Research

Abstract

BACKGROUND: Delirium is a prevalent neuropsychiatric disorder associated with increased morbidity and mortality. Half the cases remain misdiagnosed.OBJECTIVE: Assess the effectiveness of the Stanford Proxy Test for Delirium (S-PTD) in detecting delirium in an inpatient setting.METHODS: This is a comparison study. Daily assessment with S-PTD, by the patient's nurse, and a neuropsychiatric assessment by a psychiatrist. Assessments were blinded. Inclusion criteria included 18 years or older. Exclusion criteria included patient's or surrogate's unwillingness to participate, inability to consent if a surrogate was not available, and inability to communicate in English or Spanish. A total of 309 patients were approached: 27 declined participation, 4 were excluded, and 278 subjects were followed up throughout their hospital stay. In the end, 78 were excluded for lack of neuropsychiatric assessment, S-PTD, or both. One was excluded for lack of demographic data. The sensitivity and specificity of the S-PTD in detecting delirium when compared with a neuropsychiatric assessment.RESULTS: Participants were on average 60.8 years old and 54.3% were male. Patients who developed delirium were, on average, older (15.12 y, confidence interval: 8.94-21.32). A total of 199 patients were analyzed; 43 patients (21.6%) met criteria for delirium. S-PTD detected 67 days with delirium (16.5%) of 405 hospital days, while neuropsychiatric evaluation identified 83 (20.5%). S-PTD had a sensitivity of 80.72% and a specificity of 90.37%.CONCLUSION: S-PTD is an effective, comprehensive, and simple screening tool for delirium, which is robust despite fluctuating symptoms and lack of cooperation. The use of S-PTD may enhance early diagnosis of delirium.

View details for DOI 10.1016/j.psym.2019.11.009

View details for PubMedID 31926650

Abstract

Traumatic brain injury (TBI) is an alteration in brain function, or other evidence of brain pathology, caused by an external force. TBI is a major cause of disability and mortality worldwide. Post-traumatic amnesia, or the interval from injury until the patient is oriented and able to form and later recall new memories, is an important index of TBI severity and functional outcome. This article will discuss the updates in the epidemiology, definition and classification, pathophysiology, diagnosis, and management of common acute neuropsychiatric sequelae of traumatic brain injury that the critical care specialist may encounter.

View details for PubMedID 28601130

Abstract

Delirium is the most often encountered psychiatric diagnosis in the general hospital, with an incidence of up to 82% in the intensive care unit setting and with significant detrimental effects on patients' morbidity and mortality. Antipsychotics are often considered the first-line pharmacological treatment of delirium, but their use may be limited by lack of efficacy, existing contraindications (e.g., prolonged QTc intervals), or resulting side effects (e.g., akathisia). Valproic acid (VPA) is a potential alternative or adjunct treatment. It has multiple mechanisms of action, including effects on neurotransmitter modulation, neuroinflammation, oxidative stress, and transcription, all of which are implicated in the pathophysiology of delirium. Yet, data on the use of this agent in delirium are limited.In this article, we discuss postulated mechanisms of VPA action that provide a theoretical basis for its use in the treatment of hyperactive and mixed type delirium, based on the known and theorized pathophysiology of delirium. We also discuss potential side effects and considerations with use of VPA.VPA has multiple modulatory effects on neurotransmitter systems, inflammation, oxidative stress, and transcriptional changes implicated in pathophysiology of delirium. When carefully chosen, VPA can be an effective and well-tolerated treatment option for the management of hyperactive and mixed type delirium. Randomized controlled trials are needed to establish tolerability and efficacy of VPA for treatment of delirium.

View details for Web of Science ID 000366315400002

View details for PubMedID 26674479

Abstract

Patients with delirium may fail to respond to standard therapies. Sixteen patients with management-refractory hyperactive delirium responded to adjunctive valproic acid, with complete resolution of hyperactive delirium in 13 cases. A rationale for using valproic acid in such circumstances is discussed.

