Mobile Behavioral Sensing for Outpatients and Inpatients With Schizophrenia

OBJECTIVE

This study examined the feasibility, acceptability, and utility of behavioral sensing among individuals with schizophrenia.

METHODS

Nine outpatients and 11 inpatients carried smartphones for two- or one-week periods, respectively. Device-embedded sensors (accelerometers, microphone, global positioning system, WiFi, and Bluetooth) collected behavioral data and ascertained the patients' location, activity, and exposure to human speech as they went about their day. Participants rated this approach by completing usability and acceptability measures.

RESULTS

Sensing successfully captured individuals' activity, time spent proximal to human speech, and time spent in various locations. Participants felt comfortable using the sensing system (95%), and most were interested in receiving feedback (65%) and suggestions (65%). Approximately 20% reported that sensing made them upset. One-third of inpatients were concerned about their privacy, but no outpatients expressed this concern.

CONCLUSIONS

Mobile behavioral sensing was a feasible, acceptable, and informative approach for data collection among outpatients and inpatients with schizophrenia.

Health care for patients with serious mental illness: family medicine's role

Numerous studies document disproportionate physical morbidity and premature death among people with serious mental illness. Although suicide remains an important cause of mortality for this population, cardiovascular disease is the leading cause of death. Cardiovascular death among those with serious mental illness is 2 to 3 times that of the general population. This vulnerability is commonly attributed to underlying mental illness and behavior. Some excess disease and deaths result from poor access to and use of quality health care. Negative cardiometabolic effects of newer psychotropic medications augment these trends by increasing rates of obesity, diabetes, and hyperlipidemia among those treated. Researchers have developed innovative care models aimed at minimizing the disparate health outcomes of patients with serious mental illness. Most strive to enhance access to primary care, but publications on this topic appear almost exclusively in the psychiatric literature. A focus on primary care for the prevention of excess cardiometabolic morbidity and mortality in this population is appropriate, but depends on primary care physicians' understanding of the problem, involvement in the solutions, and collaboration with psychiatrists. We review health outcomes of the seriously mentally ill and models designed to improve these outcomes. We propose specific strategies for Family Medicine clinicians and researchers to address this problem.

Hepatitis C Treatment for People With Severe Mental Illness

Over 4 million people in the United States are chronically infected with hepatitis C virus (HCV), and, if untreated, over 20% of these will progress to more serious disease. Persons with severe mental illness (SMI) have markedly elevated rates of HCV infection, but treatment of persons with SMI and HCV has been controversial. Effective antiviral treatment is available, but side effects include depression and other neuropsychiatric symptoms. This article reviews the available data on neuropsychiatric side effects of interferon (IFN) treatment, discusses the limitations of the current research, and makes recommendations regarding HCV treatment in persons with SMI.

Mobile Mindfulness Intervention on an Acute Psychiatric Unit: Feasibility and Acceptability Study

BACKGROUND

Aggression and violence on acute psychiatric inpatient units is extensive and leads to negative sequelae for staff and patients. With increasingly acute inpatient milieus due to shorter lengths of stay, inpatient staff is limited in training and time to be able to provide treatments. Mobile technology provides a new platform for offering treatment on such units, but it has not been tested for feasibility or usability in this particular setting.

OBJECTIVE

The aim of this study was to examine the feasibility, usability, and acceptability of a brief mindfulness meditation mobile phone app intended to reduce anger and aggression in acute psychiatric inpatients with schizophrenia, schizoaffective disorder, or bipolar disorder, and a history of violence.

METHODS

Participants were recruited between November 1, 2015 and June 1, 2016. A total of 13 inpatients at an acute care state hospital carried mobile phones for 1 week and were asked to try a commercially available mindfulness app called Headspace. The participants completed a usability questionnaire and engaged in a qualitative interview upon completion of the 7 days. In addition, measures of mindfulness, state and trait anger, and cognitive ability were administered before and after the intervention.

RESULTS

Of the 13 enrolled participants, 10 used the app for the 7 days of the study and completed all measures. Two additional participants used the app for fewer than 7 days and completed all measures. All participants found the app to be engaging and easy to use. Most (10/12, 83%) felt comfortable using Headspace and 83% (10/12) would recommend it to others. All participants made some effort to try the app, with 6 participants (6/12, 50%) completing the first 10 10-minute "foundation" guided meditations.

