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

A supervised consultation-Liaison psychiatry training model in a general hospital in China

Consultation-liaison (CL) psychiatry is becoming a recognized subspecialty in medical settings; it is a branch of psychiatry that addresses the treatment of the medically ill. Training for CL psychiatry is still insufficient in China. We introduce our training model, supervised CL based on the Union Psychosomatic Clinical Approach with Learning Exchange (UPSCALE) model, to improve consultation-liaison skills among psychiatrists. We describe the supervision process via a clinical case. The supervisee expresses learning needs, and the supervisor selects a consultation case and performs interviews via the UPSCALE model. After the interview, the doctors provide feedback to the patients and discuss the case. The experience includes reporting summaries and experience narratives from supervisees, as well as comments and guidance from supervisors. Through the supervised consultation-liaison training model, young psychiatrists have multiple opportunities to improve learning by observing, practising, and exchanging experiences in CL psychiatry.

Proactive Psychiatry: Innovating the Delivery of Consultation-Liaison Services in a Pediatric Hospital

BACKGROUND

The benefits of a proactive consultation-liaison psychiatry service have been well documented in the adult population, including decreased length of stay (LOS), increased satisfaction among physicians, and enhanced collaborative care. However, there is no available research on the effectiveness of this model in pediatric hospitals.

OBJECTIVE

This study compared patients aged 5-18 years on a general medical floor receiving a proactive psychiatry consult to concurrent controls receiving no consult and to historical controls receiving traditional reactive consults.

METHODS

New admissions to two pediatric general medical hospital teams were reviewed on weekday mornings to identify those with active psychiatric concerns. Adjusted negative binomial regression was used to compare the primary outcome of hospital LOS between the proactive (n = 65), concurrent control (n = 63), and reactive historical control (n = 45) groups. Patient satisfaction, hospitalist satisfaction, and recommendation concordance (degree to which psychiatry recommendations were implemented by the primary team) were also compared between groups as secondary outcome measures.

RESULTS

After adjusting for age, sex, race, insurance type, reason for consult, and medical diagnosis, concurrent control patients had 14% (P = 0.295) longer mean LOS than proactive consults, and historical controls had twice (P < 0.001) the mean LOS of those with proactive consults. Response rate for patient satisfaction scores was low, but responses were modestly more favorable among patients who received proactive consultation-liaison services. Based on nine paired pediatric hospitalist presurveys and postsurveys, follow-up surveys were statistically significantly more favorable after a proactive psychiatry consult service was introduced. Concordance of recommendations was observed to be higher for proactive consults than concurrent controls for diagnoses and nonmedication (other) recommendations.

CONCLUSIONS

The positive impact of a proactive consultation-liaison psychiatry consultation model was observed in a pediatric hospital and was associated with a lower LOS than concurrent controls and historical reactive consults, higher hospitalist satisfaction among paired responses, and greater concordance of diagnosis and other non-medication recommendations.

Patient and Medical Unit Staff Experiences of Proactive and Integrated Consultation-Liaison Psychiatry in The HOME Study: A Qualitative Investigation

BACKGROUND

Consultation-liaison (C-L) psychiatry services aim to help general hospital staff provide better care for their patients. Recently, many inpatient C-L psychiatry services have adopted proactive and integrated approaches to achieve this aim. Despite these developments, there have been no interview-based studies of patients' and staff members' experiences of the new approaches.

OBJECTIVE

To gain an in-depth understanding of patients' and medical unit staff members' experiences of a proactive and integrated C-L psychiatry service for older medical inpatients (Proactive Integrated C-L Psychiatry [PICLP]).

METHODS

We conducted an interview-based qualitative study with thematic analysis. The participants were patients and staff who had experienced PICLP during The HOME Study, a randomized trial that evaluated PICLP in 24 medical units of three UK general hospitals.

RESULTS

We conducted 97 interviews: 43 with patients or their proxies (family members who were interviewed on behalf of patients with significant cognitive impairment) and 54 with staff members of all relevant disciplines. Patients and staff both described how PICLP was a helpful addition to medical care and discharge planning. It enhanced the medical unit team's ability to address psychological, psychiatric, and social needs and provide patient-centered care. They welcomed proactive biopsychosocial assessments and the broader perspective that these offered on patients' complex problems. They also valued the integration of C-L psychiatrists into the unit teams and their daily contact with them. For patients, it fostered a therapeutic relationship and helped them to be more engaged in decisions about their medical care and discharge planning. For staff, it enabled ready access to psychiatric expertise and training opportunities. The few reported experiences of PICLP being unhelpful were mainly about the greater number of clinicians involved in patients' care and a lack of clarity about professional roles in the integrated team.

CONCLUSIONS

We found that older inpatients and medical unit staff experienced PICLP as both acceptable and generally helpful. Our findings add to the existing evidence for the benefits of proactive and integrated C-L psychiatry services.

The Effectiveness of Interventions on Improving the Mental Health Literacy of Health Care Professionals in General Hospitals: A Systematic Review of Randomized Controlled Trials

BACKGROUND

Suboptimal mental health literacy levels among general hospital health care professionals negatively impact the care coordination of patients with physical-mental comorbidity.

AIMS

This review is to examine the evidence on the effectiveness of interventions to improve the mental health literacy of general hospital health care professionals.

METHODS

A systematic search of literature was conducted in 13 electronic databases with manual searching of reference lists from 1980 to 2021. Studies were screened by pre-set eligibility criteria, that is, participants who were general hospital health care professionals taking care of adult patients, the interventions aimed at improving any components of participants' mental health literacy, comparisons were alternative active intervention or no intervention, and the primary outcomes were any aspects of mental health literacy.

RESULTS

Eight randomized controlled trials (N = 1,732 participants) were included in this review. Evidence indicated that mental health literacy interventions with educational components can improve components of the health care professionals' mental health literacy, in terms of mental health knowledge and mental illness-related attitudes/stigma. In addition, few studies evaluated all components of participants' mental health literacy.

CONCLUSIONS

Based on the available evidence, educational interventions had a positive effect on components of general hospital health care professionals' mental health literacy. Health care organizations should provide educational programs to enhance general hospital health care professionals' mental health literacy. Further studies are needed to explore interventions that target all components of general hospital staff's mental health literacy and to evaluate its impact on the psychiatric consultation-liaison service utilization in general hospitals, as well as patient outcomes.

Proactive and integrated consultation-liaison psychiatry for older medical inpatients: A mixed methods description of training, care provided and clinician experience in the HOME study

OBJECTIVES

To describe the practical experience of delivering a proactive and integrated consultation-liaison (C-L) psychiatry service model (PICLP). PICLP is designed for older medical inpatients and is explicitly biopsychosocial and discharge-focused. In this paper we report: (a) observations on the training of 15 clinicians (seven senior C-L psychiatrists and eight assisting clinicians) to deliver PICLP; (b) the care they provided to 1359 patients; (c) their experiences of working in this new way.

METHOD

A mixed methods observational study using quantitative and qualitative data, collected prospectively over two years as part of The HOME Study (a randomized trial comparing PICLP with usual care).

RESULTS

The clinicians were successfully trained to deliver PICLP according to the service manual. They proactively assessed all patients and found that most had multiple biopsychosocial problems impeding their timely discharge from hospital. They integrated with ward teams to provide a range of interventions aimed at addressing these problems. Delivering PICLP took a modest amount of clinical time, and the clinicians experienced it as both clinically valuable and professionally rewarding.

