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Assertive Community Treatment Teams: Questions for Discussion

Our article "The Assertive Community Treatment Team: An Appropriate Treatment for Medical Disorders That Present With Prominent Psychiatric Symptoms" makes a case for the use of Assertive Community Treatment (ACT) teams for patients with mental disorders due to a general medical condition when the psychiatric manifestations are severe and cannot be managed in a medical clinic. An ACT team is a multidisciplinary group that provides individualized services to each consumer by going into the community (eg, a day program, a diner) or the consumers’ homes. The ACT team provides 24/7 care with the ultimate goal of community integration. The outreach is assertive, and the team persists in the face of failure. Due to a low client-to-staff ratio, the team can provide integrated services, including psychopharmacologic, substance abuse, and rehabilitative treatment and social and family services. ACT teams are often used for psychiatric patients with a history of noncompliance with treatment.

In our article, we described a young woman with Graves disease who had difficulty following treatment recommendations and who was misdiagnosed with bipolar I disorder. She would periodically exhibit irritability, agitation, and threatening behavior requiring hospitalization in a psychiatric unit. Physical signs and symptoms such as cardiac palpitations, tachycardia, hair loss, weight loss, and hyperphagia would usually accompany the psychiatric symptoms. However, there was a tendency to treat her medical and psychiatric symptoms separately and in relative isolation. The consensus of our ACT team was that she had Graves disease masquerading as a bipolar disorder. This diagnosis was based on the temporal association between clinically significant irritability and abnormal thyroid function tests. When hyperthyroid and mood symptoms co-occur, the integration of medical and psychiatric treatments should be a priority. ACT teams are suited to this task.

Here, we consider 3 questions regarding medical-psychiatric issues.

  1. What other medical-psychiatric conditions can be effectively treated by ACT teams?
    Our state hospital ACT team has been treating a patient with serious mental illness (SMI) and water intoxication due to primary polydipsia; the patient has had several medical hospitalizations. Hospitalization for water intoxication is predicated on a worsening of the psychiatric condition and a co-occurring increase in cognitive impairment. The ACT team initiates emergency hospitalization procedures and, after discharge, closely monitors the patient and encourages fluid restriction. We believe water intoxication is an example of a medical-psychiatric interaction that has rarely been studied in SMI outpatients. In fact, we could find only 1 article estimating the incidence of primary polydipsia (15.7%) in an SMI outpatient population. We wonder what medical-psychiatric conditions other ACT teams encounter that are similar in complexity to this.
  2. How might ACT teams routinely be referred patients with medical disorders that present with prominent psychiatric symptoms?
    At first, we thought of contacting medical-psychiatric inpatient units within our region to find out if they would be discharging patients who could benefit from ACT team services. However, we were unable to locate any medical-psychiatric inpatient units in the New York City region. The University of Rochester Medical Center might have the only medical-psychiatric unit (or complexity intervention unit [CIU]) in New York state, according to Telva E. Olivares, MD, Medical Director of the Behavioral Medical Surgical Unit. In operation for approximately 7 years, this 20-bed unit provides acute inpatient medical care for consumers “with mental illness and behavioral complexities, including alcohol withdrawal, delirium, catatonia, personality disorders, Munchausen, somatization, and the usual common medical reasons for admissions.” The Rochester ACT team admits some of their patients to this unit. If the New York City area has no med-psych units, perhaps inpatient consultation-liaison units could play a role in referrals to ACT teams for patients with medical disorders that present with prominent psychiatric symptoms. Would current ACT teams find this workable, or would a new type of ACT team need to be set up? This brings us to our final question.
  3. Are psychiatric ACT teams prepared to treat the medical-psychiatric patient?
    Medical monitoring and collaboration with the primary care treatment team can be added to the integrated services offered by ACT teams. The presence of nurses on a multidisciplinary ACT team has been shown to further improve integration. Unfortunately, many psychiatric ACT teams are not comfortable taking responsibility for treating common nonpsychiatric health concerns like diabetes, hypertension, and obesity. Dr Olivares told us that the Rochester ACT team includes a nurse practitioner and other nursing staff, and nurses have been very helpful in managing some patients with diabetes and hypertension. The role of psychiatric ACT teams can be expanded to include such integrated care but would require a reassessment of staffing and training.

