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, Poster Papers


POSTER PAPER PRESENTATIONS
Thursday, November 15, 2012  •  4:30 – 6:30 PM
Westin Buckhead Hotel, Atlanta, Georgia

including the poster presented for the
Alan B. Stoudemire Award for Innovation & Excellence in PM Education

 
Section A: Cardiology (1–12)
  B: Case Reports (13–30)
  C: Neuropsychiatry (31-65)
  D: Primary and Collaborative Care (66-90)
  E: Psycho-Oncology (91-101)
  F: Transplant (102-116)
  G: Potpourri (117-163)
  [T] = Trainee Paper

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Alan B. Stoudemire Award
for innovation and excellence in PM education

Crossing the Blood Brain Barrier: An Experiment in Interdisciplinary Research
Presenting Author:  Gary J. Gala
Co-Authors:  Daniel Moseley and the Philosophy & Psychiatry Research Group at the University of North Carolina

In September of 2010, we (Dan Mosley and Gary Gala) formed a reading and research group to explore the interface of philosophy and psychiatry. Our goal was to create a group of faculty and trainees, from various disciplines, who would learn to talk to one another rather than past one another. We did not consider this an easy task! We had both been part of other interdisciplinary projects and seen them fail miserably, often leading to misunderstanding between disciplines and leaving the participants with the feeling that the other discipline was (at best) irrelevant to their work. We did not want that to happen! We did not believe that if we were all simply in a room together, discussing some topic, that would be sufficient to promote understanding and true dialogue. We thought that to achieve meaningful interaction, we would have to be active leaders, interrupting the dialogue, clarifying, translating. And in fact that was the way it went. Over time our regular participants from philosophy learned a lot of psychiatry and our psychiatrists learned plenty of philosophy. The group had regular attendance from general psychiatrists, psychosomatic specialists, Freudian psychoanalysts, a Lacanian analyst, a neuroscientist, philosophy faculty from UNC and Duke, graduate students in philosophy, psychiatry residents, medical students, and nurses.

 

Section A:  Cardiology

  1. Cannabis-induced Atrial Fibrillation in a Patient with Traumatic Brain Injury
    Presenting Author:  Adekola Alao
    Co-Author:  Lauren Mikesell

    Introduction: In recent years, there have been a number of case reports demonstrating an association between marijuana smoking and onset of atrial fibrillation. The exact mechanism by which marijuana may induce atrial fibrillation remains unclear. Hypotheses focus on the well-documented role of the autonomic nervous system in the pathogenesis of atrial fibrillation. Low to moderate levels of D-9-tertrahydrocannabinol (THC), the bioactive component of marijuana, increases heart rate, blood pressure, and plasma catecholamine levels in humans.[2] Data suggests these effects are mediated by cannabinoid 1 receptor regulation of the autonomic nervous system. Stimulation of the adrenergic system is potentially proarrhythmic as it reduces action potential duration and favors automaticity, triggered activity, and re-entry. The increase in sympathetic tone following marijuana use may contribute to the development of atrial fibrillation, especially in patients with preexisting cardiovascular complications.

    Case History: The patient is a 40-year-old Hispanic man who has a history of post-traumatic stress disorder (PTSD) and traumatic brain injury (TBI), which he sustained from three military tours in Iraq and Afghanistan. The patient’s PTSD symptoms are being treated with diazepam 5mg po bid as well as remeron 15mg po qhs. He presented to the emergency department complaining of nausea and vomiting. He reported that these symptoms began after ingesting a brownie that may have contained cannabis at a housewarming party the night before. His presenting symptoms included diarrhea, diffuse abdominal pain, and chest discomfort. He developed tachycardia in the 140-150s. An EKG revealed atrial fibrillation with rapid ventricular response, premature ventricular or aberrantly conducted complexes, and nonspecific ST segment and T-wave abnormalities. Urine toxicity was positive for benzodiazepines, cannabinoids, methadone, and opioids, but negative for salicylates and acetaminophen. A repeat EKG showed atrial fibrillation, but the nonspecific ST segment and T- wave abnormalities were no longer evident in the inferior leads. Chest X-ray, echocardiogram, and CT thorax without contrast were all within normal limits. He was administered diltiazem and central access was placed in the femoral vein for adequate fluid administration. He was admitted to the hospital with a diagnosis of atrial fibrillation and gastroenteritis secondary to cannabinoid use. The patient improved after three days and was discharged for outpatient follow-up.

    Conclusion: The presence of TBI in this patient may have made him more susceptible to cardiovascular complications. However, furthermore, marijuana induces alterations in coronary vasculature that may contribute to the development of atrial fibrillation. More research is necessary to elucidate the precise mechanism involved in marijuana-induced atrial fibrillation.

    Objectives:

    1. The participants will be able to investigate the cardiovascular complications of cannabis
    2. The participants will be able to understand why individuals with traumatic brain injury may be more susceptible to cardiovascular complications of cannabis
    3. The participants will be able to apply the knowledge gained in this presentation (about the role of the autonomic nervous system in the pathogenesis of atrial fibrillation) in their practice.

    Relevance:
    Cannabis is increasing among veterans with co morbid PTSD and TBI. The presence of TBI may contribute to increased susceptibility to cardiovascular complications. The audience will benefit from this knowledge.

     
  2. [T] Clozapine-induced Myocarditis and Cardiopulmonary Failure
    Presenting Author:  Sean Moore
    Co-Authors:  James McConville, Shan Siddiq

    Background: Clozapine is the most efficacious second-generation antipsychotic in the treatment of schizophrenia; however, its use is limited to refractory cases of psychosis due to its association with a number of potentially fatal adverse side effects. In addition to agranulocytosis and other serious hematologic disorders, it has also been associated with severe idiopathic cardiopulmonary complications such as hypersensitivity myocarditis. The pathogenesis of clozapine’s cardiac toxicity is poorly understood. Fortunately, the clinical course has been well-characterized.

    Case Report: Mr. T is a 21 year-old African-American male with a history of schizophrenia who presented to an inpatient psychiatric facility after an acute decompensation of his condition. His medication regimen was changed from risperidone and haloperidol to clozapine, which was titrated up to 200 mg per day. After approximately three weeks of therapy, he was transferred to a general hospital due to an apparent multi-lobar pneumonia and progressive respiratory collapse despite aggressive antibiotic therapy.

    At the time of initial assessment by the psychosomatic team, he was on continuous positive airway pressure and was unable to speak in full sentences due to dyspnea. He was also noted to have a non-productive cough and pleuritic chest pain. His vital signs were significant for a mild fever, tachycardia, tachypnea, occasional hypotension, and oxygen desaturation. Laboratory investigations revealed a mild hypokalemia and hypocalcemia, small increase in leukocyte count (10.8-11.6 x 109/L, 78% neutrophils, all others in normal range), and elevated troponin (2.42 ng/mL). An ECG was normal, but an echocardiogram revealed an ejection fraction of 25-30% with global ventricular dysfunction. Chest radiography showed scattered consolidated airspace disease consistent with pneumonia or cardiogenic edema.

    Mr. T’s clozapine course was discontinued immediately after the psychosomatic consult. The likely diagnosis was subsequently changed to myocarditis after consultation with cardiology and infectious diseases. On the fourth day of admission, he developed a mild eosinohiphilia, as has been previously reported in cases of clozapine-induced myocarditis. A workup for other causes of myocarditis was negative.

    Supportive management was continued and Mr. T’s condition progressively improved. Over the course of the next week, his fever and respiratory distress improved markedly, his ejection fraction increased to 50-55%, his leukocyte count declined, his eosinophil differential normalized, his troponin count declined, and his chest X-ray cleared. He was discharged with outpatient follow-up eight days after this admission.

    Discussion: Mr. T displayed an example of a severe case of clozapine-induced myocarditis, a rare condition that has been associated with a great deal of morbidity and mortality. In this case, improvement occurred in the absence of therapy specifically directed toward heart failure management or immunosuppression, suggesting that early recognition of the condition and withdrawal of the offending agent can have a significant impact on morbidity due to clozapine-induced myocarditis.

    Objectives:

    1. Identify the clinical features and course of clozapine-induced myocarditis and heart failure
    2. Learn proposed mechanisms for the pathological development of this iatrogenic complication.
    3. Learn appropriate medical interventions necessary for patient survival and recovery.

    Relevance:
    Clozapine has an important role in the management of refractory psychotic illness. The risk of myocarditis is a lesser known yet potentially fatal complication of clozapine pharmacotherapy.

     
  3. [T] A Model of Liaison Psychiatry with Cardiologists
    Presenting Author:  James Zuiches
    Co-Authors:  Crystal Jimenez, Bruce Bongar, Karen Friday, John Giacomini, Alan Schatzberg

    Among cardiology outpatients, the prevalence of mental disorders has been estimated to be 35-40%. In addition, the impact of these disorders heightens risk for cardiac-related rehospitalization and mortality. Despite increasing literature on the number of cardiology patients who have underlying mental disorders, there is little documentation on how cardiologists deal with these patients. Furthermore, there are no models for offering liaison psychiatry services tailored to outpatient cardiology. The aim of this paper is present findings on the unmet needs of cardiologists with respect to handling mental health issues and articulates a model for effectively offering liaison psychiatry services to cardiology.

    Objectives:

    1. Enumerate the needs of cardiologists with respect to mental health services.
    2. Describe the cardiologist current understanding of mental illness and expectations from mental health treatments.
    3. Articulate a model for facilitating consultation referrals from cardiologists to consultation-liaison psychiatrists; such to facilitate referrals in a more timely and expeditious fashion.

    Relevance:
    The presentation offers insight into the “mental maps” cardiologists use when they encounter patient mental health issues. This insight can be used to better position consultation-liaison psychiatry services to cardiologists.

     
  4. [T] A Brief Intervention for Anxiety and Comorbid Medical Illness
    Presenting Author:  Tanya Vishnevsky
    Co-Authors:  Anne Eshelman, Lisa Miller, Maren Hyde-Nolan

    Purpose: Approximately 33-50% of patients diagnosed with a chronic medical illness have co-occurring anxiety/depression [1]. In particular, patients who have a chronic medical condition and anxiety are more likely to suffer complications when admitted to a general medical hospital, have longer hospital stays, and are more costly to treat [2]. However, little research exists on specific interventions that address anxiety disorders in medical settings [1]. Several studies suggest that cognitive-behavioral approaches may be effective in reducing anxiety among individuals with co-morbid medical conditions [3]. The aim of this study is to examine the feasibility and benefits of a brief intervention for patients who have a chronic medical condition and a co-morbid anxiety disorder.

    Methods: The sample includes 100 patients who have either been evaluated for or have already received an organ transplant. Subjects are provided with a "stress relief kit" that includes psychoeducational materials on anxiety and chronic medical conditions, sleep hygiene strategies, and a CD for relaxation training. Subjects are oriented on how to use these materials and are led through a 5-minute relaxation training exercise. In addition, subjects complete a number of measures at baseline: 1) The State-Trait Anxiety Inventory State Scale (STAI-S) at the beginning and end of the first session, 2) Hospital Anxiety and Depression Scale, and 3) Insomnia Severity Index. Subjects complete the same measures, along with a structured questionnaire about utilization of the materials 2-4 weeks following the initial session.

    Results: Data collection for the study is in process and will be completed by July 2012. The feasibility of this intervention is promising, with low cost, short duration, and high patient interest. Preliminary results suggest a decrease in anxiety levels, as indicated by lower scores on the STAI-S following the initial session. Data will also be presented on anxiety, depression and satisfaction levels at follow-up.

    Conclusions: While data collection is still ongoing, preliminary evidence is promising with regards to the feasibility of this intervention within a hospital setting. Moreover, it appears that the intervention effectively reduced subjects' anxiety immediately following the session. Using this intervention to improve patients' mental health could decrease number of complications, decrease days in the hospital, and reduce overall medical costs.

    References:

    1. Cimpean, D., & Drake, R. E. (2011). Treating co-morbid chronic medical conditions and anxiety/depression. Epidemiology and Psychiatric Sciences, 20, 141-150

    2. Marciniak, M., Lage, M., Dunayevich, E., Russell, J., Bowman, L., Landbloom, R., et al. (2005). The cost of treating anxiety: the medical and demographic correlates that impact total medical costs. Depression & Anxiety (1091-4269), 21(4), 178-184.

    3. Hynninen, M. J., Bjerke, N., Pallesen, S., Bakke, P. S., & Nordhus, I. H. (2010). A randomized controlled trial of cognitive behavioral therapy for anxiety and depression in COPD. Respiratory Medicine, 104, 986-994.

    Objectives:

    1. Understand the role of anxiety in chronic medical conditions
    2. Learn about existing interventions for anxiety in the context of chronic medical illness
    3. Learn about the feasibility and efficacy of a brief and cost-effective cognitive-behavioral intervention for organ transplant patients.

    Relevance:
    This presentation utilizes a cognitive-behavioral approach to reduce anxiety in patients who have chronic medical illness.

     
  5. [T] Prevalence of Anxiety and Mood Disorders and Use of Psychotropic Medications in Patients with Takotsubo Cardiomyopathy Compared to Patients with Acute Anterior Myocardial Infarction: A Retrospective Review.
    Presenting Author:  Lex Denysenko
    Co-Authors:  Jessica Mosier, Robin Hanson, Ethan Halpern

    Introduction: Takotsubo cardiomyopathy (TTC) is a transient, reversible acute cardiac syndrome frequently precipitated by an emotionally stressful event. Prior studies demonstrate significant variation in the prevalence of anxiety and mood disorders in TTC patients, ranging from 21-40% [1,2]. This study aims to better delineate the prevalence of psychiatric symptoms, psychotropic medication use, and the prevalence of depression and anxiety in hospitalized patients with TTC. We postulate that patients hospitalized with TTC will have higher prevalence of anxiety disorders, mood disorders, and use of psychotropic medications as compared to a control group of hospitalized patients with acute anterior myocardial infarction (AAMI).

    Methods: Subjects will be retrospectively identified using the Department of Radiology echocardiography database by searching for the past 5 years for a diagnosis of "Takotsubo Cardiomyopathy" or "Stress-Induced Cardiomyopathy." A control cohort will be identified by searching for a diagnosis of "Anterior Myocardial Infarction" or "Anterior Dyskinesis." Demographic information, past psychiatric history, psychiatric symptoms and/or disorders at time of presentation and during hospitalization, the presence of an identifiable stressor, coronary risk factors, and medication data will be collected for each subject by reviewing the electronic medical record.

    Results: We estimate that compared to AAMI patients, TTC patients are significantly more likely to receive psychotropic medications and to present with mood or anxiety symptoms during acute medical hospitalization. Descriptive statistics will be used to analyze the data for both the TTC and the AAMI control group. Results from this study will be reported and presented following statistical analysis of the above mentioned data.

    Conclusion: Patients hospitalized with TTC may also have more co-morbid mood or anxiety disorders than patients hospitalized with AAMI. These findings may warrant routine psychiatric screening and consultation for patients with TTC. Further research will be needed to determine if prompt psychiatric treatment of mood and anxiety symptoms in acute TTC patients improves clinical outcome.

    References:

    1. Vidi V, Rajesh V, Singh PP, Mukherjee JT, Lago RM, Venesy DM, Waxman S, Pyne CT, Piemonte TC, Gossman DE, Nesto RW: Clinical characteristics of tako-tsubo cardiomyopathy. Am J Cardiol 2009; 104:578-582.

    2. Mudd JO, Kapur NK, Champion HC, Schulman SP, Wittstein IS: Patients with stress-induced (takotsubo) cardiomyopathy have an increased prevalence of mood disorders and antidepressant use compared to patients with acute myocardial infarction. J Cardiac Fail 2007; 13 (6):S176.

    Objectives:

    1. To understand the relationship of takotsubo cardiomyopathy and psychiatric stressors.
    2. To investigate the prevalence of mood and anxiety disorders in patients with takotsubo cardiomyopathy.
    3. To analyze how patients with takotsubo cardiomyopathy differ from patients with acute anterior myocardial infarction.

    Relevance:
    This study is relevant to the psychiatrist who consults on cardiac patients, and has educational value to the trainee or early-career psychiatrist who may not be familiar with takotsubo cardiomyopathy.

     
  6. [T] Takotsubo Cardiomyopathy and Catatonia: An Acute Stress Connection?
    Presenting Author:  Lex Denysenko
    Co-Authors:  Adam Trenton, Rachel Shmuts, Ethan Halpern, Madeleine Becker

    Introduction: Takotsubo cardiomyopathy (TTC) is a rare syndrome often precipitated by an emotionally stressful event. It is characterized by transient left ventricular dysfunction, ECG changes, and symptoms mimicking an acute myocardial infarction. Catatonia is a psychomotor syndrome that most often occurs in the setting of a mood disorder, but also is seen in schizophrenia and general medical conditions. Here, we report the first case of a woman with co-occurring TTC and catatonia in the setting of an acute psychological trauma and complicated bereavement.

    Case Report: Ms. X was a 54 year-old female who was found by her daughter in the backyard yelling incoherently and walking in circles. Upon admission, Ms. X exhibited bizarre behavior, including unresponsive staring spells, posturing, mutism, and a coarse right arm tremor.

    Brain CT and MRI ruled out stroke or hemorrhage. EEG was normal. CBC, chemistries, thyroid function, blood and urine cultures were unremarkable. Urine drug screen was positive for cannabinoids. ECG revealed inverted T waves in all leads. Transthoracic echocardiography showed severe left ventricular dysfunction, akinesis of the mid-distal left ventricle with apical ballooning, and preservation of the basal segments, consistent with TTC.

    On hospital day 6, she desaturated during an albuterol treatment and was briefly intubated. Upon extubation, she exclaimed "my baby is dead!" and began crying about her son, who had died unexpectedly two months earlier. Psychiatry was consulted for depression. On examination, Ms. X displayed episodic posturing, with arms raised towards the ceiling and head raised off the bed for more than 30 minutes. She had total body rigidity, waxy flexibility, negativism, ambitendency, gegenhalten, grimacing, hoarse speech, increased speech latency, and episodic mutism. She was fully oriented. Her Bush-Francis Catatonia Rating Scale (BFCRS) score was 36. Twenty minutes after administration of lorazepam 1mg IV, speech hoarseness, fluency, rigidity, negativism, and tremor temporarily resolved.

    Ms. X's catatonic symptoms responded favorably to lorazepam 3mg po every 6 hours, and further improved with the addition of memantine 5mg po BID. She continued to be anxious, sad, tearful, and preoccupied with her son's death, and was transferred to inpatient psychiatry. Paroxetine was started and her mood and affect improved. She was discharged home on hospital day 25. Lorazepam and memantine were tapered with no further occurrences of TTC or catatonia on follow-up 2 months later.

    Discussion: This is the first report of TTC and catatonia occurring simultaneously. We posit three mechanisms that may have triggered both TTC and catatonia: a surge in serum catecholamines, alterations in cerebral blood flow, or a glutaminergic excess associated with decreased GABA-ergic activity. Further research regarding the role of anxiety, bereavement, and excessive serum catecholamines in patients with catatonia is needed.

    Objectives:

    1. To learn about takotsubo cardiomyopathy and its relationship with emotional stressors.
    2. To learn about catatonia and its relationship to other psychaitric disorders.
    3. To encourage further discussion regarding the possible similar pathophysiologic etiology of catatonia and takotsubo cardiomyopathy.

    Relevance:
    This case report is highly relevant to the practicing psychosomatician, early career psychiatrist or trainee, or catatonia researcher.

     
  7. WITHDRAWN  
  8. [T] Paroxetine Induced QTc Prolongation: A Case Report and Review of Literature
    Presenting Author:  Raman Marwaha
    Co-Author:  Aasia Syed

    Introduction: Prolongation of the corrected QT interval (QTc) on the electrocardiogram is an important clinical condition because it increases the risk of polymorphic ventricular tachyarrhythmia called torsades de pointes , a medical emergency that can cause sudden cardiac death. QTc prolongation can be induced by many drugs including antipsychotics and tri cyclic antidepressants . Compared with tri cyclic antidepressants , selective serotonin reuptake inhibitors like paroxetine are less likely to cause severe cardiac side effects and have a high cardiovascular tolerability. In general , paroxetine is well tolerated in the overall patient population and the most common adverse effects of paroxetine include nausea , headache , dry mouth, sweating, somnolence, insomnia, constipation, tremor and sexual dysfunction. The purpose of this paper is to report an additional side effect of paroxetine .

    Method: Case report. We present the case of a 47 year old woman with a history of stress induced cardiomyopathy, depression, and anxiety on paroxetine 60 mg daily who developed a QTc of 530 ms. Cardiology (Electrophysiology) was consulted, patient's electrolytes were normal and no other QTc prolonging factors were found. Paroxetine was held, within 24 hours of discontinuing paroxetine electrocardiogram showed a QTc of 446 ms.

    Discussion: In this case, we found a clear temporal relation between QTc prolongation and the use of paroxetine. Paroxetine, like citalopram, is known to exhibit QTc prolongation. While FDA has issued a warning that citalopram causes dose-dependent QTc prolongation, some cases of paroxetine-induced QTc prolongation have also been reported in the literature.

    Conclusion: Clinicians should be wary that paroxetine can cause QTc prolongation in patients with high risk profile. This case report also highlights the importance of routine examination of electrocardiogram and monitoring of QTc interval in patients receiving paroxetine. Clinicians should consider more frequent electrocardiogram monitoring in patients with high risk profile and electrolytes should be monitored as clinically indicated.

    References:

    1. Erfurth A, Loew M, Dobmeier P, Wendler G. ECG changes after paroxetine. 3 case reports. Nervenarzt 1998 Jul;69(7):629-31

    2. Edwards JG, Goldie A, Papayanni-Papasthatis S. Effect of paroxetine on the electrocardiogram. Psychopharmacology (Berl). 1989;97(1):96-8

    3. Wenzel-Seifert K, Wittmann M, Haen E. QTc prolongation by psychotropic drugs and the risk of Torsade de Pointes. Dtsch Arztebl Int. 2011 Oct;108(41):687-93. Epub 2011 Oct 14. Review

    4. Tseng PT, Lee Y, Lin YE, Lin PY. Low-dose escitalopram for 2 days associated with corrected QT interval prolongation in a middle-aged woman:a case report and literature review. Gen Hosp Psychiatry. 2012 Mar-Apr;34(2):210.e13-5. Epub 2011 Nov 30

    5. Altmann D, Eggmann U, Ammann P. Drug induced QT prolongation. Wien Klin Wochenschr.2008;120(5-6):128-35

    Objectives:

    1. Clinicians should be aware of the clinical cardiac side effects like QTc Prolongation of paroxetine.
    2. Clinicians should be aware that patients with high risk profile on paroxetine should have electrocardiogram monitoring for QTc prolongation.
    3. Clinicans need to be wary of starting paroxetine in patients with high risk profile.

    Relevance:
    Paroxetine is well tolerated in the overall patient population but clinicians should be wary that paroxetine can cause QTc prolongation in patients with high risk profile.

     
  9. [T] Parenteral Methadone and the Risk of Torsades de Pointes: Two Case Reports and Literature Review
    Presenting Author:  Archana Brojmohun
    Co-Authors:  Jun Yang Lou, Margo Funk

    Purpose: Methadone is a long-acting synthetic opiate frequently encountered by consultation psychiatrists and it is being increasingly prescribed for chronic pain, opioid withdrawal, and maintenance treatment for opioid dependence in both outpatient and inpatient settings. When used at therapeutic doses, methadone is associated with potential cardiac disturbances such as Torsades de Pointes, perhaps accounting for unexplained deaths in methadone users. Hypokalemia, female gender and the loading phase of methadone are known risk factors for developing dysrhythmia. However, it remains very difficult to predict which patients are likely to suffer drug-induced Torsades de Pointes, especially in the inpatient setting where the management of acute and chronic medical and psychiatric issues intersect. As a result, the consultation psychiatrist is often wary of causing cardiac arrest when prescribing methadone along with other psychotropic medications.

    Methods: We describe cases of Torsades de Pointes (TdP) in two medically hospitalized young patients in whom therapeutic doses of oral and intravenous methadone were administered.

    Results: Close cardiac monitoring at the time of the events captured the onset of dysrhythmia and allowed us to analyze in detail the clinical settings under which these events occurred.

    Conclusions: The findings of theses cases, together with a review of literature on adverse cardiac events related to methadone and specific risks of parenteral administration, highlight the potential pitfalls and warning signs that could help guide consultation liaison practitioners in prescribing and dosing methadone safely.

    References:

    1. Chugh SS, Socoteanu C, Reinier K, Waltz J, Jui J, Gunson K. A community-based evaluation of sudden death associated with therapeutic levels of methadone. Am J Med. 2008. 121(1):66-71.

    2. Yap YG and Camm AJ. Drug induced QT prolongation and torsades de pointes. Heart. 2003. 89(11):1363-1372.

    3. Kornick CA et al. QTc interval prolongation associated with intravenous methadone. Pain. 2003. 105(3): 499-506.

    4. Substance Abuse and Mental Health Service Administration (SAMHSA) Methadone-associated mortality: report of a national assessment http://www.samhsa.gov (2004) Accessed April 1, 2008

    Objectives:

    1. Participants will be able to describe optimization of the clinical setting (ECG interpretation, management of electrolytes, optimization of additional psychopharmacologic agents) before prescribing methadone.
    2. Participants will be able to identify risk factors for development of Torsades de Pointes.
    3. Participants will be able to identify risks of using parenteral methadone.

    Relevance:
    Methadone is encountered in pain management, opioid detoxification, and opioid dependence maintenance therapy. We present the risks of using methadone, clinical scenarios where dysrhythmia can occur, and safe prescribing practices.

     
  10. Heart Rate Variability (HRV) Derived Marker of Sensation during Physiological Bladder Filling in Overactive Bladder Syndrome (OAB): Do We Have a Biomarker of Urgency?
    Presenting Author:  Xavier Preud'homme

    Introduction and Objectives: OAB is a prevalent bladder storage syndrome (16% of the overall U.S. population) characterized by increased daytime and nighttime voiding frequency and by urgency, also associated with greater rates of depressive or anxiety disorders, and/or with a history of emotional, physical or sexual trauma. Yet, alike most DSM diagnoses, diagnosing OAB relies on self-report, in particular of urgency, its most bothersome symptom. Hubeaux found during rapid retrograde bladder filling in 3 OAB subjects (Ss) an increase in autonomic nervous system (ANS) sympathovagal balance (LF/HF) prior to voiding. Could ANS provide biomarkers of urgency in OAB thus distinguishing voids with perceived urgency from those without?

    Methods: Un-medicated OAB Ss with ≥10 on Blaivas′s OABSS Questionnaire, 3-day diary with ≥8 voids/24hr, ≥1 urgency; and ≥2 nocturic voids were recruited to participate in a 6-hour in-laboratory undisturbed physiological anterograde bladder filling study. Ss triggered a bell to indicate their decision to void and mark the ECG recording then reported urgency with a 5-point categorical scale (PPIUS), also used to determine voids with or without urgency. Six female Ss (5 African-Americans, 1 Caucasian) reporting at least ≥1 voids with urgency and at least ≥1 without across their first 3 voids were selected. ANS was assessed with ECG-derived HRV computing both LF/HF and coefficients of variation (CV) over short 2-minute artifact-free segments preceding each decision to void. A comparable segment from the onset of the study served as baseline from which relative changes in both ANS measures were computed for all voids per Ss. Thus, repeated measures analyses of covariance controlling for age (range: 36-70), OABSS urgency sub-score (range: 10-16), and rank of voids with urgency (1-3) was used to test the null hypothesis of no within-subject difference in relative change in ANS measures preceding the decision to void and baseline.

    Results: When controlling for the 3 covariates, a significant within-subject effect was found (p<0.04) with lower CV (mean difference = -59%) for voids with urgency compared to those without, also consistent with greater sympathovagal activation. This effect was not found for LF/HF. Notably, there was a significant interaction between the within-subject effect and ranking of voids with urgency (p=0.036) such that greater sympathovagal activation occurred later into the study possibly because of the quasi doubling of bladder filling rate from a mean of 1.2 to 2.1 ml/min.

    Conclusions: Perceived urgency was preceded by sympathovagal activation supporting carrying out further studies to assess the utility of CV as biomarker of urgency. LF/HF, another potential ANS measure of sympathovagal activation, may be less useful due to technical challenges in implementing this measure across short periods.

    Source of Funding: This study was supported by Pfizer Inc. thanks to a 2010 OAB-LUTS competitive grant.

    Objectives:

    1. Learner will be reminded of a prevalent bladder-storage disorder, overactive bladder syndrome (OAB), frequently associated with psychosomatic conditions and, alike, dependent on self-report for its diagnosis.
    2. Learner will review different ECG-derived hear-rate variability measures and review technical challenges in implementing such measures across short periods of time.
    3. Learner will explore whether hear-rate variability measures could be a biomarkers of urgency, the hallmark of OAB, and will appreciate the importance of why sympathovagal activation precedes urgent voids.

    Relevance:
    Beyond classic psychosomatic conditions are other syndromes also diagnosed on self-report like OAB, relying on urgency, a hard-to-define subjective sensation, for which psychosomaticians have useful tools capturing sympathovagal activation: HRV.

     
  11. [T] Ethical implications of LVAD Procedures: Pre-op and Post-op Considerations
    Presenting Author:  Jennifer Moore
    Co-Authors:  Christopher White, Neil Witsken

    The left ventricular assist device (LVAD) is a procedure initially introduced in the 1980’s as a means to bridge end-stage heart failure patients to the gold-standard treatment of heart transplant. More recently, this procedure has been used as a destination therapy for patients with contraindications to heart transplant, and increasingly as an alternative treatment to heart transplant. The LVAD involves extensive post-op care with mechanical upkeep and troubleshooting to maintain proper function. In addition, there is the risk of morbidity with the procedure including infections, blood clots, and device failure while benefits include decreased 2-year mortality and improved quality of life.

    An association between poor outcomes and pre-morbid psychiatric symptoms exists with the use of this device. Inherent in the pre-operative psychiatric evaluation is the question of the ethical implications in assessing a person for a procedure that could improve the quality of their life while at the same time requiring burdensome upkeep. The issue becomes complicated when you look at a person whose heart is functioning at such a minimal level that it impairs daily functioning and the possibility of death is pervasive. This circumstance, in many people would cause or exacerbate depression and anxiety and treatment may greatly improve their functioning and life expectancy. On the other hand, there are people who may become overwhelmed by the upkeep or fear of mechanical failure or infection, which could cause or exacerbate psychiatric symptoms. Evaluating psychiatrists must weigh these factors carefully to ensure their recommendations will best serve each individual heart failure patient given the disparate outcomes and responses. This poster will attempt to address the ethics involved in pre-LVAD evaluations and provide a guide for clinical considerations.

    Objectives:

    1. Understand the impact of the LVAD procedure on patient outcomes and quality of life with particular attention of pre- and post-psychiatric functioning.
    2. Identify the ethical considerations involved with pre-procedure psychiatric evaluation and the impact of this assessment on patients.
    3. Apply this knowledge to patients that are facing LVAD placement, or that have had an LVAD placed, to improve outcomes and quality of life for these patients.

    Relevance:
    With the increasing placement of LVAD, it is important to understand the risk and benefits, as well as the ethical implications of the placement to ensure educated, informed decisions.

     
  12. [T] Psychiatric Evaluation Prior to LVAD Placement: Trends, Evidence, and Guidelines
    Presenting Author:  Jennifer Moore
    Co-Authors:  Christopher White, Robert Sperry

    The left ventricular assist device (LVAD) is an increasingly common procedure for end-stage heart failure patients. This procedure, initially introduced in the 1980’s to serve as a bridge to gold-standard treatment of heart transplant, has more recently been used as a destination therapy in the case of contraindications to heart transplant and is even now being used as an alternative treatment. The procedure calls for extensive post-op care with mechanical upkeep and troubleshooting to maintain proper function. Risks of the procedure include infections, blood clots, and device failure, while benefits include decreased 2-year mortality and improved quality of life.

    There is a known association between poor outcomes with pre-morbid psychiatric symptoms and the use of this device. Due to this, standard practice involves psychiatric evaluation prior to the procedure in hopes of improving outcomes by identifying those patients who may have untreated psychiatric illness. The literature, however, on what constitutes a psychiatric pre-procedure assessment for these patients is lacking. As such, there is no standard approach to the evaluation for pre-op LVAD patients nor to the recommended interdisciplinary approach peri- and post-operatively. In this poster, we will review the psychiatric assessment process at several institutions that perform LVAD procedures. Review of these data will focus on common elements among the various institutional approaches. Furthermore, differences in assessment approaches will be highlighted for discussion. This work will provide a starting point for creating a best practice guideline for psychiatric assessment pre-procedure to improve outcomes and quality of life for patients considering LVAD placement.

    Objectives:

    1. Understand the impact of psychiatric symptoms on LVAD procedure outcomes.
    2. Identify trends in pre-procedure psychiatric assessments for LVAD placement.
    3. Develop guidelines for best practice approach to assessing patients prior to LVAD procedures to improve outcomes and quality of life.

    Relevance:
    LVAD procedures call for an interdisciplinary approach. This presentation will provide a starting point for standardizing pre-op psychiatric assessments to improve outcomes and increase awareness in the psychiatric community.

     

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Section B:  Case Reports

  1. [T] Traumatic Brain Injury in Children—Pharmacological Approach to Acquired ADHD
    Presenting Author:  Saadia Nosheen
    Co-Author: Daniel E. Gih

    Objective: Traumatic brain injury (TBI), a common condition seen in both adults and children, can lead to cognitive, social and physical complications. Attention Deficit/Hyperactivity Disorder (ADHD) induced by TBI in children (secondary ADHD or ADHD/TBI) is one consequence that has limited discussion in the literature. This poster reviews the psychopharmacologic treatment options available, their effectiveness, and what is currently under study.

    Method: A literature search was conducted using the following databases: Medline, Cochrane/EBM and PubMed from 1988-2011. Stimulants TBI, TBI, ADHD TBI, Bromocriptine, Guanfacine, Donepazil and Atomoxetine were the key search terms used. Information was extracted on study characteristics, interventions and outcome. Limits include clinical trial publication, human subjects, English language, adults and children age 0-18 years.

    Results: Eleven clinical trials evaluating the efficacy and safety of Methylphenidate (MPH) in pediatric and adult patients with TBI match the search criteria. Of the eleven identified studies with MPH, one was a chart review, one used a single blind, placebo controlled cross over design and nine were double blind placebo controlled crossovers. Other studies on the role/effect of Bromocriptine (one placebo controlled pilot study), Donepezil (one placebo control study) and Alpha2 agonist (one placebo controlled double blind crossover study) on Secondary ADHD were also reviewed. No study on Atomoxetine was found in human subjects with Secondary ADHD. These studies used several subjective and objective tests to measure behavioral and cognitive (attention, memory, learning, and cognitive processing speed) outcome. Many drugs showed encouraging pre-clinical results with neuroprotective, neurorestorative, neurogenetic and synaptogenetic properties but all phase II and III clinical trials have failed so far.

    Conclusion: There are a limited number of randomized double blind placebo controlled multi centered trials studying the effects of methylphenidate in ADHD/TBI. No randomized controlled studies in ADHD/TBI using stimulants other than MPH were found. Statistical analyses of the limited data clearly demonstrate the efficacy of short term treatment with MPH in the pediatric population. There is very scant literature available on the use of non stimulant treatment options in Secondary ADHD. More studies are required to see the effects of Amphetamine group of stimulants and non-stimulant treatment options for secondary ADHD. Based on our review, more multicentered, randomized, double blind, placebo controlled studies with larger sample sizes, longer length of treatment and wider ranges of doses must be conducted.

    Objectives:

    1. Inform about pharmacological treatment options available, their effectiveness, and what is currently under study for the ADHD caused by traumatic brain injury.
    2. Create awareness among medical professionals about the need of further research in this area.
    3. Help providers in the management of ADHD induced by TBI.

    Relevance:
    Get information about pharmacological treatment options available, their effectiveness, and what is currently under study for the ADHD caused by traumatic brain injury.

     
  2. Dextromethorphan/Quinidine for the Management of Cerebellar Cognitive Affective Syndrome: A Case Report
    Presenting Author:  Jason Caplan
    Co-Author:  John Daly

    Purpose: To report a case which illustrates a novel potential treatment for patients with cerebellar cognitive affective syndrome (CCAS).

    Methods: We present the case of a man who developed symptoms consistent with CCAS that signficantly interfered with his course of treatment after a PICA stroke. Trials of benzodiazepines and first and second generation neuroleptics failed to ameliorate his symptoms. Given that sigma-1 receptors are highly concentrated in the cerebellum (his primary locus of injury), an off-label trial of dextromethorphan/quinidine (a formulation with known potent sigma-1 agonsim) was attempted.

    Results: The patient's behavioral symptoms rapidly improved after dextromethorphan/quinidine (DM/Q) was started, allowing him to participate in therapy and ultimately be discharged from the hospital. His symptoms worsened after the medication was stopped post-discharge, and rapidly improved again once it was reinitiated.

    Conclusions: Drugs with activity at the sigma-1 receptor have demonstrated efficacy in the management of a number of neuropsychiatric conditions including pseudobulbar affect and delirium. This case describes a patient with another diagnostic entity associated with behavioral and affective changes, CCAS, who benefited from a sigma-1 agonist. More research is needed on the role of agents with sigma-1 activity (including DM/Q) in the management of CCAS and other conditions associated with agitation and other behavioral symptoms.

    Objectives:

    1. Understand the basic neuropsychiatry and clinical presentation of cerebellar cognitive affective syndrome.
    2. Appreciate the pharmacology of dextromethorphan/quinidine and its action at the sigma-1 receptor.
    3. Integrate the understanding of the pathophysiology of cerebellar cognitive affective syndrome and the mechanism of action of dextromethorphan/quindine to appreciate the potential utility of this treatment modality in this syndrome.

    Relevance:
    Dextromethorphan/quinidine may represent a novel treatment strategy for the management of cerebellar cognitive affective syndrome and other neuropsychiatric conditions that present with behavioral dysregulation.

     
  3. [T] The Use of Clinical Vignettes to Augment Learning on an Inpatient Consultation-Liaison Service.
    Presenting Author:  Robert Lloyd
    Co-Author:  Lisa Rosenthal

    Purpose: Competency in psychiatry for board certification is now being assessed in part by evaluation of recorded vignettes. To date, there has been little study of the use of vignettes in education in psychosomatic medicine during residency. Through collaborative efforts, several organizations involved in resident education have established a list of competencies to be achieved during the course of psychosomatic medicine training. On many services, these competencies are met by various exposures including supervision of consults by attending physicians, didactic courses, literature review, and self-directed readings. The patient interactions that promote learning are variable between residents and somewhat dependent on the type of consults seen by a resident while on service. While didactic lectures and reading may be valuable resources for delivering information, some individuals may also learn information and retain it better via clinic experience and supervision. We wanted to determine if reviewing a video-recorded vignette combined with attending physician supervision may further augment the learning process and knowledge retention for residents during the psychosomatic rotation in residency.

    Methods: Resident physicians and medical students involved in a consultation psychiatry rotation were administered an initial assessment on their knowledge of the topic of informed consent and capacity evaluations. Residents viewed a short video vignette of an interview related to this topic and spent 20 minutes discussing the vignette with attending physicians, with a focus on the competencies in this area. The trainees were assessed at the end of the rotation for retention of knowledge on this specific topic and their impression of the value of the exercise.

    Results: Early data suggests that the video vignette may be beneficial for supplementing their knowledge, reviewing key topics, and in distilling critical information. We are gathering data on retention of the knowledge across the rotation currently and the effects of video vignettes on learning.

    Conclusions: Using video vignettes to demonstrate competencies in key topics in psychosomatic medicine may be beneficial in increasing resident understanding of a topic area as well as positively impacting learning and knowledge retention.

    Objectives:

    1. Participants will be able to describe the impact of vignettes on residents understanding of informed consent and capacity.
    2. Participants will be able to describe how vignettes may affect retention of knowledge.
    3. Participants will be able to explain residents opinions on the use of vignettes in clinical training.

    Relevance:
    Clinical vignettes are a valuable tool to augment the learning experience for residents and create discussions on essential topics in psychosomatic medicine.

     
  4. Suggestions for Standardization of Consultation Case Presentation Format
    Presenting Author:  Colin Harrington

    Introduction: Accurate and efficient synthesis of complex neuropsychiatric and medical-surgical information is increasingly important to the CL Psychiatrist in this era of integrated care. Case presentations must be thorough and concise to allow for accurate communication of clinical information, proper diagnosis and treatment, and efficient function of the CL service. Presentation of clinical data for patients seen in consultation differs in important ways from that of the traditional admission history and physical (H&P), but there is little instruction on optimal formatting of consultation case data. Use of standard H&P presentation style often results in non-linear reporting of the medical and psychiatric history relative to more recent HPI, problematic mixing of psychiatric and medical-surgical elements of the HPI, and confusion about whether listed medications are active at the time of consultation or represent those prescribed prior to admission.

    Discussion: We propose a formatting of case presentation for patients seen in consultation that is a variation on the theme of the traditional admission H&P and that emphasizes the elaboration of relevant history in the chronologically truest fashion. History of present illness (HPI) and medical-surgical hospital course are dependent upon and more easily comprehended with knowledge of past medical history (PMH) and past psychiatric history (PPH). Thus, after an introductory statement regarding reason for consultation, it is suggested that PMH and PPH be presented in their entirety, followed by the medical-surgical HPI and hospital course up to the time of requested consultation. Introductory statements that reference "pertinent past medical history" are discouraged as they are often followed by a formal and redundant presentation of a fuller PMH. Additional recommendations include (1) elaboration of pertinent positive and negative historical psychiatric ROS within the PPH, (2) collapsing of pre-admission medications into the relevant PMH and PPH sections where they are linked to their associated diagnoses, (3) reservation of the formal "medication" section of the presentation for current hospital medications, and (4) presentation of the psychiatric elements of the HPI in the mental status exam section after report of cognitive and other objective examination findings.

    Conclusion: Optimal communication of clinical information across services and specialties is increasingly important in evolving models of integrated care. This presentation format ensures chronologically true reporting of the narrative, efficient and non-redundant presentation of neuropsychiatric and medical-surgical data, and documentation of an examination that is most accurately interpreted when presented after relevant aspects of the hospital course. A fuller rationale for these and other suggested changes in case presentation format is provided.

    Objectives:

    1. Communicate the clinical narrative of consultation cases in the chronologically truest fashion.
    2. Apply these recommendations, contrasting them with traditional H&P presentation format, to best understand the relationship between PMH, past psychiatric history, and the medical and psychiatric elements of the HPI.
    3. Appreciate the different entry point and related documentation requirements of the admitting clinician versus the consulting clinician and how this affects the presentation of clinical data within and across services.

    Relevance:
    Mandates for and evolving models of integrated care demand accurate synthesis and communication of medical-surgical and neuropsychiatric case information in support of optimal patient care and efficient C-L service function.

     
  5. [T] Death by Doctors: A Severe Case of Factitious Disorder by Proxy in a Dependent Adult
    Presenting Author:  Deirdre
    Co-Author:  James McConville

    Case Report: Ms. M is a 33 year-old female with mild mental retardation a history of multiple medical symptoms including refractory nausea and vomiting, anorexia, gastric and colonic dysmotility, dizziness, dysuria, chronic constipation, anxiety, depression, chronic pain, seizures, dyspnea and fatigue who was referred to an academic medical center for an evaluation by gastroenterology. Prior to her referral, she had presented to two local hospitals at least 116 times in the prior year with multiple extensive workups. She had received dozens of medications, including anticholinergics, antispasmodics, antibiotics, antiemetics, antipsychotics, anxiolytics, narcotics, nutritional supplements and urologic agents. She received at least 14 separate computed tomography studies of the head, abdomen and pelvis and at least six upper endoscopies as well as several colonoscopies. She also had received a cholecystectomy, partial colectomy, two percutanous enteral gastrostomy tubes, multiple chronic indwelling foley catheters and a peripherally inserted central catheter (PICC) line. None of these medications or interventions relieved her many symptoms, and in fact, she suffered multiple complications. We recognized several signs strongly suggesting that Ms. M was a victim of factitious disorder by proxy at the hands of her mother. We were able to gather necessary clinical and collateral data to make a diagnosis and then stage an intervention which resulted in successful separation from Ms. M’s mother. We were able to perform a three month follow-up evaluation which confirmed a complete remission of all physical manifestations of her multiple illnesses and significant psychosocial improvement.

    Discussion: Factitious Disorder by proxy is rarely diagnosed in cases in which the victim is an adult and therefore it may be easily overlooked by medical professionals. We review the red flags and warning signs of this deception syndrome in medical patients. We will present the ethical and legal obligations of providers faced with this clinical presentation and we present recommendations for making a definitive diagnosis, notification of state protective agencies and staging a successful intervention.

    Objectives:

    1. Identify clinical and historical warning signs suggesting factitious disorder in a dependent adult.
    2. Learn ethical and legal obligations of clinicians treating suspected victims of factitious disorder by proxy.
    3. Apply knowledge of this illness in order to stage a successful legal and medical intervention.

    Relevance:
    Factitious disorder by proxy is rarely seen in adult victims. In adult patients there are special clinical characteristics as well as medical, legal and therapuetic considerations to make.

     
  6. [T] Buprenorphine Induction with Hospitalized Opioid Dependent Patients: A Case Series
    Presenting Author:  Sejal Shah
    Co-Authors:  Nicole Herschenhous, Leena Mittal, Joji Suzuki

    The misuse of prescription opioids and opioid-related overdoses continue to be significant public health problems in the United States. Consequently, hospitals have experienced an increase in admissions of patients with opioid use disorders. These patients may require detoxification or initiation of maintenance treatment. In the hospital setting, methadone and clonidine are commonly used for the treatment of opioid withdrawal, and patients are most often referred to federally licensed methadone maintenance programs. Since 2002, buprenorphine has been available as a medication for opioid detoxification as well as for maintenance treatment. However, very little has been reported on the use of buprenorphine to manage withdrawal in opioid dependent medical inpatients or whether this facilitates the transition to outpatient buprenorphine maintenance treatment.

    The aim of this poster is to describe three cases of buprenorphine inductions attempted with medically hospitalized patients. The risks and benefits of using buprenorphine compared to both methadone and clonidine for medically ill patients, the transition to outpatient care, and the logistical issues surrounding inpatient inductions will be described. We will also describe the role CL psychiatrists can play in managing opioid use disorders in the acute medical setting and models for collaborative management of these patients in a variety of outpatient settings.

    Objectives:

    1. Increase participant’s knowledge about the use of buprenorphie with hospitalized patients.
    2. To understand the potential risks and benefits of using buprenorphine with hospitalized patients.
    3. To understand the potential risks and benefits of using buprenorphine in this setting.

    Relevance:
    Psychosomatic medicine psychiatrists frequently encounter patients who may benefit from buprenorphine treatment in the medical setting.

     
  7. Case of a 24-year-old Woman with Pervasive Denial of Pregnancy
    Presenting Author:  Olivia Joly
    Co-Authors:  Lucy Hutner, Mallika Lavakumar, Caroline Segal, Margaret Spinelli

    Aims: Denial of pregnancy is not uncommon, and it presents complex issues in terms of differential diagnoses and clinical management. It has been reported that nearly 1 in 500 women deny pregnancy at 20 weeks of gestation or later (Wessel, Buscher: Denial of pregnancy: population based study. BMJ 2002; 324:458). The differential diagnoses include psychosis, concealment, traumatic dissociation, or pervasive denial, and they exist on a continuum. The possibility of prior sexual assault must be included in the evaluation. In addition, pregnancy denial is associated with a risk for neonaticide (Spinelli M: A systematic investigation of 16 cases of neonaticide. Am J Psychiatry 2001; 158:811-813). Our study describes the case of a 24-year-old woman who presented to Columbia University Medical Center with pervasive denial of pregnancy, and aims to illustrate important features of these pregnancies.

    Methods: A literature review was conducted on pregnancy denial, sexual assault, and neonaticide; and the case of a 24-year-old patient with pregnancy denial was reviewed.

    Results: The patient arrived at Columbia University Medical Center in active labor with her third child. She reported being unaware of her pregnancy until moments before delivery. She denied experiencing any of the physical symptoms associated with pregnancy, and she denied any circumstances that could have led to conception in the prior eleven months, since the birth of her second child. The team kept the patient on continuous observation, obtained collateral information from the patient's family, alerted child protective services, and established both outpatient mental health and mobile crisis services for the patient. She was interviewed by a senior psychiatrist with expertise in denial of pregnancy and neonaticide to better assess her risk. At the end of her hospital stay, patient admitted that she was sexually assaulted by a friend's brother, which was the likely cause of conception.

    Conclusion: Elucidating the underlying cause for pregnancy denial has important implications for psychiatric care and patient's safety for childcare. Furthermore, the associated risk between pregnancy denial and neonaticide adds a layer of medico-legal considerations. Clinicians who work with obstetric populations should be aware of this issue and cognizant of its challenges in management.

    Objectives:

    1. Understand pregnancy denial and its incidence, investigate differential diagnoses and distinguish the different forms of pregnancy denial and underlying defense mechanisms that may play a role in pregnancy denial.
    2. Identify maternal and neonatal risks, including risk of infanticide, which must bear upon the clinical management, including mobilization of social support and psychiatric evaluation.
    3. Apply knowledge about frequency and potential risks of pregnancy denial to clinical practice, consider it as a possibility in any woman of childbearing age.

    Relevance:
    Pregnancy denial is common, associated with risk for poor outcome. With 60% of mental health patients female and 50% of pregnancies unplanned, providers must consider the plausibility of pregnancy denial.

     
  8. [T] Blocking out the Sirens: The Ulysses Contract in Modern Psychosomatic Medicine
    Presenting Author:  Allyson Witters
    Co-Authors:  Elizabeth Heitman, Amanda Wilson, Vidya Raj

    Background: In Homer's Odyssey, any man who heard the Sirens' beautiful song would become incapable of rational thought and consequently suffer inevitable death trying to reach them. So he could listen, Ulysses commanded his men to tie him to the ship's mast and to ignore any orders he may give to change the ship's course after hearing the Sirens. A "Ulysses Contract" is a psychiatric advance directive to override a present request from a legally competent patient in favor of a past request made by that patient.

    Case: A 40 year old Caucasian female with a history of cocaine dependence, alcohol dependence, and post-traumatic stress disorder suffered severe burns to her face, chest, and torso after a battery acid assault. She subsequently developed pathological skin picking (PSP) that resulted in repeated skin graft failures to her neck and shoulders. Multiple pharmacological agents failed to suppress her PSP. These included antihistamines, benzodiazepines, opioids, antipsychotics, sertraline and clomipramine. Use of restraints, mittens, and occlusive bandages also did not prevent PSP enough to yield a successful skin graft.

    After 4 hospital admissions in 14 months, the primary surgical team consulted the Psychosomatic Medicine Service who recommended utilizing plaster casts on her upper extremities and a thermoplastic prosthesis to the wound site upon skin grafting. A concern was raised that she would later ask to have the cast removed, leaving the wound vulnerable. After consultations with the Clinical Ethics Consultation Service, Hospital Legal Counsel, and the Psychosomatic Medicine Service, the patient and her mother (primary care giver) agreed to proceed with casting. The patient signed a formal care plan instructing that her casts not be removed until medically advised, even if she later asked for removal.

    The treatment plan involved the use of sedative medications, casting of the upper extremities, occlusive dressings, a wound V.A.C, a thermoplastic prosthesis, supportive therapy, and participation in PT/OT. After a 64 day long hospital admission she was discharged with a successful skin graft and reduction in picking behavior.

    Conclusions: The Ulysses contract involves a willful decision with the intention to bind oneself in the future. Some controversy continues as to whether a decision made by a person in one state of health is binding at a later time when the person is in a very different, and usually worse, state of health. This approach should be reserved only for life-threatening medically refractory cases. To our knowledge, this is the first case of casting utilized for psychiatric reasons reported in the literature.

    Objectives:

    1. Introduction to pathological skin picking and a brief literature review of its management.
    2. Description of the Ulysses contract and its utility in psychiatric care.
    3. Description of use of a novel multidisciplinary treatment approach in psychosomatic medicine.

    Relevance:
    This presentation discusses the Ulysses contract, which can occasionally be utilized in patients with ongoing self-destructive behaviors in order to promote their healing.

     
  9. [T] A Second Look at Steroid Psychosis: A Case Report of Corticosteroid Use for Transplant Rejection in a Psychotic Patient
    Presenting Author:  Leila Sadeghi
    Co-Author:  Janna Gordon-Elliott

    Purpose: Clinicians worry about corticosteroid use in patients with known psychiatric conditions due to concerns of provoking or exacerbating symptoms such as mania or psychosis, despite an absence of evidence in the literature [1-4]. We aim to contribute to the literature by presenting a case of successful use of corticosteroids for acute kidney transplant rejection in a patient with active psychosis.

    Methods: Case presentation and literature review

    Results: The patient is a 38-year-old woman with a medical history of pancreas and kidney transplantation and a psychiatric history of schizophrenia diagnosed subsequent to her transplantation, who was admitted to our institution actively psychotic with acute kidney rejection in the setting of medication non-adherence. In the collaboration between medicine and psychiatry services in the care of this patient, the patient's psychotic state raised the important question of whether and how safely the patient could receive corticosteroids for the treatment of her transplant rejection. Though the role of corticosteroids as a potentially life-saving and hemodialysis-sparing treatment for kidney transplant rejection is well studied, given the potential neuropsychiatric adverse effects associated with corticosteroids, it was uncertain how the patient's psychotic state should influence the decision to treat the patient with corticosteroids. This patient was managed safely on a steady dose of antipsychotic medications and benzodiazepines on the medical floor and did not experience worsening of her psychotic symptoms from high-dose corticosteroids; her kidney function improved with the combination of corticosteroids and other immunotherapy.

    Conclusion: Clinical lore contends that corticosteroids will trigger or aggravate psychosis in patients with psychotic disorders, perhaps leading to delay or avoidance in utilizing a treatment that is medically indicated. While corticosteroids have been shown to provoke psychosis in general medical populations, the few studies that have investigated their effects on patients with known psychiatric illness have not found a worsening effect [2,3,4]. This case report adds to a scarce literature on the relevance of psychiatric illness in treatment with corticosteroids. Further exploration of the relationship between psychiatric conditions and corticosteroid use is warranted to inform medical practice.

    References:

    1. Kenna HA, Poon AW, de los Angeles P, Koran LM. Psychiatric complications of treatment with corticosteroids: Review with case report. Psychiatry and Clinical Neurosciences. 2011; 65: 549-560.

    2. Stiefel FC, Breitbart WS, Holland JC. Corticosteroids in cancer: neuropsychiatric complications. Cancer Invest. 1989; 7: 479-491.

    3. Patten SB, Neutel CI. Corticosteroid-induced adverse psychiatric effects: incidence, diagnosis and management. Drug Saf. 2000; 22: 111-122.

