

Residents' visits were twice as long as Attendings' visits (28.2 versus 14.1 minutes), and residents devoted a significantly greater proportion of their talk to relationship-building (23% versus 20%) and activating/partnering (36% versus 28%) aspects of communication, whereas Attendings devoted a greater proportion to biomedically-related data-gathering/counseling/patient education (31% versus 20%). Analysis of voice tones revealed that residents were perceived as sounding significantly friendlier and more sympathetic, versus Attendings, who were rated as sounding more dominant and rushed.

CONCLUSION

These findings show distinct communication profiles and voice-tone differences. Future psychiatric communication research should address the influence of appointment length, psychiatrist/patient characteristics, and other potential confounders on psychiatrist-patient communication.