BACKGROUND:Lithium has long been considered to reduce suicidal behaviour in patients with affective disorders, but evidence from large real-world populations remains limited. OBJECTIVE:To estimate the effects of lithium initiation and continuation on suicide deaths and non-lethal suicidal behaviours among adults with bipolar disorder or major depressive disorder. METHODS:We emulated two target trials using electronic health records and administrative claims from US veterans between January 2010 and December 2022. The first trial benchmarked results against the CSP-590 randomised trial by estimating the 1-year risk of suicide-related events (non-fatal suicide attempts, hospitalisations to prevent suicide or suicide deaths) among patients with a recent suicide attempt initiating lithium versus not initiating lithium. The second trial extended follow-up to 10 years to estimate risks of suicide deaths and non-lethal suicidal behaviours separately, including subgroup analyses by age and diagnosis. An additional analysis removed the requirement of a prior suicide attempt. FINDINGS:In the benchmarking analysis, the 1-year risk ratio for suicide-related events comparing lithium initiation with no initiation was 1.06 (95% CI 1.01 to 1.12), consistent with findings from the CSP-590 trial. In the extended analysis, the 10-year per-protocol risk ratio for suicide death was 1.00 (95% CI 0.86 to 1.15) and for non-lethal suicidal behaviours was 0.96 (95% CI 0.90 to 1.02). Results were similar among individuals with and without a prior suicide attempt. CONCLUSION:When added to ongoing pharmacological treatment for patients with affective disorders, lithium may not substantially reduce suicide risk highlighting the need for additional suicide prevention strategies in this population. Limitations include lack of information on adherence, dosage or blood levels of lithium which may have obscured existing differences. CLINICAL IMPLICATIONS:Our findings suggest that adding lithium therapy to the ongoing treatment regimens of patients with affective disorders for the sole purpose of reducing suicide may not be well-tolerated or meaningfully reduce suicide risk.

BackgroundBipolar disorder remains a disabling mental health condition despite the availability of effective treatments. Collaborative chronic care models (CCMs) represent an evidence-based way to structure care for conditions like bipolar disorder. Life Goals Collaborative Care (LGCC) was designed specifically for bipolar disorder, featuring psychoeducation alongside collaborative components (e.g. nurse care management or expert psychiatric consultation). Despite the use of Life Goals across health systems, a systematic review summarizing its effectiveness has never been conducted.MethodsWe conducted a systematic review of randomized controlled trials (RCTs) of LGCC through December 2023 to help guide the field in treating bipolar disorder (PROSPERO: #404581). We evaluated study quality and outcomes in several symptom and quality of life domains.ResultsTen articles describing eight studies met inclusion criteria. All studies featured group-based LGCC; most were compared to treatment as usual (TAU). Three of eight studies found LGCC to be associated with statistically significant effects for the prevention of manic episodes. Most studies finding positive effects featured additional collaborative care components beyond psychoeducation and were conducted in capitated healthcare systems.LimitationsLimitations include: several types of potential bias in included studies; exclusion of observational studies of LGCC; lack of generalizability to pediatric populations; insufficient studies to conduct subgroup analyses; and low confidence in the quality of the evidence.ConclusionsIn this systematic review, group-based LGCC demonstrated some positive effects for reducing mania recurrence; results for other outcome domains were equivocal. Future studies should investigate one-on-one LGCC, both in person and virtually, to enhance well-being for people with bipolar disorder.

Purpose: The complexity of patients with mental healthcare needs cared for by clinical pharmacists is not well delineated. We evaluated the complexity of patients with schizophrenia, bipolar disorder, and major depressive disorder (MDD) in Veterans Affairs (VA) cared for by mental health clinical pharmacist practitioners (MH CPPs). Methods: Patients at 42 VA sites with schizophrenia, bipolar disorder, or MDD in 2016 through 2019 were classified by MH CPP visits into those with 2 or more visits ("ongoing MH CPP care"), those with 1 visit ("consultative MH CPP care"), and those with no visits ("no MH CPP care"). Patient complexity for each condition was defined by medication regimen and service utilization. Results: For schizophrenia, more patients in ongoing MH CPP care were complex than those with no MH CPP care, based on all measures examined: the number of primary medications (15.3% vs 8.1%), inpatient (13.7% vs 9.1%) and outpatient (42.6% vs 29.7%) utilization, and receipt of long-acting injectable antipsychotics (36.7% vs 25.8%) and clozapine (20.5% vs 9.5%). For bipolar disorder, more patients receiving ongoing or consultative MH CPP care were complex than those with no MH CPP care based on the number of primary medications (27.9% vs 30.5% vs 17.7%) and overlapping mood stabilizers (10.1% vs 11.6% vs 6.2%). For MDD, more patients receiving ongoing or consultative MH CPP care were complex based on the number of primary medications (36.8% vs 35.5% vs 29.2%) and augmentation of antidepressants (56.1% vs 54.4% vs 47.0%) than patients without MH CPP care. All comparisons were significant (P < 0.01). Conclusion: MH CPPs provide care for complex patients with schizophrenia, bipolar disorder, and MDD in VA.

