The Psychiatric Consultation Service at Massachusetts General Hospital sees medical and surgical inpatients with comorbid psychiatric symptoms and conditions. During their twice-weekly rounds, Dr Stern and other members of the Consultation Service discuss diagnosis and management of hospitalized patients with complex medical or surgical problems who also demonstrate psychiatric symptoms or conditions. These discussions have given rise to rounds reports that will prove useful for clinicians practicing at the interface of medicine and psychiatry. Prim Care Companion CNS Disord 2026;28(3):25f04146. Author affiliations are listed at the end of this article.

The Psychiatric Consultation Service at Massachusetts General Hospital sees medical and surgical inpatients with comorbid psychiatric symptoms and conditions. During their twice-weekly rounds, Dr Stern and other members of the Consultation Service discuss diagnosis and management of hospitalized patients with complex medical or surgical problems who also demonstrate psychiatric symptoms or conditions. These discussions have given rise to rounds reports that will prove useful for clinicians practicing at the interface of medicine and psychiatry.

Arts-based creative interventions have demonstrated positive psychological effects, including creativity, self-efficacy, and social connectivity, an approach deeply rooted in a humanistic framework that emphasizes the intrinsic value of every individual and the transformative power of creative expression. This study explored the feasibility and acceptability of a web-based music composition intervention to support survivors of serious illness hospitalized during the COVID-19 pandemic. Inspired by the New York Philharmonic Very Young Composers (VYC) program, trauma-informed care-trained teaching artists guided participants through four web-based sessions to develop unique compositions, culminating in a live, online performance. Feasibility data were based on adherence to intervention components. Acceptability data on resilience-related traits were self-reported via pre-post surveys. Fourteen participants enrolled, 12 completed all intervention sessions, and 10 attended the optional final performance. Qualitative analysis revealed five themes that contributed to participants' positive experience: (I) Novelty, (II) Skill/Perspective Gained, (III) Pleasure, (IV) Self-Efficacy, and (V) Connection to others. Results suggest that the VYC-inspired music composition intervention is a feasible and highly acceptable method for fostering resilience-associated traits in patients impacted by serious illness.

A trauma-informed care interdisciplinary team within an outpatient psychiatry practice provides a framework for intentional consideration of the impact of trauma on psychopathology and patient engagement. This column highlights practical ways in which trauma-informed principles have the potential to transform clinical processes, improve patient engagement, improve provider sense of empowerment, and decrease patient emergency department visits and inpatient care utilization. Challenges with program development, implementation, and evaluation are also identified.

Purpose of Review: Intimate partner violence (IPV) is a widespread public health issue with significant physical and psychological consequences. OpenNotes, which allows patients to view their clinical notes, presents an opportunity to enhance care for survivors by fostering transparency, trust, and patient engagement. This review provides background information on OpenNotes specifically as it relates to IPV and proposes practical recommendations for forensic nurses and clinicians in healthcare settings. Methods: We conducted a literature review of peer-reviewed publications about OpenNotes or trauma-informed IPV documentation. The writing team using an iterative process synthesized and summarized how OpenNotes can be used to support trauma-informed IPV care. Subject matter experts from various disciplines (nursing, psychiatry and social services provided feedback on the summary synthesis. Key Findings and Recommendations: best practices for leveraging OpenNotes to support IPV survivors, including strategies for sensitive documentation, shared decision-making, and interdisciplinary collaboration were identified. The benefits of OpenNotes can empower patients, reinforce trauma-informed care, and facilitate safer, more effective communication between survivors and members of their clinical team. Limitations: there are inherent limitations of a narrative review such as potential selection bias, search strategy limitations, and lack of a systematic critical appraisal of literature. Conclusions: This narrative review provides concepts for best practices in the context of documentation in electronic health records. Further exploration using rigorous methodology is needed to understand best practices, inform policy and education.

