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The emergence of the 2019 novel coronavirus (COVID-19) has dramatically altered how psychologists deliver its training. At least for the time being, virtual care has become the primary method for delivering mental health services. This has allowed patients and clinicians to continue to access and provide services in a way that would have been impossible years ago. Not only has this shift impacted patients, but it has also impacted supervision and training. The impact has been especially profound on inpatient units where the psychiatric and medical acuity is high of patients and the therapeutic milieu is an important aspect of treatment. The purpose of this paper is to review the impact of COVID-19 on pre-doctoral psychology interns during their rotation on an inpatient psychiatry unit at the start of the pandemic (January to June of 2020) and use these experiences to onboard the next class of interns in the new academic year (July 2020 to June 2021) using a hybrid model of in-person and virtual training experiences. At the end of 2020/2021 rotation, we voluntarily asked interns to complete a questionnaire that was developed based on the qualitative experiences of the previous class to assess the effectiveness of this hybrid model. We also surveyed multi-disciplinary staff members who were essential personnel and required to work in person during this time about their experiences of safety and support. With this information, we explore and offer guidance to other inpatient training sites who are likely to encounter similar challenges during this time. In particular, we discuss the integration of virtual technology into this training experience, as well as the restructuring of clinical and supervisory experiences. We highlighted several short-term strategies that we have flexibly adapted to our inpatient unit. The lessons learned herein seek to guide supervisors and trainees alike in adapting their psychology training programs to meet the evolving demands of COVID-19.

We still have little understanding of short-term predictors of suicidal thoughts and behaviors (STBs). Prior research links increased negative affect to STBs, but the vast majority of earlier work is limited by measuring negative affect at one time point and aiming to predict STBs months or years in the future. Recently, intensive longitudinal studies have shown that negative affect is associated with suicidal thoughts over relatively short, clinically useful time periods; however, the specific patterns and types of negative affect that predict STBs remain unclear. Using ecological momentary assessment (EMA) data from psychiatric inpatients hospitalized for suicide risk (n = 83), this study sought to test whether the patterns (means and variability) of two types of negative affect (anxiety/agitation and shame/self-hatred, which were derived from a larger EMA battery) during hospitalization predict STBs in the 4 weeks after discharge: an extremely high-risk time for suicidal behavior. The mean—but not the variability—of both anxiety/agitation and shame/self-hatred during hospitalization predicted the number of days with suicidal thoughts after discharge. The mean and the variability of shame/self-hatred—but not anxiety/agitation—predicted post-discharge suicide attempt. We discuss implications for assessment and treatment of suicidal individuals and propose key directions for future research. SUPPLEMENTARY INFORMATION: The online version contains supplementary material available at 10.1007/s42761-021-00058-6.

Involuntary psychiatric treatment may parallel ethnoracial inequities present in the larger society. Prior studies have focused on restraint and seclusion, but less attention has been paid to the civil commitment system because of its diversity across jurisdictions. Using a generalizable framework, this study investigated inequities in psychiatric commitment.A prospective cohort was assembled of all patients admitted to an inpatient psychiatric unit over 6 years (2012-2018). Patients were followed longitudinally throughout their admission; raters recorded legal status each day. Sociodemographic and clinical data were collected to adjust for confounding variables by using multivariate logistic regression.Of the 4,393 patients with an initial admission during the study period, 73% self-identified as White, 11% as Black, 10% as primarily Hispanic or Latinx, 4% as Asian, and 3% as another race or multiracial. In the sample, 28% were involuntarily admitted, and court commitment petitions were filed for 7%. Compared with White patients, all non-White groups were more likely to be involuntarily admitted, and Black and Asian patients were more likely to have court commitment petitions filed. After adjustment for confounding variables, Black patients remained more likely than White patients to be admitted involuntarily (adjusted odds ratio [aOR]=1.57, 95% confidence interval [CI]=1.26-1.95), as were patients who identified as other race or multiracial (aOR=2.12, 95% CI=1.44-3.11).Patients of color were significantly more likely than White patients to be subjected to involuntary psychiatric hospitalization, and Black patients and patients who identified as other race or multiracial were particularly vulnerable, even after adjustment for confounding variables.

Suicide is among the most devastating problems facing clinicians, who currently have limited tools to predict and prevent suicidal behavior. Here we report on real-time, continuous smartphone and sensor data collected before, during, and after a suicide attempt made by a patient during a psychiatric inpatient hospitalization. We observed elevated and persistent sympathetic nervous system arousal and suicidal thinking leading up to the suicide attempt. This case provides the highest resolution data to date on the psychological, psychophysiological, and behavioral markers of imminent suicidal behavior and highlights new directions for prediction and prevention efforts.

