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POSTER PAPER PRESENTATIONS
Thursday, November 17, 2011
4:00–6:00 PM — Akimel Ballroom

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THE ALAN STOUDEMIRE AWARD for Innovation & Excellence in Psychosomatic Medicine
2011 Award to Pamela Diefenbach, MD, FAPM

Educating Multiple Disciplines of Trainees in Primary Care Clinics

Purpose:  We describe a Primary Care Psychiatry teaching program within a complex clinic system that includes different levels of trainees from  different disciplines. Training methods include case-based supervision, lectures, journal article reviews, and “curb side” consultations. We describe trainee satisfaction and challenges trainees and clinic staff encounter with the clinical and education experience.

Methodology:  We reviewed computerized clinic schedules to gather the number of trainees in the multiple disciplines over the time period form 2000-2011. Trainee evaluations and 2007 Psychiatry Chief Resident and 2009 Internal Medicine Resident Surveys were used as evaluation tools.

Results:  Each year since 2000, the program has trained 5-8 PGY-3 & 4 Psychiatry Residents, 10-16 PGY-2 & 3 Internal Medical Residents, 0-5 Psychology trainees, and 0-2 Psychosomatic Medicine (PM) Fellows. The residency program evaluations use a scale of 1-7 (7 being highest). Psychiatry resident evaluation average overall was 6.1, and the Internal Medicine Residents rated from 6-7. The PM fellows use a scale 1-10 and rated the outpatient experience 9-10.

The 2007 Psychiatry Resident survey had a rating scale 1-5 with 5 being the highest.  Residents rated quality of didactics as 3.78, quality of supervision was 4.67, and clinic organization 4.89. Additional comments indicated the clinic was a unique experience, the residents had adequate time for each patient, and there was adequate guidance on the mechanics of patient care.

The 2009 Psychosomatic Fellow Survey results of 9 Internal Medicine Residents indicated that residents liked the patient population, were surprised how quickly they could assess for psychiatric illness, dispelled some of their previous ideas about psychiatry, but few  used the skills after the rotation

Challenges:  ACGME and individual programs combined have different educational requirements for the variety of trainees. All trainees spend time at different locations and sites throughout the week and are in the clinic one half day a week. Psychiatry Residents and PM Fellows spend one full year in the clinic, Internal Medicine spend one month and Psychology trainees spend 3 months up to one year depending on their level of training. Integrating the trainees experience to interact with each other is often challenging and difficult to achieve.


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    Successful Initial Implementation of Phone-Based Pill Counts as an Objective Measure of ARV Adherence
    Presenting Author:  Jordan Akerley
    Co-Authors:  Julie Adams, Kiana Bess, Malaika Edwards, Bradley Gaynes, Amy Heine, Byrd Quinlivan, Nathan Theilman, Quinn Williams, Brian Pence

    Background:  Different antiretroviral adherence measurement strategies produce different balances between competing considerations of validity and resource efficiency. Unannounced phone-based pill counts are an objective adherence measurement approach which has been previously demonstrated as reliable and valid.

    Methods:  The SLAM DUNC (Strategies to Link Antidepressant and Antiretroviral Management at Duke and UNC) Study, a randomized controlled trial to test the effect of depression treatment on antiretroviral adherence, is implementing monthly unannounced phone-based pill counts over 12 months as the primary adherence outcome measure.

    Since study launch in April 2010, 49 participants have been followed a mean of 3.1 months (range: 0-7). Participants receive a study cell phone if needed (48% have accepted a phone). Since launch, the phone assessor, blinded to study arm, has completed 170 pill counts out of 183 target monthly intervals for a completion rate of 93%. Baseline pill counts average 30 minutes in duration, while follow-up pill counts average 12 minutes. Mean adherence (percentage of pills taken over pills expected) was 88% (interquartile range: 86-100%).

    Facilitators of successful contact and measurement include provision of cell phones and reading glasses to participants, interviewer accommodation of participant availability (including off hours), and initial in-person orientation to navigating prescription labels. Challenges to collecting adherence data in this population of depressed HIV patients include low literacy, scheduling variability, housing instability, and the sharing of ARV medication amongst partners.

    Results:  Researchers should anticipate a spectrum of literacy and cognitive levels. Resource requirements are modest compared to other objective approaches to adherence measurement. The method leaves the antiretroviral management habits of participants unchanged, permitting insight into real-world pill management practices.

    Conclusions: With proper structure, unannounced phone-based pill counts can be a feasible, resource-efficient, objective approach to assessing trends in antiretroviral adherence over time and can be highly effective in reaching participants regularly.

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    5.2 Refills Remaining: How HIV Patients Really Receive, Store, and Take Their Medications
    Presenting Author:  Jordan Akerley
    Co-Authors:  Julie Adams, Kiana Bess, Malaika Edwards, Bradley Gaynes, Amy Heine, Byrd Quinlivan, Nathan Theilman, Brian Pence, Quinn Williams

    Background:  HIV patients employ various pill management strategies and face a range of pharmacy-related challenges that affect antiretroviral adherence.

    Methods:  The SLAM DUNC (Strategies to Link Antidepressant and Antiretroviral Management at Duke and UNC) Study, a randomized trial to test the effect of depression treatment on antiretroviral adherence, is implementing monthly unannounced phone-based pill counts as the primary adherence outcome measure. These contacts provide detailed windows into participants' pharmacy experiences and pill management habits.

    Results:  Of 49 participants followed to date for a mean of 3.1 (range: 0-7) months, the majority store antiretrovirals in original prescription bottles (n=27) or pillboxes (n=22); other strategies include plastic baggies (n=4) and non-antiretroviral prescription bottles (n=6) with some overlap. For confidentiality some participants remove or cross out antiretroviral labels (n=5). Those with overnight jobs vary dosing times depending on each day's schedule (n=2). One participant with a twice-daily antiretroviral alternates between double doses in the morning or evening every two weeks.

    Patients report pharmacy-related challenges to pill management. Three participants self-reported missing doses due to pharmacy errors and issues with provider reauthorizations. One participant reported routinely receiving only 2-3 pills when attempting to fill her monthly prescription, requiring multiple trips. One pharmacy dispensed 46 pills for a 60-pill prescription, listing 5.2 remaining refills. One pharmacy sent 60 150mg pills instead of 30 300mg pills, but labeled the bottle as containing 30 150mg pills, and gave no instructions to take two pills daily. Another participant with a 90-day prescription inconsistently received 60-day supplies of one antiretroviral and 30-day supplies of the second antiretroviral. Pharmacy labels confounded several participants, who received 60-tablet supplies that were dispensed in two bottles labeled 60 but contained only 30 tablets each.

    Conclusions:  Understanding the complex management techniques and pharmacy issues that impact ARV adherence will strengthen future adherence interventions.

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    Psychiatric Complications of Epilepsy Surgery
    Presenting Author:  Sherese Ali

    Introduction:  There is a high comorbidity of psychiatric disorders in patients with epilepsy, sparking interest on the psychiatric outcome of epilepsy surgery. There has been variation in reports of post-surgical psychiatric outcome and few even reports even cite psychiatric disorders arising de novo after surgery. The exact nature, prevalence and severity of psychiatric outcomes after epilepsy surgery have not been identified. Predictors of outcome such as laterality of surgery, extratemporal versus temporal resections, presence of a previous psychiatric history have all been examined, but with varying conclusions. In some instances, differences in methodology may preclude accurate conclusions about various aspects of psychiatric outcome after epilepsy surgery. As such, it is difficult to inform patients of any psychiatric risks of surgery, and consent for surgery usually does not include a discussion about psychiatric risks. Several unanswered questions exist therefore: Should psychiatric risks be part of the discussion and consent for surgery? Should we practice routine psychiatric follow up after surgery and for how long? This paper examines outcome after epilepsy surgery in a series of clinic patients, with the aim of building on the existing literature in order to help answer these questions as research on this topic accumulates.

    Method:  In this centre, all patients undergoing epilepsy surgery are referred for routine pre-operative psychiatric assessment and post-operative assessment if clinically indicated at any time during their neurology follow up assessments. A chart review of all patients who underwent epilepsy surgery was performed. Baseline demographic data, pre- and post-operative psychiatric status, neurological status and medications were documented.

    Results:  Seven of 25 patients had adverse psychiatric consequences. Psychiatric complications included behavioural and personality changes, mood swings, hypomania, and de novo psychosis. In several patients, there was a positive past psychiatric history and unfavourable social situations. Psychiatric complications appeared unrelated to successful seizure control from surgery.

    Conclusions:  Adverse psychiatric outcome is not uncommon after epilepsy surgery. The findings underscore the need for multidisciplinary, collaborative approach with routine pre- and post-operative psychiatric assessments. More data is needed to help determine what information about psychiatric risks and outcome should be conveyed to patients when giving informed consent.

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    Challenge and Opportunity of Consultation-Liaison Psychiatry in Traumatic Brain Injury Case
    Presenting Author:  Andri Andri

    Background:  High rates of mood, psychotic and substance abuse disorders following traumatic brain injury (TBI) have been found in hospitalized trauma and tertiary care referral populations. Studies have confirmed that disability caused by psychiatric disorders may contribute to the disability associated with TBI.

    Objective:  To review and discuss a case of traumatic brain injury in consultation-liaison psychiatric setting and its challenge.

    Method:  Case presentation and review article related to the case.

    Result:  A 52-years old male patient with diagnosis subarachnoid and subdural hemorrhage after motorcycle traffic accident. The attending neurosurgeon planned a craniotomy operation to the patient. Thirteen days after the operation conducted, a psychiatrist was consulted because patient was agitated, performed aggressive behavior, irritable and become silent than he used to be. A psychiatric consultation was performed and major depression disorder with aggressive behavior was the diagnosis at that time. Haloperidol 2.5mg bid and sertraline 50mg on the morning was given to patient. Patient was discharged two days after the consultation. He continued the consultation in out patient clinic a week after he discharged from hospital. He was still agitated, could not sleep well at night, felt uneasy, irritable but there was no psychotic symptom. Two weeks after the first consultation at out patient clinic, patient started to experience auditory and visual hallucination. The treatment program was modified based on the patient condition at that time. A month after the last consultation, psychotic and mood symptoms were improved although patient remained irritable, became more stubborn, acting out, dis-inhibition and frequently forgot the order of task.

    Discussion:  The TBI patients often present with a "telescoping" series of psychiatric symptoms, depending on the proximity of their clinical presentation to the serious injury producing TBI. Symptoms often change significantly over time as the patient recovers. Psychopharmacological approaches may need modification over time as different symptom profile emerge and replace each other. In this case, we see that patient symptoms change over time. The modification of the medicine was also performed to adjust the need of the patient in the current situation. The neuropsychiatric sequelae sometimes remain long after the patient recover from the trauma. A comprehensive treatment approach is needed regarding to this on going situation.

    Conclusion:  Psychiatric features of traumatic brain injury patient are changed significantly over time and sometimes remain long after the trauma recover. A comprehensive and tailor made treatment approach is needed to adjust the patient need in this on going situation.

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    Pharmacological Management of Somatoform Disorders: A Meta-Analysis
    Presenting Author:  Aniyizhai Annamalai
    Co-Authors:  Vivek Phutane, Kalyani Subramanyam, Geetha Desai, Vinod Srihari, Santosh Chaturvedi

    Background:  Somatoform disorders are one of the most common psychiatric disorders in the out patient clinics. They are present in around 20-25% of outpatients in general hospitals. Medications and psychotherapeutic approaches have evidence in the management of somatoform disorders. We aim to do a meta-analysis of pharmacological approaches in the management of somatoform disorders.

    Objective:  To determine the effectiveness and safety of pharmacotherapy in the treatment of somatoform disorder / somatization disorder.

    Data Sources:  We did a comprehensive literature search in the Cochrane library databases (upto April, 2011); Medline (1950-April, 2011); PsycINFO (1967-April, 2011). MEDLINE and PsycINFO were searched by using OvidSP interface. We searched using a combination of controlled vocabulary and text words: (1) Somatoform disorders [which includes somatoform disorders, somatization disorders, body dysmorphic disorder, undifferentiated somatoform disorder, conversion disorder, hypochondriasis] , (2) Antidepressive agents, Benzodiazepines, Serotonin Uptake Inhibitor, Anticonvulsants, Antipsychotic Agents, Analgesics. We also searched the conference proceedings in the citation index – Science (CPCI-S) and Science and Humanities (CPCI-SSH) – [1991 – April, 2011] through ISI Web of Science. We searched all references of the reports of included trials for further relevant studies.

    Study Selection:  We included all randomized controlled trials of pharmacotherapy for treatment of all types of somatoform disorders. We included all participants diagnosed with DSM-III, DSM-IV and DSM-IV-TR as well as ICD-9 and ICD-10 as any type of somatoform / somatization disorder, irrespective of their age, gender, ethnicity, functioning, co-morbidity, inpatient / outpatient status and insight into illness. We independently inspected all reports of identified studies.

    Data Extraction:  We independently extracted the data and resolved any disagreement by discussion. Total 194 articles were identified through database search, of which we removed 61 articles which came as duplicates. Remaining 133 articles were assessed for eligibility, of which 91 were excluded (Reasons: 30 were non-ranodomized, 58 were diagnostically inappropriate, and we were unable to get full texts of 3 articles). Total 42 records were included in the qualitative and quantitative analysis.

    Data Synthesis & Conclusion:  This is undergoing. We will present it during the conference.

  6. [Withdrawn]
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    Characteristics of Homeless HIV+ Psychiatric Patients
    Presenting Author:  Murray Bennett
    Co-Authors:  Christine Yuodelis-Flores, Eric Strachan, Thomas Gold

    Objective:  Little is known about the clinical characteristics of homeless HIV+ patients in psychiatric care. HIV prevalence among the homeless is estimated to be 16-35%. For HIV+ patients, homelessness increases the risk of death, non-adherence to treatment, substance use, and HIV transmission risk behaviors.

    Methods:  This retrospective descriptive study describes the clinical characteristics of 1059 homeless HIV+ patients seen in psychiatric consultation over the span of eleven years. We analyzed a quality assurance database of 5,175 patients seen in psychiatric consultation at a specialized HIV primary care clinic located in a large urban general hospital between January 1, 1998 and December 31, 2008.

    Results:  20% of HIV+ patients seen in psychiatric consultation had faced homelessness, and consistent with current literature were less likely to engage in care, twice as likely to have substance use disorder, legal or incarceration history, three times more likely to have antisocial personality disorder, and twice as likely to have PTSD, Schizophrenia or Schizoaffective disorder. However, we found our population of HIV+ homeless psychiatric patients were also twice as likely to be Black, twice as likely to be Bisexual and 13 times more likely to have history of involuntary psychiatric hospitalization. Among abused substances, cocaine (3 fold), heroin (2 fold) and IDU (2 fold) were more common. Stage 3 HIV patients were less likely to be homeless, perhaps reflecting improved access to housing for patients with an AIDS diagnosis. Validated self report survey scores (SF 12, BASIS-32) indicate that our homeless patients experienced greater severity of physical and mental illness, and functioned at a lower level.

    Conclusion:  Enhancement of HIV primary care clinics to effectively engage homeless HIV+ patients into care should include integrated addiction treatment, expertise with caring for recently incarcerated patients, and resources for the treatment of chronic mental illnesses such as schizophrenia and PTSD.

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    To Screen or Not to Screen: Thyroid Testing in an Alcohol Clinic
    Presenting Author:  Thomas Beresford
    Co-Author:  Jennifer Ratzlaff

    Background:  A review of the literature indicates an established relationship between alcohol abuse and abnormal thyroid hormone (TSH) levels. The literature does not, however, address how this find translates into clinical practice.

    Method:  As a quality-control procedure, we conducted a systematic chart review of non-cirrhotic, male, middle-aged patients (n= 185) seen consecutively over four months in an alcohol abuse clinic. We reviewed TSH levels retrospectively from electronic medical records, in two groups: patients who had been seen in the clinic (n=84) and patients who did not present for their scheduled appointment (n=101).

    Results:  Our records review revealed abnormal TSH values for 54 (29%) of the 185 patients at some point in the past (prior to May, 2010). Current (since May, 2010) TSH levels were available for 79 (43%) of them. Six of these 79 patients (8%) had abnormal TSH readings, the majority of which (5) were high. Population studies suggest rates of high TSH in men of .1%-2.3%. This suggests our clinical sample exhibits the disorder at (conservatively) approximately 3 times the normal rate. This frequency of abnormal values was comparable in patients who presented to clinic appointments (3 abnormal TSH out of 84) and those who did not (3 out of 101).

    Conclusion:  Our chart review supported previous findings of a disproportionate frequency of abnormal TSH levels occurring alongside alcohol use. It also highlighted the fact that less than half (43%) of individuals known to be in this at-risk group had current TSH test results available in their patient records. Should clinicians be testing all patients in at-risk groups such as this one? Or is such widespread screening unwarranted? Considering the known relationship of alcohol use and abnormal TSH, further exploration is needed to investigate the clinical implications of such a frequent finding.

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    Alcohol versus TBI: Differential Effects on PTSD Treatment Outcomes
    Presenting Author:  Thomas Beresford
    Co-Authors:  Chelsea Dize, Brandon Brandon

    Background:  Posttraumatic Stress Disorder (PTSD) treatment is often complicated by alcohol abuse disorders, and/or traumatic brain injury (TBI); however, researchers have struggled to disentangle the differential effects of alcohol and TBI versus TBI alone in individuals with PTSD. We examined whether clinical outcomes in intensive PTSD treatment varied by histories of a) alcohol abuse only, b) TBI only, c) alcohol abuse and TBI, or d) neither alcohol abuse or TBI.

    Methods:  Clinical outcome data were prospectively gathered from male veterans who completed a residential rehabilitation program for PTSD in 2008, n=115. Patients completed the Mississippi Scale for Combat-Related PTSD (M-PTSD), PTSD Checklist - Military Version (PCL-M), Beck Depression Inventory (BDI-II), and State-Trait Anxiety Inventory (STAI) on admission and discharge, as part of the program's standard treatment regimen. Retrospective chart reviews were then conducted to determine patients' demographics, and history of alcohol abuse and/or TBI. Of the total sample, 51 (44.3%) had a history of alcohol abuse and TBI, 36 (31.3%) of alcohol abuse only, 11(9.6%) of TBI only, and 8 (7%) neither. Data were missing for 9 patients (7.8%).

    Results:  Those patients with TBI who had not abused alcohol experienced no improvement on the M-PTSD or the trait anxiety subscale of the STAI, as compared to patients with alcohol abuse histories (p <.01). On the PCL-M, BDI, and state anxiety subscale of the STAI all patients improved significantly (p <.01), regardless of their history of alcohol abuse and/or TBI.

    Conclusions:  Individuals who have a history of TBI may be likely to show less improvement in PTSD symptoms and trait anxiety over the course of PTSD treatment, whereas patients with a history of alcohol abuse may evidence improvement even if they also have a history of TBI. Clinically, patients who stop abusing alcohol prior to treatment may improve more quickly and make greater gains as they heal from alcohol exposure. By contrast, those with TBI alone appear to make little gain on the M-PTSD, consistent with TBI recovery, which is thought to reach its maximum within one year after injury. Contradictory results on the two PTSD scales suggest that some PTSD scale items may reflect TBI rather than PTSD, echoing concerns in the literature on differentiating the two. Future research is warranted to illuminate the differential effects of alcohol and/or TBI on PTSD treatment and recovery.

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    Cognitive Impairment in Individuals with Comorbid TBI and Alcohol Abuse
    Presenting Author:  Thomas Beresford
    Co-Authors:  Brandon Schmidt, Brie Thumm

    Background:  Individuals undergoing treatment for substance abuse often have histories of head injury, including Traumatic Brain Injury (TBI). While TBI histories can be overlooked clinically, TBI patients may suffer from greater, and often times more subtle, cognitive impairment than would be expected from substance abuse alone.

    Methods:  Prospective data collected on 24 adults (1 female) enrolled in a medication trial afforded us a view of cognitive state in a sample with both conditions. All presented with a history of closed-head TBI, greater than one year before assessment, and met MINI criteria for current alcohol abuse or dependence. The Trail Making Test Part B (TMT-B) and Frontal Assessment Battery (FAB), two commonly used cognitive assessments, were administered individually during screening for the medication trial.

    Results:  The mean score on the FAB was 15.8 + 1.6. Mean time to completion on the TMT-B was 100.6 sec + 36.6 sec. On the FAB, 7 participants (29%) scored below 15.7, two standard-deviations less than the mean score for normal adults (17.3 + 1.6), while on the TMT-B 13 (54%) participants took longer than 91.6 sec, two standard-deviations more than the mean score for normal adults (57.2 + 17.2). These frequencies fell just below significance in chi Square analysis at p=0.518. We expected a positive correlation between FAB and TMT-B scores but found that the two were negatively, and significantly (p<0.05), associated.

    Conclusions:  A literature review suggests that these data provide evidence that patients with a history of TBI as well as alcohol abuse/ dependence may suffer from a greater degree of cognitive impairment than would be predicted by either diagnosis alone: over half of the sample in this case. The inverse relationship between FAB and TMT-B scores compares an instrument that assesses several frontal lobe functions with a specific measure of frontal attention and visual search. The inverse correlation significance in this small sample suggests that the two commonly used instruments show remarkably less overlap that expected.

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    HIV Providers’ Confidence and Expertise in Treating Depression as a Means of Addressing Antiretroviral Adherence and Clinical Outcomes
    Presenting Author:  Kiana Bess
    Co-Authors:  Julie Adams, Jordan Akerley, Malaika Edwards, Bradley Gaynes, Amy Heine, Brian Pence, Byrd Quinlivan, Nathan Theilman, Quinn Williams

    Purpose:  Depression is common in HIV patients and can affect antiretroviral adherence and clinical outcomes without proper diagnosis and treatment. Integration of antidepressant treatment into routine medical care may improve antiretroviral adherence in depressed HIV patients. HIV providers can play an important role in identification and management of depression, yet expertise and comfort level in managing depression can vary widely.

    Methods:  The SLAM DUNC (Strategies to Link Antidepressant and Antiretroviral Management at Duke and UNC) Study is a randomized control trial of the impact of a depression treatment intervention's impact on antiretroviral adherence and clinical outcomes in depressed HIV patients. Before study launch, staff conducted semi-structured interviews with 48 HIV providers at two study sites completed semi-structured interviews about current depression management knowledge and practices.

    Results:  Interviewees were 26 MD attendings, 15 MD fellows, 4 Physician Assistants, and 3 Nurse Practitioners. Years of HIV clinical experience ranged from <1- year-28 years (mean: 12). Providers devoted 10-100% (mean: 38%) of their time to clinical work, with 5-100% (mean: 69%) of clinical work focused on HIV treatment. Only 23% assessed depression systematically; the majority (70%) asked only when prompted by the patient's presentation and 7% never assessed depression. Providers expressed high confidence in prescribing an initial antidepressant (mean: 4.0 on 1-5 Likert scale; higher=more confident), but lower confidence in changing or augmenting antidepressants (mean: 3.0). Most (94%) identified at least one antidepressant by name. However, wWhen prescribing medicationsdosing antidepressants, 64% of providers did not consider interactions with the patient's ARVs when determining dosing. Compared to best-practices depression treatment guidelines, only 36% followed up within 2-4 weeks after starting an antidepressant, the same 36% would titrate up to the maximum recommended dose, and 27% evaluated improvement in the patient's depressive symptoms to guide dose changes. reported increasing doses based on lack of improvement in the patient's depressive symptoms. Most (64%) referred to outside mental health resources if the patient failed unresponsive to a first antidepressant. Providers were open to receiving decision support from non-prescribing clinical personnel.

    Conclusion:  Providers understood the importance of managing depression for HIV adherence and viewed it as part of their role. However, sSystematic identification of depression and best- practices depression management were uncommon. Providers generally initiated a first antidepressant but lacked in adjusting doses and medications. Providers were open to receiving decision support from non-prescribing clinical personnel. Depression management support allows for an opportunity to improve treatment in clinic with subsequent potential benefits to HIV outcomes.

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    Screening Characteristics of the Impact of Events Scale-Revised in Intensive Care Survivors Who Had Acute Lung Injury
    Presenting Author:  O. Joseph Bienvenu
    Co-Authors:  Andrew Yang, Jason Williams, Dale Needham

    Purpose:  Though questionnaires are frequently employed in intensive care unit (ICU) follow-up studies to measure post-traumatic stress disorder (PTSD) symptoms, most have not been validated against a clinical interview standard in this population. In the current study, we evaluated the Impact of Events Scale-Revised (IES-R) as a measure of PTSD symptoms in a cohort of ICU survivors who had acute lung injury (ALI).

    Methods:  Participants were consecutively recruited from the Johns Hopkins site of the ARDSNet Long Term Outcomes Study (ALTOS), a prospective cohort study evaluating ALI survivor outcomes. At 12-month follow-up post-ALI, 29 patients completed the IES-R, and, within one week, were interviewed using a semistructured diagnostic interview, the Clinician-Administered PTSD Scale (CAPS). The IES-R is a reliable 22-item self-report questionnaire developed to examine the psychological impact of a specific trauma (in this case, a critical illness and intensive care treatment). The CAPS is the current "gold" standard in PTSD clinical research; it allows for a quantitative assessment of PTSD symptoms, as well as a qualitative diagnosis (present/absent).

    Results:  The CAPS total severity score (range=0-70) and the IES-R total score (range=0.0-2.8) were strongly related (Pearson r=0.71, Spearman's rho=0.58). Five of the 29 patients had CAPS symptoms above the diagnostic threshold for PTSD. In a receiver operating curve analysis (with CAPS PTSD as the criterion variable), the area under the curve was 88% (95% confidence interval: 0.75, 1.00). At an IES-R threshold of 1.0, sensitivity=100%, and specificity=62%. At an IES-R threshold of 1.4, sensitivity=100%, and specificity=75%.

    Discussion:  The correlation between the CAPS total severity score and the IES-R total score was in the expected range for measures of the same construct in mental health research. The IES-R appears a reasonable measure of PTSD symptoms in ICU ALI survivors.

    References:

    Davydow DS, Desai SV, Needham DM, Bienvenu OJ. Psychiatric morbidity in survivors of the acute respiratory distress syndrome: a systematic review. Psychosom Med 2008; 70:512-519

    Davydow DS, Gifford JM, Desai SV, Needham DM, Bienvenu OJ. Posttraumatic stress disorder in general intensive care unit survivors: a systematic review. Gen Hosp Psychiatry 2008; 30(5):421-434

    Jones C, Bäckman C, Capuzzo M, Flaatten H, Rylander C, Griffiths RD. Precipitants of post-traumatic stress disorder following intensive care: a hypothesis generating study of diversity in care. Intensive Care Med 2007; 33:978-985

    Stoll C, Kapfhammer HP, Rothenhäusler HB, Haller M, Briegel J, Schmidt M, Krauseneck T, Durst K, Schelling G. Sensitivity and specificity of a screening test to document traumatic experiences and to diagnose post-traumatic stress disorder in ARDS patients after intensive care treatment. Intensive Care Med 1999; 25:697-704

    Twigg E, Humphris G, Jones C, Bramwell R, Griffiths RD. Use of a screening questionnaire for post-traumatic stress disorder (PTSD) on a sample of UK ICU patients. Acta Anaesthesiol Scand 2008; 52:202-208

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    Excessive Serotonin Syndrome: A Milder Case of Serotonin Syndrome
    Presenting Author:  Bradford Bobrin

    Purpose:  To describe a milder, easily treatable form of serotonin syndrome.

    Method:  Case study.

    Results:  I will describe several cases of patients with the consistant triad of encephalopathy, myoclonus/tremor and three serotinergic medications who did not have alterations in their vital signs who presented as consults for delirium and resolved within 24-48 hours after the initiation of cyproheptadine 4-8mg tid.

    Conclusion:  Change in mental status presenting with several serotinergic medications and myoclonus/tremor should have their serotinergic medications at least stopped and possibly treated with cyproheptadine.

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    Treatment Characteristics of Delirium in Severe Medical Illness
    Presenting Author:  Soenke Boettger
    Co-Authors:  Susanne Boettger, Miriam Friedlander, William Breitbart

    Objectives:  To examine treatment characteristics of delirium in the severely medically ill on the basis of the Karnofsky scale of performance status (KPS) and Memorial Delirium Assessment Scale (MDAS).

    Methods:  We analyzed our delirium database in respect to delirium in the severely medically ill (KPS<30). All subjects in the database were recruited from all psychiatric referrals at MSKCC. Measures used were the Karnofsky Performance Status Scale (KPS), Memorial Delirium Assessment Scale (MDAS) at baseline (T1), 2‑3 days (T2) and 4‑7 days (T3).

    Results:  We retrieved 111 subjects from our delirium database. Out of this sample 67 patients qualified as severely medically ill (KPS<30). KPS scores were 19.7 and 30.7 respectively. There were no significant differences in respect to age, history of dementia and MDAS scores at baseline. Phenomenologically we were able to find increased severities of disturbance of consciousness, disorientation and inability to maintain and shift attention. Etiologically increased prevalences of hypoxia and infection in KPS<30 was found. On the other side corticosteroids administration was more often associated with a KPS≥30. At T2 the resolution of delirium was significantly lower in KPS<30 (37 and 61%), but at one week of treatment delirium resolution rates were not signifcantly different (76 and 77%).

    Significance of Results:  Delirium in the severely medically ill cancer populatiSon may be characterized by an increased disturbance of consciousness, disorientation and inability to maintain and shift attention. Etiologies associated with delirium in severe medical illness were hypoxia and infection. Delirium in severe medical illness may resolve at a slower rate.

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    The Impact of Delirium on Functionality
    Presenting Author:  Soenke Boettger
    Co-Authors:  Susanne Boettger, Victor Rodack, William Breitbart

    Objective:  To examine the acute impact of delirium on the level of functioning as measured with the Karnofsky scale of performance status (KPS).

    Methods:  We analyzed our delirium database in respect to delirium and the level of functioning. All the subjects in the database were recruited from all psychiatric referrals at MSKCC. Measures used were the Karnofsky Performance Status Scale (KPS), Memorial Delirium Assessment Scale (MDAS) at baseline (T1), 2-3 days (T2) and 4-7 days (T3).

    Results:  We retrieved 111 subjects from our delirium database. The mean age of the subjects was 65.6 years. KPS scores were 24.1 at baseline, 28.6 at T2 and 33.0 at T3. Delirium severity at baseline did not influence the level of functioning, but resolution of delirium resulted in significant higher KPS scores compared to subjects with ongoing delirium at T2 (30.2 and 23.5) and T3 (35.1 and 26.2). Subjects with a KPS improvement of less than 10 (ΔKPS<10) were not significantly different in age, history of dementia and brain metastasis compared to subjects with a KPS improvement of 10 or more (ΔKPS>10). Etiologically only hypoxia was more frequently found in ΔKPS<10 (50% and 27%). MDAS scores were similar at baseline, but significantly higher at T2 and T3 in ΔKPS<10. Delirium resolution was significantly lower in subjects with ΔKPS<10 compared to subjects with a ΔKPS>10 T2 (25% and 65.4%) and T3 (62.5 and 83.3%).

    Significance of Results:  Delirium may have an acute impact on functioning and successful management of delirium may reverse the impact on the level of functioning.

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    Haloperidol, Risperidone, Olanzapine, and Aripiprazole in the Management of Delirium
    Presenting Author:  Soenke Boettger
    Co-Authors:  Susanne Boettger, Andrea Kondracke, William Breitbart

    Objectives:  To examine the safety and efficacy of Haloperidol (HAL), Risperidone (RIS), Olanzapine (OLZ) and Aripiprazole (ARI) in the treatment of delirium.

    Methods:  We performed a secondary analysis our delirium database in respect to patients treated with HAL, RIS, OLZ and ARI for delirium. Measures used were the Memorial Delirium Assessment Scale (MDAS), the Karnofsky Scale of Performance Status (KPS), and side effect rating at baseline (T1), 2-3 days (T2) and 4-7 days (T3). All measurements were integrated into the routine clinical care of patients.

    Results:  We were able to retrieve 21 case matched subjects treated with HAL, RIS, OLZ and ARI for delirium. The mean age was not statistically different between groups. Cancer diagnoses and etiologies were diverse. MDAS scores at baseline were not statistically different: HAL 19.9, RIS 18.6, OLZ 19.4 and ARI 18.0. At baseline the dosing of medication was 4.9mg for HAL, 0.9mg for RIS, 3.5mg for OLZ and 15.2mg for ARI. In HAL subjects MDAS scores declined from baseline 19.9 to 9.9 at T2 and 6.8 at T3, RIS subjects from 18.6 to 11.2 and 7.1, in OLZ subjects from 19.4 to 13.8 and 11.7 and in ARI subjects from 18.0 to 10.8 and 8.3. There were no significant differences between groups. Extrapyramidal side effects (EPS) were more commonly found in HAL and sedation was more commonly found in OLZ.

    Significance of Results:  In this secondary analysis from our delirium database Haloperidol (HAL), Risperidone (RIS), Olanzapine (OLZ) and Aripiprazole (ARI) were equally effective in the management of delirium. EPS were more common in HAL subjects and sedation more common in OLZ subjects.

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    Personality, Somatization, Quality of Life, and Response to Gluten Challenge in Celiac Disease and Non-Celiac Gluten Intolerance
    Presenting Author:  Birgitte Boye
    Co-Authors:  Margit Brottveit, Knut EA Lundin, Per Vandvik

    Objective:  Many people choose to live on gluten-free diet although they do not have celiac disease. The aim of the study is to compare patients with non-coeliac gluten intolerance (gluten sensitivity (GS)) with patients with CD regarding subjective responses to gluten challenge, personality, quality of life and degree of somatization.

    Materials and Methods:  HLA DQ2+ individuals 18-70 years on gluten free diet > 4 weeks, 22 with biopsy proven CD and 32 GS patients were included. The patients were challenged with four slices of white, gluten containing bread a day for three days. The patients completed subjective symptom severity scales (Gastrointestinal Symptom Rating Scale (GSRS-IBS) and Subjective Health Complaints Inventory (SHC)), personality questionnaires (Eysenck (neuroticism (EPQ-N) and lie (EPQ-L) scales), Buss Perry Aggression Questionnaire (BPAQ), Health Locus of Control Scale (HLCS, internal, chance and powerful others), Toronto Alexithymia Scale (TAS)), a quality of life scale (Short Form –36 (SF-36)), and scales measuring somatization (Symptom Check List –90 Revised (SCL-90 R), Giessener Beschwerdebogen (GBB)) at baseline, and in addition the patients completed the subjective severity questionnaires after the gluten challenge.

    Results:  Patients with CD and GS reported no differences in IBS symptoms at baseline. Patients with GS reported higher increase in IBS symptoms, especially pain, diarrhea and bloating symptoms after gluten challenge than CD patients. There were no differences in personality and quality of life between GS and CD patients.GS patients and CD patients had comparable low levels on somatization on both SCL-90-R and total GBB, although GS patients reported more gastrointestinal, musculoskeletal and cardiovascular symptoms than CD patients. There were no differences in the number of patients with high somatization score (SCL-90 R somatization score >1) between GS and CD patients. Only in the CD group there was a correlation between symptom increase and personality.

    Conclusion:  The GS group had the same personality traits as CD patients. There was no relationship between increase in symptoms after gluten challenge and personality traits such as e.g. neuroticism in the GS group. Furthermore, there was no general tendency for somatization in neither the GS nor the CD groups. Accordingly, such factors may not explain symptoms in the GS group. Interestingly, the quality of life was affected to the same extent in both groups. In contrast, patients with GS responded to the gluten challenge with more IBS- like symptoms than CD patients.

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    Telomeres in Bipolar II Disorder
    Presenting Author:  Birgitte Boye
    Co-Authors:  Torbjørn Elvsåshagen, Elsa Vera, Erlend Bøen, Jorunn Bratlie, Ole Andreassen, Dag Josefsen, Ulrik F. Malt, Maria Blasco

    Objectives:  Telomeres are DNA-protein structures at the ends of chromosomes that protect them from recombination and degradation.Telomeres shorten with every cell division due to the incomplete replication of linear chromosomes. Accordingly, telomeres shorten with increasing age. Telomere dysfunction is determined by the load of short telomeres, rather than by the mean telomere length. Moreover, short telomere length is associated with age-related illnesses, e.g., cardiovascular disease. It has recently been hypothesized that bipolar disorders are associated with accelerated aging. The aims of the study were to assess the load of short telomeres and the mean telomere length and their relationships with illness duration and lifetime number of depressive episodes in bipolar II disorder (BD-II).

    Methods:  Twenty-eight patients with a DSM-IV diagnosis of BD-II and 28 healthy control subjects matched for age, sex, and education participated. The load of short telomeres (percentage of telomeres < 3 kilobases) and mean telomere length in peripheral blood mononuclear cells were measured using high-throughput quantitative fluorescence in situhybridization.

    Results:  The load of short telomeres was increased in patients with BD-II relative to healthy controls (15.04% vs. 13.48%; p = 0.04) and may represent 13 years of accelerated aging. There was a trend toward shorter mean telomere length in patients than in controls (10,067 vs. 10,619 basepairs; p = 0.08). The load of short telomeres and mean telomere length were associated with lifetime number of depressive episodes, but not with illness duration.

    Conclusions:  These findings suggest that BD-II is associated with an increased load of short telomeres. Depressive episode-related stress may accelerate telomere shortening and aging. A particular attention to age-related illnesses (e.g., cardiovascular disease) among BD-II patients with a high lifetime number of depressive episodes may be warranted.

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    Diagnostic and Treatment Challenges of Limbic Encephalitis in a 2-Year-Old Female
    Presenting Author:  Kalonda Bradshaw
    Co-Authors:  Thomas Reynolds, Svidron Donette, Ortiz-Aguayo Roberto

    Purpose:  Limbic Encephalitis presents with a constellation of neurological symptoms including alteration of mental status. While usually related to paraneoplastic syndromes here we describe the case of a 2 year old female who presented with limbic encephalitis related to anti-NMDA receptor antibodies. Early diagnosis and targeted treatment interventions can lead to significant reduction of morbidity.

    Methods:  Case presentation and literature review.

    Results:  The patient is a previously healthy 2-year-old female who initially presented with difficult-to-control complex partial seizures leading to multiple readmissions over a six-week period. On the day of consultation the patient had been admitted with alteration of mental status and movement disorder due to a presumptive diagnosis of phenytoin toxicity.  Symptoms included recurrence of seizure without fevers, restlessness, inconsolable high pitch cry, thrashing, moaning, eye deviation, limpness, confusion, deregulated sleep and regression in speech. Empiric treatment with lorazepam and haloperidol was quickly discontinued due to ineffectiveness and concern for worsening of abnormal movements, respectively. Further observation in hospital showed autonomic instability which raised concern for limbic encephalitis. Following parental consent and review with pharmacy safety committee a trial of Olanzapine for ongoing agitation was initiated with moderate response. Extensive work-up did not reveal evidence of malignancies. Anti-NMDA Receptor antibodies were positive. Immune modulating therapy was initiated. She was eventually discharged to rehabilitation hospital.

    Conclusion: Anti-NMDA Receptor Encephalitis has recently been identified in children who present with limbic encephalitis without evidence of malignancy. Given that this condition often presents with psychiatric symptoms and is currently felt to be amenable to early intervention with immune modulating treatments, it is imperative that psychiatric consultants become more familiar with its presentation and management.

    References:

    American Academy of Child and Adolescent Psychiatry. Practice Parameter for the Psychiatric Assessment and Management of Physically Ill Children and Adolescents. AM. Acad. Child Adolesc. Psychiatry 2009;48(2):213-233

    Chapman MR, Vause H: Anti-NMDA Receptor Encephalitis: Diagnosis, Psychiatric Presentation, and Treatment. Am J Psychiatry 2010; 168:3

    Fremaux T, Reymann JM, Chevreuil C, et al. Prescription of Olanzapine in Children and Adolescent Psychiatric Patients. Encephale 2007;33(2):188-96

    Schimmel M, Bien C, Vincent A, Schenk W, Penzien J: Successful treatment of anti-N-methyl-D-aspartate receptor encephalitis presenting with catatonia. Arch Dis Child 2009; 94:314-316.

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    Investigating the Relationship between Plasma Cytokine Levels and Psychiatric Symptoms

    Errata:  Here and in the meeting's Final Program, this poster was titled Pancreatic Cancer, Immune Functioning, and Depression, and William Breitbart was listed as presenting author.

    Presenting Author:  Kristen Tobias
    Co-Authors:  Barry Rosenfeld, Hayley Pessin, William Breitbart

    Purpose:  Major depressive disorder (MDD) causes considerable suffering, role impairment, mortality, and significantly complicates medical illness. The high prevalence of depression in patients with pancreatic cancer exceeds not only the general population, but even that found in other types of cancer. More than 70 years of clinical research suggests a bidirectional relationship between depression and pancreatic cancer. However, the underlying mechanism behind this relationship remains an enigma, as does the precise origin of depression in medically uncomplicated populations. MDD has been hypothesized to occur as a result of dysfunction in the interaction of the nervous, endocrine, and immune systems. Increasing evidence suggests that pro-inflammatory cytokines may be involved in the pathophysiology of depression, but the extant literature remains inconclusive. Results may likely be confounded by inclusion of psychiatrically heterogeneous patient populations. Therefore, subtypes of depression may be more useful correlates of immune dysfunction than DSM-IV diagnostic classification. This study examines plasma cytokine levels in relation to a DSM-IV diagnosis of MDD, "sickness behavior syndrome" (a term commonly used to describe a psychoneuroimmunological response to infection), suicidal ideation, melancholia and depression severity in patients with pancreatic cancer and healthy controls.

    Methods:  Patients with unresectable pancreatic adenocarcinoma (Stage III and IV) and healthy controls were evaluated for study inclusion. Exclusion criteria consisted of age less than 40 years, self-report of a major psychiatric diagnosis other than depression, and medical illnesses and treatment known to affect cytokine levels. Data were collected on a sample of 74 individuals, 42 of whom were diagnosed with pancreatic cancer and 32 without a cancer diagnosis; roughly 1/3 of the sample also had a DSM-IV diagnosis of MDD (as assessed by the SCID). Depressive severity and suicidality were measured using the Hamilton Rating Scale for Depression (HRSD). A retrospective "sickness behavior" metric was developed that consists of 8 items taken from validated scales commonly used in psychiatric research. Melancholia was assessed using DSM-IV criteria as measured by HRSD items. Pro-inflammatory cytokines IL-6, TNFα, and IL-1β were assayed using standard ELISA techniques.

    Results:  Patients with pancreatic cancer had significantly higher levels of IL-6 compared to non-cancer controls (Spearman's ρ= 0.66, p < .001). There were significant correlations between IL6 and MDD (Spearman's ρ= 0.26, p < .05), "sickness behavior" (Spearman's ρ= 0.26, p < .05), depressive severity (Spearman's ρ= 0.26, p < .05), and melancholia (Spearman's ρ= 0.31, p < .01). There were no significant correlations between any of the cytokines measured and suicidal ideation. Further analyses exploring the inter-relationships among these items, as well as with other cytokines, are ongoing.

    Conclusion:  These data support a unique relationship between IL-6 and pancreatic cancer, and suggest that subtypes of depression may be more associated with pro-inflammatory cytokines than the broader diagnosis of MDD. Homogeneous patient populations and sophisticated neuropsychiatric instruments should be used to better understand the neurobiology of pancreatic cancer and depressive symptomatology.

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    Teaching in Consultation-Liaison Psychiatry: Development and Results of a Novel Curriculum
    Presenting Author:  Kristen Brooks
    Co-Author:  J. Jewel Shim

    Objective:  Though there is literature highlighting the importance of teaching residents in Psychosomatic Medicine (PM), there is neither a standardized method of providing that instruction nor an established assessment of competency in PM. As programs move toward competency-based assessments, there is a clear need for a tool to facilitate evaluation of residents. The APM Residency Education Subcommittee has recently developed a series of lectures for programs to utilize, but to date there is no established cohesive PM didactic program. With this project, we developed a curriculum for a clinical PM Service as well as an assessment tool to evaluate the effectiveness of the teaching program.

    Method:  The curriculum content was derived from multiple sources: literature on service-based curricula in PM; ACGME and Residency Review Committee (RRC) requirements in PM; Residency Training Program core requirements; Academy of Psychosomatic Medicine training guidelines; and faculty input. Thirty minute teaching and evidence based medicine sessions were developed for core topics taught across a 3 month rotation. The overall organization facilitates high-yield learning via focused sessions and a progressive structure that begins with common and acute issues in PM and then concentrates on issues specific to PM and patient care within a major tertiary care center. We then developed a case-based assessment tool to evaluate the effect of the curriculum on medical knowledge and clinical proficiency in PM as well as measured the confidence of trainees. Residents complete a pre and post PM rotation test that utilizes clinical vignettes to assess their ability to provide psychiatric evaluation in the medical setting. Expert PM psychiatrists then evaluate their responses in terms of 1) how well they met relevant core competencies and 2) their overall management of each case. In addition, residents rated their confidence in their ability to manage common issues in PM pre- and post-rotation.

