Academy of Consultation-Liaison Psychiatry

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Selection from the latest research impacting C-L Psychiatry

Current Protocols Will Not Achieve Zero Harm As Called for by Regulators

Research: Self-harm during visits to the emergency department: a qualitative content analysis

Authors: Ryan Lawrence, MD, et al.

Abstract/Extract: Little is known about what motivates suicidal and non-suicidal self-harm behaviors among patients in an emergency department. But an emphasis on engagement, rather than screening, may have greater impact on patient safety, say the authors.

They reviewed self-harm incident reports and medical records from two academic urban emergency departments, examining the question: Which factors motivate patients to engage in deliberate (non-accidental) self-harm?

A minority of self-harm events in the emergency department have clear suicidal intent, they say. Non-suicidal motives include psychosis, intoxication, aggression, managing distress, communication, and manipulation.

Goals were to:

Better understand why these events occurred.
Help clinicians better recognize high-risk situations as they are developing.
Inform how emergency departments might take steps toward achieving The Joint Commission’s goal of ‘zero harm.’

The authors conclude that most patients who self-harm have motivations other than suicide. The variety of motivations described suggest current approaches to managing self-harm risk in the emergency department are limited and will fail to achieve ‘zero harm’ as envisioned by regulatory leaders. A more effective approach to reducing risk should include universally applicable strategies for engaging patients, building a therapeutic alliance, and working toward common goals.

Importance: While this is not the first study to identify motives or precipitants for self-harm, it is the first to do so for behaviors that occur while patients are in the emergency department. Hospitals in the US (psychiatric hospitals, psychiatric units in general hospitals, and non-psychiatric units in general hospitals) have a mandate to make these events as rare as possible, ideally reducing them to zero.

Availability: Pre-publication in the Journal of the Academy of Consultation-Liaison Psychiatry (JACLP)

JACLP cover

Optimism Makes cCBT More Effective

Research: The Impact of Optimism and Pain Interference on Response to Online Behavioral Treatment for Mood and Anxiety Symptoms

Authors: Natalia Morone, MD, MS, et al.

Abstract/Extract: This study aimed to explore:

If high pain interference has a negative effect on response to computerized cognitive behavioral therapy (cCBT) for anxiety and depression.
Whether high optimism can buffer the negative effects of pain interference on cCBT outcomes.

The researchers analyed data on 403 participants from the randomized controlled clinical trial Online Treatment for Mood and Anxiety Disorders in Primary Care. It examined the impact of cCBT, with and without access to an internet support group, on health-related quality of life, mood, and anxiety symptoms.

They found that high optimism may buffer against the negative effects of pain interference on treatment response from cCBT. Primary care patients who report high pain interference yet also lack optimism may not receive as much benefit from cCBT as other groups.

Importance: The study found that even low levels of optimism had a positive effect on cCBT treatment among depressed and anxious patients with low pain interference.

Availability: Published in Psychosomatic Medicine.

Psychsomatic Medicine cover

Collaborative Care Impact on Racial/Ethnic Minority Patients

Research: Collaborative Care Expands Reach to Racial/Ethnic Minority Patients

Authors: Tina Wu, MD, et al.

Abstract/Extract: This paper is one of a series coordinated by ACLP and APA’s Council on Consultation-Liaison Psychiatry.

Racial and ethnic minorities face unique challenges accessing and utilizing mental health services in the US—including lack of insurance, communication barriers, and perceived stigma. Even when minority patients have access to mental health care, they often receive lower quality care and have worse outcomes, say the authors.

The Collaborative Care Model is a well-studied health care delivery model that aims to improve mental health care access and outcomes. Key elements include:

Utilizing patient-centered team care.
A population focus through the use of registries.
Measurement-based treatment to target.
Application of evidence-based care.

Importance: Consult psychiatrists have expanded their participation in collaborative care in primary care and specialty settings and, as a result, are often faced with addressing disparities in care for minority patient populations. The Collaborative Care Model provides access to mental health care for patients who may otherwise never present to a psychiatric clinic for treatment. This evidence-based population health approach to care amplifies the clinical impact a consult psychiatrist can have by allowing the psychiatrist to provide diagnostic clarification and management recommendations (including medication, behavioral, and social interventions) for a large number of patients, including those from racial-ethnic minority groups.

Availability: Published in Psychiatric News

Computerized Scale Valid for Predicting Suicide Attempts

Research: Predicting the Transition from Suicidal Ideation to Suicide Attempt Among Sexual and Gender Minority Youths

Author: Johnny Berona, PhD, et al.

Abstract/Extract: Sexual and gender minority youths are more likely to consider, attempt, and die by suicide than are heterosexual and cisgender youths, yet little is known about how to predict future attempts or transitions from suicidal thoughts to behaviors.

This study examined the validity of the Computerized Adaptive Test for Suicide Scale (CAT-SS) in predicting suicide attempts and the transition from suicidal ideation to attempt.

CAT-SS was administered to participants of two ongoing cohort studies of sexual and gender minority adolescents and young adults. Survival analyses examined longitudinal associations between CAT-SS scores and time to suicide attempt.

The researchers found that risk and protective factors for suicide attempts differed between youths with and without a history of suicidal thoughts. Overall, however, CAT-SS had validity in predicting future risk of the sample and of youths with suicidal ideation.

Importance: Adaptive measurement of psychopathology is a promising approach that may help characterize risk in this population.

Availability: Published by Psychiatric Services.

More Effective, Faster Impact Hailed for Neuromodulation Therapy

Research: Stanford Neuromodulation Therapy (SNT): A Double-Blind Randomized Controlled Trial

Authors: Eleanor Cole, PhD, et al.

Abstract/Extract: Intermittent theta-burst stimulation (iTBS) is approved by the US Food and Drug Administration for the treatment of treatment-resistant depression but is limited by suboptimal efficacy and a six-week duration.

The authors addressed these limitations by developing a neuroscience-informed accelerated iTBS protocol, Stanford neuromodulation therapy. The protocol has been associated with a remission rate of ∼90% after five days of open-label treatment. Here, the authors report the results of a sham-controlled double-blind trial of SNT for treatment-resistant depression. SNT was shown to be more effective than sham stimulation.

Importance: Half of all patients with depression have treatment-resistant depression—yet US Food and Drug Administration-approved stimulation is limited by its efficacy after six weeks. Here, potentially, is a more effective outcome after just five days.

Availability: Published in The American Journal of Psychiatry.

American Journal of Psychiatry

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Academy of Consultation-Liaison Psychiatry:Advancing Integrated Psychiatric Care
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