Ann L. Hackman

Use of the internet and other media for health information among clinic outpatients with serious mental illness

OBJECTIVE This study examined how people with serious mental illness access and use media to receive health information. METHODS One hundred people with serious mental illness were interviewed regarding their media use, with a focus on how they get their health information. RESULTS Among these participants, 91% had a television (M+/-SD=5.7+/-4.6 hours per day), and 74% indicated it was a primary health information source. One third of the sample had used the Internet. Of these participants, about half (53%) had gone online for health information. Younger participants and those with more education were significantly more likely to use the Internet. Among Internet nonusers, there was still interest in finding health information online; however, expense, lack of computer skills or knowledge, and difficulties with typing and reading prevented doing so. CONCLUSIONS Although this sample used television more often than the Internet as a resource, there appears to be interest among persons with serious mental illness in using the Internet as a source of health information and support.

Consumer satisfaction with inpatient psychiatric treatment among persons with severe mental illness

Consumer satisfaction with inpatient care is an important component of quality of care and a recovery-oriented system of care. This study assessed association of patient, demographic and process of care variables with inpatient satisfaction focusing on modifiable service delivery factors. Participants were 136 people with psychotic or affective disorders recruited from VA inpatient units who were interviewed with an extensive assessment. Staff teaching efforts regarding medication, illness management, substance abuse, outpatient treatment and living skills were significantly associated with greater levels of satisfaction with care, controlling for demographic and clinical variables. This may reflect value consumers place on staff time, attention and communication. Teaching may enhance self-efficacy and hope thereby facilitating recovery.

Transitioning clients from assertive community treatment to traditional mental health services.

The original assertive community treatment (ACT) model included time-unlimited treatment. However, resource restrictions and subsequent research call into question the feasibility and necessity of time-unlimited services. This study compares the outcomes of 48 individuals who successfully transitioned from ACT to less intensive Community Mental Health Center (CMHC) services to 19 persons who required return to ACT or did not remain in CMHC treatment. There were no statistically significant differences in demographics, diagnoses, and other treatment factors between the two groups.

The role of social media networks in psychotic disorders: a case report

We report the case of a young man diagnosed with schizophrenia who presented with stalking behaviors that may have been caused by problematic use or participation in social media networks (SMN). We review the possible role of SMN in the formation of his romantic delusion and offer suggestions for clinicians around incorporation of SMN questions into assessments. It is imperative to identify populations at risk of SMN-related stalking behaviors to stratify mental health resources and interventions. Additional studies are needed to further clarify the role of SMN in psychotic disorders.

Media and internet ownership and use among mental health outpatients with serious mental illness.

Objective: To determine whether people with serious mental illness (SMI) and substance use disorder (SUD) use the Internet to receive health information. Methods: One hundred people with SMI were surveyed in community mental health clinics. Results: Participants with SUD were significantly less likely to use the Internet compared to those who without SUD (.34 [.12–.95] p = .04). Internet users with SUD were significantly more likely to report accessing sites topically related to substance abuse (p = .01). Conclusion: Few participants with SMI and SUD used the Internet. Attention to educating patients about quality health information on the Internet may be warranted.

Psychiatrists' Attitudes Toward Individuals With Substance Use Disorders and Serious Mental Illness

Objective: The attitudes of psychiatrists toward individuals with highly stigmatized conditions such as substance use disorders and serious mental illness may influence treatment effectiveness. These attitudes may be influenced by factors including previous specialty training and current practice patterns. This study examined the attitudes of addiction and community psychiatrists toward individuals with diagnosed schizophrenia, polysubstance dependence, comorbid schizophrenia and polysubstance dependence, and depression. Methods: A web-based survey link was sent to the electronic mailing lists of addiction and community psychiatry associations. Results: A total of 84 respondents identified themselves as either addiction (n = 54) or community (n = 30) psychiatrists. The majority were male (70% of addiction and 57% of community psychiatrists) with an average age of 56.0 (SD = 11.86) and 52.7 (SD = 11.8), respectively. Addiction psychiatrists had less stigmatizing attitudes than community psychiatrists for individuals with polysubstance dependence (p < .0001), while community psychiatrists had less stigmatizing attitudes than addiction psychiatrists for those with schizophrenia (p < .0001). Attitudes toward individuals with dual diagnosis did not vary significantly by psychiatrist group, but both addiction and community psychiatrists had more stigmatizing attitudes for individuals with dual diagnosis (p < .0001). Conclusions: These findings suggest that even psychiatrists working with highly stigmatized groups of individuals may continue to hold stigmatizing attitudes toward people with other diseases. Future work is needed to further assess stigmatizing attitudes among psychiatrists and the impact of these attitudes on quality of care, as well as interventions such as specialized education and training to reduce such stigma among psychiatrists.

