Psychiatric Inpatient Settings Research Articles

Influence of Depression and Personality on Social Functioning in Older Adults

Among older adults there is significant comorbodity between depression and personality pathology and both are associated with poorer social functioning. Personality pathology is associated with greater prevalence, poorer recovery, and a higher likelihood of recurrence of depression in older adults. This study is a secondary analysis examining the relationships between personality traits associated with personality pathology (i.e. high neuroticism and low agreeableness), depression, and social functioning across older adults surveyed in primary care and psychiatric inpatient settings (N = 227). Individual variable as well as interaction models were examined. Higher neuroticism (FChange [1,217] = 40.119, p < .001), lower agreeableness (FChange [1,217] = 20.614, p < .001), and clinical status (i.e. primary care vs. psychiatric inpatient) (FChange [1,217] = 19.817, p < .001) were associated with poorer social functioning. Clinical status moderated the relationships between neuroticism and social functioning (B = -.0147, p = . 0341) and between agreeableness and social functioning (B = .0268, p = .0015). Interaction effects were not observed between neuroticism and depression or agreeableness and depression as they relate to social functioning. However, depression severity was observed to mediate the relationship between neuroticism and social functioning [Indirect effect = .0212, 95% CI = .0141, .0289]. These findings highlight the importance of accounting for depression and clinical status in the assessment and treatment of older adults with personality pathology. Findings warrant future research focused upon mechanisms through which personality pathology and depression influence functional status in older adults.

Pathological Traits and Interpersonal Difficulties in Depressed Older Adults: Clinical versus Community Sampling

Personality pathology, represented by high neuroticism and low agreeableness in the Five Factor Model of Personality, has been identified as a predictor of depression in mixed-age samples and preliminary studies of older adults. Research on older people, however, has not examined the differential impact of pathological personality traits and processes on depression or examined them across treatment settings. This secondary analysis examined personality traits and processes as predictors of depression, evaluated the moderating effect of interpersonal problems, and assessed stratification of these personality variables across community and clinical settings. Older adults (N=395) ranging in age from 55 to 99 (M = 72.06; SD = 10.10) from inpatient psychiatric, outpatient medical, and community settings completed self-report measures of personality traits (NEO-FFI Agreeableness and Neuroticism), processes (Inventory of Interpersonal Problems), and depression (GDS-30). Higher neuroticism predicted worsened depressive symptoms (β = .765, p < .001), as did lower agreeableness (β = -.163, p = .002) and more interpersonal problems (β = .459, p < .001). Findings partially supported the stratification of personality traits and processes by setting. Interpersonal problems moderated neither the neuroticism-depression or agreeableness-depression relationships. Personality traits and processes predict depression in older adults across care settings but do not significantly interact. Levels of pathological traits and processes vary across community and clinical settings.

Preliminary evidence supporting the practice of psychosis-risk screening within an inpatient psychiatric setting serving adolescents

Evidence supports the use of brief psychosis-spectrum screening measures to identify individuals at elevated risk for psychosis, however, there is limited research on psychosis-spectrum screening among adolescents hospitalized for acute mental health concerns. Given the psychiatric vulnerability of this population, screening efforts within inpatient settings may help identify adolescents at greatest risk for ongoing mental health concerns including psychosis. This study investigates the use of two brief screening tools to identify psychosis-spectrum symptoms in psychiatrically hospitalized adolescents. Upon intake, adolescents completed two screening measures, the PRIME Screen-Revised and the Youth Self-Report Thought Problems scale, followed by a brief interview to evaluate psychosis-spectrum diagnoses. Associations between screening scores and diagnostic status were explored to evaluate the use of these tools to identify psychosis-spectrum conditions in this population. The sample included 57 adolescents, 28 of whom met psychosis-spectrum criteria. Psychosis-spectrum status was strongly correlated with PRIME scores (r = 0.59) and Thought Problems T scores (r = 0.55). Logistic regression analyses indicated that both screening measures demonstrate promising accuracy (74–81%) for identifying adolescents meeting psychosis-spectrum criteria. The PRIME and Thought Problems scale may be appropriate screening tools for use in adolescent inpatient settings to identify those experiencing clinically significant psychosis-spectrum symptoms.