View details for DOI 10.1176/appi.neuropsych.14080190

View details for PubMedID 25803136

View details for DOI 10.1111/j.1365-2141.2008.07496.x

View details for Web of Science ID 000262635500023

View details for PubMedID 19036097

View details for PubMedCentralID PMC2636683

View details for Web of Science ID 000765384800120

Abstract

We have undertaken a genome-wide analysis of rare copy-number variation (CNV) in 1124 autism spectrum disorder (ASD) families, each comprised of a single proband, unaffected parents, and, in most kindreds, an unaffected sibling. We find significant association of ASD with de novo duplications of 7q11.23, where the reciprocal deletion causes Williams-Beuren syndrome, characterized by a highly social personality. We identify rare recurrent de novo CNVs at five additional regions, including 16p13.2 (encompassing genes USP7 and C16orf72) and Cadherin 13, and implement a rigorous approach to evaluating the statistical significance of these observations. Overall, large de novo CNVs, particularly those encompassing multiple genes, confer substantial risks (OR = 5.6; CI = 2.6-12.0, p = 2.4 × 10(-7)). We estimate there are 130-234 ASD-related CNV regions in the human genome and present compelling evidence, based on cumulative data, for association of rare de novo events at 7q11.23, 15q11.2-13.1, 16p11.2, and Neurexin 1.

View details for DOI 10.1016/j.neuron.2011.05.002

View details for Web of Science ID 000291843500008

View details for PubMedID 21658581

View details for DOI 10.1016/j.jaclp.2026.01.006

View details for PubMedID 41565073

View details for DOI 10.1016/j.jaclp.2025.10.058

View details for Web of Science ID 001632245200029

View details for DOI 10.1016/j.jaclp.2025.10.069

View details for Web of Science ID 001632245200041

View details for DOI 10.1016/j.jaclp.2025.10.140

View details for Web of Science ID 001633400000009

View details for DOI 10.1016/j.jaclp.2025.10.238

View details for Web of Science ID 001633400000102

View details for DOI 10.1016/j.jaclp.2025.10.313

View details for Web of Science ID 001632287200066

View details for DOI 10.1016/j.jaclp.2025.10.237

View details for Web of Science ID 001633400000101

View details for DOI 10.1016/j.jaclp.2025.10.170

View details for Web of Science ID 001633400000037

Abstract

The Psychiatric Consultation Service at Massachusetts General Hospital sees medical and surgical inpatients with comorbid psychiatric symptoms and conditions. During their twice-weekly rounds, Dr Stern and other members of the Consultation Service discuss diagnosis and management of hospitalized patients with complex medical or surgical problems who also demonstrate psychiatric symptoms or conditions. These discussions have given rise to rounds reports that will prove useful for clinicians practicing at the interface of medicine and psychiatry. Prim Care Companion CNS Disord 2025;27(5):25f03958. Author affiliations are listed at the end of this article.

View details for DOI 10.4088/PCC.25f03958

View details for PubMedID 40986809

Abstract

Post-operative delirium (POD) is a frequent complication in older adults following surgery, leading to higher morbidity and mortality. This study evaluates the validity of the Pre-Interventional Preventive Risk Assessment (PIPRA) tool in predicting POD in an elderly orthopedic population.We enrolled 250 patients aged 65 or over undergoing elective orthopedic surgery (knee or hip arthroplasties). Delirium was assessed using the Confusion Assessment Method (CAM) and additional DSM-5 based neuropsychiatric evaluations. The PIPRA tool was applied retroactively to generate delirium risk scores based on nine validated risk factors found within the patient's electronic medical record (EMR).Of 241 patients, 13 (5.4 %) developed POD. The median PIPRA score for delirious patients was significantly higher (24.3) compared to non-delirious patients (8.95). Logistic regression identified age (OR = 1.12) and history of cognitive impairment (OR = 10.38) as significant predictors of POD. The PIPRA tool demonstrated an area under the curve (AUC) of 0.748.Our study supports PIPRA's validity in assessing delirium risk using readily available clinical parameters from patients' EMRs. When integrated into clinical workflows, this model can preoperatively stratify delirium risk, enabling targeted interventions to prevent its onset.The PIPRA tool presents an innovative approach to evaluating POD risk in surgical populations. By identifying at-risk patients, PIPRA can facilitate informed consent discussions and the implementation of effective preventive measures. Future research should validate its performance across diverse surgical cohorts to refine predictive capabilities and optimize delirium prevention strategies.