CONCLUSION

The experience of delivering PICLP highlights the special role that C-L psychiatry clinicians, working in a proactive and integrated way, can play in medical care.

Psychiatric Consults Associated With Longer Length of Stay in Trauma Patients-A Retrospective Study

INTRODUCTION

Mental illness is a risk factor for intentional and unintentional injury and is associated with readmission. The impact of psychiatric consults on length of stay (LOS) of trauma patients is still undergoing study.

METHODS

Trauma registry at Ascension St. Mary's of Saginaw, a community level 2 trauma center, was queried. Further chart review was performed to demographically characterize the control and intervention groups. Univariate and multivariate regression was performed to identify the association between psychiatric consultation and LOS while considering demographic variables and Injury Severity Score.

RESULTS

A total of 661 patients were identified with trauma and a documented mental health disorder. 612 did not receive a psychiatric consultation and 49 did. The group without a psychiatric consultation had a mean and median LOS of 6 d and 4 d, respectively, compared to 12 d and 10 d for those with a psychiatric consult (P < 0.0001). Mean ISS scores comparable across all groups. Delirium was associated with the highest LOS with a mean of 17.25 d and a median of 14.5 d. All 11 patients transferred to a psychiatric facility at discharge received a consult for self-harm.

CONCLUSIONS

Psychiatric consultations were associated with lengthened stay of trauma patients independent of initial injury severity and documented mental health disorders, and more transfers to inpatient psych facilities. This represents an important prognostic factor for a patient's course of care and suggests that trauma physicians should be well-versed at identifying mental health issues which may require early intervention, as well as managing delirium.

The prevalence of anxiety in adult endocrinology outpatients: A systematic review and meta-analysis

INTRODUCTION

Anxiety disorders and anxiety symptoms are common mental disorders in the medically unwell and have significant impacts on patients' quality of life and engagement with psychiatric and medical services. Several systematic reviews have examined the prevalence of anxiety in specific endocrinology settings with estimates varying significantly from study to study. No meta-analysis has examined anxiety rates across the endocrinology outpatient setting. The aim of this meta-analysis is to provide endocrinologists with a precise estimate of the prevalence of anxiety - and impacting factors - in their outpatient clinics.

METHOD

PubMed, Embase, Cochrane and PsycINFO databases and Google Scholar were searched to identify studies that assessed anxiety prevalence in endocrinology outpatients published up to 23 January 2023. This was part of a larger systematic review search of anxiety prevalence in common medical outpatient clinics. Data characteristics were extracted independently by two investigators. Studies of patients 16 years and older and representative of the clinic were included. The point prevalence of anxiety or anxiety symptoms was measured using validated self-report questionnaires or structured interviews. Risk of bias was assessed using the Joanna Briggs Institute Critical Appraisal Checklist. Pooled estimates were analysed under the random-effects model and subgroup analyses on relevant variables were conducted under a mixed-effects model. Heterogeneity was assessed using the I2 statistic.

RESULTS

Fifty-nine studies with a total of 25,176 participants across 37 countries were included in this study. The overall pooled prevalence of anxiety or anxiety symptoms was 25·1% (95%CI 21·4-29·2; 6372/25,176; n = 59). Subgroup analyses revealed no difference in prevalence between outpatients with diabetes mellitus compared to other grouped endocrine disorders. Generalized Anxiety Disorder (GAD) was the most frequent clinical diagnosis 11·7% (95%CI 8·1-16·7; I2=87·93%; 443/4604; n = 17), while panic disorder was significantly higher in the non-diabetes group 9·5% (95%CI 5·9-14·9; I2=57·28%; 56/588; n = 8), compared to the diabetes group 5·2% (95%CI 3·7-7·3; I2=32·18%; 184/3669; n = 6). Estimates of prevalence were higher when assessed with a self-report scale 32·4% (95%CI 25·6-40·0; I2=96·06%; 1565/4675; n = 21) compared to diagnostic interview 17·6% (95%CI 12·2-24·7; I2=94·39%; 636/5168; n = 21). Outpatients in developing countries had higher rates of anxiety than those in developed countries. Female diabetes patients reported higher rates of anxiety compared to males.

CONCLUSION

Our study provides evidence that anxiety occurs frequently amongst endocrinology outpatients and at a higher rate than is estimated in the general population. Given the impact anxiety has on patient outcomes, it is important that effective management strategies be developed to support endocrinologists in identifying and treating these conditions in their outpatient clinics.

Implementing a workflow-integrated motivational interviewing training program for psychiatry trainees on an inpatient consultation-liaison rotation: lessons learned

Background

Effective consultation-liaison psychiatry (CLP) is proactive, collaborative, and requires providers to have proficiency with therapeutic skills beyond nosology and medication management. Motivational interviewing (MI) is an evidenced-based intervention that should be considered essential for CLP trainees to learn. Given that the demands of training and patient care are already experienced as stressful for many psychiatry trainees, the authors endeavored to create a MI training program that was integrated into trainees' normal CLP workflow.

Method

Twenty-two trainees on an inpatient CLP rotation participated in a six-week MI training program that was incorporated into their regular workflow. The program included didactic sessions with role-playing, as well as on-demand between-session coaching via an expert in MI. Trainee participation and perceptions of MI were measured via a questionnaire that was administered prior to each training session.

Results

Trainee participation in the didactic sessions was inconsistent. Questionnaire data revealed positive baseline perceptions of motivational interviewing and its usefulness in inpatient medical settings. Additionally, as trainees participated in the program, perceived knowledge of motivational interviewing as well as awareness of motivational issues among their patients increased. Finally, participation in program was not perceived as disruptive to daily workflow for the participants.

Discussion

This the first documented attempt at implementing a MI training program for CLP trainees that was integrated into their regular workflow. Preliminary data identified some encouraging trends, but also unexpected challenges. These lessons could inform how these types of training programs are implemented moving forward.

Reliability and validity of the brief psychosomatic symptom scale (BPSS) in patients from general hospitals

OBJECTIVES

To verify the Brief Psychosomatic Symptom Scale (BPSS) among patients with psychosomatic-related disorders in general hospitals and determine the threshold of BPSS.

METHODS

The BPSS is a shortened 10-item version of the psychosomatic symptoms scale (PSSS). Data from 483 patients and 388 healthy controls were included for psychometric analyses. Internal consistency, construct validity, and factorial validity were verified. The threshold of BPSS in distinguishing psychosomatic patients from healthy controls were determined using receiver operating characteristic (ROC) curve analysis. The ROC curve of the BPSS was compared with that of the PSSS and patient health questionnaire-15 (PHQ-15) by using Venkatraman's method with 2000 times Monte-Carlo simulations.

RESULTS

The reliability of the BPSS was good with Cronbach's α of 0.831. BPSS was significantly correlated with PSSS (r = 0.886, P < 0.001), PHQ-15 (r = 0.752, P < 0.001), PHQ-9 (r = 0.757, P < 0.001) and GAD-7 (r = 0.715, P < 0.001), which indicated good construct validity. ROC analyses demonstrated that the AUC of the BPSS was comparable with that of PSSS. The gender-specific threshold of BPSS was determined as ≥8 in males and ≥ 9 in females.

CONCLUSIONS

The BPSS is a brief and validated instrument for screening common psychosomatic symptoms.

Quantifying consultations to medical specialties during psychiatric inpatient admissions in a Queensland tertiary hospital

OBJECTIVES

To identify and characterise medical consultations to psychiatric inpatients.

