Research: Being Trapped and Seeing No Way Out—Effects of Entrapment on Treatment Outcome in an Interdisciplinary Pain Treatment
Authors: Larissa Bläettler, et al.
Abstract/Extract: The authors, from Switzerland and Argentina, describe how they identified entrapment, and its decrease, as important statistical predictors of outcome in the treatment of chronic pain.
They say the feeling of entrapment often arises in the context of uncontrollable and/or chronic stress and is associated with various psychopathologies. Chronic pain patients may experience their situation as unremitting and inescapable.
Their study was of 189 patients with a chronic pain disorder where psychological factors played a decisive role in its severity, exacerbation, and maintenance.
Through treatment, significantly reduced levels of entrapment were observed, associated with decreases in psychological distress and pain-related interference at discharge.
Importance: In most cases, chronic pain does not occur in isolation, but is associated with various physical and psychiatric comorbidities. With a prevalence of 20-50%, depression is the most common comorbid mental disorder in chronic pain patients. Suicidality is also prevalent; approximately 20% have suicidal thoughts and 5-14% make suicide attempts.
Entrapment seems to play an influential role among different mental disorders and may be an important risk factor for future suicide attempts. The authors describe how, in a sample of patients who had previously attempted suicide, entrapment and the number of previous suicide attempts were the only significant multivariate predictors of re-hospitalization for self-injury over a period of four years, even after controlling for suicidal ideation, depression, and hopelessness.
Given the high comorbidity of chronic pain and depression, and increased suicidality associated with both, it is reasonable to expect entrapment to play an important role in psychopathology and treatment of chronic pain. “However, to our knowledge, entrapment has not been [comprehensively] investigated in chronic pain yet,” say the authors.
Availability: Pre-publication in the Journal of the Academy of Consultation-Liaison Psychiatry (JACLP).
Computational Linguistic Analysis Applied to a Semantic Fluency Task: A Replication Among First-Episode Psychosis Patients With and Without Derailment and Tangentiality
Authors: Benson Ku, MD, et al.
Abstract/Extract: Automated tools could be useful in measuring aspects of formal thought disorder in schizophrenia and related disorders, including derailment and tangentiality, say the authors.
A new automated tool, CoVec, measures the semantic similarity among words averaged in a five- and 10-word window (Coherence-5 and Coherence-10, respectively). A prior report demonstrated that it could differentiate between patients with those types of thought disorder and patients without them.
So, in this study, the authors attempted to replicate the initial findings using data from a different sample of patients hospitalized for initial evaluation of first-episode psychosis.
“We partially replicated the prior findings, showing that first-episode patients with derailment had significantly lower Coherence-5 and Coherence-10 compared with patients without derailment,” say the authors. “Further research is warranted on this and other highly reliable and objective methods of detecting formal thought disorder through simple assessments such as semantic fluency tasks.”
Importance: Both derailment and tangentiality can be subjectively rated using the Scale for the Assessment of Positive Symptoms after a clinical research interview—but to date no automated tools for this purpose are believed to exist.
Availability: Pre-publication in Psychiatry Research.
Research: C-L Case Conference: A 73-Year-Old Man with ‘Altered Mental Status’ and Agitation
Authors: Diana Punko, MD, et al.
Abstract/Extract: The authors present a common clinical scenario of a patient with hyperactive delirium attributed to urinary tract infection and discuss the case through review of literature to teach general principles in evaluation and management of delirium.
A systematic approach to delirium includes screening, chart review, collateral interview, and the psychiatrist’s physical examination. The only definitive treatment of delirium is to diagnose and address underlying pathology, say the authors.
Thoughtful assessment includes standard tests paired with additional work-up tailored to the specifics of a given case. Non-pharmacological interventions can be helpful for delirium prevention, but antipsychotic medications are the mainstay for management of obstructive or dangerous psychomotor activity in hyperactive and mixed deliria.
After several weeks of physical therapy the patient in this case conference was successfully discharged from rehab to home with his son without need for ongoing psychopharmacologic management.
Importance: Diagnosing and managing delirium are core components of the C-L psychiatrist’s skill set. While the overall focus here is on practical guidance for trainees, C-L psychiatrists of all career stages would benefit from awareness of advancements in the field, including the changing role of the electroencephalogram.
Availability: Pre-publication in Journal of the Academy of Consultation-Liaison Psychiatry (JACLP)
Research: Prevalence and Sociodemographic Correlates of Unmet Need for Mental Health Counseling Among Adults During the COVID-19 Pandemic
Authors: Joseph Nagata, MD, et al.
Abstract/Extract: This study aimed to determine the prevalence and correlates of unmet need for mental health counseling among US adults during the COVID-19 pandemic.
The authors concluded that more than one-quarter of US adults with a positive screen for depression or anxiety experienced an unmet need for mental health counseling at the end of 2020.
The authors analyzed data from approximately 70,000 adults in the Household Pulse Survey, conducted by the US Census Bureau and other federal agencies. It aimed to provide data on the social and economic impacts of COVID-19 on US adults and incorporated the Patient Health Questionnaire-2 to assess participants for symptoms of depression, and an adapted version of the Generalized Anxiety Disorder Scale to assess participants for symptoms of anxiety, over the previous seven days.
Sociodemographic factors associated with higher odds of experiencing an unmet need for mental health counseling included: female, income below the federal poverty line, higher education, and experiencing job loss during the pandemic. Older participants and participants who identified as Asian, Black, or Hispanic/Latino had lower odds of reporting this unmet need.
The authors noted several ways of meeting the need for mental health counseling, including extending the use of telehealth past the emergency period; additional funding for mental health services; and expansion of mental health interventions at individual, community, and national levels.
Importance: More than one in four American adults who had symptoms of depression or anxiety reported an unmet need for mental health counselling—laying bare the post-pandemic challenge.
Availability: Published by Psychiatry Online.
Research: Proactive Integration of Mental Health Care in Hospital Medicine: PRIME Medicine
Authors: Mark Oldham, MD, et al.
Abstract/Extract: Proactive C-L Psychiatry has been shown to reduce hospital length of stay (LOS), increase C-L Psychiatry consult rate, and improve hospital staff satisfaction. Nursing attrition in this context had not been studied.
The authors implemented a Proactive C-L Psychiatry service called PRIME Medicine to:
The impact on LOS proved modest—trending towards a reduction of 0.16 day. But consults increased from 1.6% (40) to 7.4% (176). Time to consultation was unchanged (four to 3.8 days).
Annual per-unit nursing turnover increased from 4.7 to 5.7 on PRIME units, but from 8.5 to 12 on comparison units. Nurses citing “population” as the reason for leaving decreased from 2.7 to 1.7 on PRIME units, but increased from 1.5 to 4.5 on comparison 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,” say the authors.
Importance: The five-fold increase in psychiatric consult rate and favorable trends in nurse retention highlight important factors to be considered when determining value metrics for a Proactive C-L Psychiatry service.
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