    Results:  To date feedback, both in-person and anonymous, has been strong. Early data indicates that residents have increased subjective comfort with PM and more confidence in managing psychiatrically ill patients in the medical setting. We are currently gathering data via our case-based assessment tool to evaluate competency in psychiatric evaluation in the medical setting.

    Conclusions:  The structure and content of our curriculum enhances learning on a busy clinical service and provides one model for teaching PM to residents. Subjective competence in residents is increased. We have developed an assessment tool that will facilitate assessment of competency in PM for residents in training.

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    Effect of Methylphenidate on Cognition and Function in Apathetic Patients with Dementia of the Alzheimer Type (DAT)
    Presenting Author:  William Burke
    Co-Author:  Prasad Padala

    Purpose:  Apathy is one of the most common behavioral disturbances in persons with DAT. Apathy often dramatically influences the daily activity of the patient and causes distress for caregivers. We report here on the cognitive and functional outcomes of a randomized clinical trial investigating the effect of methylphenidate on apathy.

    Methods:  Patients with mild to moderate DAT who had apathy scores on the Apathy Evaluation Scale (AES) of >40 entered into the study after informed consent was obtained. Outcomes measured included the Apathy Evaluation Scale (AES), Clinical Global Impression (CGI, CGI-S), Mini-Mental State Examination (MMSE), Modified Mini-Mental State Examination (3MS), Activities of Daily Living (ADL), Instrumental Activities of Daily Living (IADL) and the Zarit Burden Scale (ZBS). Patients were randomly assigned to placebo or MPH initially dosed at 5mg BID and titrated to 10mg BID at two weeks. Follow up visits were scheduled at 4, 8, and 12 weeks. Study medication was then stopped and subjects returned for one additional visit at week 14. Data with a normal distribution were analyzed using a repeated measures mixed model. ADL was transformed to a binary variable and analyzed with a generalized linear mixed model. Bonferroni corrections were made to adjust for multiple comparisons.

    Results:  60 male patients were enrolled; one patient was excluded from each arm of the study leaving a total of 29 patients in each group. Mean age was 76.6 (±7.9) years. Patients who received MPH showed significant improvement on a global measure of function (CGI), global severity (CGI-S), and cognitive function (MMSE and 3MS) after 12 weeks that did not persist at the two-week follow-up. There were significantly more subjects with ADL deficits at baseline in the MPH group. The percent of subjects with any ADL deficits did not differ significantly at study end point. IADLs were not significantly different at baseline and did not show any significant difference between groups at any time point though IADLs significantly improved from baseline in the MPH group. ZBS scores did not differ at any time point between the two groups. MPH was well tolerated in this population. No patient discontinued the study due to adverse effects.

    Conclusions:  MPH treatment was associated with improved ratings of global function and in brief cognitive measures that did not persist after treatment discontinuation. Measures of ADL, IADL and caregiver burden did not differ between groups but all showed evidence of positive change from baseline within the MPH group. MPH may offer significant benefits for apathetic persons with DAT beyond a direct effect on apathy.

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    Perinatal Mental Health Treatment: OB/Gyn Providers’ Perspectives on How Barriers Can Be Overcome
    Presenting Author:  Nancy Byatt
    Co-Authors:  Kathleen Biebel, Rebecca Lundquist, Tiffany Moore Simas, Gifty Debordes-Jackson, Douglas Ziedonis

    Introduction:  Perinatal mental illness can cause tremendous suffering for mother, fetus/child and family. Untreated mental illness can lead to maternal engagement in poor health behaviors, substance abuse and suicide [1,2]. In spite of profound effects on mother, partner and child, barriers to the treatment of perinatal mental illness continue to persist [3]. The perinatal period is an ideal time to detect and treat mental illness [4] due to regular contact between mothers and health professionals. Despite the opportune time and setting, mental illness is under-diagnosed and under-treated in the obstetric setting [5]. Major change is needed to improve treatment and decrease the suffering of perinatal women. The goals of this study were to: (1) Identify barriers that OB/Gyn providers and support staff encounter in recognizing mental illness and engaging perinatal women in treatment; (2) Identify strategies to overcome barriers to treatment; and, (3) Inform the development of interventions aimed at improving treatment entry and follow-up.

    Methods:  Four, two hour focus groups were conducted with obstetric providers and staff. Focus groups were transcribed and resulting data analyzed using a modified grounded theory approach with a phenomenological emphasis.

    Results:  Key concepts regarding barriers, synthesized from discussions with OB/Gyn providers and staff, were lack of time and skills needed to diagnose, refer or treat women experiencing perinatal mental illness. Respondents reported that women felt stigmatized, minimized psychiatric illness and were often not comfortable discussing their psychiatric symptoms with OB/Gyn providers. Lack of collaboration between OB/Gyn and psychiatry providers was also perceived as a hindrance. Strategies identified to overcome provider barriers included OB/GYN provider education and training to improve psychiatric knowledge base, comfort level prescribing psychotropic medications and communication skills.

    Discussion:  Strategic changes are needed to successfully engage perinatal women in mental health treatment. These data support the development of multidisciplinary mental health treatment strategies that utilize patient psychoeducation and provider training and education to overcome patient and provider level barriers and engage women in mental health treatment.

    References:

    1. Zuckerman B, Amaro H, Bauchner H, Cabral H. Depressive symptoms during pregnancy: relationship to poor health behaviors. Am J Obstet Gynecol. 1989 May; 160(5 Pt 1):1107-11

    2. Lindahl V, Pearson JL, Colpe L. Prevalence of suicidality during pregnancy and the postpartum. Arch Womens Ment Health. 2005 Jun; 8(2):77-87

    3. Kim JJ, La Porte LM, Corcoran M, Magasi S, Batza J, Silver RK. Barriers to mental health treatment among obstetric patients at risk for depression. Am J Obstet Gynecol. 2010; 202:312

    4. Coates, Schaefer, Alexander. Detection of postpartum depression and anxiety in a large health plan. J Beh Health Serv Res 2001; 31:117-133

    5. Sword W, Busser D, Ganann R, McMillan T, Swinton M. - Women's care-seeking experiences after referral for postpartum depression. Qualitative health research. 2008; 18:1161.

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    The Experience of a Psychiatric Unit with Clinical Nurses Care in a General Hospital in Brazil
    Presenting Author:  Ana Luiza Camargo
    Co-Authors:  Alfredo Maluf Neto, Alessandra Julião, Fátima Coleman, Mara Maranhão

    Purpose:  Psychiatric wards in General Hospitals usually imply in safe environments and psychiatric nurses care for psychiatric disorders treatment. Nevertheless, they sometimes lack of a holistic treatment for patients with behavioral and clinical-surgical comorbidities. In our hospital, a psychiatric unit was developed with clinical nurses care under supervision of the Psychosomatic Medicine Department (PMD)- the Advanced Care Unit (ACU).

    It's our aim to describe the profile of patients treated in this unit in a year period, either for psychiatric treatment alone or due to psychiatric/behavioral risk in patients with a clinical-surgical conditions.

    Method:  This was a cross sectional study performed through the year 2010. All data was collected from patients charts.

    Results:  A total of 118 patients stayed in the ACU, 81 (68,6%) due to psychiatric/behavioral risk in clinical-surgical conditions ( group 1) and 37 (31,4%) for sole psychiatric care (group 2). The first group had 50% males and females, and the second group 70% of females. Age in both groups showed no relevant difference (50,9 in group 1, 43,8 in group 2, p= 0,64).

    Group 1 had 36,3% of Affective Disorders, 31,2% of Alcool and/or substance abuse or dependence , 15% of delirium 7,5% of Eating disorders, 5% of Schizofrenia and other psychotic disorders, and 2, 5% of personality disorders and demencia. In group 2, Afective Disorders was the most prevalent disorder (22 patients, 61,1%), followed by 19,4% of Schizofrenia and other psychotic disorders, 8,3% of Alcool and/or substance abuse or dependence and 5,6% of personality and anxiety disorders. Risk symptoms and behaviours - suicide ideation or attempt and aggressiveness/ agitation- had no statistically difference in both groups ( p= 0,74 and p= 0, 79).

    Referral to the ACU in group 1 was made by the patient's psychiatrist (81,1%); in group 2 referral was either made by an emergency department doctor (13,8%), through a removal from medical wards due to PMD psychiatrist intervention (50%) or after an assistant doctor spontaneous request (36%).

    Conclusions:  The majority of patients that stayed in the ACU had a clinical-surgical condition, but a profile of risk behaviors similar to the patients that were admitted for psychiatric treatment alone. If not for this unit, they would probably be treated in general wards, despite all the risk envolved. The fact that ACU provides general nurses care but also a secure environment and the supervision of the psychosomatic medicine team may have played a part in the acceptance of the health care team that their patient should be treated in this ward.

    Further studies will be necessary to show whether being treated in this particular unit can play a role in desirable outcomes, as lengh of stay, clinical or psychiatric relapse and security of care.

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    Hereditary Spastic Paraplegia and Psychosis: Linked by the Corpus Callosum?
    Presenting Author:  Jason Caplan
    Co-Authors:  Angela Osmolak, Ryan Wallenberg

    Introduction:  Hereditary spastic paraplegia (HSP) includes a group of inherited neurodegenerative disorders with a common feature of progressive weakness and spasticity of the lower extremities. HSP has previously been associated with an increased risk of psychosis in one cohort of patients, but no clear mechanism has been proposed for this association. Here, we report the case of a young woman with previously diagnosed HSP who developed signs and symptoms of psychosis and was found to have dysmorphic changes of her corpus callosum (a feature common to both HSP and schizophrenia).

    Case Report:  Ms. J was a 26 year-old woman with history of HSP first diagnosed in her mid-teens and no prior psychiatric history who was admitted with a presumed adverse reaction to baclofen. A 6-day trial of baclofen (intended to reduce her bilateral lower extremity spasticity) had been attempted two months prior to this transfer, but was discontinued due to the emergence of insomnia, prominent auditory and visual hallucinations, and reports of both suicidal and homicidal ideation which had persisted in the absence of the medication.

    An extensive work-up including EEG, head CT, and laboratory testing (including CBC, chemistries, urinalysis, paraneoplastic antibody panel, anti-thyroglobulin antibodies, and thyroperoxidase antibodies) was unrevealing. MRI of the brain was notable for diffuse white matter loss with T2 signal elevation with marked thinning of the corpus callosum (MRI images will be presented with the poster).

    Trials of risperidone, ziprasidone, and olanzapine were unsuccessful in addressing Ms. J's symptoms, though her condition rapidly improved after the initiation of aripiprazole 10 mg daily, with complete resolution of her hallucinations. The dose was increased to 15 mg daily which prompted resolution of her suicidal and homicidal ideation. As her psychosis improved, Ms. J was better able to participate in cognitive testing which revealed marked deficits of memory and attention. Her ability to care for herself did not return to her prehospitalization baseline, and after more than 2 months in the hospital, Ms. J was discharged to a group home able to care for both her medical and psychiatric needs.

    Discussion:  HSP has previously been associated with an increased risk of psychosis although no mechanism for this association has been suggested. As with our patient, thinning of the corpus callosum has been described as a radiologically distinctive (but not specific) finding in cases of HSP. Dysmorphia of the corpus callosum has also been associated with schizophrenia. We hypothesize that changes in the corpus callosum may be the underlying neuroanatomical factor that predisposes some patients with HSP to psychosis. Patients with HSP may also represent a novel population for the study of neurodevelopmental factors that lead to symptoms of psychosis.

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    Use of Quetiapine for the Treatment of Delirium in a Colombian General Hospital
    Presenting Author:  Carlos Alberto Cardeño
    Co-Authors:  Lina María Escobar, Lina Marcela Páramo, Vladimir Cortes, Natalia Arcila, Diana Restrepo, Naira Valencia, Sigifredo Ospina

    The use of quetiapine in delirium remains an indication without FDA approval, there are few studies of the use of quetiapine show despite being a safe and effective medicine evaluated in several studies.

    Purpose:  Describe the characteristics of the use of quetiapine and its clinical effectiveness in the management of delirium in the Hospital Universitario San Vicente Foundation during the period from January 1, 2008 and December 31, 2009.

    Method:  A descriptive study was carried out. We evaluated all the medical records of patients older than 18 who received quetiapine for treating psychiatrist diagnosed delirium (DSM-IV criteria) in the period described. We collected on sociodemographic characteristics, dose, time of use, response, reasons for choice and side effects.

    Results:  We evaluated 196 patients of which 94 met inclusion criteria. The average age was 47.5 years. Of the sample 44.9% of patients received deliriogenic drugs. Haloperidol prior to the use of quetiapine 69.8% with an average dose of 3.8 mg / day. The average days of use of quetiapine was 20 days. 17.7% of patients required sedation after initiation of quetiapine. 44% of patients received the same dose of medicine to suspend the high and the others did: to suspend gradual decrease (14.3%), decreased gradually to 4.4% support, abrupt discontinuation in 23.1%. 9.5% had side effects: extrapyramidal 1.06%, sedation 6.3% being most common. 74.5% of those receiving quetiapine showed improvement of delirium, 10.6% did not improve, 3.2% had worsened and 11.7% could not be determined. In 11.7% of patients had to discontinue medication.

    Discussion:  This study shows that quetiapine may be effective and well tolerated in patients with delirium. The average age of patients was 59.6 which is similar to previous studies. The dose of quetiapine in our study was lower: 56.5 mg daily compared with other investigations. A significant portion previously received haloperidol as initial treatment, showing that it is the drug of choice. The average duration of treatment was higher than in previous studies. One explanation would be the lowest average dose. Adverse events were few and of these the greater the sedation. The improvement of delirium was determined by clinical report, no scales of measurement were used.

    Conclusions:  Quetiapine appears to be a safe drug, effective and well tolerated in patients with delirium.

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    NMDA Receptor Encephalitis in a 3-Year-Old Female Presenting with Severe Agitation and Separation Anxiety
    Presenting Author:  Scott Carroll

    Purpose:  N-Methyl-D-Aspartate (NMDA) receptor antibody encephalitis is a newly defined type of autoimmune encephalitis that mainly affects children and young adults, with a strong female predominance [1]. Initially identified as a paraneoplastic syndrome, especially with ovarian teratomas, and was classified as a subtype of limbic encephalitis [2]. However, now that cell based assay is readily available, it now appears to also occur post-virally without the presence of a tumor [3]. It has characteristic clinical features and will often present as acute changes in behavior and personality such as delusions, paranoia, agitation and aggression that strongly resembles acute psychosis. However, it course is progressive resulting in memory loss, seizures, dyskinesias, confusion, autonomic dysfunction and central hypoventilation [1,4]. Treatment involves removal of the tumor if present and a combination of corticosteroids, IVIg or plasma exchange [2].

    Method:  Pt FE, a previously normal 3yo Female, initially presentation to the University of New Mexico Hospital with a sudden onset of decreased speech, poor coordination and episodes of vomiting followed by lethargy and deep sleep for 5-10 minutes. A psychiatric consultation was requested a few days after admission to see if there was a psychiatric component to her presentation. The psychiatric evaluation was further complicated by mutual charges of abuse by the divorced parents due to their highly conflicted relationship. The initial psychiatric evaluation included interviews with each parent separately and observations of the child with two different caregivers. The patient was evaluated again by this author several months later during the rehabilitation phase following her diagnosis and treatment for NMDA receptor encephalitis.

    Results:  Her initial psychiatric evaluation was significant for a number of behavioral and cognitive symptoms in addition to neurological symptoms, including an inability to sleep, severe agitation and explosive tantrums, inability to be calmed or reassured by caregivers, a persistent dysphoric mood and a preference for being naked related to skin hypersensitivity. Interestingly the behavioral symptoms vaguely resembled mania and combined with a paternal history of Bipolar disorder, could have resulted in a misdiagnoses of acute mania.

    Conclusions:  NMDA receptor encephalitis is a medical condition that can be mistaken for acute psychosis or mania if the associated cognitive and neurological symptoms are not fully appreciated.

    References:

    1. Dalmau J., et al: Anti-NMDA-receptor encephalitis: case series and anaylsis of the effects of antibodies. Lancet Neurol 7. 1091-1098. 2008

    2. Abeloff: Abeloff's Clinical Oncology 4th ed, Chapter 51 - Paraneoplastic Neurological Syndromes, copyright 2008 Churchill Livingstone

    3. Florance N.R., et al: Anti-NMDA receptor encephalitis in children and adolescents. Ann Neurol 66. 11-18. 2009

    4. Pillai S.C., et al: Cortical Hypometabolism Demonstrated by PET in Relapsing NMDA Receptor Encephalitis. Pediatric Neurology Vol 43, Issue 3, Sept 2010

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    Determinants of Using Emergency Rooms as a Usual Source of Medical Care among a National Sample of Chronically Homeless Individuals
    Presenting Author:  Lydia Chwastiak
    Co-Authors:  Jack Tsai, Robert Rosenheck

    Background:  Individuals who are homeless face substantial obstacles to obtaining appropriate medical care. Despite higher rates of psychiatric and substance use disorders, and chronic medical conditions, homeless persons are less likely to use ambulatory care services, often relying on emergency room visits for preventable medical problems. In the current study, we aim to evaluate the sociodemographic and clinical factors associated with a regular source of care among a national sample of chronically homeless individuals, including the impact of psychiatric diagnosis and psychiatric symptom severity on having a regular source of care and receipt of preventive services.

    Methods:  Data from the evaluation of the Collaborative Initiative to Help End Chronic Homelessness (CICH) were used to examine utilization of medical services among 870 chronically homeless adults in 11 US cities. We conducted bivariate and multivariate comparisons of sociodemographic and clinical factors associated with using the ER as a regular source of care compared to having a primary care provider (community health clinic, hospital-based clinic, doctor’s office, or mobile health clinic). Second, we compared the utilization of services and receipt of preventive services between these two groups.

    Results:  The study sample (n =870) was 74% male and 38.1% white (48.4% African-American; 8.0% Hispanic); mean age was 45.0 years. The mean lifetime number of years homeless was 8.2. 54.4% had a drug use disorder; 35.6% had a diagnosis of either schizophrenia or bipolar disorder. At baseline, 544 (62.5%) subjects reported having a primary care provider, and 206 (23.6%) reported that they used the ER as their regular source of care (13.9% reported some other regular source of care). Subjects who used the ER for a regular source of care were more likely to report no health insurance at all in the past year (48.5% vs 18.7%, p=0.001), and having trouble paying for healthcare (47.5% vs 26.3%, p=0.001). There were no differences between groups with respect to any psychiatric symptom score (BSI, observed psychosis scale, SF-12). Participants with a primary care provider received more preventive services in the past year, and discussed more health behaviors with a medical provider. Among the 20% of the sample who had asthma, those with a primary care provider were more likely to receive treatment (79.8% vs 54.3%, p = 0.001).

    Discussion:  In this large national sample of chronically homeless individuals, lack of insurance was the factor most strongly associated with using the ER as a regular source of care. Neither psychiatric diagnosis nor psychiatric symptom severity was associated with using the ER instead of primary care. Individuals with a primary care provider were more likely to discuss health behaviors, receive preventive services and receive treatment for chronic conditions.

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    Face Transplant: Two Year Follow-Up Report
    Presenting Author:  Kathy Coffman

    Background:  The advent of facial transplantation has raised complex ethical and psychological issues. Mortality thus far of 13 existing recipients is 15.4%, 2/13. Rejection occurs later in facial transplantation and immunosuppressant levels are initially higher, so there may be more neuropsychiatric side effects. Physical goals of transplantation include recreating the appearance of a normal face as well as regaining function and sensation.

    We identified a significant void in rating instruments applicable to this field, and developed three instruments, the Cleveland Clinic FACES score for prioritizing patients for a transplant registry, the Perception of Teasing-FACES scale, and the Facial Anxiety Scale-State.

    Aim:  Data was systematically collected over two years with a near total face transplant recipient , including: appearance self-rating, body image, mood changes, pain rating, perception of teasing, quality of life, self-esteem and social reintegration.

    Methods:  Rating scales were administered prior to the transplant and at regular intervals for two years afterwards, including the Beck Depression Inventory, Spielberg State Trait Anxiety Inventory, the Perception of Teasing –Faces scale, Facial Anxiety Scale-State, the PASTAS-State (Physical Appearance State and Trait Anxiety scale: State), the Rosenberg Self-Esteem rating scale, PAIS ( Psychological Adjustment to Illness Scale-Self-rated), SF-36 and WHO-QOL BREF.

    Results:  Appearance self-rating improved from 3/10 to 7/10 within 6 weeks of surgery. Body anxiety on the PASTAS-State ( Physical Appearance State and trait anxiety scale: State) rose from 15 at 2 weeks after transplant to 23 by 10 weeks due to steroid related weight gain and fell to 9 at 2 years post-operatively. The Facial Anxiety score rose from 2 at 2 weeks after surgery to 23 at 10 weeks and fell to 7 by the end of the second year.

    Mood changes reflected by the Beck Depression Inventory ranged from a score of 16 pre-transplant and ranged from 3-26 over two years, reflecting ongoing events in the patient’s life in addition to transplant rejection or CMV viral activity.

    Pain was rated 6-7/10 prior to facial transplantation, and fell consistently to 0/10 by day 50 during recuperation from the transplant surgery.

    Perception of Teasing-FACES scores have fallen from 25 to zero across all categories by 2 years after transplant. Self-esteem on the Rosenberg self Esteem rating scale has remained unchanged, as did anxiety on the Spielberg State Trait Anxiety rating scale.

    Quality of life has continued to improve, especially social reintegration reflected by a significant decrease in scores on the PAIS-SR (Psychological Adjustment to Illness Scale-Self-rated) from 15 to 5 by the end of two years. The PAIS-SR appeared much more useful in measuring the relevant domains in the face transplant recipient than the SF-36 or the WHOQOL-BREF, particularly in assessing psychological distress and social reintegration.

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    Medical Student Critical Concepts Course: Bringing Psychiatry into the Human Patient Simulation Laboratory
    Presenting Author:  Erich Conrad
    Co-Author:  Mark Townsend

    Purpose:  This presentation guides educators through the inception and implementation of a course designed to train medical students in the evaluation and management of delirium utilizing three different stations. The first station utilizes team based learning with a review article on delirium. The second station utilizes a website to facilitate training in skills to evaluate the presence of delirium in the ICU. The final station utilizes a human patient simulation mannequin to critically think through a case of delirium.

    Methods:  Student learning objectives and acquisition of knowledge are assessed with a pre and post test. Quality of, and satisfaction with the learning experience will be assessed with questionnaires.

    Results:  The students' degree of learning and perceptions of the course will be analyzed and presented. Difficulties inherent to the execution of the course will also be reviewed.

    Conclusions:  The newly implemented Critical Concepts Course is an opportunity for Psychiatry to join other specialties in the human patient simulation laboratory. Psychosomatic Medicine specialists are in an ideal position to train students utilizing this modality. Successful implementation of the course requires input of numerous people and multiple practice sessions.

    As data is beginning to be collected, and yet to be analyzed, further conclusions will be available at the time of presentation.

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    Clinical Issues in Cystic Fibrosis Care and Transition to Adulthood
    Presenting Author:  Mary Lynn Dell
    Co-Author:  Joseph Locala

    Objective:  To review commonly recognized clinical and ethical issues in cystic fibrosis (CF) care, as well as unique concerns raised by patients experiencing longer survival into adulthood requiring transfer of care from pediatric to adult care providers.

    Abstract:  CF is the most common lethal autosomal recessive disease in the U.S., with 1 in 2500 live births having CF disease. Median predicted survival age in the U.S. has increased from 14 years in 1969 to >36 years in 2005. Over 40% of all individuals with CF are 18 years or older.

    Virtually all organ systems with epithelial tissues are affected by this disease, leading to chronic obstructive pulmonary disease, chronic rhinosinusitis, pancreatic exocrine impairment, malnutrition, diabetes, congenital bilateral absence of the vas deferens in males, abnormal cervical mucus in females, and elevated sweat chloride. CF patients may experience numerous hospitalizations for pulmonary exacerbations, complex and time-consuming daily regimens of nebulizers, medications, and respiratory care, heightened attention to nutrition, exercise and activity limitations, multiple surgical procedures, acute and chronic pain, and limitations imposed by CF in educational, vocational, and sexual/reproductive aspects of late adolescent and adult life.

    More so than in many other chronic illnesses, the clinical, psychiatric, and ethical considerations of CF patients transitioning from adolescence into adulthood are overlapping and enmeshed, if not the very same issues described by different professional languages.

    In clinical terms, individuals transitioning from pediatric to adult CF care commonly struggle with a number of concerns, some of which are unique to CF patients and others of which are normal developmental stages impacted by the struggle with CF. The following issues will be addressed: Assuming more responsibility and accountability for daily CF care, learning to use parents and medical personnel effectively for assistance, general treatment adherence, pain management, substance abuse/dependence, eating disorders, other comorbid psychiatric disorders, educational and vocational issues, sexuality/adult relationships/marriage/parenting and transplant/palliative care/end-of-life care .

    The last two decades have witnessed phenomenal advances in the scientific understanding of molecular, biochemical, genetic, and pathophysiology of CF. New antibiotics, anti-inflammatory agents, nebulizers, airway clearance techniques, improved nutrition and pancreatic enzyme replacements and vitamin regimens, while improving quality of life and increasing life expectancy, have also contributed to new clinical and ethical considerations in CF clinical work. The longer life expectancy and improved medical care and technology has also introduced the clinical and ethical “blessings and burdens” of lung and pancreas transplants, palliative medicine, and end-of-life treatments, ethical quandaries, and psychotherapeutic needs and possibilities.

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    A Controlled Trial of a Light-Emitting Diode (LED) Light Therapy Device (The Litebook) for Treatment of Seasonal Affective Disorder (SAD)
    Presenting Author:  Paul Desan
    Co-Authors:  Ray Lam, Robert Levitan, Martin Teicher, Ybe Meesters, Colin Shapiro, Josh Rosenthal, Rachel Morehouse, Andrea Weinstein

    Purpose:  The efficacy of the Litebook, a compact LED light therapy device delivering 1,350 lux of blue-enriched, white-appearing light, in the treatment of Seasonal Affective Disorder (SAD) was tested in a randomized, double-blind, placebo-controlled trial at 8 centers in the United States, Canada and the Netherlands.

    Methods:  Subjects aged 18 to 65 with SAD (DSM-IV major depression with seasonal pattern) were seen at Baseline and Randomization visits separated by 1 week, and after 1, 2, 3 and 4 weeks of treatment. Hamilton Depression Rating (SIGH SAD) scores were obtained at each visit. Subjects with SIGH SAD ³20 at Baseline and Randomization visits were randomized to active or control treatment: exposure to LED phototherapy (The Litebook Company Ltd, Medicine Hat, Alberta) or to an inactivated negative ion generator, at a distance of 20 inches for 30 minutes a day prior to 8 AM. The ocular safety and absence of UV emissions for The Litebook were verified by an independent ACGIH hazard analysis. The clinical trial was supported by The Litebook Company Ltd, Medicine Hat, Alberta.

    Results:  Of the 106 subjects randomized, 95 completed the trial. Active and control group SIGH SAD scores did not differ significantly at randomization, 27.8 ± 4.6 versus 29.2 ± 6.2, respectively. At trial end, mean SIGH SAD score was significantly lower with active than control treatment, 12.1 ± 8.5 versus 17.2 ± 10.3 (p = 0.01, t test, completed subjects analysis), and mean SIGH SAD improvement was significantly greater, 56.6% ± 29.7% versus 40.1% ± 33.6% (p 0.013, t test). The proportion of subjects with >50% improvement in SIGH SAD scores was significantly higher with active than control treatment, 64.6% versus 36.2% (p = 0.006, chi square test). All three comparisons were also significant in the all randomized subject, LOCF analysis. No serious adverse events were observed.

    Conclusions:  Treatment with The Litebook LED light therapy device is an effective treatment for SAD. The short treatment time (30 minutes) and portability of the device may increase patient appeal and adherence over other treatment options, including chemical antidepressants and other light therapy devices. A convenient from of light therapy may be useful in the treatment of circadian rhythm disorders, including those present in the medically ill.

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    A General Psychosomatic Clinic: Opportunities, Education, and Clinical Service
    Presenting Author:  Scott Emerson
    Co-Author:  Gagandeep Singh

    We describe a small one afternoon per week psychosomatic clinic at a University Hospital. This clinic is serviced by a psychiatry resident and a psychosomatic medicine boarded psychiatrist. This provides psychiatry residents with training in dealing with complex patients and unique psychosomatic issues. It also provides an important clinical service to the other medical specialties.

    Methods:  We use a chart review to describe the patient population, referral sources and referral questions. We also report the results of a survey of residents who have trained at this clinic in the last five years (including those who are now in practice) about what was/was not useful about training at this setting.

    Results:  The clinic services a diverse set of patients and referral sources. This diversity and the complexity of patients seen enriches the educational experience of psychiatry residents.

    Conclusion:  Providing such an outpatient psychosomatic opportunity can enrich psychiatry resident education while being a valuable resource for the general medical community.

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    Suicide after Living Kidney Donation: Lessons Learned from a Single Case
    Presenting Author:  Anne Eshelman

    Introduction:  Suicide is a rare phenomenon, 11 in 100,000 in the general population, and 5 reported suicides in 51,153 living kidney donors [1]. Suicide is a tragedy, often the result of many factors simultaneously, a perfect storm . Our transplant center has performed 835 living donor kidney transplants since 1969. We want to share our experience and new protocols to promote standardization of psychiatric screening criteria and follow up strategies for living donors.

    Background:  A 49 year old woman came forward voluntarily to donate a kidney to a close friend. She wanted to help her friend prolong her life, improve quality of life and be active with her 2 daughters. The recipient was a Type I diabetic, legally blind, and was a recipient of a pancreas transplant in 2000, before developing ESRD. The donor was evaluated by the transplant team, including a psychologist, and was found to have a history of bipolar disorder II diagnosed 4 years previously after a traumatic event, and was stable on lithium for at least 3 years. She denied ever having suicidal thoughts, psychotic symptoms, or alcohol or drug abuse. Concerned about possible nephrotoxicity of lithium, the team recommended a medication change. The donor lived 5 hours from the transplant center, and was followed by her own psychiatrist, who chose to change from lithium to lamotrigine [2]. The transplant procedure went smoothly, and both donor and recipient did well. However, 2 months after donation, the donor committed suicide.

    Discussion:  This presentation reviews lessons learned from a donor suicide, the process of review, and revisions of our protocols to reduce psychiatric risks for living donors. The root cause analysis and UNOS review led to changes in our protocols to address: psychiatric exclusion criteria, coordination of care when the donor lives a distance from the transplant center, changes in psychotropic medication around the time of surgery, especially for the purpose of reducing nephrotoxicity, guidelines for required length of time for stabilization after a medication change, post-surgical follow up of donors, involving families of consenting adults, and patients withholding information and lying.

    Conclusion:  This experience has increased the transplant team's awareness of psychiatric risks. Sharing this process and our new protocols with psychiatrists and psychologists evaluating living donors should stimulate discussion, lead to a standardization of new guidelines, and prevent adverse psychiatric events.

    References:

    1. Davis C. Living kidney donors: current state of affairs, Advances in Kidney Disease, vol 16, no 4 (July), 2009: pp 242-249

    2. Patorno, E, Bohn, R, Wahl, P, Avorn, J, Patrick, A, Liu, J, and Schneeweiss, S. Anticonvulsant medication and the risk of suicide, attempted suicide or violent death. JAMA, April 14, 2010,-vol 303, No 14, p 14012-1409

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    New Onset Kleptomania after Successful Bariatric Surgery: Addiction Transfer?
    Presenting Author:  Anne Eshelman

    Introduction:  There is a growing literature on alcohol and drug addiction after successful bariatric surgery [1]. Kleptomania has many features in common with substance use disorders: etiology, treatment strategies and outcomes [2]. Alcohol abuse and psychiatric disorders are more common in families of subjects with kleptomania, suggesting a genetic relationship to other substance use disorders [3]. Stealing usually does not come to the attention of behavioral health until there are legal consequences.

    Background:  A 54 year old housewife presented for psychiatric evaluation of new onset shoplifting 5 years after successful Roux-En-Y gastric bypass surgery with 160 lb weight loss. She had a longstanding history of major depression, treated with Zoloft and Wellbutrin. She was motivated for treatment since her arrest with $200 worth of stolen merchandise at a department store. She was out on bail, and facing sentencing. Despite no financial need, she had been shoplifting up to 75% of her grocery and drug store items for several years, up to 3 times a week. She felt compelled to steal, and had perfected strategies, using reusable bags, scanning a small percent of items in the self-checkout lane, and bagging the rest. She was very savvy about electronic surveillance, and had regular stores where she shoplifted. She described a thrill, but later remorse. She had taught her children that stealing was wrong, and recalled years ago forcing her 4 year old son to return a bolt he had pocketed from an open hardware bin. She had no history of stealing prior to her weight loss. She did have a history of food addiction and episodic binge drinking. Father died of alcoholic cirrhosis.

    Treatment included weaning Zoloft and starting Topamax, a weekly 12 step program, "Shoplifters Anonymous" and individual therapy for compulsive behavior with an addiction therapist. She was strongly motivated to change, since her probation was contingent on treatment, no further stealing, as well as a fine and community service.

    Discussion:  Understanding cross-addiction after successful weight loss surgery is important for bariatric surgery programs. Pre-surgically assessing and educating candidates on their risks of new addictive behavior, and providing rapid, accessible treatment if new addictions occur may be new roles for behavioral health. Screening post-surgery for substitute addictions should include alcohol, drug use, pain medications, gambling, and sexual behaviors, as well as stealing.

    References:

    1. McFadden, KM. Cross-Addiction: from morbid obesity to substance abuse. Bariatric Nursing and Surgical Patient Care, vol 5, no2, 2010, p 145-178

    2. Grant, JE, Odlaug, BL, and Kim, SW, Kleptomania: clinical characteristics and relationship to substance use disorders. Am J Drug and Alcohol Abuse. 36:291-295, 2010

    3. Grant JE. Family history and psychiatric comorbidity in persons with kleptomania. Compr Psychiatry 2003;44:437-41

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    Munchausen by Proxy: Progressing from a Psychosomatic Perspective to a Medicolegal Perspective
    Presenting Author:  Fabien Gagnon

    Richard Asher, in 1951, described the Munchausen syndrome with patients presenting three main characteristics: simulation, mythomania, wandering. Roy Meadow, in 1977, described the Munchausen by proxy syndrome. Meadow's decription of fabricated illness corresponds in fact to a form of child maltreatment or abuse. Up to now, there is no consensus on a specific profile of perpetrators, even though we can find in the litterature many reports on the perpetrator's characteristics or behaviors. Over the years, the term Munchausen by proxy has been questionned. DSM-IV-TR defines the Munchausen by proxy as an entity covered under the Appendix B, or the category of factitious disorder NOS. In the litterature, we also find the terms "Fabricated illness" and "Medical Child Abuse". The author will present how the discipline of psychosomatic medicine conceptualized the Munchausen syndrome and the Munchausen by proxy syndrome, sometimes distancing the asessor from the gravity of the perpetrator's behaviors. We will discuss 2 cases linked to medicolegal issues related to the forensic assessment of Munchausen by proxy, and how new terms may better describe the reality of child abuse and neglect related to that disorder.

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    Alexithymia, Depression, and Somatization in a Predominantly Hispanic Population of Functional GI Disorder Patients
    Presenting Author:  Melvin Gilbert
    Co-Authors:  Joseph Yuen, Justin Capote, Adrienne Mishkin, Jean Saleh, Victoria Drake

    Objective:  To explore rates of alexithymia and depression in a predominantly Hispainc population of patients referred to a Functional GI Disorder Clinic in an urban teaching hospital setting.

    Patients and Methods:  Patients referred to a Functional GI Disorder Clinic were evaluated by a psychiatrist co-located in the clinic. Patients were administered the Somatosensory Amplification Scale (SSAS), Patient Health Questionnaire-9 (PHQ-9) and the Toronto Alexithymia Scale (TAS-20).

    Results:  High rates of health care utilization were found in this population with poor levels of symptom relief. High levels of alexithymia were noted.

    Conclusions:  Differences have been noted among varying ethnic groups with respect to health care seeking behavior. In particluar, Hispanics with GI complaints have been found to report more concern about their health in general and about bowel function in particular. Furthermore, a retrospective review of Hispanic patients diagnosed with Irritable Bowel Syndrome (IBS) found that only 63% met the Rome II criteria.

    These findings have suggested not only that cultural factors may play a role in both the presentation and treatment of Hispanic IBS patients but also that there may be a significant prevalence of somatoform disorder in this patient population.

    We present a survey of patients referred to a specialty Functional GI Disease Clinic in an urban teaching hospital setting. We found that this population is not treatment naive, yet they continue to have symptom complaints. The findings suggest that alexithymia is prevalent and may be a factor leading to somatoform presentations in this population. This suggests possible treatment strategies for this population.

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    Frontal-Temporal Dementia Presenting with Pathological Gambling: Case Report and Literature Review
    Presenting Author:  David Gittelman

    A 48 year old African-American woman presented with behavioral issues to our hospital, a large county-private health care system, after being evicted from the homeless shelter due to stealing from other residents. She was selling the stolen items in order to buy lottery tickets. She had recently been evicted from her sister's home for the same reasons. She was buying as many lottery tickets as possible, as frequently as possible, as well as playing bingo. She became angry and could not believe the shop keepers who did not corroborate her belief that she had won the lottery. She had been fully employed at the same job for 12 years and living independently with no known gambling problems until the onset of this these symptoms one year prior to admission. Her family had noticed at least one year decline in her memory and judgment as well as changes in her personality. In the hospital she exhibited poor insight into her gambling as well as flirtatious and disinhibited behavior. Psychometric testing confirmed significant deficits in her cognition consistent with dementia. She was determined as being disabled and sent to a rest home, where the same gambling behaviors persisted. A literature review revealed one case report of frontal-temporal dementia related pathological gambling presenting with strikingly similar characteristics in an Italian man of exactly the same age.

    Conclusions:  Clinicians examinig patients with pathological gambling should be alert for signs of cognitive decline in order to identify this behavior as a symptom of frontal-temporal dementia in order to differentiate it from a primary addiction; each gambling problem would require different treatment approachs.

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    Patients' Perception of Improvement with Shared Medical Appointments for Depression and Anxiety Based on the Patient Global Impression of Improvement Scale (PGI-I)
    Presenting Author:  Lilian Gonsalves
    Co-Authors:  Jerilyn Hagan Sowell, Adele Viguera

    Purpose:  Shared Medical Appointments (SMAs), also known as group visits, have become a useful vehicle in providing easier access to the physician and increased efficiency. The purpose of this paper is to evaluate treatment outcomes, specifically, patients' perception of improvement based on the Patient Global Impression of Improvement (PGI-I).

    Methodology:  In 2003, the Department of Psychiatry and Psychology at the Cleveland Clinic created a 90 minute group appointment for medication management. The participants are all women with a diagnosis of depression and/or anxiety. Each participant fills out several screening tools including the Patient Global Impression of Improvement (PGI-I), a validated self-rating scale. The patients are asked to assess their impression of change in their status since the beginning of treatment. Data from January through June of 2010 was gathered; sixty-two (62) patients completed the PGI-I.

    Results:  Overall, patients' perceptions of improvement were high. Seventy-one percent (71%) of patients reported improvement (very much improved, much improved or minimally improved); 19% reported no change and 10% indicated worsening of symptoms (minimally worse, much worse or very much worse).

    Conclusion:  SMAs, an efficient method of delivering quality care to patients, have a positive effect on the improvement of depression and anxiety as defined by the PGI-I.

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    Ultra-Short Tools for Depression Screening in Cancer Patients: Literature Review
    Presenting Author:  Rashi Aggarwal
    Co-Author:  Margaret Goracy

    Purpose:  Depression is significantly more prevalent in cancer patients than in the general population; however, it is left largely underdiagnosed and thus undertreated in these patients. The inadequate attention to depression in this particular population can be partly attributed to the absence of adequate screening tools and trained staff and to the lack of time. Identifying a concise standard tool for measuring depression in cancer patients could significantly increase the rate of screening and allow for more accurate and timely diagnosis and treatment of this condition.

    We review the literature available on brief depression screening measures used in cancer populations. We aim to determine if these tools have been sufficiently validated in the existing literature, and make a recommendation based on this review for the use of one screening test as a standard for practitioners to use and for future studies to focus on.

    Methods:  A literature search for peer-reviewed studies was conducted using Pubmed and PsycINFO.

    Results:  Nine peer-reviewed studies, encompassing 1,597 participants, met inclusion criteria and described the use of eight brief screening tools. These studies show high sensitivity and high negative predictive value, with moderate to high specificity and low to moderate positive predictive value for depression screening tools with four items or less. Thus, their reliability is comparable to that of longer screening measures, while taking significantly less time for patients to complete and oncologic staff to interpret.

    The most commonly studied screening instrument was the Combination Depression Question. Three studies (573 participants) testing this measure indicated superior sensitivity of 1, 1, and 0.91, and superior negative predictive value of 1, 1, and 0.96; its specificity was 0.86 and 0.98 in 2 studies. Another test with highly reliable results was the 2-question Patient Health Questionnaire 2 (PHQ-2), with superior sensitivity and negative predictive value of 1, moderate specificity of 0.87. However, the PHQ-2 was analyzed in only one study that consisted of significantly fewer patients (215 participants.

    Conclusions:  We recommend implementing the Combination Depression Question as a standardized screening instrument for oncologic patients. Future studies should enroll larger patient populations and compare this tool's diagnostic accuracy to that of other similarly brief depression screening tools that have been validated for use in primary care.

    References:

    1. Akizuki N et al. Development of a brief screening interview for adjustment disorders and major depression in patients with cancer. Cancer 2003; 97:2605-2613

    2. Chochinov HM et al., "Are you depressed?" Screening for depression in the terminally ill. Am J Psychiatry 1997; 154:674-6

    3. Mitchell AJ et al. Diagnostic utility of the two vs. nine item patient health questionnaire (PHQ2 V PHQ9) for major depression in early cancer. Psychooncology 2008; 17:S1-S348

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    Tossing Tabby. Throwing the Beloved Pet: An Interferon-Induced Reaction
    Presenting Author:  Kevin Hails
    Co-Author:  Emily Bray

    Introduction:  Interferon, used to treat hepatitis C, is known to cause psychiatric side effects. The most common side effect is depression, reported to occur in 10-40% of patients taking interferon. Mood lability, anger and irritability have also been noted. Frank psychosis is rare although it is more likely to occur when HIV infection is also present. The current case is a patient who appeared to have had two isolated incidents of severe impairment of impulse control while on interferon.

    Case Report:  C. L. was a 47 year-old single female with a past history of depression. She had presumably acquired hepatitis C from a transfusion years before her initial evaluation by one of the authors. The patient was referred for psychiatric evaluation by her then current hepatologist because she wanted a second course of interferon. The first course had been terminated after she developed shortness of breath secondary to newly diagnosed sarcoid made worse by the interferon. During this first course, she also impulsively threw her cat at a wall. She was immediately taken to a crisis center. She was determined not to be psychotic and was given a single dose of Clonazepam. Although the referring hepatologist elected not to treat C.L. she remained in psychiatric treatment because of her depression secondary to her medical problems. She was started on an SSRI later augmented with ziprasidone. She endorsed several times during her treatment that a primary source of pleasure in her life was caring for and nurturing stray cats. She did not have any episodes of impulsive behavior during this time.

    C.L. later found a hepatologist who was willing to treat with a second course of interferon. During the sixth month of the second course of interferon she again threw one of her cats. After another emergency evaluation, she was not diagnosed with an acute psychosis. She stopped the interferon at this time.

    Discussion:  This case demonstrates a case of impulsive behavior without psychosis or increasing irritability. The impulsive behavior was directed toward a loved object. Although the patient was being treated for depression, treatment had begun before the resumptions of the interferon and continued after the discontinuation. What appears unique about this case is the impulsive nature of her aggressive behavior and that it was directed toward a single object. Her reality testing remained intact and during treatment she did not demonstrate any psychotic symptoms.

    Although ziprasidone has caused aggression and hostility and this patient was also taking pain medications, it seems unlikely that they caused the aggressive outbursts since she was on them well before and after the incidents. Interferon remained the most likely cause of the two incidents.

