Research: C-L Case Conference: Chronic Psychosis Managed in Collaborative Care
Authors: Molly Howland, MD, et al.
Abstract/Extract: The authors discuss the case of a 60-year-old woman presented to primary care with chronic mixed depressive and hypomanic symptoms. She was referred by her primary care clinician to a randomized controlled trial comparing two models of mental health care: telehealth referral care and a Collaborative Care Model (CoCM) for individuals screening positive for bipolar disorder, post-traumatic stress disorder (PTSD), or both. The patient, who screened positive for PTSD, consented and was randomized to CoCM.
The case represents an example of using the CoCM for a complex patient population in a geographic area where psychiatric services are limited and touches on patient-, clinician-, and systems-level factors that influence outcomes in a CoCM program.
Most patients in the CoCM program at this patient’s clinic were being treated for anxiety and depression. Patients with serious mental illness such as schizoaffective disorder, like in this case, are ideally referred for treatment in specialty psychiatric settings for more intensive treatment. However, due to lack of psychiatric services or patient preference, many patients with serious mental illness receive their psychiatric care in primary care settings.
However, many primary care providers do not have adequate training or feel comfortable managing chronic psychotic disorders. As a result, there is interest in developing CoCM interventions for patients with psychosis who are seen only in primary care, say the authors.
The case highlights the benefits and challenges of implementing an effective CoCM. Some barriers here were related to training and workflows, such as working and communicating effectively as a team and managing the patient care registry. Systems-level challenges included insufficient time for CoCM tasks and staff turnover—a known problem in CoCM.
Importance: This case illustrates the need to assess both intervention and no intervention when addressing behavioral health needs for populations, and the need to consider a “different differential” to include the potential contribution of clinical systems when patients are not improving.
In this case, psychosis care was delivered by a CoCM team against the pros and cons of the alternative—likely no care. This can be a challenging calculation for clinical leadership when the ideal would be gold-standard psychiatric care for all patients. In reality, however, 96% of US counties have a shortage of psychiatric prescribers, so implementing a CoCM program, and setting quality measures to monitor outcomes, can provide access to necessary mental health care.
Availability: Pre-publication in the Journal of the Academy of Consultation-Liaison Psychiatry (JACLP)
Research: Trends in the Incidence of New-Onset Anorexia Nervosa and Atypical Anorexia Nervosa Among Youth During the COVID-19 Pandemic in Canada
Authors: Holly Agostino, MD, et al.
Abstract/Extract: The authors set out to assess the incidence and severity of newly-diagnosed anorexia nervosa or atypical anorexia nervosa in a national sample of young people at six pediatric, tertiary-care hospitals in Canada before and during the first wave of the COVID-19 pandemic.
In this cross-sectional study of 1,883 children and adolescents with newly diagnosed anorexia nervosa or atypical anorexia nervosa, the incidence of the disease increased from 24.5 to 40.6 cases per month and hospitalizations among these patients increased from 7.5 to 20 per month. The onset of illness was more rapid, and disease severity was greater at presentation, than before the pandemic.
Shortly after the pandemic was declared, public health mitigation strategies were mandated throughout Canada. Canadian provinces and territories abruptly implemented, to varying degrees, school closures, prohibitions on gatherings, closures of non-essential businesses, and cancellation of sports and extracurricular activities. Public health authorities also cautioned against unnecessary visits to health care facilities to reduce viral transmission and to maintain capacity to accommodate COVID-19 surges. Despite the substantial reduction in the number of children and adolescents brought into hospitals for medical attention during the pandemic, numerous studies have reported increased pediatric mental health visits. Protective factors against eating disorders among young people were also disrupted by the pandemic. “Social support has been identified as a protective factor during stressful periods and as key to managing and reducing disordered eating,” say the authors.
Importance: The COVID-19 pandemic has had considerable mental health consequences for children and adolescents, including the exacerbation of previously diagnosed eating disorders. Whether the pandemic is a factor associated with the concomitant increase in new-onset anorexia nervosa or atypical anorexia nervosa remains unknown. Research is needed to better understand the drivers and prognosis for these patients and to prepare for their mental health needs in the event of future pandemics or prolonged social isolation.
Availability: JAMA Network
See: Eating Disorders: SIG Leaders Challenge APA Proposed Guidelines, this issue
Research: Self-harm During Visits to the Emergency Department: A Qualitative Content Analysis
Authors: Ryan Lawrence, MD, et al.
Abstract/Extract: Some patients engage in self-harm behaviors while in the emergency department (ED), both suicidal and non-suicidal self-harm. Little is known about what motivates these behaviors. This gap in the empirical literature limits efforts to develop early identification and risk mitigation strategies. So, the authors set out to describe methods and motivations when patients self-harm in the ED.
