Psychiatry Consultation Research Articles

Using Academic Detailing to enhance the knowledge, skills and attitudes of clinicians caring for patients with behavioral and psychological symptoms of dementia: 18‐month follow‐up

AbstractBackgroundApproximately 90% of persons with dementia experience behavioral and psychological symptoms of dementia (BPSD) over the course of their illness. Primary care clinicians often provide care because specialty geriatric psychiatry consultation may be difficult to obtain. Academic detailing (AD) is an evidence‐based approach for engaging and persuading healthcare professionals to make changes in their practice. We sought to enhance the knowledge, skills and attitudes of primary care providers’ care of patients with BPSD using the AD model.MethodsWe implemented AD in an urban clinic serving a largely Black community and a rural clinic serving a largely White community. Each AD visit included didactic content, case discussion, and consultation regarding patients. Eleven visits over 18 months were planned for each site. Outcome measures included a 10‐item multiple‐choice knowledge assessment and an adaptation of the General Practitioners Attitude and Confidence Scale for Dementia at baseline, 6 and 18 months, and Likert‐scale measurement of acceptability at 6 and 18 months, all self‐report. Differences in knowledge and attitude scores were determined for those providing complete responses at baseline and follow‐up. Thematic analysis of qualitative feedback collected 18 months will be completed.ResultsFive urban and 14 rural providers completed baseline assessments. Providers were mostly White (95%) and Non‐Hispanic (100%); 47% were female (Table 1). Seventeen (89%) participated in one or more AD visits and 13 (68%) participated in the 6‐month survey. Knowledge, attitudes and confidence regarding BPSD and dementia care increased (Table 2). Assessments at 18‐months and qualitative analysis of case discussions are forthcoming and will be presented.ConclusionsAcademic detailing (AD) is a feasible way of increasing self‐reported knowledge and skills and improving self‐reported attitudes of primary care providers responsible for the care of patients with BPSD. Knowledge and confidence in BPSD and dementia care increased after 6 months’ participation in AD. During the pandemic we successfully adapted the AD model to a virtual platform, which has implications for portability of this model to other settings. The pilot data collected in this study will inform the design of a larger study to measure the impact of AD on patient outcomes.

Unique ulcerative autoinflammatory disease mistaken for factitious disorder

Autoinflammatory diseases (AID) are disorders of inappropriate innate immune system activation. Twenty-four percent of patients with AID do not have a well-defined clinical picture or pathogenic mutation and are characterized as having undefined AID. Cutaneous ulcers have been described but not outside of distinct histologic and clinical disorders. We present a unique case of undefined adult-onset AID with ulcers mistaken for a factitious disorder.A 32 year-old female with borderline personality disorder, depression, and anxiety developed recurrent cutaneous MRSA abscesses and recurrent ulcers of the extremities and scalp associated with alopecia. The ulcers were minimally-responsive to IV antibiotics, isotretinoin, oral dapsone, intralesional triamcinolone, and adalimumab. Flares of the skin disease were associated with fevers and elevated inflammatory markers.Scalp ulcer biopsies revealed numerous pigmented hair casts with trichomalacia and perifollicular lymphocytic infiltrate. One hair follicle contained bacterial cocci associated with a perifollicular neutrophilic infiltrate. These findings along with the patient's psychiatric history led to a diagnosis of trichotillomania from multiple dermatology and psychiatry consultations. The patient denied that she was inducing the lesions and sought another psychiatric consultation, who felt this was not a factitious disease. She was referred to immunology for evaluation of a possible IEI. Laboratory evaluation revealed mild hypogammaglobulinemia with IgG of 663 (768–1632) mg/dL, normal antibody response to recall antigens, but absent response to neo-antigen (Salmonella typhi). Peripheral lymphocyte phenotyping was normal except for a relative decrease in the number of memory B-cells with CD27+IgD+% of 6.9 (13.4–21.4) and CD27+IgD-% of 2.5 (9.2–18.9). Neutrophil oxidative burst was normal. Whole exome sequencing did not identify variants in genes associated with her phenotype.The patient was partially responsive to IVIG but highly responsive to high-dose intravenous methylprednisolone. She was subsequently diagnosed with undefined AID based on Eurofever registry criteria matching her clinical course and had near complete resolution of skin lesions and alopecia with the addition of anakinra.Clinicians must be vigilant for atypical presentations of AID. Our patient had signs of undefined AID but had a delayed diagnosis due to her psychiatric disorders, to which her symptoms were attributed, and a previously undescribed presentation of AID.