 

Health care integration and cost-effective care remain major challenges.

Financial disclosure: Drs Kanofsky and Woesner had no relevant personal financial relationships to report.

Acknowledgments: We thank Helle Thorning, PhD, MS, LCSW, for her thoughtful and focused feedback. She is a Research Scientist and Director of the ACT Institute, Center for Practice Innovations, Division of Mental Health Services and Policy Research at the New York State Psychiatric Institute. The ACT Institute trains members of the 78 New York State ACT teams.

We also thank Telva E. Olivares, MD, for her personal communications.

The Burden of Military Sexual Trauma in US Veterans

Sexual harassment and sexual assaults occurring within the military have begun to receive increased public attention in the wake of recent reports of the high prevalence of sexual traumas among returning veterans from Iraq and Afghanistan, as well as the public testimony of survivors and their advocates. The term military sexual trauma (MST) was developed to aid in screening and advocacy efforts within the Department of Veterans Affairs (VA). The VA defines MST as “sexual harassment that is threatening in character or physical assault of a sexual nature that occurred while the victim was in the military regardless of geographic location of the trauma, gender of the victim or the relationship to the perpetrator.” Previous studies have reported a range of estimates of the prevalence of MST, in part due to differences in the samples studied or the definition of MST used.

In our study of a contemporary, nationally representative sample of US veterans spanning World War II to more recent war eras, we found that a substantial portion of US veterans—7.6%—reported a history of MST, including 32.4% of female veterans and 4.8% of male veterans. Factors positively associated with MST in our study included female sex, younger age (the highest rate of MST was in veterans aged 18–29 years), racial/ethnic minority status, enlisted status, and history of childhood sexual abuse.

Veterans with a history of MST in our study were 2–3 times more likely than those without a history of MST to screen positive for PTSD, depression, generalized anxiety disorder, and social phobia and to report current thoughts of suicide, as well as a history of suicide attempt. They also reported greater severity of somatic symptoms, as well as lower mental and cognitive functioning and quality of life. Notably, a history of MST was associated with increased likelihood of engagement in mental health treatment, independent of PTSD and depression, suggesting that the experience of MST, in and of itself, may motivate mental health treatment seeking in veterans. Taken together, these findings suggest that MST is associated with a broad range of negative health effects and underscore the importance of integrated health care for veterans with a history of MST.

The VA has implemented universal screening initiatives and dedicated clinicians for coordination of care of veterans with a history of MST. However, underreporting of MST is thought to be common, and the majority (69.4%) of veterans with a history of MST in our study reported that the VA is not their primary source of health care. Thus, it may be helpful for health care providers in all sectors of the health care system to screen for MST in veterans and to be aware of the broad range of negative health outcomes associated with MST in this population. Expanding such efforts beyond the VA health care system may further aid in reducing the stigma faced by veterans with a history of MST and may be helpful in further reducing the culture of silence surrounding this issue.

Financial disclosure: Dr Klingensmith had no relevant personal financial relationships to report. Dr Pietrzak is a consultant for Cogstate and has received grant/research support from NIH and DoD.

For related material on mental health issues in the military, please visit StrongVeterans.com.

Behavioral Interventions for Patients With Dementia in Long-Term Care

When treating patients with dementia, behavioral approaches should usually be the first step in reducing behavioral disturbances. Nurses, social workers, activities therapists, and psychologists, for the most part, understand this point better than physicians do. Physicians may be too quick to prescribe medications to manage distressing or disruptive behaviors.

When patients with dementia display such behaviors, we must try to understand what specific needs underlie these behaviors. I think the proper mindset is, What are patients trying to tell us? Are they in pain? Are they scared? Is it too noisy? Is it too hot? Is it too cold? Is the behavior related to an old routine at this time of day? What unmet need is being expressed?

Is a patient upset because his daughter’s in Florida for the winter, and he doesn’t understand why he hasn’t seen her? Is the patient scared or angry, and, if so, about what? Is the patient having trouble hearing or seeing? Is the patient medically ill? A fundamental principle of geriatrics care is to evaluate possible medical or other reasons for behavioral problems. To me, the satisfaction of practicing geriatric medicine is the opportunity to play Sherlock Holmes under circumstances like this and try to figure out what it is that’s wrong and try to address it in a specific way rather than reaching for the prescription pad.

