Consultation-liaison psychiatry services: A survey of medical institutes in India

Multicentered Evaluation of Palliative Care Pharmacists' Interventions and Outcomes in California

Introduction: The palliative care (PC) pharmacist's role within PC teams is increasingly recognized with favorable outcomes being reported. Methods: Retrospective study evaluated hospitalized adults seen by PC pharmacists, as part of PC consultation team at three California institutions. The primary objective was to categorize pharmacists' interventions. Secondary end points included length from admission to PC pharmacist involvement and symptom improvement following pharmacist intervention. Results: Data were collected for a total of 557 patients. Over the study period, the PC pharmacists provided 1466 medication recommendations and 2545 nonsymptom-based interventions. Average length of stay (LOS) was 15.6 days with mean time to PC service referral of 3.6 days. PC pharmacist consult occurred after a mean of 4.3 days after PC team consulted. LOS was significantly lower if seen by PC pharmacist within 72 hours of PC consultation, 12.3 days versus 24.5 days (p < 0.001), as well as when serving as lead clinician 9.3 days versus 15.5 days (p < 0.001). Achievement of severity goal was significantly higher at 24 and 72 hours assessment periods when received a medication recommendation for pain, dyspnea, anxiety, and constipation. Conclusion: PC pharmacists provide substantial transdisciplinary interventions. Significantly decreased LOS was found when PC pharmacist was involved within 72 hours of initial PC consultation and when served as lead clinician. Improved symptom goal attainment was demonstrated for pain, dyspnea, anxiety, and constipation. In summary, integration of a PC pharmacist on a PC team can be relied upon to provide patient-centered, transdisciplinary care and enhance symptom management.

Profile of Patients Seen in Consultation-Liaison Psychiatry in India: A Systematic Review

OBJECTIVES

This review aimed to evaluate all the published studies from India conducted in the consultation-liaison (CL) psychiatry setting to identify the diagnostic patterns and referral rates in this setting. Understanding the same can help in organizing the services and knowing the training needs.

MATERIALS AND METHODS

A thorough literature search was done in August 2020 using different search engines (PubMed, Medknow, and Google Scholar). This was followed by an individual search of various Indian Psychiatry journals and a hand search of references in the available articles. Only those studies that described patients referred to psychiatry services from various specialties were included.

RESULTS

A total of 33 studies were selected for the review. More than half of them were published in the last 5 years. Studies have primarily reported psychiatric profile medically ill inpatients referred to CL psychiatry services, with the majority of the studies reporting the number of patients seen for the duration of at least 1 year. The referral rates for inpatients across different institutes have varied from 0.01% to 3.6%. The referral rates from emergency set-ups have varied from 1.42% to 5.4%, and in outpatients, from 0.06% to 7.17%. The most commonly diagnosed psychiatric disorders across different studies include depression; organic disorders, including delirium; substance use; intentional self-harm; and anxiety disorders.

CONCLUSIONS

A limited number of studies have reported the profile of patients seen in CL psychiatry setups. Available data from these studies suggest that referral rates to psychiatry services from other specialists are dismal. There is an urgent need to change the focus of psychiatry training at both undergraduate and the postgraduate levels to enhance the psychiatric knowledge of physicians to improve psychiatry referrals.

Delirium prevalence point: an observational monocentric study in a tertiary university hospital

BACKGROUND

Delirium is a serious and common condition that needs an upgrade of the scientific and clinical attention.

AIM

To assess the delirium prevalence in an Italian university hospital.

METHODS

The monocentric 1-day observational study cohort has been conducted on March 15, 2018; the population was composed of adult hospitalized patients. All the eligible patients have been evaluated for the presence of delirium with the 4AT.

RESULTS

We enrolled 596 patients. Twenty-nine Acute and 3 Rehabilitation Units were involved in the study. The median age of the sample was 60 (IQR 48-74) and 52% (n = 313) were male. Patients from medical units were 42% (n = 252), from surgery units 41% (n = 249), and from rehabilitation units 15% (n = 95). Results of 4AT showed that 5.4% (n = 32) had delirium (4AT = 4), 12% (n = 73) had cognitive impairment (4AT = 1-3), and 82% (n = 491) had no delirium or cognitive impairment (4AT = 0). We found association between delirium and age, BMI, mortality at 30 days, and hospital mortality. Delirium was related with Barthel Index, dementia, and anticholinesterase inhibitors. About devices in use, we observed a correlation of delirium with central venous catheter, feeding tube, and urinary catheter. Physical restraints were also correlated to delirium.

CONCLUSIONS

We confirmed the presence of delirium across the hospital units, more in medical than in surgical ones. We found associations of delirium with conditions that limit movement, such as dementia, physical restraints, or devices. The development of delirium initiates a cascade of events culminating in the loss of independence and increased morbidity.

State of mental health services in various training centers in India during the lockdown and COVID-19 pandemic

BACKGROUND

There is some information from different developed coutries that mental health services have been badly affected by the COVID-19 pandemic. Little information is available from India.

AIM

The aim of this study was to evaluate the impact of lockdown and COVID-19 pandemic on mental health services in India's various training centers.

MATERIALS AND METHODS

In an online survey, information was collected from various training centers of India through E-mail or WhatsApp.