CONCLUSIONS

This is the first known study of the use of a commercially available app as an intervention on acute psychiatric inpatient units. Acutely ill psychiatric inpatients at a state hospital found the Headspace app easy to use, were able to complete a series of meditations, and felt the app helped with anxiety, sleep, and boredom on the unit. There were no instances of an increase in psychotic symptoms reported and there were no episodes of aggression or violence noted in the record.

Use of Multimodal Technology to Identify Digital Correlates of Violence Among Inpatients With Serious Mental Illness: A Pilot Study

OBJECTIVE

The study examined multimodal technologies to identify correlates of violence among inpatients with serious mental illness.

METHODS

Twenty-eight high-risk inpatients were provided with smartphones adapted for data collection. Participants recorded their thoughts and behaviors by using self-report software. Sensors embedded in each device (microphone and accelerometers) and throughout the inpatient unit (Bluetooth beacons) captured patients' activity and location.

RESULTS

Self-reported delusions were associated with violent ideation (odds ratio [OR]=3.08), damaging property (OR=8.24), and physical aggression (OR=12.39). Alcohol and cigarette cravings were associated with violent ideation (OR=5.20 and OR=6.08, respectively), damaging property (OR=3.71 and OR=4.26, respectively), threatening others (OR=3.62 and OR=3.04, respectively), and physical aggression (OR=6.26, and OR=8.02, respectively). Drug cravings were associated with violent ideation (OR=2.76) and damaging property (OR=5.09). Decreased variability in physical activity and noisy ward conditions were associated with violent ideation (OR=.71 and OR=2.82, respectively).

CONCLUSIONS

Identifiable digital correlates may serve as indicators of increased risk of violence.

Response properties of cells in rabbit's lateral geniculate nucleus during reversible blockade of retinal on-center channel

In the vertebrate retina, visual information is segregated into an on channel excited by light increment and a complementary off channel excited by light decrement. We used 2-amino-4-phosphonobutyric acid (APB), which selectively blocks the on channel in the retina (29), to determine the contributions of the on and off pathways to response properties of neurons in the lateral geniculate nucleus (LGN) of anesthetized, paralyzed rabbits. Visually evoked responses were recorded from 46 single cells in the LGN before, during, and after vitreal perfusion with 200-1,000 microM APB. APB reversibly blocked responses of on uniform-field cells and on center concentric-field cells to stationary, flashing spots of light. Responses to off uniform-field cells and off-center concentric-field cells were largely unaffected. APB did not differentially affect responses elicited from the receptive-field centers, as opposed to the surrounds, of on-center concentric-field cells. This finding suggests that these cells are driven exclusively by the on retinal channel and that the center-surround organization of their receptive fields does not result from a convergence of the on and off pathways. We studied a small number of cells that were selective for stimulus direction or motion. In each case, APB eliminated the cell's response to a moving light edge. The surviving response to a moving dark edge retained its original direction or motion preference, suggesting that these response properties do not depend critically on interactions between the on and the off pathways. The findings obtained in the rabbit are reminiscent of the results of similar investigations in the cat (10, 11) and the monkey (25). Taken together, they indicate that in the LGN of several vertebrate species there is a precise segregation vertebrate species there is a precise segregation of on and off information, at least for some functional classes of cells. The combination of on and off information does not seem to play a major role in establishing the response properties observed at this level in the visual system.

Transdiagnostic Motivational Enhancement Therapy to Reduce Treatment Attrition: Use in Emerging Adults

Improving outcomes of youth with mental health (MH) needs as they transition into adulthood is of critical public health significance. Effective psychotherapy MH treatment is available, but can be effective only if the emerging adult (EA) attends long enough to benefit. Unfortunately, completion of psychotherapy among EAs is lower than for more mature adults (Edlund et al., 2002; Olfson, Marcus, Druss, & Pincus, 2002). To target the high attrition of EAs in MH treatment, investigators adapted a developmentally appropriate brief intervention aimed at reducing treatment attrition (TA) in psychotherapy and conducted a feasibility study of implementation. The intervention employs motivational interviewing strategies aimed at engaging and retaining EAs in outpatient MH treatment. Motivational enhancement therapy for treatment attrition, or MET-TA, takes only a few sessions at the outset of treatment as an adjunct to usual treatment. Importantly, it can be used for TA with psychotherapy for any MH condition; in other words, it is transdiagnostic. This article presents the first description of MET-TA, along with a case example that demonstrates important characteristics of the approach, and then briefly describes implementation feasibility based on a small pilot randomized controlled trial.

Working therapeutically with deaf people recovering from trauma and addiction

OBJECTIVE

This article reviews what is known about behavioral health treatment of deaf persons with comorbid trauma and addiction.

METHOD

We discuss how to work therapeutically with deaf people with comorbid trauma and addiction, both through a review of the literature and through clinical observations of the authors. The article also includes the personal stories of two people-a Deaf peer specialist and a hearing psychiatrist-who share their humbling stories about the recovery process for deaf people and the challenges of learning to become an effective Deaf mental health care provider.

FINDINGS

Deaf people report higher rates of mental health problems than the general population. Although initial empirical work with the deaf population suggests high rates of posttraumatic stress disorder (PTSD) and substance use disorder (SUD), little is known about the rates of comorbid PTSD/SUD or how to effectively address this comorbidity in treatment.

CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

Substantial work is needed to raise awareness of comorbid PTSD/SUD and provide treatment tools to agencies and providers who work with deaf clients, infusing trauma-informed care into deaf SUD services and SUD treatment into deaf mental health care. Fortunately, several endeavors are on the horizon to disseminate assessment and treatment tools to work with deaf people recovering from trauma and addiction.

Instruments for Measuring Violence on Acute Inpatient Psychiatric Units: Review and Recommendations

OBJECTIVE

Violence by patients against inpatient psychiatric unit staff is common, causing considerable suffering. Despite the Joint Commission's 2018 requirement for behavioral health organizations to use standardized instruments, no identified gold standard measures of violence and aggression exist. Therefore, accurate data are lacking on the frequency of patient-to-staff violence to guide development of safer institutional clinical policies or to assess the impact of targeted interventions to reduce violence. To inform recommendations for developing standardized scales, the authors reviewed the scoring instruments most commonly used to measure violence in recent studies.

METHODS

A comprehensive literature search for violence measurement instruments in articles published in English from June 2008 to June 2018 was performed. Review criteria included use of instruments measuring patient-to-staff violence or aggression in acute, nonforensic, nongeriatric populations. Exclusion criteria included child or adolescent populations, staff-to-staff violence, and staff- or visitor-to-patient violence.

RESULTS

Overall, 74 studies were identified, of which 74% used structured instruments to measure aggression and violence on inpatient psychiatric units during the past 10 years. The instruments were primarily variants of the Observed Aggression Scale (OAS); 26% of the studies used unstructured clinical notes and researcher questionnaires. Major obstacles to implementing measurement instruments included time and workflow constraints and difficulties with use.

CONCLUSIONS

In the past 10 years, OAS variants with evidence of validity and reliability that define aggression and violence have been consistently used. The authors propose that adapting the Modified OAS to collect real-time clinical data could help overcome barriers to implementing standardized instruments to quantify violence against psychiatric staff.

Case report of 3 patients with severe mental illness and chronic hepatitis C virus infection treated with interferon-alpha

We report on three patients with hepatitis C virus infection, severe mental illness, and substance use disorders that we treated successfully with interferon and ribavirin. This population has historically been refused such treatment on the grounds that they were unlikely to be adherent to treatment or would experience untoward psychiatric side effects. These case reports add support to the growing body of evidence that persons with severe mental illness and substance use disorders can be successfully treated for hepatitis C with careful monitoring and psychiatric oversight.

Improving Policy and Legislation Related to Healthcare Workplace Violence

Our group conducted the first known New Hampshire survey on healthcare staff experience of workplace violence. Study questions focused on experiences of workplace violence, incident reporting mechanisms, and the availability and benefit of workplace violence training programs. Results were consistent with recently published literature: violence against healthcare workers remains a serious public health problem that is under-reported, understudied, “tolerated and largely ignored.” We will discuss the aspects of policy and legislative responses to workplace violence that have been insufficient to address this problem. We also will present some strategies that, if implemented, could lead to improved policy and legislation that may be more proactive in reducing such violence.