METHOD

Retrospective cross-sectional descriptive study of 451 psychiatric inpatients' electronic medical records between 1 January and 30 June 2021 with descriptive statistics.

RESULTS

Thirty one percent (n = 131) of inpatients required medical consultation, with 382 total consultations including ward call. Half (57.9%) were telephone advice. Main consulting specialties were general medicine (25%), anaesthetics (12%), neurology (9.9%), cardiology (6.5%) and endocrinology (6.2%). Almost all (99.0%) consultations resulted in documented management plans.

CONCLUSIONS

This is the first Australian descriptive study quantifying and characterising psychiatric inpatient consultation requests. Physical and psychiatric healthcare integration requires ongoing efforts, including improved referral pathways.

A comprehensive study of medically serious suicide attempts in France: incidence and associated factors

AIMS

People who make medically serious suicide attempts (MSSAs) share a number of features with those who die by suicide, and are at a high risk of suicide themselves. Studies to date have mostly focused on clinical samples of MSSAs. An epidemiological examination at a national level can help to identify risk profiles and pathways of care in this population.

METHODS

We explored the French nationwide hospital discharge database (Programme de Médicalisation des Systèmes d'Information, PMSI) to identify any MSSA taking place between 2012 and 2019. Relevant demographic and medical information was collected about the first MSSA of each attempter. Data from 2010 and 2011 were used to verify the absence of prior attempts.

RESULTS

First occurrences of MSSAs amounted to 81 959 cases over 8 years, with a mean age of 45.8 years, and 53.6% women. Incidence was higher in women (18.1 v. 17.3 per 1 00 000). The most common suicide method was deliberate self-poisoning (64.9% of cases). In comparison, violent methods associated higher mortality and comorbidity and were more frequent in men. The most common mental disorders were mood disorders (55.6%) and substance use disorders (46.2%). A minority of MSSA survivors were hospitalised in psychiatry (32.5%), mostly women.

CONCLUSIONS

MSSAs are frequent and easy to identify. There is a need to reinforce the continuity of psychiatric care for this population given the high risk of subsequent suicide, and the low rates of psychiatric hospitalisation after an MSSA even if violent methods are used. Specific care targeting this population could reduce treatment gaps.

The Prevalence of Psychiatric Disorders in General Hospital Inpatients: A Systematic Umbrella Review

BACKGROUND

To inform the future development of consultation-liaison psychiatry services, we need accurate information on the prevalence of psychiatric disorders in the general hospital inpatient setting. Systematic reviews have summarized the literature on specific aspects of this broad topic, but there has been no high-level overview that aggregates their findings and identifies gaps in the relevant literature.

OBJECTIVE

We aimed to produce a comprehensive overview of the field, summarizing the research literature on the prevalence of psychiatric disorders (i.e., interview-based psychiatric diagnoses) in general hospital inpatients. We did this using a systematic umbrella review (systematic review of systematic reviews), which is the best and most efficient method for summarizing a broad area of research.

METHODS

We searched Ovid Medline, Ovid Embase, Ovid PsycINFO, EBSCO CINAHL, and Scopus from database inception to September 2021 for systematic reviews that provided a pooled prevalence estimate, or prevalence range, for interview-diagnosed psychiatric disorders in general hospital inpatients. Two reviewers independently assessed articles and extracted data. The review is registered with PROSPERO, number CRD42019125574.

RESULTS

We screened 11,728 articles and included 10 systematic reviews in our umbrella review. We were able to extract pooled prevalence estimates from these as follows: major depression 12% to 20%, any anxiety disorder 8%, generalized anxiety disorder 5%, panic disorder 3%, delirium 15%. We were only able to extract a prevalence range for dementia, which was 3% to 63%. We found no systematic reviews from which we could extract prevalence data for the other psychiatric disorders that we included in our searches, indicating important gaps. From these data, we estimated that approximately one-third of inpatients have a psychiatric disorder.

CONCLUSIONS

Psychiatric disorders are very common in general hospital inpatients. While the planning of consultation-liaison psychiatry services will benefit from more research on the prevalence of each of the full range of disorders encountered in the inpatient setting, our findings indicate that we already know enough to justify increased and more population-based service provision.

Surgeons Attitude toward Psychosocial Aspects of Trapeziometacarpal Osteoarthritis

Background  There is notable evidence that unhelpful thoughts (symptoms of anxiety and depression) increase symptom intensity among patients with trapeziometacarpal osteoarthritis (TMC OA). Surgeons may or may not be mindful of this line of evidence when interacting with patients. In a survey-based experiment, we randomized surgeons to be prompted about the psychosocial aspects of TMC OA. We aimed to measure the influence of mindfulness of mental health on treatment recommendations and willingness to discuss mental health interventions. Methods  We randomized 121 hand surgeons to read one of two paragraphs: (A) about biomedical treatment options for TMC OA, or (B) about the impact of mental and social aspects on TMC OA. Thereafter, surgeons were asked several questions about their opinions and treatment recommendations. Results  We found that prompting surgeons with information about the psychosocial aspects of TMC OA did not influence their attitudes or treatment recommendations. Most surgeons were willing to offer patients a workbook (92%) or psychologist referral (84%). Among the few surgeons declining to refer, their reasoning was "it would not be of any help" and "stigmatization." Conclusion  The observation that a paragraph to encourage mindfulness about the psychosocial aspects of TMC OA, which had no influence on surgeon opinions, suggests that awareness may not be a major factor accounting the relatively limited implementation of this evidence in practice to date. Surgeons seem aware of the importance of psychological influence and barriers may include availability, stigma, and a sense of futility. This is a diagnostic study that reflects level of evidence III.

Anxiety/Depression Predominance in Liaison-Psychiatry Users of a South-East Mexico Tertiary Hospital

Patients at tertiary hospitals may find themselves in need of mental health support due to the distress associated with the illness that may or not lead to a psychiatric condition. Here is an overview of the clinical cases treated by the liaison psychiatry service of a public tertiary hospital from Southeast Mexico during its first years of operation (2008–2018), with the purpose of gathering information about the status and needs of this population. A sample of 304 clinical records of patients treated for the first time by the psychiatry service was reviewed, and the distribution by demographic characteristics, diagnosis of mental illness and medical area of reference was analyzed. Anxiety and depression symptoms were the most frequent. Most patients were women, lived in Merida and returned after the first appointment. The neurology service referred most patients, yet most attended directly. General tertiary hospitals should prioritize integrating ad hoc mental and physical health care. Adult women with a profile of anxiety and/or depression would be the first target group. Some areas of opportunity for further research and improvement of mental health services are: preventive services for anxiety and depression, follow-up of patients, attention to relatives of patients at intensive care units, implementation of telehealth alternatives, training on mental health screening and inter- and intra-institutional collaboration.

Knowledge and attitude towards home treatment among referring healthcare professionals and self-referring patients to a psychiatric hospital: Better information is needed

BACKGROUND

Home treatment (HT) is a patient-centred and cost-effective alternative to acute psychiatric inpatient care. However, the progress of its implementation and utilisation in routine care is slow.

AIMS

The aim of this study was to examine the knowledge and attitude towards HT among healthcare professionals.

METHOD

This observational study included telephone-based semi-structured interviews of 140 referring healthcare professionals including 35 self-referring patients to a large psychiatric hospital in Switzerland during 6 months in 2020. We assessed their knowledge, attitude and experience with HT along with sociodemographic characteristics, professional background and the intention for the referral. We completed the interviews with routine medical data of the referred patients such as diagnoses or symptom severity.

RESULTS

Regarding referrals for inpatient treatment (involuntary and voluntary), half of the referring healthcare professionals and 80% of the self-referring patients had no prior experience or knowledge of HT. Knowledge of HT differed in the order of the participants' working places. We found that most participants were uncertain about the inclusion/exclusion criteria for HT. Despite the low levels of knowledge, attitudes towards HT were overall positive.

CONCLUSIONS

Our results indicate that a proportion of the patients referred for inpatient treatment might have been eligible for HT too. The referring healthcare professionals' and patients' unfamiliarity and uncertainty with HT seems to be an important reason that home-based treatment approaches are still underused, although they are viewed very positively. Besides providing more information to potential referring health professionals, psychiatric hospitals should always carry out a standardized evaluation if HT is an option in patients who are referred for inpatient treatment.

Contact with the health care system prior to suicide: A nationwide population-based analysis using linkage national death certificates and national health insurance data

This study aimed to discover the proportion of people dying by suicide who had non-psychiatric medical contact alone or any mental health contact in the year, month, and week prior to suicide. Data on suicide deaths (n = 74,741) of all South Koreans from 2009 to 2013 were linked with National Health Insurance (NHI) data by social security number to identify health care contact during the 12 months prior to suicide. The NHI data includes records on inpatient or outpatient service and type of health care institutes which the decedents have contacted. Among the 74,741 individuals who died by suicide, the proportion of individuals who contacted non-psychiatric health care alone was 60.1%, 46.1%, and 35.5%; and the proportion of those who had any mental health contact was 27.9%, 18.0%, and 7.9% in the year, four weeks, and week before death, respectively. Psychiatric care visits in the year, four weeks and weeks prior to death occurred most frequently in psychiatric local clinics. Non-psychiatric care visits in the year and four weeks prior to death were most common in local clinics at the primary care level, but in the one week before death, non-psychiatric care visits were common in tertiary hospital departments. This study indicates that the majority of suicide cases are not diagnosed and managed preceding death despite high general medical contact rates. It implies that suicide prevention strategy should be applied to non-psychiatric medical settings in countries with high suicide rates like South Korea.

Analysis of the care provided over a six-month period by the liaison psychiatry unit at a general hospital in Lima, Peru

INTRODUCTION

Consultation-liaison psychiatry is a branch of clinical psychiatry that enables psychiatrists to carry out a series of activities within a general hospital. The number of liaison psychiatry units around the world has increased significantly, and Peru is no exception. However, this development is heterogeneous and unknown, so recent study reports are required to reveal the characteristics and details of the clinical care services provided by these units.

AIM

To describe and report the socio-demographic and clinical characteristics of patients evaluated in the Liaison Psychiatry Unit of the Guillermo Almenara Irigoyen National Hospital in Lima, Peru, and to analyse the symptomatic and syndromic nature of the identified conditions.

METHODS

Cross-sectional descriptive study. Referrals to the Liaison Psychiatry Unit of the Guillermo Almenara Irigoyen National Hospital between May and October 2019 were studied, and a factor analysis of the symptoms was conducted.

RESULTS

In a total of 400 referrals evaluated, the average age was 58 ± 17.09 years and 61.5% of the patients were women. The rate of psychiatric consultation was 2.73%. Internal medicine (13.9%) was the service that most frequently requested a psychiatric consultation. The disorder most frequently diagnosed was anxiety (44%), and the symptoms most frequently found were depression (45.3%), insomnia (44.5%), and anxiety (41.3%). The most used treatments were antidepressants (44.3%). The exploratory factor analysis of the symptoms showed three syndromic components: delirium, depression, and anxiety.

CONCLUSIONS

The typical patient of this sample is a woman in her late 50s, suffering from a non-psychiatric medical illness, and with anxiety disorders as the main diagnosis resulting from the psychiatric consultation.

Factors Associated With 7-Day Follow-Up Outpatient Mental Healthcare in Older Adults Hospitalized for Suicidal Ideation, Suicide Attempt, and Self-Harm

OBJECTIVE

Older adults are one of the fastest growing age groups seeking emergency care for suicidal ideation and self-harm. Timely follow-up outpatient mental healthcare is important to suicide prevention, yet little is known about predictors of care continuity following hospital discharge. This study identified patient-, hospital-, and regional-level factors associated with 7-day follow-up outpatient mental healthcare in suicidal older adults.

METHODS

Retrospective cohort analysis using 2015 Medicare data for adults aged ≥65 years hospitalized for suicidal ideation, suicide attempt, or deliberate self-harm (n = 27,257) linked with the American Hospital Association survey and Area Health Resource File. Rates and adjusted risk ratios stratified by patient, hospital, and regional variables were assessed for 7-day follow-up outpatient mental healthcare.

RESULTS

Overall, 30.3% of patients received follow-up mental healthcare within 7 days of discharge. However, follow-up rates were higher for patients with any mental healthcare within 30 days prehospitalization (43.7%) compared to patients with no recent mental healthcare (15.7%). Longer length of stay and care in psychiatric hospitals were associated with higher odds of follow-up. For patients with no mental healthcare in the 30 days prehospitalization, discharge from hospitals that were large, system-affiliated, academic medical centers, or provided hospitalist-based care were associated with lower odds of follow-up. Females were more likely to receive 7-day follow-up, whereas non-white patients were less likely to receive follow-up care.

CONCLUSION

Timely follow-up is influenced by multiple patient, hospital, and community characteristics. Findings highlight the need for quality improvement to promote successful transitions from inpatient to outpatient care.

Psychiatry's role in the prevention of post-intensive care mental health impairment: stakeholder survey

BACKGROUND

Many critical illness survivors experience new or worsening mental health impairments. Psychiatry consultation services can provide a critical role in identifying, addressing, and preventing mental health challenges during and after admission to the acute medical care setting. However, psychiatry involvement in the ICU setting is lower than in other hospital settings and the conventional process in many hospitals requires other care providers to request consultation by psychiatry. Despite these differences, no studies have sought ICU provider perspectives on psychiatry consultation's current and desired role. We aimed to obtain stakeholder feedback on psychiatry's current and desired roles in the ICU, and potential benefits and drawbacks of increasing psychiatry's presence.

METHODS

A web-based survey obtained perspectives from 373 critical care physicians and advance practice providers, bedside nurses, physical and occupational therapists, pharmacists, and consultation-liaison psychiatry physicians and advance practice providers at a tertiary care center using multiple choice and open-ended questions. Descriptive information and content analysis of qualitative data provided information on stakeholder perspectives.

RESULTS

Psychiatry's primary current role was seen as assistance with management of mental health issues (38%) and suicide risk assessments (23%). 46% wished for psychiatry's increased involvement in the ICU. Perceived benefits of increased psychiatry presence in the ICU included early psychological support in parallel with medical care, identification of psychiatric factors impacting treatment, and facilitation of family understanding of the patient's mental state/delirium. An additional perceived benefit included reduction in provider burnout through processing difficult situations and decreasing family psychological distress. However, one concern included potential conflict among providers regarding treatment.

CONCLUSIONS

Those who work closely with the critically ill patients think that increased psychological support in the ICU would be beneficial. By contrast, psychiatry's current involvement is seen to be limited, perhaps driven by varying perceptions of what psychiatry's role is or should be.

