Smita Das

Reliability of self-report: paper versus online administration

This investigation compared online and paper administration of self-report measures of weight and shape concerns, mood, weight and height. The former was designed as a screening instrument for adolescent students to determine risk for eating disorders. Participants were female sophomores (N=74) from a San Francisco Bay area private high school. A counterbalanced designed was used to control for order effects. Four classes were randomly assigned to one of four conditions: (1) online-paper; (2) paper-online; (3) online-online; and (4) paper-paper. Participants completed self-report questionnaires twice, online and/or on paper, separated by 1 week. Agreement between online and paper assessment of weight and shape concerns and BMI ranged from 0.73 to 0.97 and 0.80 to 1.0, respectively. Agreement for positive mood ranged from 0.58 to 0.85 and negative mood from 0.59 to 0.82. Mean scores for weight and shape concerns and mood variables were significantly lower at the second testing. Online and paper assessment of weight and shape concerns was significantly correlated. However, there was a significant time effect. Mood was less stable and correlations between the two modes of self-report were less correlated. Online assessment may be beneficial and appropriate for many settings.

Cytisine, the world’s oldest smoking cessation aid

Growing evidence for its use as an affordable treatment globally

Dissemination of an Effective Inpatient Tobacco Use Cessation Program

The present study aimed to determine whether tobacco use cessation rates observed in controlled trials of a hospital-based tobacco use cessation program could be replicated when the program was disseminated to a wide range of hospitals in a two-stage process including implementation and institutionalization phases. Using a nonrandomized, observational design, we recruited six hospitals to participate in the study. The research team helped implement the program during the first year of participation (implementation) and then withdrew from active involvement during the second year (institutionalization). The mean 6-month self-reported cessation rates were 26.3% (range = 17.6%-52.8%) for the implementation phase and 22.7% (range = 12.9%-48.2%) for the institutionalization phase. Hospitals with paid professionals providing the program had the best outcomes. Inpatient tobacco use cessation programs are feasible to implement and should target a 6-month self-reported cessation rate of at least 25%.

Smoking, Mental Illness, and Public Health

Tobacco use remains the leading preventable cause of death worldwide. In particular, people with mental illness are disproportionately affected with high smoking prevalence; they account for more than 200,000 of the 520,000 tobacco-attributable deaths in the United States annually and die on average 25 years prematurely. Our review aims to provide an update on smoking in the mentally ill. We review the determinants of tobacco use among smokers with mental illness, presented with regard to the public health HAVE framework of “the host” (e.g., tobacco user characteristics), the “agent” (e.g., nicotine product characteristics), the “vector” (e.g., tobacco industry), and the “environment” (e.g., smoking policies). Furthermore, we identify the significant health harms incurred and opportunities for prevention and intervention within a health care systems and larger health policy perspective. A comprehensive effort is warranted to achieve equity toward the 2025 Healthy People goal of reducing US adult tobacco use to 12%, with attention to all subgroups, including smokers with mental illness.

Prospective Validation Study of the Prediction of Alcohol Withdrawal Severity Scale (PAWSS) in Medically Ill Inpatients: A New Scale for the Prediction of Complicated Alcohol Withdrawal Syndrome.

AIMS The prevalence of alcohol use disorders (AUDs) among hospitalized medically ill patients exceeds 40%. Most AUD patients experience uncomplicated alcohol withdrawal syndrome (AWS), requiring only supportive medical intervention, while complicated AWS occurs in up to 20% of cases (i.e. seizures, delirium tremens). We aimed to prospectively test and validate the Prediction of Alcohol Withdrawal Severity Scale (PAWSS), a new tool to identify patients at risk for developing complicated AWS, in medically ill hospitalized patients. METHODS We prospectively considered all subjects hospitalized to selected general medicine and surgery units over a 12-month period. Participants were assessed independently and blindly on a daily basis with PAWSS, Clinical Institute Withdrawal Assessment-Alcohol, Revised (CIWA-Ar) and clinical monitoring throughout their admission to determine the presence and severity of AWS. RESULTS Four hundred and three patients were enrolled in the study. Patients were grouped by PAWSS score: Group A (PAWSS < 4; considered at low risk for complicated AWS); Group B (PAWSS ≥ 4; considered at high risk for complicated AWS). The results of this study suggest that, using a PAWSS cutoff of 4, the tools sensitivity for identifying complicated AWS is 93.1% (95%CI[77.2, 99.2%]), specificity is 99.5% (95%CI[98.1, 99.9%]), positive predictive value is 93.1% and negative predictive value is 99.5%; and has excellent inter-rater reliability with Lins concordance coefficient of 0.963 (95% CI [0.936, 0.979]). CONCLUSION PAWSS has excellent psychometric characteristics and predictive value among medically ill hospitalized patients, helping clinicians identify those at risk for complicated AWS and allowing for prevention and timely treatment of complicated AWS.

Treating Smoking in Adults With Co-occurring Acute Psychiatric and Addictive Disorders.

