Literature Collection

OBJECTIVES: Adolescents with substance use disorders (SUDs) exhibit high rates of comorbid psychological problems. This study aimed to examine the impact of an outpatient substance use treatment programme upon the psychological wellbeing of adolescents. METHODS: A prospective study was carried out examining psychological symptoms in a group of adolescents attending the Youth Drug and Alcohol (YoDA) Addiction Service in Dublin. Participants were treated with evidenced based psychological models such as cognitive behavioural therapy, motivational interviewing and systemic family therapy. The Becks Youth Inventory was utilised to assess psychological symptoms at treatment entry and repeated three months later at follow up. RESULTS: Among 36 adolescents who were included in this study, poly-substance misuse was the norm. Almost three-quarter had a cannabis use disorder (CUD). There were significant reductions in mean subscale scores of depression (56.0 to 50.8, p = 0.003), anger (55.2 to 49.5, p < 0.001) and disruptive behaviour (61.6 to 56.5, p = 0.002) at follow up. Although there wasn't a statistically significant reduction in mean scores for anxiety, we observed a significant proportion of participants (p = 0.008) improving and moving out of a moderate to severe symptom range when examined by category. This was also the case for self-concept (p = 0.04). Furthermore this study revealed a positive correlation between the reduction in days of cannabis use and reduction in depressive scores (Pearson correlation 0.49, p = 0.01) among those with a CUD. CONCLUSION: The findings indicate that substance use treatment for adolescents is associated with important psychological and behavioural improvements.

BACKGROUND: As the death toll continues to rise in the opioid overdose epidemic, increasing access to medications for opioid use disorder (OUD), such as buprenorphine, is vital. Psychiatric clinical pharmacist practitioners (CPPs) can help bridge the gap in care but are limited in their ability to prescribe buprenorphine given federal restrictions. OBJECTIVE: This study aimed to describe a pharmacist-psychiatrist collaborative practice designed to increase access to buprenorphine for OUD in rural communities by maximizing the CPP role. PRACTICE DESCRIPTION: A CPP operating under a scope of practice with prescriptive authority to manage substance use disorders (SUDs) and comorbid mental health conditions was hired in June of 2020 at a rural Veterans Affairs (VA) hospital in Tomah, Wisconsin. PRACTICE INNOVATION: A collaborative agreement with X-waivered psychiatrists was established to manage buprenorphine for patients with OUD. EVALUATION METHODS: A retrospective chart review was conducted on all patients with an OUD diagnosis from July 1, 2020, to October 31, 2021, to assess the use of medications for OUD, comorbid psychiatric, and SUD diagnoses; active naloxone prescription; and CPP involvement in care. For patients prescribed buprenorphine, their average wait time to initiation appointment was calculated in days and compared before and after CPP implementation. RESULTS: As of October 31, 2021, there were 60 patients with OUD cared for by the Tomah VA, of whom 28 received buprenorphine comanaged with the CPP. On average, those requesting urgent access appointment for buprenorphine assessment from the CPP were seen for same-day induction appointments compared with historically an average of a 6.1 day wait for outpatient appointments and 5.8 days for scheduled inpatient inductions. CONCLUSION: Collaborative approaches to buprenorphine management with a CPP improve access to care. Although collaboration decreases time burden for X-waivered psychiatrists, care could be more efficient and timely if a CPP could independently induct, stabilize, and manage patients on buprenorphine.

BACKGROUND: The specific aims of this project were to create a fully integrated, nurse-led model of a psychiatric nurse practitioner and behavioral health care team within primary care to facilitate (1) patients receiving an appropriate level of care and (2) care team members performing at the top of their scope of practice. METHOD: The guiding model for process implementation was Rapid Cycle Quality Improvement. Three task forces were established to develop interventions in the areas of Roles and Responsibilities, Training and Implementation, and the electronic health record. INTERVENTION: The four interventions that emerged from these task forces were (1) the establishment of patient tiers based on diagnosis, medications, and risk assessment; (2) the creation of process maps to engage care team members; (3) just-in-time education regarding psychiatric medication management for primary care providers; and (4) use of a registry to track patients. RESULTS: The process measures of referrals to the psychiatric care team and psychiatric assessment intakes performed as expected. Both measures were higher at the onset of the project and lower 1 year later. The outcome indicator, number of case reviews, increased dramatically over time. CONCLUSIONS: For psychiatric nurse practitioners, this quality improvement effort provides evidence that a consultative role can be effective in supporting primary care providers. Through providing education, establishing patient tiers, and establishing an effective workflow, more patients may have access to psychiatric services.

BACKGROUND: Older people with serious mental ill health have high levels of physical comorbidity. Despite this, mental health services receive limited physical health support from primary or secondary care. This study investigated the facilitators and barriers to delivering physical healthcare for older people in mental health settings. METHODS: In total, 54 semi-structured interviews (REC:22/IEC08/0022) were conducted with different stakeholders [staff (n = 28), patients (n = 7), carers (n = 19)] across two mental health hospitals. Interviews explored the facilitators and barriers to delivering physical healthcare for older people (>65 years) receiving secondary mental healthcare (dementia and psychiatric disorders). Data were analysed thematically, underpinned by a framework of integrated care for individuals living with multimorbidity. RESULTS: A 'multidisciplinary approach' was valued, particularly to identify patients for targeted physical health support. There was felt to be a loss of physical health 'training and skills' over time, particularly amongst nursing and medical staff. Admissions to the acute hospital were potentially avoidable through improved 'support and availability of physical health expertise', to provide more proactive than reactive care. Alongside improved training and support, managing advanced care planning, end of life care and polypharmacy were perceived to facilitate improved physical healthcare in mental health settings. CONCLUSIONS: Lack of senior physical health leadership (e.g. geriatrician or general practitioner) and loss of skills and confidence in managing physical health in mental health settings have led to a low threshold for admissions to the acute hospital. In particular, services should support advanced care planning and end of life care from physical causes in mental health settings.