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We present the case of a 60-year-old woman who presented to primary care with chronic mixed depressive and hypomanic symptoms consistent with schizoaffective disorder. Patients with serious mental illness such as psychotic disorders are ideally referred for treatment in specialty psychiatric settings; however, many patients with serious mental illness receive their care in primary care settings due to patient preference or unavailability of psychiatric services. Top experts in the CL field provide guidance for this commonly encountered clinical case based on their experience and a review of the available literature. The Collaborative Care Model (CoCM) can support primary care providers in managing patients with serious mental illness. Key teaching topics include the application of the CoCM to patients with psychotic disorders, clinician- and systems-level facilitators and barriers to CoCM implementation, and quality improvement within the CoCM. Specifically, the differential diagnosis when a patient is not improving should include systems-level considerations.

Purpose Availability of mental health services is limited in the rural United States. Two promising models to reach patients with limited access to care are telehealth referral and collaborative care. The objective of this study was to assess telepsychiatrist‐ and telepsychologist‐level facilitators and barriers to satisfaction with and implementation of these 2 telehealth models in rural settings. Methods Focus groups were held in 2019 using a semistructured interview guide. Participants were off‐site telepsychiatrists (N = 10) and telepsychologists (N = 4) for primary care clinics across 3 states (Washington, Michigan, and Arkansas) involved in a recent pragmatic comparative effectiveness trial. Qualitative analysis occurred inductively by 2 independent coders. Findings Participants were satisfied with the models partly owing to good patient rapport and expanding access to care. Teamwork was highlighted as a facilitator in collaborative care and was often related to work with care managers. However, participants described communication with primary care providers as a challenge, especially in the telehealth referral arm. Barriers centered on variability of logistical processes (eg, symptom monitoring, scheduling, electronic medical record processes, and credentialing) among sites. Staff turnover, variable clinic investment, and inadequacy of training were possible explanations for these barriers. Conclusions Participants described high motivation to provide team‐based, remote care for patients, though they experienced operational challenges. Centralized credentialing, scheduling, and record keeping are possible solutions. These findings are important because consulting psychiatrists and psychologists may play a leadership role in the dissemination of these models.

The relationship between medication attitudes and adherence as well as reliable measures of medication attitudes need further study. This study examined the psychometric properties of the Attitudes Toward Mood Stabilizers Questionnaire (AMSQ) in bipolar participants and the relationship between medication attitudes and adherence, measured by the self-reported Tablets Routine Questionnaire (TRQ). Inclusion criteria included mood stabilizer treatment and 20% or more medication nonadherence. Measures were given pretreatment and posttreatment. Average age was 47 years; majority were female (69%), African American (67%), and unmarried (53%). AMSQ's test-retest reliability was ρ = 0.73 (p < 0.001). AMSQ correlated with TRQ (rs = 0.20, p < 0.01) at baseline. Factor analysis identified three factors: positive/favorable attitudes, negative/critical attitudes, and unintentional nonadherence. Change in AMSQ across time correlated with change in TRQ. The AMSQ is valid psychometrically and is sensitive to change. Medication attitudes are related to adherence behavior. Interventions should include targeting specific domains of medication attitudes, such as illness knowledge.

Background: Cotard syndrome features nihilistic delusions about one’s body or existence and is typically related to severe depression though is rarely associated with medical or neurological insults. Case presentation: The patient was a 62-year-old male with no past psychiatric history and a past medical history of congestive heart failure and consequent renal failure who presented for scheduled heart and kidney transplantation. He was started on routine post-transplant ganciclovir and steroids. Due to postoperative hypotension, empiric cefepime was initiated to cover for septic shock. One week postoperatively, the patient stated “I am dead.” He elaborated that “an intern overdilated me” during transplantation and declined tacrolimus. The patient also reported visual hallucinations of green algae and bubbles. He denied depression and was attentive and oriented. He had a Bush-Francis score of 9. MRI brain revealed no acute changes. Low-dose haloperidol was initiated for psychosis. Cefepime was discontinued, but ganciclovir and steroids were continued. Two days later, the symptoms fully resolved. Discussion: This is the first reported case of Cotard syndrome as an acute transplant complication. Though corticosteroid-induced psychosis was initially suspected, cefepime neurotoxicity is the more likely explanation given the correlation between the antibiotic and symptom courses. Older age and renal dysfunction were risk factors. Conclusions: Cotard Syndrome can be an acute complication of solid organ transplantation, where renal impairment and polypharmacy are common. Transplantation teams and consult-liaison psychiatrists should work together to manage this syndrome.