Objectives: Tobacco use is undertreated in individuals with psychiatric and substance use disorders (SUDs), with concerns that quitting smoking may compromise recovery. We evaluated outcomes of a tobacco intervention among psychiatric patients with co-occurring SUDs. Methods: Data from 2 randomized tobacco treatment trials conducted in inpatient psychiatry were combined; analyses focused on the subsample with co-occurring SUDs (n = 216). Usual care provided brief advice to quit and nicotine replacement therapy during the smoke-free hospitalization. The intervention, initiated during hospitalization and continued 6 months after hospitalization, was tailored to readiness to quit smoking, and added a computer-assisted intervention at baseline, and 3 and 6 months; brief counseling; and 10 weeks of nicotine replacement therapy after hospitalization. Outcomes were 7-day point prevalence abstinence from 3 to 12 months and past 30-day reports of alcohol and illicit drug use. Results: The sample consisted of 34% women, among which 36% were Caucasian, averaging 19 cigarettes/d prehospitalization; the groups were comparable at baseline. At 12 months, 22% of the intervention versus 11% of usual care participants were tobacco-abstinent (risk ratio 2.01, P = 0.03). Past 30-day abstinence from alcohol/drugs did not differ by group (22%); however, successful quitters were less likely than continued smokers to report past 30-day cannabis (18% vs 42%) and alcohol (22% vs 58%) use (P < 0.05), with no difference in other drug use. Conclusions: Tobacco treatment in psychiatric patients with co-occurring SUDs was effective and did not adversely impact recovery. Quitting smoking was associated with abstinence from alcohol and cannabis at follow-up. The findings support addressing tobacco in conjunction with alcohol and other drugs in psychiatric treatment.

Innovative approaches to support smoking cessation for individuals with mental illness and co-occurring substance use disorders

ABSTRACT Introduction: Tobacco remains the leading preventable cause of death in the US, accounting for over 520,000 deaths annually. While the smoking prevalence has declined over the past 50 years, those with mental illness and addictive disorders continue to smoke at high levels and with significant tobacco-related health problems. Areas covered: This review highlights the epidemiology, contributing factors, and evidence-base for intervening upon tobacco use in those with mental illness and addictive disorders. Historically underprioritized, a growing body of literature supports treating tobacco within mental health and addiction treatment settings. Critically, treating tobacco use appears to support, and not harm, mental health recovery and sobriety. This review also summarizes novel, emerging approaches to mitigate the harms of cigarette smoking. Expert commentary: People with mental illness and addictive disorders have a high prevalence of tobacco use with serious health harms. Treating tobacco use is essential. Evidence-based strategies include individual treatments that are stage-matched to readiness to quit and combine cessation medications with behavioral therapies, supported by smoke-free policies in treatment settings and residential environments. Emerging approaches, with a focus on harm reduction, are electronic nicotine delivery systems and tobacco regulatory efforts to reduce the nicotine content in cigarettes, thereby reducing their addiction potential.

Smoking Trends Among Adults With Behavioral Health Conditions in Integrated Health Care: A Retrospective Cohort Study

OBJECTIVE Individuals with behavioral health conditions (BHCs) smoke at high rates and have limited success with quitting, despite impressive gains in recent decades in reducing the overall prevalence of smoking in the United States. This study examined smoking disparities among individuals with BHCs within an integrated health care delivery system with convenient access to tobacco treatments. METHODS The sample consisted of patients in an integrated health care delivery system in 2010-a group (N=155,733) with one or more of the five most prevalent BHCs (depressive disorders, anxiety disorders, substance use disorders, bipolar and related disorders, and attention-deficit hyperactivity disorder) and a group (N=155,733) without BHCs who were matched on age, sex, and medical home facility. The odds of smoking among patients with BHCs versus without BHCs were examined over four years using logistic regression generalized estimating equation models. Tobacco cessation medication utilization among a subset of smokers in 2010 was also examined. RESULTS Although smoking prevalence decreased from 2010 to 2013 overall, the likelihood of smoking decreased significantly more slowly among patients with BHCs compared with patients without BHCs (p<.001), most notably among patients with substance use and bipolar and related disorders. Tobacco cessation medication use was low, and smokers with BHCs were more likely than smokers without BHCs to utilize these products (6.2% versus 3.6%, p<.001). CONCLUSIONS Smoking decreased more slowly among individuals with BHCs compared with individuals without BHCs, even within an integrated health care system, highlighting the need to prioritize smoking cessation within specialty behavioral health treatment.

Bus therapy: a problematic practice in psychiatry.

Crossing state lines, a man arrives alone in San Francisco, having traveled by bus on a 1-way ticket provided by a psychiatric hospital in his home state. He is disoriented,with few possessions,lacks medications and medical records, and calls 911 as he was instructed. He is brought to the county psychiatric emergency service, which,hectic and often over capacity,treats nearly 6000 patients annually (of which 39% are not San Francisco residents).The patient needs housing,a psychiatrist,case manager, primary care provider, and transfer of Medicaid or general assistance—a package known colloquially astheSan Francisco Special.Placements are challenging— the county hospital reduced its acute inpatient psychiatrycapacity50% in thelast 5years owing to budget short-falls—yet out-of-state visitors are not turned away. Shipping patients across state lines on 1-way bus fares without a treatment plan or identified residence is referred to as bus therapy, a form of patient dumping. In April 2013, the Sacramento Bee reported that more than 1500 mentally ill and questionably discharged patients from Nevada were transported by Greyhound bus to states across the country in the past 5 years.1 One-third were sent to California—San Francisco and Los Angeles counties initiated formal investigations. Patient dumping is not new. In the 1970s, with US mental health deinstitutionalization, psychiatric beds were reduced, uninsured patients were often turned away, and more patients sought emergency care. The 1986 Emergency Medical Treatment and Active Labor Act was intended to reduce patient dumping, by requiring emergency departments to screen and stabilize presenting patients (a subjective process). With continued reductions in inpatient capacity (4000 acute beds reduced nationally between 2010-2012), the impact on emergency services is expected to grow.2 People with mental illness have the right to relocate willingly and preferably when in stable condition and with facilitated continuity of care.On the other hand,patient dumping has many implications for psychiatric patients, especially the severely mentally ill. Obvious ones are potential harms owing to decompensation,poor self-care, loss of support networks, vulnerability to victimization, and/or failure to access care. In 2009, 40% of adults with serious mental illness went untreated.3