View details for DOI 10.1016/j.jpsychores.2025.112196

View details for PubMedID 40570705

Abstract

Alcohol-associated liver disease (ALD) is a rapidly increasing indication for liver transplantation (LT) globally with a significant rise in transplants for ALD with limited sobriety including patients with alcohol-associated hepatitis (AH). This evolution challenges the older paradigm that mandates prolonged periods of alcohol abstinence prior to LT. Due to the limited armamentarium of effective pharmacotherapy to treat severe AH, the mortality rates are significantly higher when LT is not available. In the patients who are transplanted for ALD with limited sobriety including AH, patient and graft survival are equivalent, if not better, compared to patients transplanted for other etiologies. However, due to the risk of alcohol relapse and other psychosocial factors, public opinion regarding early LT may continue to impact how the field moves forward particularly regarding organ stewardship and the need for equitable allocation of organs. Numerous tools for psychosocial evaluations have been developed to assist liver transplant teams to identify appropriate patients in a more uniform manner. In this review, we aim to assess the available evidence to support early LT for alcohol AH and propose directions for the future as the field continues to evolve.

View details for DOI 10.5500/wjt.v15.i4.104589

View details for PubMedID 41357372

View details for PubMedCentralID PMC12679208

Abstract

History of substance use is assessed in potential heart transplantation evaluations. The evidence base for this highly consequential practice, linking substance use disorders with poor post-transplantation outcomes, presents methodological limitations. We conducted a retrospective cohort study to address these limitations using high dimensional propensity score matching to compare heart transplant outcomes of patients with and without substance use disorders. Key outcomes included mortality, hospitalization, and organ rejection rates, controlling for confounders. A national dataset of electronic health records of >120 million patients in the United-States (2015-2023) was used to identify heart transplantation patients with substance use disorders (n=808) and controls (n=7066), matched for medical comorbidities and demographic variables. Only after adjusting for sociodemographic and comorbidities of heart transplant recipients, the results revealed no significant differences between groups with and without substance use disorders at one year in mortality (Odds Ratio (OR)=0.96 (95% CI: 0.54, 1.69, p=0.88), hospitalization (OR=1.02 (95% CI: 0.83, 1.25, p=0.840)), organ rejection rates (OR=0.96 (95% CI: 0.78, 1.18, p=0.670)), nor at 5 years in mortality (Hazards Ratio (HR) =1.15 (95% CI: 0.82, 1.61, p=0.410) and organ rejection (HR=0.98 (95% CI: 0.84, 1.14, p=0.810). Future studies must consider confounding factors when evaluating transplant criteria and outcomes in patients with substance use disorders.

View details for DOI 10.1093/ehjqcco/qcaf117

View details for PubMedID 41026891

Abstract

Psychiatric disorders are prevalent in patients with rectal prolapse. While psychiatric disorders are associated with poor surgical outcomes and worse health in general, it is unknown how they impact rectal prolapse repair.To determine rectal prolapse symptom severity in patients with psychiatric disorders and how surgical repair modified these symptoms.Retrospective analysis of a prospectively maintained database.Academic colorectal practice.Female patients with and without psychiatric comorbidities who underwent rectal prolapse repair with preoperative and 1-year postoperative Pelvic Floor Distress Inventory (PFDI-20) scores.One-year change in PFDI-20 score.Of 365 female patients in our registry, 146 met inclusion criteria. 54 (36%) had a psychiatric disorder. Depression (66%) and anxiety (44%) were the most prevalent conditions. Patients with a psychiatric disorder were significantly younger (median [IQR] age: 61 [48, 67] vs. 70 [60,77], p<0.001) but otherwise had a similar prevalence of comorbidities such as cardiac disease. Preoperative symptom profile was similar, but patients with psychiatric disorders reported higher PFDI-20 scores reflecting greater prolapse-related distress (mean [SD]: 146 [70] vs 115 [55], p = 0.01). Postoperatively, PFDI-20 scores improved significantly in both groups (adjusted mean change from baseline for patients with rectal prolapse repair: psychiatric disorders: -88 [-130, -47] vs. no psychiatric disorders: -44 [-68, -19]). Models did not reveal statistically significant differential improvement between groups, though patients with psychiatric disorders tended to have greater improvement in their scores compared to patients without psychiatric disorders.Single-center study with limited data on psychiatric comorbidity severity and disease control.Rectal prolapse patients with psychiatric disorders suffer from prolapse-related distress at baseline but experience significant improvement after surgical repair, suggesting that appropriate management of rectal prolapse can improve their quality of life. Long-term durability of symptom improvement should be the focus of further work. See Video Abstract.

