The differences between referred and non-referred patients to a psychiatric consultation-liaison service in a general hospital

OBJECTIVE

The primary aim of this study was to investigate whether there are clinical differences between patients who are referred or not referred for psychiatric consultation and liaison service. The secondary aim was to compare the perspectives of doctors, nurses and patients.

METHODS

This naturalistic, prospective and comparative study (N = 294) utilised a control sample of non-referrals (n = 177, consenting 81) and referrals (n = 177, consenting 49). The normality of the data was examined with the Shapiro-Wilk test; bivariate group comparisons were made using Mann-Whitney, Wilcoxon tests and bivariate regression analyses. Statistically adjusted group comparisons were performed with multivariate median regressions.

RESULTS

The sample presented limited representativeness. Referred patients were predominantly women, mostly living alone and not working. Compared to the non-referred patients, their disease episode and length of hospital stay were significantly longer, self-efficacy and quality of life lower and psychological stress was higher. For referred patients, there were no differences between the estimations of mental burden and the need for care among doctors, nurses and patients. Self-efficacy and appraisal of one's own burden were the best predictors of the extent of mental symptoms.

DISCUSSION

Patients in an admission ward for internal medicine referred to a psychiatric consultation-liaison service displayed a more adverse psychosocial profile and were more psychologically burdened than non-referred patients, but they are also relevantly subsyndromal burdened. Identifying and supporting burdened patients is an endeavour that requires collaborative care, especially in the transition to specialised mental health and to primary care.

Drug Treatment for Patients with Postoperative Delirium and Consultation-Liaison Psychiatry in Japan: A Retrospective Observational Study of a Nationwide Hospital Claims Database

BACKGROUND

Delirium is the most commonly experienced disorder in consultation liaisons. There are currently research and guidelines in Japan for delirium treatment. Still, there is no retrospective observational study of consultation-liaison psychiatry (CLP) and antipsychotic-centered drugs. This study aims to examine CLP's effectiveness and drug treatment.

METHODS

Using a Japanese national inpatient database of 2016 and 2017, we investigated the presence or absence of CLP for the treatment of delirium in postoperative delirium patients, the status of drug selection, delirium days, and the average days from surgery to discharge. We examined factors affecting days from surgery to discharge using multiple linear regression analysis.

RESULTS

This study was classified into a CLP group (n = 1,142) and a non-CLP group (n = 11,355). The days from surgery to discharge in the CLP and non-CLP groups was 16.7 and 17.1, respectively (p = 0.3613). There was a significant difference in the delirium days between the CLP and non-CLP groups (8.9 vs. 7.4; p < 0.00001). Haloperidol infusion was frequently used between the days from surgery to first day of delirium. It was prescribed less often than other oral drugs. Multiple regression analysis identified an association between age, men, CCI1-2, CCI ≥3, number of drugs used, days from surgery to first day of delirium, and early CLP (0-2days) with days from surgery to discharge.

CONCLUSIONS

We investigated the effectiveness of CLP and the actual conditions of pharmacotherapy for postoperative delirium. Our findings suggest that early CLP may be associated with shorter days from surgery to discharge.

Prevalence of collusion in cancer communications: A meta-analysis

INTRODUCTION

Collusion is the non-disclosure of information about diagnosis or prognosis, frequently encountered in cancer care and palliative services. Unraveling collusion is a skill and differences among communication techniques by Health Care Workers have maintained the process of non-disclosure to patients and caregivers. Identifying the prevalence of collusion in cancer care is required to improve the existing strategies across the world.

METHODS

A systematic review of the literature from 1991 to 2020 in the English language was conducted with the protocol registration on PROSPERO ID (CRD 42021249216.) to identify the pooled prevalence of collusion.

RESULTS

By using random effect model, the pooled prevalence estimate among patients for the diagnostic and prognostic collusion was 24.15, (95% CI [17.09; 32.96], Tou2 = 1.0801, I²  = 97.9%, Cochran's Q = 1058.22, df = 21, p-value < 0.001) and 37.92, (95% CI [22.46; 56.30], Tou2 = 1.9641, I²  = 98.6%, Cochran's Q = 944.26, df = 13, p-value < 0.001) respectively. There was no difference across subgroups with different types of setting for the interview, WHO regions and trend over the years.

