Consultation-liaison Programs Research Articles

The body of evidence of late-life depression: the complex relationship between depressive symptoms, movement, dyspnea and cognition

ABSTRACT Background Physical symptoms play an important role in late-life depression and may contribute to residual symptomatology after antidepressant treatment. In this exploratory study, we examined the role of specific bodily dimensions including movement, respiratory functions, fear of falling, cognition, and physical weakness in older people with depression. Methods Clinically stable older patients with major depression within a Psychiatric Consultation-Liaison program for Primary Care underwent comprehensive assessment of depressive symptoms, instrumental movement analysis, dyspnea, weakness, activity limitations, cognitive function, and fear of falling. Network analysis was performed to explore the unique adjusted associations between clinical dimensions. Results Sadness was associated with worse turning and walking ability and movement transitions from walking to sitting, as well as with worse general cognitive abilities. Sadness was also connected with dyspnea, while neurovegetative depressive burden was connected with activity limitations. Discussion Limitations of motor and cognitive function, dyspnea, and weakness may contribute to the persistence of residual symptoms of late-life depression.

Adapting the SAFETY-Acute Intervention to Improve Quality of Care for Suicidal Youth in Emergency Rooms and Medical Floors

ABSTRACT Hospitals and emergency departments (ED) are experiencing an increased number of youths with suicidality. Safety interventions used in the ED and on medical floors have not been systematically examined. In this paper, we present the implementation and feasibility of the brief SAFETY-Acute intervention (SAFETY-A), adapted for use by our consultation – liaison psychiatry service. SAFETY-A is a cognitive-behavioral therapy (CBT) family intervention for youth, developed for an ED setting. We implemented SAFETY-A in the ED and on medical floors to determine disposition of a patient to an inpatient hospital versus a lower level of care. We adapted SAFETY-A to use clinically with youths in the ED and medical floors at the Children’s Medical Center in Dallas, Texas. In this report we analyze clinical outcomes of SAFETY-A with patients 10–17 years old (N = 333), who presented to the ED and medical floors with suicide ideations (SI) or suicide attempts (SA). SAFETY-A proved to be feasible and acceptable based on clinicians’ reporting. Safety planning and home safety education were reported as the most effective components of the intervention. Patients who completed SAFETY-A were more likely to be recommended to lower levels of care than patients who did not complete all components of SAFETY-A. SAFETY-A implemented in our consultation-liaison service was associated with reduced inpatient referrals and disposition to a lower level of care. SAFETY-A shows positive outcomes as an acceptable and feasible intervention in a pediatric hospital consultation-liaison program.

Late life depression, postural instability and dyspnea: The He.s.i.o.d. study (Hexameter study in older depressed)

IntroductionLate life major depression (LLMD) is usually treated within primary care, but still with unsatisfactory outcomes and significant residual symptoms. Moreover, LLMD increases symptoms of anxiety, dyspnea, fear of falling (FOF), and risk of falls. Evidence from non-depressed patients suggests the efficacy of breathing and postural exercises; in particular, rhythmic breathing during poetry recitation was shown to improve cardio-respiratory synchronization. Thus, the aim of the HESIOD study was to test the efficacy of antidepressants plus breathing and postural exercises to improve patients’ anxiety mood, dyspnea, FOF, and postural stability.MethodsTwo non-randomised groups were compared: (1) antidepressant drugs plus weekly sessions of breathing/postural exercises based on the rhythmic recitation of hexameter poetry (intervention); (2) antidepressant drugs plus weekly sessions of group reading (comparator). Patients aged 65 +, with non-psychotic recurrent LLMD were recruited from a psychiatric consultation-liaison program for primary care. The main outcome measure was remission from depression (MADRS score ≤ 10) at 24 weeks. Secondary outcomes will include accelerometer-based measures of postural stability; patient-rated dyspnea, and FOF.ResultsPreliminary data on 34 patients show that patients receiving breathing and postural exercises displayed greater remission rates than those in the reading group (47.1% vs. 11.8%, P = 0.02). Further analyses will examine the effects on postural stability, dyspnea and FOF.ConclusionsBreathing and postural exercises may exert significant clinical advantage when added to the standard antidepressant drug therapy for LLMD. This study might prompt further research on innovative treatment strategies to improve the outcomes of late life depression in primary care.Disclosure of interestThe authors have not supplied their declaration of competing interest.

Physical Exercise for Late-Life Depression: Customizing an Intervention for Primary Care.

