From the Editor
After a suicide attempt, he was admitted through our ED. The hospitalization has been helpful: we changed his medications; the family is now more understanding of his problems; he has worked on safety planning with the team. However, could more be offered? It’s a relevant question – particularly for someone like me (I’ve worked on inpatient wards for most of my career).
In the first selection from JAMA Psychiatry, Gretchen J. Diefenbach (of Yale University) and her co-authors describe a randomized clinical trial involving 200 inpatients who received either the usual care or a focused CBT, tailored for short admissions. The one common factor: all participants had had a suicide attempt in the week prior to admission or current suicidal ideation along with a suicide attempt in the past two years. “Brief cognitive behavioral therapy–inpatient reduced 6-month post-discharge suicide reattempts and rate of readmissions when added to treatment as usual.” We discuss the paper and the clinical implications.
How accessible is mental healthcare in the US? In the second selection, Dr. Diksha Brahmbhatt and William L. Schpero (both of Cornell University) look at Medicaid recipients and psychiatric appointments in a research letter for JAMA. Using a “secret shopper” approach, they contacted clinicians in four cities, trying to book a psychiatric appointment for those covered by the public program. “In the largest Medicaid managed care plans across 4 of the largest US cities, only 17.8% of clinicians listed as in-network for Medicaid were reachable, accepted Medicaid, and could provide a new patient appointment.”
And in the third selection, Dr. Joel Yager (of the University of Colorado), a retired psychiatrist, writes personally in a piece for JAMA. In his later years, Dr. Yager’s father helped his older friends and neighbours with the burden of aging, including visiting them in hospitals when they were ill. Now, he is doing what his father did. “After all, someone has to be around to put out the lights.”
This month, the Reading of the Week celebrates its 10th anniversary. A quick word of thanks for the ongoing interest. I’ll reflect more in the coming weeks.
DG
Selection 1: “Brief Cognitive Behavioral Therapy for Suicidal Inpatients: A Randomized Clinical Trial”
Gretchen J. Diefenbach, Kayla A. Lord, Jessica Stubbing, et al.
JAMA Psychiatry, 11 September 2024
Suicide rates have increased over the past 2 decades and reached an estimated all-time high in 2022 when nearly 50 000 individuals in the US died by suicide. Suicidal crisis is a common reason for admission to psychiatric inpatient settings, which provide a safe environment while stabilizing acute suicide risk. Optimizing suicide prevention care during inpatient stays is crucial, given that the post-discharge period is one of the highest risk times for suicide attempt and death. Risk of death by suicide is particularly elevated among patients admitted for suicidal ideation or behavior and within the first 3 months of discharge. The inpatient setting presents opportunities for delivering suicide-specific psychosocial interventions given the secure environment, continuous access to treatment professionals, and reduction in daily stressors and responsibilities…
Outpatient psychosocial interventions are efficacious for suicide prevention, with larger effects found for suicide-specific treatments. However, current evidence for inpatient suicide prevention treatments is limited. Given short lengths of stay, brief interventions are needed. Post-admission cognitive therapy, which was adapted from cognitive therapy for suicide prevention to be administered in up to 6 sessions, did not reduce suicidal behaviors post-discharge compared with usual care.
So begins a paper by Diefenbach et al.
Here’s what they did:
- They conducted a randomized clinical trial at a private psychiatric hospital in Connecticut.
- They compared treatment as usual (“consisted of 24-hour multidisciplinary care based on a short-term stabilization model” that included safety planning) to treatment as usual plus brief cognitive behavioral therapy for inpatients (consisted of up to four individual therapy sessions). The CBT included components such as developing a crisis response plan, inventorying reasons for living, reducing access to lethal means, and creating a hope kit.
- Follow-up assessments were completed monthly for six months post-discharge.
- Inpatients admitted following a suicidal crisis (past-week suicide attempt or ideation with plan on admission and attempt within previous two years) were included. Those with a manic episode or schizophrenia were excluded. People with substance use disorders weren’t excluded. (!)