View details for DOI 10.1097/DCR.0000000000003964

View details for PubMedID 40970548

View details for DOI 10.1016/j.jaclp.2023.11.633

View details for Web of Science ID 001161339100153

View details for DOI 10.1016/bs.dnb.2019.05.002

View details for Web of Science ID 000631377700008

Abstract

Solitary fibrous pleural tumors are rare mesenchymal tumors that can be mistaken for mesothelioma. A positive staining of vimentin, negative staining of cytoplasmic keratin, and expression of the CD34 antigen can confirm their diagnosis. These tumors should be surgically excised although they are benign because they have malignant potential and tendency for recurrence.We present here a 63-year-old patient who had an inconclusive biopsy of a huge right intrathoracic lesion. Further testing after radical surgical resection revealed a malignant solitary fibrous pleural tumor. Surgery was complicated with injury of the thoracic duct. Patient was re-operated upon for ligation of the thoracic duct. He is doing well with no recurrence after 18 months of follow-up.In conclusion, definitive treatment for solitary fibrous tumor is radical surgical resection with close follow-up for the recurrences. Follow-up of this tumor is essential especially when it showed malignant features on pathological examination.

View details for DOI 10.1007/s11748-012-0014-6

View details for PubMedID 22566249

Abstract

Stress and stress-related chronic illness are increasing worldwide while mental health care access remains limited. Recent neurophysiological advances support the effectiveness and safety of hypnosis for stress management. In this retrospective observational study, we studied app-delivered hypnosis in 84,395 users across 282,893 stress reduction sessions. Users rated pre- and post-session stress on a 10-point Likert Scale. Data analysis utilized Linear Mixed Effects (LME) models to accommodate repeated measures and missing data. Effects of session type, user hypnotizability, age, sex, and membership were assessed. Pre-to-post stress reduction occurred consistently in each of the first 10 sessions (Cohen's d values ranging from -0.71 to -0.78), demonstrating significant improvement in stress management. Across the first 10 sessions, greater stress reduction was observed with interactive and regular-length sessions, higher hypnotizability, older age groups, and paying members. Findings provide evidence that disseminable digital formulations of hypnosis contribute meaningfully to stress reduction.

View details for DOI 10.1038/s41746-025-02182-0

View details for PubMedID 41413254

Abstract

Melatonin is an easily accessible, widely used drug for sleep issues, disrupted sleep-wake cycles, and jet lag, available in a variety of forms and dosages. Melatonin is also used in hospital settings to promote sleep onset, particularly in elderly patients, as a circadian rhythm regulator. Despite the popularity of melatonin, it is not approved by the US Food and Drug Administration (FDA). This creates ambiguity surrounding its proper usage for optimum results, including dosage and time of administration. The objective of this article is to shed light on the best timing to administer melatonin. Melatonin is a hormone that our body naturally produces to regulate our biological clock. Even though our body has a built-in "sleep system," many people still suffer from chronic sleep disorders such as insomnia. Melatonin has also proved to help prevent delirium in hospitalized patients due to its circadian rhythm regulatory effects. The elderly are at risk of developing insomnia because as one ages, melatonin production decreases. The most convenient solution for insomnia is to take melatonin supplements. To optimize the effects of melatonin supplements, proper dosage and timing must be considered. Additionally, patients who are oppositional to bedtime, which is known as bedtime resistance, are typically more willing to go to bed following melatonin administration. Melatonin administration at around 6PM (1-2hours before bedtime) is optimal to regulate sleep cycles of patients, and it can help with bedtime resistance. This should be the standard of care in all hospitals, nursing homes, and at home.

