Andrea G. Segal

Improving long-term psychiatric care: bring back the asylum.

This Viewpoint discusses new models for patient-centered, long-term psychiatric care in the United States.

Proceed with Caution: Off-label Ketamine Treatment for Major Depressive Disorder

Ketamine offers a promising new option for the treatment of depression, but its increasing off-label use is ethically and clinically inappropriate at the moment.

Sleep Disturbance Partially Mediates the Relationship Between Intimate Partner Violence and Physical/Mental Health in Women and Men

Intimate partner violence (IPV) is a worldwide health concern and an important risk factor for poor mental/physical health in both women and men. Little is known about whether IPV leads to sleep disturbance. However, sleep problems may be common in the context of IPV and may mediate relationships with mental/physical health. Data from the 2006 Behavioral Risk Factor Surveillance System (BRFSS) were used (N = 34,975). IPV was assessed in female and male participants for any history of being threatened by, physically hurt by, or forced to have sex with an intimate partner (THREAT, HURT, and SEX, respectively), and, further, as being forced to have sex with or physically injured by an intimate partner within the past year (SEXyr and HURTyr, respectively). These survey items were coded yes/no. Sleep disturbance was assessed as difficulty falling asleep, staying asleep, or sleeping too much at least 6 of the last 14 days. Logistic regression analyses, adjusted for age, sex, race, income, education, and physical/mental health, assessed whether IPV predicted sleep disturbance. Sobel–Goodman tests assessed whether relationships between IPV and physical/mental health were partially mediated by sleep disturbance. All IPV variables were associated with sleep disturbance, even after adjusting for the effects of age, sex, race/ethnicity, income, education, employment, marital status, physical health and mental health. THREAT was associated with sleep disturbance (odds ratio [OR] = 2.798, p < .0001), as was HURT (OR = 2.683, p < .0001), SEX (OR = 3.237, p < .0001), SEXyr (OR = 7.741, p < .0001), and HURTyr (OR = 7.497, p < .0001). In mediation analyses, all IPV variables were associated with mental health (p < .0001), and all were associated with physical health (p < .007) except SEXyr. Sleep disturbance partially mediated all relationships (Sobel p < .0005 for all tests). Mediation was around 30%, ranging from 18% (HURTyr and mental health) to 41% (HURT and physical health). IPV was strongly associated with current sleep disturbance above the effect of demographics and overall mental/physical health, even if the IPV happened in the past. Furthermore, sleep disturbance partially mediates the relationship between IPV and mental/physical health. Sleep interventions may potentially mitigate negative effects of IPV.

County Jail or Psychiatric Hospital? Ethical Challenges in Correctional Mental Health Care:

Approximately 20% of the roughly 2.5 million individuals incarcerated in the United States have a serious mental illness (SMI). As a result of their illnesses, these individuals are often more likely to commit a crime, end up incarcerated, and languish in correctional settings without appropriate treatment. The objective of the present study was to investigate how correctional facility personnel reconcile the ethical challenges that arise when housing and treating individuals with SMI. Four focus groups and one group interview were conducted with employees (n = 24) including nurses, clinicians, correctional officers, administrators, and sergeants at a county jail in Pennsylvania. Results show that jail employees felt there are too many inmates with SMI in jail who would benefit from more comprehensive treatment elsewhere; however, given limited resources, employees felt they were doing the best they can. These findings can inform mental health management and policy in a correctional setting.

Research Moratoria and Off-Label Use of Ketamine

ISSN: 1526-5161 (Print) 1536-0075 (Online) Journal homepage: http://www.tandfonline.com/loi/uajb20 Research Moratoria and Off-Label Use of Ketamine Andrea Segal & Dominic Sisti To cite this article: Andrea Segal & Dominic Sisti (2016) Research Moratoria and Off-Label Use of Ketamine, The American Journal of Bioethics, 16:4, 60-61, DOI: 10.1080/15265161.2016.1145285 To link to this article: http://dx.doi.org/10.1080/15265161.2016.1145285

Social Problem Solving as a Predictor of Attitudes Toward Seeking Mental Health Care and Medical Care Among Veterans

Attitudes toward seeking health care, particularly mental health care, are significantly affected by stigma. Stigma surrounding mental health care is a particularly poignant issue for military veterans who are returning home in need of both medical and psychological care. The present study aimed to investigate whether social problem solving plays a role in perceptions of stigma and subsequent attitudes toward seeking both mental health care and medical care among veterans. Social problem solving was found to be a significant predictor of psychological openness, a subscale of the Inventory of Attitudes Toward Seeking Mental Health Services (IASMHS) assessing the extent to which one is open about recognizing a problem and seeking help for that difficulty. These findings suggest that programs aimed at improving social problem solving skills may help veterans seek necessary care.