From the 1VA Bedford Healthcare System, Bedford, MA 2Departments of Psychiatry and Population and Quantitative Health Sciences, UMass Chan Medical School, Worcester, MA 3Department of Psychiatry, Boston University Chobanian & Avedisian School of Medicine, Boston, MA. Received October 18, 2023; accepted after revision December 22, 2023. Address correspondence to: Eric G. Smith, MD, PhD, MPH, VA Bedford Healthcare System, 200 Springs Rd, Bedford, MA 01730 (e-mail: [email protected]). Supplemental digital content is available for this article. Direct URL citation appears in the printed text and is provided in the HTML and PDF versions of this article on the journal's Web site (www.psychopharmacology.com). A podcast discussing this article is available online at the journal website.

Objectives: Telemental health via videoconferencing (TMH-V) can overcome many of the barriers to accessing quality mental health care. Toward this end, in 2011, the U.S. Department of Veterans Affairs (VA) established the National Bipolar Disorders TeleHealth (BDTH) Program to provide expert mental health consultation and treatment to Veterans with bipolar spectrum disorders. Methods: Initial analyses of BDTH services suggested that participants had positive changes in quality-of-care indices and clinical outcomes; however, that evaluation was based on a limited sample of both participants and VA medical centers. We were able to confirm and expand upon those early results by using nearly eight times the number of participants and more than twice as many medical centers. Results: For the 2,456 Veterans who completed the intake to our program, there were significant improvements in some of the quality metrics (e.g., lithium use) and a 54% reduction in positive suicide screens (p < 0.05). The Veterans who completed the initial and postprogram assessments (n = 815) reported a 16.6% reduction in manic symptoms (p < 0.001), a 29.3% reduction in depressive symptoms (p < 0.001), and a 21.2% reduction in mood episodes (p < 0.001). Additionally, these Veterans demonstrated significant improvements (p < 0.001) in mental health-related quality of life between the two assessments. Conclusions: These analyses provide further support for the general effectiveness and safety of telemental health via videoconferencing. Future research should examine the generalizability of these findings across various subgroups (e.g., minority patients, patients in rural areas), populations, and health care systems.

Given the increasing prevalence of wildfires worldwide, understanding the effects of wildfire air pollutants on human health, in specific, immunological pathways, is crucial. Exposure to air pollutants has been associated with cardiorespiratory disease, however, immune, and epithelial barrier alterations require further investigation. We aimed to determine the impact of wildfire smoke exposure on the immune system and epithelial barriers, using proteomics and immune cell phenotyping. A cohort from the San Francisco Bay area (n=15; age:30±10y) provided blood samples before (October 2019-March 2020; AQI=37) and during a major wildfire (August 2020; AQI=80). The exposure samples were collected 11 days (range:10-12 days) following continuous exposure to wildfire smoke. We determined temporal alterations in 506 proteins, including zonulin family peptide (ZFP), immune cell phenotypes by mass cytometry (CyTOF), and their interrelationship using a correlation matrix. Targeted proteomic analyses (n=15) revealed a decrease in Spondin-2 and an increase in Granzyme A, B, and H, KIR3DL1, IL-16, Nibrin, PARP-1, C1QTNF-1, FGF-19, and vWF after 11 days in average continuous exposure to a large wildfire smoke (p<0.05). We also observed a large correlation cluster between pathways for immune regulation (IL-16, GZMA, GZMB, GZMH, KIR3DL1), DNA repair (PARP-1, NBN), and NK cells. We did not observe any change in ZFP levels suggesting a change in epithelial barriers. However, ZFP was associated with immune cell phenotypes (Naive CD4+, and Th2 cells). We observed functional changes in critical immune cells and their proteins during wildfire smoke exposure. Future studies should consider immune changes and targets for interventions.