A December 2014 NPR story described a Minnesota nursing home facility that was able to eliminate the off-label use of antipsychotic agents for problematic behaviors by enacting a program of behavioral interventions . Tools include validation, redirecting, pet therapy, aromatherapy, massage, and white noise, as well as playing old music and providing activities that dispel boredom, such as balloon “volleyball.” A 2013 New Yorker article described a facility in Phoenix that also uses this type of individualized approach for patients with dementia so that no off-label antipsychotics are used. The atmosphere is relatively peaceful because people’s needs are addressed, focusing on their comfort in particular. Snacks are wheeled around during the day because patients may forget to eat and then not ask for food when they get hungry. Televisions are usually turned off because many shows can upset patients and distract the staff. Patients’ schedules are not dictated. Patients are allowed to continue habits from their careers, such as walking around as if working in retail or looking in staff members’ mouths as if back in the dentist’s office. Family members and staff are encouraged to accept rather than correct patients’ mistaken ideas. For example, if I’m somebody with dementia asking over and over again where my deceased wife is, and I get upset about it repeatedly, you might say to me, “Well, she may be back later. Let’s have a bowl of ice cream,” and I might very well be content with that.

Medications shouldn’t be the starting point for managing behavioral problems, except in emergencies. Behavioral interventions should be used to identify the source of problems and address them.

Financial disclosure: Dr Tariot is a consultant for Abbott, AbbVie, AC Immune, Boehringer Ingelheim, California Pacific Medical Center, Chase, CME Inc, Corium, GliaCure, Lundbeck, Medavante, Otsuka, and Sanofi-Aventis; both is a consultant for and has received research support from AstraZeneca, Avanir, Bristol-Myers Squibb, Cognoptix, Janssen, Merck, and Roche; has received research support only from Baxter Healthcare, Functional Neuromodulation, GE, Genentech, Novartis, Pfizer, and Targacept; has received other research support from NIA and AZ Department of Health Services; is a stock shareholder of Adamas; and is a contributor to a patent owned by the University of Rochester, “Biomarkers of Alzheimer’s Disease.”

The Use of Medications in Patients With Dementia in Long-Term Care

I have been involved in the care and study of people with brain diseases, particularly dementias, for my entire career. For 20 years, I was the Director of Psychiatry at a public long-term care facility with more than 600 beds. Powerful psychotropic medications should not be used for patients with dementia unless all other options have been proven to be ineffective, but we have created a problem in the last generation or two in which the instinct of responsible physicians is to reach first for a prescription. That’s how they’ve been trained, that’s how they think, and it’s the path of least resistance.

Psychotropic medications, particularly the antipsychotics, can achieve a short-term apparently desirable effect, which is essentially that the person becomes quiet and less disruptive. I and others have done considerable research on the effects of psychotropics, including quite a few of the antipsychotics, in the nursing home as well as in other settings. For instance, the CATIE-AD study was a federally funded study of over 400 individuals with dementia and agitation, aggression, or psychosis for which they received an antipsychotic or placebo. The study showed that, for the most part, the antipsychotics did not help. A large number of people experienced adverse effects without being helped; a small number of people were helped without being hurt; and a few had both positive and negative effects.

I think the CATIE-AD results conform with the main idea of a December 2014 NPR story on the use of antipsychotics in nursing homes, which is that, for the most part, these agents are unlikely to be helpful and are likely to confer adverse effects. I would not argue, however, that we should never use them, and, in fact, federal regulations don’t exactly say that. The federal regulations say to try to reduce or stop the medication or prove that it’s beneficial or necessary, which is a good mindset. I submit that any position that suggests that the solution is black or white is incorrect.

While widespread use of antipsychotics or other psychotropics in nursing homes is poor medicine and not evidence-based, I wouldn’t say we must never use them because sometimes you really have no alternative. Individualized care planning means just that, and, for some individuals, medication ends up being the best solution. But that shouldn’t be the starting point, except in emergencies.