CONCLUSIONS

Substantial prevalence of collusion goes unnoticed in cancer care. A meaningful understanding of such a large prevalence requires inquiry into the existing communication paradigm in cancer care across the world. The findings also question the need of formulating uniform interview techniques and structured assessment tools or questionnaires in cancer care to improve the disclosure rates.

Oral corticosteroid dosage and clinical presentation of psychiatric conditions after steroid use: A consultation-liaison psychiatry service's experience

Aim

Psychiatric disturbances are the major adverse effects of corticosteroids. There are no consistent conclusions regarding changes in steroid dosage and the incidence of psychiatric conditions, due in part to the lack of consistent evaluation criteria. The purpose of this research was to determine the incidence and dose‐dependency of psychiatric conditions as assessed by trained psychiatrists.

Methods

A retrospective chart review was conducted at a university hospital in Japan. We identified inpatients receiving oral prednisolone treatment, who were referred to the consultation‐liaison psychiatry team from April 2015 to March 2018. Patients were divided into high‐dose (≥0.5 mg/kg/day) and low‐dose (<0.5 mg/kg/day) groups. We investigated the associations between steroid dosage and incidence of psychiatric conditions.

Results

A total of 93 patients (35 in the high‐dose group, 58 in the low‐dose group) were included. Various psychiatric conditions, such as insomnia, delirium, depression, and psychosis, occurred during steroid therapy. The most common condition was insomnia (72%). We observed no significant differences in the patient background characteristics and the incidence of most psychiatric conditions between the high‐dose and low‐dose groups. However, there were more patients with delirium in the low‐dose group than in the high‐dose group.

Conclusions

Based on the accurate assessment of psychiatric conditions by psychiatrists, our analysis suggests that, among inpatients referred to a consultation‐liaison psychiatry team, the incidence of psychiatric conditions, with the exception of delirium, is independent of the dose of oral prednisolone.

We investigated the differences in psychiatric symptoms and clinical features according to the dose of oral prednisolone by conducting a retrospective chart review of the 93 patients referred to our consultation‐liaison psychiatry team. The results showed that psychiatric symptoms, except for delirium, were not dose‐related.

First-Episode Psychosis and the Role of the Psychiatric Consultant

OBJECTIVE

Timely recognition and treatment of first-episode psychosis (FEP) is paramount. Studies suggest a significant relationship between longer duration of untreated psychosis and poorer functional outcomes. Limited data exist that characterize how treatment for FEP is initiated by consultation-liaison psychiatric services. We conducted a systematic review of FEP treatment by a consultation-liaison service at a large academic medical tertiary care. Approach to care was reviewed including recommendations for clinical assessment and management.

METHODS

Psychiatric consultations performed at a tertiary academic center were reviewed to identify potential FEP cases during a 12-month period. Patients of ages 15-49 years, for whom the diagnostic assessment was concerning for possible FEP, were included. Demographic features and management were summarized.

RESULTS

A total of 3365 new psychiatric consults were conducted during our study period. Of these, 28 were identified as having symptoms consistent with possible FEP (0.83% of total sample). However, only 12% were referred to coordinated specialty care for psychosis after discharge from an inpatient medical or psychiatric hospital.

CONCLUSIONS

The results of our systemic chart review indicate that workup, management, and disposition recommendations for FEP patients seen by consultation-liaison services are variable, suggesting a need for a standardized, evidence-based approach in the medical setting.

Neuropsychiatric Symptoms After Brain Tumor Resection in Children and Adolescents: A Scoping Review

BACKGROUND

Brain tumors are one of the most common solid tumors in pediatric populations, with their treatments having significant neuropsychiatric impact.

OBJECTIVE

The objective of this study was to review the literature on neuropsychiatric sequelae after surgical resection of brain tumors in children and adolescents.

METHODS

Using a scoping method, we reviewed empirical articles describing pediatric patients with brain tumors who underwent partial or total resection and examined major neuropsychiatric domains postoperatively over time.

RESULTS

The initial search yielded 15,543 articles. After duplicate removal, abstract screening, and review, 44 articles were included. Cognitive deficits were the most widely studied outcomes and found to be associated with tumor location, operative variables, perioperative complications, treatment types, and psychosocial factors. Cerebellar mutism, or posterior fossa syndrome, commonly co-occurred with emotional and behavioral dysregulation after posterior fossa resections. Depression, anxiety, and somatization were frequently grouped together as "distress," with higher rates among pediatric patients with brain tumor than among healthy peers. Problematic school behaviors, antisocial, and attention-deficit traits were increased; however, several other behaviors (e.g., risky sexual behaviors, substance use) were equal or lower when compared to peers. Posttraumatic stress disorder was highly prevalent and often interfered with social functioning. Delirium, eating disorders, and longer-term outcomes received inadequate attention.

CONCLUSION

Identifying risk factors of neuropsychiatric sequelae and their impact after pediatric brain tumor resection is important for prognostication and the development of tailored management strategies for these children and adolescents.

Proactive Integration of Mental Health Care in Hospital Medicine: PRIME Medicine

BACKGROUND

Proactive consultation-liaison (C-L) psychiatry has been shown to reduce hospital length of stay (LOS), increase psychiatric C-L consult rate, and improve hospital staff satisfaction. Nursing attrition has not been studied in relation to proactive C-L.

OBJECTIVE

Our primary aim in evaluating the proactive C-L service called Proactive Integration of Mental Health Care in Medicine (PRIME Medicine) is to analyze change in LOS over 10 months using historical and contemporary comparison cohorts. As secondary aims, we assess change in psychiatric consultation rate, time to consultation, and change in nurse attrition.

METHODS

PRIME Medicine was implemented in 3 hospital medicine units as a quality-improvement project. Team members systematically screened patients arriving to assigned units for psychiatric comorbidity. Identified patients were reviewed with hospitalist teams and nurses with the goal of early intervention.

RESULTS

Including historical and contemporary comparison cohorts, the mean sample age was 62.4 years (n = 8884). Absolute LOS was unchanged, but difference-in-difference analysis trended toward reduced LOS by 0.16 day (P = 0.08). Consultation rate increased from 1.6% (40 consults) to 7.4% (176 consults). Time to consultation was unchanged (4.0-3.8 d). Annual per-unit nursing turnover increased from 4.7 to 5.7 in PRIME units but from 8.5 to 12.0 in comparison units. Nurses citing "population" as the reason for leaving decreased from 2.7 to 1.7 in PRIME units but increased from 1.5 to 4.5 in comparison units. PRIME Medicine led to increased consultation rate, and our unit-wide outcomes provide a conservative estimate of effect. Factors that may have influenced effect size include our cohort's advanced age, considerable emergency department boarding times, increasing proportion of patients discharged to skilled nursing facilities, and concurrent LOS-reduction initiatives on all units. The favorable trends in nursing attrition on PRIME units may be explained in part by our prior finding that PRIME Medicine was associated with enhanced nursing satisfaction.

CONCLUSIONS

While PRIME Medicine had no more than a modest effect on LOS, it was associated with a markedly increased psychiatric consult rate and favorable trends in nursing retention. This analysis highlights important factors that should be considered when implementing and determining value metrics for a proactive C-L service.

Evaluation of Psychiatric Morbidity in COVID-19-Positive Inpatients Referred to Consultation Liaison Psychiatry in a Tertiary Care Hospital

BACKGROUND

The COVID-19 pandemic has led to the risk of common mental illnesses. Consultation liaison psychiatry has been one of the most requested services in the face of this pandemic. We aimed to assess (a) the prevalence of psychiatric illness, (b) different types of psychiatric diagnoses, (c) presenting complaints, (d) reasons for psychiatric referrals, and (e) psychiatric intervention done on COVID-19 positive inpatients referred to consultation liaison psychiatry at tertiary care hospital.

METHOD

This was a retrospective study of data collected from April 1, 2020, to September 15, 2020. Total 300 patients were referred and diagnosed with clinical interview and Diagnostic and Statistical Manual for Mental Disorder Fifth Edition criteria. Analysis was done using chi-square test, Kruskal-Wallis test, and fisher exact test.

RESULTS

Out of 300 patients, 26.7% had no psychiatric illness. Adjustment disorder was the commonest psychiatric diagnosis (43%), followed by delirium (10%). Statistically significant differences were found for parameters like Indian Council of Medical Research Category 4 of the patient, (hospitalized severe acute respiratory infection) (P value < 0.001), medical comorbidity (P value = 0.023), and past history of psychiatric consultation (Fisher exact test statistic value <0.001). Behavioral problem (27.6%) was the commonest reason for psychiatric referral. Worrying thoughts (23.3%) was the most frequent complaint. A total of 192 (64.3%) patients were offered pharmacotherapy.