To identify which individual- and context-related factors influence the translation into clinical practice of interventions based on physical exercise (PE) as an adjunct to antidepressants (AD) for the treatment of late-life major depression (LLMD). Secondary analysis of a randomized controlled trial. Primary care with psychiatric consultation-liaison programs (PCLPs)-organizational protocols that regulate the clinical management of individuals with psychiatric disorders. Individuals aged 65 and older with major depression according to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (N = 121). Participants with LLMD were randomized to AD (sertraline) or AD plus PE (AD + PE). Participant characteristics that were associated with greater effectiveness of AD + PE (moderators) were identified, and effect sizes were calculated from success rate differences. Whether the characteristics of the study setting influenced participant flow and attendance at exercise sessions was then explored, and primary care physicians (PCPs) were surveyed regarding their opinions on PE as a treatment for LLMD. The following participant characteristics were associated with greater likelihood of achieving remission from depression with AD + PE than with AD alone: aged 75 and older (effect size 0.32), polypharmacy (0.35), greater aerobic capacity (0.48), displaying psychomotor slowing (0.49), and less-severe anxiety (0.30). The longer the PCLP had been established at a particular center, the more individuals were recruited at that center. After participating in the study, PCPs expressed positive views on AD + PE as a treatment for LLMD and were more likely to use this as a therapeutic strategy. The combination of PE and sertraline could improve the management of LLMD, especially when customized for individuals with specific clinical features. Liaison programs might influence the implementation of similar interventions in primary care, and PCPs viewed them positively.

Physical Exercise for Late-Life Depression: Effects on Heart Rate Variability

Late-life major depression is associated with increased cardiovascular risk and impaired autonomic control of the heart, as evident from reduced heart rate variability (HRV). Moreover, antidepressant drug therapy also might be associated with further reductions of HRV. In the SEEDS study, we investigated whether sertraline associated with physical exercise protocols led to improvements of HRV, compared with antidepressant drug therapy alone. Single-blind randomized controlled trial. Psychiatric consultation-liaison program for primary care. Patients aged 65-85 years with major depression, recruited from primary care. Sertraline plus structured, tailored group physical exercise (S + EX) versus sertraline alone (S) for 24 weeks. HRV indices (RR, percentage of NN intervals greater than 50 msec [pNN50], square root of the mean squared differences of successive NN intervals [RMSSD], standard deviation of heart rate [SDHR], standard deviation of the NN interval [SDNN], high-frequency band [HF], low-frequency band [LF], and their ratio [LF/HF]) were measured at baseline, week 12, and week 24. Psychiatric and medical assessments. Participants displayed significant improvements of most HRV indices over time, irrespective of the group assignment (pNN50, RMSSD, SDHR, SDNN, HF, LF, and LF/HF). Moreover, patients in the S + EX group displayed greater increases of different HRV indices(RR, pNN50, RMSSD, SDHR, SDNN, HF, and LF) compared with those in the S group. The combination of structured physical exercise and sertraline might exert positive effects on the autonomic control of the heart among older patients with major depression.

Pedagogical Implications of Partnerships Between Psychiatry and Obstetrics-Gynecology in Caring for Patients with Major Mental Disorders

Because there are no formal reviews, the authors set out to identify and describe programs that serve female patients with major mental disorders by integrating mental health care with services in obstetrics and gynecology and to describe the pedagogical implications of those programs. The authors searched PubMed for all articles describing a program in which psychiatry was formally integrated with obstetric or gynecological services, other than standard consultation-liaison programs, in the care of patients with major mental disorders. The search terms used included interdisciplinary, interprofessional, integrated, collaborative care, psychiatry, and obstetrics-gynecology or psychosomatic obstetrics-gynecology. The authors found six distinct integrated programs. These included family planning clinics that were integrated into inpatient psychiatry services; inpatient and outpatient psychiatry services for pregnant mentally ill women in close collaboration with obstetric services; a day hospital for pregnant women with psychiatric disorders in an obstetric setting; an interdisciplinary training site providing care for predominantly depressed, low-income, and minority women; a primary care HIV service for women integrated with departments of obstetrics-gynecology and psychiatry; and an obstetrics-gynecology clinic-based collaborative depression care intervention for socially disadvantaged women. Residents' involvement was described in four of the programs. These innovative and integrated programs potentially enhance the care of vulnerable and culturally diverse women with major mental disorders. The authors discuss how these programs may contribute to the education of residents in psychiatry and obstetrics-gynecology.