    4. Hall RCW, Popkin MK, Stickney SK and Gardner ER. Presentation of the steroid psychosis. J. Nerv. Ment. Dis. 1979; 167, 229-236.

    Objectives:

    1. Describe the neuropsychiatric adverse effects of corticosteroid use.
    2. Analyze a case of the successful use of corticosteroids for acute kidney transplant rejection in a patient with active psychosis.
    3. Review whether psychiatric illness is a risk factor for psychiatric adverse effects during treatment with corticosteroids.

    Relevance:
    Given the many medical indications for the use of corticosteroids, an important issue at the psychosomatic intersection is the use of corticosteroids in patients with past or present psychiatric symptoms.

     
  10. [T] Diagnostic and Treatment Challenges of Severe Anxiety in a 15-year-old Male with Fragile X Syndrome
    Presenting Author:  Gaurav Kulkarni
    Co-Author:  Laine Young-Walker

    Background: Known as the leading inherited cause of mental retardation and autism spectrum disorder world-wide, Fragile X syndrome (FXS) clinically can display a wide range of anxiety symptoms and other psychiatric comorbidities. The authors present a case to elucidate the challenges in categorizing the anxiety symptoms in these patients into a specific DSM-IV TR diagnosis and administering appropriate treatment modality.

    Case: A.M., a 15 year old male diagnosed with FXS and ADHD, referred by his primary care provider to the child and adolescent psychiatry clinic for managing "struggles with behaviors." His behavior includes "he will very quickly grab people's faces and scratch them." Behaviors initially happened with adults only, but later extended with other peers in the school. No excessive worries or fears. Seven years ago, a teacher physically abused him. It was reported and the police were involved. A.M. could not elaborate the details of the abuse neither could exemplify any post traumatic symptoms of re-experiencing, hyper-arousal or avoidance. A.M. has "some repetitive behaviors"—rocking and repeatedly asking "what is next?" No other obsessions reported. Mom stated "he is either happy or anxious." A.M. and his parents denied all other psychiatric disorders screening questionnaires.

    Result: When first seen in our clinic he was taking Risperidone 3 mg/day, Methylphenidate Extended Release (ER) 27 mg in morning and Sertraline 50 mg in morning. He has tried two other SSRIs (antidepressants) in the past with no benefit. We stopped Methylphenidate ER to see if it is contributing or increasing his anxiety and referred him for psychotherapy. With this change, anxiety improved and no significant difference in his ability to concentrate noted; but, after 4 months the anxiety symptoms relapsed. At that point, we increased Sertraline to 100 mg. In the 1 month follow up visit, the patient's behavior was worse more towards afternoon and evening hours, so we tapered his Sertraline and started Clonazepam 0.25 mg at 13:00 and bedtime. His behaviors worsened with more irritability, hyperactivity and aggression. We tapered his Benzodiazepine and added Guanfacine extended release which helped partially with symptoms relapsing in few months. We are right now tapering all his medications and continuing the psychotherapy.

    Discussion: This case illustrates the diagnostic and treatment selection challenges in FXS. A.M. had features suggestive of generalized anxiety and OCD. Also, anxiety disorder secondary to chronic medical condition and PTSD are possible diagnoses. The SSRIs most likely were activating; the irritability and aggression on Benzodiazepines reflects the high index of suspicion for side effects to be watched for in children and more so with FXS. Selecting the precise combination of medicine for psychiatric co-morbidities in FXS involves a multitude of factors that the authors will discuss in this poster.

    Objectives:

    1. Diagnosing psychiatric co-morbidities in patients with inherited causes of mental retardation.
    2. Treating psychiatric co-morbidities in patients with inherited causes of mental retardation.
    3. Applying the principles that will be discussed in the poster to taper the appropriate treatment modality for anxiety in Fragile X Syndrome patients.

    Relevance:
    Known as the leading inherited cause of mental retardation and autism spectrum disorder world-wide, Fragile X syndrome (FXS) clinically can display a range of anxiety symptoms and other psychiatric co-morbidities.

     
  11. [T] Psychosis Due to Pernicious Anemia
    Presenting Author:  Jimena Tuis Elizalde
    Co-Author:  Steven Fischel

    Introduction: Vitamin B12 deficiency is generally considered a reversible cause of dementia and psychosis of acute onset. We describe a patient with cognitive impairment and intractable delusions which did not resolve after vitamin B12 supplementation. This case exemplifies the importance of diagnosing vitamin B12 deficiency early and treating promptly to avoid permanent neuropsychiatric changes.

    Case Description: A 47-year-old disheveled woman with no past medical history presented to the Emergency Department with pancytopenia, fever, and altered mental status. Until five years prior to this hospitalization, the patient was a healthy, high functioning woman who followed a regular diet. Over the past five years, she became increasingly reclusive, began to demonstrate odd behaviors, and was unable to work. Her symptoms accelerated over the month prior to admission to the point where she would not leave her bedroom, and no longer attended to any of her activities of daily living. Upon admission, the patient received an RBC transfusion. Her anemia workup revealed low vitamin B12 with normal folate and ferritin levels, negative Coombs, and negative blood cultures. Peripheral smear revealed megaloblastic red blood cells with Howell Jolly bodies. Hematology recommended starting supplementation with subcutaneous Vitamin B12 at 1,000mcg IM per week for one month and then monthly dosing. She also received thiamine and multivitamin supplementation. She was treated with adequate trials of risperidone and olanzapine. Despite vitamin B12 supplementation and treatment with antipsychotic medication, she remained cognitively impaired, confabulatory, and delusional. She was oriented to person only, consistently believing that the date was 3 months earlier than the true date, and that she was "in a public building near the hospital." She consistently believed that she was currently working on a project for the local sewage treatment plant, and adamantly denied that she had any medical problems. Physically, she demonstrated incontinence and muscle weakness consistent with subacute combined immunodeficiency. She would only allow some help with ADL's. She ultimately required guardianship and placement in a skilled nursing facility.

    Discussion: This case report exemplifies a patient with intractable psychosis and dementia due to vitamin B12 deficiency. Disruption of the methylation process and the neurotoxic effects of homocysteine resulting from vitamin B12 deficiency can cause neuropsychiatric symptoms that include confusion, memory changes, delirium, depression, manic episodes, schizophreniform states, and other cognitive impairments. Although these changes are generally thought to be reversible, in some cases the neuropsychiatric changes caused by Vitamin B12 deficiency can be irreversible. Given her combination of cognitive, psychotic, and physical symptoms, the patient likely had developed a chronic B12 deficiency over several years. This case report illustrates the need for early recognition and treatment of vitamin B12 deficiency to avoid irreversible neuropsychiatric impairment.

    Objectives:

    1. Early detection of psychiatric symptoms suggestive of vitamin B12 deficiency.
    2. Recognize that the neuropsychiatric sequelae from vitamin B12 deficiency may be irreversible.
    3. Discuss the psychiatric treatment of patients with vitamin B12 deficiency.

    Relevance:
    In order to raise awareness of the need for early detection and treatment, we present a case of vitamin B12 deficiency that resulted in irreversible cognitive and psychiatric symptoms.

     
  12. [T] Treating a Complicated Case of Interictal Psychosis: A Review of the Psychosomatic Literature
    Presenting Author:  JaHannah Jamelarin
    Co-Author:  Christopher White

    EP is a 41 yo AAF with intractable fronto-temporal lobe epilepsy and non-adherence with anti-epileptic medication who presented with interictal psychosis requiring psychiatric hospitalization. Non-medication treatment options utilized include implanting a vagus nerve stimulator and evaluation for surgical removal of epileptogenic foci. EP was diagnosed with depression in 2007 and intermittently prescribed a SSRI. Her first psychotic episode was in 2011 with hospitalization for extreme paranoia and hallucinations. Risperdal was titrated to 3 mg daily which has led to moderate resolution of her symptoms. However EP continues to have marked non-adherence with her anti-epileptic medication making full resolution of her symptoms difficult, if not impossible.

    A PubMed search using the search term "interictal psychosis" generated 57 results including 7 reviews. Despite often being a solely psychiatric clinical presentation and requiring antipsychotic treatment, only 32% (including 2 review articles) were published in psychiatric journals. The majority have been published within the last decade reflecting the emerging interest in identifying and treating interictal psychosis. Consult psychiatrists are often asked for input regarding management of these patients since atypical antipsychotics (although effective in treating the patient's psychosis) are known to lower seizure thresholds. A further search of "interictal psychosis" AND "antipsychotic" generates 13 articles (4 published in psychiatric journals). With much of the existing evidence based on small observational studies there is a need for more research regarding interictal psychosis and how antipsychotic medication can be utilized in its treatment.

    When using a treatment option not established as standard of care or validated through clinical trials, ethical concerns can arise. In the case where psychosis is limiting the functional capabilities of EP, beneficence dictates that an attempt should be made to restore functioning likely by using antipsychotic medication. Perhaps even a depot antipsychotic could be beneficent as it would streamline her medication regimen. However, a depot would diminish her autonomy in determining when she wished to take the medication. Nonmaleficence dictates consideration of the potential of inducing more seizures through lowering the seizure threshold or developing the potentially debilitating side effects of antipsychotics. Furthermore, antipsychotic medication could be construed as treating a complication of the epilepsy. Perhaps a more judicious treatment plan would be geared toward treating her epilepsy yet this would involve an autonomous decision to be more medication adherent.

    This paper will review the psychosomatic literature on the diagnosis of interictal psychosis. It will expand its focus to the current evidence for management of interictal psychosis including a discussion of the evidence for lowering the seizure threshold with antipsychotics. Finally, the paper will examine some of the ethical considerations involved in treating a complicated case of interictal psychosis.

    Objectives:

    1. Discuss the literature available on the diagnosis of interictal psychosis.
    2. Discuss the literature on the seizure threshold lowering effects of antipsychotics and apply it toward treating interictal psychosis
    3. Discuss the ethics involved in treating interictal psychosis with antipsychotic medication

    Relevance:
    Consult psychiatrists are often asked for input regarding management patients with interictal psychosis since atypical antipsychotics (although effective in treating the patient’s psychosis) are known to lower seizure thresholds.

     
  13. [T] Aseptic Meningitis in a Depressed Adolescent on Lamotrigine: A Case Report
    Presenting Author:  Julia Burrow
    Co-Author:  Sarah Mohiuddin

    Lamotrigine (Lamictal) is an anticonvulsant medication, phenyltriazine derivative, that has been found to be efficacious in the prevention of mood episodes in adults with bipolar I disorder (Goldsmith et al., 2004). Lamotrigine is the most recent anticonvulsant to receive FDA approval for treatment of adult bipolar disorder in 2003. In addition, lamotrigine is used off label as an adjunct therapy for treatment refractory depression in both children and adults. To date, it has not been approved for treatment of mood disorders in children or adolescents; however, it is often prescribed off label in this population.

    A 17 year old Caucasian girl with a history of major depressive disorder who was prescribed lamotrigine for augmentation of treatment refractory depressive symptoms and developed a lamotrigine hypersensitivity reaction that presented as drug-induced aseptic meningitis (DIAM). She presented with a 2 day history of frontal headache, neck stiffness, and fever (up to 39.6° C) along with an erythematous, non-pruritic rash that started on her chest and arms and spread to her back on day of presentation. Just one week prior to her presentation, she had titrated her dose of lamotrigine to 50mg. A lumbar puncture was completed with increased opening pressure of 32 cm H2O and broad spectrum antibiotics were initiated. A cerebrospinal fluid (CSF) examination revealed mononuclear leukocytosis with no organisms on gram stain. CSF glucose was 65 MG/DL (normal 50-70) and protein 14 MG/DL (normal 15-45). CSF and peripheral blood eosinophilia were absent. After consultation with neurology, dermatology, ophthamology and psychiatry, the diagnosis of drug induced aseptic meningitis (DIAM) was made secondary to lamictal hypersensitivity. She was treated with IV steroids and discontinuation of lamotrigine with marked improvements over 2 days.

    The patient described in this report is unique in that the adolescent who developed DIAM did not have an underlying connective tissue disease and was prescribed lamotrigine for off-label treatment of refractory depressive symptoms. Anticonvulsant hypersensitivity reaction is a rare and potentially life threatening adverse drug reaction, well described with aromatic anticonvulsants such as phenytoin, carbamazepine, primidone and phenobarbital (Shear et al., 1988). With the increase prescription of lamotrigine for children and adolescents, awareness of an anticonvulsant hyperactivity reaction, including the risk for aseptic meningitis is critical. Anticonvulsant hypersensitivity reaction presenting as aseptic meningitis is not frequently encountered and it is important to be aware of these reactions for informed consent, best practice in clinical care and for understanding of treatment, including discontinuation and future avoidance of any aromatic anticonvulsants.

    Objectives:

    1. The physician learner will expand their understanding of a serious side effect from lamotrigine use.
    2. The physician learner will understand basic treatment modalities for lamotrigine hypersensitivity reactions.
    3. The physician learner will apply physical examination skills to monitoring for dermatologic eruptions as possible medication side effects.

    Relevance:
    This case presents an unusual and potentially life threatening side effect from lamotrigine use in adolescent depression.

     
  14. Broken Heart Syndrome (Takotsubo Cardiomyopathy) Triggered by Acute Mania: A Case Report and Literature Review
    Presenting Author:  Jose Maldonado
    Co-Authors:  Pegah Pajouhi, Ronald Witteles

    Objective: To understand the role of extreme psychological stress in the production of cardiomyopathy.

    Method: We encountered and describe the first reported case of mania-triggered Takotsubo Cardiomyopathy (TTC), also known as broken heart syndrome. In the course of studying this case we conducted an extensive review of the literature regarding the relationship between psychological stress and the development of cardiac failure.

    Results: Broken heart syndrome or TTC is a unique form of heart failure characterized by transient LV dysfunction, electrocardiographic changes that can mimic acute myocardial infarction, and minimal release of myocardial enzymes in the absence of obstructive coronary artery disease and which, almost always, completely reverses after resolution of the acute stage. The exact pathophysiology of the syndrome has not been elucidated, but the data suggests that 66% of patients suffering from this condition carry a diagnosis of either anxiety or depression. This finding, taken together with the higher frequency of a family history of anxiety or depression, and social isolation, suggests that psychosocial factors may be a predisposing risk factor in the pathophysiology of TTC, and that psychiatric disorders may facilitate the syndrome via catecholamine-induced myocardial stunning.

    Conclusions: A thorough review of the published data suggested that emotional or physical stress often preceded the onset of, and likely contributes to, the transient LV apical ballooning syndrome or TTC. Acute mania should be added to the list of psychosocial stressors that may trigger Takotsubo cardiomyopathy.

    Objectives:

    1. To understand the pathophysiology underlying TCC.
    2. To recognize the risk factors for the development of TCC.
    3. To understand the relationship between emotional states and the development of broken heart syndrome.

    Relevance:
    Clinicians should consider the possibility of TCC in the differential diagnosis of any patient presenting with findings suggestive of acute coronary syndrome, especially among postmenopausal women with acute emotional distress.

     
  15. [T] Pulmonary Foreign-body Granulomatosis in Factitious Disorder: A Case Report
    Presenting Author:  Cara Fosdick
    Co-Author:  Amy Rosinski

    Purpose: Pulmonary foreign-body granulomatosis has previously been reported in the context of IV drug abuse, as a result of foreign particle embolization (1). We present a case of pulmonary foreign-body granulomatosis, diagnosed by bronchoscopy, that aided in the final diagnosis of factitious disorder.

    Background: A 29 year old woman with Crohn's disease, and no psychiatric or IV drug abuse history, was transferred from an outside hospital for symptoms of a Crohn's flare. She had an extensive history of medical hospitalizations, and already had a central line in place. During admission, she required two transfers to the ICU for hypoglycemia, hypoxemia, and bacteremias/fungemias of multiple different pathogens. Chest CT showed ill-defined nodularity throughout both lungs. Bronchoscopy with transbronchial biopsy was performed. Pathology revealed granulomas containing microcrystalline cellulose, an inert substance often used as filler in medication tablets. Given the patient's unusual constellation of microbes in blood culture, and easy access via a central line, it was suspected that she was self-injecting cellulose containing material, causing pulmonary foreign body granulomas. A continuous observer was obtained, her room was searched, and her family was asked to take her belongings home. In her belongings, they discovered a bag of crackers containing syringes and non-opiate pill tablets. The patient admitted to injecting herself with crushed diphenhydramine and mesalamine tablets, in an effort to kill herself, not to receive attention. She denied having engaged in this behavior in the past, or injecting other contaminated material, despite suspicion otherwise. Her family acknowledged finding multiple empty syringes in her clothes and belongings over the years, but did not understand why. A diagnosis of factitious disorder was made, and she was transferred to the inpatient psychiatry service.

    Discussion: Diagnosis of factitious disorder is difficult, especially in patients with known chronic disease. Medical providers, including psychiatrists, are taught to give the patient the benefit of the doubt, and are cautioned against making accusations about intentional self-harm behaviors. While generally appropriate, this philosophy can result in missing a critical diagnosis of factitious disorder. Medical procedures such as bronchoscopy can assist the physician in making a more definitive diagnosis. Transbronchial biopsy results in this case helped a team of physicians make the diagnosis of factitious disorder, and provided specific evidence that was used to gently confront the patient and her family. Further potentially harmful treatments were avoided, and the patient was guided to the appropriate setting of care.

    Reference:

    1. Dettmeyer et al: Widespread pulmonary granulomatosis following long time intravenous drug abuse, a case report. Forensic Science International 2010;197(1-3):e27-30.

    Objectives:

    1. Consider the diagnosis of factitious disorder in patients with medically unexplained symptoms.
    2. Use diagnostic imaging and procedures to aid in making the diagnosis of factitious disorder.
    3. Understand the approach to treatment of a patient with factitious disorder.

    Relevance:
    Psychiatrists often see patients with medically unexplained symptoms, although often for evaluation of depression or suicidality. This case reminds psychiatrists to consider a diagnosis of factitious disorder.

     
  16. Manipulator's Delight: A Case Study in Diabulimia
    Presenting Author:  Karen E. Salerno
    Co-Authors:  Karen E. Salerno, Margo C. Funk

    Purpose: Insulin dependent diabetes has been called "manipulator's delight" since the control of the illness lies primarily in the hands of the patient through medication compliance; frequent checking of blood glucose levels; and regulation of diet and exercise (1). Patients can cause harm to themselves by intentionally "manipulating" their insulin regimen.

    Case: We present the case of a 40 y/o Caucasian female, working as a nurses aide, with DM Type I admitted with diabetic ketoacidosis for the third time in 6 weeks; twentieth time in the past four years. Pt endorsed a history of "diabulemia" as diagnosed by her PCP and psychiatrist. At the time of her diabetes diagnosis at age 26, she weighed 300 pounds. She was put on an insulin pump; joined Weight Watchers; and lost 144 pounds. She said of her obesity "I was trying to make myself look bad after I was sexually assaulted." She was taken off the pump secondary to a malfunction and she began to gain weight. Four years ago at a birthday party, she ate high fat food, forgot to take her insulin and noticed dramatic weight loss. Through the use of websites and chatrooms on the internet, she learned how to lose weight by withholding insulin. She now purposefully abstains from taking her home insulin regimen, a behavior most prominent with special events, like birthdays and the holidays. She checks her blood glucose 10-12 times daily "to make sure that it is high." She recognized that this behavior was a problem but didn't "know how to stop."

    Results: Diabulimia is the deliberate omission or reduction of insulin use by persons with type 1 diabetes as a method of weight control (2, 3). Although this pattern of disordered eating may be frequently seen among endocrinologists, it may not be as well known among primary care physicians and psychiatrists.

    Conclusions: A team approach between primary care, endocrinology, and psychiatry is needed to help manage this disorder. It is important for physicians to screen for diabulimia in adults, especially in pts who have risk factors such as sexual abuse; positive family history; or are health care workers. It may also be important for health care professionals to become familiar with internet websites that promote eating disorders.

    References:

    1. Kaminer, Y and Robbins, D.R. 1988. Attempted Suicide by Insulin Overdose in Insulin-Dependent Diabetic Adolescents. Pediatrics. 81 (4): 526-528.

    2. Hasken, J Kresl, L, Nydegger T, Temme, M. Diabulmia and the Role of School Health Professional. 2010. Journal of School Health. 80 (10): 465-469.

    3. Larranaga, A, Docet, M, Garcia-Mayor, R. 2011. Disordered Eating Behaviors in Type I Diabetic Patients. World J Diabetes 2 (11): 189-195.

    Objectives:

    1. Define diabulimia and health markers that may indicate a patient with diabetes is manipulating their blood sugars to influence their weight.
    2. Identify risk factors that may indicate a patient is experiencing diabulimic behaviors.
    3. Discuss how an interdisciplinary team can intervene with a patient who is diabulimic.

    Relevance:
    Much has been written about adolescent females, with diabetes, who manipulate their insulin to promote weight loss. There is limited research on how this phenomenon evolves into adulthood.

     
  17. [T] Getting Under Your Skin: A Small Case Series Highlighting Clinical and Ethical Challenges in Treating Delusional Infestation
    Presenting Author:  Priyanka Baweja
    Co-Authors:  Abhishek Jain, Mayur Pandya

    Purpose: Delusional infestation [1], or more commonly but narrowly termed delusional parasitosis [2], is a rare psycho-dermatologic condition [3]. Providing medical and psychiatric care to patients suffering from this condition presents significant challenges. Recently, scientifically unsupported information among the public, especially through the internet and media [3], has reinforced false beliefs among patients and families, and has further contributed to treatment hurdles. We aim to use a small case series to highlight ethical and treatment challenges among this population and propose possible approaches in addressing these unique issues.

    Methods: We reviewed five cases of delusional infestation encountered on our psychosomatic medicine service. We identified treatment challenges and barriers, as well as relatively positive outcomes. Using these cases, as well as recent literature, we propose approaches to enhance treatment outcomes.

    Results: Of the five patients in our case series, one refused psychiatric evaluation and psychotropic medications, two agreed to psychiatric evaluations but refused psychotropic medications, and two agreed to psychiatric evaluations and consented to psychotropic medications.

    Particular challenges we identified include: 1) patient receptiveness to psychiatric evaluation, 2) patient and family receptiveness to a psychiatric diagnosis, 3) gaining informed consent for treatment, 4) enhancing adherence to treatments and follow-up appointments, 5) providing psychiatric consultation to primary teams without seeing the patient, and 6) involuntary psychiatric commitment considerations.

    Potential approaches to address these challenges include: 1) emphasizing symptom-relief rather than diagnosis to the patient, 2) providing psycho-education to family members, 3) carefully considering whether informed consent for treatment is sufficiently obtained, 4) recommending regularly scheduled appointments with psychiatric and medical providers, 5) communicating with and providing education to primary care providers, especially when patients refuse psychiatric evaluation, and 6) considering whether or not the patient meets criteria for involuntary psychiatric commitment and whether or not it is therapeutically beneficial.

    Conclusions: Important clinical and ethical challenges arise in treating patients with delusional infestation. Ethical issues, such as those involving informed consent and involuntary commitment, must be carefully considered. Providing collaborative and integrative care with other medical providers remains an important element in enhancing treatment outcomes. Engaging the patient and developing common treatment goals may improve patient agreement and adherence to treatment.

    References:

    1. Bewley AP, Lepping P, Freudenmann RW, Taylor R. Delusional parasitosis: time to call it delusional infestation. Br J Dermatol 2010;163(1):1-2.

    2. Freudenmann RW, Lepping P. Delusional infestation. Clin Microbiol Rev 2009;22(4):690-732.

    3. Pearson ML, Selby JV, Katz KA, Cantrell V, Braden CR, Parise ME, Paddock CD, Lewin-Smith MR, Kalasinsky VF, Goldstein FC, Hightower AW, Papier A, Lewis B, Motipara S, Eberhard ML. Clinical, epidemiologic, histopathologic and molecular features of an unexplained dermopathy. PLoS One 2012;7(1):e29908.

    Objectives:

    1. Identify the clinical and ethical challenges in treating delusional infestation.
    2. Discuss practical approaches in treating patients suffering from delusional infestation.
    3. Integrate these potential approaches in a psychosomatic medicine setting.

    Relevance:
    Clinical and ethical challenges arise in treating delusional infestation. This poster will review a small case series to highlight these challenges and propose potential approaches to address these unique issues.

     
  18. [T] Shake ‘n Fake? A Case of Propriospinal Myoclonus Initially Misinterpreted as Psychogenic
    Presenting Author:  Abhishek Jain
    Co-Authors:  Nimish Thakore, Elias Khawam

    Purpose: Propriospinal myoclonus, a rare neurologic condition manifested by involuntary movements in multiple body parts, involves neural signals spreading sequentially to adjacent spinal levels [1]. This condition is not diagnosed or confirmed on routine neurological tests such as electroencephalography, electromyography, evoked potentials or conventional magnetic resonance imaging. Tests meant to specifically address the question, such as polymyography, back-averaging for readiness potentials, or diffusion tensor imaging of the cord with fiber tracking [2], are not readily available. Due to its atypical presentation and often unremarkable work-up, this condition can be easily misinterpreted as psychogenic [3]. We aim to highlight propriospinal myoclonus as a potential diagnosis to rule-out prior to diagnosing conversion disorder.

    Methods: We will review a case of propriospinal myoclonus encountered on our consultation psychiatry service. We will discuss potential factors in her presentation that raised the possibility of a psychogenic etiology and factors that led to the diagnosis of propriospinal myoclonus.

    Results: A 53-year-old woman presented with a seven-month history of random jerking movements throughout her body. She had a history of being harshly physically disciplined and sexually molested in childhood, but psychiatric evaluations revealed no active psychosocial stressors. Extensive assessments by neurologists, including an epileptologist and a movement disorders specialist, had not disclosed an etiology, and a psychiatric mechanism was inferred. A subsequent neurological assessment found a myelopathy at the C5-C6 level from an extruded intervertebral disc that was treated with anterior cervical discectomy and fusion. In the post-operative period, based on the absence of psychiatric symptoms, history of cervical cord compression, neurological examination, and overall clinical presentation, she was eventually diagnosed with propriospinal myoclonus. Although specific testing required to confirm this diagnosis was not available, her involuntary movements improved remarkably following the surgery and with medications, notably levetiracetam.

    With a relatively unremarkable neurologic work-up and psychosocial history of significant childhood trauma, the diagnosis of conversion disorder would not be unreasonable. However, absence of active psychiatric symptoms, a history of cervical cord compression, and the clinical picture of stimulus-induced, synchronous, and stereotypical myoclonic contraction of extremity and trunk muscles, suggested propriospinal myoclonus as a viable organic explanation.

    Conclusions: Propriospinal myoclonus is a rare neurologic condition with an atypical presentation that can be mislabeled as psychogenic. This case serves as a reminder of the possibility of rare neurologic conditions when considering the diagnosis of conversion disorder.

    References:

    1. Roze E, et al. Propriospinal myoclonus revisited: clinical, neurophysiologic, and neuroradiologic findings. Neurology 2009; 72: 1301-9.

    2. Roze E, et al. Propriospinal myoclonus: utility of magnetic resonance diffusion tensor imaging and fiber tracking. Mov Disor 2007; 22: 1506-9.

    3. van der Salm S, et al. Axial jerks: a clinical spectrum ranging from propriospinal to psychogenic myoclonus. J Neurol 2010; 257: 1349-55.

    Objectives:

    1. Describe the etiology and presentation of propriospinal myoclonus.
    2. Recognize propriospinal myoclonus as a potential diagnosis when considering conversion disorder.
    3. Review factors that can raise the possibility of psychogenic etiologies and factors that may warrant further medical investigation prior to diagnosing somatoform disorders.

    Relevance:
    Propriospinal myoclonus is a rare neurologic condition with an atypical presentation. This case serves as a reminder to consider the possibility of rare neurologic conditions when considering conversion disorder.

     

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Section C:  Neuropsychiatry

  1. [T] Traumatic Brain Injury in Children—Pharmacological Approach to Acquired ADHD
    Presenting Author:  Saadia Nosheen
    Co-Author: Daniel E. Gih

    Objective: Traumatic brain injury (TBI), a common condition seen in both adults and children, can lead to cognitive, social and physical complications. Attention Deficit/Hyperactivity Disorder (ADHD) induced by TBI in children (secondary ADHD or ADHD/TBI) is one consequence that has limited discussion in the literature. This poster reviews the psychopharmacologic treatment options available, their effectiveness, and what is currently under study.

    Method: A literature search was conducted using the following databases: Medline, Cochrane/EBM and PubMed from 1988-2011. Stimulants TBI, TBI, ADHD TBI, Bromocriptine, Guanfacine, Donepazil and Atomoxetine were the key search terms used. Information was extracted on study characteristics, interventions and outcome. Limits include clinical trial publication, human subjects, English language, adults and children age 0-18 years.

    Results: Eleven clinical trials evaluating the efficacy and safety of Methylphenidate (MPH) in pediatric and adult patients with TBI match the search criteria. Of the eleven identified studies with MPH, one was a chart review, one used a single blind, placebo controlled cross over design and nine were double blind placebo controlled crossovers. Other studies on the role/effect of Bromocriptine (one placebo controlled pilot study), Donepezil (one placebo control study) and Alpha2 agonist (one placebo controlled double blind crossover study) on Secondary ADHD were also reviewed. No study on Atomoxetine was found in human subjects with Secondary ADHD. These studies used several subjective and objective tests to measure behavioral and cognitive (attention, memory, learning, and cognitive processing speed) outcome. Many drugs showed encouraging pre-clinical results with neuroprotective, neurorestorative, neurogenetic and synaptogenetic properties but all phase II and III clinical trials have failed so far.

    Conclusion: There are a limited number of randomized double blind placebo controlled multi centered trials studying the effects of methylphenidate in ADHD/TBI. No randomized controlled studies in ADHD/TBI using stimulants other than MPH were found. Statistical analyses of the limited data clearly demonstrate the efficacy of short term treatment with MPH in the pediatric population. There is very scant literature available on the use of non stimulant treatment options in Secondary ADHD. More studies are required to see the effects of Amphetamine group of stimulants and non-stimulant treatment options for secondary ADHD. Based on our review, more multicentered, randomized, double blind, placebo controlled studies with larger sample sizes, longer length of treatment and wider ranges of doses must be conducted.

    Objectives:

    1. Inform about pharmacological treatment options available, their effectiveness, and what is currently under study for the ADHD caused by traumatic brain injury.
    2. Create awareness among medical professionals about the need of further research in this area.
    3. Help providers in the management of ADHD induced by TBI.

    Relevance:
    Get information about pharmacological treatment options available, their effectiveness, and what is currently under study for the ADHD caused by traumatic brain injury.

     
  2. The Use of Methylphenidate in Hypoactive Delirium in a 22-year-old Female – A Case Report and Literature Review
    Presenting Author:  Cristina Montalvo
    Co-Author:  Rashi Aggarwal

    Purpose: Hypoactive delirium continues to be a poorly understood syndrome that impairs the quality of patient care and symptom control. In addition, treatment guidelines have yet to be established for patients with this condition. Using this case study, we bring to attention the paucity of evidence for treatment of hypoactive delirium.

    Methods: We present the case of a 22 year old Caucasian female, with no psychiatric history, status post liver transplantation at the age of 3 with graft dysfunction. Psychiatric consultation was requested for evaluation of depression. The patient was reportedly not taking an active role in her recovery and “not motivated to get out of bed”. Upon examination, the patient was unable to remain awake with fluctuating consciousness, not oriented to place or time, reported visual hallucinations, and had diminished immediate memory recall. We diagnosed her with delirium due to hepatic encephalopathy with a delirium rating scale severity score of 21. Her QTc was prolonged (546 ms) so haloperidol, was contraindicated. In addition, the patient's prominent symptoms included lethargy and apathy which were impairing her treatment overall; therefore, we began her on a trial of methylphenidate 2.5 mg PO daily. Within three days, the patient became much more alert and oriented. Patient was able to lift her head off the bed, verbalize full thoughts, and manipulate objects with her hands. Her delirium rating scale severity score had decreased to 10.

    Conclusions: The majority of the literature on treatment of delirium discusses either delirium without specifying hypoactive versus hyperactive or focuses on hyperactive delirium. The current standard of treatment for delirious states includes antipsychotics such as haloperidol [1]. In the case of hypoactive delirium, psychostimulants provide a rapid speed of action of 48-72 hours. Methylphenidate has been shown to increase dopamine, norepinephrine, and possibly serotonin in the brain, all of which have decreased neurotransmitter activity in hypoactive delirium [2]. Furthermore, neuropsychiatric research and imaging suggest that prefrontal cortices, thalamus, and right basilar mesial temporoparietal cortex may play a significant role in symptoms of delirium. Methylphenidate concurrently increases activity in the prefrontal cortex and attention related areas of the parietal cortex which may help explain the relief of delirious symptoms in these patients. Most reported cases of hypoactive delirium treated with methylphenidate are affiliated with palliative care. Nevertheless, further research needs to be done to verify these findings.

    Randomized studies need to be performed that compare the effects of haloperidol and methylphenidate to determine the most effective means of treating hypoactive delirium and to establish a gold standard for treatment.

    References:

    1. Fricchione G, et al. Postoperative delirium. American Journal of Psychiatry July 2008; 165:7.

    2. Sulzer D, et al. Mechanisms of neurotransmitter release by amphetamines: a review. Prog. Neurobiology 2005; 75(6):406-433.

    Objectives:

    1. To investigate a successful means of treating hypoactive delirium and to provide information for future treatment guidelines.
    2. To apply the neuropsychiatric findings of delirium and pharmacology of methylphenidate to understand its mechanism of action in the treatment of hypoactive delirium.
    3. To analyze the current literature regarding treatment of hypoactive delirum with methylphenidate.

    Relevance:
    Hypoactive delirium is a common reason for referral to a consulting liaison psychiatrist. Nevertheless, it lacks a gold standard of treatment.

     
  3. [T] PTSD and Acquired Stuttering: Hypothesis for the Etiology of Acquired Stuttering in PTSD Based on Clinical Improvement with Clonidine Treatment.
    Presenting Author:  Jennifer Selvarajah
    Co-Author:  Adekola Alao

    Stuttering is a disorder in which the flow of speech is disrupted by involuntary repetitions and prolongations of sounds. In this report, we will describe a patient with a diagnosis of PTSD with stuttering successfully treated in part with clonidine.

    Mr. S A is a 37 year old married man who at the time of presentation was in active military service. He was diagnosed with PTSD and acquired stuttering and referred for psychotherapy with the option of choosing between cognitive processing therapy and exposure therapy. He was started on sertraline 50mg po q daily which was titrated to 100mg po q daily. Clonidine 0.3 mg po qhs was prescribed to treat his nightmares as well. Three weeks after starting clonidine treatment, his PTSD symptoms and stuttering reduced in intensity. He is now being followed for maintenance therapy at the outpatient clinic.

    Stuttering can have a significant impact on a patient’s life and in patients with PTSD. It may lead to avoidance of social situations and this may in turn interfere with other steps in healing such as the restoration of social relationships and reconnection with others. In some patients with developmental stuttering, there is an understanding of how social anxiety could in part be a learned response from negative consequences such as negative listener reactions, bullying, teasing, and social rejection and may result in anxiety in speaking related social situations. It can be considered a predictable outcome of negative communication consequences experienced in life. Clonidine, a centrally acting alpha adrenergic receptor agonist which acts at noradrenergic autoreceptors and may be responsible for reducing the release of norepinepherine in the brain.

    The patient discussed in this report experienced an improvement in their acquired stuttering after treatment. Clonidine is a centrally acting alpha adrenergic receptor agonist which acts at noradrenergic autoreceptors and may be responsible for reducing the release of norepinepherine in the brain. The excessive noradrenergic activity in the amygdala thought to mediate hyperarousal is reduced with clonidine and we hypothesize that this may work in reducing the symptoms of acquired stuttering by preventing an increase in blood flow and subsequent increase in activity of both the amydala and to the right cortical motor area. The mechanism by which stuttering is improved with clonidine treatment may be a reduction in compensatory brain activity of the right cortical motor area seen in patients with stuttering and shift activation back to the left hemisphere where Broca's area is located, thereby restoring normal relative perfusion to Broca’s area and restoring normal speech fluency.

    It would be of use to carry out more studies looking at the effect of clonidine on acquired stuttering in patients with PTSD.

    Objectives:

    1. After the presentation, the physician learner will be able to recognize the relationship between stuttering and increased in activity in the amydala and to the right cortical motor area.
    2. After the presentation, the physician learner will be able to appreciate the mechanism of action by which clonidine may be effective in treating stuttering in patients with PTSD.
    3. After the presentation, the physician learner will be able to analyze the advantages and disadvantages of using clonidine to treat patients with PTSD.

    Relevance:
    Stuttering can have a significant impact on a patient’s life and in patients with PTSD. It may lead to avoidance of social situations and interfere with other steps in healing.

     
  4. [T] When Less Is Not Nearly Enough: Thiamine Prescribing Practices for Inpatients with Alcoholism
    Presenting Author:  Elie Isenberg-Grzeda
    Co-Authors:  Brenda Chabon, Stephen Nicolson

    Background: Alcohol use disorders (AUD) are highly comorbid among medical inpatients, and consultation psychiatrists are often called to assess altered mental status (AMS) in this patient population. Wernicke’s encephalopathy (WE) is a neuropsychiatric disorder caused by thiamine deficiency that often presents with AMS, and occurs in both patients with and without AUD. As the symptoms of WE are difficult to distinguish from those caused by alcohol withdrawal or intoxication, many (about 80%) cases of WE in patients with AUD remain undiagnosed. A lack of randomized controlled trials has restricted knowledge of the amount of thiamine needed to treat suspected WE. As the absorption of oral thiamine is especially limited in alcoholics, i.v. thiamine at high doses (>100 mg) appears best in creating a gradient large enough to allow facilitated diffusion into the brain. European guidelines suggest administering parenteral thiamine at doses of 200mg-500mg TID; while in the United States, dosing of thiamine is usually much less and often given p.o. once daily. To our knowledge, there are no published studies of thiamine prescribing practices in the US.

    Objectives: We sought to examine the practices of prescribing thiamine to inpatients with AUD admitted to an American teaching hospital.

    Hypothesis: Given the lack of guidelines, most patients at risk for WE are undertreated. Methods: Subjects included male and female adults greater than 18 years old admitted to Montefiore Medical Center, on the medicine or surgical units only, and seen by the addictions psychiatry service (APS) for consultation related to AUD over a 3 month period (n=97). All data were taken from a database of information routinely collected by the APS. Data included diagnosis, length of stay, and thiamine dose, route, frequency and duration of administration. Data was analyzed by SPSS. The study complied with IRB regulations.

    Results: During this 3 month period APS consulted on 97 patients for AUD. Thiamine was administered to 86%.(n=83). Among all these cases, thiamine was dosed once daily. Ninety-two percent (n=76) received 100 mg p.o. The remainder received 50 mg po (n=4), 100 mg i.m. (n=1), 100 mg i.v. (n=2). AMS was documented in 8% of alcohol-related consults, and thiamine administration did not vary in these patients. Duration of administration correlated mostly with length of stay.

    Conclusions: Our study indicates that thiamine prescribed to inpatients with AUD is routinely under-dosed, even when identifiable risk factors for WE are present. The true prevalence of at-risk patients is likely greater than our data suggest, since AMS is only one of several known risk factors. More studies are needed to guide clinicians in prescribing high-dose thiamine. At a minimum, we recommend intravenous thiamine rather than oral, whenever possible.

    Objectives:

    1. Learners will be able to recognize the tendency of physicians to under-treat patients at risk for Wernicke’s Encephalopathy.
    2. Learners will be able to assess risk factors for Wernicke’s Encephalopathy in patients with AUD.
    3. Based on the evidence we present, learners will feel more confident prescribing thiamine appropriately to inpatients with AUD at risk for Wernicke’s Encephalopathy.

    Relevance:
    Consultation psychiatrists frequently see patients with alcohol-use disorders. Recognizing those at risk for Wernicke’s Encephalopathy and treating them appropriately can reduce morbidity.

     
  5. [T] Case Report of Inefficacy and Poor Tolerance of Antipsychotics in Treatment of Delirium Associated with Bickerstaff Brainstem Encephalitis
    Presenting Author:  Laura McLafferty
    Co-Authors:  Neil Puri, Al Alam

    Introduction: Bickerstaff brainstem encephalitis (BBE) is defined as a syndrome presenting with acute ophthalmoplegia, ataxia, and disturbance of consciousness, indicating CNS involvement. Most common preceding symptoms of BBE are related to upper respiratory infection, and most frequent initial symptoms are diplopia and gait disturbance. The antiganglioside anti-GQ1b antibody has a role in the pathogenesis of this syndrome [1]. Cerebrospinal fluid (CSF) of patients with BBE often features albuminocytological dissocaiation. BBE is most often treated with immunotherapy, including steroids, plasmapharesis, and intravenous immunoglobulin (IVIG) [1]. Although disturbance of consciousness is a defining characteristic of BBE, to date there are no studies or case reports examining the management of delirium in hospitalized patients with BBE.

    Case presentation: Patient is a sixty-five year-old Caucasian male with no psychiatric or neurologic history who presented to emergency room complaining of inability to walk, ophthalmoparesis and areflexia after one week of upper respiratory infection. He was transferred to tertiary level medical center due to respiratory distress, and tracheostomy was placed on hospital day 12. Patient received three rounds of IVIG for persistent ophthalmoparesis, areflexia, and altered mental status. Given these symptoms patient's presentation was concerning for BBE. CSF showed albuminocytological dissociation. Anti-GQ1b antibody studies were sent at outside facility but results not received. Prior to transfer patient had multiple episodes of agitation, confusion, and paranoia. Psychiatry was consulted on hospital day 20 due to persistent delirium in ICU setting. Haloperidol, quetiapine, and olanzapine were each prescribed as monotherapy for treatment of agitation and delirium. Patient's physical combativeness and delirium did not improve and even worsened with each of these medications. Patient developed akathisia while taking haloperidol. Valproic acid was prescribed and titrated to 500mg po bid to treat agitation, and reduction in agitation was noted. Clonazepam 0.5mg po qhs was prescribed as well to treat nighttime agitation. Trazodone 100mg po qhs was utilized to treat pt's insomnia. Patient's agitation resolved within a few days, and he regained full orientation. By time of transfer to physical rehabilitation facility on hospital day 53, all psychotropic medications except for clonazepam 0.25mg po qhs had been tapered and discontinued.

    Discussion: Delirium is one of the most common reasons for psychiatry consultation in the ICU setting. The defining characteristics of BBE include disturbance of consciousness. The significance of this case report is to highlight the inefficacy and poor tolerance of multiple antipsychotics, including one typical and two atypical agents, in the treatment of delirium in a patient with BBE, whose delirium was successfully treated using valproic acid and low-dose clonazepam.

    Reference:

    1. Odaka M, Yuki N, Yamada M, Koga M, Takemi T, Hirata K, Kuwabara S. Bickerstaff's brainstem encephalitis: clinical features of 62 cases and a subgroup associated with Guillain-Barré syndrome. Brain. 2003; 126: 2279-2290.

    Objectives:

    1. Apply knowledge of inefficacy of antipsychotics in treatment of delirium in patients with Bickerstaff brainstem encephalitis (BBE).
    2. Apply knowledge of poor tolerance of antipsychotics in patients with BBE.
    3. Utilize knowledge of effective psychotropic agents to successfully treatment delirium in patients with BBE.

    Relevance:
    Delirium is one of the most common reasons for psychiatry consultation in the ICU setting, and this presentation addresses treatment of delirium in patients with BBE.

     
  6. The Management of an Acutely Manic Patient with Brugada Syndrome: A Case Report
    Presenting Author:  David Edgcomb
    Co-Author:  Nancy Maruyama

    Introduction: Brugada syndrome is a genetic disease characterized by abnormal EKG findings which confers an increased risk of sudden cardiac death. Several psychiatric medications unmask the EKG findings in susceptible individuals (lithium, antipsychotics, and tricyclic antidpressants). We report on the treatment of a man with Bipolar I disorder maintained on Quetiapine and Lithium admitted to medicine with Brugada Syndrome.

    Case Report: Mr. B was a 38 year-old Philippine-born man who presented with manic symptoms: not sleeping, having racing thoughts, grandiose delusions, inappropriate behavior with staff, and wearing dark glasses indoors. He had taken extra lithium (admission level 1.8) to treat his mania. His EKG showed sinus rhythm with right bundle branch block, ST elevations in leads I, II, III, Qtc was 508. He was admitted to telemetry where lithium and quetiapine were discontinued. Cardiology was consulted and the Brugada Syndrome was thought to be due to lithium and no other intervention or electrophysiological study was deemed necessary. Serial EKGs were followed and ST elevation improved. No neuroleptics were given. Clonazepam was started for agitation. Valproate was begun for mania.

    Discussion: We review the psychiatric literature on Brugada Syndrome and discuss how to manage acute agitation, and mania in patients with this condition while on the medicine ward and after transfer to psychiatry.

    References:

    1. Darbar D, Yang T, Churchwell K, Wilde A, Roden D. Unmasking of Brugada syndrome by lithium. Circulation. 2005;112:1527–1531

    2. Laske C, Soekadar SR, Laszlo R, Plewmia C, Brugada Syndrome in a Patient Treated with Lithium. Am J Psychiatry 2007; 164:9: 1440-1441

    3. Pirotte MJ, Mueller JG, Poprawski T, A case report of Brugada-type electrocardiographic changes in a patient taking lithium. American Journal of Emergency Medicine 2008:26:e1-3.)

    4. Sandras R, Lesaffre F, Lacotte J, Nazeyrollas P. Brugada syndrome aggravated by lithium treatment. Presse Med. 2007;36:612–614

    Objectives:

    1. The participant will understand characteristics of Brugada syndrome.
    2. The participant will understand psychiatric medications can precipitate Brugada syndrome.
    3. The participant will understand how to manage an acutely manic patient with Brugada syndrome.

    Relevance:
    The participant will understand how to manage a patient with acute psychiatric symptoms whose psychopharmacolgical options are limited by a complex cardiac problem.

     
  7. [T] Psychiatric Symptoms from Profound B12 Deficiency: a case report
    Presenting Author:  Michael Rosas
    Co-Authors:  Afia Sadiq, Nancy Maruyama

    Introduction: Vitamin B12 (cyanocobalamin) deficiency is a rarely encountered but devastating nutritional syndrome involving prominent changes in the central nervous system (CNS) and hematopoietic cell lines. Clinical manifestations include delirium, personality changes, and cognitive deterioration. We present a case of a woman with profound B12 deficiency presenting with altered mental status, pancytopenia, and functional impairment in her instrumental activities of daily living.

    Case Report: JB was a 62-year-old Caucasian female with anemia and no prior psychiatric history who presented with emotional lability, disinhibition, paranoia and cognitive deterioration. In addition, the patient was noted to have a dramatic decline in functioning, according to caregivers, anorexia, and a 40 lb weight loss over six months. Behavioral symptoms included non-adherence with outpatient and inpatient medical care.

    Laboratory workup demonstrated macrocytic anemia Hemoglobin 1.8 g/dL, (normal 11-14), mean corpuscular volume 134 fL (normal= 80-100) and thrombocytopenia, platelets 8 ,000/µL (normal=150,000-450,000). Urine toxicology screen was negative for all tested substances. Other significant lab findings included normal chemistries, transaminases, and thyroid studies. Rapid Plasma Reagin was non-reactive. Computed Tomography of the head was normal. However, her B12 was markedly depleted at 61 pg/mL (normal= 200-900) in the setting of a normal folate level (5.37 ng/mL). She had elevated levels of Anti-Intrinsic Factor Antibodies consistent with pernicious anemia. It was the opinion of hematology that her anemia and behavioral symptoms were the result of her cyanocobalamin hypovitaminosis. The patient was transfused six units of packed red blood cells and two units of platelets for hematologic stabilization. She was started on daily 1mg B12 injections which were then changed to weekly after seven injections with subsequent improvement in hematological parameters over the next 7-10 days.

    The Consult Liaison service diagnosed her with dementia associated with behavioral disturbances secondary to B12 deficiency and started haloperidol and lorazepam for the patient's paranoia, agitation, and emotionally lability. The patient was subsequently transferred to psychiatry for continued treatment. Antipsychotics were recommended, but refused by the patient who was deemed to have capacity to refuse medications. Nevertheless the behavioral symptoms improved. While on medicine, the patient refused the Mini-Mental Status Exam (MMSE), but mental status exam revealed difficulty describing her history and memory deficits. On inpatient psychiatry she scored a 27/30 on the MMSE with improved memory, language, & executive function. After seven days, the patient was discharged home without any psychotropic medications, in a stable emotional state although she remained cognitively compromised and continued to have frontal executive deficits.

    Discussion: We review the psychiatric literature on Vitamin B12 deficiency, discuss the evaluation and management of this clinical presentation, and discuss the reversibility of "reversible dementias."

    Reference:

    1. Smith A.D.M. "Megaloblastic Madness." British Medical Journal Dec 24, 1960; 1840-1845.

    Objectives:

    1. The participant will learn about B12 deficiency, its treatment and associated medical conditions.
    2. The participant will understand the psychiatric symptoms associated with B12 deficiency.
    3. The participant will consider where the psychiatric symptoms of B12 deficiency should be categorized under DSM-IV-TR.

    Relevance:
    The participant will understand how to recognize and treat the psychiatric and medical consequences of profound B12 deficiency.

     
  8. [T] Temporal Lobe EEG Abnormalities in New Onset Mania: Case Report and Implications for Treatment
    Presenting Author:  Lauren Kissner
    Co-Authors:  Leia Gill

    Purpose: The relationship between focal EEG changes and the symptoms of mood disturbance have been noted many times in the literature. However, there remains a deficit in the understanding of when EEG is clinically indicated in a new onset mania, how to interpret ambiguous findings, and how to incorporate these findings into our understanding of the cause, prognosis, and treatment for our individual patients. We use the clinical course of one of our patients with new onset manic symptoms to demonstrate these concerns and challenges of treatment.

    Methods: A clinical case with prodromal confounders, atypical symptoms leading to extensive testing prior to a diagnosis, and treatment challenges will be presented. The concerns raised in his case will lead to questions needing to be further elucidated in the literature.

    Results: The patient is a 47 year old veteran involuntarily admitted to the psychiatric unit at the VA Medical Center after becoming physically aggressive with his mother to "shake Jesus into her." Family reported three days of decreased sleep, hyper-religiosity, grandiose thinking and paroxysmal psychomotor hyperactivity interspersed with periods of slowed thinking in which he was amnestic of his recent behavior and distressed by his actions. Due to a high suspicion for EEG abnormalities, our first choice for treatment was an antiepileptic mood stabilizer however we had concerns that this would mask our testing thus confusing our diagnosis, prognosis and need for subsequent treatment. He was treated with only an atypical antipsychotic until EEG confirmed focal findings in the left temporal lobe. Since it was not clearly epileptiform, there was ambiguity in the extent to which these findings might have caused the symptoms vs. the aberrant activity being a marker of the disease itself. We started the patient on valproic acid and titrated up as the atypical antipsychotic was discontinued. One year later, he had no mood disorder symptoms and follow up EEG was within normal limits.

    Conclusions: This case demonstrates the questions in the overlap between EEG abnormalities and manic symptoms. Although there is evidence in the literature of those with temporal lobe epilepsy having mood symptoms, and benefit from antiepileptics in bipolar disorder, there remain questions regarding the relevance of EEG abnormalities in patients with manic symptoms. Further investigation into a cause and effect relationship and treatment outcomes would allow us to better treat the totality of the brain dysfunction present in our patients.

    Reference:

    1. Elliot B., Joyce E., Shorvon S. Delusions, illusions and hallucinations in epilepsy: 2. Complex phenomena and psychosis. Epilepsy Research. 2009. (85) 172-186.

    Objectives:

    1. Understand the current literature relating mood disorder symptoms to EEG abnormalities.
    2. Differentiate relevant clinical factors in both diagnosis and treatment of manic symptoms with EEG abnormalities.
    3. Apply the current understanding of the relationships between manic symptoms and EEG abnormalities to novel clinical scenarios.

    Relevance:
    Addresses importance of understanding the relationship between EEG abnormalities and mania, interpreting ambiguous findings, and incorporating these findings into understanding the cause, prognosis, and treatment of our patients.

     
  9. Longitudinal Study Using Florbetapir-18 Positron Emission Tomography (PET) for Progression of β-amyloid Burden in MCI and Controls
    Presenting Author:  Paula Trzepacz
    Co-Authors:  Abhinay Joshi, Michael Pontecorvo, Christopher Breault, Ming Lu, Mark Mintun, Alan Carpenter, Daniel Skovronsky

    Purpose: Changes in β-amyloid deposition in elderly with Mild Cognitive Impairment (MCI) and cognitively normal controls (CN) over 2-years of follow-up were evaluated using F18 florbetapir PET scans.

    Methods: CN (n=49; Mini-Mental State Examination (MMSE) ≥ 29; age 71±11) and MCI subjects (n=36; Clinical Dementia Rating (CDR) 0.5, MMSE >24; age 71±10) underwent florbetapir-PET scans at baseline and approximately two years later (23±4 months). Scans were independently normalized to a standard florbetapir-PET template, and standard uptake value (SUVr) ratios calculated using the mean of predefined anatomically relevant cortical regions (precuneus, posterior cingulate, anterior cingulate, frontal, temporal and parietal) relative to entire cerebellum. Change in SUVr at 2 years was evaluated as a function of baseline PET SUVr and diagnostic group.

    Results: At baseline, 44% of MCI and 20 % of CN subjects had positive scans using an SUVr cutoff=1.10. Subjects with baseline positive scans (mean SUVr=1.37) had significant mean changes in SUVr (+0.06; p< 0.05) at two-year follow-up, whereas those with negative scans (mean SUVr=0.98) did not (mean change= +0.005; p=0.40). Interestingly, among 59 subjects who were amyloid negative at baseline, 4 (6.8%) had converted to amyloid positive on the follow-up scan, for a conversion rate of 3.5 % per year. None of the baseline amyloid positive subjects converted to amyloid negative on follow-up.

    Conclusions: These results suggest that nondemented elderly subjects with florbetapir-PET evidence of β-amyloid deposits have continued increase in amyloid burden over time. Generally, those with negative scans do not have a significant increase in amyloid plaques for up to 2 years, though a few subjects converted from negative to positive during this time.

    References:

    1. Clark CM, Schneider JA, Bedell BJ, et al. Use of florbetapir positron emission tomography for imagining beta-amyloid pathology. JAMA 2011; 305(3):275-283

    2. Wong DF, Rosenberg PB, Zhou Y, et al. In vivo imaging of amyloid deposition in Alzheimer disease using the radioligand 18F-AV-45 (florbetapir [corrected] F 18). J Nucl Med. 2010;51(6):913-920

    Objectives:

    1. To describe florbetapir PET scan results in elderly MCI and cognitively normal controls.
    2. To understand quantitative changes in β-amyloid plaque burden using florbetapir-PET after 2 years.
    3. To appreciate differences between those who had positive vs. negative baseline scans at 2 year follow-up.

