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Dealing With Diabetes & Depression

Rates of depression are significantly higher for patients with diabetes, especially those who are elderly, when compared with people without diabetes. About 20% to 30% of patients with diabetes suffer from clinically relevant depressive disorders. “Depression can worsen glycemic control in those with diabetes,” says Jason C. Baker, MD. Research suggests depression is associated with a higher risk of developing diabetes complications and adverse outcomes. Conversely, improving depressive symptoms has been shown to lead to better glycemic control. “Depression can result in reduced physical activity and a greater need for medical care and prescriptions, which in turn can increase healthcare costs and worsen quality of life,” Dr. Baker says. “In order to improve the management of patients with these two conditions, it’s imperative that healthcare providers be aware of this link and its consequences.” He adds that effective pharmacologic and non-pharmacologic treatments are available and may be of benefit in some situations. Routine Screening The stress of managing diabetes on a daily basis and the effects of the disease on the brain may contribute to depression, according to Dr. Baker. “There are multiple factors that may be at play, but one of the most important things clinicians can do is screen patients with diabetes for depression,” he says. “Oftentimes, physicians focus solely on the chief complaint or on A1C, blood pressure, and cholesterol numbers. We need to take a more holistic approach and be vigilant about seeking out depression or other mental health problems. This should become a routine part of all diabetes care.” Dr. Baker says that it can be challenging to address depression when managing patients with...
Overcoming Boarding Issues With Psychiatric ED Patients

Overcoming Boarding Issues With Psychiatric ED Patients

It is estimated that between 6% and 9% of all ED visits are from patients presenting to the emergency room with mental health problems. Unfortunately, many EDs have limited onsite mental health services, forcing many of these patients to endure long holding periods while ED personnel search for available inpatient psychiatric beds. “The problem of boarding mental health patients for long hours—sometimes days—in EDs is considerable and widespread throughout the United States,” says Scott Zeller, MD. Recently published studies have shown that the average boarding time for patients with mental health issues ranges from about 7 hours to 34 hours (Table 1). The causes of boarding in these patients are wide ranging and include a lack of available psychiatric clinicians, requirements for insurance pre-authorizations, and few resources to conduct psychiatric evaluations, among others. Many solutions have been proposed, but these have generally focused solely on increasing available inpatient psychiatric hospital beds rather than considering alternative emergency care designs. “Changing the emergency care design has the potential to provide prompt access to treatment,” Dr. Zeller says. “It might also reduce the need for many hospitalizations.” A Dedicated Psychiatric Emergency Services Model In an effort to reduce average boarding times for patients with mental health issues, one suggested option has been regional dedicated psychiatric emergency services (PES). These units are stand-alone ED specifically for psychiatric patients. At PES facilities, patients are evaluated, receive intensive treatment, and are allowed time for observation and healing. “The goal of PES programs is to stabilize acute symptoms and avoid psychiatric hospitalization when possible,” says Dr. Zeller. “A PES unit can effectively treat patients to the...
Managing Depression After Acute Coronary Syndrome

Managing Depression After Acute Coronary Syndrome

Each year, about 1.2 million Americans survive an acute coronary syndrome (ACS) event, many of whom have clinically significant and persistent depression. “Post- ACS depression has been associated with higher risk of ACS recurrence and a doubling of increased risk of all-cause mortality,” explains Karina W. Davidson, PhD. “Persistent depression after an ACS event correlates with an even higher morbidity and mortality risk. Considering its burden on the healthcare system, efforts to reduce persistent post- ACS depression are important.” Despite knowledge of these associations, routine management of depression after ACS events remains poor. Historically, clinicians have been inefficient in screening for depression and lack effective approaches to treating it. Further compounding the problem are the weak effects often linked to depression treatments and limited options if initial therapies and efforts fail. For patients who have had an ACS event, psychotherapy and/or psychotropic medications are oftentimes not integrated into care. The CODIACS Vanguard Trial At ACC.13, Dr. Davidson and colleagues presented results from the Comparison of Depression Interventions after Acute Coronary Syndrome (CODIACS) Vanguard trial. It was designed to determine the feasibility, efficacy, and costs of a centralized, stepped, patient preference–based depression care system for patients after experiencing an ACS event. The study, which was also published in JAMA Internal Medicine, involved 150 patients who had depression scores of 10 or higher (out of 60) on the Beck Depression Inventory (BDI) scale 2 to 6 months after an ACS event. “CODIACS Vanguard was designed to provide depression treatment several months after an ACS,” explains Dr. Davidson, who was lead author of the trial. “This is when most transient depressive reactions...

Protecting EDs & Providers When Patients Leave Against Medical Advice

Recent studies suggest that as many as 2% of discharges from acute care hospitals and EDs in the United States are done against medical advice (AMA). For disadvantaged inner-city facilities, this figure can jump to 6%. “Patients who leave AMA have higher readmission rates,” says Darren P. Mareiniss, MD, JD. “They’re also at greater risk for adverse health effects.” The risk of emergent hospitalization appears highest in the first several days after an AMA discharge. Considering the prevalence and ramifications these discharges can have, Dr. Mareiniss says that “emergency physicians must make every attempt to prevent patients from leaving AMA.” [polldaddy poll=7234675] In the Journal of Emergency Medicine, Dr. Mareiniss and colleagues and the Johns Hopkins Center for Medicine & Law at the Department of Emergency Medicine recently published an article that reviewed legal requirements of the AMA process and examined how properly executed AMA discharges can protect institutions. “In situations when AMA discharge is unavoidable, the key is to optimize legal protection,” Dr. Mareiniss says. Capacity & Disclosing Risks When patients sign out AMA, they must first be deemed as having decision-making capacity. “The assessment of decision-making capacity focuses on a patient’s ability to understand and communicate rational decisions,” explains Dr. Mareiniss. “They need to be able to express their choices and demonstrate an understanding of relevant information. They must also appreciate the significance of this information and its consequences.” Usually, determining capacity is relatively straightforward. However, if capacity is unclear and patients wish to leave AMA, emergency physicians should consult psychiatry whenever feasible. Prolonged observation may be necessary in some situations. In cases of intoxication, mental capacity...

Managing Low-Functioning Schizophrenics

Research suggests that one-third to one-half of patients with schizophrenia continue to experience residual symptoms or have intolerable adverse effects relating to their treatment. The effect of medications on functional outcomes has been modest, even when drug regimens are optimized. Compounding the problem are the disorganized and negative symptoms associated with schizophrenia, which are less responsive to medications than hallucinations and delusions. Today, more patients with schizophrenia are being treated in the community, but many continue to function at a low level. As such, additional interventions like cognitive therapy have been explored for schizophrenia, but these approaches have had varied success. Most cognitive therapy treatments assessed in studies have addressed delusions and hallucinations and have not focused on patients with neurocognitive impairment and poor functioning. A Novel Approach in Managing Schizophrenia In the October 3, 2011 Archives of General Psychiatry, my colleagues and I had a study published in which we assessed a novel version of cognitive therapy aimed at increasing functional outcomes and promoting recovery in low-functioning patients with schizophrenia. In addition to residual positive and negative symptoms, these individuals had trouble with information processing for memory, attention, and executive functioning. By design, our intervention shifted the emphasis from taking a symptom-oriented approach to using a person-oriented therapeutic strategy based on interests, assets, and strengths. We wanted to improve the level of functioning by enhancing productivity, independence, and the quantity and quality of social interactions. The intervention treated functional outcomes as a primary target of therapy. More patients with schizophrenia are being treated in the community, but many continue to function at a low level. Participants in the...
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