Authors: Holly Betterly, MD, et al.

Abstract: Sexual assault in the inpatient psychiatric setting is a significant problem with serious, lasting consequences. It is important for psychiatric providers to appreciate the nature and magnitude of this problem to be able to provide an appropriate response when faced with these challenging scenarios, as well as to advocate for the implementation of preventive measures.

This review of existing literature describes the epidemiology of sexual assaults in these settings, and explores the characteristics of both victims and perpetrators, with a particular focus on factors relevant to the inpatient psychiatric patient population.

Literature does not identify a way to reliably predict which patients are most likely to engage in sexually inappropriate behaviors on an inpatient psychiatric unit. But the medical, ethical, and legal challenges that such cases present are defined, followed by a review of current management and prevention strategies, and suggested future directions for research.

As is the case with sexual assault in the community, the prevalence of sexual assault in the inpatient psychiatric setting is likely underreported because of a wide range of challenges faced by both patients and staff, say the authors.

Patients may hesitate to report because of stigma, guilt, powerlessness, mistrust, concerns of being met with disbelief or retaliation, or fear of the perpetrator. Staff may hesitate out of concerns about legal implications, reliability of allegations, a culture of silence, or disbelief that such an incident could occur.

Sexual assault in the inpatient psychiatric setting presents a host of questions for providers, ranging from medical challenges (e.g., sexually transmitted infection and unintended pregnancy) to ethical challenges (e.g., how to approach an apparently delusional report of sexual assault), to legal challenges (e.g., civil liability and criminal litigation that arise from inpatient sexual behaviors).

This review aims to highlight the magnitude of the problem, illustrate the potential consequences, and outline future directions towards prevention and management strategies.

“As the field of Psychiatry continues to evolve from its paternalistic roots to person-centered care, the subject of patient sexuality remains in the dark,” say the authors. “Discussions with patients about healthy sexuality are not routine in Psychiatry. Many psychiatrists have not been trained, or are not competent in taking a sexual history or evaluating a patient’s sexual health. As a result, discussions with patients about sexual needs do not occur.”

Importance: Adults with a history of serious mental illness are at an increased risk of experiencing sexual violence, with rates two to eight times higher than in the general population. Given this increased risk, as well as the lasting consequences, sexual violence represents an area of serious concern for those who provide care to people with psychiatric disorders. Research indicates that 40% of community mental health outpatients have experienced sexual assault at some point during their adulthood, and between 5% to 45% of mental health inpatients have experienced sexual violence during an inpatient admission.

Availability: Published in General Hospital Psychiatry

Authors: Mark Zimmerman, MD, et al.

Abstract: In treatment studies of depression, response is typically defined as a 50% or greater reduction in symptom severity. However, multiple surveys of depressed patients have found that patients prioritize improved functioning and quality of life objectives over symptom improvement as the most important goal of treatment.

This study aims to widen the lens of assessing outcome by examining response in non-symptom domains in patients who are, by convention, considered non-responders to treatment.

Eight hundred and forty-four patients with major depressive disorder completed the Remission from Depression Questionnaire (RDQ), a self-report measure that assesses multiple constructs considered by patients to be relevant to assessing treatment outcome. At discharge, the patients rated the effectiveness of treatment. The 517 patients who were non-responders on the RDQ depression symptom subscale are the focus of this research.

These patients showed significant levels of improvement from admission to discharge in all non-symptom domains. “The failure to meet the conventional definition of treatment response based on symptom severity does not preclude significant improvement in non-symptom domains,” say the authors.

The current approach towards defining treatment response is not consistent with patients’ opinions of the primary goals of treatment, they say.

The study was conducted in the Rhode Island Hospital Department of Psychiatry partial hospital program, a five-day-per-week intensive treatment program. Patients meet with a psychiatrist and therapist daily and attend multiple groups per day.

Importance: The conventional manner of characterizing response is at odds with surveys and focus groups of depressed patients indicating their perspective on the primary treatment goals. And in another study of more than 2,000 patients taking an antidepressant, nearly twice as many patients indicated that their primary goal of treatment was to improve functioning rather than mood.

Availability: Pre-publication in Psychiatry Research

Authors: Joseph Cerimele, MD, MPH, FACLP, et al.

