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.

Effects of Direct-Acting Antiviral Agents on the Mental Health of Patients with Chronic Hepatitis C: A Prospective Observational Study

In chronic hepatitis C (CHC) patients, interferon-based treatments showed toxicity, limited efficacy, and psychiatric manifestations. Direct-acting antiviral (DAA) agents appeared safer, though it remains unclear if they may exacerbate or foster mood symptoms in drug-naïve CHC patients. We evaluated 62 CHC patients' mental status, before and 12 weeks after DAA therapy, by assessment scales and psychometric instruments. We subdivided patients into two groups, CHC patients with (Group A) or without (Group B) a current and/or past psychiatric history. After DAA treatment, Group A patients showed low anxiety and improved depression, no variation in self-report distress, but worse general health perceptions. No significant difference emerged from coping strategies. Depression and anxiety improved in Group B, and no change emerged from total self-reported distress, except for somatization. Moreover, Group B increased problem-focused strategies for suppression of competing activities, and decreased strategies of instrumental social support. Contrarily, Group B reduced significantly emotion-focused strategies, such as acceptance and mental disengagement, and improved vitality, physical and social role functioning. DAA therapy is safe and free of hepatological and psychiatric side effects in CHC patients, regardless of current and/or past psychiatric history. In particular, patients without a psychiatric history also remarkably improved their quality of life.

Use of Clozapine in the General Hospital

Patients with treatment-resistant schizophrenia receiving clozapine therapy are at risk of potentially serious complications in the general hospital setting, due to the complex pharmacokinetic and pharmacodynamic profile of clozapine. We summarize common clinical challenges that face clinicians who care for clozapine patients in the general hospital, and make recommendations based on the available literature and clinical experience. Early collaborative management between consultation-liaison psychiatry and other clinical teams in the general hospital is paramount to improve clinical outcomes and avoid serious complications in this patient group.

Factors Affecting Psychiatry Resident Decision to Pursue Consultation-Liaison Psychiatry or Other Subspecialty Fellowship Training

BACKGROUND

There is a national shortage of psychiatrists with subspecialty fellowship training, and many fellowship positions are unfilled.

OBJECTIVE

We conducted a survey of US psychiatry residents to better understand the motivation to pursue fellowship training and to determine any specific factors that were particularly influential in choosing a fellowship in consultation-liaison (C-L) psychiatry.

METHODS

Online surveys were distributed electronically to US general psychiatry residents through the American Association of Directors of Psychiatric Residency Training list server.

RESULTS

A total of 219 questionnaires were completed. Interest in fellowship declined during residency training. Most important factors in consideration of fellowship training were lifestyle (89%), finances (69%), and academic opportunities (63%). Specific influential factors were residency experiences, attending staff as a role model, and medical school experiences. Most important discouraging factors were extra training time, financial concerns, and belief that fellowship training was not necessary. Only 30% of residents had outpatient C-L psychiatry experiences. Few residents belonged to any subspecialty organization or attended any subspecialty meeting. Residents interested in C-L psychiatry fellowships had lower expectation of increased salary than other residents. Outpatient practice settings were seen as preferable over inpatient settings by most residents.

CONCLUSIONS

Results of this survey suggest that enhancing consultation psychiatry exposure in medical school and residency with strong role models, outpatient C-L psychiatry experiences, facilitating subspecialty organization membership and meeting attendance, emphasizing academic opportunities of fellowship training, and improving remuneration for fellowship-trained psychiatrists might be important factors that could improve recruitment into C-L psychiatry and other psychiatric fellowships.

The Educational Value of Outpatient Consultation-Liaison Rotations: A White Paper From the Academy of Consultation-Liaison Psychiatry Residency Education Subcommittee

Background

As mental health services in outpatient medical clinics expand, psychiatrists must be trained to practice in these settings.

