Ms. R, age 50, is and suicidal after she claims her newborn died suddenly 1 week ago; however, her medical history reveals that she had a hysterectomy 10 years ago. How would you treat her? [CASE] Depressed after she says her baby died Ms. R, age 50, is an African-American woman who presents to a psychiatric hospital under an involuntary commitment executed by local law enforcement. Her sister called the authorities because Ms. R reportedly told her that she is very depressed and wants to end [her] life by taking an overdose of medications after the death of her newborn 1 week earlier. Ms. R states that she delivered a child at full term in the emergency department of an outside community hospital, and that her current psychiatric symptoms began after the child died from SIDS [sudden infant death syndrome] shortly after birth. Ms. R describes depressive symptoms including mood, anhedonia, decreased energy, feelings of guilt, decreased concentration, poor sleep, and suicidal ideation. She denies substance use or a medical condition that could have induced these symptoms, and denies symptoms of mania, anxiety, or psychosis at admission or during the previous year. Ms. R reports a history of manic episodes that includes periods of elevated mood or irritability, impulsivity, increased energy, excessive spending despite negative consequences, lack of need for sleep, rapid thoughts, and rapid speech that impaired her social and occupational functioning. Her most recent manic episode was approximately 3 years before this admission. She reports a previous suicide attempt and a history of physical abuse from a former intimate partner. Neither the findings of a physical examination nor the results of a screening test for serum [beta]-human chorionic gonadotropin ([beta]HCG) are consistent with pregnancy. Ms. R's medical record reveals that she was hospitalized for a cardiac workup a week earlier and requested investigation of possible pregnancy, which was negative. Records also reveal that she had a hysterectomy 10 years earlier. Although Ms. R's sister and boyfriend support her claim of pregnancy, the patient's young adult son refutes it and states that she does stuff like this for attention. Her son also reports receiving a forged sonogram picture that his mother found online 1 month earlier. Ms. R presents an obituary from a local newspaper for the child but, on further investigation, the photograph of the infant was discovered to be of another child, also obtained online. Ms. R's family denies knowledge of potential external reward Ms. R could gain by claiming to be pregnant. Which of the following diagnoses can be considered after Ms. R's initial presentation? a) somatic symptom disorder b) major depressive disorder c) bipolar I disorder d) delusional disorder The authors' observations Ms. R reported the recent death of a newborn that was incompatible with her medical history. Her family members revealed that Ms. R made an active effort to deceive them about the reported pregnancy. She also exhibited symptoms of a major depressive episode in the context of previous manic episodes and expressed suicidal ideation. The first step in the diagnostic pathway was to rule out possible medical explanations, including pregnancy, which could account for the patient's symptoms. Although the serum PHCG level usually returns to non-pregnant levels 2 to 4 weeks after delivery, it can take even longer in some women. (1) The absence of PHCG along with the recorded history of hysterectomy indicated that Ms. R was not pregnant at the time of testing or within the preceding few weeks. Once medical anomalies and substance use were ruled out, further classification of the psychiatric condition was undertaken. One aspect of establishing a diagnosis for Ms. R is determining the presence of psychosis (eg, delusional thinking) (Table 1). …
We propose a paper that provides education on commonly used long-acting injectable antipsychotics (LAIs) to improve primary care based mental health interventions in patients with severe mental illnesses (SMIs) such as schizophrenia, schizoaffective disorder, and bipolar disorders. With the expanding interface of primary care and psychiatry across all healthcare settings, it has become increasingly important for primary care clinicians to have a broader understanding of common psychiatric treatments, including LAIs. Long-acting injectable antipsychotics have been shown to be helpful in significantly improving treatment adherence, preventing disease progression, improving treatment response, decreasing readmission rates, and reducing social impairment. We discuss evidence-based indications and guidelines for use of long-acting injectable antipsychotics. We provide an overview of the treatment of SMI with LAIs, mainly focusing on the most commonly used long-acting injectable antipsychotics, advantages and disadvantages of each, along with outlining important clinical pearls for ease of practical application. Equipped with increased familiarity and understanding of these essential therapies, primary care clinicians can better facilitate early engagement with psychiatric care, promote more widespread use, and thus significantly improve the wellbeing and quality of life of patients with severe mental illness.
Background The objective of this study is to evaluate if access to Samaritan, a digital support platform, improves the social determinants of health (SDOH) needs for patients enrolled in a jail diversion program in Jacksonville, FL. Methodology A total of 59 patients who were enrolled in a jail diversion program for homeless mentally ill misdemeanor offenders in Jacksonville, FL, participated in the study. Of the 59 patients, 47 individuals consented to participate in Samaritan while 12 declined participation. Demographics and the Health Leads Social Needs Screening Tool scores from the electronic health record were compared between groups along with average financial support from Samaritan. These non-normally distributed variables were compared using Wilcoxon rank-sum tests. Results The majority of study participants were male (92%, n = 43). The average age of study participants was 42 years. The average income from donors on the platform over three months for those who opted in was $48.80 (SD = 53.75). Among the individual Health Leads Social Needs Screening Tool questions, intact Housing was statistically significant (Z = -2.002, p = 0.045), suggesting access to a digital technology such as Samaritan might help improve SDOH needs. Conclusions Access to digital technologies, such as Samaritan, might help offenders with mental illness adjust to the many challenges they face upon reentry into the community. As such, these devices may represent one means for improving SDOH needs for disadvantaged mental health patients.
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