    Relevance:
    These results address the stability of florbetapir scan results over a two year follow-up period.

     
  10. Comparison of Florbetapir Positron Emission Tomographic Scans to Postmortem β-amyloid Histopathology in 59 Autopsy Cases
    Presenting Author:  Michael Witte
    Co-Authors:  Daniel Skovronsky, Abhinay Joshi, Mark Mintun, Michael Pontecorvo, Christopher Clark

    Purpose: The primary objective of this study was to test the sensitivity and specificity of florbetapir-PET scan during life, predicting the presence of CERAD moderate or frequent neuritic plaques at autopsy.

    Methods: Clinically normal and cognitively impaired hospice subjects nearing end of life were scanned with florbetapir F18 PET and followed until autopsy; 59 autopsies occurred within 2 years of PET scan and; 46 within 1 year. PET images were independently classified by 5 nuclear medicine physicians, who were blinded to autopsy results, as either amyloid positive or negative. The majority classification for each image across the readers was the primary PET outcome variable. Additionally, a standard uptake value ratio (SUVr) was calculated by comparing florbetapir retention in cortical regions to a reference region over the cerebellum. At autopsy, amyloid levels were categorized using CERAD criteria: moderate or frequent neuritic plaques were considered amyloid positive and sparse or no neuritic plaques were considered amyloid negative.

    Results: Sensitivity and specificity of florbetapir-PET scan, expressed as the median of readers' interpretation for detecting moderate to frequent plaques across the 59 cases, were 92% and 95%; and for the cases coming to autopsy within 12 months, were 96% and 94%. SUVr ratings for positive and negative scans using a cutoff of 1.1 resulted in similar sensitivity and specificity for detecting moderate to frequent plaques.

    Conclusions: Both visual and quantitative binary interpretation (positive or negative) of florbetapir-PET scans demonstrated significant concordance with histopathological assessment of neuritic plaques.

    References:

    1. Clark CM, Schneider JA, Bedell BJ, et al. Use of florbetapir positron emission tomography for imagining beta-amyloid pathology. JAMA 2011; 305(3):275-283

    2. Fearing MA, Bigler ED, Norton M et al. Autopsy-confirmed Alzheimer's disease versus clinically diagnosed Alzheimer's disease in the Cache County Study on Memory and Aging: a comparison of quantitative MRI and neuropsychological findings. J Clin Exp Neuropsychol 2007;29:553-60

    3. Thal LJ, Kantarci K, Reiman EM et al. The role of biomarkers in clinical trials for Alzheimer disease. Alzheimer Dis Assoc Disord. 2006;20(1): 6-15

    4. Mirra, S.S., Heyman, A., McKeel, D., et al. The Consortium to Establish a Registry for Alzheimer's Disease (CERAD). Part II. Standardization of the neuropathologic assessment of Alzheimer's disease. Neurology, 41: 479-486, 1991

    Objectives:

    1. To introduce florbetapir PET scans, a new method for visualization of β-amyloid plaques consistent with Alzheimer’s disease.
    2. To describe the relationship between florbetapir-F18 PET scan binary interpretations to CERAD post mortem pathologists’ interpretations.
    3. To understand the importance of an ante-mortem method to detect Alzheimer’s disease pathology to support differential diagnosis.

    Relevance:
    Older persons with cognitive decline (MCI or dementia) may involve Alzheimer’s pathology, but before clinical availability of florbetapir-PET, definitive detection of β-amyloid neuritic plaque had to wait until autopsy.

     
  11. Evaluating the Existing Evidence Concerning the Effectiveness of Olanzapine in the Treatment of Delirium: An Evidence-Based Analysis
    Presenting Author:  Ricardo Millán-González

    Introduction: Delirium is an acute decline of consciousness and cognition [1-2] that historically has been treated with haloperidol [3]. Because of its side effect profile, there has been a recent increase in the use of atypical antipsychotics for this indication [4].

    Objective: To systematically evaluate the literature about the use of olanzapine in the treatment of delirium using the analysis of Evidence-Based Medicine proposed by Guyatt et al [5].

    Design: The first step was the identification of a problem (conserns about the eficacy of olanzapine as a treatment for delirium), followed by the definition of a structured question (which is the evidence concerning olanzapine as a treatment for delirium?) and a sistematic search of the existing studies. Finally, an objective analysis of the validity of the results was performed.

    Results: Following a search in Medline, five studies that address the issue were identified [6-10]. All of them have major methodological shortcomings and in some cases there are important ethical concerns. For example, none of them included apropiate samples; most of them did not performed a randomized or blind-controlled trial, and none of them controlled motor states or variables with known capacity to induce delirium. No active psychiatric consultation was performed in any case.

    Conclusions: First, olanzapine has a level 3 of clinical evidence for its use as a treatment for delirium. Second, a methodological improvement in the structure of these studies is urgently required, acompanied by the strict application of the ethical principles of research. Third, a critical review of the literature is essencial to assess the scientific evidence [11].

    Objectives:

    1. To apply the systematic, evidence-based approach proposed by Guyatt et al.
    2. To analyze the existing evidence concerning the use of olanzapine in the treatment for delirium.
    3. To promote a critical reading of the scientific literature.

    Relevance:
    To discuss the existing evidence of the use of olanzapine for the treatment of delirium, while evaluating the literature available.

     
  12. Are Popular Nutraceutics (Lecithin Enriched DHA) Helpful in Prevention of Dementia?
    Presenting Author:  Joanna Rymaszewska
    Co-Authors:  Marta Jakubik, Bartlomiej Stanczykiewicz, Andrzej Szuba, Tadeusz Trziszka

    Objective: The aim of the study was to investigate anti-dementia properties of the new dietary supplements: lecithin enriched docosahexaenoic acid (DHA).

    Methods: Mouse model of Alzheimer’s Disease (strain B6C3Tg(APPswe,PSEN1dE9)85Dbo/Mmjax –Genotype HEMI and NCAR by The Jackson Laboratories) had been used. HEMI mouses and NCAR mouses were divided into two experiment groups and one control each. Mice received forage enriched 5% and 2.5% of supplement for 5 months. IR Actimeter tested the locomotor activity. The evaluation of memory was determined by Passive Avoidance test. The study "Innovative technologies of bio-preparations' production on the base of new generation of eggs" is co-financed by the European Union from the European Regional Development Fund under the Operational Program Innovative Economy, 2007-2013.

    Results: Supplementation for five months does not significant improve memory deficits in mouse model of Alzheimer’s Disease.

    Conclusions: The preclinical study did not confirm potential procognitive properties of lecithin enriched docosahexaenoic acid with this mouse model of Alzheimer’s Disease. However, previous preclinical studies showed that DHA and derivative DHA- NPD1 have positive influence on the metabolic pathways (increase the inflammatory and the pro-apoptotic processes) connected witch Alzheimer’s Disease.

    Objectives:

    1. Somatic patients like to use nutraceutics as omega-3 acids, very much. By taking them they wish to have better memory and prevention from Alzheimer disease.
    2. Physicians also prescribe omega-3 to their patients to prevent from AD.
    3. We did investigation in order to prepare possibly active nutraceutics as dementia preventive agent.

    Relevance:
    Not all nutraceutics and not omega-3 acids as dietary supplements can be preventive for dementia.

     
  13. [T] Parkinson’s Disease and Impulse Control Disorder: A Case Report and Discussion of ECT as a Treatment Option
    Presenting Author:  Yu Dong
    Co-Authors:  Adam Mirot, Shadi Zaghloul, Cassandra Hobgood, Steven Fischel

    Background: Impulse Control Disorder can occur in patients with Parkinson's disease treated with dopaminergic agents. DOMINION, a cross-sectional study of 3090 Parkinson's disease patients, reported a 6-month prevalence of pathological gambling 5%, compulsive sexual behavior 3.5%, compulsive buying 5.7% and binge eating disorder 4.3% [1]. We describe a patient with Parkinson's disease on dopaminergic medications who developed three of the above behaviors, as well as compulsive use of dopaminergic medication and drugs. We also discuss his response to ECT.

    Case Report: A 60 year old married man with a seven year history of Parkinson's disease presented to the emergency room with cellulitis. He was paranoid about hospital staff trying to kill him. The patient, who had a very distant history of cocaine use, had been staying in a motel for a week binging on crack cocaine. Family also reported that while on pramipexole over the past four years, the patient had developed an addiction to on-line gambling, losing $60,000 within a year. He also started compulsively eating and viewing pornography. Despite attempts during three subsequent hospitalizations to alter or taper his dopaminergic medications, the patient continued his behaviors. On lower doses of dopaminergic agents, he developed more frequent freezing episodes. He was also noted to abuse pramipexole. During his third hospitalization, he reported symptoms of depression due to shame and guilt, as well as anxiety anticipating freezing episodes. As he couldn't tolerate SSRIs, benzodiazepines, or quetiapine, ECT was recommended as a rescue treatment for his depression and frequent freezing episodes. His mood, Parkinsonian symptoms, and impulsive-compulsive behaviors improved significantly after four courses of ECT. Unfortunately ECT had to be discontinued due to prolonged post-ECT confusion. The patient was subsequently evaluated for deep brain stimulation and retinal cell implants, but was not approved for these procedures.

    Discussion: Impulse Control Disorder is often under-recognized and difficult to treat. Shame and guilt can be associated with uncontrolled impulsive behaviors which are often uncharacteristic for the patient. Risk factors are dopamine agonist use, high levodopa dose, younger age, unmarried, former or current smoker, and family history of gambling problems [1]. Parkinson's disease patients on dopaminergic medications should be routinely screened for impulsive and compulsive behaviors, as well as depression and anxiety. Management of these problems requires a fine balance between control of motor symptoms and neuropsychiatric symptoms. If all other options fail, ECT can be a rescue treatment.

    References:

    1. Weintraub D, et al. Archives of Neurology 2010, 67:589-595

    2. Voon V. et al. Current Opinion in Neurology 2011, 24:324-330

    3. Voon V. et al. Lancet Neurology 2009, 8: 1140-49

    Objectives:

    1. Diagnose impulse control disorder in patients with Parkinson's disease.
    2. Discuss managment strategies of impulse control disorders in patients with Parkinson's disease on dopaminergic agents.
    3. Discuss the possibility of using ECT to treat patients with impulse control disoders and Parkinson's disease.

    Relevance:
    Consultation psychiatrists need to be aware of diagnosis and treatment of patients with Parkinson's disease on dopaminergic medications who may present with impulse control disorders.

     
  14. Chronic Pain as a Prodrome to Psychosis
    Presenting Author:  William Jangro
    Co-Authors:  Jessica Mosier, Mitchell Cohen

    Introduction: Identification of prodromal symptoms of psychotic disorders is challenging and often occurs after psychosis has emerged. They typically include non-specific mood, anxiety, and attenuated psychotic symptoms. We present a case of chronic pain leading to a first psychotic episode.

    Case: Mr. B is 29-year-old man referred to a psychiatry-based pain clinic for "migratory pains all over." Pain began two years prior in his groin. He saw multiple specialists who gave equivocal diagnoses of sports hernia. Although he initially held off surgery, groin pain evolved into diffuse body pain. Finally decided to have surgery, all of his pain was relieved for several months. However, severe pain reemerged, migrating down his left leg to arm, down his left arm to right arm. He described it as "diffuse and nebulous." Reading that SSRIs help with pain, he had seen a psychiatrist because "psychiatrists are the ones who prescribe SSRIs." He reported feeling depressed since the age of 5, but did not think depression was contributing to his pain. Although recently on sertraline, he found it ineffective, and stopped it because it "made [his] penis numb." He did not want to try another SSRI due to penis numbness persisting over a month off sertraline. Instead, he came with the intention of being started on a "dopaminergic medication like pramipexole." He was not interested in discussing his psychiatric complaints. When pramipexole was not prescribed, he went elsewhere for another opinion.

    Mr. B returned 8 months later complaining of severe depression, requesting an SSRI. Since his first visit, he had gone to another pain clinic and was started on methadone. Reading that methadone had some NMDA-antagonism, he asked to be switched over to "a stronger NMDA-antagonist," memantine. Although his pain symptoms completely remitted with memantine 5mg BID, he fell out of treatment. He entered treatment with another psychiatrist for depression. While under the psychiatrist's care, he had a first episode of manic psychosis. During the episode, he became hyper-religious and believed he had to go to Texas to save a female acquaintance from unknown danger. Although lamotrigine and quetiapine broke the acute mania, he remained unconvinced that he had ever had anything other than depression. He was returning now complaining of a "serotonergic deficit" that he was more aware of now that his physical pain was gone.

    Conclusion: Prodromal symptoms of a first psychotic episode may be as difficult to elucidate as some chronic pain complaints. However, with a mandate to view pain as the "fifth vital sign," patients with somatic prodromes may easily drive their treatment at a pain clinic that does not utilize an interdisciplinary approach. Increased psychiatric involvement in pain medicine is needed to recognize and manage chronic pain with psychotic comorbidity.

    Objectives:

    1. To recognize pain as a possible prodrome symptom of psychosis.
    2. To become more familiar with assessing chronic pain syndromes.
    3. To provide a framework for management of emerging psychosis presenting as chronic pain.

    Relevance:
    Psychosomatic psychiatrists are often asked to evaluate if anxiety or depression are contributing to chronic pain. This case adds another layer by presenting psychosis contributing to pain.

     
  15. [T] The Diagnosis and Treatment of Pediatric Delirium in the Intensive Care Unit
    Presenting Author:  Elizabeth Munzig
    Co-Authors:  Susan Turkel, Julienne Jacobson

    Delirium is beginning to be recognized as a serious problem in intensive care units (ICUs). There is a lack of published literature on delirium in the pediatric ICU population. Haloperidol has been the drug of choice to control the symptoms of delirium, and atypical antipsychotics are being used with increased frequency. To address the question of management of delirium in pediatric patients in intensive care, pharmacy records were screened for all patients in the Pediatric Intensive Care Unit (PICU) and Cardiothoracic Intensive Care Unit (CTICU) who received an antipsychotic from January 1, 2005 to December 31, 2006. Corresponding psychiatric inpatient consultation records identified and paired t-tests used to compare pre- and post-medication DRS-R-98 scores. There were 31 patients in the study, 16 males and 15 females, with mean age 13 years. Drug-induced delirium and neoplasm were the most common etiologies of delirium. Olanzapine was the most commonly used antipsychotic (n=25), and risperidone (n=2) and quetiapine (n=4) were used less often. All three atypical antipsychotics decreased the DRS-R-98 score post-treatment when compared to the pre-treatment score (p<0.0001). No adverse side effects were noted in the patients who received an atypical antipsychotic to control symtoms of delirium in the ICU. While the study is limited by being a retrospective, single site study, and all patients in the PICU and CTICU are not prospectively screened for delirium, the study documented that children with delirium who received an atypical antipsychotic medication had significantly lower DRS-R-98 scores post-treatment than pre-treatment.

    Objectives:

    1. Recognize the utility of DRS-R98 in confirming the diagnosis and response to treatment of delirium in pediatric patients.
    2. Be able to apply the diagnostic criteria for delirium in pediatric patients.
    3. Be familiar with the approach to using atypical antipsychotics to control the symptoms of delirium in pediatric patients in the intensive care unit.

    Relevance:
    Psychiatrists familiar with the diagnosis and treatment of delirium in adult patients, can benefit from this presentation when caring for seriously ill pediatric patients.

     
  16. [T] Electroconvulsive Therapy for Catatonia in Gaucher’s Disease
    Presenting Author:  Nicole M. Gibler-Yates
    Co-Authors:  Nathaniel Clark, Vidya Raj, D. Catherine Fuchs

    Background: Gaucher's disease, a common lysosomal storage disease, is caused by a recessive mutation in a gene located on chromosome 1 and affects both genders. The disease involves accumulation of lipids in cells and certain organs with progression of the disease from childhood to early adulthood with stabilization thereafter. Neurological symptoms of Gaucher's disease may include epilepsy, increased tone, mental retardation, psychosis, myclonus, and convulsions. The literature has not previously described catatonia in association with Gaucher's disease.

    Case/Methods/Results: At baseline, this 15-year-old male with Gaucher's disease developed increasingly severe catatonic symptoms over the course of approximately 1.5 years. As measured by the Bush-Francis Catatonia rating scale (BFCRS), his catatonia did not resolve with lorazepam administration, and he became more irritable, aggressive, impulsive, and possibly psychotic with high doses of lorazepam (10 mg/day). We then gradually decreased the lorazepam dose to 5mg/day and administered 15 electroconvulsive therapy (ECT) treatments over 5 weeks with dramatic improvement in his catatonic symptoms of excitement, grimacing, mutism, staring, posturing, stereotypy, verbigeration, mannerisms, and impulsivity. He tolerated ECT without complications or adverse effects.

    Discussion: This case highlights the effectiveness of ECT in the treatment of catatonia in an adolescent with Gaucher's disease. While high doses of lorazepam showed little to no benefit in ameliorating his catatonic symptoms, ECT treatments over the course of several weeks proved to be beneficial. This case provides multiple educational opportunities, including the importance of evaluation for catatonia in children and adolescents with neuropsychiatric symptoms associated with heritable disorders, the treatment approach to catatonia refractory to an initial trial of lorazepam, and the state of the medical literature on safety and efficacy of ECT for neuropsychiatric complications of heritable disorders in children and adolescents.

    References:

    1. Bush G, Fink M, Petrides G, et al. Catatonia I. Rating scale and standardized examination. Acta Psychiatr Scand. 1996;93:129-136.

    2. Herrlin, K.-M and Hillborg, P. O. (1962), Neurological Signs in a Juvenile Form of Gaucher's Disease. Acta Paediatrica, 51: 137-154.

    3. Zimran A et al. Gaucher disease. Clinical, laboratory, radiologic, and genetic features of 53 patients. Medicine, 71(6): 337-53, 1992.

    Objectives:

    1. This case demonstrates the importance of evaluation for catatonia in the treatment of children and adolescents with neuropsychiatric symptoms associated with heritable disorders.
    2. We will present a review of the treatment approach to catatonia refractory to an initial trial of lorazepam.
    3. We will discuss the state of the medical literature on safety and efficacy of electroconvulsive therapy for neuropsychiatric complications of heritable disorders in children and adolescents.

    Relevance:
    This case highlights identification of catatonia in children with neuropsychiatric symptoms associated with heritable disorders and demonstrates the effectiveness and tolerability of ECT following a failed trial of high-dose lorazepam.

     
  17. [T] Memantine and Lorazepam Combination Therapy for Catatonia
    Presenting Author:  Carmen Croicu
    Co-Authors:  Jessica Yeatermeyer, Stanley Shyn

    Objective: To describe a case of catatonia responsive to only a combination of memantine and lorazepam.

    Case: A 45 year-old man with unknown psychiatric history was admitted for altered mental status. Full medical and neurologic work-ups were negative and he was thought to be demonstrating psychosis of unknown etiology. After two days receiving haloperidol, the patient became catatonic. He received three days of lorazepam, titrated to 3mg TID, and then manic symptoms emerged. Lorazepam was discontinued and valproic acid initiated. After two days, he again became catatonic. On day nine of this repeat catatonic state he was started on memantine 10mg daily, increased to 10mg BID. Lorazepam was added to the regimen after three days of memantine alone and after two days on combined treatment the patient became fully articulate, alert and in good behavioral control.

    Discussion: It has been suggested that catatonia is related to abnormalities in GABAergic, dopaminergic, and glutamatergic systems. Benzodiazepines are the first-line choice for the treatment of catatonia. However, in some cases in which patients are refractory to benzodiazepines there has been increasing interest in the use of NMDA receptor antagonists, such as memantine. Although in our patient the effect of combined treatment was dramatic and obvious, we could not definitively attribute a clinical response to a particular agent. Given that lorazepam failed to show efficacy in an initial trial, we hypothesize that memantine may have played an essential role to effectively resolve catatonia. Although the true efficacy of memantine remains elusive, case reports and recent literature support its use in catatonia.

    Conclusions: This case highlights the challenges of treating catatonia and supports the emerging role of combination therapy with lorazepam and memantine. Further studies are necessary to validate whether combination treatment is superior to monotherapy.

    Objectives:

    1. To learn about catatonia refractory to benzodiazepines.
    2. To investigate the role of memantine in treatment of catatonia.
    3. To explore the emerging role of combination therapy with lorazepam and memantine.

    Relevance:
    Challenges of treating catatonia by the psychiatrist consultant and emerging role of combination therapy with lorazepam and memantine.

     
  18. [T] Kynurenine Pathway and Major Depression: Effects of Treatment
    Presenting Author:  Vidushi Savant
    Co-Authors:  Angelos Halaris, AyeMu Myint, Edwin Meresh, Gilles Guillemain, James Sinacore

    Rationale: Major Depressive Disorder (MDD) is increasingly viewed as an inflammatory condition. Inflammatory biomarkers are elevated in patients with depression possibly contributing to heart disease, stroke and dementia. Stress associated with MDD can induce shunts in the metabolic pathway of tryptophan shifting the balance between the kynurenine and serotonin pathways. Main toxic metabolites of the kynurenine pathway are quinolinic acid (QUIN) and 3-hydroxykynurenine (3-OHK); they impair neuronal function via NMDA receptor agonism, excitotoxicity and apoptotic cell death. These effects may account for some of the cognitive symptoms of depression, such as impaired concentration and declarative memory. Chronic untreated depression can predispose to dementia due to hippocampal cell death. We examined metabolites of the kynurenine pathway (tryptophan (T), kynurenine (K), kynurenic acid (KYNA), K/T ratio, 3-OHK and QUIN) in Healthy Controls and MDD subjects at baseline (BL) and at weeks 8 (W8) and 12 (W12) following mono-therapeutic use of Escitalopram or Quetiapine. We sought correlations with depression severity and obtained blood levels of the therapeutic agents.

    Study Design: Patients diagnosed with MDD were treated with either Escitalopram (24 patients) or low dose Quetiapine (31 patients) in consecutive open labeled studies of identical design. Blood samples were collected at Baseline (BL), week 8 (W8) and week 12 (W12) of treatment while simultaneously performing clinical assessments with standard rating instruments to assess severity of depression and anxiety.

    Results: Statistical analyses were performed with SPSS software and the possible confounding effects of age, sex and BMI were taken in to consideration.

    Findings: Escitalopram group: i) Tryptophan levels increased from BL to W8 (p<0.001); ii) Kynurenine levels declined modestly from BL to W12 (p<0.015); iii) K/T ratio significantly declined from BL to W8 and remained significantly lower at W12 (p<0.001); iv) QUIN at W8 was reduced by a factor of 2 (p<0.0005) but significance was lost at W12; v) 3-OHK levels were reduced by a factor of 2.23 p<0.001) at week 12.

    Quetiapine group: i) Kynurenine levels trended downward from baseline to W8 (p<0.07) and to W12 (p<0.084); ii) 3-OHK levels were reduced by a factor of 3 (p<0.004).

    No significant differences were found between healthy controls and depressed patients at BL. None of the metabolites tested correlated significantly with HAM-D 17 scores at BL.

    Conclusions: This pathway is abnormally regulated in depression and responds differentially to Escitalopram and Quetiapine despite the fact that most patients responded favorably to both medications with more than 35% remitting in both groups. Since Quetiapine and Escitalopram have different psychodynamic profiles, aspects of the Kynurenine pathway are differentially affected. Importantly, however, both medications exert neuroprotective action by reducing toxic metabolites, notably 3OHK with Quetiapine and 3-OHK and QUIN with Escitalopram.

    Objectives:

    1. Review the metabolic pathway of tryprophan with emphasis on the Kynurenine pathway.
    2. Discuss the effect of a standard serotinin reuptake inhibitor antidepressant on the Kynurenine pathway.
    3. Discuss the effects of an atypical antipsychotic on the kynurenine pathway when used for major depression.

    Relevance:
    The treatment of depression continues to pose challenges. Available antidepressants achieve limited remission rates. A possible reason may relate to shunting of tryptophan away from serotonin toward the Kunurenine pathway.

     
  19. [T] InSPECT for Clarity when the Plot Stiffens
    Presenting Author:  Florian Bahr
    Co-Author:  Mayur Pandya

    Introduction: Parkinsonism is a clinical syndrome of tremor, rigidity, bradykinesia, and postural instability which often presents in older adults. The symptoms negatively impact quality of life and pose a significant safety risk. The causes of parkinsonism are broad and include both idiopathic Parkinson's disease (IPD) and drug-induced parkinsonism (DIP). The exact diagnosis can be challenging especially when psychiatric comorbidities and exposure to psychotropic medications are present. The clinical assessment may not easily differentiate various causes in early or mild stages of disease. The diagnosis of IPD has traditionally been confirmed by symptom response to levodopa administration. This inexact strategy, however, may delay treatment in those not suspected of having IPD or pose unnecessary risk in certain psychiatric populations where exposure to dopamine replacement therapy may exacerbate underlying clinical pathology, such as paranoia or hallucinations. A novel single-photon emission computed tomography (SPECT) technique may now facilitate diagnosis and accelerate management in patients presenting with parkinsonism of unclear etiology.

    Case: We present here a case of an 84 year old woman with a history of chronic paranoid schizophrenia who presented for an outpatient visit with parkinsonism and psychosis. She was recently seen by her neurologist for her tremor, worsening muscle stiffness, and gait difficulties. DIP was suspected due to her psychiatric history which was notable for prolonged exposure to oral antipsychotic medications, including haloperidol for 27 years. Despite discontinuation of her neuroleptic medications she experienced worsening motor symptoms over the 3 months prior to our consultation. In addition, her psychosis had worsened with more vivid visual hallucinations and delusional ideation. Based on the complicated history and presentation, we obtained a I-123-SPECT scan which showed grade 2 loss of dopaminergic neuronal terminal density in the striatum, thus confirming the diagnosis of an underlying neurodegenerative process, such as Parkinson's disease. She was subsequently started on a regimen of carbidopa/levodopa 25/100 three times daily, along with low dose olanzapine. Six weeks later, at a followup visit with her neurologist, her family reported that the parkinsonism had hallucinations had improved.

    Conclusion: This case illustrates how SPECT-imaging may help with diagnosis and treatment in clinical parkinsonism, particularly by differentiating conditions presenting with nigrostriatal degeneration from those without degeneration (i.e. drug-induced parkinsonism). An abnormal scan can facilitate and expedite decisions regarding initiation of dopaminergic treatment, which may significantly improve one's quality of life. This should always be done with caution in a patient with symptoms of psychosis and preferably in combination with a neuroleptic agent with low potential for extrapyramidal side effects.

    References:

    1. Cummings J L et al "The role of dopaminergic imaging in patients with symptoms of dopaminergic system neurodegeneration" Brain 2011: 134;3146-3166

    2. Adler CH "Differential diagnosis of parkinson's disease" Med Clin N AM 1999: 83;349-367

    Objectives:

    1. Differentiate clinical conditions associated with parkinsonism and understand underlying pathology.
    2. Appreciate the role that SPECT imaging may have in differentiating conditions presenting with nigrostriatal degeneration from those without degeneration (i.e. drug-induced parkinsonism).
    3. Apply information gained from SPECT imaging to guide treatment in the patient with parkinsonism and psychosis.

    Relevance:
    The learner will be introduced to the role that SPECT imaging has in identifying and clssifying conditions presenting with parkinsonism and how this may affect treatment.

     
  20. Novel Treatments of Alcohol Withdrawal Syndromes: A Systematic Literature Review and Case Series
    Presenting Author:  Jose Maldonado
    Co-Authors:  Yelizaveta Sher, Anne Catherine Miller

    Background: Alcohol is the second most abused substance worldwide with lifetime prevalence of alcohol dependence or abuse in general population being 13.6%. Withdrawal from alcohol might lead to seizures or delirium tremens and be lethal. While benzodiazepines are still considered to be the "gold standard" treatment for alcohol withdrawal syndrome (AWS), there are several problems associated with their use in the medical setting: (1) during severe ETOH abuse and dependence GABA receptors are down regulated, thus GABA-ergic substances may be less effective in these circumstances, leading to treatment failure or the need to use very high doses for treatment; (2) benzodiazepines are one of the most common pharmacological causes of delirium, which complicates management and prevents disposition; (3) some patients require very high benzodiazepine doses leading to respiratory depression and the need for extended monitoring and/or intubation; (4) due to cross-reactivity between benzodiazepines and alcohol there are increased rates of recidivism when benzodiazepine are used to treat AWS.

    Methods: We have conducted a systematic review of the literature (including every published report) and studied the potential usefulness of non-benzodiazepine agents (i.e., anticonvulsants and alpha-2 agonists) in the prevention and treatment of AWS. The paper will examine the available evidence for the effectiveness of non-benzodiazepine agents and compare these results to what benzodiazepines can do, highlighting advantages and pitfalls in treatment. We reviewed cases of patients in various stages of alcohol withdrawal who were treated with the non-benzodiazepine protocol by inpatient Psychosomatic Medicine service at Stanford Hospital, often after the initial attempt of the primary team to control patient's symptoms with benzodiazepines.

    Results: A number of studies that have demonstrated the efficacy and safety of anticonvulsants, alpha-2 agonists and other pharmacological as alternatives to benzodiazepines for the treatment of alcohol withdrawal. Our cases included (1) prophylactic treatment of patients at high risk for AWS with non-benzodiazepine modalities; (2) treatment of patients in moderate to severe AWS with largely non-benzodiazepine approaches; and (3) treatment of patients still in severe AWS, but now also delirious from the initial treatment with benzodiazepines by the primary team. We demonstrate quick resolution of their AWS symptoms with non-benzodiazepine approaches, as evidenced by improved mental status, vital signs, and Clinical Institute Withdrawal Assessment (CIWA) scores, as well as much decreased requirements of benzodiazepines.

    Conclusions: For decades it has been the general practice to use benzodiazepine agents for the prophylaxis and treatment of all phases of alcohol withdrawal. Yet, despite their undisputed usefulness these agents also have their difficulties. We challenge the notion of benzodiazepines as the treatment of choice for alcohol withdrawal syndromes based on ethanol's effects in the brain function and neuromodulation and offer rationale for the use of safe and effective treatment alternatives.

    Objectives:

    1. Understand the neurobiology of alcohol dependence and neurochemical mechanisms of withdrawal.
    2. Understand the mechanisms of action and range of non-benzodiazepine treatment options as alternative in the management of AWS.
    3. Examine the available evidence for the effectiveness of non-benzodiazepine agents in the management of alcohol withdrawal syndromes.

    Relevance:
    Benzodiazepine agents have certain potential pitfalls, from the development of benzodiazepine-induced delirium, to respiratory depression. This presentation tries to offer treatment alternatives that we can offer during consultation.

     
  21. [T] Use of the Montreal Cognitive Assessment as an Alternative Cognitive Screening Tool in the General Medical Hospital
    Presenting Author:  Thomas Cantey
    Co-Authors:  Michael Marcangelo, Marie Tobin

    Cognitive impairment can play a significant role in determining the course of patients in the general hospital. Traditionally, a useful screening test for cognitive impairment was found in the Mini-Mental State Examination (MMSE). Though widely available, the MMSE has garnered some criticism, most significantly, that it does not evaluate executive cognitive domains. Newer screening tools have been developed in order to address such criticism. One such tool, the Montreal Cognitive Assessment (MoCA), has been noted to employ more sensitive tests in various areas of higher level cognitive functioning in an easily administered format. Additionally, the MoCA has been shown to be a more sensitive measure of mild cognitive impairment (MCI), a condition consistent with cognitive impairment not severe enough to be termed dementia. In some studies, patients classified as having MCI by detailed neuropsychological testing were determined to have normal cognitive functioning by the MMSE. However, MCI was more likely to be identified by the MoCA. (1)

    In the current study, both the MMSE and the MoCA were performed on a population of medically hospitalized patients for whom a psychiatric consultation had been requested over a six month period. The aims of the study were to determine the feasibility of detecting MCI in a general medical hospital population, and whether a determination of mild cognitive impairment by either or both of these screening tests is linked to outcomes such as medical diagnosis, psychiatric diagnosis, length of hospital stay, and length of time to psychiatric consultation. This was done by administering the tests shortly after the time of psychiatric consultation, and matching overall scores as well as section subscores to measures such as diagnosis, number of days of total hospital stay, and number of days from admission until psychiatric consultation. Our goal is to identify a cognitive screening tool which can be used easily in the medically hospitalized patient population, which is sensitive to milder cognitive impairment and to understand what relationship, if any, early detection of MCI by such testing has on the aforementioned medical or psychiatric outcomes.

    Reference:

    1. Ziad S. Nasreddine MD et al “The Montreal Cognitive Assessment, MoCA: A Brief Screening Tool For Mild Cognitive Impairment” Journal of the American Geriatrics Society Volume 53, Issue 4, pages 695–699, April 2005

    Objectives:

    1. To enhance our understanding of measuring cognition in the general hospital.
    2. To review the use of the Montreal Cognitive Assessment (MoCA) on a consultation-liaison service and its relationship to cognitive disorders.
    3. To investigate the differences between the MoCA and other measures of cognition.

    Relevance:
    Cognitive disorders are among the most common reasons for referral to a consultation psychiatry service and assessment of these disorders is essential for proper diagnosis and management.

     
  22. Late-onset Mania Emerged in a Patient with Untreated Neorosyphilis: Psychological/Cognitive Aspects Before and After Penicillin G Treatment
    Presenting Author:  Katsumasa Muneoka
    Co-Authors:  Katsushi Kon, Masaharu Kawabe, Rui Ui, Taichi Miura, Touta Iimura, Michiko Goto, Shou Kimura

    Active neurosyphilis is uncommon after the introduction of penicillin. We evaluated the psychological/cognitive performance of a case of untreated neurosyphilis that was diagnosed as a manic episode. The case was a 65-year-old male. This was his first manic episode. After a trouble with a taxi driver, the patient was diagnosed with mania as a result of an interview with psychiatrists because of symptoms including an irritable mood, grandiosity, extreme talkativeness, and psychomotor agitation. After the administration to a hospital, neurosyphilis was revealed from laboratory data.

    He was subjected to treatment with intravenous penicillin G (16 million units every day) for 2 weeks and manic symptoms were gradually diminished. MRI and MRA imaging showed atrophy in the temporal lobe, including the hippocampus but no space-occupying lesion, like neurosyphilitic gumma and a narrowing of cerebral arteries. Slow waves observed in an EEG changed to a normal pattern after the treatment with penicillin G. Cognitive changes that followed the penicillin G treatment were evaluated with the Mini-Mental State Examination (MMSE), the Cognistat, and Bender Visual Motor Gestalt Test (B-G Test). The MMSE score was elevated from 16/30 to 21/30. Results in the Bender Gestalt Test were improved after the penicillin G treatment; 84 to 51 in total scores. The Cognistat scores generally improved but paradoxical deterioration was observed in several items. Results from MMSE and the Cognistat indicated obvious improvement in performance in copies of two-dimensiononal and three-dimensional perspective designs and the constructive ability. The B-G tests also showed marked improvement in arrangement of dots or positioning of figures. These findings indicated a remarkable improvement of visual cognition, an intact long-term memory, and a deterioration in working memory throughout the penicillin G treatment. This case investigation also demonstrated that psychological test battery was useful for precisely diagnosing and assessing late-onset mental illnesses.

    Objectives:

    1. Learn psychiatric symptoms in a manic state and apply diagnostic criteria of mania or organic psychosis.
    2. Investigate physiological examinations such as electroencephalogram, brain imaging such as magnetic resonance imaging and magnetic resonance angiography, and analyze psychological assessment including COGNISTAT.
    3. Apply the treatment with Penicillin G for neurosyphilis.

    Relevance:
    This is a rare case, today, in which current diagnostic tools were applied before and after the treatment.

     
  23. [T] Use of a Structured Assessment Tool to Examine Prevalence of Contributing Medical and Neurological Conditions Among Minority, Psychiatric Outpatients
    Presenting Author:  Neevon Esmaili
    Co-Authors:  Ricardo Ramirez, Isabel Lagomasino, Linda Chan
    Acknowledgment: Edmond Pi

    Objectives:
    To examine the prevalence of contributing medical and neurological conditions among patients in a public sector, outpatient mental health clinic, using a newly developed structured assessment tool.

    To inform whether a structured screening tool for medical disorders should be used for all psychiatric outpatients or only for those who are suspected of having a contributing medical or neurological disorder

    To determine potential risk factors for underlying medical or neurological disorders

    To assess patients’ perceptions of physical examinations as performed by psychiatrists

    Methods: Consecutive patients presenting for initial and continuing psychiatric evaluation visits were screened by two psychiatrists for medical and neurological causes of their symptoms, using a structured, streamlined, targeted assessment tool developed for the purposes of this study. The evaluation tool was based on existing literature and incorporates assessment of known medical causes of psychiatric symptoms. Frequencies were calculated for demographic and clinical characteristics. The prevalence of possibly contributing medical conditions was estimated with 95% confidence intervals. The difference in the prevalence of possibly contributing medical conditions between the consecutively screened patients vs. the ongoing patients suspected of having underlying medical conditions was examined using the 2-sided Fisher's Exact test.

    Results: The overall prevalence of contributing diagnoses in our sample of 168 outpatients was 2.4% (4). Patients with HTN were more likely to have a link between their medical diagnosis and psychiatric presentation 42% (p value 0.009) and 6% had a confirmed contributing medical disorder (p value 0.06). Patients with diabetes mellitus were more likely to have an unrelated medical disorder with 28% (p value 0.005), these patients were also significantly more like to have a confirmed secondary medical cause to their presentation (not directly related to DM, which can be associated with psychiatric symptoms independently) at 9% (p value 0.02). Head trauma, seizure disorders or CVA patients were more likely to have secondary confirmed cause at 14% (p value 0.06).

    Conclusions:There is a significant prevalence of contributing medical disorders in psychiatric patients. Vascular risk factors may predispose to contributing medical disorders. The psychiatrist should utilize medical knowledge to investigate the full differential diagnosis of psychiatric symptoms. A medical screening tool has utility in psychiatric patients. Integration of psychiatric clinics into the primary care setting would facilitate the investigation of these types of disorders.

    References (partial):

    1. Levenson, M.D., Essentials of Psychosomatic Medicine, 2007: 1st edition

    2. Gomella (2007). Chapter 1. History and Physical Examination. In L.G. Gomella, S.A. Haist (Eds), Clinician's Pocket Reference: The Scut Monkey, 11e

    Objectives:

    1. The secondary medical causes of psychiatric symptoms
    2. The need for continued use of full physician knowledge including relevant medical applications
    3. The effect that a physical examination has on the therapeutic relationship

    Relevance:
    Psychosomatic medicine is the core of this paper—the interface of mind, behavior and general physiology.

     
  24. C-Reactive Protein as a Diagnostic Parameter for Delirium
    Presenting Author:  Brad Bobrin

    This poster presents preliminary data on using C-Reactive Protein (CRP) to aid in the diagnosis of delirium. Delirium remains a clinical diagnosis and the literature on labratory values to aid in the diagnosis of delirium is inclusive to negative. CRP is readily available in most hospitals but has very little literature on it's use to predict/diagnose delirium.

    In this poster, CRPs were ordered on patients on the consult service with a clinical diagnosis of delirium. The total number of patients evaluated was 83. The mean CRP value in delirious patients was 33.4, with the max normal at our hospital being 8. Unfortunately, our lab doesn't give a value for CRPs greater than 100, just labeling them as ">100." The standard deviation for delirious patients was 29.2. For control, 34 patients without the diagnosis of delirium were chosen. The mean CRP for these patients was 21.4 with a standard deviation of 23.6. In addition, although not used in the evaluation of the means, the number of patients with CRPs >100 were comparable.

    It is thus fairly obvious from the limited analysis presented that there is significant overlap of the data, thus not allowing for clear separation between the control and the delirious group. There appears to be a slight trend for the delirious patients to have an overall higher CRP. Thus the conclusion is, at least from this small study, that CRP does not appear to give clear delineation between delirious and non-delirious patients. Of course, a greater powered study will be necessary to see a clear difference, likely on the order of 500-1000 patients. Because of the simplicity of getting this lab, this study, with more patients, would appear to be a worthwhile one, especially because of the lack of data. If a patent is found to have a high CRP, at least 10 times normal, delirium should be suspected, but more study is needed to correctly determine if such a cutoff number exists.

    Objectives:

    1. Understand what C-reactive protein measures.
    2. Recognize the signs of delirium.
    3. Understand the role of inflammation in delirium.

    Relevance:
    Delirium is one of the top CL diagnoses. The diagnosis is made clinically. Obtaining a lab value would be preferable. This poster looks at the utility of a common lab.

     
  25. The Ethical Dilemmas of Prescribing Cognitive Enhancement Drugs
    Presenting Author:  James Strain

    Should Physicians Prescribe "Smart Drugs" - Nootropics - to Enhance Student's Cognitive Capacity? An Ethical Dilemma

    Nootropics (pronounced nou.e'tropiks) — referred to as smart drugs, memory enhancers, and cognitive enhancers — are purported to improve mental functions: cognition, memory, intelligence, motivation, attention, wakefulness, and concentration.

    Assumptions:

    1. They are effective but effect size is small - 0.2-0.7.
    2. Students' requesting drugs are normal and do not need the drugs for treatment.
    3. The Cognitive Enhancing Drugs (CEDs) have minimal to no side effects. (PDR lists adverse side effects).
    4. The CEDs will not lead the user on to addiction, including: cocaine, crack, etc.

    The American Academy of Neurology (AAN) has endorsed "neuroenhancement" defined as the prescription of cognitive enhancement medications to healthy patients.

    American Psychiatric Association has stated no position on this. (For the most part these drugs are used mainly by psychiatrists).

    Survey (2008) of Scientists Subscribing to Nature Magazine

    60 Countries; One in five of polled readership had used CEDs. .

    Four Critical Themes for Nootropics - CEDs

    Do they promote indirect coercion for others' use?

    Are they dangerous? Potential significant adverse effects?

    Prohibition in the academic arena is likely to fail.

    Are they a form of cheating?

    Drug Enhancement in Sports

    Olympics says no; this is an unfair advantage.

    "Tour de France" has taken away winners found to be using body enhancers.

    Sports declare that such use of medications is unfair, unacceptable, and will disqualify a winner, or recognition for the Hall of Fame.

    Use of urine and blood tests to check truthfulness.

    Anecdotal reports suggest that 95% of elite athletes have taken them.

    Academia Has No Rules Against CEDS

    Academic and society do not have rules against the use of CEDs.

    Prevalence of methyphenidate is over 2X greater at colleges with more competitive admission criteria.

    If found using CEDs in college would the magna cum laude from Harvard or Oxford be stripped of his/her title?

    Ethical Issues

    Person's right to enhance their autonomy and mental capacity.

    Can enhance body, why not mind?

    Should physicians prescribe "off label" use of enhancers to healthy individuals using the drugs for that purpose?

    Guarantee A "Fair Playing Field"

    "Unfair advantages already ubiquitous and tolerated by society," e.g., rich vs poor, computers, books at home, parents who can pay tuition, buy tutors, coaches, Ipads versus those who can't.

    Give nootropics to everyone may level the playing field as those with lesser IQ seem to do better with them.

    Why not level up rather than dumb down?

    We welcome body building with nutrition and exercise; why not mind building with nootropics?

    The playing field is not fair.

    Social Justice

    Daniels: The allocation of health-care resources should aim at equalizing social opportunity.
     

    Objectives:

    1. To learn about the ethical dilemmas of prescribing cognitive enhances (mainly psychiatric drugs) to normals with no disability which is so prevalent in our society to assist clinical decision making.
    2. How to teach the ethics of the use of off label medication for cognitive enhancement.
    3. To know the adverse potentiality of these drugs: physiological, psychological, social.

    Relevance:
    As physicians, teachers, supervisors to trainees and other physicians, the c-l psychiatrist should know the dilemmas confronting the "off label" use of cognitive enhance medications, most often psychiatric drugs.

     
  26. [T] Loxapine for Treatment of Delirium in Older Adult Surgical Patients
    Presenting Author:  Alan Bates
    Co-Authors:  Peter Chan, Heather D'Oyley, Robert Hewko

    Purpose: Though haloperidol has long been considered the gold standard for management of delirium, there is no evidence it is more effective than a number of other antipsychotics. The theoretical advantage of haloperidol is that it is a potent dopamine antagonist with little anticholinergic effect. However, these two neurotransmitter systems are not the only ones involved in delirium, and medications such as dexmedetomidine have different targets. In addition, cardiac side effects have become a greater concern with haloperidol which can also produce significant extrapyramidal symptoms (EPS). Delirium is associated with and appears to be worsened by disturbed sleep, suggesting antipsychotics with greater sedative effect may be particularly effective. Despite being more anticholinergic than haloperidol, loxapine provides a good balance of antipsychotic effect through dopamine blockade and sedation, likely through histamine antagonism. Compared to haloperidol, it also presents less risk of EPS.

    Method: We examined the effectiveness of loxapine in treating delirium using the Delirium Rating Scale (DRS) in 31 older adult surgical patients (mean age 72, 2/3 male) in an open-label, uncontrolled trial. Treating physicians ordered loxapine according to clinical judgment. We also monitored for EPS using the Extrapyramidal Symptom Rating Scale and for QTc changes. Three participants were regular drinkers, while 6 were users of narcotics. Nine had previous history of delirium, 3 had previous diagnosis of another Axis I disorder, and 2 had underlying dementia as measured by the Clinical Dementia Rating Scale.

    Results: The mean maximum cumulative loxapine dose per day was 44mg (s.d. 31). DRS score after 2 days of treatment (mean 10.19, s.d. 6.61) was significantly reduced compared to DRS score at time of diagnosis (mean 18.68, s.d. 4.66) [t(30) = 6.65, p < 0.001]. The mean number of days to resolution of delirium was 3.2 (s.d. 2.46). Only 3 participants experienced EPS and there was no significant difference between baseline QTc (mean 422ms, s.d. 19.86) and mean QTc during treatment (mean 426ms, s.d. 18.47) in a subsample for which QTc data were available [t(11) = 0.45, p > 0.5]. There were no cardiac adverse events.

    Conclusions: Although there are several limitations to this small uncontrolled open-label study, the findings suggest loxapine is effective in treating delirium in older adult surgical patients without increasing QTc interval or commonly causing EPS. We hypothesize that part of loxapine's effectiveness is related to its sedating effects that promote nighttime sleep when the medication is given in the evening. Though it is not part of the DSM criteria for delirium, disturbed sleep is present in the vast majority of delirious patients. This has even lead some to conceptualize delirium as a state of disordered wakefulness.

    Objectives:

    1. Consider evidence that disturbed sleep is a core feature of delirium.
    2. Examine evidence that a sedating antipsychotic such as loxapine is effective in treating delirium.
    3. Evaluate hypothesis that delirium is a state of disordered wakefulness.

    Relevance:
    Delirium is very commonly managed by the CL service. We must begin to tailor antipsychotics selected for treatment to symptoms (such as disordered sleep) that each patient presents.

     
  27. [T] A Case of Creutzfeldt-Jakob Disease Presenting as Psychotic Depression
    Presenting Author:  Elizabeth Shultz
    Co-Authors:  Mayur Pandya, Donald Malone, Jr., Pozuelo Leopoldo

    Introduction: Awareness of Creutzfeldt-Jakob disease has increased with improved diagnostic measures; yet, limitations remain. Complex clinical presentations blur the picture. We present a 51 year-old woman who initially manifested a psychotic depressive episode, but was later found to have Creutzfeldt-Jakob disease.

    Case Report: A 51 year-old female with a history of schizoaffective disorder was admitted to the Mood Disorder Unit for depression with psychotic features. Ten days earlier, she saw her outpatient psychiatrist and displayed disorganized thinking, worsening paranoia, slowed gait, and blurry vision. Neurology and ophthalmology work up, including brain MRI, were normal aside from hyponatremia. She recently lost 25lbs, had labile blood pressure, and tremors. An initial workup suggested pheochromocytoma; however, a later PET scan was negative.

    Since 2006 maintenance ECT combined with medications managed her psychiatric disorder. Just prior to admission, she still responded to ECT; however, while inpatient, she experienced worsening confusion and decompensation after procedures. On the unit, she developed pneumonia, requiring BiPAP, antibiotics, and supportive care. She transferred to a telemetry unit at the community hospital and eventually to our tertiary care center.

    Over the course of her medical admission, she underwent an extensive workup. Multiple interdisciplinary teams were consulted. Outside records revealed the following negative results: EEG, brain MRI, heavy metal screen, Lyme disease, CJD, thyroid disorder, and monoclonal proteins. Current medical workup included routine labs and specialized testing included EEG, paraneoplastic panel, MRI/MRA with gadolinium, CT scan, and testing for Creutzfeldt-Jakob disease. Treatment interventions yielded minimal response. The initial CJD screen returned negative, but repeat testing and autopsy at death confirmed the diagnosis.

    Discussion: Increasing attention is given to Creutzfeldt-Jakob disease. Due to varied clinical presentations and diagnostic limitations, the diagnosis is often elusive. This case illustrates an unusual presentation in a patient with a known psychiatric history and illustrates testing limitations. Current testing can produce false negatives, and unfortunately, the only definitive testing autopsy. Imaging and biomarker use improves diagnosis. It is important to consider repeat testing as the patient's condition progresses if all other testing is inconclusive.

    References:

    1. Wood, H. Prion disease: New approaches to CJD diagnosis. Nat Rev Neurol. 2012 Apr 10.

    2. Fujita K, Harada M, Sasaki M, Yuasa T, Sakai K, Hamaguchi T, Sanjo N, Shiga Y, Satoh K, Atarashi R, Shirabe S, Nagata K, Maeda T, Murayama S, Izumi Y, Kaji R, Yamada M, Mizusawa H. Multicentre multiobserver study of diffusion-weighted and fluid-attenuated inversion recovery MRI for the diagnosis of sporadic Creutzfeldt-Jakob disease: a reliability and agreement study. BMJ Open. 2012 Jan 30;2(1):e000649.

    3. Geschwind MD, Martindale J, Miller D, DeArmond SJ, Uyehara-Lock J, Gaskin D, Kramer JH, Barbaro NM, Miller BL. Challenging the clinical utility of the 14-3-3 protein for the diagnosis of sporadic Creutzfeldt-Jakob disease. Arch Neurol. 2003 Jun;60(6):813-6

    Objectives:

    1. Recognize that there are varied presentations to prion diseases which can make diagnosis difficult.
    2. Understand the current diagnostic testing for Creutzfeldt-Jakob disease and its limitations.
    3. Consider prion diseases as a possibility in unusual psychiatric presentations with a neurologic component.

    Relevance:
    Increasing attention has been paid to recognizing and diagnosing prion diseases. This case illustrates a unique presentation in which the patient's psychiatric history complicated the diagnostic process.

     
  28. [T] Persistent Psychosis and Personality Changes Following Venous Thalamic Stroke Secondary to Hereditary Protein C Deficiency: A Case Report
    Presenting Author:  Lindsey Mortenson
    Co-Author:  Avinash Hosanagar

    Ms. M, a 36-year-old Caucasian woman on warfarin for Hereditary Protein C Deficiency, presented to our Anti-Coagulation Clinic in February 2010 limping on her right leg. She denied recent trauma. Labs were drawn and her International Normalized Ratio (INR) was 9.1, well above the therapeutic goal of 2.0-3.0. On initial evaluation by Internal Medicine, Ms. M reported taking up to six tablets of ibuprofen daily to increase the volume of her menstrual bleeding. She reported feeling “less moody” with a higher INR, preferring it to be 3.0-5.0. At a lower INR she said she felt fatigued, "like an old woman," and did not like the clotted appearance of her menstrual blood. She refused to wear dark blue hospital clothing, stating “I don’t want something bad to happen.” Because of these bizarre comments, the Psychiatry service was consulted.

    Chart review revealed a history of increasingly paranoid, bizarre and disinhibited behavior following a stroke twelve years prior. At age 25, Ms. M was found comatose in her home. She was hospitalized for one week in an ICU at an outside hospital, where a head CT revealed thrombosis of the right transverse and sigmoid sinus, as well as the straight sinus. Medical work-up revealed that Ms. M had Hereditary Protein C deficiency, which was previously undiagnosed, and this was the presumed etiology of the thrombosis. Subsequent imaging revealed bilateral thalamic infarct, greater on the right side, affecting the medial dorsal nuclei (MDN).

    Vascular lesions of the thalamus affect nuclei in various combinations, producing sensory, motor and behavioral syndromes. The specific anatomic locations that are associated with these syndromes have been identified through clinical observation, case studies, structural and functional imaging, post-mortem studies, thalamotomy, and thalamic stimulation studies. Arterial thalamic strokes, which are relatively common, generally occur in one of four major arterial territories of the thalamus: the (i) tuberothalamic, (ii) inferolateral, (iii) paramedian, and (iv) posterior choroidal vessels. Stroke in these arterial territories is associated with well-documented vascular syndromes. However, there are few accounts of venous thalamic infarcts, which are relatively rare clinical events and do not localize as well as arterial infarcts. Fortunately, advances in neuroimaging allows for mapping of venous infarcts to the nuclei supplied by comparable arterial territories.

    In this case report, we will describe in detail Ms. M’s medical and psychiatric history, the diagnostic quandary posed to the Psychiatry service, and challenges faced in the management of hospitalized patients with behavioral issues. Thalamic venous stroke as a possible etiology for psychotic illness will also be discussed.

    Objectives:

    1. Understand the behavioral sequelae of thalamic stroke.
    2. Identify common symptoms associated with stroke in each of the four major arterial territories of the thalamus.
    3. Understand how thalamic lesions affect neurocircuitry to produce psychosis.

    Relevance:
    This case will describe how the thalamus contributes to psychosis, which may aid the C/L clinician in the differential diagnosis and treatment of secondary psychosis.

     
  29. [T] Lacosamide-induced Psychosis: A Case Report and Review of Literature
    Presenting Author:  Priya Shrestha
    Co-Authors:  Priya Shrestha, Aasia Syed, Raman Marwaha

    Introduction: Anti-epileptic medications are known to have psychiatric adverse effects such as suicidality, depression, anxiety, confusion, agitation and restlessness. Lacosamide is one of the newer AED which is known to have a similar side-effect profile. The purpose of this paper is to report a case of Lacosamide induced psychosis (Tactile hallucinations and Paranoid Ideation).

    Method: Review of literature was made on psychosis AND Lacosamide AND Anti-epileptics using databases of Pubmed, Ohiolink, CWRU lib, Metrohealth Brittingham Library

    Case Report: We present a case of a 34 year old Male with past medical history of complex partial seizure disorder presenting with the delusional believes that bugs were crawling out of his penis and his family wanted to poison him. The patient had no prior psychiatric history. A week prior to the event the patient had been started on Lacosamide. After discontinuation of this drug psychosis resolved. Naranjo Scale showed a possible association between the side effect and the offending agent.