  42. The Sigma Enigma: The Role of Sigma Receptors in Pathogenesis and Treatment of Delirium
    Presenting Author:  Damir Huremovic
    Co-Authors:  Guitelle St. Victor, Madhavi-Iatha Nagalla, Begum Firdous

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    Using an EMR to Improve Metabolic Monitoring for Patients on Antipsychotic Medicines: A Quality Project Involving Internal Medicine, Family Practice, and Psychiatry
    Presenting Author:  Robert Joseph
    Co-Authors:  Mathew Davis, Abbie Ewell, Ronit Dedesma

    Purpose:  Patients with Serious Mental Illness (SMI) are known to have shorter life expectancy than the general population. Part of this is due to extraneous causes of death (suicide and substance abuse) but a significant amount of the mortality is due to preventable cardio-vascular complications of antipsychotic medicine (AM). AM, especially second generation antipsychotics (SGA) are known to cause many metabolic changes associated with CVD. These include weight gain, and disturbances of glucose and lipid metabolism. Monitoring metabolic changes in patients placed on AM has been recommended by many professional groups including the APA and ADA. Despite these recommendations systematic monitoring of metabolic changes has rarely been accomplished. We will describe a joint effort by the Departments of Family Practice (FP), Internal Medicine (IM), Psychiatry, Pharmacy and IT to monitor metabolic syndrome in patients placed on AM at Cambridge Health Alliance, a safety net primary care network in the northern suburbs of Boston.

    Method:  Baseline rates of metabolic monitoring for patients newly started on AM during 2010 were obtained from our EMR. An educational program about the morbidity assoicated with AM and the recommended guidelines was developed for all members of Departments of Psychiatry, FP and IM. The monitoring program was promoted through a series of Grand Round presentations by residents in IM and FP and through a number of lower profile presentations throughout all three departments. The EMR was then used to prompt prescribers at the time they were prescribing of the recommended monitoring guidelines. In addition a selection of "smart texts" and laboratory order sets were developed within our EMR to facilitate monitoring.

    Results:  Baseline data notes that 619 patients were started on AM during 2010. Sixty-one % of the prescriptions were written by psychiatrists, 27 % by IM and FP providers and 12% of patients had prescriptions written by both a psychiatric provider and a primary care provider. Baseline metabolic measures were obtained in 30-40% of patients without significant differences in rates between psychiatric and medical providers. Among all prescribers 23% of prescriptions were for "Other Mood" Disorders; 22% for psychotic disorders; 18 % for Bipolar Disorder; 11% for anxiety disorders; 5 % for "other" and 4% for substance use disorders. Monitoring rates increased over the months following the educational efforts and the implementation of the EMR prompts. These data will be reported.

    Conclusion:  Monitoring for metabolic side effects of AM according to guideline recommendations was poor (30-40%) at baseline (usual care). An institutional wide quality improvement program involving internal medicine, family medicine, psychiatry, pharmacy and IT was developed, implemented and led to an improvement in these rates.

  44. [Withdrawn]
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    Factors Influencing Post Liver Transplant Employment: Does Depression Have an Impact?
    Presenting Author:  Sachdeva Jyoti
    Co-Authors:  Elizabeth Gorevski, Paul Succop, George Varughese, Rebecca Scott, Jane Benjay, Jill Martin-Boone

    Background:  Depressive disorders are the leading cause of disability in the U.S. Liver transplant recipients often have significant psychiatric morbidity, including depression. One of the potential consequences of depression is the inability to work. According to the United Network of Organ Sharing (UNOS) the 1 year cost of liver transplantation is $532,400. These costs may be partially reduced by assisting liver transplant recipients to return to work. It has been established that there are several impediments serving as barriers to employment post-transplant, such as fear of losing disability and health benefits. The effect which depression has on the post-transplant patient's ability to return to work is not fully understood.

    Objective:  The primary objective of this analysis was to determine if there is any relationship between depression and post transplant employment status in liver transplant recipients.

    Methods:  Patients, > 18yo, who had received liver transplants from January 2007 to July 2009 were identified for the retrospective analysis. Individual post- transplant patient charts were reviewed for patient demographics, transplant indication, employment history, depression diagnosis, and medications. The pre-transplant charts were used to obtain family psychiatric history, patient psychiatric history, past drug, alcohol, and tobacco use, and pre-transplant employment status.

    Results:  A total of 91 patients were evaluated from which 59.3% were males, 40.7% were females, with a mean age of 56 years. Patients had a history of alcohol and drug abuse 29.7% and 30.7%, respectively. In our sample, 23% and 29% of patients were depressed pre- and post- transplant, respectively. All patients with the diagnosis of depression were receiving an antidepressant. Of these, 72% were taking a selective serotonin reuptake inhibitor (SSRI), 20% were taking a serotonin norepenephrine reuptake inhibitor (SNRI) and 8% were taking buspirone. Pre-transplant and post-transplant employment was 57.1% and 38.4%, respectively. Pre-transplant, 15.4% of patients were retired and this number increased to 24.2% post-transplant. The number of unemployed patients also increased from 10.9% to 23.1%. A logistic regression was performed to identify the factors influencing employment post-transplant, which indicated pre-transplant employment, gender (males more likely to return to work) and depression post- transplant as significant factors influencing post- transplant employment with odds rations of 128, 4.1 and 11.5 and corresponding p values of <0.0001, 0.04 and 0.008, respectively.

    Conclusion:  Compared to pre-transplant, there was an increase in unemployment and retirement, as well as a greater incidence of depression in patients after transplant. Further, post-transplant depression is significantly associated with post-liver transplant unemployment. Improved management of depression may facilitate a patient's return to work after transplant.

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    Amyloid-Beta1-42 Positive and Negative Subjects in the Alzheimer's Disease Neuroimaging Initiative: Clinical Characterization
    Presenting Author:  Richard Kennedy
    Co-Authors:  Lon Schneider, Gary Cutter

    Background:  The Alzheimer's Disease Neuroimaging Initiative (ADNI) is intended to set standards for brain imaging and biomarkers for diagnosis and treatment trials. Recent expert recommendations have advocated that CSF amyloid-beta1-42 (Aβ1-42) and other biomarkers be used as entry criteria into clinical trials to improve efficiency.

    Objective:  To characterize any clinical differences between biomarker positive and negative MCI subjects based on CSF Aβ1-42 cutoffs.

    Methods:  A total of 400 MCI subjects were selected from the ADNI database. Subject groups were based on whether individuals did or did not undergo lumber puncture (LP), and the former was subdivided into high and low Aβ1-42 based on the published cutoff of 192. Groups were compared using t-tests or Wilcoxon tests.

    Results:  Subjects who underwent LP did not differ significantly from those without LP. However, subjects with low Aβ1-42 were significantly worse at baseline than those with high Aβ1-42 on a variety of measures, including the Logical Memory II Delayed Recall and the Alzheimer's Disease Assessment Scale-Cognitive (ADAS-Cog).

    Conclusions:  Although LP does not appear to introduce a selection bias in the ADNI dataset, individuals with low Aβ1-42 show somewhat greater impairment than those with high levels that may require statistical adjustment in analyses. However, if advanced impairment is associated with poorer treatment response, the use of biomarker selection criteria may introduce confounding with poor response that cannot be corrected statistically.

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    Transcranial Magnetic Stimulation for Pregnant Women with Major Depressive Disorder
    Presenting Author:  Deborah Kim
    Co-Authors:  Neill Epperson, Emmannuelle Pare, Juan Gonzalez, Samuel Parry, Michael Thase, Pilar Cristancho, Mary Sammel, John O'Reardon

    Objective:  Despite the data that major depressive disorder (MDD) is common during pregnancy and that pregnant women prefer non-medication treatment options, there is a paucity of research examining alternative treatments for this special population. We present the results of an open label pilot study examining treatment with transcranial magnetic stimulation (TMS) in pregnant women with MDD.

    Methods:  10 women with MDD in the 2nd or 3rd trimester of pregnancy were treated with 20 sessions of 1 Hz TMS at 100% of motor threshold to the right prefrontal dorsolateral cortex. The total study dose was 6000 pulses. Antenatal monitoring was performed during treatment sessions 1, 10 and 20.

    Results:  7/10 (70%) subjects responded (≥ 50% in Hamilton Depression Rating Scale (HDRS-17) scores). No adverse pregnancy or fetal outcomes were observed. All infants were admitted to the well baby nursery and were discharged with the mother. Mild headache was the only common adverse event and was reported by 4/10 (40%) subjects.

    Conclusion:  TMS appears to be a promising treatment option for pregnant women who do not wish to take antidepressant medications. We are now proceeding with a randomized control trial to confirm our data. Any initial information available at the time of the meeting will be presented.

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    Use of Alcohol Withdrawal Protocol and Impact on LOS/Restraint Use
    Presenting Author:  Lauren LaPorta
    Co-Authors:  Neil Parikh, Avik Karmaker, James Record

    Introduction:  Alcohol dependence is a significant co-morbidity in medical/surgical hospital admissions. As many as 25% of hospital inpatients have an alcohol use disorder and most (75%) do not receive proper diagnosis or treatment. Withdrawal prophylaxis and monitoring are ordered for only a minority of patients. Psychiatric consultation is frequently requested for difficult to manage patients, usually after symptoms of withdrawal and hallucinosis present. Best prsctices dictate, however, that pateints shoul.d be screened for alcohol use disorders and treated before they become symptomatic. Such practices may lead to decreased lengths of stay, decreased use of medications and decreased use of restraints. This study undertook to examine the impact of the initiation of an alcohol withdrawal prevention protocol which provided standard screening guidelines in the medical/surgical service of a large, inner city, Level 3 trauma center.

    Methods:  Review of literature was completed and an alcohol withdrawl protocol modified after Repper-DeLisi, et al (Psychosomatics 49:292-299, Jul-Aug 2008) was implemented to standardize treatment and to provide for more routine and consistant screening for alcohol use disorders in admitted patients. Retrospective chart veiw was completed based on alcohol related DRG diagnoses for a 6 month period prior to the initiation of the protocol and for 6 months afterward.

    Results:  A modest but measurable decrease in both LOS and restraint use was observed. Further education of medical staff is planned to increase comfort and facility in using the new protocol. It is anticipated that more regular use of the protocol will lead to improved patient care and treatment with fewer complications.

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    The "Cyber CF Support Group": An Innovative Intervention for Medically Vulnerable Teens
    Presenting Author:  Carol Larroque
    Co-Author:  Nanette Concotelli

    Background:  Cystic Fibrosis (CF) is a life limiting, genetic disorder that affects approximately 30,000 people in the U.S. Adolescence can be an especially difficult time for individuals with CF. Teens with cystic fibrosis are medically counseled not to be in the same room with each other in order to prevent cross contamination with life threatening, opportunistic infections. Yet, many youngsters wish to interact with others who also experience this disorder.

    Objective:  The objective of this group intervention is to remedy the isolation of teens with CF; to provide for them a vehicle to communicate with each other in real time; and to provide emotional support and health education.

    Method:  A support group for adolescents with CF using Telehealth equipment was started in 2009 by the University of New Mexico (UNM) Pediatric Pulmonary team in conjunction with a UNM child psychiatrist. The “Cyber CF Support Group” is composed of teenagers from a variety of sites in New Mexico – one teen per site. The teens meet via tele-video communication for 45 minutes every two weeks with the assistance of a group facilitator, the UNM Pulmonary Team social worker. To achieve a successful outcome, support staff (nurse or social worker) are provided at each site; parents of the teens are encouraged to become informed about the nature of the group; and technical challenges are overcome. A satisfaction survey was developed to assess contentment with the program as well as to elicit attitudes and concerns.

    Results:  The Cyber CF Support Group has been in practice for over 18 months. It reaches into multiple communities, urban and rural, giving teens the opportunity to express themselves and develop relationships with peers. The themes that emerge from group discussions have provided insight regarding emotional needs and physical concerns of young people with CF.

    Conclusion:  For teenagers with cystic fibrosis a "cyber group" can provide a venue to meet, exchange ideas, and share concerns while seeing and talking to each other in real time. It has the capacity to dispel isolation and cement friendships. This unique group has the potential to be replicated in other regions for teens and young adults with CF as well as for those with other medical conditions.

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    Reorganizing Educational Activities on Psychosomatic Medicine Service at Stanford University Hospital: A Systematic Approach Using Medical Education Theories
    Presenting Author:  Sermsak Lolak

    Background:  As part of the Leadership Training Program sponsored by Stanford University Hospital and Stanford School of Medicine, the author designed a short project to improve the educational programs on the Psychosomatic Medicine (PSM) Service at Stanford University Hospital, a rotation site for Stanford medical students, as well as Psychiatry, Internal Medicine, and Neurology residents. The project's overall goal is to maximize the educational experience of the PSM rotation by coming up with a more formal curriculum and schedule of educational activities for the trainees, while being mindful of the already busy schedules of both attending and trainees.

    Methods:  The project was sponsored by the chief of PSM Service and Chair of the Department of Psychiatry. The author was mentored by Dr. Kelly M. Skeff, a leading international authority on medical education. A team, led by the author, was established consisting of 5 PGY2-4 residents, and 1 other attending on PSM Service. The team met on a regular basis. The author, a team leader, met with the coach (KS) and sponsors for advices and directions on the project. In addition, the progress of the project is regularly monitored by the director of the Stanford Leadership Training Program.

    Results:  We followed the approach outlined by Kern and Thomas by starting with Problem Identification and then Needs Assessment. This was done through literature review, focus group, networking with colleagues from other programs, and anonymous feedbacks from both the residents' retreat and computer-based program evaluation. A survey was constructed and distributed to current and past residents who have completed PSM rotation. We focused on identify and integrating the learners' goals and departmental goals to translate into appropriate instructional methods and context, using ACGME‘s 6 competencies and 3 domains (Knowledge, Skill, Attitude) as guidance. The results of methods above will used to design a new curriculum and schedule educational activities for PSM service.

    Conclusions:  A systematic approach: by identifying the problems, assessing the needs, "marrying " the goals of learners and educators ; was used to design a new educational activities in order to improve the educational aspect and trainees' experience on PSM service at Stanford. Final results of the survey and the project will be presented at the meeting.

    References:

    1. Kern DE, Thomas PA, Hughes MT, eds. Curriculum Development in Medical Education: A Six-Step Approach. 2nd ed. Baltimore: John Hopkins Univ Pr;2009

    2. Worley LW, Levenson JL, Stern TA, et al. Core competencies for fellowship training in psychosomatic medicine: a collaborative effort by the APA Council on Psychosomatic Medicine, the ABPN Psychosomatic Committee, and the Academy of Psychosomatic Medicine. Psychosomatics 2009;50;557-562

    3. Skeff KM, Stratos GA, eds. Methods for Teaching in Medicine. Philadelphia: ACP Pr;2010

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    Sexual Knowledge and Risky Behaviors in Adolescent and Young Adult Female Childhood Cancer Survivors: A Pilot Study
    Presenting Author:  Karen Lommel
    Co-Authors:  Emily Van Meter, Michael Tucker

    Objective:  The growing population of childhood cancer survivors has generated an interest in the special medical and mental health needs of this cohort. The Childhood Cancer Survivor Study has provided a wealth of information about the medical and psychological long-term effects of going through cancer treatment. However, there is a paucity of data about sexual knowledge and risky sexual behaviors. This population is already at risk for development of second malignancies and therefore it is important to look at possible interventions to decrease the risk of developing cancer and other medical problems as a result of risky sexual behavior (Human papilloma virus and cervical cancer or HIV-risky behaviors).

    Methods:  Participants were 18 adolescent or young adult female survivors of childhood cancer treated for cancer prior to the age of 21. The current ages of participants ranged from 14-37 and ranged from age 2-20 years old at the time of diagnosis. Fifty-six percent were treated for lymphoid leukemia, 11% for Wilm's tumor and 6% for each of the following primary tumor sites; bone, connective and soft tissue, female genital organs (other than ovary, uterus or cervix), Hodgkin's and Non-Hodgkin's lymphomas, and "other" or "ill-defined" sites. Sexual knowledge was measured using the Sexual Knowledge Test. Risky behaviors were assessed using a screening tool entitled the Adolescent Risk Inventory (ARI).

    Results:  This small cohort scored 73% (+/- 11) on the Sexual Knowledge Test with question about effects of chemotherapy on fertility being the most commonly missed question. The ARI results were reported on four attitude scales. HIV Anxiety average score of 2 (range 2-4); HIV Prevention Self-Efficacy mean score of 5.5 (range of 3-6); General Distress mean score of 2.6 (range 2-4); and General Risk 4.6 (range 3-6).

    Conclusions:  These preliminary data suggest female survivors of childhood cancer may not have accurate informatoin on the effects of chemotherapy on their own fertility. However, they scored higher on the General Risk scale (including risky sexual behaviors) of the Adolescent Risk Inventory. Further research and analyses should be performed to evaluate the influence of fertility perception on risky sexual behaviors. This study is currently in progress with an expanded cohort expected in the next 1-2 months.

    References:

    Canada AL, Schover LR, and Yisheng L. A pilot intervention to enhance psychosexual development in adolescents and young adults with cancer. Pediatr Blood Cancer 2007;49:824-828

    Lescano CM, Hadley WS, Beausoleil NI, Brown LK, D'eramo D, Zimskin A. A brief screening measure of adolescent risk behavior. Child Psychiatry Hum Dev 2007;37:325-36

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    The Role of Psychosomatic Medicine in the Development of a Comprehensive Approach for the Management of CNS Pharmacotherapy in the ICU
    Presenting Author:  José Maldonado

    Delirium is the most common psychiatric syndrome found in the hospital setting. Because its etiology is often multifactorial and because patients in all clinical services are at risk of developing it any approach to the prevention and treatment will require a multisystem, multidisciplinary approach. As consultants, Psychosomatic Medicine specialists are in a unique position to assist and guide medical colleagues in the development of a system's approach to a multisystem problem.

    At our tertiary medical center we put together a multidisciplinary ICU team dedicated at developing a comprehensive approach to CNS-Pharmacotherapy. That is, the management of all psychoactive substances affecting patient's behavior, primarily targeting management of sedation, delirium and pain. The team brought together members of all ICU services, including critical care, pulmonary, anesthesia, neurocritical care, nursing, pain management, and psychosomatic medicine in an attempt to improve the management and quality of care of intensive care patients. We had the extraordinary opportunity to work closely with a neuropharmacologist and members of our pharmacy staff in developing a set of "CNS-Pharmacotherapy Guidelines" containing specific prevention and treatment modules.

    The result of this working group was the development of a series of algorithms designed to (a) prophylax against commonly encountered neuropsychiatric problems in the ICU , such as optimizing pain management, addressing potential neuropsychiatric side effects of the ICU environment [e.g., anxiety, PTSD, sleep deprivation], instituting daily awakening routines & promoting early mobilization strategies, and minimizing the occurrence of delirium, while (b) developing robust and standardized algorithms to adequately address unavoidable ICU complications, such as detection of prodromal delirium, prediction and detection of early substance withdrawal, better pain management algorithms, and the management of neurological and psychiatric syndromes common to the ICU environment.

    This poster will review the evolution and workings of the multidisciplinary team and provide a review of the stages of development and protocol implementation throughout our intensive care units.

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    Psychosomatic Medicine Specialist as Leader: The Development of a Comprehensive, Hospital-Wide Approach for the Prevention and Treatment of Alcohol Withdrawal
    Presenting Author:  José Maldonado
    Co-Author:  Sermsak Lolak

    Current guidelines for the prophylaxis and management of alcohol withdrawal syndromes are based on the use of benzodiazepines. The rationale has always been that benzodiazepines effectively cover all phases of alcohol withdrawal. Yet, clinical experience with the use of benzodiazepines suggests difficulties in implementing prophylaxis and treatment protocols adequately. The problem appear to be related to the way benzodiazepines are administered, whether objective physiological or psychological methods are used to time dosing and the type of benzodiazepine agent used (i.e., short vs. long acting). Our clinical experience demonstrates that current benzodiazepine based- CIWA administered protocols seem to be fraught with complexities, wide range of dose administration and significant side effects. Adverse effects of benzodiazepine use seem to vary depending on the clinical setting. In the acute medical units the most frequently reported problem is under-sedation with break-through of withdrawal symptoms, often leading to the use of various benzodiazepine agents, leading to over-sedation and possibly transfer to the ICU. In the ICU, the most significantly encountered problem is over-sedation, leading to intubation and prolonged ICU stays. Another increasingly encountered problem is an indirect effect of benzodiazepines, the development of delirium. This is then not a direct consequence of alcohol withdrawal (i.e., alcohol withdrawal delirium) but an unintended consequence of benzodiazepine administration (i.e., benzodiazepine induced delirium).

    Even though benzodiazepines have been considered the standard of care for the treatment of alcohol withdrawal, and have been shown to prevent alcohol withdrawal seizures and delirium tremens, there are several potential problems with the use of BZD: abuse liability; cognition impairment; significant interactions with other CNS depressant agents (i.e., alcohol and opioid); and data suggesting their use may increase craving, early relapse to alcohol use, and increased alcohol consumption.

    At our tertiary medical center we put together a multidisciplinary institution-wide task force dedicated at developing a comprehensive approach to the detection, prophylaxis and treatment of alcohol withdrawal syndromes. The task force brought together members of all clinical medicine and surgical services, nursing, pharmacy, social work, and psychosomatic medicine in an attempt to improve the management and quality of care delivered throughout the medical center.

    Thus, under the direction of our director of Psychosomatic Medicine, our institution undertook a comprehensive review of our methods of detection and treatment of alcohol withdrawal which led to the voicing of a significant degree of frustration and dissatisfaction. The next step was the development of a toll for prediction of alcohol withdrawal; and finally the development of treatment algorithms for the prophylaxis and treatment of alcohol withdrawal states.

    This poster will review the evolution and workings of the multidisciplinary team and provide a review of the stages of development and protocol implementation throughout all units at our institution.

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    Assessing Capacity to Drive: A Practical Approach to the Psychiatrist’s Role and Responsibilities
    Presenting Author:  Dimitri Markov
    Co-Authors:  Christine Marchionni, Keira Chism, David Axelrod

    Sleep deprivation, shift work, primary sleep disorders, sleep disturbance associated with medical and psychiatric illness, and/or psychopharmacologic interventions cause excessive daytime sleepiness. Dementia affects memory, judgment, visual, spatial and motor skills. Psychiatrists are increasingly faced with medically ill patients whose driving ability may be impaired either by dementia or excessive daytime sleepiness. Drowsy driving is associated with fatality rates and injury severity that is similar to that of alcohol-related crashes. Patients with dementia are 3 to 5 times more likely to be involved in a motor vehicle accident than age-matched controls.

    This poster will offer a practical framework to approach questions related to a patient's capacity to drive in the setting of dementia and excessive daytime sleepiness. Attention will be given to both the legal foundations and how to assess capacity to operate a motor vehicle. We will offer a practical clinical approach to managing questions of driving capacity.

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    Arterial Stiffness is Associated with Menopause and Amplified by Depression
    Presenting Author:  Edwin Meresh
    Co-Authors:  Danielle Magness, Megha Chadha, Nicholas Ruys, Angelos Halaris

    Rationale:  Depressive and anxiety disorders are major risk factors for coronary artery disease (CAD) and are co-morbid. They are highly prevalent among women. Depressive symptoms among post-menopausal women appear to be an independent risk factor for cardiovascular morbidity and mortality[1]. The pathophysiology underlying this co-morbidity is unclear. Menopause is associated with increase in arterial stiffness which is known to be an independent marker of cardiovascular risk [2]. Anxiety, depression, and anger were associated with impaired brachial artery dilation among post-menopausal women [3].

    Hypothesis:  We hypothesized that menopause leads to increase in arterial stiffness and may be amplified by concomitant depressive disorder.

    Study Design:  This is an ongoing study. We have studied 29 women with major depressive disorder (MDD) and 11 healthy women for comparison. Women were subdivided into pre-menopausal (22 with MDD and 7 healthy) and menopausal (7 with MDD and 4 healthy). Diagnosis was established by structured interview using the Mini-International Neuropsychiatric Interview (MINI). The Hamilton Depression and Hamilton Anxiety scales were used. Arterial stiffness was assessed by Applanation Tonometry using the Sphygmocor device focusing on the Augmentation Index (AIx) as the dependent variable. Logistic regression was used to adjust for demographics, weight and BMI.

    Results:  The total of 40 women was subdivided into 29 pre-menopausal and 11 peri- & post-menopausal women. The AIx was significantly higher in the peri- & post-menopausal group (pre-menopausal: 12.05 vs peri- & post-menopausal: 27.72; p=0.001). In the MDD women the means of AIx were 13.86 for pre- (n=22) and 30.85 for peri- & post-menopausal (n=7) (p=0.005). In the healthy women the means of AIx were 6.35 for pre-menopausal (n=7) and 22.25 for peri- & post-menopausal (n-4) (p=0.05). We sought to determine whether depression correlate to AIx. There was a trend which was upheld in pre-menopausal and peri- & post-menopausal women for depression. However, if all peri- and post-menopausal women are selected, the correlation becomes significant at p=0.022 for depression. There is a marginally significant correlation between depression and AIx in depressed peri- and post-menopausal women.

    Conclusions:  Menopausal status is associated with arterial stiffness, the non-invasive assessment of which by Applanation Tonometry may be of practical utility. The presence of clinical depression amplifies the age-dependent increase in arterial stiffness in women. Recognition of depression in menopausal women is important. Future studies are needed to clarify the connection between depression and arterial stiffness.

    References:

    1. S. Wassertheil-Smoller et al, Depression and cardiovascular sequelae in postmenopausal women. The Women's Health Initiative, Arch Intern Med 164 (2004) 289-298

    2. Takahashi K et al, Impact of menopause on the augmentation of arterial stiffness with aging, Gynecol Obstet Invest. 2005;60(3):162-6

    3. Harris KF et al, Associations between psychological traits and endothelial function in postmenopausal women. Psychosom Med. 2003 May-Jun;65(3):402-9

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    "I Want This Baby Delivered!"
    Presenting Author:  Katherine Moore

    Purpose:  To describe general management principles and cultural issues associated with pregnancy in a Middle Eastern immigrant woman with multiple psychiatric and medical comorbidities.

    Method:  Case report.

    Results:  This poster will present the case of a 44 year old married Egyptian woman referred by her obstetrician for psychiatric consultation to our OB Psychiatry Clinic with concerns for escalating anxiety, depression, and physical symptoms as her pregnancy progressed. Her chief complaint was "I want this baby delivered!" Medical comorbidities included obesity, obstructive sleep apnea, and fibromyalgia. She had a history of prior treatment for major depression and kleptomania. Previously resistant to psychiatric consultation, she had delayed the referral, but was ultimately seen at 33 weeks. This is Mrs. H.'s first pregnancy. She expressed ambivalence throughout the course of her prenatal care and there was concern by members of the OB team regarding Mrs. H's willingness and ability to care for her baby. She highlighted multiple areas of anxiety and worry regarding her own health and how she would handle labor and delivery and the postpartum period. She had been resistant to various suggested psychopharmacologic strategies to help manage anxiety except use of lorazepam. Mrs H. hoped that this psychiatrist would help her negotiate a pre-term delivery with the obstetrician. At the initial psychiatric consultation she was willing to engage in a discussion of longer term management recommendations including medication and psychotherapeutic interventions, albeit somewhat reluctantly.

    Conclusions:  Mrs. H. continues to progress with her pregnancy at the time of this submission. Literature will be presented regarding treatment of depression during pregnancy and decision making within that context, somatization within pregnancy, cultural issues associated with psychiatric management at a larger psychiatric level and a review of cultural issues associated specifically with pregnancy and the postpartum. I will also highlight collaborative management strategies between psychiatry and our community-based OB/Gyn practice.

    References:

    Bitzer J: Somatization disorders in obstetrics and gynecology. Arch Womens Ment Health 2003; 6:99-107

    Cohen LS et al: Treatment of mood disorders during pregnancy and postpartum. Psychiatr Clinic North Am 2010; 33(2):273-93

    Wisner KL et al: Risk-Benefit Decision Making for Treatment of Depression During Pregnancy. Am J Psychiatry 2000; 157:1933-1940

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    Psychiatric Consultation: Medication Recommendations and Implementation
    Presenting Author:  Beena Nair
    Co-Authors:  Hoyle Leigh, Ronna Mallios

    Introduction:  Psychotropic drugs are often recommended by psychiatric consultants. The Psychiatric Consultation Liaison Service (C-L) at UCSF Fresno developed a quality assurance program concerning the appropriateness of the drug, dosing and schedule, explicit indication and adherence to the drug recommendation by the requesting physician.

    Method:  We did a retrospective chart review of 100 randomly selected patients seen by the C-L service for consultation January 1 to December 31, 2010. Each record was reviewed for appropriateness of drug, dosing and schedule, explicitness of indication, and adherence. When no medications were recommended, the appropriateness, indication and adherence to recommendation were assessed. In addition to descriptive statistics, chi square test was used to determine associations among the variables.

    Results:  Of the 100 patients, 51% were females and 49% males, age of patients ranged from 16 to 92 with a mean age of 49.3. For 24 patients, no drugs were recommended. There was no significant gender difference between the patients with drug recommendation and no drug recommendation. Primary Axis I psychiatric diagnosis included depression (32.1%), delirium (23.3%), psychosis (11.4%), bipolar (6.3%), adjustment disorder (4.4%), schizoaffective disorder (4.4%), PTSD and ASD (3.2%), substance related (3.1%), anxiety disorder (2.5%). Psychotropic medications recommended included SSRI/ SNRI (23.9%), mirtazapine (5.7%), other antidepressants (9%), second generation antipsychotics (20.1%) of which quetiapine was most used (8.8%), first generation antipsychotic (6.9%) of which haloperidol most commonly used (5.7%), anticonvulsant mood stabilizers (1.3%), benzodiazepines (18.9%) of which lorazepam was most used (11.3%), anticholinergics (5%), and cognitive enhancers (1.3%).

    For 24 patients for whom no drugs were recommended, the recommendation was considered appropriate in 100% of the patients. Among those patients for whom drugs were recommended, overall appropriateness for recommendation was 94.1%. For dose appropriateness of the drug recommended, 98.5% of the recommendations were appropriate for the diagnosis stated. For appropriateness of drug schedule, 91.1% of the recommendations were fully appropriate. For explicitness of indication, only 57.8% were explicit while 62.5% of non-drug recommendations were explicit. The overall adherence rate by the primary physician for drug recommendation was 81.5% and for no drug recommendation was 95.8%.

    Discussion:  Our findings indicate that drug recommendation occurs in more than 3/4 of consultations, and that they are mostly appropriate, and that the recommendations are implemented in most cases. Consultants tended to be less explicit in recommending presumably familiar drugs, e.g., antidepressants. Nevertheless, explicitness of indication for drugs needs improvement.

    Conclusions:  Drug recommendations are generally appropriate in C-L settings, and are implemented regularly. We need to be more explicit concerning indications for drug therapy.

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    Screening for Depression in HIV-Infected Patients Using the Hospital Anxiety and Depression Scale and the Beck Depression Inventory
    Presenting Author:  Ricard Navinés
    Co-Authors:  Jordi Blanch, Aracelli Rousaud, Esteban Martínez

    Purpose:  Depression is a common comorbidity in people with HIV/AIDS, frequently impacting disease status and adherence to antiretroviral treatment. For care managers quick and simple identification of patients at high risk for depression can be both a challenge and a priority. The aims of this study was to compare the Spanish version of the depression subscale of the Hospital Anxiety and Depression Scale (HADS-D), the cognitive-affective subscale of the Beck Depression Inventory (BDI-12) and the total BDI scale (BDI-21),as screening tools for major depression in a Spanish sample of HIV infected patients, assessing their sensitivity, specificity and predictive values.

    Methods:  Patients referred to our Consultation-Liaison Unit from the Infectious diseases department were interviewed using the Structured Interview for DSM-IV and completed both the BDI and HADS scales.
    Results of the Receiver Operating Characteristic (ROC) analysis was used to construct individual ROC curves utilizing the entire BDI and the subsets of the cognitive-affective items and the HADS-D scale calculating the area under the curve (AUC) of each scale.

    Results:  Seventy-six (59% men; 41% women) HIV-infected patients with a mean age of 35 years were assessed. The prevalence of depression was: 34.7% using DSM-IV criteria; 85.5% using the BDI-21 with a cutoff of 15, 64% using the cognitive-affective subscale of the BDI-12 with a cutoff of 10; and 41.3% using the HADS-D with a cutoff of 10 (HADS-10).

    For the HADS-D (>10) the area under the ROC curve for major depression was 0.75 (95% CI: 0.64-0.87), sensitivity 74.1%, specificity 77.1%, positive predictive value (PPV) 64.5%, and negative predictive value (NPV) 84.1%. For the BDI-12 the area under the ROC curve for major depression was 0.66 (95% CI: 0.54-0.79), sensitivity 85.2%, specificity 47.9%, PPV 47.9%, and NPV 85.2%. For the BDI-21 the area under the ROC curve for major depression was 0.61 (95% CI: 0.49-0.74), sensitivity 89, specificity 22.9%, PPV 42.2%, and NPV 87.1%.

    Conclusions:  Results of the present study suggest that the HADS-D scale would represent the best choice for screening depression in HIV-infected patients, followed by cognitive-affective BDI subscale and the total BDI scale.

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    Role of Pharmaco-Genomic Testing (PGT) in Personalized Medicine: Three Cases from an Outpatient Community-Based Psychosomatic Medicine Practice
    Presenting Author:  Shehzad Niazi

    Purpose:  Personalized Medicine is an emerging field. Personalized treatment plan can be formulated using genetic data. Holmes et al have reviewed the pharmaco-genetic studies in this context [1]. Personalized medicine in psychiatry is an area of great promise and challenge [2]. Pharmaco-genomic testing (PGT) is one tool that can be used to guide clinical decisions. PGT, its application and current state of evidence in Psychiatry has already been described in detail [3]. PGT has been generally well received by patients [4]. There are barriers to its widespread implementation. Rundell et al studied use of PGT in a tertiary care center [5]. I am going to review three cases illustrating how PGT can be used in a community-based outpatient Psychosomatic Medicine practice.

    Methods:  I selected three patients who had PGT done to assess variants of Cytochrome P450 2D6, 2C9 and 2C19 iso-enzymes. Testing was performed at Mayo Clinic Lab. These patients showed three different patterns of polymorphism. This helped in formulating an individualized treatment plan.

    Results:  Patient A was heterozygous for CYP2C19 and CYP2C9 polymorphism. This genotype is associated with Intermediate Metabolizer phenotype. He had markedly reduced or no activity of CYP2D6.

    Patient B was heterozygous for CYP2C9 and CYP2D6, associated with intermediate to extensive metabolizer phenotype. She carried *17 promoter polymorphism for CYP2C19 that results in increased expression of CYP2C19.

    Patient C was homozygous for CYP2C9 and CYP2D6consistent with extensive metabolizer phenotype. She had *17 promoter polymorphism for CYP2C19. This may result in increased expression of CYP2C19 enzyme.

    Discussion:  Genetic factors and Pharmaco-genomic testing can provide valuable information. Based on these and other factors a clinician can formulate an individualized plan for more effective treatment. I discuss how different phenotypes of above-mentioned patients informed individualized treatment plans. Further research is needed to assess cost effectiveness of such approach.

    References:

    1. Holmes, M.V., et al., Fulfilling the promise of personalized medicine? Systematic review and field synopsis of pharmacogenetic studies. PloS one, 2009. 4(12): p. e7960

    2. Evers, K., Personalized medicine in psychiatry: ethical challenges and opportunities. Dialogues in clinical neuroscience, 2009. 11(4): p. 427-34

    3. Mrazek, D., Psychiatric Pharmacogenomics2010, New York: Oxford University Press

    4. Haddy, C.A., et al., Consumers' Views of Pharmacogenetics--A Qualitative Study. Res Social Adm Pharm, 2010. 6(3): p. 221

    5. Rundell, J.R., et al., Pharmacogenomic testing in a tertiary care outpatient psychosomatic medicine practice. Psychosomatics, 2011. 52(2): p. 141-6

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    Physician Health, Physician Health Committees (PHCs), and the Consultation-Liaison Psychiatrist
    Presenting Author:  Shehzad Niazi

    Purpose:  Health is “state of complete physical, mental and social well-being and not merely the absence of disease or infirmity” [1]. Physician health should be considered as such. Practice of medicine is rewarding yet stressful. Level of stress varies across specialties. Emergency physicians, surgeons and general practitioners reported the highest levels of distress, while administrative physicians, community health and clinical specialists reported the lowest levels of distress [2].

    Shanfelt et al [3] found that 40 % of surgeons in US were experiencing burnout. It was a single greatest predictor of satisfaction with their career. Stress can lead to burnout, and affects quality of life. It also can lead to medical errors [4] and has the potential to cause reduced productivity, loss in revenue, diminished citizenship and sub-optimal performance.

    Joint commission requires hospitals to have a process to identify and manage health of physicians. Establishing a Physician Health Committee (PHC) usually fulfills this requirement. Not all outpatient-based clinics have PHCs.

    Consultation Liaison (C-L) Psychiatrists have a unique role and expertise to lead in this critical area. Their knowledge of human behavior, substance abuse, emotional disturbances, bio-psycho-social treatment approach and interactions with colleagues across specialties prepares them well to help other physicians.

    Methods: Marshfield Clinic is a large multispecialty group of approximately 800 physicians. We have two joint PHCs. One serves main campus in Marshfield and its affiliated hospital staff. Second PHC serves Northwestern Division and affiliated hospital in Rice Lake, WI. We will use them as case studies to discuss purpose, formation, functions and activities of PHCs. We will then discuss specifically how a C-L Psychiatrist can be well suited to lead such efforts.

    Results: PHC Marshfield Center has been operating since 2003. PHC Northwest Division is a newer committee. Ongoing strategic planning and reorganization is affecting future direction. Both committees are lead by Psychiatrists. Chair of PHC Marshfield Center has extensive experience in various leadership positions. PHC NW Division is lead by a C-L Psychiatrist. These committees are well received and have leadership support.

    Discussion: Physician health is a critical area that needs more attention. C-L Psychiatrists have a unique role in this field. Evidence based interventions to promote physician health need to be developed and implemented at various levels of physician’s career.

    References:

    1. WHO, Constitution of the World Health Organization, 2006, World Health Organization: New York. p. 1-20

    2. Lepnurm, R., W.S. Lockhart, and D. Keegan, A measure of daily distress in practising medicine. Can J Psychiatry, 2009. 54(3): p. 170-80

    3. Shanafelt, T.D., et al., Burnout and career satisfaction among American surgeons. Ann Surg, 2009. 250(3): p. 463-71

    4. Shanafelt, T.D., et al., Burnout and medical errors among American surgeons. Ann Surg, 2010. 251(6): p. 995-1000

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    Implementing NCCN Distress Management Guidelines in a Community Setting, Utilizing Existing Resources
    Presenting Author:  Shehzad Niazi

    Purpose:  GLOBOCAN (http://globocan.iarc.fr/) estimated 12.7 million cancer cases and 7.6 million cancer deaths in 2008 worldwide [1]. Estimates in US projected 1,529,560 new cancer cases and 569,490 deaths from cancer in 2010 [2]. A meta-analysis found that all types of depression occurred in 20.7% of cancer patients, depression or adjustment disorder in 31.6%, and any mood disorder in 38.2% [3]. NCCN (National Comprehensive Cancer Network) uses term “Distress” to describe unpleasant emotional experience of cognitive, behavioral, emotional, social, and spiritual nature[4].In one study doctors’ sensitivity to recognize distress in cancer patients was only 28.87%[5]. Recognition alone does not lead to improved outcomes.

    NCCN guidelines consider recognition, monitoring, documenting and prompt treatment of distress in cancer patients a standard of care[4]. One major barrier in its implementation is limited access to Psychiatric services, especially in community based oncology practices.

    Method:  Model was developed to implement NCCN guidelines in a community based oncology service, utilizing existing resources.

    Local resources at Rice Lak Ctr, Marshfield Clinic consisted of two Oncologists, one Nurse Practitioner, one Radiation Oncologist, one CL Psychiatrist, a therapist and their support staff. Model was developed to implement guidelines at Rice Lake Center. Process measures are included for monitoring and quality improvement. Program is developed so that it can be later replicated in other regional centers.

    In this model every patient is screened using Distress Thermometer[4]. Oncology team identifies patients with moderate to severe level of psychological distress and
    initiates referrals. Psychiatrist decides further psychiatric treatment. Oncology team also can refer directly to therapist, chaplainry, social work or financial services. Distress Thermometer is also used at follow up visits for high-risk patients.

    During initial phase, patients are being seen by a Psychiatrist in Behavioral Health building. Soon they will be evaluated in oncology department to provide more coordinated care. Current practice has allowed assessing demand. Soon, a collaborative Distress Management Clinic in department of Oncology is to start. Next phase will be to explore implementation in other centers.

    Discussion:  Existing resources potentially can be used to implement NCCN guidelines. Barriers to implementation are discussed.

    References:

    1. Jemal, A., et al., Global cancer statistics. CA: a cancer journal for clinicians, 2011. 61(2): p. 69-90

    2. Jemal, A., et al., Cancer statistics, 2010. CA: a cancer journal for clinicians, 2010. 60(5): p. 277-300

    3. Mitchell, A.J., et al., Prevalence of depression, anxiety, and adjustment disorder in oncological, haematological, and palliative-care settings: a meta-analysis of 94 interview-based studies. The lancet oncology, 2011. 12(2): p. 160-74

    4. NCCN, NCCN Treatment Guidelines in Oncology TM: Distress Management v.1.2010. 2010: p. 1-50

    5. Fallowfield, L., et al., Psychiatric morbidity and its recognition by doctors in patients with cancer. British journal of cancer, 2001. 84(8): p. 1011-5.

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    [T] EPS Post 5mg of Haldol in an Adolescent Treated for Acute “Aggression and Psychosis” in Delirium
    Presenting Author:  Bahar Altaha

    17 year old male in his usual state of health until he developed severe diffuse muscle pain to the point that he could not walk after 2 hours long wrestling practice.He was taken to the ER and found to have an CK of 59126 and was admitted to the hospital with diagnosis of rhabdomyolysis.He was medicated with various narcotics for pain and aggressively hydrated without improvement of urine output and progressive worsening of creatinin and BUN, leading to an acute renal failure and later in the day developing respiratory failure, requiring intubation.

    Overnight he became increasingly agitated, confused, had hallucinations and received one dose of haldol 5 mg.

    After he was given haldol, patient had difficulty to communicate (glossopharyngeal dystonia), started to have an upward lateral gaze (oculogyric crises) and looking at the monitor next to his bed and had difficulty to move his neck (spasmodic retrocollis).

    Psychiatry team diagnosed him with delirium and EPS post haldol.

    This is a classic example of misdiagnosis of delirium with psychosis and development of EPS in adolescent after one dose of 5 mg Haldol .The risk of developing EPS after one dose of antipsychotics is significantly higher in children and adolescents and careful dosing and/or other alternatives should be considered to treat agitation.

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    [T] Aphasia with Non-Convulsive Epileptic Seizures Presenting as a Conversion Disorder
    Presenting Author:  Florian Bahr
    Co-Authors:  Emmanuel Obusez, Kathleen Franco

    A 62-year-old African-American female presented to the emergency department (ED) with difficulty speaking. This was preceded by a sudden act of running up and down the staircase hysterically, dressed only in a t-shirt and underwear on the evening prior to ED visit. She had also been described by family as crying and staring out the window into the distance. She had not acted or behaved abnormally prior to that event. A detailed and thorough physical examination revealed no focal or global neurologic deficits. A full laboratory work-up was unremarkable for any infectious etiology or metabolic disturbances. Toxicology screen was negative. A CT scan of the brain without contrast showed no evidence of acute intracranial hemorrhage. A CT of the neck and CT arteriogram of the aortic arch, carotids, cervical vertebral arteries and intracranial circulation were without acute findings and minimal atherosclerotic calcific changes. At the ED, she was treated with 1 mg lorazepam for anxiety and restlessness. Although neurology cleared the patient and requested psychiatry, a portable EEG was ordered.

    The family revealed that 4 weeks earlier there was a death in her family. Her brother with whom she was close had passed and she had difficulty dealing with the death.

    She was able to comprehend and process verbal language but failed several times while trying to verbally articulate her thoughts. This caused her considerable frustration and agitation. The aphasia improved a few hours later after breaking into tears while discussing her brother’s death. With slight remission of the aphasia but still with severely limited speech, she recalled running up and down the staircase, but did not understand why she had done that. She denied confusion or disorientation but recalled feeling agitated. She denied drug use or substance overdose for many years. She admitted she had been severely depressed for the weeks after his death. On mental status exam, she was well groomed and appeared her age. She had poor eye contact and rapport was difficult. She reported depressed mood and her affect was constricted. Her speech was hesitant and aphasic but her thoughts were goal oriented. She reported no hallucinations, delusions, illusions or suicidal ideations. Her insight was intact and she had good judgment.

    Lorazepam given at by the ED physicians and our interview may have resulted in an ‘emotional catharsis.’ The EEG, performed after lorazepam, was consistent for a focal epilepsy arising from the right parasagittal regions with moderate diffuse encephalopathy. On follow-up 15 days later, the patient denied episodes of seizures or similar episodes of aphasia. We will summarize the differential diagnosis and treatment options.