Inpatient pediatric psychology consultation-liaison program development: 5-year practice patterns and implications for trends in health care.

Inpatient pediatric psychology consultation-liaison program development: 5-year practice patterns and implications for trends in health care.

Philanthropist Endows Chair in C-L Psychiatry

Back to table of contents Previous article Next article Professional NewsFull AccessPhilanthropist Endows Chair in C-L PsychiatryMark MoranMark MoranSearch for more papers by this authorPublished Online:15 Apr 2005https://doi.org/10.1176/pn.40.8.00400009A $5 million gift from Sidney E. Frank, founder and chair of the Sidney Frank Importing Company, will endow a new distinguished professorship in psychiatry and behavioral sciences at New York Medical College.The Sidney Frank Distinguished Professorship in Psychiatry and Behavioral Sciences has been filled by Michael Blumenfield, M.D., who is a professor of psychiatry, medicine, and surgery at the college.“It is my desire that this gift reflect my commitment to and my admiration for New York Medical College,” said Frank in a statement.“ It is a vote of confidence in Dr. Blumenfield and the entire psychiatry department. I am proud to have my name aligned with their good works, and I look forward to the outcomes of the Sidney Frank Distinguished Professorship program.”Former APA President Joseph T. English, M.D., who is professor and chair of the department of psychiatry and behavioral sciences at New York Medical College, told Psychiatric News that the donation will support a variety of new educational programs for psychiatry residents and medical students, particularly in the area of consultation-liaison psychiatry.“One of Mr. Frank's objectives is that patients in general hospital services who have psychiatric disorders receive excellent care,” English said. “Dr. Blumenfield is responsible for our consultation-liaison programs and will have his teaching and clinical activities greatly enhanced by virtue of the gift. But most of all, Mr. Frank's appreciation of what psychiatry has to offer patients will lead others to support good care, teaching, and research by virtue of his extraordinary generosity.”Among the programs that will be supported by the donation are a fellowship program in psychosomatic medicine, a summer internship program in the department for students completing their first year of medical school, a visiting professorship exchange program between New York Medical College and outstanding international medical universities, a research fund to encourage young investigators within the department of psychiatry to explore important areas of their research, and another fund to support underinsured patients so they can receive proper diagnostic services and short-term psychotherapy.The Sidney Frank Importing Co. Inc. is the creator of Grey Goose Vodka and an importer of a number of popular brands of liquor including Jägermeister Liqueur, Corazón Tequila, and Gekkeikan Saké.According to the company's Web site, Frank was born in Norwich, Conn., and attended Brown University before heading to Asia, where he represented Pratt and Whitney Motors during World War II. Upon his return to the United States in 1945, Frank found work with Schenley Distillers, where he was responsible for the success of such brands as Dewar's White Label and Ancient Age.Today Frank, an avid golfer and art collector, lives in New Rochelle, N.Y., with his wife, Marian. He has two children and five grandchildren.He is chair of the board of the Sidney and Louise Frank Foundation and is active in a variety of professional, cultural, and charitable organizations. He has donated money to Brown University, the American Heart Association, and the White Plains Hospital Center, among other institutions.A press release about Sidney Frank's donation is posted online at<www.nymc.edu/depthome/pr/NR2005/03-04-05.asp>.▪ ISSUES NewArchived

Financing of Child Psychiatry Pediatric Consultation-Liaison Programs

Child psychiatrists and pediatricians recognize the importance of providing psychosocial care for children and their families in medical settings. Consultation-liaison and behavioral pediatric programs provide most of the training in this area. Twenty-nine pediatric consultation-liaison program directors participated in an initial and follow-up telephone survey about their programs. In the 5 years between the surveys, there was a drastic reduction in federal funding for these programs. The findings include a change in the number and composition of both staff and trainees. There were major shifts in the financial support of the programs. The programs were involved in fewer activities and in more restricted settings at the time of the follow-up survey. Financing of pediatric consultation-liaison programs plays a major role in shaping the structure and function of the programs.

Future directions in consultation-liaison psychiatry.

Consultation-liaison psychiatry in the United States has had to reassess its priorities with the change in health care economics in the 80 s. Liaison programs and educational programs for primary care staff are jeopardized. The emphasis has shifted from liaison to reimbursable consultation activities. Hospital stays are shorter with emphasis on outpatient and prepaid settings. Less expensive health care professionals are often asked to see patients previously evaluated by psychiatrists. This paper will discuss the need for focused cost-effective liaison services in this climate. Funding strategies for consultation-liaison programs, models of staffing consultation-liaison services, continuity of care from inpatient to outpatient services, integration of consultation-liaison psychiatrists in prepaid health care settings, primary-care educational programs, and psychosocial intervention programs for high-risk primary-care patients will be discussed.