PROBLEM:Trauma-informed care (TIC) provides a medical framework for addressing and mitigating the negative consequences of trauma. In response to student and faculty advocacy, medical schools are developing trauma-informed curricular content. However, medical education literature does not present a comprehensive assessment rubric to evaluate medical students' acquisition of trauma-informed clinical skills. APPROACH:A committee of medical students, trainees, and faculty developed a longitudinal TIC curricular theme at Harvard Medical School (HMS). Guided by the National Collaborative on Trauma-Informed Health Care Education and Research competencies, the committee created a set of medical student TIC competencies from July to December 2019. From November 2021 to November 2022, 3 committee subgroups generated new TIC descriptors for each HMS entrustable professional activity (EPA), then circulated these to other subgroups, external experts, and stakeholders for review and feedback. From April to June 2023, the committee iteratively reviewed the materials until reaching consensus for content and pedagogy. The committee integrated TIC content into HMS's existing EPAs expected of students, provided anchoring descriptions of each level, and achieved consensus using a process of iterative review with TIC content experts. OUTCOMES:The committee identified 10 TIC competencies and revised all 13 general HMS EPAs to include specific items based on these competencies. The committee incorporated at least 1 trauma-informed competency into each HMS EPA. NEXT STEPS:This novel set of HMS EPAs provides a framework for assessment of TIC clinical skills. Faculty will be trained to correctly and reliably incorporate TIC competencies into patient care and to use the TIC-inclusive EPAs for student assessment, ensuring that TIC is standard medical practice at HMS. This work may facilitate the adoption of trauma-inclusive EPAs by other institutions to educate the next generation of physicians to practice TIC and thus promote a more accessible, safe, and equitable health care system.

BACKGROUND:Spanish-speaking trauma and burn patients have unique needs in their postdischarge care navigation. The confluence of limited English proficiency, injury recovery, mental health, socioeconomic disadvantages, and acute stressors after hospital admission converge to enhance patients' vulnerability, but their specific needs and means of meeting these needs have not been well described. STUDY DESIGN:This prospective, cross-sectional survey study describes the results of a multi-institutional initiative devised to help Spanish-speaking trauma and burn patients in their care navigation after hospitalization. The pathway consisted of informational resources, intake and follow-up surveys, and multiple points of contact with a community health worker who aids in accessing community resources and navigating the healthcare system. RESULTS:From January 2022 to November 2023, there were 114 patients identified as eligible for the Non-English-Speaking Trauma Survivors pathway. Of these, 80 (70.2%) were reachable and consented to participate, and 68 were approached in person during their initial hospitalization. After initial screening, 60 (75.0%) eligible patients had a mental health, social services, or other need identified via our survey instrument. During the initial consultation with the community health worker, 48 of 60 patients with any identified need were connected to a resource (80%). Food support was the most prevalent need (46, 57.5%). More patients were connected to mental health resources (16) than reported need in this domain (7). CONCLUSIONS:The Non-English-Speaking Trauma Survivors pathway identified the specific needs of Spanish-speaking trauma and burn patients in their recovery, notably food, transportation, and utilities. The pathway also addressed disparities in postdischarge care by connecting patients with community resources, with particular improvement in access to mental healthcare.

INTRODUCTION:Collectively, studies from medical and surgical intensive care units (ICU) suggest that long-term outcomes are poor for patients who have spent significant time in an ICU. We sought to identify determinants of post-intensive care physical and mental health outcomes 6-12 months after injury. METHODS:Adult trauma patients [ISS ≥9] admitted to one of three Level-1 trauma centers were interviewed 6-12 months post-injury to evaluate patient-reported outcomes. Patients requiring ICU admission ​≥ ​3 days ("ICU patients") were compared with those who did not require ICU admission ("non-ICU patients"). Multivariable regression models were built to identify factors associated with poor outcomes among ICU survivors. RESULTS:2407 patients were followed [598 (25%) ICU and 1809 (75%) non-ICU patients]. Among ICU patients, 506 (85%) reported physical or mental health symptoms. Of them, 265 (52%) had physical symptoms only, 15 (3%) had mental symptoms only, and 226 (45%) had both physical and mental symptoms. In adjusted analyses, compared to non-ICU patients, ICU patients were more likely to have new limitations for ADLs (OR ​= ​1.57; 95% CI ​= ​1.21, 2.03), and worse SF-12 mental (mean Δ ​= ​-1.43; 95% CI ​= ​-2.79, -0.09) and physical scores (mean Δ ​= ​-2.61; 95% CI ​= ​-3.93, -1.28). Age, female sex, Black race, lower education level, polytrauma, ventilator use, history of psychiatric illness, and delirium during ICU stay were associated with poor outcomes in the ICU-admitted group. CONCLUSIONS:Physical impairment and mental health symptoms following ICU stay are highly prevalent among injury survivors. Modifiable ICU-specific factors such as early liberation from ventilator support and prevention of delirium are potential targets for intervention.