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    [T] Differential Diagnosis of Psychiatric Symptoms in NMDA-R Encephalitis: A Case Report Highlighting the Role of Psychosomatic Medicine Service
    Presenting Author:  Sepideh N. Bajestan
    Co-Authors:  Christina T. Khan, Sermsak Lolak, José R. Maldonado

    Background:  Since it was initially described in 2007, Anti-N-methyl-D-Aspartate-Receptor (NMDA-R) encephalitis has posed challenges to treating physicians. The symptoms fluctuate from psychosis, seizures, autonomic instability to unresponsive/catatonic states. It affects young adults and occurs with/without malignancy. Most patients have a prodromal flu-like phase, followed by psychosis. Although 75% of patients have substantial recovery with tumor resection/ immunotherapy, psychiatrists are frequently consulted and many of patients are admitted with diagnosis of acute psychosis. It is therefore crucial for psychiatrists to be familiar with this disease. The authors review the literature, while presenting a case to illustrate the challenges in managing psychiatric symptoms.

    Case Report:  28-year-old male with no prior medical or psychiatric history, presented with progressive agitation, altered mental status, and erratic behavior. He was started on empiric treatment for meningoencephalitis. After having seizures, he was started on levetiracetam and phenytoin and the former was later switched to divalproex-sodium. He progressed to an unresponsive state, was intubated and transferred to our facility. Patient experienced fever, brady/tachycardia, hypo/ hypertension and diaphoresis. He again experienced seizures and was restarted on levetiracetam, which later due to agitation, was switched to lacosamide and divalproex-sodium. Psychiatry was consulted for treatment of agitation and delirium. Patient's psychiatric symptoms fluctuated from agitation and psychosis, to unresponsiveness/catatonia and increased muscle tone/rigidity. Pt was started on dexmedetomidine, quetipine, memantine, rivastigmine with good response and was successfully extubated. Haloperidol IV PRN was used for management of extreme agitation. The patient received five plasmapharesis exchanges with modest improvement. Divalproex-sodium was increased to treat agitation and prevent seizures. The extensive infectious/autoimmune /paraneoplastic work-ups resulted in only positive serum NMDA-receptor antibodies which explained the patient's presentation. During the course of hospitalization, while on quetiapine, and after receiving IV haloperidol for severe agitation, patient progressed into a non-responsive episode with rigid extremities, tachycardia and hypertension which responded well to IV lorazepam. Catatonia or seizure as features of NMDA-receptor encephalitis, and neuroleptic malignant syndrome (NMS) were the main differential diagnoses. Later, patient received IVIG with marked improvement in agitation, confusion, tremulousness and muscular rigidity.

    Discussion:  The concurrent use of psychiatric medications with other therapeutic modalities makes clinical outcomes difficult to assess. Although haloperidol is often recommended for treatment of agitation in delirium, in NMDA-receptor encephalitis atypical antipsychotics may be preferred as extra- pyramidal side effects of typical antipsychotics may exacerbate the baseline rigidity. IV benzodiazepine may be beneficial in catatonic attacks as it may treat both catatonia and seizure as possible etiologies. During the catatonic episode described above, a normal CPK, absence of fever and good response to IV lorazepam, decreased the likelihood NMS. Clinicians need to be mindful about the nature and progress of this illness, and differential diagnosis of agitation syndrome.

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    [T] Yoga and the Mind: A Systematic Review of Randomized Control Trials to Examine the Benefits of Yoga for Major DSM- IV-TR Diagnoses
    Presenting Author:  Meera Balasubramaniam
    Co-Author:  Murali Doraiswamy

    Purpose:  Yoga is gaining popularity the world over as an intervention for ‘reducing stress' and ‘promoting wellness'. Although hormonal and neurochemical explanations have been propounded, there is a dearth of objective data to establish its value in psychiatric illnesses. Existing forms of treatment such as mindfulness have considerable overlap with principles of yoga. The demand for clinically efficacious, safe, patient acceptable and cost-effective forms of treatment for psychiatric illness is ever growing. This systematic review seeks to examine the available evidence for the benefit of yoga in the treatment of psychiatric disorders and provide directions for future research.

    Methods:  A MEDLINE search was conducted using the terms ‘yoga' and ‘psychiatry' or ‘depression' or ‘anxiety' or ‘psychosis' or ‘memory' or ‘attention' or ‘cognition' or ‘sleep'. Studies conducted between 2000 to 2011, with yoga as the independent variable and one of the above mentioned terms as the dependent variable were included. Studies in which the yoga was not the main intervention were excluded.

    Results:  The above mentioned search yielded a total of 364 articles, of which 64 were randomized control trials. After considering exclusion criteria, two independent reviewers considered 25 studies for the analysis. Preliminary analysis suggested that there were 13 studies examining the effect of yoga on depression, 9 studies examining the effect on anxiety, including 1 on PTSD, 3 studies examining the effect on cognition, 2 studies each examining attention and sleep, 1 study each on eating disorders and smoking cessation. 3 studies explored ‘stress' using independent rating scales. There were 8 studies exploring the effect of yoga on more than one domain. According to preliminary analysis, 18 studies showed statistically significant benefit in the group receiving yoga.

    Conclusion:  The trials vary greatly in terms of their sample size, type (breathing vs. exercise based) and duration of intervention, demographic characteristics of the sample and outcome measures. Also, a vast majority of these trials have been performed in Asia, thereby limiting their generalizability. However, the review serves to draw attention to the value of yoga as a possibly useful and safe adjunct to existing treatment modalities.

    References:

    Vedamurthachar, A., Janakiramaiah, N., Hegde, J.M., Shetty, T.K., 2006. Antidepressant efficacy and hormonal effects of Sudarshan Kriya Yoga (SKY) in alcohol dependent individuals. Journal of Affective Disorders, 94, 249-253

    Kamei, T., Toriumi, H., Kimura, S., Ohno, H., Kumano, K. 2000. Decrease in serum cortisol during yoga exercise is correlated with alpha wave activation, Percept Mot Skills, 90, 1027-1032

    Sinha, S., Singh, S.N., Monga, Y.P., Ray, U. 2007. Improvement of glutathione and total antioxidant status with yoga, J Altern Complement Med, 13, 1085-1090

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    [T] Not Seeing the Ephedra for the Crystal Meth: Health Supplement-Exacerbated Psychosis in an Urban Community Setting
    Presenting Author:  Alan Bates
    Co-Author:  Gordon MacEwan

    Ma-huang, better known as ephedra, has been used for hundreds of years in traditional Chinese medicine and its primary active ingredient, ephedrine, was an early treatment for asthma. More recently, ephedra has been marketed as an aid to weight loss and/or building muscle bulk. Ephedra was an extremely popular supplement in the US until mounting evidence of dangerous cardio and cerebrovascular side-effects, including the deaths of two sports celebrities, prompted the FDA to ban its sale in 2004. Prior to this, several case reports described psychiatric side-effects of ephedra including psychosis, mania, depression, dependence, and suicidal ideation. Still available in Canada as a decongestant, and likely still available to US residents via the internet, ephedra continues to be used for its promises of weight loss and muscle gain.

    We report a case of a woman in her mid-forties who presented to psychiatric services with psychosis and labile affect that was diagnosed as methamphetamine-induced psychosis, possibly with underlying bipolar disorder. She had been functioning relatively well until the age of 40 when she broke up with a long-term boyfriend, lost her apartment and vehicle, and wound up in shelters in downtown Vancouver where she began to use crystal meth. Even following a few involuntary admissions and initiation of an antipsychotic depot, she frequently expressed feelings of being persecuted by organized crime and women who she believed were running the city. She also became very irritable, sometimes confronting people on the street, over all the "pornography and garbage" she perceived to be around the city. While this all could have been explained by methamphetamine-induced psychosis, the temporal pattern of her symptoms did not readily map to her times of crystal meth use. In addition, she often complained of a racing heart and concerns that she was going to have a heart attack despite always trying to stay in shape by walking long distances and lifting weights. Further history regarding her cardiac symptoms revealed she had been using ephedra on and off since her 20s and was currently using 8-16mg daily. Using the cardiac symptoms as a concern we shared with her, we convinced her to discontinue the ephedra. Following this, she became significantly more organized, no longer expressed persecutory delusions, was able to voluntarily enter a detox centre, moved from shelter-like accommodation to more permanent housing, and returned to earning some income. Though the etiology of our patient's psychosis was likely multifactorial, we believe the ephedra played a significant role and that the commercial availability of ephedra should be reviewed by Health Canada. This case also demonstrates the need to screen for use of health supplements in patients whose symptoms are readily explained by "hard" street drugs.

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    [T] Late Onset Obsessive Compulsive Symptoms as a Precursor to Frontotemporal Lobar Degeneration.
    Presenting Author:  Patricia Bauza
    Co-Author:  Maryland Pao

    Background:  It has been reported that compulsive behaviors may be the first symptoms of frontotemporal lobar degeneration (FTLD). This may be secondary to orbitofrontal-subcortical abnormalities which are known to be associated with both FTLD and obsessive compulsive disorder (OCD). One of the major differences between FTLD and OCD is the age at onset. While onset of FTLD occurs predominantly between 45 and 65 years of age, the mean age at onset of OCD is between 20 and 25 years of age.

    Method:  Using case reports and a computerized search of literature on Pub Med and Online Mendelian Inheritance in Man (OMIM), we reviewed 32 research reports to investigate how late onset obsessive thoughts and compulsive behaviors may represent an early presentation of FTLD and to determine whether manifestations of compulsive behavior in FTLD differ qualitatively from compulsive behavior observed in idiopathic or acquired OCD.

    Results:  Compulsive behaviors are common presenting symptoms among FTLD patients and may result from an inability to inhibit urges to perform compulsive movements due to damage to frontal-striatal circuits. Studies suggest that neuronal degeneration in FTLD begins in the caudate nuclei, providing a structural basis for the development of obsessive/compulsive behaviors. Orbital frontal cortex (OFC) lesions lead to deficits in decision making cognition and may play a role in representing and altering the reward value of primary and secondary reinforcers. This area is affected early in the course of FTLD and OCD. Serotonin is likely involved in the pathogenesis of behavioral disturbances in patients with FTLD supported by the finding of reduced levels of post synaptic serotonin in post mortem studies of FTLD patients.

    Conclusion:  The combination of frontal, frontal-striatal, and medial temporal pathology in FTLD predispose its victims to compulsive acts. Late onset compulsive behaviors should alert the clinician to the possibility of an organic etiology (neurodegenerative). In patients presenting with features suggestive of FTLD delusions, collateral information and other neuropsychiatric symptoms should be sought as they may not be volunteered spontaneously but can contribute to the early decline in interpersonal conduct. Rational therapy for OCD will depend on a detailed understanding of the neuronal circuitry and physiologic mechanisms underlying such behaviors. A better understanding of the underlying mechanisms involved in obsessive/compulsive symptoms may have treatment implications for both FTLD and OCD.

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    [T] Identification and Management of Posterior Fossa Syndrome and Delirium in a 3-Year-Old Male
    Presenting Author:  Kalonda Bradshaw
    Co-Authors:  Regina Jakacki, Roberto Ortiz-Aguayo

    Purpose:  Posterior Fossa Syndrome is characterized by diminished speech output, hypotonia, truncal ataxia, and emotional lability after removal of posterior fossa tumors. It occurs in up to 25% of patients undergoing surgery to remove medulloblastoma. It is unclear as to how often Posterior Fossa Syndrome presents with superimposed delirium. It is important that Posterior Fossa Syndrome be recognized by clinicians who treat children because it is a debilitating condition that commonly affects patients following resection of a posterior fossa tumor and it may have long-term sequela. It is also paramount to recognize concomitant presence of delirium because it presents additional difficulties in management and post-operative recovery.

    Methods:  The authors present the case of a 3 year old patient who developed posterior fossa syndrome with treatment recalcitrant associated behavioral symptoms. Evaluation strategies as well as clinical and systems processes related to treatment decision making and delivery are reviewed.

    Results:  The patient is a 3 year-old male with disseminated medulloblastoma status-post near-gross total resection of the posterior fossa mass. Post-operatively he was noted to have neurological deficits that included: generalized weakness, mutism, hemiparesis, and cranial nerve deficits. Behavioral symptoms included: inconsolable high pitched crying, insomnia, agitation and intractable irritability otherwise consistent with posterior fossa syndrome. Fluctuations of consciousness and aggression were also noted. Over a 72 hour period, trials of haloperidol, lorazepam, and phenobarbital were attempted with little success. Clonidine resulted in some improvement in sleep with little change in behaviors. Psychiatric consultation was obtained at this time. Evaluation was consistent with posterior fossa syndrome with superimposed delirium. Following parental consent and review with pharmacy safety committee a brief trial of low-dose Olanzapine was initiated with marked sustained improvement in all behavioral symptoms. There were no noted side effects and the child was able to quickly transition to intense physical and cognitive rehabilitation and is currently doing well off of psychotropic medications.

    Conclusion:  Although it is well known that Posterior Fossa Syndrome follows surgical resection of posterior fossa tumors; especially medulloblastoma, there are no clear recommendations for the acute management of the associated behavioral symptoms. To our knowledge this is the first report of successful treatment with Olanzapine in a three year old with signs and symptoms consistent with Posterior Fossa Syndrome and superimposed delirium. Further studies to determine who is most at risk for this syndrome and the role for adjuvant psychiatric evaluation and management are warranted.

    References:

    Kupeli S, Yalcin B, Balginer B, et al. Posterior Fossa Syndrome After Posterior Fossa Surgery in Children with Brain Tumors. Pediatric Blood Cancer 2011;56:206-210

    Fremaux T, Reymann JM, Chevreuil C, et al. Prescription of Olanzapine in Children and Adolescent Psychiatric Patients. Encephale 33(2):2007,188-96

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    [T] Boundary Crossings and Violations: How Well Are Residents Informed? A Cross-Departmental Study among Non-Psychiatric Residents
    Presenting Author:  Archana Brojmohun
    Co-Author:  Jeanne Lackamp

    Objective:  The purpose of this study was to 1) assess the level of non-psychiatry resident education about boundary crossings and violations, and 2) identify the effects of a 45-minute lecture on increasing awareness and education about boundary crossings and violations on healthcare professionals in different specialties.

    Background:  In March 1992, the American Medical Association updated its "Code of Ethics" after the Journal of the American Medical Association published a report ("Sexual Misconduct in the Practice of Medicine") from the Council of Ethical and Judicial Affairs in 1991. One of the Council's conclusions was that "education on the issue of sexual attraction to patients and sexual misconduct should be included throughout all levels of medical training." The report clearly stated that its conclusions apply to all medical specialties.

    Methods:  An anonymous, twelve-question survey was distributed before the lectures. The questions described scenarios depicting boundary crossings and violations. The subjects were asked to designate whether the scenarios consisted of crossings, violations, neither, or "I don't know." Consent was implied by completing the surveys, and subjects were given adequate time to do so before a 45 minute lecture entitled "Boundary Crossings and Violations: A Slippery Slope" was delivered by the author. . After the lecture, subjects were given as much time as required to complete identical post-lecture questions.

    Results:  A total of 26 residents completed the survey: 10 from Family Medicine, 8 from Obstetrics and Gynecology, and 8 from Internal Medicine. The pre-lecture mean scored for Family Medicine, Obstetrics and Gynecology were 4.5, 5.5 and 5.4. Those increased to 8.8, 9.5 and 9.5 on the post-lecture survey. In addition, the median and standard deviations were also calculated. A paired t test was administered and the two tailed p value for Family Medicine was 0.0013 while that for Obstetrics and Gynecology and Internal Medicine were both0.0003 showing statistical significance.

    Conclusions:  This small pilot study suggests two conclusions: 1) residents in these three non-psychiatric specialties are not adequately educated about issues of boundary crossings and violations, and 2) a lecture format is adequate to increase their knowledge of these topics. Our goal is to eventually improve the quality of education provided about boundary crossings and violations at all levels of medical training and among different specialties.

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    [T] Herbal Remedies and Memory Loss: A Review
    Presenting Author:  Sari J. Burns
    Co-Authors:  Michael J. Serby, David M. Roane

    Purpose:  Increased rates of dementia throughout the world are creating an emergent need for successful preventive and treatment strategies. Despite a lack of any significant scientific basis, herbal and other "complementary alternative medicine" (CAM) remedies are being aggressively marketed for both prophylactic and therapeutic effects in regard to memory disorders (1). This paper reviews the small number of placebo-controlled trials of some herbal and other CAM drugs in the recent years to assess their efficacy.

    Methods:  We searched Pubmed and Google Scholar for relevant peer-reviewed literature examining the effects of herbal remedies on memory loss in elderly human subjects since 2008. For both searches, we used the terms "Herbal Remedies," "Gingko Biloba", "Phosphatidylserine", "Phosphatidylcholine", "Omega 3 polyunsaturated fatty acids" or "Ginseng" in combination with the terms "Memory loss" or "Dementia".

    Results:  The search yielded eleven papers. Of the five papers on Gingko Biloba, three focused on prevention and two on treatment. The prevention papers found no significant evidence of efficacy in prevention of cognitive decline. However, one of the treatment papers yielded statistically significant evidence that Gingko Biloba improved neuropsychiatric and cognitive symptoms in demented elderly with behavioral problems. The Phosphatidylserine paper found treatment may be effective when targeted to patients with early memory complaints rather than patients with advanced dementia. Four papers studied Omega-3 fatty acids and found conflicting results. In the prevention studies, one paper found no protective effect on cognition, and the second a reduced likelihood of Mild Cognitive Impairment (MCI). Of the treatment studies, one reported slight improvement in global clinical functioning in patients with MCI, and the other found treatment was not effective in patients with mild or moderate Alzheimer's Dementia (AD). Lastly, the search yielded one ginseng article noting improvements in cognitive scores in patients with probable AD. In all studies, no significant adverse effects were noted.

    Conclusions:  Our data reflects that there have been a small number of placebo-controlled trials of some herbal and other CAM drugs in the recent years. These studies reflect that efforts to prevent or delay dementia via the use of Gingko Biloba have not been successful. As a treatment for dementia, Gingko Biloba may be effective for demented patients with behavioral problems, demonstrating improvements in neuropsychiatric symptoms and cognition. Both Phosphatidylserine and Ginseng studies found significant improvements in cognition, however limitations and confounding factors make these results suspect for treatment recommendation. The Omega-3 fatty acid studies concluded there is insufficient evidence to warrant use of this class of agents in dementia. Our data concludes that more research is warranted.

    Reference:

    Serby, Michael J., Yhap, Christine, Landron, Eva Y. A Study of Herbal Remedies for Memory Complaints. J Neuropsychiatry Clin Neurosc. 2010 22: 345-347

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    [T] Pseudolabor Born Out of Psychogenic Nonepileptic Seizures: A Case Report of Multisymptom Conversion Disorder.
    Presenting Author:  Richard Carlson, Jr.
    Co-Author:  Jason Caplan

    Background:  Psychogenic nonepileptic seizures (PNES) are a familiar trigger for psychiatric consultation. PNES in pregnancy have not been well described. The conversion phenomenon of pseudolabor (featuring prolonged abdominal muscle contractions during pregnancy) has only been described twice previously. We report a case of a pregnant woman admitted for seizure-like episodes who subsequently developed symptoms potentially consistent with preterm labor.

    Case Report:  A 34 year-old Caucasian G4P3 woman with no known psychiatric history was transferred to a major tertiary care hospital at 27 weeks of pregnancy following 9 seizure episodes in one day. She had been diagnosed with epilepsy a year and a half prior when she began experiencing generalized tonic-clonic events prompting initiation of levetiracetam and topiramate.

    Following admission to an epilepsy monitoring unit equipped with continuous video electroencephalography (vEEG), consultation from the OB/GYN service revealed a normal 27 week pregnancy. On the first night of the admission the patient had a monitored seizure episode and was diagnosed with PNES after vEEG did not demonstrate any epileptiform activity.

    The next morning, the patient began to complain of uterine contractions occurring regularly every 10-15 minutes, each lasting 3-5 minutes with abrupt onset and descent. The OB/GYN service was again called to assess the patient and exam was noted as unchanged. Cervical and vaginal cultures were obtained, and fetal fibronectin (FFN) was collected. A Maternal-Fetal Medicine (MFM) consult was called and based on the tocodynamometry reading during a contraction episode, the attending MFM physician determined that these events were not consistent with uterine contractions. The external tocodynamometer did not exhibit a smooth muscle waveform and on palpation, the "contractions" were actually abdominal skeletal muscle stiffening. In the setting of a reassuring physical exam, tocodynamometry findings and a negative FFN, there was insufficient evidence to suggest preterm labor and tocolytic medications were withheld. The psychiatric consultation service was called to assess the address the diagnosis of conversion disorder with PNES and suspected pseudolabor.

    Conclusion:  This case report illustrates an important, rarely described conversion phenomenon known as pseudolabor (prolonged abdominal muscle contractions mimicking labor in pregnant patients). Previous reports have documented misdiagnoses of preterm labor and aggressive treatment with tocolytics, unnecessarily exposing both mother and fetus to potentially severe adverse effects. Thorough workup (including sterile vaginal exam, transvaginal ultrasound, FFN testing, and external tocodynamometry with palpation of both the uterus and abdomen during contractions) can help delineate pseudolabor from true uterine contractions. Clinicians across all disciplines should be aware of this rare conversion phenomenon in order to forestall any unnecessary treatment for preterm labor.

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    [T] New Onset Psychosis in Usher's Syndrome
    Presenting Author:  Kyle Cedermark
    Co-Authors:  Gioia Guerrieri, Christopher Sola

    Background:  Ushers syndrome, the most common diagnosis of combined sensory vision and hearing loss in the world, is a rare autosomal-recessive disorder and can be a diagnostic challenge for the psychiatrist asked to assess for mood disturbances in the context of inherent perceptual and communication impairments [1]. A handful of case reports have discussed the onset and treatment of psychosis in patients with Usher's syndrome, though the etiology remains unclear [2] and is not limited to neuronal destruction of the visual and auditory pathways [3].

    Case Description:  Psychiatry was asked to consult on the sudden onset of psychosis in a 62-year-old, premorbidly high-functioning Caucasian female with known Ushers syndrome since age 30, no cognitive impairment, psychiatric history, or active medical concerns apart from a three-month rapid deterioration of vision. She was terrified by shadow faces with bright red mouths (named Cleo and John) and feared that "spies" were monitoring and following her. She noted near-continuous auditory disturbances characterized by an unintelligible adult chorus. She taped her windows and doors shut and contacted law enforcement repeatedly. She was previously independent and had social, family, and significant technological support for her hearing and vision loss.

    Results:  Initial medical evaluation was unremarkable. She was started on 1 mg risperidone, experiencing a reduction of auditory and visual disturbances within two days. Following an unintentional cessation of risperidone, she was treated for heightened anxiety related to worsening perceptual disturbances and restarted on her medication. One month later, she presented with extrapyramidal symptoms, worsening anxiety, and depressive symptoms when she was told that her vision further deteriorated and she would soon be blind.

    Conclusion:

    • The differential diagnosis included Major Depressive Disorder with Psychotic Features, Charles Bonnet syndrome, Schizophrenia, and Psychosis due to a General Medical Condition.
    • The role of psychopharmacology to treat hallucinations and associated anxiety should be closely examined in patients with a baseline impairment of auditory and visual function and incorporate collateral information.
    • Reassurance, patient education (reinforced by friends and family), and frequent outpatient followup proved to be an effective treatment modality.

    References:

    1. Hess-Röver J, Crichton J, Byrne K, Holland AJ. Diagnosis and treatment of a severe psychotic illness in a man with dual severe sensory impairments caused by the presence of Usher syndrome. J Intellect Disabil Res. 1999 Oct;43(5):428-34

    2. Kimberling WJ, Hildebrand MS, Shearer AE, Jensen ML, Halder JA, Trzupek K, Cohn ES, Weleber RG, Stone EM, Smith RJ. Frequency of Usher syndrome in two pediatric populations: Implications for genetic screening of deaf and hard of hearing children. Genet Med. 2010 Aug; 12(8):512-6

    3. Schaefer GB, Bodensteiner JB, Thompson JN Jr, Kimberling WJ, Craft JM. Volumetric neuroimaging in Usher syndrome: evidence of global involvement. Am J Med Genet. 1998 Aug 27;79(1):1-4

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    [T] Consultations for Capacity and Behavioral Disturbance: Delirium Recognition by Non-Psychiatric House Staff
    Presenting Author:  Stephanie Cheung
    Co-Author:  Nancy Maruyama

    Purpose:  There is evidence from the early years of Consultation-Liaison Psychiatry that non-psychiatric physicians frequently misdiagnosed delirium. We examined whether primary teams, particularly surgery and ICUs, recognized delirium, and whether common reasons for consults would be depression or psychosis based on prior literature [3,4,5].

    Methods:  We reviewed psychiatric consults on inpatients at a tertiary care hospital that were done over ten consecutive months in 2009. We examined congruence between the consultant's diagnosis of delirium and the consultee's reason for consultation.

    Results:  In the ten month period there were 750 consults done by trainees. One hundred and thirty-two had "delirium" in the top two diagnoses in the differential. Of these, the most common consult reasons were not about depression or psychosis, but about behavior (28.8%) and capacity (26.5%). Delirium was asked in only 8.3% of consults across primary teams; Surgery asked in 20% compared to Medicine's 5.3%. In ICU cases, 0% was initiated because of a delirium question. If similar terms were included to count as "delirium", the rate of delirium recognition rose.

    Conclusions:  The data suggests that delirium was not recognized for itself as much as it was recognized for the problems it caused. In the consultations reviewed, non-psychiatrists requested consults mostly for the behavioral and administrative issues that arise from delirium. Given the morbidity of delirium, CL psychiatrists should increase efforts to educate consultees about delirium and regard capacity and behavior consults as "rule out delirium", particularly ICU cases.

    References:

    1. Maldonado J. Pathoetiological Model of Delirium: A Comprehensive Understanding of the Neurobiology of Delirium and an Evidence-Based Approach to Prevention and Treatment. Critical Care Clinics 2008;24:789-856

    2. Maldonado J. Delirium in the Acute Care Setting: Characteristics, Diagnosis, and Treatment. Critical Care Clinics 2008;24:657-722

    3. Tiamson ML, Wallack JJ, Bailer PA. The misdiagnosis and under-recognition of organic mental disorders among patients referred for psychiatric consultation. Psychosomatics1994;35:215

    4. Armstrong SC, Cozza KL, Watanabe KS. The Misdiagnosis of Delirium, Psychosomatics 1997;38:433-439

    5. Trzepacz P, Meagher D. Delirium. In Levenson J, editor. The Textbook of Psychosomatic Medicine. Arlington, Virginia: American Psychiatric Publishing, 2011. p. 71-114

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    [T] Catatonia as a Manifestation of Tacrolimus Neurotoxicity in Organ Transplant Patients: A Case Series
    Presenting Author:  Amit Chopra
    Co-Authors:  Piyush Das, Abhishek Rai, Preetha Kuppuswamy, Xiaofan Li, John Huston, Kemuel Philbrick, Christopher Sola

    Purpose:  Tacrolimus, a macrolide antibiotic with potent immunosuppressive properties, is an effective treatment used to prevent rejection after organ transplantation. Approximately 5-8% of the patients suffer from tacrolimus induced serious neurotoxic side effects including confusion, dysarthria, seizures, and coma. Catatonia has been rarely reported as a manifestation of tacrolimus neurotoxicity.

    Methods:  We report two organ transplant patients who presented with catatonia as a manifestation of tacrolimus induced neurotoxicity.

    Case 1
    57 year old female with remote psychiatric history of major depression and alcohol abuse and medical history significant for type II diabetes status post kidney-pancreas transplantation. She developed bifrontal headaches, systolic hypertension, confusion and focal neurological deficits after an increment in tacrolimus dosage. She had multiple ER visits and hospital admissions to Neurology service and extensive neurological work-up was negative except for an abnormal EEG with nonspecific generalized slowing over the left temporal lobe. She developed catatonic symptoms including mutism, negativism, motoric immobility and periods of decreased responsiveness. She became somnolent with one time oral administration of lorazepam. Both confusion and catatonic symptoms resolved fully after reduction in tacrolimus dosage.

    Case 2
    60 year old male with history of PTSD and hepatitis C status post orthoptic liver transplantation. He was initiated on triple immunosuppressant prophylaxis including prednisone, mycophenolate and tacrolimus. He was admitted to hospital for complaints of mutism, staring spells, agitation and purposeless body movements with in one week of liver transplantation. EEG revealed triphasic waves and diffuse slow waves suggestive of encephalopathy. CT chest revealed localized lung infection without any clinical evidence of sepsis (negative blood cultures). He developed paradoxical agitation with one time intravenous lorazepam challenge and had an ineffective trial of low-dose quetiapine. Tacrolimus was substituted with cyclosporine leading to complete resolution of catatonia.

    Results:  Serum tacrolimus levels were normal in both patients at the onset of neurotoxicity. MRI changes including edema in the subcortical white matter in bilateral or unilateral parieto-occipital regions were not evident in one of the patients who underwent head MRI, a finding absent in nearly 60 % of patients with tacrolimus induced neurotoxicity. Catatonia in one of these patients resolved with reduction in tacrolimus dosage and switching to cyclosporine in another case.

    Conclusions:  Catatonia can present as a manifestation of tacrolimus induced neurotoxicity. Early recognition and treatment of tacrolimus toxicity is crucial as it can lead to irreversible neurological damage and even death. Therefore, high index of suspicion for tacrolimus neurotoxicity is warranted in patients presenting with signs of confusion/catatonia despite normal serum tacrolimus levels and head MRI findings. Catatonic symptoms may completely resolve either by reduction in tacrolimus dosage or switching it to immunosuppressants like cyclosporine.

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    [T] Resolution of Delirium after Antipsychotic Rotation
    Presenting Author:  Michael Christo
    Co-Author:  John Shuster

    Background:  Delirium is common in acutely ill patients and can result in substantial morbidity and mortality if left untreated. Antipsychotics are the mainstay of pharmacologic management of delirium, but initial therapies are not always satisfactorily effective.

    Objective:  To consider clinical situations when rotation to alternative antipsychotic therapy might be beneficial for cases of delirium unresponsive to initial therapy.

    Case Summary:  We present the case of a 49 year old African American female with a history of peripheral vascular disease, hypertension, chronic renal failure, diabetes, and depression who was admitted to the Vascular Surgery service at a university medical center for treatment of an infected left axillary-femoral graft. Complications necessitated a left above-the-knee amputation. On post operative day 9 from the graft removal (post operative day 6 from the amputation) the psychosomatic medicine service (PSM) was asked to evaluate for the patient for acute agitation and delirium. The patient was judged to be delirious, with a baseline Folstein Mini-Mental State Exam score of 12/30. Pertinent laboratory included a creatinine of 2.59, WBC count of 13.8, homocysteine of 16.9 μmol/L, and a packed cell volume of 27%. The patient was afebrile but had persistently elevated blood pressures. Her delirium was deemed secondary to sepsis in a patient with chronic vascular disease, and treatment was initiated with oral olanzapine 5 mg twice daily and 5 mg sublingually every 4 hours as needed for moderate agitation, along with haloperidol 5mg IV every 4 hours as needed for severe agitation (she received minimal amounts of haloperidol before it was discontinued). After two days, her agitation was increasing and the dose of olanzapine was increased to 5mg mg twice daily and 10mg at bedtime, with continuation of the PRN sublingual olanzapine. She was unable to cooperate with Physical Therapy. After seven days of olanzapine, she was switched to oral risperidone 1 mg twice daily and the olanzapine and haloperidol were discontinued. One day after this switch was made she was noted to be much less agitated and was cooperative with nursing and physical therapy staff. She was less confused and her speech was clear and affect brighter. After three days of risperidone treatment she was stable enough for transfer to a rehab facility. Folstein Mini-Mental State exam was completed on day four of risperidone treatment and scored 21/30.

    Discussion:  We will present a strategy and pharmacologic rationale for antipsychotic rotation in the treatment of delirium.

    Conclusion:  While olanzapine and haloperidol have been shown to be effective as a treatment for delirium and are in common use for this off-label indication, consideration should be given to a trial rotation to alternative therapies if delirium worsens or does not improve with treatment.

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    [T] When Family Conflict Involves Dementia: The Effectiveness of Emotionally-Focused Couple Therapy
    Presenting Author:  Kristine Dangremond
    Co-Authors:  Louis Joseph, James Griffith

    Clinicians often fall into therapeutic nihilism when intractable family conflict is due in large part to a demented family member's memory impairment, loss of executive functions, or other cognitive impairment. Emotionally-focused couple therapy (EFT) is distinguished by its reliance upon emotional, rather than cognitive processes. EFT focuses upon accurate assessment of family members' attachment needs and specific interventions that target cycles of conflict arising from family members' responses to their attachment needs. It differs from cognitive-behavioral, psychodynamic, or family systems therapy in the extent to which it does not rely more upon an impaired family member's capacities to self-observe, to reflect, and to problem-solve. As such, EFT may be better fitted for couple or family therapy when chronic conflict involves cognitive impairment. We present two brief EFT family therapies, the first a single-session intervention involving a couple in severe conflict largely due to the husband's frontotemporal dementia; and the second an 8-session EFT family therapy involving a cognitively-impaired mother who had with brain metastases and was in severe conflict with her adult son. In both cases, the EFT interventions led to long-term resolution of conflict in the relationships. We will discuss the rationale and guidelines for EFT when cognitive impairment is centrally involved in family conflict.

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    [T] Recurrent Psychosis Induced by Hydroxychloroquine in a Patient with Chronic Q Fever
    Presenting Author:  Piyush Das
    Co-Authors:  Abhishek Rai, Amit Chopra, Kemuel Philbrick

    Purpose:  Hydroxychloroquine is an anti-malarial drug, also used for the treatment of rheumatoid arthritis, lupus erythematosus and chronic Q fever. Anti-malarial drugs like quinacrine, chloroquine and mefloquine have been reported to cause psychosis. To the best of our knowledge, this is the first case report of recurrent psychosis induced by hydroxychloroquine.

    Methods:  Mr. X is a 43-year-old male sheep farmer with no personal or family psychiatric history. He developed acute Q fever, a common occupational hazard in sheep farmers. For this, he was initially treated with doxycycline for two weeks with partial improvement. Several months later, a relapse prompted reinitiation of doxycycline, this time along with rifampin and hydroxychloroquine. Rifampin was replaced with ciprofloxacin after one month due elevated liver enzymes; three months after this, he developed psychotic symptoms including visual, auditory and tactile hallucinations. Discontinuation of hydroxychloroquine, ciprofloxacin and doxycycline was followed by complete resolution of psychotic symptoms.

    Seven months later, hydroxychloroquine was reinitiated following diagnosis of chronic Q fever (based on persistently positive Q fever serology). After three months, he was admitted to the vascular surgery service for management of uncontrolled hypertension requiring left-sided aortorenal bypass. Four days after surgery, he experienced recurrent psychosis and described it as an exact "play back" of his first psychotic episode. Hydroxychloroquine was immediately discontinued. On examination, there was no evidence of delirium. He denied alcohol and drug abuse. Laboratory investigations were within normal limits. His psychotic symptoms resolved three days after discontinuation of hydroxychloroquine. In the interim, olanzapine (5 mg x 1) was the only neuroleptic he had received. On a follow-up visit with outpatient psychiatry eight days after resolution of psychosis, he remained symptom free.

    Results:  This case adds to the scant literature on psychosis associated with anti-malarials. This adverse effect may be considerably delayed after initiation of hydroxychloroquine due to its long half-life (40 days) and its cumulative concentration in the brain with chronic administration. The metabolism-inducing effect of rifampin on hydroxychloroquine via cytochrome 2D6 likely explains why psychosis did not appear until after rifampin had been discontinued: serum levels of hydroxychloroquine likely increased after discontinuation of rifampin.

    Conclusion:  Psychosis can be a rare adverse effect of hydroxychloroquine treatment. When it occurs, the onset of psychosis is likely to be delayed after initiation of hydroxychloroquine. Caution must be exercised in the concomitant use of CYP 450 enzyme inhibitors with hydroxychloroquine. Concomitant use of CYP 450 enzyme inducers like rifampin may afford protection against psychosis. Prompt discontinuation of hydroxychloroquine will likely resolve psychotic symptoms, thereby preventing unnecessary long-term antipsychotic use.

  78. [Withdrawn]
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    [T] A Case of Fulminant Neuroleptic Malignant Syndrome
    Presenting Author:  David Edgcomb
    Co-Authors:  Nancy Maruyama, Joel Wallack

    Introduction:  More recent data suggests neuroleptic malignant syndrome (NMS) has an incidence of 0.02 % in patients treated with antipsychotics and is associated with a mortality rate of 10% in the United States [1]. Consultation-liaison psychiatrists rarely see a case of fulminant neuroleptic malignant syndrome.

    Case Report:  We present the case of AS, a 54 year-old man with a long history of Bipolar Disorder Type I with psychotic features treated with risperidone and valproic acid by an Assertive Community Treatment team. He had a medical history of obesity, diabetes mellitus, chronic obstructive pulmonary disorder (COPD), hyperlipidemia, hypertension, and obstructive sleep apnea. He was admitted to our hospital with respiratory failure, intubated, and transferred to the medical intensive care unit (MICU) where he was treated for pneumonia vs. COPD exacerbation. He continued to receive his outpatient psychiatric medications and his simvastatin via nasogastric tube. On hospital day 8 he developed a fever of 108.4 F. When his creatine phosphokinase (CPK) continued to rise, psychiatry was consulted. CPK ultimately reached 65,000 U/L. Interestingly, the patient had no muscle rigidity on physical exam. The patient developed renal failure, disseminated intravascular coagulation, and lab results consistent with NMS including leukocytosis, hypocalcemia, elevated PT and INR, and elevated transaminases. He died less than 24 hours after he was seen by psychiatry.

    Literature Review and Discussion:  We review the literature on severe cases of NMS, examine controversies regarding diagnostic criteria of NMS, and the evidence on clinical recommendations about treatments including supportive therapy, pharmacologic agents, and electroconvulsive therapy (ECT). We also discuss when psychotropic treatment regimens should be continued in the MICU.

    Sources:

    1. Strawn, Jeffrey R., Paul E. Keck Jr., and Stanley Caroff. "Neuroleptic Malignant Syndrome." Am J Psychiatry 164:6, June 2007 870-876

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    [T] Development of a System-Wide Education Program to Address Involuntary Commitment to Substance Abuse Treatment as a Patient Disposition Option
    Presenting Author:  Jeffrey Eisen
    Co-Authors:  Prudence Baxter, Robert Joseph

    Consult-Liaison psychiatrists are frequently called upon to evaluate and address disposition options for patients with substance abuse and dependence concerns. In the state of Massachusetts, one disposition alternative includes petitioning for the involuntary commitment of substance abuse or dependent patients under Chapter 123, Section 35 of the Massachusetts General Laws. Departments across the Cambridge, MA-based Cambridge Health Alliance, ranging from medicine and psychiatric emergency departments and inpatient units to outpatient addiction and internal medicine clinics, expressed interest in considering the Section 35 petition as a potential disposition alternative for patients, but lack of knowledge about the petitioning process, complicated logistics, questions of effectiveness, and ethical concerns created barriers to implementation. As such, a Cambridge Health Alliance Consult-Liaison Psychiatry team member developed a Section 35 education program to enable clinicians to address these challenges and make informed decisions with regard to including mandatory treatment as part of a patient disposition plan. The education program included presentations, educational didactic sessions, and roundtable discussions. Ongoing plans include integration with medicine and psychiatry resident education; creation of a central repository of information and procedures; a Section 35 system-wide committee to address complex patient cases, as well as barriers to implementation; and a study to track Section 35 petitions at Cambridge Health Alliance affiliated District Courts since the onset of system-wide education.

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    [T] Psychiatric Disorders and Postoperative Outcome in Hispanic Patients Receiving Bariatric Surgery
    Presenting Author:  Silvia Fernandez
    Co-Authors:  Ingrid Barrera, Dominique L. Musselman, M. Beatriz Currier

    Objective:  In Caucasians, multiple studies have linked severity of obesity to childhood abuse and adult psychopathology, including mood, anxiety, and binge eating disorders. (Wildes et al 2008) However, few studies have examined the prevalence of childhood abuse, psychiatric disorders, and disordered eating behaviors in Hispanics seeking weight loss surgery (Azarbad et al, Guarjardo-Salinas et al.). Similarly, the impact of childhood abuse and pre-operative psychopathology, upon post-operative (bariatric surgical) outcome in this population, remains unclear. The primary objective is to compare the prevalence and impact of childhood abuse, psychiatric co-morbidity and disordered eating behaviors in Hispanic and non-Hispanic patients upon outcomes after bariatric surgery.

    Methods:  Patients seeking bariatric surgery at University-affiliated and community hospitals were referred for pre-operative psychiatric clearance. Psychiatric assessment included the Structured Clinical Interview for DSM-IV; dimensional self-report scales including the Childhood Trauma Questionnaire, Beck Depression Inventory, Binge Eating Scale, and important demographic and medical covariables Post-operative outcomes including magnitude of weight loss and medical complications will be assessed at 3 and 6 months. Using PASW 18, independent t-tests and ANOVA regression were used to compare continuous variables, and Chi-square to compare categorical variables.

    Results:  The sample of 20 Hispanic and 20 non-Hispanic patients (16 males, 24 females) had a mean age 43 years and mean BMI of 46kg/m2. The rate of childhood abuse was similar: 60% in Hispanics vs. 55% in non-Hispanics. Lifetime prevalence of mood, anxiety, substance abuse, or eating disorders was similar: 75% of Hispanics vs. 55% of non-Hispanic patients. Disordered eating behaviors (e.g. grazing, sweet eating) were also common in both groups, despite Hispanics reporting a higher rate of night eating syndrome, (60% vs. 30%). Post-operative outcome data is pending.

    Conclusions:  Our preliminary data suggest that rates of: a) childhood abuse, and b) mood, substance abuse and eating disorders are common among morbidly obese Hispanics seeking bariatric surgery, and similar to those of non-Hispanic individuals. The association of these variables with post-operative outcome will be assessed, thereby clarifying the need for pre-surgical screening of such.

    References:

    1. Azarbad L, Corsica J, Hall B, Hood M. Psychosocial correlates of binge eating in Hispanic, African American, and Caucasian women presenting for bariatric surgery. Eating Behaviors. 11: 79, 2010

    2. Flegal K, Carroll M, Ogden C, Lester C. Prevalence and Trends in Obesity Among US Adults,1999-2008. JAMA 303(3):235-241,2010

    3. Grilo C, Masheb R, Brody M, Toth C, Burke-Martindale C, Rothschild B. Childhood Maltreatment in Extremely Obese Male and Female Bariatric Surgery Candidates. Obesity Research 13(1):123,2005

    4. Levine MD, Courcoulas AP, Pilkonis PA, Ringham RM, Soulakova JN, Weissfeld LA, Rofey DL. Psychiatric Disorders amo

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    [T] Upper Extremity Self-Amputation and Replantation – A Case Illustrating the Traumagenic Neurodevelopmental Model of Psychotic Behavior
    Presenting Author:  Lawrence Fung
    Co-Authors:  Sermsak Lolak, José Maldonado

    Introduction:  Self-amputation is a tragic and rare complication of severe mental illness. Most affected individuals suffer from schizophrenia spectrum psychosis (i.e., schizophrenia and psychotic depression). A systematic review of published case reports revealed that a psychotic illness was present in 79.4% of the cases. Other reported diagnoses relating to the condition include body integrity identity disorder, dissociative identity disorder, and body dysmorphic disorder. Some commonly described precipitating factors of self-amputation include feeling guilty about having done "bad things" with the hand and following quotes literally from the Bible. The case discussed below uses some of the elements of the traumagenic neurodevelopmental model to explain the relationships between childhood trauma, dissociative symptoms and psychotic behaviors.

    Case Report:  Mr. A is a 45-year-old previously successful actor with a history of delusional disorder and past suicidal attempt who amputated his own left hand with a Buck knife. He has fixed delusions about being HIV positive, and having spread the virus to a male sexual partner. He also felt guilty about having sexually offended his younger brothers when he was a child. These guilty feelings became increasingly more overwhelming prior to the incident, and led him to self-amputate his left hand to declare that he was sorry. After he cut his hand, he stopped the bleeding by putting a belt on his arm, cleaned the backyard with a water hose, put his hand in a bag, and finally called 911. In the emergency room, he adamantly refused consent for replantation of his hand. Psychiatry was consulted and ultimately determined that the patient did not have capacity to consent for the procedure. Replantation was performed, but he insisted that he could live without his left hand.

    Case Formulation and Conclusions:  Patient grew up in a highly dysfunctional family with an alcoholic and abusive father with bipolar disorder. He witnessed his father's chronic physical abuse of his mother and experienced chronic verbal abuse by his father. Several authors have attributed the psychotic amputations to unconscious sexual conflicts. One of the sequelae of patient's traumatic childhood was his childhood sexual exploration on his younger brothers. Further, he developed delusions about being HIV positive and transmitting it to another individual. These experiences have become painful memories which precipitated patient's guilty feelings and desire to punish himself by self-amputation. The way he executed the self-amputation suggested both psychotic and dissociative symptomatology. Overall, this series of life events and symptoms are consistent with schizophrenia spectrum disorders, as explained by the traumagenic neurodevelopmental model of schizophrenia. The patient is currently undergoing both pharmacologic and psychotherapeutic treatments. His ideation about not wanting his hand and fixed delusions about HIV have dissipated. Future treatment is focused on resolving his central conflicts by psychotherapy.

