Authors: Rachel Caravella, MD, et al.

Abstract: De-escalation of behavioral emergencies in the inpatient medical setting may involve restrictive clinical interventions that directly challenge patient autonomy.

The authors describe a quality improvement framework used to examine associations between patient characteristics and behavioral emergency de-escalation strategies.

They examined behavioral emergency response team (BERT) management at a US urban, tertiary-care medical center over a three-year period. BERT data from an existing dataset were combined with demographic information from the hospital’s electronic medical record.

The sample included 902 patients and 1,532 BERT events. The most frequent intervention reached was verbal de-escalation and the least frequent was four-point restraints. Proportions of de-escalation methods were compared according to race/ethnic groups.

As a result of the findings, the authors’ C-L Psychiatry service began a long-term, exploratory, quality improvement project to re-examine common clinical practices and identify areas where bias may impact the clinical management of behavioral emergencies.

“We describe the development of a novel QI framework that included analysis of existing clinical datasets to identify patterns in behavioral emergency management strategy based on the patient’s race, ethnicity, age, gender, and language,” say the authors. “We describe how the results were used to increase awareness, promote group discussion, and guide our team’s QI efforts towards areas that may be vulnerable to racism, or other forms of bias. We intend that this framework inform other C-L services or behavioral emergency response team teams seeking to promote equity and guide self-assessment.”

Importance: This project may inform other C-L Psychiatry teams seeking to promote equity in care. It illustrates that a quality improvement framework utilizing existing clinical data can be used to engage in organizational introspection and identify potential areas of bias in BERT management.

Availability: Published by the Journal of the Academy of Consultation-Liaison (JACLP).

Authors: Vanessa Salvador, et al.

Abstract: This study of self-harming young people in Portugal shows that most of the participants who wanted to stop their self-harm behaviors did not seek help.

Those who did so said they could not hide the physical injuries/scars any longer, or that someone had seen them self-harm. Those who did not seek help tended to devalue their behavior.

Both groups presented high levels of suicidal ideation and higher severity of self-harm methods were associated with higher levels of family conflict.

Participants were 222 young Portuguese adults aged between 18 and 25 years with a history of deliberate self-harm (DSH). Participants completed a self-report questionnaire which included an open-ended question focused on the reasons that may or may not contribute for seeking help. When they asked, or thought about asking, for help their expectations of health care workers centered on problem-solving, confidentiality, understanding and trust, support, and unburdening.

With extensive background referencing and analysed results, the authors describe two studies aimed at enriching understanding of help-seeking behaviors. Their research included mapping participants’ expectations when deciding to seek help from social networks and health care professionals. The authors concluded: “Young people seem to favor the capacity of their social network or health care practitioner to solve the problem—in other words, primarily to help them cease their behavior.”

One of the most significant barriers encountered to seeking help is the stigma, shame, and fear of negative reactions, which encourages secrecy, increases feelings of isolation, and erodes levels of perceived support. Fear of consequences, shame, and perceived burdensomeness represented one-third of the motives for not seeking help. Another barrier is the absence of the desire to stop: half of participants said they didn’t want to stop.

Importance: As the authors say: “Identifying facilitators and barriers to help-seeking can be a relevant step in planning and managing interventions within deliberate self-harm.”

Availability: Published by Psychiatry Research.

Authors: Lisa Horowitz PhD, MPH, et al.

Abstract: Given the increasing rates of suicide and nonfatal suicide attempts among Black youth in the US it is crucial that screening tools are valid in identifying Black youth at risk of suicide, say the authors. This study assessed the validity of the Ask Suicide-Screening Questions (ASQ) among Black youth.

This analysis used pooled data from three ASQ validation studies of pediatric medical patients aged 10-21. All participants completed the ASQ and the gold standard Suicidal Ideation Questionnaire.

Of the 1,083 participants, 330 (30.5%) were non-Hispanic Black and 753 (69.5%) were non-Hispanic White. The ASQ psychometric properties for Black and White participants were equivalent (sensitivity = 94% vs. 90.9%; specificity = 91.4% vs. 91.8%, respectively).

Importance: The authors conclude: “There were no significant differences in ASQ psychometric properties between Black and White youth, indicating that the ASQ is valid for screening Black youth at risk of suicide.”

Availability: Published by the Journal of the Academy of Consultation-Liaison (JACLP).

Authors: Kathleen Sheehan, MD, et al.

Abstract: The research team set out to examine how Project ECHO Integrated Mental and Physical Health (ECHO-IMPH) influences the attitudes and approaches of primary care providers and other participants towards patients with complex needs.

ECHO-IMPH was launched in January 2019 and, to date, eight investigative ‘cycles of care’ have been conducted. Between August 2020 and March 2021, 164 providers from two ECHO-IMPH cycles were invited to participate in this impact study; 22 agreed. Data was analyzed using the Braun & Clarke method for thematic analysis.

Three major themes were identified. Participants described:

• Enhanced knowledge and skills.
• Changes in attitude and approach.
• Space for reflection and exploration.

Participants said ECHO-IMPH helped them to view patients more holistically, which led to greater patient-centered care in their practice. Additionally, skills gained in ECHO-IMPH gave participants concrete tools needed to have more empathetic interactions with patients who had complex needs.

“ECHO-IMPH created a safe space for participants to reflect on their practice with patients with complex needs,” say the authors. “Participants applied newly acquired knowledge and skills to provide more empathetic and patient-centered care for patients with complex needs. Based on the shift in perspectives described by participants, transformative learning theory was proposed as a model for how ECHO-IMPH created change in participants’ practice.”

Importance: Patient complexity captures interconnected elements of multi-morbidity across physical, mental, and psychosocial domains. However, clinical guidelines are usually focused on single conditions, rarely considering multiple issues, even when these frequently co-occur. Patients with complex needs often have poorer clinical outcomes and higher mortality rates. To improve care for individuals with complex needs, providers need specialized training to enhance knowledge about how these domains can affect each other and increase skill in implementing appropriate care strategies to address these sometimes competing concerns.

In Ontario, a high proportion of complex patient care is addressed within primary care due to the province’s geographically dispersed population and distribution of specialized care. However, practitioners managing this care often have limited training in the care of those with co-occurring mental and physical illness, and may have limited access to specialist support, particularly in remote and under-serviced areas. Moreover, patients sometimes prefer to not to include additional health professionals in their care.

Continuing professional development interventions such as this ECHO-IMPH cycle, funded by the Ontario Ministry of Health, are an avenue to addressing this challenge.

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