Consultation-liaison Psychiatrists Research Articles

Developing a Clinical Pathway for Somatic Symptom and Related Disorders in Pediatric Hospital Settings.

Somatic symptom and related disorders (SSRDs) are commonly encountered in pediatric hospital settings. There is, however, a lack of standardization of care across institutions for youth with these disorders. These patients are diagnostically and psychosocially complex, posing significant challenges for medical and behavioral health care providers. SSRDs are associated with significant health care use, cost to families and hospitals, and risk for iatrogenic interventions and missed diagnoses. With sponsorship from the American Academy of Child and Adolescent Psychiatry and input from multidisciplinary stakeholders, we describe the first attempt to develop a clinical pathway and standardize the care of patients with SSRDs in pediatric hospital settings by a working group of pediatric consultation-liaison psychiatrists from multiple institutions across North America. The authors of the SSRD clinical pathway outline 5 key steps from admission to discharge and include practical, evidence-informed approaches to the assessment and management of children and adolescents who are medically hospitalized with SSRDs.

“Professionalism, Physicianhood, and Psychiatric Practice”: Conceptualizing and Implementing a Senior Psychiatry Resident Seminar in Reflective and Inspired Doctoring

Professionalism, although broadly acknowledged to be an important goal of medical education, needs to be taught well. We describe the content selection and structure of an elective professionalism seminar for advanced trainees in psychiatry at the Massachusetts General Hospital. We critically evaluate the curriculum content based on participant feedback. We successfully implemented and sustained for 8 years a monthly, 10-session professionalism seminar for advanced trainees in psychiatry. The average number of participants was 4-8 residents or fellows out of a possible 12-16. The curriculum covers 3 broad domains: physicianhood, bioethics, and medical/psychiatric practice. Participants felt that they were more reflective of their practice and that were given a vocabulary to do so. Physician burnout emerged as a key professional concern. Professionalism can be taught in a seminar but requires reaching to other disciplines (history of medicine, philosophy, and sociology) to make it meaningful and utile. Consultation-liaison psychiatrists through their interdisciplinary and team-based work are ideally situated to teach professionalism that emphasizes commonalities of psychiatry with the other medical specialties and fosters leadership.

Psychiatric Disorders in Complex Regional Pain Syndrome (CRPS): The Role of the Consultation-Liaison Psychiatrist.

Background Complex regional pain syndrome (CRPS) is a multifactorial disorder with complex aetiology and pathogenesis. At the outpatient pain clinic of Magdeburg University Hospital, all patients, without exception, are subject to permanent psychiatric care delivered by a consultation-liaison psychiatrist. In CRPS, psychological stabilization and treatment of the neuropathic aspects are equally important. The aim of this single-center retrospective study was to determine mental/psychiatric defects impairing pain processing at the time of investigation and show the effects of treating mental disorders and neuropathic pain with the same psychotropic drugs. Method On admission, the consultation-liaison psychiatrist examined the mental state of every patient in a semistructured interview according to AMDP (working group for methods and documentation in psychiatry). Due to the model of the Department of Anaesthesiology, we are able to compare the group of CRPS patients with all other outpatients treated for pain. Results The medical treatment of psychiatric dysfunction leads to an analgesic effect. Only every second CRPS patient had an additional psychiatric diagnosis, and 15.6% were diagnosed with depressive mood disorders and show a higher prevalence of depressive symptoms than the general population and exceed the mean for all patients treated in our pain clinic. Conclusions In neuropathies, treatment of the neuropathic pain has a modulating effect on mental disorders. As CRPS patients are frequently affected by depressions, and owing to the connection between depression and suicidal tendencies, patients should be seen by a consultation-liaison psychiatrist, and nonpsychiatrists should pay special attention to this patient group.

Consultation-liaison psychiatry and physician-assisted death.