Implementation of treatment escalation plans in an old age psychiatry inpatient hospital

A treatment escalation plan (TEP) enables timely and appropriate decision making in the management of deteriorating patients. The COVID-19 pandemic precipitated the widespread use of TEPs in acute care settings...

Risk Assessment of Electroconvulsive Therapy in Clinical Routine: A 3-Year Analysis of Life-Threatening Events in More Than 3,000 Treatment Sessions.

Background: Extensive research has reported that electroconvulsive therapy (ECT) can be highly effective in approximately 80% of patients suffering from depression. Its clinical use is mainly limited by historical objections and the concern about unwanted adverse effects (AEs), including serious and potentially life-threatening adverse events (pLTAEs), induced either by ECT or by anesthesia. Objective risk estimation is, therefore, a decisive factor in determining an indication for ECT.Methods: This paper presents a retrospective analysis of 3-year safety protocols and patient files of 157 patients who received a total of 3,106 ECT applications in a psychiatric inpatient setting at a psychiatric community hospital. This patient group comprises 5.3% of inpatients admitted with comparable diagnoses. Adverse events were analyzed from standardized safety protocols and patient files with a focus on pLTAEs.Results: Adverse events were reported for 30 (19.1%) of the 157 participants during 39 (6.1%) of 641 hospital stays. Serious pLTAEs occurred during three electroconvulsive stimulations in three patients, who needed action through the administration of medication or mechanical respiration. No patient suffered permanent damage to health, and no patient died. The incidence of these and other AEs was independent of sex, age, and diagnosis of patients, and anesthesia medication. Minor AEs occurred more often with higher stimulus doses and an increasing number of treatments.Conclusion: The low incidence rate of 0.097% of serious pLTAEs that require medical action may allow the conclusion that ECT is a rather safe treatment when performed in a controlled setting. The beneficial risk profile of ECT performed in the standard care of psychiatric hospitals suggests a more generous indication of this treatment method. We recommend that ECT facilities collect individual safety data to allow a reliable judgment of their institutional ECT risk profile.

Brief mindfulness-oriented interventions (MOIs) to improve psychiatric symptoms in a psychiatric inpatient unit: a randomized controlled feasibility trial

ABSTRACT Background Mindfulness-based interventions are effective in treating numerous psychiatric symptoms, but data about brief mindfulness-oriented intervention (MOI) use with psychiatric inpatients are limited. We investigated whether a brief MOI was feasible and effective in reducing psychosis and other symptoms in a psychiatric inpatient unit. Methods In an assessor-blinded feasibility randomized-controlled trial, adult psychiatric inpatients were randomized to the intervention or control group. Feasibility outcomes included enrollment rate, retention rate and intervention-completion rate. The quantitative outcome was the impact on symptom reduction (mean and % difference in Brief Psychiatric Rating Scale (BPRS) between baseline and 7-day follow-up scores). Exploratory outcomes included improvement in quality of sleep, mindfulness and quality of life. Qualitative intervention feedback was obtained from therapists and participants. Results Feasibility outcomes were 39.2% participant enrollment, 85% study completion and 81.8% intervention completion. No symptom outcomes significantly differed. There were no significant differences in exploratory outcomes. Interventionists reported system-level barriers in treatment delivery; patients subjectively reported enjoying the intervention. Discussion The MOI is feasible in the inpatient psychiatric setting. There were no significant effects on psychiatric symptoms during the follow-up period, but no adverse effects were reported. Therapeutic effects could be further investigated in longer-term interventions and larger confirmatory RCTs.

Workplace characteristics of forensic and nonforensic psychiatric units associated with posttraumatic stress disorder (PTSD) symptoms.