Outcomes of Care for Ischemic Heart Disease and Chronic Heart Failure in the Veterans Health Administration

Importance The Department of Veterans Affairs (VA) operates a nationwide system of hospitals and hospital-affiliated clinics, providing health care to more than 2 million veterans with cardiovascular disease. While data permitting hospital comparisons of the outcomes of acute cardiovascular care (eg, myocardial infarction) are publicly available, little is known about variation across VA medical centers (VAMCs) in outcomes of care for populations of patients with chronic, high-risk cardiovascular conditions. Objective To determine whether there are substantial differences in cardiovascular outcomes across VAMCs. Design, Setting, and Participants Retrospective cohort study comprising 138 VA hospitals and each hospital’s affiliated outpatient clinics. Patients were identified who received VA inpatient or outpatient care between 2010 and 2014. Separate cohorts were constructed for patients diagnosed as having either ischemic heart disease (IHD) or chronic heart failure (CHF). The data were analyzed between June 24, 2015, and November 21, 2017. Exposures Hierarchical linear models with VAMC-level random effects were estimated to compare risk-standardized mortality rates for IHD and for CHF across 138 VAMCs. Mortality estimates were risk standardized using a wide array of patient-level covariates derived from both VA and Medicare health care encounters. Main Outcomes and Measures All-cause mortality. Results The cohorts comprised 930 079 veterans with IHD and 348 015 veterans with CHF; both cohorts had a mean age of 77 years and were predominantly white (IHD, n = 822 665 [89%] and CHF, n = 287 871 [83%]) and male (IHD, n = 916 684 [99%] and CHF n = 341 352 [98%]). The VA-wide crude annual mortality rate was 7.4% for IHD and 14.5% for CHF. For IHD, VAMCs’ risk-standardized mortality varied from 5.5% (95% CI, 5.2%-5.7%) to 9.4% (95% CI, 9.0%-9.9%) (P < .001 for the difference). For CHF, VAMCs’ risk-standardized mortality varied from 11.1% (95% CI, 10.3%-12.1%) to 18.9% (95% CI, 18.3%-19.5%) (P < .001 for the difference). Twenty-nine VAMCs had IHD mortality rates that significantly exceeded the national mean, while 35 VAMCs had CHF mortality rates that significantly exceeded the national mean. Veterans Affairs medical centers’ mortality rates among their IHD and CHF populations were not associated with 30-day mortality rates for myocardial infarction (R2 = 0.01; P = .35) and weakly associated with hospitalized heart failure 30-day mortality (R2 = 0.16; P < .001) and the VA’s star rating system (R2 = 0.06; P = .005). Conclusions and Relevance Risk-standardized mortality rates for IHD and CHF varied widely across the VA health system, and this variation was not well explained by differences in demographics or comorbidities. This variation may signal substantial differences in the quality of cardiovascular care between VAMCs.

Deceiving Without Debriefing: A Pragmatic Overreach?

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Expanding long-term care options for persons with serious mental illness--reply.

Remy were drawn from the instrument development study and reflect scores associated with the 7 dimensions of the instrument but not the total instrument.1 In the RESTORE trial, all physicians and nurses received training and were required to successfully complete a posttest prior to enrolling patients. We established interrater reliability checks on the SBS and monitored interrater reliability throughout the trial in both intervention and control PICUs. The overall κ score for the SBS was 0.87 (95% CI, 0.83-0.91). Any PICU falling below 80% agreement implemented a quality improvement plan and the interrater reliability was rechecked. As noted in our article and in the supplementary materials, sedation assessments were completed more frequently in the intervention compared with control PICUs, presumably because the data were used by the intervention PICUs to target sedation. Adherence to sedation assessment elements in our protocol was high; the daily SBS target was prescribed on 98% of intubation study days and achieved 95% of the time in intervention patients. We have no data on how nurse turnover or experience may have confounded the RESTORE study. As noted in our supplemental materials, the experience level of the PICU nursing workforce was good, with a median of 6.2 years (interquartile range, 5.1-8.3 years) across sites, and most nurses had bachelor’s degrees (median, 80%; interquartile range, 74%-90% across sites). In addition, we had few protocol deviations stemming from enrolled patients receiving care from a nurse who was not trained in using the RESTORE protocol. Clinical trials and observational studies2 may differ in their conclusions for the reasons that Remy cites, and there may be additional bias introduced in observational studies that may be difficult to identify, as well as the inherent differences between a toddler with acute respiratory failure and a 50-yearold adult with a medical or surgical problem.