Challenges in pharmacologic management of the hospitalized patient with psychiatric comorbidity

Impact of Abrupt Interruption of Home Psychotropic Medications at ICU Admission

Background: Abrupt discontinuation of home psychotropic medications is common among critically ill patients but may precipitate clinically significant withdrawal. Objective: To determine the percent of patients with interruptions in home psychotropic medications upon intensive care unit (ICU) admission and to identify outcomes associated with these interruptions. Methods: This was an institutional review board-approved, single-center, retrospective study of critically ill patients with a history of mental illness taking an antipsychotic or antidepressant medication. The primary outcome was the percent of patients with interruption in at least one home psychotropic medication for ≥24 hours upon ICU admission. Secondary outcomes included time to psychotropic re-initiation, percent of home psychotropic medications restarted in the ICU, ICU length of stay (LOS), delirium, withdrawal-related complications, need for acute antipsychotics or benzodiazepines, and reasons for psychotropic interruption. Results: Among 183 patients, 93 (50.8%) had interruptions in home psychotropic therapy for ≥24 hours upon ICU admission. Mean time to reinitiation of at least one psychotropic agent was 1.4 days, and 16.4% of patients did not have any home psychotropics restarted. Patients with psychotropic interruption had a longer ICU LOS (P = 0.01) and greater incidence of ICU delirium (P < 0.01). Withdrawal-related complications were similar between groups. Acute antipsychotic use was greater in patients with psychotropic interruption (P < 0.01). Acute benzodiazepine use was not different between groups (P = 0.87). Most patients did not have a documented reason for therapy interruption. Conclusion and Relevance: Unless contraindicated, clinicians should attempt to restart home psychotropic medications as soon as possible in critically ill patients.

Drug Interactions of Chronic Neuropsychiatric Drugs in Neuro-critical Care

Neuro psychiatric illnesses are commonly recognised these days in the intensive care especially with the increasing aging population and more intensive care admissions. However they are still inadequately diagnosed and treated disease entities as a majority of these patients do not seek the help of specialists psychiatrists Of course the number of drugs used in psychiatry has explosively increased in recent years. As a corollary to this, the phenomenon of drug- drug interaction between psychiatric drugs and other drugs has come to the forefront. Drug- drug interaction (DDI)) is the response (pharmacological or clinical) of altered drug effects or increase in adverse effects when two or more drugs are used simultaneously^1,2 This effect may be different from the usual action of the individual drugs when used alone. Potential drug- drug interaction (PDDI) are those where theoretically there may be an interaction between the drugs but have not clinically occurred.^1,2

Psychiatric consultation requests by inpatient medical teams: an observational study

Background

We describe the way psychiatric issues are addressed by inpatient medical teams through analysis of discussions of patients with behavioral health concerns and examination of teams’ subsequent consultation practices.

Methods

We observed morning rounds for nine inpatient medical teams for approximately month-long periods, for a total of 1941 observations. We compared discussions of patients admitted for behavioral health related medical conditions between those who did and did not receive a psychiatric consultation, developing categories to describe factors influencing consultation or other management.

Results

Out of 536 patients, 40 (7.5%) received a psychiatry consult. Evaluation of a known concern (i.e., substance use, affective disorder, or suicidal ideation) was the most common reason for referral (41.7%). Requests for medication review were second (30.6%). Thirty patients with concomitant behavioral and medical health issues did not receive a psychiatry consult. Cirrhosis with active substance use was the most common medical diagnosis (15), followed by alcohol withdrawal (9).

Conclusions

Four primary themes emerged from our data: positive identification of behavioral health issues by physicians, medication management as a primary reason for referral, patient preference in physician decision-making, and poor management of substance abuse. Our results identify two potential areas where skills-building for inpatient physicians could have a positive impact: management of medication and of substance abuse management.