Consultation-liaison (C-L) psychiatrists are involved in physician-assisted death (PAD) teams in many permitting jurisdictions. This paper will describe our Canadian PAD experience over 2 years, highlighting the role of C-L psychiatrists, at a large hospital network that provides medical assistance in dying (MAID, as this is called in Canada). We will describe the Canadian criteria for MAID, our multispecialty MAID team experience and the roles, issues and concerns experienced by C-L psychiatrists. Some brief patient examples will be provided. Our MAID team has managed 186 MAID inquiries, assessed 95 MAID requests and provided 49 MAID interventions over a 24 month period. The 2 co-leaders of the MAID team, 8 assessors and 1 intervention physician are C-L psychiatrists. Each of the MAID criteria: grievous medical condition, advanced state of irreversible decline, intolerable suffering, natural death reasonably foreseeable, voluntary request, capacity and informed consent pose specific challenges to be resolved in the assessment. Several unique MAID issues, including the role of education and mandatory psychiatric assessment and protocols will also be discussed. Our experience shows that C-L psychiatrists are well-situated to provide vital expertise and leadership to multispecialty PAD teams.

Validation of the Stanford Proxy Test for Delirium (S-PTD) among critical and noncritical patients

BackgroundThe Stanford Proxy Test for Delirium (S-PTD) is a tool developed to be completed by nurses at the end of their shift. It was designed to use the knowledge acquired during a full shift of nurse-patient interaction. The objective of our study was to validate the S-PTD among a mixed sample of patients in both the intensive care unit (ICU) and non-ICU settings. MethodsA cross-sectional study was conducted in an ICU and three general medical wards in a tertiary care hospital. Patients were independently and blindly assessed for delirium by (1) the patients' primary nurses using the S-PTD at the end of their shift, and (2) a Consultation liaison psychiatrist who conducted a neuropsychiatric evaluation based on the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). ResultsA total 288 patients were included in current analysis. Using the S-PTD, delirium was identified in 72 (25.0%), while an expert neuropsychiatric examination, based on DSM-5 identified delirium in 75 (26.0%) patients. This study demonstrated that the S-PTD has very strong discriminative ability (area under the curve= 0.946, p<0.001). An S-PTD cut-off score ≥3 was associated with an 82.7% sensitivity, an 95.3% specificity, an 86.1% positive predictive value, a 94.0% negative predictive value, and a 92.0% overall diagnostic accuracy. These results were similar in both ICU and general ward patients. ConclusionThe S-PTD has excellent sensitivity and specificity in detecting delirium in both ICU and ward patients, even when compared with the gold-standard, a DSM-based neuropsychiatric examination.

Competency Is Key in Autonomy Regarding End-of-Life Care Decisions

Back to table of contents Previous article Next article Professional NewsFull AccessCompetency Is Key in Autonomy Regarding End-of-Life Care DecisionsMark MoranMark MoranSearch for more papers by this authorPublished Online:6 Jun 2018https://doi.org/10.1176/appi.pn.2018.5a26AbstractCase law and research on the desire to die by patients with terminal illness points to a role for psychiatrists who are consulting on or treating patients with terminal illness that may be far more nuanced than traditionally understood. Ellen DallagerOutlining that evolution during a symposium at APA’s 2017 Annual Meeting in San Diego, Rebecca Brendel, M.D., J.D., a consultant to APA’s Ethics Committee, cited as crucial the 1990 Supreme Court case Cruzan v. United States, establishing that patients have broad rights of self-determination that extend to end-of-life care, and the subsequent passage of the 1990 Patient Self-Determination Act. In those two landmark cases, patient autonomy emerged as one cornerstone in the patient’s right to make end-of-life care decisions or to designate a health care proxy to do so. “Since a patient’s competency to make decisions is central to autonomy, consultation-liaison psychiatrists became involved in this—not just because these were for the most part medically ill patients in the hospital, but because we are used to doing capacity evaluations on a daily basis for all kinds of medical questions,” Brendel said. Predictably, discussion about end-of-life care options would be extended from withholding and withdrawing treatment to more affirmative plans by patients to determine the timing and manner of one’s death. In 1997, Oregon passed the Death With Dignity Act, the first state to make it legal for physicians to prescribe a lethal dose of medication to a terminally ill patient wishing to end his or her life. Meanwhile, research on the desire to die by patients with life-threatening illness was evolving. A significant body of early research in consultation-liaison psychiatry (primarily with cancer patients) appeared to establish that a desire to die was highly correlated with treatable major depression. This work was pioneered by, among others, consultation-liaison psychiatrists William Breitbart, M.D., Linda Ganzini, M.D., and Jimmie Holland, M.D.Brendel said three essential points stand out from that work:The difference between patients with advanced cancer who had a desire to hasten death and those who did not was depression.If these patients were treated for depression, they no longer desired to hasten their death.People with depression made more restrictive advance directives about what they would want done for them at the end of life than those who were not depressed, and if their depression was treated, they would reverse those restrictive advance directives.However, the picture regarding the relationship between depression and all desires to die began to appear less clear, she said, among patients with neurodegenerative disease (such as amyotrophic lateral sclerosis) who may be able to say at what point in their disease they would like to die, but who may not necessarily be depressed. Also variable and complex are patients with spinal cord injury. “If you talked to newly quadriplegic patients in the period immediately following the spinal cord injury, there was a high desire to die early on and a recognition, for those patients who were ventilator-dependent, that they could make that decision not to be on life-sustaining treatment,” Brendel said. “The problem with that is that if you look at them a year later and talk to these patients about what their quality of life is, they will still physically not be what they were [prior to the injury], but they will tell you, on average, that their quality of life is much higher in many, if not most, respects than it had been prior to their injury.”Now, with data from states such as Oregon that permit physician-assisted death, it has become even clearer that while depression may be present in the severely ill, many patients who desire to control the timing and manner of their death in the setting of terminal illness are not depressed. So, how do psychiatrists, charged with the task of assessing competence or treating concomitant mental illness in terminally ill patients, proceed in an era when the law increasingly recognizes that patients have claims about choosing the timing and manner of their death? “First, we have to see that not all desires to die are suicide in the traditional view—that by definition they result from mental illness and should be prevented,” she said. “But we also cannot and must not retreat from engaging in this dialogue. If we say that just because a patient has a legal right to die, he or she is thereby entitled to make that decision, then we abdicate our professional responsibility to help our patients both in the work of living and in the work of dying.” ■ ISSUES NewArchived