CONCLUSIONS

Psychiatric morbidity was quite high (73.3%) among them and adjustment disorder was the commonest (43%) psychiatric diagnosis followed by delirium (10%). Pharmacotherapy was prescribed to 64.3% patients and psychosocial management was offered to most of the referred patients.

Pilot Assessment of Patient and Provider Characteristics Associated With Satisfactory Consultation-Liaison Telepsychiatry Encounters

Background

The COVID-19 pandemic created pressure to attempt remote consultation, but there are limited data on the use of telepsychiatry in general, and almost none about the experience of telepsychiatry in a consultation-liaison context.

Objective

We looked for attributes that correlated with satisfactory tele-encounters.

Methods

Eleven consultation-liaison attending surveys and 8 attendings' tele-encounter logs from March to June 2020 were completed and reviewed to assess for patient and provider characteristics associated with barriers to using telepsychiatry.

Results

A vast majority of 223 tele-psychiatric encounters were acceptable to providers in terms of technology (82%) and their ability to form a connection with the patient (78%). In multivariable logistic regression models, an unresolvable difficulty in using the platform was less common for female patients (odds ratio = 0.239, P = 0.002) and more common for patients who prefer a non-English language (odds ratio = 9.059, P < 0.001); achieving a personal connection that felt right was also less likely for patients who prefer a non-English language (odds ratio = 0.189, P = 0.001).

Conclusions

Telepsychiatry has previously been limited to outpatient use and, generally, for providers and patients who specifically preferred it. However, abrupt transition to the use of telepsychiatry to limit contagion risk was mostly satisfactory in our center; identifying for which patient encounters it is most and least appropriate will help guide future use.

Identifying the Most Important Consultation-Liaison Psychiatry Publications in 2020 Using a Novel Literature Assessment Instrument

BACKGROUND

As the science of consultation-liaison psychiatry advances, the Academy of Consultation-Liaison Psychiatry's Guidelines and Evidence-Based Medicine Subcommittee reviews articles of interest to help academy members remain familiar with the latest in evidence-based practice.

OBJECTIVE

We identify the 10 most important articles for clinical practice in consultation-liaison psychiatry from 2020 using the new Importance and Quality instrument for assessing scientific literature.

METHODS

The subcommittee published annotated abstracts for 97 articles on the academy website in 2020. Reviewers then rated all articles on clinical importance to practice and quality of scholarship using the Importance and Quality instrument. We describe the 10 articles with the highest aggregate scores and analyze the reliability of Importance and Quality instrument.

RESULTS

Twenty-four raters identified the top 10 scoring articles of 2020. These articles provide practical guidance on key areas of consultation-liaison psychiatry including management of COVID-19, lithium treatment for complex patients, medical risks among patients with severe mental illness, and substance use disorders in medical settings. The assessment instrument demonstrated good to excellent interrater reliability.

CONCLUSION

These articles offer valuable guidance for consultation-liaison psychiatrists regardless of their practice area. Collaborative literature reviews with standardized assessments help clinicians deliver evidence-based care and foster a high standard of practice across the specialty.

Adaptations Made to Pediatric Consultation-Liaison Psychiatry Service Delivery During the Early Months of the COVID-19 Pandemic: A North American Multisite Survey

BACKGROUND

The COVID-19 pandemic led to rapid changes in clinical service delivery across hospital systems nationally. Local realities and resources were key driving factors impacting workflow changes, including for pediatric consultation-liaison psychiatry service (PCLPS) providers.

OBJECTIVE

This study aims to describe the early changes implemented by 22 PCLPSs from the United States and Canada during the COVID-19 pandemic. Understanding similarities and differences in adaptations made to PCLPS care delivery can inform best practices and future models of care.

METHODS

A 20-point survey relating to PCLPS changes during the COVID-19 pandemic was sent to professional listservs. Baseline hospital demographics, hospital and PCLPS workflow changes, and PCLPS experience were collected from March 20 to April 28, 2020, and from August 18 to September 10, 2020. Qualitative data were collected from responding sites. An exploratory thematic analysis approach was used to analyze the qualitative data that were not dependent on predetermined coding themes. Descriptive statistics were calculated using Microsoft Excel.