- Main outcomes: suicide attempts and readmissions. Suicidal ideation was measured using self-reporting.
Here’s what they found:
- 4 137 were screened; 213 were found eligible and randomized (with several then excluded).
- Demographics & substance use. The mean age was 32.8 years; most participants were female (58.5%) and White (61.5%). 60.0% of participants had a substance use disorder.
- Suicide attempts. “Brief cognitive behavioral therapy–inpatient reduced the occurrence of suicide attempt over 6 months post-discharge by 60% (odds ratio, 0.40… number needed to treat, 7) in the entire patient group…”
- Readmissions. The rate of psychiatric readmissions was reduced by 71% (rate ratio, 0.29…) in those without a substance use disorder.
- Suicidal ideation. Participants in the CBT group also reported lower levels of suicidal ideation, although only at one and two months post-discharge.
- Attrition. More than half of participants completed six-month follow-up assessments; remaining participants were mostly lost to follow-up.
A few thoughts:
1. This is a good paper, practical and thoughtful, and published in an excellent journal. There is much to like here, including a six-month follow-up period.
2. The main finding in two sentences: “Relative to treatment as usual (which in this study included safety planning and caring contacts), the addition of BCBT-inpatient reduced the odds of suicide attempt by 60% over 6 months post-discharge. The rate of psychiatric readmissions was also reduced by over 70%, but only in participants without SUDs.”
3. Could this therapy save lives?
4. Needless to say, the authors feel that there is great clinical relevance. “Given recent evidence that post-discharge suicide rates have not improved over the past 50 years it is time for the field to shift to new treatment models for inpatient suicide prevention.”
5. These are good results, yes, but we should temper our enthusiasm? This study was done at one private hospital in the United States, where admissions tend to be short (the average length of stay for a participant was less than 13 days). And let’s not forget that the attrition rate was high.
6. And there are barriers to scaling up. As the authors note: “Dissemination of this treatment protocol may not be possible without substantial hospital investment, for example, by creating new positions for specialist suicide prevention staff, who have been trained to administer the BCBT-inpatient protocol with high fidelity.”
7. So, yes, let’s temper our enthusiasm, but let’s also look forward to more research in this important area. Could an inpatient in the future be offered a focused therapy after a suicide attempt the way he is now offered a med review, family meetings, and safety planning?
The full JAMA Psych paper can be found here:
https://jamanetwork.com/journals/jamapsychiatry/article-abstract/2823589
Selection 2: “Access to Psychiatric Appointments for Medicaid Enrollees in 4 Large US Cities”
Diksha Brahmbhatt and William L. Schpero
JAMA, 31 July 2024
Medicaid enrollees face a disproportionate burden of severe mental illness yet have lower access to treatment. Psychiatrists are less likely than other physicians to accept insurance, especially Medicaid. This disparity is exacerbated by inaccurate health plan provider directories: a previous claims-based study of 2018 Medicaid managed care directories revealed that in some plans, over 90% of listed mental health care prescribers did not actively participate in the Medicaid program, but claims-based studies cannot assess wait times or enrollees’ direct experiences with accessing care.
Here’s what they did:
- They conducted a “secret shopper” audit study to examine availability of and wait times for adult appointments.
- They selected at random “80 psychiatric prescribing clinicians (psychiatrists, nurse practitioners, and physician assistants) listed as accepting new patients from the provider directories for the Medicaid managed care plans with the highest enrollment in New York City, Los Angeles, Chicago, and Phoenix.”
- Callers used a calling script pretending to be Medicaid enrollees looking for the soonest available appointment. If an appointment couldn’t be provided, a consultation with an alternate clinician was requested.
- They examined appointment availability, wait times, and reasons an appointment could not be made with the sampled clinician.
Here’s what they found:
- 320 clinicians were called.
- Appointments. 27.2% had appointments available, including 17.8% with the sampled clinician and 9.4% with an alternate clinician at the same practice.
- City. Appointments by city: 36.3% in New York City; 30.0%, Phoenix; 27.5%, Chicago; and 15.0%, Los Angeles.
