Authors: Kahlo Baniadam, MD, et al.

Abstract: C-L psychiatrists are frequently consulted to assess and manage severe opioid use disorder in hospitalized patients requiring treatment for complications related to their opioid use disorder.

The authors describe the case of a 43-year-old male with severe opioid use disorder (OUD) who recently underwent bilateral amputations for his leg wounds at another hospital and left before medically advised. He subsequently presented to the authors’ hospital for pain and was admitted for ongoing infection.

An understanding of the ethical considerations surrounding patient-directed discharge (previously referred to as ‘against medical advice’), appropriate opioid agonist dosing strategies, and post-discharge planning can improve outcomes for these patients, who often face significant stigma within the health care system, say the authors.

In this particular case, the patient with severe OUD, complicated by ongoing intravenous drug use, hepatitis C, and chronic leg wounds status post recent bilateral above-the-knee amputation, was admitted for suspected wound infection and severe bilateral lower extremity pain.

Ten days prior to this admission, the patient was admitted to another hospital for sepsis secondary to deep leg abscesses; amputation was planned. He used illicit substances there and requested to leave.

“Hospital-based management of severe opioid use disorder can present many challenges,” say the authors. “OUD is among the most common substance use disorders encountered in hospitalized patients, and chronic dependence on opioids can have significant effects on other health conditions; despite this, it remains underrecognized. Even when recognized, sufficient treatment of opioid withdrawal symptoms is uncommon.”

Rates of hospitalizations from medical complications of OUD have increased dramatically in the past two decades, many of which are due to infectious complications of injection drug use, say the authors. Many of these patients require ongoing medical care after hospital discharge, such as IV antibiotics for 4-6 weeks and wound care.

Importance: Patients with OUD encounter many challenges when hospitalized. This case illustrates how appropriate treatment of pain and withdrawal symptoms can reduce patient-directed discharges; why the term ‘against medical advice discharge’ is problematic; and how to navigate barriers to discharge planning. “Doing so can ensure humane and optimal clinical care for these patients,” say the authors.

Availability: Journal of the Academy of Consultation-Liaison Psychiatry (JACLP)

Authors: Vinod Rao, MD, PhD, et al.

Abstract: The authors sought to determine:

• Whether receiving an initial stimulant prescription for attention deficit hyperactivity disorder (ADHD) from a provider whom a patient has never seen in person is associated with increased risk for stimulant use disorder (stimUD) or other substance use disorders (SUDs), and…
• Whether receiving an initial stimulant prescription during a telehealth versus in-person appointment is associated with increased risk for stimUD or SUD.

This was a retrospective cohort study using electronic health record data from March 1, 2020, to August 25, 2023, from a not-for-profit, academically affiliated medical system in the Northeastern US. Eligible study subjects were ≥12 years old with ADHD and initial receipt of any stimulant prescription during the study period. Exclusion criteria included a non-nicotine SUD diagnosis at the time of initial stimulant prescription.

The sample included 7,944 patients. After adjustment for covariates, a purely telehealth-based relationship versus any in-person relationship did not significantly alter risk for SUD (adjusted odds ratio=0.85, 95% CI=0.60, 1.20) or stimUD (adjusted odds ratio=1.28, 95% CI=0.34, 4.85). A telehealth versus in-person appointment at the time of the initial stimulant prescription did not significantly alter risk for subsequent SUD (adjusted odds ratio=1.15, 95% CI=0.92, 1.44) but was associated with significantly higher risk for stimUD (adjusted odds ratio=6.18, 95% CI=1.34, 28.46).

Importance: Results suggest that receipt of a stimulant prescription for ADHD via telehealth does not alter the risk for SUD, but receipt of an initial stimulant prescription via telehealth may signal increased risk of subsequent stimUD. However, the results, particularly for stimUD, require replication in other health care settings.

Availability: The American Journal of Psychiatry.

See also: Comparing Prescription Opioid, Benzodiazepine, and Stimulant Misuse Rates Among Patients With and Without Telehealth Service Use

Authors: Andreas Hofmann, Dr. med., et al.

Abstract: Highlights are:

• Machine learning offers novel tools for risk assessment in forensic psychiatry.
• The use of 27 variables might help to identify problematic cases upon admission.
• Risk of treatment-adverse events with negative outcome could thereby be reduced.

Adverse events such as compulsory measures, absconding, illicit substance use, self-harm, aggressive behavior, and prolonged hospitalization pose significant challenges in forensic psychiatric inpatient care. This study introduces a machine learning-based tool to predict these events in patients with schizophrenia spectrum disorders (SSD) upon admission.