BackgroundDiabetic Ketoacidosis (DKA) and hyperosmolar hyperglycemic state (HHS) are life-threatening conditions that send nearly 180,000 patients to the ICU each year, with mortality rates up to 5-10%. Little is known about the impact of concurrent psychiatric disorders on specific DKA/HHS outcomes. Identifying these relationships offers opportunities to improve clinical management, treatment planning, and mitigate associated morbidity and mortality.MethodsWe conducted a retrospective review including adult DKA/HHS admissions within a large Massachusetts hospital system from 2010 – 2019. We identified patients admitted inpatient for DKA or HHS, then filtered by ICD-9-CM, ICD-10-CM codes for psychiatric diagnoses that were present in patients EMR at any point in this observational period. Outcomes included number of inpatient admissions for DKA/HHS, age of death, rates of discharging against medical advice (AMA) from any inpatient admission, and ESRD/dialysis status. Multivariate regression was conducted using R software to control for variables across patients and evaluate relationships between outcomes and concurrent psychiatric disorders. Significance was set at p <0.05.Results7756 patients were admitted for DKA or HHS, 66.9% of which had a concurrent psychiatric disorder. 54.5% of these patients were male, 70.4% White, and an average age of 61.6 years. This compares with 26.1% with concurrent psychiatric condition within the general diabetes population, 52.1% of which were male, 72.1% White, and an average of 68.2 years . A concurrent psychiatric disorder was associated with increased odds of rehospitalization (aOR= 1.62 95%Cl 1.35 - 1.95, p<0.001), of being diagnosed with end-stage renal disease and on dialysis (aOR = 1.02 95% Cl 1.002 – 1.035, p = 0.02), and in leaving AMA (aOR = 6.44 95%Cl 4.46 – 9.63, p <0.001). The average age of death for those with a concurrent psychiatric disorder had an adjusted mean difference in years of -7.5 years (95% Cl -9.3 5.8) compared to those without a psychiatric disorder.Conclusion66.9% of patients with DKA/HHS have a concurrent psychiatric disorder. Patients with a concurrent psychiatric disorder admitted for DKA/HHS were more likely to have multiple admissions, to leave AMA, to be on renal dialysis, and have a lower age of mortality.

Background:To describe factors that influence interprofessional staff decisions and ability to implement trauma-informed care (TIC) in a level-one emergency department (ED) trauma center. Methods:This qualitative research study consisted of semi-structured interviews and quantitative surveys that were conducted between March and December 2020 at an urban trauma center. Eligible participants were staff working in the ED. Interview questions were developed using the Theoretical Domains Framework (TDF), which is designed to identify influences on health professional behavior related to implementation of evidence-based recommendations. Interview responses were transcribed, coded using Atlas software, and analyzed using thematic analysis. Results:Key themes identified included awareness of TIC principles, impact of TIC on staff and patients, and experiences of bias. Participants identified opportunities to improve care for patients with a trauma history, including staff training, more time with patients, and efforts to decrease bias toward patients. Most participants (85.7%) felt that a TIC plan, tiered trauma inquiry, and warm handovers would be easy or very easy to implement. Conclusion:We identified key interprofessional staff beliefs and attitudes that influence implementation of TIC in the ED. These factors represent potential individual, team-based, and organizational targets for behavior change interventions to improve staff response to patient trauma and to address secondary trauma experienced by ED staff.