Workplace factors associated with the development of posttraumatic stress disorder (PTSD) in inpatient psychiatric settings have received limited attention. In this study, we examined critical exposures, patient care stressors, and aspects of workplace environment that are potentially associated with PTSD symptoms in a sample of 633 clinical staff (68% nursing staff, 70% female) who provided direct day-to-day care for patients, and indicated they worked in either forensic (57%) or nonforensic units (43%). Forensic staff reported more direct exposure (74%) to a wider variety of potentially traumatic events and chronic stressors than nonforensic staff (66%). Forensic staff also endorsed more PTSD symptoms. Using the PTSD Checklist for DSM-5 (PCL-5; Diagnostic and Statistical Manual of Mental Disorders-Fifth Edition, DSM-5), 22% of forensic staff and 11% of nonforensic staff met the screening cut-off for possible PTSD; PTSD symptom scores were predicted both by direct exposure and unit type. Additionally, workplace environment and organizational trust were negatively correlated with PTSD symptom scores, where forensic staff reported a greater degree of incongruence with their workplace and lower levels of trust in management, compared with nonforensic staff. These results offer a snapshot of the more adverse work environment and associated risks faced by clinical staff on forensic units compared with nonforensic settings. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Management of the COVID-19-Infected Psychiatric Inpatients: Unique Infection Prevention Considerations and Evolving Strategies.

Reason for ReviewThe COVID-19 pandemic has affected the way healthcare services are provided and created challenges to the delivery of behavioral health in the inpatient setting. Here, we present our front-line experience of infection prevention for the psychiatric patient in the COVID era.Recent FindingsThere are unique challenges surrounding COVID-19 precautions within inpatient psychiatric settings. The challenges presented to psychiatric care by COVID-19 begin in the emergency department and follow the patient through the continuum of care once admitted to the facility. Unit infrastructure, patient population, treatment modalities, staffing considerations, and discharge planning are distinct instances where COVID-19 protocols that are well-suited for other hospital settings necessitate revision for psychiatric settings.SummaryThe purpose of this communication is to add to the current body of shared experience of infection prevention for the psychiatric patient in the COVID-19 era.

Psychiatric court reports and diversion outcomes in a remand prison over three years.

There has been a notable increase in requests for psychiatric reports from District Courts for persons remanded to Ireland's main remand prison, Cloverhill. We aimed to identify if reports were prepared for persons with severe mental illness and if they led to therapeutic benefits such as diversion to healthcare. Measures of equitability between Cloverhill and other District Courts were explored. For District Court-requested reports completed by the Prison Inreach and Court Liaison Service (PICLS) at Cloverhill Prison from 2015 to 2017, we recorded clinical variables and therapeutic outcomes such as diversion to inpatient psychiatric settings. Of 236 cases, over half were diverted to inpatient or outpatient psychiatric care. One-third of remand episodes were admitted to a psychiatric hospital, mainly in non-forensic settings. Nearly two-thirds had major mental illness, mainly schizophrenia and related conditions. Almost half had active psychosis. Cases in Cloverhill District Court and other District Courts were similarly likely to have active psychosis (47% overall) and hospital admission (33% overall). Voluntary reports were more likely to identify active psychosis, with over 90% diverted to inpatient or outpatient community treatment settings. This is the first large scale study of diversion outcomes following requests for psychiatric advice from District Courts in Ireland. Requests were mainly appropriate. Over half led to diversion from the criminal justice system to healthcare settings. There is a need for a complementary network of diversion initiatives at every stage of the criminal justice system to effectively divert mentally ill individuals to appropriate settings at the earliest possible stage.

32.6 Comparing Efficacy of Psychotropic Medications to Control Agitation Among Pediatric Patients Hospitalized With ODD

ODD complicates management of aggression, especially in pediatric inpatient psychiatric units. We studied the initiation of various classes of psychotropic medications for reducing aggression in an inpatient psychiatric unit setting.

Therapeutic alliance in mental health care: When language issues challenge provider-patient relationships.

The field of psychiatric nursing provides unique opportunities for nurse-patient interactions. Nurses working in inpatient psychiatric settings face constant challenges that may hinder the development of meaningful nurse-patient interactions. Peplau's theory of interpersonal relations emphasized the importance of nurse-patient relationships in nursing care. Therapeutic alliance can help promote nurse-patient relationships and may help nurses and patients achieve their goals. This article presents several phases of a concept-building process that illustrates the importance of therapeutic alliance and its application in mental health care.