RESULTS

Twenty-two academic hospitals in the United States and Canada responded to the survey, with an average of 303 beds/hospital. Most respondents (18/22) were children's hospitals. Despite differences in regional impact of COVID-19 and resource availability, there was significant overlap in respondent experiences. Restricted visitation to one caregiver, use of virtual rounding, ongoing trainee involvement, and an overall low number of COVID-positive pediatric patients were common. While there was variability in PCLPS care delivery occurring virtually versus in person, all respondents maintained some level of on-site presence. Technological limitations and pediatric provider preference led to increased on-site presence.

CONCLUSIONS

To our knowledge, this is the first multicenter study exploring pandemic-related PCLPS changes in North America. Findings of this study demonstrate that PCLPSs rapidly adapted to COVID-19 realities. Common themes emerged that may serve as a model for future practice. However, important gaps in understanding their effectiveness and acceptability need to be addressed. This multisite survey highlights the importance of establishing consensus through national professional organizations to inform provider and hospital practices.

Limitations of Traditional Models for Medical Decision-Making Capacity and Ethical Clinical Practice in Light of the SARS-CoV-2 Pandemic

The coronavirus disease 2019 (COVID-19) pandemic has upended psychiatric practice and poses unprecedented challenges for maintaining access to quality care. We discuss the ethical challenges of treating a patient with schizophrenia in need of hospitalization but who declined severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) surveillance testing. The traditional framework of capacity assessment depends on the patient’s ability to weigh risks and benefits, but this framework is of limited utility in context of the COVID-19 pandemic; the personal benefits of testing for the patient are unclear and in fact may not outweigh the risk of being declined psychiatric care. Moreover, classic capacity assessment does not well account for physicians’ obligations to other patients and the public health. We conclude that physicians cannot coerce surveillance testing, and we consider the implications of requiring SARS-CoV-2 testing for accessing mental health treatment.

Association between the timing of consultation-liaison psychiatry interventions and the length of stay in general hospital

BACKGROUND

Psychiatric comorbidities are frequent in patients admitted in general hospital and are associated with greater lengths of stay (LOS). Early consultation-liaison psychiatry (CLP) interventions may reduce the LOS but previous studies were underpowered to allow subgroup analyses and have generally not considered the severity of the condition for which patients were admitted ('disease severity').

AIMS

To investigate the association between the timing of CLP interventions and LOS in a general hospital.

METHOD

We retrospectively included 4500 consecutive patients admitted in non-psychiatric wards of a university hospital between 2008 and 2016 who had a first CLP intervention. We used general linear models to examine the association between the referral time, defined as log(days before the consultation)/log(LOS), and log(LOS), adjusting for age, gender, year of admission, place of residence, main psychiatric diagnosis, admission to the intensive care unit (ICU), main physical condition and disease severity.

RESULTS

Referral time was associated with log(LOS) (β = 0.31; P <0.001), notably for older patients (β = 0.43; P <0.001) and those admitted to the ICU (β = 0.50; P <0.001), but not for those with psychotic disorders (β = -0.20; P = 0.10). The association was confirmed when considering the expected LOS for each patient. For instance, for an expected LOS of 10 days, a CLP intervention on day 3 compared with day 6 was associated with a reduction of the actual LOS of 2.4 days.

CONCLUSIONS

Earlier CLP interventions were associated with a clinically significant shorter LOS in a large population even after adjusting for disease severity. Early CLP interventions may have benefits for both patients and health-related costs.

Culturally informed psychotherapy in Asian consultation-liaison psychiatry

Psychotherapy provides substantial benefits for patients with medical illness. Western-based psychotherapies are commonly practiced by consultation-liaison psychiatrists in Asia. Although such interventions benefit Asian patients, they are limited by their cultural applicability. Sociocultural factors shape the meaning, expression, and treatment of medical illnesses. In helping patients with medical problems, it is imperative that psychiatrists be mindful of the value of culture in their clinical work. The concept of the self, religion, spirituality, adaptation, coping, and defense mechanisms are all culturally determined. This article discusses how these concepts impact the practice of psychotherapy in the Asian consultation-liaison psychiatry setting. Currently, there is a dearth of systematic research about this subject matter. Most studies describe the application of Western-based psychotherapies for patients with medical illness with little input as to cultural modifications or implications of such interventions. The authors of this article identify culturally consonant psychotherapeutic techniques in the Asian consultation-liaison psychiatry context. Furthermore, they also propose general guidelines in the cultural adaptation of psychotherapy interventions or development of indigenous psychotherapies.