INTRODUCTION We investigated whether the Death/Suicide Implicit Association Test (D/S-IAT) predicted suicidal ideation (SI) in psychiatric inpatients. METHODS One hundred eighty veterans admitted for either SI or suicidal behavior (SB) (the primary sample) (N = 90) or alcohol detoxification (N = 90) completed the D/S-IAT and scales measuring SI. Correlation and regression coefficients were measured between the D/S-IAT (as a full-scale or dichotomized score [D > 0]) and self-reported current or imminent SI (over the next 1-3 days). RESULTS In the primary sample, the full-scale D/S-IAT was significantly correlated with the intensity of current SI (r = 0.22, p = 0.04) and especially with wishes to be dead (r = 0.35, p < 0.001). The intensity of imminent SI was significantly predicted by the full-scale (p = 0.02) and dichotomized D/S-IAT score (p = 0.05) in a multiple regression model. However, no significant associations were observed when both the D/S-IAT score and current (present/absent) or imminent SI (occurred/did not occur) were dichotomous measures. In participants receiving alcohol detoxification, the D/S-IAT significantly predicted only wishes to be dead (r = 0.33, p < 0.001). CONCLUSION The full-scale D/S-IAT score predicted the current intensity of wishes to be dead in both inpatient samples, and current and imminent SI in participants admitted for SI/SB. The dichotomized D/S-IAT score did not predict the simple occurrence of SI.

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Background: Given the increasing prevalence of wildfires worldwide, understanding the effects of wildfire air pollutants on human health—particularly in specific immunologic pathways—is crucial. Exposure to air pollutants is associated with cardiorespiratory disease; however, immune and epithelial barrier alterations require further investigation. Objective: We sought to determine the impact of wildfire smoke exposure on the immune system and epithelial barriers by using proteomics and immune cell phenotyping. Methods: A San Francisco Bay area cohort (n = 15; age 30 ± 10 years) provided blood samples before (October 2019 to March 2020; air quality index = 37) and during (August 2020; air quality index = 80) a major wildfire. Exposure samples were collected 11 days (range, 10-12 days) after continuous exposure to wildfire smoke. We determined alterations in 506 proteins, including zonulin family peptide (ZFP); immune cell phenotypes by cytometry by time of flight (CyTOF); and their interrelationship using a correlation matrix. Results: Targeted proteomic analyses (n = 15) revealed a decrease of spondin-2 and an increase of granzymes A, B, and H, killer cell immunoglobulin-like receptor 3DL1, IL-16, nibrin, poly(ADP-ribose) polymerase 1, C1q TNF-related protein, fibroblast growth factor 19, and von Willebrand factor after 11 days’ average continuous exposure to smoke from a large wildfire (P < .05). We also observed a large correlation cluster between immune regulation pathways (IL-16, granzymes A, B, and H, and killer cell immunoglobulin-like receptor 3DL1), DNA repair [poly(ADP-ribose) 1, nibrin], and natural killer cells. We did not observe changes in ZFP levels suggesting a change in epithelial barriers. However, ZFP was associated with immune cell phenotypes (naive CD4+, TH2 cells). Conclusion: We observed functional changes in critical immune cells and their proteins during wildfire smoke exposure. Future studies in larger cohorts or in firefighters exposed to wildfire smoke should further assess immune changes and intervention targets.

Importance Suicide and suicide attempts are persistent and increasing public health problems. Observational studies and meta-analyses of randomized clinical trials have suggested that lithium may prevent suicide in patients with bipolar disorder or depression. Objective To assess whether lithium augmentation of usual care reduces the rate of repeated episodes of suicide-related events (repeated suicide attempts, interrupted attempts, hospitalizations to prevent suicide, and deaths from suicide) in participants with bipolar disorder or depression who have survived a recent event. Design, Setting, and Participants This double-blind, placebo-controlled randomized clinical trial assessed lithium vs placebo augmentation of usual care in veterans with bipolar disorder or depression who had survived a recent suicide-related event. Veterans at 29 VA medical centers who had an episode of suicidal behavior or an inpatient admission to prevent suicide within 6 months were screened between July 1, 2015, and March 31, 2019. Interventions Participants were randomized to receive extended-release lithium carbonate beginning at 600 mg/d or placebo. Main Outcomes and Measures Time to the first repeated suicide-related event, including suicide attempts, interrupted attempts, hospitalizations specifically to prevent suicide, and deaths from suicide. Results The trial was stopped for futility after 519 veterans (mean [SD] age, 42.8 [12.4] years; 437 [84.2%] male) were randomized: 255 to lithium and 264 to placebo. Mean lithium concentrations at 3 months were 0.54 mEq/L for patients with bipolar disorder and 0.46 mEq/L for patients with major depressive disorder. No overall difference in repeated suicide-related events between treatments was found (hazard ratio, 1.10; 95% CI, 0.77-1.55). No unanticipated safety concerns were observed. A total of 127 participants (24.5%) had suicide-related outcomes: 65 in the lithium group and 62 in the placebo group. One death occurred in the lithium group and 3 in the placebo group. Conclusions and Relevance In this randomized clinical trial, the addition of lithium to usual Veterans Affairs mental health care did not reduce the incidence of suicide-related events in veterans with major depression or bipolar disorders who experienced a recent suicide event. Therefore, simply adding lithium to existing medication regimens is unlikely to be effective for preventing a broad range of suicide-related events in patients who are actively being treated for mood disorders and substantial comorbidities. Trial Registration ClinicalTrials.gov Identifier:NCT01928446