    Discussion: Lacosamide like other AEDs is known to cause many psychiatric side effects like suicidality, depression, anxiety, confusion [5]. However, to our knowledge psychosis has rarely been reported. There have been some reported cases in the literature [1]. Psychosis as an adverse-effect of Lacosamide is not a very well-established finding. The case report here highlights the importance of monitoring patients for psychosis when they are started on lacosamide. When starting patients on lacosamide, clinicans should be mindful of possible psychiatric side-effects including psychosis. Levitracetamine , Vigabatrine, Topiramate and Zonisamide are AEDs known to cause psychosis [5,2].

    References:

    1. Current Review in Clinical Science, Clinical Perspectives on Lacosamide.
    Jonathan J Halford, MD and Marc Lapointe, Pharm D, BCPS, BCNSP.

    2. Psychiatric adverse events during Levitiracetam Therapy
    M.Mula MD, M.R.Trimble , MD, FRCP, FRCPsych, A.Yuen MD,MRCP; RSN Liu, MD,MRCP; and J.W.A.S. Sander, MD, MRCP, PHD

    3. Epileptic Psychoses and anticonvulsant drug treatment
    Masato Matsuura

    4. Vigabatrin and Psychosis
    JWAS Sander, Y M Hart, MR Trimble, SD Shorvon

    5. Psychotropic Effects of antiepileptic drugs
    Alan B Ettinger

    Objectives:

    1. Different side effects of anit epileptic drugs
    2. Mechanism of action of Lacosamide
    3. Overlap of psychosis and seizures

    Relevance:
    Monitoring AED for psychosis.

     
  30. [T] Mania Following Dengue Fever
    Presenting Author:  Jessica Harder
    Co-Author:  Samata Sharma

    Background: Dengue fever is a potentially lethal infection found worldwide and expected to become increasingly common in the U.S partially due to climate changes and global travel. This flavivirus infection, transmitted by Aedes mosquitoes, may be frequently underdiagnosed in developed regions. Dengue has been demonstrated to be a neurotrophic virus with neurologic sequelae including Guillain-Barre syndrome, ICH, CVA, isolated nerve palsies, and encephalopathy. However, its neuropsychiatric sequelae remain understudied.

    Case Study: 48 y/o M with a history of dysthymia acquired dengue virus infection in 2008 and developed his first-ever hypomanic episode while recuperating from acute illness. Symptoms included feeling "elated" and "ecstatic," rapid speech, thinking more quickly and writing prolifically. These hypomanic symptoms were followed by a suicidal depression, partially treated with low-dose citalopram. Two years later, the patient presented to a teaching hospital with residual insomnia, ruminations, and irritability despite ongoing SSRI treatment. Exam showed restricted affect and mild PMR. Lamotrigine was started for mood stabilization with subsequent improvement in mood and irritability. However, lamotrigine was discontinued for possible SJS and the patient has since been maintained on only citalopram without further manic symptoms.

    Methods: Literature review using keywords for neuropsychiatric mood disruption and "dengue fever" revealed four additional cases involving known dengue fever with subsequent neuropsychiatric disturbances suggestive of a manic state. In all cases, the episodes were isolated, time limited, and resolved completely. However, longitudinal follow-up data was limited. An ongoing database review for neuropsychiatric complications in recorded dengue cases treated over the past ten years at Brigham and Women's hospital is currently underway.

    Discussion: This is the first case of mania following dengue documented in the American literature. The case and the literature review highlight a neuropsychiatric response to dengue fever with clinical features closely resembling the idiopathic manic state of bipolar disorder. However, the pathogenesis of mania after dengue fever, and its optimal clinical management , remain unclear. Rapp et al. suggest three possible mechanisms: metabolic encephalopathy, viral encephalitis, or post-viral autoimmune mediated encephalitis, and Puccioni-Sohler et al. include hemorrhage as an additional possible etiology. More generalized immunoreactivity, however, as described by Ramos et al. might better explain a manic reaction and would support an autoimmune etiology as the strongest out of the several possibilities hypothesized by the authors above. These data suggest that the mania secondary to dengue fever may involve a different mechanism than that of idiopathic bipolar mania, and may not require long-term mood stabilization for prevention of additional episodes. However, more information will be needed to inform and create best clinical decision-making practice guidelines.

    Objectives:

    1. Understand the basic neuropsychiatric complications which may arise as a result of Dengue infection
    2. Discuss similarities and differences in clinical presentation and pathogenesis of mania resulting from Dengue infection when compared with mania resulting from idiopathic bipolar disorder.
    3. Consider differing treatment algorithms and variabilities in longitudinal care needs when assessing and managing neuropsychiatric mood complications from flavivirus infection as compared to idiopathic mood disorder presentations.

    Relevance:
    With wider spread and greater prevalence of dengue infection, even in the developed world, a knowledge of its neuropsychiatric sequellae may prove valuable in the psychiatric C-L setting.

     
  31. [T] Walks like a duck, quacks like duck, not a duck! Atypical Anxiety as Presentation of Narcolepsy
    Presenting Author:  Kecia-ann Blissett
    Co-Authors:  Anna Irwin, Margo Funk, Leopold Pozuelo, Nancy Foldvary, Douglas Moul

    Background: Episodic anxiety can affect a patient's quality of life and chronic anxiety can be debilitating. Although anxiety is a common psychiatriic disorder, identify the correct underlying etiology is imperative for treatment. We report a case of a 22 y/o male with anxiety symptoms that had limited response to standard antianxiety treatment. We underscore the importance of including narcolepsy in the differential diagnosis of a new onset anxiety disorder.

    Case: 22 year old male with history of testicular embryonic carcinoma, status post orchiectomy and limbic encephalitis presented with anxiety in the setting of extremity weakness, with sudden postural loss at times associated with emotional stressors. Anxiety predated the hospitalization for three months and had limited benefit with outpatient SSRI and benzodiazepines. His hospital presentation of anxiety consisted of racing thoughts, feelings of loss of control, tachycardia, and hyperventilation. EEG findings were negative for seizures but indicated concerns for a sleep onset REM disorder. Paraneoplastic workup was positive for Anti Ma-1 antibody. MRI of brain showed near total resolution of the previous limbic hyperintensities. There was limited benefits with stimulants and chemotherapy for the REM disorder during the hospital stay. An outpatient follow up Polysomnogram and Multiple Sleep Latency Test confirmed narcolepsy with cataplexy.A trial of IVIg was conducted. After receiving a 5 day course of IVIg, anxiety symptoms greatly improved as well as his lower extremity weakness. Cataplexy events resolved. The patient has required intermitternt IVIG infusion to prevent relapse of narcoleptic symptmoms, including anxiety

    Discussion: Although prodromal depresion symptoms are reported with narcolepsy, anxiety symptoms have not been associated as frequently with narcolepsy, lending itself to a further pathophysiological understanding. Considering that hypocretin neurotransmission is involved in stress regulation, it is noteworthy that that narcolepsy has an impairment in hypocretin signaling, raising the possibility that anxiety symptoms may be a primary disease phenomena in narcolepsy. Though there has been limited data supporting efficacy of IVIg treatment in autoimmune narcolepsy there has been no previous evidence on it's effect on narcolepsy secondary to anti Ma-1 paraneoplastic encephalitis.. Presumbly, the IVIg was instrumental in treating the comorbid anxiety of our narcoleptic patient.

    Conclusion: C-L psychiatrists need to be cognizant of psychiatric manifestations of narcolepsy, which can include anxiety In addition, future studies are needed to assess the IVIG efficacy in the anti Ma-1 associated narcolopesy

    References:

    1. Fortuyn HA, Mulders PC, et al. Narcolepsy and psychiatry: An evolving association of increasing interest. Sleep Medicine 2011;12(7):714-719.

    2. Fortuyn HA, Lappenschaar MA, Furer JW, et al. Anxiety and mood disorders in narcolepsy: a case-control study. Gen Hosp Psychiatry 2010;32(1):49-56.

    Objectives:

    1. Identify the psychiatric manifestations of narcolepsy that include depression as well as anxiet
    2. Review possible mechanistic pathways why anxiety manifest in narcolepsy patients, based on the hypocretin dysregulation, common in stress responses as well as narcolepsy.
    3. Familiarize the C-L psychaitrist with the novel treatments used in narcolepsy which include intravenous immunoglobulin (IVIG) infusions

    Relevance:
    C-L psychiatrists increasingly use their diagnostic acumen in atypical anxiety presentations. Our case illustrates that anxiety can present with narcolepsy in which anxiety relief was attained only after narcolepsy treatment.

     
  32. Delirium Secondary to Pregabalin (Lyrica™) Withdrawal
    Presenting Author:  Paul Ragan

    Purpose: Substance withdrawal delirium is commonly seen in intensive care units and often caused by dependence on alcohol and/or sedative-hypnotic medications. Other GABAergic agents, such as baclofen, can also cause withdrawal delirium. Not well known is delirium from pregabalin (Lyrica™) withdrawal. It is used for the treatment of partial-onset seizures and neuropathic pain. It is similar to gabapentin in structure (a gamma-aminobutyric acid analogue) and they both inhibit calcium influx and the subsequent release of excitatory neurotransmitters. Unlike gabapentin, however, pregabalin was placed into Schedule V because of its acute euphoric effects (suggesting some abuse potential) and its withdrawal effects, although both were considered less severe than Schedule IV substances such as benzodiazepines. One case report of pregabalin abuse, dependence and withdrawal was found in the literature.

    Methods: Clinical case report of two patients who presented in separate intensive care units with delirium which were traced to pregabalin withdrawal.

    Results: Case 1: 63 y.o. married Caucasian woman, retired school teacher, with no prior psychiatric or substance abuse history, presented with worsening delirium following bioprosthetic aortic valve replacement. Pre-operative medications for fibromyalgia included pregabalin 400 mg/day and baclofen 10 mg t.i.d. and had been discontinued. No other cause of delirium could be discerned. Baclofen was restarted, however, when the patient remained confused and was increasingly agitated, pregabalin 50 mg po b.i.d. was resumed and patient was treated with propofol infusion for 24 hours. The patient became sedated and her delirium cleared rapidly over the next few days.

    Case 2: A 26 y.o. Caucasian woman with a history of opiate abuse and chronic back pain from multiple corrective surgeries for scoliosis was admitted for mild confusion and salicylate poisoning (peak level 59.9 mg/dL) after taking increasing amounts of BC powder after a fall. Urine drug screen was negative for opiates or benzodiazepines. Chronic pregabalin treatment (100 mg bid) was verified by the patient's pharmacy. When on the next day the patient's delirium worsened, pregabalin withdrawal delirium was suspected. This was treated with a modified phenobarbital protocol (total dose 1540 mg) with rapid resolution of the delirium permitting the patient to be discharged hospital day 4.

    Conclusions: Pregabalin's oral absorption is rapid (Tmax 1 hour vs. 3-4 hours for gabapentin), extensive, and proportional to the administered dose. Pregabalin's pharmacological and pharmacokinetic properties suggest that it is able to be abused, can cause tolerance, and may lead to significant withdrawal syndromes including withdrawal delirium.

    References:

    1. Grosshans M, Mutschler J, Hermann D, et al. Pregabalin abuse, dependence, and withdrawal: A case report, Am J Psychiatry 2010;167:869-70

    2. Oaklander AL, Buchbinder BR. Pregabalin-withdrawal encephalopathy and splenial edema: A link to high-altitude illness? Ann Neurol 2005;58:309-312

    Objectives:

    1. Describe the evidence suggesting pregabalin may lead to tolerance.
    2. Describe the evidence supporting pregabalin withdrawal can cause delirium.
    3. Describe treatment options for pregabalin withdrawal delirium.

    Relevance:
    Pregabalin prescriptions and usage for neuropathic pain have dramatically escalated since its introduction, yet its pharmacological properties that can cause tolerance, dependence, and withdrawal are not widely appreciated.

     
  33. [T] Malignant Catatonia in a Patient with New Diagnosis of Glucose 6-PhosphateDehydrogenase Deficiency
    Presenting Author:  Alric Hawkins

    Background: Glucose 6-PhosphateDehydrogenase Deficiency (G6PD) is an X-linked inherited disorder with clinical manifestations primarily related to sequalae of hemolytic anemia. Previous studies have reported a linkage between this inherited illness and psychiatric diagnoses including both mood and psychotic illness with catatonia (Bocchetta). In spite of this, there have been few recent studies that have examined this linkage between mental illness and the disorder. So, we currently report on a case of a patient who presented with mania and malignant catatonia with a review of the available literature of patients with co-occurring mental illness in the context of the disorder.

    Case: The patient is a 19 year old African-American male, who initially presented to an outside hospital with complaints of altered mental status and fever at home in the context of cannabis use. Extensive work-up was undertaken and he was found to have G6PD and given a preliminary diagnosis of a seizure disorder after he had a positive response to a benzodiazepine and was started on levetiracetam. He was discharged to home for one day before presenting to the Vanderbilt University Medical Center Emergency Department where psychiatry was consulted to assist with further evaluation after his condition worsened at home. He was found to manifest multiple symptoms consistent with malignant catatonia including tachycardia and fever. He was started on lorazepam with only partial response and was then transitioned to electroconvulsive therapy (ECT). He ultimately received 4 bilateral ECT treatments and was discharged to home on a stable dose of lorazepam at 2 mg given three times daily with no recurrence of symptoms since that time.

    Conclusions: Patients with G6PD deficiency appear to be at risk of developing related psychiatric sequalae, and should be screened and treated appropriately to minimize adverse outcomes related to their mental illness.

    Reference:

    1. Bocchetta, Alberto. Psychotic Mania in Glucose-6-phosphate-dehydrogenase-deficient subjects. Annals of General Hospital Psychiatry. 2003; 2:6.

    Objectives:

    1. Review a case of a patient presenting with malignant catatonia in the context of a new diagnosis of glucose-6-phosphate dehydrogenase deficiency.
    2. Review the available literature related to co-morbid psychiatric illness in patients with glucose-6-phosphate dehydrogenase deficiency.
    3. Review the treatment outcome of a new onset mental illness in a patient with glucose-6-phosphate dehydrogenase deficiency.

    Relevance:
    The relevance is that it will review a case of a patient seen in consultation for a new onset psychiatric illness with new diagnosis of an inherited medical illness.

     
  34. Spontaneous Intracranial Hypotension in Patient with Ataxia and Cognitive Decline
    Presenting Author:  Debra Kangisser
    Co-Authors:  Jennifer Ferreira, Rebecca Kuenzler, Ather Taqui, Margo Funk

    Purpose: To understand of the cause of spontaneous intracranial hypotension, its variable clinical presentation, and approach to diagnosis and treatment. It is suspected that SIH is a result of an intrinsic weakness of the spinal membrane or an abnormality of the brain or spinal structures that leads to a CSF leak and the symptoms of SIH are often be misdiagnosed. Intracranial hypotension generally is considered to be a benign condition, and most cases resolve with conservative management. However, some atypical and disabling presentations have been presented with neurocognitive deficits, and even death.

    Methods: Examination of Spontaneous Intracranial Hypotension (SIH) as it relates to a case presentation of patient who presents with headache, ataxia and cognitive decline. Case will review the pathologic features related to Intracranial Hypotension (ICH) as probable cause for symptoms. When CSF volume is depleted and downward displacement of the brain causes traction on these supporting structures. Descent of the brain is exaggerated in the upright posture, which explains the orthostatic nature of symptoms in ICH. This sagging brain can lead to stupor related to diencephalic compression and ataxia to compression of posterior fossa elements. Additional theory looks at dilation of intracranial vascular structures as the pathophysiological mechanism causing symptoms in patients with ICH. Such dilation might also cause diapedesis of cells and protein into the subarachnoid space, explaining certain CSF changes.

    Results: Diagnosing and treating SIH is critical while always considering differential throughout the patients evaluation. In this particular case study Neuroimaging and CSF studies were used to help make the diagnosis. Neuroimaging can be used to help diagnose ICH, including MRI, radioisotope cisternography, CT and CT myelography. Some findings on MRI are diffuse thickening of the pachymeninges with enhancement, engorgement of venous sinuses, subdural fluid collections, enlargement of the pituitary gland, and downward displacement of the brain. Treatment usually consists of bed rest, fluids and caffeine as well as intravenous or oral hydration, increased salt intake, and steroid therapy. When conservative treatment fails an epidural blood patches are generally considered to be a safe and effective treatment. Epidural infusion of saline may also yield immediate relief for patients if other methods fail. Surgical correction may be required if a dural tear or other meningeal defect has been demonstrated. Treatment for this particular case included IV fluids and blood patch with partial resolution of symptoms.

    Conclusion: Spontaneous intracranial hypotension can resolve spontaneously or with conservative treatment. However, the duration of symptoms among patients who seek medical care can ranged from weeks, months or years and lead to a considerably compromised quality of life. Delay in diagnosis can lead to ongoing disability and follow up for resolution of symptoms is imperative.

    Objectives:

    1. To be able to understand and define spontaneous intracranial hypotension and give examples of its variable clinical presentation.
    2. Explain the theory behind the anatomical and pathophysiological mechanisms to intracranial hypotension symptoms.
    3. Discuss neuro-imaging and testing used in the diagnosis of SIH and treatment options.

    Relevance:
    Neurocognitive and motor related disorders with delayed diagnosis can compromise quality of life. CL psychiatry partner in the diagnosis of this unique case of encephalopathy which offers pertinent teaching points.

     
  35. TBI, Chronic Pain, PTSD, and Buprenorphine
    Presenting Author:  Adelakola Alao
    Co-Author:  Jamie Vizcarra

    Background: Chronic pain is a serious complication of TBI reported by a majority of these patients regardless of severity of the injury. Treatment of chronic pain can be challenging as patients with TBI may be on highly sedating medications like benzodiazepines and anticonvulsants for impulse control. Use of opioid analgesics may increase the risk of respiratory depression. Buprenorphine is a partial mu (μ) receptor agonist which plateaus at a higher dose where it begins to behaves as an antagonist. This property limits its dose-dependent respiratory depression. Buprenorphine thus has the advantage of effective analgesia with minimal sedation and may be useful for treating chronic pain among TBI patients already taking benzodiazepines.

    Case History: A 27-year-old Iraq War veteran with no previous psychiatric history sustained severe traumatic brain injury (TBI) following a blast from an improvised explosive device. He developed severe PTSD controlled by combination therapy using benzodiazepines and venlafaxine. The patient experienced intractable headache and shoulder pain which were disabling and unresponsive to non-steroidal anti-inflammatory agents, tramadol, gabapentin, or NMDA-receptor antagonists. Opioid analgesics were not preferred for pain management given the risk of respiratory depression. He was treated with sublingual buprenorphine/naloxone and dose was maintained at 8/2mg three times per day. This resulted in significant improvement and patient was able to function relatively pain free

    Conclusion: Treatment of patients with PTSD and other co-morbid conditions can be complex as there are limited therapeutic options. With the awareness of possible benefits, more studies are needed to evaluate the efficacy of buprenorphine in patients with TBI and chronic pain/pain from poly-trauma. It may also be of clinical interest to unravel the effects of mu receptor antagonsism towards PTSD symptom control.

    References:

    1. Lahz S, Bryant RA. Incidence of chronic pain following traumatic brain injury. Archives of physical medicine and rehabilitation 1996; 77(9):889-91

    2. Heel RC, Brogden RN, Speight TM, Avery GS. Buprenorphine: a review of its pharmacological properties and therapeutic efficacy. Drugs 1979; 17(2):81-110

    3. Martin WR, Eades CG, Thompson JA, Huppler RE, Gilbert PE. The effects of morphine- and nalorphine-like drugs in the nondependent and morphine-dependent chronic spinal dog. J Pharmacol Exp Ther 1976; 197(3):517-32

    4. Human Psychopharmacology. 2002 Jun:17(4):181-5

    Objectives:

    1. To investigate the effects of buprenorphine versus other opioids in the context of treating pain in patients with TBI and PTSD.
    2. To have other providers be more curious about possible benefits of mu antagonism on symptoms of PTSD.
    3. to have more discussion about the complexity of treating polytrauma patients.

    Relevance:
    To investigate the effects of buprenorphine versus other opioids in the context of treating pain in patients with TBI and PTSD.

     

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Session D:  Primary and Collaborative Care

  1. Integrating Mental and Primary Care among Chinese Americans Using Collaborative Care
    Presenting Author:  Benjamin Woo

    Purpose: Chinese Americans are at high risk for under-utilizing mental health services, and the primary care setting is an excellent context to address and reduce such health disparities [1,2,3]. Collaborative care for depression treatment is an approach to decrease stigma associated with mental illnesses and to increase access to care. Utilizing early career psychiatrists who are language proficient may further enhance integration of depression care in primary care settings. This study sought to assess the prevalence of depressive and medical disorders, as well as likelihood of accepting mental health treatments, among Chinese Americans in a Los Angeles community clinic.

    Methods: The sample for this study consisted of 292 patients who received primary care from Herald Christian Health Center (HCHC) in Los Angeles. HCHC serves low-income Chinese Americans with limited English proficiency. This predominantly immigrant population faces challenging economic and social conditions, as majority of these patients lacked health insurance, were low-income (less than 200% poverty), and linguistically isolated. Depression was determined using the Patient Health Questionnaire-9 (PHQ-9). Baseline clinical and demographic factors were obtained for analyses.

    Results: 45 (15.4%) patients screened positive for depression (PHQ-9 score ≥ 10). Comparing these patients with the patients who did not have depression found no differences in age, gender, number of medical conditions, or anxiety disorders. Patients who screened positive for depression were more likely to already be on antidepressant medications (5/45 versus 8/247; p <0.01). Among the depressed patients, 29 (64.4%) patients accepted collaborative care provided by a culturally proficient team (a registered nurse and an early career psychiatrist who are both fluent in Chinese.) Furthermore, 6 (13.3%) depressed patients accepted additional treatment on top of the collaborative care model by enrolling in therapy provided by a mental health center.

    Conclusions: This study found a prevalence of 15.4% for current depressive disorders among Chinese Americans in primary care in Los Angeles. While depressed patients were more likely to already be on antidepressant medications, overall treatment utilization rate remains low. A culturally sensitive collaborate care model may enhance acceptance of depression care among Chinese Americans in primary care settings.

    Objectives:

    1. To analyze the prevalence of Chinese Americans under-utilizing depressive mental health services.
    2. To investigate whether culturally enhanced collaborative care could improve mental health utilization rate among Chinese Americans.
    3. To create a model on how early career psychiatrists may continue to grow and thrive in their identities as psychosomaticians.

    Relevance:
    This study attempts to provide baseline characteristics on a culturally enhanced collaborative care for depression treatment in a primary care clinic for Chinese Americans utilizing an early career psychiatrist.

     
  2. The Association of Pre-Sepsis Depressive Symptoms and Incident Cognitive Impairment in Survivors of Severe Sepsis
    Presenting Author:  Dimitry Davydow
    Co-Authors:  Catherine Hough, Kenneth Langa, Theodore Iwashyna

    Background: Severe sepsis has been shown to be independently associated with substantial, persistent cognitive impairment in survivors [1]. Yet, it is unknown which patients with severe sepsis are at greatest risk of developing cognitive impairment. This study utilizes an ongoing longitudinal cohort of older Americans to test the hypothesis that pre-sepsis depressive symptoms are associated with an increased risk of incident cognitive impairment in severe sepsis survivors.

    Methods: Our study cohort is from the Health and Retirement Study (1998-2006), a longitudinal investigation of community-dwelling U.S. adults over age 50. Included in the analysis were 447 patients without cognitive impairment before sepsis who survived 540 hospitalizations for severe sepsis and completed at least one follow-up interview. Severe sepsis was identified using Medicare claims. Depressive symptoms were assessed prospectively with an 8-item version of the Center for Epidemiologic Studies Depression Scale. We used a cutoff score of 4 or higher on the 8-item CES-D to define clinically significant depressive symptoms. Cognitive function was assessed using versions of the Telephone Interview for Cognitive Status (TICS). We used logistic regression with robust standard errors to examine associations between substantial depressive symptoms at any interview before sepsis and incident cognitive impairment (either mild or moderate-to-severe cognitive impairment) at any interview after sepsis.

    Results: The prevalence of substantial depressive symptoms in patients with normal cognition before sepsis was 38% (95%Confidence Interval [CI]: 34%, 42%). At a median of 0.9 years after severe sepsis, 17% (95%CI: 14%, 20%) were cognitively impaired, of which 40% (95%CI: 30%, 50%) had mild cognitive impairment and 60% (95%CI: 50%, 70%) had moderate-to-severe cognitive impairment. In unadjusted analyses, pre-sepsis substantial depressive symptoms were associated with post-sepsis incident cognitive impairment (Odds Ratio [OR] 2.56, 95%CI: 1.53, 4.27). After adjustment for demographics (age, sex, race, education, marital/partnered status), health-risk behaviors (alcohol use and smoking), baseline medical comorbidity, clinical characteristics of the sepsis episode (organ dysfunction score, hospital length of stay, intensive care unit admission, as well as requirements for mechanical ventilation, major surgery, and dialysis), and pre-sepsis TICS scores, pre-sepsis substantial depressive symptoms remained the strongest factor associated with post-sepsis incident cognitive impairment (OR 2.58, 95%CI: 1.45, 4.59). In our secondary analyses, pre-sepsis substantial depressive symptoms were significantly associated with post-sepsis incident mild cognitive impairment (OR 3.66, 95%CI: 1.51, 8.87) and post-sepsis incident moderate-to-severe cognitive impairment (OR 2.08, 95%CI: 1.12, 3.85) in our final models.

    Conclusions: Pre-sepsis substantial depressive symptoms are independently associated with incident post-sepsis cognitive impairment. Depressed older adults may be particularly at risk for developing cognitive impairment after a serious medical illness such as severe sepsis.

    Reference:

    1. Iwashyna TJ, Ely EW, Smith DM, et al. Long-term cognitive impairment and functional disability among survivors of severe sepsis. JAMA 2010;304:1787-1794.

    Objectives:

    1. The physician learner will identify which older adults hospitalized for serious medical illnesses such as severe sepsis are at greatest risk for subsequent cognitive impairment.
    2. The physician learner will apply knowledge gained to their psychosomatic medicine practice in regards to older adults with comorbid depression and serious medical illnesses such as severe sepsis.
    3. The physician learner will analyze new evidence of the detrimental effects of depression on health outcomes following serious medical illnesses such as severe sepsis.

    Relevance:
    The effect of depression on health outcomes such as cognitive impairment following severe sepsis is of importance to psychosomatic medicine physicians who assist in the care of these patients.

     
  3. Depression Assessment in Bariatric Surgery Candidates: Diagnostic Interview versus Self-Report Inventory
    Presenting Author:  Sanjeev Sockalingam
    Co-Authors:  Stephanie Cassin, Raed Hawa, Susan Wnuk, Sarah Royal, Marlene Taube-Schiff, Allan Okrainec

    Major depressive disorder is one of the most common psychiatric disorders among obese bariatric surgery candidates, with lifetime and current rates approximating 42% to 51% and 10% to 25%, respectively. A pre-surgery diagnosis of current or lifetime depression has been associated with less weight loss. Furthermore, pre-surgery depression predicts post-surgery depression at 24-36 months, and post-surgery depression has been shown to attenuate weight loss and psychosocial outcomes. Given the potential implications of depression on bariatric surgery outcomes, pre-surgery psychiatric assessment is recommended to assess suitability for bariatric surgery. The purpose of this study was to compare rates of depression in bariatric surgery candidates according to a clinician administered structured interview and a self-report depression screening inventory. Bariatric surgery candidates (N = 244) completed the MINI International Neuropsychiatric Interview (MINI) and Patient Health Questionnaire-9 (PHQ-9) as part of their pre-surgery psychiatric assessment. According to the MINI, rates of current and lifetime depression were 1.6% and 35.5%, respectively. In contrast, according to the PHQ-9, 34.0% of patients endorsed symptoms consistent with a current "diagnosis" of depression, and 52.2% of patients exceeded the cutoff for moderate depression (PHQ-9 score > 10). The rates of current depression on the MINI were much lower than has been previously reported, whereas the lifetime rates on the MINI and current rates on the PHQ-9 were in line with previous findings. The results suggest that bariatric surgery candidates may be reluctant to disclose current depressive symptoms during a suitability interview, and more forthcoming on a dimensional self-report inventory.

    Objectives:

    1. Describe the implications of depression on bariatric surgery outcome and the importance of conducting a pre-surgical psychiatric assessment.
    2. Discuss the rates of depression in bariatric surgery candidates according to a clinician administered diagnostic interview and a self-report depression inventory.
    3. Describe the arguments in favor of including a self-report depression inventory in the pre-surgical psychiatric assessment of bariatric surgery candidates.

    Relevance:
    This paper is directly related to the mission of APM because it focuses on the assessment of individuals with comorbid psychiatric and general medical conditions (i.e., depression and morbid obesity).

     
  4. Preventive Counseling for Chronic Disease: Missed Opportunities in a Community Mental Health Center
    Presenting Author:  Lydia Chwastiak
    Co-Authors:  Maria-Cristina Cruza-Guet, Amy Carroll-Scott, Michael Sernyak, Jeannette Ickovics

    Background: The tremendous burden of cardiovascular risk among persons with serious mental illness underscores a critical need for prevention. Cochrane reviews support the efficacy of primary care clinician counseling to increase smoking cessation, physical activity and the consumption of fruits and vegetables. Active involvement by community mental health clinicians might represent a powerful population-based strategy to prevent diabetes and cardiovascular disease among persons with serious mental illness. The extent to which mental health providers at community mental health centers provide specific counseling about CVD risk factors has not previously been reported.

    Methods: This cross-sectional descriptive study examines the rates of specific counseling about cardiovascular risk factors (smoking, diet, and exercise) by mental health providers at an urban community mental health center (n=154). In April 2011, staff members were sent a survey through Survey Monkey, including questions about demographics, health behaviors and health status, and questions about their clinical training, experience and practice. Bivariate and stepwise linear regression analyses were conducted to identify those clinician characteristics associated with counseling more than 50% of clients about diet, exercise and smoking.

    Results: 65% of staff members responded to the survey, for a sample of 154 clinical providers. The sample was 68.5% female. The mean age of the providers was 46.1 years; 56.4% had been out of training for more than 10 years. Among the respondents, 24.7% were social workers, 20.1% were psychiatrists, and 16.7% were nurses. The survey included three separate questions about the provision of specific counseling about smoking cessation, diet, and exercise. For the primary outcome, we identified those clinicians who reported counseling more than 50% of their clients about each of these health risks. 36.9% of participants counseled clients about smoking cessation, 54.5% provided counseling about nutrition and a healthy diet, and 60.1% provided counseling about recommended levels of physical activity; 29.1% counseled more than 50% of their clients about all three risk factors. Bivariate analyses were used to indentify clinician characteristics associated with counseling about CVD risk. In a hierarchical linear regression analyses of these characteristics, mental health providers who counseled clients about all three CVD risk factors were less likely to be obese, and were more likely to be female, have higher self-rated health, and were more likely to have received formal training about how to counsel patients about CVD risk.

    Discussion: This is the first study to examine the routine clinical practice of community mental health clinicians in addressing CVD risk at an urban community mental health center. These findings suggest that both training for mental health clinicians about CVD risk and also support for improving clinician health status may improve the preventive care provided at community mental health centers.

    Objectives:

    1. Understand whether monitoring of cardiovascular risk is part of routine care at community mental health centers.
    2. Describe the characteristics of mental health clinicians who counsel clients about cardiovascular risk factors.
    3. Consider options in one's own practice setting to increase routine monitoring of cardiovascular risk.

    Relevance:
    The cardiovascular health disparities among community mental health center patients represents a crisis for psychiatrists who work with patients with serious mental illness.

     
  5. Integrative Medicine Approaches for Anxiety and Mood Disorders for Women Who Are Pregnant or Nursing
    Presenting Author:  Kelly Brogan
    Co-Author:  Philip Muskin

    Anxiety and mood symptoms, from mild through diagnosable disorders, are common in women who are pregnant and nursing. There is inadequate data to support any pharmacological treatment as offering no risk to fetus/infant. Nevertheless, women who are suffering these symptoms require treatment. Integrative Medicine approaches may offer alternatives and complements for women faced with these treatment decisions. We will review the data and use of POLYUNSATURATED FATTY ACIDS, S-ADENOSYLMETHIONINE (SAMe), LIGHT BOX THERAPY, CRANIAL ELECTRICAL STIMULATION, AS WELL NUTRITIONAL CONSIDERATIONS AND TARGETED INTERVENTIONS SUCH AS VITAMIN D AND FOLATE/L-METHYLFOLATE. One technique that poses no risk to the fetus or infant, but can provide significant relief of anxiety symptoms, IS coherent breathing. The impact of breath technique will be reviewed along with a hypothesis of the mechanism of action of breath on anxiety. The participants will learn a technique that can be used with patients immediately after the workshop.

    Objectives:

    1. Attendants will gain familiarity with lifestyle considerations in the reproductive age patient
    2. Attendants will learn techniques related to evidence-based breathing practice
    3. Attendants will gain familiarity with evidence-based alternative treatment options in the pregnant patient with mood/anxiety symptoms

    Relevance:
    Pregnant women and/or women who are nursing often require treatment for anxiety and depression. Such patients frequently consult with practitioners of psychosomatic medicine who need to know alternative treatment techniques.

     
  6. Strengthening Alliances with Families Team (SAFTeam), a Program to Support Staff in Dealing with Difficult Families in a Large Pediatric Academic Center
    Presenting Author:  Harrison Levine
    Co-Authors:  Jenny Reese, Cindy Buchanan

    As a large pediatric academic medical center we frequently encounter patients and families who are challenging to care for. A sick child can be one of the most stressful events that parents encounter, and often this stress is taken out on staff caring for the child. This can be in the form of verbal abuse, threat of physical violence, or obstruction to care. Also, some parents have underlying untreated or partially treated mental health conditions that can make interactions challenging. We know that repeated exposure to secondary trauma, including threat of or experience of violence or abuse by patients or their families can lead to burnout and compassion fatigue for staff. Therefore, a program was put into place at our organization to support staff in dealing with difficult patients and families. Our hypothesis is by designing and implementing a team to support staff in dealing with difficult families, the program will be utilized and interventions will be made. The mission of the SAFTeam is to provide education and support for staff in dealing with difficult patients and families, while promoting high quality family centered care. The SAFTeam is a multidisciplinary group whose purpose is to provide evaluation and support during situations where relationships between the healthcare providers and patients and families are challenging.

    Any staff member can request a SAFTeam consult. At the time of the consult, a member of the SAFTeam contacts the requesting provider and seeks more information about the case. Preliminary recommendations are given and interventions suggested. If it is deemed beneficial for the SAFTeam to convene, this is done typically within 24 hours (or next business day) of the consult request. From program inception, March 2009, until June of 2011, there were 48 SAFTeam consultations requested.

    Conclusions: The design and implementation of a program to provide education, support and intervention for staff in dealing with difficult families is well utilized across a variety of patient types and diagnoses. Further investigation is underway to better describe outcomes associated with this program, including impact on patient length of stay and readmission, interventions implemented, and staff satisfaction with the program.

    Objectives:

    1. Understand the purpose of the SAFTeam and how it relates to hospital staff.
    2. Review highlights of theoretical underpinnings for SAFTeam
    3. Review the practical aspects of how the SAFTeam is called, how it functions.

    Relevance:
    The SAFTeam is a multidisciplinary group whose purpose is to provide evaluation and support during situations where relationships between the healthcare providers and patients and families are challenging.

     
  7. Depression Collaborative Care: Using Education to Improve Patient Outcomes
    Presenting Author:  Travis Fisher
    Co-Author:  Lorin M. Scher

    The utility and effectiveness of a collaborative care model to treat depression in the primary care setting has been established in multiple studies. Barriers of cost and personnel availability often impede implementation of such programs if grants or research funding are unavailable. Novel approaches to this problem are needed for healthcare systems to adequately address the chronic disease burden that depression represents.

    Our hypothesis is that telephone-based education to and monitoring of patients via a depression care coordinator (DCC), and primary care physician education via the psychiatrist, will be sufficient to improve depression outcomes without the components of traditional psychotherapy or direct patient contact by the psychiatrist.

    A year-long pilot project was developed in collaboration with the Chronic Disease Management team at the University of California Davis Health System, funded by a pay-for-performance initiative. Two primary care clinics comprising a 20 physician cohort were selected as the pilot locations. 176 patients were identified with a major depressive disorder diagnosis charted in the last 12 months. Active patient enrollment occurred for 7 months and consisted of both direct physician referrals as well as mailers send to the identified patients. Patients completed a PHQ-9 at enrollment and at points throughout the study. A licensed LCSW provided education and support telephonically, as well as written educational materials via mail. The LCSW also assessed improvement with the CGI scale.

    Physician education was provided by two psychiatrists at 4 one-hour “lunch and learn” sessions. Topics included depression treatments, medical co-morbidities, and differential diagnosis. Physician attendance was tracked and their attitudes about mental health assessed at study initiation. Both patient and provider satisfaction was surveyed after the project ended.

    46% of contacted patients were enrolled; 47% declined, and 7% were excluded after further evaluation by the LCSW. Only 36 patients completed the study, limiting its statistical power. There was a statistically significant improvement from pre-treatment PHQ-9 (-4.21, p= 0.0038) and a trend for improvement in CGI (-0.116, p= .15).

    This study suggests that clinical outcomes can be improved by better educating patients and primary care physicians about depression. Using this model, our mental health staff was able to influence outcomes for larger number of patients than would have otherwise been possible. Patients and physicians expressed a favorable view of the program. There were limitations to this study. Direct mailing proved disproportionately ineffective in recruiting patients compared to an EMR referral. An unexpectedly shortened enrollment period led to a smaller patient population than intended, limiting its statistical power. We were unable to assess subgroups, or relationship between variable with statistical significance due to this. We believe that on the whole, this project demonstrates another viable model of collaborative depression care.

    Objectives:

    1. The physician learner will be able to investigate novel designs for collaboration between mental health and primary care to improve patient outcomes.
    2. The physician learner can apply knowledge obtained from this program to educate primary care colleagues about depression collaberative care.
    3. The physician learner can investigate the possibility of creating a telephone-based patient education program to improve depression outcomes at their home institution.

    Relevance:
    Psychosomatic medicine practitioners are uniquely equipped to collaborate with primary care in consultative models, by their training at consulting on patients with medical comorbidity and liasoning with medical colleagues.

     
  8. Clinician Documentation of Discussions with OEF/OIF Veterans Following Positive Brief Assessments for Suicidal Ideation
    Presenting Author:  Steven Dobscha
    Co-Authors:  Kathryn Corson, Lauren Denneson, Kovas Anne, Matthew Bair, Drew Helmer

    Background: Structured brief assessments for suicidal ideation (BASI) are administered in Department of Veterans Affairs Medical Centers (VAMCs) following positive depression and posttraumatic stress disorder screens. The most commonly used BASI tools have five or fewer questions, but specific assessment tools and scoring algorithms vary across VAMCs. A positive BASI should trigger a more thorough assessment of suicide risk, to be conducted by a clinician within one day of BASI. However, little is known about how these tools are being used or about the impact of their use on subsequent care.

    Objective: Describe clinician documentation of discussions related to suicide risk with Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) veterans following positive BASIs.

    Methods: We linked Department of Defense data to VA Decision Support System (DSS) data to identify OEF/OIF veterans screened for depression (using the Patient Health Questionnaire [PHQ-2 or PHQ-9]) between April 2008 and September 2009 in primary care settings of three large, geographically-distinct VAMCs. Medical record review was used to identify veterans who had positive PHQ screens and who were administered BASIs, as well as the content of all clinician-veteran discussions related to suicide risk occurring within a day of BASIs.

    Results: Of 1,017 veterans administered BASIs, 230 (23%) had positive BASIs. Clinicians documented acknowledgement of positive assessments for 214 (93%) of cases. Of these 214 patients, 61% denied current thoughts of suicide. Clinicians documented active SI having occurred within the prior month for 19%, and passive SI for 53%. For a majority of patients (>65%) clinicians documented exploration for risk factors including hopelessness, past suicide attempts, psychiatric (including substance use) disorders, and pain, as well as relationship and occupational problems. A medication initiation or change was noted for 58% of patients, and mental health follow-up was arranged for 93%. Clinicians documented inquiries about firearms for only 23% of the patients, and recommendations to restrict access to firearms for 6%. Documented recommendations to increase or modify social support occurred for only 9%.

    Conclusions: Many veterans who have positive BASIs deny current suicidal ideation when assessed by a clinician. VA clinicians almost always acknowledge BASI results in their notes, and frequently document discussions of risk factors for suicide. However, documented exploration for access to firearms, as well as recommendations to limit access to firearms, are rare. Additional education or systems changes may be indicated to augment clinicians' ability and comfort in conducting and documenting suicide risk assessments and taking appropriate clinical actions.

    Objectives:

    1. Describe risk factors associated with suicide and suicidal ideation.
    2. Describe methodologies used to collect information related to depression screening and brief suicidal ideation assessment in the VA.
    3. Apply knowledge of risk factors and what clinicians do to address suicide risk after brief structured assessments to clinical practice.

    Relevance:
    Suicide is devastating for patients, families and clinicians. Clinicians may have opportunities to intervene when patients present with suicidal ideation.

     
  9. Suicidal Ideation in the Postpartum Period
    Presenting Author:  Kimberly Klipstein
    Co-Authors:  Madeleine Fersh, Susan Bodnar-Deren, Elizabeth Howell

    Purpose: Despite increased efforts by ACOG and the APA over the last several years to raise awareness of postpartum depression and its consequences, depression is still responsible for significant morbidity and mortality in the postpartum period. The prevalence of suicide, a dire outcome of depression, however, has been less well studied in this population. The goal of the current study was to assess the prevalence of suicidal ideation, as well as to identify risk factors associated with this phenomenon, in a large cohort of women enrolled in a randomized controlled trial of a behavioral intervention to reduce postpartum depression at a large urban, academic medical center.

    Methods: We analyzed suicide data within the MADE-IT studies (Mothers Avoiding Depression through Empowerment Intervention) consisting of two trials, one comprised of black and Hispanic women, and the other comprised of Caucasian and women of other races. These were large randomized controlled trials at the Mount Sinai Medical Center in New York that sought to evaluate the effectiveness of a 2-step behavioral educational program compared with enhanced usual care to reduce postpartum depressive symptoms. Women were screened for depression and suicide using the EPDS and the PHQ-9 at the time of delivery and at 3 weeks, 3 months and 6 months postpartum.

    Results: Out of a total of 1080 participants, 222 screened positive at baseline for depression (EPDS > 10 and/or PHQ-9>10). Thirty-one screened positive for SI (question #10 on EPDS and/or #9 on PHQ9) and of those, 2 were found to have suicidal intent on psychiatric interview (6%). Factors associated with positive screens for SI up to 6 months postpartum included positive depression screening (p <.0001), past history of depression (p=.0059), US-born (p = .0096), pregnancy complications ( p = .002), poor social supports (p = .033), low self efficacy (p = .019) and GAD7 score >10 (p < .0001). Women of Asian or Pacific Island descent had significantly higher rates of suicidal ideation compared with Caucasian, African American or Latina women (p = .0013). Age, parity, marital status, socioeconomic status (SES), and level of education were not significant.

    Conclusions: In accordance with the existing literature we found that positive depression screens, history of depression, and pregnancy complications were highly associated with postpartum suicidality. In contrast, age, race, parity, marital status and SES were not found to be related. Variables significantly associated in our study not previously studied in the literature include being US-born, being of Asian or Pacific Island decent and screening positive for high anxiety on the GAD7. Medical centers should expand screening methods to detect depression, anxiety and suicidality in the postpartum period and ensure the availability of appropriate outpatient referrals for women with positive screens.

    Objectives:

    1. To assess the prevalence of suicidal ideation and intent in women with postpartum depression and thus gain appreciation for the morbidity and mortality of this disease.
    2. To be able to identify potential risk factors for suicidal ideation in postpartum women.
    3. To consider implementing screening tools to better identify women at risk for suicidal ideation and to ensure appropriate mental health referrals are available.

    Relevance:
    Given the paucity of literature on suicidality in postpartum women, our goals are to assess prevalence and risk factors for suicidal ideation and to encourage the use of screening tools.

     
  10. Barriers and Facilitators to Addressing Perinatal Depression in Obstetric Settings
    Presenting Author:  Nancy Byatt
    Co-Authors:  Biebel Kate, Liz Friedman, Gifty Debourdes-Jackson, Jeroan Allison, Douglas Ziedonis

    Background: Perinatal depression is common and can cause suffering for mother, fetus/child and family [1,2]. The perinatal period is an ideal time to detect and treat depression due to regular contact between mothers and health professionals. Despite the opportune time and setting, depression is under-diagnosed and under-treated in the obstetric setting [3]. Caring and committed providers are frustrated and confused [4], and mothers do not feel seen, heard or understood by their providers [5].

    Objectives: (1) Identify postpartum women's perspective on how perinatal depression is addressed in obstetric settings; (2) Identify strategies for improvement of the delivery of depression care in OB/Gyn settings; and, (3) Inform the development of interventions aimed to improve the delivery of perinatal depression care in obstetric settings.

    Methods: Four, two hour focus groups were conducted women 3 months - 3 years postpartum (n=27), who identified experiencing symptoms of perinatal depression. Focus groups were transcribed and resulting data analyzed using a grounded theory approach.

    Results: Participants reported individual, provider and systems-level barriers and facilitators to seeking perinatal depression treatment. Women reported feeling stigmatized and afraid of losing parental rights. Women also described negative experiences with medical providers, including feeling dismissed by providers and therefore uncomfortable discussing mental health concerns. A lack of provider knowledge and skill set to address depression was noted by participants. Participants recommended an integrated approach, including psychoeducation, peer-support, and provider education and training in order to improve perinatal depression care in the obstetric setting.

    Conclusion: Barriers occurring at the individual, provider and systems-level hinder women from addressing issues of perinatal depression and receiving appropriate care. These data suggest strategies that integrate depression and obstetric care in order to support OB/Gyns providers and staff in their role as front line providers to perinatal women. Future efforts could focus on the development of multidisciplinary treatment strategies that utilize patient psychoeducation and provider training and education to overcome barriers and engage women in depression treatment.

    References:

    1. Paulson JF, Keefe HA, Leiferman JA. Early parental depression and child language development. J Child Psychol Psychiatry 2009;50:254-62.

    2. Deave T, Heron J, Evans J, Emond A. The impact of maternal depression in pregnancy on early child development. BJOG 2008;115:1043-51.

    3. Birndorf CA, Madden A, Portera L, Leon AC. Psychiatric symptoms, functional impairment, and receptivity toward mental health treatment among obstetrical patients. Int J Psychiatry Med 2001;31:355-65.

    4. Byatt N BK, Lundquist R, Moore Simas T, Debourdes-Jackson G, Allison J, Ziedonis D. Overcoming the Barriers to Perinatal Mental Health Treatment: Perspective of Ob/Gyn Providers In; 2012 (submitted).

    5. Dennis CL, Chung-Lee L. Postpartum depression help-seeking barriers and maternal treatment preferences: a qualitative systematic review. Birth 2006;33:323-31.

    Objectives:

    1. Identify postpartum women’s perspective on how perinatal depression is addressed in obstetric settings.
    2. Identify strategies for improvement of the delivery of depression care in OB/Gyn settings.
    3. Utilize findings to inform the development of interventions aimed to improve the delivery of perinatal depression care in obstetric settings.

    Relevance:
    Perinatal depression is common and can cause suffering for mother, fetus/child and family. Despite the opportune time and setting, depression is under-diagnosed and under-treated in the obstetric setting.

     
  11. [T] Tackling the Taboo: Overcoming Barriers to Talking about Suicide in the Primary Care Setting
    Presenting Author:  Katy LaLone
    Co-Authors:  Sarah Zakaria, Karen Abram, Joan Anzia

    Purpose: It has been estimated that as many as 75% of those who commit suicide have been seen by a primary physician in the preceding month.1 Consequently, the primary care setting presents an unique venue for physicians to detect patients at risk for suicide and to begin early interventions.1 Limited data exists as to what barriers prevent physicians from discussing suicide with their patients or how to better improve their education.

    This purpose of this pilot study is to 1) determine barriers to conducting suicide assessments of outpatients by obstetrics and gynecology, medicine, and surgery residents; and 2) to determine if a one hour interactive lecture targeting five barriers to talking about suicide in a primary care setting can reduce residents’ perceived barriers. Findings will help to improve teaching methods to reduce specialty-specific barriers to talking about suicide in primary care settings.

    Methods: All residents from the obstetrics and gynecology, medicine, and surgery residencies at Northwestern University in all post graduate years (OBGYN n=36; Medicine n=40; Surgery n= 35) will be invited to attend a separate one hour interactive lecture on overcoming barriers to talking about suicide in a primary care setting. Before and after each lecture, residents will be asked to complete a brief survey that assesses prior experience with suicidal persons and attitudes toward conducting suicide assessments in the outpatient setting. They will also be asked to identify basic sociodemographic characteristics. The lecture targets five barriers with video demonstrations of patient interviews showing strategies to overcoming barriers.

    Results: We will first describe pre-lecture scores on each barrier to conducting suicide assessments for the total sample. We will examine whether scores differ across specialties or by sociodemographic characteristics. Second, with each participant acting as their own control, we will examine whether individual change scores are significant and whether they differ across specialties or by sociodemographic characteristics.

    Conclusions: We will discuss the extent of barriers to suicide assessments pre and post lecure and which groups are most at risk. We will then discuss effectiveness of this lecture on reducing various barriers. Discussion with focus on the utility of implementing such and intervention into the curriculum of other non-psychiatry residency programs with the hope of decreasing barriers to assessing suicide and thereby enabling residents to better identify and intervene on behalf of a suicidal patient in a primary care setting. Any trends identified by the demographic data which was collected may also help provide some insight into how to develop better curriculum for teaching non-psychiatric residents about suicide risk assessments.

    Reference:

    1. Feldman, M., et al. Let’s Not Talk About It: Suicide Inquiry in Primary Care. Annals of Family Med. 2007: 5(5): 412-417.

    Objectives:

    1. Recognize some of the unique barriers that prevent non-psychiatrist residents from performing an effective suicide risk assessment in an outpatient setting.
    2. Analyze the effectiveness that a one hour lecture given to obstetrics and gynecology, medicine, and surgery has at reducing residents' perceived barriers to performing an effective suicide assessment.
    3. Consider how individual and specialty-specific demographic trends from the residents surveyed can help to develop better curriculum for teaching non-psychiatric residents about suicide risk assessments.

    Relevance:
    Overcoming barriers to talking about suicide can help to primary care physicians to better detect patients at risk for suicide and begin early interventions.

     
  12. Psychiatry’s Contribution to Berwick’s Triple Aim in Accountable Care Organizations (ACOs)
    Presenting Author:  Roger Kathol
    Co-Authors:  Elisabeth Kunkel, Alexis Giese, Irvin "Sam" Muszynski

    Accountable care organizations (ACOs) are networks of providers being developed by a variety of health care stakeholders as a part of health care reform legislation (Affordable Care Act—ACA). Most psychiatrists are unfamiliar with the organizational components of ACOs and do not know how they could contribute to their local and regional success through the integration of psychiatric services with medical care. Dr. Roger Kathol will open the symposia with a discussion of core features of ACOs and their variability nationally but will emphasize the role that psychiatrists could play in them to improve the patient experience, augment health outcomes, and lower total health care costs (triple aim). Dr. Elisabeth Kunkel will describe ongoing implementation of value-added clinical programs in her setting that contribute to the triple aim and ultimately ACO development in the Jefferson medical system. Dr. Alexis Geise will discuss implementation of ACOs in Colorado from a health plan’s perspective and the potential for significant psychiatric contributions to health and cost outcomes if coordinated medical and mental health clinical delivery can be coupled with integrated payment procedures. Mr. Sam Muszynski, Director of Healthcare System and Financing at the American Psychiatric Association, will provide vision for psychiatry’s role in ACOs from a national perspective and direct discussion.

    Objectives:

    1. Represent the interests of psychiatry while participating in the development of an ACO.
    2. Create value-added psychiatric programs for ACOs that foster Berwick's triple aim.
    3. Foster psychiatric payment practices within an ACO that allow building sustainable mental health and substance use disorder services.

    Relevance:
    Psychiatrists must become familiar with what ACOs are and how they can contribute to improving health at lower cost as ACOs are developed as a part of health reform.

     
  13. Using Capnography to Assess Ventilation Patterns in Anxious Patients
    Presenting Author:  Lisa J. Rosenthal
    Co-Authors:  Robert Brett Lloyd, Matthew Maas

    Purpose: Psychological distress and anxiety are common in mechanically ventilated patients. Distinguishing anxiety from respiratory insufficiency is challenging, but is a common question for the consultation psychiatrist. We present a case of a patient with both anxiety and respiratory insufficiency during mechanical ventilation and discuss the use of capnography to guide assessment.

    Methods: Case report of a 66 year old man with severe anxiety and respiratory failure due to Guillain-Barre syndrome. Multiple episodes of distress and irregular ventilation patterns, as well as apnea alarms, occurred during his prolonged period of mechanical ventilation. Some episodes occurred during ventilator weaning after reduction of inspiratory pressures, and others on stable ventilator settings. Capnography was used to help differentiate respiratory insufficiency from anxiety based on changes in end tidal CO2 (ETCO2). Hyperventilation from anxiety decreases ETCO2 transiently, but is often followed by a compensatory period of slowed breathing, or benign apnea.

    Results: Episodes of tachypnea and distress that occurred during ventilator weaning were associated with reduced average tidal volumes, and eventually increased ETCO2 from baseline, indicating acute respiratory acidosis from his respiratory insufficiency. For example, one episode of distress occurred when pressure support was decreased from 12 to 8 cmH20. Tidal volumes decreased from 564 to 385 ml and ETCO2 increased from 40 to 52 mmHg. The distress was attributed to respiratory insufficiency and subjectively improved with an increase in pressure support to 10 cmH2O. Episodes of rapid breathing and distress that occurred without apparent provocation were associated with diminished ETCO2 from baseline indicating hyperventilation. For example, with baseline ETCO2 45 mmHg, an episode of anxiety occurred with a decrease in ETCO2 to 37 mmHg. The distress was attributed to anxiety and improved with benzodiazepine administration. During. After some anxious periods, resolution was accompanied by episodes of hypopnea or brief intervals of benign apnea while ETCO2 increased to baseline, but not beyond, indicating compensatory apnea. Dangerous aberrant breathing problems, associated with increased ETCO2 during apnea alarms, were not observed.

    Conclusions: Anxiety often coincides with rapid, aberrant breathing. Determining whether psychological distress is the provocation or consequence by bedside evaluation is challenging, and frequent arterial blood gas (ABG) sampling is infeasible. Capnography can be correlated with an initial ABG sample and then used for continuous monitoring to objectively evaluate breathing patterns. Anxiety causes true hyperventilation, and capnography shows decreased ETCO2 during episodes, often followed by normalization to baseline by a period of hypopnea or brief apnea.

    Objectives:

    1. To improve assessment of anxiety in mechanically ventilated patients.
    2. To apply the use of capnography to guide assessment of aberrant breathing patterns in mechanically ventilated patients.
    3. To analyze results of arterial blood gas sampling and capnography to understand breathing patterns in mechanically ventilated patients.