The Only Thing I Have to Fear Is Fear Itself

This autobiographical essay provides a discussion of how understanding being counterphobic limited the physician's ability to be realistically afraid during the intial phase of the COVID-19 pandemic.

Proactive Consultation-Liaison Psychiatry: American Psychiatric Association Resource Document

In 2019, the American Psychiatric Association Council on Consultation-Liaison (C-L) Psychiatry convened a work group to develop a resource document on proactive C-L psychiatry. A draft of this document was reviewed by the Council in July 2020, and a revised version was approved by this Council in September 2020. The accepted version was subsequently reviewed by the American Psychiatric Association Council on Health Care Systems and Financing in November 2020. The final version was approved by the Joint Reference Committee on November 24, 2020, and received approval for publication by the Board of Trustees on December 12, 2020. This resource document describes the historical context and modern trends that have given rise to the model of proactive C-L psychiatry. Styled as an inpatient corollary to outpatient collaborative care models, proactive C-L provides a framework of mental health care delivery in the general hospital designed to enhance mental health services to a broad range of patients. Its 4 elements include systematic screening for active mental health concerns, proactive interventions tailored to individual patients, team-based care delivery, and care integration with primary teams and services. Studies have found that proactive C-L psychiatry is associated with reduced hospital length of stay, enhanced psychiatric service utilization, reduced time to psychiatric consultation, and improved provider and nurse satisfaction. These favorable results encourage further studies that replicate and build upon these findings. Additional outcomes such as patient experience, health outcomes, and readmission rates deserve investigation. Further studies are also needed to examine a broader array of team compositions and the potential value of proactive C-L psychiatry to different hospital settings such as community hospitals, surgery, and critical care.

Teaching Psychopharmacology in the Medically Ill: A Problem-Based Learning Card Game for Consultation-Liaison Psychiatry Didactics

INTRODUCTION

Our educational report discusses a unique card game that provides an engaging, and competitive strategy for teaching psychopharmacology in the medically ill. It engages the players and helps them learn how to justify medical decisions in the context of complicated medical comorbidity.

METHODS

We describe a problem-based learning approach where learners are presented with randomized diagnoses and complications and are then forced to make prescription decisions for treatment from a limited and randomized supply of medication cards. Each round is facilitated by the teacher, who engages the teams and/or individual players in discussions regarding the rationale and justification of the medication decisions. These treatment plans are scored according to the appropriateness of the medication choice and the process is repeated.

DISCUSSION

The game is flexible regarding players' levels of education and has been played by medical students, psychiatry residents, and fellows throughout their years of training. Overall feedback has been positive from facilitators and trainees and the game has been a valuable source of engaging learners in the process of making complex medication decisions in the medically ill.

Association between discontinuation of benzodiazepine receptor agonists and post-operative delirium among inpatients with liaison intervention: A retrospective cohort study

BACKGROUND

Several studies have investigated the association between benzodiazepine receptor agonist (BZDRA) use during the perioperative period and an elevated incidence of delirium. However, no study has focused on the time course of BZDRA use, including continuation, discontinuation, initiation, and no use. This study aimed to examine the influence of the time course of BZDRA use on post-operative delirium.

METHODS

This retrospective cohort study was conducted by reviewing medical records. We included patients who were scheduled for surgery under general anesthesia and had been referred to a liaison psychiatrist for pre-operative psychiatric assessment. The patients were classified into four groups based on the pre- and post-operative time course of oral BZDRA use, as follows: continuation, discontinuation, initiation, and no use (never used). The primary outcome was the prevalence of post-operative delirium in non-intensive care unit settings. We also performed stratified analyses according to age, the presence of cognitive impairment, the presence of delirium history, and antipsychotic drug use on admission.

RESULTS

Among 250 patients, 78 (31%) developed post-operative delirium. The Discontinuation group had a higher rate of delirium (49%, 24/49) than the other groups (Continuation [14%, 4/29]; Initiation [38%, 3/8], Never used [29%, 47/164], p = 0.008).