Les adolescents aux urgences psychiatriques : motifs de consultation, diagnostics psychiatriques et orientation

IntroductionThe CPOA (Centre Psychiatrique d’Orientation et d’Accueil) is the largest psychiatric emergency center in France, with more than 10,000 consultations per year. The aim of our retrospective observational study is to describe the population of patients aged 15 to 18 years (18 years old not included) consulting our center (reasons for consultation, psychiatric diagnoses, referral decision by specifying the structures to which these minors are referred) and to describe a predictive model for the decision to hospitalize. MethodsAll consecutive patients aged over 15 and under 18 consulting in the CPOA between January 1, 2017 and December 31, 2021 were included in the study. The characteristics of our study sample are described in terms of proportions for qualitative variables and with means and standard deviations for quantitative variables. The probability of being hospitalized was modeled on the entire sample using a multivariate Probit model for which the hypotheses of validity were tested. ResultsWe have recorded 2712 visits, corresponding to 1873 patients included in our study (mean age=16.2±0.72, 54% girls), i.e. an average of 5.2% of the total patients. The main reasons for consultation were depressive ideations (22%), anxiety (19%), and suicidal thoughts (18%). The most frequently diagnosed psychiatric disorders according to the 10th revision of the International Classification of Diseases were F30-39 (mood disorders) (34%), F40-48 (neurotic, stress-related and somatoform disorders) (24%) and F60–69 (personality and behavioral disorders) (11%). Among the patients with an indication for hospitalization, i.e. 27%, 85% were admitted in adult units and fewer than 12% in adolescent specific units, while among the patients with an outpatient care, i.e. 65% in total, only 11% were referred to child psychiatry consultations. An older age, a suicide attempt in the week preceding the visit to the psychiatric emergency department, suicidal behaviour and suicidal ideations, hetero-aggressive behaviour, psychomotor agitation or excitement, delusions, wandering, running away or pathological travel, and a diagnosis of type F20–F29 (Schizophrenia, schizotypal disorder and delusional disorders) and F30–F39 were significantly predictive of a decision to hospitalize. ConclusionPsychiatric hospitalization of adolescents consulting due to psychiatric emergencies is a major problem. The predictive factors for hospitalization reflect an absolute need for immediate care. Unfortunately the lack of structures dedicated to adolescents is such that three quarters of adolescents end up hospitalized in adult structures, which is neither appropriate nor acceptable.

Coronavirus Disease 2019 (COVID-19) Pandemic’s Effect on Child and Adolescent Mental Health: Analysis of Pediatric Intensive Care Unit and Consultation-Liaison Psychiatry Service

The Coronavirus Disease (COVID-19) pandemic has contributed to a co-occurring psychiatric epidemic. Children and adolescents have been particularly impacted, with disruptions in continuity of learning and healthcare. Psychological stressors such as fear of infection, boredom, decreased socialization, supply shortages, and incomplete information have contributed to low mood, irritability, insomnia, and emotional exhaustion. Our study contributes to this research by quantifying the devastating psychiatric toll that the COVID isolation period and virtual schooling had on the mental health of children. The Loyola University Medical Center (LUMC) Consultation-Liaison Psychiatry Service (CLP) (Maywood, IL) designed a study to identify and analyze data regarding the total number of CLP consult requests, patient presentations to the emergency department (ED), and admissions to the Pediatrics floor and Pediatric Intensive Care Unit (PICU) during the COVID pandemic. IRB approval was obtained for this retrospective chart review study. ED visits and Pediatric floor/PICU admissions of all pediatric patients (6-18 years old), specifically those related to mental health, were identified using ICD-9 diagnostic coding for the dates of March 2019 through February 2022. The total number of admissions and encounter diagnoses were analyzed and compared between 3 pandemic periods: Pre-pandemic phase (March 2019-February 2020), acute pandemic phase: isolation/virtual schooling (March 2020-February 2021), and chronic pandemic phase: post-isolation/virtual schooling (March 2021-February 2022). During the chronic pandemic phase, ED visits and Pediatric floor/PICU admissions of all pediatric patients were identified via manual chart review of existing CLP patient lists. The total number of admissions, along with diagnoses during encounters, were compared between the 3 periods and psychiatric admissions were further subcategorized into intentional drug overdoses. In the pre-pandemic phase, there were 39,304 total encounters for children (6-18 years), with 11,189 ED-only visits, and 3,043 inpatient admissions. In the acute pandemic phase, total encounters fell to 15,779, with 4,631 ED-only visits, and 2,578 inpatient admissions. Pre-pandemic, 0.55% of all pediatric encounters required psychiatry consults compared to 1.32% after the onset of the pandemic. During the pre-pandemic phase, there were 27 PICU admissions for psychiatric-related conditions (i.e. intentional ingestion) or 4.52% of all PICU admissions. During the acute pandemic period, there were 57 PICU admissions for psychiatric-related conditions or 11.19% of all PICU admissions. Specifically, there was a rise in intentional ingestion cases from 25 prior to the pandemic to 44 after the onset of the pandemic. During the chronic pandemic period, there were 43 PICU admissions for psychiatric-related conditions. Of those 43 admissions, 33 were intentional drug overdoses. Total encounters during this phase were comparable to the pre-pandemic phase (39,304 encounters pre-pandemic vs. 32,544 encounters in chronic pandemic phase).At this large academic medical center, the pandemic has had a clear impact on total pediatric encounters, with a rise in the number of PICU admissions for psychiatric-related conditions. Findings from this study can be used to inform public policy and develop guidelines in preparation for future pandemics. Safeguards should be put in place to address the significant effects that social isolation and virtual schooling have on the mental health of children, including but not limited to widespread therapy sessions incorporated into the virtual school day and socially distanced in-person activities when safe.

