Diagnostic Agreement between Physicians and a Consultation-Liaison Psychiatry Team at a General Hospital: An Exploratory Study across 20 Years of Referrals

The 'revolving door' of mental illness: A meta-analysis and systematic review of current versus lifetime rates of psychological disorders

OBJECTIVES

Therapists have long observed a phenomenon referred to as the 'revolving door' of mental health services, in which individuals often develop, seek treatment for, and recover from multiple mental illnesses across their life. However, this has not been systematically examined. If this phenomenon is widespread, one would expect that the number of lifetime disorders would exceed that of current disorders. The aim of this meta-analysis was to test this hypothesis.

METHODS

A search was conducted of the following databases: MEDLINE, PsycINFO and Web of Science. In total, 38 studies were included in the current review; 27 of these contained sufficient quantitative data to be included in the meta-analysis, addressing the primary research aim. The remaining 11 studies were included in the systematic review only.

RESULTS

Meta-analyses of the 27 studies indicated that the average number of lifetime disorders was 1.84 times that of current disorders. Previous treatment significantly moderated this relationship, while the clinical nature of the sample did not. Examination of the remaining studies revealed common temporal sequences, indicating disorders which typically develop first or consequently to other disorders.

CONCLUSIONS

These findings provide support for the revolving door of mental illness, suggesting a need for transdiagnostic treatments and broader conceptualisation of relapse prevention.

Knowledge and dispensing practice of community pharmacists towards antipsychotic medicines in a Nigerian metropolitan city - a cross-sectional study

BACKGROUND

Antipsychotic drugs are prescription-only-medications which require valid prescriptions before it can be obtained from a pharmacy. On the other hand, community pharmacists in developing countries have sometimes been implicated in over-the-counter dispensing of prescription-only-medications.

OBJECTIVE

This study investigated the accessibility of antipsychotic drugs without prescriptions from community pharmacies, and the factors responsible for the over-the-counter dispensing of antipsychotics by community pharmacists.

METHODS

An exploratory cross-sectional mixed method survey design using pretested structured questionnaires among 119 community pharmacists, simulated patients in 119 community pharmacies, and one-on-one in-depth interview among eleven (11) community pharmacist-owners/superintendent pharmacists were utilized for data collection. The knowledge of the pharmacists on antipsychotics including classification, side effects, and dispensing practices were explored. Qualitative data was analyzed with thematic analysis, while quantitative data was analyzed using descriptive statistics.

RESULTS

Majority of the community pharmacists (87.4%) showed good knowledge of antipsychotics as it relates to the different classes and the side effects peculiar to each class. Antipsychotic medications were dispensed by 85 (71.4%) of community pharmacists without a prescription. One-on-one in-depth interview sessions with community pharmacist owners/superintendent pharmacists demonstrated that community pharmacists are knowledgeable about antipsychotics and their side effects. Reasons given for dispensing this class of drugs without prescription included emergencies, and knowledge of the person as being on the drugs long-term. About 4% pharmacists were adamant on dispensing only with prescription.

CONCLUSION

Community pharmacists in Ibadan metropolis readily dispense antipsychotics without valid prescriptions despite having an optimal knowledge about the negative implications of doing so. This could be due to weak legislation and regulation of drug laws. There is a need for more stringent regulations as well as adequate sensitization about the negative effects of inappropriate dispensing of prescription-only-medications.

The Management of Children and Youth With Pediatric Mental and Behavioral Health Emergencies

Mental and behavioral health (MBH) visits of children and youth to emergency departments are increasing in the United States. Reasons for these visits range from suicidal ideation, self-harm, and eating and substance use disorders to behavioral outbursts, aggression, and psychosis. Despite the increase in prevalence of these conditions, the capacity of the health care system to screen, diagnose, and manage these patients continues to decline. Several social determinants also contribute to great disparities in child and adolescent (youth) health, which affect MBH outcomes. In addition, resources and space for emergency physicians, physician assistants, nurse practitioners, and prehospital practitioners to manage these patients remain limited and inconsistent throughout the United States, as is financial compensation and payment for such services. This technical report discusses the role of physicians, physician assistants, and nurse practitioners, and provides guidance for the management of acute MBH emergencies in children and youth. Unintentional ingestions and substance use disorder are not within the scope of this report and are not specifically discussed.