CONCLUSIONS

Abrupt discontinuation of BZDRAs during the perioperative period may be a risk factor for post-operative delirium and should therefore be avoided.

Implementation of a Psychiatry Consultation-Liaison Service "Conseminar"

BACKGROUND

The field of consultation-liaison psychiatry has generated a relatively small number of rigorous clinical trials that guide clinical care. Consequently, there is a need for a consensus-building process to inform best practices for common clinical dilemmas in consultation-liaison psychiatry.

OBJECTIVE

We review several consensus-building approaches in academic medicine and describe a novel educational process called a "conseminar," which is intended to minimize the variability in teaching and practice on a service staffed by multiple faculty members.

METHODS

The conseminar is an iterative group exercise among faculty who attend on a consultation-liaison service. Faculty members generate a list of candidate topics and then prioritize those topics for a focused and critical literature review, aided by a librarian. In the absence of definitive clinical trial data or established practice guidelines, the faculty articulates a consensus "best-practice" approach and creates a brief document that summarizes specific recommendations for learners on the service.

CONCLUSIONS

The conseminar process can minimize variability among consultation-liaison faculty within a single institution with respect to the diagnostic and treatment recommendations conveyed to trainees. Furthermore, conseminar documents can be shared across institutions to promote more consistent teaching and practice within consultation-liaison psychiatry.

The Management Experiences, Priorities, and Challenges of Medical Directors in the Subspecialty of Consultation-Liaison Psychiatry: Results of a Needs Assessment

BACKGROUND

Medical directors need management skills, yet few studies describe the specific tasks that directors consider most important, their confidence for these tasks, and how their confidence develops. We studied these questions among directors in the subspecialty of Consultation-Liaison Psychiatry.

METHODS

A needs survey was sent to 48 registrants of a new forum for Consultation-Liaison Psychiatry directors. The survey asked about 6 professional experiences, the relative importance of 14 management tasks, and the directors' confidence in managing these tasks, using 7-point Likert scales. Correlations between experiences, task importance, and task confidence were performed.

RESULTS

Twenty-seven directors responded (56% response). The experiences that correlated most with management confidence were years in practice and health care leadership training, yet approximately half of responders were directors for ≤5 years and had received minimal training. Management tasks with the highest importance included demonstrating value of their service and roles for nonphysician clinical staff on their teams. Significant associations were identified between years in practice and confidence for leading faculty scholarship, trainee staffing ratios and roles, fee coding, measurement of faculty clinical productivity, and faculty recruitment. Leadership training correlated with confidence in demonstrating service value, measuring faculty clinical productivity, novel models of care, and growing a new service.

CONCLUSION

Consultation-Liaison directors with fewer years of experience and minimal health care management training need time and support to grow into their roles. They should be pointed toward training opportunities to improve their confidence to lead the wide range of management tasks that are important to their roles.

Consultation-Liaison Psychiatry During COVID-19 Lockdown: A Retrospective Chart Review

The coronavirus disease 2019 (COVID-19) pandemic has caused a major psychosocial impact in the community due to its direct effects and restrictive control strategies, e.g. lockdown. The current pandemic, a highly stressful situation, can predispose not only vulnerable but previously well-adjusted individuals for psychological disorders. A retrospective chart review of consultation-liaison psychiatry (CLP) case records was conducted for one month before and after the start of lockdown. Patients seen during lockdown were relatively younger; t = 1.8, p = 0.074. The most common psychiatric emergency was a suicidal attempt (34.3%) and delirium (35.4%) during and before lockdown, respectively. The probability of the emergency psychiatry presentation for attempted suicide increased significantly during lockdown (odds ratio (OR) 8.0, 95% CI 2.03 to 31.57, p = 0.003). The most common stressors for CLP patients with suicide attempts during lockdown were relationship issues and loss of privacy. It seems that stressors arising due to the current crisis are not only highly severe and multiple but qualitatively different. Further studies with larger sample sizes and from other parts of the country can further improve our understating of the psychological impact of the COVID-19 pandemic in the affected community. Needless to say, higher vigilance in the community for at-risk individuals, availability, and awareness about telemedicine services can play an important role to combat the risk of suicide during the lockdown.

