A study to improve the quality of writing clinic letters to patients attending the outpatient clinic

AimsIn many countries (including the UK and Australia) it is still common practice for hospital doctors to write letters to patients’ general practitioners (GPs) following outpatient consultations, and for patients to receive copies of these letters. However, experience suggests that hospital doctors who have changed their practice to include writing letters directly to patients have more patient centred consultations and experience smoother handovers with other members of their multidisciplinary teams. (Rayner et al, BMJ 2020)The aim of the study was to obtain patient's views to improve the quality of clinical letters sent to them, hence the level of communication and standards of care.MethodAn anonymous questionnaire was designed and posted to collect information from patients attending one of the South County Mental Health outpatient clinic in Derbyshire. 50 random patients were selected between March to November 2020. Patients were asked to provide suggestions to improve the quality of their clinic letters written directly to them and copies sent to their GPs.ResultOut of 50 patients 48% (n = 24) responded. Majority of patients (92%) expressed their wish to receive their clinic letters written directly to them and 79% preferred to be addressed as a second person in the letters. More than half (54%, N = 13) of them would like to have letter by post. Majority of them (92%, N = 22) wished to have their letter within a week of their consultations.Patients attending clinics felt that the communication could be better improved through writing clearly: a) reflection of what was discussed during the consultation b) updated diagnosis c) a clear follow-up plan d) current level of support e) medication change f) emergency contact numbers g) actions to be carried out by their GP and further referrals should there be any.ConclusionPatients in community prefer to have their clinic letters directly addressing them in second person. It was noted that the letters needed to reflect accurately on what was discussed during the consultation in order to have patient centered consultations. This in turn would improve communication and thus rapport, trust and overall therapeutic relationship.

Asian-Americans Remain Low Utilizers of County Mental Health Services

The National Latino and Asian American Study (NLAAS, 2002–2003, n =2095) indicated that Asian-Americans (AA) use mental health services less frequently than the general population (8.6% vs. 17.95%). Even AA who have been diagnosed with mental health disorders use mental health services less frequently than their non-AA counterparts (34.1% versus 41.1%)2. AA in Riverside County count for 7.4% of the population, or about 181,356 individuals, according to the 2018 census estimates. The objective of the study is to examine and compare rates of utilization of mental health services by AA specifically in the Riverside County setting. This study utilizes data on patients’ ethnicity, age, gender, and diagnosis as collected annually by the Riverside County Department of Mental Health from the fiscal year of 2017–2018. It compares the prevalence of psychiatric disorders and the rate of utilization of mental health services by AA in the county to the data collected by the NLAAS. The total number of AA using mental health services in Riverside County is 669, which totals 1.73% of all individuals accessing the same services. The number of AA using mental health services represented 0.45% of the total AA population in Riverside County. AA in Riverside County are utilizing MH services even less than the national rates (0.45% vs 8.6% nationally from NLAAS data). The gap in care illustrated by these results exemplifies not only the disparity in utilization of MH services seen in this particular ethnic group, but portrays the stagnant results from Riverside County s attempts to address this issue. Possible reasons for the disparity include lack of access, stigma, recovery, migration, and a lack of culturally-competent care. A reimagined outreach initiative may help to better address this issue. Riverside County already has implemented an AA Task Force, holds health fairs at local churches in the communities, supports a UCR School of Medicine student-run free clinic, and is active in NAMI events.

Schizophrenia polygenic risk score and 20-year course of illness in psychotic disorders

Understanding whether and how the schizophrenia polygenic risk score (SZ PRS) predicts course of illness could improve diagnosis and prognostication in psychotic disorders. We tested whether the SZ PRS predicts symptoms, cognition, illness severity, and diagnostic changes over the 20 years following first admission. The Suffolk County Mental Health Project is an inception cohort study of first-admission patients with psychosis. Patients were assessed six times over 20 years, and 249 provided DNA. Geographically- and demographically-matched never psychotic adults were recruited at year 20, and 205 provided DNA. Symptoms were rated using the Schedule for the Assessment of Positive Symptoms and Schedule for the Assessment of Negative Symptoms. Cognition was evaluated with a comprehensive neuropsychological battery. Illness severity and diagnosis were determined by consensus of study psychiatrists. SZ PRS was significantly higher in first-admission than never psychotic groups. Within the psychosis cohort, the SZ PRS predicted more severe negative symptoms (β = 0.21), greater illness severity (β = 0.28), and worse cognition (β = −0.35), across the follow-up. The SZ PRS was the strongest predictor of diagnostic shifts from affective to non-affective psychosis over the 20 years (AUC = 0.62). The SZ PRS predicts persistent differences in cognition and negative symptoms. The SZ PRS also predicts who among those who appear to have a mood disorder with psychosis at first admission will ultimately be diagnosed with a schizophrenia spectrum disorder. These findings show potential for the SZ PRS to become a tool for diagnosis and treatment planning.

ADVANCING POLICY TO BUILD A BEHAVIORAL HEALTH WORKFORCE THAT ADDRESSES THE NEEDS OF OLDER ADULTS

California’s Mental Health Services Act has infused funding for workforce education and training into the public mental health system. However, funding has not kept pace with an existing behavioral health workforce shortage crisis, the rapid growth of an aging population, and the historical lack of geriatric training in higher education for the helping professions. This study draws on findings from a recent evaluation of how older adults are served by California’s public mental health delivery system, and a review of state planning documents and academic literature, to describe gaps and deficiencies in the workforce that serves older adults. While California has more than 80,000 licensed behavioral health professionals in a variety of disciplines, very few have specialized training in geriatrics. Across the U.S., there are fewer than 1,800 geriatric psychiatrists and only about 3% of medical students take any geriatrics electives during their training. Very few nurses (1%), psychologists (4%), or social workers (4%) have training in and/or specialize in geriatrics. Of additional concern in California is the lack of representation of ethnic and racial minorities, and rural/urban geographic disparities in the distribution of the behavioral health workforce. Recommendations for advancing policy change to improve the preparation and distribution of the geriatric behavioral workforce are presented to three distinct audiences: state policymakers and administrators; educational institutions, accrediting bodies, and licensing boards; and county mental health/behavioral health departments and their contracted providers.