The American Psychiatric Association treatment guidelines for Alzheimer’s disease and other dementias stress the importance of informing the person responsible for the welfare of the individual with dementia about all of the potential pros and cons of any medication, including the black box warnings associated with antipsychotics and the elderly. We consider it mandatory that that communication is provided, and the fact that informed consent was given is to be communicated in the documented record.

Meta-analyses indicate that anti-dementia therapies, the cholinesterase inhibitors and/or memantine, alleviate neuropsychiatric symptoms in persons with dementia, and, in terms of medication, most guidelines consider those drugs the mainstay of treatment. They seem to be effective at reducing milder forms of neuropsychiatric signs and symptoms and may be able to delay the emergence of more severe symptoms. They are probably not very effective once symptoms are severe, but proactive use of these medicines, where appropriate, may mitigate some of these problems in the long run.

Research shows that anticonvulsants, which were in vogue for a while, and benzodiazepines really don’t seem to help and primarily confer adverse events. On the other hand, recent evidence suggests that non-antipsychotic medicines like certain antidepressants, for instance citalopram, may be effective in relieving some forms of agitation, although side effects need to be taken into account as well. So, antipsychotics are the most potent but probably the most dangerous medications to use in patients with dementia. First-line medication would be the anti-dementia agents. Second-line treatment would be selective use of certain antidepressants. Anticonvulsants don’t seem to be effective, and antipsychotics are a choice of last resort. Behavioral interventions are crucial and are the subject of my next blog entry.

Financial disclosure: Dr Tariot is a consultant for Abbott, AbbVie, AC Immune, Boehringer Ingelheim, California Pacific Medical Center, Chase, CME Inc, Corium, GliaCure, Lundbeck, Medavante, Otsuka, and Sanofi-Aventis; both is a consultant for and has received research support from AstraZeneca, Avanir, Bristol-Myers Squibb, Cognoptix, Janssen, Merck, and Roche; has received research support only from Baxter Healthcare, Functional Neuromodulation, GE, Genentech, Novartis, Pfizer, and Targacept; has received other research support from NIA and AZ Department of Health Services; is a stock shareholder of Adamas; and is a contributor to a patent owned by the University of Rochester, “Biomarkers of Alzheimer’s Disease.”

What Does Accountable Care Mean for Early Career Psychiatrists?

We are in the midst of a shift in the framework of health care delivery in America. Currently, most health care professionals in America are reimbursed for care provided, whether that service is for acute illness or preventive care, and reimbursement comes from the patient’s pocket, the insurance company, or the government. This model incentivizes health care providers to perform high-cost procedures and care for acute illness rather than provide preventive care and care for chronic illness.

A new model is emerging in the form of the Accountable Care Organization (ACO) and is often described as “population health care.” ACOs care for a population of patients with a fixed amount of reimbursement per member for a fixed amount of time. In an editorial in the October 30, 2014, issue of the New England Journal of Medicine, Dr Lawrence Casalino described the central goal of the ACO program as improving the value of care provided, defined by improved quality at a reduced cost. Dr Casalino also elaborated on potential pitfalls that may hinder development of the ACO movement and skewed motives that may hamper increase in true value of care provided. In the same issue, Song et al and McWilliams et al described the experiences of some of the pioneering ACOs, and, broadly speaking, these studies showed an improvement in quality and reduction in cost.

What will this movement mean for early career psychiatrists? Along with other fields, we will increasingly be required to demonstrate the quality of care that we provide. While providing high-quality care has always been paramount in medicine, how do we demonstrate that we are doing this? Using measurement-based care systems and demonstrating adherence to treatment guidelines are two ways to systematically measure quality of care in psychiatry.

I recommend that early career psychiatrists familiarize themselves with outcomes measures that can be implemented in routine clinical care. In the clinic, we ask our patients to tell us, for example, about their mood over the past 3 months. However mood, like pain, is difficult to remember accurately. When I introduce outcomes measures to my patients, I say that this measure will help both of us recall the specifics of symptoms at certain time points in the course of treatment, which will give us data to use in individualized treatment decisions.