Is Consultation-Liaison Psychiatry 'Getting Old'? How Psychiatry Referrals in the General Hospital Have Changed over 20 Years

There is an ever-growing awareness of the health-related special needs of older patients, and Consultation-Liaison Psychiatry Services (CLPS) are significantly involved in providing such age-friendly hospital care. CLPS perform psychiatric assessment for hospitalized patients with suspected medical-psychiatric comorbidity and support ward teams in a bio-psycho-social oriented care management. Changes in features of the population referred to a CLPS over a 20-year course were analysed and discussed, especially comparing older and younger referred subjects. Epidemiological and clinical data from all first psychiatric consultations carried out at the Modena (North of Italy) University Hospital CLPS in the period 2000–2019 (N = 19,278) were included; two groups of consultations were created according to the age of patients: OV65 (consultations for patients older than 64 years) and NONOV65 (all the rest of consultations). Consultations for OV65 were about 38.9% of the total assessments performed, with an average of approximately 375 per year, vs. the 589 performed for NOV65. The number of referrals for older patients significantly increased over the 20 years. The mean age and the male/female ratio of the sample changed significantly across the years in the whole sample as well as both among OV65 and NOV65. Urgent referrals were more frequent among NOV65 and the rate between urgent/non urgent referrals changed differently in the two subgroups. The analysis outlined recurring patterns that should guide future clinical, training and research activities.

Psychiatric presentation of patients with acute SARS-CoV-2 infection: a retrospective review of 50 consecutive patients seen by a consultation-liaison psychiatry team

BACKGROUND

Reports of psychiatric morbidity associated with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection tend to be limited by geography and patients' clinical status. Representative samples are needed to inform service planning and research.

AIMS

To describe the psychiatric morbidity associated with SARS-CoV-2 infection (confirmed by real-time polymerase chain reaction) in referrals to a consultation-liaison psychiatry service in Qatar.

METHOD

Retrospective review of 50 consecutive referrals.

RESULTS

Most patients were male. Median age was 39.5 years. Thirty-one patients were symptomatic (upper respiratory tract symptoms or pneumonia) for coronavirus disease 2019 (COVID-19) and 19 were asymptomatic (no characteristic physical symptoms of COVID-19 infection). Seventeen patients (34%) had a past psychiatric history including eight with bipolar I disorder or psychosis, all of whom relapsed. Thirty patients (60%) had physical comorbidity. The principal psychiatric diagnoses made by the consultation-liaison team were delirium (n = 13), psychosis (n = 9), acute stress reaction (n = 8), anxiety disorder (n = 8), depression (n = 8) and mania (n = 8). Delirium was confined to the COVID-19 symptomatic group (the exception being one asymptomatic patient with concurrent physical illness). The other psychiatric diagnoses spanned the symptomatic and asymptomatic patients with COVID. One patient with COVID-19 pneumonia experienced an ischaemic stroke. Approximately half the patients with mania and psychosis had no past psychiatric history. Three patients self-harmed. The commonest psychiatric symptoms were sleep disturbance (70%), anxiety (64%), agitation (50%), depressed mood (42%) and irritability (36%).

CONCLUSIONS

A wide range of psychiatric morbidity is associated with SARS-CoV-2 infection and is seen in symptomatic and asymptomatic individuals. Cases of psychosis and mania represented relapses in people with schizophrenia and bipolar disorder and also new onset cases.

The state of play - the first national survey of consultation-liaison psychiatry services in New Zealand

OBJECTIVE

The aim of this study was to conduct the first national survey of consultation-liaison psychiatry (CLP) services in New Zealand.

METHOD

An online survey based on the Multidimensional Matrix for Consultation-Liaison Psychiatry (mMAX-LP) was circulated to a psychiatrist at each of 12 identified CLP services nationally during April-May 2018. Existing data for Middlemore Hospital (where the lead author is based) were added later for completion.

RESULTS

Most CLP services in New Zealand are funded and managed by the mental health division, operate within office hours, and have psychologists and other allied health staff external to their service. However, there was significant heterogeneity amongst these services in terms of structure and function and in particular, the coverage of emergency departments and young/older patient groups.

CONCLUSION

This first national survey has provided a snapshot of CLP services in New Zealand in 2018 and found striking heterogeneity. The survey has established a baseline for future local and international comparisons.