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    [T] A Systematic Review and Meta-Analysis of Antipsychotics vs. Placebo in the Treatment of Hospitalized Patients with Delirium
    Presenting Author:  Douglas Gartrell
    Co-Authors:  Mark Ehrenreich, Pinar Miski, Seth Himelhoch

    Context:  Antipsychotic medication has long been considered first line pharmacologic treatment for hospitalized patients with delirium. However, not until recently have studies been done to test their efficacy using a placebo control.

    Objective:  To review studies comparing antipsychotics to placebo in the treatment of hospitalized patients with delirium.

    Data Sources:  Pubmed and PsycINFO were searched from inception to January, 2011, using the terms “delirium” and “antipsychotic.” Searches were limited to English and RCT’s. Reference lists of relevant studies were also searched.

    Study Selection:  Studies were eligible if they used an antipsychotic, typical or atypical, and a placebo control. Subjects could have any demographic or medical diagnoses and be in the ICU (with or without intubation) or on other units. Studies could use any delirium rating instruments and outcome measures. Eligible studies were identified independently by the author and a colleague. Three of 21 studies identified by data search were eligible.

    Data Extraction:  Data was extracted by the author. Inspection of eligible studies revealed that data could be extracted for the number of patients with resolution of delirium by a specified day. Data on mortality by a specified day could also be extracted.

    Results:  Meta-analyses showed antipsychotics superior to placebo for resolution of delirium (1.21 RR, 1.03 – 1.42 95% CI, p = 0.022); but no difference in mortality between antipsychotics and placebo (1.03 RR, 0.92 – 1.15 95% CI, p = 0.571). Study effects were not heterogenous for delirium resolution or mortality (I-squared = 0.0% for both). Studies differed in primary outcome measures, instruments for rating delirium, and patient populations.

    Conclusion:  This review suggests that antipsychotics are superior to placebo for delirium in the hospital without a difference in mortality. Additional placebo controlled studies with more standardized use of delirium scales and outcome measures are needed.

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    [T] Documentation of Decision-Making Capacity, Informed Consent, and Health Care Proxies: A Study of Surrogate Consent
    Presenting Author:  Anna Glezer
    Co-Authors:  Theodore Stern, Elizabeth Mort, Atamian Susan, Joshua Abrams, Rebecca Brendel

    Background:  Patients in the general hospital are asked to make decisions about their medical care. However, some patients are unable to express a choice, to understand the information provided, to weigh the options, or to make a decision for themselves; when this occurs, the task of making an appropriate medical decision is left to another - a substitute decision-maker (SDM).

    Objectives:  We sought to understand the practice patterns that surround surrogate consent. We hypothesized that SDMs would be used frequently in patients with altered mental status (AMS) but that there would not be complete compliance with regulations about documentation of health care proxies (HCP) or in documentation of clinician assessment of a patient's decision-making capacity.

    Methods:  We conducted a retrospective chart review on inpatients who underwent a lumbar puncture. We documented whether patients had a HCP, if their mental status was evaluated before informed consent for lumbar puncture was obtained, if the patients' capacity was addressed in this assessment, and whether a SDM was asked to provide the informed consent.

    Results:  Consistent with our hypotheses, we found that many patients did not have documentation of a HCP in the record- only 24% had evidence of a HCP in the chart. The mental status was assessed before each procedure, but documentation regarding assessment of decision-making capacity was often lacking. Of those patients who had a SDM sign the consent form, only 12% had documentation of their decision-making capacity, and in none of the records of patients who signed their own consent form was there a reference to decision-making capacity.
    Conclusions: The findings of this pilot investigation suggest there is need for improvement in our evaluation and documentation of altered mental status and a patient's ability to make informed decisions. Several quality-improvement suggestions are provided to address this issue.

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    [T] Antipsychotic Prescribing in the Cardiothoracic ICU: Practicing What We Preach?
    Presenting Author:  Janna S. Gordon-Elliott
    Co-Authors:  Laura K. Kent, David K. Vawdrey, Hannah Wunsch, Robert N. Sladen, Peter A. Shapiro

    Purpose:  To evaluate the relationship between psychiatric consultation and antipsychotic medication prescribing practices in the cardiothoracic surgical intensive care unit (CTICU).

    Methods:  We conducted a retrospective chart-review of cases receiving psychiatric consultation identified from a database of all patients admitted to our institution’s CTICU from July 2006 through January 2009. Data on diagnostic impressions, attention paid to the electrocardiogram, and recommendations for antipsychotic medication were collected and analyzed.

    Results:  There were 3207 CTICU admissions over the study period; 391 patients (12%) received one or more doses of antipsychotic medication,; 117 (4%) had psychiatric consultations. Of patients treated with antipsychotic medication, only 87 (22%) were seen by a psychiatric consultant. Among those seen by a psychiatrist, the initial impression was delirium in 66 cases (56%), and, when all follow-up visits were included, delirium was diagnosed in 73 cases (62%), and 85 cases (73%) fell within a broader category including delirium and related organic mental syndromes (e.g., terms such as “metabolic encephalopathy.”) 82% of patients seen by a psychiatrist received antipsychotic medication, either recommended by the psychiatrist, or ordered independently by CTICU staff. Among the 73 cases in which the psychiatric consultant recommended the use of an antipsychotic medication, there were only 27 (37%) in which the consultant noted the QTc interval. Of the 15 cases in which the QTc was observed to be prolonged, aripiprazole was recommended in eight (53%), first- and second-generation antipsychotic agents were recommended in the other cases. In the 32 cases in which no diagnosis of delirium or a related organic mental syndrome was made, there were 13 (40%) in which the psychiatric consultant recommended an antipsychotic medication.

    Conclusions:  Among CTICU patients, 12% received an antipsychotic medication, most without “benefit” of a psychiatric consultation. When psychiatric consultations were obtained, delirium and related organic mental syndromes were identified in nearly three-quarters of cases, and antipsychotic drugs were very frequently used and recommended. Although cardiac conduction disturbances and prolonged QT interval are a known complication of antipsychotic agents and a risk factor for malignant ventricular arrhythmias, psychiatric consultants infrequently noted the QTc, even for patients already treated with antipsychotic medications or when consultants recommended antipsychotic therapy. For subjects with a prolonged QTc recognized by the consulting psychiatrist, aripiprazole (an antipsychotic agent that appears to carry low risk of QTc prolongation) was frequently but not always the recommended medication. It is also notable that the recommendation of an antipsychotic was not limited to the treatment of delirium and related syndromes, with 40% of those without such a diagnosis receiving an antipsychotic medication recommendation, perhaps in some cases without a standard indication. Further evaluation of antipsychotic prescribing and monitoring practices, particularly in critically-ill patients, is warranted.

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    [T] “Do-It-Yourself” Gender Reassignment? A Dangerous Product of the Information Age
    Presenting Author:  Patrick Gresham
    Co-Author:  Anne Eshelman

    Introduction:  The Internet provides the most extensive library of knowledge and resources in history. Even those with limited health literacy now have access to studies and data used by professionals. Even one of the most life-altering medical decisions, gender reassignment, has been unveiled to the public as a decision they can now make without medical oversight.

    Case Report:  A 40-year-old Caucasian male, ND, presented to the inpatient psychiatric unit with suicidal ideation following a fight with his wife, who discovered the patient's pursuit of gender reassignment. ND was sent from the Emergency Department after treatment for a self-inflicted 6cm laceration to his wrist, resulting in severed tendons. ND had studied graduate-level biochemistry, and admitted to importing several medications from the South Pacific island of Vanuatu for 7 months to transition to a female gender. Through the use Spironolactone, Cyproterone, Estradiol, and Finasteride, (obtained without a prescription from an Internet-based pharmacy) ND had achieved a more feminine appearance, and also had significant hyponatremia (sodium 129) and an elevated creatinine (1.5) from doubling the recommended maximum dose of Spironolactone. All hormone therapy was discontinued during admission, resulting in normalized labs within days.

    Discussion:  The decision to embark on gender reassignment impacts both the patient and his social environment, including spouse, family members, and co-workers. Before hormone therapy is initiated, patients should first demonstrate the ability to live as their chosen gender for a period of at least one year in what is termed the "real-life experience" in order to work through realistic expectations and the adjustment of significant others(2).

    Anyone with access to a search engine can uncover online communities containing how-to guides and pharmacological resources for hormone therapy. Some offer advice specifically for minors seeking unsupervised transition (4, 5). ND made an effort to conceal his activities from both his care providers and his family. The emotional dysregulation that accompanied his unsupervised use of hormones, along with his domestic conflict, culminated in his suicide attempt.

    Conclusions:  Mental health professionals can play a key role in ensuring that not only is the patient accurately diagnosed, but psychologically and socially prepared for hormonal intervention [1]. By circumnavigating such assessment, patients place themselves in danger of both medical morbidity as well as psychosocial trauma. Mental health professionals must be aware of these possibilities when treating patients presenting with issues of gender identity. Patients' physical and mental well-being may be at risk with only a few desperate clicks.

    References:

    1. The Harry Benjamin International Gender Dysphoria Association's Standards of Care For Gender Identity Disorders, Sixth Version: Walter Meyer III M.D. et. al.

    2. Louis J. Gooren, M.D., Ph.D. Care of Transsexual Persons. N Engl J Med 2011; 364: &1251-1257.

    3. http://groups.yahoo.com/group/TsDoItYourselfHormones

    4. http://www.tsroadmap.com/early/transsexual-hormones.html

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    [T] Pharmacogenomic Testing and Healthcare Utilization among Depressed Patients in a Tertiary Care Outpatient Psychiatric Consultation Practice
    Presenting Author:  Maria Harmandayan
    Co-Authors:  James Rundell, Jeffrey Staab

    Background and Aims:  The authors tested the hypothesis that identification of pharmacogenomic genotype is associated with decreased future healthcare utilization in depressed patients, after controlling for other factors that might differentiate tested and untested patients.

    Methods:  This is a retrospective, case-controlled study of 38 subjects who received all medical and psychiatric care within a single health system during an 8-year period of time. Nineteen patients who received pharmacogenomic testing as part of an index psychiatric consultation were compared to a control group of 19 patients, matched by consulting psychiatrist, who did not have testing performed. Only patients with complete sets of medical and psychiatric clinical data were included in the study. Statistical analyses included between-group comparisons of the number of medical and psychiatric hospital admissions, outpatient primary and specialty care consultations, and follow-up visits, before and after index psychiatric consultation.

    Results:  Tested patients on average had significantly fewer time-adjusted post-index psychiatric admissions (0.8 v 3.8, p<0.05) and fewer time-adjusted outpatient psychiatric and other mental health specialty evaluations (4.2 v 9.9, p<0.05) than untested patients. There were no between-group differences in numbers of medical-surgical admissions or outpatient visits.

    Conclusion:  These findings are preliminary evidence that pharmacogenomic genotype testing may be associated with decreased mental health care utilization after testing. If these results are replicated, they may support targeted use of pharmacogenomic testing in clinical practice. Prospective study is indicated as to whether and how pharmacogenomic testing may improve clinical care and cost outcomes in a psychiatric consultation practice.

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    [T] Predictors of Higher PHQ-9 Scores in Hispanic Patients Attending a Primary Care Clinic
    Presenting Author:  Agdel Hernandez
    Co-Author:  Nancy Maruyama

    Introduction:  Minority groups are more likely to seek help for mental health problems in primary care settings. The current study examines the effect of common risk factors for depression in minority Hispanic populations [2,3,5]. We looked at gender, income, unemployment, acculturation, legal status, trauma exposure and medical co-morbidity on PHQ-9 depression scores among patients attending a primary care clinic with integrated psychiatric care. The clinic served low income, uninsured residents, the majority of whom were immigrants [1].

    Methods:  We reviewed 135 charts of clinic patients for age, gender, country of origin, number of years living in the U.S.A, initial PHQ-9 score, legal status, employment status, past medical history, trauma history and Axis I diagnoses.

    Results:  Most were female (91%), mean age was 43.09 (SD11.89), and 35% were from El Salvador. Most patients had a history of trauma exposure (87%) and unemployment (62%). By legal Status, 47% were undocumented, 39% documented, and 14% had unknown status. 65% had no medical conditions. Of the factors analyzed only female gender was statistically significant as a determinant of elevated PHQ-9 scores in this sample. All other factors which included unemployment, legal status, history of trauma and medical conditions were not significant.

    Conclusions:  Unexpectedly, the only predictor of depression as measured by elevated PHQ-9 was female gender. Although this study did not demonstrate any other predictors of increased PHQ-9, clinicians working with Hispanic populations should be alert to trauma history, immigration status, unemployment, acculturation and medical co morbidities which might be risk factors of depression, particularly in women.

    References:

    1. Kaltman et al. (2009) Meeting the mental health needs of low income immigrants in primary care. A community adaptation of an evidenced based model.

    2. Alegria et al. (2007) Prevalence of psychiatric disorders across Latino subgroups in the United States. American Journal of Public Health, 97 (1), 68-75

    3. Lewis-Fernandez et al (2005), Depression in US Hispanics: Diagnostic and Management Considerations in Family Practice. JABFP, 18 (4) 282-296

    4. Marin et al ( 2006) Mental Illness in Hispanics: A review of the Literature ; Focus IV (1) 23-27

    5. Delgado et al ( 2006), Depression and Access to treatment among U.S Hispanics: Review of Literature and Recommendations for policy and research; Focus IV (1) 38-47

    6. Ruiz, Pedro (2002) Hispanic access to Health /Mental Health Services, Psychiatric Quaterly,73 (2) 85-91

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    [T] Depression Treatment Outcomes in High-Risk Latina Mothers Served in a Collaborative Care Program
    Presenting Author:  Hsiang Huang
    Co-Authors:  Ya Fen Chan, Jürgen Unützer, Karen Tabb, Nida Sieu, Wayne Katon

    Background:  Collaborative care involves the cooperation of the primary care physician, the care coordinator, and the consulting psychiatrist to provide coordinated and stepped care for mental health ­disorders in the primary care setting. Collaborative care models have been shown to be effective for the treatment of depression in Latino populations with comorbid medical conditions. However, to date, there have been no studies examining depression treatment outcomes among low income Latina pregnant and mothering patients.

    The Mental Health Integration Program (MHIP) is a collaborative care system that treats a diverse safety net population that includes the disabled, veterans, elderly, and mothers in Washington State. The purpose of this study is to examine the variations in and predictors of depression treatment outcomes of high risk Latina mothers across 3 community health centers/clinics (A, B, and C) in King County, WA. Clinic A is a Latino focused clinic, while Clinics B and C are general community health centers. Clinic A was selected as the reference group in the study.

    Methods:  MHIP includes 17,783 patients. Of the 1,339 high risk mothers in the program, 1004 (74.98%) reported ethnicity information. Of the 523 Latina mothers served by MHIP, 332 from 3 clinics had probable depression (PHQ-9≥10) and were included in the analysis. Chi-square test, Kaplan Meier survival analysis, and Cox proportional regression (adjusting for sociodemographic and clinical characteristics) were used for the analysis.

    Results:  Across the 3 clinics, patients differed on pregnancy status, living situation, and comorbidity severity. Patients across the 3 clinics had significantly different proportions of their patients achieving 50% reduction in PHQ-9 (Clinic A: 69.57%, Clinic B: 82.35%, Clinic C: 59.06% (X2, p=0.003)). In the fully adjusted Cox proportional model, there was no significant difference in achieving a 50% reduction in PHQ-9 score among the 3 clinics. Among all patients in the sample, those who were pregnant at baseline had a hazard ratio (HR)=0.89 (95% CI: 0.82-0.96), those who reported they needed more support had a HR=0.94 (95% CI: 0.90-0.98), and those with an anxiety disorder at baseline had a HR=0.69 (95% CI: 0.58-0.82) of achieving a 50% reduction in PHQ-9 scores.

    Conclusion:  Our analysis demonstrates that patient characteristics such as having an anxiety disorder, being pregnant, and needing support are associated with a decreased chance of improvement in depression outcomes for high risk Latina mothers in this collaborative care program. In general, these patients had robust depression improvements in the program. In addition, after adjusting for patient characteristics, general community health centers (B and C) performed equally well with the Latino focused community health center (A). These findings will help in guiding this and other collaborative care programs in improving treatment processes and outcomes for this patient population.

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    [T] Outcomes Assessment: Making Sure It's Not Only Valid, but Patient-Friendly As Well
    Presenting Author:  Vrashali Jain
    Co-Authors:  George Tesar, Zhiyuan Sun

    Rationale and Methods:  In December 2007 the Cleveland Clinic Neurological Institute (CCNI) initiated the Knowledge Project©, a computer-supported outcomes assessment program designed for routine collection of patient-rated health status. In addition to population-specific data, all CCNI centers (e.g., epilepsy, sleep disorder, movement disorders, etc.) collect patient-entered data assessing quality of life, depression and anxiety. Instruments used include the European Quality of Life - five dimension, short-form (EQ5D), the PHQ-9, and the GAD-7. The EQ5D assesses five domains, including mobility, self-care, performance of daily activities, pain, and mood. Each dimension is rated on a 1-3 scale. The three choices for rating anxiety/depression include: "I am (1) ‘not', (2) ‘moderately' or (3) ‘extremely' anxious or depressed". We were interested to know whether those patients who indicated they were neither depressed nor anxious on the EQ5D, might be able to bypass the PHQ-9 and GAD-7. If so, the number of survey responses required of some patients might be reduced from 17 to 1. Data available for analysis derived from 1,676 clinical encounters at which each of the EQ5D, PHQ-9 and GAD-7 were completed. PHQ-2 and GAD-2 were calculated from the available data. Statistical analysis was performed to determine the sensitivity and specificity of the short-form screeners.

    Results:  Preliminary data analysis indicates insufficient sensitivity of the EQ5D for use as a depression or anxiety screener. Of the 641 patients who endorsed having no depression or anxiety on the EQ5D, 72 (11.2%) scored in the depressed range on the PHQ-9 (total score >=10). The reasons for this discrepancy are unclear. Further analysis is expected to show that incorporating PHQ-2 and GAD-2 ratings will eliminate the false-negative ratings if the EQ5D were used alone. Any patient with scores of 3 or more (maximum, 6) on either the PHQ-2 or GAD-2 would be required to complete both the PHQ-9 and the GAD-7, thus reducing the burden of survey questions from 17 to a minimum of 5 for patients who indicate having no anxiety or depression on the EQ5D.

    Conclusion:  The EQ5D, which incorporates assessment of depression and anxiety as one of its five measures, does not by itself serve as an adequate depression or anxiety screening instrument. It appears that patients who rate themselves as neither depressed nor anxious on the EQ5D should also complete at least the PHQ-2 and the GAD-2 to capture the small but significant number of patients with significant depression that might otherwise escape detection. These data will be used to adjust the KP survey measures thus reducing the total time spent by patients entering health status data prior to routine clinic visits.

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    [T] Variable Rates of Childhood Adversity in Psychosomatic Syndromes: A Comparison across Four Common Conditions.
    Presenting Author:  Fritz Jean-Noel
    Co-Author:  Jeffrey Staab

    Purpose:  In the 1800's, Freud developed a theory that psychosomatic symptoms arise from unresolved "psychical traumas," often connected to childhood abuse or neglect. Most studies have found higher rates of abuse or neglect in patients with psychosomatic syndromes than control populations. However, few investigations have conducted side-by-side comparisons of childhood adversity in different psychosomatic conditions. If childhood adversity is a primary risk factor for psychosomatic illness, then its prevalence and relationship to other clinical variables should be similar across psychosomatic presentations. This study examined that hypothesis. Four distinct psychosomatic syndromes were compared - behavioral spells, functional gastrointestinal disorders, chronic pain (mostly fibromyalgia), and chronic dizziness.

    Methods:  Medical records of patients referred to a tertiary outpatient psychosomatic medicine practice between July 2008 and June 2010 were reviewed. Consecutive patients with one of the conditions of interest were identified consecutively. Subjects with behavioral spells (n=47), functional GI disorders (n=51), chronic pain (n=51), or dizziness (n=50) were selected randomly from the potential subject pool. Study variables included demographics; self-rated anxiety (GAD-7), depression (PHQ-9), and somatic symptoms (from a standardized 63-item review of symptoms checklist); personal and family psychiatric histories; and reports of childhood physical, sexual, or emotional abuse, and neglect. Experienced psychiatric nurses or master's level therapists collected childhood adversity data using standardized questions in face-to-face interviews during initial clinical consultations. Group differences in demographics, symptom burden, and historical data were identified. Statistical analyses compared rates of childhood adversity by diagnostic group before and after controlling for other variables.

    Results:  This study included three times as many women (146) as men (53) with no group differences in sex ratio. Subjects with dizziness were oldest (mean age 50±19 years); those with spells were youngest (41±16). GI (44±16) and pain (44±14) subjects were intermediate in age. The overall rate of childhood adversity (physical, sexual, emotional abuse or neglect) varied significantly across psychosomatic conditions - pain (38%), spells (30%), GI (22%), dizziness (16%). Emotional abuse trended highest in pain subjects (31%). Physical (19%) and sexual abuse (15%) and neglect (11%) trended highest in spells subjects. Childhood adversity was significantly associated with pain and spells diagnoses for women and subjects with family histories of psychiatric illness, moderate or greater anxiety scores, and fewer than the median number of somatic complaints. Severity of depression and proportion of subjects living alone were higher in pain and spells groups, regardless of the presence or absence of childhood adversity.

    Conclusions:  Rates of childhood adversity and interactions between adversity and other clinical variables differed across four psychosomatic conditions that were compared using identical methods in this study. This suggests that childhood adversity imparts varying degrees of risk for psychosomatic syndromes. More sophisticated theories about psychosomatic effects of childhood adversity are needed.

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    [T] Anti YO Mediated Paraneoplastic Cerebellar Degeneration in a 42-Year-Old Woman with Recently Diagnosed Breast Cancer — A Case Report
    Presenting Author:  Richard Key
    Co-Author:  Philip Bialer

    Background:  Paraneoplastic syndromes are characterized by neuronal dysfunction arising from autoimmune response to neuronal proteins expressed by tumors elsewhere in the body. Paraneoplastic cerebellar degeneration is a rare type of paraneoplastic syndrome associated with a variety of autoantibodies including Anti Yo targeting cytoplasmic antigens of Purkinje cells in the cerebellum. Patients will typically present with moderate to severe cerebellar signs including trunk and limb ataxia, dysarthria, diplopia, and vertigo which may develop acutely or over time. The neurological syndrome often precedes diagnosis of malignancy and treatment of either the cancer or autoimmune process does not reliably alter the course of illness.

    Methods:  We present the case of a 42 year old woman with no significant medical or psychiatric history who developed neck pain of unclear etiology followed by progressively worsening cerebellar dysfunction and eventual discovery of breast cancer and presence of Anti-YO antibodies. A literature review was conducted using the keywords paraneoplastic, anti-YO, and cerebellar degeneration.

    Results:  Over the span of 6 months the patient progressed from her usual state of health to having severe ataxia, dysmetria, diplopia, dysarthria, and pseudobulbar affect. She was diagnosed with Miller Fisher Syndrome and managed expectantly with physical therapy. Sertraline 25mg was started to treat depressive symptoms with some benefit. After several hospitalizations for deteriorating motor function a mass in her breast was discovered and found to be Her2/Neu+ ER/PR- invasive carcinoma which was treated with excision. Paraneoplastic antibody screen returned strongly positive for anti-YO. An attempt to treat her pseudobulbar affect with olanzapine was unsuccessful and possibly exacerbated her symptoms. Treatment with IVIG with equivocal benefit for her cerebellar deficits and she briefly returned home before placement at subacute physical rehabilitation facility.

    Conclusions:  Earlier recognition of this autoimmune syndrome could lead to earlier intervention for the underlying malignancy and avoid treatments targeting erroneous neurological or psychiatric diagnoses as well as providing an opportunity for earlier support of the patient and family.

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    [T] Catatonia: A "Frozen Condition"?: A Proposed Treatment Algorithm Based on Case Studies and Literature Review
    Presenting Author:  Andrew Kim
    Co-Author:  Cristinel Coconcea

    Objective:  According to recent statistics, 5-9% of all psychiatric inpatients show some catatonic symptoms. Of these, 25-50% are associated with mood disorders, 10-15% are associated with schizophrenia, and the remainder are associated with other mental disorders. Psychiatric literature also suggests that catatonia related to medical conditions may account for as many as 20% to 30% of cases of catatonia; thus recognizing this syndrome and being familiar with its treatment is vital for the consultation-liaison psychiatrist [1]. Recent developments in the treatment of catatonia are raising the GABAa vs GABAb hypothesis of catatonia. Based on analysis of treatment-resistant and treatment responsive cases of catatonia, as well as on literature review, an evidence-based algorithm for treating catatonia, that includes the use of zolpidem, is proposed.

    Method:  This presentation describes 7 cases of benzodiazepine-resistant catatonia responding to treatment with zolpidem and critically reviews the current literature on the pathophysiology and treatment of catatonia, proposing an algorithm for the treatment of this condition that includes the use of zolpidem.

    Results:  All 7 patients in this report exhibit similar catatonic symptoms, lack of response (or partial response) to other treatments, and similar patterns of response to zolpidem, including an initial zolpidem challenge test. From the review of the literature on catatonia, there is growing evidence suggesting the role of GABAa agonists in the treatment of catatonia, as well as for the possible pro-catatonic effect of the GABAb agonists, with important potential clinical applications in the treatment of this severe condition.

    Conclusion:  Zolpidem, a GABAa specific agonist appears to be a new and safe therapeutic approach for catatonia, potentially useful in benzodiazepine-resistant patients. More research will be needed in order to replicate and further understand the mechanism and sites of its activity. Various agents described in the literature as useful for the management of catatonia are critically reviewed in terms of mechanism of activity and strength of evidence, and an evidence-based algorithmic approach to the treatment of catatonia is proposed.

    Reference:

    1. Carroll BT, Goforth HW: Medical catatonia. In Catatonia: from psychopathology to neurobiology Edited by: Caroff SN, Mann SC, Francis A, Fricchione GL. Washington, DC: American Psychiatric Publishing; 2004:121-127

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    [T] Safety of Venlafaxine during Lactation: A Case Study in Pharmacokinetics for the Consult Psychiatrist
    Presenting Author:  Eric Koperda
    Co-Author:  Chris White

    Perinatal mood disorders are common and challenging to treat. One such complexity arises when a patient on psychiatric medication desires to breastfeed. There is scant research regarding the safety and efficacy of psychotropic drugs in this population, unfortunately. Thus, consult psychiatrists are left with a difficult choice when confronted with mental illness in a lactating woman: initiate pharmacotherapy despite lack of evidence, withhold it and allow the disease to run its natural course, or advise against breastfeeding. Such decisions need not be made blindly.

    When randomized-controlled clinical trial results are not available, physicians can turn to pharmacokinetics and the art of estimation. Pharmacokinetic data are published in drug monographs and elsewhere in the literature. They can be applied to evaluate potential drug levels in any particular lactating woman and infant. These numbers, in turn, can inform the physician's assessment and advice.

    This poster will examine current evidence for peri-partum treatment of mood disorders, will review practical pharmacokinetic principles, and finally using a case-based approach will explore application of the evidence base and basic pharmacokinetics to clinical decision-making. A case study involving a 28-year-old woman with depression treated by venlafaxine and her infant girl will guide the discussion.

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    [T] Excessive Vomiting in Pregnancy Results in Wernicke Encephalopathy: A Case Report
    Presenting Author:  Dharmendra Kumar
    Co-Authors:  Felix Geller, John Wagner, Wang Lei, Mary Jo Fitz-Gerald, Robert Schwendimann

    Vomiting is a common occurrence in pregnancy; however, excessive prolonged vomiting may lead to hyperemesis gravidarum (HG). HG has been clearly identified as etiological factor for wernicke encephalopathy (WE), but this is rare as only 60 cases reported so far. WE is a potentially fatal but reversible condition, that if untreated can lead to coma, Korsakoff's psychosis and death, with mortality ranging from 10 to 20%. We are presenting a case of HG complicated by WE, were diagnosis was delayed because its rarity.

    Ms C. is a 21 year old gravida 1 para 0; at 14 weeks of pregnancy admitted because of elevated liver enzyme, persistent vomiting for 3-4 weeks and mild confusion. She had cholecystectomy for suspected cholescystits 2 weeks prior to admission. Current Ultrasound abdomen failed to show any abnormality.

    One third day of admission Ms C's liver enzymes and vomiting improved on supportive treatment, but she continued to exhibit confusion and was unable to walk. Ms C. was considered to have altered mental status with conversion disorder as differential because of recent breakup with her boyfriend and unplanned pregnancy. Neurological examination was positive for weakness of lower limb left> right, power 3/5 unsteady gait, bilaterally decreased DTR, dysdidokinesia and past pointing. Patient had drooping eyelids with limited gaze R>L as well as up gaze palsy and horizontal nystagmus. She was confused with poor attention, concentration and recall. Thiamine 100 mg IV for 5 days followed by oral thiamine 100 mg per day recommended. After 24 hours of thiamine, the patient's neurological picture improved to where she was more energetic, and exhibited less opthalmoplegia. However, she continued to have significant horizontal nystagmus in the lateral visual fields bilaterally, with severe lower extremity weakness, her thought process was very slow and memory was poor. MRI of the brain showed areas of hyper intensity in both thalami and mallillary bodies bilaterally, with no mass effect or hemorrhage. Thus, the diagnosis of WE was made. Ms C. was then referred for physical therapy. She continued to exhibit poor memory, raising the question of an amnestic syndrome in the future. This may be attributed to delayed diagnosis of WE.

    WE is caused by a deficiency of thiamine (vitamin B1) which involves in glucose metabolism particularly in brain. The need for thiamine increases during pregnancy and lactation. Body store may be depleted within 2 week if not replenished. WE should be treated only on suspicion and one should not wait for radiological findings to make a definitive diagnosis. Thus, it is the opinion of the authors that vulnerable (pregnant, eating disorders and malnourished psychotic) patients should be given prophylactic thiamine.

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    [T] Educational Level and Psychiatric Diagnosis in a General Hospital Consultation Service
    Presenting Author:  Gretchenjan Lactao
    Co-Authors:  Hoyle Leigh, Ronna Mallios

    Purpose:  Most of current research suggests that education may be protective against psychiatric disorders. The purpose of this study was to explore the relationship between educational level and psychiatric diagnoses in a general hospital psychiatric consultation setting.

    Methods:  UCSF Fresno Psychiatric Consultation Service maintains a database of all patients seen by the service since 2002. We selected all patient records between the ages of 25 and 65, for the period of 2002-September, 2010, whose educational level could be ascertained. The educational level was categorized into 3 groups: Pre-secondary (less than high school), Secondary (some high school or high school graduate), and Post-secondary (any education after high school). Once the subjects were grouped into one of the three educational levels, the Axis I diagnosis/diagnoses for each record was reviewed and patients with mood disorder spectrum, psychotic disorder spectrum, substance related disorders, and adjustment disorders were selected. Any records whose Axis I diagnosis was unclear or related to medical condition were excluded. Ultimately the selection process yielded 832 subjects, 87 in the pre-secondary group, 434 in the secondary group, and 311 in the post-secondary group. Since the number of the "pre-secondary" subjects was significantly low compared to the other levels, these subjects were combined with the "secondary" group; the combined subjects were grouped as "secondary or less". For each psychiatric disorder spectrum, a Pearson-Chi Squared test was used to analyze the relationship between educational level and presence of the diagnosis.

    Results:  The distribution of diagnosis was: Mood disorder spectrum, 488 (58.1%); Psychosis spectrum, 150 (18%); substance use disorders, 247 (29.7%); Adjustment disorders, 91 (10.9%). In the mood disorder spectrum group, there were significantly more patients with post-secondary education compared with those with other than mood disorder (40% vs 33%, p<0.05). As for psychotic disorder spectrum, significantly more patients had " secondary or less" education (72% vs 61%, p<0.01). There were no statistically significant differences in the educational level in substance use disorders and adjustment disorders.

    Conclusions:  There were significant differences in the general educational levels of mood disorder and psychotic disorder patients who received psychiatric consultation in a general hospital. Mood disorder patients were more likely to have more than high school education compared to non-mood disorder patients, and patients with psychotic disorders were less likely to have educational levels higher than high school. These findings tend to confirm the notion that education is a protective factor in psychosis, but perhaps not so much in mood disorders, substance use disorders, and adjustment disorders.

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    [T] “Molly’s Plant Food” Ingestion with Resultant Serotonin Syndrome: A Review and Case Report
    Presenting Author:  Elizabeth LiCalzi
    Co-Author:  Amanda Wilson

    Background:  A new synthetic hallucinogenic amphetamine marketed as "bath salts" or "Molly’s Plant Food" similar to ecstasy can be legally obtained in convenience stores, smoke shops, and gas stations across the United States. These substances come in the form of crystals and consist of synthetic hallucinogenic stimulants with psychoactive effects similar to MDMA. There have been case reports describing the effects of these substances in Europe and the UK, but minimal reports of its use or intoxication in the United States. Intoxication with this substance can cause euphoria, anxiety, paranoia, agitation, tachycardia, hypertension, delusions, diaphoresis, and weight loss. Its use is rapidly becoming more common among teenagers and young adults. We report an interesting case of serotonin syndrome after ingestion of "Molly’s Plant Food".

    Case:  The patient is a 44 year-old Caucasian male with a history of bipolar disorder, alcohol dependence, and liver cirrhosis admitted to the medical ICU with altered mental status, seizures, and psychosis with subsequent respiratory failure and intubation. Early in his hospitalization, the patient exhibited clonus, rigidity, tremors, tachycardia, and fever consistent with serotonin syndrome. His preliminary urine drug screen was positive for amphetamines with confirmatory testing positive for pyrovalerone, a norepinephrine and dopamine reuptake inhibitor, and 3,4 methylene dioxybenzaldehyde (piperonal), a synthetic precursor of MDMA. These two compounds have been found in the relatively new synthetic drugs of abuse called “bath salts” or “Molly’s Plant Food”. After extubation, the patient reported using a large amount of "Molly's plant food" in a suicide attempt. He also reported taking ziprasodone, sertraline, and trazodone as prescribed; however his urine drug screen was negative for ziprasodone.. Supportive treatment in the ICU as well as benzodiazepines resulted in resolution of psychosis and serotonin syndrome.

    Conclusion:  This case illustrates the importance of recognizing the potential intoxication, abuse, and consequences of this relatively new synthetic drug of abuse, “Molly’s Plant Food”. Intoxication and overdose with this substance may present with psychosis and potential serotonin syndrome and should be considered in the differential with a new onset of either of these states.

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    [T] Electroconvulsive Therapy for Treatment of Depression in a Patient with Cerebral Palsy
    Presenting Author:  Alastair McKean
    Co-Authors:  Reba King, Christopher Sola

    Objective:  To discuss a cerebral palsy patient with major depressive disorder, recurrent and severe that was successfully treated with electroconvulsive therapy (ECT) and to review the relevant literature.

    Method:  Case Report

    Introduction:  Cerebral palsy is a spectrum of non-progressive neurological disorders characterized by motor dysfunction that effect 2 to 3 out of every 1000 people. There are no current epidemiological data on the prevalence or incidence of depression in adult populations with this condition. A literature review revealed only one case series of four cerebral palsy patients with depression that were treated with ECT.

    Case:  A 49 year old woman with cerebral palsy and a psychiatric history of major depressive disorder, recurrent and severe and chronic pain disorder was admitted following a suicide attempt involving alcohol and trazodone. After her attempt, she remained dysphoric and persistently suicidal. Due to the severity of her symptomatology and prior history of positive outcome with ECT, this modality was utilized again. Bupropion, lamotrigine and gabapentin were tapered. Following medical clearance, she underwent a course of sixteen ECT treatments. Her mood began to improve and active suicidal ideations abated following the sixth treatment. At that point, her treatment was augmented by the initiation of liothyronine, and duloxetine was initiated as a maintenance intervention. Mirtazapine was started at night for sleep and appetite stimulation. She had a baclofen-dispensing intrathecal pump for spasticity that was not altered during ECT. She experienced mild cognitive difficulties which were addressed by switching the ECT lead placement from bitemporal to right unilateral after her second treatment. She also experienced some post-ECT akathisia and muscle pain which were treated successfully with midazolam after each treatment.

    Conclusion:  This case contributes to the small extant literature that affirms the safety and utility of ECT in treating depression in patients with cerebral palsy.

    References:

    Foster T, Rai AI, Weller RA, Dixon TA, Weller EB. Psychiatric complications in cerebral palsy. Curr Psychiatry Rep. 2010 Apr; 12(2):116-21

    Rasmussen KG, Zorumski CF, Jarvis MR. Electroconvulsive therapy in patients with cerebral palsy. Convuls Ther 1993; 9:205-208

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    [T] Psychosocial and Ethical Issues in Genetic Testing: A Failure to Communicate?
    Presenting Author:  Michelle Jesse
    Co-Authors:  Robert Dempsey, Anne Eshelman

    Introduction:  Wilson's disease (WD; hepatolenticular degeneration) is a rare autosomal recessive disease, causing an error in the metabolism of copper. Presentation can vary significantly as copper accumulates in various organ systems and becomes toxic, but primarily accumulates in the brain and the liver. Age of onset occurs in childhood or young adulthood, although there is evidence across the lifespan. The prognosis of WD, if treated, is uncertain as there is considerable variability in presentations. Treatment includes copper-chelation, prevention of copper intestinal absorption, and/or liver transplant in patients with acute fulminant hepatic failure. If left untreated, mortality is expected within 6 months to 5 years.

    Presentation of a case of a 17-year-old female with siblings with confirmed WD who presented in acute fulminant liver failure, after reported negative genetic testing.

    Background:  Two years prior, the oldest of four sisters was transferred to a multiorgan transplant center (family resided 120 miles away, Medicaid insurance) with abdominal discomfort, nausea/vomiting and found to be in acute fulminant hepatic failure due to WD. She was listed for a transplant within three days and transplanted within six days at age 19. She was discharged home eleven days following transplant and has since had minimal complications. The remaining three sisters were screened for WD, including LFT's and serum ceruloplasmin. The two middle sisters had negative screening studies and received no further follow-up or genetic testing. The fourth/youngest sister was diagnosed with biopsy proven WD and is currently being treated with copper chelation therapy.

    Case Presentation:  Recently, the third sister (17 years old), two years prior had a negative screen, was transferred (day 1) to a multiorgan transplant center with symptoms of malaise, nausea/vomiting, loose stool, tea-colored urine, leg swelling, and generalized abdominal pain over the past 10 days. Physical exam showed a fully lucid young woman with mild jaundice, lower extremity edema, and abdominal tenderness. Laboratory studies confirmed she was in acute fulminant hepatic failure and a full transplant evaluation was initiated (day 2). Pretransplant psychiatric examination found a cognitively intact, psychologically and developmentally normal female. Copper chelation therapy was initiated on day 4 and day 6 the patient was placed on UNOS waiting list at Status 1 (priority). However, her condition began to deteriorate and she died on day 10 prior to receiving a transplant.

    Discussion:  Who is responsible for ensuring patients with genetic risk are appropriately screened and followed? What tests are the standard of care? Does inadequate testing actually harm patients and give a false sense of security? Who is responsible for at risk family members? Should a transplant hospital screen at risk siblings and monitor them? What education should families receive on warning signs and urgency? Ethical issues in genetic testing will be reviewed.

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    [T] BMI 10 or 50? Evaluating Patients with Eating Disorders on Consultation-Liaison Service
    Presenting Author:  Weronika Micula-Gondek

    Background:  Eating disorders are potentially life-threatening conditions. Based on the DSM-IV categorical approach, we commonly think of Anorexia nervosa or Bulimia nervosa as the main eating disorders. However, Eating Disorder Not Otherwise Specified (Eating Disorder NOS) tends to be the most common, and accounts for increasing prevalence of eating disorder behaviors over the past decade. Several authors suggest that combining categorical and dimensional approaches may be useful in diagnosis and treatment of these patients.

    Method:  Based on encountered two unique cases of patients with eating disorders, the author discusses the symptomatology of eating disorders and the diagnostic caveats that clinicians face while evaluating those patients.

    Results:  The author suggests the use of a brief screening module to help address key components of eating disorder symptoms while evaluating patients on the Consultation- Liaison service, with the goal to improve recognition and facilitate prompt referrals to specialized treatment centers.

    Conclusion:  Although extreme emaciation and morbid obesity are apparent, some patients with eating disorders remain undiagnosed until late in the course of disease. Early identification and treatment is paramount, since it may prevent disease progression and reduce the risk of chronic health consequences.

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    [T] Functional Impairment, Work Instability, and Financial Loss in Early Inflammatory Arthritis
    Presenting Author:  Sally Mustafa
    Co-Authors:  Karl Looper, Phyllis Zelkowitz, Margaret Purden, Murray Baron

    Purpose:  Inflammatory Arthritis is associated with a high degree of work dysfunction and financial burden. In this study, we examine the extent of work dysfunction and financial loss as well as their association with disease characteristics during the first year of inflammatory arthritis.

    Methods:  Patients (n = 104) in the early phase (more than six weeks, less than one year duration) of inflammatory arthritis (EIA) were recruited from a larger EIA registry. Questionnaires recorded sociodemographic data and disease characteristics including pain assessed using the Short Form McGill Pain Questionnaire (MPQ) and physical functioning assessed by the Medical Outcomes Study Short Form 36 (SF-36). The Rheumatoid Arthritis Work Instability Scale (RA-WIS) was used to measure patient-perceived functioning in the workplace and the Financial Loss Questionnaire (FLQ) was used to measure financial loss.

    Results:  Participants' mean age was 56.09 years, 70.2% were females and 48.1% were working. Average yearly income was less than $60 000 for 38.5% of the sample. With only a 7.38 months duration of illness, 29.4% of our patients suffered a medium and 13.7% a high risk of work loss as measured by RA-WIS. Thirty five percent reported a financial loss such as using savings or borrowing money. Linear regression analysis showed MPQ and SF-36 to be contributing to RA-WIS (p < .001) and younger age and SF-36 to contribute to financial loss (p < .001).

    Conclusions:  This study identifies pain and physical dysfunction as potential modifiable risk factors for negative socioeconomic repercussions of illness in EIA.

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    [T] Caregiving and Disease Severity in Early Inflammatory Arthritis (EIA)
    Presenting Author:  Sally Mustafa
    Co-Authors:  Margaret Purden, Karl Looper, Phyllis Zelkowitz, Murray Baron

    Purpose:  Inflammatory arthritis can be stressful to both caregivers and care recipients. We examine how caregiving involvement (frequency of caregiving behaviours performed) and caregiving appraisal (subjective evaluation of the caregiving experience regarding burden, satisfaction and impact) as perceived by both patients and their caregiving spouses relate to disease severity and mental health of patients during the first year of inflammatory arthritis.

    Methods:  Patients in the early phase (more than six weeks, less than one year duration) of inflammatory arthritis were recruited from a larger EIA registry which recorded sociodemographic data and disease characteristics. Pain was assessed using the Short Form McGill Pain Questionnaire (MPQ), disease severity was measured with the Disease Activity Score in 28 joints (DAS28), and physical functioning was assessed by the physical outcome score of Medical Outcomes Study Short Form 36 (SF-36). Current depressive symptoms were measured using the Center for Epidemiologic Studies - Depression Mood Scale (CES-D). Caregiving involvement was assessed using the Caregiving Involvement Questionnaire (CIQ) while caregiving appraisal was measured using the Caregiving Appraisal Scale (CAS) completed by both patients and their caregiving spouses.

    Results:  The study sample consisted of 73 EIA patients living with a spouse. Mean age was 54.3 years, 64.4% were females and mean illness duration was 7.48 months. Patients' positive caregiving appraisal was associated with better physical functioning (p = .046), less number of swollen (p = .032) and tender (p = .007) joints, less disease severity (p = .005) and less total depressive mood (p < .001). Positive caregiving appraisal by the spouse was also significantly correlated to better physical functioning (p = .008) and less disease severity (p = .038) in patients. In multivariate analysis, disease severity was explained by the patients' appraisal of the caregiving context after controlling for depression and caregiving involvement (p = 0.035).

    Conclusion:  This study indicates that in EIA, patients' caregiving appraisal is important to consider when approaching disease management. Clinicians are encouraged to include both patients and their spouse caregivers in interventions to improve the recovery experience.

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    [T] Parenting Disability, Parenting Stress, and Child Behavior in Early Inflammatory Arthritis
    Presenting Author:  Sally Mustafa
    Co-Authors:  Phyllis Zelkowitz, Karl Looper, Margaret Purden, Murray Baron

    Purpose:  Inflammatory Arthritis is associated with physical dysfunction and emotional distress. In this study, we examine how disease characteristics are associated with mental health, parenting disability, parenting stress and child behavior during the first year of inflammatory arthritis.