At Penn State Psychiatry, we are implementing a systematic program of diagnostic and outcomes measurements to enhance clinical care and quality programs. Health care organizations will be increasingly interested in these kinds of data, as objective outcomes data can be collected in the aggregate to show outcomes by treatment provider or treatment setting.

Measurement-based care in psychiatry has been recommended by experts and called for in APA Practice Guidelines. Familiarity with published treatment guidelines issued through professional organizations or government health care systems abroad (eg, American Psychiatric Association, British Association for Psychopharmacology, Canadian Network for Mood and Anxiety Treatments, National Institute for Health and Clinical Excellence) is crucial for understanding the standard of care and for measuring one’s own treatment efficacy. Health care is changing, and being able to demonstrate quality of care will be increasingly important in psychiatry as in all of medicine.

Financial disclosure: Dr Saunders is a consultant for Profiles in Knowledge.

Patient Falls and Psychiatric Medications

Patient falls, some of which are fatal, were the subject of a sentinel event alert by The Joint Commission on Accreditation of Healthcare Organizations in 2000, and fall reduction was a 2014 Joint Commission national patient safety goal. In 2014, The Joint Commission’s Center for Transforming Healthcare reported that a pilot project to prevent falls was able to reduce both falls and injuries from falls at the 7 participating organizations.

Behavioral health facilities have not been rigorously studied, but a 2009 study in Pennsylvania found that falls in psychiatric hospitals were more frequent than in medical-surgical facilities (21.7% vs 15.4%), with patient harm as a result of falls also greater in psychiatric facilities (9.6% vs 3.7%). The association of medications with falls was significantly greater in behavioral health facilities than in non–behavioral health hospitals (70.3% vs 57.6%).

Behavioral health units have a number of risk factors for falls. Many of the patients are taking multiple psychiatric as well as medical medications that can cause sedation and orthostatic hypotension. Some of the patients may also be confused or agitated, while others may have gait impairment or extrapyramidal symptoms. Detoxification of alcohol-, opioid-, or benzodiazepine-dependent patients presents a fall risk, even in younger patients, because patients may be in a delirium from the intoxicating substance and/or be cognitively impaired from the medications commonly used in detox protocols. A study of psychiatric inpatients found that risk factors for falls included a diagnosis of depression and confusion or disorientation. The majority of falls occurred when patients were attempting to get out of bed, walk to the bathroom at night, or move from a sitting to standing position.

A retrospective analysis of 148 psychiatric inpatients found that those who fell were more likely to have an acute medical condition, complain of more physical symptoms, and be prescribed more medications than those who didn’t fall. Fallers were significantly more likely than nonfallers to be taking antihypertensive medications (19% vs 3%) and clonazepam (42% vs 18%). Benzodiazepines generally appear to add to fall risk. In a study of nursing home residents, patients taking benzodiazepines experienced a 44% greater rate of falls than nonusers. Additionally, imidazopyridine sleep aids (eg, zolpidem) have been associated with confusion, daytime somnolence, and dizziness in older inpatients, and falls may result. Antidepressants and antipsychotics also may increase the risk of falls via drowsiness, imbalance, confusion, orthostatic hypotension, and involuntary muscle contraction.

The Centers for Medicare & Medicaid Services has taken a strong stand on antipsychotic medication by setting a goal to reduce the use of these medications in nursing homes by 30% from 2012 to the end of 2016, with exclusion only for the diagnoses of schizophrenia, Tourette’s syndrome, and Huntington’s disease. More studies should be done to look at which antipsychotics and doses are most risky for falls and if any may be deemed as less risky to use. One nursing home study found that, while falls were more common among residents taking high doses of quetiapine (> 150 mg/d) or risperidone (> 2 mg/d) compared with residents not taking an antipsychotic, low doses of quetiapine or risperidone and any dose of olanzapine were not associated with a higher risk of falls.

Medical professionals, especially psychiatrists, need to become more educated, aware, and involved in fall prevention. The Institute for Clinical Systems Improvement protocol summary to prevent falls in inpatients recommends that a complete falls assessment should be made by the physician, nurse, and pharmacist. Unnecessary medications need to be discontinued. Medications with the side effects of sedation, confusion, and orthostatic hypotension need to be evaluated and altered appropriately.

Financial disclosure: Dr King had no relevant personal financial relationships to report.