Pre-vocational therapy in mental health. Clients' desired and achieved productivity status

Background Knowledge about work-related occupational therapy in psychiatric inpatient and day hospital clients is limited. Aims The aim of the study was to explore the desired and achieved productivity status in mental health service users participating in a pre-vocational therapy (PVT) intervention. Outcome variables were productivity status and achievement of desired productivity status at discharge, and change or persistence of productivity status between admission and discharge. Methods This is a short-term prospective study based on observational data from health records (N = 98). Results At admission, 53.2% of participants named a clear desired productivity status; 46.8% did not. Of the former, 76.9% expressed a desire for employment or education on the regular job market; 28.0% achieved their desired outcome at discharge, whereas 72.0% did not. Overall, 58.5% retained, established or increased productive activities, while 41.5% were not engaged in or had reduced productive activities at discharge. These two groups differed in socio-economic and social-security-related characteristics, treatment-related characteristics and psychiatric diagnosis. Conclusions and significance Some, but not all kinds of clients in acute psychiatric inpatient and day hospital settings manage to take a first step towards productive activities during the first phase of treatment.

A Case for Psychiatric Leadership in Dispositional Capacity Assessment.

Dispositional capacity assessment, which evaluates a patient's ability for self-care after hospital discharge, is a novel concept with important implications for work in consultation-liaison, inpatient, and emergency psychiatric settings. In this Open Forum, the authors present an illustrative case, review literature relevant to dispositional capacity, and explore social theory that elucidates the concept. Psychiatrists are specifically positioned to provide leadership in this area. Psychiatrists should consider further developing and formalizing criteria for dispositional capacity assessment.

Nursing Staff Attitude, Subjective Norms, Perceived Behavior Control, and Intention to Provide Tobacco Treatment in a Psychiatric Hospital.

Although the nursing staff is fundamental in assisting individuals with mental illnesses (MI) to stop tobacco use, they often have mixed feelings about providing tobacco treatment (TT) services to people with MI in inpatient psychiatric settings. Therefore, this study aimed to understand factors associated with nursing staff's intentions to provide TT interventions for individuals diagnosed with MI in a psychiatric facility using the constructs of the theory of planned behavior (TPB). Secondary data analysis was performed using cross-sectional data collected from 98 nursing staff who worked in a state inpatient psychiatric facility. A 15-item questionnaire was used to assess nursing staff intentions to provide TT services based on TPB constructs, including attitudes (four items), subjective norms (four items), perceived behavioral controls (four items), and intentions (three items) toward providing TT. The mean scores of each subscale ranged from 1 to 7. A logistic regression analysis was used to examine the relationship between TBP constructs and nursing staff intentions to provide TT for people with MI. Nursing staff had an acceptable mean score in the intentions subscale (4.34 ± 2.01). Only two constructs of TPB explained nursing staff intentions to provide TT: subjective norms (OR = 2.14, 95% CI [1.46, 3.13]) and perceived behavioral control (OR = 2.33, 95% CI [1.32, 4.12]). The constructs of the TPB, the subjective norms, and the perceived behavior control were able to predict nurses' intentions to provide TT for inpatients in a psychiatric setting. Accordingly, we suggest implementing policies that make TT a normative practice while supporting the confidence and competence of nurses to deliver TT in psychiatric facilities.

Factors associated with psychiatric admission and subsequent self-harm repetition: a cohort study of high-risk hospital-presenting self-harm

Background Individuals presenting to hospital with self-harm of high lethality or high suicidal intent are at high risk of subsequent suicide. Aim To examine factors associated with psychiatric admission and self-harm repetition following high-risk self-harm (HRSH). Method A cohort study of 324 consecutive HRSH patients was conducted across three urban hospitals (December 2014–February 2018). Information on self-harm repetition was extracted from the National Self-harm Registry Ireland. Logistic regression models examined predictors of psychiatric admission and self-harm repetition. Propensity score (PS) methods were used to address confounding. Results Forty percent of the cohort were admitted to a psychiatric inpatient setting. Factors associated with admission were living alone, depression, previous psychiatric admission, suicide note and uncommon self-harm methods. History of emotional, physical or sexual abuse was associated with not being admitted. Twelve-month self-harm repetition occurred in 17.3% of cases. Following inverse probability weighting according to the PS, psychiatric admission following HRSH was not associated with repetition. Predictors of repetition were recent self-harm history, young age (18–24 years) and previous psychiatric admission. Conclusion(s) Findings indicate that psychiatric admission following HRSH is not associated with repeated self-harm and reaffirms the consistent finding that history of self-harm and psychiatric treatment are strong predictors of repetition.