Objective: Maintaining healthful, safe, and productive work environments for workers in correctional settings is a matter of deep consequence to the workers themselves, the institutions they serve, the incarcerated individuals with whom they share space, and inevitably, to our wider community. We hypothesized that an examination of the academic literature would reveal opportunities for an improved approach to research in these settings. Methods: We performed a scoping literature review using search terms related to the occupational and environmental health of workers in correctional environments, limited to studies performed in the United States. Results: A total of 942 studies underwent title and abstract screening, 342 underwent full-text review, and 147 underwent data extraction by a single reviewer. The results revealed a body of literature that tends strongly toward analyses of stress and burnout of correctional staff, largely based on self-reported data from cross-sectional surveys. Those studies related to physical health were predominantly represented by topics of infectious disease. There were few or no studies examining exposures or outcomes related to diagnosable mental health conditions, musculoskeletal injury, environmental hazards, medical or mental health staff, immigration detention settings, or regarding incarcerated workers. There were very few studies that were experimental, longitudinal, or based on objective data. Discussion: The National Institute for Occupational Safety and Health (NIOSH) has promulgated a research strategy for correctional officers that should guide future research for all workers in correctional settings, but realization of these goals will rely upon multidisciplinary collaboration, specific grants to engage researchers, and an improved understanding of the barriers inherent to correctional research, all while maintaining rigorous protection for incarcerated persons as an especially vulnerable population.

People are at risk of toxic metal and metalloid exposure (henceforth called metals) due to their prevalence in the environment and from combustions sources, such as from wildfires and fossil fuels. To date, however, no method exists to identify immune cell types at the single-cell level and simultaneously quantify cell surface or intracellular metal content. We tested a novel application of cytometry by time-of-flight (CyTOF) to simultaneously phenotype blood leukocytes and quantify the environmental metals present in immune cells. First, a young cohort of children (n=43) with known chronic exposure to elevated air pollution from the San Joaquin Valley in California was used to test whether there were high levels of metals in immune cells. Another older cohort of adults (n=15) exposed to a known wildfire event was used to validate the method. Using CyTOF, we stained isolated peripheral blood mononuclear cells with metalconjugated antibodies and then measured metal levels by recording open channels in which no metal-conjugated antibody was used to stain the cell. In the young cohort of children exposed to elevated air pollution, we detected bromide, cadmium, antimony, tantalum, tungsten, mercury, and lead. In the adult cohort we were not only able to detect those same metals, but found the levels significantly increased in comparison to the child cohort with t-tests showing elevated metal levels in the adult cohort for bromide (p<.01) antimony (p<.0001), tungsten (p<.0001) and mercury (p<.001). Simultaneous measurement of metal levels while phenotyping cells on the single cell level is possible using CyTOF and increases our understanding of the impact of environmental metal exposure on biological systems.

The intent of this research is to better understand the role of mucosal and gut proteins with respect to total IgE levels in atopic diseases and determine if these peptides could be potential blood-based biomarkers.

Previous studies in the Gulf of Mexico and Atlantic states have suggested that a suite of possibly abiotic and biotic attributes is responsible for salt marsh dieback, e.g., drought, soil waterlogging, soil chemistry, top-down consumers control, etc. However, there are no conclusive answers in current literature explaining what led to marsh dieback in past decades, especially from the spatiotemporal perspective. Exploring all Landsat-retrieved marsh dieback events in 1990-2019, this research investigates the spatiotemporal relationships between the dieback series and the associated environmental variables in an intertidal marsh in South Carolina (SC). Based on our previous study, a series of marsh dieback events in the past 30 years were identified and dieback pixels in the estuary were extracted. Among these were the most severe marsh dieback events (1991, 1999, 2000, 2002, 2004, and 2013). Daily Evaporative Demand Drought Index (EDDI), daily precipitation data from Parameter Elevation Regressions on Independent Slopes Model (PRISM), and station-based water quality observations (dissolved oxygen, specific conductivity, salinity, turbidity, pH, and temperature) in the estuary were retrieved. Integrated with the proof-by-exhaustion method, statistical analysis showed marsh dieback were highly related to moisture imbalance in a period of 90 days before the dieback events. Respectively, pH for Clambank and Debidue Creek, salinity and turbidity for Thousand Acre were found to be the key water quality variables influencing marsh dieback besides drought. This study cogitates the environmental influence on coastal marsh dieback from a spatiotemporal perspective using a long-term satellite time series analysis. The findings could provide insights into marsh ecological resilience and facilitate coastal ecosystem management.

Background Timothy's law to reduce mental health care disparities was enacted in January 2007 in New York state (NY). According to Timothy's law, "if a patient is suffering from a Biologically Based Mental Illness, or is a Child with Serious Emotional Disturbances, the Inpatient mental health benefit will be the same as for any other illness". An assessment of its impact on inpatient mental health care is lacking. We provide a rigorous study of this policy intervention’s effect over the first year of its implementation. Methods We used a quasi-experimental design to combine the difference-in-difference method and propensity score weighting. Data are from inpatient records in NY and California (CA) (as a control) between January 2006 to December 2006 (the pre-enactment year in NY) and January to December 2007 (the enactment year) for non-Medicare/Medicaid patients hospitalized in both years with specific illnesses covered by Timothy's Law. Change in length of stay from 2006 to 2007 was measured for each patient, and the differences observed in NY and California were compared to each other (Difference-in-Difference), with differences in the characteristics of patients in NY and California addressed through Propensity Score Weighting (PSW). Results Before Timothy's Law was enacted (2006), length of stay (LOS) in NY was 16.3 days on average, and length of stay per hospitalization (LOSPH) was 11.72 days on average for the 1237 patients under study in 2006. In 2007, LOS increased by 4.91 days in NY (95% CI (2.89, 7.01)) compared with similar patients in California, and LOSPH by 3.25 days (95% CI (1.96, 4.57)). Among patients with serious mental illness diagnoses, LOS in NY increased by 7.07 days (95% CI (4.15, 10.17)), and LOSPH by 4.04 days (95% CI (1.93, 6.03)) compared to California. Conclusions Our study strongly suggests that, within the time frame of just a single year, Timothy's Law significantly increased inpatient mental healthcare utilization in NY. Our study raises the possibility that similar laws in other locations could have similar effects.

Objective: Maintaining healthful, safe, and productive work environments for workers in correctional settings is a matter of deep consequence to the workers themselves, the institutions they serve, the incarcerated individuals with whom they share space, and inevitably, to our wider community. We hypothesized that an examination of the academic literature would reveal opportunities for an improved approach to research in these settings. Methods: We performed a scoping literature review using search terms related to the occupational and environmental health of workers in correctional environments, limited to studies performed in the United States. Results: A total of 942 studies underwent title and abstract screening, 342 underwent full-text review, and 147 underwent data extraction by a single reviewer. The results revealed a body of literature that tends strongly toward analyses of stress and burnout of correctional staff, largely based on self-reported data from cross-sectional surveys. Those studies related to physical health were predominantly represented by topics of infectious disease. There were few or no studies examining exposures or outcomes related to diagnosable mental health conditions, musculoskeletal injury, environmental hazards, medical or mental health staff, immigration detention settings, or regarding incarcerated workers. There were very few studies that were experimental, longitudinal, or based on objective data. Discussion: The National Institute for Occupational Safety and Health (NIOSH) has promulgated a research strategy for correctional officers that should guide future research for all workers in correctional settings, but realization of these goals will rely upon multidisciplinary collaboration, specific grants to engage researchers, and an improved understanding of the barriers inherent to correctional research, all while maintaining rigorous protection for incarcerated persons as an especially vulnerable population.