Objectives

The Academy of Consultation-Liaison Psychiatry residency education subcommittee convened a writing group with the goal of summarizing the current evidence about outpatient consultation-liaison psychiatry (CLP) training and providing a framework for CLP educators who are interested in developing outpatient CLP rotations within their programs.

Method

MEDLINE (via PubMed), Embase, and PsycINFO (via OVID) were reviewed each from inception to December 2019, for psychiatric CLP services in ambulatory settings that involved residents or fellows. The CLP education guidelines were reviewed for recommendations relevant to outpatient CLP. We also searched MedEd portal for published curriculums relevant to CLP. The group held 2 conferences to reach consensus about recommendations in setting up outpatient CLP rotations.

Results

Seventeen articles, 3 Academy of Consultation-Liaison Psychiatry–supported guidelines, and 8 online didactic resources were identified as directly reporting on the organization and/or impact of an outpatient CLP rotation. These manuscripts indicated that residents found outpatient CLP rotations effective and relevant to their future careers. However, the literature provided few recommendations for establishing formal outpatient CLP training experiences.

Conclusions

Outpatient CLP rotations offer multiple benefits for trainees, including exposure to specific clinical scenarios and therapeutic interventions applicable only in the outpatient setting, increased continuity of care, and the unique experience of providing liaison and education to non-mental health providers. The article outlines recommendations and examples for developing outpatient CLP rotations which CLP educators can incorporate in their programs.

Design and Implementation of a Regional Inpatient Psychiatry Unit for Patients who are Positive for Asymptomatic SARS-CoV-2

Background

Patients with psychiatric illnesses are particularly vulnerable to highly contagious, droplet-spread organisms such as SARS-CoV-2. Patients with mental illnesses may not be able to consistently follow up behavioral prescriptions to avoid contagion, and they are frequently found in settings with close contact and inadequate infection control, such as group homes, homeless shelters, residential rehabilitation centers, and correctional facilities. Furthermore, inpatient psychiatry settings are generally designed as communal spaces, with heavy emphasis on group and milieu therapies. As such, inpatient psychiatry services are vulnerable to rampant spread of contagion.

Objective

With this in mind, the authors outline the decision process and ultimate design and implementation of a regional inpatient psychiatry unit for patients infected with asymptomatic SARS-CoV-2 and share key points for consideration in implementing future units elsewhere.

Conclusion

A major takeaway point of the analysis is the particular expertise of trained experts in psychosomatic medicine for treating patients infected with SARS-CoV-2.

End-of-Life Care in Individuals With Serious Mental Illness

Background

Approximately 4.5% of the population live with serious mental illness (SMI), a term referring to mental health disorders that are chronic, impair function, and require ongoing treatment. People living with SMI are at risk of premature mortality relative to people without SMI. Chronic medical illnesses contribute significantly to mortality among individuals with SMI. The standard of care for individuals with serious medical illnesses includes palliative care. However, the provision of palliative care has not been operationalized for individuals with SMI.

Objectives

To review existing data on end-of-life and palliative care for individuals with serious medical illness and comorbid serious mental illness. To operationalize the role of the consultation-liaison (C-L) psychiatrist in such care, with a particular eye towards redressing disparities.

Methods

In this narrative review, we draw upon a review of the literature on end-of-life and palliative care provision for individuals with serious medical illness and comorbid serious medical illness. We also draw upon the experiences of the authors in formulating best practices for the care of such patients.

Results

Individuals with SMI are at risk of suboptimal end-of-life care. Patient, clinician, and system-level factors all contribute to disparities including decreased access to palliative care, uneven continued engagement with mental health services, and low rates of advance care planning. C-L psychiatrists can use their expertise at the intersection of medicine and psychiatry to address such disparities by (1) correcting misassumptions, (2) promoting advance care planning, (3) engaging long-term caregivers, (4) recognizing social needs, (5) ensuring ongoing access to psychiatric treatment, and (6) addressing suffering.