The Feasibility and Acceptability of Sharing Video Recordings of Amyotrophic Lateral Sclerosis Clinical Encounters With Patients and Their Caregivers: Pilot Randomized Clinical Trial

BACKGROUND

Multidisciplinary clinics (MDCs) provide benefits to patients with amyotrophic lateral sclerosis (ALS) and their caregivers, but MDC visits are information-heavy and can last 4 hours, with patients and caregivers meeting with multiple specialists within each MDC visit. There are questions about the effectiveness of current methods of sharing information from MDCs with patients. Video recordings are a promising new method of sharing information that may allow patients and caregivers to revisit the MDC and remind them of clinical recommendations and conversations.

OBJECTIVE

The objective of this trial is to determine the feasibility and acceptability of sharing information through video recordings of ALS MDC visits with patients and caregivers.

METHODS

This study was a randomized, controlled pilot trial with 3 months of follow-up from April 2021 to March 2022 in a rural multidisciplinary neurology clinic. We recruited patients with ALS, their caregivers, and their clinicians. Patients and their caregivers were randomized to either receive their normal after-visit summary (treatment as usual) or to receive their normal after-visit summary and a video recording of their MDC visit (video). Each specialist visit had its own recording and was accessible by patients and caregivers using a secure web-based platform called HealthPAL over a 3-month follow-up period. Primary study outcomes were feasibility and acceptability of the video intervention measured by recruitment rate (target: 70%), percentage of participants watching videos (target: 75%), and the Feasibility of Intervention Measure and Acceptability of Intervention Measure (targets: 3/5). We hypothesized that video recording would be feasible and acceptable to patients and their caregivers.

RESULTS

Of the 30 patients approached, 24 were recruited, while all caregivers (n=21) and clinicians (n=34) approached were recruited. A total of 144 specialist visits were recorded, approximately 12 specialist visits at a median of one MDC visit per patient. Of the recorded patients, 75% (9/12) viewed videos. High median intervention feasibility (4, SD 0.99) and acceptability (4, SD 1.22) of intervention measures were reported by patients and caregivers in the intervention arm. High median intervention feasibility (5, SD 0.21) and acceptability (4.88, SD 0.4) were reported by clinicians. Of the 24 patients, 50% (n=12) did not complete a 3-month follow-up, primarily due to death (n=10).

CONCLUSIONS

Video recording is highly feasible and acceptable for patients, caregivers, and clinicians at a rural ALS clinic. Our level of attrition is a useful benchmark for future studies in MDC populations. Despite high rates of patient death, 1-week assessments highlight the value of recordings for both patients and caregivers.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04719403; https://clinicaltrials.gov/study/NCT04719403.

Finding the Value: Identifying the Key Elements of Recorded Clinic Visits From the Perspective of Patients, Clinicians, and Caregivers

OBJECTIVE

We aimed to understand what patients, caregivers and clinicians identified as the most important information from their audio-recorded clinic visits and why.

METHODS

We recruited patients, caregivers and clinicians from primary and speciality care clinics at an academic medical centre in New Hampshire, U.S. Participants reviewed a recording or transcript of their visit, identifying meaningful moments and the reasons why. Two researchers performed a summative content analysis of the data.

RESULTS

Sixteen patients, four with caregivers, from six clinicians participated. Patients, caregivers and clinicians identified a median of 7.5 (3-20), 12.5 (6-50) and 18 (4-31) meaningful visit moments, respectively. Moments identified were similar across stakeholders, including patient education, symptoms, recommendations and medications. Four themes emerged as a rationale for finding visit information meaningful: providing and receiving information, sharing the patient experience, forming a care plan, and providing emotional support. Clinicians rarely identified patient statements as important.

CONCLUSION

There was considerable agreement between patients, clinicians and caregivers regarding visit information that is most valuable. Patient contributions may be undervalued by clinicians.

PRACTICE IMPLICATIONS

These findings can be used to improve patient-centred visit communication by focusing visit summaries and decision support on information of the most value to participants.

Reframing Older Adults’ Violence Toward Staff as Self-Protection

One of the first studies on workplace violence in nursing homes was published in 1985. Forty-five (45) years later, resident violence against staff continues to increase in incidence and severity. At the request of a state senator, a New Hampshire psychiatrist formed a research group to conduct the first New Hampshire survey on staff experience of workplace violence. Study questions focused on experiences of workplace violence and incident reporting, and the availability and benefit of workplace violence training programs. Results were consistent with recently published literature: violence is an expected, normalized element when providing care; potential repercussions and perceived resident lack of intent were major reasons for incident non-reporting. Analysis of study results and review of the literature led to the question: Are older residents’ violent behaviors towards staff an act of self-protection?