Posters Contribute to C-L Psychiatry Knowledge Base
Accepted posters for CLP 2021 were based on the highest quality with a focus on scientific value, original data, and level of scholarship
A further random selection of posters accepted for presentation at CLP 2021 demonstrates the extent of research and studies being undertaken in support of C-L Psychiatry across a wide spectrum of subspecialties. A first selection was in last month’sACLP News.
ACLP’s Oral Papers & Posters Subcommittee this year received 288 abstracts for consideration as posters. Chair Michael Marcangelo, MD, DFAPA, FACLP, has added comments.
UCSF End of Life Option Act 2016-2020: A retrospective chart review
Lead presenters: Eric Weaver and Jordie Martin, University of California San Fransisco
The End of Life Option Act (EOLOA) went into effect in June 2016 and legalized physician aid-in-dying (PAD) in California. State-level statistics are available on California patients accessing physician aid-in-dying (e.g., in 2018, 51% female and 68.8% had cancer) but little is known about outcomes at individual institutions.
EOLOA requires capacity assessments by one attending and one consulting physician. At UCSF Medical Center, all patients must also undergo a formal mental health assessment before being prescribed PAD medications.
This poster describes a retrospective chart review of all adult patients at the medical center who were prescribed PAD medications June 2016-May 2020. The data expands upon the presenters’ prior work reviewing patients who requested PAD 2016-2019. The prior chart review found that 73% of patients requesting PAD had cancer. A majority (69%) of patients were prescribed PAD medications.
Presented data will include demographics and clinical characteristics, including mental health diagnoses and patients’ reasons for electing PAD. Data will be compared to available state-level statistics.
The need for mental health assessments for patients electing for PAD has long been debated; however, there has been very limited data describing this population or the reasons individuals request PAD.
Dr. Marcangelo: “Psychiatrists are often, but not always, asked to evaluate patients requesting physician aid-in-dying. This poster will present information about patients seeking aid-in-dying and, importantly, will include information about the psychiatric histories of the patients. While policy in both the US and other countries has moved physician aid-in-dying forward as an available and legal health care option, knowledge about the impact remains limited and at times shrouded in mystery. This poster will help attendees know more about the patients seeking such care and allow the discussion about parameters for being eligible to move forward.“
COLLABORATIVE & INTEGRATED CARE
Collaborative care for patients with breast cancer
Lead presenter: Christine Beran, MD, University of North Carolina at Chapel Hill
In contrast to previous studies that evaluated the effectiveness of the collaborative care model (CoCM) for patients with cancer under the direction of their primary care physician, the presenters aimed to demonstrate that the model is effective for treatment of depression and anxiety for this population when care is managed by their medical oncologists in the oncology clinic setting.
Depression and anxiety affect patients with cancer at a higher prevalence compared to the general population. CoCM is an evidenced-based care delivery approach that improves patient outcomes in anxiety and depression and increases provider satisfaction in both primary care and specialty settings.
The presenters implemented a CoCM pilot project involving medical oncologists, a Masters-prepared counselor and a psychiatric consultant in an academic medical center oncology clinic. They are evaluating the effectiveness of the model in reducing anxiety and depressive symptoms in patients with breast cancer in an oncology clinic.
The team hypothesize there will be a reduction in baseline PHQ-9 and GAD-7 scores for patients. “We suspect that the oncology providers and patients will find the program to be a beneficial resource and will be satisfied with the services provided.”
For patients with comorbid medical illness in a primary care setting receiving CoCM, response or remission rates of depression have been shown to be 40% (Rossom et al, 2017).For patients with cancer who had a good cancer prognosis, rates of treatment response under the direction of their primary care provider were as high as 62% at 24 weeks (Sharpe et al, 2014).“Given our pilot includes patients with all stages of prognosis, we anticipate treatment response will be more comparable to depression and anxiety response and remission rates of 40% seen in patients with comorbid medical illness.”
Dr. Marcangelo: “Collaborative care has become the standard of care for outpatient consultation psychiatry in primary care settings and there are numerous examples of it moving into speciality care settings. This poster will review the impact of developing a collaborative care model in oncology for patients with breast cancer and extend earlier work by having a broader range of patients enrolled. Guidance from the authors can help attendees learn more about establishing their own programs and allow for enhanced understanding of how individual patients’ needs may differ based on presentation.”
Creating an effective clinic model for post-COVID mental health treatment
Lead presenter: Roseanne Mauch, MD, The University of Colorado
A brain health outreach program for those hospitalized with COVID-19 is being developed by The University of Colorado’s C-L Psychiatry service and Psychiatric Consultation for the Medically Complex clinic.
Patients with COVID-19 have increased risk of cognitive and psychiatric sequelae due to intrinsic viral properties, hyperinflammatory state, and increased disposition to intensive care unit level care. Several institutions are creating new clinic protocols to meet the needs of this population.
The program described in this poster makes use of two arms:
The first assesses those discharged from the hospital using a screener developed by the UCH post-COVID-19 hospitalization program.
The second screens patients currently admitted to the hospital with COVID-19 using psychiatric and neurocognitive screeners.
Both allow patients to be referred to post-COVID-19 mental health treatment for evaluation and treatment. Evaluation includes psychiatric interview and additional screeners including: Hospital Anxiety and Depression Scale (HADS), Montreal Cognitive Assessment (MoCA) and PTSD Checklist for DSM-5 (PCL-5). Additional neuropsychiatric evaluation via Repeatable Battery for the Assessment of Neuropsychological Status (RBANS), and cognitive rehabilitation referral, are available. Clinic treatment includes pharmaceuticals, individual therapy referral, or referral to a COVID Survivorship Support Group.