Equitable psychiatry, telehealth, and the COVID-19 pandemic: Analysis of national data.

At the beginning of the COVID-19 pandemic, it was foreseen that the number of face-to-face psychiatry consultations would suffer a reduction. In order to compensate, the Australian Government introduced new Medicare-subsidized telephone and video-linked consultations. This study investigates how these developments affected the pre-existing inequity of psychiatry service delivery in Australia. The study analyses five and a half years of national Medicare data listing all subsidized psychiatry consultation consumption aggregated to areas defined as Statistical Area level 3 (SA3s; which have population sizes of 30 k-300 k). Face-to-face, video-linked and telephone consultations are considered separately. The analysis consists of presenting rates of consumption, concentration graphs, and concentration indices to quantify inequity, using Socio Economic Indexes for Areas (SEIFA) scores to rank the SA3 areas according to socio-economic disadvantage. There is a 22% drop in the rate of face-to-face psychiatry consultation consumption across Australia in the final study period compared with the last study period predating the COVID-19 pandemic. However, the loss is made up by the introduction of the new subsidized telephone and video-linked consultations. Referring to the same time periods, there is a reduction in the inequity of the distribution of face-to-face consultations, where the concentration index reduces from 0.166 to 0.129. The new subsidized video-linked consultations are distributed with severe inequity in the great majority of subpopulations studied. Australia-wide, video-linked consultations are also distributed with gross inequity, with a concentration index of 0.356 in the final study period. The effect of this upon overall inequity was to cancel out the reduction of inequity resulting from the reduction of face-to face appointments. Australian subsidized video-linked psychiatry consultations have been distributed with gross inequity and have been a significant exacerbator of the overall inequity of psychiatric service provision. Future policy decisions wishing to reduce this inequity should take care to reduce the risk posed by expanding telepsychiatry.

Life stress and Bipolar Disorder: regarding a clinical case

IntroductionResearch on life stress in bipolar disorder largely fails to account for the possibility of a dynamic relationship between psychosocial stress and episode initiation. The kindling hypothesis states that over the course of recurrent affective disorders, there is a weakening temporal relationship between major life stress and episode initiation that could reflect either a progressive sensitization or progressive autonomy to life stress.ObjectivesTo explore the concept of the Kindling model applied to bipolar disorder and to present a clinical case of a bipolar patient whose latter mood episodes were caused by adverse life events.MethodsWe performed a non-systematic literature review using the most relevant papers found on the database PubMed with the keywords “kindling effect”, “allostatic load”, “bipolar disorder” and “prevention”. Description of the clinical case report.ResultsThe phenomenon of kindling was first discovered by Goddard in 1967 who described it in epilepsy. Later, Post applied it to the bipolar disorder, arguing that the initial episodes of both unipolar and bipolar affective disorders are often precipitated by psychosocial stressors, but after multiple recurrences, not only do precipitated episodes continue to occur, but so do spontaneous ones as well. We present the case report of a 62 years old woman, divorced, diagnosed with type 1 bipolar disorder since she was 20 years old. She always have had poor adherence to her medication and follow-up with Psychiatry consultation, with a non-containing sociofamily environment that does not promote clinical stability. Over the time, her admissions on the Psychiatry ward were more frequent and precipitated by adverse life events, mainly caused by the deteriorated relationship with her children.ConclusionsThe kindling model clarifies aspects of the longitudinal course of episode development, recurrence, and progression to spontaneity, as well as further conceptual and theoretical rationales for intervention in order to prevent illness progression.Disclosure of InterestNone Declared