Data from 370 court-mandated forensic inpatients treated at an academic center in Zurich, Switzerland, were retrospectively analyzed. Twenty-seven variables, available upon admission in clinical settings, were tested using six machine learning algorithms (support vector machines (SVM), logistic regression, naive Bayes, gradient boosting, fine trees, and neural networks).

Predictive performance was assessed using metrics such as area under the curve (AUC) and balanced accuracy. SVM demonstrated the highest performance, achieving an AUC of 0.79 and a balanced accuracy of 69.8%.

These results suggest that the tool can identify patients at higher risk for problematic treatment courses, enabling earlier interventions and more efficient resource allocation.

The simplicity of the model, based on routinely collected data, enhances its clinical applicability, say the authors. However, validation studies in multi-center and international settings are essential to confirm its robustness and generalizability. Nevertheless, the tool represents a promising step toward integrating machine learning into forensic psychiatry to improve treatment outcomes and patient safety.

Importance: In forensic psychiatry, a number of prognostic tools exists for predicting criminal recidivism, but few tools for predicting difficult treatment courses. RIPTOSO, a novel tool, is particularly designed for forensic inpatients diagnosed with any schizophrenia spectrum disorder. If patients at high risk for expressing difficult behavior can be identified when admitted to a forensic-psychiatric care facility, a corresponding reaction and intervention tailored to the individual’s risk- and need-based requirements can be established. In other words, RIPTOSO allows for more effective resource allocation.

Additionally, the authors expect a lower prevalence of critical incidents during treatment, thus a shorter duration of treatment and confinement. This would not only result in a reduction of overall costs, but more importantly could directly benefit patients and forensic health care staff.

Availability: Published by Psychiatry Research

Authors: Vivek Mathesh, BSA

Abstract: Approximately one-third of adults in the US complete a medical advance directive in their lifetime. However, few complete a psychiatric advance directive (PAD), despite the high prevalence of psychiatric illness.

PADs help those with mental illness specify their care preferences during periods of acute psychiatric illness. Given the minimal research regarding PAD usage, the use of PADs in clinical practice remains poorly understood.

This study aims to use electronic health record data to investigate and describe PAD usage in a large, county health system.

All of 41,421 patients were included in this electronic health record analysis. No PAD documents were found in this population—even though the PAD template was published on the hospital website.

“Further work is needed to educate providers on the importance of PADs and promote appropriate and inclusive PAD usage at the health system level,” say the authors.

Importance: This research identifies a significant gap in PAD utilization—designed to empower patients and improve psychiatric care—and emphasizes the potential for increased PAD use in clinical care. It highlights current obstacles to PAD implementation while offering actionable next steps for how PADs can fit into the larger flow of patient care.

There is also an apparent lack of knowledge of what these documents are and how they can be helpful for individuals with mental illness, they say. “Additional education for providers and patients is needed to increase PAD utilization in order to support greater autonomy and empowerment for those experiencing a mental health crisis.”

PAD users are able to specify their preferences for the treatment they receive in a mental health crisis, including medication preferences, electroconvulsive therapy, and how staff respond in a behavioral emergency. PADs are distinct from other AD documents in that they allow patients to state their preferences for or against various psychiatric treatments.

“A sense of self and agency is vital in the recovery from severe mental illness,” say the authors. “In addition, PAD planning increases treatment adherence and cooperativity. Patients who have specified a particular medication regimen on their PAD are more likely to adhere to the medication plan in a 12‐month period after their hospitalization compared to those who didn’t adopt a PAD with specified medications.

“As a PAD is written, the reciprocal relationship between provider and patient is strengthened since care providers have less ambiguity when seeking to understand patient preferences and patients have more protection against unwanted care.”

In a study by Swanson et al. over a two‐year period, patients without a completed PAD were nearly twice as likely to be subject to coercive treatments during a mental health exacerbation compared to those who completed a PAD.

Despite these benefits, little research has been done on the implementation of PADs and how psychosocial factors affect the spectrum of PAD usage. Obstacles to the implementation of PADs include: the reluctance of stakeholders due to time constraints during encounters, the assumption that documented treatment preferences may unduly influence future clinical decision-making and the lack of understanding of PADs by clinicians.

Furthermore, psychosocial barriers that impair completion rates of PADs include pessimism about the usefulness of PADs, communication discrepancies between patients and clinical staff, and a lack of a defined processes for PAD use.

Availability: Pre-publication in Psychiatric Research & Clinical Practice.