Conclusions

There are significant disparities in the end-of-life care of individuals with SMI. C-L psychiatrists have expertise to ally with medical providers and redress these disparities.

Updates in Consultation-Liaison Psychiatry: 2019

BACKGROUND

The scientific literature in consultation-liaison psychiatry continually expands, and remaining familiar with the most current literature is challenging for practicing clinicians. The Guidelines and Evidence-Based Medicine Subcommittee of the Academy of Consultation-Liaison Psychiatry writes quarterly annotations of articles of interest to help Academy members gain familiarity with the most current evidence-based practices. These annotations are available on the Academy Website.

OBJECTIVE

We identify the 10 most important manuscripts for clinical practice in consultation-liaison psychiatry from 2019.

METHODS

Sixty-four abstracts were authored in 2019. Manuscripts were rated on clinical relevance to practice and quality of scholarship. The 10 articles with the highest aggregate scores from 19 raters are described.

RESULTS

The resulting articles provide practical guidance for consultation psychiatrists on several topic areas including the treatment of substance use disorders.

CONCLUSION

We suggest that these clinical findings should be familiar to all consultation-liaison psychiatrists regardless of practice area. Regular article reviews and summaries help busy clinicians deliver cutting-edge care and maintain a high standard of care across the specialty.

Online Curriculum in Transplant Psychiatry

BACKGROUND

Transplant psychiatry is a subspecialty of consultation-liaison psychiatry that focused on evaluation, treatment, and research of mental health problems in organ transplant recipients and organ donors. To date, there is no literature about training programs that would ensure psychiatrists acquire the necessary knowledge and skills required to meet the clinical needs of these patients.

OBJECTIVES

The author describes the implementation of an online curriculum in transplant psychiatry created at the request of physicians located outside the United States.

METHOD

A 3-session online interactive course focused on knowledge relevant to transplant psychiatry was held in the fall of 2018. While the instructor was based in the United States, all attendees were located in Pakistan. The impact of the course was evaluated via precourse and postcourse surveys assessing knowledge level, interest in transplant psychiatry, and level of comfort with transplant psychiatry evaluations in the pretransplantation and posttransplantation settings.

RESULTS

Nine participants attended at least one of the 3 sessions, and 6 attended all 3 sessions. There were no significant events regarding the implementation of the curriculum. The response rate to the questionnaire was 100% before the course and 88.8% after the course. Precourse and postcourse tests indicated the curriculum had a positive impact on the level of knowledge and level of confidence in addressing problems relevant to transplant psychiatry.

CONCLUSIONS

Online curriculum for highly specialized areas of psychiatry is feasible and can have a positive impact on knowledge levels and confidence in addressing clinical challenges.

The multi-dimensional matrix for consultation-liaison psychiatry (mMAX-LP)

OBJECTIVE

Consultation-liaison psychiatry (CLP) services are particularly susceptible to heterogeneity, developing haphazardly in response to local interests and perceived need. This hampers the generalisability of comparisons between services in terms of service models, resource requirements and outcome data. The objective of this paper therefore is to chronicle the development of a method to meaningfully describe, map and compare different CLP services.

METHOD

A review of the literature was followed by multiple site visits in both New Zealand and England, and an extended process of consultation and feedback.

RESULTS

Sixteen dimensions common to CLP services were extracted to create a multi-dimensional matrix (mMAX-LP) which had three broad clusters (structure, coverage and relationship with physical health services). The model was applied and discussed with the previously visited hospitals over the succeeding five years. Additionally, the matrix was tested, and its utility demonstrated during the planned reconfiguration of CLP services at a large teaching hospital in South Auckland, New Zealand by tracking the evolution of CLP services.

CONCLUSIONS

mMAX-LP shows promise as a useful model for profiling and comparing CLP services; mapping their evolution over time; and sign-posting future service development.