    Methods:  Patients (n = 104) in the early phase (more than six weeks, less than one year duration) of inflammatory arthritis (EIA) were recruited from an EIA registry, which recorded sociodemographic data and measures of pain, physical functioning and disease severity. Patient perceived parenting disability, parenting stress, depression and children's behavior problems were assessed.

    Results:  Participants having children under 18 living with them (n = 29) were selected for the analyses. Mean age was 41.97 years and 69% were females. Pain (p = .038), physical dysfunction (p = .003) and tender joints (p = .025) were associated with parenting disability. Parenting disability was associated with depression (p = .000) and parenting stress (p = .031). Parenting stress was associated with child internalizing (p = .010) and externalizing (p = .003) behavior problems while parenting disability was associated with child externalizing (p = .022) behavior problems.

    Conclusions:  This study indicates that physical aspects of EIA affect parenting function which is associated with both parent and child distress.

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    [T] Delirium, Neuroleptics, Cardiac Arrhythmias: Comparison of Recommendations and Risk Factor Documentation Made by a Consultation-Liaison Psychiatry Service for Delirium over Two 10-month Periods in 2004 and 2009
    Presenting Author:  Shruti Mutalik
    Co-Authors:  Daniel Safin, Nancy Maruyama, Stephanie Cheung

    Purpose:  For several decades neuroleptics have been the mainstay in the treatment of behavioral disturbances in delirium. However, neuroleptics can prolong QTc and increase risk of cardiac arrhythmias. In the past two years the CL team made a concerted effort to increase awareness of the cardiac risks of neuroleptics during individual supervision and through grand rounds presentations. We compared the medication recommendations and the documentation of risk factors for cardiac arrhythmias by a consultation liaison service over two ten month periods, five years apart, based on the possible influence of the increased awareness of neuroleptic induced QTc prolongation.

    Methods:  We reviewed all consultations done by resident psychiatrists (PGY2-PGY6) at a tertiary care teaching hospital in NYC from January to October 2004 and a ten month period from January to October 2009. We examined all consultations where Delirium appeared on Axis I. We collected the following variables: age, gender, whether neuroleptics were advised, whether an EKG was advised or documented, the neuroleptic recommended, (including dose, route and schedule, whether standing, prn, or both), and Methadone which is another QTc prolonging medication). We also examined whether other potential causes of QTc prolongation such as hypocalcemia, hypomagnesemia and hypokalemia and their levels were documented.

    Results:  We examined 145 consults from 2004 and 154 from 2009 for a total of N= 299. Between 2004 and 2009 there was no difference in patient age, gender or whether neuroleptics were advised (63.4% vs 70.1%). There were significant increases in the documentation and recommendation of EKGs and the documentation of potassium, calcium, magnesium levels. From 2004 to 2009, the rate of EKG documentation rose from 3.4% to 17.5%, while the rate of advising that an EKG be checked rose from 1.4% to 22.1%. QTc was documented once in 2004 and 26 times in 2009. Calcium documentation rose from 33.8% to 55.2%. Doses of haldol were not significantly different for 2004 and 2009 (mean= 2.3 mg).

    Conclusions:  Our data suggest that between 2004 and 2009 there was a dramatic increase in the awareness of the cardiac risks of neuroleptics in delirious patients as reflected by documentation in consults. The data suggest that efforts to educate psychiatrists can improve their awareness of cardiac risks of neuroleptics used to treat delirious patients and potentially improve the care of these patients. Unfortunately the documentation rate remained low. Further educational efforts are recommended.

    Reference:

    1. Ray , WA, Chung, CP, Murray, KT, Stein, CM: Atypical antipsychotic drugs and the risk of sudden cardiac death, NEJM, 2009; 360;3:225-235

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    [T] Comparison of Pre-Cardiac Catheterization Depression and Anxiety Symptoms among Angina Pectoris Patients with or without Coronary Heart Disease
    Presenting Author:  Savitha Puttaiah
    Co-Authors:  Jon Resar, Allison Carlson, David Yuh, Roy Ziegelstein, Hochang Lee

    Background:  Approximately 9.8 million Americans are estimated to experience angina pectoris annually, with 500,000 new cases of angina occurring every year [1]. Suspecting obstructive coronary heart disease (CHD) as the cause of angina, 1.7 million patients with angina undergo cardiac catheterizations annually [1]. However, a substantial proportion - up to 30% -- of all coronary catheterization in the US results in normal coronary angiogram [2,3].

    Objective:  To examine the association between pre-catheterization mood symptoms (depression and anxiety) and the presence of coronary heart disease based on the coronary angiogram among patients with angina pectoris.

    Methods:  86 consecutive subjects (mean age: 64.4 +/-10.1 years; female: 34.9%) with angina pectoris were assessed based on PHQ-9 (Patient Health Questionnaire), GAD-7 (Generalized Anxiety Disorder 7) and SAQ (Seattle Angina Questionnaire) five to seven days prior to their scheduled cardiac catheterization. Based on the results of the coronary angiogram, we compared the prevalence and severity of depression and anxiety symptoms among those with normal versus stenotic coronary arteries.

    Results:  Of eighty-six subjects, forty-seven had coronary arteries with no stenosis (n=12) or mild stenosis (n=35) and were recommended medical management only, while thirty-nine had severe coronary stenosis and underwent percutaneous coronary intervention (PCI; n = 27) or Coronary Artery Bypass Graft Surgery (CABG; n = 12). Mean PHQ-9 score (5.6+ 4.2 vs. 3.9 +/- 3.5; p-value = 0.073) and prevalence (21.3% versus 5.3%; p-value: 0.031) of clinical depression (defined as PHQ-9>10) was higher among the no/mild coronary stenosis group than the PCI/CABG group. No difference was found in the mean GAD-7 score or prevalence of clinical GAD (defined as GAD-7>10) between the two groups.

    Conclusion:  Depression is more common among patients with no or mild coronary stenosis than among those with severe coronary stenosis which requires PCI or CABG surgery. Presence of pre-catheterization depression may have a predictive role on the results of coronary angiogram in patients with angina pectoris.

    References:

    1. American Heart Association. Heart disease and stroke statistics, 2008

    2. Lichtlen PR, Bargheer K, Wenzlaff P. Long term prognosis of patients with angina-likechest pain and normal coronary angiographic findings. J Am Coll Cardiol, 1995; 25:1013-8

    3. Kemp HG, Kronmal RA, Vliestra RE, Frye RL. Seven year survival of patients with
    normal or near normal coronary arteriograms: a CASS registry study. J Am Coll Cardiol, 1986; 7:479-83

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    [T] “I Have Rocks in My Head.” A Report of Bilateral Basal Ganglia Calcifications in a Suicidal and Delusional Patient
    Presenting Author:  Laurel Ralston
    Co-Author:  Leo Pozuelo

    Introduction:  Idiopathic bilateral basal ganglia calcification (IBBGC), frequently known as Fahr’s disease, is a rare neurodegenerative condition characterized by idiopathic symmetric calcifications of the basal ganglia, and multiple neuropsychiatric symptoms. Literature profiling the psychiatric symptoms is sparse. We present a 42-year-old female, hospitalized with an amitriptyline overdose of lethal intent and characteristic basal ganglia and frontal lobe calcifications.

    Case description:  The patient has a history of migraines, hypothyroidism and chronic ankle pain treated with amitriptyline. In 2002 she was involved in a car accident and head CT revealed dense symmetric calcifications within the basal ganglia, thalami and anterior frontal lobes.
    She was admitted to MICU, intubated and treated aggressively with a bicarbonate drip. She had no history of past suicide attempts or psychiatric hospitalizations and had never been evaluated by a psychiatrist.

    In the months leading to her overdose, she was increasingly depressed, labile and impulsive. She developed the delusion that her teenaged son was also severely depressed. Days prior to her overdose, she purposely medicated him with 200mg amitriptyline without his knowledge. On the day of her overdose, she aimed a loaded gun at him with homicidal intent, but he fled. She considered murder more humane than abandoning him.

    Hospital course involved airway stabilization, QRS monitoring and treatment of metabolic acidosis. Head CT revealed stable calcifications since 2002. CBC, CMP, Mg, PO4, PTH and TSH were normal. Toxicology screen was negative. Records from eight months prior noted a referral to neurology for new involuntary jerking movements of all extremities. Neurological exam during hospitalization was grossly normal. Cognitively, she complained of changes including visuospatial deficits, short-term memory loss and difficulty with word finding and object identification. By hospital day five, she was able to confirm her history and acknowledge her illegal behavior but still felt the homicidal gesture was morally justified. She was started on citalopram, 20mg daily. She remained severely depressed and complained of visual hallucinations for the last month. On day nine, she was transferred to inpatient psychiatry, major depression with psychotic features was diagnosed, and aripiprazole, 5mg daily, was added. On day fifteen, she was discharged to police custody with mild mood improvement.

    Discussion:  The patient’s presentation of depression, delusions and hallucinations may be attributable to the calcifications of her basal ganglia, thalami, and frontal lobes. Previous case reports associate bilateral basal ganglia calcifications with depression, mania, hallucinations, paranoia and dementia. Psychiatric and behavioral manifestations are known to be common in other basal ganglia diseases, but more data needs to be gathered specific to IBBGC.

    Conclusion:  Clinicians should be aware of potential psychiatric symptoms in patients with symmetric basal ganglia calcifications, and that these symptoms may present prior to or independent of neurological symptoms.

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    [T] Relative Popularity of Atypical Antipsychotics on a Consultation-Liaison Service from 2002–2010
    Presenting Author:  Rachel Rose
    Co-Authors:  Hoyle Leigh, Ronna Mallios

    Introduction:  The purpose of this study was to determine if the burgeoning knowledge regarding the side effects of atypical (second-generation) antipsychotics over time changed the relative popularity of these medications in a psychiatric consultation-liaison setting over the course of 9 years. We examined which atypical antipsychotic was chosen by a consultant for a patient with a psychotic illness when the patient had never before been on an atypical antipsychotic. We specifically sought to determine if the use of olanzapine changed over time. For many years after its FDA approval in 2000, olanzapine was considered to be a popular antipsychotic due to its effectiveness. New disclosures regarding its metabolic side effects, including metabolic syndrome, dyslipidemia, obesity, and diabetes were revealed in 2006, and substantiated by studies in the following years. We hypothesized that this new data regarding its role in the development of metabolic disturbances would have resulted in a significant decrease in its use after 2006.

    Methods:  From the Psychiatric Consultation Database at UCSF Fresno, we identified 752 patients who were diagnosed by the consultant with schizophrenia, schizoaffective, or other psychotic illness, out of 6023 patients seen during the period of January 2002 to October 2010. Among those patients, there were 152 patients who were newly started on an atypical antipsychotic by the psychiatric consultation service. Patients who had ever been on any atypical antipsychotic prior to the consultation were excluded, but patients who had ever been on any first-generation antipsychotic were not excluded. There were no uses of clozapine, and only one use each of paliperidone and ziprasidone, so these medications were excluded from analysis. We compared the relative use of olanzapine, quetiapine, risperidone, and aripiprazole between the baseline years (2002-2005) and each year following baseline using Chi-squared analysis with Fisher's exact test (2-sided).

    Results:  Olanzapine was initially the most popular antipsychotic (36.8% during 2002-2005), and its use decreased each year after 2007, down to a statistically significant decrease to 11.8% in 2010 (p<=0.05 compared to baseline). The use of aripiprazole increased annually after 2007, from a baseline of 11.8% in 2002-2005 to statistically significant increases of 41.7 % in 2009 (p<=0.003) and 47.1% in 2010 (p<=0.002). The use of risperidone and quetiapine remained relatively stable over the time period 2002-2010.

    Conclusions:  The changes in the use pattern of olanzapine and aripiprazole appear to correlate with the time in which there was increased knowledge regarding the extent of the metabolic side effects of olanzapine including metabolic syndrome, dyslipidemia, obesity, and diabetes, and the relative lack of these side effects in aripiprazole when compared to other atypical antipsychotics. This study suggests that having updated knowledge regarding medication side effects does result in significant changes in medication use patterns in the psychiatric consultation setting.

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    [T] Clinical Correlates of Smoking in Alcoholic Liver Transplant Patients
    Presenting Author:  James Roth
    Co-Authors:  Terry Schneekloth, Sheila Jowsey, Adriana Vasquez, Lois Krahn, Daniel Hall-Flavin, Jennifer Geske

    Background:  Tobacco smoking is a highly prevalent comorbidity in alcoholics undergoing liver transplant. In a previous study, 54% of the liver transplant recipients reported both tobacco and alcohol use pre-transplant. The aim of this study was to examine smoking history in relation to survival and alcohol relapse in alcohol dependent liver transplant recipients.

    Methods:  Beginning October 1, 2004, 155 patients with DSM-IV diagnosis of alcohol dependence undergoing orthotopic liver transplantation at the three sites of the Mayo Clinic were offered study enrollment. Subjects entered the study either pre-transplant or post-transplant with anticipated 2-10 year follow-up. All patients underwent pre-transplant psychiatric assessment, and smoking data was abstracted from the psychiatric and medical record for determination of smoking status at time of transplant. Post-transplant data was collected through phone contact and routine clinical follow-up appointments at 4, 8, 12, 18 and 24 months and annually thereafter. Post-transplant data included alcohol use and smoking status. Chi-square and Fisher's exact tests were used to compare proportions of post-liver transplant patients who died and those who relapsed by smoking status.

    Results:  There was no association between smoking status at time of transplant (never, former, current) and death (p=0.32). Smoking status was associated with alcohol relapse (p=0.0008); 7/23 (30.4%) of non-smokers relapsed, 3/81 (3.7%) of former smokers relapsed, and 8/42 (19%) of current smokers relapsed. A comparison of proportions of relapse in never smokers versus current smokers was not significant (p=0.298), whereas comparison between the former smoker and current smoker groups was significant (p=0.0076), indicating that low relapse rates in former smokers is the critical factor in the significant findings.

    Conclusions:  In this preliminary analysis of prospective data on 155 alcohol dependent subjects receiving liver transplant, smoking status was not associated with death during the course of the study. Smoking status was associated with relapse to alcohol with current smokers more likely to relapse to alcohol use than former smokers. There was an unanticipated positive association between never smoking and post-transplant alcohol relapse apparently driven by low relapse rate in former smokers.

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    [T] Too Much of a Good Thing? Can Pain Treatment Lead to Depression?
    Presenting Author:  Anne Ruminjo
    Co-Authors:  Carol Alter, Maryland Pao

    Introduction:  Research has shown the complex relationship between pain and depression. Additionally, there has been increased emphasis on following the World Health Organization guidelines developed for treatment of cancer pain to avoid undertreatment of pain. Subsequently, the long-term use of prescription opioids in the treatment of non-cancer pain has increased with limited assessment of the risks of long-term opioid use. When psychiatrists are asked to evaluate and manage mood disorders in patients with chronic pain due to medical illness, they frequently assess risk from an addiction perspective and ignore the role of opioids in inducing depressive disorders. We discuss a case of long-term use of prescription morphine for the treatment of chronic osteoarthritis in a patient who developed depression.

    Case:  A 65 y.o. African-American female with a reported history of depression, multiple medical conditions including osteoarthritis was referred by her primary care physician (PCP) for treatment of depression. The patient reported a history of major depressive disorder, treated in the last year with citalopram 40mg po once daily, to which she had responded well initially. On presentation, she endorsed symptoms of a depressive disorder including depressed mood, increased sleep (daytime), decreased concentration, increased fatigue, hopelessness, decreased motivation and anhedonia with worsening symptoms over the last few months. A review of the patient's medical history and medications was significant for continuous joint pain (osteoarthritis) and no pain relief despite the use of morphine 30mg po twice daily for the last few years. Treatment was initially started with bupropion XL 150mg po once daily. At follow-up a few weeks later, there was no treatment response.
    Collateral information obtained from the patient's daughter revealed concerns about use of multiple medications, noticeable decrease in attention and increased daytime somnolence. The patient's PCP also corroborated this report. The role of the psychosomatic team emerged as a liaison with patient's PCP, in involving the patient's daughter in treatment and in continued education about the role of uncontrolled pain and long-term opioid use in depression.

    The patient was initially ambivalent about discontinuing her opioids but she agreed to a slow taper of morphine and its eventual discontinuation while also beginning treatment with intraarticular steroids for osteoarthritis. Within 3 months the patient's symptoms of depression remitted and her functioning improved significantly. She reported better pain control and was only on citalopram 20mg once daily for depression.

    Conclusion:  Chronic use of prescription opioids is frequently overlooked as a cause of depression and even when recognized fails to be addressed if the patient does not meet criteria for an addiction disorder. Psychosomatic medicine psychiatrists have a role to play in the continuous assessment of risk- benefit profile when a patient has long-term opioid use in chronic non-cancer pain.

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    [T] Levamisole-Induced Neutropenia and Skin Necrosis after Cocaine Use
    Presenting Author:  Ryan A. Salahi
    Co-Author:  Carolina Retamero

    Purpose:  There are sparse reports in the literature of cocaine adulterated with levamisole inducing serious dermatologic conditions ranging from erythema multiforme minus and maius, and retiform purpura to Stevens-Johnson Syndrome (SJS) and Toxic Epidermal Necrolysis (TEN). SJS and TEN are more serious forms of these desquamating skin disorders and are potentially life-threatening.

    We present a case of a 24 year old female with Levamisole-induced neutropenia and SJS. She initially presented to an outside hospital with nausea, vomiting, and chest pain after cocaine use. She was subsequently found to have left 4th toe cellulitis and vaginal candidiasis and neutropenia with a white blood cell count of 1.6 K/mm3 and 13% polymorphic neutrophils. She was then transferred to our hospital's burn unit for evaluation and treatment of SJS/TEN and found to have levamisole-induced neutropenia and associated skin necrosis. She was initially seen by the consultation and liaison psychiatric team for evaluation and management of depression. Upon discharge, she was admitted to a drug rehabilitation facility for treatment of her cocaine dependence, and relapsed shortly after discharge. She was subsequently admitted to the psychiatric service for suicidal ideation and exacerbation of her major depressive disorder and cocaine dependence.

    Methods:  The OVID database was searched using the following keywords: levamisole, cocaine and levamisole, cocaine and stevens-johnson syndrome, and cocaine and adulterants.

    Results:  Cocaine and cocaine adulterated with levamisole have been implicated in a number of serious adverse effects ranging from seizures, headaches, ischemic cerebrovascular accidents, intracerebral hemmorhages, cerebral vasculitis, Churg-Strauss vasculitis, palpable purpura and Henoch-Schonlein vasculitis. Levamisole is an anti-helminthic medication developed in the 1960's, approved in 1991 by the FDA as adjuvant therapy with fluorouracil in the treatment of colorectal cancer. It was withdrawn from the US market in 1999. The recent popularity of levamisole as an adulterant has resulted in its detection in 70% of seized lots of cocaine enetering the United States. There is a paucity of literature or case reports on bullous skin disease and its association with cocaine/levamisole use. It is important to educate patients and physicians about this potentially lethal side effect in order to obtain the appropriate consultations (hematology, rheumatology, and surgery/burn service) and provide the appropriate level of care in a timely manner to prevent the development of TEN and possible death from generalized desquamation and systemic complications.

    Conclusions:  Co-occurring substance use disorders and specifically cocaine abuse and dependence is extremely common among psychiatric inpatients. A variety of common cocaine adulterants have been described in the literature. It is important to recognize this rare but serious reaction to a particular adulterant (levamisole) in order to halt its progression and to prevent possible fatal outcomes. We will provide a review of the literature of cocaine adulterated with levamisole and its dermatologic sequelae.

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    [T] Cardiac Transplantation in Adult Patients with Mental Retardation: Do Outcomes Support Consensus Guidelines?
    Presenting Author:  Emma Samelson-Jones
    Co-Authors:  Donna M. Mancini, Peter A. Shapiro

    Purpose:  Selection criteria guidelines list mental retardation (MR) as a relative contraindication to heart transplantation but not to kidney transplantation, despite the fact that there are only two reported cases describing the outcomes of heart transplantation in people with MR. This paucity of outcomes literature leaves the relative exclusion of people with MR from life-saving treatment with little empirical basis of support. A defensible basis for patient selection requires more evidence.

    Methods:  Of the 2199 heart transplants performed between 1978 and 2010 at New York-Presbyterian Hospital Columbia University Medical Center, there were five cases in which the recipients were adults with MR or comparable acquired intellectual impairment due to anoxic brain injury. The authors performed a retrospective chart review of these five patients, and considered the outcomes in the context of the existing literature on heart and kidney transplantation in people with MR. They also reviewed the ethical reasoning that guides how recipients of solid organ grafts are chosen. RESULTS: In the case series, survival times to date range from 4 to over 16 years, with 4 of 5 patients still alive, and a median survival of greater than 12 years. Medical non-adherence was a significant factor in only one of the five cases. In that case, the patient's medical non-adherence was due to a functional decline in the primary caretaker.

    Discussion and Conclusions:  The "minimum threshold of benefit" approach to the allocation of scarce resources has been adopted by transplant programs in the United States. Under this approach, any person who has a reasonable likelihood of a pre-specified minimum threshold of benefit from a transplant should be given an equal opportunity at obtaining an organ. The argument regarding MR as a contraindication rests, therefore, on an empirically testable question about the capacity of MR patients to achieve a minimal threshold of benefit. The available evidence overwhelmingly suggests that people with MR can greatly benefit from heart transplantation, provided that they have appropriate social supports. As such, people with MR meet the minimum threshold of benefit standard. Mental retardation per se should not be considered a contraindication either to referral to transplant centers or to heart transplant candidacy.

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    [T] Delirium in the Critically Ill Pediatric Patient: An Examination of Olanzapine to Reduce Symptom Severity
    Presenting Author:  Sean Sassano-Higgins
    Co-Authors:  Nicholas Freudenberg, Julienne Jacobson, Susan Turkel

    Background:  Delirium is a neuropsychiatric disorder characterized by acute onset of disturbances in attention, consciousness, cognitive processing, perception, and sleep-wake cycle, occurring in association with underlying medical illness. The few studies that have investigated delirium in critically ill children and adolescents have used differing diagnostic criteria, and have not employed control groups or procedures to blind investigators' observations, making internal validity questionable and generalization difficult.

    Objective:  To examine the efficacy of olanzapine for the treatment of delirium in the pediatric intensive care unit using methodological procedures to reduce bias and allow for greater generalization to the critically ill pediatric population.

    Method:  A retrospective longitudinal design was used. Psychiatric consult records of patients admitted to the Children's Hospital Los Angeles pediatric intensive care unit (PICU) or cardiothoracic intensive care unit (CTICU) over a four-year period with the diagnosis of "Mental Disorder due to general medical condition NOS" or "Delirium due to a general medical condition" were examined. The Delirium Rating Scale was used to assess delirium severity at the time of initial psychiatric evaluation and five days after initial psychiatric evaluation. Information regarding psychotropic medication administration was removed from the record prior to scoring. Following assessment of delirium severity, data were unblinded, and olanzapine administration was examined as a between groups variable. Patients admitted to the PICU or CTICU during the same four-year period who were diagnosed with delirium, but did not receive psychotropic medication, served as the control group.

    Results:  Olanzapine was administered to 31 patients. The control group was composed of 28 patients. Significantly greater improvement in delirium symptoms from the initial to final psychiatric evaluation was found for the olanzapine group relative to the control group (Molanzipine=9.74, Mcontrol=3.82, t(57)=3.46, r=0.42, 95%CI=0.18-0.61). This finding remained statistically significant after controlling for differences in initial delirium severity between the olanzapine group (Molanzapine=19.12) and the control group (Mcontrol=14.07) (ANCOVA F(55)=6.22, r=0.38, 95%CI=0.14-0.58).

    Discussion:  This study documents the efficacy of olanzapine to address symptoms of delirium in the intensive care unit, with a study design that reduces expectancy effects by blinding evaluators to medication administration, and provides a control group to examine the natural history of delirium symptoms without medication administration. Although the non-randomized, retrospective design of the study precludes determination of a causal relationship, the study demonstrates patients with delirium treated with olanzapine had fewer and less severe symptoms of delirium after initiation of psychotropic medication than delirious patients who did not receive psychotropic medication.

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    [T] Oxytocin, Social Support, and Sleep Quality in HIV+ Minority Women
    Presenting Author:  Julia Seay
    Co-Authors:  Erin M. Fekete, Armando Mendez, Michael H. Antoni, Neil Schneiderman

    Purpose:  Previous research suggests that both social support and sleep quality can significantly impact health-related outcomes in women living with HIV. High levels of oxytocin (OT), a stress hormone associated with social behavior, and social support may have salutary effects on sleep quality in animal and human populations. In women living with HIV (WLWH), higher levels of OT have shown to moderate the effects of perceived stress on immune system decrements, which may work through differences in health behaviors (e.g., sleep) and/or interpersonal processes (e.g., social relationships). Investigating how OT influences social relationships and health-related behaviors may lead to better understanding of disease management in WLWH. The current study examines naturally circulating OT, social support, and sleep quality in a sample of low-income WLWH. Given that OT may moderate the influence of psychosocial factors on immune status in WLWH, we hypothesized that OT may moderate the influence of social support on sleep as a health behavior.

    Methods:  Study participants were 71 low-income WLWH aged 20-49 (Mean age = 38.4, SD = 7.3; 86% Afro-Caribbean). Participants had been diagnosed with HIV for an average of 7.8 years (SD = 4.4 years) and were all taking HAART medications, with 69% of participants reporting ≥ 95% medication adherence. Participants reported the amount of support received from various sources (e.g., friends, relatives, health care providers) using the UCLA Social Support Inventory (UCLASSI) and their sleep quality using the Pittsburgh Sleep Quality Index (PSQI). Morning peripheral venous blood samples were taken to measure naturally circulating levels of OT using ELISA immunoassay procedures. To clarify the association between these specific variables, covariates included length of time since HIV diagnosis and perceived stress (Perceived Stress Scale; PSS).

    Results:  Moderated hierarchical regression analyses revealed a significant interaction between social support from friends and OT in explaining women's sleep quality. Specifically, for women with high levels of endogenous OT, social support from friends was associated with less sleep disturbance (t= -2.97, p< .05). In contrast, at low levels of OT, social support from friends was associated with higher levels of sleep disturbance (t= 2.37, p<.05). No other interactions emerged between OT and other sources of social support in explaining participants' sleep quality.

    Conclusion:  Results suggest that the beneficial effects of supportive relationships on sleep quality, particularly from friendships, may be enhanced by high levels of OT. Interestingly, high social support is related with sleep disturbance in women with low levels of OT, suggesting that qualitative aspects of social relationships and their effects may vary as a function of OT level. Research examining the relationships between OT, social interactions, and health-related outcomes may aid in informing interventions to improve disease management in WLWH.

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    [T] Childhood Environment as a Predictor of Perceived Health Status in Late Life
    Presenting Author:  Sejal Shah
    Co-Authors:  Arthur Barsky, George Vaillant, Robert Waldinger

    Background:  Prior studies have shown that self-rated, global health is a valid and reliable predictor of morbidity and mortality. However, perceived health does not appear to be highly associated with objective measures of health, and therefore, understanding the determinants of these subjective self-ratings of their health is of great significance. This study examined predictors of perceived health in late life over and above objective indicators of health.

    Method:  Participants were members of the Study of Adult Development, a longitudinal study of men (N=268) followed for seven decades beginning in late adolescence. Childhood environment characteristics, including warmth of home atmosphere and relationship with parents and siblings, were assessed during home visits and interviews with respondents' parents at entry into the study. Personality characteristics were measured by the NEO Personality Inventory, which was completed by participants at age 60. At ages 65, 75, and 80, current health status was measured by an independent physician not affiliated with the Study, and perceived health was assessed via self-report questionnaires. Linear regression analyses were conducted to examine childhood environment and personality traits as predictors of perceived health status at these 3 time points, while controlling for concurrent objective health.

    Results:  Neuroticism was inversely correlated to perception of health at ages 65, 75, and 80. Extraversion positively predicted perceived health at these ages. Conscientiousness was also positively correlated at age 75. Childhood environment predicted perceived health at all 3 time points even after controlling for age 60 personality traits and concurrent objective health.

    Conclusions:  While it has been shown that objective health status and personality factors predict perceived health in late life, this study demonstrates that the quality of childhood environment makes a unique contribution to perceived health in late life above and beyond known predictors, including objective health and personality factors.

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    [T] Inpatient Suicide: The Mayo Clinic Experience
    Presenting Author:  Julia Shekunov
    Co-Author:  J. Michael Bostwick

    Purpose:  To describe one hospital’s experience with actively suicidal medical or surgical inpatients over 12 years, with the goal of exploring the features, and ultimately modifiable risk factors, of nonpsychiatric inpatient suicide.

    Methods:  Using the resources of the Sentinel Event Tracking System database as well as records for the Minnesota Adverse Events Statute, we conducted a retrospective chart review of Mayo Clinic patients from 1998-2010 who attempted suicide while hospitalized on a medical or surgical unit.

    Results:  There were eight inpatient suicide attempts; 1 was fatal. Each one occurred in the patient’s room at a mean of 5 days after admission (range, 0-18 days). Four occurred by medication overdose, 2 by wrist cutting, 1 by strangulation, and 1 by swallowing of foreign objects. Two patients had been admitted for surgery, 2 for alcohol withdrawal, 1 for chest pain, 1 for overdose, and 2 for metastatic cancer. Only the latter 2 had a poor prognosis. Two of 8 patients endorsed suicidal ideation on admission. Four had been seen by a psychiatrist earlier in their admission; 1 was seen in the ED after presenting with overdose, and the remaining consults addressed alcohol dependence, depression and question of conversion disorder. Possible precipitating factors were identified in all 8 patients and included social issues in 2, inadequate pain control in 3 (including shortness of breath in 1 patient and anxiety in another), and delirium in 3 (including 2 patients in alcohol withdrawal). Six patients had a prior diagnosis of major depression, with several comorbidities including alcohol dependence in 2, PTSD in 2, and 3 with personality disorders. All 6 had at least 1 prior psychiatric hospitalization, and 4 had a history of prior suicide attempts. Two patients had no significant psychiatric history, although 1 was diagnosed with adjustment disorder with anxiety and depressed mood during this hospitalization. Three patients had a history of substance abuse as well as evidence of use in the week prior to hospitalization.

    Conclusions:  Suicide in a medical or surgical inpatient setting is a rare yet devastating occurrence. Although only 1 patient was admitted due to suicidality, the majority of patients in this series had a psychiatric history, and half had been seen by a psychiatrist during their admission. Nonetheless, their suicide attempts were neither predicted nor prevented. The next step is a case-control study to determine the modifiable risk factors and characteristics specific to suicidal patients hospitalized on medical or surgical units. We expect to have these results in time for the APM annual meeting.

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    [T] Tricyclic Antidepressant Drug Abuse in Consultation Psychiatry
    Presenting Author:  Raymone Shenouda
    Co-Author:  Paul Desan

    Purpose:  A recent consultation regarding altered mental status in a middle-aged female patient who admitted to frequent use of doses of 400 to 600 mg of amitriptyline spurred us to review cases of patients abusing antidepressant medications, encountered during inpatient hospital consultation.

    Methods:  Records of patients seen during a 15-year period on the consultation services at Yale New Haven Hospital (New Haven, CT) and the Massachusetts General Hospital (Boston, MA), were examined.

    Results:  Fourteen clear cases were identified of individuals repeatedly using tricyclic antidepressant medications not in accord with medical prescription. Ages ranged from 29 to 60. Eight (57%) were male. Thirteen (93%) had a comorbid substance dependence diagnosis, 11 (79%) with polysubstance dependence, 2 (14%) with alcohol dependence and 1 (7%) with opiate dependence. Of 11 cases with polysubstance dependence, 7 included opiate dependence: thus, overall 8 (57%) cases had a diagnosis of opiate dependence. Of these, 3 were in methadone maintenance and 1 had a history of methadone maintenance. The tricyclic drug abused was amitriptyline in 11 cases, doxepin in 2 cases, and imipramine in 1 case. Only two cases had a primary psychiatric disorder independent of substance use (major depression, borderline personality disorder). Patterns of abuse ranged from sporadic binge to habitual heavy use. Illustrative cases will be presented.

    Conclusions:  Patients abusing tricyclic drugs span a wide age range and include similar numbers of each gender. Most patients have a concurrent substance use disorder, most commonly opiate dependence. No specific primary psychiatric disorder predominates. These results are consistent with evidence from other research reports that tricyclic antidepressants have an abuse potential which is not appreciated by most psychiatrists. Tertiary amine tricyclic agents have sedating, anticholinergic and antihistaminic properties that may underlie the abuse potential of these agents. Our results, with other reports in the literature, suggest that abuse of tricyclic antidepressants is particularly associated with opiate use, and could be related to pharmacological synergy between these agents. Consultation psychiatrists should be aware of the possibility of this easily missed medication misuse.

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    [T] Surviving Aortic Dissection: Does Life Go On?
    Presenting Author:  Janet Shu

    Mood influences physical health and physical problems influence the mental health of patients. In the intersection between cardiology and psychiatry, research has shown that depression predicts mortality after acute coronary events such as myocardial infarction [1,2]. In the intersection between oncology and psychiatry, multiple papers discuss how patients cope with the mental health consequences of a cancer diagnosis [3,4]. Most data are based on middle-aged and elderly individuals. Very little is known about how acute cardiovascular events psychologically affect younger adults in their twenties or thirties (based on personal pubmed review).

    This case study describes the complex issues faced by a man in his mid thirties, with no previous psychiatric history, who is faced with an aortic dissection. This patient exemplifies the interconnection between medical and psychiatric problems, making it clear that providers must collaborate to provide optimal care. Of interest would be to ascertain whether treatment of depression, known to decrease risk for ACS recurrence, can be applied to hypertensive management as secondary prevention [5].

    References:

    1. Davidson KW and Korin MR. Depression and cardiovascular disease: selected findings, controversies, and clinical implications from 2009. Cleve Clin J Med. 2010 Jul;77 Suppl 3:S20-6

    2. Sher Y et al. The impact of depression in heart disease. Curr Psychiatry Rep. 2010 Jun;12(3):255-64

    3. Mazzotti E et al. Predictors of existential and religious well-being among cancer patients. Support Care Cancer. 2010 Nov 25

    4. Vehling S et al. Is advanced cancer associated with demoralization and lower global meaning? The role of tumor stage and physical problems in explaining existential distress in cancer patients. Psychooncology. 2010 Nov 8

    5. Davidson KW et al. Psychological theories of depression: potential application for the prevention of acute coronary syndrome recurrence. Psychosom Med. 2004 Mar-Apr;66(2):165-73

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    [T] Inadvertent Polysubstance Overdose including the Novel Drug 4-ACO-DMT
    Presenting Author:  Elizabeth Shultz
    Co-Authors:  Tamara Lee, Kathy Coffman

    Introduction:  Abuse of novel synthetic drugs is facilitated by the shared online accounts of user-documented experiences as well as by the availability of legally abused substances and prescription drugs from unregulated online sources. To increase awareness of the tryptamine hallucinogen 4-Acetoxy-dimethyltryptamne (aka 4-ACO, 4-ACO-DMT, psilocetin, O-acetylopsin), we report a psychiatry consult case of polysubstance overdose.

    Case Report:  A 21 year old white male presented to the MICU with respiratory failure following accidental polysubstance overdose. His history included past Ritalin and Adderall use for ADHD, Seroquel, Zoloft and Effexor use for fibromylagia, substance abuse (marijuana, mushrooms, LSD, electric cigarettes, alcohol), and a history of panic attacks. According to the state’s Automated Reporting System, the patient had received prescriptions for Zolpidem, Diazepam, and Clonazepam from two different doctors within six months prior to admission.

    On the night prior to admission, the patient had three cups of poppy seed tea made with dry pods, 60 mg of 4-ACO, and 90 mg of dextromethorphan, all of which were ordered online and consumed orally. The next morning, he was found by a friend to be unarousable for three hours, after which time he demonstrated signs of aspiration and respiratory distress prompting the friend to call EMS. Prior to admission, the patient was intubated, receiving versed, vecuronium and IV fluids.

    The hospital course was significant for hyperkalemia, respiratory acidosis, acute kidney injury, elevated amylase, elevated CK and CKMB with normal troponins, and positive urine opiates and benzodiazepines. After a five-day course of Unasyn for suspected pneumonia, correction of electrolytes, IV fluids, continued telemetry and respiratory support, the patient improved medically although he declined participation in outpatient or inpatient chemical dependency interventions. The patient later denied this drug use was a suicide attempt. He described the effects of 4-ACO to cause enhanced color perception. ADHD was excluded via Wender Utah rating scale. Symptoms were inconsistent with fibromyalgia.

    Discussion:  4-ACO is a hallucinogenic tryptamine similar to psilocin with a 10-15 minute onset and up to 14 hours of drug effect, including: synesthesias, euphoria, dysphoria, confusion, auditory or visual hallucination, disorientation, paranoia, paralysis, mydriasis, respiratory depression, GI symptoms, tachycardia. Feigning ADHD, panic disorder, and fibromyalgia may provide the patient with amphetamines, benzodiazepines, and opiates to augment other substances. According to online accounts, 4-ACO may be abused with alcohol, marijuana, benzodiazepines, opiates, amphetamines, psilocin, ketamine, inhalants, syrian rue, peruvianus, bk-MBDB, 2C-E, 2C-T-7, 5-MEO-DMT, 5-HO-MIPT, diphenhydramine, dextromethorphan, and/or methylone. Despite lethal consequences, users may have denial about their chemical dependency, as 4-ACO and similar drugs are excluded from routine toxicology screens and may be legally obtained online. In this case, the combination of 4-ACO with opiates and benzodiazepines appears to have resulted in severe respiratory depression and aspiration pneumonia.

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    [T] Depression and Incident Diabetic Retinopathy: A Prospective Cohort Study
    Presenting Author:  Nida Sieu
    Co-Authors:  Wayne Katon, Elizabeth Lin, Joan Russo, Evette Ludman, Paul Ciechanowski

    Objective:  This study examined whether depression is associated with a higher incidence of diabetic retinopathy among adults with type 2 diabetes, after controlling for health risk behaviors and sociodemographic and clinical characteristics.

    Method:  This prospective cohort study consisted of 2,359 patients with type 2 diabetes enrolled in Pathways Epidemiologic Follow-Up Study, a prospective population-based cohort study investigating the impact of depression in primary care patients with diabetes. The predictor of interest was baseline severity of depressive symptoms assessed with the Patient Health Questionnaire-9 (PHQ-9). The outcome was incident diabetic retinopathy. Diabetic retinopathy incidence was assessed using logistic regression as the primary analysis, and time to incident cases of diabetic retinopathy was examined using Cox proportional hazards model as a secondary analysis.

    Results:  Over a 5-year follow-up period, the risk of incident diabetic retinopathy was estimated to increase by up to 15% for every significant increase in the severity level of depressive symptoms (five points increment on the PHQ-9 score) (for every one point increase on the PHQ-9: odds ratio 1.026, 95%CI (1.002, 1.051) and hazard ratio 1.025, 95%CI (1.009, 1.041)).

    Conclusion:  A significant correlation was found between depression severity and incident diabetic retinopathy. Diabetic patients with depression have a higher risk of developing diabetic retinopathy. Improving depression treatment in patients with diabetes could potentially contribute to diabetic retinopathy prevention.

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    [T] Psychiatric Co-Management in the Treatment of Paradoxical Vocal Cord Motion. A Case Report
    Presenting Author:  Aasia Syed
    Co-Author:  Margo C Funk

    Purpose:  The purpose of this abstract is to increase awareness about paradoxical vocal cord motion (PVCM) - a medical condition that often requires effective psychotherapeutic and psychopharmacological co- management.

    Background:  This is a case of a 42 year old woman from rural Ohio who had experienced nine episodes of complex laryngeal strider, in previous sixteen months. All of these episodes had been preceded by hoarseness and difficulty swallowing, which then led to severe difficulty in breathing. Her vitals during these episodes were notable for tachypnea, tachycardia, and significant oxygen desaturation by pulse oxymetry. A diagnosis of PVCM was established after direct laryngoscopy. She was advised for treatment options, tracheostomy versus Botox injections to her vocal cords which she deferred. At this point she came to our facility for second opinion. Her physical exam was unremarkable. Further laboratory investigations and imaging studies were all within normal limits. During her admission she had two similar episodes. During one of them she lost consciousness, but recovered after receiving emergency treatment with oxygen and ativan. Afterwards she was monitored on telemetry. Otolaryngology reconfirmed the diagnosis of PVCM after direct laryngoscopy during one of the episodes. They advised speech therapy for breathing techniques and recommended psychiatry consult for anxiety.

    On the initial interview with psychiatry, the patient expressed anger towards her doctors for attributing her serious physical symptoms to anxiety and did not want to talk with us. We recommended that the primary team must continue further investigations. However, we continued to follow patient for anxiety which we believed was secondary to these episodes. She talked about longstanding childhood sexual abuse by her father. He once placed his hands around her neck and threatened to strangulate her if she tried to tell or tried to run away. She agreed to continue psychotherapy after discharge. On follow up interview she reported improvement of her symptoms without the need for Botox injections to her vocal cords or tracheostomy.

    Discussion:  PVCM is sometimes called treatment -refractory asthma. It is characterized by vocal cord adduction during inspiration. Etiological factors include asthma, respiratory irritants, gastro esophageal reflux disease and psychological factors. Common signs and symptoms of PVCD include hoarseness, wheezing, shortness of breath, cough and throat tightness. A history of childhood sexual abuse or trauma is common and it may contribute to the appearance or maintenance of symptoms which can interfere with medical care. Effective psychotherapeutic and psychopharmacological co -management may greatly enhance their quality of life by helping them avoid unnecessary invasive treatments such as intubations, botox injections in vocal cords and tracheostomies. PVCM management consists of patient education, reassurance, heliox, oxygen, speech therapy, psychotherapy, hypnosis, and biofeedback, benzodiazepines and appropriate medications for associated psychiatric disorders.

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    [T] Does a New Diagnosis of Cancer Precipitate a Psychotic Disorder in Vulnerable Patients?
    Presenting Author:  Elena Tuskenis
    Co-Author:  Marie Tobin

    A new diagnosis of cancer is traumatizing and can be associated with the emergence of post-traumatic stress symptoms (PTSS). Studies have shown that full syndrome post-traumatic stress disorder (PTSD) may occur in up to 4% of newly diagnosed cancer patients, and in up to 35% of treated cancer patients [1]. PTSS are even more common, presenting in up to 20% of patients with early-stage cancer, and in up to 80% of those with a cancer recurrence [2]. Additionally, Breslau and colleagues have shown that there is an increased likelihood of developing PTSS in response to stressful life events in patients with greater cumulative premorbid trauma [3]. Furthermore, exposure to trauma has been associated with the development of psychotic symptoms. The likelihood of developing psychotic symptoms in response to trauma increases with the severity of the trauma [4]. Based on these observations, we raise the question of whether or not a new diagnosis of cancer in patients with premorbid trauma is sufficient to precipitate a psychotic disorder.

    We also explore the role of concurrent PTSS in developing a psychotic disorder. We report two cases of patients with a history of premorbid trauma and associated post traumatic stress symptoms who developed delusional disorder after cancer diagnosis and treatment. In the cases presented, we assess thoroughly the cumulative burden of lifetime traumatic events. We explore the possibility of a kindling effect in causing PTSS. We consider the potential of a new cancer diagnosis to precipitate a psychotic disorder in patients with concurrent PTSS.

    References:

    1. Green BL, Rowland JH, Krupnick JL, et al: Prevalence of posttraumatic stress disorder in women with breast cancer. Psychosomatics 1998; 9:102-111

    2. Cella DF, Mahon SM, Donovan MI: Cancer recurrence as a traumatic event. Behav Med 1990; 16:15-22

    3. Breslau N, Chilcoat HD, Kessler RC, et al: Previous exposure to trauma and PTSD effects of subsequent trauma: results from the Detroit area survey of trauma. Am J Psychiatry 1999; 156:902-907

    4. Krabbendam, L: Childhood psychological trauma and psychosis. Pscychological Medicine 2008; 38:1405-1408

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    [T] Posterior Reversible Encephalopathy Syndrome: High Blood Pressure-Induced Brief Psychotic Disorder
    Presenting Author:  John Vraciu
    Co-Author:  Chris White

    Purpose:  Posterior reversible encephalopathy syndrome (PRES) is a common condition where consult-liaison psychiatry will become involved when a patient with markedly elevated blood pressure develops psychiatric symptoms. In this syndrome the psychosis occurs in the context of cerebral vascular deregulation, likely at the blood brain barrier. A case based approach is used to examine the current information on the treatment and causes of posterior reversible encephalopathy syndrome presenting in the context of psychosis, as it relates to psychosomatic medicine.

