Journal Article Annotations
2017, 1st Quarter
Annotations by Naomi Schmelzer, MD MPH
Also of interest:
In an effort to formulate consensus recommendations on the medical evaluation of patients presenting to the emergency department with psychiatric complaints, a task force of the American Association of Emergency Psychiatry reviewed existing literature on this topic for Part I of their series. This article presents a clarification of terminology and a thorough review of the existing literature on the topic as well as available protocols. In addition, it highlights points of controversy and areas where further data is needed. Part II of the series, which includes the consensus recommendations, will follow in a subsequent article.
The finding: A study comparing a Tetris-based behavioral intervention versus an attention-placebo control task was administered to patients presenting to an emergency room within six hours of a motor vehicle accident. The primary outcome, the number of intrusive memories logged over the subsequent week, was found to be reduced in the intervention condition when compared to the control group.
Strengths and weaknesses: An approach driven by a need for novel non-pharmacologic treatments, and stemming from cognitive science principles including memory consolidation theory and a prediction that cognitive tasks with high visuospatial demands will selectively disrupt sensory aspects of memory, this randomized control study supported the hypothesis that a behavioral intervention using the widely available video game Tetris, played for 20 minutes following presentation to the emergency department after a traumatic event, would reduce the number of intrusive memories in the following week. Additional strengths include the brief time-limited nature of the intervention, and that it was easy to engage patients in the task with no adverse side effects reported. The study overall has promising results, though it was a limited proof-of-concept study and requires a larger trial with greater participant numbers to demonstrate a lasting effect at one month.
Relevance: The emergency department is often providing psychological first aid immediately following a traumatic experience with the goal being to minimize symptoms of acute stress and prevent PTSD, though evidence-based preventive interventions from neuroscience translated into clinical care are lacking. This is a novel intervention strategy that is easy to administer, is low-cost, and requires little staff training. This, and similar approaches, have the potential to be used as part of the emergency psychiatry armamentarium of PTSD treatment as a preventative strategy.
The finding: Among patients presenting to an emergency room with exacerbation of psychosis, psychiatrists’ assessment of medication adherence was statistically independent of measured therapeutic plasma blood levels. For example, of the 97 patients included in the study, 33 patients were found to have therapeutic drug levels of which 11 were clinically assessed as having been non-adherent by the emergency physician. Of the 53 patients assessed to be adherent to their antipsychotic medication, 43 had detectable plasma levels and 10 patients had undetectable levels.
Strengths and weaknesses: This is a study aiming to assess the accuracy of emergency physicians’ clinical assessment of medication adherence by comparing findings with measured drug levels. Although factors such as periodic adherence and timing of dosages may have affected values, this measurement serves as a more objective indicator of medication use.
Relevance: The discrepancies between standard clinical assessment for medication adherence and serum drug level demonstrated by the outcome of the study suggests the potential for clinical utility of therapeutic drug monitoring via rapid assays in the ED setting, though more investigation is needed. Feedback and review of discrepant cases may guide improvement of clinical assessment techniques.