Psychiatric and psychosocial implications in cancer care: the agenda of psycho-oncology

Because of the increasing global cancer burden and the WHO epidemiological estimation in terms of number of new cases, deaths and long-survivors worldwide, an interdisciplinary approach, including psychiatric and psychoncology care is mandatory in oncology. About 50% of cancer patients have in fact been shown to have psychiatric disorders, including clinically significant emotional distress and/or unrecognised or untreated psychosocial conditions as a consequence of cancer at some point during the cancer trajectory. These problems are associated with the patient's reduction of quality of life, impairment in social relationships, longer rehabilitation time, poor adherence to treatment and abnormal illness behaviour. Because of these reasons, the internationally recognised IPOS Standards of Quality Cancer Care underline that psychosocial cancer care should be recognised as a universal human right; that quality cancer care must integrate the psychosocial domain into routine care and that distress should be measured as the sixth vital sign after temperature, blood pressure, pulse, respiratory rate and pain. In spite of social inequalities still existing between countries in the organisation and implementation of psychosocial oncology, recommendations and guidelines are available regarding screening, assessment and intervention to psychiatric and psychosocial disorders across the trajectory of cancer. The clinical and political agenda of psychoncology as a mandatory component of a whole comprehensive person-centred approach to cancer should therefore be acknowledged in psychiatry.

Mental health care in oncology. Contemporary perspective on the psychosocial burden of cancer and evidence-based interventions

With cancer incidence increasing over time worldwide, attention to the burden of psychiatric and psychosocial consequences of the disease is now mandatory for both cancer and mental health care professionals. Psychiatric disorders have been shown to affect at least 30-35% of cancer patients during all phases of the disease trajectory, and differ in nature according to stage and type of cancer. Other clinically relevant distressing psychosocial and existential conditions (e.g. demoralisation, health anxiety, loss of meaning and existential distress) not included as 'disorders' in the usual diagnostic and nosological systems (i.e. meta-diagnostic conditions) have also been shown to be present in another 15-20% of cancer patients. In this editorial, we will present a summary of the extensive literature regarding the epidemiology of the several psychosocial disorders affecting cancer patients as a cause of distress and burden to be taken into consideration and addressed in cancer care through evidence-based intervention.

Advancing the Mission of Consultation-Liaison Psychiatry Through Innovation in Teaching

BACKGROUND

Consultation-liaison (C-L) psychiatry, similar to other medical specialties, relies on the education of students, residents, fellows, and life-long learners for growth of the field. C-L psychiatry is unique as it exists at the intersection of psychiatry with other medical subspecialties. Traditional teaching methods have been used in C-L psychiatry programs for more than 50 years, while technology has recently advanced as available resources and the learning styles of today's learners have evolved. A growing number of younger trainees are taking advantage of new ways to learn.

OBJECTIVES

We sought to examine both traditional and novel teaching methodologies and how each of these educational methodologies fits within adult learning theory and in the context of how digital natives learn about C-L psychiatry.

METHODS

In this narrative review, we drew upon the experiences of the authors as both life-long learners and educators. We then reviewed the literature pertaining to teaching methods that have been used in C-L psychiatry as well as emerging methods that could potentially be used in C-L psychiatry.

RESULTS

C-L psychiatry has used traditional teaching methods such as readings, didactic lectures, case-based rounds, and problem-based learning. Novel teaching methodologies such as teaching rotations, simulations, social media, podcasts, movie clubs, and the use of mobile tablet computers have been used in general psychiatry and other medical specialties, while literature specific to C-L psychiatry was sparse.

CONCLUSIONS

Opportunities abound to make use of new teaching methodologies and technologies to appeal to future generations of C-L psychiatrists.

