Availability of psychiatric consultation-liaison services as an integral component of palliative care programs at Japanese cancer hospitals

Status of inpatient pain therapy using the example of a general and abdominal surgery normal ward - a prospective questionnaire study to review a pain therapy algorithm ("real-world data")

Objectives

The mean pain intensity for inpatient consultations, for example in cancer patients, is known. However, the proportion of necessary consultations in the total volume of patients of a ward or a hospital, the general pain intensity in a surgical ward and the relationship between pain medication, length of stay and therapeutic success are unknown. The aim of the study was to examine surgical patients in a single normal ward subclassified into various groups (-/+ surgery, ICU stay, cancer, consultation for pain therapy etc.) during half a year with regard to their pain. For this purpose, the pain score (NAS) was recorded daily for each patient during the entire hospital stay and the change was assessed over the clinical course.

Methods

In 2017, all consecutive new admissions to a normal ward of general surgery at a university hospital ("tertiary center") were monitored over half a year according to a standardized procedure. Pain severity (measured by the "Numeric rating scale" [NRS] respectively "Visual analogue scale" [VAS]) from admission to discharge was recorded, as well as the length of stay and the administered medication. Patient groups were sub-classified as surgery, intensive care unit, cancer and pain consultation. An algorithm in two parts (part 1, antipyretics and piritramide; part 2, WHO-scheme and psychotropic drugs), which was defined years before between surgeons and pain therapists, was pursued and consequently used as a basis for the evaluation of the therapeutic success.

Results

269 patients were included in the study. The mean pain intensity of all patients at admission was VAS 2.2. Most of the groups (non-cancer, intensive care unit [ICU], non-ICU, surgical intervention (=Operation [OP]), non-OP, pain intensity greater than VAS 3) were significantly reduced in pain at discharge. An exception in this context was patients with cancer-associated pain and, thus, initiated pain consultation.

Conclusions

Since three quarters of the consultation patients also reported cancer pain, it might be possible that the lack of treatment success in both the consultation and cancer groups is associated with cancer in these patients. However, it can be shown that the successfully treated groups (without ICU-based course) had a mean length of stay from 4.2 ± 3.9 up to 8.4 ± 8.1 days (d), while the two unsuccessfully treated groups experienced a longer stay (mean"cancer", 11.1 ± 9.4 d; mean"consulation", 14.2 ± 10.3 d). Twenty-one consultation patients, in whom it had been intended to improve pain intensity, could not be successfully treated despite adapted therapy - this can be considered a consequence of the low number of patients. Since the consultation patients were the only patient group treated with part 2 of the algorithm, it can be concluded that part 1 of the algorithm is sufficient for a mean length of stay up to 9 days. For all patients above this time point, a pain consultation with adaption of medical treatment should be considered.

Consultation-liaison psychiatry in Japan: a nationwide retrospective observational study

BACKGROUND

Consultation-liaison psychiatry (CLP)-professional psychiatric care provided to coordinate with surgical or medical treatment of inpatients with psychiatric disorders-was included in universal health coverage in Japan in 2012. Despite evidence of benefits of CLP, basic data and geographic distribution information regarding CLP at the national level remain unclear. This study aimed to 1) identify the geographic disparity of CLP in Japan and 2) investigate the association between number of consultations per CLP patient and region.

METHODS

We retrospectively analyzed anonymized data retrieved from the Japanese administrative inpatient database regarding inpatients who were provided CLP between April 2012 and March 2017. Demographic characteristics were summarized and geographic disparity by prefecture was visualized for fiscal years 2012 and 2016; we also summarized the data according to region. Multivariate linear regression analysis was used to investigate association between the number of consultations per CLP patient and region after adjusting for covariates.

RESULTS

Data from a total of 46,171 patients who received 138,866 CLP services were included. Results revealed more patients aged 75-84 years received CLPs than any other age group (29.7%) and the overall male/female ratio was 53:47 in 2016. In 2012 and 2016, 24.2 and 30.7% of CLP patients, respectively, were transferred to other hospitals; 9.7 and 8.8%, respectively, discharged due to the death. CLP services were provided in 14 prefectures in 2012 and 33 by 2016; 14 prefectures had no available CLP services. After adjusting for covariates, Tohoku (β = - 0.220, p < 0.034), Chugoku (β = - 0.160, p < 0.026), and Shikoku (β = - 0.555, p < 0.001) had a significant negative correlation with the number of consultations per CLP patient compared with Hokkaido region (an adjusted R square (R2) = 0.274).

CONCLUSIONS

Our study clarified the characteristics of patients in Japan who received CLPs and the geographic disparity in CLP services. Although 5 years had passed since CLP was introduced, the results imply wide availability of CLP nationally. The analysis data provided may inform future policies to improve CLP services.

Why are hospital doctors not referring to Consultation-Liaison Psychiatry? - a systemic review

BACKGROUND

Consultation-Liaison Psychiatry (CLP) is a subspecialty of psychiatry that provides care to inpatients under non-psychiatric care. Despite evidence of benefits of CLP for inpatients with psychiatric comorbidities, referral rates from hospital doctors remain low. This review aims to understand barriers to CLP inpatient referral as described in the literature.