Molly Howland,1 Kevin C Allan,1 Caitlin E Carlton,1 Curtis Tatsuoka,2–4 Kathleen A Smyth,3 Martha Sajatovic1,2,4,5 1Case Western Reserve University School of Medicine, 2Neurological and Behavioral Outcomes Center, University Hospitals Case Medical Center, 3Department of Epidemiology and Biostatistics, 4Department of Neurology, 5Department of Psychiatry, Case Western Reserve University School of Medicine, Cleveland, OH,USA Objectives: Patients with cognitive impairment may have difficulty reporting their functional and cognitive abilities, which are important clinical outcomes. Health care proxies may be able to corroborate patient self-reports. Several studies reported discrepancy between patient and proxy ratings, though the literature is sparse on changes over time of these ratings. Our goals in this 12-month study were to compare patient and proxy reports on functioning, cognition, and everyday executive function, and to further elucidate correlates of patient–proxy discrepancy. Methods: This was a prospective cohort study of individuals older than 70 years who ranged from having no cognitive impairment to having moderate dementia who had a proxy available to complete instruments at baseline (N=76). Measurements included Alzheimer’s Disease Cooperative Study–Activities of Daily Living Inventory (ADCS-ADLI), Neuro-QOL Executive Function, PROMIS Applied Cognition (PROMIS-Cog), Mini-Mental State Examination (MMSE), and Geriatric Depression Scale. Results: Patient- and proxy-rated ADCS-ADLI were correlated at baseline and at 1-year follow-up. Patient and proxy ratings were discrepant on Neuro-QOL Executive Function and PROMIS-Cog. Greater patient–proxy discrepancy on PROMIS-Cog was associated with younger age and less depression, and greater patient–proxy discrepancy on Neuro-QOL Executive Function was associated with less depression and worse cognitive impairment. Patient–proxy discrepancy increased over time for everyday executive function. Changes in proxy-rated but not patient-rated ADCS-ADLI correlated with MMSE changes. Conclusion: Patients and proxies generally agree in reporting on activities of daily living. Patient and proxy reports differ in their respective evaluation of cognitive functioning and everyday executive function. Ratings from both sources may be preferred for these two domains, though studies using gold standard measures are necessary. It is important that clinicians are aware of the differences between patient and proxy perspective to create an accurate clinical picture and guide treatment. Keywords: agreement, activities of daily living, dementia, executive function, caregiver

PROMIS(®) Applied Cognition is a short self-assessment of cognitive abilities and concerns that eliminates the need for a trained rater and provides online question banks that can be uniformly used across health care providers. This 12-month prospective study of 281 elderly individuals evaluates self-perceptions of cognitive functioning in relation to objective cognition, or assessment by an external rater, and compares PROMIS® Applied Cognition Abilities and Concerns subsets with commonly used "legacy" instruments. PROMIS® correlated with objective legacy measures (the Mini-Mental State Examination [MMSE] and Saint Louis University Mental Status [SLUMS] examination), depression (measured with the Geriatric Depression Scale [GDS]), anxiety, and activities of daily living. PROMIS® and MMSE correlations remained after controlling for depression and anxiety. PROMIS® associated more strongly than MMSE with depression, highlighting the relationship between subjective cognitive deficit and depression. One-year changes in PROMIS® correlated with one-year changes in MMSE and GDS. The PROMIS® Abilities subset more strongly correlated with objective cognition, whereas the Concerns subset more strongly correlated with depression and activities of daily living. PROMIS® seems to be a reasonable prescreening tool to identify patients with cognitive decline or psychological distress.

Background Internalized stigma, which occurs when stigmatized individuals accept society's assessment and incorporate this assessment into their sense of self, is prevalent in individuals with bipolar disorder (BD). This study explored the correlates of internalized stigma in a research sample of patients with BD who were poorly adherent to their medications. Methods Both quantitative and qualitative analyses were performed. Scores of 115 individuals with BD on the Internalized Stigma of Mental Illness (ISMI) scale were correlated with scores on the General Self-Efficacy (GSE) Scale, Brief Psychiatric Rating Scale (BPRS), Montgomery–Asberg Depression Rating Scale (MADRS), and Young Mania Rating Scale (YMRS). Regression was run for GSE (dependent variable) and ISMI (independent variable). In-depth qualitative interviews were conducted on a representative subsample (N = 21). Results Internalized stigma levels were moderately high. Internalized stigma and self-efficacy correlated, and internalized stigma related to self-efficacy after adjusting for demographic variables (age, gender, years of education), comorbidities, and symptom severity (BPRS and MADRS). Internalized stigma was also associated with the BD symptoms of depression, anxiety, guilt feelings, suspiciousness, and hallucinogenic behaviors. No association was found with mania. Conclusions Because internalized stigma has strong psychosocial and psychiatric symptom associations, it is recommended that clinicians address both societal stigma and internalized stigma. Strategies such as cognitive–behavioral therapy may help modify BD patients' internalized stigma.

Background: Self-management of bipolar disorder (BD) is challenging for many individuals. Material: Interviews were used to assess perceived barriers to disease self-management among 21 high-risk patients with BD. Content analysis, with an emphasis on dominant themes, was used to analyze the data. Results: Three major domains of barriers emerged: individual barriers (psychological, knowledge, behavioral and physical health); family/community-level barriers (lack of support and resources); and provider/healthcare system (inadequate communication and access to care). Conclusion: Care approaches providing social and peer support, optimizing communication with providers and integrating medical and psychiatric care may improve self-management of BD in this vulnerable population.

Poor medication adherence is a pervasive problem that causes disability and suffering as well as extensive financial costs among individuals with bipolar disorder (BD). Barriers to adherence are numerous and cross multiple levels, including factors related to bipolar pathology and those unique to an individual’s circumstances. External factors, including treatment setting, healthcare system, and broader health policies, can also affect medication adherence in people with BD. Fortunately, advances in research have suggested avenues for improving adherence. A comprehensive review of adherence-enhancement interventions for the years 2005–2015 is included. Specific bipolar adherence-enhancement approaches that target knowledge gaps, cognitive patterns, specific barriers, and motivation may be helpful, as may approaches that capitalize on technology or novel drug-delivery systems. However, much work remains to optimally facilitate long-term medication adherence in people with BD. For adherence-enhancement approaches to be widely adapted, they need to be easily accessible, affordable, and practical.

To directly compare the 1-year stability of Mini-Mental State Examination (MMSE) score and Saint Louis University Mental Status (SLUMS) examination score and correlate score changes with demographic variables, clinical factors, and functional domains.A sample of 304 study participants was recruited from residential and clinical settings in Ohio. Follow-up assessments were administered after 1 year with a retention rate of 92% (n = 281). Functional domains included the Instrumental Activities of Daily Living (IADL) scale.MMSE and SLUMS scores correlated with each other (r = 0.65, P < 0.001) and with two functional measures, including the IADL (r = 0.27, r = 0.24, P < 0.001). However, the MMSE and SLUMS frequently placed the same subject into different categories. Rates of reversion and conversion varied between the two tests. The 1-year changes in MMSE raw score correlated with changes in three functional domains as well as age (P < 0.05), while SLUMS raw score changes did not correlate with any functional measures.Our large, longitudinal data set allowed us to compare the tests' stability, which differed between the SLUMS and MMSE. The MMSE may be more sensitive than the SLUMS to 1-year cognitive changes influencing functional abilities.