Late diagnosis of attention deficit hyperactivity disorder and cocaine abuse

IntroductionAdult ADHD diagnosis sometimes represents a challenge for the clinician, due to the comorbid psychiatric diseases that are often associated and which complicate de recognition of the primary symptoms of ADHD. The prevalence of ADHD in adult populations is 2’5% and it is a relevant cause of functional impairment.ObjectivesPresentation of a clinical case of a male cocaine user diagnosed with adult ADHD.MethodsLiterature review on adult ADHD and comorbid substance abuse.ResultsA 43-year-old male who consulted in the Emergency Department due to auditory hallucinosis in the context of an increase in his daily cocaine use. There were not delusional symptoms associated and judgment of reality was preserved. Treatment with olanzapine was started and the patient was referred for consultation. In psychiatry consultations, he did not refer sensory-perceptual alterations anymore, nor appeared any signals to suspect so, and he was willing to abandon cocaine use after a few appointments. He expressed some work concerns, highlighting that in recent months, in the context of a greater workload, he had been given several traffic tickets for “distractions.” His wife explained that he had always been a inattentive person (he forgets important dates or appointments) and impulsive, sometimes interrupting conversations. In the Barkley Adult ADHD Rating Scale he scored 32 points.He was diagnosed with adult ADHD and treatment with extended-release methylphenidate was started with good tolerance and evolution, with improvement in adaptation to his job and social environment. Since then, the patient has moderately reduced the consumption of drugs, although he continues to use cocaine very sporadically.ConclusionsEarly detection of ADHD and its comorbidities has the potential to change the course of the disorder and the morbidity that will occur later in adults. Comorbidity in adult ADHD is rather the norm than the exception, and it renders diagnosis more difficult. The most frequent comorbidities are usually mood disorders, substance use disorders, and personality disorders. Treatment of adult ADHD consists mainly of pharmacotherapy supported by behavioral interventions. When ADHD coexists with another disorder, the one that most compromises functionality will be treated first and they can be treated simultaneously. The individual characteristics of each patient must be taken into account to choose the optimal treatment.Disclosure of InterestNone Declared

Trazodone induced euprolactinemic galactorrhea – a case report

IntroductionTrazodone is an antidepressant that exerts its effect through serotonin reuptake inhibition and 5-HT2A and 5-HT2C receptor antagonism. Galactorrhea, as well as the increase in prolactin levels, have been seldom related to antidepressants. These adverse effects are more frequently observed with antipsychotic medication.ObjectivesTo present and discuss a case of Trazodone induced galactorrhea in a 24-year-old female patient diagnosed with a moderate depressive episode, without psychotic symptoms.MethodsClinical case description and literature review.ResultsWe present the case of a healthy 24-year-old woman, medicated with oral contraceptives, presented to a Psychiatry Consultation due to worsening depressive and anxious symptoms. Prolonged-release Trazodone was initiated with the indication to gradually titrate up to 300 mg/day. On the third day of treatment (at the time, at a dose of 75 mg/day), the patient began to experience breast pain and galactorrhea. On the seventh day, due to continuation of the complaints, she went to a Gynecology Consultation, having carried out an analytical study, in which a prolactinemia value was registered within the normal range (18 ng/mL). The possibility of pregnancy or continued intake of anabolizing steroids was excluded. The condition reversed upon discontinuation of the drug.ConclusionsThe endocrine and reproductive effects of antidepressants are uncommon and galactorrhea is only rarely mentioned as a possible adverse effect of this type of medication. The neurobiological mechanisms underlying this association are unclear. The existing literature points to the possibility that serotonergic antidepressants act by suppressing dopamine neurotransmission (by indirect inhibition of the tuberoinfundibular pathway), facilitating the release of prolactin and thus contributing to the increase in its levels. However, there are also case reports of antidepressant-induced galactorrhea in the presence of normal prolactin levels. In the present case, a state of euprolactinaemia was, in fact, verified. The findings reinforce the importance of carrying out more studies and on a larger scale, to better clarify the mechanisms underlying this association.Disclosure of InterestNone Declared

Obsessive-compulsive disorder after traumatic brain injury: case report.