How Have Views on Nutrition and Mental Health Changed?

Human knowledge of the relationship between nutrition and mental function probably goes back in time for many thousands of years, but it has been documented for “only” ~2,700 years. Join us now for a fun ramble through history.

When was the first report of a clinical trial on the impact of nutrition on mental/cognitive health? It’s in the Bible, in the first part of the Book of Daniel. At the beginning of the Babylonian Exile that lasted about 50 years until ~538 BCE, King Nebuchadnezzar pillaged Jerusalem and took captives back to Babylon. Nebuchadnezzar wanted the captured youths, who would train for 3 years to serve in his palace, to eat the same food as the royal family. One captive, Daniel, did not like the idea of “defiling” his body with a diet that seems to have been rich in meat and alcohol. So Daniel proposed a 10-day trial in which he and 3 friends would be given only legumes and water, and then the king could compare the 4 of them with those eating the royal diet. The result, variously translated, was that after 10 days, “in all matters of wisdom and understanding, … he found them ten times better” than the others. In other words, diet affected brain function! (Side note: Some people now follow a “Daniel diet.”)

What was the view of the ancient Greeks toward food and nutrition? Is there any quotation more frequently attributed to Hippocrates than this one? “Let food be thy medicine, and medicine be thy food.”

How did people in the modern era view nutrition and mental health prior to the explosion of pharmaceuticals in the mid-20th century? Mrs Beeton’s Book of Household Management, first published in 1861, provided a guide to running a household in Victorian Britain. This 1,112-page tome mostly contains recipes but also has sections on how to manage children, the servants, and properties, as well as a section dedicated to how to keep well—a large portion of which discusses the role of food. A section devoted to “invalid” cookery shows the wisdom of the time about the importance of diet:

Diet can often cure where drugs are useless or worse. Diet is always harmless where drugs are usually dangerous. Every year diet plays a larger part in the skilled treatment of disease. And yet we often see unskilled women, who would hesitate before changing their children’s diet from roast meat and milk puddings, more than before pouring down their throats all manner of powerful medicines. For the majority of common ailments, some slight change of diet is by far the best remedy.

For the most part, Mrs Beeton was talking about the treatment of physical ailments; however, she also appreciated the role that food played in the expression of psychological symptoms: “If we consider the amount of ill-temper, despondency, and general unhappiness which arises from want of proper digestion and assimilation of our food, it seems obviously well worth while to put forth every effort, and undergo any sacrifice, for the purpose of avoiding indigestion, with its resulting bodily ills.”

Are there North American examples of Mrs Beeton-type wisdom before the current age of pharmaceuticals? We found a major reference used throughout the American west and the prairie provinces of Canada in the early 20th century. The 1910 book The People’s Home Library was a source of in-depth, practical knowledge, especially for those living far from health care for themselves or their livestock. In three volumes, The People’s Home Library taught you how to cook, treat various ailments, make soap, increase your supply of breast milk, build a house, care for your livestock, and much more. One volume is entirely recipes (the other two are about medical and livestock issues). When we found a copy in rural Alberta, we found text that said, “The number one cause of acquired insanity is imperfect nutrition.” Food was always known to be important, including for mental health.

Has processing of food resulted in a poorer diet? Perhaps some of us heard our grandparents talk about how they ate prior to World War II, before processed food became widely available. Some will recall their attitude that food processing (in particular, preservation by canning and freezing) improved our nutrition enormously. It enabled the population-at-large to eat produce year round that otherwise was available only in the summer. But the early days of processing that broadened accessibility of fruits and veggies gradually gave way to packaged food. In a future post, we will review some of the research comparing the mental health of people who eat mostly processed food to that of people who eat a traditional diet.

So, our ancestors knew that nutrition is a big part of the mental health picture. We believe that the rise of the pharmaceutical era eclipsed the rich historical knowledge that our ancestors had about the importance of food for maintaining good mental health.

This blog entry is adapted from a previous entry that can be found athttp://www.madinamerica.com/2013/04/study-the-past-if-you-would-define-the-future-confucius/.

Financial disclosure: Drs Kaplan and Rucklidge had no relevant personal financial relationships to report, and no company has ever funded any of their studies.