Although it is recognized that exposure to ambient air pollution containing particulate matter with a diameter of less than 2.5 micrometers (PM2.5) is responsible for more than a million cases of childhood asthma per year, the underlying mechanisms remain to be precisely addressed. It has not been demonstrated whether increased levels of exposure to PM2.5 is associated with dysregulation of monocytes in healthy and asthmatic children, or if pollution primes monocytes to develop a hyperinflammatory response termed "trained immunity". We characterized phenotypic and functional markers specific to monocyte subsets from 56 children (6-8-year-old) using mass cytometry (CyTOF). Analyses were performed by manual gating and R programming. We utilized an in vitro approach to train monocytes with PM2.5 and then assess their response upon secondary stimulation with house dust mite or lipopolysaccharide. Increased exposure to PM2.5 was associated with elevated numbers of classical monocytes and the reduction of non-classical monocytes in children. Heterogenous sub-clusters of each monocyte subset further demonstrated both phenotypic and functional markers differentially regulated in children exposed to low vs high PM2.5. Exposure to high levels of PM2.5 predisposed children with asthma to develop a monocyte signature distinct from that of healthy controls. PM2.5-mediated training of monocytes provoked a hyperinflammatory response characterized by the upregulation of proinflammatory mediators. Specific alterations of monocytes associated with PM2.5 exposure suggest an immune signature for the prognosis of asthma in children living in areas with high PM2.5. Immune pathways underlying pollution-induced trained immunity may provide novel therapeutic targets.

This study examined if lithium's association with suicide risk varies by diagnosis. We performed separate 1:1 high-dimensional propensity score (hdPS)-matching in US Veterans with and without bipolar disorder starting lithium or valproate. Among individuals with bipolar disorder, actively receiving lithium (compared to valproate) was not associated with suicide risk. However, in intent-to-treat analyses (following all individuals with bipolar disorder starting lithium or valproate for all 365 days, regardless of whether they stopped the medication), starting lithium was significantly associated with higher one-year risks of suicide (HR = 1.50, 95% CI: 1.05-2.15, p = 0.03). These intent-to-treat risks were attributable entirely to transiently elevated suicide risks observed among individuals no longer receiving lithium (significant at 180 days [HR = 6.10, CI: 1.37-27.3, p = 0.02] but not 365 days [HR = 2.05, CI: 0.88-4.79, p = 0.10]). Among individuals without bipolar disorder, depending on the analysis, actively receiving lithium was associated with nonsignificantly (HR = 0.43, CI: 0.15-1.20, p = 0.11) or significantly (HR = 0.28, CI: 0.08-0.98, p = 0.047) decreased one-year suicide risks. Study limitations included limited power, brief follow-up, and potential residual confounding. Residual confounding is suggested by the observation that more individuals diagnosed with suicidal ideation started lithium than valproate (with this difference being statistically significant for individuals with bipolar disorder, p = 0.0012). If it were possible to correct for this potential confounding, then the suicide-related risks associated with among individuals discontinuing lithium would be expected to be less, and the suicide-related benefits associated with actively receiving lithium (already statistically significant in some analyses among individuals without bipolar disorder) would be expected to increase. Further research is needed.

OBJECTIVES:Reducing seclusion and restraint use is a prominent focus of efforts to improve patient safety in inpatient psychiatry. This study examined the poorly understood relationship between seclusion and restraint rates and organizational climate and clinician morale in inpatient psychiatric units.METHODS:Facility-level data on hours of seclusion and physical restraint use in 111 U.S. Department of Veterans Affairs (VA) hospitals in 2014 to 2016 were obtained from the Centers for Medicare & Medicaid Services. Responses to an annual census survey were identified for 6646 VA inpatient psychiatry clinicians for the same period. We examined bivariate correlations and used a Poisson model to regress hours of seclusion and restraint use on morale and climate measures and calculated incident rate ratios (IRRs).RESULTS:The average physical restraint hours per 1000 patient hours was 0.33 (SD, 1.27; median, 0.05). The average seclusion hours was 0.31 (SD, 0.84; median, 0.00). Physical restraint use was positively associated with burnout (IRR, 1.76; P = 0.04) and negatively associated with engagement (IRR, 0.22; P = 0.01), psychological safety (IRR, 0.48; P < 0.01), and relational climate (IRR, 0.69; P = 0.04). Seclusion was positively associated with relational climate (IRR, 1.69; P = 0.03) and psychological safety (IRR, 2.12; P = 0.03). Seclusion use was also nonsignificantly associated with lower burnout and higher engagement.CONCLUSIONS:We found significant associations between organizational climate, clinician morale, and use of physical restraints and seclusion in VA inpatient psychiatric units. Health care organization leadership may want to consider implementing a broader range of initiatives that focus on improving organizational climate and clinician morale as one way to improve patient safety.