IntroductionAlthough not the most prevalent clinical presentation, obsessive compulsive (OC) symptoms have been reported after TBI. Post-TBI OC disorder (OCD) cases are rare, so that OC symptoms in this setting are frequently described as OC personality disorders (OCPD).Generally, the clinical features of post-TBI OCD are thought to be similar to those observed in idiopathic OCD, assuming the probable involvement of structures such as the orbitofrontal cortex, basal ganglia, limbic and thalamic systems in its pathophysiology, although no anatomical location clearly associated with post-TBI OCD being recognized.ObjectivesBrief systematic review of OCD post-TBI and case report.MethodsBibliographic research using Pubmed. Clinical interviews and file consultation, with patient informed consent.ResultsWe present a case of a 63-year-old patient referred to the Psychiatry Consultation due to obsessive thoughts of dirt and contamination, accompanied by compulsive cleaning and sanitizing behaviors with at least 3 years of evolution with a history of TBI and right frontopolar hemorrhage 5 years ago. These behaviors significantly impaired his functionality (cleaning objects on average 300 to 700 times a day, spending hours in the shower). The patient had insight for the excessive behaviors and its daily impairment.ConclusionsPsychopathology in the post-TBI context is not infrequent, however reported cases of post-TBI OCD are described as rare in the current literature. The short description of this phenomenon implies the need for more studies focused on the study of the phenomenology of post-TBI OCD. For example, while OCD and obsessive-compulsive symptoms tend to be recognizable psychiatric phenomena, neurobehavioral sequelae in a post-TBI context can present multiple manifestations and resemble OC phenomena, without actually constituting OCD.Disclosure of InterestNone Declared

Evaluation of social autonomy of schizophrenic patients

IntroductionSchizophrenia is a debilitating and mutilating mental illness, generally progressing in a Chronic way . It is at the origin of a limitation of social autonomy and source of psychological distress .Objectivesevaluate the effective social autonomy of schizophrenic patients.Methodsit is a cross-sectional study carried out at the EPS psychiatry consultation in Mahdia during a period of 3 months, with schizophrenic patients meeting the DSM 5 criteria, having an age varying from 19 to 65 years and whose duration of evolution was at least of one year. Have been excluded those in a state of decompensation, presenting a severe organic disease or having a major cognitive impairment. Information was collected from patients and fromtheir medical records using a pre-established questionnaire. The scale of social autonomy (EAS) of Legay with 17 items grouped into 5 dimensions was used for the evaluation.ResultsThe general characteristics of the 360 schizophrenic patients who met the inclusion criteria, revealed an average age of 40.2 years, a sex ratio of 2.33, a majority of single (55.8%), a low level of education(66.7%), an absence of professional activity (67.3%) and a deteriorated socioeconomic level (68.6%).Clinical Characteristics noted an average onset age of the disorder of 26 years, an average duration of evolution of 14 years and a preponderance of the residual type and of the episodic evolutionary course with residual symptoms between episodes respectively in 40.6 and 76.4%. The average of EAS scores were 39.08. Three quarters of the population (75.7%) had a score below 59. 24.3% of patients had scores between 60 and 108 signifying impaired social autonomy.ConclusionsThe evaluation of effective social autonomy is essential for any therapeutic project considering psychosocial integration and rehabilitation of schizophrenic patients.Disclosure of InterestNone Declared

Alexithymia in adolescents treated for psychiatric disorders: A study of the relationship with Alexithymia in parents and with the parental link

