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PURPOSE: The objective is to report outcomes of an interdisciplinary group-based residential chronic pain recovery program (CPRC), located in a private non-profit psychiatric hospital. The chronic pain program was aimed at treatment and engagement in self-care of both pain and co-occurring disorders in a residential facility that also offered treatment for specific psychiatric disorders. PATIENTS AND METHODS: A retrospective chart review was conducted that included a convenience sample of 131 patients admitted from March 2012 through August 2017 who completed treatment. An interdisciplinary team of professionals provided psycho-behavioral therapy, movement therapies and medication management. Patients completed a battery of psycho-social and demographic questionnaires on admission and before discharge of the program. RESULTS: Significant differences were noted in pain severity, pain interference, depression and anxiety (p<.01) between admission and discharge, and the Chronic Pain Coping Inventory demonstrated significant differences in guarding (p <.001), asking (p =.018), exercise (p <.001), relaxation (p <.001), and pacing (p=.024). Of patients using opioids on admission, at discharge, 37% had tapered and remained off all opioids, 43% were using buprenorphine for opioid use disorder, and 20% continued on analgesic opioids. CONCLUSION: Treatment was associated with reductions in pain severity and interference, in anxiety and in depression as well as improvements in pain coping. Additionally, there was a reduction in reliance on opioids for pain relief.

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BACKGROUND: Self-rated screening studies suggest higher prevalence rates for bipolar disorder than previously thought, but the validity of self-administered diagnostic tools has not been well established in mood-disordered patients with substance misuse. METHOD: We conducted a cross-sectional assessment of 113 English-speaking, nonintoxicated adults aged 18-69 years who were seeking treatment for mood or anxiety symptoms and substance use symptoms. (Subjects with anxiety complaints at initial presentation were included to possibly increase the pool of subjects with mood symptoms upon formal evaluation.) Subjects were consecutively evaluated from January 2010 through May 2011 at the time of voluntary admission to a private, not-for-profit psychiatric hospital. All subjects completed the Mood Disorder Questionnaire (MDQ), followed by a psychiatrist's review of their responses, using the MDQ as a semistructured interview. MDQ item and total agreements were compared for patient self-report versus clinician interview, alongside analysis of reasons for discordance. DSM-IV-TR criteria were used as the basis for diagnoses of bipolar disorder, other mood disorders, and substance use disorders. RESULTS: An MDQ positive (+) status was scored more often by subjects through self-report (56%) than by the clinician after review of subjects' MDQ responses (30%) (P < .001). Patients' self-rated MDQ(+) status had high sensitivity (0.77), modest specificity (0.52), low positive predictive value (0.38), and high negative predictive value (0.86) for bipolar I or II diagnoses. MDQ item ratings having the lowest patient-clinician concordance were irritability (κ = 0.12), racing thoughts (κ = 0.15), and distractibility (κ = 0.10), while highest concordance was observed for excessive spending (κ = 0.54), increased goal-directed activity (κ = 0.59), and hypersexuality (κ = 0.77). Patient-clinician MDQ item discordance most often resulted from patients' affirmative mania symptom endorsements during past intoxication states. Logistic regressions indicated that discordant patient-clinician MDQ total scores were significantly associated with the number of lifetime substances of abuse (odds ratio = 1.43; 95% CI, 1.02-1.99) but not with any 1 particular substance. CONCLUSIONS: Past or current substance misuse confounds the reliability of MDQ bipolar self-assessment screening. Clarification of MDQ self-rated responses via interview probing yields a more sensitive and specific indicator of likely bipolar diagnoses.

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BACKGROUND: Among substance use disorder (SUD) patients, mood instability and high-risk behaviors may suggest the presence of bipolar disorder. However, active substance abuse impedes efforts to diagnose bipolar illness validly in patients with mood complaints. METHOD: The authors retrospectively reviewed records for 85 adults admitted sequentially over a 1-year period (August 1, 2005, to July 31, 2006) to a private inpatient dual-diagnosis unit for substance abuse/dependence and mood disorders. A senior research psychiatrist conducted diagnostic interviews based on DSM-IV criteria to ascertain current and lifetime manic or hypomanic episodes during abstinent periods. RESULTS: Only 33% of subjects with suspected bipolar diagnoses (28/85) met DSM-IV criteria for bipolar I or II disorder. DSM-IV bipolar patients were significantly older (p = .029) and more likely to have made past suicide attempts (p = .027), abused fewer substances (p = .027), and were less likely to abuse cocaine (p < .001) than those failing to meet DSM-IV criteria. Inability to affirm bipolar diagnoses most often resulted from insufficient DSM-IV "B" symptoms associated with mania or hypomania (55% or 45/82), inability to identify abstinent periods for assessing mood symptoms (36%, 29/81), and inadequate durations of manic/hypomanic symptoms for DSM-IV syndromic criteria (12%, 10/84). Patients not meeting DSM-IV criteria were most often presumed to have bipolar disorder solely on the basis of the presence of mood instability, although this feature held little predictive value for DSM-IV bipolar diagnoses. CONCLUSIONS: Many patients with active SUDs who are diagnosed in the community with bipolar disorder may not actually meet DSM-IV criteria for bipolar I or II disorder. Caution must be exercised when attempting to diagnose such patients, particularly when mood instability or cocaine use is present.

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OBJECTIVE: Practice settings for American psychiatrists were examined for recent trends. METHODS: Surveys were conducted in 1996 (N=970) and 2002 (N=917) among members of the American Psychiatric Association. RESULTS: Between 1996 and 2002 the percentage of direct patient care hours in publicly funded settings increased from 40 to 50 percent for early-career psychiatrists and from 29 to 44 percent for mid-career psychiatrists. By 2002 the percentage of direct patient care hours was higher in publicly funded settings than in solo office practices for early-career psychiatrists (50 percent versus 17 percent) and mid-career psychiatrists (44 percent versus 29 percent). CONCLUSIONS: The popular image of the psychiatrist sitting in a private office does not conform with current survey data, which show that psychiatric practice is increasingly taking place in publicly funded settings. Because it extends to mid-career psychiatrists, the shift from private office practice to publicly funded settings is not just a manifestation of early-career psychiatrists' earning a salary while building up their private practices but is a more enduring change in the landscape of psychiatric practice. The authors discuss the implications of these findings with regard to professional identity and training of psychiatrists.

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