Physical Functional Limitations in a First-Admission Cohort at Midlife: Findings From the Suffolk County Mental Health Project

Background Psychosis is a risk factor for aging-related conditions and early mortality. Little is known about the age-specific risk of objectively measured physical functional limitations among individuals with serious mental illness. Methods The Suffolk County Mental Health Project is a prospective study of individuals hospitalized for the first time for psychosis. To assess physical functioning at midlife and to identify emerging risk factors for older-age changes, 101 participants with schizophrenia (mean age = 47.2, SD = 8.0 years; 41.6% female) and 112 participants with other psychoses (mean age = 48.2, SD = 9.5 years; 45.5% female) were assessed for chair-rise and balance limitations 20 years after diagnosis. A never-psychotic comparison group of 237 age/sex/geographically matched community controls was similarly assessed (mean age = 50.3, SD = 8.8 years; 44.7% female). Logistic regression was used to examine group differences in prevalence of poor performance and demographic, medical, and treatment correlates. Results Chair-rise limitations (45.5% [35.8–55.3]) and balance limitations (17.2% [9.8–24.5]) were common in individuals with schizophrenia. Prevalence of chair-rise limitations was higher in schizophrenia (46.3%) than in other psychotic disorders (31.9%) and never-psychotic group (22.1%), whereas risk of balance limitations was higher in schizophrenia (17.2%) compared with never-psychotic controls (8.1%). Schizophrenia was a significant risk factor for chair-rise (adjusted odds ratio = 3.01 [1.79–5.08], p < .001) and balance limitations (adjusted odds ratio = 2.63, [1.25–5.51], p = .010). Multivariable analysis of symptom severity found avolition was associated with chair-rise limitations, but not balance, independent of diagnosis. Conclusion Physical limitations are crucial because they identify existing problems with mobility and portend an increased risk of disability and death. Because participants with schizophrenia were at increased risk of physical limitations, assessments of chair-rise and balance limitations may be critical to monitoring individuals with psychosis.

Schizophrenia Polygenic Risk Score and 20-Year Course of Illness in Psychotic Disorders

Understanding whether and how the schizophrenia polygenic risk score (SZ PRS) predicts course of illness could improve diagnostics and prognostication in psychotic disorders. We tested whether the SZ PRS predicts symptoms, cognition, illness severity, and diagnostic changes over the 20 years following first admission. The Suffolk County Mental Health Project is an inception cohort study of first-admission patients with psychosis. Patients were assessed six times over 20 years, and 249 provided DNA. Geographically- and demographically-matched never psychotic adults were recruited at year 20, and 205 provided DNA. Symptoms were rated using the Schedule for the Assessment of Positive Symptoms and Schedule for the Assessment of Negative Symptoms. Cognition was evaluated with a comprehensive neuropsychological battery. Illness severity and diagnosis were determined by consensus of study psychiatrists. SZ PRS was significantly higher in first-admission than never psychotic groups. Within the psychosis cohort, the SZ PRS predicted more severe negative symptoms (β= 0.21), lower GAF (β= −0.28), and worse cognition (β= −0.35), across the follow-up. The SZ PRS was the strongest predictor of diagnostic shifts from affective to non-affective psychosis over the 20 years (AUC = 0.62). The SZ PRS predicts persistent differences in cognition and negative symptoms. The SZ PRS also predicts who among those who appear to have a mood disorder with psychosis at first admission will ultimately be diagnosed with a schizophrenia spectrum disorder. These findings show potential for the SZ PRS to become a powerful tool for diagnosis and treatment planning.

Common Taxonomy of Traits and Symptoms: Linking Schizophrenia Symptoms, Schizotypy, and Normal Personality

The associations among normal personality and many mental disorders are well established, but it remains unclear whether and how symptoms of schizophrenia and schizotypal traits align with the personality taxonomy. This study examined the joint factor structure of normal personality, schizotypy, and schizophrenia symptoms in people with psychotic disorders (n = 288) and never-psychotic adults (n = 257) in the Suffolk County Mental Health Project. First, we evaluated the structure of schizotypal (positive schizotypy, negative schizotypy, and mistrust) and normal traits. In both the psychotic-disorder and never-psychotic groups, the best-fitting model had 5 factors: neuroticism, extraversion, conscientiousness, agreeableness, and psychoticism. The schizotypy traits were placed on different dimensions: negative schizotypy went on (low) extraversion, whereas positive schizotypy and mistrust went on psychoticism. Next, we added symptoms to the model. Numerous alternatives were compared, and the 5-factor model remained best-fitting. Reality distortion (hallucinations and delusions) and disorganization symptoms were placed on psychoticism, and negative symptoms were placed on extraversion. Models that separated symptom dimensions from trait dimensions did not fit well, arguing that taxonomies of symptoms and traits are aligned. This is the first study to show that symptoms of psychosis, schizotypy, and normal personality reflect the same underlying dimensions. Specifically, (low) extraversion, negative schizotypy, and negative symptoms form one spectrum, whereas psychoticism, positive schizotypy, and positive and disorganized symptoms form another. This framework helps to understand the heterogeneity of psychosis and comorbidity patterns found in psychotic disorders. It also underscores the importance of traits to understanding these disorders.