- Wait. Median wait times by city: 11 days in Phoenix; 23 days, Chicago; 28 days, New York; and 64 days, Los Angeles. See graph below.
- Reachability. “Among the 263 sampled clinicians with whom appointments could not be made, 15.2% had a listed number that was incorrect or out of service and 35.0% did not answer the phone on either of 2 attempts.”
1. This is a good research letter.
2. The main finding in a sentence: fewer than one in five Medicaid clinicians could provide an appointment. (!)
3. And timeliness was a problem, too.
4. Ouch.
5. For those who assume access would be markedly better in a country like Canada with a public healthcare system, Goldner et al. suggest otherwise in a CJP paper:
https://journals.sagepub.com/doi/abs/10.1177/070674371105600805
The full JAMA Psych research letter can be found here:
https://jamanetwork.com/journals/jama/article-abstract/2821639
Selection 3: “Someone Has to Be Around to Put Out the Lights”
Joel Yager
JAMA, 18 July 2024
At 90 years of age, my father had a strong sense of purpose. He was living independently in a large retirement condominium community in Southern Florida with his wife of almost 10 years, Tess, whom he married a year after my mother died.
Over the previous few years, throughout his late 80s, each time we spoke, which was usually at least once or twice a week, my father would tell us about 1 or 2 friends or neighbors who had become so cognitively impaired that they had to be moved from their condominiums to nursing homes, who were dying, or who had died. Over the years, most of their good friends and acquaintances disappeared, predeceasing them or declining from dementia. My father and Tess found their friendship circle to be constantly shrinking, leaving them with fewer and fewer companions with whom to socialize.
It was around this time that my father revamped his purpose in life.
So begins an essay by Dr. Yager.
He describes his father’s efforts. “Instead of being immersed in the typical diversions of southern Florida retirement, he began to focus on helping those remaining individuals and their families ‘tie things up,’ usually in some small fashion. He guided them to local resources, helped them clean out their rooms and closets, visited the sick and dying, and dropped in on them in their new facilities, at least until these individuals could not recognize him. He also assisted families, most of whom did not live nearby, with funeral arrangements and planning remembrances.” As his father explained: “Someone has to be around to put out the lights.”
Dr. Yager has followed in his father’s footsteps. “Now in our 80s, my wife Eileen and I, a retired pediatrician and retired psychiatrist, respectively, are starting to experience the same types of occurrences among our own relatives, friends, and acquaintances. Each month, we learn about someone close to us who has died or who is grappling with significant physical decline in the grips of a fatal illness. They are struggling with progressive Parkinson disease, heart failure, chronic lung disease, debilitating arthritis, metastatic cancers, dementia, and a slew of other maladies.”
“Eileen and I increasingly find ourselves in situations like the ones my father faced a generation ago. This life cycle stage seems inevitable, but it’s certainly not one we thought about much in advance. Although we empathized with my father and Tess when they encountered and confronted these situations in their time, we never envisioned that we would have to contend with them ourselves. Not that we were immune, but we simply avoided or ignored these psychosocially significant inevitabilities, as we tend to do with other issues concerning end-of-life matters.”
He notes the satisfaction. “Although we finish some days emotionally drained, we are always grateful for the opportunities to be of assistance. We also hope that if and when we ourselves decline to the point of becoming unable to function independently, and/or when we die, that others will be around to help us and our families with both the emotional and practical aspects of fading lives, dying, and death.”
A few thoughts:
1. This is a well written essay.
2. A haunting line on aging: “The only way to avoid these situations, it seems, is by dying first or by developing dementia first so that you really don’t know what’s going on around you.”
3. Past Readings have considered practice and retirement. In a paper for CMAJ, Dr. Jon Hunter discussed his decision to end his work with some long-standing patients as he moves towards the twilight of his career. The Reading can be found here:
The full JAMA paper can be found here:
https://jamanetwork.com/journals/jama/article-abstract/2821246
Reading of the Week. Every week I pick articles and papers from the world of Psychiatry.
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