RESULTS

Responses were received from 109 institutes. The majority of the responses were received from state-funded government medical colleges and private medical colleges. Since the lockdown and COVID-19 pandemic, brain stimulation treatments have completed stopped. Other, most affected services included electroconvulsive therapy, inpatient services, outpatient services, and psychotherapy services. However, there was an expansion of teleconsultations services because of the lockdown and the COVID-19 pandemic. In three-fourth of the centers mental health services were being provided to the patients with COVID-19 infection. In most of the institutes, mental health professionals were involved at different levels in the COVID-19 responsibilities. These included providing helpline services to the general public, screening people in quarantine for mental health issues, providing clinical care to COVID-19 patients, screening health care workers (HCWs) for mental health issues, and training the HCWs.

CONCLUSION

COVID-19 pandemic and lockdown have led to the collapse of regular mental health services. The present study also shows that mental health professionals are playing a significant role in addressing the prevailing psychiatric morbidity, specifically related to the COVID-19 related issues, and taking care of the HCWs.

Delirium in hospitalized older adults

Delirium is a common and underdiagnosed problem in hospitalized older adults. It is associated with an increased risk of poor cognitive and functional outcomes, institutionalization, and death. Timely diagnosis of delirium and non-pharmacological prevention and management strategies can improve patient outcomes. The Confusion Assessment Method (CAM) is the most widely used clinical assessment tool for the diagnosis of delirium. Multiple variations of the CAM have been developed for ease of administration and for the unique needs of specific patient populations, including the 3-min diagnostic CAM (3D CAM), CAM-Intensive Care Unit (CAM-ICU), Delirium Triage Screen (DTS)/Brief CAM (b-CAM), 4AT tool, and ultrabrief delirium assessment. Strong evidence supports the effectiveness of nonpharmacologic strategies as the primary intervention for the prevention of delirium. Multicomponent delirium prevention strategies can reduce the incidence of delirium by 40%. Investigation of underlying medical precipitants and optimization of non-pharmacological interventions are first line in the management of delirium. Despite a lack of evidence supporting use of antipsychotics, low dose antipsychotics remain second line for off-label treatment of distressing psychoses and/or agitated behaviors that are refractory to non-pharmacological behavioral interventions and pose an imminent risk of harm to self or others. Any antipsychotic prescription for delirium should be accompanied by an appropriate taper plan. Follow up with primary care providers on discharge from hospital for ongoing screening of cognitive impairment is important.

Consultation-liaison psychiatry in India: Where to go from here?

Consultation-liaison psychiatry (CLP) is a young and upcoming subspecialty of psychiatry. When one looks at the history of CLP in India, the progress in the area of CLP paralleled that seen in various developed countries. However, over the years, compared to developed countries, CLP started lagging behind in India. In India, CLP services are mostly been provided as per the consultation model and true liaison model practice is missing. There has been meager research in the area of CLP in India, and there is marked heterogeneity in training across different centers. There is lack of specialized training programs in this country. Considering the increasing emphasis on providing person-centered care, there is a need to shift the focus of training from identifying and managing only primary psychiatric disorders to interphase of psychiatry and other disciplines.

Evaluation of psychiatry training in India: A survey of young psychiatrists under the aegis of research, education, and training foundation of Indian Psychiatric Society

AIM

The aim of this study is to assess the perception of the young psychiatrists (aged ≤45 years) about their training received during the postgraduate training period.

METHODOLOGY

An online E-mail survey using Survey Monkey electronic platform evaluated the perception of 451 psychiatrists about their own perception of training received during the postgraduation period.

RESULTS

About two-third (n = 308; 68.3%) of the respondents reported that their overall training was 'good' or 'very good'. However, training was rated as poor/very poor in subspecialties of child and adolescent psychiatry and geriatric psychiatry by 26.2% and 26.9% of the participants, respectively. Exposure/training was rated as "poor/very poor" by more than one-fifth of the participants in areas of repetitive transcranial magnetic stimulation and deep brain stimulation (69.9%), rehabilitation psychiatry (47%), forensic psychiatry (45.5%), psychodynamics (40.5%), neuroimaging (38.1%), psychotherapy (34.8%), orientation to private practice (26.9%), statistics (34.1%), writing skills (24.4%), ethical principles of research (23.5%), women mental health (23.3%), psychosexual medicine (22.7%), and research methodology (21.5%). Regarding academic activities involving writing skills, although majority (72.5%) of the participants reported being involved in writing case reports and half (50.3%) reported involvement in writing original articles, but exposure to writing other types of article was quite low. Training in different types psychotherapies in the form of adequate exposure, carrying out and supervision to different types of psychotherapy was inadequate/low for psychodynamic psychotherapies, rational emotive therapy, dialectical behavior therapy, eclectic psychotherapy, and other kind of therapies. A high proportion of respondents reported having good competence in the administration of modified electroconvulsive therapy and making presentation in academic fora just after passing degree from their institutes and at the time of survey (current competence). When comparisons were done between the different groups of institutes, significant difference was noted across all aspects of training.

CONCLUSIONS

The present survey reflects that there is a variation in the psychiatry training in India. Accordingly, it can be said that there is a need to develop a model for competency-based training program at the level of the Indian Psychiatric Society in consonance with training regulatory bodies like the Medical Council of India, which can be implemented across the country to harmonize the training.