New “Clinical Pearls” Added to Academy’s Online Resources

Four new “clinical pearls”—where members talk to camera about their specialist interest—are now online. They join a growing resource of knowledge and experience in specialty clinical areas relevant to all C-L psychiatrists.

Crisis/suicide safety planning for suicidal patients

Scott Simpson, MD, MPH, Denver Health Medical Center, Denver

Dr. Simpson says discussing a suicide safety plan is “a very powerful way to spend just a few minutes with your patient.”

Its three main elements are:

• Identifying a patient’s triggers.
• Identifying coping skills which the patient can use when those triggers occur.
• Identifying any caring contacts the patient may have who can help the patient use the crisis plan.

Dr. Simpson also identifies “red flags” which he defines as events patients customarily encounter that are concurrent with suicidal ideation, such as social withdrawal.

“This intervention, from start to finish, doesn’t take more than a few minutes,” he says, “and so timing is not a good reason not to do it, especially when you consider that this is a very effective way for improving patient outcomes, including from the point of view of reducing hospitalization, and reducing suicide attempts many months after you see a patient.”

Identifying and understanding malingering in patients

Mary Jo Fitz-Gerald, MD, MBA, DLFAPA, FACLP, LSUHSCS School of Medicine, Shreveport

Dr. Fitz-Gerald says that, in identifying patients who may be malingering, on the psychiatric continuum we’re looking at somatic symptom disorders, versus factitious disorders, versus malingering. What is motivating the patient distinguishes between the three.

Malingering, or outright deception, can occur related to disability claims and personal injury cases; or, in an emergency department especially, the patient may not be able to afford food and lodgings for the night. That is, “there is some obvious secondary gain.” Or, we may know the patient well, and may suspect that the patient’s presentation as suicidal does not match with their complaints.

So, how do you deal with it? First, says Dr. Fitz-Gerald: “You have to have a high index of suspicion.” Secondly, you may want to obtain collateral, such as by accessing the patient’s health records electronically, if available, from across the country.

But, even if your suspicions are aroused, “that in itself doesn’t mean [the patient’s] current complaints aren’t valid” and you still need to do a full risk assessment—and also take account of your own feelings at the time. She advises: “Take everything as serious when you are considering suicidality.”

The agitated traumatic brain injury patient

R. Brett Lloyd, MD, Northwestern University, Chicago

Dr. Lloyd addresses four ways to approach treatment for patients with brain injury who are agitated:

• What are the target symptoms and how do we measure the level of agitation?
• What are the differential diagnoses beyond the brain injury itself?
• What are the non-pharmacological measurement interventions we can employ—the mainstay treatment for these patients?
• What medication should be considered to address underlying pathology, while balancing the risk of non-intervention with potential risks from side-effects?

Moreover, treatment strategies need to be under regular review, he says. “In brain injury, things are evolving week to week as the patient’s brain is trying to heal, and while it [one treatment] may be essential one week, it should always be reconsidered whether it is still necessary.”

Dr. Lloyd starts his vignette by exploring the causes of brain injury and the neurological effects of brain injury—and how these can impact treatment. “One of the difficulties when we start to think about treating agitation is the fact that neurotransmitters are depleted and a lot of the medications we use as psychiatrists require some degree of integral transmitter systems.” In addition, secondary causes of injury, such as hydrocephalus or systemic infectious processes, impact how the brain is able to function and recover.

Agitation—anything from restlessness, to emotional inability or inattention, to violence—complicates treatment, through longer hospitalizations and rehabilitation; less likelihood that the patient will transition back home after a hospital stay; patients being correlated with lower cognitive scores; and patients, family members or staff being put at risk.

Schizophrenia and cardiovascular disease

Lisa Rosenthal, MD, FACLP, Northwestern University, Chicago

Dr. Rosenthal says that C-L psychiatrists can “make a great impact” by ensuring patients with schizophrenia are offered the same treatments and standards of care as their peers.

Evidence shows patients with schizophrenia are offered the same treatments and standards of care only about 50% of the time.

Such intervention by C-L psychiatrists will help to offset the elevated risk of death and shorter life expectancy of patients with schizophrenia.

“How do most people with schizophrenia die?” asks Dr. Rosenthal. “People with psychiatric illnesses share the same major causes of death as everyone else, particularly in higher income countries. This means that cardiovascular disease is the No.1 killer of humans on earth, and it is the No. 1 killer of patients with severe mental illness.”

About 30-40% of the elevated risk is due to suicide and injuries from accidents; but 60-70% is due to medical illnesses, the vast majority of which are cardiovascular diseases. These patients are also 7-10 times more likely to die of respiratory illnesses than their peers without schizophrenia.

So why aren’t patients with schizophrenia offered standard treatments and standard quality of care? Using a case study at her own institution, Dr. Rosenthal describes how some clinicians assume people with schizophrenia will not adhere to treatment plans.

“We don’t have quality evidence that supports that assumption,” she says.

Such evidence may exist for patients with psychiatric diagnoses such as severe depression, but two robust studies show that people with schizophrenia may actually have better adherence than their peers who do not have schizophrenia.

“We need to advocate for the holistic treatment of patients with psychotic disorders,” says Dr. Rosenthal. “This includes…standardized medical care.”

Many of our patients, she says, have fascinating biopsychosocial complexities—and, when caring for patients with so many complicated needs, we should remember principles of medical care: we need to pay attention to their morbidity and mortality.

At present, however, schizophrenia decreases longevity by 20 years.

The four new “pearls” are here.

Already online before these latest additions are: