Michael I. Casher

The Effects of Cannabis on Inpatient Agitation, Aggression, and Length of Stay

ABSTRACT Objective: This study examines the association between cannabis use and the hospital course of patients admitted to the psychiatric inpatient unit with a diagnosis of schizophrenia, schizoaffective disorder, or bipolar disorder. Many confounding variables potentially contribute to the clinical presentation of hospitalized patients in the psychiatric unit. Illicit drug use, in particular, has been associated with acute agitation, and questions can be raised as to what lasting effects drug use prior to admission may have throughout a patients hospital stay. Methods: Subjects with a discharge diagnosis of bipolar disorder, schizophrenia, schizoaffective disorder, or psychosis not otherwise specified (N = 201) were retrospectively identified, and those with positive results of urine drug screen for cannabis on admission were compared to negative counterparts. Agitation and aggression were measured using an adaptation of the Excited Component of the Positive and Negative Syndrome Scale (PANSS-EC). These markers were also quantified by comparing charted episodes of restraint and seclusion and administration of as needed medications, such as benzodiazepines and antipsychotics. Results: Positive urine drug screen results for cannabis was correlated with young (p = .001) males (p = .003) with bipolar disorder (p = .009) exhibiting active manic symptoms (p = .003) at the time of admission. Cannabis use was further associated with a shorter length of stay (p = .008), agitation triggering adapted PANSS-EC nursing assessments (p = .029), and oral medications as needed (p = .002) for agitation. Conclusions: Cannabis use, as defined by positive urine drug screen results, was more common in patients with bipolar disorder and was accompanied by a higher incidence of inpatient agitation. Although these patients also had short hospital lengths of stay, there was no clear relationship between level of agitation and length of stay across all patient groups. One possible explanation for patients with bipolar disorder experiencing short lengths of stay is that their source of agitation may be more closely related to a complex effect of cannabis use rather than a sole etiology of mental illness. Inpatient clinicians should be aware of patient cannabis use proximate to admission.

Persistence of metabolic monitoring for psychiatry inpatients treated with second‐generation antipsychotics utilizing a computer‐based intervention

Monitoring and intervention for metabolic abnormalities secondary to second‐generation antipsychotics (SGAs) remain weak areas of performance in mental health care. This study evaluated the sustained impact of a computerized physician order entry (CPOE) pop‐up alert designed to improve rates of laboratory metabolic monitoring of patients treated with SGAs in an inpatient psychiatry unit. Interventions carried out by the psychiatry team to manage metabolic abnormalities found on screening were also identified.

Complex case: A biofeedback intervention to control impulsiveness in a severely personality disordered forensic patient by Rick Howard, Klaus Schellhorn and John Lumsden

With this case report of successful biofeedback treatment for a severely disordered and treatmentrefractory forensic patient, the authors contribute to arguments for consideration of the inclusion of biofeedback for a group of extremely challenging patients. The term ‘complex patient’ barely captures the patient MN, whose psychopathology cuts across diagnostic borders and includes a mixed personality disorder with borderline, antisocial and histrionic features, paedophilia, attentional difficulties that may meet criteria for Attention Deficit Disorder/ Attention Deficit Hyperactivity Disorder, borderline intellectual functioning and an unspecified mood disorder. Prior to his transfer from a prison to a forensic hospital, the unremitting severity of his sexual deviance led to placement on a testosteronelowering agent, and his level of mood instability resulted in treatment with carbamazepine. Strengths of this case report include the extensive initial psychometric and psychological evaluation of the patient and the documentation of significant post-treatment improvement in biobehavioral (Flanker test) and electrophysiological (Go/No Go contingent negative variation) measures, as well as patient self-report of decreased impulsivity and improvement in attention/cognition at the study endpoint and at 3months of follow-up. This paper is a welcome addition to the literature on therapeutic interventions in severely personality disordered patients from several perspectives. Much of this patient’s history and behavioural presentation are characteristics of antisocial personality disorder (ASPD) and accompanying paedophilia, areas of psychopathology much neglected in psychiatric literature, with diagnoses for which therapeutic pessimism bordering on nihilism has led in the US to relegation of these patients to the criminal justice system. Patients with ASPD have significant deficits in mentalization, attachment and impulse control (Leichsenring et al., 2003), ego weaknesses that make them poor candidates for many psychotherapies and that render these patients destructive to a hospital-based therapeutic milieu. Indeed, MN had shown poor motivation and compliance with routine psychotherapies in the past. An advantage for forensic-type patients of neurofeedback treatments is that they work at basic neurophysiologic levels and focus on brain functioning rather than psychopathology; consequently these procedures largely bypass the need

How to Approach Clinical Supervision

The academic physician’s assignment as a supervisor of trainees is an honor and a privilege, yet he or she may not have had formal preparation for teaching in the clinical setting but likely learned through personal experience. It is important for the academic physician to formally review the role and reflect on the qualities he or she found most helpful (and otherwise) and those he or she would most want to emulate. This chapter addresses both theoretical and practical aspects of clinical supervision in inpatient and outpatient settings.

The academic psychiatric hospitalist: a model for treatment and training in the academic inpatient setting.

Recent years have seen the expanding presence of hospitalists, most prominently in internal medicine, but also in other areas such as neurology, pediatrics, and psychiatry. In contrast to a burgeoning literature on general medicine hospitalists, very little has been written about the role of psychiatric hospitalists-psychiatrists who work exclusively in the hospital setting-and the advantages of this model in the inpatient setting. The authors trace the history of hospitalists in psychiatry and argue that this model can fit well with the clinical and teaching mission of the modern academic psychiatry inpatient program. High quality care of acutely ill psychiatric inpatients involves a body of knowledge and a set of core competencies that may be best served by psychiatric hospitalists.