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.

Variables associated with concordance or discordance for delirium diagnosis between referring and consulting physicians at a Tertiary Hospital in Colombia: Prospective observational study

Delirium is an acute state of impaired consciousness and a medical urgency. Its broad range of alterations in mental status make diagnosis challenging. Awareness and accurate provisional diagnosis by nonpsychiatric clinicians are important for prompt management. Because delirium symptoms overlap and mimic other neuropsychiatric conditions, a referral to a consultant psychiatrist is often needed. The aim of this study was to determine the discriminating variables that are associated with concordance or discordance for a DSM-5 delirium diagnosis made by the consultation/liaison (C/L) psychiatrist as compared to the referral diagnosis/reasons given by the referring physicians for inpatients from a Tertiary Hospital in a Latin-American country. Prospective study of a cohort of 399 consecutive patients admitted to any ward of a university hospital in Medellin-Colombia and referred by a specialist physician to the C/L Psychiatry service. Analyses for diagnostic concordance used a nested sample of 140 cases diagnosed with delirium by the psychiatrist. Two multivariate logistic models were run, for delirium diagnosis concordance and discordance between the referring physician and C/L psychiatrist. The referral diagnosis was concordant with that of Psychiatry in 90/140 patients in 64.3%, with 35.7% discordance. Increasing age (OR = 1.024) and internal medicine ward (OR = 3.0) were significantly related (Wald statistic P < .05) to concordance in the multivariate analysis whose model accuracy was 68.6%. Trauma/orthopedics ward (OR = 5.7) and SARS-CoV-2 infection (OR = 3.8) were important contributors to the model fit though not significant. Accuracy of the discordance model was 70.7%, where central nervous system (CNS) disorder (OR = 6.1) and referrals from ICU (OR = 4.9), surgery (OR = 4.6), neurology/neurosurgery (OR = 5.1) and another consultant (OR = 4.7) were significantly related (Wald statistic P < .05), while metabolic/endocrine disorder (OR = 2.7) was important for model fit, but not significant. Concordance for delirium diagnosis was higher from services where education, guidelines and working relationships with C/L Psychiatry could have contributed beneficially whereas, surprisingly, CNS disorders and neurology/neurosurgery services had higher discordance, as well as the ICU. Routine use of brief sensitive delirium assessment tools such as the DDT-Pro could enhance provisional delirium diagnosis.

Delirium in COVID-19 and post-liver transplant patients: an observational study

OBJECTIVE

Delirium is a major complication in hospitalised patients. This study aimed to compare the mortality trends of patients with delirium according to the underlying physical condition.

METHODS

Hospitalised patients diagnosed with delirium by the Modena Consultation-Liaison Psychiatry Service (Italy) during 2020 were enrolled. Three groups were identified: COVID; after orthotopic liver transplant (OLT); other conditions. The full medical records were screened to retrieve socio-demographic and clinical data. INTERMED score and Delirium Rating Scale were used to retrospectively rate bio-social-complexity and delirium severity. Early (20 days) and end of study (31^st January 2021) mortality were ascertained for each subject.

RESULTS

A total of 103 patients were enrolled. Patients hospitalised for COVID showed higher INTERMED scores (two-tailed t-test, p = 0.019) and higher 20-day mortality (HR = 3.68, p = 0.014). When considering a 1-year follow-up, the main predictor of mortality was patients' age in all three subgroups (HR = 1.06; p = 0.003).

CONCLUSION

Our results suggest that patients hospitalised for COVID-19 with delirium showed higher bio-psycho-social complexity and higher short-term mortality, regardless of the severity of delirium. OLT patients showed lower mortality and bio-psycho-social complexity, despite being still considered as 'complex', according to the INTERMED score. Future research should focus on understanding the underlying mechanisms in the relationship between delirium and mortality.Key pointsPatients hospitalised for COVID-19 with delirium were found at risk of higher short-term mortality and higher bio-psycho-social complexity.OLT patients showed lower overall mortality and lower bio-psycho-social complexity than the other two groups, despite being still in the 'complex' range according to the INTERMED score.Future research should assess the areas of impact of delirium in patients affected by COVID-19, considering short- and long-term outcomes.