View details for DOI 10.1017/S109285292510062X

View details for PubMedID 41126740

View details for DOI 10.4274/eajem.galenos.2025.49358

View details for Web of Science ID 001570928800001

View details for DOI 10.3928/00485713-20250529-01

View details for Web of Science ID 001580586800001

Abstract

Post-operative delirium (POD) is a frequent complication in older adults following surgery, leading to higher morbidity and mortality. This study evaluates the validity of the Pre-Interventional Preventive Risk Assessment (PIPRA) tool in predicting POD in an elderly orthopedic population.We enrolled 250 patients aged 65 or over undergoing elective orthopedic surgery (knee or hip arthroplasties). Delirium was assessed using the Confusion Assessment Method (CAM) and additional DSM-5 based neuropsychiatric evaluations. The PIPRA tool was applied retroactively to generate delirium risk scores based on nine validated risk factors found within the patient's electronic medical record (EMR).Of 241 patients, 13 (5.4 %) developed POD. The median PIPRA score for delirious patients was significantly higher (24.3) compared to non-delirious patients (8.95). Logistic regression identified age (OR = 1.12) and history of cognitive impairment (OR = 10.38) as significant predictors of POD. The PIPRA tool demonstrated an area under the curve (AUC) of 0.748.Our study supports PIPRA's validity in assessing delirium risk using readily available clinical parameters from patients' EMRs. When integrated into clinical workflows, this model can preoperatively stratify delirium risk, enabling targeted interventions to prevent its onset.The PIPRA tool presents an innovative approach to evaluating POD risk in surgical populations. By identifying at-risk patients, PIPRA can facilitate informed consent discussions and the implementation of effective preventive measures. Future research should validate its performance across diverse surgical cohorts to refine predictive capabilities and optimize delirium prevention strategies.

View details for DOI 10.1016/j.jpsychores.2025.112196

View details for PubMedID 40570705

Abstract

The Psychiatric Consultation Service at Massachusetts General Hospital sees medical and surgical inpatients with comorbid psychiatric symptoms and conditions. During their twice-weekly rounds, Dr Stern and other members of the Consultation Service discuss diagnosis and management of hospitalized patients with complex medical or surgical problems who also demonstrate psychiatric symptoms or conditions. These discussions have given rise to rounds reports that will prove useful for clinicians practicing at the interface of medicine and psychiatry. Prim Care Companion CNS Disord 2025;27(2):24f03873. Author affiliations are listed at the end of this article.

View details for DOI 10.4088/PCC.24f03873

View details for PubMedID 40250403

Abstract

Serotonin syndrome presents with the triad of neuromuscular excitability, autonomic disturbance, and altered mental status, resulting from excess serotonergic tone. Isoniazid (INH), a core agent for the management of tuberculosis (TB), is a weak, non-selective monoamine oxidase inhibitor (MAOI), and there have been minimal reports of its potential to contribute to serotonin toxicity. We present a complex case of INH-associated serotonin toxicity in a patient with autism spectrum disorder and co-occurring severe TB in the critical care setting. The patient was on rifampin, INH, pyrazinamide, and ethambutol regimen (RIPE) for pulmonary TB. Due to severe, refractory agitation for over a week, which prevented weaning of sedation and extubation, psychiatry was consulted. The psychiatry team worked to address agitation through a combination of haloperidol, lithium, valproic acid (VPA), and pregabalin. The patient developed serotonin toxicity, which persisted despite the cessation of psychotropics with serotonergic potential. This report illustrates the potential of INH's MAO inhibition to contribute to the development of serotonin toxicity. Consulting psychiatrists should exercise caution when recommending psychotropics to patients receiving INH and should take into account pharmacodynamic and pharmacokinetic interactions associated with its use. We recommend regular screening for serotonin toxicity in patients on INH and other agents that can increase serotonergic serum levels.

View details for DOI 10.7759/cureus.82362

View details for PubMedID 40385781

View details for PubMedCentralID PMC12083208

Abstract

The Psychiatric Consultation Service at Massachusetts General Hospital sees medical and surgical inpatients with comorbid psychiatric symptoms and conditions. During their twice-weekly rounds, Dr Stern and other members of the Consultation Service discuss diagnosis and management of hospitalized patients with complex medical or surgical problems who also demonstrate psychiatric symptoms or conditions. These discussions have given rise to rounds reports that will prove useful for clinicians practicing at the interface of medicine and psychiatry.Prim Care Companion CNS Disord 2025;27(1):24f03823.Author affiliations are listed at the end of this article.