    Methods:  A primary literature review was performed using the terms posterior reversible encephalopathy syndrome and brief psychotic disorder.

    Results:  New onset brief psychotic disorders and mania are rare in middle aged males and organic causes such as posterior reversible encephalopathy syndrome should be considered [1]. PRES typically results in cerebral edema of subcortical white matter of the occipital and parietal lobes and it is usually reversible by control of blood pressure or removal of the underlying cause [2,4]. Currently no medications have been FDA approved for the treatment of psychiatric manifestations of PRES, but since seizures often occur in patients with PRES, aggressive use of antiepileptic medications should be used to prevent seizures and control mood symptoms of this disease [3]. Because haloperidol is not associated with the adverse effect of causing hypertension, it was used along with valproic acid to treat the patient's psychosis and agitation with success [5].

    Conclusions:  As psychosomatic medicine practitioners, it is important to recognize posterior reversible encephalopathy syndrome as a possible cause when a patient presents with a new onset psychosis or manic episode in the context of elevated blood pressure. If treated only as a psychiatric manifestation, essential tight blood pressure control may not occur and the symptoms may continue and worsen to the point of irreversibility.

    References:

    1. Rodriguez R, et al. P03-112- Gender differences in Brief psychotic disorder. European Psychiatry, Vol. 25, Issue: Date: 2010, pp. 1092

    2. Mirza A. Posterior reversible encephalopathy syndrome: A variant of hypertensive encephalopathy. Journal of Clinical Neuroscience, 2006; Vol. 13, issue:5 pp. 590-595

    3. Skiba V, Etienne M, Miller JA. Development of chronic epilepsy after recurrent episode of Posterior Reversible Encephalopathy Syndrome associate with Periodic Lateralized Epileptiform Discharges. Seizure: European Journal of Epilepsy, Vol. 20, Issue:1, Date: January, 2011, pp.93-95

    4. Narbone MC, et al. PRES: Posterior or potentially reversible encephalopathy syndrome? Neurological Sciences, Vol. 27, Issue: 3, Date: July 2006, pp. 187 - 189

    5. Miyaji, Shingo, Yamamoto, et al. Comparison of the risk of adverse events between riperidone and haloperidol in delirium patients. Psychiatry and Clinical Neurosciences. , Vol. 61, Issue: 3, Date: June 2007, pp. 275-282

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    [T] Acute Urinary Retention Precipitated by Buprenorphine/Naloxone
    Presenting Author:  Katherine Walia
    Co-Author:  Adekola Alao

    Purpose:  Buprenorphine/naloxone is a partial mu agonist and kappa receptor antagonist that has been used for pain control since the late 1960's and has FDA approval for treatment of opiate dependence (Wesson and Smith 2010). The main adverse effects associated with buprenorphine include respiratory and central nervous depression as well as gastrointestinal symptoms. The purpose of this paper is to report an additional side effect of this medication.

    Method:  In this paper, we report the occurrence of acute urinary retention caused by buprenorphine/naloxone combination. We also discuss possible mechanisms of this side effect. Although the manufacturers of buprenorphine/naloxone recommend caution with the use of this medication in cases of urethral stricture or prostatic hypertrophy, there are no reported cases suggesting acute urinary retention with buprenorphine/naloxone. There is a previous report of urinary retention with sublingual buprenorphine without naloxone in the setting of pain control (Murray and Feneley 1982).

    Results:  We are reporting the case of a 40 year old man with a history of Post Traumatic Stress Disorder (PTSD) as well as polysubstance dependence who developed urinary retention as well as a rash after his first dose of buprenorphine/naloxone. The patient was later treated at the emergency department with urethral catheterization and subsequent full recovery.

    Conclusion:  Practitioners should be aware of this potential side effect of buprenorphine/naloxone combination and its management.

    References:

    1. Wesson, DR and DE Smith. Buprenorphine in the treatment of opiate dependence. Journal of Psychoactive Drugs. Jun 2010;42(2):161-175

    2. Fudala PJ, Bridge TP, Herbert S, et al. Office-based treatment of opiate addiction with a sublingual-tablet formulation of buprenorphine and naloxone. N Engl J Med. 2003 Sep 4;349 (10): 949-58

    3. Reckitt Benckiser Pharmaceuticals Inc. Buprenorphine Drug Label. Available at: http://www.fda.gov/downloads/Drugs/DrugSafety/
    PostmarketDrugSafetyInformationforPatientsandProviders/UCM191529.pdf.
    Accessed 6/20/10.

    4. Murray KH and RC Feneley. Endorphins--a role in lower urinary tract function? The effect of opioid blockade on the detrusor and urethral sphincter mechanisms. Br J Urol. 1982 Dec;54(6):638-40

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    [T] Staying Against Medical Advice: When Patients Refuse Discharge from Hospital
    Presenting Author:  Jo Ellen Wilson
    Co-Author:  John Shuster

    Background:  Consultation psychiatrists are frequently asked to evaluate patients who do not follow the medical recommendations of the primary treatment team. While consultations are often ordered to evaluate patients who make requests to leave the hospital against medical advice (AMA), patients may also opt to decline recommendations to leave the hospital. As a guide to care and management, the published literature on the approach to the patient who chooses to stay in hospital AMA is much smaller than that for patients who request to leave AMA.

    Objective:  To present a case of a patient who repeatedly and against medical advice refused discharge and to discuss a differential diagnosis of sources of this behavior and an approach to management of this clinical situation.

    Method (Case Summary):  We present the case of a 19 year old white male with a history of migraines, somatoform disorder, anxiety disorder, and polysubstance dependence who initially presented 3 days prior to consultation with various diffuse somatic complaints including headache, nausea and vomiting. He was diagnosed with status migrainosus and admitted to the Medicine service. Two days later following improvement of his symptoms with medical therapy and negative medical workup, the patient was discharged and requested a prescription for narcotic pain medications. On the day of discharge, the patient never left the medical campus and presented back to the Emergency Department with various complaints including migraine headache, a seizure (likely pseudoseizure) and a dystonic reaction. After serial evaluations and discharges, he presented for his fourth ED admission within 24 hours of discharge, and psychiatry was consulted. After psychiatric evaluation, the patient agreed to leave the medical center and went home with a plan for outpatient follow-up care, as recommended.

    Discussion:  We will present a differential diagnosis and a proposed management approach for psychiatric consultations for the patient who opts to stay AMA.

    Conclusion:  Patients who decline recommendations to leave the hospital present a unique challenge for the hospitalist, other admitting physicians, and the consultation psychiatrist in many respects. A thoughtful approach to the broad range of possible etiologies of this behavior and clear but careful intervention based on an understanding of the causes of this behavior can prevent both harm to a patient who often has limited insight and misuse of expensive clinical care resources.

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    [T] Cardiologist Perceptions of Mental Health Issues
    Presenting Author:  Daniel Zuiches
    Co-Authors:  Laurie Black, Karen Friday, John Giacomini, Bruce Bongar

    Cardiovascular disease is the number one cause of death globally. Among cardiology outpatients, the prevalence of mental disorders has been estimated to be 35-40%. In addition, the impact of these disorders (e.g., depression, anxiety, irritability) heightens cardiac risk. Given the impact of mental health on cardiovascular health, this study is aimed at assessing the training, perceptions, and practices of general cardiologists and cardiology fellows with respect to the assessment and treatment of mental disorders. Preliminary findings suggest that cardiologists have limited training in assessment and management of adherence issues associated with mental illness. Furthermore, community-based cardiologists may have limited understanding of the mental health treatment options and resources available for referral beyond recommending that the patient talk to their primary care physician.

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    A Proposed Model of Psychiatry and Psychology in Composite Tissue Allotransplantation (Hand Transplant)
    Presenting Author:  Michelle Nichols
    Co-Author:  Laura Howe-Martin

    This presentation will overview the mental health literature regarding composite tissue allotransplantation (hand transplantation or CTA) and our involvement in a unique pre-transplant evaluation program specifically designed for CTA that incorporates both psychiatry and psychology. CTA is a relatively new alternative to classic prosthetics and remains in the experimental stages. Only approximately 70 hand transplants have been completed worldwide (as of March 2011). Despite multiple references throughout the medical/surgical literature regarding the necessity of having a pre-transplant psychiatric evaluation, there appears to be a dearth of literature on the specific role(s) and expectations of mental health professionals in the process of CTA.

    As members of a consultation-liaison psychiatry team, we provide pre-transplant evaluation and management services for the solid organ programs in place at UT Southwestern Medical Center and its affiliated teaching hospital, Parkland Hospital (i.e., kidney, liver, heart, and lung, as well as pre-LVAD placement). This presentation will review the state of the mental health literature regarding CTA. We will use extrapolations from other transplant literature to propose reasonable methods for going forward with pre-CTA mental health evaluations. Specific methods, evaluation components, and contraindications for CTA will be presented. We will also review the very unique ethical considerations associated with CTA that are not typically considered with solid organ transplant. Finally, we will propose a model for the mutual participation of psychiatry and psychology, within a broader transplant team, to better serve this population's specific and varied needs.

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    An International Psychiatry Elective — Improving Psychiatric Care and Providing a Unique Educational Experience
    Presenting Author:  Stephen Nicolson
    Co-Author:  Anne Rohs

    Background:  Neuropsychiatric conditions account for over a quarter of the worlds total disability-adjusted life years and the disease burden is disproportionately high in low and middle income countries (LAMICs) (Patel, 2007). Resources for mental health in LAMICs are limited by scarcity, inequity and inefficiency. Namely, there are not enough mental health workers to provide services, enough research to direct efficient treatment, nor enough public health leaders to guide program implementation (Saxena, 2007). Uganda is a typical example of a low income country, with about one psychiatrist per one million people. In the Kisoro, a rural district in the southwestern corner of the country that borders Rwanda and the Congo, there are no psychiatrists for its quarter million residents. There are few healthcare resources and physicians are scarce. As CL psychiatrists are have a unique skill-set to help improve mental healthcare in resource limited settings (Bauer, 2010), this rural community is an ideal place for CL psychiatry assistance.

    Purpose:  To improve mental healthcare in a rural Ugandan community, while providing an innovative psychosomatic medicine elective for a fourth year psychiatry resident.
    Methods: The month-long elective consists of a) preparatory reading material on Ugandan culture, cross-cultural psychiatry, and tropical neuropsychiatry; b) on-site (in Kisoro) supervision by Psychosomatic Medicine faculty (SN); c) liaison activities with non-psychiatric physicians, traditional healers, and community outreach personnel in Kisoro focused on basic psychiatric diagnosis and treatment; d) clinical experience in the Kisoro Distric Hospital, the community Mental Health Clinic and via home visits; e) training local psychiatric providers (clinical officers, psychiatric nurses) in American psychiatric practices; f) from these same local providers, receiving hands on education in Ugandan cultural influences on psychiatric presentation. In addition the resident is expected to give a presentation to medical students and residents who are interested in going to Kisoro as well as a Grand Rounds talk for the hospital to share in their experience. SN also maintains year-round availability to psychiatric and non-psychiatric personnel in Kisoro to provide continuous consultation on an as needed basis when he back in the Bronx.

    Results:  In each of the past two academic years, one fourth year resident has gone to Kisoro, each with a unique experience. The form of the elective continues to evolve as does the delivery of psychiatric care in the Kisoro district. Based on our recommendations, the local hospital has assigned an additional psychiatric nurse to work in the mental health clinic and on the inpatient consultation service. A fund for decanoate injections has been started. In the coming academic year, two residents as scheduled to go to Kisoro separately, thus strengthening our ability to help, and learn from the people of Kisoro.

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    A Double-Blind, Randomized, Placebo-Controlled Trial of Ramelteon for the Treatment of Insomnia and Mood Stability in Patients with Euthymic Bipolar Disorder
    Presenting Author:  Edward Norris
    Co-Authors:  Karen Burke, Julia Correll, Kenneth Zemanek, Joel Lerman, Michael Kaufmann

    Purpose:  Abnormalities in circadian rhythms are prominent features of bipolar I disorder (BPD). Literature suggests that disrupted 24-hour sleep-wake circadian rhythms are associated with an increased risk of relapse in bipolar disorder. Bipolar patients have shorter, and more variable, circadian activity patterns even when not acutely ill. It is proposed that normalizing the circadian rhythm pattern of bipolar patients will improve their sleep; and consequently, also lead to fewer mood exacerbations. Ramelteon offers a mechanism to re-synchronize the suprachiasmatic nucleus. The administration of ramelteon for bipolar patients will improve sleep and will cause fewer mood exacerbations.

    Methods:  This single-site, double-blind, randomized, placebo-controlled study evaluated the efficacy of ramelteon in the treatment of insomnia and mood stability in patients with euthymic bipolar disorder for up 6 months of maintenance treatment. Men and women aged 18 to 65 who were currently experiencing sleep difficulties were randomized to receive ramelteon or placebo in double blind fashion. Sleep (PSQI) and mood symptoms (MADRS, YMRS) were evaluated at 4 week intervals.

    Results:  90 individuals signed informed consent and 83 participants were enrolled in the study and were randomized to receive ramelteon (n = 42) or placebo (n = 41). There was no evidence of group differences on background variables; nor were there differences between groups on any of the measures used to monitor disease progression, including PSQI, YMRS, MADRS, or CGI. Overall, there were 40 patients who relapsed (48.2%). The results of the Cox regression analyses indicated that the ramelteon group (Odds Ratio 0.48, p=.024) was significantly less likely to relapse over the course of the 24 week study than patients in the placebo group. Kaplan Meier curves also indicated significantly longer median survival times in the drug group (Mdn = 188 days since baseline) versus the placebo group (Mdn=84 days since baseline) X2(1) = 5.33, p =.02. There were no serious adverse events in this study.

    Conclusions:  This is the first study to examine the potential of ramelteon at treating sleep and mood in patients with bipolar disorder. The present study shows that ramelteon was very effective in maintaining stability for individuals with bipolar disorder. Patients treated with ramelteon were approximately 50% more likely to remain stable throughout the trial. In other words, ramelteon treated participants were about twice as likely not to become depressed or manic during the 6 month treatment period.

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    Factors Related to Psychiatric Readmissions in a Large Community Academic Hospital
    Presenting Author:  Edward Norris
    Co-Authors:  William Stern, Karen Burke, Julia Correll, Michael Kaufmann

    Objectives:  The purpose of this study was to analyze factors related to readmission to the acute care behavioral health unit in an academic community hospital, with a special focus on comorbid medical conditions. Through this analysis, the research team sought to identify subpopulations that might merit more personalized medical care. The emergence of the concept of an Accountable Care Organization (ACO) suggests potential to improve the quality of patient-centered, effective, efficient, safe, timely, and equitable care. This study represents a necessary and replicable first analysis that might be performed by any integrated system (potential ACO) to identify features of the acute care psychiatric population. Results from this study and subsequent studies can then be utilized to formulate effective strategies and/or processes that better manage patients with comorbid diagnoses. The research reported here features the first use of multiple regression techniques used to analyze psychiatric readmissions in relation to a set of behavioral and medical comorbidities as suggested by current literature.

    Methods:  6457 unique patients were admitted to the psychiatric unit at Lehigh Valley Hospital in Allentown, PA from July 1, 2007 to June 30, 2009. Characteristic data were recorded based on the literature on readmissions. This data included primary psychiatric diagnosis, the presence of a secondary medical diagnosis and/or a secondary behavioral health diagnosis. Chi-square goodness-of-fit tests were used to analyze significant association between categorical variables. Interval variables were analyzed using an independent samples t-test. The targeted outcome was identifying significant relationships between three periods of 30-day, 90-day and 365-day readmissions and potential related factors.

    Results:  3231 patients (50.04%) were identified as having at least one comorbid medical diagnosis. Over the two years, 398 patients (6.2%) were readmitted at 30-days, 687 patients (10.6%) at 60-days and 1195 patients (18.5) at 365 days. The presence of a secondary comorbid medical diagnosis was also associated with readmission at all three levels (p<0.001). Diabetes was the most consistent comorbid medical factor in readmissions at all three levels with significant relations also identified for both COPD and Hypothyroidism at 60 and 90 days.

    Conclusions:  The significant relationship between select medical comorbidities and psychiatric readmissions underlines the need for increased integration of mental and physical care when treating this vulnerable population. This analysis is the first step in creating community-based care strategies that use population data to identify and treat community demand. Using interdisciplinary care coordination and the Patient Centered Medical Home model may help to improve the overall care for patients with behavioral health issues.

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    Aripiprazole Withdrawal Dyskinesia in Children Complicated by Continued Stimulant Therapy
    Presenting Author:  Roberto Ortiz-Aguayo
    Co-Authors:  Sansea Jacobson, Donette Svidron, Thomas Raynolds

    Purpose:  To describe two cases of Aripiprazole withdrawal dyskinesia in children, complicated by continued stimulant therapy. It has only been in recent years that childhood movement disorders produced by withdrawal of dopamine antagonist agents in the setting of ongoing stimulant therapy have been described, with most literature focused on older atypicals. To our knowledge, there are no previous reports of acute onset movement disorders in childhood in the setting of withdrawal from aripiprazole and ongoing stimulant therapy.

    Method:  Case descriptions and literature review.

    Results:  Case 1: 13yo male diagnosed with Bipolar Disorder, ADHD, and OCD treated with aripiprazole for one and a half years. His other medications included trazodone, atomoxetine, methylphenidate transdermal patch, and immediate release methylphenidate. Aripiprazole 10mg was discontinued over a 6 week period. Two weeks later, the patient developed acute onset of involuntary twitching of face, mouth, and bilateral upper and lower extremities. His neurologic examination was pertinent for near continuous movement of his oral-lingual musculature along with intermittent choreiform movements of his distal lower extremities.

    Case 2: 9yo male diagnosed with ADHD, ODD and delayed speech and motor skills. Over a two year period, he received regular administration of oral aripiprazole. Aripiprazole 30mg was then abruptly discontinued due to loss of insurance coverage. Other medications included d-methylphenidate, atomoxetine, and clonidine. Within two weeks of discontinuing aripiprazole, he began experiencing restlessness and involuntary movements of his upper and lower extremities in addition to intermittent facial contortions and uncontrollable lip and tongue movements. His neurologic examination was pertinent for persistent choreoathetotic movements in all extremities and akathisia.

    Treatment for both children included discontinuation of stimulant medications and as needed administration of diphenhydramine for symptomatic relief. One week follow-up exam for each child noted a near resolution of involuntary movements, although worsening of disruptive behaviors.

    Conclusions:  Although there seems to be a decreased risk of withdrawal diskinesia with aripiprazole, combination treatment with stimulants appears to carry the risk of this drug-induced movement disorders in vulnerable populations. Increased awareness of this potential side effect is key given recent trends in combining second generation antipsychotics and stimulants in the treatment of challenging child psychopathology. Further research is needed to identify risk factors, prevention strategies, evidence based treatments and educational interventions for families and non specialty providers regarding this phenomena in children.

    References:

    Robert L. Rodnitzky. Drug-Induced Movement Disorders in Children. Seminars in Pediatric Neurology, Vol 10, No 1 (March), 2003: pp 80-87

    Conner DF, Benjamin S, Ozbayrak KR. Case Study: Neuroleptic Withdrawal Dyskinesia Exacerbated by Ongoing Stimulant Treatment. Journal of the American Academy of Child and Adolescent Psychiatry, 34:11, 1995: pp 1490-1494

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    Suicide Scripts as a Predictor of Eventual Lethality
    Presenting Author:  Chaitanya Pabbati
    Co-Authors:  Gil Harmon, Nora King, Megan Chang, J. Michael Bostwick

    Purpose:  Extensive data supports index suicide attempts as having great value in predicting subsequent attempts, while demographic data coupled with past medical and psychiatric history may assist in anticipating long-term lethality. We postulate that the motivation behind an attempt, as embodied by determination of a suicide script, will help to more accurately predict which patients are at an elevated risk for future events.

    Gardner and Cowdry first introduced the concept of suicide scripts in 1985 as a means of describing the motivation behind a suicide attempt. We have expanded their initial four categories to ten, allowing more specific characterization of a patients’ motivation behind their attempt. We hypothesize that certain scripts will prove to be associated with higher rates of eventual lethality.

    Methods:  We developed our cohort by identifying 5,700 individuals who presented to an Olmsted County medical facility between 1986 and 2010 and received a billing or diagnosis code corresponding to suicidal ideation, suicidal behavior, or non-accidental self-inflicted injury. Patients with a prior attempt or residence outside of Olmsted County were excluded, leaving us with a cohort of roughly 3,300. We are reviewing charts for demographic and index event information that will permit assignment of a script. Using a retrospective-prospective design, we are querying the Rochester Epidemiology Project and the National Death Index to determine which subjects have died as well as a cause of death.

    A pilot study of 100 charts indicated inter-rater reliability of 95% for script assignment. Chi-square analysis will be used to establish associations between script categories and eventual outcome, as well as with secondary variables.

    Results:  We propose that certain scripts will be associated with an increased likelihood of suicide. Cases classified as True Suicidal Ideation for example, should demonstrate a higher eventual lethality than those identified as Self-Mutilation. A pilot study of 100 cases shows that nearly 70% of our cohort is eligible for scripting, with True Suicidal Ideation, Retributive Rage, and Drugs/Alcohol as the most prevalent categories. Further, we anticipate finding associations between certain scripts and previously determined risk factors for suicidal behavior.

    Conclusions:  At the November meeting we will introduce our expansion of Gardner and Cowdry’s model for characterizing suicidal behavior. We expect to have preliminary data showing relationship between specific script categories and suicide risk for up to 24 years following an index attempt. Subsequent analyses will likely show similar correlations between specific scripts and established risk factors, further validating the clinical utility of suicide scripts.

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    Curricula for Psychosomatic Medicine Competencies in Pediatrics, Family, and Liaison Psychiatry
    Presenting Author:  Maryland Pao
    Co-Authors:  Audrey Walker, Paul Jones, Joyce Chung

    Background:  The core competencies for Psychosomatic Medicine Fellowship training proposed collaboratively by more than 40 leaders in psychosomatic medicine were published in 2009 (Worley et al, 2009). These include essential competencies in pediatrics, family and liaison psychiatry. Examples of core pediatric topics within the knowledge competencies include eating disorders and neurodevelopmental disorders (II B #18, #19, Worley et al, 2009). Regarding families, the competencies document stated that PM psychiatrists should be competent at gathering information from the patient, other medical providers, and families, and specifically at understanding "the emotional state of family and caregivers and the capacity to function as stable social supports" (I B #9, Worley et al, 2009). Liaison skills are addressed under medical professionalism (V A, Worley et al, 2009) and systems-based practice skills (VI, Worley et al, 2009). Building on the PM core competencies, child psychiatrists specialized in psychosomatics are in the process of developing core competencies for Pediatric Psychosomatic Medicine (Nguyen, Walker, Pao 2008).

    Objective:  To educate adult psychosomatic medicine psychiatrists about specific knowledge, skills and attitudes expected of effective and competent physicians in the areas of pediatrics, family assessment and liaison skills.

    Methods:  In this interactive workshop, participants will become familiar with and discuss proposed curricula for training PM psychiatrists in the core pediatric, family and liaison topics described. Dr. Audrey Walker will present the pediatric psychosomatic medicine fellowship program at the Montefiore Medical Center/Albert Einstein College of Medicine with a detailed curriculum and supervision recommendations as a model of core competency development. Dr. Maryland Pao (Workshop Chair) will give a brief overview of what an adult PM Fellow needs to know about developmental and eating disorders. Dr. Paul Jones will present a flexible core curriculum for PM fellows on assessing and working with families in a busy hospital consult environment. Dr. Joyce Chung will discuss the essential elements of communicating with other teams and hospital staff (liaison deconstructed) and discuss how best to evaluate PM Fellows in this area.

    Results:  Participants who complete this workshop will suggest curricular content covering pediatrics, family assessment and intervention, and liaison psychiatry for PM psychiatrists, which they can use as a starting place towards developing and implementing relevant curricula in their home institutions. How best to do this will vary from program to program, based in part on clinical context (inpatient vs outpatient), patient population, scheduling, available teaching and supervisory resources, and program philosophy. Individual programs can expand on any or all of these, as appropriate to their own training goals, resources and schedules.

    Conclusions:  Specific content areas of competence for PM Fellows continue to be identified. Documentation of assessment of certain skills (e.g., liaison skills, assessment of families) needs to be standardized and methods of measuring competence need to be addressed.

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    Treating Brain Tumors Together: A Multidisciplinary Brain Tumor Clinic
    Presenting Author:  Sarah Parsons
    Co-Authors:  Rose Vick, Aaron Spalding, Todd Vitaz, Mary Helen Davis

    More than 200,000 people in the United States are diagnosed with a brain tumor each year. The diagnosis of a brain tumor can create distress for patients and their families; they may experience anxious or depressive symptoms in response to a new diagnosis or recurrence. Unlike other critical illnesses, brain tumors themselves can alter somatosensory function, for example limbic system activation or suppression from tumor mass effect or infiltration, which can add to disability and distress. In addition to treatment related stressors, patients face the overwhelming challenge of managing other responsibilities, which may include work, family, and other health related concerns.

    A unique and comprehensive model of care delivery is the Brain Tumor Center. Norton Cancer Institute and Norton Neuroscience Institute have collaborated to form multidisciplinary team to meet all of the patient's treatment needs in one location. The team consists of a neurosurgeon, radiation oncologist, behavioral oncologist, rehabilitation physician, speech pathologist, and nurse navigator. All specialists collaborate in a weekly clinic to provide convenient, improved, and expedited care to this specialized population. The presence of a psychosomatically trained psychiatrist offers a unique opportunity to quickly address the needs of patients and families, while decreasing the burden of additional medical appointments, the stigma associated with mental health, and fragmentation of patient care. The collaboration between surgery, oncology, rehabilitation, and psychiatry providers improves health care delivery to brain tumor patients and their families.

    This integrative model of care will be discussed in detail along with a description of the interaction between various specialists. Demographic data for our patient population will be presented. Diagnoses encountered and treatment modalities will also be discussed.

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    When the Past Becomes the Present: Sexual Trauma History in Gynecological Oncology Patients
    Presenting Author:  Sarah Parsons
    Co-Authors:  Mary Helen Davis, Mary Gordinier

    Every six minutes, an American woman is diagnosed with gynecologic cancer, including cervical, endometrial, ovarian, peritoneal, tubal, vaginal, and vulvar cancers. The diagnosis can be distressful and create an emotional reaction. This distress is greatly amplified and complicated in a woman with a history of sexual abuse. Most gynecological oncology practices do not adequately screen for, address, and offer treatment to survivors of sexual abuse. When this aspect of a cancer patient is overlooked, problems can arise over the course of treatment. Treatment compliance and adherence can be compromised, decreasing positive outcomes for this population.

    Norton Cancer Institute introduced a pilot program in one gynecologic oncology clinic to regularly screen for sexual trauma and provide psychiatric referral as needed. The development and implementation of the program will be presented. Demographic data will be provided. The impact of the program on this patient population and gynecologic oncology providers will be explored.

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    Helping the Helpers: Providing Support to Oncology Providers
    Presenting Author:  Sarah Parsons
    Co-Authors:  Rose Vick, Kelley Woggon, Mary Helen Davis

    Staff support is an area of great need in oncology inpatient settings. Stress levels are high in this group of providers due to acuity of patients, complex technological equipment involved in patient care, noise levels from alarms, precise attention to detail required for care and extensive interaction with families in crisis. Prolonged high levels of stress may lead to "burnout" which can be described as a syndrome of: emotional exhaustion, depersonalization and reduced sense of personal accomplishment. Burnout often leads to staff turnover and dissatisfaction, which negatively impacts the organization, patient care and the individuals. Various staff support models have been piloted within Norton Hospital in the past with little participation from staff. Development of an oncology specific inpatient staff support program, called Taking Care, will be described. Due to the success of the Taking Care program at the initial hospital site, the program is being expanded to include other hospitals within the organization. Challenges and successes of implementing a staff support program will be described including feedback from management and participants. The process of adapting and expanding the program to a new site will also be reviewed.

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    Going Gentle into That Good Night: Specialized Training to Help Navigate End of Life Issues
    Presenting Author:  Sarah Parsons
    Co-Authors:  Elizabeth Archer-Nanda, Barbara Head

    Behavioral oncology providers often care for patients and families not only through their cancer journey, but also at the end of life. Navigating end of life issues is complex and overwhelming at times. The entire treatment team, including oncologists and nursing staff are involved and affected by a patient's decline and eventual passing. Programs exist to provide education and support to those on the front lines of end of life care. The End of Life Nursing Education Consortium was created in 2000 as a way to deliver education to nurses providing end of life care needs to patients and families. This national program is available, through local trainers, to successfully educate and ease the burden on direct care providers.

    The core curriculum of ELNEC will be described in detail, including how nursing and other members of the treatment team can benefit from the training. The development of ELNEC training through an integrated behavioral oncology practice will be reviewed, including the potential replicate this service and training at other institutions.

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    Psychosomatic Physicans at Tumor Board
    Presenting Author:  Sarah Parsons
    Co-Authors:  Mary Helen Davis, Elizabeth Archer-Nanda, Rose Vick

    Tumor board review is a standard tool used across the United States to provide patients with a comprehensive, multidisciplinary treatment plan. Psychiatry is not usually included as part of this collaborative team. Norton Cancer Institute has an initiative to include behavioral oncology in most tumor board discussions system wide. This change has allowed for even further collaboration between psychiatry, surgery, and oncology. The case discussion has become more in depth with a better understanding of the patient as a whole. Topics discussed during the course of tumor board include prognosis, grief reactions, emotional response, quality of life, and overall level of functioning of the patient. The presence of a psychosomatically trained psychiatrist at tumor board review has allowed for environmental change, ease of psychiatric referral, improvement of appropriateness of psychiatric referral, and improvement in collaboration.
    The process and period of adjustment incorporating behavioral oncology into tumor board review will be discussed. Case examples will be provided to illustrate the value of integrating psychiatry into tumor board discussion.

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    The Spectrum of Psychiatric Sequelae Following Use of "Bath Salts"
    Presenting Author:  Thomas Penders
    Co-Author:  Richard Gestring

    Over the past year new designer stimulant drugs have made their appearance around the world. Sold as “legal highs” and promoted on the Internet, these substances are sold openly in convenience stores and “head shops” labeled as “Bath Salts”, for external use only.

    Since the introduction of these substances, derivatives of the substance cathinone, a naturally occurring stimulant, poison control centers, law enforcement, hospital emergency departments and inpatient psychiatric units have witnessed a small epidemic of adverse physiological and neuro-psychiatric adverse effects.

    Two specific chemical structures have been identified, Methylmethcathinone (Mephadrone) and Methylenedioxypyrovalerone (MDPV).

    A series of cases have demonstrated unusual patterns of paranoid hallucinations combined with marked persistence and substantial memory impairment for stimulant abuse behaviors. Considering this pattern as more indicative of delirium than psychosis, rapid response to low-dose antipsychotic medications has been shown. Other presentations presented symptoms of depressive and anxiety disorders. This paper presents a series of cases, reviews the pharmacology and spectrum of psychiatric presentations associated with the use of these agents, and includes guidance about treatment.

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    Autoimmune Causes of Psychosis: A Case Series
    Presenting Author:  Michael Peterson

    Psychotic episodes may be related to a primary psychiatric disorder or as a part of non-psychiatric medical conditions. These may include metabolic, infectious, drug-induced or autoimmune etiologies. While relatively uncommon, a number of autoimmune disorders may cause profound psychotic episodes. Without a full evaluation, these may be mistaken for a primary psychiatric disorder and the primary etiology may not be uncovered. Further, symptomatic treatment with antipsychotics will neither address the primary pathophysiology, nor prevent progression, recurrence or persistence.

    A series of cases evaluated and treated at an academic medical center are discussed. Diagnosis and treatment were coordinated by a primary service with consultations by the psychosomatic medicine service and other specialties. The diagnostic modalities (laboratory, imaging, and electrophysiology) utilized, and a brief description of treatment and outcomes are provided. The specific case presentations are complemented by a brief review of the literature on psychosis due to autoimmune disorders and will present:

    -- Specific autoimmune disorders associated with psychosis
    -- Recommended laboratory studies
    -- Typical imaging (CT, MRI, and EEG) findings in these disorders.

    The recognition of non-psychiatric medical conditions leading to psychosis is a critical skill for the psychosomatic medicine practitioner. Familiarity with these autoimmune disorders may improve the diagnosis of atypical psychoses.

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    Improvement in Self-Reported Executive Function after Deep Brain Stimulation in Patients with Parkinson’s Disease
    Presenting Author:  Uyen Pham
    Co-Authors:  Anne-Kristin Solbakk, Espen Dietrichs, Inger Marie Skogseid, Mathias Toft, Jon Ramm-Pettersen, Ane Konglund, Terje Sæhle, Dag Aarsland, Ulrik Fredrik Malt, Stein Andersson

    Introduction:  Deep brain stimulation (DBS) of the subthalamic nucleus has been demonstrated to be an effective treatment of motor impairment in advanced Parkinson's disease (PD). However, consequences of DBS for non-motor function need further investigation. DBS has been associated with changes in cognitive function, but the findings vary across studies. Some report mild improvement in some aspects of cognition, whereas other studies have indicated mild reductions, particularly in executive control functions. Executive functions refer to higher order control processes that are a prerequisite for adaptive thinking, emotion and behavior. The main goal of the present study was to examine whether DBS treatment affects how PD patients perceive their level of functioning on measures of executive function in everyday life.

    Patient inclusion:  All patients with PD who are assigned to DBS at the Oslo University Hospital -Rikshospitalet are asked to participate in the project on a consecutive basis.
    Inclusion criteria are symptoms of PD ≥ 5 years, c) severity of PD ≥ 20 points in UPDRS motor scale, d) Mattis Dementia Rating Scale > 130, e) marked fluctuation of symptoms and/or troublesome dyskinesias and/or severe tremor and intolerable side effects of dopaminergic drugs, and e) failure of oral medical treatment to sufficiently control symptoms.

    Methods:  The Behavior Rating Inventory of Executive Function-Adult version (BRIEF-A: Gioia et al., 2005) was used preoperatively and at 12 months post-surgery to assess self-reported behavioral manifestations of executive function in everyday living. The BRIEF-A includes nine non-overlapping clinical scales corresponding to common behavioral and metacognitive aspects of executive function.

    Results:  Preliminary results from 12 PD patients (11 males/1 female) treated with DBS are reported. Mean age was 64 years (range 60-71) and mean level of education was 13 years (range 8-18). Preoperatively, PD patients reported more executive difficulties compared to the normative sample. However, BRIEF-A scores significantly improved 12 months after DBS on all three main indexes: Global Executive Composite, Behavioral Regulation Index, and Metacognitive Index. On the subscale level, patients with PD reported significantly less problems at 12 months post-surgery on scales tapping working memory, planning, organization of materials and belongings, initiation of activity as well as ability to flexibly shift between tasks and activities. Subscales measuring emotional control and impulsive behavior showed improvement at trend-level.

    Conclusion:  The results show that patients with medically intractable Parkinson's disease who underwent DBS of the subthalamic nucleus experienced a significant improvement in key domains of executive functioning that are important in everyday living. As a next step, we will investigate whether the positive changes in self-reported executive function are accompanied by an improvement in performance based neuropsychological measures of cognitive executive control.

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    Practice and Training Opportunities for Psychology on a Consultation Liaison Service at a Safety Net Hospital
    Presenting Author:  Christopher A. Pierce
    Co-Authors:  J. Christopher Sheldon, Thomas M. Dunn, Juli M. Vierthaler, Yuko Yamato, Robert House

    Purpose:  Psychological services can provide high quality contributions to the Consultation-Liaison (C-L) Psychiatry Services at safety-net hospitals by providing brief intervention and standardized cognitive assessments. The disadvantaged populations seen in these settings have high rates of mental health and cognitive issues but low levels of resources. Consequently, utilizing psychology interns can be quite cost-effective and can enhance learning for psychiatry residents. Limited information has been published concerning contributions psychology practice might bring to inpatient C-L Psychiatry services. Even less has been published regarding training opportunities for psychology on a C-L service or the benefits to the service provided by psychology trainees. This presentation describes the contributions of a psychology internship program to the Consultation-Liaison Psychiatry team at a major metropolitan medical center.

    Methods:  Review of two years of data regarding services provided and patients served by trainees in a psychology internship program. In addition, we solicited and incorporated the direct experience of interns on that rotation.

    Results:  During a single year, the C-L team conducted over a thousand initial consultations. Not surprisingly, many of the consultation requests were for aging and elderly patients. About one fifth of consult requests are patients 65 and over and one third were 65 and older. The largest source of referrals came from internal medicine. Other relatively large referral sources included the Medical Intensive Care Unit and Surgery or the Surgery Intensive Care Unit. Smaller referral sources included the Correctional Care Medical Facility, Neurology, OB/GYN, Pediatric Intensive Care, and Rehabilitation. The most common reason for referral was suicidal ideation or attempt. Other prominent referral questions included substance abuse, depression, questions of capacity to make medical decisions, capacity to live independently upon discharge, need for guardianship, and the assessment of possible dementia. Psychology interns conducted initial patient assessment, determine diagnoses, and develop treatment recommendations, with the exception of medication recommendations. Psychology interns were particularly well-qualified to provide short-term psychotherapy. Furthermore, psychology interns brought the unique ability to provide psychological and neuropsychological assessment to the C-L service. This service was particularly economically beneficial for the hospital in facilitating discharge to an appropriate placement and decreasing length of stay. This was particularly relevant to questions of capacity or need for guardianship. The training experience received very positive evaluations by psychology interns.

    Conclusions:  The Psychiatric Consultation-Liaison service in a general safety-net hospital setting provides a fertile environment for psychology internship training. Psychology trainees can make a unique contribution to the C-L service that expands the range of services provided and referral questions that can be addressed.

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    A Diabetes Education Group for Women Living with Type 2 Diabetes Mellitus and Symptoms of Depression or Anxiety
    Presenting Author:  Cassandra Racco
    Co-Author:  Mona Gupta

    Purpose:  Diabetes mellitus is a chronic disease that affects over 2 million Canadians. Approximately 90% of those affected have Type 2 diabetes and approximately half are women. Because of its chronicity, demands for constant self-care, and risk of developing serious long-term complications, diabetes is a psychologically demanding disease. Compared to the general population, people living with diabetes experience higher rates of psychiatric disorders including depressive disorder and generalized anxiety disorder. In comparison to men, women living with diabetes are at increased risk of experiencing specific mental illnesses such as depression. Mental health has a major impact on diabetes self-management and quality of life. Researchers have argued that interventions to treat mental illness must be integrated into diabetes education programs in order to improve both diabetes and mental health-related outcomes. Given that a substantial portion of diabetes education takes place in community settings any such intervention should be deliverable in community settings. However, there exists no comprehensive program, community-based or otherwise, specifically designed to meet the mental health needs of persons with diabetes. Thus, the purpose of this project was to develop and deliver a group-based intervention aimed at providing emotional support to patients with Type 2 diabetes that could be offered feasibly in community settings.

    Methods:  A 12-week long group intervention was developed by a team of investigators with diverse areas of expertise working in both hospital and community settings in consultation with members of the target population. Prior to the start of the group, 10 participants completed surveys characterizing their pre-group levels of symptoms. Weekly group sessions based on the manual were co-facilitated by a psychologist and a diabetes nurse. Ten women completed the group. During the two week period following the last session, 9 participants completed a second set of surveys assessing symptom levels and satisfaction, and participated in an oral interview assessing feasibility, learning, and quality of the group experience.

    Results:  Preliminary results indicate that participants valued convenience: they were satisfied by the group location proximate to public transit, but expressed a desire for later scheduling to meet the needs of working people. Participants described the group as providing a supportive environment where they felt less alone in managing diabetes and derived a sense of comfort from the fact that others experienced similar struggles. As a result, they recommended that the group should last longer than 12-weeks. The perceived benefits of the group went beyond support as participants noted the benefit of receiving both peer and professional feedback regarding the instrumental and psychological challenges of living with diabetes.

    Conclusion:  Analysis of pre- and post-group symptom levels is ongoing. At this stage, such a group intervention is both feasible and desirable to patients and professional.

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    Prognostic Awareness and Distress in Terminally Ill Cancer Patients
    Presenting Author:  Julia Radomski
    Co-Authors:  Jordana Jacobs, William Breitbart, Hayley Pessin, Barry Rosenfeld, Wendy Lichtenthal, Allison Applebaum, Elissa Kolva, Megan Olden

    Purpose:  This study examines the relationship between prognostic awareness and psychological distress in terminally ill cancer patients. Though a handful of studies have researched prognostic awareness and distress in cancer patients, conclusions have been inconsistent. This is the first study to examine the relationship between different elements of patient prognostic awareness, such as the length of time they have known about their prognosis, and their level of psychological distress.

    Methods:  Participants were terminally ill cancer patients (n=143), the majority (n=78) of whom were receiving inpatient-palliative care while the remainder (n=65) were receiving outpatient, life-extending care. Patients were administered a series of self-report questionnaires as part of their participation in a larger study. A measure of prognostic awareness (Prigerson, 1992; Ray et al., 2006) was used to assess patients' perception of their health status (ranging from healthy to terminally ill), how long they have been aware of their prognosis, and their anticipated life-expectancy. Based on responses to these and other questions, clinicians rated the patients as having no awareness, limited awareness, or full awareness (Chochinov 2000). The Hospital Anxiety and Depression Scale (HADS) was used to evaluate psychological distress on two subscales, depression and anxiety.

    Results:  Over 50% of the participants reported awareness of their terminal health status (n = 73), while 32.2% had limited prognostic awareness (n = 46), and 16.8% had no awareness (n = 24). The level of psychological distress differed significantly between the three prognostic awareness groups (p=0.002). Patients with full awareness were the most distressed (HADS Mean = 13.87), followed by patients who had no awareness (HADS Mean = 11.00), and limited awareness (HADS Mean = 8.75). Among the 80 participants (55.9%) that indicated some knowledge of their prognosis, the length of time participants had known about their terminal prognosis was not significantly correlated with psychological distress (r=-0.08). However, those with limited awareness indicated they had known their prognosis longer (Mean=27.0) than those with full awareness (Mean=18.0). Additional analyses exploring the elements of awareness (e.g., anticipated life-expectancy, acceptance of the prognosis) and their relationship with psychological distress will be described.

    Conclusions:  Participants who were fully aware were significantly more distressed than participants who indicated only limited awareness. These findings could have implications on physician-patient communication and further analysis is needed to explore whether distress related to prognostic awareness changes over time.

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    Clonidine Treatment of Nightmares among Patients with Comorbid PTSD and Traumatic Brain Injury
    Presenting Author:  Syed Razi

    Introduction:  Exposure to any event that poses actual or imagined death or injury with production of intense fear, helplessness, or horror can lead to Post traumatic stress disorder (PTSD). Autonomic dysregulation is thought to explain many of the physiologic changes seen in patients with PTSD. Clonidine Treatment of Nightmares among Patients with Co- Morbid PTSD and Traumatic Brain Injury

    Case 1
    Mr. F, a 48 years old man of Bosnian origin developed PTSD symptoms after fighting in the Bosnian war for 15 months. He reported witnessing the loss of his mother, two brothers and a nephew along with friends, neighbors and other relatives He emigrated to the United States of America and presented with symptoms of depression, flashbacks, exaggerated startled response as well as nightmares of the war events including decomposed bodies of his relatives. He was treated with venlafaxine XR 225mg po q daily and olanzapine 10mg po q daily without any relieve of his nightmares. He was later started on clonidine 0.1 mg po qhs. Within 2 weeks of starting clonidine, he reported improvement in the severity and duration of his nightmares and improved quality of his sleep After one month of initiation of clonidine, his dose was increased to 0.1 mg twice daily and patient’s olanzapine was slowly discontinued. The patient continues to maintain remission one year after initiation of treatment.

    Case 2
    Mr. H is a 33 year old Iraq and Afghanistan wars active military soldier who was involved in several combat scenarios in which lives were lost. He presented with symptoms of PTSD and TBI including nightmares, flashbacks, and exaggerated startle response as well as avoidant behavior. He was treated with cognitive processing therapy, citalopram 20mg po q daily and clonazepam 1mg po bid prn as well as prazosin 4 mp po qhs. However, his nightmares did not respond significantly until prazosin was replaced with clonidine. He was initially started on clonidine 0.1 mg po qhs which was gradually titrated up to 0.3mg. The patient’s nightmares symptoms resolved about 2 weeks after initiation of treatment and the patient remains in remission on a combination of citalopram and clonidine.

    Discussion:  Clonidine is a centrally acting alpha-agonist agent that is used to treat hypertension stimulates alpha-adrenoreceptors in the brain stem. This action results in reduced sympathetic outflow from the central nervous system. We hypothesize that this central mechanism of action is why clonidine is effective in treating nightmares among patients with PTSD.