An evaluation of single question delirium screening tools in older emergency department patients

ObjectivesTo determine the diagnostic performances of several single question delirium screens. To the patient we asked: “Have you had any difficulty thinking clearly lately?” To the patient's surrogate, we asked: “Is the patient at his or her baseline mental status?” and “Have you noticed the patient's mental status fluctuate throughout the course of the day?” MethodsThis was a prospective observational study that enrolled English speaking patients 65 years or older. A research assistant (RA) and emergency physician (EP) independently asked the patient and surrogate the single question delirium screens. The reference standard for delirium was a consultation-liaison psychiatrist's assessment using Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR) criteria. All assessments were performed within 3 h and were all blinded to each other. ResultsOf the 406 patients enrolled, 50 (12%) were delirious. A patient who was unable to answer the question “Have you had any difficulty thinking clearly lately?” was 99.7% (95% CI: 98.0%–99.9%) specific, but only 24.0% (95% CI: 14.3%–37.4%) sensitive for delirium when asked by the RA. The baseline mental status surrogate question was 77.1% (95% CI: 61.0%–87.9%) sensitive and 87.5% (95% CI: 82.8%–91.1%) specific for delirium when asked by the RA. The fluctuating course surrogate question was 77.1% (95% CI: 61.0%–87.9%) sensitive and 80.2% (95% CI: 74.8%–84.7%) specific. When asked by the EP, the single question delirium screens' diagnostic performances were similar. ConclusionsThe patient and surrogate single question delirium assessments may be useful for delirium screening in the ED.

Mythbusters: C-L Psychiatrists Separate Fact From Fiction

Back to table of contents Previous article Next article Annual MeetingFull AccessMythbusters: C-L Psychiatrists Separate Fact From FictionRobert Boland,M.D.Robert Boland,Search for more papers by this authorM.D.Published Online:15 Mar 2018https://doi.org/10.1176/appi.pn.2018.3b18AbstractConsultation-liaison psychiatrists seem to encounter more than their share of myths due to the collaborative nature of their work with other fields of medicine.In this “post-factual” age of “fake news,” we have become all too familiar with the power of half-truths, opinions, and assertions to take on the appearance of facts. This is not new—medicine has a long history of taking anecdotes and repeating them so frequently that they become accepted dogma. One recent example was the unusual warning added to a 1980s letter to the editor in the New England Journal of Medicine that purported to show that the risk of iatrogenic addictions from opioid prescriptions is rare, warning that this modest letter has been “heavily and uncritically cited”. Robert Boland, M.D., is president of the Academy of Psychosomatic Medicine.Most doctors have their pet peeves about something they were told or read in a textbook that might not have stood up to scrutiny. Although this pervades medicine, we consultation-liaison psychiatrists feel particularly drawn to this subject, working as we do between psychiatry and other fields of medicine, and in this interface half-truths and frank misunderstandings seem particularly common. With this in mind, when the Academy of Psychosomatic Medicine—soon to be the Academy of Consultation-Liaison Psychiatry—was invited by our APA president to present a presidential symposium, I chose to ask representative members to present a favorite example of a myth that they have encountered. I purposely asked psychiatrists at different stages of their careers, so we have both the wisdom of prominent psychiatrists in our field as well as the new experiences of midcareer and younger consultation-liaison psychiatrists.For example, among leaders of our field, Peter Shapiro, M.D., at Columbia University has devoted much of his career to understanding the interface between cardiology and psychiatry. He will critically review the “accepted” idea that QTc intervals are the best method for predicting whether psychotropics will cause arrhythmias.Similarly, Sejal Shah, M.D., and in this regard David Gitlin, M.D., will examine whether the belief that psychiatrists are the best suited for performing suicide evaluations is itself a myth. Alcohol use and abuse seem particularly prone to fake news, and Sparsha Reddy, M.D., will examine the relationship between Wernicke’s encephalopathy and alcohol use, whereas I will take on the age-old question of whether alcohol really kills brain cells. These are just a few examples of the myths, legends, and “old wives’ tales” that can occur in a field that is both a science and an art. We have no doubt that many members of the audience will have their own examples of things that “just ain’t so,” and we hope to save time to share those as well. ■“Mythbusters: Consultation-Liaison Doc-tors Separate Medical Fact From Fiction” will be held on Wednesday, May 9, from 8 a.m. to 11 a.m. For location, download the APA Meetings App (see ad below) or check the program guide distributed on site at the meeting. ISSUES NewArchived

Developing Our Workforce and Advancing Collaborative Care.

Back to table of contents Previous article Next article Reviewing the Clinical LandscapeFull AccessDeveloping Our Workforce and Advancing Collaborative CarePeter F. Buckley, M.D.Peter F. BuckleySearch for more papers by this author, M.D.Published Online:16 Oct 2017https://doi.org/10.1176/appi.focus.154S02AboutSectionsPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack Citations ShareShare onFacebookTwitterLinked InEmail The number of medical students who elect psychiatry as their career choice is disappointingly low in the United States, averaging 4% of each year’s graduating class since [year]. Quality, not quantity, matters more, one might say. Well, unfortunately, there is no evidence that “the brightest and the best” are going into psychiatry. If anything, there are multiple forces working against the perpetuation of our psychiatry workforce (1). That said, there has been an upturn in interest in psychiatry, culminating in 923 U.S. medical students going into psychiatry residencies this year, up from 850 in 2016, a cumulative 52% increase over the past 16 years.This is encouraging and in line with the enthusiasm within our field regarding the current momentum in neurobiological understandings of mental disorders, as well as with the perceived professional satisfaction and quality of life among practicing psychiatrists. This increase in the “production” of psychiatrists is, however, not keeping up with the rate of population growth, the retirement of psychiatrists, and the compelling and unmet needs for care. Data from the 2017 report by the Medical Director Institute of the National Council for Behavioral Health (2) attest to both the workforce deficit and the overwhelming need for mental health clinicians. The shortage of psychiatrists is estimated to be 6.4% and is anticipated to become more drastic, with a 12% workforce deficit (approximately 6,000 psychiatrists) projected by 2025. Thus, while the pipeline efforts of increases in the number of medical students into psychiatry are encouraging, this present shortage and predicted shortage are daunting. It is unlikely—given sustained retirements, burnout, workplace challenges (funding, etc.)—that we will be able to remedy this deficit solely by increasing our physician pipeline.We need to alter this situation, and we need to address “guild issues” that diminish our clinical effectiveness as well as our ability to advocate effectively on behalf of our patients. We need to recognize that simply producing more child psychiatrists, adult psychiatrists, consultation liaison psychiatrists, addiction specialists, and forensic psychiatrists will not make a meaningful difference in the lack of mental health clinicians. In tandem with judicious growth of the number of general and specialist psychiatrists, we need to embrace our many other clinician colleagues—psychologists, nurses, social workers, counselors, rehabilitation counselors, and peer support specialists. We also need to embrace models of care that maximize integrative deployment of our collective mental health teams. We need to embrace telepsychiatry (as well as emergent mobile health and related technological interfaces) as a key approach to extend our therapeutic effectiveness, especially in our efforts to address the mental health needs of rural populations. The extent to which we can develop our services in tandem with other medical services will further advance our reach, our perceived value among our peers, and our ability to reduce the stigma that keeps people in need from seeking care.Dr. Buckley is dean of the School of Medicine, Virginia Commonwealth University (VCU), and executive vice-president for Medical Affairs, VCU Health, Richmond, Virginia.References1 Buckley PF, Nasrallah HA: The psychiatry workforce pool is shrinking: what are we doing about it? Curr Psychiatr 2016; 15:23–24, 95Google Scholar2 The Psychiatric Shortage: Causes and Solutions. Washington, DC, National Council for Behavioral Health, Medical Director Institute,March 28, 2017. www.thenationalcouncil.orgGoogle Scholar FiguresReferencesCited byDetailsCited byNone Volume 15Issue 4 Fall 2017Pages 3s-3sTreating the Invisible Wounds of War: Focus on PTSD and TBI PDF download