    Relevance:
    Evaluating anxiety in the context of mechanical ventilation is a common consultation question for the psychiatrist. This poster will improve understanding and evaluation of aberrant breathing patterns in these patients.

     
  14. WITHDRAWN  
  15. [T] Prevalence of Atypical Antipsychotics Use Among Women of Childbearing Age
    Presenting Author:  Ulas M. Camsari
    Co-Author:  Adele C. Viguera

    Objective: Reproductive safety data of the atypical antipsychotics are limited. Despite this, atypical antipsychotics are widely prescribed for a variety of indications. The objective of this study was to examine the prevalence of atypical antipsychotic use among women of childbearing age compared to men.

    Methods: We identified cases through the Cleveland Clinic’s Knowledge Program (KP) which is a comprehensive initiative across the Neurological Institute to collect patient reported outcomes as part of the EPIC electronic health record (EHR). We included all outpatient subjects seen in the outpatient Psychiatry and Psychology Department at from January 1, 2008 to December 31, 2010. The process was approved by our Institutional Review Board.

    Results: Of the 4345 outpatient subjects seen in either Psychiatry or Psychology with data from the KP, 1073 had received at least one atypical antipsychotic during the study period, resulting in a study sample comprised of 613 females and 460 males. In this group, 76.3% were Caucasian (N = 814), 18.3% were African-American (N = 195), 1.0% were Hispanic (N = 11), 1.0% were from other racial-ethnic minority groups (N = 11), and 3.4% of the sample were missing racial data. For marital status, 65.0% were single (N = 684), 28.2% were married (N = 297), 5.5% were divorced (N = 58), 0.1% were widowed (N = 1), and 1.2% had were unknown (N = 13). The average age was 33.3 ± 7.9 years. In this sample, 28.1% were on more than one medication (N = 302). The prevalence of atypical antipsychotic use among females was 23 % (613/2655) vs. Males 27% ( 460/1690). The most commonly prescribed treatment was quetiapine (N = 593, 55.3%), followed by aripiprazole (N = 301, 28.1%), risperidone (N = 217, 20.2%), olanzapine (N = 203, 18.9%), ziprasidone (N = 126, 11.7%), paliperidone (N =33, 3.1%), clozapine (N = 24, 2.2%), asenapine (N =13, 1.2%), and finally iloperidone (N = 1, 0.1%). Women were more likely than men to be prescribed aripiprazole (31.2% vs. 23.9%, p = 0.009) and quetiapine (60.7% vs. 48.0%, p < 0.001). Women were less likely than men to be prescribed risperidone (15.8% vs. 26.1%, p < 0.001) and ziprasidone (10.1% vs. 13.9%, p =0.04).

    Conclusions: Nearly 25% of childbearing –aged women seen in an outpatient psychiatry clinic were treated with an atypical antipsychotic. Quetiapine is the most commonly prescribed agent across gender. Reproductive safety data for the atypical antipsychotics are extremely sparse. However given the association of these agents with weight gain, diabetes, and hypertension raises other concerns with regard to safety when these drugs are used during childbearing age.

    Objectives:

    1. Investigate reproductive safety data of the atypical antipsychotics.
    2. Examine the prevalence of atypical antipsychotic use among women of childbearing age compared to men.
    3. Examine the prevalence of specific atypical antipsychotic agents among women of childbearing age.

    Relevance:
    There seems to be some concerns with regard to safety of atypical antipsychotic agents when prescribed during childbearing age.

     
  16. Posttraumatic Stress Disorder Symptoms after Acute Lung Injury: A Two-Year Prospective Longitudinal Study
    Presenting Author:  O. Joseph Bienvenu
    Co-Authors:  Jonathan Gellar, Benjamin Althouse, Elizabeth Colantuoni, Thiti Sricharoenchai, Kristin Sepulveda, Pedro Mendez-Tellez, Carl Shanholtz, Cheryl Dennison, Margaret Herridge, Peter Pronovost, Dale Needham

    Background: Critically ill patients face tremendous stresses in intensive care units (ICUs), including respiratory insufficiency, painful procedures, systemic inflammation, high levels of endogenous and exogenous catecholamines to maintain blood pressure, and delirium with associated psychotic experiences, all in the context of reduced autonomy and a limited ability to communicate. By definition, critical illnesses are life-threatening, and many patients have memories of extremely frightening delirium-related psychotic experiences that occurred in the ICU. The point prevalence of PTSD or clinically significant PTSD symptoms in these patients (20-30%) is comparable to that of rape victims and combat soldiers. This study describes the 2-year incidence and duration of PTSD symptoms after an archetypical severe critical illness, acute lung injury (ALI), and examines patient baseline and critical illness/ICU-related risk factors.

    Methods: This prospective, longitudinal cohort study recruited patients from 13 ICUs in 4 hospitals, with follow-up 3, 6, 12, and 24 months after ALI onset. The outcome of interest in the 186 ALI survivors was an Impact of Events Scale-Revised (IES-R) score ≥1.6 ("PTSD symptoms" - in a prior study of ALI survivors, this ≥1.6 threshold had excellent screening properties for DSM-IV PTSD).

    Results: During 2-year follow-up, 66 patients (35%) developed PTSD symptoms, with greatest incidence by 3-month follow-up. Of 56 patients with incident PTSD symptoms who survived to 24-month follow-up, the median and modal durations were 12 and 21 months, respectively; 35/56 (62%) had IES-R scores ≥1.6 at 24-month follow-up. Psychiatric treatment was more common in survivors with PTSD symptoms compared to survivors without PTSD symptoms: 50% (vs. 25%) took psychiatric medications (p=0.003), and 40% (vs. 17%) saw a psychiatrist (p=0.003). Risk factors for PTSD symptoms (hazard odds ratio, 95% confidence interval) were pre-ALI depression (1.96, 1.06-3.64), ICU length of stay (for a doubling of days, 1.39, 1.06-1.83), proportion of ICU days with sepsis (per decile, 1.08, 1.00-1.16), high ICU opioid doses (mean morphine-equivalent ≥100 mg/day, 2.13, 1.02-4.42), and proportions of ICU days on opiates (per decile, 0.83, 0.74-0.94) or on systemic corticosteroids (per decile, 0.91, 0.84-0.99). Initial severity of illness, maximum organ failure, and proportions of ICU days delirious or comatose were not associated with post-ALI PTSD symptoms.

    Conclusions: Incident PTSD symptoms are common, long-lasting, and associated with treatment-seeking during the first 2 years after ALI. Pre-ALI depression and a longer ICU length of stay were risk factors for post-ALI PTSD symptoms. Sepsis may affect risk by compromising the blood-brain barrier, thus allowing catecholamines in the peripheral circulation to enter the brain and enhance traumatic memory formation/fear conditioning. In-ICU systemic corticosteroid administration may be protective, as seen in previous small studies in other populations. Adequate but not excessive opioid pain control in the ICU may also protect against post-ALI PTSD symptoms.

    Objectives:

    1. Define acute lung injury (ALI) / acute respiratory distress syndrome (ARDS), its causes, and its incidence, mortality, and morbidity.
    2. Apply knowledge of prior studies on the prevalence of and risk factors for PTSD symptoms in survivors of ALI/ARDS and other critical illnesses to work with these patients.
    3. Apply new knowledge regarding the incidence and duration of PTSD symptoms in ALI survivors, including information on risk factors and their neurobiological relevance to PTSD symptoms, to work with patients.

    Relevance:
    Experts in psychosomatic medicine should be aware of the physical, cognitive, and other psychiatric difficulties that critical illness survivors face, in order to provide informed care for these patients.

     
  17. Psychiatry-Family Practice Liaison: Assessment of Current Practices and Evolving Needs in a Large, Community-based Teaching Hospital
    Presenting Author:  Katalin Margittai

    Purpose: In 2011, the Department of Psychiatry at the North York General Hospital (NYGH), did a needs assessment to ascertain both the educational and the service needs of affiliated Family Physicians (FPs), with the ultimate goal of reducing psychiatric outpatient referrals and increasing capacity within Family Practice to manage patients with mental illness.

    Methods: An internet survey was constructed, and all FPs affiliated with NYGH were invited to participate via email. The survey comprised 3 components: (1) demographic questions; (2) questions targeting clinical practice and utilization of Mental Health services; and (3) questions gauging interest in continuing medical education (CME). Statistical Analysis was performed using the IBM SPSS Statistics 19 software and the critical level of significance was set at 5%.

    Results: 92/308 eligible FPs completed the questionnaire, with 1/5 practicing less than 10 years (early career - EC) and 2/3 practicing over 20 years (later career - LC). 82 % referred between 1-5 patients for some mental health service per month, and 87 % had made an outpatient referral in the past month - with 20% expressing dissatisfaction therein. Regarding their own comfort level: only Major Depression and Anxiety Disorders were comfortably handled by over 60%; however, there was a significant difference between EC and LC physicians with LCs more likely to feel very confident in general (t(70.81) = -2.21, p = 0.031). As for CME, a Thursday evening presentation in February was the most popular choice, but only 11% of respondents committed to attending, with another 47% who might attend. Topics of greatest interest (over 40 votes each) were ADHD and Affective Disorders.

    Conclusions: Liaising successfully with FPs in a community teaching hospital presents some unique challenges. Initial CME efforts targeting EC physicians and focusing on ADHD and Affective Disorders may provide the first steps towards a successful collaborative partnership.

    References:

    1. Clatney, L., Macdonald, H., Shah, S. M. Mental health care in the primary care setting: family physicians' perspectives. Can Fam Physician 2008, 54(6), 884-889.

    2. Kisely, S., Duerden, D., Shaddick, S., & Jayabarathan, A. Collaboration between primary care and psychiatric services: does it help family physicians? [Comparative Study]. Can Fam Physician 2006; 52, 876-877.

    3. Lucena, R., Lesage, A., Élie, R., Lamontagne, Y., Corbière, M. Strategies of Collaboration Between General Practitioners and Psychiatrists: A Survey of Practitioners' Opinions and Characteristics. Can J Psychiatry 2002;47:750-758

    Objectives:

    1. To understand how internet technology can be used for the collection of survey data.
    2. To appreciate some of the differences in practice and in educational needs between early career (EC) and later career (LC) Family Physicians.
    3. To apply innovative strategies in order to effectively liaise with Family Physicians (FPS), and increase their capacity to provide ongoing treatment to their patients with mental illness.

    Relevance:
    Psychiatrists could benefit from understanding the needs of their primary care colleagues, in order to provide relevant, innovative CME to enhance their capacity to cope with their mentally ill patients.

     
  18. [T] Maternal Mental Health Consultations in a University Medical Center — Patterns and Correlates: A Pilot Study
    Presenting Author:  Amritha Bhat
    Co-Authors:  Allison Hadley, Sidney Zisook

    Purpose: Ten to twelve percent of women experience an episode of major depressive disorder during pregnancy or in the postpartum period (Banti et al, 2011). Maternal depression can have both short term and longer lasting effects on child development (Brand et al, 2009). Early detection and treatment can therefore be useful; it can be achieved by using screening tools and by having an integrated service or active communication between the obstetric and psychiatric services. A collaborative care model is utilized at the UCSD Medical center at Hillcrest. Apart from a predetermined score of 10 on the EPDS (Cox et al, 1987) which prompts a request for a psychiatric consultation, psychiatrists are called upon to see patients when obstetric providers are concerned regarding findings on the patient's mental status examination. This is a potentially rewarding setting for early detection and intervention. In this context we assessed the relationships between EPDS score above the "clinically significant" cutoff of 10 with psychiatric diagnoses and consultations.

    Methods: All mothers who delivered at UCSD Hillcrest between March 2011 and December 2011 are included in this chart review. Sociodemographic details, EPDS scores, obstetric, medical and psychiatric history and details of psychiatric consultations / recommendations will be recorded for each case. Descriptive statistics will be used to determine prevalence of psychiatric disorders, Chi square tests to determine the relationships between categorical sociodemographic data and psychiatric diagnoses, and logistic regression to determine the relationship between EPDS scores and psychiatric diagnoses.

    Results: This is an ongoing study and results will be shared as they become available. It is hoped that the following questions will be answered.

    • What is the percentage of high EPDS scores (>10) at the first antenatal visit?
    • What is the percentage of women with high EPDS scores (>10) at the first postpartum visit?
    • What percentage of women had a psychiatry consultation during their admission for delivery with high and low EPDS scores?
    • What is the correlation between EPDS scores and Psychiatric consultation?
    • What are the sociodemographic correlates of psychiatric disorders in this population?

    Conclusions: This is an ongoing study and conclusions will be made as results become available.

    Objectives:

    1. To emphasize the importance of collaborative care in perinatal mental health.
    2. To describe the correlates of psychiatric disorders in this population.
    3. To examine the correlations of EPDS scores with psychiatric diagnosis.

    Relevance:
    Examines the utility of two methods of early detection of perinatal mental health problems in women – the screening instrument EPDS; and psychiatric consultations obtained based on clinical judgement.

     
  19. [T] Care Managers’ Experiences in a Collaborative Care Program for Depression
    Presenting Author:  Hsiang Huang
    Co-Authors:  Amy M. Bauer, Jessica Knaster Wasse, Anna Ratzliff, Ya-Fen Chan, David Harrison, Jürgen Unützer

    Background: Collaborative care is a model of integrated behavioral health care designed to treat and manage common mental disorders in the primary care setting. Behavioral health care is provided by a team that includes a primary care provider, a care manager based in the primary care clinic, and a team psychiatrist. Care managers have regularly scheduled consultations with the team psychiatrist to conduct psychiatric case reviews and develop a treatment plan which may include medication recommendations, brief psychotherapeutic interventions by the care manager, and referrals to specialty mental health services.

    Although the number of collaborative care programs in the U.S. is increasing, no studies have yet examined the experiences of care managers caring for patients in this model of care. Funded by King County and administered by Public Health-Seattle & King County in collaboration with Community Health Plan of Washington, the High Risk Mothers program of the Mental Health Integration Program (MHIP) is a collaborative care program that provides behavioral health services for women who have a mental health need and who are either pregnant or parenting a child under 18 years old and low income. Between 2008 and 2010, 1,244 high risk mothers were enrolled in this program. The purpose of this qualitative study was to conduct a focus group of care managers in order to explore aspects of the program that have led to successful treatment of patients as well as barriers to such successes.

    Methods: As part of a quality improvement project, we conducted a focus group interview with six care managers caring for low income mothers with behavioral health needs in a safety net program in King County, WA. Using thematic analysis, codes were organized into themes that describe the care managers' experiences.

    Results: Two organizing themes along with associated themes emerged: 1) Assets for improving depression outcomes (provider-patient racial/ethnic/language concordance, benefits of seeing patients in primary care, treatments for depression, good engagement with patients, and care coordination) and 2) Barriers to improved depression outcomes (difficulty connecting with services, multiple psychosocial stressors, difficulty engaging with patients, severity of psychiatric illness, and need for more psychiatric support).

    Conclusion: Numerous potentially modifiable factors including levels of engagement, motivational interviewing, and increased psychiatric support were identified by care managers who work in primary care as affecting depression care and outcomes. Implications for the recognition of these factors by the consulting psychiatrist will be discussed.

    Objectives:

    1. Describe the roles of the care manager and consulting psychiatrist in an integrated behavioral health care program.
    2. Describe the potentially modifiable factors for effective depression care as identified by care managers.
    3. Understand how these factors can be used by the consulting psychiatrist to work more effectively with care managers in order to improve depression care for patients treated in integrated settings.

    Relevance:
    This presentation aims to inform potential ways of improving depression care in integrated behavioral health care programs.

     
  20. Comorbidities of Gastroparesis Patients Admitted for Exacerbation of Gastroparetic Symptoms to Temple University Hospital
    Presenting Author:  Natalia Ortiz
    Co-Authors:  Henry Parkman, Mary Morrison, Abhinav Sankineni, Amina Hanif

    Background: Gastroparesis is a motility disorder of the stomach in which delayed gastric emptying is seen in a symptomatic patient. Nausea, abdominal pain, early satiety, and weight loss are the main symptoms. Increased anxiety and depressive symptoms have been associated with increased physician rated severity of gastroparesis symptoms. (NIH Gastroparesis Clinical Research Consortium Registry: January 2007-August 2009). (Hasler W, et al, 2010). The aim of this study was to determine the prevalence of psychiatric disorders in gastroparesis patients admitted to the hospital for a gastroparesis exacerbation.

    Method: Adult gastroparesis patients (confirmed by positive gastric emptying study) admitted to the hospital were approached for participation. After signing informed consent, subjects were assessed using the SCID (Structured Clinical Interview for DSM-IV) to establish psychiatric diagnoses.

    Results:
    Subjects
    : Twenty-nine inpatients admitted with gastroparesis exacerbation consented to participate. Nine patients refused or were discharged before interview. Subjects had a mean age of 36.8 years (SD = 13.5) and were predominantly women (80%). The majority (65%) of the subjects were white, 20% were African American, 5% Hispanic and 10 % other. All subjects were unemployed and most (55%) were single.
    Psychiatric diagnoses: Almost all of the subjects (90%) were diagnosed with an anxiety disorder and over half (60%) the subjects were diagnosed with current major depression (MDD). Of those with an anxiety disorder, 61% had a diagnosis of generalized anxiety disorder, 17% had a diagnosis of Post traumatic stress disorder, 11% had Panic disorder with agoraphobia, 5.5% had Obsessive compulsive disorder and 5.5% had Anxiety disorder NOS. Comorbidity was common in the anxiety disorder group, with 22% having more than one anxiety diagnosis and 44.4% having comorbid MDD. From the patients with depression, current unipolar MDD was diagnosed in 60%, with 8.3% diagnosed with bipolar and 8.3% with Depression NOS. Only 25% of the subjects who were diagnosed with a depressive disorder were taking full dose antidepressants, but half (53.8%) were on low dose tricyclic antidepressants for pain. Most patients (75% ) were taking opioids for gastroparesis pain. No patients had an eating disorder or somatoform disorder prior to the onset of gastroparesis. Conclusions: In this small sample of refractory gastroparesis patients, there is a high prevalence of anxiety and depressive disorders. Interestingly, many of these patients were undertreated pharmacologically. Treatment of comorbid psychiatric disorders may improve the overall well-being of gastroparesis patients with recurrent exacerbations.

    Objectives:

    1. To investigate the presence of psychiatric comorbidities in patients with gastroparesis.
    2. To analyze the comorbidities between depression and anxiety in patients with acute exacerbation of gastroparesis.
    3. To investigate the presence of premorbid eating disorders in patients with current gastroparesis.

    Relevance:
    Patients with gastroparesis have impaired gastric emptying. Its prevalence is more common in women than men (9.6, 37.8 per 100,000 respectively). From 1994-2005 its hospitalizations have increased by 158%.

     
  21. Defining Psychiatric Issues in a Population of Obstetric Inpatients
    Presenting Author:  Lucy Hutner
    Co-Authors:  Alexandra Sacks, Caroline Segal

    Aims: Consultation-liaison psychiatrists often manage psychiatric issues arising in the antenatal and immediate postpartum periods. To our knowledge, there are no data on psychiatric consultations for obstetric inpatients in the United States. Our study aimed to characterize the consultations performed by an obstetrics psychiatry service at Columbia University Medical Center. We hypothesized that 1) specific subtypes of psychiatric presentations would be identified, and 2) mood disorders would be prevalent, which might serve as a basis for risk stratification in the postpartum period.

    Methods: A retrospective chart review of 126 consecutive consultations was conducted, analyzing psychiatric, social work, and obstetric notes.

    Results: Nearly half (44%) of consultations were requested due to past psychiatric history alone. Patients on antenatal services were more likely to be followed longitudinally (87%), whereas postpartum patients were typically seen once (61%). Patients with mood disorders accounted for a majority (60%) of consultation requests. Consultations regarding patients with mood disorders were more likely to arise from the postpartum service (73%) as compared to the antepartum service (19%). Consultation requests for adjustment reactions to pregnancy complications or loss were also common (24%). Other subpopulations were identified, such as patients with active substance abuse (10%) and primary psychotic disorders (9%). Acute presentations, such as suicidality or thoughts of harming the pregnancy, were uncommon (5% and 2%, respectively), but they were correlated with being seen on an urgent basis in the labor and delivery unit (r=.30, p<.001; r=.46, p<.001).

    Conclusion: This study characterizes the population of obstetric inpatients evaluated by a liaison psychiatry service. Our results identify several subtypes of psychiatric presentations within this population. Mood disorders were highly prevalent, and they often were identified on the basis of past psychiatric history alone. Identification of population subtypes may lead to improved screening, assessment, and early intervention efforts in the antenatal and immediate postpartum periods.

    Objectives:

    1. To understand the populations seen by consultation liaison psychiatrists in an obstetric setting.
    2. To learn about the particular psychiatric challenges of consultation liaison psychiatrists in an obstetric setting.
    3. To understand how study data may be used to build screening and risk stratification programs on inpatient obstetric units.

    Relevance:
    To learn more about obstetric populations seen in the inpatient consultation psychiatric setting.

     
  22. [T] Identification of Risk Factors Leading to Physician Disengagement in Chronic Pain Patients
    Presenting Author:  Archana Brojmohun
    Co-Author:  Margo Funk

    Purpose: Patients with chronic pain can pose unique challenges to the primary team and often the consultation liaison psychiatrist is consulted to assist with elements of: chemical dependency; emotional distress related to true or perceived uncontrolled pain; assessment of secondary gain; or capacity evaluation. With such patients, the CL psychiatrist may identify issues involving inadequate communication between the patient and healthcare team, and in extreme cases may discover elements of physician disengagement. We define physician disengagement to mean physical or emotional detachment of the physician from the treatment of a patient. Chronic pain patients are at high risk. In this pilot study, we aim to identify the most common risk factors that can lead to disengagement in patients with chronic pain.

    Methods: We present an index case of a 40 year old male with a history of chronic pancreatitis and alcohol abuse who presented with worsening abdominal pain. While on the medical inpatient unit, he was labeled as having medication seeking behaviors and he perceived that his pain was not being adequately treated. During his hospital stay, he expressed suicidal ideation due to his pain and homicidal ideation towards his treatment team. The primary physician elected to no longer see the patient and deferred face to face evaluations to the house staff, who documented limited daily interactions. After an episode where the emergency medical response team was called to assess the patient for fever, rigors and uncontrolled pain, the patient's care was eventually transferred to a different physician and treatment team.

    Results: A chart review is being conducted reviewing all patients between January 1st 2011 and December 31st 2011, inclusive, who had received concomitant psychiatric and pain management consults. A data collection tool consisting of 12 risk factors or "markers" for disengagement was derived from the index case so as to identify similar occurrences. Examples of markers included: medication seeking behaviors, hasty discharge, a substance abuse and psychiatric history among others. The criteria that occur most commonly in 60 % or more of the charts reviewed will be considered as a marker for physician disengagement.

    Conclusions: Physician disengagement is a very important hazard to be considered in the doctor-patient relationship, especially when patients with chronic pain are involved. Early intervention with a multidisciplinary approach is recommended to optimize physician-patient communication and prevention of physician disengagement.

    Objectives:

    1. To define the term “Physician Disengagement” including both emotional and physical disengagement based on identified markers.
    2. To identify markers leading to physician disengagement.
    3. To show that those markers can potentially identify high risk patients at the time of admission so that a multidisciplinary approach can be used prior to physician disengagement.

    Relevance:
    Physician disengagement is physical or emotional detachment of the physician from the treatment of a patient.The consultation liaison psychiatrist needs to recognize this phenomenon, especially with the chronic pain patient.

     
  23. Right to Die: Complicated Bioethical Issues in the Decisional Capacity Assessment
    Presenting Author:  Michael J. Peterson
    Co-Authors:  Kyle J. Benner, Elliot R. Lee

    Purpose: Evaluation of decisional capacity is one of the common psychosomatic consultations. Patient decisions involving a desire to die (DTD) statement require a higher standard of capacity, given the irreversible implications of the decision. When a patient is determined to have decisional capacity, principles of autonomy support a patient’s “right to die”, and generally allow that person to refuse care, even if it may hasten their death. However, psychiatric consultants are often reluctant to support this autonomy, given the strong association of depressive symptoms and the wish to die, as well as the potential overlap with suicidal ideation. Given these concerns, in addition to cognitive ability, a thorough assessment of depressive symptoms is critical given the association of DTD statements with current depression, and particularly hopelessness. Right to die capacity assessments may be further complicated by additional ethical and/or legal factors including: current or past psychotic disorder; current incarceration; or refusal of lifesaving ‘standard’ care. Although these pose a challenge for the treating and consulting physicians, they also present an opportunity for structured learning for fellows, residents, and medical students who are part of the consulting service.

    Method/Results: Case examples of decisional capacity assessments involving a patient’s right to die are discussed. Each case involved a patient’s DTD statement, but with additional ethical and/or legal issues. A sample approach to these cases is presented, and applied to each case. The outcome of each case, as well as a discussion of how the recommendations from the psychiatric consultation may have differed using this approach will be presented. An exploration of specific ‘complicating’ factors, including decision making in incarcerated patients, patients with a psychotic disorder, and in patients with a diagnosis considered terminal only without ‘standard’ treatment. Application of approach and specific elements to education of students and residents discussed.

    Conclusion: Although right-to-die decisional capacity assessments may be complicated and pose ethical and legal dilemmas, they also present an opportunity for the consultation-liaison psychiatrist. A systematic approach to the decisional capacity assessment, incorporating a thorough evaluation of depressive symptoms and the patient’s motivations for the DTD statement provide a basis for further evaluating additional complicating factors. Both the approach, and open case discussion provide a valuable educational platform for medical students, residents, and psychosomatic fellows.

    Objectives:

    1. The learner will be able to apply a systematic approach to decisional capacity assessments.
    2. The learning will be able to investigate the role of depression in end of life decisions.
    3. The learning will be able to investigate additional ethical and legal factors complicating decisional capacity assessments.

    Relevance:
    Right to die decisional capacity assessments are a common but complicated part of psychosomatic consultations. Discussion of related issues is pertinent to improving practice and training residents and fellows.

     
  24. Impact of a Primary Care-Mental Health Integration Program on Primary Care Provider Attitudes Regarding Access to Mental Health Services for Their Patients
    Presenting Author:  Brian Bronson
    Co-Author:  Steven Cercy

    Purpose: The President's New Freedom Commission on Mental Health recommended providers "screen for mental disorders in primary care, across the lifespan, and connect to treatments and supports (DHHS, 2003)." However PCPs often experience limited access to high quality mental health services for their patients (Trude 2003). The impact of integrating mental health services directly into primary care on PCP attitudes about mental health access has not been studied. As PCPs are key stakeholders in initiatives to improve access to mental health services for their patients, their opinions about the impact of integration programs are an important outcome measure.

    Methods: A primary care-mental health integration program staffed by 3.6 FTEs for approximately 17,000 patients in a VA facility primary care clinic was implemented towards improving mental health acess. Components included brief screening and referral, same day access, limited treatments and referral support. Before and after implementation, thirteen PCPs completed a six item attitudes survey about access to mental health services, using a five-point likert scale with choices ranging from highly unfavorable to highly favorable. A Wilcoxon Signed Ranks test was used to compare pre and post differences on each item, categorizing the responses as either favorable, versus unfavorable or netural.

    Results: After program implementation, PCPs indicated they 1)were more likely to make a referral if 'on the fence,' (P=0.025) 2)had more direct interaction with mental health providers over patients they referred (P=0.025), 3)that their patients were more likely to actually see a mental health provider after referral (P=0.046) and that they perceived 4)better access to mental health services for their patients (P=0.083) and 5)better access to alcohol and substance abuse services for their patients (P=0.046). The perceived quality of mental health services did not change significantly (P=0.32);though this was explained by the near unanimously favorable ratings in both the pre and post implementation periods.

    Conclusions: PCPs expressed significantly more favorable attitudes about referring their patients for mental health services after implementation of a primary care-mental health integration program aimed at improving access. These findings provide additional evidence of value for integrated care programs.

    References:

    1. New Freedom Commission on Mental Health. Achieving the Promise: Transforming Mental Health Care in America. Final Report. Rockville, MD: US Department of Health and Human Services; 2003. DHHS publication SMA-03-3832.

    2. Trude S, Stoddard J: Referral Gridlock: Primary Care Physicians and Mental Health Services. Journal of General Interal Medicine. 2003.18.442-449.

    Objectives:

    1. Learn the components of primary care - mental health integration programs.
    2. Understand the rationale for integrated care programs.
    3. Learn the impact of integrated care on primary care provider attitudes regarding mental health services for their patients.

    Relevance:
    The presentation is relvant to the conference theme of primary care - mental health integration.

     
  25. [T] A Bioethical Dilemma: A Surrogate Decision Maker for End of Life Issues, Who Also Happens to Be a Person of Interest in the GSW to the Head of the Patient
    Presenting Author:  Waqar Rizvi
    Co-Author:  Aasia Syed

    Introduction: Medicine did not get to where it is today without overcoming obstacles and controversial issues. With the advancement of biology and medicine, it's only natural to have debatable concerns arise. Patients and their families may not always see eye to eye with their Primary Care Team, and may not agree with the "Hippocratic Oath-driven" desire of the Doctor making the HealthCare decisions. When these problems occur in the clinical/hospital setting, Physicians may find it necessary to call on assistance from an unbiased discipline; i.e. the BioEthics team.

    Method: Case report: A 48 YO F with a PMH of Bipolar Disorder and Migraine presents with a GSW to the head, resulting in bullet fragments in the frontal lobe. The husband refuses any life-saving medical intervention (including blood transfusions, ventilator and neurosurgical interventions), on account of being next of kin and respecting the patient's wishes about end of life issues, which they reportedly often discussed. The patient is taken off the ventilator per husband's directives, and maintained only on NC oxygen and IV fluids. She is unconscious, barely responsive, and needs transfusions and surgery. The surgical team requested a Psychiatry Consult for the patient's DMC. She performed exceptionally well on all Mental Status Exams performed, only lacking in recollection of the events leading up to her current presentation, suffering from Transient Global Amnesia. Unclear at this point, is if it was a Suicide or a Homicide, as she and her husband were the only individuals known to be present in the room. The BioEthics team was called upon, and it was learned that the husband actually would have had the right to make the decision for the patient at the time, regardless of how shady his behavior was. However, it was learned from the collaboration between the BioEthics team and the involved law enforcement that the husband was a person of interest in the case.

    Discussion: This was quite a difficult case to "call down the middle" so to speak. Naturally, many emotions were flying all over the place; on the ends of the Physicians, as well as on the end of the patient's husband. The BioEthics Department played a critical role in communicating with local authorities to find out vital information that changed the decision making process in this case.

    Conclusion: Physicians work with the Hippocratic Oath in mind, and at heart, while patients may not. As imperative as it is to respect the wishes of the patient and their family, we may at times doubt the family's ulterior motives. BioEthics is a department specializing in such ethical dilemmas. Especially when multiple persons are involved. Key to remember is, that communication is key.

    Objectives:

    1. The physician learner will be able to better understand the need for open communication amongst varying departments, especially in sensitive cases.
    2. The physician learner will be able to better utilize the Resources available at hand, but not so readily used; such as the Bioethics Department.
    3. The physician learner will be able to confidently apply his/her knowledge of how to facilitate through difficult situations or ethical dilemmas.

    Relevance:
    As long as there is the field of medicine, there will be a question of ethical dilemmas. We physicians must learn to utilize the expertise of BioEthicists, in such dilemmas.

     

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Section E:  Psycho-Oncology

  1. Development of a Novel Psycho-Oncology Curriculum for Residents on an Inpatient Consult-Liaison Psychiatry Rotation
    Presenting Author:  Ryan Kimmel
    Co-Authors:  Mitchell Levy, Suzanne Murray, Jennifer Seibert, Kjersti Braunstein

    Purpose: The University of Washington Medical Center (UWMC) has aggressively expanded its Inpatient Oncology Service. In particular, the UWMC now has a very active stem cell transplantation unit. This focus has significantly increased the number of oncology patients seen by the Consult-Liaison Psychiatry (CLP) Service. With this project, we set out to develop, to our knowledge, the first psycho-oncology curriculum geared towards psychiatry residents on inpatient consult-liaison rotations.

    Methods: The authors took the American Psychosocial Oncology Society Fellowship curriculum topics, identified common, inpatient-specific subjects, and then consolidated the themes into overarching foci of: basic stem-cell transplant biology, cancer and depression, cancer-specific psychopharmacology issues, psychiatric symptoms of paraneoplastic syndromes, psychiatric side effects of cancer medications, resilience, and at-the-bedside supportive therapy for demoralization. We identified the existing education vs. service constraints of the resident schedule and formulated a plan for six, 20-minute didactics. We then engaged in a formal needs assessment with the residents to confirm or refute our assumptions about their prior psycho-oncology training, the palatability of our novel didactic schedule, and resident overall comfort with each proposed topic. Finally, the authors formalized the course goals and objectives, identified a range of educational strategies, and developed individual lesson plans.

    Results: We developed a faculty guide so that any attending on the CLP rotation can deliver all six of the 20-minute didactics. Each resident will be exposed to all six didactics during their CLP rotation. We also provide the residents with a reference reading list in order to engage in further, in-depth study of the topics.

    Conclusions: Trainee knowledge will be evaluated via demonstrated practice during the CLP rotation, as well as formal self-assessment of comfort level with the material. Written feedback from residents will be used to further enhance the curriculum.

    Objectives:

    1. Recognize the need for psycho-oncology education for residents at their own institution.
    2. Consider a novel didactic schedule that does not significantly impact the service schedule.
    3. Identify common psychiatry consult-liaison requests and R2 learning opportunities for oncology inpatients.

    Relevance:
    Most academic institutions have their psychiatry residents rotate on an inpatient consult-liaison service. Stem-cell transplant patients, with their specific psychopharmacologic and psychologic challenges, would benefit from informed consultants.

     
  2. [T] Existential Pain Presented with Diffuse Somatic Pain and Resolved with the Decision to Pursue Comfort Care
    Presenting Author:  Yelizaveta Sher
    Co-Authors:  Sermsak Lolak, Jose Maldonado

    Purpose: To demonstrate the significance of helping the patient to make his own medical decision in the face of terminal illness and existential suffering

    Methods: The case of a young man with severe heart failure and tremendous difficulty making a decision to undergo Ventricular Assistive Device (VAD) implantation will be discussed. Patient's difficulty with decision was impressively marked by diffuse somatic body pain of existential quality. The psychiatric consultants' team helped patient arrive at his medical decision which for him meant to decline the VAD. His pain greatly diminished with this decision.

    Results: The patient is a 34 year old single man with severe heart failure on diet and fluid restrictions and complicated by renal failure. Psychiatry was consulted to evaluate his candidacy for VAD implantation. Patient was treated for hypoactive delirium and depression. Over the course of hospitalization, the patient was struggling to make a decision whether to pursue VAD and this internal struggle was marked by significant diffuse body pain, not medically explained, and treated with narcotics. Patient agreed to undergo the VAD placement after the visit and urgings of his family. He was found to have adequate capacity to make such decision. He nevertheless continued to experience severe physical pain and depression. Psychiatry engaged this patient to discuss his preferences and priorities in life. With our discussions and his own contemplations, patient finally made a decision not to undergo VAD and opted for comfort care. Patient expressed tremendous peace with his decision and his physical pain and requirements for opiates have significantly diminished. He spent his last days in emotional peace and enjoyed his family's company, as well as simple but important activities of eating, drinking, and watching cartoons.

    Conclusions: Existential suffering can express itself not only through emotional, but also physical pain. Psychosomatic medicine consultants, palliative care doctors, and primary team physicians have an important role in understanding patient's existential suffering and aiding them through the difficult life-and-death decisions. This process can provide a tremendous relief to the patient and improve their quality of life, even if in the last few days.

    References:

    1. Appelbaum PS, Assessment of Patients' competence to consent to treatment. New England Journal of Medicine 2007 Nov 1;357(18):1834-40.

    2. Boston P, Bruce A, Schreiber R, Existential suffering in the palliative care setting: an integrated literature review. Journal of Pain and Symptom Management 2011 Mar;41(3):604-18.

    3. Eshelman AK, Mason S, Nemeh H, Williams C, LVAD destination therapy: applying what we know about psychiatric evaluation and management from cardiac failure and management. Heart Failure Reviews, 2009 Mar;14(1):21-8

    Objectives:

    1. The physician learner will be able to recognize and apply the concept of "existential suffering" to patients faced with life-death dilemmas.
    2. The physician learner will be able to appreciate, recognize, and explain the physical and emotional challenges for the patient after they underwent VAD implantation.
    3. The physician learner will be mindful of the existential aspect when evaluating for capacity in medically and ethically complicated patients.

    Relevance:
    Psychosomatic medicine specialists take care of very sick patients who often have to make difficult life-and-death decisions. This presentation will exemplify such case and provide the audience with needed tools.

     
  3. Effect of Fatigue, Depression and Neurocognitive Functioning in Head and Neck Cancer Patients Receiving Chemoradiation
    Presenting Author:  Beatriz Currier
    Co-Authors:  Ingrid Barrera, Rachel Lerner, Rachel Freed, Eric Halpern, Michael Abramowitz, Michael Samuels, Nagy Elsayyad, Maria Rueda-Lara, Nicole Mavrides, Maria Lopez, Philip Harvey, Dominique Musselman

    Purpose: Although research has found that "depressive" symptoms decrease by 4 weeks after cessation of radiation treatment (RT), reports indicate that in over 30% of head and neck (HN) cancer patients, fatigue and appetite loss persist for up to 52 weeks, especially in those with advanced stage tumors and radiation or multimodality treatment. However little is known about the effects chemoradiation has on neurocognitive functions and mood. This pilot, prospective study examines the prevalence, magnitude and course of fatigue, depression, and neurocognitive deficits in patients receiving RT or RT concurrent with systemic agents for squamous cell carcinoma (SCC) of the head and neck (HN).

    Methods: Fifty, Hispanic and Non-Hispanic men and women, with SCC of the HN will undergo definitive radiation therapy (60-70 Gy in six to seven weeks) alone (N=10), or concurrent chemoradiation with cisplatin (N=20), or concurrent radiation therapy with cetuximab (N=20). After obtaining informed consent, subjects will be evaluated using various measures: self-report questionnaires to assess fatigue (Multidimensional Fatigue Inventory) and depressive symptoms (Inventory of Depressive Symptomatology), as well as a brief clinician-administered neurocognitive battery (Brief Visuospatial Memory Test, Trails Making Test A and B, and Controlled Oral Word Association) at baseline, midway through treatment (week #3) , at the end of treatment (week #6), and finally at 12 weeks after completing treatment. To evaluate the effects of time (radiation therapy) and systemic agents, two-way analysis of variance for repeated measures will be used. Relevant patient and disease-related variables (including age, cancer stage and site, history of surgery, radiation dose, etc.) will be entered into these analyses as covariates.

    Results: Data collection and analysis is ongoing.

    Conclusion: Our findings will expand the limited information regarding the neurocognitive and behavioral effects of RT in combination with systemic chemotherapy or biological therapy in Hispanic and Non-Hispanic patients with SCC of the HN.

    Research Implications: By understanding the incidence, magnitude, and time course of neurobehavioral dysfunction suffered by patients undergoing treatment for SCC of the HN, investigation of relevant, underlying neurobiological pathways can proceed, including the radiation-induced genetic and epigenetic changes contributing to persistent symptoms.

    Clinical Implications: Improved understanding of the incidence and course of such symptoms in SCC patients, will lead to intervention strategies to ameliorate these symptoms and improve quality of life in cancer survivors.

    Objectives:

    1. Understand incidence of fatigue, depression and neurocognitive impairments in patients with squamous cell carcinoma of the head and neck undergoing radiation treatment alone or in conjuction with systemic agents.
    2. Improve understanding of the specific cognitive domains affected over time by radiation treatment alone or in conjuction with systemic agents.
    3. Examine the extent to which fatigue ia associated with depression and neurocognitive changes.

    Relevance:
    Improved understanding of the incidence and course of such symptoms in SCC patients, will lead to intervention strategies to ameliorate these symptoms and improve quality of life in cancer survivors.

     
  4. [T] Posttraumatic Stress Disorder Precipitated by Antiandrogenic Treatment for Prostate Cancer: A Case Report and Review
    Presenting Author:  Nadia Quijije
    Co-Authors:  Jonathan Stewart, Shirrin Ahmadi

    Purpose: Gonadotropin-releasing hormone (GnRH) agonists such as goserelin are used to induce testosterone or estrogen deprivation and are used in a number of illnesses, including prostate cancer and endometriosis. The reduced plasma concentrations of androgens and estrogens are associated with physiologic and psychiatric effects. Psychiatric symptoms linked to GnRH agonists include depression, emotional lability, poor concentration, fatigue and low energy.

    Method: We report a 65 year old male with a history of prostate cancer treated with external beam radiation and goserelin. A temporal relationship between posttraumatic stress disorder (PTSD) and depressive symptoms and the initiation of goserelin treatment is demonstrated. A literature review was conducted using the keywords goserelin, anxiety, depression and PTSD.

    Results: Chart review and collateral history from the patient's wife described a euthymic, high functioning businessman with only modest claustrophobic symptoms treated with cognitive-behavioral therapy; there was no history of psychiatric treatment prior to initiation of goserelin. No pertinent past medical history. He was diagnosed with prostate cancer, Gleason grade 8, in 2009, and treated with external beam radiation therapy and adjunctive goserelin for two years. After initiation of hormone therapy he developed symptoms of depression and anxiety, particularly flashbacks of his service in Vietnam and hypervigilance. He also endorsed symptoms of fatigue and hot flashes. The anxiety and mood symptoms worsened over the two years of hormone therapy and led to functional impairment and outpatient psychiatric care. Despite cessation of goserelin treatment, the mood and PTSD symptoms persisted, eventually leading to psychiatric hospitalization. Literature review reveals a great deal of information about psychiatric side effects of GnRH agonists, but this literature is mostly confined to adverse effects in women; there is very limited literature about such effects in men.

    Conclusion:

    • Psychiatric consultants should be aware of the physiologic and psychiatric effects of GnRH agonists in males.
    • Clinicians should be vigilant for adverse psychiatric effects, especially anxiety and depression, in men treated with GnRH agonists.
    • Patients and families should be educated on potential psychiatric side effects of GnRH agonists such as goserelin.

    References:

    1. P.M. Conn, W.F. Crowley. Gonadotropin-releasing hormone and its analogs. Annu Rev Med, 45 (1994), pp. 391-405

    2. van Tol-Geerdink JJ, Leer JW, van Lin EN, Schimmel EC, Stalmeier PF. Depression related to (neo)adjuvant hormonal therapy for prostate cancer. Radiother Oncol. 2011 Feb;98(2):203-6. Epub 2011 Jan 20.

    3. Warnock JK, Bundren JC. Anxiety and mood disorders associated with gonadotropin-releasing hormone agonist therapy. Psychopharmacol Bull. 1997;33(2):311-6.

    4. Kohen I, Koppel J. Goserelin-induced new-onset depressive disorder.Psychosomatics. 2006 Jul-Aug;47(4):360-1.

    5. Stone P, Hardy J, Huddart R, A'Hern R, Richards M. Fatigue in patients with prostate cancer receiving hormone therapy.Eur J Cancer. 2000 Jun;36(9):1134-41.

    Objectives:

    1. To review and make psychiatric consultants aware of the potential physiologic and psychiatric effects of GnRH agonists in males.
    2. To be aware of adverse psychiatric effects of GnRH agents, especially depression or anxiety symptoms in order to screen and treat as needed.
    3. Be able to educate patients, families, and other clinicians of the potential psychiatric side effects of GnRH agents such as Goserelin.

    Relevance:
    As psychiatric consultants, we need to be aware of the psychiatric adverse effects of GnRH agents such as Goserelin in order to best assist both referring clinicians and patients.

     
  5. [T] Psychiatric Effects of Leuprolide in Patients with Prostate Cancer
    Presenting Author:  Amy Shah
    Co-Author: Muhammad Aslam

    There are several case reports in the psychiatric literature of gonadotropin-releasing hormone (GNRH) agonists, like leuprolide, being related to depression in patients who are being treated with prostate cancer. The loss of testosterone is also correlated with increased fatigue and decreased cognition. Providers should be aware to watch for moodiness, irritability, tension, anxiety, and loss of vigor when patients are being started on leuprolide. Fortunately, these symptoms return to near baseline around 3 months of stopping this medicine. In the following poster presentation, there will be 2 cases of real patients who have been treated for this condition. Finally, there will be a discussion about this form of treatment.

    A primary literature review was performed using the terms depression and leuprolide in PubMed:

    Cherrier MM, Aubin S, Higano CS. Cognitive and mood changes in men undergoing intermittent combined androgen blockade for non-metastatic prostate cancer. Psychooncology. 2009; 18(3): 237-247.

    Piri WF, Greer JA, Goode M, Smith MR. Prospective study of depression and fatigue in men with advanced prostate cancer receiving hormone therapy. Psychooncology. 2008; 17(2): 148-153.

    Warnock JK, Bundren JC, Morris DW. Depressive symptoms associated with gonadotropin-releasing hormone agonists. Depression and Anxiety. 1998; 7:171-177.

    Objectives:

    1. To achieve a greater understanding of the effects of leuprolide and hormonal therapies.
    2. To realize the emotional toll hormonal therapies take on men with prostate cancer.
    3. To demonstrate the interplay between medical treatments and psychiatry, including the bioethical dilemmas it may create.

    Relevance:
    This audience will benefit from this presentation because it highlights a little discussed topic. Furthermore, it uses actual patient case examples which bring this problem to life.

     
  6. Outpatient Psychiatric Consultations at an NCI-Designated Cancer Center: A Retrospective Chart Review
    Presenting Author:  Rachel Lynn
    Co-Authors:  Jennifer Gotto, Liz Cooke, Lina Mayorga, Marcia Grant

    Purpose: Prevalence of comorbid psychiatric syndromes in the general population has been described. The rates and ranges of psychiatric syndromes found within the cancer patient population are poorly classified. Rates of depressive syndromes as high as 58% have been described in a general cancer population. We attempted to describe both the population of cancer patients seen, and the psychiatric illnesses diagnosed, in the outpatient psychiatry consultation clinic at a cancer center in Southern California.

    Methods: The study design is a retrospective chart review of 75 initial Outpatient Psychiatric Consultations over 9 months in 2011. Data were analyzed using the statistical software SPSS. Analysis included simple frequencies and descriptive statistics.

    Results: 75 patients seen in psychiatric consultation (61% female; 39% male) had a mean age of 55. A majority of patients had one of three underlying cancer diagnoses at the time of referral: Hematologic malignancies 32%, Breast Cancer 25% and Head/Neck Cancers 11%. 47% of patients seen were given a clinical diagnosis of a mood disorder. Anxiety disorders were diagnosed in 18% of patients, and 16% with adjustment disorders. Substance use disorders were found in 9% of patients seen, cognitive disorders in 9% and 3% of patients were noted to have a primary psychotic disorder.

    Conclusions: While higher rates of mood syndromes were found in this subset of cancer population, in comparison to expected prevalence among adults, anxiety and substance abuse were found in equal rates as compared to community prevalence.

    References:

    1. Kessler RC, Chiu WT, Demler O, Walters EE. Prevalence, severity, and comorbidity of twelve-month DSM-IV disorders in the National Comorbidity Survey Replication (NCS-R). Archives of General Psychiatry, 2005 Jun;62(6):617-27.

    2. Kessler RC, Berglund PA, Demler O, Jin R, Walters EE. Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the National Comorbidity Survey Replication (NCS-R). Archives of General Psychiatry. 2005 Jun;62(6):593-602.

    3. Miller K, Massie MJ. Depressive disorders. In: Psycho-oncology. 2nd ed. New York, NY: Oxford University Press; US; 2010:311-8

    Objectives:

    1. Have an updated view of distribution of psychiatric illnesses in the cancer population (last comprehensive data in '80s)
    2. Understand the increased rate of depressive disorders seen in cancer, validating other ongoing issues like how to set up screening in cancer centers
    3. recall that there are still very real rates of anxiety and substance abuse seen in this population, seen in conjunction with the increased rates of depressive disorders

    Relevance:
    Provide an updated description of the population of patients seen and illnesses encountered in the cancer setting. Guide providers arranging services for and screening of these patients.

     
  7. Sexual Trauma History in Gynecologic Oncology Patients
    Presenting Author:  Sarah Parsons
    Co-Authors:  Mary Gordinier, Sibyl Cagata, Mary Helen Davis

    Every six minutes, an American woman is diagnosed with gynecologic cancer, including cervical, endometrial, ovarian, peritoneal, tubal, vaginal, and vulvar cancers. The diagnosis can be distressful and create an emotional reaction; this distress is greatly amplified and complicated in a woman with a history of sexual abuse. Most gynecological oncology practices do not adequately screen for, address, and offer treatment to survivors of sexual abuse. When this aspect of a cancer patient is overlooked, problems can arise over the course of treatment. Treatment compliance and adherence can be compromised, decreasing positive outcomes for this population. Norton Cancer Institute introduced a pilot program in one gynecologic oncology clinic to regularly screen for sexual trauma and provide psychiatric referral as needed. Population data collected over 18 months will be presented. Demographics of the patients will be described. The effect of psychiatric intervention and subsequent differences in compliance, adherence, and outcomes for these gynecologic oncology patients will also be presented.

    Objectives:

    1. Appreciate the importance of screening for a sexual trauma history in gynecologic cancer patients.
    2. Understand the impact psychiatric referral may have on this patient population.
    3. Apply this type of screening to other similar populations.

    Relevance:
    Psychosomatic physicians are often involved in the psychosocial care of cancer patients. Exploring the incidence and impact of sexual trauma is an important part of providing care to this population.

     
  8. A Case of Suspected Breast Cancer in a Non-decisional Schizophrenic Woman
    Presenting Author:  Kimberly Stoner

    Purpose: To highlight the difficulty that non-decisional schizophrenic patients may have receiving healthcare services in a timely manner.

    Methods: A case report of a schizophrenic patient with suspected breast cancer.

    Results: DB, a 46 y/o female with schizophrenia underwent a mammogram ordered by her family physician that revealed a breast mass. She was lost to follow up. Two years later a repeat mammogram confirmed the mass, but DB did not show up for her subsequent appointment. Nearly five years after her first mammogram, repeat imaging demonstrated an enlarging mass, but DB refused a biopsy. Seven years after her initial mammogram, DB was admitted involuntarily to a psychiatric hospital. DB's breast mass had ulcerated and was bleeding through her clothing. She was transferred to a medical hospital due to anemia. DB speculated that her breast mass could be "a punishment from God." A consulting psychiatrist concluded that DB lacked decision making capacity and guardianship paperwork was filed. An ethics consult was also requested as care providers questioned the beneficence of depriving DB of her autonomy near the end of her life given that her breast cancer was likely too advanced to be effectively treated. Permanent guardianship was awarded four months later. DB discharged to a residential hospice eight days later and died the next morning.

    Women with schizophrenia may be at increased risk for breast cancer (Bushe, Bradley, Wildgust, & Hodgson, 2009). While cases of schizophrenia impeding the treatment of breast cancer have been reported previously (Paul, 1996 and Moini & Levenson, 2009), a recent study concluded that schizophrenia does not affect treatment delivery or outcomes (Sharma, Ngan, Nandoskar, Lowdell, Lewis, Hogben, Coombes & Stebbing, 2010). However, an important limitation of this study was that its subjects were included based on a medical record review revealing diagnoses of schizophrenia and breast cancer. Only schizophrenic women capable of accessing the health care system, scheduling and completing a mammogram, and agreeable to a breast biopsy were included which may represent a fraction of schizophrenics who experience fewer barriers to obtaining healthcare services.

    Conclusions: Psychiatrists working collaboratively in primary care settings should promptly evaluate decision making capacity in patients with schizophrenia to facilitate schizophrenic patients receiving essential healthcare services.

    References:

    1. Bushe, C.J., Bradley, A.J., Wildgust, H.J. & Hodgson, R.E. (2009). Schizophrenia and breast cancer incidence: A systematic review of clinical studies. Schizophrenia Research, 114, 6-16.

    2. Moini, B. & Levenson, J.L. (2009). A forgotten diagnosis: Simple schizophrenia in a patient with breast cancer. Psychosomatics 50, 87-89.

    3. Paul, M. (1996). Assessment of mental capacity: A dilemma. British J Psychiatry, 168, 519.

    4. Sharma, A., Ngan, S., Nandoskar, A., Lowdell, C., Lewis, J.S., Hogben, K., Coombes, R.C., Stebbing, J. (2010). Schizophrenia does not adversely affect the treatment of women with breast cancer: a cohort study. Breast, 19, 410-412.

    Objectives:

    1. Identify risk factors for breast cancer present among many schizophrenic women such as obesity, hyperprolactinemia, reduced parity, smoking, sedentary lifestyle and lack of breast feeding.
    2. Recognize that schizophrenic patients with disordered thought processes or other cognitive impairments may lack decision making capacity with regards to their own healthcare.
    3. Appreciate the need to facilitate the delivery of appropriate preventive services to schizophrenic patients in a collaborative primary care setting to reduce disparities in health outcomes.

    Relevance:
    Primary care physicians may offer screening tests to patients who lack decision making capacity. Psychiatrists working in a collaborative model have an opportunity to improve the provision of preventive services.

     
  9. Profiles of Preoperative Neuropsychological Functioning in Hispanic and Non-Hispanic Patients with Cancer Seeking Stem Cell Transplant
    Presenting Author:  Maria Lopez
    Co-Authors:  Maria Rueda-Lara, Rachel Lerner, Ingrid Barrera, Nicole Mavrides, Beatriz Currier

    Purpose: The process of stem cell transplant (SCT) for cancer treatment is rigorous and presents a challenge to patients' physical and mental functioning. Investigations of mental health functioning of patients seeking SCT has revealed some evidence of pre-transplant impairments in cognitive and psychiatric functioning for some patients (Harder et al., 2005), which appears to improve by 3 months post-transplant follow up (Beglinger et al, 2007). Given that cognitive impairment has been associated with poor outcome among transplant patients (Booth-Jones et al., 2005), it is imperative that we identify patients with cognitive limitations in order to provide interventions that improve medical outcomes. Despite a growing literature, data are limited regarding cognitive functioning among different cancer types and treatment history. Even less is known about pre-transplant neuropsychological functioning among Hispanics as compared to non-Hispanics. The current study will investigate cognitive functioning among Hispanics and non-Hispanic pre-transplant patients across cancer type and treatment history.

    Participants & Methods: English- and Spanish-speaking participants seeking SCT at the University of Miami Sylvester Comprehensive Cancer Center are being recruited. Data from a projected 50 evaluable participants (25 each Hispanic/non-Hispanic) will be included in the final analyses. As a part of their pre-operative evaluation, participants complete the Repeatable Battery for the Assessment of Neuropsychological Status (RBANS), which measures immediate and delayed memory, attention, language and visual-spatial functioning. Participants also complete the State-Trait Anxiety Inventory (STAI) and the Beck Depression Inventory, Second Edition (BDI-II).