Evidence for differential opioid use disorder in schizophrenia in an addiction treatment population

Although people diagnosed with schizophrenia are known to have elevated risks of abuse and dependence for nicotine, alcohol, cocaine, and cannabis, it is less clear if schizophrenia is associated with higher rates of opioid use disorders compared to either the general population or individuals with other major psychiatric disorders. Here we examine a large publicly available database from substance abuse treatment centers to compare how frequently patients with schizophrenia report problems with heroin or other opioid drugs compared to other major drugs of abuse. For comparison, the pattern of substance abuse in schizophrenia is contrasted with individuals with major depression, bipolar disorder, and the entire sample of individuals seeking substance abuse treatment. We find that a significantly lower proportion of patients with schizophrenia are reported to have problems with heroin (5.1%) relative to the entire treatment population (18.2%). The schizophrenia sample also had a significantly lower proportion of individuals with a non-heroin opioid problem (7.2%) compared to the entire treatment population (14.8%), patients with depression (23%), and patients with bipolar disorder (17.3%). In contrast, the schizophrenia sample had significantly higher proportions of individuals with problems with alcohol, cocaine, and cannabis relative to the treatment population. Although these data do not allow conclusions on the relative rate of opioid addiction in schizophrenia compared to the general population, the results suggest a discrepancy in patterns of drug choice that may aid our understanding of schizophrenia and substance use comorbidity.

The Psychiatric Note in the Era of Electronic Communication

The electronic medical record (EMR) is a central component of health care reform and is already implemented in many settings (Blumenthal, 2009). Some clinicians may find this a desirable and others an undesirable development (Baron, 2007; Garg et al., 2005; Mangalmurti et al., 2010; Sittig and Classen, 2010); however, increasing numbers of mental health clinicians now face the challenge of using the EMR wisely and therapeutically in settings in which such systems are now, or soon will be, operative (Mojtabai, 2007). This article illustrates how the EMR can be used to benefit patients and providers while understanding that as with all change there are potential anticipated and unanticipated problems. In most ways, the psychiatric note in the EMR is not radically different from traditional notes in paper medical records. The EMR note continues to address the tasks of documenting the psychiatric assessment, current treatment regimens, outcomes, and future treatment steps. However, the legibility and accessibility of EMR notes greatly increase the degree of “sharedness” of treatment assessment and planning with cotreaters and patients. The increased degree of “sharedness” of the EMR can foster treatment continuity and effective communication between a team of providers. To reap these benefits, the EMR requires us to produce clear, comprehensive but relatively brief notes. Although clear concise notes were desirable in the paper-based medical record, the EMR makes such notes essential. The EMR will be more readily available to the patients and other clinicians, potentially posing issues for the patient clinician alliance but also potentially increasing the opportunities for greater clinician-patient collaboration. While the paper charts were always “permanent,” the new accessibility of an EMR results in notes that are also more easily retrieved. This raises concerns regarding potentially “sensitive” information discussed during mental health treatment. We illustrate the potential benefits and clinical concerns using 2 clinical vignettes in 2 different treatment settings. Dr. A and Dr. H work in settings in which the EMR is being introduced. Dr. A works in a tertiary care academic medical center and treats Mr. J for depression and narcissistic personality disorder with combined medication and psychotherapy. An EMR would make the diagnosis of narcissistic personality disorder more transparent and result in a discussion between Dr. A and his patient that may enhance or threaten their working alliance. Dr. H works at the local community mental health center and treats Mr. B for schizophrenia. Mr. B has ongoing delusions regarding a computer chip in his head, and may react poorly to the news that his notes are now available in electronic format.

Ethics and the Treatment of the Mentally Ill, Homeless Person: a Perspective on Psychiatry Resident Training

ObjectiveThe authors outline the unique ethical challenges that psychiatry residents face in working with individuals who are homeless and mentally ill. The authors also propose steps to develop effective teaching methods with residents working with these patients.MethodsThe authors reviewed literature relevant to the training of psychiatry residents in ethics and treating individuals who are homeless and mentally ill.ResultsThe authors summarize current literature and, with the use of case examples, provide guidelines for effective teaching.ConclusionsTeaching psychiatry residents who are working in the community with individuals who are mentally ill and homeless needs to address a number of unique ethical conflicts that arise in this area. The authors outline approaches to this teaching.

Rational Protection of Subjects in Research and Quality Improvement Activities

This Open Forum illuminates shortcomings with the basis for determining degree of oversight of health services research and quality improvement activities. Using a federally regulated definition of research rather than a direct appraisal of risk to patients can misallocate effort from activities with higher risk for patients to those with lower risk. The case of the Johns Hopkins multicenter study of central line safety checklists in intensive care units is cited. Definitions of research promulgated by the Office of Human Research Protection are reviewed, and an alternative model based on patient risk is proposed. Suggestions for how quality improvement work fits into the larger paradigm of research are made.