Collage of 2012 Meeting Locale

ACADEMY OF PSYCHOSOMATIC MEDICINE • 59th Annual Meeting

Bioethics at the Interface of Psychiatry & Medicine

November 14–18, 2012

InterContinental Buckhead Hotel, Atlanta, GA


Home > Annual Meeting > 2012 > Program Schedule > Session Details, Oral Papers


ORAL PAPER PRESENTATIONS
Friday, November 16, 2012  •  10:30 AM – 12:30 PM

and Dlin/Fischer Award
for the best paper submitted for presentation at the Annual Meeting
Friday, November 16, 2012  •  9:30 – 10:15 AM

 
Session A: Cardiology
  B: Delirium
  C: Ethics / Oncology
  D: Primary and Collaborative Care
  E: Surgery / Transplant
  F: Potpourri
  G: Webb Fellows
  [T] = Trainee Paper

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Dlin/Fischer Award
for the best paper submitted for presentation at the Annual Meeting

Post-traumatic Stress and Depressive Symptoms, Alcohol Use and Cognitive Impairment Three Months After Medical-Surgical Intensive Care Unit Admission: A Prospective Cohort Study
Presenting Author:  Dimitry Davydow, MD, MPH
Co-Authors:  Douglas Zatzick, Catherine Hough, Wayne Katon

Background: Millions of Americans are admitted to intensive care units (ICUs) annually. Prior studies have suggested that critical illnesses and their treatments may increase risk for adverse mental health outcomes, though few have taken into account prior psychiatric history. This study examines potential risk factors for posttraumatic stress disorder (PTSD) and depressive symptoms, alcohol misuse, and cognitive impairment in non-traumatically injured ICU survivors three months after hospitalization.

Methods: We prospectively enrolled 150 non-trauma patients without cognitive impairment admitted to an ICU for ≥ 24 hours. Demographics and clinical information were obtained through medical record review and in-person interview. The baseline interview included assessment of acute stress symptoms with the PTSD Checklist-civilian version (PCL-C), lifetime history of major depression with the Mini International Neuropsychiatric Interview major depressive episode module, and alcohol misuse with the Alcohol Use Disorders Identification Test (AUDIT). Outcomes were obtained 3 months post-ICU through telephone interviews. The follow-up interview included assessment of PTSD symptoms with the PCL-C, depressive symptoms with the Patient Health Questionnaire-9, post-ICU alcohol use with the AUDIT, and cognitive function with the Telephone Interview for Cognitive Status. We used multiple linear regression to examine potential risk factors for all outcomes.

Results: At baseline, 38.9% had a history of psychiatric illness or substance abuse documented in their medical records, 29% met criteria for lifetime history of major depression, 13.4% exhibited problematic drinking behavior in the year pre-ICU, and 15.4% had in-hospital probable acute stress disorder (ASD). Follow-up interviews were completed with 131 (87.3%) patients. Patients who did not complete follow-up were less educated and were more likely to be admitted to the ICU for a gastrointestinal diagnosis. At 3 months post-ICU, 29.8% had clinically significant depressive symptoms, 16% had clinically significant PTSD symptoms, 29% had mild or moderate cognitive impairment and 13.7% had severe cognitive impairment, while only 3.8% exhibited problematic drinking behavior. In multiple linear regression, in-hospital probable ASD and greater in-hospital exposure to opioids were independently associated with increased post-ICU PTSD symptoms. History of major depression, greater lifetime traumatic event exposure, in-hospital probable ASD and greater in-hospital exposure to opioids were independently associated with increased post-ICU depressive symptoms. Baseline problematic drinking, greater in-hospital exposure to benzodiazepines, and in-hospital probable ASD were independently associated with increased post-ICU alcohol use. A pre-ICU history of psychiatric illness or substance abuse, non-white race, and less education were independently associated with worse cognition.

Conclusions: Critical illness survivors have high rates of psychiatric illness before and after ICU admission, as well as a high prevalence of post-ICU cognitive impairment. Both prior psychiatric and substance use history and acute care factors may play important roles in identifying critical illness survivors at greater risk for adverse outcomes.

Objectives:

  1. The physician learner will be able to investigate potential risk factors for adverse mental health and cognitive outcomes in non-injured critical illness survivors.
  2. The physician learner will be able to investigate the prevalences of posttraumatic stress disorder and depressive symptoms, alcohol misuse, and cognitive impairment following intensive care unit admission.
  3. The physician learner will apply information learned from this presentation to identify patients surviving ICU admission for critical illnesses that may require close follow-up to prevent adverse outcomes.

Relevance:
Psychosomatic medicine providers care for critical illness survivors in inpatient and outpatient care settings, making this presentation ideal for this specific audience.

 

Session A:  Cardiology
Moderator/Discussant:  Lawson Wulsin, MD, FAPM

Psychological Correlates of Patients with Non-Cardiac Chest Pain and Effects of Treatment
Presenting Author:  Edwin Meresh, MD, MPH
Co-Authors:  Matthew Niedzwiecki, Vidushi Savant, Aparna Sharma, Paula Olivieri, Angelos Halaris

Rationale: Non-cardiac chest pain (NCCP) defined as persistent angina-like chest pain with no evidence of cardiac impairment is a common functional somatic symptom. Patients presenting with functional somatic symptoms are likely to have associated depression, anxiety, somatosensory amplification and specific personality traits [1]. Personality and emotional factors are common in NCCP patients and are associated with health care utilization leading to high health care costs [2]. The management of psychosomatic syndrome such as NCCP is challenging, with antidepressants being used at times to treat pain perception and co-morbid depression and anxiety. It is unclear whether psychological traits and somatosensory amplification associated with NCCP also respond to antidepressants. Following is an analysis of NCCP patients with depression, anxiety, illness behavior and somatosensory amplification, before and after escitalopram treatment.

Study Design: This open-label pilot study included patients diagnosed with NCCP. The screening assessment included completion of the 62- item Illness Behavior Questionnaire (IBQ), a self-report instrument used to measure patient's attitudes, ideas, affects, and attributions in relation to illness, State Trait Anxiety Inventory (STAI), Somatosensory Amplification Scale (SAS), Hamilton Rating Scale for Depression (HAMD), Hamilton Rating Scale for Anxiety (HAMA), Beck Depression Inventory (BDI) and the McGill Pain Questionnaire (MPQ). Subjects underwent a baseline assessment (visit 2) and received escitalopram in gradually increasing doses. They were reassessed at weeks 2, 4, 8, and 12. Subjects completed HAMD, HAMA, BDI and MPQ at weeks 2, 4, 8 and 12, IBQ, STAI & SAS at week 12. Escitalopram blood levels were measured at specified visits.

Preliminary Results: NCCP group (n=8) IBQ score mean baseline/post treatment. was: 24.5/18.25 (p<0.015), general hypochondriasis: 4.875/3.625 (p<0.012), disease conviction: 4.625/3.75 (p<0.131), psychologic vs. somatic perception of illness: 1.875/2 (p<0.407), affective inhibition: 3.875/2.75 (p<0.053), affective disturbance:3.875/2.75 (p<0.053), denial:1.75/1.875 (p<0.381), irritability 3.625/2 (p<0.006).

MPQ score mean baseline/post treatment: 21.125/ 8.125 (p<0.002), HAMA: 30.5/ 8.875(p<0.0005), HAMD: 23.75/7.125 (p<0.002), BDI: 25.125/12.75 (p<0.004). State Anxiety Inventory: 57.75/45.625 (p<0.004) Trait Anxiety Inventory: 53/47 (p< 0.099), SAS: 30.5/29.25 (p<0.206)

Conclusion: This pilot study indicates that patients with NCCP exhibit abnormal illness behavior, underlying somatosensory amplification, increased pain perception, anxiety and depression. Treatment with escitalopram decreased abnormal illness behavior, pain perception, depression and anxiety. Although state anxiety improved, trait anxiety and somatosensory amplification did not. Within the Illness Behavior Questionnaire, general hypochondriasis and irritability improved significantly. Further studies are needed to determine whether personality traits in NCCP patients may be amenable to specific psychotherapeutic interventions in addition to medications.

References:

1. Wise TN, Mann LS. The relationship between somatosensory amplification, alexithymia, and neuroticism. J Psychosom Res. 1994 Aug;38(6):515-21

2. White KS et al. Alexithymia and anxiety sensitivity in patients with non-cardiac chest pain. J Behav Ther Exp Psychiatry. 2011 Dec;42(4):432-9

Objectives:

  1. Physician learner will apply information from this presentation to diagnose and treat psychiatric co-morbidities of non cardiac chest pain.
  2. Physician learner will understand the concept of abnormal illness behavior in patients with non cardiac chest pain.
  3. Physician learner will be able to look for personality traits in patients with non cardiac chest pain.

Relevance:
Non-cardiac chest pain is associated with patient suffering and health care costs. This presentation will address the psychiatric comorbidities in patients with non-cardiac chest pain and treatment.

[T] Depressive Symptoms after CABG Surgery: A Meta-Analysis
Presenting Author:  Simha Ravven, MD
Co-Authors:  Caroline Bader, Armin Azar, James Rudolph

Objective: Depression is highly comorbid with coronary artery disease (CAD). Clinicians face the question of whether patients' depressive symptoms will improve after CABG. The objective of this meta-analysis was to determine course of depressive symptoms after CABG surgery.

Method: Scientific databases were searched for studies assessing depression before and after CABG. Meta-analyses were performed for depression at early (1-2 weeks), recovery (>2 weeks - 2 months), mid (>2 months - 6 months), and late (>6 months) time points. Relative Risk (RR) was calculated for dichotomous depression outcomes. For continuous depression outcomes, the standardized mean difference (SMD) was calculated for each postoperative time point. The analyses were stratified by timing of preoperative depression assessment: proximal (≤1 week), and remote (>1 week) baseline. Heterogeneity and publication bias were analyzed.

Results: Thirty-nine studies were included in the meta-analysis. Twelve reported ichotomous outcomes, 18 reported continuous outcomes, 9 reported both. In studies with dichotomous depression outcomes, risk of depression was increased early (RR 1.27, 95% CI 1.01-1.61). There was a significantly decreased risk of depression at recovery (RR 0.78, 95% CI 0.67-0.90), mid (RR 0.64, 95% CI 0.58-0.70) and late (RR 0.68, 95% CI 0.58-0.79) time points without heterogeneity. In studies with continuous depression outcomes, timing of pre-operative depression assessment was important. When depression was assessed >1 week before surgery, there was a significant reduction in depressive symptoms at the recovery, mid, and late time points.

Conclusions: Risk of depression decreased post-CABG in both dichotomous and continuous variables. While depression improves overall after CABG, not all patients will experience improvement. The timing of preoperative and postoperative depression is important. Assessing depression> 1 week before surgery and >2 weeks after yields more clinically meaningful results.

Objectives:

  1. To understand the time course of depressive symptoms after coronary artery bypass graft surgery from an evidence-based perspective.
  2. To learn when to screen for depression before and after CABG surgery.
  3. To learn the importance of depression screening in those with coronary artery disease.

Relevance:
Depression iscomorbid with CAD. Clinicians face the question of whether patients' depressive symptoms will improve after CABG. This presentation is relevant to C-L psychiatrists and those in general practice.

Ethical Challenges in Advanced Heart Failure: Integrating Palliative Care into LVAD and Heart Transplant Teams
Presenting Author:  Anne Eshelman, PhD
Co-Authors:  Celeste Williams, Leslie Bricker

Over 5.7 million in the US have heart failure (HF), 20% of the population, with 670,000 new diagnoses each year. HF care, including medications, transplantation, and devices costs $39 billion per year (1).

Cardiologists and thoracic surgeons are motivated to rescue people from death from acute heart attacks, saving lives, but then are left treating chronic HF. When aggressive treatment options have been exhausted, patients may be referred to palliative medicine (PM) as a last resort. Those who choose to specialize in heroic rescue strategies may see this as a failure, and withdraw emotionally. Referral may be seen by patients and families as giving up and abandonment.

PM doctors may only meet patients when they are physically, emotionally, and cognitively debilitated. Integrating PM and advanced care planning before initiation of aggressive interventions for HF may provide better care for patients and families.

In order to give informed consent for a transplant or device, patients need to consider their values and meaning of quality of life. The process often falls short, with many patients not fully understanding risks and benefits, and 70% of surgical patients not actually reading consent forms (2). Even if the process is effective, patients' wishes may change over time with the reality of advancing illness.

The transition from heroics to hospice may not be smooth. End of life decisions are common in patients with ventricular assist devices (VAD). In a study of 68 VADs implanted at the Mayo Clinic, 54% requested withdrawal of the device when they felt quality of life not consistent with their values (3). Only 2 had decisional capacity and 12 decisions were made by surrogates.

We present an initiative integrating PM before transplant or device implantation, with a family meeting to address end of life issues. Facilitating communication, discussing goals of care and "what if ?" scenarios early can reduce later stress for patients, family and staff when decisions must be made. Advance directives can be clarified for patients and family, beginning the ongoing discussion that continues as medical status and preferences change.

We describe brief case vignettes and the process: 1) Introduction of the need for end of life planning to the heart transplant (HT)/VAD team, 2) Education of PM team on HT and VADs, 3) implementation of routine PM consults, 4) Active role of PM on the HT /VAD team, and 5) Collaboratively developing guidelines for withdrawal of devices at patient request.

References:

1. Hunt SA et al. J Am Coll Cardiol. 2005.

2. Krumholz,H. JAMA 2010 303(12) 1190. Informed Consent to Promote Patient-Centered Care.

3. Mayo Clinic Proceedings 2010 vol 85(9), p 791-7

Objectives:

  1. Participants will learn the value of collaboration between palliative medicine and heart failure teams.
  2. Understand the process to develop collaboration between palliative medicine and heart failure teams.
  3. Review ethical issues from the perspective of patients and families, as well as medical teams.

Relevance:
C-L Psychiatrists and health psychologists have the opportunity to facilitate collaboration between heart failure and palliative medicine teams.

Psychotropic Exposures and Hypertensive Disorders of Pregnancy
Presenting Author:  Amy Hostetter, MD, MSc
Co-Authors:  Sarah H. Juul, Emily Stagnaro, Bettina T. Knight, Zachary N. Stowe, D. Jeffrey Newport

Purpose: Hypertensive disorders complicate 12-22% of pregnancies, accounting for approximately 16% of maternal deaths in developed countries. Gestational hypertension can result in placental abnormalities, small for gestational age infants, preterm delivery, as well as preeclampsia, eclampsia, and HELLP. Several psychotropic medications have been associated with non-puerperal hypertension, but little is known about such risk in pregnancy. As more than one-third of pregnant women in the United States take a psychotropic medication, understanding all reproductive risks of these agents is mandatory. This study aimed to describe the relationship between commonly used psychotropics and hypertensive disease in pregnancy (gestational hypertension, preeclampsia, eclampsia, and HELLP syndrome).

Methods: A cohort of 600 pregnant women presenting to the Emory Women’s Mental Health Program was included in the study. Women with chronic hypertension were excluded (n=12). Clinical and demographic characteristics, such as maternal age, race, obesity, nulliparity, and third trimester exposures to antidepressants, mood stabilizers, stimulants, anticonvulsants, atypical antipsychotics, benzodiazepines, tobacco, and caffeine were evaluated as potential predictors of hypertensive disorders in pregnancy by logistic regression analysis. As known risk factors, advanced maternal age, obesity, nulliparity, and black race were included as a priori covariates in the model.

Results: 76 women (12.7%) developed a hypertensive disorder in pregnancy (gestational hypertension (n=42), preeclampsia (n=30), eclampsia (n=3), and HELLP syndrome (n=1)). Adjusting for confounders, logistic regression revealed third trimester exposures to SNRIs (OR=2.18, p=0.02) and stimulants (OR=7.56, p=0.004) were significantly associated with hypertensive disorders in pregnancy. As expected, obesity (OR =2.39, p=0.007) and nulliparity (OR=2.07, p<=0.007) were also associated with hypertensive disorders in pregnancy. Post hoc analysis of venlafaxine dose-response effects revealed a marked increase in gestational hypertension (46%) when the dose exceeded 225 mg/day.

Conclusions: SNRI and stimulant use during the third trimester was associated with hypertensive disorders in pregnancy. In contrast to previous study, SSRI use was not associated with hypertensive disease of pregnancy. Given the morbidity and mortality of hypertensive disorders during pregnancy, these findings should be considered when counseling women on the use of SNRIs and stimulants in pregnancy, and frequent monitoring of blood pressure is advised with use of these medications.

Objectives:

  1. Understand the prevalence and associated morbidity of hypertensive disorders in pregnancy.
  2. Identify risk factors for hypertensive disorders of pregnancy, including some psychotropic medications.
  3. Counsel pregnant women effectively on the risk of hypertensive disorders of pregnancy when exposed to psychotropic medications.

Relevance:
This study furthers our understanding of the risk of hypertensive disorders among pregnant women exposed to psychotropic medications, which is relevant to variety of mental health practitioners.

Metabolic Risk in HIV-Infected Patients Receiving Atypical Antipsychotics
Presenting Author:  Carrie Ernst, MD
Co-Authors:  Madeleine Fersh, Catherine Daniels-Brady, Kimberly Klipstein

Purpose: A number of studies have linked HIV antiretroviral therapy (HAART) with metabolic abnormalities. At the same time, atypical antipsychotics are often associated with metabolic disturbances, prompting concern about their use in already high-risk populations. There is sparse research on prevalence, safety, and indications for atypical antipsychotic prescribing among HIV+ patients with psychiatric disorders.

Methods: We conducted a retrospective chart review of all HIV patients seen by psychiatrists over a 1 month period at a large, urban, academically-based clinic and examined metabolic parameters and other clinical characteristics associated with antipsychotic use.

Results: Of 101 subjects, 35 were prescribed an atypical antipsychotic (34.6%). Among the atypical antipsychotic recipients, 26% were diagnosed with schizophrenia or schizoaffective disorder, 20% with bipolar disorder, 23% with MDD, and 51% with a comorbid or independent anxiety disorder (including PTSD). Nearly all antipsychotic recipients (31/35) had at least one risk factor for metabolic syndrome and 7/35 [31%] had 3 or more metabolic risk factors. One in 5 antipsychotic recipients had a BMI >30, 17/35 (49%) had hypertension, and 10/35 (29%) carried a diagnosis of Type II diabetes. Consistent with prior reports, CD4+ count was moderately but significantly correlated with number of metabolic risk factors (r=.28, p=.005). Among patients diagnosed with a dyslipidemia (n=33), 17 (52%) were taking an antipsychotic, while patients with no diagnosed dyslipidemia less often took an antipsychotic (18/68, or 26%) (p=.013). Additionally, medications for dyslipidemias were taken by more antipsychotic recipients (13/35) than antipsychotic non-recipients (12/65) (p=.04).

Conclusions: Analysis shows that about a third of HIV patients at an urban, academic medical clinic are receiving atypical antipsychotics for a host of psychiatric conditions including off label indications such as anxiety disorder. Metabolic disturbances appear highly prevalent among these patients. Clinicians should therefore thoughtfully assess risks and benefits in making pharmacotherapy decisions in such patients.

References:

1. Freudenreich O, Goforth HW, Cozza KL, et al. Psychiatric treatment of persons with HIV/AIDS: An HIV-Psychiatry Consensus Survey of Current Practices. Psychosomatics 2010; 51:480-488

2. Maglione M, Maher AR, Hu J, et al. Off label use of atypical antipsychotics: an update. Rockville (MD): Agency for Healthcare Research and Quality (US); 2011 Sep. Report No.: 11-EHC087-EF.

3. McKean A, Monasterio E. Off-label use of atypical antipsychotics: Cause for concern? CNS Drugs 2012; Epub ahead of print

4. Mondy K, Overton ET, Grubb J, et al. Metabolic syndrome in HIV-infected patients from an urban midwestern US outpatient population. Clin Infect Dis 2007; 44: 726-734

5. Vergara-Rodriguez, Pamela. Metabolic syndrome and associated cardiovascular risk factors in the treatment of persons with human immunodeficiency virus and severe mental illness. Pharmacology & therapeutics 2009; 124: 269-278

Objectives:

  1. Identify risk factors for metabolic syndrome in HIV-infected patients receiving atypical antipsychotics.
  2. Examine atypical antipsychotic prescribing patterns amongst outpatients in an urban academic HIV clinic.
  3. Reinforce the role for collaboration between psychiatrists and primary care physicians in managing adverse metabolic effects of psychotropics prescribed in a medically compromised patient population.

Relevance:
This presentation will familiarize attendees with information on the prevalence and characteristics of metabolic disturbances among psychiatric outpatients with HIV who receive atypical antipsychotics.

 

Session B:  Delirium
Moderator/Discussant:  Thomas W. Heinrich, MD, FAPM

Attitudes and Beliefs of Nurses and Trainees Regarding Delirium in the ICU Setting
Presenting Author:  Scott R. Beach, MD
Co-Authors:  Donna T. Chen, Jeff Huffman

Purpose: Up to 85% of ICU patients develop delirium at some point during their ICU stay, and delirium is a risk factor for prolonged admission, poor functional recovery, and mortality. Despite the prevalence and impact of delirium, frequently it goes undiagnosed, with as few as 30% of delirious patients actually recognized as such. Unfortunately, delirium has not been a prominent focus of medical education. Previous surveys have investigated attitudes and beliefs regarding delirium among critical care physicians and nurses working in an ICU setting. To our knowledge, this is the first investigation of the attitudes and beliefs of medical students and housestaff, and the first time that change in attitudes and beliefs has been assessed following a psychiatric intervention.

Methods: Beginning in September 2009, one author (SB) served in a newly-created role for nine months as a dedicated psychiatric consultant to an intensive care unit. The role included performing a portion of psychiatry consults for that unit and directly interacting with fourth-year medical students (MS), critical care nurses (CCN), and internal medicine residents (IM) via weekly attendance at team rounds. In July 2009, pre-intervention online surveys were distributed to clinical staff on the units (CCN: n=23; IM: n=31; MS: n=13) and two control groups (psychiatry residents [Psy: n=29] and OB/GYN residents [OB: n=10]). Participants were asked to respond to 12 statements regarding delirium on a 5-point Likert scale from "Strongly Disagree" to "Strongly Agree." Examples of statements included, "Delirium is a preventable illness" and "Obtaining a psychiatric consultation is very useful in managing patients with delirium." At the end of the nine-month intervention (June 2010), the same online survey was distributed to the same groups, though not always identical respondents (CCN=25; IM=23; Psy=23; OB=6; MS=7).

Results: IM, Psy, OB and MS groups showed no statistically significant differences between the pre- and post surveys for any of the items. For the CCN group, only responses to the statement "Patients with new onset anxiety or depression in the ICU most commonly have delirium" showed a significant change between surveys (17.39% agree vs. 56.0% agree; χ2=7.62, p=0.006).

Conclusions: Though this intervention was reported subjectively as being "very helpful" in terms of enhancing the overall care of patients, the presence of a psychiatry consultant rounding with the ICU team once weekly for nine months was not sufficient to meaningfully affect the attitudes and beliefs of trainees and nurses regarding delirium. These results strongly suggest that robust and lasting changes in attitudes regarding delirium may require more intensive efforts that could include a longer intervention, greater frequency of rounding, or additional didactic teaching.

Objectives:

  1. Participants will understand the general attitudes and beliefs of critical care nurses and trainees from various specialties regarding delirium in the ICU .
  2. Participants will anlyze the impact of an educational intervention involving an on-site psychiatric consultant on those attitudes and beliefs.
  3. Pariticpants will apply the results of the study to creating more impactful methods of changing the attitudes and beliefs of their ICU colleagues.

Relevance:
Delirium in the ICU setting represents a large proportion of consultation requests on a general C-L service, and education of our colleagues is a key role of the consultant psychiatrist.

Inflammation in Patients with Delirium?
Presenting Author:  Tatiana Falcone, MD
Co-Authors:  Kathleen Franco, Catalina Draggici, Isabel Mira-Avendano, Robert Butler, Sheridan Stull, Damir Janigro

Purpose: Different studies have reported increase of inflammatory markers in patients with delirium. In recent years, there has been a proliferation of interest in the brain-specific protein S100B, its manyphysiological roles and its behavior in various neuropathological conditions. Some studies have reported increase of S100B in patients with delirium. The main purpose of this study was to compare the levels of S100B in patients with and without delirium and investigate differences in S100B levels after the delirium was resolved.

Methods: Patients were recruited from the ICU and the CL service at Cleveland Clinic. After being diagnosed with delirium by the Consultation Liaison Fellows and Intensive Care physician, the Richmond Agitation and Sedation Scale (RASS) and the Delirium Rating Scale were obtained to assess the severity of delirium. A psychiatric interview (by the CL fellow) to assess other psychiatric comorbidities was also part of the assessment. All patients' samples underwent serum analysis of S100B.

Results: 37 patients with delirium were included; serum S100B levels were compared with 59 healthy volunteers without delirium matched by age, gender and ethnicity. Significant differences in the levels of S100B between patients with and without delirium were observed (p=0.004).

Some alterations on the monocytes levels of patients with delirium were observed. This alterations became non-significant when excluding patients with history of infection or taking antibiotics. After the delirium was resolved, levels of S100B decreased for those patients with available samples (post-delirium).

Conclusions: Inflammation may contribute to the pathogenesis of delirium. S100B may play a role helping the physician in the medical floor identify the patients with delirium early. More studies are needed to elucidate the role of pro-inflamatory cytokines in the pathophysiology of delirium.

References:

1. Van Munster B, Korevaar J, Zwinderman A et al. Time-Course of Cytokines during Delirium in Elderly Patients with Hip fractures. JAGS 56: 1704- 1709 2008

2. Van Munster B, Korevaar J, Korse C et al. Serum S100B in elderly patients with and without delirium. Int J Geriatr Psychiatr 25: 234-239 2010

3. Van Munster B, Bisschop P, Zwinderman A et al. Cortisol, Interleukins and S100B in delirium in the elderly

4. Hamed S, Hamed E and Abdella M. Septic Encephallopathy: Relationship to serum and CSF of adhesion molecules, lipid peroxides and S100B protein

Objectives:

  1. At the end of the presentation participants will be able to identify inflammatory markers increased in patients with delirium.
  2. At the end of the presentation participants will be able to identify the role of S100B in patients with delirium.
  3. At the end of the presentation C-L psychiatrist will be able to recognize the role of inflammation in the pathophysiology of delirium.