A Model of Collaborative Spiritual and Psychiatric Care of Oncology Patients

Many oncology patients see both chaplains and consultation-liaison (C-L) psychiatrists during medical hospitalizations. Studies show that spirituality and mental health influence one another, and that patients often prefer that physicians understand their spirituality. Though models of inpatient chaplaincy-psychiatry collaboration likely exist, none are apparent in the literature. In this study, we present one model of chaplaincy-psychiatry collaboration, hypothesizing that both specialties would find the intervention helpful. From April through December 2015, the C-L psychiatry service at Brigham & Women's Hospital piloted 13 sessions of interdisciplinary rounds, where chaplains and C-L psychiatrists discussed common oncology patients. Participants completed questionnaires including quantitative and qualitative prompts before the intervention, after each session, and at the study's conclusion. Eighteen individuals completed baseline questionnaires. Between baseline and final surveys, the proportion of participants describing themselves as "very satisfied" with the 2 services' integration rose from 0-36%. The proportion of participants feeling "not comfortable" addressing issues in the other discipline declined from 17-0%. The most frequently chosen options on how discussions had been helpful were that they had enhanced understanding of both patient needs (83.3%) and the other discipline (78.6%). Qualitative data yielded similar themes. At conclusion, all respondents expressed preference that interdisciplinary rounds continue. This study describes a model of enhancing collaboration between chaplains and C-L psychiatrists, an intervention not previously studied to our knowledge. A pilot intervention of the model was perceived by both specialties to enhance both patient care and understanding of the other discipline.

Acute Management of Substance-Related and Addictive Disorders: A Review

A variety of intoxication and withdrawal syndrome cases commonly present to the emergency department and are brought to the attention of the consultation-liaison psychiatrist. The most common intoxication and withdrawal syndromes seen in this setting include alcohol, stimulants, opioids, and cannabinoids. After completion of an appropriate medical evaluation and assessment of the particular intoxication or withdrawal syndrome, effective treatment methods for these disorders can be applied with good outcomes in many cases. Knowledge of these common syndromes allows the consultation-liaison psychiatrist to provide these proven treatment methods, improving patient morbidity and mortality associated with these syndromes. [ Psychiatr Ann . 2017;47(4):192–199.]

