Psychiatric comorbidities in adults with sickle cell disease: A narrative review

Although descriptions of quality of life and patient reports of mood in sickle cell disease (SCD) have become more common in the literature, less is known about psychiatric illness prevalence, presentation, and treatment, particularly for adults. We provide a narrative review of what is known about common and debilitating psychiatric conditions such as depression, anxiety, and cognitive impairment, specifically for adults with SCD. We discuss the limitations of the current evidence, make provisional recommendations, and identify opportunities for research and improved care.

The Stresses of Surrogate Decision-Making: Contributing Factors and Clinicians' Role in Mitigation

BACKGROUND

Surrogate Decision-Makers (surrogates) are frequently employed in decision-making for critically ill adults. There are insufficient data considering the surrogate experience, stress, and potential for mitigation.

METHODS

An anonymous online survey queried (1) medical situation (2) total stress (3) demographics (4) potential factors, including sources of information about patient wishes, external sources of support or competing stressors, and their interactions with the medical team through the experience.

RESULTS

108 respondents were included; 91 completed all items. Most respondents ranked their experience as a surrogate as one of the most stressful experiences of their lives; this was associated with whether it was an end-of-life decision (P = .003), Respondent Religion (P = .015), or religious or spiritual beliefs (P = .024), and having their own health problems (P = .008). On individual Likert responses, surrogates reported significant stress mitigation when they felt they had been helpful (P < .001), knew the patient's wishes (P = .0011), specifically discussed patient wishes (P < .001), or patient's wishes were documented (P < .001). Items about surrogate-team interaction also met significance, including the physician being communicative and available (P < .001), respectful (P = .007), honest (P < .001), and validating (P = .001).

CONCLUSIONS

Surrogate stress is an evolving area for research. Significant factors included relationship with the medical team, making this an important area for HPM to play a key role in mitigating surrogate stress.

Ensuring privacy in telemedicine: Ethical and clinical challenges

Data privacy in telemedicine has been extensively considered and reviewed in the literature, such as explorations of consent, who can access information, and the security of electronic systems. However, privacy breaches are also a potential concern in the physical setting and surroundings of the patient. Here we review clinical situations in which there is unanticipated loss of privacy, as well as potential physical and psychological safety concerns for the patient and others when privacy is limited. We identify ethical concerns and explore the challenges of supporting full true autonomous decision-making in this situation. We close with preliminary recommendations at the patient, clinician, and systems levels to help ensure privacy is maintained.

Expecting more: the case for incorporating fertility services into comprehensive sickle cell disease care

Assisted reproductive technologies (ART) are not yet systematically available to people with sickle cell disease or their parents. Fertility care for these groups requires addressing sickle cell disease-associated infertility risks, fertility preservation options, pregnancy possibilities and outcomes, and, when needed, infertility treatment. People with a chance of having a child with sickle cell disease can use in-vitro fertilisation with preimplantation genetic testing to conceive a child unaffected by sickle cell disease. Also, parents of children with sickle cell disease can use this technology to identify embryos to become potential future matched sibling donors for stem cell transplant. In the USA, disparities in fertility care for the sickle cell disease community are especially stark. Universal screening of newborn babies' identifies sickle cell disease and sickle cell trait, guidelines direct preconception genetic carrier screening, and standard-of-care fertility preserving options exist. However, potentially transformative treatments and cures for patients with sickle cell disease are not used due to iatrogenic infertility concerns. In diversely resourced care settings, obstacles to providing fertility care to people affected by sickle cell disease persist. In this Viewpoint, we contend that fertility care should be incorporated into the comprehensive care model for sickle cell disease, supporting alignment of treatment goals with reproductive life plans and delivering on the promise of individualised high-quality care for people with sickle cell disease and their families. We consider the obligation to provide fertility care in light of medical evidence, with acknowledgment of formidable obstacles to optimising care, and powerful historical and ethical considerations.

Consultation-Liaison Telepsychiatry: A Coded Thematic Analysis of Clinicians' Reported Experiences

BACKGROUND

Telepsychiatry is now common practice. Within consultation-liaison psychiatry (CLP), previous work has shown that telepsychiatry is feasible and satisfactory. To date, there has not been qualitative work done within CLP to describe the clinician's experience with telepsychiatry.

OBJECTIVE

This study aimed to perform a thematic analysis of clinicians' perceived benefits and limitations of providing telepsychiatry in CLP.

METHODS

An anonymous clinician survey querying demographics, education, training, technological experience, and practice characteristics was distributed via social media and professional listservs, the quantitative results of which are presented elsewhere. Two questions (What was the best/worst aspect of adapting to telepsychiatry?) required free-text responses; comments were allowed elsewhere. We performed a thematic analysis of the text responses because of its flexibility and ability to develop new insights. We synthesized and generated a codebook iteratively. Initial coding was completed by 3 co-authors independently, followed by discussion to build consensus. We used qualitative content analysis to better understand common trends and frequencies in the data. Saturation of themes was reached.