We present a case of Torsades de Pointes (TdP) in a patient with COVID-19 infection and multiple TdP risk factors including QT-interval prolongation, hemodialysis, bradycardia, and treatment with remdesivir, citalopram, and quetiapine. The case was complicated by post-resuscitation anxiety superimposed on a history of medical trauma since childhood. Top experts in the field of consultation-liaison psychiatry, trauma informed care, and cardiac electrophysiology provide perspectives on this case with a review of the literature. Key teaching topics include identification of TdP risk factors in patients with a complex illness; the necessity for prompt electrophysiology consultation in clinical scenarios with high risk for TdP; and the approach to patients with medical trauma using a trauma-informed lens. We highlight the contributions of COVID-19, the pharmacokinetics of QT-interval-prolonging psychotropic medications, the risks of hemodialysis, and the role of remdesivir-induced bradycardia in this first reported case of TdP in a patient treated with remdesivir.

Objective: Compared to other age groups, young adults are at risk of suffering COVID-19 pandemic-related psychological problems. Prior research suggests that such adverse events (like the pandemic) can initiate adaptive psychological changes, referred to as posttraumatic growth (PTG); however, limited studies have examined the moderating role of PTG among young adults in the United States with regard to COVID-19-related distress. Thus, this study examines whether pandemic-related distress has a differential effect on young adults' mental health symptoms based on varying levels of PTG. Method: Using the data from 661 participants who completed all three waves of the CARES study (T-1: April-August 2020; T-2: September 2020-March 2021; T-3: April-May 2021), a moderator analysis was performed using the PROCESS Macro to determine the moderating effect of PTG. Results: In our data, higher levels of PTG buffered the effects of pandemic-related distress from 2020 on depressive symptoms in 2021; PTG did not show a moderating effect with anxiety as an outcome. Conclusions: Understanding the moderating role of PTG would help to further understand the mental health trajectories of young adults in the United States who are particularly distressed by the pandemic. Our findings suggest the importance of further exploring contributors to PTG for young adults, particularly among those who have experienced high levels of pandemic-related distress to date.

OpenNotes reflects an international trend towards transparency in patient care. By giving patients access to their clinical notes, OpenNotes aims to increase efficiency and shared decision making between patients and clinicians, and to improve patient adherence to care. After being piloted in three US hospital systems in 2010, OpenNotes became the federal mandate in the USA in April, 2021, through the 21st Century Cures Act, which required that patients be granted access to the entirety of their electronic medical record. However, as with the implementation of the electronic medical record itself, tradeoffs and unforeseen consequences can occur.

Diversity, equity, and inclusion (DEI) have become increasingly recognized as essential to the practice of high-quality patient care delivery and the support of members of the clinical environment. A solid understanding of DEI contributes to a better grasp of what drives health care disparities and yields improved clinical outcomes for minority populations. This column discusses how individuals can practically promote DEI by describing the design and implementation of DEI in an academic psychiatry department. The authors highlight the powerful role of departmental initiatives in establishing best practices for DEI and lessons learned through the work of the psychiatry department's DEI committee.

INTRODUCTION:Trauma exposure is a highly prevalent experience for patients and clinicians in emergency medicine (EM). Trauma-informed care (TIC) is an effective framework to mitigate the negative health impacts of trauma. This systematic review synthesizes the range of TIC interventions in EM, with a focus on patient and clinician outcomes, and identifies gaps in the current research on implementing TIC. METHODS:The study was registered with PROSPERO (CRD42020205182). We systematically searched peer-reviewed journals and abstracts in the PubMed, EMBASE (Elsevier), PsycINFO (EBSCO), Social Services Abstract (ProQuest), and CINAHL (EBSCO) databases from 1990 onward on August 12, 2020. We analyzed studies describing explicit TIC interventions in the ED setting using inductive qualitative content analysis to identify recurrent themes and identify unique trauma-informed interventions in each study. Studies not explicitly citing TIC were excluded. Studies were assessed for bias using the Newcastle-Ottawa criteria and Critical Appraisal Skills Programme (CASP) Checklist. RESULTS:We identified a total of 1,372 studies and abstracts, with 10 meeting inclusion criteria for final analysis. Themes within TIC interventions that emerged included educational interventions, collaborations with allied health professionals and community organizations, and patient and clinician safety interventions. Educational interventions included lectures, online modules, and standardized patient exercises. Collaborations with community organizations focused on addressing social determinants of health. All interventions suggested a positive impact from TIC on either clinicians or patients, but outcomes data remain limited. CONCLUSION:Trauma-informed care is a nascent field in EM with limited operationalization of TIC approaches. Future studies with patient and clinician outcomes analyzing universal TIC precautions and systems-level interventions are needed.

Objective: To evaluate the Social Vulnerability Index (SVI) as a predictor of long-term outcomes after injury. Background: The SVI is a measure used in emergency preparedness to identify need for resources in the event of a disaster or hazardous event, ranking each census tract on 15 demographic/social factors. Methods: Moderate-severely injured adult patients treated at one of three level-1 trauma centers were prospectively followed six to 14 months post-injury. These data were matched at the census tract level with overall SVI percentile rankings. Patients were stratified based on SVI quartiles, with the lowest quartile designated as low SVI, the middle two quartiles as average SVI, and the highest quartile as high SVI. Multivariable adjusted regression models were used to assess whether SVI was associated with long-term outcomes after injury. Results: A total of 3,153 patients were included [54% male, mean age 61.6 (SD = 21.6)]. The median overall SVI percentile rank was 35th (IQR: 16th-65th). Compared to low SVI patients, high SVI patients were more likely to have new functional limitations (OR, 1.51; 95% CI, 1.19-1.92), to not have returned to work (OR, 2.01; 95% CI, 1.40-2.89), and to screen positive for PTSD (OR, 1.56; 95% CI, 1.12-2.17). Similar results were obtained when comparing average with low SVI patients, with average SVI patients having significantly worse outcomes. Conclusions: The SVI has potential utility in predicting individuals at higher risk for adverse long-term outcomes after injury. This measure may be a useful needs assessment tool for clinicians and researchers in identifying communities that may benefit most from targeted prevention and intervention efforts.

What individuals think, say, and do produces workplace culture. In health care, the COVID-19 pandemic has reshaped every aspect of this framework. Today, people think and talk through screens and do so in isolation. When clinical care delivery, operational processes, and work environments have all transformed so rapidly, the demands and stresses on our clinician workforce are bound to mount. So how do leaders facilitate optimal communication among frontline teams? Culture refers to the set of shared and widely accepted beliefs, values, and social practices of a group [1]. Eff ective communication that integrates complete transparency on the dynamic nature of operations, particularly during times of crisis, forms the foundation for building a culture of wellness for clinicians. With the onset of the COVID-19 pandemic, however, clinical care delivery, operational processes, and work environments have all transformed rapidly to adapt to the remote world. Such changes have markedly amplifi ed the demands and stresses on clinicians [2]. Though large-scale deployment of telehealth has facilitated access to convenient medical care, the virtual medium may diminish the perception of humanism within the patient encounter. Mass home-confi nement directives such as quarantines and social distancing have amplifi ed social isolation. Remote work environments reducing interaction among colleagues have placed camaraderie and peer support at risk. Worklife balance has shifted: with children attending school remotely in the home environment, clinician parents are struggling with the concurrent tasks of working and child-rearing. While entire medical systems have rallied to support clinicians during a time in which clinicians have demonstrated increased altruism, the longterm risk of burnout has risen substantially [3]. To nurture trust, achieve values alignment, and strengthen workplace culture—all core elements of a strategy to prevent burnout [4]—communication of a shared mission in a time of crisis must be clear, consistent, and sincere. So how do leaders facilitate optimal communication among frontline teams, generating the inclusion, intentionality, and interactivity that achieves such trust and sustains engagement [4]? This article discusses the role of optimizing transparency and communication within the framework of medical teams as an essential component of a strategy to address clinician burnout, particularly during COVID-19. Using interventions in the department of psychiatry at Brigham and Women’s Hospital as a representative case study, the authors of this paper discuss strategies implemented for frontline clinical teams consisting of physicians, nurses, medical assistants, and social workers. This article aims to address the following: