Acute Psychiatry Research Articles

Predictive care: a protocol for a computational ethnographic approach to building fair models of inpatient violence in emergency psychiatry

IntroductionManaging violence or aggression is an ongoing challenge in emergency psychiatry. Many patients identified as being at risk do not go on to become violent or aggressive. Efforts to automate...

The Lester Tool : An audit of its use on an acute psychiatry inpatient wards.

IntroductionPeople with severe mental illness have an increased vulnerability to cardiovascular disease due to multilple biopsychosocial factors and a potential adverse effects of longer term treatment with anti-psychotic medications. Treatment of severe and enduring mental illness with antipsychotic medications is likely to cause metabolic changes leading to weight gain and dyslipidaemia, thus increasing risk of cardiovascular disease. Cardiometabolic risk screening can be done using Lester Tool which also provides recommendations for interventions.ObjectivesTo identify the compliance to Lester Tool in the monitoring of cardiometabolic risk factors and intervention provided on acute psychiatry inpatients.MethodsWe carried out a retrospective audit of 30 patients on regular antipsychotic medication on an adult inpatient ward in Macclesfield, United Kingdom. Electronic records were reviewed to establish whether the smoking status, lifestyle, BMI, blood pressure, blood glucose and blood lipid were documented with evidence of interventions being provided.ResultsOf all 30 patients, none had shown compliance to all the parameters within the Lester Tool. 100% of the smoking status was documented, amongst which 78% were provided with interventions. 7% has lifestyle and diet status documented, of which 50% were given dietary advice. 80% had BMI documented, amongst which none were provided with any intervention. 90% had blood pressure documented, of which 50% were given any intervention. 40% had blood glucose documented, of which all were provided with intervention. 57% had blood lipid documented, of which none were provided with any intervention.ConclusionsOur results have shown the need of further awareness on the usefulness of the Lester Tool in an acute inpatient ward. Our recommendation would be to regularly train and educate inpatient staff to ensure that all the necessary parameters be monitored and provided with interventions.Disclosure of InterestNone Declared

What is the role of gender in perceived coercion during psychiatric admission?

This paper explores factors linking gender with increased perceived coercion, perceived negative pressures and procedural injustice during psychiatric admission. We used validated tools to perform detailed assessments of 107 adult psychiatry inpatients admitted to acute psychiatry admission units at two general hospitals in Dublin, Ireland, between September 2017 and February 2020. Among female inpatients (n = 48), perceived coercion on admission was associated with younger age and involuntary status; perceived negative pressures were associated with younger age, involuntary status, seclusion, and positive symptoms of schizophrenia; and procedural injustice was associated with younger age, involuntary status, fewer negative symptoms of schizophrenia, and cognitive impairment. Among females, restraint was not associated with perceived coercion on admission, perceived negative pressures, procedural injustice, or negative affective reactions to hospitalisation; seclusion was associated with negative pressures only. Among male inpatients (n = 59), not being born in Ireland appeared more relevant than age, and neither restraint nor seclusion were associated with perceived coercion on admission, perceived negative pressures, procedural injustice, or negative affective reactions to hospitalisation. Factors other than formal coercive practices are primarily linked with perceived coercion. Among female inpatients, these include younger age, involuntary status, and positive symptoms. Among males, not being born in Ireland appears more relevant than age. Further research is needed on these correlations, along with gender-aware interventions to minimise coercive practices and their consequences among all patients.

Preventing, reducing, and attenuating restraint: A prospective controlled trial of the implementation of peer support in acute psychiatry.