    Descriptive statistics, such as frequencies, univariate analyses (means, standard deviations, medians) and bivariate analyses (such as chi-square tests of association, two-sample t tests, bivariate correlational analyses) will be used to describe patterns and levels of neuropsychological functioning among these cancer patient participants. Demographic data to be analyzed will include age, sex, education, language spoken (i.e., English or Spanish). Disease characteristics to be analyzed include cancer type (i.e.., myeloma, lymphoma, or leukemia), disease duration and remission, and therapy history preceding SCT (i.e., chemotherapy alone, radiotherapy alone, or combination). In order to determine differences across cancer type and differences between Hispanics and non-Hispanics, analyses of covariance (ANCOVA) will be utilized. Potentially confounding factors (e.g., age, education), will be identified and controlled as indicated in the analyses.

    Results: Data collection and analysis is ongoing as this study is currently in progress.

    Conclusions: Pre-SCT patients with cognitive deficits are at elevated risk for poor medical outcomes. Little is known regarding pre-transplant cognitive differences among Hispanics as compared to non-Hispanics with regards to cancer type and treatment history. Findings from this study will be discussed in the context of identifying important factors that may place pre-transplant patients at risk for poor medical outcomes, so that critical intervention services can be implemented.

    Objectives:

    1. Inevestigate cognitive differences among Hispanic and non-Hispanic pre-stem cell transplant cancer patients.
    2. Investigate cognitive differences among pre-stem cell transplant cancer patients with different treatment histories.
    3. Investigate cognitive differences among pre-stem cell transplant cancer patients with Leukemia, Lymphoma and Myeloma.

    Relevance:
    Findings will be discussed in the context of identifying important factors that may place pre-transplant patients at risk for poor medical outcomes, so that critical intervention services can be implemented.

     
  10. [T] Tamoxifen and Depression: Duration of Antidepressant Use Following Tamoxifen Discontinuation
    Presenting Author:  Laurel Ralston
    Co-Author:  Isabel Schuermeyer

    Objective: Research suggests that tamoxifen, an estrogen receptor modulator used in breast cancer treatment, may be an independent variable leading to depression in this population. Many studies have reviewed the use of antidepressants during tamoxifen therapy, but there are no clear guidelines on how long to continue antidepressant treatment after tamoxifen is discontinued. Therefore, we review the literature for variables to consider when deciding management of recurrent depression after tamoxifen discontinuation.

    Methods: A case report of a woman who became depressed on tamoxifen and remained depressed after tamoxifen was discontinued will be used to review the literature on the etiology, course and treatment of tamoxifen induced depression.

    Results: Tamoxifen appears to affect mood through its inhibition of protein kinase C. It has a half life of 7 days and most evidence suggests that tamoxifen-induced depression clears within 2 weeks of discontinuing the drug. It's likely that continued symptoms would primarily be related to hormonal changes, psychosocial stressors and physical impairment that put this population at increased risk for depression. For women who must complete a full course of treatment, tamoxifen-induced depression responds well to antidepressants. Antidepressants with strong CYP2D6 inhibition are not recommended due to concern they may decrease tamoxifen efficacy.

    Conclusion: A recurrence of depression after discontinuing tamoxifen is more likely due to hormonal or psychosocial stressors than a lasting medication effect. It is important to educate patients on this, as they may otherwise attribute all symptoms to tamoxifen and jeopardize recognition of other risk factors. In the breast cancer population, clinicians are advised to follow the standard of care and continue antidepressant treatment for nine to twelve months after a first major depressive episode.

    Objectives:

    1. Identify risk factors for depression in the breast cancer population and consider the role of antidepressants in treatment.
    2. Review the mechanism of action for tamoxifen and the significance of protein kinase C inhibition.
    3. Summarize the relationship between mood, estrogen and neurotransmitter levels.

    Relevance:
    This presentation will be of interest to any providers managing psychiatric medications in the breast cancer population.

     
  11. WITHDRAWN

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Section F:  Transplant

  1. [T] Adherence to Tacrolimus, Rejection, and Psychiatric Morbidity in Adult Liver Transplant Recipients
    Presenting Author:  Yelena Zack
    Co-Authors:  Rachel Annunziato, Kelley Chaung, Sander Florman, Leona Schluger, Eyal Shemesh, Thomas Schiano, Swapna Vaidya

    Purpose: Nonadherence to treatment is a major cause of morbidity in transplant recipients. It is therefore important to identify a robust measure of adherence in this population (1). Calculating the standard deviation (SD) of a series of clinically-obtained tacrolimus blood levels captures the degree of fluctuation in the way individuals take their prescribed dose. A higher SD = more variability in medication-taking = less adherence. A higher SD is indeed associated with a much higher incidence of rejection episodes in pediatric transplant recipients. This adherence measure has been validated in several pediatric transplant centers (1), but it is seldom used in adults. We wanted to see if this measure could be validated in adult liver recipients .We hypothesized that higher SD of tacrolimus blood levels will be associated with allograph rejection in a group of adult liver transplant recipients with compromised outcomes as evidenced by a need to perform a biopsy. We also hypothesized that substance abuse history and psychiatric illness will be associated with higher SD's and rejections.

    Methods: This is an interim analysis of an ongoing IRB-approved retrospective chart review of transplant recipients, focusing on a randomly selected cohort of 99 patients who received a liver transplant at our institution and had a biopsy for any reason between 1968 and 2010. The Biopsy results were obtained at least one year after the Transplant date and the Tacrolimus levels were recorded at least 6 months after Transplant.

    Results: Amongst biopsied patients, a higher SD was significantly associated with acute rejection as hypothesized [mean SD in patients with rejection, 4.8; mean SD in patients whose biopsy did not show acute rejection, 3.8, p=0.04, 95% CI = (-2.01) - (-0.05)]. There was no significant relationship between higher SD's or rejection episodes and substance abuse history or psychiatric illness as elicited by clinical evaluations performed by transplant social workers.

    Conclusion: As hypothesized, those results indicate that higher SD's of tacrolimus levels are associated with allograft rejection amongst patients who had a biopsy due to a clinical deterioration. Our results re-affirm and strengthen the rationale for the use of the SD method as an adherence measure in adults. The finding that less adherence and rejections were not associated with substance abuse or psychiatric morbidity as determined by routine clinical assessments is surprising. It could be due to the relatively small sample size. It could also indicate that those clinical assessments do not always correctly identify psychiatric morbidity.

    Reference:

    1. Shemesh, E. and Fine, R. N. (2010), Is calculating the standard deviation of tacrolimus blood levels the new gold standard for evaluating non-adherence to medications in transplant recipients? Pediatric Transplantation, 14: 940-943

    Objectives:

    1. Understand the importance of having a standard measure for compliance with immunosuppressant therapy amongst transplant patients.
    2. Apply the use of this standard deviation measure to monitor compliance amongst transplant patients in an uniform way.
    3. Understand the co-relation between psychiatric co-morbidity and substance abuse and non compliance amongst transplant patients.

    Relevance:
    Non compliance with immunosuppressants is a behavioral issue which leads to rejection amongst transplant patients . Monitoring non compliance can help identify psychiatric factors that may predispose to rejection.

     
  2. Psychosocial Characteristics and Treatments: Alcoholic Liver Disease (ALD) versus Non-ALD Patients
    Presenting Author:  Hong Yin
    Co-Authors:  Vani Ray, Han-Yang Chen, Vani Nilakantan, Pooja Madan, Shiva Kumar, Ishan Sinha, Julie Offutt

    Purpose: There is limited research comparing patients with ALD and non-ALD. This descriptive study aims to examine the differences between ALD and non-ALD patients on demographics, psychosocial history, and treatments used for the management of alcoholism and comorbid psycho-pathology.

    Methods: This study was conducted in a community tertiary care hospital in Milwaukee, WI. Data was extracted from the electronic medical records using ICD-9 codes for alcoholic and non-alcoholic liver diseases, from 1/1/2009 to 3/31/2011. Following IRB approval, a retrospective chart review of patients with liver diseases was performed. This included information about the patients' demographics, psychosocial history, and treatments employed for both alcoholism and comorbid psycho-pathology. For statistical analyses, t-test, chi-square or fisher's exact test was performed to examine the mean or proportional difference of variables between groups. All statistical analyses were performed using SAS 9.2.

    Results: Out of the total study population of 388 patients, 256 patients (66%) had ALD. The ALD population had a significantly higher proportion of Caucasians (66% vs. 53%, P<0.001), but there was no significant difference in age. ALD patients had a greater proportion of individuals with suicidal ideation (SI) (12.5% vs. 5.3%, p=0.026) and mood disorders (52.7% vs. 40.9%, p=0.027). Additional Axis I pathology (e.g. eating disorders and cognitive disorders) not categorized as mood, anxiety, or thought disorders were also more prevalent in ALD patients compared to non-ALD patients (36.7% vs. 23.5%, p=0.008). There was no significant difference in the proportion of ALD vs. non-ALD patients who had pharmacologic and/or behavioral management of their psychiatric pathology. About 30% of non-ALD patients and 51% of ALD patients currently consume alcohol. However, only 36.3% of ALD patients received formalized treatment for their alcoholism. ALD patients also had significantly higher dependence on nicotine (51.2% vs. 25.8%, p<0.001) compared to the non-ALD population.

    Conclusions: Both ALD and non-ALD patients had significant co-morbid psychopathology, which was addressed predominantly by pharmacotherapy. About 64% of ALD patients did not receive any treatment addressing alcoholism. Only 20.3% of ALD patients received optimal treatment of pharmacotherapy and counseling. These findings warrant further examination of the practice patterns of primary care and gastroenterologists who typically manage ALD patients.

    References:

    1. Bathgate, A.J. Recommendations for Alcohol-Related Liver Disease.

    2. Yates, William R., Martin, Maureen, LaBrecue, Douglas, Hillebrand, Don, Voigt, Michael, and Pfab, Debra. A Model to Examine the Validity of the 6-Month Abstinence Criterion for Liver Transplantation. Psychosomatics.1996; Volume 37: No. 3: 249-253.

    3. Bergmark A. On treatment mechanisms-what can we learn from the Combine study Addiction: 2008 May; 103(5):703-5. epub 2008 Jan 8.

    Objectives:

    1. Following the presentation, the physician will be able to note the demographic differences in ALD vs. non-ALD patients.
    2. The physician will compare and contrast the psycho-pathology found in ALD and non-ALD patients.
    3. The physician will note, compare, and contrast the management of alcoholism and psycho-pathology in ALD and non-ALD patients seen in practice.

    Relevance:
    ALD can be affected dramatically with optimal psychiatric management. Understanding the demographics, psychosocial history, and current management in practice of ALD vs. non-ALD patients helps identify means of enhancing care.

     
  3. Feasibility of a Health Coaching Program for Transplant Patients
    Presenting Author:  Sheila Jowsey
    Co-Authors:  Tara McCoy, Kristin Vickers Douglas, Julie Hathaway, Susanne Cutshall

    Purpose: Transplant patients manage chronic illness, undergo a surgical procedure and participate in intense follow up care in order to achieve graft survival. A health coach could provide assistance with these tasks. Health coaching provides patients with self management tools, coping strategies and assist in self activation in order to master complex medical regimens. Health coaching has been utilized successfully in a variety of chronically ill populations including diabetes, asthma, hypertension, cancer pain, obesity and more (Newnham-Kanas et al., 2009). The aim of this survey was to assess the feasibility and interest of transplant patients in a health coaching intervention to assist with ongoing management of their medical needs.

    Methods: This was an IRB approved survey of 50 solid organ transplant patients who came to the Mayo Clinic in Rochester, Minnesota between 09/2011-1/2012. Patients were either undergoing evaluation for transplant candidacy, were pre-transplant or post-transplant. Participants were given a brief description of health coaching along with a self-report survey of items created for the study. Statistical analysis consisted of descriptive statistics.

    Results: 26 out of 49 (52%) of the patients reported they would be interested in meeting with a health coach, 11 out of 49 (22%) would not be interested and 12 out of 49 (24%) did not know. Regarding what they’d like to discuss with a health coach; 60% - increasing physical stamina or exercise plans, 46%-weight management or nutrition counseling, 42% -coping with stress and anxiety or emotional changes through transplant, 38% -coping with physical symptoms, 26% -improving self care strategies, 26%-making health behavior change., 22% -taking medication or adjusting to the medical care plan and 14% - improving communication with the medical team. Some other areas the came up include: “budgeting money”, “sleepiness” and general “support and advice”. Regarding number of times they’d like to meet with their coach; 12% stated 1-2 times, 10% stated 4-6 times and 56% stated ‘as long as it is helpful’. 76% were willing to have follow-up visits over the phone after initial in-person session. For best time for transplant health coaching; 12 % preferred before listing, 38% -pre-transplant, 36%-in the first 3 months post transplant, 26%-3 month to 1 year post transplant, 8 %-after 1 year post transplant and 20% -anytime pre or post transplant

    Conclusions: The majority of transplant patients would be interested in consulting with a health coach at some point during the transplant journey. They were interested in consulting with a health coach on a variety of different topics pertaining to healthy behavior change and management of their graft and medical regime. Patients were interested in seeing a coach at many different time points in the transplant journey.

    Objectives:

    1. To become familiar with the concept of health coaching.
    2. To understand the relevance in the transplant setting.
    3. To understand the feasibility of a health coaching intervention in the transplant setting.

    Relevance:
    To assist psychosomatic medicine specialist in providing innovative services to meet the needs of complex medically ill patients.

     
  4. Early Liver Transplantation for Alcoholic Cirrhosis: Outcomes for Those with ≤ 6 Months Abstinence
    Presenting Author:  Terry Schneekloth
    Co-Authors:  Sheila Jowsey, Julie Heimbach, Tara McCoy, Michael Charlton

    Purpose: Relapse in liver transplant recipients with alcohol-induced liver disease (ALD) has been associated with poorer long-term survival. Several studies suggest up to 50% resume some degree of alcohol use within 5 years. Length of pre-transplant abstinence has been positively associated with post-transplant sobriety, with <3 months abstinence as a strong predictor of relapse (Hartl et al., 2011). Minimum 6 months pre-transplant abstinence is a widely used norm, though patients with less abstinence have been found to benefit from transplant and maintain sobriety (Mathurin et al., 2011). These findings support less rigid cut-offs to qualify for transplantation. Patients at our institution too ill to complete pre-transplant addiction treatment or attend AA are asked to verbally contract to attend post-transplant treatment. This study reviews outcomes in those with ≤6 months pre-transplant abstinence at our institution over the past decade.

    Methods: This was an IRB approved retrospective study of liver transplant recipients at Mayo Clinic, Rochester, Minnesota between 1/1/2000 and 12/31/2011. Patients identified in the Mayo Transplant Center registry with an alcohol-related diagnosis (ALD, alcohol abuse, alcohol dependence, alcoholic hepatitis) as a cause of their liver disease were reviewed for length of pre-transplant abstinence. Clinical data was abstracted from the electronic medical record for those with ≤6 months abstinence at time of transplant. Variables included age, sex, race, date of last clinical contact, post-transplant alcohol relapse (any consumption of alcohol), and date of death. Statistical analysis consisted of descriptive statistics.

    Results: Of 1228 total liver transplantations, 260 (21%) of the patients had an alcohol-related diagnosis as the primary or secondary indication for liver transplant. Twenty of 260 (8%) had ≤6 months abstinence at the time of transplantation, with mean of 3.7 months abstinence in this group. The majority were male (85%) and Caucasian (95%) with a mean age of 51.3 years. Follow-up time ranged from 1 month to 109 months. Seven of 20 (35%) are known to have relapsed to some degree of alcohol use post-transplant, and 4 of the 20 (20%) have died. Two of the four deceased patients were non-compliant with post-transplant care, and 1 of the 2 non-compliant patients was a known relapser.

    Conclusions: This retrospective analysis of 20 subjects with ALD and ≤6 months abstinence at the time of transplant found a relapse rate of 35%, which is less than rates observed at several centers for patients with longer abstinence. Eighty percent of these patients survive and only one known relapser has died. Non-compliance was a problem in at least 10%. These data support previous studies suggesting that carefully selected patients with limited pre-transplant sobriety may do well post-transplant without relapse and alcohol-related morbidity.

    Objectives:

    1. The physician learner will be able to identify evidence-based predictors of relapse to alcohol use in liver transplant recipients.
    2. The physician learner will be able to discuss issues critical to the assessment of alcoholic patients pursuing liver transplant with limited pre-transplant abstinence.
    3. The physician learner will be able to consider the role for early transplant in carefully selected alcoholic patients.

    Relevance:
    This topic is of central importance to the the C/L psychiatrist involved in the assessment of liver transplant candidates and addresses a controversial issue pertinent to the field.

     
  5. [T] From Bariatric Surgery to End-Stage Liver Disease: Evidence for Addiction Transfer?
    Presenting Author:  Lisa Miller
    Co-Author:  Anne Eshelman

    Purpose: While the idea of food addiction as a diagnosis is a controversial topic, there is growing research that suggests the possibility of addiction transfer from food to drugs and alcohol in bariatric surgery patients. Post-surgery, 5-30% of patients have shown addiction transfer behaviors, typically transferring to alcohol. Alcohol is the most common new addiction due to easy access, quicker absorption, reduced ability to metabolize, and increased consumption to achieve desired effect. While many bariatric centers encourage patients to not consume any alcohol post-surgery, many patients continue to consume alcohol and do not understand its' effects.

    Case Presentation: Ms. C, age 39, was transferred to our medical center with liver failure, hepatic encephalopathy, and GI bleeding. She was being considered for liver transplant because of end stage liver disease due to alcoholic cirrhosis and nonalcoholic steatohepatitis.

    Ms. C had gastric bypass surgery in 2005 at a bariatric surgery center in Mexico. Prior to surgery, she engaged in many behaviors consistent with food addiction, including continuing to eat even when feeling sick or satisfied, eating to alleviate negative emotions, sneaking/hiding food, continuing pattern of overeating, the inability to eat foods in normal portions, and obsessive about body image. After surgery, she lost 200 pounds. Her drinking increased from a 6 pack of beer on the weekends to 2-3 pints per week; however, her family suspected she was drinking more and was hiding the actual amount. She was not educated about the effects alcohol could have post-surgery. It is this increase in alcohol consumption that is believed to be the reason Ms. C developed cirrhosis and was evaluated for a liver transplant. Ms. C was in the hospital for several days when she developed multi-organ failure and became too sick for transplantation. She died in the hospital about 2 weeks after admission.

    Conclusions: Ms. C's increased alcohol consumption after bariatric surgery was likely an addiction transfer from food to alcohol. Additionally, morbidly obese patients are likely to have nonalcoholic steatohepatitis and the effects of alcohol and this disease are cumulative. It is important for bariatric centers to understand addiction transfer and educate their patients on the risks of potential addiction transfer. Psychiatrists and psychologists should screen patients both prior to surgery to evaluate their risk as well as post-surgery to determine if patients have developed any new addictive behaviors.

    References:

    1. McFadden, K.M. (2010). Cross-addiction: From morbid obesity to substance abuse. Bariatric Nursing and Patient Care, 5(2), 145-178.

    2. Hagedorn, J.C. et al. (2007). Does gastric bypass alter alcohol metabolism? Surgery for Obesity and Related Disease, 3, 543-548.

    3. Macias, J.A.G. & Leal, F.J.V. (2003). Psychopathological differences between morbidly obese binge eaters and non-binge eaters after bariatric surgery. Eating and Weight Disorders, 8, 315-318.

    Objectives:

    1. To understand the signs of food addiction.
    2. To understand addiction transfer.
    3. To learn how to evaluate their patients for the risk of addiction transfer after significant weight loss.

    Relevance:
    Psychiatrists and psychologists should screen patients both prior to surgery to evaluate their risk as well as post-surgery to determine if patients have developed any new addictive behaviors.

     
  6. Age-related Differences in Medication Adherence in Pediatric Renal Transplant Recipients
    Presenting Author:  Atsuko Inoue
    Co-Authors:  Takashi Oshimo, Hiroko Chikamoto, Remi Sato, Sachiko Nakamura, Sachi Okabe, Sayaka Kobayashi, Katsuji Nishimura, Motoshi Hattori, Jun Ishigooka

    Purpose: The risk of medication non-adherence is high among pubescent patients; thus, providing medication support appropriate to the developmental stage of the patient is a challenge that must be overcome in order to improve their long-term prognosis. The present study investigates the factors that influence medication adherence in child and adolescent renal transplant recipients.

    Methods: A questionnaire survey was mailed to the children and youths who received a kidney transplant and their families. The questionnaire contained (1) quality of life (QOL), using the Kid-KINDLR, Kiddo-KINDLR, and SF36; (2) anxiety, using the State-Trait Anxiety Inventory for Children and State-Trait Anxiety Inventory, (3) depression, using the Depression Self-Rating Scale for Children and Self-Rating Depression Scale. The questionnaire also contained open-ended questions on their daily medication management routine, and a multiple-choice question with 4 options about how often did they skip their medicines.

    Responses were received from a total of 51 persons (29 males and 22 females) across various groups (17 elementary school students, 12 junior high school students, and 22 senior high school students; response rate: 63.0%). The mean age of each group was 9.97±1.70 years, 14.08±1.14 years, and 17.19±1.10 years. The average age at the time of transplantation was 9.16 ± 4.30 years, average number of years after transplantation was 4.78 ± 3.16 years. Further, 77.8%, 69.2%, and 87.0% of elementary, junior, and senior high school students respectively had received a kidney from a living donor.

    Results: The responses to the open-ended questions indicated that medication of elementary school patients is managed mainly by their families. In contrast, 41.7% of the junior high patients, and 61.9% of the senior high patients reported self-medication management. On the basis of their responses to the aforementioned multiple-choice question, the patients were divided into two groups-those who forget or do not forget their medicines respectively. Variance between individuals in terms of anxiety, depression, and quality of life of the recipients and their families was examined using the Mann-Whitney U test. The junior high patients who forget to take their medicines (n = 3) exhibited significantly lower scores for total QOL and family-related QOL but significantly higher State Anxiety scores. The duration of treatment after transplantation was significantly longer for senior high patients who forget to take medicines (n = 7), but this group's scores for mental health-related QOL were significantly lower.

    Conclusions: Medication adherence in junior high school patients is likely to be influenced by family relationships and QOL, and in senior high school students, by the length of the treatment and presence of mental health problems. However, owing to the limited sample size of the present study, additional studies with more subjects should be conducted in the future to confirm the present findings.

    Objectives:

    1. To investigate the reality of the medication management in pediatric kidney transplant patients.
    2. To analyze the factors which are related to the immunosuppressant adherence in child and adolescent kidney transplant patients.
    3. To investigate how to support pediatric kidney transplant patients to enhance the medication adherence according to their stage of development.

    Relevance:
    To investigate the factors which are related to the medication adherence in pediatric kidney transplant patients in Japan, and discuss appropriate support according to the stage of development.

     
  7. [T] Body Image in a Kidney Transplant Clinic
    Presenting Author:  Michael Bolton
    Co-Author:  Amy Christianson

    Previous research suggests that body image concerns may be present in patients suffering from other medical, surgical and traumatic conditions. It has also been suggested that the study of body image in these areas may lead to greater rapport, compliance, and outcomes.

    The study of body image in the literature of eating disorders and plastic surgery suggests that body image is a measurable concept with psychological implications. Furthermore, the awareness that body image influences motivation and behavior, and perhaps quality of life, is documented in the literature.

    The kidney remains the most commonly transplanted organ in the world, and there are more people waiting for kidney transplants than any other organ, suggesting an opportunity to impact a large population of patients. Body image has not been widely studied in kidney transplant patients, however, despite the physical and psychological changes that occur in this population.

    This report presents four patients who were referred to the transplant psychiatry team. These cases illustrate the diversity of issues with body image, and of the kidney transplant patients who have them; in every case, however, the body image concerns were central to the patients' psychiatric complaints, and their body image concerns had not previously been addressed. In addition, the body image concerns in these patients may have contributed to changes in behavior, compliance issues, and reduction in quality of life. Body image concerns included dissatisfaction with scars, appearance of dialysis access, weight gain, short stature, and an abdominal wall defect. Resulting behavior modifications included changes in clothes selection, refusal to participate in activities requiring revealing the affected body area, reduced social interaction, and non-adherence with medications and medical advice.

    A concurrent search of the most common search engines (including Medline, Ovid, PsychInfo, and others) using the terms "body image" and "kidney transplant" returned only one item specific to body image in kidney transplant patients. A second search using the terms "body image" and "dialysis" returned two items specific to body image in renal patients.

    Difficulty studying body image in kidney transplant patients stems from many sources, including lack of awareness of the problem, lack of transplant-specific body image measures, and multiple confounding factors in this population, including dialysis and access history and co-morbid conditions. At the same time, body image changes are likely present in this large population and may contribute to depression, anxiety, poor adherence, poor quality of life, and worse medical and surgical outcomes.

    Based on a review of the existing literature and a sample of kidney transplant patients, the further study of body image in patients undergoing kidney transplant procedures is warranted. Results of this research may be applicable to other solid-organ transplants as well.

    Objectives:

    1. Summarize the concept of body image, and highlight its potential influences on motivation, behavior, and quality of life.
    2. Review existing literature on body image in renal patients, particularly those with kidney transplants, and emphasize the need for further study in this area.
    3. Discuss several kidney patients which illustrate the impact of body image on motivation, behavior, or quality of life.

    Relevance:
    The topic of body image is an area which has not been widely studied in the medical literature, despite its far-reaching impact on the psychological well-being of psychosomatic patients.

     
  8. [T] Positive THC Urine Toxicology of Liver Transplant Patients: Reliable or Smoke Screen?
    Presenting Author:  Anne Eshelman
    Co-Authors:  Erin Ross, Lisa Miller, Agnes Wrobel

    Purpose: Pretransplant psychosocial evaluation is an important part of the transplantation process, frequently including substance use/abuse history. Full abstinence from alcohol and illegal substances is often a requirement prior to transplantation. Many transplant centers implement repeated random drug screening to assess ability to maintain abstinence. In the case of cannabis, screening for the presence of 11-nor-9-carboxy-9-tetrahydrocannabinol (THC) may be misleading after use cessation, particularly in chronic, or heavy, users who are experiencing liver impairment. Therefore, THC level alone may not be the best indicator of continued cannabis use or abstinence.

    Case Report: A 56-year-old Caucasian male (VE) with end stage liver disease received evaluation for liver transplantation. His initial urine toxicology screen indicated a THC level of 568 ng/mL with a THC/creatinine ratio of 148 ng/mL. Initial psychiatric assessment was significant for daily cannabis abuse for the past 30 years. VE was told that he would need to demonstrate 6 months of abstinence from marijuana. He consistently maintained that he quit using marijuana 3 months prior to his initial evaluation. Three months following this evaluation a urine toxicology screen indicated a THC level of 434 ng/mL and THC/creatinine ratio of 111 ng/mL. Forty-three days later VE was subjected to another random urine drug screen revealing significantly lower, but still positive, THC level and THC/creatinine ratio. VE's statements of abstinence and his continued positive levels appeared inconsistent, resulting in considerable debate regarding whether VE had met the transplant substance use criteria of 6 months of abstinence.

    Conclusion: The urine THC/creatinine ratio is the best monitor to determine the possibility of continued drug usage. With abstinence, the ratio typically decreases within one week by a factor of two or more [2]. Serial examination of THC/creatinine ratio is an appropriate means of confirming current versus past cannabis use. In healthy controls, infrequent use of cannabis is typically detected for 5 to 14 days, and heavy, chronic use from several weeks to a month [1]. However, one patient with severe impaired liver function had positive results for 202 days after cessation [1]. Despite the continued levels of THC in VE's urine, the declining THC/creatinine ratio was suggestive of his significant reduction of cannabis use or possible abstinence. Still unclear is his actual cessation date, as liver impairment may have significantly impacted his liver's ability to metabolize THC reserves.

    References:

    1. Chaiffetz, D., DiMartini, A.F., &Venkataramanan, R. (2011). Prolonged excretion half- life of 11-nor-9-carboxy-9-THC following cessation in a chronic, heavy marijuana user: Implications for liver transplant assessment, Psychosomatics, 52, 190-193.

    2. Huestic, M.A. & Cone, E.J. (1998). Differentiation new marijuana use from residual drug excretion in occasional marijuana users. Journal of Analytical Toxicology, 22, 445-454.

    Objectives:

    1. Examine the differences between THC and THC/Creatinine laboratory cannabis testing.
    2. Awareness of how liver impairments may impact THC metabolization.
    3. Review of a chronic cannibis user who continued to display THC levels after 202 of cessation of use.

    Relevance:
    Through the discussion of a liver transplant case study, the difference laboratory cannabis tests will be reviewed, as well as, how liver impairments may impact cannabis metabolization.

     
  9. [T] Motivational Interviewing: A Rescue Strategy after Rejection Due to Noncompliance in a Young Heart Transplant Recipient
    Presenting Author:  Caroline Saulino
    Co-Authors:  Anne Eshelman, Mauricio Velez

    Introduction: Treatment noncompliance in organ transplantation can lead to increased morbidity and mortality. Post-transplant medication regimen is of particular concern, given that patients must maintain life-long adherence to immunosuppressants to avoid potentially fatal organ rejection. Motivational Interviewing (MI) is a communication style helpful in exploring patients' ambivalence to change, and is shown to increase positive behavioral outcomes when used to address issues of noncompliance.

    Background: MB is a 22-year-old, Caucasian male with a history of hypertrophic cardiomyopathy (diagnosed age 11) with progressive deterioration leading to heart failure. At age 16, he underwent orthotopic heart transplantation. He had a complicated post-surgical hospitalization, with subsequent cardiac arrest and a prolonged period of hemodialysis dependent renal failure. MB had no history of rejection episodes prior to assuming management of his own care during transition from adolescence to adulthood.

    Case Presentation: Once responsible for his care, MB became increasingly noncompliant. A review of medical record revealed significant noncompliance with regard to medications, missed appointments, disregard of contact from cardiology, missed lab-work, and nutritional and physical activity recommendations.
    Over a year and a half, MB ultimately required three separate hospitalizations for severe acute cellular and humoral rejection. He was treated with routine courses of IV corticosteroids, plasmapheresis and IVIG. However, on his third hospitalization he also received rituximab and bortezomib due to recurrent humoral rejection. He was repeatedly informed of the importance of treatment compliance.
    Transplant psychiatry was consulted for noncompliance on first admission. MB was resistant to psychiatry and reluctant to build rapport. Following second admission, a family meeting was held including MB, his mother, cardiology, and transplant psychiatry. He was again informed of the necessity of compliance, questioned regarding reasons for noncompliance, and told that he would not be a candidate for future transplant due to his poor compliance. At that time, patient disengaged, and his mother was advised to reassume responsibility for his care.
    Transplant psychiatry was again consulted on third admission. After several encounters of rapport building, Motivational Interviewing strategies were introduced (in context of two, 15-20 minute follow-ups) to target MB's ambivalence to making necessary lifestyle changes (strict medication compliance, healthy nutrition, and appropriate physical activity). MI strategies included asking permission, exploring pros/cons of change, eliciting change talk (personal reasons for change), and provoking extreme scenarios. Session dialogue will be included.
    Following use of MI strategies, patient has required no further hospitalization in past four months. He has maintained therapeutic levels of immunosuppressant medications, with no further evidence of rejection.

    Discussion: Who should be responsible for a chronically ill patient's care during transition from adolescence to adulthood? How can MI be useful in helping young patients assume responsibility for their own care? Related ethical issues will be discussed.

    Objectives:

    1. Understand the effectiveness of motivational interviewing in targeting patient ambivalence to healthy behavior change.
    2. Learn to integrate an effective method of communication (motivational interviewing) to improve patient outcomes within the context of a 15 minute consultation.
    3. Examine how the use of motivational interviewing can reduce frustration with noncompliant patients.

    Relevance:
    Highlight important ethical issues related to responsibility of care during patient transition from adolescence to adulthood; how motivational interviewing can increase patient motivation to take responsibility for care.

     
  10. Use of Nutraceuticals in Transplant Patients: “Doctor Can I use XanGo Juice?”
    Presenting Author:  Kathy Coffman

    Purpose: Patients are using various nutraceutical juice beverages, such as Acai, noni and mangosteen that can potentially interact with immunosuppressant drugs. This case report illustrates problems associated with nutraceuticals.

    Methods: This 57 year old female kidney transplant candidate had chronic migraine headaches treated with an aspirin and caffeine pill until 5 years ago due to kidney failure, and due to being on lithium for Bipolar 2 disorder. The patient had not had a manic episode in 30 years. The patient had been using XanGo juice, an extract of mangosteen for migraines, chronic sinusitis and pedal edema. She had been a chronic analgesic user for 40 years, including Naprosyn and ibuprofen. She also used L-Lysine for her cold sores, and had tried acupuncture for her headaches in the past. She was taking Nucinta for pain, which can cause serotonin syndrome if combined with SSRIs. Her score on PHQ-9 was 4 and on the GAD-7 was 5. She had no history of substance abuse other than cannabis from age 17-18 years old. She had a family history of Bipolar 1 disorder in a maternal cousin, and one brother with major depression. Labs showed lithium level of 0.4,BUN 57, creatinine 4.09, TSH 1.28, and QTc was 449. Score on the Mini-mental Status Exam was 29/30.

    Results: The extract used in XanGo is epsilon-Mangostin, which is reportedly active at muscarinic, andhistaminergic sites and alters bradykinin receptor mRNA. This substance decreases CRP, a marker for inflammation, but has not been reported to alter cytokines. The substance increases Serotonin and affects Cytochrome 2A and 2C, but did not have reported effects on Cytochrome 3A4, which is the main route of metabolism of the main transplant drugs such as tacrolimus and cyclosporine. A recent study showed that Mangosteen was second to pineapple juice in inhibiting CYP1A1, CYP1A2, CYP2E1, and CYP3A11 in mice.

    Derivatives of garcinia mangostana are touted for antibacterial, antifungal,antiviral and cytotoxic effects, but safety claims are based on studies with small sample sizes and short duration. There has been one case of severe lactic acidosis from mitochondrial toxicity perhaps due to daily mangosteen juice ingestion for 1 year. A closely related species, garcinia caombogia may be a hepatotoxin.

    XanGo is a mixture of Mangosteen juice, with apple, blueberry, cherry, cranberry, grape, pear, raspberry, and strawberry juices. This product sells for $37.50 for 750 ml (25.35 oz) versus $5-6 for similar sized bottles of pomegranate juice.

    Despite not having direct effects on the immunosuppressants, the patient was advised to cease use of XanGo due to the possibility that the substance could have previously unknown properties that could affect the outcome with kidney transplantation.

    Objectives:

    1. Claims for the benefits of nutraceutical products are often based on weak medical evidence such as studies with small sample sizes and short duration, but bolster a multi-million dollar industry.
    2. The participant will learn the potential interactions between mangosteen juice and Cytochrome P450 enzymes.
    3. The participant will learn the adverse effects associated with chronic mangosteen juice ingestion.

    Relevance:
    Nutraceutical products contain botanical substances that can interact with various prescription medications. Clinicians should be aware of trends in the industry of nutraceutical beverages and their pseudoscientific health claims.

     
  11. Screening for Low Testosterone in the Transplant Psychiatry Clinic
    Presenting Author:  Kathy Coffman

    Purpose: Low testosterone is recognized as a cause of sexual dysfunction in men and affects mood, fatigue, and cognitive functioning. Low testosterone has also been linked to comorbidities: diabetes, heart failure and metabolic syndrome. Major depression has been shown to be a stronger factor in sexual functioning than hypogonadism. Hypogonadism in depressed men has been shown to affect orgasm and desire, but not arousal.

    All male transplant patients being treated for depression that reported sexual dysfunction were tested for total testosterone levels to see whether there was a need for intervention. One recent paper showed testosterone gel to be superior to testosterone patch for erectile dysfunction, therefore this is a condition that can be readily treated if detected. In the past, many men were not interested in monthly testosterone shots.

    Methods: The patients were interviewed about sexual dysfunction as part of standard treatment for depression. If no total testosterone level had been obtained in the past, and the patient agreed to have levels drawn this was done; none refused.

    Results: Studies done in the past have been small and mainly related to osteoporosis in heart and kidney transplant patients rather than complaints of sexual dysfunction. Patients in our transplant psychiatry clinic included kidney, kidney-pancreas, liver, lung and small bowel transplant patients. Using a cut-off of 250 ng/100ml there were 38.5% below that level. Using a cut-off of 300 ng/100 ml as done in one of the older kidney transplant papers, a total of 46.2% patients were below that level.

    Conclusion: The transplant literature shows mixed results with some studies showing that testosterone levels returns to normal within 6 months of liver transplant; however, in heart transplant and kidney transplant recipients testosterone levels may remain low regardless of the type of immunosuppression used. There are few studies, and they are limited, like this study by small sample size. There is no other published data on pancreas or small bowel transplant patients and low testosterone. The only paper on lung transplant patients referred to men with cystic fibrosis.

    Some studies indicate there may be some impairment in the hypothalamic axis. Testosterone has been thought to remain normal in liver patients pre-and post liver transplant, which differs from this study. The finding that in our transplant psychiatry clinic, 46.2% (12/26) of the patients with depression and sexual dysfunction had testosterone below 300 ng/100ml indicates that screening for low testosterone may be beneficial in all male transplant patients, whether pre- or posttransplant. Testosterone levels ranged from 75-1199. The patient with the highest level denied using exogenous androgens. In general, male transplant patients with erectile dysfunction, particularly if on SSRIs should be tested for low testosterone.

    Objectives:

    1. The participant will learn the psychiatric and medical co-morbidities associated with low testosterone in male patients.
    2. The participant will become aware of the literature in low testosterone in transplant patients, and need for more systematic research in this area.
    3. The participants will recognize the high frequency of low testosterone in depressed male transplant patients with sexual dysfunction, and the utility of screening.

    Relevance:
    The impact of sexual dysfunction in male transplant patients, and high frequency of this treatable condition indicates that screening is likely to significantly affect quality of life in transplant patients.

     
  12. [T] Health Literacy and Numeracy in Transplantation: What Is Our Ethical Responsibility to Ensure Understanding?
    Presenting Author:  Maren Hyde-Nolan
    Co-Authors:  Anne Eshelman, Lisa Miller

    Purpose: Successful organ transplantation requires long term adherence to complex medical regimens. Pre-surgical evaluations need to assess candidates’ cognitive ability to take medication accurately and follow directions. This study screened candidates for health literacy, health related numerical ability, and general cognitive ability.

    Half of Americans have limited health literacy, the ability to obtain, process, and understand basic information required to make health decisions. In the absence of gross cognitive deficits, physicians are often unaware of their patients’ limitations, which may impair communication with medical professionals, understanding of diagnoses, and adherence to treatment regimens.

    Methods: This study screened 98 patients with end stage disease during the work up for transplantation (67.3% M; 62% Caucasian). The sample included 39% needing liver transplant, 19% kidney, 18% heart, 14% lung, and 10% bone marrow transplant. Screening included the Montreal Cognitive Assessment (MoCA), a brief measure of cognitive functioning, the Rapid Estimate of Adult Literacy in Medicine (REALM) and a measure of medical math (MM); 4 items specific to calculating simple nutrition and medication changes.

    Results: Higher education was related to both higher reading level (F=14.08, p<.001) and medical math (r=.44, p<.001). Reading level was also significantly related to medical math (F=20.00, p<.001). Both were related to cognitive functioning on the MoCA (REALM F=17.85, p<.001; MM r=.45, p<.001) as well as subscales: executive functioning (F=3.03, p=.03; r=.37, p=.001), attention (F=18.66, p<.001; r=.29, p=.01), language (F=13.26, p<.001; r=.28, p=.01), abstraction (F=5.77, p=.004; r=.24, p=.04), delayed recall (F=7.31, p=.001; r=.27, p=.02), and orientation (F=3.64, p=.03; r=.28, p=.02). Strikingly, although 95.9% had ≥ a 9th grade education, only 70% of the sample could read at the 9th grade level, and 48.7% of the sample scored < 4/4 on simple medically related arithmetic.

    Conclusions: Doctors and nurses are likely unaware of deficits which may impact understanding and adherence. Simply inquiring about patients’ education level is not sufficient to accurately assess health literacy. Providers have an ethical responsibility to screen for health literacy and identify patients who need more assistance. Recommendations can then be provided in ways that these patients are able to comprehend, thus leading to increased medical compliance and better outcomes.

    References:

    1. Arozullah AM, et al. (2007). Development and validation of a short-form, rapid estimate of adult literacy in medicine. Medical Care. 45(11), 1026-1033.

    2. Nasreddine ZS, et al. (2004). The Montreal Cognitive Assessment (MoCA): a brief cognitive screening tool for detection of mild cognitive impairment. Neurology. 62(7), A132.

    3. Paasche-Orlow MK, et al. (2005). The prevalence of limited health literacy. Journal of General Internal Medicine. 20, 175-184.

    Objectives:

    1. Appropriately assess health literacy levels in patients undergoing organ transplantation.
    2. Identify patients who require more assistance based upon obtained health literacy levels.
    3. Provide appropriate recommendations for patients based upon obtained health literacy levels.

    Relevance:
    Providers have an ethical responsibility to screen for health literacy and identify patients who need more assistance. Appropriate recommendations can lead to increased medical compliance and better outcomes.

     
  13. The Stanford Integrated Psychosocial Assessment for Transplantation (SIPAT) – A Year Later: Predictability of Psychosocial and Medical Outcomes
    Presenting Author:  Jose Maldonado
    Co-Authors:  Yelizaveta Sher, Heavenly Swendsen, Evonne David, Danica Skibola, Catherine Sullivan, Kimberly Standrige, Sermsak Lolak

    Background: There is a limited amount of organs available for transplantation, thus it is important to carefully assess patients to assure the most success after transplantation. We developed and tested a new pre-transplant assessment tool: the Stanford Integrated Psychosocial Assessment for Transplantation (SIPAT) which evaluates known psychosocial risk factors for organ transplantation, which has been shown to have excellent inter-rater reliability (Pearson's correlation coefficient = 0.853) and to be highly predictive of the transplant psychosocial outcome (P < 0.001).

    Methods: We identified patients receiving heart, lung, liver or kidney transplant during the period of 6/1/2008 through 7/31/2011 at Stanford Hospital who were assessed with the SIPAT pre-transplantation and were closely followed by our transplant team post-transplantation. We then reviewed and compared prospectively accumulated psychosocial and medical outcomes up to one year of follow-up, including: organ survival (primary outcome); and patient survival, rejection episodes, medical re-hospitalization, infection rates, non-compliance rates, psychiatric decompensation, new or recurrent substance abuse, failure of support system, and albumin levels (secondary outcomes). Patients were compared according to their categorical (SIPAT score equal or below 20 and SIPAT score of 21 and greater) division and continuous SIPAT scores.

    Results: A total of 216 patients were identified during the index period (including 46 heart, 58 lung, 58 liver and 54 kidney transplant patients). Of these, 179 patients had SIPAT score of 0 - 20, while 37 patients had scores 21 - 68. Although there was no significant difference in the primary outcome (e.g., organ failure), patients with higher SIPAT scores had statistically significant higher rates of psychiatric decompensation (p=0.005), non-adherence with medical treatment (p=0.012), and most significantly they had a statistically significant higher rate (p=0.017) and a greater number of medical hospitalizations. For example, while 54 % of patients with SIPAT scores ≤20 had one or more post-transplant hospitalization, 73 % of those with SIPAT scores ≥ 21 were hospitalized. Moreover, while on average a patient with SIPAT score ≤ 20 had 2.2 hospitalizations per year (weighted), a patient with SIPAT score ≥ 21 experienced 3.1 hospitalizations during the same period. We acknowledge the follow-up course is limited and expect that continued surveillance of subjects and an extended follow-up period will yield even more significant results.

    Conclusions: The SIPAT is a comprehensive screening tool designed to assist in the psychosocial assessment of organ transplant candidates, while standardizing the evaluation process and helping identify subjects who are at risk for negative outcomes after transplantation, which allows for the development of interventions directed at improving the patient's candidacy. The outcomes of the current study suggest the SIPAT is a promising pre-transplantation assessment tool whose results may help predict not only psychosocial outcomes, but also medical outcomes after the transplantation.

    Objectives:

    1. The audience will be able to indentify the psychosocial risk factors for organ transplantation patient.
    2. The audience will be able to appreciate the psychosocial evaluation of the transplant candidates with the new assessment tool SIPAT.
    3. The audience will understand and appreciate which psychosocial and medical outcomes are predicted by the pre-transplant application of the SIPAT.

    Relevance:
    SIPAT is a new assessment tool created for evaluating known psychosocial risk factors. In this presentation, we report the newest findings on its predictive characteristics during one year post-transplant period.

     
  14. Psychosocial Characteristics of Potential Liver and Kidney Transplant Candidates
    Presenting Author:  Jorge Luis Sotelo
    Co-Authors:  Ingrid Gabriela Barrera, Rachel Freed, Rachel Lerner

    Purpose: The selection of appropriate candidates for solid organ transplantation is essential and a key role of the health care professional who conducts the pre-transplant psychosocial evaluation is to identify factors that may predict poor post-transplantation outcomes and make recommendations to improve the likelihood of a satisfactory post-transplant outcome. This pilot, retrospective study examines the psychosocial factors prevalent in patients with end-stage liver and kidney disease being considered for transplantation at the Miami Transplant Institute.

    Methods: One hundred men and women with end-stage liver or kidney disease were evaluated during routine pre-transplant psychosocial evaluation. They participated in a structured interview and completed the Beck Depression Inventory-2nd edition (BDI-II), Repeatable Battery for the Assessment of Neuropsychological Status (RBANS), NEO Personality Inventory-# (NEO-PI-3), State-Trait Anxiety Inventory (STAI), Alcohol Use Disorders Identification Test (AUDIT), Drug Abuse Screening Test (DAST), and Multidimensional Scale of Perceived Social Support Social Support. The goal of the pre-transplant psychosocial evaluation at our institution is to obtain information on five important domains for each patient assessed: personality characteristics, psychopathology (depression and anxiety symptoms), substance use disorders, available social support, and cognition. The psychosocial profile of the liver transplant candidates and kidney transplant candidates were compared. In addition, the medical records of patients who underwent transplantation were reviewed to determine which pre-transplant factors were associated with good or poor outcomes.

    Results: Data collection and analysis is ongoing.

    Conclusion: Our findings will expand upon the literature of psychosocial factors associated with poor post-transplant outcomes and will identify similarities and differences between two different patient populations of transplant candidates, those with end-stage kidney disease and those with end-stage liver disease.

    Objectives:

    1. Understand the psychosocial factors commonly found among solid organ transplant candidates.
    2. Determine which psychosocial variables are associated with desirable or poor post-transplant outcomes.
    3. Understand the similarities and differences in the psychosocial profiles of patients with end-stage kidney disease and end-stage liver disease.

    Relevance:
    This presentation will expand upon the existing literature of psychosocial profiles of transplant candidates and will highlight the profiles of minorities, which have not been studied in great detail.

     
  15. Ethical Considerations in the Evaluation of Altruistic Kidney Donors: An Interesting Case and a Review of the Current World Literature
    Presenting Author:  Jorge Luis Sotelo
    Co-Authors:  Ingrid Gabriela Barrera, Rachel Freed

    Purpose: Due to the shortage of available organs for donation, transplant centers around the world evaluate individuals interested in donating to a nonrelative, a process known as altruistic donation. These individuals have generally had positive psychological outcomes. A comprehensive evaluation process, which includes neuropsychological testing, is utilized at the Miami Transplant Institute for the evaluation of altruistic donors. We present the controversial case of a young woman who underwent this comprehensive evaluation and was eventually found to be a good candidate for kidney donation.

    Methods: The existing world literature on altruistic solid organ donation was reviewed with special emphasis on ethical considerations and psychological outcomes. The case of a 23-year-old woman who was compelled to undergo a pre-kidney-donation evaluation at the Miami Transplant Institute is reviewed. She became interested in donating to an individual who had received attention from the local media for the manner in which she had made public her need for a kidney. Prior to donation, she was administered a structured diagnostic interview and the Repeatable Battery for the Assessment of Neuropsychological Status (RBANS), Millon Clinical Multiaxial Inventory-III (MCMI-III), NEO Personality Inventory-3 (NEO-PI-3), Beck Depression Inventory-II (BDI-II), Multidimensional Scale of Perceived Social Support (MSPSS), and State Trait Anxiety Inventory (STAI). Three months post-donation she was again interviewed and administered the RBANS, BDI-II, STAI, and SF-36v2 Health Survey.

    Results: Our donor had a good physical and psychological recovery from kidney donation surgery and her pre-donation attitude of contributing to the welfare of others was enhanced by her experience, about which she had no regrets.

    Conclusion: Our case highlights how a case with some ethical challenges eventually resulted in a favorable psychological outcome because of the effort that was devoted to adequately assess the candidate.

    Objectives:

    1. Understand the discrepancy between the number of individuals with end stage organ disease in need of a transplant and the organs available.
    2. Understand challenging ethical considerations in the unique situation of altruistic solid organ donation.
    3. Review the psychological outcomes in altruistic donors and describe a comprehensive evaluation battery developed for the assessment of these donors.

    Relevance:
    This case and literature review will highlight the psychological outcomes of altruistic donors and the ethical considerations inherent in the assessment of individuals who choose to donate to a nonrelative.

     

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Session G:  Potpourri

  1. Psychiatric Predictors of Pre-Surgery Dropout Following Suitability Assessment for Bariatric Surgery
    Presenting Author:  Sanjeev Sockalingam
    Co-Authors:  Stephanie Cassin, Sean Crawford, Kristen Pitzul, Attia Khan, Raed Hawa, Timothy Jackson, Allan Okrainec

    Introduction: Bariatric surgery is recognized as a treatment for severe obesity and requires comprehensive interdiscplinary assessment, including psychiatric or psychological assessment, to determine suitability for this procedure. Despite the development of thorough pre-surgery assessment pathways within bariatric surgery programs, little is known about factors influencing patient drop out pre-surgery.

    Objective: The objective of this study was to explore the relationship between psychiatric factors and patient drop out during the pre-surgery assessment for suitability.

    Methods: A total of 367 subjects who were referred to the Toronto Western Hospital Bariatric Surgery Program for Roux-en-Y gastric bypass surgery were recruited for the study. All subjects underwent a structured psychiatric interview using the MINI International Neuropsychiatric Interview administered by a psychiatrist or psychologist in the program to determine psychiatric diagnosis. Subjects were classified as "Drop Outs" if they attended a least one pre-surgery assessment appointment and were compared to patients who completed bariatric surgery.

    Results: The presence of an anxiety disorder, substance use disorder or Axis I psychiatric disorder in the past was significantly higher in the pre-surgery Drop Out group. This group also exhibited a significantly higher rate of either a past or current post-traumatic stress disorder, current generalized anxiety disorder and past substance use disorder.

    Conclusions: A past history of an anxiety or substance use disorder may play a role in patient "drop out" during the bariatric surgery pre-operative phase. Additional psychosocial support, such as cognitive behavioral therapy or motivational interviewing, may help reduce patient "drop out" durign the pre-surgery phase.

    Objectives:

    1. Describe the importance of adherence to bariatric surgery outcomes.
    2. Identify psychiatric risk factors for "drop out" pre-bariatric surgery.
    3. Discuss potential interventions to reduce patient drop out during the pre-bariatric surgery assessment phase.

    Relevance:
    These study results will help clinicians identify psychiatric factors increasing the risk of non-adherence to appointments pre-surgery and may apply to other surgical populations requiring pre-surgery assessments.

     
  2. Integrating Mental and Primary Care among Chinese Americans Using Collaborative Care
    Presenting Author:  Benjamin Woo

    Purpose: Chinese Americans are at high risk for under-utilizing mental health services, and the primary care setting is an excellent context to address and reduce such health disparities (1,2,3). Collaborative care for depression treatment is an approach to decrease stigma associated with mental illnesses and to increase access to care. Utilizing early career psychiatrists who are language proficient may further enhance integration of depression care in primary care settings. This study sought to assess the prevalence of depressive and medical disorders, as well as likelihood of accepting mental health treatments, among Chinese Americans in a Los Angeles community clinic.

    Methods: The sample for this study consisted of 292 patients who received primary care from Herald Christian Health Center (HCHC) in Los Angeles. HCHC serves low-income Chinese Americans with limited English proficiency. This predominantly immigrant population faces challenging economic and social conditions, as majority of these patients lacked health insurance, were low-income (less than 200% poverty), and linguistically isolated. Depression was determined using the Patient Health Questionnaire-9 (PHQ-9). Baseline clinical and demographic factors were obtained for analyses.

    Results: 45 (15.4%) patients screened positive for depression (PHQ-9 score ≥ 10). Comparing these patients with the patients who did not have depression found no differences in age, gender, number of medical conditions, or anxiety disorders. Patients who screened positive for depression were more likely to already be on antidepressant medications (5/45 versus 8/247; p <0.01). Among the depressed patients, 29 (64.4%) patients accepted collaborative care provided by a culturally proficient team (a registered nurse and an early career psychiatrist who are both fluent in Chinese.) Furthermore, 6 (13.3%) depressed patients accepted additional treatment on top of the collaborative care model by enrolling in therapy provided by a mental health center.

    Conclusions: This study found a prevalence of 15.4% for current depressive disorders among Chinese Americans in primary care in Los Angeles. While depressed patients were more likely to already be on antidepressant medications, overall treatment utilization rate remains low. A culturally sensitive collaborate care model may enhance acceptance of depression care among Chinese Americans in primary care settings.

    Objectives:

    1. To analyze the prevalence of Chinese Americans under-utilizing depressive mental health services.
    2. To investigate whether culturally enhanced collaborative care could improve mental health utilization rate among Chinese Americans.
    3. To create a model on how early career psychiatrists may continue to grow and thrive in their identities as psychosomaticians.

    Relevance:
    This study attempts to provide baseline characteristics on a culturally enhanced collaborative care for depression treatment in a primary care clinic for Chinese Americans utilizing an early career psychiatrist.

     
  3. Understanding Medical Legal Tools and Strategies: The Key to Tax Reduction and Lawsuit Prevention
    Presenting Author:  Daniel McNeff

    The presentation is all about proper structuring of medical professionals' legal entities (Living Trusts, Family Limited Partnerships, Partnerships, C and S Corps and LLC's) to accomplish the following:

    * Understand of correct legal deductions of each entity and correct partnership structuring for lawsuit prevention and tax reduction.

    * Structure your practice for maximum tax reduction and malpractice protection and prevention.

    * Maintain the focus of medical practice on improved patient care rather than malpractice defense.

    * Ensure 100% protection of personal and professional assets from lawsuits through applied risk management.

    * Reduce malpractice insurance costs and taxes.

    * Keep focus on patients (not legal defense, taxes, etc) keeping medical practice costs down, keeping patient costs down.