IntroductionAlexithymia is defined as a disorder involving difficulties in identifying, describing feelings and an outward-oriented way of thinking with restricted imaginary processes. Our objectives were to study the link between parents’ alexithymia and that of adolescents treated for psychiatric disorders on the one hand, and to study the relationship between alexithymia in adolescents and the parental link perceived by them, on the other hand.ObjectivesTo study the relationship between the alexithymia of parents and that of adolescents followed for psychiatric disorders on the one hand, and to study the relationship between alexithymia in adolescents and the parental bond perceived by them on the other go.MethodsA descriptive and analytical cross-sectional study was carried out at the pediatric psychiatry consultation at the Hédi Chaker University Hospital in Sfax during a period of one year from January 2019 to December 2019. We recruited 116 people: 53 adolescents, 44 mothers and 19 fathers. . We used an information sheet, the TAS-20 score (Toronto Alexithymia Scale) and the PBI (Parental Bonding Instrument)ResultsTwo-thirds of the patients were alexithymic. A climate of domestic violence increased the adolescent’s emotional difficulties. Half of the mothers and one-third of the fathers were alexithymic. The total alexithymia score (TAS-20) in adolescents was positively correlated with the total alexithymia score (TAS-20) in the parents (p=0.03 for the mother and p = 0.02 for the father Adolescent difficulty in identifying emotions (DIE) was associated with difficulty describing emotions (DDE) in both parents (p=0.01 for mother and p<10-3 for father). The teenager had difficulty describing his own emotions when his mother was having the same difficulty. Outward thinking in adolescents were associated with more alexithymic traits in the mother. Maternal care scores were significantly and negatively correlated with adolescent TAS-20, DIE, and DDE scores (p=0.01, p=0.01, and p=0.04). Maternal protection score was positively and significantly correlated with TAS-20, DIE, and DDE scores (p=0.01, p=0.01 and p=0.02). The father’s protection score was positively and significantly correlated with TAS-20, DIE and DDE scores (p<10-3, p=0.04 and p=0.01). The overprotective attitude of parents perceived by the adolescent has therefore been associated with more alexithymia in adolescents.ConclusionsParticular attention must therefore be paid to the emotional difficulties of adolescents followed in child psychiatry, as well as those present with their parents. These difficulties can create interpersonal difficulties and affect the parental bond perceived by the child.Disclosure of InterestNone Declared

Asynchronous Consultations in Geriatric Psychiatry: Experiences in a Rural Academic Health System

More Americans are living longer and entering old age than ever before. The number of adults age 65 years and older in the United States (US) is projected to grow to more than 83.7 million by 2050. Today's 65-year-olds can expect to live, on average, another 19.4 years. However, the outcomes of extending longevity have not kept pace with the US healthcare system's ability to improve mental and cognitive well-being. The 2012 Institute of Medicine (IOM) report estimates that 14%–20% of the elderly population is afflicted by a mental health or substance use condition, including dementia-related behavioral and psychiatric symptoms. Despite this clear growing demographic need, the number of physicians formally trained in geriatric psychiatry and geriatric medicine is shrinking, limiting the availability of specialty care to this vulnerable demographic. This disparity is magnified in rural settings and/or historically disadvantaged areas/populations where access to geriatric psychiatrists and geriatric medicine specialists may be severely limited, if available at all.This session will cover the development, implementation, and preliminary outcome measures of two asynchronous geriatric psychiatry consultation programs, one EMR based e-consultation program and one on-demand telephone consultation program, that have been developed by geriatric psychiatrists at Dartmouth-Hitchcock Medical Center. Our aim is to demonstrate how similar asynchronous geriatric psychiatry consultation programs could be feasibly implemented at essentially any site or within any health system to begin to address the limited availability of specialty geriatric psychiatry expertise, especially in rural and/or historically disadvantaged areas/populations.

Attaining Access and Comfort: Providers’ Qualitative Feedback on a Tele-geriatric Psychiatry Consultation Service within the Veterans Health Administration

Attaining Access and Comfort: Providers’ Qualitative Feedback on a Tele-geriatric Psychiatry Consultation Service within the Veterans Health Administration

Decision-Points in Adapting Veteran's Affairs Tele-Geriatric Psychiatry Consultation Service to New Regions

Decision-Points in Adapting Veteran's Affairs Tele-Geriatric Psychiatry Consultation Service to New Regions

Changes in emergency psychiatric consultations in time of COVID-19: a retrospective observational study in the Verona Academic Hospital over the two pandemic years 2020–2021

BackgroundDuring the first months of the COVID-19 pandemic, local health authorities in most Italian regions prescribed a reduction of ordinary outpatient and community mental health care. The aim of this study was to assess the impact of the COVID-19 pandemic on access to the emergency departments (ED) for psychiatric consultation in the pandemic years 2020 and 2021 compared to 2019.MethodsThis is a retrospective study conducted by using routinely collected administrative data of the two EDs of the Verona Academic Hospital Trust (Verona, Italy). All ED psychiatry consultations registered from 01.01.2020 to 31.12.2021 were compared with those registered in the pre-pandemic year (01.01.2019 to 31.12.2019). The association between each recorded characteristic and the year considered was estimated by chi-square or Fisher’s exact test.ResultsA significant reduction was observed between 2020 and 2019 (-23.3%) and between 2021 and 2019 (-16.3%). This reduction was most evident in the lockdown period of 2020 (-40.3%) and in the phase corresponding to the second and third pandemic waves (-36.1%). In 2021, young adults and people with diagnosis of psychosis showed an increase in requests for psychiatric consultation.ConclusionsFear of contagion may have been an important factor in the overall reduction in psychiatric consultations. However, psychiatric consultations for people with psychosis and for young adults increased. This finding underlines the need for mental health services to implement alternative outreach strategies aimed to support, in times of crisis, these vulnerable segments of the population.