Abstract: People with bipolar disorder commonly present for treatment in primary care settings. Collaborative care and co-located specialty care models can improve quality of care and outcomes, though it is unknown which model is more effective.

So the authors compared 12-month treatment outcomes for primary care patients with bipolar disorder randomized to treatment with both models. They conducted a secondary analysis of 191 patients diagnosed with bipolar disorder treated during a comparative effectiveness trial in 12 Federally Qualified Health Centers in three states. Characteristics and outcomes were assessed at enrollment and at 12 months.

The primary outcome was measured in mental health quality of life scores (Veterans RAND 12-Item Health Survey Mental Health Component Summary); secondary outcome measures included depression and anxiety symptom scores, euthymic mood state, and recovery. T-tests and multiple linear and logistic regression models were used.

Among participants, the Veterans RAND 12-Item Health Survey Mental Health Component Summary scores increased using both models. The mean Mental Health Component Summary change did not differ by model. Secondary outcomes also improved at 12 months compared to baseline measured by the Hopkins Symptoms Checklist, Generalized Anxiety Disorder-7, and Recovery Assessment Scale, and did not differ significantly by model.

Importance: The effectiveness of collaborative care and of co-located specialty care appear similar. Both are associated with substantial improvements in mental health quality of life and symptom reduction.

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

Authors: George Sayde, MD, MPH, et al.

Abstract: Post-intensive care unit recovery programs for survivors of critical illness related to COVID-19 remain limited, ever-evolving, and under active investigation. Mental health professionals have an emerging role within this multidisciplinary care model.

This study explores the design and implementation of an intensive care unit follow-up clinic in New Orleans during the COVID-19 era. Survivors of a critical illness due to COVID-19 were offered multidisciplinary outpatient treatment and systematic psychological screening up to six months after the initial clinic visit.

Seventy-seven patients were identified to be at high risk of post-intensive care syndrome (PICS) from March to November 2020, and of this cohort, 44 (57.14%) survived their COVID-19 hospitalizations. Of the surviving patients contacted, 21 established care in the PICS clinic and returned for at least one follow-up visit.

At initial evaluation, 66.7% of patients demonstrated clinically meaningful symptoms of post-traumatic stress disorder. At three-month follow-up, 9.5% of patients showed significant post-traumatic stress disorder symptoms. Moderate-to-severe symptoms of anxiety were present in 38.1% of patients at initial evaluation and in 4.8% of patients at three months. Moderate-to-severe symptoms of depression were present in 33.4% and 4.8% of patients at initial visit and at three months, respectively.

Importance: A PICS clinic opened by dually-trained internist-psychiatrists serves as a successful post-hospitalization model of care for COVID-19 intensive care unit survivors. This type of health care infrastructure expands the continuum of care for patients enduring the consequences of a critical illness.

The authors identified a high prevalence of post-traumatic stress, anxiety, and depression, along with other post-intensive care unit complications warranting an intervention. The prevalence of distressing psychological symptoms diminished across all domains by three months.

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

Authors: Corinne Carlton, MS, BS, et al.

Abstract: The study followed-up adolescents with social anxiety disorder (SAD) during the COVID-19 pandemic, approximately five years following their participation in an Attention Bias Modification Training (ABMT) program.

It aimed to evaluate current functioning and quality of life (QoL) during emerging adulthood. Participants included 27 young adults who completed a randomized controlled trial of ABMT and were available for follow-up. Participants filled out self-report measures of QoL and functioning and underwent a clinical interview to assess current severity of social anxiety.

Clinician-rated symptoms of SAD significantly decreased from post-treatment to five-year follow-up. Additionally, results demonstrated that social anxiety severity was significantly related to poorer, self-reported physical and psychological health as well as poorer functioning with regard to social distancing fears. When evaluating change in symptoms over time, increases in social anxiety severity over a five-year period significantly predicted worsened social distancing fears during COVID-19.

Importance: Social anxiety disorder is a chronic and functionally impairing psychological disorder characterized by recurring fears about one or more social or performance situations. SAD tends to develop during adolescence, and, if left untreated, tends to follow a chronic course into adulthood.

Availability: Published in Psychiatry Research