Psychiatry and primary care: Can a working relationship develop?

This article explores the relationship between psychiatrists and primary care physicians. Expectations and results of attempts to train nonpsychiatric physicians in the care of the mentally ill are reviewed. The failure of this effort, along with the stigma against psychiatry has led to poor treatment of disturbed patients by primary care physicians. Using other mental health professionals as both educators and clinicians in primary care training programs over the past 20 years has resulted in a different referral pattern system for the mentally ill than for any other group of patients. Although the gap between psychiatry and the rest of medicine has widened, there are models of interaction and cooperation that are explored. The development of consultation-liaison programs has been a most important effort. The need for all of medicine to recognize the relationship between mind and body is stressed.

Making the case for consultation-liaison psychiatry: Issues in cost-effectiveness analysis

There is an increasing need to rationally allocate scarce resources to improve the efficiency of health care and reduce costs. Evidence suggests that consultation-liaison psychiatry has important clinical and economic benefits. This article defines cost-effectiveness and cost benefit analyses, describes basic principles for CEA and in that context critiques recent literature relevant to consultation-liaison psychiatry, and discusses potential contributions and dangers that such studies might offer. There is a need within the health care field for systematic and sophisticated decisions by policy makers. Well designed and comprehensively analyzed studies of the cost-effectiveness of consultation-liaison programs will not only contribute toward advancing the field of consultation-liaison psychiatry but also toward informing the decisions of health policy makers.

Psychiatric consultations at the NIH

The history of the consultation-liaison psychiatry movement in America is briefly reviewed. Evaluation of a consultation-liaison program in a research hospital setting at NIH is described in the context of the historical paradigm.

Consultation-liaison psychiatry and funding: Why can't alice find wonderland?

Consultation-liaison psychiatry programs have long suffered from a lack of direct financial support. In this article, the authors report on the various mechanisms that the surveyed consultation-liaison programs use to obtain funding and present a review of research findings demonstrating the cost effectiveness of liaison psychiatry in offsetting more expensive medical expenditures.

Teaching medical gerontology

This is a report of a pilot project designed to explore the feasibility of using the clinical Adult Service Psychiatry Consultation-Liaison Program at the University of Michigan as the locus for teaching medical gerontology to psychiatric and medical/surgical house officers and medical students. The goals, general techniques, educational content, and implementation procedures are described. Evidence was obtained that teaching medical gerontology through the program is both feasible and effective. Since a nonphysician gerontologist implemented the clinically based teaching program, the project is an example of the possibilities inherent in a multidisciplinary clinical teaching program.

Incorporation of Gerontology into Medical Education

Despite the increasing importance of gerontology to medical practice, it has been difficult to incorporate it into the curriculum of most medical schools. The aim of this project was to explore the feasibility of introducing gerontology into medical education by utilizing the framework of an existing clinical program. A gerontologist used the structure and resources of a Psychiatry Consultation-Liaison Program for this purpose. Three groups of target trainees were identified: psychiatry residents on their Liaison rotation; junior medical students on their psychiatry clerkship; and medical-surgical house officers in the general hospital. The objectives were to impart didactic information and to counteract negative attitudes leading to disinterest in evaluating and treating the elderly. The results indicated a positive impact on all three trainee groups, and a diffusion of the gerontologic innovation from the initial locus of a clinical sub-unit into the medical center and the medical school.

Handbook of Psychiatric Consultation

With a wide theoretical scope and down-to-earth practical suggestions on the consultation process, this Handbook describes many different clinical situations, including consultations to agencies. It is a scholarly, general, and yet detailed guidance for the psychiatric consultation. It is often didactic, with explicit directions about procedures, techniques, possible dangers, and mistakes. As Henry Brosin states in his foreword, this volume becomes a true handbook, as it is called in the title, as well as a specialty text. There are sections on the fundamentals of the consultation process and useful chapters on diagnosis and management. There are also sections on the special aspects of consultations with surgeons, pediatricians, and community services. A teaching program is outlined in detail, as is a consultation liaison program. The guidance to the literature is thoroughgoing and carefully prepared. Dr. Schwab has attempted a comprehensive task, and he has succeeded in furnishing us with a text