Blended Care in In-Patient Acute Psychiatric Care. The Example of a Group Training for Social Competences in Adults-A Pretest-Posttest Feasibility Study.

Introduction: Deficits in social skills can be an important modulating factor in the development and progress of various mental disorders. However, limited resources in inpatient care often impede effective social skills training. This study investigates the feasibility of a blended group training for social skills (SST) in an inpatient psychiatric setting. Methods and Analysis: For this one-group pretest–posttest trial, inpatients with a diagnosed mental disorder were recruited. Participation in the blended SST lasted four weeks and took place within usual inpatient psychiatric care. The blended intervention comprised four face-to-face group sessions and three complementary online modules within four weeks. Assessments took place before (t1) and after (t2) the training. Feasibility outcomes (use, acceptance, satisfaction, implementability into usual psychiatric inpatient care) and effectiveness outcomes regarding social skills were assessed. Results: N = 15 participants were recruited. Most patients completed all questionnaires (93%) and all modules of the blended SST concept (60%). All participants (100%) would recommend the blended intervention to a friend. Regarding social skills, exploratory analyses revealed a non-significant medium-sized effect (Cohen’s d = 0.5 95%CI 0.3 to 1.25, p = 0.08). Discussion: This trial shows that a blended care SST is feasible for the use in acute psychiatric inpatient care setting. Although the wards were acute, with high turnover and change of inpatients, 60% of participants were treated per protocol over four weeks. Overall, the evidence on blended care concepts in psychiatric care settings is extremely poor to date. Hence, this trial should encourage intensified blended inpatient psychiatric care research.

Written exposure therapy for posttraumatic stress symptoms and suicide risk: Design and methodology of a randomized controlled trial with patients on a military psychiatric inpatient unit

Studies of active duty service members have shown that military personnel who screen positive for posttraumatic stress disorder (PTSD) are more than twice as likely to make a suicide attempt. Evidence-based PTSD treatments can reduce suicidal ideation; however, it can be challenging to provide evidence-based, trauma-focused, PTSD treatment to high-risk patients on an acute psychiatric inpatient unit because the priority of care is stabilization. Treatment for PTSD requires more time and resources than are typically afforded during inpatient hospitalizations. Written Exposure Therapy is an evidence-based, five-session, trauma-focused treatment for PTSD that may overcome the implementation challenges of providing PTSD treatment in an acute inpatient psychiatric treatment setting. This paper describes the design, methodology, and protocol of a randomized clinical trial. The goal of the study is to determine if five 60-min sessions of Written Exposure Therapy enhanced with Crisis Response Planning for suicide risk reduces the presence, frequency, and severity of suicidal ideation, suicidal behavior, rehospitalization, and non-suicidal, self-injurious behaviors. The study also will determine if Written Exposure Therapy for Suicide reduces posttraumatic stress symptom severity among military service members, veterans, and other adult military beneficiaries admitted to an acute psychiatric inpatient unit for comorbid suicide ideation or attempt and PTSD symptoms compared with Treatment as Usual. The study is designed to enhance the delivery of care for those in acute suicidal crisis with comorbid PTSD symptoms.

What is the impact of staff wearing uniforms in psychiatric inpatient settings?