At the time of submission, 97 patients had been screened in arm one and 47 in arm two.Between both arms, about 42% of the population identifies as female, 57% as male. About 31% are non-English speakers; 21% of those outreached agreed to future check-ins, and 14% requested clinic referral.
By using this two-armed approach, the service has been able to more effectively outreach patients and refer them to appropriate care, say the presenters. Though data is not complete, outreaching patients via the second arm seems to elicit more referral needs than the first arm.
As data continues to be collected, the model is expanding to outreach high-risk patients for neuropsychiatric sequelae. “This will…inform a new standard of care for COVID survivors,” say the presenters.
Dr. Marcangelo: “This poster submission couldn’t be more timely. As more than 35 million Americans have been diagnosed with COVID-19, more attention is being paid to “Long COVID.” The neuropsychiatric effects of the virus over time are still poorly understood and this submission can explain early efforts at establishing a care model for patients recovering from COVID-19. As a recent editorial in the New England Journal of Medicine highlights, the standards of care for Long COVID are still being established and this submission will provide additional information about the needs and outcomes of patients.”
TRAINING & EDUCATION
Complexity, intersectionality, and CBME: A needs assessment for an HIV Psychiatry educational experience
Lead presenter: Alan Wai, MD, University Health Network
As postgraduate education transitions to Competency-Based Medical Education (CBME), there is growing recognition that traditionally siloed competency domains inadequately capture an approach to complexity.
HIV illness and its interface with Psychiatry form syndemics with other comorbidities and can serve as an excellent model to develop educational competencies that capture complexity. The presenters aim to develop a competency-based framework that integrates an approach to medically and psychiatrically complex populations, exemplified by the care needs of patients affected by HIV, mental illness, and substance use disorders.
The presenters conducted a focus group interview that involved multiple stakeholders including clinical providers, community agencies, and people living with HIV to identify current learning needs and gaps. They used an inductive then deductive approach to analyze the transcript, and generated a list of codes to develop a competency-based framework to guide training experiences that reflect the needs of this population.
Competency domains with supporting specific competencies were developed from thematic analysis of the manuscript of the focus group. Domains encompassed themes including:
Comprehensive understanding of complexity for individuals with triple diagnosis.
Integrated medical and neuropsychiatric assessment and management of patients with triple diagnosis.
Navigation of systems of care across community and hospital systems, including interdisciplinary models of care for individuals with triple diagnosis.
Psychotherapeutic skills as a means for engagement and traversing barriers to health for this complex population.
The needs assessment process brought key stakeholders together and illustrated the importance of interdisciplinary collaboration in caring for complex populations; recognizing that much of the care for patients with complex health needs occurs in teams or collaborative systems, or through collaboration between community and hospital resources.
“The transition to CBME is an opportune moment to ensure that educational frameworks for learners foster an approach, to medical and psychiatric complexity, that is informed by stakeholders from a variety of perspectives, including patients and community AIDS service organizations,” say the presenters. “C-L psychiatrists are well poised to lead development of these CBME learning objectives that prepare our future physicians, in Psychiatry and other specialties, to care for those with multifaceted needs. Future evaluations of learner experiences can assess the effectiveness of this framework in preparing trainees for practice in supporting this patient population.”
Dr. Marcangelo: “This submission is a nice example of how qualitative methods can be used to improve education. By incorporating information learned from patients, providers, and support, this submission will describe how to develop competencies in the care of patients with HIV. Descriptions of educational content development are highly valuable as attendees participate in similar processes at their home institutions and being able to engage with the poster authors to learn about their experience will be worthwhile.”
Psychological adaptive mechanism maturity, age, and depression symptoms in advanced-stage cancer patients
Lead presenter: Thomas Beresford, MD, School of Medicine, University of Colorado Denver
Previously, the presenting team has reported that the maturity of Psychological Adaptive Mechanism (PAM) endorsement, but not depression symptom severity, predicted five-year survival rates in adult cancer patients.
That study controlled for age as a significant variable. In this investigation, the presenters hypothesized that increased age would correlate significantly with greater PAM maturity and fewer depression symptoms in a larger sample.
In this study,adult cancer outpatients completed the Defense Style Questionnaire (DSQ) as a measure of PAM status and the Beck Depression Inventory (BDI), and provided additional clinical data.
Contrary to the presenters’ hypothesis, DSQ PAM maturity endorsement did not correlate with increasing age. Greater PAM maturity ratio on the DSQ, however, both provided inverse associations with total BDI symptom frequency. Age was inversely associated with BDI mood and somatic scores. Items that worsened BDI symptom frequency included self-reported mood-altering anti-cancer medications and any psychiatric history. Cancer stage, time since diagnosis, and chemotherapy treatment did not correlate with DSQ or BDI scores.
The results suggest that PAM maturity predicted fewer depression symptoms while younger age predicted more depression symptoms in this clinical sample.
Antidepressant medication use improved depression symptoms while subjective mood changes due to cancer medication and any history of psychiatric disorder made them worse.
Further research should target factors that improve PAM maturity and that improve cancer-related depression in younger clinical groups, say the presenters.
Dr. Marcangelo: “This submission is a data-driven exploration of factors that impact depression in patients with cancer. It examines psychological constructs in addition to demographic variables and gives detailed (and perhaps unexpected) information about who is at risk for depression in oncology. The poster also provides support for therapeutic interventions for patients with cancer to improve their risk for depression. This submission is an example of cutting-edge work being done in C-L Psychiatry and that adopts multiple approaches to assessment in an effort to improve outcomes in our patients.”