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Assessment of Co-occurring Disorders, Levels of Care, and ASAM Requirements
Published in Tricia L. Chandler, Fredrick Dombrowski, Tara G. Matthews, Co-occurring Mental Illness and Substance Use Disorders, 2022
Elizabeth Reyes-Fournier, Tara G. Matthews, Tom Alexander
Population-specific high-intensity residential treatment is an appropriate level of care for persons who present for treatment with an element of imminent harm (Ries et al., 2014). For a person with co-occurring disorders, this could include risk related to substance use, acute medical concerns, or suicidal or homicidal ideation. The population-specific aspect of this level of care is clarified as being related to the provision of treatment for persons who may have a functional impairment that limits engagement in a full range of intensity of residential treatment services (Ries et al., 2014). This level of care also maintains a living structure that allows the resident to plan their days while having staff support, ability to connect with treatment, and use skills associated with self-help such as AA or NA. Again, 24-hour structured treatment is offered at this level of care, including the use of counselors who are trained to deliver needed services (Ries et al., 2014).
Mood Disorders
Published in Vincenzo Berghella, Maternal-Fetal Evidence Based Guidelines, 2022
Madeleine A. Becker, Tal E. Weinberger, Leigh J. Ocker
Thyroid function tests and a complete blood count are useful for identifying other medical conditions that can present with symptoms of depression. Prompt psychiatric consultation should be obtained when depression is suspected, especially when symptoms are severe or when psychotic or suicidal features are present. The presence of psychosis, or suicidal, or homicidal ideation or intent should be considered an emergency.
Pharmacological management
Published in David B Cooper, Care in Mental Health—Substance Use, 2019
Cynthia MA Geppert, Kenneth Minkoff
For individuals with high-risk presentations such as command homicidal ideation, there is an urgent need to establish a trusting, therapeutic alliance that will allow initiation of medications that takes priority over diagnostic certainty.
Impact of regulatory safety warnings and restrictions on drug treatment of epilepsy
Published in Expert Opinion on Drug Safety, 2023
Amanda W. Pong, Ivana Tyrlikova, Alexander J. Giermek, Pavel Klein
The FDA has issued several black box warnings that have negatively impacted ASM use. In 2012, FDA approved a new ASM, perampanel. Perampanel has a new mechanism of action (MOA), noncompetitive antagonism of the glutamatergic receptor AMPA, and promise of improving seizure control in patients refractory to ASMs with other MOAs. The approval came with black box warning of ‘life-threatening’ ‘homicidal ideation.’ The black box warning has affected clinicians’ willingness to use medication and has essentially marginalized perampanel. During the first 3 years of its commercial use, 6,534 patients were treated with it, out of the ~500,000 target patients with focal DRE: approximately half the number of patients treated at the same time point with eslicarbazepine and brivaracetam, approved in 2013 and 2015 without black box warnings. The warning is based on ‘homicidal ideation’ reported in 6/4,368 patients treated in the clinical development program. These included 5/6 patients with prior psychiatric disease, 2/6 patients in whom the effect occurred ~1–1.5 years after treatment start, during open-label extension study; and 4/6 patients each in whom PMP was continued and symptoms resolved with dose unchanged (2) or reduced (2) (Eisai data on file).
Child and Adolescent Psychiatric Inpatient Care: Contemporary Practices and Introduction of the 5S Model
Published in Evidence-Based Practice in Child and Adolescent Mental Health, 2022
Casey D. Calhoun, Elizabeth A. Nick, Kyrill Gurtovenko, Aaron J. Vaughn, Shannon W. Simmons, Rebecca Taylor, Eileen Twohy, Jessica Flannery, Alysha D. Thompson
Intake evaluations, which are necessarily brief, may not be sufficient to make diagnostic determinations and identify appropriate services. In these circumstances, a more in-depth, comprehensive psychological evaluation may be warranted. Given the short LOS, clinicians should carefully review past records and attempt to coordinate any co-occurring evaluations to streamline the evaluation process. Established guidelines suggest a comprehensive evaluation should include a number of key elements (Blader et al., 2008; Gosselin & DeMaso, 2008). Of paramount importance is the evaluation of risk of harm to self and others. Risk evaluations are used to determine safety precautions needed during the inpatient stay and level of care needed post-discharge. Evaluating self-harm and suicide should consider the spectrum of suicide risk (e.g., passive ideation, plan/intent, access to means) and involve consideration of chronic (e.g., family history) and acute (e.g., severe stress) risk factors, particularly history of impulsive and risky behavior (Berstein et al., 2019). Evaluations of homicidal ideation should similarly include questions assessing relevant risk factors (e.g., impulsivity, poor distress tolerance, acute stressors, substance use, neurologic conditions, mania, psychosis) and access to weapons (Berstein et al., 2019).
Ethnoracial differences in treatment-seeking veterans with substance use disorders and co-occurring PTSD: Presenting characteristics and response to integrated exposure-based treatment
Published in Journal of Ethnicity in Substance Abuse, 2022
Delisa G. Brown, Julianne C. Flanagan, Amber Jarnecke, Therese K. Killeen, Sudie E. Back
The data for this secondary analysis was obtained from a larger randomized clinical trial that examined the efficacy of COPE (Back et al., 2015) versus RP (Kadden et al., 1992) among treatment-seeking military veterans with current SUD/PTSD (Back et al., 2019). Participants were recruited via flyers posted in the local Veterans Affairs (VA) hospital and community hospitals, as well as advertisements in local newspapers and social media. Inclusion criteria were: a) U.S. military veteran, b) 18 to 65 years old, c) met DSM-IV diagnostic criteria for current PTSD and had a score of ≥ 50 on the Clinician-Administered PTSD Scale (Blake et al., 1995); and d) met DSM-IV diagnostic criteria for a current SUD and had used substances in the past 90 days. Exclusion criteria were: a) ongoing enrollment in another treatment for SUD or PTSD, b) suicidal or homicidal ideation with intent, c) psychiatric conditions that would likely require a higher level of care or could interfere with treatment (e.g., psychotic disorder), and d) severe cognitive impairment as measured by the Mini-Mental Status Examination (Folstein et al., 1975). Participants taking psychotropic medication were required to be stabilized on the medication for 4 weeks prior to enrollment. Eighty-one participants were enrolled in the study. Two participants identified as a race other than AA or White and were removed from analysis, leaving a total sample size of n = 79 (30 AA and 49 White) for the current study.