An overview of the rehabilitation and psychiatric diagnoses of patients referred to a psychiatry consult liaison service at an inpatient rehabilitation hospital.

Patients presenting for inpatient rehabilitation following injury or illness are commonly affected by comorbid psychiatric illness. Currently, little is known about the utilization of a psychiatry consult service in an inpatient rehabilitation hospital. To identify which rehabilitation patient populations most frequently received psychiatric consultation and recognize the most common psychiatric comorbidities after the implementation of a psychiatry consult liaison (PCL) service. A retrospective observational study in the form of a chart review examining the utilization patterns of a psychiatric consultation liaison service in the inpatient rehabilitation setting. Chart review was performed to extract patient demographics (age and sex), rehabilitation diagnosis, cause of rehabilitation diagnosis (intentional, accident, self-inflicted, or disease), reason for referral to psychiatry, and psychiatric diagnosis on initial consultation. Statistical software was used for statistical analysis to answer the pre-specified research questions. A 178 bed, free-standing, academic rehabilitation hospital located in an urban Canadian center. Any patient admitted to the inpatient rehabilitation hospital who received a psychiatric consultation between September 2016 and December 2019 was eligible for inclusion. A total of 1016 charts were reviewed in the initial chart review and 1008 were included. The most common rehabilitation diagnoses that were associated with a psychiatric consult were (% admissions receiving consultation): amputations (38%); burns (35%), neurologic disorder (28%), deconditioning (14%), and musculoskeletal injury (7%). Although 20% of patients did not meet criteria for a psychiatric diagnosis, most common psychiatric diagnoses included mood disorder, adjustment disorder, neurocognitive disorder, and delirium. There are significant perceived needs for psychiatric services in the inpatient rehabilitation setting. Although some patient groups such as patients with amputations, burns, and trauma may exhibit the highest utilization, the service supports mental health needs from many patient groups.

The impact of rounds with a psychiatry team in the intensive care unit: A prospective observational pilot study evaluating the effects on delirium incidence and outcomes

BackgroundDelirium in the intensive care unit (ICU) is a common but serious condition that has been associated with in-hospital mortality and post-discharge psychological dysfunction. The aim of this before and after study is to determine the effect of a multidisciplinary care model entailing daily ICU rounds with a psychiatrist on the incidence of delirium and clinical outcomes. ObjectiveTo assess the impact of a proactive psychiatry consultation model in the surgical ICU on the incidence and duration of delirium. MethodsThis was a prospective, single institution, observational controlled cohort pilot study of adult patients admitted to a surgical ICU. A control group that received standard of care (SOC) with daily delirium prevention care bundles in the pre-intervention period was compared to an intervention group, which had a psychiatrist participate in daily ICU rounds (post-intervention period). The primary outcome was delirium incidence. The secondary outcomes were: delirium duration, ventilator days, hospital and ICU length of stay, and in-hospital mortality. ResultsA total of 104 patients were enrolled and equally split between SOC and intervention groups; 95 contributed to analysis. The overall incidence of ICU delirium was 19%. SOC and intervention groups had similar rates of delirium (21% vs 18%, p = 0.72). None of the secondary outcomes statistically significantly differed between the two groups. ConclusionDelirium in ICU patients is a potentially preventable condition with serious sequelae. There was no difference in delirium incidence or duration between patients receiving SOC or patients who had multidisciplinary rounds with a psychiatrist.

An initial investigation of the role of depressive and anxious syndromes in Problematic Internet Use in adolescence and young adults

Depressive and anxious syndromes have been proposed as risk factors and as consequences of Problematic Internet Use (PIU). There has been no study relating affective symptoms in subjects with Problematic Internet Use and those with major depressive and anxious syndromes. In this study, three samples were collected: two from ambulatory clinical settings of the North Lisbon Hospital Centre (1. Centre for PIU and 2. Out-patient psychiatry consultation for adolescents and young adults) and a control group from Faculdade de Medicina da Universidade de Lisboa. Internet use profile and affective psychopathology were assessed and socio-demographic characteristics were controlled. The results revealed that both the PIU group and the clinical group presented significantly higher depression and anxiety scores than the control group while there was no significant difference between them. Also, Problematic Internet Users, similarly to the clinical group, tend to live in less functional families. We speculate that the similitude between samples and yet such different clinical presentations could be explained if Internet acted as a buffer to affective psychopathology. These findings warrant exploring the possibility of PIU as new (and generation biased) psychopathology of depressive or anxious states.

Supporting Veterans, Caregivers, and Providers in Rural Regions With Tele-Geriatric Psychiatry Consultation: A Mixed Methods Pilot Study

ObjectivesCross-facility tele-geriatric psychiatry consultation is a promising model for providing specialty services to regions lacking sufficient geriatric psychiatry expertise. This evaluation focused on assessing the feasibility and acceptability of a consultation program developed by a geriatric psychiatrist in a Veterans Health Administration regional telehealth hub. DesignConcurrent, mixed methods program evaluation. SettingA region served by a VA health care system telehealth hub. ParticipantsPatients with at least 1 geriatric mental health encounter with a geriatric psychiatrist consultant during a 1 year-period; referring providers. InterventionVirtual psychiatric evaluation of Veterans with time-limited follow-up and e-consultation with providers. MeasurementsInterviews with consultant, medical record data, and referring provider surveys. ResultsThree hundred fifteen Veterans (M = 76.0 ± 9.64 years; 40% rural-dwelling) had 666 encounters (M = 2.11 ± 1.78) with most occurring via clinical video telehealth (n = 443; 67.6%), e-consultation (n = 99; 15.1%), or video to home (n = 95; 14.5%). Most encounters were related to neurocognitive disorders, depressive disorders, trauma-related disorders, or serious mental illness. Referring providers (N = 58) highly recommended the program, reported high satisfaction, followed through with recommendations, and believed that this program increased access to geriatric psychiatry. ConclusionsThis single program was shown to be feasible, acceptable, and valued by the referring providers. The findings highlighted the complex presentations of Veterans referred, and the current unmet need of providers of such Veterans, providing impetus for wider implementation.

New and Persistent Sedative Prescriptions Among Older Adults Following a Critical Illness: A Population-Based Cohort Study

ICU survivors often have complex care needs and can experience insufficient medication reconciliation and polypharmacy. It is unknown which ICU survivors are at risk of new sedative use posthospitalization. For sedative-naive, older adult ICU survivors, how common is receipt of new and persistent sedative prescriptions, and what factors are associated with receipt? This population-based cohort study included ICU survivors aged≥ 66 years who had not filled sedative prescriptions within≤ 6months before hospitalization (sedative-naive) in Ontario, Canada (2003-2019). Using multilevel logistic regression, demographic, clinical, and hospital characteristics and their association with new sedative prescription within≤ 7days of discharge are described. Variation between hospitals was quantified by using the adjusted median OR. Factors associated with persistent prescriptions (≤ 6months) were examined with a multivariable proportional hazards model. A total of 250,428 patients were included (mean age, 76 years; 61%male). A total of 15,277 (6.1%) filled a new sedative prescription, with variation noted across hospitals (2%[95%CI, 1-3] to 44%[95%CI, 3-57]); 8,458 (3.4%) filled persistent sedative prescriptions. Adjusted factors associated with a new sedative included: discharge to long-term care facility (adjusted OR [aOR], 4.00; 95%CI, 3.72-4.31), receipt of inpatient geriatric (aOR, 1.95; 95%CI, 1.80-2.10) or psychiatry (aOR, 2.76; 95%CI, 2.62-2.91) consultation, invasive ventilation (aOR, 1.59; 95%CI, 1.53-1.66), and ICU length of stay≥ 7days (aOR, 1.50; 95%CI, 1.42-1.58). The residual heterogeneity between hospitals (adjusted median OR, 1.43; 95%CI, 1.35-1.49) had a stronger association with new sedative prescriptions than the Charlson Comorbidity Index score or sepsis. Factors associated with persistent sedative use were similar with the addition of female subjects (subdistribution hazard ratio, 1.07; 95%CI, 1.02-1.13) and pre-existing polypharmacy (subdistribution hazard ratio, 0.88; 95%CI, 0.80-0.93). One in 15 sedative-naive, older adult ICU survivors filled a new sedative within≤ 7days of discharge; more than one-half of these survivors filled persistent prescriptions. New prescriptions at discharge varied widely across hospitals and represent the potential value of modifying prescription practices, including medication review and reconciliation.