The use of restraint as a means of managing patients is considered a critical factor that interferes with recovery. Strategies to create a less restrictive environment within psychiatric facilities are therefore eagerly sought. Peer support workers (PSWs) are increasingly employed in mental health settings. The prevailing theory is that PSWs have the potential to contribute to conflict and restraint prevention efforts in acute psychiatric wards. However, to date, research in support of this claim remains limited. The present study aimed at assessing the effectiveness of employing peer support workers with regard to reducing the use of restraint. This prospective controlled pre-post study sought to evaluate the implementation of peer support in one locked ward compared to treatment as usual (TAU) with no implementation of peer support in a second locked ward of a psychiatry department in Berlin, Germany. The pre-post comparison was planned to consist of two assessment periods of 3 months each, taking place directly before and after peer support implementation or TAU. Both assessments were extended to a period of 6 months, before and after the initially planned 12-month implementation process, in order to balance the effects of disruptions and of the COVID-19 pandemic. Using routine data, the proportion, frequency, and duration of mechanical restraint, forced medication as well as mechanical restraint in combination with forced medication, were evaluated. In the control group, an increase in the proportion of patients subjected to measures of restraint was found between pre- and post-assessment, which was accompanied by a further increase in the mean number of events of restraint per patient within this group. In the intervention group, no significant change in the application of restraint was observed during the study period. There is some indication that peer support may be protective with regard to restraint in acute wards. However, our study faced major challenges during the implementation process and the post-assessment period, such as COVID-19 and staff reorganization. This may have led to peer support not reaching its full potential. The relationship between the implementation of peer support and the use of restraint therefore merits further investigation.

Human-Animal Bond Generated in a Brief Animal-Assisted Therapy Intervention in Adolescents with Mental Health Disorders.

The human-animal bond is crucial for the proper development of animal-assisted therapy (AAT) sessions. However, in specific cases such as in AAT focused on psychiatric patients who are admitted to acute units, there is only a short period of time available to establish this bond. To assess the degree of HAB generated after two AAT sessions in adolescents admitted to acute psychiatry units. A prospective multicenter cohort study aimed at adolescents aged 13 to 17 years admitted to the acute child and adolescent psychiatry unit of three hospitals. Two weekly 1 h group sessions of AAT with therapy dogs. The Center for the Study of Animal Wellness Pet Bonding Scale Survey (CSAWPB). One hundred and fourteen adolescents participated. A positive perception of the dog was generated, achieving a good level of bonding and attachment. The results obtained make it possible to affirm that a short period of time is enough to establish a good HAB between patients and therapy dogs. This study aims to contribute to the study of non-pharmacological interventions as a complement to pharmacological treatments in adolescents with mental health disorders.

Safe Spaces: Mitigating Potential Aggression in Acute Care Psychiatry.

Awareness of potential aggression and violence is crucial when treating patients experiencing mental health crises in psychiatric emergency and inpatient settings. To provide a practical overview for health care workers in acute care psychiatry, the authors summarize relevant literature and clinical considerations on this important topic. Clinical contexts of violence in these settings, possible impact on patients and staff, and approaches to mitigating risk are reviewed. Considerations for early identification of at-risk patients and situations, and nonpharmacological and pharmacological interventions, are highlighted. The authors conclude with key points and future scholarly and practical directions that may further assist those entrusted with providing psychiatric care in these situations. Although working in these often high-paced, high-pressured settings can be challenging, effective violence-management strategies and tools can help staff optimize the focus on patient care while maintaining safety, their own well-being, and overall workplace satisfaction.

Meaning Analysis and Alienation: A Method of Immanent Critique in Acute Psychiatry

In acute psychiatry, where people with severe mental disorders are frequently treated, there can be contradictions between concepts of illness among, e.g., patients and healthcare professionals, and also between medical and legal aspects. These contradictions do not manifest themselves openly but are immanent in the social practices of the treatment teams as contradictions between the social level and the individual level. They can lead to alienation, which may be reflected in poorer quality of treatment, such as the more frequent use of coercive measures or poorer adherence to therapy in patients. In the normal daily routine of a clinic, these contradictions are mostly hidden by hierarchical structures or by unbalanced concepts of psychiatric illness, or external critique is used to try to solve these contradictions. However, another way of dealing with these contradictions could be to analyze the potential and causes for alienation through systematic analysis and transformation of the whole system of a psychiatric ward to reduce the level of contradiction within it. The aim of this work is to use the concept of meaning elaborated by Luhmann to identify and recognize alienation potentials as concretely as possible and thus make them accessible to immanent critique. Meaning in Luhmann's use of the term serves to reduce complexity in a social context and always opens up consequential possibilities for action. Consequential limited possibilities at the level of action in a rigid social system (which psychiatric wards can be) can-at an individual level-lead to people subordinating themselves to the rigid system to an excessive degree and thus alienating themselves from the system. Thus, a rigid system with a narrowing of consequential possibilities excludes meaningful consequential possibilities. This leads to alienating contradictions and to possibilities of world appropriation being missed. The aim of the current analysis is not to make a general critique of psychiatry but to improve the theoretical basis to better understand the problem of alienation in acute psychiatry as a symptom of system-immanent contradictions and thus open up the possibility of transforming systems, e.g., psychiatric acute care units, by means of immanent critique.

Long Term Evaluation of the Implementation of the Safewards Model - Results of a Follow-Up-Study Among Patients and Staff in Acute Psychiatric Wards

Evaluation of long-term effects of the implementation of the Safewards Model (SM) among staff and patients in acute psychiatry in Germany. Assessment of ward atmosphere, job satisfaction, fidelity, and coercive interventions in 2 locked wards directly before and 15 months after implementation of the SM. Ward atmosphere was assessed significantly better after implementation, job satisfaction was still above-average at both times, coercive interventions declined significantly in one ward, fidelity and degree of implementation were still high. The implementing of the SM in locked wards in acute psychiatry can also have positive effects in long run.

The risk of not knowing – A predictive validity study of the “Don't know” scores on a violence screen in acute psychiatry

Access to information about risk factors of violence for patients admitted to acute psychiatric wards may be sparse. This prospective study from three acute wards explored associations between items scored “Don't know” and violence during hospital stays ( N = 1435) and the first three months after discharge ( N = 461) when using a violence risk screening tool (Violence risk screening - 10; V-RISK-10). When V-RISK-10 was scored at admission and “Don't know” was weighted 0 or 1, the area under the curve of the receiver operating characteristics (AUC) was 0.79 and 0.82 for inpatient violence and 0.79 and 0.80 for post-discharge violence. “Don't know” scored at admission was significantly associated with inpatient violence for eight risk items and with violence after discharge for seven items. Numbers of “Don't know” scores decreased substantially at discharge. A substantial proportion of those scores seemed to change into “Maybe/moderate” or “Yes”. There were some differences in single items in the associations of “Don't know” with violence and the distribution of scores. Findings indicate that items scored “Don't know” at the time of admission may be associated with violence during hospital stay and after discharge. More research is needed to elaborate these findings. • Don't know scores on risk factors were significant for inpatient violence. • Risk screening at admission was significant for post-discharge violence. • Assessment and management of post-discharge violence risk may start at admission.

Comparison of antipsychotic prescribing practices following failure of antipsychotic monotherapy in the acute care setting.

Numerous strategies exist following antipsychotic monotherapy failure including transition to another antipsychotic, dosing above FDA recommendations, or dual antipsychotic therapy. This study described antipsychotic prescribing practices on an acute psychiatry unit following antipsychotic monotherapy failure and compared outcomes to determine if any strategy resulted in superior short-term outcomes. This retrospective chart review assessed postintervention time to discharge for patients with schizophrenia or schizoaffective disorder requiring therapy change following treatment failure. Secondary outcomes included 30-day readmission rate, length of stay, and discharge chlorpromazine equivalents. There were no differences in number of past antipsychotic trials between groups (4.8 vs 4.5; P = .73). Of all the patients, 73% (n = 30) discharged on alternative antipsychotic monotherapy while 27% (n = 11) discharged on dual antipsychotic therapy. No patients had doses increased above FDA recommendations. The alternative antipsychotic group had shorter mean postintervention time to discharge (8.8 vs 20.6 days; P = .003) and shorter mean length of stay (16.7 vs 32.1 days; P = .03). Median time to discharge was not statistically significant (6.4 vs 14.0 days; P = .17). The dual antipsychotic group had higher mean chlorpromazine equivalents (723 mg vs 356 mg; P = .002). There was no difference in 30-day readmission rates (16.7% vs 27.3%; χ2 = 0.5765; P = .45). This study found that following failure of antipsychotic monotherapy, transition to an alternative antipsychotic was associated with decreased mean time to discharge as compared to dual antipsychotic therapy. Further studies are needed to assess long-term clinical implications of these findings.

Predictors of future suicide attempts in individuals with high suicide risk admitted to an acute psychiatry suicide intervention unit in India. A survival analysis study.

Determination of suicide vulnerability remains challenging in mental illness. Variability in risk factors identified compound its poor predictability. Longitudinal studies, offering more reliable indices of risk, from developing countries are conspicuously limited. Furthermore, research advances allude to inherent vulnerability. This study, the first of its kind from India, consequently aimed to delineate factors influencing subsequent attempts in mental illness and acute suicidality. Baseline and follow-up information (up to five years) was obtained from medical records of individuals (n=130) with acute suicidality [recent attempt (first attempt/ reattempt) and high-risk ideators]. Variables were compared between individuals with, and without subsequent suicide attempts. Time to attempt and factors influencing the same was determined using survival analysis, and Cox proportional hazard for estimating the likelihood of a subsequent suicide attempt. Median duration of follow up of the sample (n=130) was 23 months. The sample comprised of individuals with a recent attempt (first-time attempt), recent reattempt and recent high-risk ideators. Subsequent suicide attempts were noted in 30 (23.1%) patients. Baseline sociodemographic and clinical variables, including suicidality, could not differentiate individuals with a subsequent suicide attempt. Survival analysis indicated that 65% of subsequent attempts occurred within 9 months of discharge. Family history of suicide and the presence of impulsive-aggressive traits were associated with both, reduced survival time and overall increased risk of a subsequent suicide attempt. This study delineates both, the time frame associated with greatest risk, as well as individuals most likely to reattempt suicide. It thereby offers insights into potential windows of opportunity to mitigate prospective suicide risk. Strategies such as enhanced after-care and integrating specific interventions to attenuate impulsive-aggressive behaviors could be a focus to prevent future attempts, thereby decreasing rates of suicide amongst those with mental illness. Furthermore, the findings of this study reaffirm the role of factors that independently confer vulnerability to suicide. Traversing noted regional variations, the findings importantlyreinforce the distinct pathophysiological underpinnings of suicide in mental illness.

Seclusion, Restraint, Therapeutic Alliance, and Legal Admission Status: What Really Matters?

To determine the relationships, if any, between use of seclusion and restraint and factors such as demographic parameters, diagnosis, legal admission status (voluntary or involuntary), symptoms, cognitive function, global functioning, therapeutic alliance, attitudes toward medication, and insight, among psychiatry inpatients in Ireland. We used validated tools to perform detailed assessments of 107 adult psychiatry inpatients admitted to acute psychiatry units at 2 general hospitals in Dublin, Ireland over a 30-month period, between September 2017 and February 2020. The most common diagnoses in our sample were affective disorders (46.7%), schizophrenia and related disorders (27.1%), and personality and behavioral disorders (11.2%). Over a quarter (n=29, 27.1%) of the participating patients had involuntary legal status. Of the 107 patients, 11 patients (10.3%) experienced sedation and/or physical restraint, with 9 patients (8.4%) experiencing at least 1 episode of seclusion and 10 patients (9.3%) experiencing at least 1 episode of physical restraint. On the basis of multivariable analyses, seclusion was associated with younger age and involuntary status, while physical restraint was associated with involuntary status. Each multivariable model explained just over one third of the variance in the distribution of these seclusion and restraint practices. Use of seclusion and restraint was most strongly associated with involuntary admission status and, in the case of seclusion, younger age, rather than sex, diagnosis, symptoms, cognitive function, global functioning, therapeutic alliance, attitudes toward medication, or insight. The network of interactions between involuntary status and use of seclusion and restraint merits much closer attention, especially as use of seclusion and physical restraint appears to be associated with involuntary legal status independent of level of symptoms, therapeutic alliance, or insight.

Emergency medical care of patients with psychiatric disorders - challenges and opportunities: Results of a multicenter survey

BackgroundPre-clinical psychiatric emergencies are generally treated by emergency medical staff. The subsequent clinical treatment is often conditioned by interaction problems between emergency medical staff and psychiatric clinical staff.ObjectivesTo identify problems affecting interaction between emergency medical and psychiatric care of mentally ill patients and pinpoint aspects of optimized emergency care.MethodsTo shed light on the interaction problems an anonymous, questionnaire-based, nonrepresentative survey of 98 emergency physicians (EM) and 104 psychiatrists (PS) practicing in acute psychiatry was conducted between March 1, 2021 and October 1, 2021.ResultsThe chi-square test for multiple response sets revealed consistently significant differences (p < 0.001) between EM and PS with respect to the questions analyzed. Approximately 36% of EM reported not to be adequately qualified to handle psychiatric emergencies (p = 0.0001), while around 50% of respondents were neutral in their assessment in how to deal with psychiatric emergencies. 80% of EM reported a negative interaction (rejection of patients) with PS when referring a psychiatric emergency patient to the acute psychiatric unit. The most common reasons for refusal were intoxication (EM: 78.8%, PS: 88.2%), emergency physician therapy (EM: 53.8%, PS: 63.5%), and not resident in the catchment area of the hospital (EM 68.8%, PS: 48.2%). In the casuistry presented, most respondents would choose “talk down” for de-escalation (EM: 92.1%, PS: 91.3%). With respect to drug therapy, benzodiazepine is the drug of choice (EM: 70.4%, PS: 78.8%). More EM would choose an intravenously (i.v.) or a Mucosal Atomization Device (MAD) administration as an alternative to oral medication (i.v.: EM: 38.8%, PS: 3.8%, p = 0.001, MAD: EM: 36.7%, PS: 10.6%, p = 0.006). Significantly more EM would seek phone contact with the acute psychiatric hospital (EM: 84.7%, PS: 52.9%, p = 0.0107). A psychiatric emergency plan was considered useful in this context by more than 90% of respondents. The need for further training for EM with regard to treating psychiatric clinical syndromes was considered important by all respondents. In particular, the topics of “psychogenic seizure,“ “intoxication,“ and “legal aspects of psychiatric emergencies” were considered important (Mann-Whitney U test, p < 0.001).ConclusionThe interaction-related problems identified in the emergency medical care of pre-clinical psychiatric patients relate to non-modifiable, structural problems, such as insufficient admission capacity and non-existent or inadequate monitoring capabilities in acute psychiatric hospitals. However, factors such as the education and training of EM and communication between EM and PS can be improved. Developing personalized emergency care plans for psychiatric patients could help to optimize their care.

Short-term aerobic exercise for depression in acute geriatric psychiatry: study protocol for a randomized controlled trial

BackgroundMajor depression is one of the main mental illnesses in old age, with acute exacerbated episodes requiring treatment in geriatric psychiatry. A meta-analysis showed that aerobic exercise in moderate intensity has large effects in older adults with major depression, but there is no evidence of aerobic exercise in geriatric psychiatry. Therefore, this study aims to analyze the feasibility and effects of an ergometer-based aerobic exercise on depressive symptoms.MethodsA single-center randomized controlled trial will be conducted in an acute geriatric psychiatric hospital. Inpatients allocated to the intervention group will receive a 2-week aerobic ergometer program. The control group will receive seated flexibility exercise in addition to usual care. The overall effects on the patients’ depressive symptoms will be measured by clinical global impression of change (CGI) as the primary outcome. Changes in depressive symptom domains, physical (in)activity, and aerobic performance as well as the dosage of applied antidepressants will be examined as secondary outcomes.DiscussionThis short-term aerobic exercise program is expected to decrease depressive symptoms in acute exacerbated periods in older adults. The results may increase the evidence for implementing physical activity interventions in acute hospital settings. The disease-related motivation for exercise in acute exacerbated depressive periods will be the most challenging aspect. The treatment of depression requires new cost-effective approaches, especially in acute geriatric psychiatry with potential benefits for patients, family members, and clinicians.Trial registrationGerman Clinical Trial Register ID: DRKS00026117Trial statusProtocol Version 1.2 dated February 23, 2022. By February 23, 2022, the trial had recruited a total of 15 participants in two wards at the Department of Geriatric Psychiatry at the LVR-Hospital Cologne. Recruitment started on November 12, 2021. The recruitment is expected to continue for at least 12 months.

The Use and Safety of Leave From an Acute Inpatient Psychiatry Unit: A Retrospective Review of Pass Outcomes for 4 Years.

Leave passes provide authorized leave for hospitalized patients from a psychiatric inpatient unit. Although providing day passes was once a relatively common practice, there are relatively few data describing their safety and efficacy. This descriptive study examines the use of leave passes in an adult inpatient unit at a university hospital between 2017 and 2021, with attention to reasons for granting the day pass, duration, and outcome of the pass. During the study period, 10 patients with primary psychotic or mood disorders received 12 passes for housing coordination, COVID-19 vaccination, or major family events. There were no fatalities or abscondments. One patient experienced severe agitation and engaged in nonsuicidal self-injurious behavior. A second patient showed mild, redirectable psychomotor agitation upon return to the unit. The remaining 10 passes were uneventful. Our findings support the view that patients with diverse diagnoses can safely be provided leave from an inpatient setting with adequate planning and support, yielding a low incidence of adverse events.

Locked in and locked out: sequelae of a pandemic for distressed and vulnerable teenagers in Ireland

ObjectiveThe aim of this study is to investigate the impact of the coronavirus pandemic on teenage psychiatry referrals following crisis presentation to the adult emergency department (ED) of an Irish tertiary hospital. In doing so, this study will specifically examine the effect of COVID-19 on self-injurious behaviour, suicidality and substance use among older adolescents (age 16/17 years).MethodsThis is a retrospective descriptive analysis of acute adolescent psychiatry referrals assessed out-of-hours via the adult ED psychiatry service across three consecutive time points (during the months of March, April and May) from pre-pandemic, 2019 (T1); initial pandemic, 2020 (T2); and peak pandemic, 2021 (T3). Data were obtained via the hospital’s ED-specific electronic database, review of original assessment notes and cross-referenced by manually extracting data logged in the on-call register.ResultsCrisis psychiatry assessments of teenagers during on-call hours trebled during the period of this study (p < 0.001). Although ED/crisis referrals initially decreased overall at the start of the pandemic, the rate of teenage referrals remained constant, before increasing as restrictions tightened in lockdown. The negative impact of COVID-19 on teenagers’ ability to cope was found to be statistically significant (p = 0.001). Changes in rates of self-harming and/or suicidal behaviours were not statistically significant between 2019, 2020 and 2021 (p = 0.082). Alcohol misuse occurred in up to one-third of cases across each timeframe and remained virtually constant throughout the pandemic. Drug misuse decreased from onset of COVID-19 (p = 0.01).ConclusionsTo our knowledge, this is the first study to specifically examine the impact of COVID-19 on suicidality, self-harming behaviours, substance misuse and on-call ED presentations of teenagers in Ireland. This study demonstrates that coronavirus-related stress is associated with negative mental health sequelae for vulnerable at-risk older adolescents, as evidenced by a rise in ED presentations and on-call referrals since the onset of the pandemic. Presentation of increased numbers of under-18’s for psychiatry assessment at the adult ED/general hospital indicates a deepening chasm between available and aspirational emergency (adolescent-specific) psychiatric care in the community. Mobilising resilience factors and maximising coping skills for at-risk youth will inform tailored intervention and support strategies along with adequate resourcing of services for vulnerable adolescents in the community.

An Audit to Assess the Level Pregnancy Screening Conducted on Admission for Female Inpatients on an Acute Psychiatric Ward

AimsCurrently, practice is that if patients of childbearing age provide a urine sample on admission they will also be consented to test for pregnancy. As many new patients may refuse to provide a urine sample often due to their mental state or concerns about drug testing this results in some patients not being tested for pregnancy during admission unless required for medication or at patient request. Given the high level of vulnerability and the medication implications for pregnant patients, ascertaining pregnancy status early on in admission is beneficial to patients found to be pregnant. Therefore, we aimed to audit how pregnancy status is assessed and documented on admission and aim to improve the practice where areas for development are identified.MethodsOver the 6 month period July-December 2021 there were 105 inpatient admissions on an acute female psychiatry ward. Using a random number generator 15 patients from this cohort were selected and their notes audited as to whether a urine pregnancy test or bHCG serum pregnancy test was completed on admission. If not, we searched the admission notes for documentation of ‘pregnancy, last menstrual period (LMP), sexually active status, contraceptive use’.ResultsOf the 15 patients audited, 7 had a documented urine pregnancy test on admission (47%). Of the 8 patients that had not had testing only 1 patient had documentation of contraceptive use prior to admission, the other 7 non-tested patients had no notes regarding their LMP/contraception. 2 patients who did not have a pregnancy test had in fact had a urinary drug screen on admission, this coincided with a time of approximately 1 month when there were no urine pregnancy test strips available on the ward. At this time serum bHCG or LMP were not routinely used. One of these patients was found one month later to be pregnant.ConclusionWe propose based on our findings that a more robust enquiry as to the risk of pregnancy should be conducted on admission for female acute inpatients. We have made recommendations that this should be in the form of a checklist to be conducted as part of the nursing admissions assessment such that if a urine sample is refused then a form detailing LMP, contraceptive use and any recent unprotected sexual activity will be completed. This can then be reviewed by the medical team prior to commencing medications. The use of this checklist will be reaudited between January-June 2022.

Cardiovascular Disease Risk in SMI Across Various Settings in a Semirural Area – a Study During COVID-19 Pandemic

AimsThe risk for cardiovascular-related death is predicted to be higher in individuals with Serious Mental Illness (SMI) due to increased prevalence of common cardiac risk factors like smoking, physical inactivity, poor diet, substance use and hyperlipidemia among them.MethodsThe aim of this retrospective study was to evaluate the physical health of patients with SMI in various settings- acute inpatient, tertiary care hospital and community.We estimated the cardiovascular disease risk of schizophrenia patients with the aid of Framingham Risk Score (FRS) assessment tool, which can quantitatively predict both the heart age and 10-year CVD Risk percentage of patients aged ≥ 30 years. The clozapine to norclozapine ratio was compared with triglyceride levels, body weight, BMI, and fasting blood glucose in patients after treatment with clozapine. Southlake Regional Health Center's practice was compared with the national standards set by Diabetes Canada 2018 guidelines by conducting a clinical audit.68 non-diabetic, patients aged ≥ 30 years with all the risk factor records for FRS assessment were selected from a cohort of 183 patients registered in the schizophrenia clinic of Southlake Regional Health Centre. The data were collected from patient records from the 75 patients registered with Assertive Community Treatment Team in Georgina, Ontario.The sample size of the study on inpatients was 49 participants from the acute psychiatry ward consisting of 28 females and 21 males during the month of November 2021.ResultsMales, on average, were found to have an intermediate 10-year CVD risk (~11.2%; FRS total points: 11.27) in comparison to females who, on average, had a low 10-year CVD risk (~7.3%; FRS total points: 11.19). 26% of the patients using FRS were calculated to be at high risk and 28% with intermediate risk of developing a CVD. The average heart age of the sample patients was 60 years, which was 9 years higher than the total average age (51 years). The investigated biomarkers of Hemoglobin A1C, triglycerides, and glucose serum concentration were examined graphically, separated into categories of the ratio measurements of 0–2, 2–3, and 3+. For all biomarkers, lower values were more desirable. Triglycerides were the lowest in the 3+ ratio category. Hemoglobin A1C and glucose serum concentration were lowest in the 0–2 ratio category.100% of patients with diabetes had their blood sugar levels measured and 66.67% were referred to an endocrinologist. In patients without diabetes, 91.30% had their blood sugar levels measured, 39.13% had their HbA1C levels measured, and 6.52% had neither their HbA1C, nor their blood sugar levels measured.ConclusionCardiovascular complication can be one of the leading causes of death in the next 10 years among schizophrenia patients due to age, poor lifestyle choices, and current estimations via the FRS assessment tool. Further studies need to be conducted with a larger sample size and more recent data to examine any adverse lifestyle changes in schizophrenia patients during the pandemic, which could have negatively influenced their cardiovascular health. It is recommended that doctors weigh the risks vs benefits of prescribing clozapine to patients with high triglyceride levels.

How may cultural and political ideals cause moral distress in acute psychiatry? A qualitative study

BackgroundThere is growing public criticism of the use of restraints or coercion. Demands for strengthened patient participation and prevention of coercive measures in mental health care has become a priority for care professionals, researchers, and policymakers in Norway, as in many other countries. We have studied in what ways this current ideal of reducing the use of restraints or coercion and attempting to practice in a least restrictive manner may raise morals issues and create experiences of moral distress in nurses working in acute psychiatric contexts.MethodsQualitative interview study, individual and focus group interviews, with altogether 30 nurses working in acute psychiatric wards in two mental health hospitals in Norway. Interviews were recorded and transcribed. A thematic analytic approach was chosen.ResultsWhile nurses sense a strong expectation to minimise the use of restraints/coercion, patients on acute psychiatric wards are being increasingly ill with a greater tendency to violence. This creates moral doubt and dilemmas regarding how much nurses should endure on their own and their patients’ behalf and may expose patients and healthcare personnel to greater risk of violence. Nurses worry that new legislation and ideals may prevent acutely mentally ill and vulnerable patients from receiving the treatment they need as well as their ability to create a psychological safe climate on the ward. Furthermore, persuading the patient to stay on the ward can cause guilt and uneasiness. Inadequate resources function as external constraints that may frustrate nurses from realising the treatment ideals set before them.ConclusionsMental health nurses working in acute psychiatric care are involved in a complex interplay between political and professional ideals to reduce the use of coercion while being responsible for the safety of both patients and staff as well as creating a therapeutic atmosphere. External constraints like inadequate resources may furthermore hinder the healthcare workers/nurses from realising the treatment ideals set before them. Caught in the middle nurses may experience moral distress that may lead to physical discomfort, uneasiness and feelings of guilt, shame, and defeat.Pressure on nurses and care providers to reduce or eliminate the use of coercion and reduction of health care spending are incompatible demands.

Reducing readmission rates for individuals discharged from acute psychiatric care in Alberta using peer and text message support: Protocol for an innovative supportive program

BackgroundIndividuals discharged from inpatient psychiatry units have the highest readmission rates of all hospitalized patients. These readmissions are often due to unmet need for mental health care compounded by limited human resources. Reducing the need for hospital admissions by providing alternative effective care will mitigate the strain on the healthcare system and for people with mental illnesses and their relatives. We propose implementation and evaluation of an innovative program which augments Mental Health Peer Support with an evidence-based supportive text messaging program developed using the principles of cognitive behavioral therapy.MethodsA pragmatic stepped-wedge cluster-randomized trial, where daily supportive text messages (Text4Support) and mental health peer support are the interventions, will be employed. We anticipate recruiting 10,000 participants at the point of their discharge from 9 acute care psychiatry sites and day hospitals across four cities in Alberta. The primary outcome measure will be the number of psychiatric readmissions within 30 days of discharge. We will also evaluate implementation outcomes such as reach, acceptability, fidelity, and sustainability. Our study will be guided by the Consolidated Framework for Implementation Research, and the Reach-Effectiveness-Adoption-Implementation-Maintenance framework. Data will be extracted from administrative data, surveys, and qualitative methods. Quantitative data will be analysed using machine learning. Qualitative interviews will be transcribed and analyzed thematically using both inductive and deductive approaches.ConclusionsTo our knowledge, this will be the first large-scale clinical trial to assess the impact of a daily supportive text message program with and without mental health peer support for individuals discharged from acute psychiatric care. We anticipate that the interventions will generate significant cost-savings by reducing readmissions, while improving access to quality community mental healthcare and reducing demand for acute care. It is envisaged that the results will shed light on the effectiveness, as well as contextual barriers and facilitators to implementation of automated supportive text message and mental health peer support interventions to reduce the psychological treatment and support gap for patients who have been discharged from acute psychiatric care.Trial registrationclinicaltrials.gov, NCT05133726. Registered 24 November 2021