Is It My Childhood, Adulthood, or Am I Just Crazy Enough to Be a Psychiatrist?

Dr Iskandar: “You must’ve had a bad childhood” is what my internal medicine attending physician said when I told him during medical school that I was going into psychiatry. Years later, when I decided to survey primary care residents in two teaching hospitals about their perspectives on mental health, I couldn’t resist asking a question about what they think of us. The question was, what percentage of mental health care professionals (MHPs) do you think has mental health problems? The answer choices were 25%, 50%, 75%, and over 75%.

Of course, my selfish reason was to know what they really think of me when I work or sit at lunch with them daily. Unfortunately, the survey revealed a positive correlation between primary care residents’ advancing training level and their growing belief that MHPs have mental health problems. While 60% of first-year and 70% of second-year residents reported a belief that 25% and 50% of MHPs, respectively, have mental health problems, 80% of third-year residents reported a belief that more than 75% of MHPs have mental health problems.

In denial, I told myself that these results are not statistically significant, and maybe they do not represent our colleagues’ true perceptions of us. But, if true, how do the perceptions of primary care residents form and grow with time?

I decided to ask Dr Eric Vance, my mentor and a coauthor of the study, about his experiences dealing with the perceptions of others about his career choice.

Dr Vance: In my experience, the survey confirms the perceptions of many people outside of our profession—that those who become MHPs end up there due to having their own mental health problems. As for me, I recall choosing the field due to thinking that the brain was the most interesting organ in the body (and meeting a couple of cool psychiatrists in med school). Of course that didn’t keep my father from asking why I didn’t choose to be a “real doctor.” My father passed away before he repaired all the damage caused by his own narcissism, but, by entering psychiatry, I’ve been able to gain enough insight to control my own. Perhaps if I hadn’t become an MHP, my unexamined narcissism would’ve served me in the role of a ruthless businessman, or a tyrannical surgeon terrorizing residents and medical students. I’ve also heard the common perception that psychiatrists as a group are “a bunch of oddballs.” I acknowledge that I’ve met many colorful MHPs over the years, but do we really have more mental disorders than the pathologist with Asperger’s, the depressed internist with no bedside manners, or the addicted anesthesiologist? I’m not sure I went into the field to “figure out my own problems,” but I think maybe it has helped a bit. In any case, most people eventually realize that very few of us can solve our own problems, and the help of another person is often needed to guide us. That person is often an MHP.

Dr Iskandar: Then, should we accept the perception or fight it?

Financial disclosure: Drs Iskandar and Vance had no relevant personal financial relationships to report.

See also “Why Become a Psychiatrist? The Id Speaks” by Aditya Joshi, MD.

How Does Nutrition Affect the Brain?

The two of us are so pleased to be invited to blog on the role of nutrition in mental health. As research psychologists (and Julia is also a clinical psychologist) who have spent years studying nutrition in relation to mental health, behavior, and brain development, we know how beneficial good nutrition can be for some people with mental health problems. But we also know that many people reading this blog are unaware of the tremendous scientific inroads made on this topic over the last decade. Julia is faced with this issue when teaching clinical psychology students, many of whom enter the field believing that the only ways to influence psychological symptoms are talk therapies and psychotropics. They are typically genuinely surprised that our brains can be influenced by what we eat.

Even some people who are very knowledgeable about the importance of good nutrition and other lifestyle factors for physical health are not yet aware that these lifestyle variables also significantly influence brain health. Here is why we find this disconnect so strange: THE BRAIN IS PART OF THE BODY.

It seems inane even to write that statement, especially to this audience, but many of us in the health field refer to “mind-body connections” and “mind-body medicine,” perpetuating the myth of separation. We even separate mental health (“the mind”) from neurological function (“the brain”). But brain health, mental health, and bodily health are interconnected. Nutrients are needed for all cellular growth and metabolism, and the brain places large demands on energy metabolism. Here are two bits of information that we find somewhat amazing and that illustrate this fact:

  1. The brain is approximately 2% of our whole body weight, but it consumes 20% of our metabolism. In other words, the brain is constantly and disproportionately demanding nutrients.
  2. Every single minute, almost a quart of blood passes through your brain. Why? That quart of blood is bringing nutrients and oxygen (and other metabolic products) to every single nook and cranny in your cranium. So, we can ask ourselves—what have we eaten in the last day or so? Those are the chemicals bathing our brains.