National Survey on Pediatric Acute Agitation and Behavioral Escalation in Academic Inpatient Pediatric Care Settings

Pediatric acute agitation and behavioral escalation (PAABE) is common and disruptive to pediatric inpatient health care. There is a paucity of literature on PAABE in noncritical care inpatient pediatric care settings with little consensus on its evaluation and management. In January 2016, a 34-question survey was e-mailed to pediatric hospitalists and consultation-liaison psychiatrists through their respective professional listservs. Excluded responses included incomplete surveys, and surveys from providers in community care settings. The survey consisted of multiple-choice questions, rating scales, and free-text responses relating to the identification, education, and evaluation and management of PAABE at the respondent's respective hospital. Responses were obtained from 38 North American academic children's hospitals. Of the respondents, 69.3% were pediatric hospitalists and 30.7% were pediatric psychiatry consultants. Most respondents practice in urban areas (84.2%), and in hospitals with ≥100 beds (89.4%). Overall, 84.2% of the respondents encountered PAABE at least once a month and as frequently as every week. Most respondents (70.0%) rated PAABE as an 8 or higher on a 10-point Likert scale. Despite being highly important and common, 53.9% of respondents do not screen for risk factors for PAABE, 63.6% reported no formal process to facilitate caregiver involvement in managing PAABE, and 59.7% indicated no physician training in PAABE evaluation and management. Many pediatric hospitals identify PAABE as a great concern, yet there is little training, screening, or standardization of care in PAABE. There is a need to consolidate existing knowledge regarding PAABE, while developing enhanced collaboration, training, and standardized practice in inpatient PAABE.

Non-cardiac Chest Pain: A Review for the Consultation-Liaison Psychiatrist

Patients presenting with chest pain to general practice or emergency providers represent a unique challenge, as the differential is broad and varies widely in acuity. Importantly, most cases of chest pain in both acute and general practice settings are ultimately found to be non-cardiac in origin, and a substantial proportion of patients experiencing non-cardiac chest pain (NCCP) suffer significant disability. In light of emerging evidence that mental health providers can serve a key role in the care of patients with NCCP, knowledge of the differential diagnosis, psychiatric co-morbidities, and therapeutic techniques for NCCP would be of great use to both consultation-liaison (C-L) psychiatrists and other mental health providers. We reviewed prior published work on (1) the appropriate medical workup of the acute presentation of chest pain, (2) the relevant medical and psychiatric differential diagnosis for chest pain determined to be non-cardiac in origin, (3) the management of related conditions in psychosomatic medicine, and (4) management strategies for patients with NCCP. We identified key differential diagnostic and therapeutic considerations for psychosomatic medicine providers in 3 different clinical contexts: acute care in the emergency department, inpatient C-L psychiatry, and outpatient C-L psychiatry. We also identified several gaps in the literature surrounding the short-term and long-term management of NCCP in patients with psychiatric etiologies or co-morbid psychiatric conditions. Though some approaches to the care of patients with NCCP have been developed, more work is needed to determine the most effective management techniques for this unique and high-morbidity population.

Assistance in Dying: Deepening Understanding of Novel Ethical Issues in Psychiatry

Assistance in Dying: Deepening Understanding of Novel Ethical Issues in Psychiatry

Crossing the bridge – A prospective comparative study of the effect of communication between a hospital based consultation-liaison service and primary care on general practitioners' concordance with consultation-liaison psychiatrists' recommendations

ObjectiveConcordance with consultation-liaison (CL) psychiatrists' recommendations by general practitioners (GP) has hardly been studied systematically. We studied if telephone calls or written notes from a hospital based CL-service to GPs, whose patients were treated on medical-surgical wards, can improve GP-concordance, as compared to the usual communication pathway by standard discharge letters written by hospital physicians, and if higher GP-concordance improves outcomes of depressive and anxious symptoms. Methods116 inpatients of a general hospital referred to a CL-service with depression and anxiety were allocated to three groups of communication pathways between CL-service and GPs: (1) A telephone call (TC) by CL-psychiatrists with GPs, (2) a copy of the psychiatric consultation report (CR) was handed out to patients, (3) GPs received standard discharge letters of the hospital physicians (communication as usual, CAU). Six weeks after the CL-episode, patients were phoned at home and asked about implementation of recommendations by their GP's. The Hospital Anxiety and Depression Scale (HADS) was used to monitor anxious and depressive symptoms. ResultsGP-concordance was highest in the TC group, followed by the CR group with significant improvements in medication and psychotherapeutic recommendations compared to CAU. Higher concordance was associated with a significant greater decrease in HADS depression scores but not anxiety scores after 6weeks. ConclusionTelephone communication between CL-psychiatrists and GPs improve GPs' concordance with psychiatric recommendations. This easy-to-implement intervention takes about 10min time but prevents loss of information. It may enhance quality of GPs' mental health care and lead to improved outcomes.