Relevance:
Delirium is one of the most frequent consults in C-L psychiatry, this presentation will focus on the role of inflammation in patients with delirium, looking at one specific biomarker S100B.

[T] Distress Associated with Delirium Experience in Critical Care Setting
Presenting Author:  Nicolas Bergeron, MD
Co-Authors:  Lison Gagné, Gabrielle Servant, Nathalie Bélanger, Marie-Claude Boily, Thien Tuong Minh Vu, Suzie Bond, Marc-Jacques Dubois

Purpose: Aim of this study is to evaluate the level of distress associated with delirium in the context of an illness requiring intensive care.

Methods: Between November 2009 and September 2011, 60 patients were evaluated using the Memorial Delirium Assessment Scale (MDAS) during an episode of delirium in a critical care setting. Patients with a history of psychotic or bipolar disorder were excluded.

Data on sociodemographic variables, reason of admission, number of days intubated, duration and psychomotor subtypes of delirium were collected.

After the resolution of delirium, consent was obtained to assess the level of distress (0-4) associated with the delirium experience for patients, family and nursing staff using the Delirium Experience Questionnaire (DEQ). The level of distress (0-4) associated with intubation and physical restraints was also evaluated.

Results: Subjects were male (80%), Caucasian (98%) with a mean age of 56 years old (SD 18.9). Thirty-three (55%) patients enrolled in the study were admitted for a general critical condition and 27 (45%) for severe burn injuries. Fifty-six (93%) were intubated for a median of 7 days (interquartile range [IQR], 2-14) and 55 (92%) went under physical restraints.

Mean MDAS score was 19.2 (SD 5.0) overall and 46 (77%) subjects presented moderate to severe levels of delirium. Median duration of delirium was 11.5 days (IQR, 5-18). Psychomotor subtypes were distributed as follow: 5 (8%) hypoactive, 28 (47%) hyperactive and 27 (45%) mixed.

The majority (83%) remembered being confused and median distress reported was 3 (IQR, 2.5-4). Recall of intubation and physical restraints were respectively 32% and 51% with associated mean distress of 2 (IQR, 1-4) and 3 (IQR, 2-4). Intubation duration was not associated with level of distress. Median distress related to delirium as experienced by a family member and caring nurse were respectively 3 (IQR, 2-4) and 1 (IQR, 0-2).

Delirium severity was overall not associated with stress response except for burn injury survivors where severe delirium was significantly associated with a light to moderate distress level (p=0.002). Duration of delirium episode and psychomotor subtypes were not associated with the different distress levels.

Conclusions: Delirium in a critical care setting produces significant distress to patients and their family. Severe delirium experienced after a traumatic burn injury may be associated with lower distress compare to a critical general condition. Hypotheses explaining a protective mechanism should be explored and include dissociation associated with trauma, alcohol or drug effect, massive analgesia and psychological denial.

Objectives:

  1. Describe the impact of delirium experienced in a critical care setting by patients, family and nursing staff.
  2. Compare the level of distress associated with delirium in relation to its severity, duration and psychomotor presentation.
  3. Compare the level of distress associated with delirium after a traumatic event causing a burn injury and an illness requiring intensive care.

Relevance:
Delirium is frequently reported as a stressful experience and severe illnesses requiring intensive care may enhance the distress. Understanding the impact of these comorbid experiences may help clinicians improve care.

Neuropathogensesis of Delirium: A Review of Current Etiological Theories & Common Pathways
Presenting Author:  Jose Maldonado, MD

Background: Delirium is a neurobehavioral syndrome caused by the transient disruption of normal neuronal activity secondary to systemic disturbances, and is characterized by disturbances of attention and other cognitive functions. The development of delirium has been associated with increased morbidity and mortality, increased risk of delivery of care to medical and nursing staff, and high levels of emotional distress to patients, families, and medical caregivers (including the development of post-traumatic stress disorder), greater care costs, poor functional and cognitive recovery, and prolonged hospital stays. Despite its high prevalence and high morbidity there is a lot that is not understood about delirium. Known risk factors for delirium include advanced age, preexisting cognitive impairment (including dementia), medications (especially those with high anticholinergic potential), sleep deprivation, hypoxia and anoxia, metabolic abnormalities, and a history of alcohol or drug abuse.

Methods: We have conducted a systematic analysis of the literature and studied the best supported hypotheses proposed for the neurobiology of delirium. This paper represents a review of published literature and summarizes the top six proposed theories and highlights their interrelation. The hypotheses included in this literature review are: "Physiologic Stress", "Neuroinflammatory", "Large Neutral Amino Acids", "Neuroendocrine", "Oxidative Stress", "Neurotransmitter", "Diurnal Dysregulation", and the ‘‘Neuronal Aging" hypotheses.

Results: For decades it has been postulated that metabolic processes must be involved in its etiology. Yet to date, there is no single unitary pathophysiological mechanism identified. Over the years, a number of theories have been proposed in an attempt to explain the processes leading to the development of delirium. Each researcher or group has focused in a given area of metabolic dysfunction based theoretical basis (e.g., dopamine excess or acetylcholine deficiency theories), observational and experiential evidence (e.g., sleep deprivation, aging), or empirical data (e.g., specific pharmacological agents association with post-operative delirium; intra-operative hypoxia). This paper summarizes the six most prominent theories explaining the phenomena of delirium and highlights areas of commonality with the intent of increasing an appreciation for the underlying pathophysiological mechanisms, help focus future research, and assist in developing prophylactic and treatment strategies.

Conclusions: The paper will demonstrate the fact that most of these theories are complementary, rather than competing. Thus, it is likely that none of these theories by themselves explain the phenomena of delirium, but rather that two or more of these, if not all, act together to lead to the biochemical derangement we know as delirium.

Objectives:

  1. Understand the most significant theories regarding the neurobiology of delirium.
  2. Understand the mechanisms by which physiologic stress may alter neurochemistry leading to the behavioral symptoms associated with delirium.
  3. Examine the relationship between current hypothesis and current delirium management practice and future trends.

Relevance:
Despite its prevalence and negative consequences, the pathophysiology of delirium remains poorly understood. This presentation will shed some light and highlight the relationship between risk factors and underlying mechanisms.

Delirium Prevention on a General Medical Floor: A Replication of the Hospital Elder Life Program in a Community Hospital
Presenting Author:  Thomas Zaubler, MD, MPH
Co-Authors:  Jill Giordano, Kerry Murphy, Lori Rizzuto, Rachael Santos, Christine Skotzko, Rami Bustami

Purpose: Occuring in 14% to 56% of general hospital patients, delirium is especially common in the elderly and is associated with increased morbidity, mortality and excess healthcare costs. The Hospital Elder Life Program (HELP), a delirium prevention program developed at Yale, entails protocols targeting six delirium risk factors (cognitive impairment, sleep deprivation, immobility, visual impairment, hearing impairment and dehydration). This study explores a replication of the HELP protocol at a community hospital and its impact on the rate of delirium and length of stay (LOS).

Methods: Utilizing a standardized screen for delirium, baseline rates of delirium and LOS were established on a 38-bed general medical floor at Morristown Medical Center for patients 70 and older from November 2010 through February 2011. Subsequently, all patients 70 and older were enrolled in HELP and delirium rate and LOS were tracked for all patients. Rate of delirium once the HELP protocol was well established on the medical floor from July 2011 through March 2012 was compared against the baseline rate using the Chi-square test. LOS was also compared during these same time periods, but excluding March 2012 due to incomplete data, using the Mann-Whitney U test. In order to determine excess direct care costs attributable directly to delirium, the cost of caring for patients 70 and older admitted with a diagnosis of pneumonia who had delirium during their hospitalization was compared to the cost of caring for patients with pneumonia who did not develop delirium during their hospitalization. Potential increased revenue for the hospital was calculated based on the LOS reduction for patients enrolled in HELP.

Results: 595 subjects were included. Average age was 82.8 years (SD = 6.9), with 62% females and 95% whites. From November 2010 through February 2011 (baseline), among 215 patients 70 and older evaluated for delirium, 20% tested positively for delirium. From July 2011 through March 2012, the rate of delirium for the 380 patients 70 and older enrolled in HELP was 12%; a significant 40% reduction in the rate of delirium (p = 0.019). Median LOS significantly decreased from 6 days to 4 days (p <0.001). 8% of patients were either transferred from or to another unit for an acute medical or surgical problem, and LOS calculations excluded days spent on another unit. For the 380 patients enrolled, the savings in direct care costs was $36,480, or $48,670 annually. The potential increased revenue due to the decreased length of stay for the 380 patients enrolled was $760,000, or $1,014,000 annually.

Conclusion: With the implementation of a delirium prevention protocol (HELP), rates of delirium and LOS were significantly decreased for elderly patients on a general medical floor yielding significantly increased potential revenue and costs savings.

Objectives:

  1. Identify the prevalence/incidence data, morbidity and increased mortality associated with delirium in patients on a general medical floor.
  2. Apply methods targeted at preventing the onset of delirium.
  3. Identify benefits of delirium prevention including improved patient well being, decreased length of stay, decreased morbidity and decreased costs.

Relevance:
Delirium is a highly common problem in general hospital patients associated with increased morbidity, mortality and significant excess health care costs. Strategies aimed at prevention can be highly beneficial.

 

Session C:  Ethics / Oncology
Moderator/Discussant:  Philip A. Bialer, MD, FAPM

The Physician Role in Civil Commitment: Interstate Differences
Presenting Author:  Michael J. Peterson, MD, PhD
Co-Authors:  Elliot R. Lee, Kyle J. Benner

Purpose: Involuntary hospitalization for treatment of psychiatric disorders is a common situation faced by psychiatrists. The decision to pursue a civil commitment poses challenges ethically and requires knowledge of and adherence to applicable state statutes. Commitments require the involved parties to balance autonomy and beneficence to best improve safety and treatment of individuals. The standard of “dangerousness” has been mandated nationally by the U.S. Supreme court decision in Lessard v. Schmidt. However, each state has individual authority on how this standard is applied. States vary in key factors, including the degree of authority and autonomy granted to the physician, police agency, and local mental health staff. Interpretation of “dangerousness” criteria by each of these agencies may vary greatly, and result in disparate process and eventual outcome.

Method: Three example cases from our hospital’s consultation service are presented as test cases. Narrative descriptions of expected outcomes will be obtained from psychiatrists with practice experience in states in our region (Upper Midwest). The results from this sample will direct the preparation of a survey to be distributed to a national sample of psychiatrists for a broader picture of interstate differences across the U.S.

Results: Narrative descriptions of expected process and outcome of sample civil commitment scenarios will be presented to compare and contrast interstate differences from Upper Midwest states. Our survey for broader sampling of interstate differences will also be presented.

Conclusion: Interstate differences in statutes can create marked differences in the process and outcomes of the civil commitment process. These differences impact the practice of physicians and the experience of patients. Emergency and psychosomatic psychiatrists in particular need to be aware of these statutes and be able to appropriately balance the roles of physician, police, and mental health worker. A survey of physicians across states will provide a snapshot of differences in these statues, as well as physician perceptions of the relative benefits and limitations.

Objectives:

  1. Able to apply knowledge of statutes governing civil commitments to regular practice.
  2. Analyze how the physician role in civil commitment statutes may influence patient care and outcomes
  3. Weigh the relative benefits and costs of pursuing civil commitment for a patient,

Relevance:
This presentation will explore how state statutes influence the civil commitment process, and alter the balance of beneficence and autonomy for patients and physicians.

[T] Ethical Implications of Delaying Electroconvulsive Therapy (ECT) for the Purpose of Obtaining Informed Consent: A Case of Malignant Catatonia
Presenting Author:  Murat Altinay, MD
Co-Authors:  Margo Funk

Case: 46 year old male with past medical history significant for type-I Diabetes Mellitus and recent viral upper respiratory tract infection, initially admitted to an outside hospital after being having found unresponsive at home, breathing, with blood glucose in 400s. His initial MRI demonstrated temporal lobe lesions worrisome for herpes simplex virus (HSV) encephalitis and he was started on Acyclovir empirically which caused a temporary improvement in symptoms. On day 22, the patient was transferred to a rehabilitation facility where he demonstrated some recovery – was able to walk, hug his wife, mouth words. On day 36 he developed fever, chills, and decline in neurologic status and was readmitted to the OSH where he was diagnosed with staphylococcus bacteremia. He was transferred to our institution on day 67 for a second opinion. An extensive medical and neurologic workup was performed to evaluate ongoing unresponsiveness. All testing was negative, except for EEG which demonstrated mild diffuse encephalopathy and brain MRI with FLAIR hyperintensity of the left temporal lobe, thought to be remote infarct rather than residual from HSV encephalitis. On day 106, psychiatry was consulted for evaluation of agitation and possible NMS, though CK was normal. On exam, pt demonstrated perseverative motor hyperactivity, rigidity, mutism, fixed non-reactive gaze, positive grasp reflex, autonomic hyperactivity including diaphoresis, fever, hypertension and tachycardia. Per the primary team, his exam was consistent since presentation. Assessment by the psychiatry team was consistent with malignant catatonia and after a failed trial of benzodiazepines and bromocriptine, electroconvulsive therapy (ECT) was recommended.