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    Delirium Clinical Pathway for Surgery: Process and Outcomes
    Presenting Author:  Carole Richford
    Co-Authors:  Maria Corral, Stephen Fitzpatrick, Grant Millar, Julia Raudzus, Peggy Simpson

    Delirium in surgical patients is a medical emergency. It is associated with increased length of hospital stay, sustained poor cognitive status and worsened patient morbidity and mortality. Although intervention is guided by practice guidelines and expert opinion post-surgical delirium remains largely under recognized, under reported and under treated. However, a mounting body of evidence suggests that post operative delirium may be predicted, prevented and reduced in severity by comprehensive clinical assessment, prevention and early intervention.

    An evidence based delirium clinical pathway was developed to assess the flow of surgical patients through the pre- and post-operative course at St. Paul's Hospital, a medium sized teaching hospital in downtown Vancouver. Patient assessments were done pre-operatively, post-operatively, at discharge and one month follow-up. Specific markers were selected to predict delirium (age, history of alcohol abuse, MOCA (Montreal Cognitive Assessment) score, GDS ( Geriatric Depression Scale), IADLs (Independent Activities of Daily Living) and serum sodium, potassium, albumin and glucose. The CAM (Confusion Assessment Method) was used to establish a baseline delirium screening score pre-operatively and throughout the post-operative period. Key non-pharmacological risk factors and interventions (PRISME) were identified and also documented in the post-operative period.

    The focus of this presentation will be on the process of designing the delirium clinical pathway for surgical patients and the current results from the observational research study data.

    References:

    Dasgupta M and Dumbrell AC. Preoperative Risk Assessment for Delirium After Noncardiac Surgery: A Systematic Review. J Am Geriatr Soc (2006) 54:1578-1589

    Maldonado JR. Pathoetiological Model of Delirium: a Comprehensive Understanding of the Neurobiology of Delirium and an Evidence-Based Approach to Prevention and Treatment. Crit Care Clin 24 (2008) 789-856

  147. top

    A Structured Group Psychotherapy Program Improves Adjustment to Lipodistrophy in HIV+ Patients: Preliminary Data
    Presenting Author:  Araceli Rousaud
    Co-Authors:  Jordi Blanch, Ricard Navines

    Objective:  To evaluate the immediate efficacy of a specific group therapy program in improving quality of life and adjustment to body changes due to fat redistribution (lipodistrophy syndrome) in HIV+ patients taking antiretroviral treatment.

    Methods:  The therapy program consisted of 12 weekly two-hour sessions following a structured cognitive-behavioral group psychotherapy program focused on development of coping strategies, including specific psychoeducational interventions in nutrition and physical exercises. Eight HIV-positive patients with generalized lipodistrophy (affecting face, button and extremities) who referred psychological impairment due to body changes participated in a group therapy. Repeated measures Friedman test was used to analyse changes on the modified version of the Dermatological Quality of Life Inventory (DQLI) administered at three time points: T1 (one month before therapy), T2 (first session), and T3 (last session)

    Results: All participants (six women, and two men) completed the therapy program. A significant improvement was observed during the intervention time (between T2 and T3). No changes were observed during baseline (between T1 and T2). Issues raised by group participants were problems with dressing, fear of stigmatization, social isolation, and difficulties in sexual relations.

    Conclusions:  Preliminary data show that our psychotherapy program improves quality of life and psychological adjustment to lipodistrophy body changes in HIV infected patients. Further groups should be performed to confirm its efficacy.

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    Professionalism in Psychosomatic Medicine in the Digital Age: Keeping Trainees on Track
    Presenting Author:  Ann Schwartz
    Co-Author:  Wendy Baer

    Developing an understanding of professionalism during medical education is an essential aspect of the development of a physician. The rapid emergence of social media including Facebook and YouTube has added a new dimension to defining, teaching and role modeling professionalism in the medical field. While social media sites offer great opportunity to widely distribute valuable health care information as well as provide physicians with a venue to de-stress, there is also the potential for lapses in professionalism. In this new digital age, trainees and lifelong learners must learn to be mindful of professionalism while using social media in order to protect their privacy as well as the image of physicians.

    The purpose of this presentation is to review the challenges and opportunities at the interface of professionalism and social media for physicians. We will first review the important attributes defining professionalism, including altruism, accountability, excellence, duty, honor, integrity, and respect for others. Given that the consultation-liaison psychiatrist may be the only exposure that other physicians and hospitalized patients have to mental health care or psychotherapy, the CL psychiatrist must be able to quickly and simply define the role of psychiatry in medicine and to educate other physicians and patients about the connections between the mind and the body. This responsibility as a steward of the field best fits under the category of professionalism and will be addressed in this workshop.

    Facebook, Twitter, Skype and Youtube are an everyday part of life for most young people; medical students and psychiatric residents and fellows are no exception. Once a trainee leaves the hospital or clinic, they may feel comfortable speaking, acting or posting in a way that they would not in front of supervisors or patients. The possibility for professional lapses using technology is endless. Development of a culture of professionalism among the faculty is an essential so that appropriate behaviors will be modeled to trainees and included in educational activities in ongoing basis. Constructive feedback is an essential component of medical and psychiatric education. However, commenting on a trainee's performance in a useful way is not always easily done and faculty must consciously consider how best to help the trainee understand their performance and how to improve. Participants will be encouraged to share their own experiences that exemplify successful and unsuccessful efforts at providing feedback, specifically related to lapses in professionalism.

    Guidelines for communicating to trainees the importance of caution when using web-based media will be discussed amongst attendees. Sample topics and relevant, thought provoking questions generated from our practices are outlined. In addition, case vignettes are offered to exemplify issues with regard to professionalism raised by digital and social media in medical practice.

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    Psychotropic Medication in Failure to Thrive
    Presenting Author:  Akhil Shenoy
    Co-Authors:  Yelena Kalitenko, Melissa Ozga

    Failure to thrive (FTT) or cachexia is a common condition in the elderly population. It can also be the presenting symptom of a variety of medical and psychiatric conditions including cancer, HIV, cirrhosis, kidney disease, substance abuse, and depression. It is a state of malaise, weight loss, and biochemical changes including electrolyte abnormalities, hypoalbuminemia, anemia, and hypocholesterolemia. This systematic review of the literature on psychotropic medication in this population would aide the consultation-liaison psychiatrist in drug choice for psychiatric conditions in patients who are cachectic or FTT. The authors review the literature on tricyclics, SSRIs, SNRIs, stimulants, and antipsychotics in patients with cancer cachexia, AIDS and discuss medication induced FTT and the pharmacokinetic considerations in using psychotropics in this population. Highly protein bound psychotropics require specific dose reductions in FTT. Stimulants are sometimes directly used to improve the malaise and the fatigue of FTT. The 5-HT3 antagonism of mirtazapine and olanzapine has added utility to help reduce nausea and induce appetite. Depression, delirium, and dementia should be adequately assessed in FTT for safe and effective psychotropic use.

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    Medication-Induced Visual and Auditory Hallucinations 19 Years after Kidney Transplantation
    Presenting Author:  Gen Shinozaki

    In psychosomatic medicine practice, psychiatrists encounter patients with wide range of medical conditions who are treated with variety of medications. Psychosomatic psychiatrists are challenged with sorting out the etiology of potential adverse reaction from those medications.

    Case Report:  55 year old Caucasian married male, with a significant medical history of kidney transplant for polycystic kidney disease 19 years ago, was referred to mental health evaluation due to visual hallucination and auditory hallucination over 2 months.
    He reported persistent theme of the hallucinations, with which a family of father, mother and a boy appeared in his house and called him in loud voices. Especially they claimed that the boy is a product of the mother and the patient.

    He reported that those hallucinations began within 10 days after he was started on sertraline 100mg daily for his anxiety,. He was also placed on eszopiclone for his sleep. Those medications were provided by his primary care physician, who recommended tapering off eszopiclone after being informed about his hallucinations. This patient also discontinued sertraline by himself.

    After discontinuation of sertraline, his visual hallucination disappeared. By the time of the initial mental health evaluation, those visual hallucinations were gone, but he still heard voices from the mother, father and the boy. For his residual auditory hallucinations, he was started on quetiapine 50mg tid. After failed attempt of tapering off from quetiapine with recurrence of same hallucinations, risperidone 2mg bid was initiated, due to failed response to even higher dose of quetiapine 100mg tid.

    Discussion:  Initially his hallucinations were thought to be triggered by either sertraline or Eszopiclone or the combination of both. However, even after the discontinuation of both, he repeatedly suffered from hallucinations. Those were initially controlled by quetiapine, which became ineffective after first return of the hallucination. Risperidone was effective to control his recurrent hallucination, but after tapering off of risperidone, the hallucination came back. Based on the time course, apparently sertraline or Eszopiclone cannot be the etiology of his hallucination.

    Mycophenolate Mofetil was suspected, but he has been on it for more than a decade. Same situation for prednisone and morphine. Each medication was reviewed one by one, and Alendronate (Fosamax) was found to have one case report of auditory hallucinations and visual disturbances (Coleman 2004). There are only limited numbers of case reports about hallucination associated with bisphosphonates.

    This is a class of medication widely used not specific for unique patient group, rather for many different patients group. Although the prevalence of adverse event with hallucinations seem to be rare with this class of medication, it would be helpful for psychosomatic psychiatrists to be aware of this rare, but bothersome side effect from bisphosphonates.

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    Isoniazid-Induced Psychosis
    Presenting Author:  Sacheen Shrestha

    Case Report:  "Ms. B," a 63-year-old white woman with a history of major depressive disorder, developed an acute onset of psychotic symptoms after she was started on prophylactic isoniazid (INH) for a positive tuberculin (purified protein derivative) test. She was also on pyridoxine for prophylaxis against neuropathy associated with INH.

    Her psychotic symptoms included visual hallucinations of "midgets" coming out of her refrigerator and air-conditioner, and tactile hallucinations of insects burrowing under her skin. She was eventually hospitalized because of worsening of these symptoms.

    Initially, INH-induced psychosis was not suspected, and she was treated with quetiapine in the hospital for her psychosis. The dose of quetiapine was titrated to 800 mg daily over the course of a few weeks. The intensity of psychotic symptoms decreased after treatment with quetiapine for 7 days, and Ms. B was discharged home.

    She continued to receive quetiapine at the same dosage in the outpatient clinic for several weeks. However, she continued to complain of bugs infesting her apartment and crawling under her skin. At this point, we considered the possibility that her psychotic symptoms could have been secondary to INH. Her INH was discontinued, and her symptoms resolved completely after 3 weeks.

    Discussion:  With the increasing prevalence of tuberculosis in the United States, and guidelines emphasizing the importance of prophylactic treatment of latent tuberculosis, more people are expected to receive INH as it continues to be a first-line drug for treatment and prophylaxis. Literature reviews reveal a growing number of cases of isoniazid-induced psychosis. Most of the reported symptoms include paranoid delusions, visual and auditory hallucinations, suicidality, irritable mood, and disorientation. INH-associated psychosis has been reported in patients on multiple as well as monodrug therapies and in treatment regimens with and without pyridoxine. The treatments for isoniazid-induced psychosis include discontinuation of INH3 and addition of an antipsychotic, or a combination of both.

    The suggested mechanism for INH-associated psychosis involves INH’s altering the levels of catecholamines and serotonin by inhibiting monoamine oxidase or by inducing pyridoxine deficiency, or both. The clinical presentation of this patient is similar to that of previous cases described; however, our patient presented with tactile hallucination, a symptom that has not been frequently reported. Ms. B also had a successful resolution of symptoms after treatment with quetiapine and pyridoxine and discontinuation of INH. Treatment with risperidone, without discontinuation of INH, has also been shown to be effective; however, in this case, Ms. B’s psychotic symptoms did not resolve on concurrent treatment with INH and quetiapine.

    Conclusion:  Acute onset of psychosis in an INH-exposed patient should cause suspicion of this psychiatric side effect of anti-tubercular therapy and lead to consideration of discontinuation of INH and a trial of antipsychot.

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    Temporal Lobe Phenomena: Seizures or Psychosis?
    Presenting Author:  Gagandeep Singh

    Epilepsy of temporal lobe origin may result in mental states remarkably similar to those seen in the primary psychosis. These are often under recognized even by psychiatrists. To make matters more confusing some of these patients will present with psychotic symptoms that are persistent and hard to classify. Particular attention to the patient narratives can help in making this diagnosis. This is important as these patients require different treatment options that persons with primary psychosis. Identification and treatment of this condition can be gratifying.

    I use a case presentation format and if possible video EEG data (if presenting orally) to illustrate these diagnostic conundrums and to review the psychiatric presentation of temporal lobe epilepsy. Particular attention will be paid to patient narratives in making a diagnosis. I will also review the state of current clinical knowledge in the identification and treatment of temporal lobe epilepsy.

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    Does Attachment Style Influence Depression and Somatic Symptoms in Hepatitis C?
    Presenting Author:  Sanjeev Sockalingam
    Co-Authors:  Diana Blank, Abdulqader Al Jarad, Fahad Alosaimi, Susan Abbey

    Background:  Evidence suggests that hepatitis C virus (HCV) infected patients are vulnerable to a common triad of depression, pain and fatigue. The inter-relationship between these symptoms in the HCV population raises the question of potential intrinsic psychosocial mechanisms, such as adult attachment style. We aimed to further characterize the impact of the various attachment styles (secure, fearful, pre-occupied and dismissive) on depressive and physical symptoms in the HCV-infected population.

    Methods:  During the 18-month study period, 99 HCV infected patients were assessed using the Hamilton Depression Rating Scale (HDRS), Fatigue Severity Scale(FSS), Patient Health Questionnaire-15(PHQ-15) for physical symptoms, the Relationship Questionnaire for attachment style and the Toronto Alexithymia Scale(TAS-20). Mean scores for each measure were compared between the four attachment styles using an ANOVA. A multiple linear regression analysis was performed to determine predictors of depressive, fatigue and physical symptoms.

    Results:  The distribution of attachment styles for the sample was as follows: secure attachment (30%), preoccupied (29%), dismissive (25%) and fearful (15%). Patients with fearful attachment style had significantly higher depressive symptoms compared to secure attachment style, however, fearful style was not a significant predictor of depression, physical symptoms and fatigue. Only physical symptoms were a significant predictor of depressive symptoms as per the HDRS. We found an inter-relationship between fatigue and somatic symptoms while depression alone was a predictor of somatic symptoms. Alexithymia was not a significant predictor of depression, fatigue or physical symptoms in the regression models.

    Conclusion:  Although our study did not identify fearful attachment style as a predictor of psychopathology and physical symptoms in HCV infected patients, patients with a secure attachment style had lower depressive symptoms and alexithymia. Our study findings support a theoretical model for triad of depression, fatigue and physical symptoms in HCV and argue for a high index of suspicion of depression in HCV-infected patients presenting with multiple somatic symptoms and fatigue.

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    Impact of Immigration on Gender Differences in Schizophrenia
    Presenting Author:  Magdalena Spariosu

    Introduction:  A personal or a family history of immigration is an important risk factor for schizophrenia. This study compares the gender differences in patients with schizophrenia, born and residing in USA, with those who immigrated to the US from any Spanish speaking country or from countries in the Former Soviet Union.

    Method:  24 Charts of Schizophrenic patients at the Maimonides Medical Center-CMHC, between the ages of 20 to 60 years old were randomly selected from each of the three following groups n=(72): those born in the US; those born in Russia; and those born in a Hispanic country. Each group had an equal number of men and women. The following data was extracted from each chart: age, marital status; level of education; employment history; history of having children; age of onset; number of admissions; number of abused substances; number of positive symptoms and negative symptoms of schizophrenia; number of side effects from antipsychotic medications; and the presence of mood symptoms.

    Results:  The Hispanic patients had the similar results to U.S. patients in regard to marital status. However, more Hispanic women were mothers in comparison to U.S. born women. The illness was manifested earlier in Hispanic women than men. Hispanic women had more admissions and a longer length of stay than Hispanic men. However, the shortest length of stay on the inpatient unit was in the Hispanic patients. The level of education and the employment history was better in Hispanic men than women.

    The Russian patients have the earliest onset of illness. The Russian women had an earlier onset of illness than Russian men. Throughout all 3 groups, women developed a greater number of side effects than male patients. The highest level of education on average in all the groups was 11th grade.

    Conclusion:  A personal history of immigration may be a significant factor in gender differences in schizophrenia. The frequency of symptoms in Schizophrenia in women patients appear to be negatively influenced by migration, by having the illness expressed at earlier age.

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    West Nile Virus Encephalitis Masquerading as Mania: A Case Report
    Presenting Author:  Guitelle St.Victor
    Co-Authors:  Begum Firdous, Damir Huremovic, Jacques Vital-Herne

    Purpose:  The purpose of this poster is to illustrate one of the principal challenges in the domain of Consultation-Liaison Psychiatry: medical conditions presenting as psychiatric illnesses in the medical setting and challenges CL psychiatrists face in diagnosing and treating such cases.

    Method:  Case Report

    Introduction:  Very often, medical illnesses masquerade as psychiatric conditions, frustrating the medical team when C-L psychiatrists request more testing for 'medically stable patients'. If not assessed properly under such pressure, the diagnosis can be missed and the treatment lacking, which can lead to disastrous consequences for the patient.

    Case Presentation:  Mrs F was a 53 year-old Hispanic female admitted to the medical floor after beeing discharged from a neighborhing hospital one week prior; her presenting symptoms at the first hospital were similar to those exhibited during the index hospitalization. Her medical history was remarkable for type II diabetes, subarachnoid hemorrhage and VP shunt placement four years ago.She had no prior psychiatric history and lived happily at home with her husband.She reported beeing admitted because people were out to kill her because of her ability to heal the sick. She was uncooperative,hypervigilant,distractible,loud,pressured,tangential,with persecutory and grandiose delusions described above. She was unable to sustain attention and concentration during the interview,saying the year was 2012(in 2010). On subsequent evaluations,she became more labile,hitting staff,peeking into other patients's rooms behind the curtains. Her husband described a one-month period of such erratic behaviors,which culminated in the patient taking off her clothes,cussing him and running naked outside,leading to this admission.

    An initial diagnosis of delirium not otherwise specified was made by the C-L team who suggested neurology and neurosurgery consults to assess the shunt, rule out seizures, normal pressure hydrocephalus as the husband reported recent weakness and difficulty walking. The work-up was subsequently negative and the patient deemed cleared for transfer to Psychiatry. The C-L team objected to the transfer,instead,insisted for a lumbar puncture which revealed west nile virus Ig G of 3.57.The encephalitis was treated symptomatically and the agitation responded to Haloperidol 4mg daily and Valproic Acid 750mg daily. The patient stabilized and left the hospital three weeks later.

    Conclusion:  This case illustrates the need for C-L psychiatrists to perform exhaustive evaluation, work-up and differential diagnosis for all patients with no prior psychiatric history who present with new onset psychosis. It also reminds us that beeing popular is not the essence of C-L Psychiatry,but competent doctoring is.

    Reference:

    Hall D, Tyler K, Frey K, Kozora E, Arciniegas D. Signs and symptoms Following West Nile Fever. J Neuropsychiatry Clin Neurosci 20;122-123, February 2008

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    Developing a Buprenorphine Clinic for Opioid-Dependent Pregnant Women
    Presenting Author:  Joji Suzuki
    Co-Author:  Leena Mittal

    Prescription opioid dependence is a rapidly growing epidemic in the US. Although buprenorphine has been available as an effective office-based treatment for opioid dependence since 2002, the demand for treatment remains high due to numerous factors. Most notably, there are insufficient numbers of physicians choosing to obtain the required training and DEA waiver. Pregnant women with opioid dependence who elect treatment with buprenorphine face additional and significant hurdles in obtaining treatment because most prescribers do not feel adequately trained to provide bupenorphine treatment during pregnancy, greatly limiting access to this important treatment.

    The aim of this poster is to report on the development of a buprenorphine treatment program for opioid dependent pregnant women in an academic medical center. The Director of the Reproductive Psychiatry Consultation Service and the Medical Director of Addictions partnered to develop a buprenorphine clinic with services closely integrated into a group of busy academic obstetric practices. The available scientific literature on the use of buprenorphine for pregnant opioid dependent women was reviewed, including the long-awaited MOTHERS trial published in December of 2010. Support was sought for and obtained from the leadership in both the Departments of Psychiatry and OB/GYN. A detailed proposal was then prepared which outlined the important elements of the clinic. Integration of OB, psychiatric, and addiction services was an important goal from the beginning. Prescribers with perinatal experience and buprenorphine training and therapists specializing in addictions counseling were identified. We ascertained space both embedded within obstetrics and within outpatient psychiatry offices and clarified the logistics of patient flow. The referral, intake, induction, follow-up, and therapy visits were planned in detail including documentation requirements. Psychiatric, pain, and addiction rating scales were selected for administration at initiation of treatment. Input was solicited from stake holders and all members of the treatment team that including mental health and obstetric physicians and social workers in order to identify the needs and characteristics of the patient population served as well as the needs of the referring treaters.

    The obstacles and potential challenges of providing buprenorphine to pregnant women in an integrated psychiatric and obstetric setting will be discussed. A case report of a pregnant patient in the clinic will also be reviewed and presented.

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    Assessing Non-Medical Use of Opioids in Hospitalized Pain Patients
    Presenting Author:  Joji Suzuki
    Co-Author:  Fremonta Meyer

    Purpose:  Consultation psychiatrists are often asked to comment on the possibility of opioid misuse in hospitalized pain patients. However, the diagnosis is complicated by the limited utility of DSM-IV tolerance/withdrawal criteria for opiate dependence in pain patients, the inability of routine urine toxicology screens to differentiate between legitimate and illicit opiate ingestion, and the tendency of patients to underreport substance use histories for fear that pain will be inadequately treated. The previously validated Screener and Opioid Assessment for Pain Patients (SOAPP) is a patient self-report tool predicting opioid misuse that has been studied only in the outpatient setting, and does not assess directly observable patient behaviors. A novel instrument that assesses behaviors during a patient's hospitalization, in conjunction with patient self-report and urine toxicology, may assist the psychiatric consultant in identifying patients requesting opioids for non-medical reasons.

    Methods:  Hospitalized patients receiving opioids who receive a psychiatric consultation are eligible for inclusion. Subjects complete the Brief Pain Inventory (BPI), SOAPP, and SCID modules for alcohol and substance use disorders. The newly developed 11-item instrument, Opiate Misuse Checklist (OMC), is completed via chart review and verbal interview of the patient's medical team.

    Results:  A total of 38 individuals have been screened for inclusion in the study. 29 individuals were excluded (6 declined to participate, 15 excluded due to delirium or suicidality, and 8 did not meet inclusion criteria), yielding a total of 9 subjects meeting criteria and providing informed consent. Subjects were mostly female (77.8%) and white (88.9%), and mean age of 50.2 (SD 14.6, range 36-80). Two subjects (22.2%) were referred for psychiatric consultation specifically to evaluate the non-medical use of opioids. Other consultation questions included assessment and management of: anxiety or depression (33.3%), alcohol withdrawal (22.2%), delirium (11.1%), and anorexia (11.1%). Four subjects (44.4%) met criteria for a DSM-IV opioid use disorder. The mean OMC score was 3 (SD 2.1). The mean BPI pain rating and functional impairment scores were 9.0 (SD 8.9) and 6.8 (SD 1.8), respectively. Although not significant, subjects referred specifically to evaluate the non-medical use of opioids scored higher on the OMC (4.50 vs. 2.57), lower on the BPI average pain score (7.35 vs. 9.46), and higher on the BPI functional impairment score (7.75 vs. 6.51). Higher scores on the OMC were also found, although not significant, in those subjects meeting criteria for DSM-IV opioid use disorder (3.25 vs. 2.8) and those scoring positively (>9) on the SOAPP scale (3.4 vs. 2.5).

    Conclusions:  Although continuing research is needed, preliminary results indicate that patients referred for psychiatric consultation to evaluate the non-medical use of opioids tend to score higher on the OMC than patients referred for other psychiatric indications.

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    Nine-Year-Old Male with Catatonia Secondary to Non-Convulsive Status Epilepticus
    Presenting Author:  Donette Svidron
    Co-Authors:  Kristin Dalope, Kalonda Bradshaw, Roberto Ortiz-Aguayo

    Purpose:  To describe the case of a child presenting with catatonia found to be secondary to non-convulsive status epilepticus. To our knowledge, there are very limited case reports of catatonia presenting as a manifestation of non-convulsive status epilepticus in the pediatric population.

    Method:  Case descriptions and literature review.

    Results:  The patient is a 9 yo male diagnosed with ADHD NOS and ODD with prior medical history only significant for an intensive care admission for Trazadone toxicity at five years of age. On day of admission he presented to hospital with lethargy. He had not recently received any of his prescribed medications and there were concerns for ingestion of an unknown pill. Physical exam was significant for 3+ cogwheeling in all extremities, hypersomnolence, bilateral ankle clonus, automatisms, echopraxia, echolalia, and waxy flexibility. A diagnostic and therapeutic trial with lorazepam led to temporarily improved alertness and motor function. A diagnosis of catatonia is made at this time. His presentation fluctuated between stupor and catatonic excitement. Toxicology screens were negative. EEG was ordered as part of work up for catatonia. Non-convulsive status epilepticus was confirmed. Treatment with clonazepam and levetiracetam lead to sustained clinical and electroencephalographic improvement. Subsequently he tolerated re-challange with home medication regimen of mixed-amphetamine salts and guanfacine. Patient was discharged home on prior medication regimen as well as levetiracetam, pyridoxine, clonazepam, and benztropine. At one and six month follow up visits, there was no recurrence of catatonic symptoms or seizure.

    Conclusions:  Catatonia is a condition with a wide range of etiologies. Although catatonia has been well described in adult psychiatry literature, less is known about this condition in children. Here we described catatonia as the presenting symptom of non-convulsive status epilepticus in a prepubescent boy with multiple psychiatric co-morbidities but no history of mood disorder, psychosis or epilepsy. This underscores the importance of early symptom recognition, thoughtful differential diagnostic formulation and consideration of EEG as part of clinical assessment. Prompt implementation of treatment is likely to reduce symptom burden and morbidity.

    References:

    Fink M, Taylor MA. Catatonia: A clinician's guide to diagnosis and treatment. Cambridge: Cambridge University Press, 2006

    Lahutte B, Cornic F, Bonnot O, et al. Multidisciplinary approach of organic catatonia in children and adolescents may improve treatment decision making. Prog Neuropsychopharmacol Biol Psychiatry 2008; 32;1393-8

    Lim J, Yagnik P, Schraeder P, Wheeler S. Ictal catatonia as a manifestation of non-convulsive status epilepticus. J Neurol NeurosurgPsychiatry 1986;49;833-6

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    Comorbidity of Mental Disorders in Japanese Obese Candidates for Intragastric Balloon Placement Therapy
    Presenting Author:  Yoshiyuki Takimoto
    Co-Authors:  Shuji Inada, Kazuhiro Yoshiuchi, Fumihiko Hatao, Toshimasa Yamauchi, Akira Akabayashi

    Background:  At the University of Tokyo Hospital, special treatment for obesity is provided by a multidisciplinary team. Doctors in the department of Psychosomatic Medicine are part of the team with doctors from the departments of Diabetes Metabolic Diseases Internal Medicine, Stomach and Esophageal Surgery because obesity is generally associated with some psychosocial factors. Intragastric Balloon Placement (IGB) therapy is a temporal therapy for obese patient who are refractory to conventional medical therapy. IGB placement therapy for obese patients has started since Feb.2007 at our hospital. All candidate patients for IGB placement therapy are assessed by psychosomatic medicine doctors because comorbid mental disorders may affect the course of obesity after IBP therapy.

    Methods:  Between February 2007 and 2010, thirty-three obese patients (16 male and 17 female; age 48.2 +/- 6.4years) were admitted as candidates for IGB placement therapy. In all patients, psychosocial factors and psychiatric diagnoses were assessed.

    Results:  The average of body mass index in the patients was 42.9 +/- 3.2 kg/m2. Six patients were excluded from the program of IGBplacement therapy because of their mental disorders. The mental disorders consisted of major depressive disorder in three patients, bipolar disease in one patient, mental retardation in one patient and pervasive development disorder in one patient.

    Conclusion:  Obese patients could have comorbid mental disorders. Therefore, they should be treated by a multidisciplinary medical team.

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    Psychosomatic Considerations for Patients with Substance Abuse and Its Complications across the Life Cycle
    Presenting Author:  Susan Turkel
    Co-Authors:  Elham Mizani, Mark Hrymoc, Laura Markley

    When consulting in community and hospital settings, the consultation-liaison psychiatrist is often confronted with questions of the medical complications of substance abuse and dependence. This symposium will focus on some of these questions in patients from infancy through adolescence to adulthood, and address the consequences of intrauterine exposure to drugs of abuse on newborns and growing children, the relationship of attention deficit hyperactivity disorder and substance abuse in adolescence, the impact of chronic opioid dependence on pain management in medical and surgical patients, and the identification and management of abuse of newer over the counter, "natural", and "designer drugs" currently seen in the community.

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    Prevalence and Clinical Factors of Delirium among Elderly Cancer Patients with Poor Physical Status in General Wards
    Presenting Author:  Megumi Uchida
    Co-Authors:  Toru Okuyama, Yoshinori Ito, Tomohiro Nakaguchi, Tatsuo Akechi, Shigeki Sato, Hiromitu Takeyama, Takashi Joh, Mikinori Miyazaki, Masaki Sakamoto, Takeshi Kamiya

    Purposes:  Delirium is one of the common psychiatric complications for patients with cancer. Previous studies indicated that elderly hospitalized patients and patients with advanced or terminal cancer are at high risk from delirium. It is well known that delirium is easily missed in general wards. But there were few studies which investigated its prevalence and causes of aged cancer inpatients with poor physical status in general wards.

    The purposes of this study are to explore the prevalence of delirium among elderly cancer patients with poor physical status and to investigate clinical factors which are useful to identify at risk patients for delirium with cancer in general wards.

    Method:  Patients aged 65 or older with lung malignancy or gastroenterological cancer were continuously sampled when admitted to the university hospital. If they met eligibility criteria, they were invited to the survey. Eligibility criteria were as follows: (A) incurable cancer (B) poor Eastern Cooperative Oncology Group (ECOG) performance status (defined 2-4 on a 0-4 scale) (C) general conditions which were sufficient to enable the completion of the survey (D) no plans to have operations. Psychiatrists diagnosed delirium by DSM-IV-TR and participants were assessed using the Delirium Rating Scale-Revised-98 (DRS-R98) within 4 days of admission. We selected assumed delirium related factors from data which clinicians could get easily. We sought clinical information through medical records and oncologists answered clinical prognosis prediction, Palliative Performance Scale (PPS) and Palliative Prognostic Index (PPI). In addition, patients were asked about their demographic data and physical symptom. This study was approved by the Institutional Review Board and written informed consent was obtained from each patient. If patients were incompetent, we obtained both oral consent from them and written consent from their proxies.

    Results:  Among eligible 73 patients, complete data were available from 58 patients. The mean ± SD and median age were 73.2 ± 5.5 and 73 respectively. The original cancer sites are lung (74% n=43) and digestive organ (26% n=15).Their ECOG performance status are 2 (38% n=22), 3(41% n=24) and 4(21% n=12). 26 patients (44.8 (95%CI: 32 to 58) %) met DSM-IV-TR delirium criteria. Subtypes of delirium defined by DRS-R98 were as follows: 15 patients were hypoactive delirium (25.9%), 1 patient was mixed (1.7%) , 1 patient was hyperactive (1.7%) and 9 patients were subthreshold (15.5%). Patients with higher scores of PPI and prescriptions of steroid were more vulnerable to delirium.

    Conclusion:  The prevalence of delirium among aged cancer patients with poor physical status in general wards just after their admission was as high as that of among patients in palliative care wards. In addition, more than half delirious patients were diagnosed as hypoactive subtype and easy to be missed.

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    Prevention of Delirium in a Hospitalized Elderly Population: The Need for Standardized Physician and Nursing Interventions
    Presenting Author:  Karina Uldall
    Co-Authors:  Jessica Dunn, Kellie Meserve, Beth Irby

    Purpose:  To identify common causes of hospital-acquired delirium (HAD) among older adults admitted to a private, non-profit urban medical center in order to develop a comprehensive, standardized delirium prevention protocol.1,2

    Methods:  Patients admitted to the Acute Care of the Elderly (ACE) Unit at a 336 bed private, non-profit urban hospital were assessed on admission and every 12 hours thereafter using the Confusion Assessment Method (CAM)3 by nursing staff trained in the use of the CAM. Data were collected over a two week study period. HAD was defined as CAM negative screening on admission and during the first 24 hours of hospitalization, followed by CAM positive screening thereafter. All patients were monitored for 15 factors commonly associated with delirium: alcohol/benzodiazepine withdrawal, anemia, dehydration, elimination problems, fever, foley catheter use, immobility, infection, medications, metabolic abnormalities, malnutrition, hypoxemia, restraint use, sensory deprivation/ overload, and sleep impairment. Patients with HAD were compared to non-delirious patients using 2-tailed t-tests and Chi-square analyses with respect to demographics and type/number of factors associated with delirium. Standardized physician and nursing interventions were developed to address each of the factors associated with HAD.

    Results:  Of the 63 patients admitted, 33% were delirious at admission and 16% developed HAD. Patients with HAD were significantly older (t -3.6, df 40, p<0.001) than non-delirious patients. There was no significant difference between the frequency of individual factors associated with delirium in the non-delirious and hospital-acquired delirious group. Elders with hospital-acquired delirium were significantly more likely to have multiple, simultaneous factors contributing to the presence of delirium (t -4.8, df 40, p < 0.0001), with HAD patients having a mean 4.3 factors compared to 2.4 factors in the non-delirious group.

    Conclusions:  Delirium is typically caused by multiple, co-occurring factors in an elderly population, offering several opportunities for physician and nursing interventions to avoid the "tipping point" after which delirium occurs. Methods for implementing 15 standardized interventions in a non-academic, community setting and the effectiveness of those interventions will be presented.

    References:

    1. Inouye SK, Schlesinger MJ, Lydon TJ. Delirium: A Symptom of How Hospital Care Is Failing Older Persons and a Window to Improve Quality of Hospital Care. Am J Med 1999; 106:565-573

    2. Inouye SK, Bogardus ST, Charpentier PA, et al. A Multicomponent Intervention to Prevent Delirium in Hospitalized Older Patients. NEJM 1999; 340:669-676

    3. Inouye SK, van Dyck CH, Alessi CA et al. Clarifying Confusion: the Confusion Assessment Method: a New Method for Detection of Delirium. Ann Intern Med 1990; 113: 941-8

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    Risk Factors for Delirium in Patients Undergoing Hematopoietic Stem Cell Transplantation
    Presenting Author:  Michelle Weckmann
    Co-Author:  Leigh Beglinger

    Background:  Increasingly, non-hospice palliative care teams are asked to provide care for cancer patients undergoing hematopoietic stem cell transplant (HSCT). Evidence suggests that early recognition and treatment of delirium can improve long term outcomes yet little is known about the risk factors for delirium in this population.

    Research Objectives:  Determine the risk factors for delirium in hospitalized patients following stem-cell transplantation.

    Methods:  Fifty-four patients admitted to an academic hospital for HSCT were assessed prospectively throughout their stay for delirium using The Memorial Delirium Assessment Scale (MDAS) and the Delirium Rating Scale (DRS). Patient's self-reported medical history and computerized medical records were used to identify transplantation risk factors.

    Results:  The incidence of delirium (MDAS ≥ 8 orDRS >12) was 34% and occurred with highest frequency during the initial 2 weeks following transplantation. Post-transplantation risk factors for developing delirium were higher serum creatinine, higher blood urea nitrogen, lower creatinine clearance, and hypoxia; additionally, lower albumin and lower hemoglobin showed a correlation but were not statistically significant. There was no observed association with functional status, transplant type, disease severity, medical comorbidity, sex, age, or conditioning regimen.

    Conclusions:  At least a third of patients who undergo HSCT experience an episode of delirium after transplantation. Fewer risk factors than expected where associated with delirium in this patient population, but the associated risk factors (BUN, Cr, hypoxia) were routinely followed. Consideration should be given to closely monitoring the mental status of HSCT patients for the 48hrs following abnormal l

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    Decisional Aides to Help Train Non-Psychiatrists in Evidence-Based Use of Antipsychotics for Dementia
    Presenting Author:  Michelle Weckmann
    Co-Author:  Ryan Carnahan

    Purpose:  Behavioral disturbances and psychosis in dementia pose significant challenges to healthcare providers and family caregivers. Atypical antipsychotics have been the mainstay of treatment for a number of years. However, evidence has shown that they may have limited effectiveness, and increase the risk of mortality and cerebrovascular events among users with dementia [1]. Despite these warnings, antipsychotic use in people with dementia remains common. Training providers to understand other aspects of care that impact behavioral disturbances, and appropriate antipsychotic selection and use, may improve antipsychotic utilization patterns and, as a result, the safety and quality of life of people with dementia.

    Iowa is a state with a significant number of rural practitioners; we obtained funding to develop innovative ways of reaching out to clinicians who may lack access to local expert consultation with psychiatric specialists. The AHRQ-funded comparative effectiveness research review and summary guide (CERSG) on off-label antipsychotic use provides an excellent overview of the evidence on efficacy, effectiveness, and adverse events of antipsychotics in patients with dementia. [2,3]

    Methods:  We formed a collaboration between the University of Iowa Older Adults Center for Education and Research on Therapeutics, the Iowa Geriatric Education Center, the Iowa Foundation for Medical Care, and Iowa Health Systems to adapt and disseminate the CERSG within a comprehensive program to guide providers in the care of patients with dementia and behavioral disturbances. The initial focus is on reaching providers in rural Iowa, but we believe these clinical decision aids and educational material have a wider appeal.

    Results:  We designed and modified (based on focus groups) numerous adaption products. These include a series of case-based presentations available in electronic formats targeted towards clinicians and direct care providers; decision aides to guide care in print, web, and personal digital assistant formats; and products for patient families including a guide to facilitate shared decision making on antipsychotic use.

    Conclusion:  We believe these products are a useful way to educate primary care providers and nursing home staff on evidence based antipsychotic use for behavioral challenges in dementia. The purpose of this paper session is to inform and share the developed products.

    References:

    1. Jeste DV et al. ACNP white paper: update on the use of antipsychotic drugs in elderly persons with dementia. Neuropsychopharmacology 2008;33:957-70

    2. Shekelle P et al. Comparative Effectiveness of Off-Label Use of Atypical Antipsychotics. Available at: http://effectivehealthcare.ahrq.gov/index.cfm/search-for-guides-reviews-and-reports

    3. Saha S et al. Comparative Effectiveness of Off-label Use of Atypical Antipsychotic Drugs. A Summary for Clinicians and Policymakers, AHRQ Pub. No. 07-EHC003-2. Available at: http://effectivehealthcare.ahrq.gov/index.cfm/search-for-guides-reviews-and-reports/

  166. A Primary Role for Autonomic Imbalance in the Development of Metabolic Syndrome
    Presenting Author:  Lawson Wulsin
    Co-Author:  Jennifer Perry

  167. [Withdrawn]
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    Screening for Mental Illness in the Medical Setting
    Presenting Author:  Paula Zimbrean
    Co-Authors:  Fatimah Tahil, Christine Skotzko, Ani Annamalai, Lydia Chwastiak

    The prevalence of untreated mental health issues in medical setting is a well recognized problem nationwide and is considered to be related with increased morbidity, lower quality of life and increased health care costs. Attempts are being made at perfecting screening instruments in particular populations or targeting specific diagnosis. This workshop will present recent results in implementing screening for mental illness in particular medical settings: postpartum women in OBGYN clinics, refugee primacy care clinics and cardiology/cardiac surgery programs. We will discuss modalities to ensure adequate interventions following positive screening results.

    Dr Fatimah Tahil, will present the implementation of the mandatory postpartum screening for postpartum depression (PPD). On an institution basis, the Edinburgh Postnatal Depression Scale (EPDS) was adopted and a system process was developed using a multi-disciplinary approach. Guidelines were developed to trigger appropriate referrals and intervention to social workers and to Psychiatric consultants Dr Tahil will describe the legal background for this action, the results of the screening and the interdepartmental programmatic process from screening to referral.

    Dr. Paula Zimbrean and Dr. Ani Annamalai, will present the introduction and results of a mental health screening for refugees in a Primary Care Clinic over a two year period. Refugees carry a high prevalence of anxiety and depressive disorders. Any mental health intervention must be validated for specific language and cultures. In addition, the socio-demographic profile of the refugee population is changing continuously, which requires repeated revisions of screening for psychiatric disorders. Will describe the challenges of implementing the screening in this population and based on our results, future directions of development.

    Dr. Christine Skotzko will address ongoing attempts to implement screening for depression in Cardiology programs at a large not for profit health care institution. Despite extensive research documenting the impact of depression on morbidity/mortality and numerous well validated tools, unexpected areas of resistance consistently work against implementation. An overview of prospective planning required to assure that positive screens will get necessary assessment and referrals for psychiatric care will be presented.

    Participants will be encouraged to discuss their experience with screening for mental illness in various settings and future directions.

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    Comparison of Standard Traige versus Psychiatric Triage in a General Emergency Department
    Presenting Author:  Leslie Zun
    Co-Author:  Lavonne Downey

    Objectives:  The purpose of the study was to compare the current, standard emergency department triage protocol (Canadian system) for all patients to triage protocol specific for psychiatric patients (Australian Triage) for patients presenting with behavior complaints. The secondary purpose is to ascertain whether psychiatric triage better assesses the patient's need for intervention.

    Methods:  A convenience sample of patients who presented with a psychiatric complaint at triage was given the normal triage assessment by the nurse at triage. A secondary triage assessment using the Australian psychiatric triage protocol was performed by a research fellow that includes all observed and reported elements of the psychiatric triage, agitation assessment using the Richardson Agitation Sedation Scale (RASS), and a patient's self-assessment of the degree of psychiatric distress and agitation.

    Results:  A total of 100 patients were enrolled in the study Their initial triage score using the Canadian system was divided with 48% being urgent, 25% emergent, 11% resuscitation, 13% less urgent and 4% non urgent. The Australian Psychiatric triage categories were less divided with 75% coding as no danger to self or others, 18% scoring as in moderate distress, 6% possible danger and 1% definite danger to self and others. There was no significant relationship between the standard triage, RASS scores, self assessment questions, and total minutes in the ED or throughput times. The only significant relationship was between the psychiatric triage and the RASS scores (F=18.5, p- .00) and some of the self assessment questions.

    Conclusions:  The use of the standard system (Canadian) does not correlate with patients being seen within the time frames recommended, the patients self assessment of urgency, and the RASS system of rating symptoms of psychiatric presentations. The psychiatric triage system (Australian) rated the patients as much less urgent as compared to the standard system. It did however, correlate with the RASS system and the patient's own self assessment.

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    Attitudes Toward People with HIV or AIDS in a Ukrainian Population
    Presenting Author:  Nataliya Zhabenko
    Co-Author:  Olena Zhabenko

    Background:  According to the report of UNAIDS in 2009, the Ukraine has the second highest number of annual HIV infections in the European Region. Stigmatization and discrimination against people with HIV is the number one issue for those individuals. People infected with HIV could be avoided by society; stigma is associated with different health-related problems. The purpose of this study was to evaluate medical practitioners' and nonmedical specialists' attitudes toward people with HIV or AIDS.

    Methods:  180 individuals took part in this exploratory study. Sample comprised 83.4% medical practitioners (medical students were included); the rest participants were people without medical education. Participants were 51.7% women with a mean (SD) age of 30.6 (12.9). Participants completed a short demographic survey. Acceptance of people who have AIDS or are infected with HIV was assessed with the self-administered 10-item instrument "Attitudes toward people with HIV or AIDS" (it was selected from the Centers for Disease Control and Prevention, the Handbook for Evaluating HIV Education). Total scores can range from 50 points (high acceptance of persons with HIV or AIDS) to 10 points (low acceptance of persons with HIV or ADIS). In the current study, the Cronbach alpha coefficient was .78. Descriptive statistics were used to characterize the sample and bivariate correlation examined the relationship between two variables.

    Results:  The mean total score in the scale was 37.3 (SD = 6.1). Age was associated with positive attitudes toward people with HIV and AIDS (p<.05). Younger participants reported higher acceptance of persons with HIV or AIDS. No significant differences between gender and attitude toward people with HIV or AIDS were found (p>.05). As expected, medical practitioners showed greater total score, compare to nonmedical specialists (38.0 ± 6.0 vs. 34.0 ± 5.5, respectively, p<.05). A one-way between-groups analysis of variance was conducted to explore the impact of medical specialty on levels of positive attitudes toward people with HIV or AIDS. Medical practitioners were divided into 4 groups according to their specialty (surgeons, therapists, psychiatrists, students). There was not a statistically significant difference at the level in total score for the 4 groups.

    Conclusion:  In this study we evaluated the level of attitudes toward people with HIV or AIDS in a Ukrainian population. Young age and having medical education were significantly associated with the positive attitudes toward people with HIV and AIDS.


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