View details for DOI 10.4088/PCC.24f03823

View details for PubMedID 40048280

View details for DOI 10.1016/j.jaclp.2025.10.248

View details for Web of Science ID 001632287200001

Abstract

People with cystic fibrosis (PWCF) and their caregivers may face the prospect of lung or liver transplantation as cystic fibrosis (CF) progresses. Despite the links between psychological distress, poor adherence and survival outcomes, their mental health needs may not be consistently addressed.We conducted a narrative review of mental health aspects of transplantation in PWCF, including health-related quality of life (HRQoL), pre-transplant psychosocial evaluation, neuropsychiatric complications, and psychosocial and psychopharmacologic interventions.Depression, anxiety and post-traumatic stress are common in this population, along with neuropsychiatric complications including cognitive impairment, delirium, side effects of immunosuppression, and drug-drug interactions. CF-specific guidelines recommend routine screening for depression, anxiety, and unmet palliative care needs for PWCF throughout the lifespan. Peri-transplantation, systematic monitoring can modify risk factors for and identify and treat delirium. Guidelines recommend screening, evaluation, and referral to care for depression, anxiety, and PTSD within 6 months post-transplant for PWCF and caregivers. Mental health intervention studies indicate there is potential to improve depression, anxiety, HRQoL, and medical outcomes.As CF progresses, patients and caregivers require preparation for the psychosocial aspects of transplant evaluation, including the salience of social support, treatment adherence, and the importance of early interventions for mental health and substance use disorders. Specialists in mental health, palliative care, and pain management can be enlisted to improve symptoms and functioning in PWCF and caregivers at all stages of the transplant process. Psychological and psychopharmacologic interventions may require adaptation to target the specific needs of PWCF with advanced disease.

View details for DOI 10.1016/j.rmed.2025.108407

View details for PubMedID 41067290

View details for DOI 10.1007/s40596-025-02222-7

View details for PubMedID 40921916

View details for PubMedCentralID 10920402

View details for DOI 10.4088/PCC.25cr03966

View details for PubMedID 40875884

Abstract

Medication management in women with bipolar disorder (BD) in the perinatal period is challenging, given that many patients taper or stop medication during pregnancy, and the postpartum period is an extremely high-risk period for relapse. The objective of this narrative review was to investigate the perinatal efficacy as well as potential adverse effects on the child of common treatments for bipolar disorder. These treatments include lithium, lamotrigine, other antiepileptics, quetiapine, olanzapine, aripiprazole, other antipsychotics, antidepressants, benzodiazepines, Z-drugs, and other sleep medication. Despite the worldwide decline in lithium use, it remains the gold standard for acute and maintenance treatment of BD, and we continue to advise its use in women of reproductive age. In contrast, medications with a high risk for teratogenicity such as valproate and carbamazepine should be avoided in women of childbearing potential. Women with bipolar disorder are at very high risk of relapse after delivery, but this risk is more than twofold lower with adequate pharmacological prophylaxis. We advise to make a written perinatal bipolar relapse prevention plan in collaboration with the patient, family, and healthcare professionals, which includes a description of: (1) maintenance treatment during pregnancy, (2) preferred mode of delivery, (3) medication immediately after delivery and the first months postpartum for relapse prevention, (4) preferred plan for feeding (breast-feeding versus bottle-feeding), (5) strategies to assist women in ensuring adequate sleep and stable circadian rhythm in the first weeks after delivery, and (6) how to recognize the first symptoms of relapse and which intervention strategies to take.

View details for DOI 10.1007/s40263-025-01202-7

View details for PubMedID 40593436

View details for DOI 10.1001/jamanetworkopen.2024.26465

View details for PubMedID 39110463

View details for PubMedCentralID PMC11307129

View details for DOI 10.3928/00485713-20230404-01

View details for Web of Science ID 000994144200007

Abstract

The Psychiatric Consultation Service at Massachusetts General Hospital sees medical and surgical inpatients with comorbid psychiatric symptoms and conditions. During their twice-weekly rounds, Dr Stern and other members of the Consultation Service discuss diagnosis and management of hospitalized patients with complex medical or surgical problems who also demonstrate psychiatric symptoms or conditions. These discussions have given rise to rounds reports that will prove useful for clinicians practicing at the interface of medicine and psychiatry.Prim Care Companion CNS Disord 2025;27(1):24f03823.Author affiliations are listed at the end of this article.

