Divide on When to Start Anti-Psychotic LAIs; Restraint Toll; Wilderness Tx Failures

LONG BEACH, Calif. — Notable studies presented at the American Psychiatric Nurses Association (APNA) annual meeting included posters on the divide among clinicians on the appropriate time to begin treatment with long-acting injectable anti-psychotics (LAIs), the toll that use of restraint on children and adolescents takes on psychiatric nurses, and the failure of teen wilderness therapy programs to adjust or monitor for psychiatric medications.

Divide Over Best Practices for LAIs

LAIs have revolutionized the treatment of schizophrenia in recent years by allowing clinicians to offer therapies that last for weeks instead of a day. However, a new survey suggested that there’s disagreement among clinicians on the best time to start them, reported Donna Rolin, PhD, APRN, of the University of Texas at Austin, and colleagues, in a poster presentation.

Among 156 clinicians surveyed via email, 35% of whom were psychiatrists and 32% of whom were psychiatric-mental health advanced practice registered nurses (APRNs), 50% of APRNs said LAIs would be offered after the first psychotic episode and 35% said they would be offered after the first relapse compared with approximately 42% and 40% of non-APRNs.

About 12% of both groups said they’d be offered after two to three relapses.

APRNs also said they were less likely to have experience with LAIs in general (16% vs 3% of non-APRNs, P=0.002).

“Attitudes were generally positive about LAIs across the sample,” noted Rolin and colleagues, who added that “prescribers should consider offering LAIs as a standard practice anytime an oral anti-psychotic is considered, which could include the first episode of an illness.”

Psychiatric Nurses Bear Heavy Burden in Restraint Cases

Among 10 child and adolescent psychiatric nurses interviewed, none reported being offered support after a situation in which a patient had to be restrained, even though they all said they looked after their fellow staff members following these high-stress moments.

In fact, when asked if anyone inquired about how they were doing after these encounters, all 10 nurses “looked surprised,” according to Valerie Seney, PhD, of the University of Massachusetts Dartmouth, in a poster presentation.

According to one nurse, “I’m always the one who asks if everybody else is okay.” Another said that during restraint incidents, “you disconnect from the kid. You no longer are thinking about the trauma or the kid’s emotions. You certainly are not thinking about yourself and what you may be feeling. You are just thinking, ‘I need to get this kid under control for his safety and the staff.'”

Two nurses reported crying later — one “sobbing all the way home” while driving, and another who “just started crying” while with her kids.

For the qualitative study, Seney conducted 30- to 60-minute interviews with the 1o nurses. She identified three themes: “A lack of time to reflect emotionally, a shutting down of emotions to deal with the restraint process, and delayed response to moral distress.”

“Leadership must take the time and develop programs/tools that address the nurse’s perceptions, emotions, and strain and highlight taking time for self-care in order to prevent burnout and fatigue,” she concluded in the poster.

Wilderness Therapy Programs Lack Medication Monitoring

For decades, American teenagers with behavioral or substance abuse problems have been sent to “wilderness therapy” programs with boot camp-style approaches to discipline. The programs have long been controversial, with critics linking them to abuse and deaths.

Of 34 wilderness programs surveyed, 66% “do not provide adjustment or monitoring for psychiatric medications,” reported Kathy Cozonac, MSN, of the Duke University School of Nursing in Durham, North Carolina, in a poster presentation.

Furthermore, more than three-quarters of the surveyed programs were for-profit, and only 3% accepted insurance. The average cost to complete a program was $30,000 to $70,000, and 38% had no accreditation.

For most, wilderness therapy “is an expensive stop on the way to residential therapy,” Cozonac wrote in the poster. “It requires complete trust from families, but it does so without the safety net of careful oversight. Quality of programs varies widely, and significant safety failures have caused injury and death. Robust legislation is needed to protect participants.”