Do Consultation Psychiatrists, Forensic Psychiatrists, Psychiatry Trainees, and Health Care Lawyers Differ in Opinion on Gray Area Decision-Making Capacity Cases? A Vignette-Based Survey

Previous research in the area of medical decision-making capacity has demonstrated relatively poor agreement between experienced evaluators in "gray area" cases. We performed a survey to determine the level of agreement about gray area decision-making capacity case scenarios within and between individuals of different professional backgrounds. Participants received a survey consisting of 3 complicated decision-making capacity vignettes with an accompanying "yes/no" question regarding capacity and a certainty scale for each vignette. Participants were identified from mailing lists of professional organizations and local hospitals. We received responses from psychiatry trainees, consultation-liaison psychiatrists, forensic psychiatrists, and lawyers with experience in health care law. Results were analyzed using SPSS. Across the 3 vignettes, the percentage agreeing that the individual described had capacity to refuse medical treatment ranged between 35% and 40% for trainees, 33% and 67% for consult psychiatrists, 41% and 76% for forensic psychiatrists, and 40% and 83% for health care lawyers. Only question 2 reached significance between-group differences (Pearson χ(2) = 11.473, p < 0.01). Across vignettes, trainees were less likely to consider patients to have capacity for decision-making than were forensic psychiatrists and lawyers. As found in previous research, agreement among experienced evaluators appears generally low in gray area capacity cases. It is noteworthy that individuals of different professional backgrounds at times offer divergent between-group opinions on capacity.

Comparing consultation-liaison psychiatrist's and neurologist's approaches to delirium - A retrospective analysis.

To compare the diagnostic, management, and treatment recommendations made by consultation-liaison psychiatrists (CLP) and neurologists (CLN) for suspected delirium and to investigate factors that may have influenced the choice for a particular consultation service. In this retrospective case analysis, we screened the files of 1882 (CLP: 1112, CLN: 770) inpatients seen by CLP and CLN at the Charité - University Medicine, Berlin, Germany, in 2013. This revealed a total of 148 (CLP: 99, CLN: 49) delirium patients. Information found on the consultation form and in the patients' files was used for data collection and subsequently analyzed. Intensive care and surgical units preferably called CLP, while internists consulted more CLN and patients suffering from neurological or psychiatric preconditions were more often seen by the respective specialist. Despite no significant difference between psychomotor activity levels among the groups, CLP recommended significantly more pharmacological interventions (p = 0.000) and CLN ordered significantly more diagnostic procedures (p = 0.000). Our results show considerable differences between CLP and CLN treatment recommendations, which may indicate a conflicting approach to delirium work-up, not accountable to unequal patient characteristics. These preliminary results are not conclusive and should be followed up by high evidence level research.

Anti-N-Methyl-D-Aspartate Receptor Encephalitis: A New Challenging Entity for Consultation-Liaison Psychiatrist

Anti-N-methyl-D-aspartate receptor (anti-NMDAR) encephalitis is a relatively newly identified autoimmune neuropsychiatric disorder that predominantly affects children and young adults. Although psychiatric symptoms are highly prevalent and frequently severe, it has mainly been reported in neurological, but not psychiatric, literature. Understanding this form of encephalitis, its quick diagnosis and which treatment to provide are of utmost importance for consultation-liaison (C-L) psychiatrists. The aim of this paper was to describe a case of anti-NMDAR encephalitis with severe psychiatric manifestations, who showed impressive recovery but required intensive involvement of the C-L psychiatry team. We emphasise the behavioural aspects, psychiatric symptoms and challenges faced by the CL consultant across the different phases of the treatment. We report the different treatment phases for a young woman with anti-NMDAR encephalitis who developed severe neuropsychiatric symptoms, with a focus on the role and challenges faced by the C-L psychiatrist. The literature is reviewed for each of these challenges. This case illustrated that even extremely severely affected patients may show impressive recovery, but require long lasting psychiatric care. C-L psychiatrists are faced with numerous challenges where only little literature is available. C-L psychiatrists play a pivotal role throughout the multidisciplinary care of patients with anti-NMDAR encephalitis and should be informed about this entity.