Incorporating Behavioral Health Providers onto Inpatient Medical Teams: A Feasibility Study

Behavioral health providers (BHPs) have long been incorporated into clinical medical settings, however, they have yet to be included in inpatient hospital settings. Inclusion of BHPs in this setting is logical given the high rates of psychosocial problems experienced by hospitalized patients and because BHPs can effectively treat psychosocial challenges, including mental health disorders and behavioral health difficulties. We worked to determine the feasibility of incorporating BHPs onto the inpatient medical team and to discover if integrating BHPs onto the team could decrease the barriers present in standard consult-liaison models of care. Researchers collected information on patient and provider satisfaction with BHP services and tracked admission diagnosis, reasons for referral, and interventions delivered. Results indicated that the integration of BHPs onto the inpatient team is feasible and reduces numerous barriers. The incorporation of BHPs onto inpatient medical teams can mitigate barriers experienced within the current consult-liaison model.

Changes of consultation-liaison psychiatry practice in Italian general hospitals: A comparative 20-year multicenter study

INTRODUCTION

Conducted under the auspices of the Italian Society of Consultation Liaison Psychiatry (SIPC) the aim of this study was to describe the characteristics of Consultation Liaison Psychiatry (CLP) activity in Italy (SIPC-2-2018) over the past 20 years by comparing with data from the first Italian nation-wide study (SIPC-1-1998).

METHODS

We collected data on CLP visits of 3,943 patients from 10 Italian hospitals over a period of 1 year. Data were compared with those from the SIPC-1 1998 study (4,183 participants). Patients were assessed with the same ad hoc 60-item Patient Registration Form recording information from five different areas: Sociodemographic, hospitalization-related, consultation-related, interventions and outcome.

RESULTS

Compared with participants from the previous study, SIPC-2-2018 participants were significantly older (d = 0.54) and hospitalized for a longer duration (d = 0.20). The current study detected an increase in the proportion of referrals from surgical wards and for individuals affected by onco-hematologic diseases. Depressive disorders still represented the most frequent psychiatric diagnosis, followed by adjustment and stress disorders and delirium/dementia. Also, CLP psychiatrists prescribed more often antidepressants (Φ = 0.13), antipsychotics (Φ = 0.09), mood stabilizers (Φ = 0.24), and less often benzodiazepines (Φ = 0.07).

CONCLUSION

CLP workload has increased considerably in the past 20 years in Italy, with changes in patient demographic and clinical characteristics. A trend toward increase in medication-based patient management was observed. These findings suggest that the psychiatric needs of patients admitted to the general hospital are more frequently addressed by referring physicians, although Italian CLP services still deserve better organization and autonomy.

General hospital specialists' attitudes toward psychiatry: a cross-sectional survey in seven countries

OBJECTIVE

Psychiatric comorbidities are common in physical illness and significantly affect health outcomes. Attitudes of general hospital doctors toward psychiatry are important as they influence referral patterns and quality of care. Little is known about these attitudes and their cultural correlates. The aim of this study was to identify attitudes toward psychiatry among general hospital specialists in relation to culture of the practice setting and other clinician factors (gender, age, seniority and specialty).

METHODS

A cross-sectional, descriptive study was carried out in seven countries (New Zealand, China, Sri Lanka, Russia, Israel, Brazil, the Netherlands). Data were collected from senior medical staff of various disciplines using an updated version of Mayou and Smith's (1986) self-administered questionnaire.

RESULTS

A total of 889 hospital doctors participated. While favourable attitudes toward both psychiatric consultation and management were endorsed by a majority, significant differences were also observed between countries. Subgroup differences were mostly confined to gender, acuity of practice setting and specialty. For example, female doctors in Russia (χ²=7.7, p=0.0056), China (χ²=9.2, p=0.0025) and the Netherlands (χ²=5.7, p=0.0174) endorsed more positive attitudes compared with their male counterparts, but this gender effect was not replicated in the total sample. Chronic care specialists were overall more inclined to manage patients' emotional problems compared with those working in acute care (χ²=70.8, p (adjusted)<0.0001), a significant finding seen also in individual countries (China, New Zealand, the Netherlands, Russia). Physicians were more favourably disposed toward psychiatry compared with other specialists, especially surgeons, in all countries except Israel.

CONCLUSIONS

This study adds to evidence for the association of medical attitudes with individual clinician factors and demonstrates that the influence of these factors varies by country. Understanding these issues may help to overcome barriers and improve quality of care provided to general hospital patients.

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.

A qualitative study to investigate Swiss hospital personnel's perceived importance of and experiences with patient's mental-somatic multimorbidities

BACKGROUND

Mental-somatic multimorbidity in general hospital settings is associated with long hospital stays, frequent rehospitalization, and a deterioration of disease course, thus, highlighting the need for treating hospital patients more holistically. However, there are several challenges to overcome to address mental health conditions in these settings. This study investigated hospital personnel's perceived importance of and experiences with mental-somatic multimorbidities of patients in hospital settings in Basel, Switzerland, with special consideration of the differences between physicians and nurses.

METHODS

Eighteen semi-structured interviews were conducted with nurses (n = 10) and physicians (n = 8) in different hospitals located in Basel, Switzerland. An inductive approach of the framework analysis was used to develop the themes.

RESULTS

Four themes emerged from the data analysis: 1) the relevance of mental-somatic multimorbidity within general hospitals, 2) health professionals managing their emotions towards mental health, 3) knowledge and competencies in treating patients with mental-somatic multimorbidity, and 4) interprofessional collaboration for handling mental-somatic multimorbidity in hospital settings.The mental-somatic multimorbidities in general hospital patients was found to be relevant among all hospital professionals, although the priority of mental health was higher for nurses than for physicians. This might have resulted from different working environments or in efficient interprofessional collaboration in general hospitals. Physicians and nurses both highlighted the difficulties of dealing with stigma, a lack of knowledge of mental disorders, the emphasis place on treating somatic disorders, and competing priorities and work availability, which all hindered the adequate handling of mental-somatic multimorbidity in general hospitals.

CONCLUSION

To support health professionals to integrate mental health into their work, proper environments within general hospitals are needed, such as private rooms in which to communicate with patients. In addition, changes in curriculums and continuing training are needed to improve the understanding of mental-somatic multimorbidities and reduce negative stereotypes. Similarly, interprofessional collaboration between health professionals needs to be strengthened to adequately identify and treat mentally multimorbid patients. A stronger focus should be placed on physicians to improve their competencies in considering patient mental health in their daily somatic treatment care.

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.

Mortality Rates during Hospitalization and Affecting Factors in Geriatric Delirium Patients: a Retrospective Cohort Study

Background and Purpose

The purpose of this study was to investigate the prevalence of mortality during hospitalization among patients diagnosed with delirium at geriatric consultations requested in the previous one year, together with the factors affecting this.

Methods

The electronic medical records of geriatric consultations requested from the psychiatry department between January 1, 2019 and December 31, 2019 were examined from the automation system. The 200 geriatric delirium patients were included in the study. Patients' age, sex, length of hospital stay (LOHS), time between hospitalization and consultation, the department requesting consultation, reason for consultation request, psychiatric recommendations after consultation, reason for hospitalization, number of comorbid medical diseases, number of daily medications used, and history of psychiatric disease were retrieved from the electronic medical records in the automation system.

Results

LOHS and time from hospitalization to consultation were longer in the exitus group. Numbers of comorbid disease and daily medications used were higher in the died patients. Male gender, higher numbers of comorbid diseases, and daily medications were predictors of death.

Conclusions

Early detection of delirium may be important for short term results of disease. When evaluating these patients, reviewing the drugs used as much as possible can affect the outcome of the disease.

Quality assessment of a consultation-liaison psychiatry service

BACKGROUND

Consultation-Liaison Psychiatry (CLP) provides services for patients with medical-psychiatric comorbidity at the general hospital. Referral satisfaction is considered as one of the most important outcome measures of CLP interventions. Our aim was to assess the levels of satisfaction with the CLP service amongst medical staff at a university hospital in Denmark.

METHODS

Medical staff answered an online survey regarding their experience with different aspects of inpatient and outpatient CLP services.

RESULTS

There were 152 responses from 16 medical units, with a survey return rate above 85%. Measured on a 5-point Likert scale, there was a median rating of 4 in response to questions regarding communication and organizational aspects, a median rating of 5 in response to questions regarding overall evaluation of the CLP service on both inpatient and outpatient questionnaire. The questions regarding treatment quality were rated with a median of 4 on the inpatient questionnaire and 2 of the outpatient questionnaire items, and with a median of 5 on 2 outpatient items. Physicians´ evaluations were statistically more positive than nurses´. As a group, respondents already employed before the CLP unit was established and those who used the CLP services more were statistically significantly more satisfied then respondents employed after the establishment of the CLP unit and those who used the CLP service less.

CONCLUSION

The CLP services were positively appreciated and considered to be valuable among medical hospital staff. We believe that Consultation-Liaison Psychiatry deserves further help to implement and expand its services in general hospital settings. In addition, our results underline the feasibility of surveys as quality measures of clinical care.

Initial assessment of patients with putative functional disorders in medical settings

Patients presenting with symptoms suggestive of functional disorder are very frequent in practice. While it is always necessary to exclude treatable organic pathology, there are important clues in the presentation that can help the clinician. In particular, it is important to identify pathological health anxiety early in assessment, as failure to do so may lead to unnecessary investigations and the dangerous path of reinforcing reassurance. Because full assessment of functional symptoms takes time, it is suggested that a clinical support nurse with some training in psychological management should be available to guide the management of the patients with these disorders. Such support nurses, based in the clinic, offer a seamless way of providing care that is not achieved by external referral to psychologists or equivalent staff.

Clinical Profile and Length of Hospital Stay in a Sample of Psychogeriatric Patients Referred to Consultation Liaison Psychiatric Unit

Background and objectives: There has been a recent increase in older patients admitted to general hospitals. A significant percentage of hospitalized older patients are ≥75 years old, which differ from the patients aged 65 to 74 years old in terms of functional status at patient discharge. This study aims to compare sociodemographic, clinical features, and factors associated with length of hospital stay in youngest-old and oldest-old populations of inpatients referred to the consultation liaison psychiatry unit. Material and methods: This is an observational, cross-sectional, retrospective, and comparative study. We obtained data from a sample of 1017 patients (≥65 years) admitted to a general hospital and referred from different services (medicine, surgery, etc.) to the consultation liaison psychiatry unit. The sample was divided into two groups of patients: youngest-old (65–74 years) and oldest-old (≥75 years). Psychiatric evaluations were performed while the patients were on wards at the hospital. Psychopharmacs were started as needed. A comparative analysis was carried out and predictive factors related to length of hospital stay were calculated. Results: The reference rate to consultation liaison psychiatry unit was 1.45% of the total older patients hospitalized. Our study demonstrates differences between the groups of older people: the oldest-old group were mainly female (p < 0.001), had more previous psychiatric diagnoses (p < 0.001), physical disabilities (p = 0.02), and neurocognitive disorders (p < 0.001), they used more antipsychotics (p < 0.001), and more frequently had a discharge disposition to a nursing home (p = 0.036). The presence of physical disability (beta = 0.07, p < 0.001) and logtime to referral to consultation liaison psychiatry unit (beta = 0.58, p < 0.001) were associated with increased length of hospital stay. Conclusions: Youngest-old and oldest-old people should be considered as two different types of patients when we consider clinical features. The time to referral to consultation liaison psychiatry unit seems to be a relevant factor associated with length of hospital stay.

When Mind Meets the Brain: Essentials of Well-Coordinated Management of Psychiatric Disorders in Neurological Diseases

BACKGROUND

The management of psychiatric disorders in neurological diseases (PDND) creates special challenges that cannot be adequately addressed by either psychiatry or neurology alone. However, the literature on clinician-friendly recommendations on how to coordinate neurological and psychiatric care is limited.

OBJECTIVE

This narrative review will provide practical instructions on how to efficiently integrate psychiatric and neurological care in inpatient management of PDND.

METHODS

We reviewed articles published as recently as January, 2021 in five electronic databases. We included articles that assessed human care, focused on adults, and examined how to better coordinate care between different medical specialties, particularly, between psychiatry and neurology.

RESULTS

Eighty-four manuscripts were included in this review, of which 23 (27%) discussed general principles of well-coordinated care of PDND in inpatient settings (first part of this review), and 61 (73%) were used to provide recommendations in specific neurological diseases (second part of this review).

CONCLUSIONS

General principles of well-coordinated care of PDND include recommendations for both the primary team (usually neurology) and the consulting team (psychiatry). Primary teams should delineate a specific question, establish roles, and follow up on the recommendations of the consulting team. Consultants should do their independent assessment, be organized and specific in their recommendations, and anticipate potential problems. One of the most important aspect to develop well-coordinated care is the establishment of clear, frank and, preferably oral, communication between the teams. Practical difficulties in the management of PDND include pharmacodynamic and pharmacokinetic interactions as well as mutual dependency between psychiatry and neurology.

Analysis of the Care Provided Over a Six-Month Period by the Liaison Psychiatry Unit at a General Hospital in Lima, Peru

INTRODUCTION

Consultation-liaison psychiatry is a branch of clinical psychiatry that enables psychiatrists to carry out a series of activities within a general hospital. The number of liaison psychiatry units around the world has increased significantly, and Peru is no exception. However, this development is heterogeneous and unknown, so recent study reports are required to reveal the characteristics and details of the clinical care services provided by these units.

AIM

To describe and report the socio-demographic and clinical characteristics of patients evaluated in the Liaison Psychiatry Unit of the Guillermo Almenara Irigoyen National Hospital in Lima, Peru, and to analyse the symptomatic and syndromic nature of the identified conditions.

METHODS

Cross-sectional descriptive study. Referrals to the Liaison Psychiatry Unit of the Guillermo Almenara Irigoyen National Hospital between May and October 2019 were studied, and a factor analysis of the symptoms was conducted.

RESULTS

In a total of 400 referrals evaluated, the average age was 58±17.09 years and 61.5% of the patients were women. The rate of psychiatric consultation was 2.73%. Internal medicine (13.9%) was the service that most frequently requested a psychiatric consultation. The disorder most frequently diagnosed was anxiety (44%), and the symptoms most frequently found were depression (45.3%), insomnia (44.5%), and anxiety (41.3%). The most used treatments were antidepressants (44.3%). The exploratory factor analysis of the symptoms showed three syndromic components: delirium, depression, and anxiety.

CONCLUSIONS

The typical patient of this sample is a woman in her late 50s, suffering from a non-psychiatric medical illness, and with anxiety disorders as the main diagnosis resulting from the psychiatric consultation.

Surgical experience for patients with serious mental illness: a qualitative study

BACKGROUND

People with serious mental illness (SMI) have significantly worse surgical outcomes compared to the general population. There are many contributing factors to this complex issue, however consideration of the surgical experience from the patient's own perspective has never been undertaken. This lack of understanding prevents the provision of truly patient centred care and may limit the impact of potential improvement initiatives. Therefore this study aims to describe and better understand the surgical experience from the perspective of patients with SMI.

METHODS

Within this qualitative study, semi-structured, audio-recorded interviews were conducted between August 2019 - June 2020, with 10 consenting participants with SMI who had surgery in the previous 2 years. A thematic analysis approach was used to explore both the positive and negative aspects of the participant's surgical experience commencing from pre-operative consultation to hospital discharge and follow-up.

RESULTS

Four main themes and related subthemes emerged including i) the perceived lack of mental ill health recognition, ii) highly variable patient and clinician interactions, iii) the impact of healthcare services, and iv) strategies for improvement.

CONCLUSION

Surgical patients with SMI want to be treated like everyone else whilst still having their mental ill health acknowledged and proactively managed despite this rarely occurring, which is valuable information for all surgical teams to consider and learn from. Participants were able to describe several readily implementable strategies to potentially improve their care and overall surgical experience, and as such highlight considerable opportunities for these to be tested and evaluated for this underserved patient group.

Consultation-Liaison Psychiatry Services in Ireland: A National Cross-Sectional Study

Objective: This study aimed to describe the provision of consultation-liaison psychiatry (CLP, also known as liaison psychiatry) services in acute hospitals in Ireland, and to measure it against recommended resourcing levels. Methods: This is a survey of all acute hospitals in Ireland with Emergency Departments, via an electronic survey sent by email and followed up by telephone calls for missing data. Data were collected on service configuration, activity, and resourcing. Data were collected from CLP or proxy services at all acute hospitals with an Emergency Department in Ireland (n = 29). This study measured staffing and activity levels where available. Results: None of the services met the minimum criteria set out by either national or international guidance per 500 bed general hospital. Conclusions: CLP is a relatively new specialty in Ireland, but there are clear international guidelines about the staffing levels required to run these services safely and effectively. In Ireland, despite clear national guidance on staffing levels, no services are staffed to the levels suggested as the minimum. It is likely that patients in Ireland's acute hospitals have worse outcomes, and hospitals have unnecessary costs, due to this lack. This is the first study of CLP provision in Ireland and demonstrates the resource constraints under which most services work and the heterogeneity of services nationally.

A survey of primary care practitioners' referral habits and recommendations of allergen-specific immunotherapy for canine and feline patients with atopic dermatitis

BACKGROUND

A recent pilot study of primary care veterinarians' attitudes regarding canine atopic dermatitis and initiation of allergen-specific immunotherapy (ASIT) revealed several barriers to specialist referral (in the USA) and use of ASIT as a treatment modality.

HYPOTHESIS/OBJECTIVES

The primary objective was to collect data on referral habits and ASIT practices among a much larger cohort of primary care veterinarians located around the world, and to explore barriers to referral and management of atopic diseases of dogs and cats with ASIT.

METHODS AND MATERIALS

An online survey, administered through the Veterinary Information Network (VIN, Davis, CA, USA), asked participants to self-report their referral habits and immunotherapy recommendations, and rate barriers and motivating factors using Likert-scale responses.

RESULTS

Of 827 survey responses, 97.6% identified as primary care practitioners. A larger number of practitioners (84.5%) reported seeing atopic dogs often, compared with atopic cats (9.7%). Fewer of these veterinarians (56.6%) referred atopic cats for specialist care, compared to atopic dogs (73.5%). Timely communication, sharing long-term management of the case, and provision of local continuing education were identified as factors associated with increased willingness to refer. A higher proportion of practitioners reported recommending ASIT for dogs (44.3%) than for cats (16.0%). Only 56.0% of respondents considered success rates of ASIT to be acceptable, while 27.9% were neutral on the topic.

CONCLUSIONS AND CLINICAL RELEVANCE

Dermatology specialists might build stronger relationships with referring veterinarians through timely case follow-up and provision of continuing education regarding the long-term benefits of ASIT and symptomatic management practices.

Proactive Integrated Consultation-Liaison Psychiatry: A new service model for the psychiatric care of general hospital inpatients

OBJECTIVE

To describe a new service model for the psychiatric care of general hospital inpatients, called Proactive Integrated Consultation-Liaison Psychiatry ('Proactive Integrated Psychological Medicine' in the UK).

METHOD

The new service model was developed especially for general hospital inpatient populations with multimorbidity, such as older medical inpatients. Its design was informed by the published literature and the clinical experience of C-L psychiatrists. It was operationalized by a process of iterative piloting.

RESULTS

The rationale for the new model and the principles underpinning it are outlined. Details of how to implement it, including a service manual and associated workbook, are provided. The training of clinicians to deliver it is described. The effectiveness and cost-effectiveness of this new service model is being evaluated. Whilst we have found it feasible to deliver and well-accepted by ward teams, potential challenges to its wider implementation are discussed.

CONCLUSION

Proactive Integrated Consultation-Liaison Psychiatry (PICLP) is a fusion of proactive consultation and integrated care, operationalized in a field-tested service manual. Initial experience indicates that it is feasible to deliver. Its effectiveness and cost effectiveness for older patients on acute medical wards is currently being evaluated in a large multicentre randomized controlled trial (The HOME Study).

The impact of increasing general hospital admissions on Consultation-Liaison Psychiatry

OBJECTIVE

The objective of this study was to identify changes in patients referred to CLP at a typical inner urban teaching hospital over two decades in the context of increased hospital admissions.

METHOD

Multivariate analyses were conducted on data collected for all referrals to CLP at Royal Melbourne Hospital between 1998 and 2017. Analyses were conducted with reason for referral, current psychiatric contact, psychiatric diagnosis, discharge destination and follow up as dependent variables, and the year and annual hospital admissions as independent variables.

RESULTS

Annual hospital admissions grew at a rate (4.6%), greater than the annual increase in beds (2.0%). Psychosis, suicide attempt, past psychiatric history and behaviour became more common reasons for referral, whilst depression and somatisation became less common. Transfers to and from mental health inpatient units increased.

CONCLUSIONS

An increasing proportion of patients seen by CLP have 'acute' problems. Patients with somatisation and depression are seen less frequently. These findings indicate that CLP services need to provide timely assessment and work closely with other elements of the local mental health service in order to optimise patient flow and ensure continuity of care. Local strategies may be required to ensure an adequate breadth of experience for trainees.

A pilot study to identify perceived barrier and motivating factors of primary veterinarians in the USA for specialty referral and management of atopic dermatitis with allergen-specific immunotherapy

BACKGROUND

Allergen-specific immunotherapy (ASIT) may decrease clinical signs and potential neosensitization in dogs with canine atopic dermatitis (cAD). Identification of barriers to referral and specialty level case management may improve clinical outcome and satisfaction for both clients and primary veterinarians.

HYPOTHESIS/OBJECTIVES

The objective of this cross-sectional, descriptive, survey-based pilot study was to identify factors influencing a veterinarian's decision to recommend dermatology referral and prescribe ASIT for management of cAD.

METHODS AND MATERIALS

An online survey was administered to small animal veterinarians through two veterinary associations in the western United States. Participants were asked to rate factors using Likert scales.

RESULTS

Of 60 responses, 18 (30%) rarely or never recommended ASIT. The top three factors against recommending ASIT included successful pharmaceutical management (100%), clients' concern for cost (94.4%) and veterinarians' perceptions that immunotherapy is unable to reduce pharmacological dependency (83.4%). The top three motivating factors included concerns for glucocorticoid adverse effects (83.3%), animal/owner quality of life (77.8%) and risk of antimicrobial resistant infection (55.6%). Results of the secondary objective revealed that 19 of 60 (31.7%) respondents rarely or never refer atopic pets to a dermatologist, citing cost of referral, availability of serological testing, and perception of limited benefits as the greatest barriers.

CONCLUSIONS AND CLINICAL SIGNIFICANCE

Numerous factors appear to influence decisions to recommend referral or ASIT for management of pets with cAD. Further work is needed to determine if these can be generalized to larger populations with a goal of providing suggestions to bridge these gaps and improve outcomes.

Challenges of Establishing a de novo Consultation-Liaison Psychiatry Service in a Tertiary Hospital: Practical considerations and challenges

Consultation-liaison psychiatry (CLP), also known as psychosomatic medicine, is a subspecialty of psychiatry that focuses on the care of patients with mental health disorders and general medical/surgical conditions. Integrating CLP services facilitates diagnosis and management of patients with complex comorbidities. This article aimed to report the practical considerations and challenges associated with establishing a de novo CLP service in a tertiary hospital in the Gulf region. This includes discussing the rationale and clinical and educational benefits as well as the resources required for establishing a CLP service.

Depression in the medically ill

BACKGROUND

Depressive disorders are significantly more common in the medically ill compared to the general population. Depression is associated with worsening of physical symptoms, greater healthcare utilization and poorer treatment adherence. The present paper provides a critical review on the assessment and management of depression in the medically ill.

METHODS

Relevant articles pertaining to depression in the medically ill were identified, reviewed and synthesized qualitatively. A systematic review was not performed due to the large breadth of this topic, making a meaningful summary of all published and unpublished studies not feasible. Notable studies were reviewed and synthesized by a diverse set of experts to provide a balanced summary.

RESULTS

Depression is frequently under-recognized in medical settings. Differential diagnoses include delirium, personality disorders and depressive disorders secondary to substances, medications or another medical condition. Depressive symptoms in the context of an adjustment disorder should be initially managed by supportive psychological approaches. Once a mild to moderate major depressive episode is identified, a stepped care approach should be implemented, starting with general psychoeducation, psychosocial interventions and ongoing monitoring. For moderate to severe symptoms, or mild symptoms that are not responding to low-intensity interventions, the use of antidepressants or higher intensity psychotherapeutic interventions should be considered. Psychotherapeutic interventions have demonstrated benefits with small to moderate effect sizes. Antidepressant medications have also demonstrated benefits with moderate effect sizes; however, special caution is needed in evaluating side effects, drug-drug interactions as well as dose adjustments due to impairment in hepatic metabolism and/or renal clearance. Novel interventions for the treatment of depression and other illness-related psychological symptoms (e.g. death anxiety, loss of dignity) are under investigation.

LIMITATIONS

Non-systematic review of the literature.

CONCLUSION

Replicated evidence has demonstrated a bidirectional interaction between depression and medical illness. Screening and stepped care using pharmacological and non-pharmacological interventions is merited.

Implementation of the CLiP database

PURPOSE

The purpose of this paper is to review the findings from an audit of the implementation of a consultation-liaison psychiatry (CLiP) database in all inpatients referred to a CLiP service at the largest hospital in Malaysia with the aim of improving the quality CLiP services.

DESIGN/METHODOLOGY/APPROACH

All inpatient referrals to the CLiP team were recorded over a three-month period and compared to previous audit data from 2017. Four audit standards were assessed: the reporting of referrals, timeliness of response indication of reason for referral and presence of a management plan.

FINDINGS

The compliance of reporting using the CLiP form was 70.1 per cent compared to 28 per cent in the audit data from 2017 after interventions were conducted. Analysis of the completed CLiP form reveals that 89 per cent of referrals were seen within the same working day. All referrals included the reason for referral. The most common reason for referral was for depressive disorders, but post-assessment, delirium was the most common diagnosis. In total, 87.8 per cent satisfied the audit criteria for a completed written care plan.

ORIGINALITY/VALUE

Specialised CLiP services are relatively new in Malaysia and this is the first paper to examine the quality of such services in the country. Interventions were effective in improving the compliance of reporting using the CLiP database. The findings suggest that the CLiP services are on par with international audit standards. Furthermore, data from this clinical audit can serve as a benchmark for the development of national operating policies in similar settings.

A systematic review of proactive psychiatric consultation on hospital length of stay

OBJECTIVE

Roughly half of general hospital patients may have a psychiatric issue that impacts care, yet most of these are not recognized during hospital admission. Proactive mental health screening offers an opportunity for timely identification and clinical attention to improve outcomes.

METHOD

We conducted a PRISMA systematic review of Pubmed, Embase, PsycINFO, and Cochrane Library for proactive models of psychiatric consultation to reduce hospital length of stay (LOS) in adult inpatients. For each study, we evaluated the level of evidence and defined the study sample, means of group allocation, screening process, interventions, and outcomes.

RESULTS

Of the 12 included studies, the 8 whose screening was informed by clinicians with mental health care expertise or whose providers were integrated with primary services reported a reduction in LOS. Two of these also reported favorable cost-benefit analyses. All positive studies represent versions of either psychiatrists embedded within medical or surgical settings or a multidisciplinary team-based model.

CONCLUSIONS

Proactive CL psychiatry with clinically-informed screening and integrated care delivery appear to reduce LOS. Further studies are needed to explore a broader range of outcomes, hospital populations beyond hospital medicine, and additional benefits of proactive integrated mental health care in the general hospital.

Consultation-liaison psychiatric service utilization by suicide attempters

CONTEXT

There is sparse Indian literature on consultation-liaison psychiatric (CLP) service utilization by suicide attempters who generally present first to the accident and emergency departments and are seen by the psychiatrist only after the initial stabilization.

AIMS

The aim of the study is to study the psychiatric referral, review, and psychopharmacological intervention rates among suicide attempters and to study factors associated with psychiatric referral.

SETTINGS AND DESIGN

Retrospective, medicolegal case register-based, explorative analysis of suicide attempters presents to a rural tertiary care hospital in south India.

SUBJECTS AND METHODS

Eight hundred and twenty-nine medicolegal case files of individuals whose diagnosis was recorded as either suicidal attempt, deliberate or intentional self-harm, and poisoning or hanging were analyzed for different variables.

STATISTICAL ANALYSIS USED

Descriptive frequencies, Pearson's Chi-square and logistic regression analysis to know the association of psychiatric referral with different variables, were performed using the Statistical Package for the Social Sciences, version 16.

RESULTS

A little more than half of the suspected suicide attempters (51.4%) were referred for psychiatric review, and majority of those referred (93.7%) were reviewed by the psychiatrist. Psychiatric referral was significantly associated with a relatively younger age, positive past and family history of suicidal behavior, mode of attempt (pesticide poisoning and attempted hanging were more likely to be referred), and a longer duration of hospitalization.

CONCLUSIONS

The low referral rate but an overwhelming review rate among those referred shows that probably referrer factors are responsible for this and so CLP for suicide attempters needs to be strengthened by sensitizing the referring doctors on the importance of the psychiatric referral and the need to avoid discharge within the first 24 h.