Electroconvulsive therapy for trichotillomania in a bipolar patient

A recent review on the use of electroconvulsive therapy (ECT) in obsessive-compulsive-related disorders (OCRDs) identified reports of trichotillomania (TTM) in only three patients, but it did not describe the specific effect of ECT on hair-pulling behaviors. The authors present a case report of Mrs. A, a 77-year-old widowed housewife with a lifelong history of episodic TTM and bipolar disorder who was effectively treated with ECT. However, on each attempt to withdraw ECT, her condition deteriorated. Eventually, a decision was made to maintain ECT (one session every week), which resulted in no further relapse over the followup period. ECT shows some potential promise for reducing hair-pulling behaviors in the context of severe depression.

Cultural Humility for Consultation-Liaison Psychiatrists

BACKGROUND

Case presentation and analysis is a useful way to revisit key clinical themes, broad concepts, and teach others, especially when it comes to cross-cultural clinical issues. Patients from different cultural backgrounds tend to have different explanatory models of illnesses and related help seeking behaviors. Ineffective communication between clinicians and patients from nonmajority cultural groups may lead to less satisfaction with care and disparities in access to health care and in treatment outcomes.

CONCLUSIONS

To address health disparities, psychiatrists need to be able to understand the illness beliefs of all patients, particularly those from diverse cultural backgrounds. Using cultural humility to work with patients from all cultures by understanding the patients' values and preferences is a key attitude for successful cross-cultural clinical encounters.

Suicide Risk Screening in Pediatric Hospitals: Clinical Pathways to Address a Global Health Crisis

BACKGROUND

Youth suicide is on the rise worldwide. Most suicide decedents received healthcare services in the year before killing themselves. Standardized workflows for suicide risk screening in pediatric hospitals using validated tools can help with timely and appropriate intervention, while attending to The Joint Commission Sentinel Event Alert 56.

OBJECTIVE

Here we describe the first attempt to generate clinical pathways for patients presenting to pediatric emergency departments (EDs) and inpatient medical settings.

METHODS

The workgroup reviewed available evidence and generated a series of steps to be taken to feasibly screen medical patients presenting to hospitals. When evidence was limited, expert consensus was used. A standardized, iterative approach was utilized to create clinical pathways. Stakeholders reviewed initial drafts. Feedback was incorporated into the final pathway.

RESULTS

Clinical pathways were created for suicide risk screening in pediatric EDs and inpatient medical/surgical units. The pathway outlines a 3-tiered screening process utilizing the Ask Suicide-Screening Questions for initial screening, followed by a brief suicide safety assessment to determine if a full suicide risk assessment is warranted. This essential step helps conserve resources and decide upon appropriate interventions for each patient who screens positive. Detailed implementation guidelines along with scripts for provider training are included.

CONCLUSION

Youth suicide is a significant public health problem. Clinical pathways can empower hospital systems by providing a guide for feasible and effective suicide risk-screening implementation by using validated tools to identify patients at risk and apply appropriate interventions for those who screen positive. Outcomes assessment is essential to inform future iterations.

Psychosocial Predictors of Cognition in Bariatric Surgery

BACKGROUND

Obesity affects individuals worldwide and is currently the 5^th leading cause of death according to the WHO. Bariatric surgery is an effective strategy that produces durable long-term weight loss. There is a bidirectional interplay between mental health and obesity; with higher depression and anxiety in the obese population as well as significant effects on weight loss for people with mental health disorders.

OBJECTIVE

Our cross-sectional study aimed to examine psychosocial predictors of cognition for the pre-operative bariatric surgery population and its effect on work productivity.

METHODS

Demographic data, perceived cognitive deficits (PDQ-5), depression scale (PHQ-9), anxiety (GAD-7), Quality of life (SF36) and work impairment (LEAPS) was collected from 302 pre-operative bariatric surgery candidates at their initial assessment. Multiple regression was conducted with perceived cognitive deficits as the dependent variable. A secondary analysis was done controlling for anxiety and depression.

RESULTS

Variables that were significantly associated with perceived cognition were anxiety, depression, work productivity and overall mental health quality of life. Perceived cognition was also significantly associated with work impairment independent of mood symptoms.