The practice of therapeutic skills outside of sessions in which they are learned is one presumed key component of cognitive behavioral therapy (CBT). Yet, our understanding of how skills practice relates to clinical outcomes remains limited. Here, we explored patients’ emotional responses to CBT skills practices in a pilot study pairing smartphone app-delivered skills reminders and guided practice (ecological momentary intervention [EMI]) using ecological momentary assessment (EMA). Participants (n = 25) were adults recently hospitalized for a suicide attempt or severe suicidal thinking. They received brief inpatient CBT (1 to 3 sessions covering core CBT skills from the Unified Protocol), followed by one month of EMI and EMA after discharge. On average, participants reported modest reductions in negative affect after skills use (i.e., immediate responses; median time elapsed = 4.30 minutes). Additionally, participants tended to report less negative affect when the timepoint preceding the current assessment included EMI skills practice, rather than EMA alone (i.e., delayed responses; median time elapsed between prompts = 2.17 hours). Immediate effects were unrelated to longer-term clinical outcomes, whereas greater delayed effects were associated with lower symptom severity at follow-up. Future studies should further examine how CBT skills use in daily life may alleviate symptoms.

Patients suffering from borderline personality disorder (BPD) are at elevated risk for suicidal thoughts and behaviors (STBs), but this well-described and clinically important association is not well-understood. Prior research suggests that STBs often function as an attempt to escape aversive affect, and that people with BPD experience stronger emotion reactivity and greater discomfort with emotion than those without BPD. Here, we tested whether negative affective states are more likely to predict suicidal thoughts among those with BPD than those without this disorder. Data on affective states and suicidal thoughts were collected several times per day from 35 psychiatric inpatients using their smartphones to capture real-time associations between negative affect and suicidal thoughts. Results revealed that the association between negative affective states (e.g., abandonment, desperation, guilt, hopelessness, loneliness, rage, self-hatred, and upset), and severity of suicidal thinking was stronger among those with BPD than among those without BPD. This finding has implications for risk assessment and intervention in the clinical setting: for a given degree of reported negative affect, patients with BPD experience more suicidal ideation than those without. Further research needs to be done to elucidate the mechanism of this effect.

This commentary, which presents an expanded version of the keynote address at the 2012 Conference on ‘Global Climate Change Without the United States’, outlines Palau’s role in attempting to motivate international action on climate change. It explains two initiatives: the passage of a United Nations (UN) General Assembly resolution highlighting the security implications of climate change, and the attempt to obtain an advisory opinion from the International Court of Justice on the responsibility of states for climate change. The two avenues are located ‘inside the system’ in that they target well-established organs of the UN system. However, they are ‘outside the box’ because they seek to bypass and ultimately jump-start the international negotiation process that has unfolded under the auspices of the UNFCCC.

Variations in streamflow at falls and cascades can create transitory barriers to upstream passage of adult anadromous salmonids. In this study, we evaluated the ability of six anadromous salmonids (coho salmon Oncorhynchus kisutch, pink salmon O. gorbuscha, chum salmon O. keta, sockeye salmon O. nerka, Chinook salmon O. tshawytscha, and steelhead O. mykiss) to pass five sets of falls or cascades within Ward Creek, Alaska, a stream regulated by Connell Dam. The study focused on determining suitable instream flow releases to afford passage. Each set of falls was surveyed under three flow conditions (about 0.91, 1.34, and 3.0 m3/s), and access portals were identified. Using computed stage—discharge relationships and published swimming and jumping criteria, we evaluated the falls barrier potential over a range (0.23–11.33 m3/s) of flows. Analysis indicated pink salmon and chum salmon would be relegated to the area below the lower two falls. Flows affording passage over all five falls for the other sp...

Floodwater is often extracted for consumptive purposes from western mountain streams in the United States. The long-term extraction of floodwater may alter the morphological and ecological balance of such streams. Scale model experiments based on eight mountain gravel-bed streams in Idaho were conducted to test the effects of floodwater extraction on stream morphology. The model channel transported a poorly sorted mix of model "gravel," as well as copious amounts of model "sand." The channel had a discontinuous floodplain, developed its own bar morphology, and contained large model colluvium as well as a bedrock platform. A mobile-bed equilibrium was first developed using a repeated hydrograph. The experiment was then repeated using a sliding cutoff discharge. The discharges in the hydrograph that were below a given cutoff discharge were reduced to 30% of bankfull discharge. By raising the cutoff discharge, it was possible to study the effect of increasing severity of floodwater extraction on stream morphology. The experiments indicated an increase in sand content on the bed surface and a decrease in the standard deviation of fluctuations in bed elevation with increasing severity of floodwater extraction.