METHODS

We searched on Medline, PsychINFO, CINAHL and SCOPUS, using MESH and the following keywords: 1) Consultation-Liaison Psychiatry, Consultation Liaison Psychiatry, Consultation Psychiatry, Liaison Psychiatry, Hospital Psychiatry, Psychosomatic Medicine, the 2) Referral, Consultation, Consultancy and 3) Inpatient, Hospitalized patient, Hospitalized patient. We considered papers published between 1 Jan 1965 and 30 Sep 2015 and all articles written in English that contribute to understanding of barriers to CLP referral were included.

RESULTS

Thirty-five eligible articles were found and they were grouped thematically into three categories: (1) Systemic factors; (2) Referrer factors; (3) Patient factors. Systemic factors that improves referrals include a dedicated CLP service, active CLP consultant and collaborative screening of patients. Referrer factors that increases referrals include doctors of internal medicine specialty and comfortable with CLP. Patients more likely to be referred tend to be young, has psychiatric history, live in an urban setting or has functional psychosis.

CONCLUSION

This is the first systematic review that examines factors that influence CLP inpatient referrals. Although there is research in this area, it is of limited quality. Education could be provided to hospital doctors to better recognise mental illness. Collaborative screening of vulnerable groups could prevent inpatients from missing out on psychiatric care. CLP clinicians should use the knowledge gained in this review to provide quality engagement with referrers.

Psychiatry trainees’ views and educational needs regarding the care of patients with a life-limiting illness

Objective:

People with a life-limiting physical illness experience high rates of significant psychological and psychiatric morbidity. Nevertheless, psychiatrists often report feeling ill-equipped to respond to the psychiatric needs of this population. Our aim was to explore psychiatry trainees’ views and educational needs regarding the care of patients with a life-limiting physical illness.

Method:

Using semistructured interviews, participants’ opinions were sought on the role of psychiatrists in the care of patients with a life-limiting illness and their caregivers, the challenges faced within the role, and the educational needs involved in providing care for these patients. Interviews were audiotaped, fully transcribed, and then subjected to thematic analysis.

Results:

A total of 17 psychiatry trainees were recruited through two large psychiatry training networks in New South Wales, Australia. There were contrasting views on the role of psychiatry in life-limiting illness. Some reported that a humanistic, supportive approach including elements of psychotherapy was helpful, even in the absence of a recognizable mental disorder. Those who reported a more biological and clinical stance (with a reliance on pharmacotherapy) tended to have a nihilistic view of psychiatric intervention in this setting. Trainees generally felt ill-prepared to talk to dying patients and felt there was an educational “famine” in this area of psychiatry. They expressed a desire for more training and thought that increased mentorship and case-based learning, including input from palliative care clinicians, would be most helpful.

Significance of Results:

Participants generally feel unprepared to care for patients with a life-limiting physical illness and have contrasting views on the role of psychiatry in this setting. Targeted education is required for psychiatry trainees in order to equip them to care for these patients.

Preliminary report of improved sleep quality in patients with dry eye disease after initiation of topical therapy

PURPOSE

Dry eye disease (DED) is potentially associated with sleep and mood disorders. This study evaluated sleep quality in patients with DED using a questionnaire-based survey before and after topical eyedrop treatment. The effectiveness of sleep and ophthalmic services in assisting with sleep problems in patients with eye disease was also assessed.

METHODS

Seventy-one consecutive patients with DED visiting eight general eye clinics in various locations answered a questionnaire containing the Pittsburgh Sleep Quality Index and Hospital Anxiety and Depression Scale. Photophobia and chronotype (morningness/eveningness) were also evaluated with two representative questions from established questionnaires (National Eye Institute Visual Function Questionnaire-25 and Morningness/Eveningness questionnaire). Follow-up evaluation was conducted by interview or mail 3-10 months after the initial evaluation. A sleep service was established in two eye clinics to identify possible ocular diseases related to sleep and mood disorders; it comprised a questionnaire, sleep diary, actigram, medical interviews, visual field testing, retinal ganglion cell layer thickness measurement, and DED examination.

RESULTS

Patients with newly diagnosed DED exhibited a greater improvement in sleep after DED treatment compared with patients with established DED. Improvement in Pittsburgh Sleep Quality Index was significant (P<0.05) and strongly correlated with improvement in Hospital Anxiety and Depression Scale (P<0.05) for new patients, but not for patients with established DED. Ten eye clinic patients visited the sleep service and nine of them had DED. They were successfully treated with eyedrops and sleep services, which included blue-light-shield eyewear and wearable blue-light therapy lamps according to their problem.

CONCLUSION

Sleep quality improved in patients with DED after topical treatment with or without the sleep service. Psychiatric treatment focusing on sleep disorders could be beneficial for patients with DED.

Effects of integrated psychosocial care for distress in cancer patients

BACKGROUND

Despite some clinical guidelines for incorporating integrated psychosocial care (combining psychological screening and psychological intervention, including adequate collaboration with mental health specialists) into routine oncology practice, definitive empirical evidence regarding the effectiveness of such care remains unavailable. Here the findings of recent experimental studies are reviewed to provide guidance regarding this issue.

METHODS

Comparative studies examining integrated psychosocial care were reviewed.

RESULTS

Studies examining interventions that include both screening and psychological care have produced contradictory results regarding effectiveness, but all the studies that have examined the effect of psychological care after the identification of distress using systematic screening have shown positive results.

CONCLUSIONS

Integrated psychosocial care may affect patients with significant distress, but the adequacy of introducing such care into routine oncology practice remains debatable.