View details for DOI 10.4088/PCC.24f03823

View details for PubMedID 40048280

Abstract

Despite being a debilitating, costly, and potentially life-threatening condition, depression is often underdiagnosed and undertreated. Previsit Patient Health Questionnaire-9 (PHQ-9) may help primary care health systems identify symptoms of severe depression and prevent suicide through early intervention. Little is known about the impact of previsit web-based PHQ-9 on patient care and safety.We aimed to investigate differences among patient characteristics and provider clinical responses for patients who complete a web-based (asynchronous) versus in-clinic (synchronous) PHQ-9.This quality improvement study was conducted at 33 clinic sites across 2 health systems in Northern California from November 1, 2020, to May 31, 2021, and evaluated 1683 (0.9% of total PHQs completed) records of patients endorsing thoughts that they would be better off dead or of self-harm (question 9 in the PHQ-9) following the implementation of a depression screening program that included automated electronic previsit PHQ-9 distribution. Patient demographics and providers' clinical response (suicide risk assessment, triage nurse connection, medication management, electronic consultation with psychiatrist, and referral to social worker or psychiatrist) were compared for patients with asynchronous versus synchronous PHQ-9 completion.Of the 1683 patients (female: n=1071, 63.7%; non-Hispanic: n=1293, 76.8%; White: n=831, 49.4%), Hispanic and Latino patients were 40% less likely to complete a PHQ-9 asynchronously (odds ratio [OR] 0.6, 95% CI 0.45-0.8; P<.001). Patients with Medicare insurance were 36% (OR 0.64, 95% CI 0.51-0.79) less likely to complete a PHQ-9 asynchronously than patients with private insurance. Those with moderate to severe depression were 1.61 times more likely (95% CI 1.21-2.15; P=.001) to complete a PHQ-9 asynchronously than those with no or mild symptoms. Patients who completed a PHQ-9 asynchronously were twice as likely to complete a Columbia-Suicide Severity Rating Scale (OR 2.41, 95% CI 1.89-3.06; P<.001) and 77% less likely to receive a referral to psychiatry (OR 0.23, 95% CI 0.16-0.34; P<.001). Those who endorsed question 9 "more than half the days" (OR 1.62, 95% CI 1.06-2.48) and "nearly every day" (OR 2.38, 95% CI 1.38-4.12) were more likely to receive a referral to psychiatry than those who endorsed question 9 "several days" (P=.002).Shifting depression screening from in-clinic to previsit led to a dramatic increase in PHQ-9 completion without sacrificing patient safety. Asynchronous PHQ-9 can decrease workload on frontline clinical team members, increase patient self-reporting, and elicit more intentional clinical responses from providers. Observed disparities will inform future improvement efforts.

View details for DOI 10.2196/50192

View details for PubMedID 38712997

View details for Web of Science ID 001043057201067

Abstract

OBJECTIVES: This study aims to compare primary care providers and medical assistants in degrees of comfort, confidence, and consistency when addressing behavioral health concerns with patients before and after the implementation of a model of integrated behavioral health in primary care (IBHPC), and evaluate whether these perceptions differ based on increased access to behavioral health clinicians.METHODS: This longitudinal study was conducted at 2 primary care clinics in Northern California while implementing an IBHPC model. The Integrated Behavioral Health Staff Perceptions Survey was administered to assess the comfort, confidence, and consistency of behavioral health practices. Confidential online surveys were distributed to primary care faculty and staff members before and post-implementation. Responses from providers and medical assistants were compared between pre- and post-implementation with linear regression analyses. The relationships between accessibility to behavioral health clinicians and a change in comfort, confidence, and consistency of behavioral health practices were explored using a linear mixed-effects model.RESULTS: A total of 35 providers and medical assistants completed the survey both before and post-implementation of IBHPC. Over time, there were increasingly positive perceptions about the consistency of behavioral health screening (P=.03) and overall confidence in addressing behavioral health concerns (P=.005). Comfort in addressing behavioral health concerns did not significantly change for either providers or staff over time. Medical assistants were initially more confident and comfortable addressing behavioral health concerns than providers, but providers' attitudes increased post-IBHPC implementation. Improved access to behavioral health clinicians was associated with greater consistency of screening and referral to specialty mental health care (P<.001).CONCLUSION: The present study is the first to explore differences in provider and medical assistant perceptions during the course of an IBHPC implementation. Findings underscore the importance of integrating medical assistants, along with providers, into all phases of the implementation process.

View details for DOI 10.1177/21501319221146918

View details for PubMedID 36625239

View details for Web of Science ID 000672228200020

View details for Web of Science ID 000672228200023

View details for DOI 10.1016/j.psym.2020.06.009

View details for PubMedID 32977990

View details for DOI 10.1016/j.psym.2020.09.004

View details for PubMedID 33097226