Related topics to explore in our future blog posts include the following:

  • The history of nutrition and mental health, going back ~2700 years
  • How mental health and nutrition were viewed prior to the development of psychotropic medications in the 1950s and '60s
  • The scope of single-nutrient treatments from 1920 to the present
  • The emergence of broad-spectrum nutrient treatments in the 21st century
  • Epidemiologic data on the relationship between nutrition and mental function
  • The 2013 development of the field of ‘nutritional psychiatry’ and the new scientific group ISNPR (International Society for Nutritional Psychiatry Research)
  • Nutritional treatment options for various mental disorders (watch Julia’s recent TEDx talk)
  • The role of microbiota in mental health
  • The psychological effects of starvation: what are the lessons from the Minnesota Starvation Experiment and the Dutch Hunger Winter famine?
  • How does nutrition research in the past decade lead to a new conceptualization of mental illness?
  • Whether supplementation is necessary for the “normal” population
  • New publications that influence public policy
  • The challenges of studying and publishing on dietary influences on mental health
  • The importance of increased nutrient intake after natural disasters
  • And so much more: What do we know about nutrients and addictions? What is the mechanism by which nutrition influences mental health? What does nutrition have to do with inflammation?

We look forward to discussing these topics with you.

This blog entry is adapted from a previous entry that can be found at http://www.madinamerica.com/2013/04/nutrition-and-mental-health/.

Financial disclosure: Drs Kaplan and Rucklidge had no relevant personal financial relationships to report, and no company has ever funded any of their studies.

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Aggressive Inpatients in a Community General Hospital

Patients who are aggressive and present with characteristics and behaviors associated with a significant risk for physical violence are not uncommon in the acute inpatient behavioral health units of general hospitals.Treating the aggressive patient challenges clinicians to safely, expeditiously, and effectively manage the needs of both the aggressive patient and the unit’s entire patient population.

Several factors contribute to the admission of aggressive patients to general hospitals’ psychiatric units, including the closing of state hospitals; insufficient housing for mentally ill, intellectually disabled, and addicted individuals; the recurrent problem of community treatment unsuccessfully managing aggressive patients; and controversy regarding if or when these patients’ actions necessitate incarceration. And, although staff may hope this trend of admitting aggressive patients abates, studies have stated that this population merely reflects society and will, therefore, continue to be present.

Research has shown that acts of aggression are most likely to occur within the first or second week of hospitalization. Predictors have frequently been utilized to identify which patients are most at risk for aggressive behavior while hospitalized and are typically grouped by categories such as demographics (eg, age, sex, history of violence, psychosocial factors), clinical characteristics (eg, diagnosis, substance use, personality disorders, symptoms, severity of illness), contextual factors (eg, unit environment), and staff contributors (eg, communication skills, aggression training).

The results of our prospective study on aggressive patients cited younger males with a history of previous violence, past psychiatric admissions, and severe symptoms of agitation (defined as excessive, purposeless motor activity) as being more at risk for aggressive behavior during acute psychiatric hospitalization than other patients. Additionally, our results suggested that positive psychotic symptoms, a diagnosis of bipolar disorder, and substance use also contributed to aggressive behavior. We also identified a relationship between the participants’ severity of illness and level of aggressiveness.

In study participants, paranoia was the symptom most successfully reduced/treated by medication. The medications we used for our study participants seemed efficacious, as significant improvements were seen in psychometric scale scores (CGI-S and MOAS) from baseline to last visit; however, the overall positive effects of the therapeutic inpatient environment and routine must also be considered as important contributors to patient improvement.

Our study showed high rehospitalization rates for aggressive patients, which suggests that patients with aggression issues are difficult to treat and difficult to keep in compliance with treatment on an outpatient basis. This finding highlights the need to strengthen community mental health centers through an increase in public-private partnerships.

Financial disclosure: Dr Mittal is a consultant for Janssen, Otsuka, and Teva. Ms Nourse had no relevant personal financial relationships to report.​

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