The sample included 184 self-harm incidents involving 118 patients. A wide variety of self-harm methods were present in the data. Suicidal intent was present in a minority of incidents. Other motives included psychosis, intoxication, aggression, managing distress, communication, and manipulation.
These findings suggest risk mitigation strategies that emphasize suicide screening, reducing environmental hazards, and increasing observation are unlikely to achieve the goal of zero harm. Strategies focusing on engagement may create more fruitful opportunities to improve patient safety
“Motivations are often complex and not always easily identified or articulated,” say the authors. “Underreporting of events likely occurred.”
Importance: US psychiatric hospitals, psychiatric units in general hospitals, and non-psychiatric units in general hospitals have a mandate to make these events as rare as possible, ideally reducing them to zero. The Joint Commission’s National Patient Safety Goal 15 focuses on preventing inpatient suicide, emphasizing screening and assessment to identify high-risk patients, removing risks from the environment (e.g., ligature points), and closely monitoring high-risk patients. Moreover, The Joint Commission has promoted the phrase “zero harm” as an aspirational goal for health care organizations. Despite the urgency of reducing self-harm, existing literature offers few insights into how to achieve this goal, especially among patients in the ED.
Availability: Pre-publication in the Journal of the Academy of Consultation-Liaison Psychiatry (JACLP)
Research: A Functional MRI Facial Emotion-processing Study of Autism in Individuals with Special Educational Needs
Authors: Andrew McKechanie, MD, et al.
Abstract/Extract: This research is from a team at The Patrick Wild Centre, University of Edinburgh, UK, which specialises in research into autism, fragile X syndrome, and intellectual disabilities.
The question of whether there is any overarching biological finding that underlies the differences in reciprocal social communication and interaction in autism has been the subject of considerable investigation.
This study aimed to investigate the functional imaging associations of autism in individuals with special educational needs (SEN) and demonstrate the feasibility of such research.
The study included 18 individuals with SEN, of whom nine met criteria for autism. The task examined the blood-oxygen-level dependent response to fearful and neutral faces.
The team suggest that autistic characteristics in individuals with SEN are associated with changes in fearful facial emotion processing analogous to those previously reported in autistic individuals without SEN, and who are of average or above average cognitive ability. They speculate this may relate to reports of the experience of ‘hyper-mentalisation’ in social situations as reported by some autistic individuals.
Importance: It had been hypothesised that the principal finding would be of a reduced neural response to emotional (fearful) faces in the autistic group; and indeed this was borne out in the between-group comparison of response to fearful faces versus baseline. However, perhaps the more interesting finding was that of enhanced response in the autistic group to neutral facial stimuli.
Availability: Published in Psychiatry Research
Research: Uncovering Barriers to Screening for Distress in Patients with Cancer via Machine Learning
Authors: Moritz Günther, MD, et al.
Abstract/Extract: Current-day medical services ought to be evidence-based, efficacious and cost-effective, acknowledge the authors. And screening for distress in patients with cancer is recommended in treatment guidelines globally to provide psycho-oncological services to those in need. Psychologic needs are present in 30-50% of patients with cancer and persistent in survivors in 20-40%. The distress thermometer and problem list have been established internationally as brief instruments to assess distress and its main physical, emotional, and spiritual sources. Nurses are requested to screen patients repeatedly with these instruments during outpatient visits and in at least bi-weekly intervals during inpatient treatment.
Yet, despite these requirements, screening rates remain low, ranging around 40% in inpatient treatment and 22%-74% in outpatient treatment settings. Psychologic distress and manifest mental disorders are overlooked in 30-50% of patients with cancer, say the authors. “International cancer treatment guidelines recommend routine screening for distress in order to provide psychologic support to those in need,” they say. “Yet, institutional and patient-related factors continue to hinder implementation.”
This study aims to investigate factors associated with nil-screening for distress in patients with cancer.
Importance: Results of the study have clinical relevance for improving distress screening rates. In addition, they can help nurses and residents responsible for screening to avoid pitfalls, such as overlooking patients with short lengths of stay, or those who are not discussed at a tumor board. “Ideally, this could provide anchor points for clinical supervisors and practitioners to optimize the thoroughness of screening,” say the authors.
Availability: Pre-publication in the Journal of the Academy of Consultation-Liaison Psychiatry (JACLP)
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The Academy of Consultation-Liaison Psychiatry is a professional organization of physicians who provide psychiatric care to people with coexisting psychiatric and medical illnesses, both in hospitals and in primary care. Our specialty is called consultation-liaison psychiatry because we consult with patients and liaise with their other clinicians about their care.
With nearly 2,000 members, the Academy is the voice of consultation-liaison psychiatry in the US with international reach.
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Michael Sharpe, MA, MD, FACLP
ACLP President