Results: Ohio law prohibits the administration of ECT to patients who cannot provide informed consent unless the patient has a court-appointed legal guardian designated for ECT. In this case, due to the patient’s county of origin and requirements by the court to “bundle” guardianship of person and estate, court proceedings were delayed for nearly two months. In the meantime, on day 120 the patient underwent brain biopsy, which was unrevealing. He then developed numerous complications, including new onset uncontrolled seizures and new localized mass effect on brain MRI at the left temporal lobe biopsy site. He was deemed to no longer be an ECT candidate and was transferred to a long term acute care facility for ongoing care.

Conclusions: In this case, the delay of ECT for the purpose of obtaining guardianship for medical and ECT decision-making, restricted access to a potentially life-saving therapy such that by the time it was considered “legal” to perform ECT, he had developed prohibitive complications. We review the literature and ethical implications.

Objectives:

  1. The participant will be able to identify the definition, causes, signs, symptoms and treatment of malignant catatonia.
  2. The participant will learn about current regulations on ECT treatment in different states and will have a better treatment plan in patients who cannot give written informed consent.
  3. The participant will have the opportunity to assess his/her own approach to ethical issues stemming from laws, regulating the practice of medical treatments.

Relevance:
We discuss ethical implications of delaying ECT, a potentially life saving treatment, for the purpose of obtaining informed consent in a case of malignant catatonia due to a medical condition.

A Longitudinal Examination of Fear, Anxiety, and Depression in Patients Receiving Radiation Therapy for Cancer
Presenting Author:  Terry Rabinowitz, MD
Co-Authors:  Samuel Woodworth, Katherine Clark, Thomas Roland, Stacey Wilson, Alan Howard

Objectives: A diagnosis of cancer and the need for radiation therapy may place significant burden on a patient. We observed many of these patients to have fear, anxiety, and depression, any of which can affect treatment adherence and interest in symptom control or cure. Knowing when these symptoms might first appear, reach maximum intensity, and (possibly) resolve will help consulting psychiatrists to anticipate their occurrence and to develop targeted therapies aimed a each disorder.

To better understand the natural history of these conditions, we performed a longitudinal study of fear, anxiety, and depression severity before, during, and after a course of radiation therapy in a cohort of patients with different types of cancer and different primary sites. This is the first longitudinal study of these three conditions in the same patient cohort.

Methods: Patients (N=29) completed questionnaires (PHQ-9, BAI, and Fear Questionnaire, adapted) before beginning treatment, weekly during treatment, and one month after treatment. Medication data were also collected.

Results: Intensity scores ranged from “none” to “severe” for all three conditions. Within patients, condition severity did not change during treatment (average duration = 6 weeks; range = 3-8 weeks). Depression was more prevalent in patients with cancer of the head and neck or GI tract compared with patients having either lung or breast cancer. Patients with GI cancers had virtually no fear throughout treatment.

All patients were taking pain medications corresponding to at least Level 1 of the WHO Analgesic Ladder. About one-quarter of the patients were taking an antidepressant or benzodiazepine. Compared with patients taking no psychotropic medications, patients taking one or more had significantly higher scores for fear, anxiety, and depression intensity throughout their radiation therapy course.

Conclusions: Our findings suggest that fear, anxiety, and depression are prevalent among patients receiving radiation therapy and that once present, condition severity does not vary much over the course of treatment. This was the case both for patients taking and not taking psychotropic medications and, because we were able to follow patients longitudinally, suggests that for patients with higher severity scores (i.e., those taking psychotropic medications), the medication intervention was suboptimal, at least during the course of radiation therapy. Because none of these patients were under the care of a psychiatrist during this study, we conclude that timely psychiatric consultation for patients with higher severity scores will lead to better symptom control during an intense and arduous time in the life of a person with cancer. This ongoing study will also help to determine the extent to which cancer site may predict the likelihood and intensity of psychiatric comorbidity.

Objectives:

  1. Describe differences in intensity of fear, anxiety, and depression among patients with different types of cancer who are receiving radiation therapy.
  2. Develop better strategies to treat common psychiatric symptoms in patients receiving radiation therapy for cancer.
  3. Identify patients receiving radiation therapy for cancer at high risk for developing fear, anxiety, or depression.

Relevance:
Patients receiving radiation therapy may have fear, anxiety, or depression during a treatment course. Better understanding symptom trajectory will enable psychiatrists to target therapies aimed at improved symptom control.

SMaRT Oncology-3: A Multi-Centre Randomised Controlled Trial of a Multi-Component Intervention for Major Depression in Patients with Lung Cancer
Presenting Author:  Jane Walker, MBChB, MSc
Co-Authors:  Michael Sharpe, Gordon Murray

Purpose: Major depression is common in people with lung cancer, who typically have severe medical comorbidities as well as very limited life expectancy. There is little evidence to guide its management in this patient group.

We have developed a multi-component intervention (‘Depression Care for People with Cancer', DCPC) based on the collaborative care model, that we have found, in a clinical trial, to be superior to usual care for depressed cancer patients with good prognosis (1;2). In this intervention cancer nurses follow a treatment manual that specifies: (a) patient education about depression; (b) how to encourage adherence to antidepressants and achieve appropriate increases in activity and (c) how to deliver a brief psychological treatment (Problem Solving Treatment) that teaches patients techniques to regain control over their problems. A psychiatrist trains the nurses and supervises treatment delivery, advises patients' primary care practitioners about medication and also sees patients directly as necessary. The approach is underpinned by systematic monitoring of patients' progress so that treatment can be adjusted as needed.

We have adapted DCPC for patients with lung cancer by using shorter treatment sessions which are delivered at the patient's home, focusing on pleasurable as well as physical activities and working closely with primary care practitioners to ensure rapid and optimised prescribing.

We have evaluated the efficacy of this adapted intervention compared with usual care in a two-arm parallel group randomised controlled trial (3).

Methods: We recruited patients with lung cancer and major depression (identified by systematic screening) from seven centres in Scotland, UK. Participants were allocated to treatments using web-based, allocation concealed randomisation. The primary outcome was average depression severity assessed using scores on the 20-item Hopkins Symptom Checklist (SCL-20) collected every four weeks over 32 weeks by research assistants blind to treatment allocation. Secondary outcomes included severity of anxiety, pain and fatigue, self-rated depression improvement, quality of life and satisfaction with depression care.

Results: We recruited 142 participants; 68 were allocated to DCPC and 74 to usual care.

We are now in the final stage of data collection. The trial results will be available by September 2012 and will be presented.

References:

1. Walker J,Sharpe M. Depression Care for People with Cancer: a collaborative care intervention. Gen Hosp Psychiatry 2009;31(5):436-441.

2. Strong V,Waters R,Hibberd C,Murray G,Wall L,Walker J et al. Management of depression for people with cancer (SMaRT oncology 1):a randomised trial. Lancet 2008;372(9632):40-48.

3. Walker J, Cassidy J, Sharpe M. The third symptom management research trial in oncology (SMaRT oncology-3):a randomised trial to determine the efficacy of adding a complex intervention for major depressive disorder (depression care for people with lung cancer) to usual care, compared to usual care alone in patients with lung cancer. Trials 2009;10:92.

Objectives:

  1. Describe the effects of an innovative intervention for major depression on outcomes in patients with lung cancer and associated comorbidities.
  2. Understand how to overcome the challenges of conducting a clinical trial evaluation of depression interventions in people with limited life expectancy.
  3. Apply the results of this novel trial to everyday practice.

Relevance:
C-L psychiatrists are often called upon to advise about depression management in patients with severe medical problems including lung cancer. This presentation will inform that work.

A 500 Patient Multi-Centre Randomised Cost-Effectiveness Trial of Collaborative Care for Major Depression in Cancer Patients: SMaRT Oncology-2
Presenting Author:  Michael Sharpe, MA, MD
Co-Authors:  Jane Walker, Gordon Murray

Purpose: Major depression is common in people with cancer. We have developed a multi-component intervention for it (‘Depression Care for People with Cancer', DCPC) based on the collaborative care model [1]. We previously found, in a 200 patient ‘proof of concept' trial, that DCPC is superior to usual care in depressed cancer patients with a good prognosis, identified by screening cancer clinics [2].

This trial aimed to determine the ‘real world' effectiveness and cost-effectiveness of DCPC when compared with usual care in a varied, good prognosis, cancer outpatient population.

Methods: We recruited cancer patients with an estimated prognosis of 12 months or more and major depressive disorder (identified by screening cancer clinics) from six clinical centres in Scotland, UK. Participants were allocated to treatments using web-based, allocation concealed randomisation.

Patients allocated to DCPC received manual based treatment delivered by cancer nurses that included: (a) education about depression and cancer; (b) support for adherence to antidepressants and increases in activity and (c) a brief psychological treatment (Problem Solving Treatment). C-L psychiatrists trained the nurses, supervised treatment delivery, advised patients' primary care practitioners about medication and saw patients directly as necessary. The approach was underpinned by systematic monitoring of the patients' progress so that treatment could be adjusted as needed.

Patients allocated to usual care recieved this from their primary care doctor and oncologist who were told the patient was depressed, and who were free to refer to other providers.

The primary outcome was treatment response defined as a 50% reduction in depression score on the 20-item Hopkins Symptom Checklist (SCL-20) at 24 weeks. We also assessed costs of care anxiety, pain and fatigue and quality of life up to 48 weeks [3].

Results: We have recruited 500 participants and are now in the final stage of outcome data collection (and have more than 90% complete data).

The trial results will be available by the time of the meeting and will be presented together with an account of the issues we encountered implementing DCPC.

References:

1. Walker, J. and M. Sharpe, Depression Care for People with Cancer: a collaborative care intervention. General Hospital Psychiatry, 2009. 31(5): p. 436-441.

2. Strong, V., et al., Management of depression for people with cancer (SMaRT oncology 1): A randomised trial. The Lancet, 2008. 372(9632): p. 40-48.

3. Walker, J., J. Cassidy, and M. Sharpe, The second Symptom Management Research Trial in Oncology (SMaRT Oncology-2): a randomised trial to determine the effectiveness and cost-effectiveness of adding a complex intervention for major depressive disorder to usual care for cancer patients. Trials, 2009. 10: p. 18.

Objectives:

  1. Learn about latest data on collaborative care management of depression in cancer patients
  2. Know how collaborative care is delivered in a cancer setting
  3. Know the challenges and solutions to the large scale implementation of depression treatment in this setting.

Relevance:
Depression in the medically ill is a major part of the work of CL psychiatrists. This presentation provides the latest data on a collaborative care approach in cancer patients.

 

Session D:  Primary and Collaborative Care
Moderator/Discussant:  James R. Rundell, MD, FAPM

[T] Primary Care-based Screening and Pathways of Care for Post-traumatic Stress Disorder at a VA Hospital
Presenting Author:  Elliot Lee, MD, PhD
Co-Authors:  Rachel Molander, Eileen Ahearn, Dean Krahn

Integration of Mental Health care in the primary clinic has proven to be an effective model of care in multiple psychiatric disorders. We previously examined the efficacy of screening for pos-traumatic stress disorder (PTSD) in an Integrated Care setting. In that study, 587 veterans not already in the mental health clinic had positive PTSD screens. Sixty eight percent (409 of 587) of these veterans had an initial evaluation by integrated care mental health staff. In this study we examine the treatments that were initiated for patients after referral to Integrated Care.

During the year period of September 2009-2010, 409 veterans were referred to integrated care after a positive PTSD screen. Of this group, 63% (257 of 409) subsequently went on to receive specialty mental health care. Fifty nine percent of these 257 veterans eventually were given a primary diagnosis of PTSD (152 of 257). We analyzed the treatments given to the veterans (n=152) who were diagnosed with PTSD. Both medication and therapy were initiated in 65 of 152 (43%) veterans. Medication alone was initiated in 47 of 152 (31%) of veterans, while therapy alone occurred in 31 of 152 (20%) of veterans. Selective serotonin reuptake inhibitors were used in 67% of patients receiving medications. Evidence based treatments of cognitive processing therapy (CPT) and prolonged exposure therapy (PE) occurred in 41 % of patients receiving therapy. Of those veterans receiving CPT, 45 % had 11 or more treatments. We analyzed the PTSD Checklist (PCL) scores at baseline and after CPT treatment. There was statistically significant improvement in PCL scores when patients had at least 11 CPT sessions.

In summary, almost all of our patients ( 94%) diagnosed with PTSD in our clinic received medication treatment, therapy or both for their PTSD symptoms. In those receiving CPT, an analysis of outcome data enabled us to determine that a minimum of 11 CPT sessions were necessary for significant clinical improvement. This study shows the real world flow of patients from screening to treatment, allowing us to monitor our success in getting patients into treatment and enabling us to measure the clinical efficacy of our treatments.

Objectives:

  1. Examine screening for PTSD in primary care settings.
  2. Understand role of integrated care in evaluation and treatment.
  3. Examine evidence based treatments for PTSD.

Relevance:
Study examines integration of mental health into primary care setting with initial screening and treatment of PTSD.

A Clash of Custom and Culture: Hidden Barriers to the Integration of Behavioral Health Care and Primary Care
Presenting Author:  Robert Joseph, MD, MS

The benefits of integrating behavioral health (BH) care into primary care (PC) are supported by a significant body of research. The prevalence of mental illness in primary care populations, the co-morbidity between medical and mental illness, the bi-directional negative influence of each on outcomes of the other and the limited accessibility of conventional behavioral health care is now well established. The literature is replete with demonstration programs which have proven the viability and effectiveness of caring for a variety of mental disorders in primary care while improving outcomes and reducing health care costs. This evidence plus the advent of the “medical home” and “global payment” have led policy makers plus third party payers to increasing support models of integrated BH care and has made integration a central tenant of health care reform.

BH integration in PC exists on a spectrum from a traditional referral system to systems with full service co-location and a common medical record. The evidence for integrated care is most robust for the model of “collaborative care” reported by Katon and others. Despite the evidence in support of such models and the growing support of policy makers barriers remain which may inhibit wide scale implementation and sustainability of integrated models. Barriers include the division of administrative leadership, financing and reimbursement structure, remaining BH “carve outs”, nonaligned incentives among care givers and separate medical records and locations. Beyond these systemic issues subtle differences between BH and PC exist in our traditions, mission and methodologies, or, in other words, the “culture” of BH v PC. These cultural differences are both ingrained and over-determined and can cause significant tension and misunderstanding between BH and PCP’s leading to adverse effect on our efforts at integration.

This presentation will elucidate a series of cultural differences which have traditionally separated the practice of medicine from behavioral health and which commonly inhibit effective integration. Specific examples of these differences and the ways in which they interfere with effective integration will be examined.. Examples will include concrete and structural differences in practice as well as differences in “values” between PCP’s and BH providers. We will review how these cultural issues are reinforced by traditional training in our respective disciplines. Finally, the presentation will address the challenges of integration to the field of Psychosomatic Medicine (PM) and the unique opportunity PM has to help overcome the cultural differences and remain at the forefront of the integration effort.

References:

1. Katon W, et. Collaborative care for patients with depression and chronic illnesses. New England Journal of Medicine. 2010 Dec: 363:2611-2620.

2. Gilbody S, et al. Collaborative Care for Depression: A Cumulative Meta-analysis and Review of Longer-term Outcomes. Arch Intern Med. 2006;166:2314-2321.

Objectives:

  1. The audience will be better able to analyze conflicts between disciplines in their efforts to integrate BH and PC.
  2. Participants will be able to apply aspects of the program to reduce conflict between Primary Care and Behavioral Health services.
  3. The audience will be able to apply these concepts to training initiatives for both PC providers, PM fellows and other BH providers working in integrated settings.

Relevance:
The integration of behavioral health and general medical care has become a prominent aspect of health care reform. Recognizing and addressing cultural barriers of integration will facilitate the integration process.

Combined Medicine-Psychiatry Rounds: Building New Bridges
Presenting Author:  Ellen Coffey, MD
Co-Authors:  Mark Linzer, Michael Popkin

Purpose: Safety net hospitals serve patients with disproportionately high rates of mental illness. Patients with chronic mental illness may have far shorter life expectancies related to difficulty getting care, challenges in cooperating for diagnostic tests, and increased rates of metabolic syndrome as a side effect of psychotropic medications. While it seems obvious that combining efforts of medicine/primary care and psychiatry would be advantageous, there are barriers. Physical distance, lack of familiarity with personnel and unit capabilities, rotating medicine staff, and cultural differences all contribute to a gap between the specialties.

We sought to determine whether an ongoing combined psychiatry and medicine conference could improve communication and collaboration across services in a public teaching hospital.

Methods: The setting is a safety net hospital with 102 inpatient psychiatric beds. Patients with severe mental health problems and medical comorbidities are accepted. Psychiatric care teams include nurse practitioners who coordinate most non-psychiatric care during the day, and a physician assistant overnight.

Rounds occur Tuesday mornings at 0730. Departing night staff and day nurse practitioners share any interesting or perplexing patients, identifying questions about diagnosis and management, including who and when to call for help. Differential diagnoses are developed, while systems issues and further learning needs are identified. Articles and updates on systems issues are shared by email during the week or at the next session.

Participants are encouraged to complete a brief questionnaire at the end of the rounds. Individuals can complete the questionnaire on multiple occasions. The questionnaire addresses scholarly approach, quality of learning experience, collegiality, and whether objectives are met ( four point scale from poor to excellent). Open ended questions query how rounds have been helpful and suggestions for improvement.

Results: Attendance started with 1-2 physicians and 4 NPs/PAs, More physicians, nurses, crisis unit staff, pharmacists, psychologists and trainees of all programs started to attend, with an attendance high of 36. Survey results of 62 attendees give high marks for scholarly approach(3.54/4), quality of learning experience ( 3.56/4), collegiality(3.76/4), and meeting the objective of bringing medicine and psychiatry together to discuss issues of common interest(3.65/4). Other gains in the combined medicine psychiatry program have included 1) trial of a "trigger list" of worrisome vital signs, symptoms or lab results to engage medicine consults for help with stabilization, 2) expanded mental health staff in medicine clinic, and 3) development of a satellite medicine clinic in the psychiatric day treatment program.

Conclusions: A combined psychiatry and medicine conference has served as a catalyst to improve communication and collaboration across services. Costs are time of attendance, and positive outcomes have been striking. Other institutions with engaged physician champions should strongly consider this approach.

Objectives:

  1. Describe a simple but effective format for combined medicine psychiatry rounds.
  2. List three elements contributing to success of combined medicine psychiatry rounds conference.
  3. Consider novel opportunities for psychiatry - medicine collaboration in addition to inpatient consult liason service.

Relevance:
We describe a novel simple, low cost but highly effective medicine-psychiatry collaboration that's led to growth of inpatient and outpatient services in a short time frame.

The Group Health Mind Phone: An Analysis of a Primary Care / Behavioral Health Integration Tool
Presenting Author:  Alexander Thompson, MD, MBA, MPH
Co-Authors:  Bradley Steinfeld, Larry Marx, Ryan Caldeiro, Paul Fishman

Purpose: Group Health Cooperative (GH) is a non-profit, combined care provider and health insurer. It covers 660,000 members and has over 1,000 physicians, 25 primary care clinics, and seven behavioral health clinics. The Mind Phone (MP) is Group Health's virtual psychiatry consultation-liaison service. The Mind Phone supports any GH provider through consultation around diagnosis, treatment planning, triage, and system navigation. We review an evaluation of four aspects of the MP: 1) The overall use of the service by PCPs; 2) The reasons for MP consultation; 3) PCP satisfaction with the service; and 4) Any potential health care cost changes among patients whose PCPs used the MP compared to controls.

Methods: We identified 2,684 MP consultations made between October 1, 2009 and June 1, 2011. When present, face-to-face primary care encounters were linked to the MP call. A survey was sent to 201 PCPs involved in a face-to-face encounter associated with a MP consultation. For the cost analyses, controls (patients with a behavioral health diagnosis but no MP consultation) were identified from among 66,314 primary care encounters for 36,868 people seen during the same period.

Results: The distribution of PCPs using the MP is uniform with a small number of high users. While larger clinics have higher volumes, more frequent use is linked to specific clinics and its providers. There is a generally uniform distribution of calls over time with spikes at the start and end of a month. The most common diagnoses at a PCP visit linked to a MP call are (in order of frequency): anxiety, depression, and substance abuse.

There was a 26% response rate to the provider survey. Providers reported calling the MP primarily for medication questions. More than 75% reported receiving contact immediately or within 30 minutes. Ninety-eight percent of providers reporting being "satisfied" or "very satisfied" with the service.

Cost data suggest a spike in costs for cases (compared to controls) in the months preceding the index visit and virtual consult. Following the visit, costs return to parallel that of controls. Emergency department costs were $100 per member per month lower than the year prior to the virtual consult and inpatient costs fell from between $200 and $600 per member per month.

Conclusion: Effectively integrating behavioral health into primary care is an important part of a patient-centered medical home (1). That integration is easier in a structured delivery system, like GH, where the medical home has been shown effective (2, 3). A virtual psychiatry consultation service has the potential for being an "active ingredient" in a truly integrated health care delivery system. This service at GH is well liked by PCPs and may help decrease health care costs.

Objectives:

  1. Discuss models of integrating behavioral health care into primary care settings.
  2. Describe the patient centered medical home and the importance of integrating behavioral health into the medical home.
  3. Describe an analysis of the Group Health virtual psychiatry consultation service and how it may serve as an important part of an integrated care system.

Relevance:
This presentation discusses a unique, large, virtual psychiatry consultation service. This type of service may help other care systems effectively integrate behavioral health into primary care settings.

Rapid Follow-up after Psychiatric Emergency Room Visit Reduces Subsequent Recidivism
Presenting Author:  Cheryl McCullumsmith, MD, PhD

Patients presenting to emergency rooms in psychiatric crisis pose a unique problem of follow-up care. Many do not require inpatient hospitalization yet do not have insurance or ability to gain access to adequate urgent psychiatric care. In May 2009, we established the Transitional Psychiatry Clinic (TPC) to provide rapid short term followup and transition to permanent care for patients presenting to UAB's emergency room with psychiatric crisis. This clinic was free, with free medications and appointments were generally within 2 weeks of the original ER visit. Patients were seen in the TPC clinic for up to 3 months while a more permanent psychiatric home could be established. This study examines characteristics of the 390 patients referred to the TPC for care from May 2009 to May 2011 as well as predictors of both going to the TPC appointment and returning to UAB's emergency room or within 9 months of the initial emergency room psychiatric evaluation.

Of the 390 patients referred to TPC over 2 years, 45 % were women, 55 % were white, 61 % had no insurance (28 % governmental insurance and 11 % private insurance). 62 % had LOS in ER of less than 10 hours. Discharge diagnoses were : 39 % depressive disorder, 7 % adjustment disorder, 5 % personality disorder, 3 % had malingering a, 13.3 % substance induced mood or psychotic disorder, 11 % cocaine dependence (11 % had a positive USD for cocaine)and 12 % alcohol dependence. 47 % had a new medication prescribed from the ER and 15 % had medications refilled.

41.2 % of patients referred to the TPC arrived for this follow-up appointment. Predictors of not arriving (no-show) to the TPC appointment included younger age, alcohol dependence diagnosis, malingering diagnosis, more ER visits in the year prior to the index visit and a longer wait to the transitional clinic appointment.

For patients who went to the scheduled TPC appointment, the mean time to a return visit to the ER with a psychiatry complaint was 86.1 days (±12.8 days) compared to 65.3 days (±10.1 days)for those who did not go to their scheduled TPC appointment (up to 9 months after initial ER presentation visit). Further, for patients who had a scheduled TPC appointment within 3 days of their original emergency room visit, the mean time to a return visit to the ER with a psychiatry complaint was 129.7 days (±23.9 days) compared to 64.0 days (±7.9 days)for those whose scheduled TPC appointment was 4 or more days from their original ER visit. This analysis of one year outcomes after an index psychiatry emergency room visit suggests that rapid follow-up reduced subsequent utilization of the emergency room.

Objectives:

  1. 1. Describe characteristics of a transitional psychiatric clinic and its role in the continuum of care.
  2. 2. Characterize patients presenting to emergency rooms in psychiatric crisis
  3. 3. Investigate the need for rapid follow-up for those in acute psychiatric crisis

Relevance:
This paper demonstrates the critical importance of rapid follow-up for patients presenting in psychiatric crisis in the emergency room setting.

Integrating Collaborative Care in Psychosomatic Medicine: Evaluation of General Hospital Cost Perspectives from a "Transmural" Collaborative Care Program (the Med Psych Center Approach)
Presenting Author:  Carsten Leue, MD

Objective: Collaborative care services providing care at the interface of medical and psychiatric comorbidity in the general hospital are still widely organized by using specific disease management models. Previous work suggests that psychosomatic care may gain in effectiveness by merging different disease related approaches to joined collaborative care solutions. However, evidence regarding (cost-) effectiveness is scarce and divergent.

Method: A "transmural" form of merged collaborative care, the Medical Psychiatric Center (MPC) was created between a tertiary care University Medical Center (hereafter: UMC) and a primary care Community Mental Health Center (hereafter: CMHC) with a view to treat somatic and psychiatric multimorbidity initially inside and, if acceptable, subsequently outside the hospital, bridging the gap to General Practice. A record linkage study was conducted, linking cost data of hospital medical service use, length of stay (LOS) and transmural mental health care interventions in patients referred to the MPC over a two-year period. Analyses quantified pre-post cost changes around MPC referral.

Results: Referral rates were highest for somatoform disorders (28%), anxiety disorders (34%) and mood disorders (44%) in different comorbid somatic conditions. Comparisons revealed lower costs of medical service use (p < 0.001) and LOS (p < 0.01) after referral to the MPC. Conversely, cost of transmural psychiatric interventions was higher after MPC referral (p < 0.001) as was cost of psychological interventions (p < 0.001). Overall, total costs were lower after MPC referral (- € 84.5; 95%CI - € 143.3 to - € 25.8; p-value < 0.001) and could not be explained by general cost developments in the hospital over the period of investigation. Thus, the hospital related annual cost saving was approximately 1000, - Euro per patient.

Conclusion: A novel transmural collaborative care approach towards treatment of common somatoform or affective disorders in different somatic conditions, guiding patients from inside the hospital to accept primary mental health care, is feasible, acceptable and cost-effective.

Objectives:

  1. The physician learner will be able to evaluate General Hospital cost parameters regarding integrated care solutions.
  2. The physician learner will be able to distinguish between cost developments with and without integrated care in complex patients with somatic and psychiatric comorbidity.
  3. The physician learner will be able to apply relevant organisational considerations of integrated care into daily medical practice.

Relevance:
The relevance of costsavings in psychosomatic healthcare is all the more important, since adequate allocations of healthcare will get a major topic of policymakers due to limited resources.

 

Session E:  Surgery / Transplant
Moderator/Discussant:  Marian Fireman, MD, FAPM

[T] Skin Biopsies in Delusional Infestation – Does it Change Patient Outcome?
Presenting Author:  Ashley A. Foster, BS
Co-Authors:  Sara A. Hylwa, Mark D.P. Davis, Mark R. Pittelkow, J. Michael Bostwick

Purpose: Delusional infestation (DI) is a disease in which patients falsely believe that they are infected with foreign pathogens. Whereas the clinical diagnosis is generally made on the basis of a medical history and physical exam alone, skin biopsies also have been recommended for part of the initial dermatologic evaluation. Koo et al and others have suggested that skin biopsies can serve not only as a diagnostic tool, but also as a mechanism for improving therapeutic alliance in the DI population. To our knowledge, no objective literature supports skin biopsy improving physician-patient relationships or overall treatment outcomes, including whether the patient will agree to psychiatry referral or take antipsychotic medications. We therefore investigated whether biopsy results affected physician-patient alliances and management in DI patients.

Methods: A retrospective review was performed on charts of all patients presenting to Mayo Clinic Rochester, MN that met criteria for a DI diagnosis and received a skin biopsy between 2001-2007. Patient responses to biopsy results and treatment recommendations were recorded and analyzed. Statistical comparisons between patients undergoing biopsies and those who did not were performed to assess for potential differences between the two groups.

Results: During the seven-year study period, 147 patients were identified who met DI criteria, 80 of whom (54%) underwent biopsies. No biopsy result supported true infestation. In 26 cases (32%), physicians recorded patients’ emotional reaction: 22 (85%) of these reactions were negative, with the patients not reassured by the biopsy result, while the remaining four patients (15%) felt satisfied and reassured by the negative biopsy results. Regarding outcomes, the majority of patients who received biopsies did not have psychiatry consultations after the procedure (60 (75%)). For these 60 patients (75%) not having seen a psychiatrist, the two most common reasons were 1) the physician not offering a psychiatric evaluation (22 (37%)) and 2) patients refusing a psychiatric evaluation when they were offered (19 (32%)). 55 patients (69%) were not prescribed psychiatric medication after biopsy. Additionally, biopsied patients were found to be statistically less likely to be prescribed a psychotropic medication than patients who did not undergo a biopsy (p=0.013).

Conclusions: While biopsies do have value in DI patients when physicians have strong reasons to suspect organic skin disease, they are not helpful when DI is the prime diagnostic consideration. Our experience indicates that a skin biopsy did not establish a therapeutic alliance, did not improve the physician-patient relationship, and did not lead to patient agreement to psychiatry referral or psychotropic medications prescription.

Objectives:

  1. To gain insight in identifying a patient with suspected Delusional Infestation.
  2. To investigate the utility of an invasive skin biopsy in the work-up and diagnosis of Delusional Infestation.
  3. To better facilitate the appropriate management and treatment plans in a patient with suspected Delusional Infestation.

Relevance:
The data in this abstract discusses whether an invasive skin biopsy is of any value to the diagnosis, physician-patient relationship, or therapeutic alliance, in patients with suspected Delusional Infestation.

A Consultation-Liaison Psychiatry Outpatient Clinic for Patients with Hepatitis C Treated with Interferon Alpha
Presenting Author:  Gopinath Ranjith, MB BS, MRCPsych

Purpose: A significant proportion of patients with hepatitis C undergoing treatment with interferon alpha and ribavirin suffer significant behavioural symptoms such as depression and irritability [1]. Gastroenterologists are often reluctant to start interferon alpha treatment in patients with a past history of psychiatric disorders without a psychiatric assessment. There are few descriptions of service models for these patients. At St Thomas' Hospital in London we have established a consultation-liaison outpatient clinic for this group of patients. The purpose of this study is to describe the work carried out in this clinic.

Methods: All new assessments carried out in the clinic in 2011 were included and the electronic medical records examined. We looked at the following: reasons for referral, whether the referrals were pre-treatment or post-treatment with interferon alpha, past history of psychiatric disorder, past history of psychotropic medication use, mental status at the time of the assessment and management recommendation. In the case of the post-treatment referrals and patients followed up post treatment we also looked at the predominant symptoms and treatment.

Results: 28 new assessments were carried out in the clinic of which 21 were initially seen pre-treatment and 7 were seen post-treatment. In the pre-treatment group a history of depression was the most common reason for referral (85%); other reasons included a history of bipolar disorder, anger management problems and panic disorder. Of the 21 patients seen pre-treatment the recommendations included treating with monitoring for emergence of symptoms in 10 (47.6%), continuation of existing psychotropic medication in 8 (38.1%) and starting an antidepressant in 3 (14.3%). In the latter group 2 had sub-threshold depression and in only one case with past history of interferon-induced depression was true prophylactic antidepressant treatment recommended. Of the 10 patients seen in the clinic post-treatment 6 had a combination of depression and irritability, 2 had depression without significant irritability and 3 had prominent irritability without depression.

Conclusions: A history of depression is the most common reason for referral to the consultation-liaison outpatient clinic. The most common treatment recommendation was to go ahead with treatment without psychotropic medications. Continuation of antidepressant treatment was recommended in those already on it. Prophylactic treatment was initiated in patients with previous interferon-related depression and those with sub-threshold depression at the time of assessment [2]. Depression with irritability was the commonest interferon-induced presentation.

References:

1. Asnis GM, De La Garza II (2006) Interferon-induced depression in chronic hepatitis C: a review of its prevalence, risk factors, biology, and treatment approaches. Journal of Clinical Gastroenterology, 40: 322-35.

2. Galvao-de Almeida A, Guindalini C, Batista-Neves S et al (2010) Can antidepressants prevent interferon-alpha-induced depression? A review of the literature. General Hospital Psychiatry, 32: 401-5.

Objectives:

  1. Understand the type of patients referred to a consultation-liaison outpatient clinic for patients with hepatitis C
  2. Apply the knowledge to develop consultation-liaison outpatient clinics for patients with hepatitis C
  3. Apply the knowledge to use psychotropic medications appropriately to prevent and manage interferon alpha-related psychopathology

Relevance:
Specialists in consultation-liaison psychiatry are referred patients with hepatitis C who are about to start interferon treatment. This presentation would be relevant in developing an outpatient clinic for these patients.

Face Transplant: Psychological Outcomes at Three-year Follow-up
Presenting Author:  Kathy Coffman, MD

Purpose: Facial transplantation raises complex ethical and psychological issues. Mortality thus far of 18 existing recipients is 11.1% (2/18) through 2011. 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 three 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 three 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-SR (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. Anxiety about body image and facial anxiety both fell roughly in half by the end of the third year. Beck Depression Inventory fell from 16 prior to transplant to a low of 3, and was 9 at last rating at 3 years, mainly due to deaths in the family rather than related to face transplantation. Chronic daily pain was 6-7/10 prior to transplant and 0/10 by day 50. Perception of Teasing –FACES scores fell from 25 to 9 by the end of year 3. Quality of life has improved on the Social Environment Domain of the PAIS-SR where the score dropped from 15 to 1 by the end of year 3, indicating marked improvement in social reintegration. The patient is speaking about organ donation and domestic violence locally, nationally and internationally. Self-esteem on the Rosenberg self Esteem rating scale remained unchanged, as did anxiety on the Spielberg State Trait Anxiety rating scale.

Conclusions: 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. Rating scales specific to body image and facial anxiety (PASTAS and Facial Anxiety Scale-State) were superior to a general measure of anxiety ( Spielberg State Trait Anxiety Inventory). More standardized data collection would help determine whether the risks of immunosuppression are offset by sustained improvement in quality of life of recipients over time.

Objectives:

  1. The participants will learn the main differences between facial transplantation and solid organ transplantation.
  2. The participants will hear about the main ethical issues in face transplant.
  3. The participants will learn which rating scales are useful in face transplant recipients for measuring anxiety about the face and body,self-esteem, and quality of life regarding social reintegration.

Relevance:
Facial transplantation is new field with differences from solid organ transplantation. Standardizing data collection may help resolve questions about whether risks of immunosuppression are outweighed by improved quality of life.

Prevention of Psychiatric Morbidity and Poor Psychosocial Outcomes in Living Organ Donors: Efficacy in a Pilot Clinical Trial
Presenting Author:  Mary Amanda Dew, PhD
Co-Authors:  Andrea F. DiMartini, Annette J. DeVito Dabbs, Allan Zuckoff, Galen E. Switzer, Abhinav Humar, Henkie Tan

Purpose: Living organ donors constitute 45% of all donors in the U.S. and the protection of living donors' well-being is among the foremost priorities in transplantation. Nevertheless, the risk of poor psychosocial outcomes in the first several years postdonation remains high: up to 54% of donors report clinically significant psychiatric symptomatology, poor perceived physical well-being and strained spousal or other family relationships. No preventive interventions have developed or tested for efficacy in preventing these problems in living donors. Following work to develop and examine the feasibility of a new intervention, we are currently testing its efficacy in living kidney and liver donors. The intervention utilizes motivational interviewing (MI) to address residual ambivalence (i.e., lingering feelings of hesitation and uncertainty that remain after approval for surgery and that coexist with the donor's intention to donate).

Methods: Of 156 individuals screened for residual ambivalence to date, 115 had scores indicating the presence of ambivalence on a standard scale. Of these, 96 have been enrolled (13 refused; 3 were not enrolled because they were scheduled for surgery within 24 hours). Subjects were randomized in a 2:2:1 ratio to (a) receive the 2-session telephone-based MI intervention (+ usual care), (b) participate in an active comparison control group (2 telephone sessions providing information about healthy lifestyle habits) + usual care, or (c) receive usual care only. The intervention and active comparison condition are administered before donation. Study outcomes (psychiatric symptoms, somatic complaints, familial interpersonal relationships) are assessed at 6 weeks and 3 months postdonation.

Results: To date, 83 individuals have completed the trial; the remainder are in progress. By 3 months postdonation, results show that MI intervention subjects are less likely to have anxiety symptoms (37%) than subjects in the active comparison (58%) or usual care only group (66%)(p<.05). MI subjects are also less likely to have negative feelings about the donation (33.3% vs. 55% and 72% in the remaining groups)(p<.05). With regard to somatic complaints, subjects in the MI intervention report fewer somatic symptoms related to the donation (M=3.3, SE=0.6) than the active comparison (M=5.8, SE=0.6) and usual care only group (M=5.1, SE=0.9)(p<.05). Similarly, in the MI group, 83% report fatigue and 24% report pain, compared to 93%/43% and 93%/50% respectively in the remaining two groups (p's<.05). Finally, 40% of the MI group report unexpected medical problems compared to 71% and 62% in the remaining two groups (p<.05). No significant group differences in familial interpersonal relationships have been observed (all p's > .05).

Conclusions: A novel intervention designed to prevent poor psychosocial outcome in living organ donors appears promising in terms of reducing the risk for psychiatric and somatic complaints postdonation. A large multisite trial to fully evaluate efficacy of the intervention is warranted.

Objectives:

  1. Understand existing evidence on living donor psychiatric and psychosocial outcomes post-donation.
  2. Understand the issues and early results of testing a novel prevention intervention for living donors.
  3. Use the initial findings from the pilot study as a springboard for generating new ideas about prevention research in the living donor population.

Relevance:
Mental health professionals evaluate prospective donors for psychosocial suitability and provide treatment for donation-related psychiatric complications. Knowledge of strategies to prevent such complications is vital for donors' care.

Early Treatment of Depressive Symptoms Improves Post-Transplant Survival
Presenting Author:  Andrea DiMartini, MD
Co-Authors:  Mary Amanda Dew, Shari Rogal, Paulo Fontes

Purpose: In a prior analyses we demonstrated depressive symptomatology in the year following liver transplant (LTX) was the strongest predictor of survival. We now examined in that same group of LTX recipients whether treatment for depression within the first year improved survival.

Methods: In a longitudinal study we followed 167 patients transplanted for alcoholic liver disease. We assessed symptoms of depression using the Beck Depression Inventory (BDI) every three months for the first post-LTX year. At each of the four time points, we classified subjects as showing low (0-9.5), mild (9.51-16.5) and high (16.51 and above) depressive symptoms. Using cluster analysis we then identified three trajectories of depressive symptoms within that first year: consistently low distress (n=95), low distress that rises over time (n=41) and consistently high distress (n=31). We also examined antidepressant medication prescriptions for the first year. We used the Antidepressant Treatment History Form (ATHF) to rate the adequacy of antidepressant treatment (scores <3 inadequate treatment). For the cox regression model we grouped individuals first based on whether they were in a depression trajectory (the rising or consistently high distress groups) or not (consistently low distress group). We additionally categorized members of the depression groups as to whether they were on adequate antidepressant treatment (n=31) or not (inadequately treated or not on medications; n=41).

Results: Patients were predominantly Caucasian (95%), males (84%), ages 50+8, 47% with hepatitis C and Charlson comorbidity scores 7.0 + 1.4. Of the depressed groups 53% (n=38) were on antidepressants. By ATHF scores 18% (n=7) were judged inadequately treated (either dose or duration). Antidepressant therapy was initiated within 30 days for 25%, 3 months for 54%. The consistently high distress group was more likely to be treated (χ 2 = 9.8, df=1, p=0.008) and treated adequately (χ 2 = 11.0, df=1, p=0.003).

We found significant differences in survival between the groups (χ 2 = 29.8, df=11, p=0. 002) controlling for medical variables. The low distress group had the best survival and was significantly better than the depressed, not treated group (HR 2.6, p=0.000). The hazard ratio for the depressed group that received adequate treatment showed that treatment confers two times higher likelihood for survival compared to the depressed not treated group although this effect was marginal in our small sample (HR 2, p=0.09). By 10 years only 38% of the depressed not treated group survived compared to 50% of the depressed treated group and 59% of the non-depressed group.

Conclusions: Specific trajectories of moderate to severe depressive symptoms can emerge within the first post-LTX year and are associated with poorer survival. Additionally we found evidence that treating depression can improve survival, increasing the odds twofold over untreated depressive symptoms.

Objectives:

  1. To understand the significance of depression on liver transplant outcomes.
  2. To learn about the evolution of depressive symptoms following liver transplantation.
  3. To understand the timing and adequacy of treating depression following liver transplantation and its impact on survival.

Relevance:
Depression is common following many medical/surgical procedures. Adequate and early identification are critical to symptom relief and improving quality of life and may be critical for improving survival.

 

Session F:  Potpourri
Moderator/Discussant:  J. Michael Bostwick, MD, FAPM

Health Literacy and Antidepressant Medication Adherence among Adults with Diabetes: The Diabetes Study of Northern California (DISTANCE)
Presenting Author:  Amy M. Bauer, MD, MS
Co-Authors:  Andrew J. Karter, Melissa M. Parker, Wayne Katon, Nancy Adler, Alyce S. Adams, Howard H. Moffet, Dean Schillinger

Purpose: Many Americans have some difficulties with health literacy. Inadequate health literacy is associated with worse disease control for chronic medical conditions including diabetes and may be particularly problematic for patients with co-morbid depression, due to misinformation about depression, stigma, and the adverse effects of depression on cognition. However the relationship between health literacy and depression treatment has not been studied. In this study, we determine whether adults with diabetes and inadequate health literacy have poorer adherence to prescribed antidepressant medication.

Methods
Participants were selected from an ethnically-stratified random sample of 20,188 adults with diabetes answering a comprehensive survey in English, Spanish, Cantonese, Mandarin, or Tagalog from the DISTANCE Study.[1] Eligibility was limited to 2040 patients who i) were newly prescribed an SSRI, SNRI, bupropion or mirtazapine between 2006 and 2010 (index prescription), ii) had no antidepressant treatment for at least 12 months preceding the index prescription, and iii) had continuous pharmacy benefits for at least 12 months thereafter. Indicators of non-adherence were based on pharmacy utilization according to validated methods [2]: primary non-adherence (index antidepressant was not dispensed); early non-persistence (no refill of index antidepressant or alternative); and new prescription medication gap (NPMG; proportion of the time that the person is without index or alternative antidepressant during 12 months after initial prescription order). We also determined the proportion of patients who were non-persistent (based on days’ supply dispensed) at 180 days and 365 days. The independent variable, health literacy, was based on a validated 3-item self-report scale (available for 1366 participants), scored dichotomously as any health literacy problems (inadequate; scores 0-14) versus none (adequate; score = 15).[3]

Results: The majority (72%; n=984) of patients prescribed an antidepressant reported inadequate health literacy. Primary non-adherence was uncommon (4%) and did not differ by health literacy status. Patients with inadequate health literacy were significantly less likely to refill an antidepressant (55% versus 62%, p<0.05), had poorer overall adherence based on NPMG (mean proportion of gap days 0.41 versus 0.35, p<0.05; 57% versus 50% of patients had NPMG > 20%, p<0.05), and were more likely to be non-persistent at 180 days (64% versus 45%, p<0.01) and 365 days (68% versus 62%, p<0.05). Multivariate models adjusting for covariates and exploring potential mediators and effect modifiers will be presented.

Conclusions: Inadequate health literacy was common among diabetic adults prescribed antidepressants and associated with lower antidepressant adherence, reducing the likelihood of receiving continuation and maintenance phase antidepressant therapy. Findings underscore the importance of national efforts to address health literacy, improve public understanding of depression treatment, and simplify health communications for everyone.

References:

1. Moffet et al. Int J Epidemiol.2009;38(1):38-47.

2. Karter et al. Health Serv Res.2009;44:5:1640-61.

3. Chew et al. Fam Med.2004;36(8):588-94.

Objectives:

  1. Recognize that inadequate health literacy is common among diabetic adults treated with antidepressants.
  2. Describe associations between health literacy and antidepressant medication adherence among diabetic adults.
  3. Understand the importance of national efforts to address inadequate health literacy and simplify health communications.

Relevance:
Awareness of the importance of inadequate health literacy is critical for consultation-liaison psychiatrists who are frequently in a position to improve the effectiveness of depression treatment for patients with diabetes.

Positive Psychological Interventions in Medical Psychiatry Patients
Presenting Author:  Jeff Huffman, MD
Co-Authors:  Christina DuBois, Scott Beach, Carol Mastromauro, John Denninger

Background: Optimism and related positive psychological states have been independently associated with superior outcomes in patients with medical illness. Existing positive psychological interventions appear effective in improving mood symptoms for patients with clinical depression, but have not been developed for patients with acute psychiatric illness. Our objective was to explore the feasibility and initial impact of these interventions in a cohort of patients admitted to a medical psychiatry unit.

Methods: Eligible subjects were patients admitted to the medical psychiatry inpatient unit of an urban academic medical center with suicidal ideation or following a suicide attempt. Patients with current mania, psychosis, or cognitive impairment were excluded using standardized instruments, and those who did not speak English or were unable to write were also excluded. Enrolled subjects completed one of ten candidate positive psychology interventions, selected at random, each day until discharge. Each exercise required patients to perform a mental or physical activity related to a positive psychological domain (e.g., gratitude, optimism, purpose, forgiveness) and write about the experience on a structured form. Subjects rated their optimism and hopelessness (5-point Likert scale) prior to and after the exercise, and also rated the ease of completion of each exercise. Mean improvements in optimism and hopelessness were calculated for each exercise, and quantitative and qualitative assessments of ease of completion were recorded.

Results (final results will be presented at the Annual Meeting; these results represent interim data): Thus far, a total of 23 subjects have enrolled and completed at least one exercise. Subjects completed a mean of 4.0 exercises during their acute admission; subjects completed 88.5% (92/104) of assigned exercises. Mean rating of ease of completion was 3.6/5. The vast majority of exercises led to improvement in self-rated optimism and hopelessness. Exercises related to using personal strengths, writing a letter of gratitude, and recalling three positive events led to the greatest improvements in optimism and hopelessness, while exercises focused on forgiveness and performing acts of kindness performed the worst.

Conclusions: Medical psychiatry patients can successfully complete positive psychology exercises, even during a hospitalization related to suicidality, and they found such exercises easy to complete and at least transiently helpful with regard to hopelessness and future orientation. Exercises in specific domains (e.g., gratitude) appear to be substantially more helpful than others (e.g., forgiveness). Additional data on the utility of these exercises in this population is required to develop practical and effective positive psychology interventions.

Objectives:

  1. Describe positive psychology exercises
  2. Discuss the impact of positive psychology exercises in medical psychiatry patients
  3. Outline future directions for research in this area

Relevance:
Psychosomatic medicine practitioners would benefit from additional tools to improve mood, optimism, and hopelessness in medical psychiatry patients

[T] Use of Interpreters with Patients of Limited English Proficiency: A Literature Review and Pilot Study
Presenting Author:  Dahlia Woods, MD
Co-Authors:  Stephanie Cheung, Nancy Maruyama, Nancy Maruyama

Purpose: Patients' language use comprises a significant component of psychiatric examination. Consequently, discordance of language spoken by psychiatrist and patient poses a major, and increasingly frequent obstacle to accurate psychiatric assessment. Twenty-three million people (8.1%) in the U.S. had limited English proficiency (LEP) in 2000. This number is projected to grow to 67 million (19%) by 2050. To understand the significance of this trend, we reviewed the literature on use of interpreters in psychiatric assessment and examined data on use of interpreters by a consultation liaison service.

Methods: We searched for medical articles published between 1992 and 2012 with the search string "interpreter use limited English proficiency (physician OR psychiatrist OR psychiatry)" on scholar.google.com. This returned 1240 articles. Only three measured use of interpreters in clinical services, of which none mentioned psychiatrists. Additionally, we reviewed documentation of interpreter use on consults performed by a CL service over 6 months at an 899-bed tertiary care medical center in a busy multi-ethnic urban center.

Results: Of the three articles, two involved ED patients and one involved medical/surgical inpatients. Physician/examiner use of interpreters ranged from 50.9% - 66%. Use of trained interpreters was 12% - 14%, and use of friends or relatives as interpreters was 28% - 34.5%. None of the above studies involved psychiatrists. Data from a psychosomatic teaching service served as a comparison. Between February and September, 2011 there were 1089 consult requests; 88 involved known LEP patients, 49 (56%) consults were available for review. Use of interpreters was documented in 30 cases (61.22%). Whether they were trained interpreters was not stated.

Conclusions: Although physicians/examiners used interpreters, documented use of trained interpreters was low. No studies were found that measured psychiatrists' use of interpreters with LEP patients. Because of psychiatry's dependence on language for assessment, there should be more frequent use of trained interpreters than that in non-psychiatric assessments. In the small pilot study, the rate of documentation of any interpreter use in a psychosomatic teaching service did not differ from that recorded for ED and inpatient settings. This warrants expanded study and highlights potentially treacherous pitfalls for psychosomatics. Future studies of the use of interpreters by psychiatrists should include examination of whether untrained or trained interpreters are used. Untrained interpreters' errors may have greater clinical impact, compromising diagnostic accuracy.

References:

1. Leman, P. Interpreter Use in an inner-city accident and emergency department. J. Accid Emerg Med 1997;14:98-100.

2. Baker D., et al. Use and Effectiveness of Interpreters in an Emergency Department. JAMA 1996;275:783-788.

3. Schenker Y, et al. Patterns of interpreter use for hospitalized patients with limited English proficiency. J. Gen Intern Med. 2011 Jul;26(7):712-7.

Objectives:

  1. To understand the need for and the underutilization of interpreters in clinical settings.
  2. To understand the limitations of using ad hoc interpreters rather than trained interpreters and the impact that interpreter errors can have on diagnostic accuracy, treatment, and patient-provider relationship.
  3. To understand the need for additional research on the use of interpreters in medical, and more specifically in psychiatric care.

Relevance:
Psychosomatic medicine handles consults for such things as capacity and cognitive disorders. If there is language discordance, it is crucial to use trained interpreters for diagnostic accuracy.

[T] 'Bath salts': Implications of This Novel Stimulant for General Hospital Psychiatrists
Presenting Author:  Gerald Winder, MD
Co-Authors:  Seema Calip, Avinash Hosanagar

Background: The high prevalence of substance abuse in the general hospital population requires consult and liaison psychiatrists to adeptly diagnose and manage the wide array of medical and psychiatric side effects that accompany a panoply of drugs of abuse. A group of novel stimulants that are becoming more frequently observed in emergency rooms and general medical floors are so-called ‘bath salts'.

Methods: We present two clinical cases along with a detailed review of the available literature that outlines the drugs' basic chemistry, appearance, and methods of delivery as well as illustrates typical patterns of usage, intoxication/withdrawal characteristics, and treatment recommendations.

Discussion: ‘Bath salts' are designer drugs comprised of any number of cathinones, a class of chemicals derived from the Khat plant that share many features of amphetamine, noradrenaline, and ecstasy. Two common examples are 3,4-methylenedioxypyrovalerone (MDPV) and 4-methylmethcathinone (mephedrone). They are marketed locally and through online retailers as legitimate products in order to evade legal control and facilitate widespread dissemination. Though preliminary efforts are underway in the United States to restrict their usage and distribution, there remains a general unawareness on the part of hospital and emergency psychiatrists regarding the drugs' physiological effects. While they mimic many of the effects of other known stimulants, they are not detected on standard urine screens. Their effects include cardiovascular changes, metabolic derangements, acute psychosis, and are often associated with a withdrawal phenomenon which may include suicidal ideation. There are no controlled trials for treatment of either the intoxication or withdrawal syndromes associated with these drugs and treatment is presently documented as primarily supportive.

Conclusion: Given the global extent of manufacture, distribution, availability through various outlets including head shops, convenience stores, and Internet retailers there is comparatively little medical literature informing providers how to recognize these drugs or treat those who use them. Identifying and understanding the physiological and neurobehavioral effects of ‘bath salts' is becoming increasingly important to hospital psychiatrists in the United States.

References:

1. Spiller et al., 2011 Clinical experience with and analytical confirmation of "bath salts" and "legal highs" (synthetic cathinones) in the United States. Clinical Toxicology, 49 (6) (2011), pp. 499-505

2. Winstock et al., 2011 Mephedrone: Use, subjective effects and health risks. Addiction, 106 (11) (2011), pp. 1991-1996

3. Wood et al., 2010 Recreational use of mephedrone (4-methylmethcathinone, 4-MMC) with associated sympathomimetic toxicity. Journal of Medical Toxicology: Official Journal of the American College of Medical Toxicology, 6 (3) (2010), pp. 327-330

Objectives:

  1. Understand the physiological effects of 'bath salts'.
  2. Distinguish 'bath salts' from other stimulants of abuse.
  3. Learn to recognize and manage patients who have used 'bath salts'.

Relevance:
This presentation provides an overview of the psychological and physiological effects, along with practical management strategies, of a novel stimulant that is becoming increasingly prevalent in general hospital settings.

Severity of Health Anxiety Across a Spectrum of Neurotologic Diagnoses
Presenting Author:  Jeffrey Staab, MD, MS
Co-Authors: Eliane Von Sohsten

Purpose: The concept of health anxiety is poised to enter the DSM-5 as one component of the proposed Somatic Symptom Disorders. However, the relationship of health anxiety to other psychiatric and physical illnesses is incompletely understood. This study examined links between health anxiety, state anxiety, depression, somatic symptom burden, and disability within one medical specialty, neurotology. By limiting subject selection to one medical specialty, investigators restricted subjects’ chief complaints to one set of physical symptoms (in this case vestibular problems), allowing them to examine the effects of other physical illness characteristics such as time course (acute, chronic, episodic) and type of disorder (peripheral, central, functional) on the prevalence and severity of health anxiety.

Methods: 162 subjects with primary neurotologic problems were identified from a larger cross-sectional study of health anxiety. Investigators abstracted neurotologic and psychiatric diagnoses from multidisciplinary evaluations. Subjects completed self-reports for health anxiety (short Heath Anxiety Inventory, S-HAI), state anxiety (GAD-7), depression (PHQ-9), somatic symptom burden (67-item symptom checklist), and disability (Sheehan Disability Scale). Mean S-HAI scores were compared using pairwise t-tests across five neurotologic groups [acute peripheral vestibular disorders, episodic peripheral vestibular illness (Meniere’s disease), episodic central nervous system disorder (vestibular migraine), chronic central nervous system disorders (e.g., stroke), functional neurotologic disorder (chronic subjective dizziness)] and five psychiatric groups (health anxiety/hypochondriasis, anxiety and depression, anxiety alone, depression alone, no diagnosis). Predictors of health anxiety and its relationship to disability were examined using general linear modeling.

Results: Mean S-HAI scores varied significantly across psychiatric groups from 20.1 (health anxiety) to 11.7 (no diagnosis), but not across neurotologic groups (16.2 to 12.2). Linear modeling found significant relationships between health anxiety and psychiatric comorbidity. In separate models, psychiatric self-reports and psychiatric diagnoses predicted severity of health anxiety. No such relationship was identified for neurotologic morbidity. Linear modeling also showed that health anxiety impaired daily functioning independently of other variables. S-HAI scores predicted interference with home life (statistically significant) and social/leisure endeavors (trend), but not work or school activities after controlling for state anxiety, depression, somatic symptom burden, and neurotologic diagnoses.

Conclusions: Health anxiety is an independent cause of medical-psychiatric morbidity. It frequently co-exists with, and its severity correlates with, other anxiety and depressive disorders, as is the case for all mood and anxiety disorders. In contrast, it appears to be relatively independent of the characteristics of co-existing physical illnesses. Health anxiety adversely affects daily functioning beyond the impairment caused by co-existing psychiatric and physical conditions.

References:

1. Braddock AE, Abramowitz JS. Listening to hypochondriasis and hearing health anxiety. Expert Rev Neurother. 2006;6(9):1307-12.

2. Salkovskis PM, Rimes KA, Warwick HM, Clark DM. The Health Anxiety Inventory: development and validation of scales for the measurement of health anxiety and hypochondriasis. Psychol Med. 2002;32(5):843-53.

Objectives:

  1. Become more familiar with the concept of health anxiety in psychosomatic medicine
  2. Appreciate the dimensional nature of health anxiety and its relationship to specific characteristics of physical illnesses, using five neurotologic conditions as illustrative examples
  3. Understand the interactions among health anxiety, state anxiety, depression, and somatic symptom burden in patients with physical illnesses, again using neurotologic conditions as examples

Relevance:
Health anxiety is an important concept in psychosomatic medicine. This study explored its range, severity and interaction with physical and psychological illness characteristics in patients with five different neurotologic disorders.

[T] Recalibrating Suicide Risk after Index Suicide Attempts
Presenting Author:  Chaitanya Pabbati
Co-Authors:  Nora King, Megan Chang, Linda Drozdowicz, John Bostwick

Purpose: It is established that a history of attempted suicide robustly predicts eventual completed suicide. We believe that the current literature underestimates the lethality – immediate or eventual – of suicide attempts. Many prominent studies contain two fallacies: 1) Patients are not reliably studied from their first attempt thus excluding those who initially complete, and 2) First attempts resulting in death are not counted as attempts. We hypothesize that tracking suicidal behavior from first self-harm attempts, deadly or not, will better represent the prevalence of completed suicide after attempts that come to medical attention.

Methods: This cohort was created by identifying 4,606 individuals who presented to Olmsted County medical facilities between 1986 and 2007 and received a billing or diagnosis code corresponding to suicidal ideation, suicidal behavior, or non-accidental self-inflicted injury. Charts were reviewed to establish that the coded diagnoses represented to actual suicide attempts or self-injurious behaviors. Patients with prior attempts or residence outside of Olmsted County were excluded, leaving 1,533 patients with index self-harm attempts. Using the Rochester Epidemiology Project, each event was investigated for demographic and outcome information. The cohort was screened through the National Death Index to identify the dead and causes for their deaths.

Results: The cohort of 1,533 included 577 men (37.6%) and 956 women (62.4%). 77 men (13.3%) and 21 women (2.2%) completed suicide. 50 of the 77 men (64.9%) died on the index attempt for a rate of 8.6%. Among women 13 of 21 (61.9%) died on the index attempt for a rate of 1.4%. Of index attempt survivors, 27 of 527 (5.1%) males and 8 of 943 (0.85%) females eventually killed themselves. Average time to complete suicide was 1.34 years for males and 0.75 years for females. Average age at death was 42.8 years for male suicides and 52.1 years for females.

Conclusions: We believe that this is the first study examining suicide risk in a cohort with all subjects followed from documented first attempts. We found a female-male attempt ratio of 1.7-to-1, not the widely quoted 4-to-1. Male-female completion ratio was 6-to-1, not the widely quoted 4-to-1. By including deaths resulting from index attempts, 13.3% of male attempters and 2.2% of female attempters completed a suicide attempt. For both men and women, nearly two-thirds of the total suicides happened during index attempts. For survivors of their index attempts, the completion rates dropped to 5.1% of surviving males and 0.85% of surviving females. While suicide attempt history is clearly a risk factor for subsequent suicide, we conclude based on high proportions of both males and females dying during index attempts that suicide prevention should be aimed at individuals – particularly men – before they make their first attempt.

Objectives:

  1. Understand the association between index suicide attempts and long-term lethality.
  2. Be able to discern risk factors for completed suicide between males and females.
  3. Understand the temporal patterns which exist for subsequent completed suicides.

Relevance:
This presentation will help audience members understand the importance of pro-actively preventing suicide attempts in their patients, and also to understand the importance of post-attempt follow-up.

 

Session G:  2011-2012 Webb Fellows
Moderator/Discussant:  Dimitry Davydow, MD, MPH

Joan Camprodon
Joan A. Camprodon, MD
Chris Celano
Christopher M. Celano, MD
Chris Celano
Felicia K. Wong, MD
Our fourth
2011-2012 Webb Fellow,
Eliza (Leeza) Park, MD,
will present her paper
at the
2013 Annual Meeting
in Tucson.

Imaging Biomarkers of Major Depressive Disorder and Suicide: A Combined Functional Connectivity MRI and ECT Study
Presenting Author:  Joan A. Camprodon, MD

Background:  Major depressive disorder (MDD) affects one in eight Americans and is associated with significant cost, morbidity and mortality. Over 90% of people who commit or attempt suicide have a diagnosable psychiatric disorder, with mood disorders and MDD in particular being the most prevalent. Electroconvulsive therapy (ECT) is the most effective intervention we have in psychiatry with remission rates of 70-90% for MDD, which compare very favorably to the 30-50% remission rates of pharmacological interventions. In addition, ECT has been proven to be effective against suicide with remission rates of 80%. Cognitive side effects, particularly amnesia, are frequent and sometimes intolerable in patients receiving ECT, representing a common reason to abort treatment. Despite the high efficacy of ECT against MDD and suicide, its mechanisms of therapeutic and iatrogenic action are poorly understood, which limits further therapeutic development.

Study Aims:  This project will use functional connectivity MRI (fcMRI) and psychometric clinical scales to study patients with Major Depressive Disorder (MDD) and suicidal thoughts receiving electroconvulsive therapy. Our aims are the following:

  1. To study the mechanism of action of ECT at the circuit level by determining the changes in functional connectivity of mood and memory circuits that correlate with clinical improvement and iatrogenic cognitive effects after ECT.
  2. To study the use of fcMRI as a state biomarker for MDD and suicidality.
  3. To study the use of fcMRI as a treatment biomarker (i.e. predictor of response) for MDD and suicidality.

Methods:  Patients will be recruited from the Massachusetts General Hospital ECT service. A Structured Clinical Interview for DSM disorders (SCID) will be used to verify inclusion and exclusion criteria. Patients will be scanned before and after a full course of ECT. In addition, clinical and cognitive scales will be used to measure MDD severity, suicidality, and cognition at the same time points. Standardized seed-based correlational analysis will be used to analyze the functional MRI data and covariance methods will be applied to analyze the interaction of physiological and clinical change.

Conclusion:  As part of my Webb Fellowship presentation, I will discuss the rationale, methodology and current implementation of this ongoing study.

Positive Psychology: A Novel Intervention for Patients with Cardiovascular Disease
Presenting Author:  Christopher M. Celano, MD
Co-Authors:  C.A. Mastromauro, J.K. Boehm, H. Benson, G.L. Fricchione, J.W. Denninger, J.C. Huffman

Background:  Depression in patients with cardiovascular disease (CVD) is common, persistent, and independently associated with progression of atherosclerosis, recurrent cardiac events, and mortality. In contrast, positive affective states, such as optimism, are associated with improved cardiovascular health and reduced rates of cardiac mortality. Positive psychology (PP) interventions focus on the amplification of positive life experiences and affective states; these interventions have been used increasingly in patients without comorbid medical illness but have yet to be tested in patients with cardiovascular disease.

Methods:  We will review the evidence linking positive affective states (e.g., optimism) with positive cardiac outcomes as well as the potential mechanisms underlying these associations. Next, we will discuss PP, its major domains of focus, and the evidence for its efficacy in non-cardiac populations. Finally, we will review the results from a PP pilot study (n = 30) comparing an 8-week, telephone-based, PP intervention with relaxation response and attentional control interventions in patients hospitalized with acute cardiac illnesses.

Results:  Positive affective states, including optimism, emotional vitality, and emotional well-being, have been associated with reduced rates of incident CVD, complications following cardiac surgery, and all-cause and CVD-related mortality. PP interventions, which aim to improve optimism and other positive affective states, have been shown to be more effective than placebo at increasing well-being and decreasing depression in physically healthy individuals. In our pilot study, subjects in the PP arm completed more weeks of the intervention; had higher scores on most ratings of acceptability; and had the greatest numerical improvements in scores of depression, optimism, anxiety, and mental HRQoL compared to the relaxation response and control conditions.

Conclusions:  PP interventions are useful at increasing well-being and reducing depression in non-cardiac populations. Given this efficacy, PP may provide a useful adjunctive treatment in patients with CVD and could have a positive impact on medical and psychological outcomes. In our preliminary study, we discovered that a telephone-based PP intervention is feasible and subjectively helpful to patients who were recently hospitalized for an acute cardiac event.

Integrated Care: Strategies for Successful Program Development
Presenting Author:  Felicia K. Wong, MD

Integrated care has been gaining increasing recognition as an optimal health care delivery model through which both physical and mental health concerns are addressed in a consolidated setting.  While the importance of integrated care to the future of mental health care has been embraced by both the psychiatric and psychosomatic medicine communities, the question remains:  now that we “get it”, how do we “do it”?  How does one introduce integrated care to a health care system that is inherently slow and resistant to change?

Historically, the role of psychosomatic medicine psychiatrists (PMPs) has been primarily that of an inpatient consultant to help medical specialists manage acutely ill patients.  Now, with the advent of integrated care and focus on preventative medicine, there is increasing demand for PMPs to assist our medical colleagues in outpatient medical settings.  In this capacity, PMPs possess several important skills that make them uniquely suited to assume a leadership role in the promotion and development of outpatient psychiatric consultation programs.  As a consultant, we must be adept at problem solving and teamwork.  As a liaison, the PMP must be a skilled communicator, and at times, may be called upon as a mediator.  Furthermore, we must have the opportunity to effectively educate and help non-psychiatric physicians treat patients with psychiatric disorders.   

In this presentation, I will review an often overlooked, but critical, skill set that PMPs must develop if they wish to promote integrated care—branding and pitching.  I will share my experience as an early career PMP who has been able to apply my psychosomatic medicine training and marketing skills in order to help my hospital system, the Kaiser Permanente West Los Angeles Medical Center, develop innovative and collaborative programs between psychiatry, primary care, and other medical specialties.


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