DISCUSSION

Anxiety and depression are prevalent in the pre-operative bariatric surgery population, significantly affecting cognition, and should be routinely screened. Work performance was also affected by cognition in our population but the link between obesity and cognition needs to be further explored.

CONCLUSIONS

We identified a significant association between perceived cognition and psychosocial factors in pre-operative bariatric surgery candidates. Further studies will be needed to better explore obesity and its impact on cognition.

Screening for emotional disorders in patients with cancer using the Brief Symptom Inventory (BSI) and the BSI-18 versus a standardized psychiatric interview (the World Health Organization Composite International Diagnostic Interview)

BACKGROUND

Given the adverse consequences of psychiatric and psychosocial morbidity on the quality of life for patients with cancer, prompt detection of psychological symptoms is mandatory. The authors examined the properties and accuracy of the Brief Symptom Inventory (the 53-item version [BSI] and the 18-item version [BSI-18]) for the detection of psychiatric morbidity compared with the World Health Organization Composite International Diagnostic Interview (CIDI) for International Classification of Diseases-10th Revision psychiatric diagnoses.

METHODS

A convenience sample of 498 patients with newly diagnosed cancer who were recruited in cancer outpatient services participated in the CIDI interview and in BSI and BSI-18 assessments.

RESULTS

The prevalence of psychiatric morbidity was 39.75%. When participants were classified as cases using the BSI standard case rule, agreement with the CIDI was potentially acceptable (sensitivity, 72.7%; specificity, 88.7%). In contrast, the accuracy of the BSI-18 in identifying cases was poor according to the standard case rule, with very low sensitivity (29.3%) (misclassification rate, 28.7%). By using a first alternative case-rule system (a BSI-18 global severity index [GSI] T-score ≥57), sensitivity marginally improved (45%), whereas a second alternative case-rule system (a GSI T-score ≥50) significantly increased sensitivity (77.3%). In receiver operating characteristic curve analysis, a further cutoff GSI T-score ≥48 exhibited good discrimination levels (sensitivity, 82.3%; specificity, 72.4%). There were some differences in GSI cutoff T-scores according to the International Classification of Diseases-10th Revision diagnosis and sex.

CONCLUSIONS

The BSI appeared to have acceptable diagnostic accuracy compared with a standardized psychiatric interview. For the BSI-18, it is mandatory to use alternative case-rule systems, to identify patients with psychiatric morbidity. Cancer 2018;124:2415-26. © 2018 American Cancer Society.

Clinical Severity Alone Does Not Determine Disposition Decisions for Patients in the Emergency Department with Suicide Risk

BACKGROUND

Boarding of patients with suicide risk in emergency departments (EDs) negatively affects both patients and society. Factors other than clinical severity may frequently preclude safe outpatient dispositions among suicidal patients boarding for psychiatric admission in the ED.

OBJECTIVE

To determine the extent to which nonclinical factors preclude safe outpatient discharge from the ED among patients boarding for psychiatric admission based on suicide risk.

METHODS

A survey regarding the importance of 13 clinical and 19 nonclinical barriers to safe outpatient disposition was administered in the ED to 40 adults who were determined by psychiatrists to require inpatient level of psychiatric care due to suicide risk. A second survey regarding whether addressing the nonclinical factors would have enabled a safe outpatient disposition in each case was administered to the psychiatrists who evaluated each patient participant.

RESULTS

Out of 40 patient participants, 39 cited at least one nonclinical factor that could have enabled a safe outpatient disposition had it been correctable in the ED. According to the psychiatrists who made the decision to hospitalize, 10 (25%) of the patient participants could have been discharged had social support become available.

CONCLUSION

Both clinical and nonclinical factors affect disposition from the ED after an evaluation for suicide risk. Attention to nonclinical factors should be considered in programmatic efforts to reduce ED boarding of patients with suicide risk.