    Remember, the economy is in a mess. People are more likely to resort to acts of desperation to get by. Taxes are getting higher and higher. Delayed discovery is being publicized giving ideas to create lawsuits. Society in general has accepted the idea of lawsuits as a legitimate way to get income; even if the lawsuit is filed with false pretense, they are looking for a settlement. This poster will illustrate how to protect 100% of personal and business assets while reducing taxes with the same tools.

    Objectives:

    1. Analyze current entities, investigate possibilities to structure entities for maximum tax reduction and lawsuit prevention.
    2. Maintain focus on patient's medical diagnosis with no threat to practice defensive diagnosis. Investigate ways to protect against delayed discovery.
    3. Create and apply strategies that will provide peace of mind through applied risk management tools. Create peace of mind for the practice and more focus on patients.

    Relevance:
    Society in general has accepted lawsuits as a legitimate way to get income; even if the lawsuit is filed with false pretense, they are looking for a settlement, targeting physicians.

     
  4. [T] Edema, a Rare but Serious Side Effect of Quetiapine
    Presenting Author:  Maria Hussain
    Co-Author:  Kola Oyewumi

    Background: Quetiapine is a widely used atypical antipsychotic medication approved in many jurisdictions for the treatment of Schizophrenia spectrum disorders and Mood disorders. Recently the indication has expanded to include children and adolescents in U.S.A. It may not be too long before approval for use in geriatrics is obtained as well. Indeed its off-label use in this population is common knowledge.

    Purpose: The purpose of this article is to provide a case-based review of quetiapine-induced edema, highlighting the factors that contribute to the development of this side effect, to better guide clinicians in the management and monitoring of their patients on quetiapine. We also report the first case of quetiapine-induced edema in a patient with first episode psychosis.

    Results: Our review indicates that quetiapine-induced edema is more common in females, in patients on polypharmacy, and it is independent of the time on quetiapine. However, in our patient with first episode psychosis, polypharmacy was not a factor.

    Conclusion: Quetiapine-induced edema can be extremely distressing for the patient, leading to non-compliance and relapse of psychiatric symptomatology. Additionally, it can lead to multiple unnecessary investigations, which are tedious and cumbersome for the patient, and also a burden on the scarce resources. With the increasing number of approved uses of quetiapine, we need to be cognizant of this distressing adverse effect.

    Objectives:

    1. To review the expanding range of approved and off-label uses of quetiapine, as well as the recent increasing reports of edema associated with quetiapine therapy.
    2. To summarize the factors associated with quetiapine induced edema.
    3. To discuss the clinical implications of quetiapine induced edema in every day practice.

    Relevance:
    Quetipaine is a widely used atypical antipsychotic with FDA approved and off label indications. It is therefore imperative that physicians recognize this distressing side effect which can have important implications.

     
  5. [T] Levamisole: A Common Cocaine Adulterant with Life-Threatening Side Effects
    Presenting Author:  Carolyn Auffenberg
    Co-Authors:  Lisa Rosenthal, Nehama Dresner

    Levamisole (Ergamisol) is a synthetic imidazothiazole derivative that has been used legally as both an antihelminthic and immunomodulatory medication. This drug was withdrawn from the US market in 2000 due to risk of serious side effects - most common of which was agranulocytosis.

    The purpose of this poster is to use a case-presentation of a patient who presented to the emergency room after using cocaine to introduce the morbidities of levamisole-adulterated cocaine to the psychosomatic literature.

    To accomplish this, a brief review of the literature will be presented summarizing the history of illicit drug contamination, as well as the various theories of how levamisole has entered into over 70% of the illicit cocaine consumed in the US. This poster will also present the well-documented complications of levamisole both from its time as a legal therapeutic and those seen more recently, since its introduction to illicit cocaine as a "cutting" agent. Most of these complications are immune-mediated, and include neutropenia and agranulocytosis, cutaneous vasculopathy, and a reversible multifocal inflammatory leukoencephalopathy.

    A case will be discussed, of a patient with a cutaneous vasculopathy thought secondary to levamisole-adulterated cocaine. This case will include a series of images documenting the development of the characteristic dermatologic changes and a brief explanation of the proposed pathogenesis.

    Finally, this poster will suggest areas of future research as well as special considerations and counseling points for patients who develop the known complications as above after use of levamisole-adulterated cocaine.

    Objectives:

    1. Identify Levamisole as a common cocaine adulterant.
    2. Understand the theories of levamisole's presence in illicit cocaine.
    3. Identify the life-threatening side effects of levamisole exposure.

    Relevance:
    Psychosomatic teams are often consulted regarding cocaine intoxication/withdrawal, and should understand that levamisole is an additive in cocaine which has life-threatening side effects, including neutropenia, agranulocytosis, and cutaneous vasculopathy.

     
  6. [T] Prescription Drug Monitoring Programs and Their Potential Role in Psychosomatic Practice
    Presenting Author:  Curtis McKnight
    Co-Author:  David Kasick

    Purpose: Prescription drug monitoring programs (PMPs) have been used in the United States since the 1930s. More recent factors including universal internet access, coupled with efforts to curtail prescription drug diversion, "doctor shopping," and overdose deaths have led to increasing PMP availability since the late 1990s [1]. PMPs have the capacity to receive and distribute controlled substance prescription information to authorized users, and now exist in 37 states [2]. Similar to other evolving technologies, some providers may be unaware of currently available PMPs or how to use them effectively. Given the complexities of patients seen in psychosomatic practice, clinicians would benefit from further education on PMPs and their optimal use.

    Methods: Authors conducted a brief review of literature by identifying articles published in English through PubMed and Google Scholar using search term: "prescription drug monitoring program." Articles were selected for further review based on the relevance of their title and abstract. This review was combined with and directed by clinical experience and daily use of one specific PMP: the Ohio Automated Rx Reporting System (OARRS). The authors also solicited clinical scenarios from colleagues and clinicians practicing in various psychosomatic practice settings.

    Results: Sixteen articles were selected for review based on relevance and availability. Most reviewed articles addressing PMPs were found in pain management or pharmacology literature, with some discussion in emergency medicine and dental literature. One reviewed article was found in psychiatry literature. Although PMPs were initially envisioned as tools to foster conservative prescribing, they have also been perceived as useful in other ways, including in some situations leading to dose escalation and increased opioid prescribing. Other potential benefits, for example identifying patients at risk for benzodiazepine withdrawal syndromes, have not been described. Regional and interstate differences exist, and some PMPs are now interconnected to further disseminate information across state lines. Optimal use of PMPs requires familiarity with state and regional systems. Information on these systems has been slow to disseminate among providers.

    Conclusions: Although prescription drug monitoring programs have become widely available, descriptions of their existence, use, and impact have been modest. PMPs have augmented clinical practice through foreseen mechanisms as well as the opportunity for unintended benefits. Practicing psychosomatic clinicians may benefit from further education on optimal use of their local PMP.

    References:

    1. Joranson DE, Carrow GM, Ryan KM, et al. Pain management and prescription monitoring. Journal of Pain and Symptom Management. 2002;23(3):231-238.

    2. Available at: www.deadiversion.usdoj.gov/faq/rx_monitor.htm. Accessed 3/23/2012

    Objectives:

    1. Investigate your local prescription drug monitoring program.
    2. Analyze ways the use of a prescription drug monitoring program can improve your practice.
    3. Create awareness in colleagues of local prescription drug monitoring programs.

    Relevance:
    Patients seen in psychosomatic practice have pharmacologic complexities. Clinicians would benefit from further education on prescription drug monitoring programs and their optimal use.

     
  7. The Psychosomatic Medicine and Health Psychology Teaching Experience in Costa Rica: A Collaborative Approach
    Presenting Author:  Ricardo Millán-González
    Co-Authors:  Rocío Vindas-Montoya, Eric Hirsch-Rodríguez

    Background: Psychosomatic Medicine (PM) is the area of psychiatry that deals with the diagnosis/treatment of psychiatric illness in medically ill patients [1,2]. Health Psychology (HP) is the field of Psychology that uses psychological knowledge to promote, diagnose, treat, rehabilitate and maintain mental and physical health [3]. During the last decades, PM has been part of the curriculum of residency programs (RP) in North America and Europe [4,5]. In Latin America, with a few exceptions, PM has not been taught as such. In Costa Rica (CR), there is one RP in psychiatry [6] and one in Clinical Psychology (CP) [7], both of them managed by the University of CR (UCR). Until now, none of them contained a PM or HP module. While health services are increasingly tending to be integrated, often multidisciplinary team members do not feel comfortably prepared to work in these type of environments [8].

    Purpose:
    1. To develop a new course in PM and HP as a part of the RP in psychiatry and CP of the UCR.

    2. To present a theoretical-practical approach of how to integrate the teaching of PM and HP.

    3. To promote collaborative work among the different mental health professionals in CR.

    Methods: After reviewing both RP, a course on PM and HP was designed as part their curriculum. The course was divided in two parts. The first one consisted on introductory lectures given by three facilitators: two PM and one HP specialists. In the second part, one resident from each program formed pairs. Each pair had to present a case based on case vignettes that dealt with a certain illness or organ dysfunction, but presenting it from the PM and the HP perspective. After that, they had to propose an integrative framework of the case. Finally, an open discussion, intended to find the best approach for the patient, was performed.

    Results: The course will be finished before the next APM. Feedback from the residency trainees is expected to expand our results. We expect the students at the end of the course be able to:

    - show competencies in diagnosing and treating medically ill patients.

    - develop an interdisciplinary approach for medically ill patients.

    - work in a collaborative way with other health professionals.

    Conclusions: PM and HP are two new disciplines in CR. Considering the resources available, an integrative approach of teaching them would likely impact its practice in our country. The facilitators interactions and collaborative work throughout the course provide the students with a model of interdisciplinary team work. The course gives the students diagnostic and therapeutic tools to be applied during the rotations in the general hospitals.

    Objectives:

    1. To develop a new course in PM and HP as a part of the RP in psychiatry and CP of the UCR.
    2. To present a theoretical-practical approach of how to integrate the teaching of PM and HP.
    3. To promote collaborative work among the different mental health professionals in CR.

    Relevance:
    1. To inform the audience about teaching techniques in Psychosomatic Medicine in Costa Rica. 2. To present an integrative approach of teaching Psychosomatic Medicine and Health Psychology.

     
  8. Using Portable Computers to Increase the Efficiency of Evaluating Psychiatric Emergencies: A Pilot Program
    Presenting Author:  Edward Norris
    Co-Authors:  Anthony Buchman, Rosanne Teders, Michael Kaufmann

    Purpose: In order to increase the efficiency and throughput of psychiatric patients in the Emergency Department (ED), the Psychiatric Evaluation Service (PES) piloted a program to use portable laptop computers with electronic medical records and real-time data entry instead of traditional data capture on paper and then transfer to electronic medical record via a desktop computer.

    Methods: Prior to the use of laptop computers, baseline data was collected over a period of two months and included case completion (the time from the start of the case until report is called to the unit), length of stay post-case completion (the time from report to unit until patient departure to the unit), and ED length of stay (the total time spent in ED). Data from adult patients who were evaluated in Lehigh Valley Health network's ED during the evening shift and were admitted to Lehigh Valley Health Network's inpatient behavioral health unit were examined for this pilot. Evening staff was trained on electronic data entry and equipped with portable laptop computers equipped with the electronic medical record. Data was then collected over six months and analyzed.

    Results: At baseline 29 charts were reviewed. On average, the time to case completion was 141.8 minutes, length of stay post case completion was 57.6 minutes, and ED length of stay was 499.3 minutes. The number of case completion under 60 minutes was 0, and the number of cases with ED length of stay less than 6 hours was 6 (21%). After the initiation of laptop computers, 106 charts were reviewed over 6 months. On average, the time to case completion was 79.7 minutes, length of stay post-case completion was 69.4 minutes, and ED length of stay was 395.4 minutes. The number of case completion under 60 minutes was 39 (37%), and the number of cases with ED length of stay less than 6 hours was 46 (43%).

    Conclusions: The use of laptop computers increased the efficiency of ED patient evaluation with an average decrease of ED length of stay of 103.9 minutes. The increased efficiency has allowed PES to evaluate new patients later into workers' shifts and better manage the flow of psychiatric emergencies.

    References:

    1. Mirin, S., & Summergrad, P. (2011). The evolving academic health center: challenges and opportunities for psychiatry. Academic Psychiatry: The Journal of The American Association Of Directors Of Psychiatric Residency Training And The Association For Academic Psychiatry, 35(2), 89-95.

    2. Murphy, J., Fenichel, G., & Jacobson, S. (1984). Psychiatry in the emergency department: factors associated with treatment and disposition. The American Journal Of Emergency Medicine, 2(4), 309-314.

    Objectives:

    1. Participants will review delay issues of psychiatric patient flow in Emergency Departments.
    2. Participants will describe a new evaluation process for Emergency Department visits.
    3. Participants will compare the outcomes of a new evaluation process on the length of Emergency Department visit.

    Relevance:
    Psychiatric Emergency Departments often use Psychosomatic Medicine physicians and staff to evaluate patients. Decreasing the length of stay in emergency departments improves appropriate and quality patient care and staff satisfaction.

     
  9. Evaluating Psychiatric Patients’ Attitudes of a Shared Electronic Medical Record
    Presenting Author:  Edward Norris
    Co-Authors:  Julia Correll, Jaime Bongiovi, David Dykewski, Gail Stern, Michael Kaufmann

    Purpose: As our large regional health network engages in the transition from a private behavioral health record to an integrated electronic medical record, as required by the Affordable Care Act, opportunities arise to assess patients' perception of this process. As part of ongoing quality improvement, the Department of Psychiatry surveyed mental health outpatients in "integrated" primary care medical practices about their perceptions of a shared electronic medical record.

    Methods: An eight-question survey was distributed to outpatients in a variety of primary care settings where mental health services were performed including both specialty and primary care offices. Patients provided basic demographic information including gender and age range. The questions were scored on a four point Likert scale from (1) I disagree completely to (4) I agree completely. Higher scores indicated greater agreement. Questions focused on patients' awareness of the shared record, patients' comfort level with sharing of mental health information, and patient concerns about stigma and privacy.

    Results: 95 surveys were completed. Respondents were 57% female, 27% male and 16% did not disclose gender. There were no differences from a gender standpoint. Patient's ages were grouped and 3% of patients were age 18-20, 7% were age 20-29, 14% were age 30-39, 23% were are 40-49, 41% were 50 or older and 11% did not disclose age range. Independent sample t-tests were used to examine differences between age and gender categories. There were no statistically significant differences between groups. The highest mean score was 3.73 (SD = 0.66) for "I am comfortable with my mental health records being shared with my primary care physician." The two lowest average scores were 2.69 (SD = 1.15) for "I am (not) worried about mental health stigma as it relates to the electronic medical record," and 3.14 (SD = 1.03) for "I am now (not) more selective about what I tell my provider with a shared electronic record."

    Conclusions: During a transition from a private mental health record to a shared electronic medical record, mental health patients were generally comfortable with the idea of and transition to a shared electronic medical record. Answers to stigma and privacy concerns scored slightly lower than other questions but still indicate patients' overall agreement with a shared medical record.

    References:

    1. Ennis, L., Rose, D., Callard, F., Denis, M., & Wykes, T. (2011). Rapid progress or lengthy process? Electronic personal health records in mental health. BMC Psychiatry, 11, 117.

    2. Gaylin, D., Moiduddin, A., Mohamoud, S., Lundeen, K., & Kelly, J. (2011). Public attitudes about health information technology, and its relationship to health care quality, costs, and privacy. Health Services Research, 46(3), 920-938.

    Objectives:

    1. Participants will review issues of sharing a private psychiatric medical record.
    2. Participants will recognize patients’ attitudes about switching to a shared electronic medical record.
    3. Participants will analyze patients’ agreement with a shared electronic medical record.

    Relevance:
    Understand patients’ attitudes about a shared electronic medical record will help Psychosomatic Medicine transition more effectively as a shared patient record is required due to the Affordable Care Act.

     
  10. [T] Treatment Recommendations for Abuse of Newer Synthetic Compounds
    Presenting Author:  Sibyl Simon
    Co-Author:  Marie Tobin

    Background: The last 2 years have seen a spike in the use of synthetic compounds such as "K2" (synthetic cannabis) and "bath salts" (methylenedioxypyrovalerone or MDPV) as drugs of abuse. Easily obtained from gas stations and convenience stores, their lack of expense and easy availability have caused a dramatic increase in use, specifically in the adolescent population, and to lesser extent in all age groups. Consequently, on October 21, 2011, the DEA issued a temporary one year ban on MDPV classifying it as a schedule I substance, while a previous one year ban was made on "K2" in November of 2010. The psychiatric morbidity related to these substances forms a distinct constellation of symptoms which should be noted carefully because of lack of available tests for detection of these substances and to facilitate prompt treatment. There has been a sharp rise in the cases of synthetic substance abuse leading to acute hospitalizations in medical and psychiatric units with the majority of cases centered on two distinct substances, "K2" and "bath salts." Known by a variety of names, "K2," "spice," or "incense" is a large and complex variety of synthetic cannabinoids, most often cannabicyclohexanol, JWH-018, JWH-073, or HU-210, which are used in an attempt to avoid the laws that make cannabis illegal, the substance mimics the abuse effects of cannabis. MDPV is 3,4-Methylenedioxypyrovalerone, a designer drug of the phenethylamine class. MDPV is structurally related to cathinone, an active alkaloid found in the khat plant, 3,4-methylenedioxymethamphetamine (MDMA), methamphetamine, and other schedule I phenethylamines and is a central nervous system (CNS) stimulant.

    Case Descriptions: We present two cases, one involving abuse of alcohol and "bath salts" leading to significant medical utilization due to misdiagnosis, and the second case highlighting symptoms related to chronic K2 usage. Signs and symptoms of usage of "bath salts" are based on their mechanism of action as a Norepinephrine-Dopamine reuptake inhibitor, causing effects as stimulant agents. Euphoria, anxiety, agitation, hallucinations, psychosis with suicidal thoughts and actions result with the accompanying physiological signs of tachycardia, hypertension, vasoconstriction and insomnia. "K2" typically results in lethargy, hallucinations, acute psychosis, and with prolonged use, refractory psychosis.

    Treatment Recommendations: Based on experience and anecdotal evidence suggests that psychiatric morbidity related to "K2" use is most often helped by prolonged antipsychotic treatment, preferably with mood stabilization properties, for example atypical antipsychotic medications. MDPV is best treated with supportive care and benzodiazepines initially, however given the abuse potential in this population, benzodiazepine use is recommended for acute treatment only. The anxiolytic effects of gabapentin have proved effective, without the problem of dependence. Future studies are urgently needed in this area to properly identify evidence-based, safe and effective treatments for presentations of the above noted symptoms.

    Objectives:

    1. Understand the effects of newer synthetic compounds, including psychiatric and physiological signs and symptoms.
    2. Based on careful history taking and physical exam, apply the treatment recommendations provided to reduce morbidity related to drug abuse.
    3. Investigate further treatment options and possible detection mechanisms for patients abusing synthetic agents.

    Relevance:
    To provide a deeper understanding of the prevalance, effects and possible treatments of acute synthetic abuse, an area which currently has limited clinical data.

     
  11. Psychogenic Adipsia Presenting as Acute Kidney Injury
    Presenting Author:  Colin Harrington
    Co-Authors:  Joseph Grossman, Katherine Richman

    Introduction: Consultation to cases of psychogenic polydipsia and hyponatremia is common on a CL Psychiatry service. We report on a much less common case of psychogenic adipsia-oligodipsia that presented with acute kidney injury (AKI).

    Case Description: A 47 year old man with a past medical history notable for gout, hypertension, and hyperlipidemia presented to the emergency department (ED) with a 1 month history of fatigue, pruritis, dizziness, poor appetite, and a 25 pound weight loss. He was in his usual state of health until 2 months prior to presentation when he experienced upper respiratory symptoms and epistaxis with a subsequent disturbance in sensations of smell and taste. Evaluation in the ED noted mild cognitive dysfunction and normal vital signs. Admission lab work revealed a BUN of 207 mg/dl, serum creatinine of 8.9 mg/dl, serum sodium of 134 meq/L, and HgB of 7.0 g/dl. Urinalysis and additional metabolic studies were unremarkable.

    Initial lab work and history suggested a diagnosis of AKI due to a primary renal process, with associated uremic symptoms of fatigue, pruritis, and anorexia. Counter to expectations, he responded very well to hydration with improvement in his serum creatinine to 1.96 mg/dl on hospital day (HD) 4, consistent with a pre-renal cause of AKI. Evaluation for intrinsic renal disease and obstructive uropathy, including renal ultrasound, was unrevealing. Plans for renal biopsy were deferred due to rapid improvement in renal function. On further questioning, he reported marked anosmia and dysguesia after experiencing URI symptoms 2 months PTA, with subsequent severe anorexia and complete restriction of solids and liquids. He denied associated nausea, vomiting, dysphagia, or odynophagia.

    Initial neuropsychiatric evaluation was notable for intact cognition. There was no evidence of a formal thought disorder, psychosis, mania, depression, or anxiety. Neurologic exam was non-focal. He suggested that his decision to restrict oral intake was unwise, and reported being pleased that he was recovering. Over the latter 2 days of hospitalization, he grew more impatient, irritable, and suspicious of physicians and staff - perceiving intentional deception across different discussions regarding diagnosis and treatment. He left the hospital AMA before brain imaging to rule out a central cause of adipsia could be completed.

    Discussion: Adipsia-oligodipsia is a condition marked by an absence of thirst and typically presents with hypernatremic dehydration. Thirst is tightly linked to serum osmolarity and to intravascular volume status and is stimulated by hypertonicity and hypovolemia. The hypertonic signal to thirst is engaged much earlier than that of hypovolemia. Adipsia typically results from central lesions that impair normal thirst and/or ADH secretion. Adipsia due to psychiatric disease has been described in the literature, but is extremely rare. Putative mechanisms leading to adipsic, eunatremic dehydration and associated reversible AKI are discussed.

    Objectives:

    1. Identify cases of renal failure associated with psychiatric disease.
    2. Analyze metabolic studies and course of illness that allow for differential diagnosis of psychiatric versus primary renal disease.
    3. Apply this case presentation to consultation to psychiatric patients with disorders of water metabolism.

    Relevance:
    Disorders of water ingestion and metabolism such as psychogenic polydipsia are common in psychiatric patients on a Consultation Psychiatry service. This case highlights a less common condition of psychogenic adipsia.

     
  12. [T] Implementation and Results of Curriculum Restructuring on Inpatient Psychosomatic Medicine Service at Stanford University Hospital
    Presenting Author:  Yelizaveta Sher
    Co-Authors:  Sermsak Lolak, Jose Maldonado

    Background: Last year, we started a project of restructuring the curriculum and educational activities on the Psychosomatic Medicine Service at Stanford University Hospital [1]. We followed the approach outlined by Kern and Thomas by starting with Problem Identification and then Needs Assessment [2]. This was done through literature review, focus group, networking with colleagues from other programs, anonymous feedback from both the residents' retreat and computer-based program evaluation, as well as formal needs assessment survey. The results of methods above were utilized to design a new curriculum and schedule of educational activities, using ACGME‘s 6 competencies and 3 domains (Knowledge, Skill, Attitude) as guidance [3]. The emphasis was to make sure all trainees rotating through PM service receive more or less same content of education regardless of case variety or service attending. This was achieved by creating a "Weekly Focuses" grid as a template for weekly educational components of the service, which includes weekly didactics by attendings and fellow, discussion, supervision, and presentation by trainees. In addition, as a part of weekly teaching sessions delivered by the Psychosomatic Medicine fellow, trainees receive "the quiz" that covers important topics in CL. The residents are asked to study and provide detailed answers to the questions.

    Methods: We implemented the new curriculum/schedule of activities of the PSM service described above in July, 2011. To evaluate the effect of the new curriculum, a survey was given to all the PGY-2 psychiatry residents rotating through PSM service from July, 2011 through June, 2012 after they completed the PSM rotation. The results were analyzed and compared with the results of the same survey given to the residents in 2010 prior to the curriculum change. In addition, we also obtained the data from the residents' anonymous feedback of the program and attending (via institution online evaluation program).

    Results: Preliminary findings as well as feedbacks from individual residents were largely positive. The final results of the survey will be presented at the meeting.

    References:

    1. Lolak, S. Reorganizing Educational Activities on Psychosomatic Medicine Service at Stanford University Hospital: A systematic approach using medical education theories. Poster Presentation. APM annual meeting, November, 2011 Arizona

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

    3. Accreditation Council for Graduate Medical Education. Program Requirements for Graduate Medical Education in Psychiatry. www.acgme.org/acgmeweb/

    Objectives:

    1. Be familiar with a standarized curricullum development approach to restucturing of program education, including assessing problem areas and identifying areas for growth.
    2. Describe the impact of the change in curriculum on trainees' educational experience.
    3. Apply the above knowledge to the programs at the participants' home instutions.

    Relevance:
    Academic inpatient psychosomatic medicine specialists have an important mission to teach while maintaining a busy service. It is thus paramount to be able to develop the most effective teaching curriculum.

     
  13. [T] Consult-Liason Psychiatry Resident Roles in the Involuntary Commitment Process in Wisconsin
    Presenting Author:  Kyle Benner
    Co-Authors:  Elliot Lee, Michael Peterson

    Purpose: The emergency assessment of patients with psychiatric illness is required component of psychiatry residency education. When developing treatment recommendations, psychiatry residents must consider the risks and benefits of inpatient psychiatric hospitalization for patients. A key consideration during this discussion is whether voluntary or involuntary hospitalization is appropriate. Initiating an involuntary civil commitment challenges the resident to navigate laws and procedures, which lie on the boundary of the medical-legal interface. This is a critical, but complicated, part of resident education, encompassing elements of emergency and forensic psychiatry, and psychosomatic medicine.

    In 1971, the U.S. Supreme Court clarified the use of involuntary civil commitment in the case Lessard vs. Schmidt originating in Wisconsin. Now 40 years following that decision, Wisconsin is left with a series of laws, which seek to more carefully protect patients' rights and defer to individual counties to complete assessment and funding for involuntary commitment. This process is under chapter 51.15 and 51.20 of Wisconsin statues and provides for emergency detention of an individual if they present with a treatable mental illness that is cause for them to be imminently dangerous to themselves or others, dangerous due to impaired judgment, or unable to care for themselves. This is a police action with mandatory authorization by a designated county crisis worker. The evaluating psychiatrist or other physician does not have jurisdiction to authorize an involuntary commitment in any way. This is a learning experience for residents as we navigate the system and coordinate between primary medical teams, police, and county crisis.

    Method: We present a case demonstrating the multiple systems involved of a 32 year old female, who was admitted to a Internal Medicine Service following a severe suicide attempt via overdose and stab wound to abdomen.

    Results: Following a consult request by the Internist, inpatient psychiatric treatment was recommended by both consult psychiatrist and the patient's outpatient psychiatrist, but refused by the patient. County crisis was then contacted for assessment. Over the next 27 hours, 3 separate emergency detention decisions were made by in person evaluations by 3 separate designated crisis workers, alternating for or against. There were >10 calls between the psychiatry service and crisis, and coordination with both the primary team and outpatient psychiatry. Police were also involved as patient tried to leave the hospital while maintaining she continued to plan to harm herself. Ultimately the patient was placed under an inpatient civil commitment.

    Conclusion: This case shows a real world example of on the job training of this process for psychiatry residents in Wisconsin. Important elements of this case and how they apply to residency education in emergency and psychosomatic medicine are discussed.

    Objectives:

    1. Understand current involuntary commitment and emergency detention process in Wisconsin.
    2. Examine Consult Liason Psychiatry Service role in coordinating multiple systems of care.
    3. Investigate avenues for resident education in this process.

    Relevance:
    The Consult Liason Psychiatry service often has to work with multiple systems of care. In Wisconsin, the involuntary commit law requires coordination of legal and mental health services.

     
  14. [T] Evaluating the Effectiveness of C-L Services
    Presenting Author:  Mallika Lavakumar
    Co-Authors:  Emily Gastelum, Filza Hussain, Ralph Wharton, Jon Levenson, Philip Muskin, Peter Shapiro

    Background/Purpose: A consensus on measures for evaluation of the performance of Consultation-Liaison (CL) Services is lacking. Metrics reported in existing literature, including improvement in detection of alcohol use disorders, decrease in hospital length of stay, and lowering cost of hospitalization, do not appear to have been widely adopted. The purpose of this study is to investigate the use of measures to evaluate the performance of academically-oriented CL Services in the United States.

    Methods: In March 2012, a confidential and voluntary web-based survey was distributed to training directors of the 53 Psychosomatic Medicine fellowship programs in the United States included in the program listing maintained by the Academy of Psychosomatic Medicine. The survey addressed opinions among leaders in the field about the nature and use of appropriate performance measures for a CL service.

    Results: Data collection is ongoing. Preliminary results (n = 25) show that 60% of respondents do not have any service performance measures in place. Decrease in length of stay, decrease in clinical costs, patient satisfaction, and consultee satisfaction are measures currently used by a small number of services to evaluate their performance. 64% of respondents were of the opinion that consultee satisfaction would be a valuable indicator of the CL service’s performance, but only 20% of respondents have a system in place to assess this outcome.

    Conclusions: Consultee satisfaction is the outcome most commonly perceived by Psychosomatic Medicine fellowship directors as likely to be a useful measure of CL Service performance. Existing instruments for assessment of consultee satisfaction require further assessment for ease of use, validity, and reliability, and new or improved assessment tools may be necessary.

    References:

    1. Desan PH, Zimbrean PC, Weinstein AJ, Bozzo JE, Sledge WH. Proactive psychiatric consultation services reduce length of stay for admissions to an inpatient medical team. Psychosomatics. 52(6):513-20, 2011 Nov-Dec.

    2. Diehl A. Nakovics H. Croissant B. Reinhard I. Kiefer F. Mann K. Consultation-liaison psychiatry in general hospitals: improvement in physicians' detection rates of alcohol use disorders. Psychosomatics. 50(6):599-604, 2009 Nov-Dec.

    3. Goldberg RJ. Burock J. Harrington CJ. Quality indicators in consultation-liaison psychiatry. Psychosomatics. 50(5):550, 2009 Sep-Oct.

    4. Levenson JL, Hamer RM, Rossiter LF. A randomized controlled study of psychiatric consultation guided by screening in general medical inpatients. American Journal of Psychiatry. 149(5):631-7, 1992 May.

    5. Popkin MK. Mackenzie TB. Callies AL. Improving the effectiveness of psychiatric consultation. Psychosomatics. 22(7):559-63, 1981 Jul.

    Objectives:

    1. To add to the limited literature on quality assessment measures of a C-L service.
    2. To explore the general opinion amongst CL psychiatry programs across the US about the use of consultee satisfaction as a measure of quality assessment.
    3. To use the information gathered from this survey in order to create a quality assessment tool.

    Relevance:
    No standardized tool currently exists to measure the effectiveness of a psychiatry consult service. This survey is the first step in developing such a tool.

     
  15. Amantadine and Minocycline as Adjunctive Depression Therapy in the General Hospital
    Presenting Author:  Brad Bobrin

    Often on the C-L service we are faced with patients with depression that has not responded well to traditional treatments. In addition, rapid response would be prefered in the medical setting as opposed to the slow onset of action of traditional treatments. There exist currently two effective and rapid treatments, that of ECT and IV Ketamine. However, both of these are often unobtainable in the community hospital. Therefore another option in treating these patients would be a great help. Here is presented one such possible alternative. This poster will describe several cases of improvements in depressed mood in patients on the C-L serviece after receiving either amantadine or minocycline. These patients were originally treated with these medications for other reasons. Three of the patients were receiving minicycline for the treatment of pain and two of the patients receiving amantadine for apathy. In most of the cases the response was rapid and dramatic, although with the minocycline, one could not definitely determine whether or not the improved mood was from the pain relief alone. The rationalle for presenting this information is to generate interest and awareness of these two glutamate antagonists which are inexpensive, relatively safe and usually on formulary in the general hospital. Hopefully this poster will generate more research into the potential treatment usefulness of glutamate antagonists. The potential mechanism of action of glutamate antagonists will be reviewed along with other cases in the literature.

    Objectives:

    1. Be able to confidently use glutamate antagonists in refractory depression treatment.
    2. Understand the possible mechanism of glutamate antagonists and how they may treat depression.
    3. Recognize which medications have gluatamatergic activity that may potentially be used in depression treatment as these medications all have different potentcies and receptor affinities.

    Relevance:
    This presentation will attempt to demonstrate alternative treatment for depressed patients in the general hospital when traditional treatment either does not work or is unavailable, such as ECT.

     
  16. [T] Patient Satisfaction with an Electronic Suicide Screening Using the Columbia Suicide Severity Scale in an Outpatient Psychiatry Clinic
    Presenting Author:  Laurel Ralston
    Co-Authors:  Adele Viguera, Irene Katzan

    Objective: An estimated 40 % of suicide victims see a physician in the month before their suicide. The objective of this study was to assess patient satisfaction to routine suicide screening using the Columbia Suicide Severity Rating Scale (C-SSRS) as part of a standardized set of patient reported outcomes.

    Methods: At routine outpatient visits, patients completed a validated self-administered version of the Columbia Suicide Severity Rating Scale using an electronic tablet. Afterwards, patients were approached by a clinician in the waiting room and asked to complete a brief patient satisfaction survey (12 questions) to query about their experience and concerns with routine suicide screening.

    Results: To date, we have surveyed 50 patients and plan to survey 100 patients. The majority of patients had a primary diagnosis of mood disorder (66%), followed by anxiety disorder (22%), substance abuse (8%) and schizophrenia (4%). Mean age was 46.3 years (range 19-74 years), and 56% of the sample was female. 92% were pleased that healthcare providers asked about suicide and 82% supported the idea of regular suicide screening. 78% of patients reported the electronic tablet was easy to use, and 44% felt that pre-appointment screening made discussing sensitive topics, such as suicide, easier. Only one patient reported that suicide screening increased suicidal thoughts. While only 44% of patients reported their physician reviewed screening results with them, 72% felt their physician would find the information useful. 36% were uncomfortable with non-psychiatric medical providers having access to suicide screening results.

    Conclusion: Adult patients surveyed in an outpatient psychiatry clinic generally support suicide screening by using electronic patient reported outcomes. The majority of patients felt the screen was easy and useful to their care. Asking about suicide does not increase suicidal thoughts in this patient population, and in fact, using a pre-appointment screening may help some patients feel more comfortable bringing up the topic of suicide. A significant number of patients worried about having suicide screening results in their general medical record. This needs to be kept in mind as we explore the possibility of suicide screening in non-psychiatric outpatient clinics.

    Objectives:

    1. Identify effective suicide screening methods.
    2. Review patient satisfaction with self administered screening scales and electronic tablets.
    3. Consider patient hesitations with suicide screening and possible barriers to expanding screening to non-psychiatric outpatient visits.

    Relevance:
    This qualitative study describes patients' opinions regarding suicide screening in an outpatient psychiatry clinic. Patient satisfaction with such screening can better inform implementation strategies.

     
  17. [T] The Importance of Code Status Discussions in the Psychiatric Hospital: Results of a Single Site Survey of Psychiatrists
    Presenting Author:  Alastair McKean
    Co-Authors:  Maria Lapid, Jennifer Geske, Simon Kung

    Purpose: Documentation of code status at the time of admission to any hospital is a requirement. However, discussion of code status with psychiatric inpatients can be challenging, especially for those who are suicidal, suffering from severe depression, psychosis, cognitive impairment, or other psychiatric conditions that may impair their ability to participate in such a discussion. Currently, no standards exist on proper documentation or discussion of code status in this hospitalized population. As a first step to developing an educational program on effective code status discussions in our hospital, we surveyed psychiatry faculty and trainees regarding their perceptions on its importance.

    Methods: We conducted an electronic survey using a 25-item questionnaire which included demographic questions and 5-point Likert scale items regarding opinions about code status among psychiatric inpatients. Psychiatry faculty and trainees at our institution were invited to complete the online survey.

    Results: The survey response rate was 34% (n=30, 15 faculty and 15 trainees). Most respondents felt that they had received adequate training to inquire about code status. Both faculty and trainees strongly agreed that code status was important to address with patients, although faculty placed a higher level of importance on assessing code status than trainees (p=0.046), especially in those patients with recent suicide attempt (p=0.024).

    Conclusion: Psychiatric faculty and trainees alike endorsed the importance of assessing code status during psychiatric admissions. Educational programs are needed on strategies to properly and effectively conduct code status discussions.

    Objectives:

    1. The learner will come to understand barriers and situations that affect physician perceptions on the relevance of assessing code status.
    2. The learner will be able to appreciate deficits in training in assessing code status in psychiatric patients.
    3. The learner will be able to apply knowledge from this survey to help formulate the education of clinicians on addressing code status in psychiatric patients.

    Relevance:
    This information will assist in recognizing barriers to assessing code status in psychiatric in-patients in order that clinicians might be better educated to engage in effective code status discussions.

     
  18. [T] A Physician's Duty at 30,000 Feet: In-Flight Emergencies and the Psychiatrist
    Presenting Author:  Alastair McKean
    Co-Author:  Michael Bostwick

    Purpose: Limited data show only 3.5% of in-flight emergencies involve psychiatric chief complaints. Therefore, a responding psychiatrist usually faces a situation outside his scope of practice. No data exists on whether psychiatrists fail to respond to emergencies from a lack of familiarity and or discomfort with handling acute medical situations. What skills would a psychiatrist bring to an in-flight medical problem? Since psychiatrists are physicians, is it ethically reasonable for them to refuse to answer the call of duty?

    Methods: Case Report

    Results: On a transpacific flight, assistance was requested for a non-English speaking 85-year-old woman with a history of dementia, cardiac stenting and DMII. A psychiatrist and neurosurgeon respond. The physicians interviewed the patient's daughter who noted her mother developed weakness and confusion over the past hour. The neurosurgeon dealt with such symptoms routinely and proceeded to take charge and examine the patient. Right-sided upper and lower extremity weakness was noted. She was alert but orientation was difficult to assess. Vitals showed hypertension with normal pulse and respirations. The physicians concurred that the patient was likely having a TIA or evolving stroke. They reclined the patient, administered oxygen and Aspirin 325 mg. The neurosurgeon discussed the patient with a physician on the ground deciding the patient's care would not be best served by diverting to a small island with limited facilities. Continuing to the destination, the psychiatrist used his skills to liaise with the crew and explain the plan of care. He made regular checks on the patient every thirty minutes and provided support to nurses who came to assist and care for the patient. The psychiatrist also explained the situation and provided support to the patient's daughter.

    Conclusion: The basic management of many in-flight medical problems will be familiar to psychiatrists. If the psychiatrist responds to a situation that is in the expertise of a fellow responder, they should defer to the judgment of that physician. Beyond medical knowledge, however, just as the neurosurgeon above has special expertise, so too does the psychiatrist. Working with teams, communication and providing empathic support are attributes that permit a psychiatrist to contribute uniquely to an emergent medical situation. Psychiatrists must know their limitations, acknowledge them and offer help that is within their sphere of competence. We conclude that psychiatrists possess skills that would be of particular use in an in-flight emergency and as physicians it would be unethical to deny help to those in need.

    Reference:

    1. Matsumoto K, Goebert D. In-flight psychiatric emergencies. Aviat Apce Environ Med 2001; 72:919-23.

    Objectives:

    1. The learner will appreciate the ethical issues surrounding psychiatrists responding to an in-flight medical emergency.
    2. The learner will be able to explore skills, as a psychiatrist, which they could bring to an in-flight medical emergency.
    3. The learner could potentially apply this knowledge to respond more confidently were they to encounter an in-flight medical emergency.

    Relevance:
    In-flight medical emergencies are something most psychiatrists that travel by air will experience at some point. It focuses on the ethics of responding and the skills that can be offered.

     
  19. Evaluating Pain, Negative Mood, and Resilience in Patients Affected by Fabry Disease
    Presenting Author:  Alicia Lelis
    Co-Authors:  Ron Duran, William Wilcox, James Garbanati, Linda Beckman

    The purpose of the current study was to evaluate pain, negative mood, and resilience in individuals diagnosed with Fabry disease. Fabry disease is a rare condition and this is the first study to examine all of these variables together. A total of 75 men and women with Fabry disease were recruited from Cedars-Sinai Fabry Center. This study utilized a variety of instruments including: a Demographic questionnaire, Brief Pain Inventory, Resilience Scale, Beck Depression Inventory-II, and Beck Anxiety Inventory. The results indicate that pain intensity is positively correlated with depression and anxiety, while pain intensity is negatively correlated with resilience. The results also showed that pain frequency acts as a moderator between resilience and depression. While there were no statistically significant differences between males and females with FD, there were clinically significant differences in the depression scale between the sexes.

    The clinical implications of this study are significant. Even though FD is a multi-system disease, resilience appears to be a key factor in successful adaptation to the disease. Clinicians should focus their attention on resilience skills and training rather than solely trying to assess and medicate depression, anxiety, and pain. Future studies in the FD population are needed on the effect of resilience training on the ability to manage adversity and decrease the risk or symptoms of pain, depression, and anxiety

    Objectives:

    1. The clinician will be able to identify differences in pain, resilience, depression, and anxiety in males and females with Fabry disease.
    2. The clinician will be able to identify the importance of resilience training for individuals with Fabry disease.
    3. The clinician will be able to identify the associations between pain, pain frequency, resilience, depression and anxiety in the Fabry disease population.

    Relevance:
    Fabry disease is a rare genetic disorder. This study examined pain, pain frequency, resilience, anxiety, and depression. This novel study was meant to improve psychological treatment in this population.

     
  20. Comorbidity of Posttraumatic Stress Disorder (PTSD) and Chronic Idiopathic Urticaria (CIU): A Preliminary Case Control Study of PTSD and Bipolar II Disorder Patients
    Presenting Author:  Madhulika A. Gupta
    Co-Author:  Aditya K. Gupta

    Purpose: Psychologic stress is known to play a role in urticaria, however the association between PTSD, a classic stress-mediated syndrome, and CIU, has received little attention (1,2). Emotional dysregulation and the state of sympathetic hyperarousal in PTSD have been implicated as possible pathogenic factors underlying CIU in PTSD (1). We examined the prevalence of CIU in PTSD versus Bipolar II Disorder, which are both disorders of emotional dysregulation.

    Methods: 20 consecutive patients with a diagnosis of PTSD or Bipolar II disorder were assessed for CIU. CIU was diagnosed if the patient reported at least a 6 month history of recurrent urticaria for which no cause had been determined after standard medical investigations. All patients were referred by primary physicians for psychiatric care and met the DSMIV-TR criteria for PTSD or Bipolar II Disorder. Two patients with both PTSD and Bipolar II diagnoses were included in the PTSD group.

    Results: There were 11 PTSD [10 female, 1 male; mean (SD)age: 46.5 (7.5) years; race: all white] and 9 Bipolar II [all female; mean (SD) age: 29.6 (6.7) years; race: all white] patients. The duration of PTSD in all cases was at least 6 months. 8/11 (72.7%) PTSD patients versus 1 out of 9 (11.1%) Bipolar II patients had CIU (p<0.006, Chi square test). 9 out of 11 PTSD patients had a history of childhood trauma and met the criteria for PTSD with Delayed Onset (DSMIV-TR). The 2 remaining PTSD patients had work-related trauma. All patients had chronic PTSD. The urticarial reaction presented in 2 forms: (i) as part of a general state of sympathetic hyperarousal where the patient would break out in generalized hives; and (ii) in minority of cases the urticaria was localized to sites of previous abuse or trauma eg., an urticarial streak on the forearm where the patient had been repeatedly tied down during an abuse ritual.

    Conclusions: There was a high frequency of CIU in PTSD (72.7%) versus Bipolar II Disorder(11.1%) (p<0.006) patients. A cause for the urticaria is typically not identified in over 70% of urticaria patients. Unlike Bipolar Disorder, PTSD is associated with a state of hypervigilance, and histamine is the major wake-promoting neurotransmitter in the central nervous system (CNS). Histaminergic neurons display elevated discharge activity during states of increased vigilance. Elevated CNS histaminergic activity may also be a factor in the high frequency of recurrent 'idiopathic' urticaria observed in PTSD.

    References:

    1. Gupta MA, Gupta AK. Chronic idiopathic urticaria and post-traumatic stress disorder (PTSD): An under-recognized comorbidity. Clinics in Dermatol 2012; 30: 351-354 (in press).

    2. Chung MC, Symons C, Gilliam J, et al. The relationship between posttraumatic stress disorder, psychiatric comorbidity, and personality traits among patients with chronic idiopathic urticaria. Compr Psychiatry 2010; 51: 55-63.

    Objectives:

    1. To recognize the association between PTSD and chronic idiopathic urticaria (CIU), as treatment of the PTSD is necessary for effective management of the CIU.
    2. To recognize that CIU often develops in PTSD with Delayed Onset, which can manifest years after the initial trauma, and therefore the CIU may not be associated with the PTSD.
    3. To recognize that hypervigilance, a central feature of PTSD, is associated with elevated CNS histaminergic activity which may also play a role in the pathogenesis of urticaria in PTSD.

    Relevance:
    PTSD is a relatively common condition, associated with a high frequency of CIU. It is important to recognize this association and treat the PTSD for effective management of the CIU.

     
  21. [T] Delusional Infestation Is Typically Comorbid with Other Psychiatric Diagnoses: Review of 54 Patients Receiving Psychiatric Evaluation at Mayo Clinic
    Presenting Author:  Sara Hylwa
    Co-Authors:  Ashley Foster, Jessica Bury, Mark Davis, Mark Pittelkow, Michael Bostwick

    Objective: Delusional infestation, which encompasses both delusions of parasitosis and delusions of infestation with inanimate objects (sometimes called Morgellons disease), has been said to represent a distinct and encapsulated delusion, that is, a stand-alone diagnosis. Anecdotally, we have observed that patients with delusional infestation often have one or more psychiatric comorbid conditions and that delusional infestation should not be regarded as a stand-alone diagnosis. The purpose of this study was to identify whether patients with delusional infestation have psychiatric comorbid conditions. We therefore identified patients who had been formally evaluated in the Department of Psychiatry during their visit to Mayo Clinic.

    Method: We retrospectively searched for and reviewed the cases of all patients with delusional infestation seen from 2001 through 2007 at Mayo Clinic, Rochester, Minnesota, and who underwent psychiatric evaluation. The diagnoses resulting from psychiatric evaluation were analyzed.

    Results: During the 7-year study period, 109 patients seen for delusional infestation at Mayo Clinic were referred to the Department of Psychiatry, 54 (50%) of whom actually followed through with psychiatric consultation. Of these 54 patients, 40 (74%) received additional active psychiatric diagnoses; 14 patients (26%) had delusional infestation alone. Abnormal personality traits were rarely documented.

    Conclusions: Most patients with delusional infestation have multiple coexisting or underlying psychiatric disorders. Therefore, evaluation by a psychiatrist, when possible, is advised for all patients with delusional infestation.

    Objectives:

    1. Identify patients with delusional infestation.
    2. Recognize that this is not an isolated diagnosis; patients with delusional infestation frequently have additional co-mobid psychiatric diagnosis that require proper diagnosis through psychiatry.
    3. Encourage further research regarding work-up and treatment of patients with delusional infestation.

    Relevance:
    This presentation is highly relevant to an audience interested in psychosomatic medicine as delusional infestation is a psychiatric disease that generally manifests itself via the skin.

     
  22. [T] Capacity Consults in a Tertiary Care Medical Center: Revisited
    Presenting Author:  Afia Sadiq
    Co-Authors:  Michael Rosas, Stephanie Cheung, Nancy Maruyama

    Purpose: Consultations for capacity are a frequent request to our service, averaging 16% of consults each month. There were a number of scholarly papers on the subject between 1985 and 1999 and two from 2000 to 2009. We examined whether there have been changes in: the rate of requests for capacity evaluations, the most common capacity questions, the demographics and psychiatric diagnoses of the patients evaluated.

    Methods: We reviewed consults seen by PGY 2 through PGY 5 trainees supervised by psychosomatic medicine attendings from November 2011 to February 2012.

    Results: A total of 621consults were requested during this time; 99 were for capacity. Of these 50 (46 %) were available for evaluation. Some consults requested assessment of more than one capacity question. The most common questions were capacity to leave AMA (36%), capacity to make medical (34%) or discharge (34%) decisions. The most common Axis I diagnoses were Substance Use Disorders (85%), Cognitive Disorders (31%), Cluster B personality Disorders (13%), and a smaller, but consistent, number had serious mental illness (10%). 60% were male, mean age was 59.1 (range 21-90). 56% of AMA discharge cases lacked capacity, 59% of medical decision making patients and 65 % of discharge planning cases lacked capacity.

    Conclusions: The rate of requests for capacity consults was similar to the highest rate described in institutions where consults were not mandated by the administration (15%). Most rates were lower (5-8%, 7%, 10%), so our rate may be an increase and reflect the push for short hospital stays. Consults may be requested for problems that impede prompt treatment and discharge. The top three capacity questions remained the same. AMA discharge was the most frequent question followed by a tie between discharge planning and medical decision making capacity. There were no requests to evaluate capacity to manage funds or for guardianship, as in previous reports. Contrary to prior studies Substance Use Disorders were the most common Axis I diagnoses, followed by Cognitive Disorders. There remained a smaller but consistent number of the seriously mentally ill. Our findings might be due to our location in an urban setting and requires replication. Unlike previous literature we identified Cluster B Personality disorders as a diagnosis in 13% of cases. Although not surprising, it has not been documented before, to our knowledge.

    References:

    1. Farnsworth MG, “Competency Evaluations in a General Hospital,” Psychosomatics (1990) 31:60-66.

    2. Knowles FE, Liberto J, Baker FM, Ruskin PE, Raskin A. “Competency Evaluations in a VA Hospital,” General Hospital Psychiatry (1994)16:119-124.

    3. Kornfeld DS, Muskin PR, Tahil FA, “Psychiatric Evaluation of Mental Capaciaty in the General Hospital: A Significant Teaching Opportunity,” Psychosomatics (2009)50:468-473.

    4. Mebane AH, Rauch HB, “When Do Physicians Request Competency Evaluations?” Psychosomatics (1990)31:40-46.

    Objectives:

    1. The participant will be familiar with the literature on capacity consultations in the general medical hospital.
    2. The participant will be aware of the most common reasons for capacity consultations.
    3. The participant will know the most frequent Axis I and II diagnoses of patients requiring capacity consults.

    Relevance:
    There were a number of scholarly papers on capacity consults in the 1980's and 1990's; two since 2000. We present new data and discuss the implications.

     
  23. [T] Depressive Symptoms among Patients Attending a Diabetes Care Clinic in Rural Western Kenya
    Presenting Author:  Kristen Shirey
    Co-Authors:  Stephanie Cheng, Simon Manyara, Ryan Tomlin, Jemima Kamano, Sonak Pastakia

    Background: The prevalence of diabetes is growing globally, and in sub-Saharan Africa the number of patients with diabetes is growing at more than double the rate worldwide. Likewise, depression accounts for an ever-increasing proportion of the global burden of disease. The relationship between depression and chronic diseases including diabetes is well-recognized in the developed world, but there is a dearth of data about diabetes and depression in sub-Saharan Africa. Given the disability caused by depression alone as well as its potential impact on disease severity and adherence to medication and clinic visits among people with co-morbid diabetes, it is urgent to study the prevalence of depression in diabetic patients in these resource constrained settings.

    Purpose: To describe the prevalence of depressive symptoms as measured by questions from the ultrabrief screening tool, the Patient Health Questionnaire-2 (PHQ-2), and to describe the associations between depressive symptoms and adherence to medications and clinic visits in a cohort of diabetic patients in a rural, resource-constrained clinic setting in western Kenya.

    Methods: A retrospective chart review was conducted in a diabetes clinic in Webuye, Kenya. Data was collected from records of 253 diabetic patients attending routine clinic visits, including age at diabetes diagnosis, alcohol and tobacco use, diabetes medication usage, and the PHQ-2, an ultrabrief screening measure for depression.

    Results: In this diabetes clinic cohort of 253, 55% of patients were female. The mean age of clinic attenders was 57.6 years. 53 patients, or 20.9%, responded “yes” to one or both of the depression screening questions and 37, or 14.6%, responded “yes” to both questions. 68% of those screening positive for depression with at least one question were female (p=0.023). 13.2% of patients who screened positive for depression were lost to follow-up at 12 months following initial survey, as compared with 7.5% of patients who screened negative for depression and 8.7% of all diabetes clinic patients. While there was a trend toward loss to follow-up among those screening positive for depression, this study was not powered to detect a statistically significant difference (p=0.269). There were no significant differences in alcohol use, HIV status, or diabetes medication usage between the two groups.

    Conclusions: These findings suggest that depression is common among people with diabetes in rural western Kenya. Further study is indicated to investigate the prevalence of depression, associated risk factors, and relationships between depression, medication and clinic visit adherence, and disease severity among people with diabetes and other chronic diseases in sub-Saharan Africa.

    Objectives:

    1. Describe the prevalence of depressive symptoms among diabetic patients attending a clinic in rural western Kenya.
    2. Describe the associations between gender and depressive symptoms in patients attending a western Kenyan diabetes clinic.
    3. Investigate the relationship between diabetes and depression among understudied populations in sub-Saharan Africa.

    Relevance:
    Globally, the burden of mental illness is rising. Relationships between mental and physical health are well-established in Western populations; it is essential to explore such relationships in diverse patient populations.

     
  24. WITHDRAWN  
  25. [T] Can an Ethics Committee Significantly Increase the Number of Advance Directives in the Electronic Medical Record?
    Presenting Author:  Morgan Hurst
    Co-Authors:  Anne Eshelman, Marilyn St. Amand

    Purpose: Advance Directives (AD) are intended to promote patient autonomy and clarify patients' wishes and beliefs at the end of life. The Patient Self Determination Act of 1991 requires hospitals, skilled nursing facilities, home healthcare agencies, and providers of healthcare to provide patients with a written summary of patients' healthcare decision-making rights and policies related to advance directives (1). However, the completion rate of AD in the US remains low, ranging from 5-15% (2). The purpose of this study is to assess the effectiveness of interventions to improve completion of AD.

    Methods: The Institutional Biomedical Ethics Committee of a large general hospital is sponsoring an "Advance Directive Blitz", targeting 1) employees, 2) hemodialysis patients, and 3) medical inpatients. Print material and a video on hospital TV and website provide information on AD, with frequently asked questions. Data is collected on patient satisfaction with the video, and the number of new advance directives entered into the electronic medical record (EMR) in the 3 months post Blitz, compared to 3 months pre-Blitz.

    Intervention: The "AD Blitz" includes print material, a video, and patient satisfaction survey, and targets 3 discrete populations: 1) Employees 2) Hemodialysis units randomly assigned to either standard care or an "AD blitz", and 3) Medical inpatients, trained by nurse managers and staff nurses to encourage advance care planning with all inpatients.

    Results: The number of new AD will be accessed through the EMR, and reviewed by specialty area and demographic data. Patient satisfaction with the DVD will be assessed with a brief survey, to identify any barriers to completion. The AD Blitz is scheduled for June, 2012 and data will be analyzed by 10/12.