RESULTS

A total of 333 behavioral health clinicians completed the survey, including 197 CLP participants. Most respondents (98.5%) responded to at least 1 open-answer question, with 314 reporting the worst aspects of telepsychiatry and 315 reporting the best aspects. Respondents made insightful comments about boundaries, public health implications, and the need for training. We categorized the results into implications for practice, therapeutic relationship, and uniquely affected populations.

CONCLUSIONS

These results show that telepsychiatry has both unique benefits and limitations within CLP. Our work examines and describes these nuances. We believe that future use of telepsychiatry will be synergistic with in-person care and that the 2 modalities will be used together to maximize benefits. A public health focus on improving Internet access and simplifying interstate licensure would improve equitable access and utilization of outpatient telepsychiatry. Telepsychiatry can be successful for inpatient Consultation-Liaison work but requires thoughtful triage and teamwork.

Survey of Provider Experiences of Telepsychiatry and Tele-Consultation-Liaison Psychiatry

Background

The COVID-19 pandemic created pressure to implement telepsychiatry across practice models.

Objective

We sought to evaluate the overall success of this change and to identify what types of practice settings, provider groups, and patient groups were best served by telepsychiatry and telepsychotherapy utilization. We were particularly interested in how providers of consultation-liaison psychiatry adapted to remote care.

Methods

An anonymous provider survey querying demographics, education, training, technological experience, practice setting, treatment modalities, patient groups, transition process, and outcomes was made openly available via social media and professional listservs. We used multivariable regression modeling to evaluate for predictors of the positive outcomes of overall satisfaction, subjective ability to diagnose and treat patients adequately using exclusively telepsychiatric platforms, and patient satisfaction by proxy.

Results

Three hundred thirty-three respondents, mostly young (59.4% younger than 50 years), female (69.7%), and physicians (67.9%), completed the survey. One hundred ninety-seven (59.1%) worked in consultation-liaison psychiatry. Of the total, 85.9% gave affirmative answers to overall satisfaction. Multivariable linear regression models found that satisfaction was predicted by general comfort with technology (P < 0.001), but negatively correlated with having technical issues (P < 0.001), a priori skepticism (P < 0.001), clinician being male (P = 0.004), and treating LGBTQ+ patients (P = 0.022). Completeness was associated with having training in telehealth (P = 0.039) and general comfort with technology (P < 0.001) but negatively associated with treating LGBTQ+ patients (P = 0.024) or inpatients (P = 0.002). Patient satisfaction by proxy was positively associated with general comfort with technology (P < 0.001) and the respondent being a nonphysician (P = 0.004) and negatively associated with encountering a technical issue (P = 0.013) or treating inpatients (P = 0.045). Consultation-liaison psychiatrists had similar results overall and were more likely to have other staff assist in making televisits effective (mean [standard deviation]: −1.25 [3.57] versus −2.76 [3.27], P < 0.001) especially if consultative (mean [standard deviation]: −0.87 [3.67] versus −2.39 [3.01], P = 0.010).

Conclusions

This study suggests high rates of overall satisfaction in telepsychiatry adoption, even in consultation-liaison psychiatry. There is distinct benefit in bolstering training, providing technical support, and addressing skepticism. Future research should include patient surveys and control groups and should focus on vulnerable populations such as sexual and gender minorities.

Pilot Assessment of Patient and Provider Characteristics Associated With Satisfactory Consultation-Liaison Telepsychiatry Encounters

Background

The COVID-19 pandemic created pressure to attempt remote consultation, but there are limited data on the use of telepsychiatry in general, and almost none about the experience of telepsychiatry in a consultation-liaison context.

Objective

We looked for attributes that correlated with satisfactory tele-encounters.

Methods

Eleven consultation-liaison attending surveys and 8 attendings' tele-encounter logs from March to June 2020 were completed and reviewed to assess for patient and provider characteristics associated with barriers to using telepsychiatry.

Results

A vast majority of 223 tele-psychiatric encounters were acceptable to providers in terms of technology (82%) and their ability to form a connection with the patient (78%). In multivariable logistic regression models, an unresolvable difficulty in using the platform was less common for female patients (odds ratio = 0.239, P = 0.002) and more common for patients who prefer a non-English language (odds ratio = 9.059, P < 0.001); achieving a personal connection that felt right was also less likely for patients who prefer a non-English language (odds ratio = 0.189, P = 0.001).

Conclusions

Telepsychiatry has previously been limited to outpatient use and, generally, for providers and patients who specifically preferred it. However, abrupt transition to the use of telepsychiatry to limit contagion risk was mostly satisfactory in our center; identifying for which patient encounters it is most and least appropriate will help guide future use.