Journal Article Annotations
2017, 1st Quarter

Emergency Psychiatry

Annotations by Naomi Schmelzer, MD MPH
April 2017

Preventing intrusive memories after trauma via a brief intervention involving Tetris computer game play in the emergency department: A proof-of-concept randomized controlled trial
Accuracy of clinician assessments of medication status in the emergency setting: A comparison of clinician assessment of antipsychotic usage and plasma level determination

Also of interest:

Anderson EL, Nordstrom K, Wilson MP, et al: American Association for Emergency Psychiatry Task Force on Medical Clearance of Adults Part I: Introduction, Review and Evidence-Based Guidelines
West J Emerg Med 2017; 18(2):235-242

In an effort to formulate consensus recommendations on the medical evaluation of patients presenting to the emergency department with psychiatric complaints, a task force of the American Association of Emergency Psychiatry reviewed existing literature on this topic for Part I of their series. This article presents a clarification of terminology and a thorough review of the existing literature on the topic as well as available protocols. In addition, it highlights points of controversy and areas where further data is needed. Part II of the series, which includes the consensus recommendations, will follow in a subsequent article.

PUBLICATION #1 — Emergency Psychiatry

Preventing intrusive memories after trauma via a brief intervention involving Tetris computer game play in the emergency department: A proof-of-concept randomized controlled trial

Iyadurai L, Blackwell SE, Meiser-Stedman R, et al

Mol Psychiatry 2017; Mar 28 (Epub ahead of print)

After psychological trauma, recurrent intrusive visual memories may be distressing and disruptive. Preventive interventions post trauma are lacking. Here we test a behavioural intervention after real-life trauma derived from cognitive neuroscience. We hypothesized that intrusive memories would be significantly reduced in number by an intervention involving a computer game with high visuospatial demands (Tetris), via disrupting consolidation of sensory elements of trauma memory. The Tetris-based intervention (trauma memory reminder cue plus c. 20 min game play) vs attention-placebo control (written activity log for same duration) were both delivered in an emergency department within 6 h of a motor vehicle accident. The randomized controlled trial compared the impact on the number of intrusive trauma memories in the subsequent week (primary outcome). Results vindicated the efficacy of the Tetris-based intervention compared with the control condition: there were fewer intrusive memories overall, and time-series analyses showed that intrusion incidence declined more quickly. There were convergent findings on a measure of clinical post-trauma intrusion symptoms at 1 week, but not on other symptom clusters or at 1 month. Results of this proof-of-concept study suggest that a larger trial, powered to detect differences at 1 month, is warranted. Participants found the intervention easy, helpful and minimally distressing. By translating emerging neuroscientific insights and experimental research into the real world, we offer a promising new low-intensity psychiatric intervention that could prevent debilitating intrusive memories following trauma.

On PubMed: Mol Psychiatry 2017; Mar 28 [Epub ahead of print]

Annotation

The finding: A study comparing a Tetris-based behavioral intervention versus an attention-placebo control task was administered to patients presenting to an emergency room within six hours of a motor vehicle accident. The primary outcome, the number of intrusive memories logged over the subsequent week, was found to be reduced in the intervention condition when compared to the control group.

Strengths and weaknesses: An approach driven by a need for novel non-pharmacologic treatments, and stemming from cognitive science principles including memory consolidation theory and a prediction that cognitive tasks with high visuospatial demands will selectively disrupt sensory aspects of memory, this randomized control study supported the hypothesis that a behavioral intervention using the widely available video game Tetris, played for 20 minutes following presentation to the emergency department after a traumatic event, would reduce the number of intrusive memories in the following week. Additional strengths include the brief time-limited nature of the intervention, and that it was easy to engage patients in the task with no adverse side effects reported. The study overall has promising results, though it was a limited proof-of-concept study and requires a larger trial with greater participant numbers to demonstrate a lasting effect at one month.

Relevance: The emergency department is often providing psychological first aid immediately following a traumatic experience with the goal being to minimize symptoms of acute stress and prevent PTSD, though evidence-based preventive interventions from neuroscience translated into clinical care are lacking. This is a novel intervention strategy that is easy to administer, is low-cost, and requires little staff training. This, and similar approaches, have the potential to be used as part of the emergency psychiatry armamentarium of PTSD treatment as a preventative strategy.

PUBLICATION #2 — Emergency Psychiatry

Accuracy of clinician assessments of medication status in the emergency setting: A comparison of clinician assessment of antipsychotic usage and plasma level determination

Lopez LV, Shaikh A, Merson J, Greenberg J, Suckow RF, Kane JM

J Clin Psychopharmacol 2017; 37(3):310-314

PURPOSE:
The present study aimed to assess the level of agreement between clinicians’ routine assessments of medication status and plasma levels of commonly prescribed antipsychotic medications in patients presenting to an emergency room with an exacerbation of psychosis.
METHODS:
We studied 105 patients presenting to an emergency room and admitted to an inpatient psychiatric unit with a diagnosis of schizophrenia, schizoaffective disorder, bipolar I disorder, or psychotic disorder not otherwise specified and a prior outpatient medication regimen including risperidone, olanzapine, quetiapine, aripiprazole, or paliperidone. Plasma levels of antipsychotics were drawn and sent to a specialty laboratory for testing.
FINDINGS:
Of the 97 patients with usable samples, 33 (34%) were found to have therapeutic antipsychotic levels. Of these, 22 were judged by emergency room staff to be taking their medications at the appropriately prescribed doses, whereas 11 were judged not to be taking medication at all. Sixty-four patients were found to have subtherapeutic antipsychotic levels, 31 of whom had been assessed to be taking medication as prescribed. Emergency assessment of medication status predicted therapeutic and nontherapeutic antipsychotic levels at rates of 41.5% and 75%, respectively. Emergency staff assessment was statistically independent from the likelihood of having a therapeutic antipsychotic level.
IMPLICATIONS:
In patients presenting to emergency rooms with exacerbations of psychosis who are subsequently admitted to an inpatient facility, common assessments of medication status are frequently misleading. Readily available methods for rapidly measuring antipsychotic plasma levels in clinical settings are needed for clinicians to make reliable assessments.

On PubMed:
J Clin Psychopharmacol 2017; 37(3):310-314

Annotation

The finding: Among patients presenting to an emergency room with exacerbation of psychosis, psychiatrists’ assessment of medication adherence was statistically independent of measured therapeutic plasma blood levels. For example, of the 97 patients included in the study, 33 patients were found to have therapeutic drug levels of which 11 were clinically assessed as having been non-adherent by the emergency physician. Of the 53 patients assessed to be adherent to their antipsychotic medication, 43 had detectable plasma levels and 10 patients had undetectable levels.

Strengths and weaknesses: This is a study aiming to assess the accuracy of emergency physicians’ clinical assessment of medication adherence by comparing findings with measured drug levels. Although factors such as periodic adherence and timing of dosages may have affected values, this measurement serves as a more objective indicator of medication use.

Relevance: The discrepancies between standard clinical assessment for medication adherence and serum drug level demonstrated by the outcome of the study suggests the potential for clinical utility of therapeutic drug monitoring via rapid assays in the ED setting, though more investigation is needed. Feedback and review of discrepant cases may guide improvement of clinical assessment techniques.