    Conclusions: Targeting awareness of advance care planning can increase the number of advance directives in the electronic medical record, clarify patients' goals of care, and reduce family conflict at the end of life.

    References:

    1. American Bar Association. Health care advance directives: what is the patient self-determination act. Available at www.abanet.org/publiced/practical/patient_self_determination_act.html

    2. Ramsaroop, S., Reid, M., Adelman, R. (2007) Completing an advance directive in the primary care setting: what do we need for success? The American Geriatrics Society, 55, 277-283.

    Objectives:

    1. To determine efficient ways of promoting advance directives by assessing simple interventions to improve completion of advance directives in the clinical population.
    2. To promote discussion and education among healthcare providers to discuss advance directives with patients.
    3. Review of the current literature of interventions designed to increase completion of advance directives. Understand the importance of patients having advance directives.

    Relevance:
    This presentation will address how Institutional Biomedical Ethics Committees can increase the completion of advance directives to promote patient autonomy and facilitate shared decision making between patients and doctors.

     
  26. Pre-session Exercise Improves Mental Health Component of Quality of Life (QOL) in Hospital–based Hemodialysis Patients
    Presenting Author:  Sanjai Dayal
    Co-Authors:  David Tovbin, Eldad Vexler, Giora Margolis, Luna Avnon

    Purpose: Exercise can improve the quality of life (QOL) and mental health of hemodialysis (HD) patients. Poor physical activity is common in HD patients, perhaps due to their high incidence of co-morbid diseases and depression. We implemented a tightly supervised pre- HD exercise program since intra-dialytic training may pose too much of a burden for our elderly patient population with high co-morbidity. We hypothesized that this program will improve exercise performance, QOL, and mental health.

    Methods: 13 patients (8 patients > 65 years old), with high co-morbidity, performed exercise on the stationary bicycle under supervision before their HD session. Exercise time and intensity were increased over 3 months. Exercise work, QOL (KDQOL-36), and depression (CES-D10) were evaluated monthly.

    Results: Baseline mood and QOL were low in approximately half the patients and were inversely correlated with the initial amount of work at 1 month (depression: r = -0.058, p < 0.05; mental composite: r = 0.69, p = 0.01; physical composite: r = 0.58, p < 0.05; symptoms of disease: r = - 0.55, p = 0.06; burden of disease: r = 0.57, p = 0.05). Exercise work increased from months 1 to 3 (281 to 552 Newton, p < 0.01). Three months of exercise was associated with reduced depression (30%, p = 0.09), and improvement in the QOL subscales of mental composite (17 %, p = 0.002), effects of disease (20 %, p = 0.04), symptoms (12 %, p = 0.065), and burden of disease (22 %,p = 0.08), but not of the physical composite.

    Conclusion: While HD patients often suffer from a higher incidence of co-morbid diseases, it is largely their perception of the impact of their disease, and not the physical constraints of the disease itself, which are the major obstacles in encouraging exercise participation in HD patients. 3 months of supervised pre-HD exercise was associated with improvement in exercise work, QOL, and mental health in elderly HD patients with high co-morbidity.

    References:

    1. Kimmel PL. Psychosocial factors in dialysis patients. Kidney International 2001;59:1599-1613. http://www.nature.com/ki/journal/v59/n4/full/4492198a.html

    2. Kutner NG. How can exercise be incorporated into the routine care of patients on dialysis? Int Urol Nephrol 2007;39(4):1281-5.

    3. Covic A, Seica A, Gusbeth-Tatomir P, Gavrilovici O, Goldsmith DJ Illness representations and quality of life scores in hemodialysis patients. Nephrol Dial Transplant 2004:19(8):2078-83

    4. Delgado C, Johansen KL Barriers to exercise participation among dialysis patients. Nephrol Dial Transplant 2012:27(3):1152-7

    Objectives:

    1. To understand the interplay of biological and psychosocial factors in the course of chronic disease and their effects on mental health & QOL.
    2. To understand the importance of collaboration between specialists to help patients whose condition transcends any one discipline.
    3. To individualize exercise regimens to improve a patient’s mental health, exercise performance, and QOL (ie. intradialytic vs pre-session exercise).

    Relevance:
    Hospital staff tend not to emphasize the importance of exercise in HD patients. Encouragement can help alter illness perceptions and improve patients’ quality of life, exercise work, and mental health.

     
  27. Eating Disorders: An Interdisciplinary Model of Care
    Presenting Author:  Julia Raudzus
    Co-Authors:  Grant Millar, Maria Corral, Stephen Fitzpatrick, Carole Richford

    Purpose: The St. Paul’s Eating Disorder Program provides tertiary in-patient and out-patient services for adults for the province of British Columbia. The mandate includes clinical services, education, research and outreach activities supporting a network of services that span all regions of the province.

    The program is an interdisciplinary model of care between psychiatry, internal medicine, nursing, dieticians, occupational therapy and other auxiliary services to provide the most effective treatment services for these patients.

    Patients may be seen in a variety of clinical settings including a dedicated 7 bed in-patient unit, interdisciplinary out-patient clinics with case management and in collaborative care on the medicine units for acutely unstable patients admitted for re-feeding.

    Over the last several years the St. Paul’s program has worked to develop standardized care plans, including involuntary certification under the mental health act, to help manage these complex medical and psychiatric patients.

    Specifically behavioural care plans have been instituted for eating disorder patients admitted to the clinical teaching unit at St. Paul’s Hospital in attempt to minimize therapy interfering behaviours and shorten the length of hospital time required for medical stabilization.

    Methods: A chart review of patients admitted to the clinical teaching unit at St. Paul’s Hospital with a primary diagnosis of an eating disorder will be completed for 2010 and 2011. Utilization of the standard care plan and length of stay will be evaluated. These statistics will be compared to the care of eating disorder patients admitted prior to the institution of a standard care plan. An example of a standardized care plan will be provided.

    Results: It is our expectation that the utilization of a standard behavioural care plan shortens the length of stay for patients with eating disorders to the clinical teaching unit.

    Conclusions: The utilization of case management and care planning has resulted in a more streamlined effective delivery of care where communication, boundary setting and goals (medical and psychiatric stability) are achieved in a timely manner.

    This consolidated team approach has been developed to improve the quality of care delivered to these patients.

    References:

    1. Halmi, KA et al. Salient components of a comprehensive service for eating disorders. World Psychiatry 2009; 8:3 150-155.

    2. Treasure, J et al. Eating Disorders. Lancet 2010; 375: 583-593.

    Objectives:

    1. To review the delivery of tertiary eating disorder services in an acute care setting.
    2. To review an interdisciplinary model of care with both in-patient and out-patient services.
    3. To review the benefits of an interdisciplinary model of care for complex medical and psychiatric patients.

    Relevance:
    Eating disorder patients are challenging secondary to the level of psychiatric comorbidity and medical complications. Consult psychiatrists play a key role in patient management given the requirement of multidisciplinary care.

     
  28. Cutaneous Body Image (CBI) Dissatisfaction and Suicidal Ideation in a Nonclinical Sample
    Presenting Author:  Madhulika A. Gupta
    Co-Author:  Aditya K. Gupta

    Purpose: Dissatisfaction with cutaneous body image (CBI), defined as the mental representation of the skin, hair and nails, has been associated with suicidal ideation and cases of completed suicide in some patients with cosmetically disfiguring skin disorders (1). In order to further evaluate this construct, we examined the relation between CBI dissatisfaction, suicidal ideation and feelings of hopelessness and worthlessness in nonclinical subjects.

    Methods: 311 consecutive consenting non-clinical community-based participants (71 men and 240 women; mean ± SD age: 38.4 ± 14.9 years) from London, Ontario, Canada, completed a survey which included the Cutaneous Body Image Scale (CBIS)(2) and the Brief Symptom Inventory(BSI)(3) which has been used to measure a wide range of psychopathologic symptom dimensions among medically ill patients, with ratings of symptoms (on a 5-point scale ranging from ‘Not at all' to ‘Extremely') including 4 items (from the Depression subscale of the BSI) related to suicidal ideation, hopelessness and worthlessness (BSI items ‘Thoughts of ending your life', ‘Feeling of hopelessness about the future', ‘Thoughts of death or dying', and ‘Feelings of worthlessness') over the previous 1 week. The items that were not endorsed as ‘Not at all' were categorized as a ‘Yes' response. A high CBIS score denotes greater satisfaction with CBI.

    Results: 19.2% of women versus 6.7% of men (p<0.05) endorsed a ‘Yes' response to the item ‘Thoughts of ending your life' over the previous 1 week; a higher frequency of a ‘Yes' rating was endorsed for the remaining 3 items. The women who endorsed a ‘Yes' response to any of the 4 items related to suicidal ideation, hopelessness and worthlessness had significantly lower (p<0.001) CBIS scores, indicating greater dissatisfaction with CBI. A similar, but nonsigificant trend was observed among the men. The CBIS score correlated negatively (Pearson r= -0.31, p<0.001) with the Depression subscale of the BSI however this correlation was no longer significant (partial r= -0.07, p=0.2) once the possible confounding effect of Interpersonal Sensitivity(BSI), an index of lack of ease during interpersonal interactions, was partialled out statistically.

    Conclusion: Cutaneous body image dissatisfaction is associated with suicidal ideation, feelings of hopelessness and worthlessness among nonclinical women. There was a similar but non-significant trend among the non-clinical men. This relation appears to be mediated in part by the lack of ease during interpersonal interactions and possible feelings of social alienation.

    References:

    1. Cotterill JA, Cunliffe WJ. Suicide in dermatological patients. Br J Dermatol 1997; 137 (2): 246- 250.

    2. Gupta MA, Gupta AK, Johnson AM. Cutaneous body image: Empirical validation of a dermatologic construct. J Invest Dermatol. 2004 Aug;123(2):405-6.

    3. Derogatis LR, Spencer PM. Brief Symptom Inventory (BSI): Administration and procedures, manual 1. Clinical Psychosomatic Research, Johns Hopkins University School of Medicine, Baltimore, 1982.

    Objectives:

    1. Recognize that cutaneous body image, defined as the mental representation of the skin and its appendages, is an important contruct that can significantly impact the psychological state of the individual.
    2. Recognize that cutaneous body image, a construct that has received little attention, is clinically relevant in non-clinical individuals and not just individuals with a cosmetically disfiguring skin condition.
    3. Recognize that cutaneous body image dissatisfaction may be associated with a higher frequency of suicidal ideation, and/or feelings of hopelessness and worthlessness even among individuals without a disfiguring skin condition.

    Relevance:
    Cutaneous body image dissatisfaction, like other more well studied dimensions of body image (eg., related to body weight) can be associated with suicidal ideation even in non-clinical settings.

     
  29. [T] Examining the Correlation between Borderline Personality Disorder and Pain Disorders in the Consultation-Liaison Setting.
    Presenting Author:  Melinda Tyler
    Co-Author:  Hoyle Leigh

    The purpose of this study was to examine the relationship between borderline personality disorder and the incidence of chronic pain disorders in the Psychiatry Consultation Liaison hospital setting.

    Method: Data was gathered from charts of patients comprising the Psychiatry Consultation-Liaison (C-L) database at Community Regional Medical Center in Fresno, California. The incidence of chronic pain diagnoses occurring in borderline disordered patients was determined over a period of 7 years. For comparison, the incidence rates of chronic pain disorders in patients with antisocial personality disorder or adjustment disorder were also examined.

    Results: The incidence of chronic pain disorders in patients with a diagnosis of borderline personality was greatest of all three subject populations, at 20%. In patients with a diagnosis of antisocial personality, the incidence of chronic pain disorders was lowest at 0%. The incidence of chronic pain disorders in patients with a diagnosis of adjustment disorder, considered to be the most psychologically "normal" population in the C-L database, was 7.2%. All incidences were differed significantly from one another at p values of less than 0.05.

    Discussion: These results indicate that posessing a diagnosis of borderline personality correlates strongly with a greater likelihood of having a chronic pain disorder, compared to adjustment disorder, or antisocial personality. Furthermore, the incidence of chronic pain disorders in the adjustment disordered group of patients was similar to previous reports in the scientific literature for patients without a psychiatric diagnosis. Interestingly, possessing a diagnosis antisocial personality appears to be a protective factor against developing a diagnosis of a chronic pain disorder.

    References:

    1. Personality and personality disorders in chronic pain. (2000) Current reviews in pain: 4(1): 60-70.

    2. Mental disorders in chronic pain patients. (2007) Journal of pain and palliative care pharmacotherapy: 21(4):13-9.

    3. Chronic pain and psychopathology: research findings and psychopathology (2002) Psychosomatic medicine: 64(5):773-86.

    4. The relationship of pain to heightened feelings of distress. (2008) Pain management nursing: Jun; 9(2):73-80.

    5. Personality factors and disorders in chronic pain (1999). Seminars in Clinical Neuropsychiatry. Jul;4(3):155-66.

    Objectives:

    1. Apply findings to the practice of psychiatry in the consultation-setting.
    2. Facilitate treatment of difficult patients with chronic pain in the hospital setting.
    3. Further investigate etiologies of treatment-refractory cases of chronic pain.

    Relevance:
    The audience will be provided with further information as to the prevalance of chronic pain disorders in the psychiatric medically hospitalized popultation.

     
  30. Prazosin for the Treatment of Atripla-related Nightmares in Two Patients with HIV
    Presenting Author:  Sara Nash

    Purpose and Background: The anti-retroviral medication Atripla is a single, once-daily dosing of tenofovir (TDF), emtricitabine (FTC), and efavirenz, and an effective, convenient, and popular treatment for patients with HIV. While neuropsychiatric side effects of the efavirenz component have been described as mild or transient, they can be persistent and even treatment limiting. Vivid dreams or nightmares, as well as insomnia, are among the most common symptoms of CNS toxicity, affecting up to 44% of patients on the medication. Prazosin, an alpha(1)-adrenergic receptor blocker, has been well demonstrated to decrease nightmares and improve quality of sleep in patients suffering from posttraumatic stress disorder by diminishing arousal mediated by norepinephrine, which plays a prominent role in sleep-wake physiology and pharmacology. The possibility that Atripla-induced sleep problems might respond to prazosin was raised with two patients experiencing these symptoms.

    Methods: Two patients on Atripla therapy complicated by nightmares and insomnia were initiated on prazosin starting at 1 mg and their responses to treatment were observed clinically.

    Results: Both patients experienced improvement in severity of vivid dreams. One patient requested an increase in prazosin to 2 mg, but decreased back to 1 mg because he did not want to take multiple pills. Though dreams were improved from baseline, he continued to have nightmares and ultimately discontinued Atripla. The second patient experienced immediate cessation of nightmares and significant improvement in sleep upon starting prazosin 1 mg. Shortly into the treatment he had an episode of orthostatic hypotension and noted ongoing light-headedness that led to discontinuation of prazosin. While his overall sleep quality diminished after stopping prazosin, he has had to date no recurrence of vivid dreams.

    Conclusions: Prazosin seems a promising treatment for Atripla-related vivid dreams. Further work on this topic will help better define this relationship.

    References:

    1. Scourfiled A, Zheng J, Chinthapalli S et al. Discontinuation of Atripla as first-line therapy in HIV-1 infected individuals. AIDS 2012 (Epub ahead of print)

    2. Kenedi CA, Goforth HW. A systematic review of the psychiatric side-effects of efavirenz. AIDS Behav. 2011; 15:1803-1818.

    3. Dierks MR, Jordon JK, Sheehan AH. Prazosin treatment of nightmares related to posttraumatic dress disorder. Ann Pharmacother. 2007; 41(6):1013-1017.

    4. Miller LJ. Prazosin for the treatment of posttraumatic stress disorder sleep disturbances. Pharmacotherapy. 2008; 28(5):656-666.

    5. Mitchell HA, Weinshenker D. Goodnight and good luck: norepinephrine in sleep pharmacology. Biochem Pharmacol. 2010; 79(6):801-809.

    Objectives:

    1. To understand the mechanisms by which prazosin has been helpful in the treatment of nightmares in posttraumatic stress disorder.
    2. To analyze the ways in which Atripla-related sleep disorders affect patients and their decisions regarding HIV treatment.
    3. To apply an understanding of alpha(1)-adrenergic receptor blockade for the treatment of nightmares in PTSD to the treatment of vivid dreams resulting from anti-retroviral treatment in patients with HIV.

    Relevance:
    This presentation will stimulate thinking about a novel approach to reducing Atripla-induced nightmares in order to relieve troublesome symptoms and potentially improve adherence to HIV therapy.

     
  31. [T] Evolving Training Models in Ambulatory Psychosomatic Clinics
    Presenting Author:  Robert Joseph
    Co-Authors:  Amy Bauer, Matthew Grover, Joseph Carmody, Daniel Safin

    Psychosomatic Medicine (PM) practice has traditionally taken place within the general hospital on medical and surgical units. More recently, the collaborative management of mental illness in ambulatory medical clinics and the management of physical illness in mental health clinics between PM clinicians and primary care physicians (PCPs) have become common. Little attention, however, has been paid to formal training of psychiatrists and psychosomatic medicine fellows in outpatient PM settings. The challenges of outpatient PM are unique to the setting and require a unique set of skills, particularly in the areas of the boundaries of responsibility, resource management, and the education of PCPs. Outpatient PM clinics also provide the opportunity to develop longitudinal relationships with patients, primary care providers, and specialists.

    We will present a sample of experiences from the perspective of several recent graduates of PM programs. Creative ways of negotiating these challenges will be presented from real world examples. We hope that this discussion will lead to a better understanding of the myriad approaches to these patient care needs. We will argue that outpatient PM settings are an ideal setting for the training of medical students, psychiatry residents, and PM fellows.

    Objectives:

    1. Participants will be able to identify two different models of collaborative care between psychosomatic medicine (PM) clinicians and primary care physicians (PCPs).
    2. Participants will be able to identify three challenges unique to outpatient PM.
    3. Participants will be able to identify two possible solutions to the challenges within outpatient PM.

    Relevance:
    Collaborative models between PM clinicians and PCPs have become common. These models can be used to expose medical students, psychiatry residents, and PM fellows to the expanding opportunities within PM.

     
  32. WITHDRAWN  
  33. [T] Maternal Antenatal Psychological Symptoms and Temperament in 1 to 4-month-old Infants
    Presenting Author:  Amritha Bhat
    Co-Authors:  Roopashree Chowdayya, Sumithra Selvan, Arif Khan, Russell Kolts, Krishnamachari Srinivasan

    Purpose: We planned to examine the association between maternal antenatal psychological distress and temperament in infants 1 to 4 months old independent of birth outcome, i.e., in full term normal birth weight infants. We also planned to study the association between salivary cortisol and temperament in infants. We hypothesized that maternal antenatal psychological distress would be correlated with difficult infant temperament and that salivary cortisol levels in infants, being a marker of HPA axis function, would be associated with dimensions of infant temperament such as intensity, adaptability and mood.

    Methods: Pregnant women attending routine antenatal check up at the Obstetrics and Gynecology outpatient department of St. John's Medical College Hospital and anticipating delivery at St. John's Hospital were invited to participate in the study. The criteria for inclusion were: single (non-twin) pregnancy, no pregnancy-induced hypertension or gestational diabetes in the current pregnancy, no maternal use of alcohol / drugs or smoking, and full term infants (37 or greater weeks in gestation) with normal birth weight (above 2500 g). All pregnant women (for a total of 100 subjects) who met these criteria and whose infants were between 1 and 4 months age between July 2006 and February 2007 were included.

    Antenatal psychological distress was measured using the General Health Questionnaire-28 and Infant temperament was measured using the Early Infancy Temperament Questionnaire. Infant saliva was collected using salivary sorbettes and saliva was analyzed for cortisol using the competitive immunoenzymatic colorimetric method.

    Results: In this study, maternal antenatal psychological distress was not significantly associated with difficult temperament in infants. Infant salivary cortisol was significantly higher in infants with higher scores on the intensity scale of the EITQ.

    Conclusions: These results introduce the possibility of cultural differences in the relationship between antenatal distress in the mother and infant temperament. The observed lack of association between maternal antenatal psychological distress measured in the third trimester and difficult infant temperament in a non-western population could be due to cultural factors linked to child rearing practices or to the measures employed to study infant temperament. Salivary cortisol may be a useful biological marker in the identification of children with "difficult" temperaments.

    References:

    1. O'Connor TG, Heron J, Golding J, Beveridge M, Glover V. Maternal antenatal anxiety and children's behavioral / emotional problems at 4 years. Br J Psychiatry 2002; 180: 502-508.

    2. Mohler E, Parzer P, Brunner R, Wiebel A, Resch F. Emotional stress in pregnancy predictshuman infant reactivity. Early Hum Dev 2006; 82 (11): 731-737

    3. Gartstein MA, Gonzalez C, Carranza JA, Ahadi SA, Ye R, Rothbart MK, Yang SW. Studyingcross cultural differences in the development of infant temperament: People's Republic of China, the United States of America and Spain. Child psychiatry and human development 2006. 37: 145-161.

    Objectives:

    1. To assess if there is a correlation between maternal antenatal psychological distress and infant temperament.
    2. To examine if 1 to 4-month-old infants of mothers with antenatal psychological distress constitute a high risk group for later development of psychological disorders by virtue of a difficult temperament.
    3. To evaluate if salivary cortisol levels are correlated with dimensions of temperament.

    Relevance:
    Identification of high risk groups is important for models of indicated and selective prevention in psychiatry. This study examines temperament of infants of mothers with antenatal psychological distress.

     
  34. [T] Enhancing Resident Physician Awareness of Out-of-Pocket Psychotropic Medication Costs to Improve Patient Care
    Presenting Author:  Sheryl Fleisch
    Co-Authors:  Ted Turner, Jamie Montgomery, Tanya Fabian

    Purpose: Many patients discharged from hospitals are unable to afford their psychotropic medications, resulting in medication non-adherence and subsequent relapse. The purpose of this study is to assess knowledge of out-of-pocket medication costs and attitudes toward cost effective prescribing practices among psychiatry resident physicians at a large academic medical center.

    Methods: An anonymous online survey was disseminated to all resident physicians to assess baseline knowledge of out-of-pocket psychotropic medication costs and to evaluate attitudes toward cost effective prescribing practices. Resident physicians attended a 4 hour comprehensive workshop provided by the pharmacy department, received both written and online resources, and were also encouraged to consult transitional care pharmacists within the institution. A post-intervention anonymous online survey was then conducted to determine whether the intervention was effective in enhancing awareness of out-of-pocket psychotropic medication costs.

    Results: A total of 67 of 78 residents (86%) completed the initial online survey. Baseline knowledge of the out-of-pocket costs of psychotropic medication was limited. Out of a 5-point Likert scale, resident physicians ranked the following categories highest: believing cost influences whether patients fill prescriptions (4.64), believing physicians should be knowledgeable about the cost of medications they are prescribing (4.48), and feeling comfortable with medications available on the $4 generic program (4.33). Resident physicians ranked the following categories lowest: accessing drug cost information prior to writing a prescription (2.93), awareness of manufacturer-sponsored patient assistance programs (2.88) and awareness of patient copayment amounts when prescribing medications (2.78). Results from the post-intervention survey on enhancing resident physician awareness of out-pocket-cost of psychotropic medication costs will also be presented.

    Conclusion: Resident physicians recognize the importance of being knowledgeable about the cost of medications and understand the impact of cost on prescription filling. However, they do not routinely access drug cost information for the prescriptions they write nor do they understand all factors that influence cost of prescriptions for patients. Ongoing educational interventions increase resident physician awareness of out-of-pocket psychotropic medication costs which may ultimately facilitate medication access and promote adherence, thereby improving patient care.

    Objectives:

    1. Assess resident physician baseline knowledge of out-of-pocket psychotropic medication cost.
    2. Describe resident physician attitudes regarding the potential link between medication cost and medication access and adherence.
    3. Evaluate the impact of an educational intervention on resident physician awareness of out-of-pocket psychotropic medication cost.

    Relevance:
    Assess knowledge of out-of-pocket medication costs and attitudes toward cost effective prescribing practices among psychiatry resident physicians at a large academic medical center and provide educational interventions.

     
  35. House Staff Attitudes Towards Health Care Proxies
    Presenting Author:  Melanie Schwarz
    Co-Authors:  Joshua Ramjist, Gregory Todd

    Health care proxies serve as a surrogate decision makers for patients who are incapacitated and lack decision making capability. Prior research in this area of study is scarce, with a lack of studies investigating health care provider's personal attitudes and use of health care proxies. Many or all hospitals are required to not only inquire if patients have a health care proxy but also give patients information and the opportunity to execute a health care proxy during the patient's hospitalization. Health care providers have the opportunity to facilitate this discussion with patients about this vital component in their overall care plan. It is frequently hospital house staff who are present at this juncture in a patient's care when access to a designated health care proxy is most crucial. However, as we demonstrate, most health care providers, specifically hospital house staff, not only lack their own health care proxy but do not have an understanding of the details of the health care proxy and how to execute one.

    We surveyed 132 house staff during their orientation to the hospital in July 2011. Results showed that 9 house staff members had a health care proxy. While the overwhelming majority of house staff recognize it to be moderately to extremely important (96.9%) 47.7% had not thought about having their own health care proxy and 42.4% believed a loved one will just make their medical decisions on their behalf. Given these results it leads us to be at least concerned as to how we can expect patients to have an understand of health care proxies and actually have one when hospital house staff to not have this knowledge or have a proxy themselves? Based on this further investigation as to the attitudes towards health care proxies of not only house staff but health care providers is important. Further investigations into the interventions to increase health care providers understanding of and hopefully their own executing a health care proxy would be warranted.

    Objectives:

    1. The physician learner will learn about house staff's understanding of health care proxies.
    2. The physician learner will learn about the percentage of house staff who have health care proxies.
    3. The physician learner will understand the need for further education regarding health care proxies of health care providers.

    Relevance:
    Psychiatrists are often are called to assess decisional capacity regarding medical care. A health care proxy is essential to ensure an incapacited patient received the care of the choice.

     
  36. [T] Cannabis Hyperemesis
    Presenting Author:  Afton Bergel
    Co-Authors:  Zimri Yaseen, Nancy Maruyama

    Purpose: Cannabinoid hyperemesis is an often under-recognized clinical syndrome of intractable vomiting associated with compulsive showering, which may be seen by the Consultation-Liaison Psychiatrist. There have been several case reports in the Gastroenterology literature and a report in the German psychiatric literature. We describe a case and review the literature.

    Case report: MM was a 19 year old single US-born woman diagnosed with undifferentiated somatoform disorder, oppositional defiant disorder and cannabis dependence since age 12. From age fourteen she had a history of multiple Emergency Department visits for abdominal pain, nausea and vomiting clear emesis. CT abdomen in 2007 revealed non-specific minimal thickening of the terminal ileum. However, she never followed-up with attempts to obtain endoscopy or colonoscopy because she reported feeling better. The patient also described suffering with anxiety attacks (palpitations, shortness of breath, nausea and vomiting) following family conflict which she attempted to alleviate with daily cannabis smoking. Additionally she described frequent episodes of nausea/vomiting relieved by showering.

    She was admitted with persistent vomiting following an alcohol binge. Psychiatric consultation was requested to evaluate the patient for Obsessive Compulsive Disorder because she and her mother reported she would shower repeatedly during the day, six times a day for up to three to four hours at a time. She denied intrusive thoughts and compulsive behaviors such as excessive handwashing. Lipase was 65, liver enzymes and WBC were within normal limits, and she was afebrile. She was treated with famotidine, ondansetron, thiamine, and multivitamins. She had no evidence of alcohol withdrawal.

    Conclusion: We discuss the differential diagnosis for our patient and the limitations of this case study (lack of a complete gastrointestinal work-up, confounding psychiatric disorders such as somatoform and anxiety disorders). Nevertheless, the association of compulsive showering with vomiting and chronic, daily cannabis use strongly suggests the presence of cannabis hyperemesis syndrome.

    References:

    1. Allen JH, de Moore GM, Heddle R, Twartz JC, “Cannabinoid hyperemesis: cyclical hyperemesis in association with chronic cannabis abuse.” Gut. 2004 November; 53(11): 1566–1570.

    2. Chepyala P, Olden KW. “Cyclic vomiting and compulsive bathing with chronic cannabis abuse.” Clin Gastroenterol Hepatol 2008 Jun;6(6):710-2. Epub 2008 May 5

    Objectives:

    1. The participant will learn the key features of cannabis hyperemesis syndrome.
    2. The participant will understand the complexities involved in the differential diagnosis of cannabis hyperemesis.
    3. The participants will understand important treatment considerations.

    Relevance:
    Cannabinoid hyperemesis is an often under-recognized clinical syndrome of intractable vomiting associated with compulsive showering, which may be seen by the Consultation-Liaison Psychiatrist.

     
  37. CBT and Supportive Therapy Treatment of an Hispanic Patient Population with Irritable Bowel Syndrome
    Presenting Author:  Melvin Gilbert
    Co-Author:  Justin Capote

    Participants were gathered from an Irritable Bowel Syndrome (IBS) specialty clinic in an urban teaching hospital. Patients of the IBS clinic were systematically screened using the Patient Health Questionnaire (PHQ-9), Somatosensory Amplification Scale (SAS), and the Toronto Alexithymia Scale (TAS-20). Screening revealed high rates of alexithymia and somatization specifically among a predominantly Hispanic female demographic. These patients were then selected for a 12 week support style CBT group focusing on IBS education and symptom management while introducing progressive muscle relaxation (PMR) techniques and lessons focused on expanding emotional vocabulary. Reasonable goals of symptom control were discussed and patients were instructed to keep a daily symptom diary as they were introduced to a series of muscle relaxation exercises designed to mitigate anxiety-related symptoms while honing the patient's discernment of bodily cues. Special interest was taken during group to allow for the exchange of personal experiences in a validating and normalizing environment. The patients were then followed up one month after group termination to assess for any sustained benefits.

    Objectives:

    1. To present treatment strategies for patients with alexithymia and somatization.
    2. To present treatment strategies to achieve better outcomes in treating a predominantly Hispanic, urban patient population.
    3. To evaluate cultural factors relevant in treating an urban teaching hospital patient population.

    Relevance:
    The audience will gain better understanding as to how to assess and treat an underserved minority population.

     
  38. [T] Hot-Spotting Psychiatric Comorbidity: A Case of Nonadherence and the Ethics of Competency to Make Medical Decisions
    Presenting Author:  Jennifer Moore
    Co-Authors:  JaHannah Jamelarin, Christopher White

    DM is a 36 yo AAF with diabetes mellitus type 1 who has utilized hospital resources at an alarming rate. In one year, she had 18 hospitalizations related to nonadherence amassing charges over $500,000. During several admissions, psychiatry consultants diagnosed an underlying psychiatric disorder (depression and factitious disorder) contributing to her behavior. Nonadherence with a diabetic diet and intentional episodes of hypoglycemia placed her at imminent risk of self harm, and she was involuntarily admitted to the inpatient psychiatry service. An affidavit for probate to inpatient psychiatric treatment was filed and obtained. Despite psychiatric treatment, DM remained nonadherent as well as intentionally misleading about caloric intake. The question of DM’s competency to be guardian of her own person arose. Ultimately it was determined that DM lacked competency and a guardian was appointed.

    This case highlights an extreme example of psychiatric illness impeding adequate medical treatment. Most medical system struggles with “frequent flyers” and the high cost they accrue. A new trend is “hot spotting” these top utilizers to design interventions to simultaneously improve their care while decreasing their healthcare cost to the system. This poster will describe a retrospective sample of high psychiatry consult service utilizers based on total number of unique inpatient consults at a major academic hospital over the course of one year. Identifying trends in both barriers and facilitators with these patients will allow the system to work in an interdisciplinary fashion to ensure quality of care while reducing cost through minimizing high utilization and ineffective treatment.

    Finally, this poster will discuss the ethics of guardianship as utilized in our case. Guardianship raises issues regarding restriction of autonomy. Physicians are caught between respect for a patient’s autonomy while still acting with beneficence and nonmalifecence. By providing DM with structure, her quality of life improves with the hope that she gains insight and can make her own decisions with conscious motivations. Justice dictates that the healthcare system seek to balance DM’s needs against the needs of other utilizers.

    This poster discusses the similarities between patients frequently evaluated by the psychiatry consult service at a major academic hospital. Highlighting the ethical complexities of one solution (guardianship) we seek to foster discussion regarding whether a more paternalistic approach should be taken in similar cases to conserve resources while improving the longevity and health of our patients.

    Objectives:

    1. Understand the impact of high utilization by particular patients with comorbid medical and psychiatric illness to both their individual care and to the healthcare system as a whole.
    2. Discuss the ethical dilemma faced by physicians in the case of nonadherence to balance patient autonomy while still acting with beneficence and nonmalifecence.
    3. Develop strategies to improve patient outcomes while decreasing overall cost to the healthcare system.

    Relevance:
    This presentation addresses an issue faced by all healthcare providers and presents one possible solution while acknowledging its ethical implications, as well as recognizing trends to help improve overall outcomes.

     
  39. [T] Casey's Law: A New Ohio Law Allowing Civil Petitions for the Involuntary Treatment of Substance Use Disorders
    Presenting Author:  Abhishek Jain
    Co-Author:  Kathleen Franco

    Purpose: On March 22, 2012, Casey's Law went into effect in Ohio allowing for family and friends to petition for the involuntary treatment of an individual's substance use [1]. This law is modeled after Casey's Law in Kentucky. We aim to clarify this law, discuss its application and limitations, and review the pros and cons of involuntary chemical dependence treatment.

    Method: We report the first case in which Casey's Law was encountered on our consultation psychiatry service. We discuss practical considerations of this law, especially in a consultation psychiatry setting. After reviewing the literature, we aim to summarize the pros and cons of involuntary chemical dependence treatment.

    Results: A 24-year-old female with about a one-year history of alcohol dependence was brought to the medical emergency department by her parents following alcohol relapse. Psychiatric history included posttraumatic stress disorder, bipolar disorder, borderline personality disorder, and a recent suicide attempt. Over the previous year, the patient's parents had attempted, without success, multiple approaches to engage the patient in chemical dependence treatment. Prior to bringing her to the emergency department, her parents and a family lawyer had already begun the process for involuntary substance use treatment. She was initially medically admitted, but eventually involuntarily transferred to a psychiatric facility where she awaited transfer to a locked inpatient chemical dependence rehabilitation facility. In the absence of this recently passed law, the patient would likely have been discharged directly home once medically cleared because she refused further inpatient treatment.

    Casey's Law in Ohio requires that the petitioner (family or friend) pay all costs involved in the treatment. Additionally, the patient will not be ordered to undergo involuntary treatment unless he or she presents an imminent risk, or substantial likelihood in the near future, of danger to self or others as a result of substance use. Furthermore, the treatment must take place in a certified alcohol and drug addiction program or by certain licensed individuals [1].

    Literature indicates that coerced treatment for addiction is often negatively perceived, and introduces practical and ethical challenges, but can be effective [2, 3].

    Conclusion: A recently passed Ohio law allows for family and friends to petition for an individual to be involuntarily treated for substance use. Practical limitations in implementing this law exist. Although coerced treatment can be effective, the outcomes with this particular law are unclear and warrant further investigation.

    References:

    1. Ohio Revised Code. Section 3793.31-3793.39

    2. Nace EP, et al. Socially sanctioned coercion mechanisms for addiction treatment.Am J Addict. 2007 Jan-Feb;16(1):15-23.

    3. Sullivan MA, et al. Am J Addict. Uses of coercion in addiction treatment: clinical aspects. 2008 Jan-Feb;17(1):36-47.

    Objectives:

    1. Interpret laws regarding involuntary substance use treatment.
    2. Discuss the application of involuntary substance use treatment laws in a psychosomatic medicine setting.
    3. Compare involuntary and voluntary substance use treatment outcomes.

    Relevance:
    The audience will be exposed to the clinical utility and practical application of new state laws that allow civil petitions for the involuntary treatment of substance use disorders.

     
  40. [T] Suspicion of Factitious Disorder in a Transgendered Patient: Ethics and Countertransference
    Presenting Author:  Murat Altinay
    Co-Author:  Margo Funk

    Case: 23 year old female to male transgendered patient with past psychiatric history significant for Generalized Anxiety Disorder and past medical history significant for Endometriosis, Stable Bronchial Asthma and recent Laparoscopic Appendectomy, admitted for recurrent rectal bleeding and abdominal pain after having gone through an extensive negative work up at an outside hospital where he left against medical advice. During his current, month-long admission on the GI service the patient underwent: EGD, Colonoscopy, Push Enteroscopy, Antegrade and Retrograde Double Balloon Endoscopy, tagged RBC scans (x2), Provocative Angiogram and a Capsule Endoscopy, all of which were unable to show active bleeding. The patient continued to report abdominal pain, daily bloody stools and labs demonstrated significant blood-loss anemia which required multiple transfusions of pRBCs. The primary team was suspicious of fabricated symptoms and ordered a sitter, who was instructed to monitor the patient at all times, including restroom use. The psychiatry team was concurrently consulted to assess for factitious disorder and/or malingering.

    Results: Psychiatric evaluation revealed high levels of anxiety and distress and was thought to be consistent with Adjustment Disorder in the context of being kept under 24 hour surveillance without privacy. There was no initial evidence for primary or secondary gain and it was thought by the psychiatry team that the patient might be a victim of bullying in the healthcare setting. As the psychiatry team was planning to move forward with a Minnesota Multiphasic Personality Inventory (MMPI) for more quantitative assessment of his personality and behavioral patterns, the nursing staff noticed inconsistencies with the pt's PICC line and then found a bloody syringe hidden in the patient's bathroom. This was highly suggestive of factitious behavior by pulling blood from the PICC and injecting it into his rectum. After being confronted, the patient denied these behaviors, but continued to have drops in hemoglobin requiring another transfusion. In discussion with the psychiatry team, the patient was allowed to "save face" with the suggestion that the "bleeding may stop on its own." His H/H then normalized and remained stable. Concurrent with the discovery of the bloody syringe, new collateral from the patient's family revealed a strong history of opioid abuse and drug seeking behavior.

    Conclusions: Members of the Lesbian Gay Bisexual Transgender (LGBT) community experience unique stressors such as bullying, discrimination, and loss of privacy that can affect both mental health and the attainment of equitable healthcare. In this case, the "protective countertransference" of the psychiatry team led to delay in the suspicion of malingering and factitious disorder.

    Objectives:

    1. The participant will be able to identify three unique stressors to the LGBT community in the healthcare setting.
    2. The participant will be able to describe strategies for protecting privacy in the setting of the workup for factitious disorder.
    3. The participant will have the opportunity to assess his/her own approach to experiences with “positive” countertransference.

    Relevance:
    In this presentation, we will discuss ethical and countertransference issues in a case involving a transgendered man accused of factitious disorder.

     
  41. Anxiety – the "Other" Comorbidity: Has It Been Neglected?
    Presenting Author:  George Tesar
    Co-Authors:  Vrashali Jain, Imad Najm

    Rationale: Most research on psychiatric comorbidity in epilepsy has focused on depression, with far less attention to anxiety. Anxiety disorders, however, are the most prevalent psychiatric disorders in the general population, and they increase suicide risk. Have we been ignoring an important problem in the care of epilepsy patients?

    Methods: This is a retrospective, cross-sectional study of screening measures and corresponding psychiatric diagnoses in 414 epilepsy patients evaluated by a board-certified psychiatrist. Sensitivity and specificity of the GAD-7 were determined using the psychiatrist's diagnoses as the external reference. Other screening measures included the EQ5D index (EQ5DI) and the PHQ-9. t-tests were used to assess differences between mean EQ5DI, PHQ-9 and GAD-7 scores for each of eight diagnostic subgroups. Statistical calculations were two-tailed with significance level at .05. The study was approved by the Cleveland Clinic Investigational Review Board.

    Results: Primary psychiatric diagnoses in the 414 epilepsy patients included depression (182, 44%), adjustment disorder (53, 13%), anxiety disorder (39, 9.4%), no diagnosis (39, 9.4%), organic mood disorder (33, 8%), cognitive/behavioral disorder (32, 8%), somatoform disorder (23, 5.6%) and other (13, 3%). Depression was further subdivided into MDD/mod-severe (65, 37%), atypical depression (60, 34%), organic mood disorder (27, 16%), depression NEC (17, 9.7%), and dysthymia (5, 3%). In the MDD/mod-severe group (n=65), 7 had a co-morbid diagnosis of anxiety disorder. Mean GAD-7 scores for the following subgroups were Group A(MDD/mod-severe with comorbid anxiety) = 14.43; Group B (MDD/mod-severe) = 12.12; Group C (atypical depression) = 9.56, and Group D (anxiety disorders) = 9.00. EQ5DI were .61, .59, .73, and .73, respectively (A vs B: p=.197 and B vs D: p=0.027). At a cut-point of 10, GAD-7 sensitivity and specificty were .46 and .70, respectively.

    Discussion: The most common psychiatric co-morbidity in this patient cohort was depression with mod-severe MDD in 15.7% and anxiety disorders in 9.4%. Those with a principle diagnosis of anxiety disorder rated themselves as significantly less anxious on the GAD-7 (9.00) than patients with either uncomplicated MDD (14.4) or MDD+anxiety disorder (12.1). This is perhaps contrary to expectation, but may also help explain the rather low sensitivity and specificity of the GAD-7 screening instrument. That is, patients who received a subsequent diagnosis of anxiety disorder tended to have low GAD-7 scores contributing presumably to a comparatively high rate of false negative GAD-7 screens whereas those with the highest GAD-7 scores had moderate-to severe depression and no co-morbid anxiety disorder contributing to low specificity, i.e., a high-rate of false positive screens.

    Conclusion: These results support the well-documented finding that depressive disorders are the most common psychiatric co-morbidity in patients with epilepsy. They also are consistent with the impression that anxiety disorders do not necessarily warrant more attention, but rather that symptomatic anxiety is a significant and disabling feature of moderate-severe depression in patients with epilepsy.

    Objectives:

    1. Will be able to assess the impact of anxiety and anxiety disorders in patients with epilepsy.
    2. Will recognize that anxiety as a feature of major depression may be more intense and disabling than when it presents as an anxiety disorder.
    3. Will appreciate the value of screening tools in the collaborative management of psychiatric disorders in patients with epilepsy.

    Relevance:
    C-L psychiatrists collaborate in the care of patients with epilepsy. This presentation will enhance appreciation of the role screening instruments play in management of patients with epilepsy and psychiatric comorbidities.

     
  42. WITHDRAWN  
  43. [T] Management of Intravenous Substance Users on the General Medical Ward
    Presenting Author:  Alric Hawkins

    Background: The direct and indirect consequences of substance abuse are major issues that continue to strain the health care system. One of these consequences is the introduction of infectious agents into the body through intravenous drug use, which can cause a myriad of medical problems including both local and systemic illness. This has recently become a more complicated issue due to increasing resistance patterns amongst infectious agents, which are now often requiring the ongoing need for prolonged courses of intravenous antibiotics. In the current health care environment, where cost is a major consideration, these therapies are typically given as an outpatient with placement of semi-permanent intravenous access, such as a peripherally inserted central catheters. However, difficulties are posed by potentially transitioning a patient with known intravenous drug use to unsupervised outpatient treatment with ongoing intravenous access. Unfortunately, little data has been published on ideal management of these patients. So, we will review the management of such patients in our medical center over the last 12 months in order to gain a better understanding of the presentations, treatment issues, and outcomes to serve in developing a more standardized approach to managing such patients in the future.

    Methods: A retrospective chart review is undertaken of patients referred for consultation by the inpatient psychiatric consultation service at Vanderbilt University Medical Center and evaluated for assistance with managing substance related issues. Inclusion criteria include all patients who were seen by the infectious disease service with recommendation for prolonged intravenous antibiotic therapy in the context of known or suspected, active intravenous substance use. Patients are excluded if unrelated medical problems are the primary reason for ongoing hospitalization need. Data was collected and compiled concerning each patient's background, medical course, and ultimate treatment outcome.

    Conclusions: Patients with the need for prolonged intravenous antibiotic therapy pose a variety of issues for the healthcare system, especially when complicated by active intravenous drug use. Given the potential health risk to patients under these circumstances, a standardized plan of care will likely be beneficial in improving the quality of care that they receive with the ultimate goal of improving their outcomes in regards to both their acute medical issue and their substance-related illness.

    Objectives:

    1. Analyze the medical background of patients who present for treatment of infections related to intravenous drug use.
    2. Analyze the medical course of patients who present for treatment of infections related to intravenous drug use.
    3. Analyze the treatment outcomes of patients who present for treatment of infections related to intravenous drug use.

    Relevance:
    The relevance of this presentation is that will offer an analysis of the management of a group of patients often seen in inpatient consultation psychiatry.

     
  44. A New Model for Systemic Medical-Psychiatric Care Delivery for Complex Patients
    Presenting Author:  Steven Frankel
    Co-Author:  James Bourgeois

    Overview: We propose a poster representing an innovative model of care delivery for management-intensive, complex cases with chronic systemic-medical and co-morbid psychiatric illness. The extra cost of their makes accurate diagnosis and targeted treatment especially critical when working with this group of patients. This model utilizes a multispecialty, multidisciplinary team with the leadership of a physician who we designate, the Medical-Psychiatric Coordinating Physician (MPCP). This team leadership role may be compelling for psychosomatic medicine (PM) subspecialists and psychiatrists with combined Internal/Family Medicine-Psychiatry training (IM/FM-Psych).

    The MPCP manages the work of all the professionals involved in a case and generally provides part of the direct treatment. The MPCP creates a treatment plan, monitors treatment progress, mediates differences among team members, and serves as liaison with the patient and family. Complexity is added to the MPCP's role by the fact that the multiple personalities involved in these team-based treatments require continual oversight.

    Many of the referrals to MPCPs are likely to come from PCPs, as they seek care for their most complex, high resource utilizing cases.

    Method: The authors pilot tested this treatment model with 52 complex cases, each followed empirically for at last 18 months. Subjects were selected from a pool of office-based patients according to the following criteria: (1) at least two other professionals, usually physicians, had been involved in their care, (2) at least one other treatment had been attempted previously and had failed, (3) the patient required multiple visits in addition to those scheduled, and/or extra phone calls or emails for their support. .

    Results: Comprehensive chart review indicated improvement in at least two clinical dimensions (reduced utilization, treatment adherence, symptomatology, quality of life) in 44 of 52 patients following adoption of the MPCP-led model. According to our experience, treatment of this group of patients utilizing MPCP-led teams is generally associated with efficiency in resource use, including physician time, earlier identification of appropriate patients and initiation of treatment, and optimized outcomes. The clinical advantages of this approach appears to translate into efficiency and cost offset over time, in spite of the "overhead" of placing a physician in the central role.

    Conclusions: From our pilot study, the MPCP-led multispecialty team method appears effective in targeting ongoing outpatient treatment of highly complex cases with prominent psychiatric co-morbidity. As such, we believe that the MPCP represents a viable expansion of outpatient psychosomatic medicine.

    Additional Considerations: The proposed poster will be supported by a book by the authors of the poster entitled Comprehensive Care for Complex Patients: The Medical-Psychiatric Coordinating Physician Model. Publication is scheduled for November 2012 by Cambridge University Press.

    Objectives:

    1. Be able to conceptualize an extended role for Psychosomatic Medicine involving the long term care of patients and the responsibility for managing a multidisciplinary treatment team.
    2. Be able to better differentiate "complex patients" from more typical patients with co-morbid systemic medical-psychiatric illness.
    3. Understand the proposed benefits of this model, as compared to other, more widely used, models, for work with complex patients e.g. models utilizing case manager leadership.

    Relevance:
    The model of care we introduce extends the outpatient duties of PSM physicians, giving them greater primary responsibly for the majority of patients they encounter.

     
  45. Depression and Fatigue in Chronic Hepatitis C Patients
    Presenting Author:  Stephen Ferrando
    Co-Authors:  Mohammad Tavakkoli, Andrew Talal

    Introduction: Depression and fatigue are prevalent comorbidities inflicting chronic hepatitis C (CHC) patients. We report some of the clinical predictors of depression and clinically significant fatigue in a convenience sample of hepatitis C patients seen in a university HCV clinic.

    Methods: A total of 167 patients with CHC filled out the Patient Health Questionnaire-9 (PHQ-9) and Fatigue Severity Scale (FSS) at the time of clinic visit. A diagnosis of major depressive disorder (MDD) suggested by the PHQ-9 score was confirmed by clinical interview. Clinically significant fatigue (CSF) was determined by an FSS score of ≥ 41. Logistic and multiple regression models were used to analyze clinical correlates of depression and fatigue, respectively (Stata 11.2).

    Results: Thirty-three percent of patients had MDD and 52% had CSF, with a moderate positive correlation between the two conditions (CC=0.40). Sixty-one percent of patients were HIV-positive, among whom the rates of both MDD and CSF were significantly lower than those in HIV-negative patients (OR=0.47, p<0.05). With regard to drug use status, the rate of MDD was lowest in patients not using IV drugs (OR=0.28; p<0.01), and highest in those on methadone therapy (OR=3.57; p<0.01). As for fatigue, less severe fatigue was associated with not being an active IV drug user (coef.=-9.6; p<0.01), being a former IV user (coef.=-9.7; p<0.01), or lack of hepatitis C treatment history (coef.=-7.2; p<0.02). More severe fatigue, on the other hand, was observed in patients on selective serotonin reuptake inhibitor (SSRI) treatment (coef.=6.09; p<0.05).

    Discussion: Being HIV-positive appears to be associated with lower rates of both MDD and CSF in CHC patients. This may be partially explained by more extensive psychosocial support for people living with HIV as compared to patients without it. This, however, merits further examination in better-controlled studies. The higher rates of depression observed in patients on methadone therapy might be due to the known side effects of methadone. Contrary to expectation, our results do not confirm findings from earlier studies regarding a higher risk of depression among patients on interferon therapy. For fatigue, not using IV drugs was associated with lower rate and severity of fatigue, while being on hepatitis C treatment was associated with higher rates, which may be attributed to the adverse effects of interferon therapy. This also appears to be true for patients treated with SSRIs, which may be ineffective in treating fatigue or have fatigue as an intrinsic side effect. Taken together, these findings emphasize the importance of routine screening and evaluation of depression and fatigue in CHC populations, encourage further study into their multifactorial etiology, and underline the need for investigating more effective treatments.

    Objectives:

    1. Describe clinical factors affecting rate of depression in chronic hepatitis C patients.
    2. Describe clinical factors affecting rate of clinically significant fatigue in chronic hepatitis C patients.
    3. Describe the impact of HIV serostatus on rates of depression and fatigue in chronic hepatitis C patients.

    Relevance:
    Fatigue and depression commonly affect patients with chronic hepatitis C. A knowledge of factors influencing these conditions can help clinicians provide better care for patients.

     
  46. “Rub-a-dub-dub: The New Designer Drug”
    Presenting Author:  Smila Kodali
    Co-Authors:  Clark Herniman, Aasiya Syed, Tony Johnson

    Introduction: Methylenedioxypyrovalerone (MDPV) and mephedrone, marketed as "Bath Salts," are new designer drugs that have recently emerged in the hospital setting as a cause of psychiatric and medical symptoms.

    • MDPV is a synthetic drug that acts as a norepinephrine-dopamine reuptake inhibitor. Mephedrone meanwhile acts as a 5-HT and dopamine releasing agent. These agents are often sold alone or mixed with other less common designer drugs, such as flephedrone or methylone, as "bath salts." They are often marketed as "not for human consumption" in order to avoid scrutiny from the FDA and DEA. Abusers ingest these drugs by various means to achieve an amphetamine like "high." They can be insufflated, injected, smoked, or ingested.

    • Typically the state of intoxication lasts 3-4 hours; however, there have been reports in the literature of users developing long-standing psychosis from use of these compounds. Patients may experience delusions, hallucinations, agitation, and paranoia. There have also been reports of rhabdomyolysis, kidney failure, and cardiac problems.

    We describe our experience with four patients following "bath salt" ingestion. We also catalogued their common symptoms in order to aid clinicians in diagnosing abuse of these new designer drugs

    Methods: Case reports. We describe our experience with four patients following "bath salt" ingestion

    Results: This poster addresses 4 cases of bath salt ingestion, presenting symptoms, comorbidities, and treatment.  We found that intoxication caused sympathomimetic reactions as well as psychotic symptoms.  Our patients experienced side effects such as delusions, paranoia, tachycardia, paranoia, hallucinations, etc.  We illustrated some of the major adverse effects of intoxication from bath salts.  We also discuss how these patients were treated with antipsychotics.

    Conclusion: We hope to raise awareness to the potential for severe psychotomimetic and stimulant effects of "bath salt" use.  Our diagnosis and treatment of four "Bath Salts" abuse cases are described, which may be useful as "bath salt" use becomes more common. We address the importance of history taking and gathering collateral information to aid in this process.

    Objectives:

    1. Investigte a new trend of designer drugs that do not always have a clear etiology and are similar to other drugs.
    2. Diagnose and have understanding on how to treat patients with bath salt ingetion.
    3. Create a better understanding of MDPV.

    Relevance:
    MDPV is a growing drug in the USA and hard to recognize. Physicians would benefit from learning how to daignose and treat this new trend amongst patients.

     
  47. Suicidal Ideation Complicating Bone Marrow Transplation
    Presenting Author:  Isabel Schuermeyer
    Co-Author:  Beth Dixon

    Purpose: The guidelines for bone marrow transplant (BMT) vary from institution to institution, however, when a patient has suicidal ideation - remotely or acutely - transplant teams may choose not to proceed. Since patients that require bone marrow transplantation do not have the luxury of time, it is imperative that any exacerbations of a psychiatric illness be treated quickly. One of the goals of our psychosocial oncology program is to stabilize these patients so that they can undergo a bone marrow transplant.

    Methods: Three recent cases will be discussed along with the treatment plans and ethics involved. One case focuses on a patient who had a long history of recurrent major depression who developed severe suicidal ideation just prior to admission for transplantation. The second case is of a patient who had suicidal ideation while inpatient a few months prior to needing BMT. The final case is of a patient who had a history of suicidal ideation, with inpatient psychiatric admission, years prior to development of her hematological illness.

    Results: For all three patients, immediate psychiatric and psychological interventions in collaboration with the oncology team resulted in the ability to proceed with bone marrow transplant. There were slight delays for all three, and one patient did have a short inpatient psychiatry stay for stabilization.

    Conclusions: Even with significant comorbid psychiatric illnesses that are in an acute exacerbation, patients can safely undergo bone marrow transplantation.

    Objectives:

    1. Participants will explore the role of psychiatric consultation for patients preparing to proceed to bone marrow transplantation.
    2. Participants will understand the limited nature of research in this area.
    3. Participants will be able to identify ways to manage patients with either acute or chronic suicidal ideation so that bone marrow transplantation can be safely completed.

    Relevance:
    Often times psychosomatic medicine practitioners are asked to evaluate patients with suicidal ideation. With a collaborative approach, these patients can be safely taken for bone marrow transplant.

     

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