The Diagnostic Performance of the Richmond Agitation Sedation Scale for Detecting Delirium in Older Emergency Department Patients.

Delirium is frequently missed in older emergency department (ED) patients. Brief (<2minutes) delirium assessments have been validated for the ED, but some ED health care providers may consider them to be cumbersome. The Richmond Agitation Sedation Scale (RASS) is an observational scale that quantifies level of consciousness and takes less than 10seconds to perform. The authors sought to explore the diagnostic accuracy of the RASS for delirium in older ED patients. This was a preplanned analysis of a prospective observational study designed to validate brief delirium assessments for the ED. The study was conducted at an academic ED and enrolled patients who were 65years or older. Patients who were non-English-speaking, deaf, blind, comatose or had end-stage dementia were excluded. A research assistant (RA) and a physician performed the RASS at the time of enrollment. Within 3hours, a consultation-liaison psychiatrist performed his or her comprehensive reference standard assessment for delirium using Diagnostic and Statistical Manual of Mental Disorders Fourth Edition, Text Revision (DSM-IV-TR) criteria. Sensitivities, specificities, and likelihood ratios with their 95% confidence intervals (CIs) were calculated. Of 406 enrolled patients, 50 (12.3%) had delirium diagnosed by the consult-liaison psychiatrist reference rater. When performed by the RA, a RASS other than 0 (RASS > 0 or < 0) was 84.0% sensitive (95% CI=73.8% to 94.2%) and 87.6% specific (95% CI=84.2% to 91.1%) for delirium. When performed by physician, a RASS other than 0 was 82.0% sensitive (95% CI=71.4% to 92.6%) and 85.1% specific (95% CI=81.4% to 88.8%) for delirium. Using a RASS > +1 or < -1 as the cutoff, the specificity improved to approximately 99% for both raters at the expense of sensitivity; the sensitivities were 22.0% (95% CI=10.5% to 33.5%) and 16.0% (95% CI=5.8% to 25.2%) in the RAs and physician raters, respectively. The positive likelihood ratio was 19.6 (95% CI=6.5 to 59.1) when performed by the RA and 57.0 (95% CI=7.3 to 445.9) when performed by the physician, indicating that a RASS > +1 or < -1 strongly increased the likelihood of delirium. The weighted kappa was 0.63, indicating moderate interobserver reliability. In older ED patients, a RASS other than 0 has very good sensitivity and specificity for delirium as diagnosed by a psychiatrist. A RASS > +1 or < -1 is nearly diagnostic for delirium, given the very high positive likelihood ratio.

Efficacy of brief interdisciplinary psychotherapeutic intervention for motor conversion disorder and nonepileptic attacks

ObjectiveThe objective was to compare a brief interdisciplinary psychotherapeutic intervention to standard care as treatments for patients recently diagnosed with severe motor conversion disorder or nonepileptic attacks. MethodsThis randomized controlled trial of 23 consecutive patients compared (a) an interdisciplinary psychotherapeutic intervention group receiving four to six sessions by a consultation liaison psychiatrist, the first and last sessions adding a neurological consultation and a joint psychiatric and neurological consultation, and (b) a standard care group. After intervention, patients were assessed at 2, 6 and 12 months with the Somatoform Dissociation Questionnaire (SDQ-20), Clinical Global Impression scale, Rankin scale, use of medical care, global mental health [Montgomery and Asberg Depression Rating Scale, Beck Depression Inventory, mental health component of Short Form (SF)-36] and quality of life (SF-36). We calculated linear mixed models. ResultsOur intervention brought a statistically significant improvement of physical symptoms [as measured by the SDQ-20 (P<.02) and the Clinical Global Impression scale (P=.02)] and psychological symptoms [better scores on the mental health component of the SF-36 (P<.05) and on the Beck Depression Inventory (P<.05)] and a reduction in new hospital stays after intervention (P<.05). ConclusionA brief psychotherapeutic intervention taking advantage of a close collaboration with neurology consultants in the setting of consultation liaison psychiatry appears effective.