Although antipsychotic polytherapy is considered appropriate in limited circumstances (e.g., during a brief "cross-titration" period when switching medications), its increasing prevalence indicates use beyond this limited scope. Despite absence of support in the medical literature and higher costs, antipsychotic polytherapy is common in the treatment of schizophrenia and related disorders. The highest utilization of antipsychotic polytherapy occurs on psychiatric inpatient units, and in 2008, the Joint Commission released the first set of 7 hospital-based inpatient psychiatric services (HBIPS) core measures, 2 of which assess antipsychotic polytherapy at time of discharge.To describe the effect on antipsychotic polytherapy at time of discharge of a 2-part quality improvement program composed of educational seminars and prescriber-specific feedback provided to 11 psychiatrists in 4 acute inpatient psychiatric units in 2 hospitals.In a regional academic health care system, we determined the prevalence of antipsychotic monotherapy and polytherapy at time of discharge for all patients discharged on standing antipsychotic medications during 3 periods: (a) a 3-month baseline period (August 2006 through October 2006); (b) in July 2007, after delivery of 4 educational luncheon seminars to 11 psychiatrists from November 2006 through June 2007; and (c) in June 2008, following the provision of monthly prescriber-specific audit feedback from August 2007 through June 2008. To prepare nurses for the change and address possible safety concerns, an educational module was delivered to the psychiatric nursing staff at "best practice" day lectures held in the first quarter of 2007. General themes in the educational presentations included literature-based reviews of (a) safety and efficacy of antipsychotic polytherapy, (b) medical risks of antipsychotic medications, (c) specific versus nonspecific effects of these medications, and (d) effectiveness of first- versus second-generation antipsychotic medications. The prescriber-specific audit feedback was provided in paper form and masked the identity of the other prescribers. The chief of service reviewed audit feedback individually with each psychiatrist on a quarterly basis. The primary outcome measure was the percentage of patients prescribed 2 or more antipsychotics at discharge. A secondary outcome measure was the percentage of patients prescribed 3 or more antipsychotics at discharge. Differences in the primary outcome measure, comparing (a) July 2007 with the baseline period and (b) June 2008 with July 2007, were analyzed using Fisher's Exact tests. The Cochran-Armitage test for trend was used to assess the relationship between the primary outcome measure and the extent of the intervention, measured as the 3 time periods. For the secondary outcome measure, the Goodman-Kruskal gamma test for ordered categorical data was calculated to examine the association between the the proportion of patients receiving 1, 2, or 3 or more antipsychotics at discharge and the 3 time periods.The percentage of patients prescribed 2 or more antipsychotics at discharge declined from 33.9% at baseline (132 of 389 patients), to 21.8% after delivery of the educational modules (44 of 202 patients, P = 0.002), and to 12.2% after audit feedback (18 of 147 patients, P = 0.023; Cochran-Armitage test for trend P0.001). When antipsychotic use was classified as 1, 2, or 3 or more antipsychotic medications, more extensive intervention was associated with decreased combination use (Goodman- Kruskal gamma = 0.39, P0.001). In the baseline period, 5.9% of patients were prescribed 3 or more antipsychotics at discharge. Following completion of the educational and audit components, respectively, the proportion of patients prescribed 3 or more antipsychotics declined to 2.5% and then to 0.0%.Educational modules presented to psychiatrists and nurses in group settings were associated with a decrease in the rate of prescribing 2 or more antipsychotics at discharge from acute psychiatric inpatient units. Addition of monthly audit feedback provided to psychiatrists was associated with further decreases.

This case, a composite drawn from clinical experiences, is designed to present a growing challenge in inpatient care. Specifically, patients presenting with symptoms that require hospitalization ha...

This paper describes data broadcasting from the perspective of broadcasters who have experimented with it. Valuable suggestions for implementation including cost estimates and technical alternatives are covered. Several opportunities for broadcasters seeking to implement this capability are outlined

A study was conducted to develop flushing flow recommendations for maintaining the quantity of salmonid spawning gravels in the North Fork of the Feather River, a regulated stream in California, U.S.A. This required the development of a technique which would prescribe flows to remove sediments from the gravels without removing the gravels themselves, which are in finite supply in the river. Field studies involved the use of a ‘two-point-are’ procedure which allowed depth, velocity, and substrate measurements to be concentrated over spawning gravels at each site. Measurements were repeated at each site at three different flows ranging from 1.7 to 11.3 m3 s−1. The local velocity and depth measurements were used to evaluate hydraulic conditions within areas containing spawning gravels. Four flow levels were derived which would provide varying degrees of sediment transport and flushing; (1) surficial flushing of gravels; (2) mobilization of gravels; (3) surficial flushing of cobbles; and (4) mobilization of cobbles. Results of the study indicated a flushing flow of 56.6 m3 s−1 occurring as a planned release or natural flow for from 1–3 days would be sufficient to transport sediment from spawning gravels. This flow was intermediate to levels which maximize surficial gravel flushing and levels which maximize surficial cobble flushing.

The BM-Test-Glycemie 1-44 test strip facilitates self-monitoring without the use of a photometer. In a population of 33 diabetic patients (age 24.8 +/- 2.9 years) 94% took part in home monitoring for 6-10 months. Of 29 who answered a questionnaire 25 preferred blood glucose testing to urine testing. In a "beta-cell school" it was taught that it is rational if home monitoring of blood glucose is combined with a tailored insulin treatment consisting of long-acting insulin (Ultralente) as a basal insulin and regular insulin (Actrapid) as a meal insulin. In a group of 24 labile diabetic patients 17 preferred this regime compared to earlier use of intermediate acting insulin and regular insulin. Six of these preferred the regular insulin to be taken in three doses. Hypoglycemia, when it occurred, was less distressing in symptoms than previously. Among patients with recent onset of diabetes active participation with dose reduction was seen during the honey-moon stage. The regime is logical and generative, offers a basis for an individualized therapy and a high remission frequency may be expected.