Background: Uniform has traditionally been worn in psychiatric inpatient and other mental health settings, but there has been a move to non-uniform in recent years. Some services have made the change back to uniform, raising questions about the potential impact on patients and staff.&lt;br/&gt;Aim: To review the impact of uniform within a psychiatric inpatient or mental health setting.&lt;br/&gt;Method: Databases were searched for articles exploring the impact of uniform use using specified search terms. Articles were assessed for suitability with inclusion and exclusion criteria, critically appraised, then analysed for themes using thematic analysis.&lt;br/&gt;Results: 17 papers were included in the review. Thematic analysis identified five main themes and 29 subthemes. Main themes were Attitudes and interactions, A freer environment, Are you both nurses?, The 'ideal self' and There are more important things. A critical appraisal of the articles suggested issues with validity and reliability, which are discussed.&lt;br/&gt;Discussion: Studies identified that wearing non-uniform facilitated positive changes in both patients and staff. This raises the potential negative impact of uniform on both patients and staff, and the role of power imbalance in these settings is discussed. Further themes around identification of staff out of uniform were considered.&lt;br/&gt;Implications for practice: The use of uniform in mental health and psychiatric inpatient settings should be considered carefully, due to the potential negative impact, whilst also recognising the importance of staff identification and supporting professional identity.

Safety of pharmacotherapy in a psychiatric inpatient setting and the QT interval

Background; Events associated with a risk of death are the most serious complications of pharmacotherapy; One of these complications is prolongation of the QT interval leading to Torsades de Pointes, a life-threatening condition that can result in asystole and sudden death. Factors contributing to the development of the long QT syndrome include heredity, structural abnormalities of the heart, electrolyte disorders, female gender, advanced age, use of drugs with certain electrophysiological properties, and drug-drug interactions. Consideration of all these factors can help achieve the most accurate and objective assessment of the risk of these rhythm disturbances.&#x0D; Aims to assess the risk of prolongation of the QT interval and the development of Torsades de Pointes in psychiatric inpatients.&#x0D; Methods. The study enrolled 500 patients who received medical care in a psychiatric inpatient setting. The risk of QT interval prolongation and development of Torsades de Pointes was assessed using the MedSafety Scan medical decision support system.&#x0D; Results. Of the 500 patients treated in the psychiatric inpatient setting, 224 had a risk of QT interval prolongation and developing Torsades de Pointes; the incidence was highest in the group of elderly patients. The mean risk score was 7.59 3.29 in general, 6.02 3.14 in patients aged under 65 years, and 9.16 2.62 in subjects over 65 years of age. An analysis of the frequencies of risk factors for prolongation of the QT interval and Torsades de Pointes revealed that patients aged over 65 years most commonly had atrial fibrillation, chronic heart failure, heart valve disorders, hypertension, and a history of myocardial infarction. Patients under 65 years of age more commonly received medicinal products prolonging the QT interval and drug combinations that can lead to potential drug-drug interactions of relevant clinical significance.&#x0D; Conclusion. The obtained results indicate the importance of assessing the risk of QT interval prolongation and development of Torsades de Pointes in psychiatric inpatients as an affordable preventive tool that can increase the safety of drug therapy.

The relationship between ethnic background and the use of restrictive practices to manage incidents of violence or aggression in psychiatric inpatient settings

Restrictive practices raise considerable concern in mental health inpatient care. Previous studies suggest there are disparities in the use of restrictive practices to manage service users of different ethnic groups. The present study analyses the relationship between ethnicity and the use of restrictive practices to manage incidents of violence or aggression in inpatient settings across an NHS Mental Health Trust. Three years’ worth of routinely collected incident data were analysed using multilevel multiple logistic regression to assess the relationship between ethnic group and four types of restrictive practices: physical restraint (without prone), physical restraint (with prone), seclusion, and rapid tranquilization. We controlled for a range of demographic variables and the type and severity of the incident. Adjusted analyses showed that service users with a Black African [Odds Ratio = 1.96, 95% CI: 1.36–2.83, P < 0.001], Black Caribbean [Odds Ratio = 1.76, 95% CI: 1.08–2.85, P = 0.022], Black Other [Odds Ratio = 1.76, 95% CI: 1.27–2.44, P = 0.001], and Mixed [Odds Ratio = 1.88, 95% CI: 1.11–3.18, P = 0.019] ethnic background were more likely to be secluded, and Black Caribbean [Odds Ratio = 1.45, 95% CI: 1.02–2.07, P = 0.040] service users were more likely to be restrained in prone position. We did not detect differences in the use of physical restraints without prone or in the use of rapid tranquilization. Our findings illustrate the need to focus on outcomes for different ethnic groups when implementing restraint reduction programmes.